1. Chapter 21
Incident Management

2. National EMS Education Standard Competencies (1 of 3)
EMS Operations
Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.
Incident Management
Establish and work within the incident management system.

3. National EMS Education Standard Competencies (2 of 3)
Multiple-Casualty Incidents
Triage principles
Resource management
Hazardous Materials Awareness
Risks and responsibilities of operating in a cold zone at a hazardous material or other special incident.

4. National EMS Education Standard Competencies (3 of 3)
Mass-Casualty Incidents due to Terrorism and Disaster
Risks and responsibilities of operating on the scene of a natural or man-made disaster.

5. Introduction
You should be able to identify the signs of a hazardous materials incident.
It is important for you to understand:
The purpose of an incident management system
The framework of the National Incident Management System (NIMS)
Basic triage

6. Hazardous Materials Incidents
HazMat are substances that are toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure.
During a HazMat incident, your top priority is to protect yourself and bystanders from exposure and contamination.

7. Response to HazMat Incidents (1 of 5)
Identify the substances involved.
Federal law requires that all vehicles containing certain quantities of hazardous materials display a HazMat placard.
The placard should include a four-digit identification number.

8. Response to HazMat Incidents (2 of 5)
Courtesy of the U.S. Department of Transportation

9. Response to HazMat Incidents (3 of 5)
Emergency Response Guidebook lists:
Most common hazardous materials
Their four-digit identification numbers
Proper emergency actions to control the scene
Emergency care of patients who become ill or injured after exposure
Courtesy of the U.S. Department of Transportation

10. Response to HazMat Incidents (4 of 5)
Unless you have received training, keep away from the contaminated area.
Notify the dispatcher of the suspected presence of HazMat.
Identify victims who have sustained an acute injury as a result of exposure.
Remove them from the contaminated area and have them decontaminated.
Give necessary care and transport.

11. Response to HazMat Incidents (5 of 5)
Very few specific antidotes or treatments exist for most HazMat injuries.
Emergency treatment usually consists of supportive care.
EMRs should receive specific additional training in hazardous waste operations and emergency response (HAZWOPER).

12. Multiple-Casualty Incidents (1 of 3)
Situations with more than one sick or injured individual
Require a very different method of operation from other emergency medical calls
I deleted the second bullet (it adds nothing) and promoted the third up a level.

13. Multiple-Casualty Incidents (2 of 3)
Variables in multiple-casualty incidents
Severity of the crash
Access routes
Available resources
Response times
Levels of emergency training
Overall experience of the EMS system

14. Multiple-Casualty Incidents (3 of 3)
Your goal should be to:
Provide the greatest medical benefit for the greatest number of people.
Match patients’ medical needs with appropriate treatment and transportation.

15. © David Crigger, Bristol Herald Courier/AP Photos
The Visual Survey (1 of 2)
As you are on the way to the scene, prepare yourself mentally for what you may find.
Where will additional help come from?
How long will it take for help to arrive?
© David Crigger, Bristol Herald Courier/AP Photos

16. The Visual Survey (2 of 2)
When you arrive at the scene, force yourself to stay calm.
Make a visual assessment of the scene.
Number of potential patients
Severity of their injuries
How much and what kind of help you will need

17. Your Initial Radio Report (1 of 3)
Use clear language, be concise, be calm, and do not shout into the microphone.
The key points to communicate are:
Location of the incident
Type of incident
Any hazards
Approximate number of patients
Type of assistance required

18. Your Initial Radio Report (2 of 3)
Good rule of thumb: Request one ambulance for every five patients.
When calling for additional resources:
Determine the perimeters for emergency vehicles only.
Establish a one-way route for emergency traffic to approach the scene and a separate one-way route for emergency traffic to exit.

19. Your Initial Radio Report (3 of 3)
When calling for additional resources: (cont’d)
Allow adequate room for emergency vehicles that need to be close to the scene.
Keep vehicles and personnel who are not needed at the scene at a staging area nearby.

20. Casualty Sorting (1 of 13)
Triage is the sorting of patients into groups according to their need for treatment.
Should be simple and fast
Do not worry about diagnosing patients.
START triage system
Lets EMRs triage each patient in 60 seconds or less, based on breathing, circulation, and mental status

21. Casualty Sorting (2 of 13) Triage tagging
Patients are tagged so that other rescuers can easily recognize their triage level.
Tagging uses colored surveyor’s tape or colored paper tags.

22. Casualty Sorting (3 of 13) Triage tagging (cont’d)
Priority One (red tag): immediate care; injuries are life threatening.
Priority Two (yellow tag): urgent care; can delay up to 1 hour.
Priority Three (green tag): delayed care; can delay up to 3 hours.
Priority Four (gray or black tag): patient is dead; no care is required.

23. Casualty Sorting (4 of 13) First step in START: get up and walk
Tell all the people who can get up and walk to move to a specific area.
If patients can walk, they rarely have life-threatening injuries.
These patients are the “walking wounded,” designated as Priority Three (green tag).

