This document discusses the role of emergency physicians in responding to chemical, biological, radiological, nuclear, and explosive (CBRNE) terrorist attacks. It defines key terms like disaster, mass casualty incident, and terrorism. It outlines the objectives of emergency physicians in such situations using the "7Ds in Disasters" framework. It also reviews lessons learned from past terrorist attacks involving weapons of mass destruction. The document emphasizes the importance of early detection through syndromic surveillance since the initial presentations of bioterrorism agents can be non-specific.

1. The Role of
Emergency Physician
in Response to
CBRNE Attack
Dr. Chew Keng Sheng
Emergency Medicine
Universiti Sains Malaysia

2. Objectives
 Definitions
 Key criteria for determining a terrorist attack
 Overview on selected terrorists’ attacks and WMDs
 Major Lessons Learnt from Previous Disasters
 Syndromic Surveillance
 Defining roles of EPs in response to CRBNE Terrorist
Attacks – ―7Ds in Disasters‖
 Q&A

3. Definitions of Disaster, Mass
Casualty Incidents and
Terrorism

4. Definitions
 Disaster – defined as a sudden ecologic
phenomenon of sufficient magnitude to
require external assistance
 In the Emergency Department, disaster exists
when the number of patients presenting in any
given space of time are such that even
minimal care cannot be offered without
external assistance.

5. Definitions
 Disasters occur when normal, basic services of
a society become disrupted to such extent that
widespread human and environmental losses
exceed the community‟s management
capacity (SAEM Disaster Medicine White Paper
Subcommittee)
 Disasters characterized by large numbers of
deaths and injuries are also referred to “Mass
Casualty Incidents”

6. Definitions
 However, disasters are not defined only by a
given number of victims
 Example: The arrival of one VIP guest with
severe medical or trauma emergency conditions
can completely disrupt normal operations of
even the most efficient emergency departments.
 In short, the essence of the concept of disaster
is it has a “massive disruptive impact”

7. Definitions
 Mass Casualty Incidents (MCI) – events
resulting in a numbers of victims large enough
to disrupt normal course of emergency and
health care services of the affected community
 Disasters result in MCIs, but encompass a
broad range of calamities beyond just the high
numbers of casualties
 ―All MCIs are disastrous, but not all disasters are
due to MCIs‖

8. Definitions
 Disasters can be divided into two:
 Natural Disasters OR Man-made Disasters
 External Disasters (events occurring outside the
hospital) OR Internal Disasters (events involving
the physical structures of hospital itself - e.g. fire,
lab accident involving radioactive materials)
 Terrorism – man made, external disasters

9. Directive 20, National Security
Council
 A Disaster is
1. an event that occurs
suddenly.
2. complex in nature.
3. loss of lives.
4. destruction of property
and/or environment.
5. disruption of the
community daily
activities

10. Three Levels According to Directive
20, NSC
 Level 1
 Localized, well-controlled, manageable by local
authorities
 Level 2
 Well-controlled, management at state or national
level
 Level 3
 Complete destruction, disruption of routine
activities,

11. Directive 20, NSC
 Disaster can be divided into 3 level
LEVEL 1
1. Localized major incident
2. Under controlled
3. Not complex
4. Small no. of casualties and property loss
5. Minor disruption of daily community activities
6. Manageable by the local authorities requiring
7. Multisectoral involvement.
 Example: bus accident, train derailment, landslide.

12. Directive 20, NSC
 LEVEL 2 Disaster
1. Widespread over a large area but under controlled
2. Complicated and complex
3. Large no. of casualties and property loss.
4. Affecting daily community activities
5. Not manageable by the local authorities requiring
6. Assistance from other states or National Authorities
7. Support required, Regional or National Support
 Examples: Highland Towers Collapse, Greg Storm
Sabah, Bright Sparklers.

