1
Florida Heart CPR*
Terrorism
1 hour
Objectives: Upon completion of this course, the participant will be able to define the
aspects of incident management, various chemical and biological agents and the
proper responses to them and discuss aspects of planning and pre-planning for terrorist
attacks.
INTRODUCTION
Emergency Medical Services (EMS) often co-manage initial scenes in many medium- to
large-scale incidents involving large numbers of casualties. Occasionally, EMS also
manages the scene until state or federal agencies arrive. The tragic events of
September 11, 2001 underscore the importance of EMS planning and anticipating such
events.
Many authorities consider the United States a continuing high-profile target. For all
Americans, the attack on the World Trade Center on September 11, 2001, brought
home the tragic realization that America is not immune to terrorism. Philip Stern, an
expert on terrorism with the Fairfax Group, said, "As an open society and a democracy,
this country is particularly vulnerable. We have free passage, coast-to-coast, anyone
can apply for a visa to visit and the population is enormous and diversified."
Some feel that such an inviting atmosphere makes terrorist activities inevitable. Many of
the terrorist groups of today appear more and more likely to use weapons of mass
destruction. Perhaps even more disturbing is the belief that terrorists are leaning toward
the use of more technologically advanced weapons and communications. Access to the
Internet and information on the World Wide Web facilitates tremendous technological
advancement in destructive potential.
All of these issues underscore the importance of proper education in EMS and advance
planning. Terrorist activity may have various mechanisms, including chemical or
biological weapons and explosives, as well as new methods of destruction. Full
response to a terrorist incident requires in-depth interagency planning involving police;
fire; EMS; regional, state, and national emergency organizations; as well as a wide
array of ancillary services. Assign each agency respective roles as soon as possible,
well in advance of potential terrorist acts.
ASPECTS OF TERRORISM
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Determining the actual extent of the terrorist threat in the United States is difficult, as it
is poorly defined and rapidly changing. James Alan Fox, Dean of Northeastern
University's Criminal Justice Program in Boston, believes the 2 current motivations for
terrorism are revenge and attention.
Several terrorist incidents in the United States highlight the lethal nature of terrorist acts:
the World Trade Center attacks and bombing, the Atlanta Olympic bombing, and the
Oklahoma Federal Building bombing.
All Americans remember the tragic events of September 11, 2001. However, not all
remember the World Trade Center bombing in 1993, which killed 6 people and injured
more than 1000. In April 1995, the Federal Building in Oklahoma City was bombed,
killing 168 people. A pipe bomb was detonated in Centennial Park during the 1996
Olympic Games in Atlanta, Georgia, killing 2 people and wounding more than 100. Such
events emphasize the potential loss of life and property caused by terrorist activities.
PREPLANNING
Effective response to a terrorist incident hinges on comprehensive planning and
interagency cooperation. Address and resolve jurisdictional issues well in advance.
After a plan has been devised, update it regularly to reflect changes in resources,
population, terrorist activities, or potential targets. Local police, fire, EMS, and Disaster
& Emergency Services (DES) agencies should form the first line of response. Other
agencies that may be involved include the following:
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Secret Service
Bureau of Alcohol, Tobacco, and Firearms (BATF)
State disaster agencies
Military or reserve units
Specialized medical units
Depending on circumstances, state or federal response agencies, such as the
Emergency Broadcast System, Federal Aviation Administration, or National Weather
Service may need to become involved.
An act of terrorism in a metropolitan area may cause major health and medical
consequences that could rapidly overwhelm virtually all local health facilities; thus,
ongoing contact with state and national agencies is recommended highly. The Federal
Bureau of Investigation (FBI) is the federally designated lead agency in a confirmed
domestic terrorist event. Depending on location, however, some federal agencies may
not be on-site for 24 hours or more.
On a national level, the US Government has established the National Disaster Medical
System (NMDS). This organization assists in providing medical care and transportation
for disaster victims. The NDMS comprises sections of the Department of Health and
Human Resources, the Department of Veterans Affairs, the Department of Defense,
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and the Federal Emergency Management Agency (FEMA). Any state can enlist the
services of NDMS, which provides assistance at the disaster site, evacuates patients,
and finds beds for evacuated patients. Congress also has established a Domestic
Preparedness Program that provides enhanced training for local first responders and
forms metropolitan medical strike teams in major cities.