24. Casualty Sorting (5 of 13) Second step in START: begin where you stand
Move through the remaining patients.
Stop at each patient to provide a quick assessment and tagging.
Find and tag the Priority One patients.
Examine them, correct life-threatening airway and breathing problems, tag them with a red tag, and move on.

25. Casualty Sorting (6 of 13)
The START triage system is based on three observations:
Breathing
Circulation
Mental status

26. Casualty Sorting (7 of 13)

27. Casualty Sorting (8 of 13) Breathing
Patients with breathing rates of greater than 30 breaths/min: Priority One
Patients with breathing rate of less than 30 breaths/min: move on to the next step
Patients who need help maintaining an open airway: Priority One
If you are in doubt as to the patient’s ability to breathe: Priority One

28. Casualty Sorting (9 of 13) Breathing (cont’d) Circulation
Patients who are not breathing and do not start breathing with airway maneuvers: Priority Four
Circulation
Check the patient’s carotid pulse.
Weak or irregular pulse: Priority One
Strong pulse: move on to the next step

29. Casualty Sorting (10 of 13) Circulation (cont’d)
Weak pulse: treat for shock
Absent pulse: Priority Four

30. Casualty Sorting (11 of 13) Mental status
Determine whether the patient responds to verbal stimuli.
Patients who can follow simple commands and have adequate breathing and circulation: Priority Two
Unresponsive patients: Priority One

31. Casualty Sorting (12 of 13)
START is designed to help rescuers find the most seriously injured patients
Injured patients do not always remain in the same condition.
The process of shock may continue.
Some conditions become more serious as time goes by.
If possible, recheck the condition of Priority Two and Priority Three patients.

32. Casualty Sorting (13 of 13)

33. Working at a Multiple-Casualty Incident (1 of 2)
If you are not the first person to arrive, report to the incident commander.
If you are the first on the scene:
Make the initial overview.
Clearly and accurately report the situation to the dispatcher.
Conduct the initial START triage.

34. Working at a Multiple-Casualty Incident (2 of 2)
As more highly trained personnel arrive, report your findings to the person in charge by noting:
Approximate number of patients
Number of patients whom you have triaged
Additional assistance required
Other important information

35. National Incident Management System (1 of 3)
Developed by the US Department of Homeland Security
Provides a consistent and unified approach to handling emergency incidents
Used to handle the immediate response, mitigation, and long-term recovery of small and massive natural and human-made incidents

36. National Incident Management System (2 of 3)
Six major areas are addressed within the scope of NIMS.

37. National Incident Management System (3 of 3)
EMRs fall within the first category.
Three major components of Command and Management:
The Incident Command System (ICS)
Multiagency Coordination Systems
Public Information Systems

38. Terrorism Awareness (1 of 2)
Terrorism is the systematic use of violence by a group to intimidate a population or government to achieve a goal.
Terrorist acts may be instigated by a country’s citizens or by people from other countries.

39. Terrorism Awareness (2 of 2)
Methods used to incite terror
Explosives
Fire
Chemicals
Viruses
Bacteria
Radiation

40. Weapons of Mass Destruction
Any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure
Include explosive, chemical, biologic, and nuclear weapons
The preferred WMD to date has been explosive devices.

41. Potential Targets and Risks (1 of 3)
Potential terrorist targets
Bridges, tunnels, pipelines, and harbors
National monuments
Housing developments and automobile dealerships
Computer networks and data systems
Farms and agricultural installations
Schools, government buildings, churches, and shopping centers

42. Potential Targets and Risks (2 of 3)
© Galina Barskaya/ShutterStock, Inc.
© Susan Tansil/ShutterStock, Inc.
© Steve Allen/Brand X Pictures/Alamy Images
© phdpsx/ShutterStock, Inc.

43. Potential Targets and Risks (3 of 3)
EMRs should always be alert for hazards.
Although you should be prepared for terrorist events, most of your emergency medical calls will not be for these events.

44. Agents and Devices (1 of 11)
Explosives and incendiary devices
Explosives produce a concussion that destroys property and inflicts injury and death.
Incendiary devices are designed to start fires.
The first indication that such a device is present is the explosion or fire from its deployment.
Courtesy of Captain David Jackson, Saginaw Township Fire Department

45. Agents and Devices (2 of 11)
WMD safety considerations
Be alert for safety hazards.
Do not enter an area that may be unsafe until properly trained personnel assess the risks.
Be alert for the possibility of a second explosive device.
Use the same safety skills you developed for other types of emergency situations.
Staging should occur upwind and uphill.

46. Agents and Devices (3 of 11)
Chemical agents
Pulmonary agents
Gases that cause immediate distress and injury
Cause intense coughing, gasping, shortness of breath, and difficulty breathing
Metabolic agents
Affect the body’s ability to use oxygen at the cellular level
Most common metabolic agents: cyanides

47. Agents and Devices (4 of 11)
Chemical agents (cont’d)
Insecticides
Class of poisonous chemicals that are inhaled or absorbed through the skin
Absorption produces SLUDGE-like symptoms.