13. Directive 20, NSC
 LEVEL 3 Disaster
1. Involves a very large area.
2. Loss of many lives.
3. Total Destruction of infrastructure and public facility.
4. Complicated and complex.
5. High risk to rescue workers.
6. Complete disruption of daily community activities.
7. Major destruction of resources.
8. All local resources destroyed and assistance from external
resources required.
 e.g. Earthquake, typhoons, volcanoes, war.

14. Disasters Vs Emergencies
Routine Emergencies Disasters
Interaction with familiar Interaction with unfamiliar
parties parties
Familiar tasks/procedures Unfamiliar
tasks/procedures
Intra-organization Intra- and inter-
coordination organization coordination
Intact communications, Disrupted
roads, etc. communications, blocked
roads, etc

15. Disasters Vs Emergencies
Routine Emergencies Disasters
Familiar terminology Unfamiliar, organization-
specific terminology
Local press attention National/international
media attention
Resources adequate for Resources overwhelmed for
management management capacity

16. Know Your Role!
Hospital Director
INCIDENT SITE
MEDICAL
MANAGER
NGO COMMAND POST ADVANCED MEDICAL POST Temporary
Medical/Health Officer Morgue
Acute Treatment Manager
•JPA 3
Medical Red Team Yellow Team Green Team Evacuation Transport
•SJAM Triage Officer Leader Leader Leader Officer Officer
•MRCS. Admin. Admin. Ambulance
Clerk Doctors & Paramedics Clerk Drivers
PRE-HOSPITAL MANAGEMENT ORGANIZATION

17. Key Criteria Defining a Terrorist
Attack
 Violence
 "the only general characteristic [of terrorism] generally agreed
upon is that terrorism involves violence and the threat of
violence"
 -Walter Laqueur of the Center for Strategic and International Studies
 Psychological Impact and Fear
 attack was carried out in such a way as to maximize the
severity and length of the psychological impact.
 Perpetrated for a Political Goal
 This is often the key difference between an act of terrorism
and a hate crime or lone-wolf "madman" attack
 The political change is desired so badly that failure is seen as
a worse outcome than the deaths of civilians.

18. Key Criteria Defining a Terrorist
Attack
 Targeting of non-combatants
 It is commonly held that the distinctive nature of terrorism
lies in its deliberate and specific selection of civilians as direct
targets.
 Much of the time, the victims of terrorism are targeted not
because they are threats, but because they are specific
"symbols, tools, or corrupt beings" that tie into a specific
view of the world that the terrorist possess.
 Their suffering accomplishes the terrorists' goals of instilling
fear, getting a message out to an audience, or otherwise
accomplishing their political end.
 (en.wikipedia.org)

19. Overview of Selected Terrorist
Incidents
 Bombing of WTC New York City 1993
 Sarin Gas Attack by Aum Shinrikyo in Matsumoto,
Japan, 1994
 Truck Bomb explosion of Alfred P. Murrah Building in
Oklahoma, 1995
 Sarin Gas Attack by Aum Shinrikyo in five subway train
stations simultaneously in Tokyo, 1995
 WTC Bombing, New York, September 11, 2001
 US Anthrax Incident, 2001
 Bombing in Bali, Indonesia 2002

20. Major Lessons Learnt
 Incident Confirmation
 At time of incident (whether biological, chemical or even
high explosive incidents), most people at the scene and even
the initial responders did not recognize the event as a terrorist
attack
 E.g. during the Sarin Gas Attack in Matsumoto, Japan,
emergency responders initially thought that the first victims
were ill from food poisoning, contaminated water, or natural
gas
 To improve early detection, a process called Syndromic
Surveillance is employed

21. Syndromic Surveillance
 A method to aid the early detection of
bioterrorism events
 This is to respond to bioterrorism attack – time
is essential
 This type of surveillance involves collecting and
analyzing statistical data on health trends – such
as symptoms reported by people seeking care in
emergency rooms or other health care setting –
or even sales of flu medicines.