In evaluating sites of potential terrorist activity, consider the release of chemical or
biological agents into crowded and contained areas, such as sports stadiums, office or
public buildings, and transportation systems (eg, the Tokyo subway Sarin incident).
Such places provide tempting targets despite on-site security. Rapid identification of the
chemical or biological agent is critical to proper disposition of patients and to
management of affected areas. Disasters of human agency, particularly involving
hazardous materials (HAZMAT), radioactive materials, or chemical agents, may
produce unfamiliar medical problems that cannot be identified rapidly in readily available
emergency medicine (EM) literature. Utilize all possible resources early in the incident
to ensure proper identification of the agent and prompt initiation of proper protocols.
INCIDENT MANAGEMENT
Most of the principles of incident management are similar to those of mass casualty
incidents. Primary concern in potential terrorist incidents is to secure the area and to
ascertain the severity and nature of the threat. Keep in mind that delayed explosives or
materials intended to harm rescue workers may have been planted at the site. Primary
and secondary perimeters must be established and secured. Determine if a cleared,
downwind perimeter is needed, and establish one if required.
Early involvement of support and ancillary services, mutual aid agencies, and local
agencies in the planning process is prudent. After identifying the potential threat,
determine which type of protective equipment is necessary. Emphasis must be placed
on decontamination and protection of rescuers and victims.
After establishing a decontamination and triage area, rescuers should put on
appropriate protective clothing before entering the affected area and beginning rescue
efforts. The first focus is on supportive care with emphasis on aggressive airway control
and decontamination. Issues associated with simultaneous containment, neutralization,
and/or decontamination may be addressed by ancillary agencies. Following initial triage,
patients are given primary or aggressive aid depending on their presentation and the
resources available. Decontaminate and transport patients to a facility that has been
informed about the etiology of the incident as soon as feasible. Secure and clean the
area to complete the physical response. Record keeping, analysis of the incident, and
investigations conclude the complete response.
SELECTED AGENTS OF TERRORISM: CONVENTIONAL EXPLOSIVES
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An explosive is a normally stable material that, when introduced into a chemical
reaction, converts rapidly from a solid or liquid to an expanding gas. Explosives are
categorized as either low grade or high grade. Low-grade explosives burn quite rapidly.
Black powder, the original low-grade explosive, served as the basis for development of
smokeless gunpowder and some rocket propellants. Other examples of low-grade
explosives are nitrostarch, nitrocellulose, and commercial fireworks.
High-grade explosives, also termed "detonating explosives," are more stable than lowgrade explosives, frequently requiring trauma or shock for detonation. Nitroglycerin is
the original high-grade explosive. Ammonium nitrate is another example of the early
types of detonating explosives. Composition B, C-3, C-4, and TNT were developed
later. Other examples include Amatol 80/20, RDX, PETN, and dynamite. Initiating highgrade explosives are a separate class of very sensitive high-grade explosives, such as
lead styphnate and lead azide.
The Unabomber, known for constructing and using pipe bombs, is an example of a
terrorist who targeted specific victims. The pipe bomb is easy to construct using readily
available components and published step-by-step instructions. The Unabomber was
very careful in his choice of components used to assemble bombs, complicating the
search for his identity.
SELECTED AGENTS OF TERRORISM: CHEMICAL AGENTS
Chemical agents were first used extensively in World War I with dramatic results against
unprepared troops. Although far less lethal than conventional explosives, chemical
weapons can affect and incapacitate large numbers of troops in a short time. Chemical
warfare agents were defined by the United Nations in 1969 as "chemical substances,
whether gaseous, liquid or solid, which may be employed because of their direct toxic
effects on man, animals, or plants." The ready availability of precursors of modern
chemical weapons and copious documentation on their preparation make the use of
chemical weapons for terrorist actions far more likely than use of nuclear or biological
weapons. In addition, potential terrorists could easily locate a chemical production
facility, sabotage it using chemical or conventional explosives, and allow ambient winds
to spread the toxins. The resultant environmental contamination would fulfill many
terrorists' objectives of generating fear, trepidation, and panic among the population.
