Weapons of Mass Destruction and the EMS Provider

1. Weapons of Mass Destruction and the EMS Provider WILL\GRUNDY EMS 3rd Trimester CME WMD/Disaster OCTOBER 2010 CME

2. WMD • Goal of terrorist • Kill or maim • Population feel unsafe • Destabilize society • Spread fear, panic • Types of WMD • Nuclear • Chemical • Biological • Explosives

3. WMD • Recent Terrorist Events • 1984 – Salmonella in salad bars in Oregon • 45 hospitalized/750 ill • 1993 – World Trade bombing • Cyanide contamination • 1995 – Oklahoma City bombing • 759 injured/168 dead • 1995 – Sarin release in Tokyo subway • 5,500 injured/12 dead • 1996 – Atlanta Centennial Park bombing during Olympic Games • 2000 – USS Cole suicide bombing in Yemen • 17 US sailors killed, 39 injured • 2001 - World Trade Center and Pentagon attacks • 3000 + dead • 2001 – Bioterrorism Anthrax Mailings in US • 22 cases, 5 inhalation deaths

4. WMD • Types of Terrorist Groups: • Violent religious groups • Doomsday cults • Extremist political groups • Technology terrorists • Single-issue groups

5. WMD • WMD and Hazmat Incidents • Crime scene • Psychosocial impact may be tremendous • EMS/hospital resources may be overwhelmed • Responders/providers at a greater risk for injury • Goals of Emergency Responders at an Incident: • Self-Protection • Saving Lives • Preserving the Crime Scene

6. WMD • Threat Level • Threat level issued by the Department of Homeland Security. • Changes as new Intelligence is evaluated by National Security Professionals.

7. WMD • Recognizing a Terrorist Event • Type of location • Type of call • Number of patients • Victims’ statements • Pre-incident indicators

8. WMD • Response Actions • Scene safety • Responder safety • Notification procedures • Establishing command • Reassessing scene safety

9. WMD • Types of Weapons of Mass Destruction • Nuclear • Chemical • Biological

10. WMD – Nuclear Incident • Radiological/Nuclear Devices • Radiological dispersal devices • Dirty bombs • Nuclear weapons • Nuclear bombs/missiles • Special Atomic Demolition Munitions

11. WMD – Nuclear Incident • Types of Radiation • Alpha • Beta • Gamma • X-Ray

12. WMD – Nuclear Incident • Alpha radiation • Least penetrating form, only travels a few centimeters • Can be stopped by a sheet of paper, clothing, and epidermis of the skin • Dangerous when • Ingested • Inhaled • Absorbed

13. WMD – Nuclear Incident • Beta radiation • Charged particles have the mass of an electron • Have either a negative or positive charge • In air - travels less than 1 foot to several feet • Travel deeper than alpha particles – stopped by dermis • Can be stopped by bunker gear • Can cause burns, more serious if absorption occurs or if inhaled or ingested • Contamination can spread to other persons or things

14. WMD – Nuclear Incident • Gamma rays • High-energy electromagnetic radiation rays • Penetrate body & cause damage by ionizing molecules in their path, lead shields • Biochemical transformation of ionized molecules is instantaneous and may lead to biologic effects manifesting later • Gamma ray does not cause contamination of victim • Victim is of no risk to others, said to have been irradiated

15. WMD – Nuclear Incident • Protective Measures/ Determination of Exposure Depends on: • Time (Amount of time exposed) • Shorter time - less radiation absorbs • Distance (Away from source of radiation) • Greater distance - less radiation absorbs • If source of radiation emanates from a single point, radioactivity falls inversely with the square of the distance • Shielding (Objects that broke down/stopped radiation) • Dense materials • Different parts of body tolerate different amounts of radiation

16. WMD – Nuclear Incident • Signs and Symptoms of Radioactive Exposure • Varies depending on: • Amount of radiation • Route of exposure • Low exposure: nausea, vomiting, diarrhea • Moderate exposure: first-degree burns, hair loss, depletion of immune system, cancer • Severe exposure: Second/third-degree burns, cancer, death