22. Syndromic Surveillance
 Because bioterrorist agents such as anthrax,
plague, and smallpox initially present ―flu-like‖
symptoms, a sudden increase of individuals with
fever, headache, or muscle pain could be
evidence of a bioterrorist attack.
 By focusing on symptoms rather than confirmed
diagnoses, syndromic surveillance aims to detect
bioterror events earlier than would be possible
with traditional disease surveillance systems.

23. Syndromic Surveillance
 In other words, the term syndromic surveillance
refers to methods relying on detection of clinical
case features that are discernable before
confirmed diagnoses are made

24. Syndromic Surveillance

25. Recommended Website
Centers for Disease Control and Prevention –
(http://www.bt.cdc.gov/)
Emergency Preparedness & Response

26. Major Lessons Learnt
 Command and Control
 Unlike smaller emergencies where one single Incident
Commander in charge, in a terrorist attack, numerous
agencies and organizations involved
 The need to speedily establish a secure perimter around the
incident.
 Failure to do so during the Oklahoma bombing
 Communications
 Communications failure
 Overloaded land lines and cell phones with calls from public
trying to obtain info about their loved ones

27. Major Lessons Learnt
 Initial Responders
 Traditionally initial responders are defined as the local police,
firefighters, EMDs, paramedics. Well trained, part of daily
routine
 In overwhelming terrorist attacks, other professionals were
needed at the scene – NGOs, volunteers, mental health
workers
 These individuals thrust into new roles – without proper
training.
 Safety of these responders – 1993 WTC bombing, 124
emergency responders injured; in Oklahoma bombing, one
nurse killed from falling debris.

28. Major Lessons Learnt
 The Volunteers
 Volunteers, though well intentioned, often created problems
 Most not familiar with the emergency command and control
system
 The Victims
 At most disasters, victims left the scene and sought medical
help on their own
 Need for rapid establishment of a centralized database
containing identification victims from all responding medical
sites.
 E.g. in Bali Bombing – internet database used extensively

29. Major Lessons Learnt
 Psychological Effects
 PTSD – Example 11 months after 9/11 incident,
1277 stress related illnesses reported
 Need for debriefing and de-stressing; short briefings
prior to change of shift for responders
 Tokyo Sarin Attack and Anthrax threat – created
unique psychological fear – the healthy but anxious
lots taxed the health services at a time when others
needed care.
 Need for proper public education

30. Major Lessons Learnt
 Mortuary Affairs
 Temporary morgues, body bags
 Body decay
 Rapid identification of victims – for family members,
law, insurance companies, etc; the need for DNA
analysis
 Example – Oklahoma bombing – unavoidable delays
in official death notifications added emotional
trauma to the already bereaved families
 The need for religious sensitivity in handling bodies

31. Major Lessons Learnt
 Duration of event
 Prolonged duration – strained the human and material
resources; depletion of stocks
 Need for regular work shifts
 Criminal Investigations
 One of the main difference between natural disaster and
man-made disaster
 The concern to preserve the evidence
 Medical emergency responders help protect the evidence by
only touching and removing items when necessary

32. Major Lessons Learnt
 Media
 Mixed blessings
 Disseminate information
 Yet, in an effort to provide information ASAP, sometimes
media give false and confusing information
 VIP Visits
 Politicians, celebrities, etc
 Timing of these visits sometimes interfered with ongoing
recovery efforts

33. Overview
 Chemical Weapons  Radiation
 Nerve Agents – G series (GA,  α radiation
GB, GD), V series  β radiation
 Blood Agents - cyanides  γ radiation
 Blistering Agents  Nuclear
 Biological Weapons  A bomb (Atomic)
 Biological Agents – viruses (e.g  H bomb (Hydrogen)
Ebola), bacteria (Yersenia
pestis, anthrax)  Explosives
 Biological Toxins – botulism,  Large scale - Incendiary
ricin, Staphylococcal bombs, Napalm-B, Mark 77
Enterotoxin B  Smaller scale - Molotov
Cocktail (Poor man’s hand
grenades)