Chemical agents are separated into 2 broad categories, lethal and nonlethal. Lethal
agents include cyanides, nerve agents, vesicants, and choking agents. Nonlethal
agents include lacrimating, emesis-inducing, and incapacitating agents.
Lethal chemical agents
Cyanide compounds
Although they have been used since World War I, cyanide compounds are highly
volatile, rendering them less useful than chlorine. The military designates hydrogen
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cyanide (AC) and cyanogen chloride (CK) as the substances used in warfare. Cyanide
and its compounds are among the most rapidly acting chemical agents. Signs and
symptoms include air hunger, hyperpnea, apnea, seizures, coma, and death. Cyanide
poisoning is treated with a combination of nitrites and thiosulfates available in
commercial kits. Protective masks, gowns, and gloves are necessary until the patient is
decontaminated completely.
Nerve agents
Nerve agents are chemicals that inhibit acetylcholinesterase irreversibly. They combine
with acetylcholine (ACH) to prevent transmission at the neuromuscular junction and
affect both the sympathetic and parasympathetic nervous systems. Salivation,
lacrimation, urination, defecation, and emesis (SLUDGE) are common signs. Muscarinic
effects may cause the most serious complications, including bronchoconstriction,
laryngospasm, and respiratory depression or arrest. These nerve agents may be
delivered by droplet, vapor, or both. Symptoms of skin exposure appear much more
slowly than those from inhalation. Onset of symptoms varies from 1 minute to a few
hours. If cyanide compounds are inhaled or absorbed through the mucus membranes,
death can occur in 1-10 minutes.
Therapy includes atropine sulfate, with as much as 10-40 mg required in some
instances. Currently, the US Army uses 2-PAM (pralidoxime chloride), although it is not
completely effective. It is least effective against Soman (GD). Pretreatment with
pyridostigmine competitively inhibits the nerve agent. Pyridostigmine combines
reversibly with ACH, which can resume neurotransmission after disassociation.
However, such pretreatment does not protect against seizures.
Current nerve agents include Tabun (GA), Sarin (GB), Soman (GD), and VX. Local
decontamination of these agents includes washing with soap and water. Health care
providers should wear full protective gear until the patient is cleared by an
environmental health specialist. VX, considered the most toxic of the nerve agents, is
also the most difficult to decontaminate because of its low volatility.
Choking agents
Causing pronounced irritation to the upper and lower respiratory tracts, these agents
are potentially dangerous because of a period of latency. A victim with dyspnea and
mild chest discomfort may deteriorate after several hours to apnea and subsequent
death. Chlorine is a widely used chemical that falls into the choking agent class.
Chlorine causes upper- and lower-respiratory irritation, lacrimation, chest pain, dyspnea,
coughing, laryngeal edema, pulmonary damage, and pulmonary edema.
Treatment is symptomatic with nebulized sodium bicarbonate. Decontaminate by
copious flushing of affected areas with water. Medical providers need no special
protection from chlorine-exposed patients.
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Vesicant agents
Vesicant agents, also termed blistering agents, may be toxic to the lungs, eyes, and
mucous membranes. They are named for their tendency to cause blisters. Mustard gas
is the best-known vesicant, originally used in World War I. It is a primary tissue irritant
and has no significant allergenic component. Lesions are primarily cutaneous, but
respiratory, ocular, and GI manifestations may occur, as well as cough, bloody sputum,
and dyspnea. Areas of exposure become erythematous and progress to bullae, similar
to toxic epidermal necrolysis. Symptoms may not occur for several hours after
exposure. No antidote is available.
Other vesicants include sulfur mustard (HD), nitrogen mustard (HN), agent T, and
phosgene oxime (CX). Lewisite, unlike mustard and mustard derivatives, causes
immediate pain and skin irritation.
