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Chapter 50
Terrorism
National EMS Education
Standard Competencies
EMS Operations
Knowledge of operational roles and
responsibilities to ensure patient, public, and
personnel safety.
National EMS Education
Standard Competencies
Mass-Casualty Incidents
Due to Terrorism and Disaster
• Risks and responsibilities of operating on
the scene of a natural or man-made
disaster
Introduction
• Terrorist attacks have sharply increased
over the last decade.
− Your personal health and safety should be your
primary concern.
− Additional training and drills can help develop
response skills.
Terrorism
• A violent act dangerous to human life to
intimidate or coerce a government, the
civilian population, or any segment thereof,
in furtherance of political or social objectives
Terrorism
• Terrorism is often
used as a form of
asymmetric
warfare.
• Terrorists tend not
to discriminate
when selecting
their targets.
© ZUMA Wire Service/Alamy Images
International Terrorism
• Acts of terror committed by foreign agents
− International terrorism subgroups:
• Non-state-supported terrorism
• State-sponsored terrorism
• State-directed terrorism
Domestic Terrorism
• Perpetrators are
citizens of the
country attacked
• Example:
− Centennial
Olympic Park
bombing in 1996
© Michael Green/AP Photos
Types of Terrorist
Organizations
• Violent religious groups/doomsday cults
− Seek apocalyptic violence or mass murder
− Eradicate or cleanse a region of people who
don’t practice their faith
Types of Terrorist
Organizations
• Extremist political/social groups
− Looking for political, economic, social freedom
− Influence economic or immigration politics and
geopolitical borders to claim or reclaim land
Types of Terrorist
Organizations
• Technology or “cyber” terrorists
− Attack technologic infrastructure
− “Hack” into systems and introduce corruptive
programs
Types of Terrorist
Organizations
• Single-issue terrorist groups
− Threaten or use violence as a way to advance
their views and goals
• Narcoterrorists
− Goal of manufacturing, distributing, and selling
drugs without prosecution
Types of Terrorist
Organizations
• Other subcategories include:
− Hate groups
− Patriot groups
− Militia groups
−
−
−
−
Common-law groups
Cult groups
Single-issue groups
Lone wolves
Types of Terrorist
Organizations
• Al Qaeda is the most infamous international
terrorist organization.
− Exhibit apocalyptic violence to affect political,
geopolitical, and religious goals
Recognizing a Terrorist Event
(Indicators)
• Acts of terror are usually covert.
• High-value targets for terrorists include:
− Military bases and centers
− Public transportation
− Chemical plants or transportation
− Government buildings and hospitals
− Public gathering places
Recognizing a Terrorist Event
(Indicators)
• The National Advisory System replaced the
Homeland Security Advisory System.
− Alerts responders to potential for attack
− Includes steps to take for protection
− Specifies if the threat is:
• Elevated
• Imminent
Recognizing a Terrorist Event
(Indicators)
• While on duty you should observe:
− Preincident indicators
− Type of location
− Type of call
− Number of patients
− Victims’ statements
Response Actions
• If you suspect an attack:
− Ensure scene safety and personal safety.
− Notify dispatch and/or supervisor.
− Request additional specialized resources.
− Establish command.
− Initiate multiple-casualty incident procedures.
Scene Safety
• Do not enter the scene if there is any doubt
that it is not safe.
− Best location for staging is upwind and uphill
− Wait for assistance from trained personnel.
Scene Safety
© Dennis MacDonald/Alamy Images
© pbpgalleries/Alamy Images
• Failure to park your
vehicle at a safe
location places you
and your partner in
danger.
Responder Safety
• Responder health and safety can suffer
more than usual during WMD incidents.
− Events can cloud decision making and create
tunnel vision.
Responder Safety
• You need the following:
− Awareness of self-preservation measures
− Culture of safety within your organization
− Previous knowledge and experience with PPE
− Proper PPE
− Self-enforcement of all protective measures
Responder Safety
• Best form of protection is preventing contact
with the agent
− The greatest threat in a WMD attack:
• Contamination
• Cross-contamination
Notification
Procedure/Resource Requests
• As soon as you suspect a terrorist or WMD
event, notify the dispatcher.