34. Explosives
The use of Napalm-B in
Vietnam in 1966
Molotov Cocktail (Reference: en.wikipedia.org)

35. How Prepared are the ED?
 In 1997, Burgess et al. reported that only 44.2% of
hospital EDs had the ability to handle any chemically
contaminated patients from HAZMAT
 41.1% - no designated decontamination facilities
 Greenberg et al. in June 2000, conducted a survey to
assess the level of preparedness of hospital EDs in a
large metropolitan area to evaluate and treat victims of
a terrorist biological or chemical agent release
 44 out of 62 ED directors responded to the questionnaire

36. How Prepared Are the EDs?
(Figures given in percentage) Yes No DK
Decon facilities 90.7 9.3 0
Ability to decon:
a. < 10/Hr 83.3 - -
b. 10-19/Hr 7.4 - -
c. 20-50/Hr 5.6 - -
d. >50/Hr 3.7 - -
Written plan for handling post-decon waste water 63 18.5 18.5
Written plan for handling contaminated clothings 42.6 29.6 27.8
Presence of detection equipment in ED 14.9 68.5 16.7
Personal Protective Clothing 87 13 0
(Greenberg et al., 2000)

37. Suggested Criteria for Minimum Preparedness of
EDs to Evaluate and Treat Victims of Biological or
Chemical Agent Release
1. At least one EP who has completed formal training
regarding biological and chemical WMD
2. Ability to decon ≥10 patients/Hr
3. Written policies addressing the evaluation and
treatment of biological and chemical casualties
4. Written cooperative agreements with local agencies
addressing issues of biological and chemical terrorism
5. Participation in a disaster exercise involving biological
or chemical agents within the past 12 months
6. Self characterized adequate supplies of appropriate
antidotes

38. Antidotes
Atropine and oxide
(2 PAM CI)
injection auto-
injector

39. Roles of Emergency Physician in
DISASTERS –EIGHT „D‟s
 Detection and Diagnosis
 Rapid Recognition
 Declaration and Activation
 Activate contingency plans
 Establish intra-hospital, inter-hospital, inter-agencies, inter-states, international
communications
 Defense
 Self-protection
 Decontamination
 Delegations
 Drugs
 Disposition
 Delivering right patients to right place and right time
 Debriefing and De-stressing

40. The Main Problem with Biological
Weapon
 Biological weapons can be divided into two categories
 Overt (Announced)
 First responders (fire fighters or law enforcement) are most likely to
respond to the announced release, or more likely the hoax
 Covert (Unannounced)
 First responders would probably be the GPs, family doctors, EPs, etc.
 Furthermore, patients exposed to biologic agents
usually present with vague symptoms associated with
flulike illnesses (latency period).

41. Overt Attack
 First responders (trained fire fighters or law enforcement) are
most likely to respond to the announced release, or more likely
the hoax
 In recent anthrax attack, an example would be the letter received
and opened in a Senator’s office in the Hart Senate Office
Building.
 The envelope contain a letter stating that it contained anthrax
spores and the opener was going to die.
 First responders called, the presence of spores of Bacillus
anthracis confirmed.
 Exposed individuals given prophylaxis. To date, none in the
Senate Building has developed anthrax

42. Covert Attack
 Current NO REAL TIME environmental monitoring
for a covert release of biological weapon
 A covert attack would probably go unnoticed, with
those exposed leaving the area long before the act of
terrorism became evident
 Furthermore, because of the incubation period, the first
signs of the biological agent released not be recognized
until days or weeks later.
 Thus those first responders would probably be the
family doctors, GPs, EPs, etc

43. Factors indicative of a Potential
Bioterrorism Event
 Multiple simultaneous patients with similar clinical syndrome
 Severe illnesses, especially among the young and otherwise
healthy
 Predominantly respiratory symptoms
 Unusual (non-endemic) organisms
 Unusual antibiotics resistance
 Atypical clinical presentation of disease
 Unusual patterns of disease such as geographic co-location of
victims
 Intelligent information – tips from law enforcement, discovery
of delivery devices, etc
 Reports of sick or dead animals or plants
 (Richards et al., 1999)