Medical providers require protective masks and clothing for patient management.
Decontaminate by blotting and cleansing with soap and water. Avoid scrubbing and hot
water.
Nonlethal chemical agents
Lacrimator agents
Lacrimator agents (tear gases) are widely used by law enforcement and the military.
The most common effects are nasal and ocular discharges, photophobia, and burning
sensations in the mucous membranes. Prolonged exposure may produce tightness in
the chest, shortness of breath, and malaise and may cause vesiculations or bullae.
Physical injuries may be observed from explosive discharge or kinetic effects of
projectiles. At least 1 death has been attributed to lacrimator agents.
Most patients can be decontaminated fully by undressing, showering, and washing with
soap and water. Medical personnel should use protective masks, gowns, and gloves,
since lacrimator agents are transmitted by physical contact.
Types of lacrimator agents include bromobenzyl cyanide (CA), orthochlorobenzylidenemalonitrile (CS), dibenoxazepine (CR), 2-chloroacetophenone (CN),
chloroacetophenone in chloroform (CNC), and chloroacetophenone and chloropicrin in
chloroform (CNS).
Emesis-inducing agents
Emesis agents, also termed nausea gases, are not used routinely in the United States.
They produce respiratory and skin irritation effects similar to those of lacrimator agents,
as well as profound nausea. Examples of such compounds include adamsite (DM),
diphenylcyanoarsine (DC), and diphenylchloroarsinine (DA).
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No decontamination is required in the field, and diluted bleach solution has proven
effective for definitive cleaning. Ordinary clothing protects against these agents;
chemical insert masks and standard gloves are adequate.
Incapacitating agents
The possibility of a nonlethal incapacitating agent has long intrigued military
commanders. Several agents have been tested, including lysergic acid diethylamide
(LSD), mescaline, psilocybin, and psilocin. The only successful agent in production is
benzilate (BZ).
BZ is a delayed onset (1-4 h) agent causing tachycardia, dizziness, vomiting, blurred
vision, stupor, confusion, and random activity. Affected persons may be docile,
belligerent, stuporous, or confused. They may appear intoxicated.
Decontaminate by washing with soap and water or with dilute bleach solution.
Protective masks with charcoal filters provide adequate protection. Gloves are not
necessary, since the agent is not absorbed through the skin.
SELECTED AGENTS OF TERRORISM: BIOLOGICAL AGENTS
The Biological and Toxin Weapons Convention of 1972 banned the development,
production, and stockpiling of biological weapons not required for peaceful intentions.
The United States, United Kingdom, Soviet Union, and 67 other nations signed this
document. Despite the fact that no biological agents have been used officially in warfare
to date, the prospect of their use raises many concerns. Terrorism's history suggests
the potential for the use of biological agents. Many authorities fear the use of biological
agents more than the use of chemical agents, since antidotes and specific
countermeasures are available for some chemical weapons. Use of biological agents in
terrorist acts potentially could cause tens of thousands of casualties and cost the US
economy billions of dollars.
Various scenarios involving use of biological weapons are possible, from a sudden
epidemic to a subacute, prolonged pandemic. Pathogens might be disseminated without
anyone's realizing it until after the incubation period ends, by then exposing hundreds or
thousands of civilians. Anticipating and controlling the dissemination of biological
weapons may be difficult, causing complications for terrorists and intended victims. The
effects of a biological agent also could evolve as a slowly developing, hard-tocategorize cluster of widely scattered cases, inadvertently allowing further dissemination
of the pathogen until the connection is recognized.
Certain aspects of a disease outbreak may combine to prompt suspicion of terrorist
activity, including temporal patterns of illness, selected populations of victims, clinical
presentation of illness, certain strains or species of pathogens, geographic location,
morbidity or mortality patterns, antimicrobial resistance patterns, residual infectivity,
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route of exposure, weather or climate conditions, incubation period, or concurrence with
other terrorist activities.
The number of potential biological agents is nearly impossible to estimate. Agents range
from simple viruses to bacteria and compounds derived from vertebrate animals.
Biological agents are classified into 2 broad groups, infectious and noninfectious.