• Establish a safe staging area.
• Request HazMat teams as early as
possible.
Command
• If Incident Command System (ICS) is in
place, find medical staging supervisor for
assignment.
− Paramedics who arrive first may need to
establish “EMS or Medical Command.”
Command
• Tasks of first arriving paramedic:
− Report to incident command post.
− Establish a medical branch.
− Determine scope of incident.
− Gather and disseminate information to dispatch.
Command
• Tasks of first arriving paramedic (cont’d):
− Assign a supervisor for the following areas:
• Decontamination
• Treatment
• Transportation
• Staging
• Rehabilitation
− Report EMS activities to operations chief.
Command
• Expect heavy police presence.
− Provide site security.
− Monitor victims.
− Canvas witnesses.
• Paramedics should fully comply with law
enforcement requests.
Secondary Device or Event
• Terrorists often plant secondary devices to
go off after initial bomb.
− Never become so involved in a task that you do
not look around to reassess the scene.
Weapons of Mass Destruction
• Anything used as a weapon designed to
bring about mass death, casualties, and/or
massive damage to property and
infrastructure
Weapons of Mass Destruction
• Grouped in four major categories:
− Explosives/incendiary devices
− Chemical
− Biologic
− Radiologic/nuclear weapons
Weapons of Mass Destruction
• WMDs are highly desirable.
− Easy to obtain or create
− Geared towards killing large numbers of people.
− Technical recipes are found readily on the
internet.
Explosives/Incendiary
Weapons
• Explosives are
most common
weapon used by
terrorists.
Ammonium Nitrate or
“Fertilizer” Bombs
• Commonly used as an industrial-grade
fertilizer
• Requires special license for purchase
• Can be mixed to create an extremely
explosive compound
Suicide Bombers
(Human Bombs)
• Low-cost, lowtechnology, and
low-risk
© Musadeq Sadeq/AP Photos
• Destructive power
of explosives with
timing/accuracy of
human guidance
Chemical Agents
• Man-made substances that can have
devastating effects on living organisms
• Produced in multiple forms:
− Liquid
− Powder
− Vapor
Chemical Agents
• Categorized as:
− Vesicants or blister agents
− Respiratory or choking agents
− Nerve agents
− Metabolic or blood agents
− Irritating agents
Chemical Agents
• Chemical weapon classifications:
− Properties or characteristics of an agent
− Persistency and volatility
− Route of exposure
• Vapor hazard
• Contact hazard
Vesicants (Blister Agents)
• Primary route of exposure is the skin
• Cause burn-like blisters
• Agents consist of:
− Mustard (H)
− Lewisite (L)
− Phosgene oxime (CX)
Vesicants (Blister Agents)
• Signs of exposure on the skin include:
− Skin irritation, burning, and reddening
− Immediate intense skin pain
− Formation of large blisters
− Gray discoloration of skin
− Swollen and closed or irritated eyes
− Permanent eye injury
Vesicants (Blister Agents)
• Signs of inhalation of vapors include:
− Hoarseness and stridor
− Severe cough
− Hemoptysis
− Severe dyspnea
Vesicants (Blister Agents)
• Sulfur mustard
− Brownish,
yellowish oily
substance
− Persistent
− Distinct smell of
garlic or mustard
− Quickly absorbed
• Considered a
mutagen
Courtesy of Dr. Saeed Keshavarz/RCCI, Research Center of Chemical
Injuries/IRAN
Vesicants (Blister Agents)
• Sulfur mustard (cont’d)
− Patients generally do not show signs or
symptoms for 4 to 6 hours.
− Affected area will progressively redden and
develop into large blisters.
− Attacks cells within bone marrow
Vesicants (Blister Agents)
• Sulfur mustard (cont’d)
− Main complication is secondary infection
− Regarded as a persistent but it does release
vapors.
• Creates upper and lower airway compromise
• Damages and swells airways
Vesicants (Blister Agents)
• Lewisite (L) and phosgene oxime (CX)
− Produce similar blister wounds to sulfur mustard
− Highly volatile
− Immediate and intense pain
− May have grayish discoloration at site
− Tissue damage also occurs.