44. ON SITE MANAGEMENT
WORK MATRIX
YELLOW ZONE
OSC
(POLICE )
M.E.L.O.
FORENSIC
P.K.T.K.
QUARTER
O.M.C. MASTER
BOMBA
MEDICAL
BASE SAR
M.E.S.A.R.O.
SAR
CRTICAL
S.CRITICAL SPECIALISTS
N.CRITICAL SJAM COMMAND POST
MRCS
DEAD JPA 3 F.F.C. - BOMBA
RESCUERS BOMBA
S.B.
SAR TEAM
RED ZONE

45. ON SITE MANAGEMENT – TRIAGE SYSTEM
TO NEAREST APPROPRIATE HOSPITAL
GREEN

46. Victims Collecting Point
Impact Zone
Working Area
COLLECTING POINT
Advance Medical Post

47. Simple Triage and Rapid Treatment
START Triage System
* Victims who can
walk are first identified
and be diverted to one
designated area

48. Disaster Operation and the SAVE
Concept

49. Basic/Simple Advanced Medical Post
WHITE GREEN
TRIAGE
AREA
EVACUATION
RED YELLOW

50. Standard Advanced Medical Post
NON-ACUTE
WHITE GREEN
TRIAGE
AREA
NON-
ACUTE
EVACUATION
ACUTE
RED YELLOW
ACUTE

51. Disaster Zoning

52. VICTIM FLOW
―Conveyor Belt‖ Management
Triage Evacuation Triage Treatment
Treatment
Impact Collecting
ADVANCE TRANSFER HOSPITAL
Zone Point
MEDICAL POST
Victim Flow Transport Resource Flow

53. Initiating Isolation
 Ideally be decontaminated outside the hospital
 Approach from upwind direction
 Isolate at least 100 m radius (initial isolation) for hot zone
 If large spill, 500 m; and if on fire (flammable substances), 800 m
 Establish three zones
 Hot zone
 where the spill/contamination occurred
 Only trained personnel with proper attire to enter
 Only the most immediate life threats addressed here – like opening up airway,
cervical spine immobilization, bleeding control
 Warm zone
 area for thorough decontamination
 Theoretically no risk of primary contamination but secondary contamination
still possible

54. Initiating Isolation

55. Initiating Isolation
Initial Isolation
Protective
Action Zone

56. Principles of Decontamination
 Removal of clothings
 most important step
(accomplishes 80-90% of
decon)
 From top to bottom
 The more the better
 Privacy is an issue
 Water flushing the best
 Typically shower 3 – 5min
 Decon ASAP
 Expect a 5:1 of unaffected:
affected casualties ratio
 First responders must self-
decon too

57. Decontamination

58. Emergency Decontamination

59. Summary
 Terrorist Attacks are disastrous – but that does
not mean that there is nothing we can do.
 Though we are probably helpless in preventing
them from coming, yet our preparedness would
hopefully be able to lessen the magnitude of
severity of the attack

60. Sarin Gas Attack on Tokyo Subway
 Attack on 20th March
1995 was the second
attack – 12 people died.
Shoko Asahara –
Founder of AUM First attack 1994 – 7
Shinrikyo died.
 How many perpetrators
were involved and how
many train stations were
contaminated?
Ikuo Hayashi
– one of the  How did they do it?
perpetrators

61. The Attack
 Attack at approximately 7:55 AM on March 20, 1995.
 8:16 AM - the St Luke's ED was alerted
 520-bed tertiary care
 located near the affected subway stations (within 3 km)
 received the largest number of victims from the subway
attack.
 services comparable to those of any medical center within the
United States.
 Within hours of the terrorist incident, St Luke's
emergency department received 640 patients.

62. The Attack
 8:28 AM - the first subway victim arrived at the St
Luke's ED. This patient was ambulatory and arrived
without assistance from ambulance personnel. The
patient's only complaints were of eye pain and dim
vision.
 8:43 AM – arrival of first ambulance arrived
 During the next hour, approximately 500 additional
subway victims, including 3 patients who were in
cardiopulmonary arrest on arrival, presented to the ED
 Five of the female patients were pregnant.