Infectious agents
This group includes viruses, bacteria, protozoa, and fungi. The list of potential
pathogens is extremely long, although an abbreviated list of agents can be considered
that is based on previous use as agents during wartime. The synopsis presented for
each disease is meant only as an overview. Consult definitive texts for complete
information.
Anthrax
Caused by Bacillus anthracis, anthrax causes a necrotizing hemorrhagic mediastinitis.
Death usually occurs in 24-36 hours. Standard precautions, including masks, gowns,
gloves, and isolation, are sufficient. Vaccine is available.
Brucellosis
Highly infectious Brucella species are less commonly fatal than anthrax. Fever, malaise,
osteomyelitis, and genitourinary (GU) infections may occur. Endocarditis typically is the
cause of death. Standard precautions are sufficient. Include precautions against direct
contact if draining lesions are present.
Encephalitis viruses
Venezuelan, Eastern, and Western equine encephalitis viruses are likely to be used in
weapons. Fever, headache, confusion, obtundation, dysphasia, seizures, paresis, and
death may be observed. The Eastern variety has the highest mortality rate at 50-75%. A
vaccine for Venezuelan equine encephalitis (VEE) is available, and effective vaccines
for the others are currently in development. Standard precautions are sufficient;
however, mosquito control is suggested, since mosquitoes are a vector.
Clostridium botulinum
An epidemic of descending and progressive bulbar and skeletal paralysis in afebrile
patients may suggest botulinum poisoning. Respiratory failure is the most frequent
cause of death. Since an antitoxin is available, standard precautions are sufficient.
Yersinia pestis (plague)
Plague usually manifests as pneumonia, culminating in respiratory failure and shock. A
vaccine is available, yet precautions are required against pulmonary and droplet
exposure.
Coxiella burnetii (Q fever)
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A zoonotic disease with domestic livestock as vectors, Q fever varies in its
manifestations. Fever, chills, and headache are the most common symptoms, although
malaise, diaphoresis, and myalgia often are observed. Mortality rate is low, even when
the disease is untreated. A vaccine is under investigation. Standard precautions are
sufficient.
Rift valley fever
A hemorrhagic virus infection, Rift valley fever manifests with symptoms such as
malaise, fever, prostration, generalized vascular permeability, and abnormal circulatory
regulation. Several different varieties of hemorrhagic viruses are documented, including
Ebola. Most are highly infectious and cause morbidity. Some carry high mortality rates.
Depending on the strain, a vaccine may be available. Precautions against direct contact
are recommended. Additional precautions may be necessary if massive hemorrhage is
present.
Smallpox virus
Smallpox may be a viable biological weapon, since the last natural case occurred in
1977 and the smallpox vaccine no longer is produced. Aerosol exposure causes
viremia, malaise, fever, headache, delirium, and prolonged rash. Morbidity is caused
primarily by secondary bacterial pneumonia. Precautions against aerosol infection are
necessary.
Francisella tularensis (tularemia)
Tularemia, a zoonotic disease, occurs in ulceroglandular or typhoidal form. Typhoidal
form manifests as fever, prostration, and respiratory symptoms. Mortality rate in
typhoidal tularemia is approximately 35%. Standard precautions are sufficient. A
vaccine is available as an investigational drug.
Noninfectious agents
Allergic agents come from a variety of sources, including mite and insect particles,
feathers, epithelium, hair, urine, feces, and powdered enzymes. Problems caused by
these agents may include respiratory symptoms, conjunctivitis, and/or dermatitis.
CONCLUSION
Responding to a terrorist event can represent a tremendous drain on resources for all
agencies involved. The potential for death and destruction is tremendous. Agencies
responsible for responding to terrorist events can reduce potential injury, illness, and
death only through complete and ongoing planning.
BIBLIOGRAPHY
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ERRI: ERRI Daily Intelligence Report-Excerpts from FBI Report on Domestic
Terrorism. Aug 18, 1997; Vol 3: 230[Full Text].
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Franz DR, Jahrling PB, Friedlander AM: Clinical recognition and management of
patients exposed to biological warfare agents. JAMA 1997 Aug 6; (5): 399411[Medline].