17. WMD – Nuclear Incident • Emergency medical care radiation victims • Main focus on emergency care • Treatment of associated injuries • Removal from further radiation exposure & decontamination • Irradiated – patient has been exposed but does not have radioactive material on their body, clothing or inside him/her. • Contaminated victim – patient has radioactive material on body, clothing or inside him/her. • Must minimize internal contamination & incorporation • If internal contamination has occurred • Hospital treatment to minimize chance of incorporation should be considered ASAP

18. WMD – Nuclear Incident • Emergency medical care • Irradiated patient poses no immediate risk to rescuer • Contaminated patient should be approached with PPE. • First priority - provide lifesaving emergency care • Remove victim from danger zone • Initiate basic trauma care • Avoid internal contamination from mouth-to-mouth ventilation by used other PPV devices • Remove clothing, seal in plastic bag, leave in contaminated zone • Rarely is contaminated victim a threat to rescuers if care taken. • Use precautions when handling contaminated victim to prevent spread of radioactive materials and minimize internal contamination

19. WMD – Nuclear Incident • Decontamination • Prevent or minimize transfer of contaminant to an internal site • Reduce amount of radiation dose from contaminant • Prevent spread of contamination to other persons and areas • Advance hospital notification & plan for orderly transfer care • Notify hospital as early as possible • Control person assigned to limit access to area - follow instructions • Physician assess life-threatening injuries • Safety officer determines whether victim is contaminated • Paramedics and EMTs monitored by radiation safety officer • At “clean” line, remove contaminated clothing in sequence outlined • Complete body survey of each staff member should be done • If paramedics and EMT’s are contaminated, consult a physician for post exposure follow-up

20. WMD – Chemical Incident • Chemical agents • Cause immediate havoc & destruction • Public instantly aware and defensive measures can begin immediately • Nerve & cyanide gas can cause death in minutes • Blistering agents cause early as well as delayed effects, which build intensity • Other agents may not cause symptoms until hours after exposure

21. WMD – Chemical Incidents • Characteristics of Chemical Agents • Persistency/volatility • Route of exposure • Vapor hazard • Contact hazard

22. WMD – Chemical Incidents • Types of Chemical Agents • Nerve Agents • Cyanide Agents • Sulfur Mustard • Pulmonary Agents

23. WMD – Chemical Incidents • Nerve Agents • Dissemination • Act by disrupting normal transmission of nerve impulses to muscles, organs, and glands • Results in excess secretions & paralysis • Liquid at rooms temperature • Can be dispersed by missiles, sprayers, and other devices • Liquid nerve agent can be absorbed through the skin • Vapor can be inhaled and also absorbed through the eye or skin • VX, GD, Sarin • Clinical effects • Outpouring of secretions from every organ & orifice • Effects involuntary muscles: Bronchoconstriction, gastrointestinal cramps, constricted pupils • Over stimulation of skeletal muscle • Eventual paralysis • Death results from paralysis of respiratory muscles & secretions in lungs • CNS effects follow large exposures – seizures, loss of consciousness, respiratory arrest • Route entry dictate which symptoms appear first & time to severe toxicity • Liquid on skin will also first cause local effects • Clinical signs guide field treatment with appropriate antidote

24. WMD – Chemical Incidents • Nerve Agent Recognition Dumbbells: • Diarrhea • Urination • Miosis • Bradycardia - Bronchospasm • Emesis • Lacrimation • Seizures, Salivation, - Sweating • Nerve Agent Recognition Sludgem: • Salivation • Lacrimation • Urination • Diarrhea • Gastrointestinal cramps • Emesis • Miosis • Muscular twitching

25. WMD – Chemical Incidents • Prehospital care considerations for Nerve Agents • Eliminate continued exposure, stop absorption • Vapors • Move victim to fresh air • Remove outer clothing • Be aware entering closed spaces • Liquids • Remove clothing • Remove blotches & blot visible agent • Scrape off with a tongue blade or flat instrument • Blot liquid with absorbent material • Flush with large amounts water • Deactivation on skin • Flush eyes with water - 15 min • Use protective clothing