63. The Attack
 9:20 AM - hospital directors activated the
hospital's disaster plan.
 This resulted in the cancellation of all routine
surgeries and outpatient activity.
 More than 100 doctors and 300 nurses and
volunteers were immediately called to care for
victims
 Victims into three clinical groups - mild,
moderate and severe

64. The Attack
 Mild cases (528, or 82.5%) - only eye signs or
symptoms (eg, miosis, eye pain, dim vision, decreased
visual acuity) on presentation
 released after a maximum of 12 hours of ED observation
 Moderate cases (107, or 16.7%) - systemic signs and
symptoms (eg, weakness, difficult breathing,
fasciculations, convulsions) BUT not require
mechanical ventilation
 Severe cases (5, 0.78%) - emergency respiratory support
(eg, intubation and ventilation support)

65. Outcomes of Patients Admitted to St.
Luke‟s Hospital ED, Tokyo

66. Lessons Learnt
 Delay in confirming the nature of the toxin
 Delay in organizing an effective mass casualty
strategy
 Poor ventilation in patient reception area
 Secondary exposure by medical staffs treating
the patients
 Inadequate provision of privacy to remove
contaminted clothings
 Inadequate shower facilities

67. Treatment
 Three drugs are the mainstay treatment
 Atropine
 Counteract primarily the muscarinic effect
 Administer doses of 2 mg every 5 – 10 min to minimize dyspnea,
airway resistance or respiratory secretions
 Pralidoxime
 To reactivate acetylcholinesterase and counteract the nicotinic effect
 Over time, OP-acetylcholinesterase bond becomes irreversibly
covalent and resistant to reactivation by pralidoxime (―aging‖
process)
 But still, Pralidoxime should never be withheld.
 Diazepam
 The only effective anticonvulsant drugs for nerve gas poisoning
patients with seizure

68. Nerve Gas Agents
 Are organophosphates
 Inhibits acetylcholinesterase, block degradation of Ach at postsynaptic
membrane.
 Two main classes
 G series
 ―G‖ because accidentally first discovered by German scientist, Dr. Gerhard
Schrader
 GA (Tabun), GB (Sarin), GD (Soman) and GF (cyclosarin). Why no GC?
 SARIN (most toxic of the four in G series) named in honor of its discoverers:
Gerhard Schrader, Ambros, Rüdiger and Van der LINde.
 V series
 V stands for ―venomous‖. Examples: VX, VR
 All G series – watery, high volatility, serious vapor hazard; VX –
oily, less vapor hazard, but poses a greater environmental hazard
over time.

69. Nerve Gas
 Different from organophosphate insecticides
 Much more toxic
 VX – most toxic substance synthesized de novo
(botulinism toxin – biological)
 Unlike typical OP, no association with urination
 Bradycardia is rare
 Its miosis effect does not respond to systemic
therapy

70. Actions of Cholineseterase Inhibitors
 Muscarinic Effects
 SLUDGE
 Salivation, Lacrimation,
Urination, Diarrhea, GI
pain, Emesis
 DUMBELS
 Diarrhea, Urination,
Miosis, Bronchorrhea,
Emesis, Lacrimations,
Salivation

71. Clinical Features
 There is no delay effects
 Symptoms of sarin gas occur within seconds of
inhalation and peak at 5 minutes.
 If patients remaining asymptomatic 1 hour after
possible exposure, have not been contaminated.
 In vapor exposed – miosis first appeared but in
liquid exposed – miosis usually last sign
 Unlike botulinism toxin, flaccid paralysis never
on initial presentation.