Vesicants (Blister Agents)
• Vesicant agent treatment
− No antidotes for sulfur mustard or CX exposure
− BAL (British Anti-Lewisite): antidote for agent L
− Ensure patient is decontaminated before ABCs
are initiated.
Pulmonary Agents
(Choking Agents)
• Gases that cause immediate harm to those
exposed
• Primary route of exposure: respiratory tract
− Damages lung tissue, causing fluid to leak
− Produce respiratory-related symptoms
Pulmonary Agents
(Choking Agents)
• Chlorine (CL)
− Distinct odor of bleach
− Creates a green haze when released as gas
− Initially produces upper airway irritation and
choking sensation
Pulmonary Agents
(Choking Agents)
• Chlorine (CL) (cont’d)
− Later symptoms may include:
• Shortness of breath
• Chest tightness
• Hoarseness and stridor
• Gasping and coughing
Pulmonary Agents
(Choking Agents)
• Phosgene
− Produced from chemical welfare but also a
product of combustion
− Potent with delayed symptoms
− Smells similar to freshly cut grass or hay
Pulmonary Agents
(Choking Agents)
• Phosgene (cont’d)
− Symptoms of mild
exposure:
• Nausea
• Chest tightness
• Severe cough
• Dyspnea on
exertion
− Symptoms of
severe exposure:
• Dyspnea at rest
• Excessive
pulmonary edema
Pulmonary Agents
(Choking Agents)
• Pulmonary agent treatment
− Remove patient from contaminated
atmosphere.
− Aggressive management of ABCs
− There is no antidote.
− May include pharmacotherapy
Nerve Agents
• Designed to kill large numbers of people
with small quantities
• Belong to class called organophosphates
• Block cholinesterase from working
− Causes organs to be overstimulated and
burnout
Nerve Agents
• G agents
− Sarin (GB)
• Colorless and
odorless liquid
• Highly lethal
− Soman (GD)
• 5 times as lethal
as GB
• Fruity odor
• No color
− Tabun (GA)
• ¹/₂ as lethal and
36 times as
persistent as GB
• Fruity odor
• Looks like GB
Nerve Agents
• G agents (cont’d)
− V agent (VX)
• Clear oily agent
• No odor
• 100 times more
lethal than GB
• Very persistent
Nerve Agents
• Once the agent
has entered the
body there will be a
pattern of
symptoms.
Nerve Agents
• Nerve agent treatment
− After decontamination, aggressively treat the
patient.
− Manage the ABCs.
• Seizing patients require nerve agent antidote kits in
addition.
Nerve Agents
• Nerve agent treatment (cont’d)
− Antidote for nerve agent exposure:
• DuoDote Antidote Kit contains a single injection of
atropine and 2-PAM chloride.
• Medication is delivered using the same technique as
an auto-injector.
Nerve Agents
Industrial
Chemicals/Insecticides
• Organophosphate is a common chemical in
insecticides.
• Industrial chemicals do not have sufficient
lethality to be effective WMDs.
Industrial
Chemicals/Insecticides
• Metabolic agents (cyanides)
− Hydrogen cyanide (AC) and cyanogen chloride
(CK) affect the body’s ability to use oxygen.
− Cyanide
• Colorless gas
• Odor similar to almonds
Industrial
Chemicals/Insecticides
• Low-dose
symptoms include:
− Dizziness
− Light-headedness
− Headache
− Vomiting
• High-dose
symptoms include:
− Shortness of
breath
− Tachycardia
− Seizures
− Cardiac arrest
Industrial
Chemicals/Insecticides
• Cyanide agent treatments
− Several antidotes
− Trained personnel wearing proper PPE:
• Removes patient from source of exposure
• Removes patient’s clothing to prevent off-gassing
Industrial
Chemicals/Insecticides
• Cyanide agent treatments (cont’d)
− Support the patient’s ABCs and gain IV access.
− Severe exposure requires aggressive
oxygenation and ventilation.
− If there is no antidote, initiate transport
immediately.