26. WMD – Chemical Incidents • Care for Nerve agents • Advanced aid • Advanced treatment for nerve agents includes • Antidotes • Prepackaged autoinjectors, time is crucial • Recommended dose is based on clinical presentation • MARK I kits or Duodote • Atropine • Pralidoxime

27. WMD – Chemical Incidents • Cyanide Agents • Effective fast killer • Found in nature & industry • Lethal if ingested • Smells like almonds • Clinical effects • Brain, heart, affected first • Short breath; increase pulse, blood pressure; unconscious, seizes, stops breathing • Effect dose • Distinguishing cyanide, nerve agent poisoning • Cyanogens chloride – converts to cyanide in the body

28. WMD – Chemical Incidents • Sulfur Mustard • Belongs to vesicants or “blister agents” • Incapacitating rather than lethal • Affect skin, eyes, organs including bone marrow and lungs • Clinical effects • Skin, eye, airway common effects • First sign, skin appears red, blisters form, outer skin separates from dermis • Dark-brown-black skin peels off, intact skin underneath • Mustard so reactive with body; no mustard will be present in blister fluid so no chemical contamination risk

29. WMD – Chemical Incidents • Pulmonary Agents • Dissemination • represents hazard • Concentration of pulmonary gases & physical properties affect • Signs of exposure • Timing of symptoms • Ammonia is a very soluble agent and reactive to water producing fumes • Phosgene, less soluble - effects breathing • Clinical effects • Suspected signs & symptoms • Lung irritation • Pulmonary edema • When lungs fill with fluid • Shortness of breath • Persistent cough develops • Frothy sputum • Oxygen exchange is impaired, becomes hypoxic

30. WMD – Biologic Incidents • Biologic agents overview • Likely suspected days after release • Stay alert to signs & symptoms • Decontamination - not significant issue • Agent is not on patient, but in patient • Always protect your health • Follow principles of infection control • Large outbreak press all health workers into service • Preplanning essential • Adhere basic principles of infectious disease

31. WMD – Biologic Incidents • Biologic agents concerns • Incubation period • Most not contagious • Smallpox, plague can be spread • Creates fear, panic • Biologic agents • Include • Bacteria • Viruses • Fungi

32. WMD – Biologic Incidents • Biologic agents • Deliberately spread • Kill or immobilize large numbers • CDC category • Invades body, multiplies and causes illness • Not all contagious • Understand basic control principles • Paramedics and EMT’s must follow rules of infection control

33. WMD – Biologic Incidents • The spread of biologic agents • Spores downwind, or food and water contaminated • Aerosolized dissemination vehicle • Garden spray canister • Crop duster, airplanes, moving vehicles with mounted sprayers • Wind & weather conditions effect distribution • Difference between indoor and outdoor distribution • Vector spread

34. WMD – Biologic Incidents • Detecting biologic event • Weapons may not be suspected until hours or days after release • Victims who travel from site - spread to others • Maintain high index suspicion • Clues • Large number victims similar illness • High mortality rate • Illness unusual for area or out of season • Discover cause ASAP

35. WMD – Biologic Incidents • Biologic Agents include: • Smallpox • Plague • Viral hemorrhagic fevers • Anthrax • Tularemia • Botulism

36. WMD – Biologic Incidents • Smallpox • Clinical illness • Variola virus causes smallpox • Incubation period - 12 days • Sudden onset • 2-3 days later • Lesions initially appear round and flat • Sameness different than lesions in chickenpox, lesions are all in same stage of development

37. WMD – Biologic Incidents • Plague • Clinical illness • Incubation period 2-4 days • Acute onset of fever, chills, headache, body aches, hemoptysis • Respiratory failure - death can ensue • Bubonic plague • Bubonic form transmitted by fleas • Raised tender lymph nodes, buboes • Can enter blood stream and lungs • Pneumonic plague • Can be spread by: • Aerosolized distribution of bacteria • Droplets to other persons • Carries almost 100% fatality rate if untreated