72. Differences between Nerve Agents
and Cyanide
Characteristics Nerve Agent Cyanide
Odor None Bitter Almond
Eyes Miosis (unresponsive Pupils normal or
to nalaxone), dim dilated
vision, pain and
lacrimation
Oral, nasal and Copious secretions Relatively few
respiratory system secretions
Skin Profuse sweating, Profuse sweating,
cyanosis likely sometimes also
cyanosis

73. Differences between Nerve Agents
and Cyanide
Characteristics Nerve Agent Cyanide
Initial CVS response HPT, tachycardia Often hypotension
Muscle Weakness, Twitching of body
generalized parts (but not
fasciculations, fasciculation)
eventually paralysis
Arterial Blood Gas Resp alkalosis or High AG, above
and Acid Base hypoxemia with normal venous
Balance respiratory acidosis oxygenation

74. Vesicants
 Cause blistering and irritations to eyes, skin and airway
(example – Mustard)
 Ophthalmic effect – conjunctivitis, corneal damage,
temporal or permanent visual loss
 Skin effect – blistering like 2nd degree burn
 Systemic toxicity – BM suppression, leukopenia
 Indicators of fatal exposure
 Airway burn within 6 hours
 Burn >25%
 Absolute WBC <200/mm3

75. Blood Agents
 Blood agents such as cyanide
 Bind to cytochromes within mitochondria and inhibit cellular oxygen use
 Low-dose exposures result in tachypnea, headache, dizziness, vomiting,
and anxiety.
 Symptoms subside when the patient is removed from the source
 In higher doses the symptoms progress to seizures, respiratory arrest, and
asystole within minutes of exposure.
 Victims should be removed from the area, should have their
clothing discarded, and should receive oxygen (100%).
 If no improvement occurs, the cyanide antidote is given (amyl
nitrate, sodium nitrite, sodium thiosulfate)

76. Anthrax
 Current assessment suggests that three biologic agents—anthrax,
plague, and smallpox—represent the greatest threat
 Bacillus anthracis
 a gram-positive spore-forming bacterium, is the causative agent of
anthrax
 the spores are extremely hardy
 survive for years in the environment
 the disease is caused by exposure to the spores
 normally a disease of sheep, cattle, and horses and is rarely seen in
developed countries because of animal and human vaccination programs
 disease in humans can occur when spores are inhaled, ingested, or
inoculated into the skin
 spores germinate into bacilli inside macrophages
 bacteria then produce disease by releasing toxins that cause edema and
cell death.

77. Nuclear and Radiation Attack
 Terrorists selecting radiation as a means to inflict
casualties are unlikely to employ nuclear weapons
 are heavily guarded
 difficult to move due to their size and weight
 easy to detect
 Sabotage at nuclear power stations is possible, but
given tight security, multiple safety systems, and thick
concrete housings surrounding the reactors, the threat
is probably low

78. Nuclear and Radiation Attack
 Instead, simple radiologic devices, such as those used
by hospitals for radiation therapy, are thought to be the
source of choice.
 These sources are plentiful and usually unguarded
 The only wartime use of atomic and nuclear energy
was the detonation of atomic bombs over
Hiroshima and Nagasaki in 1945.
 However, with the dissemination of technical
information and raw materials, many nations now have
nuclear weapons in their arsenals. The real possibility
of terrorist groups obtaining and using such
weapons also exists.

79. Bombings of Hiroshima and
Nagasaki
 The first event occurred on
the morning of August 6,
1945, when the US dropped
a uranium gun-type device
code-named "Little Boy" on
the Japanese city of
Hiroshima.
 The second event occurred
three days later when a
plutonium implosion-type
device code-named "Fat
Man" was dropped on the
city of Nagasaki.
(en.wikipedia.org)

80. Being Exposed or Being
Contaminated?
 Being exposed to heat; or being  The first step of recognizing
burned (external and internal contamination is to
burn)? understand the difference
between exposure to and
contamination by radiologic
agents.
 Exposure is defined by an
individual's proximity to
material emitting ionizing
radiation.
 Actual touching, inhaling, or
swallowing that material is
contamination.