Holstege CP, Kirk M, Sidell FR: Chemical warfare. Nerve agent poisoning. Crit
Care Clin 1997 Oct; (4): 923-42[Medline].
Howell JM, Altieri M, Fletcher J, eds: Emergency Medicine. W B Saunders Co;
1998.
Leonard RB, Teitelman U: Manmade disasters. Crit Care Clin 1991 Apr; (2): 293320[Medline].
Macko S: Terror comes to America. EmergencyNet NEWS Service. Jul 30, 1996;
Vol 2: 212.
May HL, et al: Emergency Medicine, 2nd ed. Little, Brown, and Company; 1992.
Noah DL, Sobel AL, Ostroff SM: Biological warfare training: infectious disease
outbreak differentiation criteria. Mil Med 1998 Apr; 163(4): 198-201[Medline].
Rosen P, et al: Emergency Medicine: Concepts and Clinical Practice, 3rd ed.
Mosby-Year Book; 1992.
Sharp TW, Brennan RJ, Keim M: Medical preparedness for a terrorist incident
involving chemical or biological agents during the 1996 Atlanta Olympic Games.
Ann Emerg Med 1998 Aug; 32(2): 214-23[Medline].
Simon JD: Biological terrorism. Preparing to meet the threat. JAMA 1997 Aug 6;
278(5): 428-30[Medline].
Slater MS, Trunkey DD: Terrorism in America. An evolving threat. Arch Surg
1997 Oct; (10): 1059-66[Medline].
Staten CL: Emergency Response to Chemical/Biological Terrorist Incidents.
Emergency Response & Research Institute. Aug 7, 1997.
Sullivan JB, Krieger GR: Hazardous Materials Toxicology: Clinical Principles of
Environmental Health. Baltimore: Williams & Wilkins; 1992.
Tintinalli J, Krome R, et al: Emergency Medicine: A Comprehensive Study Guide.
McGraw-Hill; 1997.
Tucker JB: National health and medical services response to incidents of
chemical and biological terrorism. JAMA 1997 Aug 6; 278(5): 362-8[Medline].
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Florida Heart CPR*
Terrorism Assessment
1. Effective response to a terrorist incident hinges on
a. Comprehensive planning
b. Interagency cooperation
c. Prior knowledge
d. A and B
2. The first line of response should be formed by:
a. Local police
b. Disaster and Emergency Services
c. EMS
d. All of the above
3. The _______ is the federally designated lead agency in a confirmed domestic
terrorist event.
a. CIA
b. FBI
c. NSA
d. FEMA
4. Primary concern in potential terrorist incidents is to
a. Secure the area
b. Evacuate potential victims
c. Ascertain the severity and nature of the threat
d. A and C
5. After establishing ________, rescuers should put on appropriate protective
clothing before entering the affected area and beginning rescue efforts.
a. A secure perimeter
b. Killing the terrorist
c. A decontamination and triage area
d. A and B
6. Lethal chemical agents include choking agents and:
a. Cyanides
b. Nerve agents
c. Vesicants
d. All of the above
7. Nonlethal chemical agents include
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a.
b.
c.
d.
Lacrimating agents
Emesis-inducing agents
Incapacitating agents
All of the above
8. The ________ of 1972 banned the development, production, and stockpiling of
biological weapons not required for peaceful intentions. The United States,
United Kingdom, Soviet Union, and 67 other nations signed this document.
a. Biological Weapons Treaty
b. Chemical Warfare Act
c. Toxic Weapons Agreement
d. Biological and Toxin Weapons Convention
9. The list of infectious agents is incredibly extensive and includes:
a. Viruses and bacteria
b. Protozoa
c. Fungi
d. All of the above
10. Responding to a terrorist event can represent a tremendous drain on resources
for all agencies involved. The potential for death and destruction is tremendous.
Agencies responsible for responding to terrorist events can reduce potential
injury, illness, and death only
a. Through open communication
b. Through complete and ongoing planning
c. With extensive funding
d. Government programs
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