48. Agents and Devices (5 of 11)
Chemical agents (cont’d)
Nerve agents
Among the most deadly chemicals developed
Cause SLUDGE-like symptoms
Sarin, soman, tabun, and V agent (VX)
Blister agents
Produce burn-like blisters, pain, skin irritation, severe shortness of breath, and severe coughing
Include sulfur mustard and Lewisite

49. Agents and Devices (6 of 11)
Safety considerations when dealing with chemical agents
Anytime multiple people experience unexplained symptoms, suspect a common agent as the cause.
Your primary role is to recognize that a problem exists and to avoid contaminating yourself, other rescuers, and bystanders.
Stay upwind and call for assistance.

50. Agents and Devices (7 of 11)

51. Agents and Devices (8 of 11)
Biologic agents
Naturally occurring substances that produce diseases
Incubation period: the time from exposure to the time the person shows symptoms of the disease
The first awareness of a biologic incident would likely come from hospital emergency departments.

52. Agents and Devices (9 of 11)
Safety considerations when dealing with biologic agents
Be alert for unusual patterns of diseases with flulike symptoms.
Practice appropriate standard precautions.
Call for specially trained assistance and wait in a safe location.
Patients need to be decontaminated.

53. Agents and Devices (10 of 11)
Radiologic agents
Ionizing radiation is a kind of energy that is formed by the decay of a naturally occurring or human-made radioactive source.

54. Agents and Devices (11 of 11)
Radiologic agents (cont’d)
Radiation cannot be seen, felt, or detected without special instruments.
A dirty bomb is an explosive device containing a small amount of radioactive material.
Stay away from the blast site until specially trained teams check for radiation.
Courtesy of Atomex Scientific and Production Enterprise (

55. Your Response to Terrorist Events (1 of 3)
In all emergencies, the same safety rules apply:
Good scene safety
Vigilant standard precautions
Courtesy of FEMA

56. Your Response to Terrorist Events (2 of 3)
Be prepared and know the limits of your training.
Many types of terrorist events require you to stay a certain distance away to avoid contaminating additional people.
Be alert for secondary devices.

57. Your Response to Terrorist Events (3 of 3)
Establish an ICS as soon as possible.
Know your role in working within the ICS.
Treat these incidents as mass-casualty situations.
Establish good working relationships with appropriate local, state, and federal agencies.

58. Summary (1 of 5)
During a HazMat incident, your top priority is to recognize that a hazard is present and to protect yourself and bystanders from exposure and contamination from the hazardous material.

59. Summary (2 of 5)
The START system is a simple triage system that you can use at multiple-casualty incidents. It sorts patients in groups so that the most serious patients are treated and transported first.
NIMS is designed to provide a unified approach to emergency incidents of any size.

60. Summary (3 of 5)
The goal of terrorists is to intimidate a population or government so as to achieve a goal. Terrorists may use many approaches to incite terror, including the use of explosives, fire, chemicals, viruses, bacteria, and radiation.

61. Summary (4 of 5)
Chemical agents are human-made substances that can have devastating effects on living organisms. They include pulmonary, metabolic, insecticides, nerve, and blister agents.
Biologic agents are organisms that cause disease.

62. Summary (5 of 5)
Radiologic weapons can create a massive amount of destruction. They include radiologic dispersal devices, also known as dirty bombs.
EMRs need to consider their safety, the safety of other rescuers, and the safety of bystanders whenever dealing with a terrorist-related event.

63. Review The first step in the START triage process involves:
quickly determining who is most injured.
asking all the people who can get up and walk to move to a specific area.
opening the airway of unconscious victims.
calling dispatch.
I capitalized the answers.

64. Review
Answer:
B. asking all the people who can get up and walk to move to a specific area.

65. Review
Which of the following patients would be tagged as a Priority One (red tag)?
the patient who cannot maintain an open airway
the patient with a strong carotid pulse
the patient who does not start breathing with airway maneuvers and does not have a pulse
the patient with a broken femur

66. Review
Answer:
A. the patient who cannot maintain an open airway

67. Review
The function of the National Incident Management System (NIMS) is to:
assist EMS providers in managing natural disasters.
oversee the operations of all EMS and fire agencies in the United States.
provide a consistent and unified approach to handling emergency incidents.
educate city governments regarding foreign terrorist attacks.
I capitalized the answers.

68. Review
Answer:
C. provide a consistent and unified approach to handling emergency incidents.

69. Credits
Opener: Courtesy of Captain David Jackson, Saginaw Township Fire Department
Background slide image (ambulance): © Comstock Images/Alamy Images
Background slide images (non-ambulance): © Jones & Bartlett Learning. Courtesy of MIEMSS.