81. Personal Protection Equipment
(PPE)
 PPEs are respiratory equipment, garments, and
barrier materials used to protect rescuers and
medical personnel from exposure to biological,
chemical, and radioactive hazards.
 The goal of PPE is to prevent the transfer of
hazardous material from patients or the
environment to health care workers.
 Different types of PPE may be used depending on the
hazard present
 PPE can be divided into
 Civilian PPE – especially those working in hot zone (IDLH)
 Military PPE
(www.emedicine.com)

82. SCBA
 SCBA: Self Containing Breathing Apparatus
 Vs SCUBA: Self Containing Underwater Breathing
 consists of a full face piece connected by a hose to a
portable source of compressed air.
 the open-circuit, positive-pressure SCBA is the most
common type
 this SCBA provides clean air under positive pressure
from a cylinder; the air then is exhaled into the
environment.
 (www.emedicine.com)

83. Civilian PPE
 Self-contained breathing apparatus
 Supplied-air respirator
 Air-purifying respirator
 High-efficiency particulate air filter
 HEPA filters
 0.3-15 micron
 efficiency of 98-100%
 exclude aerosolized BWA particles in the highly infectious 1- to 5-mm
range
 Surgical mask
 Protective Clothing
 (www.emedicine.com)

84. Levels of Civilian PPE
 Level A
 SCBA and a totally encapsulating chemical-protective
(TECP) suit
 highest level of respiratory, eye, mucous membrane, skin
protection
 Level B
 positive-pressure respirator (SCBA or SAR)
 nonencapsulated chemical-resistant garments, gloves, and
boots, which guard against chemical splash exposures.
 highest level of respiratory protection with a lower level of
dermal protection.
(www.emedicine.com)

85. Levels of Civilian PPE
 Level C
 APR and nonencapsulated chemical-resistant clothing, gloves,
and boots.
 same level of skin protection as Level B, with a lower level of
respiratory protection.
 used when the type of airborne exposure is known to be
guarded against adequately by an APR.
 Level D
 standard work clothes without a respirator.
 In hospitals, it consists of surgical gown, mask, & latex gloves
(universal precautions).
 no respiratory protection and only minimal skin protection
(www.emedicine.com)

86. Decontamination
 Extenal Decontamination
 Gross Decontamination
 Removal of clothings; done before reaching hospital
 Secondary Decontamination
 Designated site at ED; with advice from Radiation Safety Officer;
head to toe survey
 Internal Decontamination
 Blockade of enteral absorption
 Gastric lavage
 Use emetic agents – Barium sulphate
 Blockade of end organ uptake
 Potassium Iodide

87. References
 Kales, S. N. & Christisni, D. C. (2004) Acute Chemical
Emergencies. NEJM, 350, 800-8.
 Greenberg, M. I., Sherri, M. J. & Gracely, E. J. (2002)
Emergency Department Preparedness For The
Evaluation And Treatment of Victims of Biological or
Chemical Terrorist Attack. Journal of Emergency Medicine,
22, 273-78.
 Roy, M. J. (Ed.) (2004) Physician's Guide to Terrorist
Attack, Totowa, New Jersey, Humana Press.

88. References
 Schultz, C. H., Koenig, K. L. & Noji, E. K. (1996) Current
Concepts - A Medical Disaster Response To Reduce Immediate
Mortality After An Earthquake. NEJM, 334, 438-44.
 Richards, C. F., Burnstein, J. L., Waeckerie, J. F. & Hutson., H.
R. (1999) Emergency Physician and Biological Terrorism. Annals
of Emergency Medicine, 34, 183-190.
 Mandl, K. D., Overhage, J. M., Wagner, M. M., Lober, W. B.,
Sebastiani, P., Mostashari, F., Pavlin, J. A., Gesteland, P.,
Treadwell, T., Koski, E., Hutwagner, L., Buckeridge, D. L.,
Raymond, D. A. & Grannis, S. (2004) Implementing Syndromic
Surveillance: A Practical Guide Informed by the Early
Experience. Journal of the American Medical Informatics Association,
11, 141-150