Industrial
Chemicals/Insecticides
Biologic Agents
• Organisms generally found in nature and
can cause disease or death
• Primary types found in a biologic event:
− Viruses
− Bacteria
− Neurotoxins
Biologic Agents
• WMD biologic agents pose difficult issues.
− Can be completely undetectable
− Symptoms similar to other common illnesses
• Spread in various ways:
− Dissemination
− Disease vector
Biologic Agents
• Communicability
− How easy it is for the disease to be spread from
one human to another
• Incubation
− Time between exposure and start of symptoms
Viruses
• Germs that require a living host to multiply
and survive
− Attacks healthy cells and replicates itself to
spread throughout the host
Viruses
• Smallpox
− Highly contagious
disease
− Before blisters
show, patient has:
• High fever
between 101°F
and 104°F
• Body aches and
headaches
Courtesy of CDC
Viruses
• Smallpox (cont’d)
− The most contagious phase is when blisters
begin to form.
− There is a vaccine.
• Has been linked to medical complications
• Only offered to first responders
Viruses
• Viral hemorrhagic fevers (VHFs)
− A group of diseases
• Ebola
• Rift Valley
• Yellow fever viruses
Viruses
• VHFs (cont’d)
− Causes blood to
seep out from the
tissues and blood
vessels
− Begins with flulike
symptoms
Courtesy of Professor Robert Swanepoel/National Institute for Communicable
Disease, South Africa
Bacteria
• Does not require a host to multiply and live
• Larger and more complex than viruses
• Can be fought with antibiotics
• Most infections begin with flulike symptoms.
Bacteria
• Inhalation and cutaneous anthrax
− Deadly bacterium that lies dormant in a spore
• Germ is released when exposed to optimal
temperature and moisture
Bacteria
• Inhalation and
cutaneous anthrax
(cont’d)
− Routes of entry
• Inhalation
• Cutaneous
• Gastrointestinal
Courtesy of James H. Steele/CDC
Bacteria
Courtesy of CDC
• Plague
− Natural vectors are
rodents and fleas.
− Bubonic plague
• Not contagious
Courtesy of CDC
• Infects lymphatic
system
• Can lead to sepsis
Bacteria
• Plague (cont’d)
− Pneumonic plague
• Lung infection, also known as pneumonia
• Contagious
• Higher death rate
• Easier to disseminate
Neurotoxins
• Most deadly substances known to humans
• Produced from:
−
−
−
−
Plants
Marine animals
Molds
Bacteria
• Route of entry:
− Ingestion
− Inhalation
− Injection
Neurotoxins
• Botulinum toxin
− Most potent neurotoxin
− Produced from bacteria
− Affects the nervous system’s ability to function
• Causes muscle paralysis
• Patient will go into respiratory arrest.
Neurotoxins
• Ricin
− Derived from mash
left from the castor
bean
− Causes:
• Pulmonary edema
• Respiratory and
circulatory failure;
death
Courtesy of Brian Prechtel/USDA
Neurotoxins
• Ricin (cont’d)
− Quite stable and extremely toxic
− Ingestion causes rapid onset of:
• Nausea
• Vomiting
• Abdominal cramps
• Severe diarrhea
Neurotoxins
• Ricin (cont’d)
− Ingestion signs
and symptoms:
• Fever
• Muscle aches
• Nausea
• GI bleeding
− Inhalation signs
and symptoms:
• Irritation of eyes,
nose, and throat
• Profuse sweating
• Cyanosis
Neurotoxins
• Ricin (cont’d)
− Treatment is supportive.
• Intubation
• Ventilation
• Positive end-expiratory pressure
• Treatment of pulmonary edema as appropriate
Other Paramedic Roles During
a Biologic Event
• Syndromic surveillance
− Monitoring of patients presented to emergency
departments and alternative facilities
− Recording of EMS call volume and use of overthe-counter medications
Other Paramedic Roles During
a Biologic Event
• Points of distribution (PODs)
− Strategically placed facilities preestablished for
distribution of:
• Antibiotics
• Antidotes
• Vaccinations
• Other medications and supplies
Other Paramedic Roles During
a Biologic Event
• PODs (cont’d)
− Medications may
be delivered within
12 hours anywhere
in country
− Containers known
as “push packs”
Courtesy of the Strategic National Stockpile/CDC
Radiologic/Nuclear Devices
• Only two publically known incidents
involving the use of a nuclear device
− Hiroshima
− Nagasaki
Radiation
• Energy emitted in the form of rays or
particles
− Found in radioactive material
• Radioactive material is unstable.