38. WMD – Biologic Incidents • Viral hemorrhagic fevers • Group of related illnesses, cause • Damage to small vessels • Leakage from vessels • Bleeding • Animals or insects carry viruses • Respiratory transmission by aerosol dissemination • Makes possible bioterrorism agent • Human-to-human transmission occurs by direct contact with • Infected blood & secretions • Organs • Semen • Different viruses cause viral hemorrhagic fever • Marburg • Ebola • Greater concern • Clusters of cases and deaths have been described in Africa in past 3 decades • 316 cases evolved from one single case • One of the most lethal hemorrhagic fever viruses, 50%-90% mortality rate

39. WMD – Biologic Incidents • Anthrax • Caused by bacterium bacillus anthracis • Forms spores when host dies, returns to active when a new host found • Spore form of bacteria is resistant • Typically occurs in animals • Spore invades body through inhalation or break in skin • Three forms • Inhalational • Cutaneous • Gastrointestinal • Clinical illness • Inhalational occurs when spores inhaled deep into alveoli • Invades lymph nodes • Cause chest pain, shortness breath, flulike symptoms • Fast growing, makes toxins, accumulate in lungs, around brain • Treated early doxycycline, chance recovery good • Treated late, fatal • 2-6 day incubation period

40. WMD – Biologic Incidents • Tularemia • Clinical illness • Inhaled form results in sudden onset fever, chills, aches, fatigue, headache, loss body fluids 3 days after exposure • Follows bite, ulcer forms at site, lymph glands proximal to bite tender, swollen • Fever, malaise • Untreated, 35% mortality rate • Acquired through bites of • Deerflies • Mosquitoes • Ticks • Or contact with blood or tissue fluids of infected animals • Known to hunters as “deerfly fever” or “rabbit fever”

41. WMD – Biologic Incidents • Botulism • Paralysis from head downward • Caused by toxin produced by clostridium botulinum • Toxin produced by bacterium • Effects manifest within 24 hours • 60% mortality rate if untreated • Hazardous if inhaled • Clinical illness • Head-downward, descending paralysis • Death from asphyxia • Flaccid, no muscle tone

42. Lack of EMS Focus at the National Level Impedes Local Preparedness • From JEMS, March 24, 2010, regarding a report from the federal Commission on the Prevention of Weapons of Mass Destruction, Proliferation and Terrorism: “The nation will never be prepared for a biological or any other WMD event until EMS gets the consolidated national recognition and funding it deserves and desperately needs.” • Case in point: Despite fact that EMS personnel will be on frontline of biological event response -- and that funding, training and coordination of first responders are significant issues -- "local efforts" is closest report comes to addressing EMS role in WMD preparedness.

43. Do-It-Yourself WMD Training • JEMS: “The lack of a single Congressionally mandated agency or administration for EMS means the dollars for biological weapons preparedness and other WMD readiness are simply not going to flow -at least not in adequate amounts.” • What does this mean to you? Training and coordination efforts on the local level are more important than ever. If the feds won’t help, you need to do it yourself.

44. WMD • Summary • Paramedics and EMT’s must be aware Nuclear, Biologic, Chemical threats to search recognize possible Nuclear, Biologic, Chemical scenarios • Paramedics and EMT’s understand knowledge specific agents necessary to recognize, triage, treat, transport victims WMD agents • Nuclear, Biologic, Chemical terrorist distinguished from hazardous materials incident by intentional nature, purposely hidden hazard, extremely toxic material, massive decontamination, secondary devices, crime scene

45. WMD • Summary • Nuclear, Biologic, Chemical weapons are disseminated by breaking/bursting agents, munitions, spraying devices, contamination ventilation systems, vectors • Signs Nuclear, Biologic, Chemical include multiple casualties who were well, all with same complaints, similar time onset, signs symptoms unusual for season, geographic area, particular age group, spread by vector unusual for region • Surveillance EMS, ED patients for syndrome respiratory complaints, GI complaints, neurologic complaints/fever, rash caused by WMD agents, results in early investigation, early identification of Nuclear, Biologic, Chemical release