Radiation
• Energy emitted
from a strong
radiologic source
has four
categories.
− Alpha
− Beta
− Gamma (x-rays)
− Neutron radiation
Sources of Radiologic Material
• Thousands of radioactive materials found
are generally used to benefit humankind.
− Once it has been used for its purpose the
leftover material is called radiologic waste.
• Remains active but is no longer useful.
Radiologic Dispersal Devices
(RDD)
• Any container designed to disperse
radioactive material
− Generally requires a bomb (dirty bomb)
− Has potential to injure with both radioactive
material and explosives
− Destructive capability is limited by explosives
that are attached to it
Nuclear Energy
• Released by altering or splitting active
atoms
• Results in an immense amount of energy
• Nuclear material gives of all forms of
radiation.
Nuclear Weapons
• Kept in secure facilities
• After the fall of the former Soviet Union
many small devices were lost.
− Special atomic demolition munitions (SADMs)
How Radiation Affects the
Body
• Effects vary depending on amount and
route of entry
• Three levels of exposure:
− Radioactive exposure
− External contamination
− Internal contamination
How Radiation Affects the
Body
• Radiation can enter through all routes of
entry as well as through irradiation
• Symptoms of acute radiation sickness
− Nausea
− Vomiting
− Diarrhea
Medical Management
• Exposure to a radiation source does not
make a patient contaminated or radioactive.
− Occurs when radioactive source is on the body
− Must have initial treatment from HazMat
responder before treatment begins
Protective Measures
• To protect yourself from the source, use:
− Time
− Distance
− Shielding
Summary
• You may be called to respond to a terrorist
event. Prepare yourself mentally and
physically.
• Weapons of mass destruction complicate
the management of an incident.
• Terrorism is a violent act to intimidate or
coerce a group to further political or social
objectives.
Summary
• International and domestic terrorist groups
are categorized as violent religious
groups/doomsday cults, extremist
political/social groups, technology or cyber
terrorists, single-issue terrorist groups, and
narcoterrorists.
• NTAS replaced the color-coded system with
threat levels of elevated or imminent.
Summary
• Based on the threat level take appropriate
actions and precautions.
• Clues as to whether an emergency is the
result of an attack include the type of
location, type of call, number of patients,
patients’ statements, and preincident
indicators.
• If you suspect a terrorist or WMD event,
ensure the scene is safe before entering.
Summary
• Notify the dispatcher and inform of the
nature of the event, additional resources
needed, estimated number of patients, and
upwind or optimal route of approach.
• Establish a staging area, keeping in mind
access and exit routes.
• Constantly assess and reassess the scene
for safety.
Summary
• A weapon of mass destruction is any
nuclear, chemical biologic, or explosive
weapon or agent designed to bring mass
death, casualties, or damage to property
and infrastructure.
• Explosives are the most common weapons
of terrorists.
Summary
• Chemical agents include vesicants or blister
agents, respiratory or chocking agents,
nerve agents, metabolic or blood agents,
and irritating agents.
• Exposure to nerve agents is treated with an
antidote delivered as an auto-injector.
Summary
• Biologic agents include viruses such as
small pox and those that cause viral
hemorrhagic fevers, bacteria, and
neurotoxins.
• Standard precautions are extremely
important when treating patients exposed to
biologic agents.
Summary
• Nuclear or radiologic weapons can create
massive destruction.
• Patients who are potentially exposed to
radioactive material must be
decontaminated before contact.
Credits
• Chapter opener: © Gulnara Samoilova/AP Photos
• Backgrounds: Red—© Margo Harrison/
ShutterStock, Inc.; Green—Jones & Bartlett
Learning; Gold—Jones & Bartlett Learning.
Courtesy of MIEMSS; Purple—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.