Bioterrorism

A. Anthrax

1. Anthrax is an acute infectious disease caused by the spore-forming bacterium B anthracis. Anthrax most often occurs in warm-blooded animals. However, it also can infect humans. Symptoms of disease vary. Usually, though, symptoms appear within 7 days after exposure. The most common form of anthrax is cutaneous anthrax. 2. Treatment a. Direct person-to-person spread of anthrax usually does not occur. Only rare cases of person-to-person transmission have been reported when there has been exposure to discharge from open lesions of cutaneous anthrax. b. Treatment with antibiotics should be early; if left untreated, the disease can be fatal.

Blister agents

1. Blister agents or vesicants are chemicals with highly irritating properties that produce fluid-filled pockets on the skin and damage to the eyes, lungs, and other mucous membranes. 2. Treatment a. After ensuring personal safety (including the use of appropriate PPE), the initial assessment and treatment of the patient should begin with airway, ventilatory, and circulatory support, as needed.

A. CBRNE science database

1. CBRNE is an abbreviation for the categories of WMDs: Chemical, Biologic, Radiologic, Nuclear, and Explosive agents. 2. This program uses small teams, working groups, and task groups in an ongoing effort to meet the following objectives: a. To provide coordinated strategic, technical, and operational leadership, advice, and guidance for all levels of the medical response, with focus on medical and public health impacts and interventions relating to CBRNE incidents b. To improve overall public health emergency preparedness by having systems prepared, responsive, and resilient to limit the adverse health impacts of CBRNE emergencies c. To apply evidence-based decision making to preparedness planning for, response to, and recovery from a CBRNE incident 3. The ASPR CBRNE Science website offers resources to enhance national preparedness and "just-in-time" response, with a focus on medical management, for the following groups of incidents: a. Radiation emergencies b. Chemical emergencies c. Nuclear detonation (state and local planning)

A. Plague

1. Plague is caused by the bacterium Y pestis. This bacterium is found in rodents (e.g., chipmunks, prairie dogs, ground squirrels, rats, mice) and their fleas in many areas of the world. 2. There are three types of pneumonic plague arising from the lungs, all of which are caused by the bacterium Y pestis. Bubonic plague arises in the lymph nodes and leads to swelling that produces buboes. Septicemic plague occurs when the lymph infection spreads to the bloodstream. 3. Treatment a. Pneumonic plague is spread through the respiratory droplets of an infected person. Thus, patients with the disease should be isolated. Standard precautions and personal respiratory protection for all caregivers are crucial.

Critical Biologic Agents and Responder Databases A. The Centers for Disease Control and Prevention (CDC) has published a list of biologic agents. The list is divided into categories A, B, and C

1. Category A agents are the highest priority and pose a risk to national security. These agents can be easily disseminated or transmitted from person to person. Because these agents cause a high death rate and have the potential to cause a major public health problem, they might cause public panic and disruption. Category A agents require special action for public health preparedness. a. An example of a category A agent is B anthracis (anthrax). 2. Category B agents are the second-highest priority. They are fairly easy to disseminate. They cause moderate illnesses and have a lower death rate than do category A agents. These agents require specific enhancements of diagnostic capacity and disease surveillance. a. An example of a category B agent is C burnetii (Q fever). 3. Category C agents are the third-highest priority. They include new pathogens that could be engineered for mass dissemination in the future. These agents are widely available and are easy to produce and dispense. They have the potential to cause a high rate of death and sickness. a. An example of a category C agent is Nipah virus.

A. Emergency responder guidelines

1. Emergency responder guidelines have been established by the Office of Justice Program, Office for Domestic Preparedness, to prepare for and respond to incidents of domestic terrorism. These incidents may involve chemical and biologic agents and nuclear, radioactive, and explosive devices. 2. Recommended guidelines for EMS providers are as follows: a. Recognize hazardous materials incidents. b. Know the protocols used to detect the potential presence of WMD agents or materials. c. Know and follow self-protection measures for WMD events and hazardous materials events. d. Know procedures for protecting a potential crime scene. e. Know and follow agency/organization scene security and control procedures for WMD and hazardous material events. f. Possess and know how to use equipment properly to contact dispatchers or higher authorities to report information collected at the scene and to request additional assistance or emergency response personnel. Know how to characterize a WMD event and be able to identify available response assets within the affected jurisdiction(s).

White phosphorus

1. Incendiary devices built with white phosphorus present special concerns. White phosphorus ignites when exposed to oxygen at temperatures above 84°F (30°C). 2. Exposure causes deep thermal and chemical burns. If fragments of the chemical remain, they can reignite when bandages are removed because of the reexposure to oxygen. D. Emergency care 1. Emergency care depends on the nature of the attack. Care may include providing care for burns or inhalation injuries at a small-scale event. 2. It is crucial to personal safety not to enter the scene until the area is determined to be safe.

A. Explosives are categorized as follows:

1. Low-order explosives a. Explode with velocities of less than 3,300 feet/s (1,000 m/s) b. Examples: gunpowder, fireworks, natural gas, flammable gas-air mixtures 2. High-order explosives a. Explode with velocities of 10,000 to 30,000 feet/s (3,000 to 9,000 m/s) b. Examples: plastic explosives (C4 and Semtex), ANFO (ammonium nitrate/fuel oil), TNT (trinitrotoluene), military bombs 3. Improvised explosive devices a. Either low- or high-order explosives b. Contain a fuel, an oxidizer (e.g., ANFO), and projectiles c. Examples: pipe bombs, letter bombs, backpack or satchel bombs, vest bombs, dirty bombs, vehicle bombs

Nerve agents

1. Nerve agents were used in military conflicts in the Persian Gulf in the 1980s. They also were used in terrorist attacks in Japan in 1995 and in Syria in 2017. They are the most toxic and rapidly acting of the known chemical warfare agents.

A. Botulism

1. One type is foodborne botulism, which is caused by eating foods that contain the botulism toxin. The second type is wound botulism (Figure 57-3), which is caused by toxin produced from a wound infected with C botulinum. The third type is infant botulism. This type is caused by consumption of the spores of the botulinum bacteria, which then grow in the intestines and release toxin. 2. Treatment a. Botulism is not spread from person to person. If diagnosed early, foodborne and wound botulism can be treated with an antitoxin.

Poisonous gases

1. Poisonous gases were popular weapons during World War I. They are produced in large quantities worldwide for use in the industrial sector and are widely available. 2. Chlorine is a yellow-green gas with an odor that has been described as a mixture of pineapple and pepper. 3. Phosgene (also known as CG) is a poisonous gas that appears as a gray-white cloud and smells like newly mowed hay. 4. The federal government has distributed caches of nerve agent antidotes throughout the country in CHEMPACK containers. EMS CHEMPACK containers contain a sufficient number of autoinjectors to treat about 450 patients. Each CHEMPACK contains Mark-1 or ATNAA autoinjector kits, atropine sulfate, pralidoxime, AtroPens, diazepam (solution and autoinjectors), and sterile water. When needed, designated EMS or law enforcement officials will transport the CHEMPACK to the incident site. 5. Treatment a. No antidotes exist for chlorine or phosgene poisoning. Treatment for exposure to these gases consists of removing them from the body as soon as possible and providing supportive medical care. All patients should be moved to an area of fresh air and to the highest ground possible.

A. Ricin

1. Ricin is a potent protein cytotoxin, a chemical that is derived from the beans of the castor plant (R communis) (Figure 57-4). 2. Treatment a. No antidote exists for ricin poisoning. Treatment is aimed at avoiding exposure and eliminating the toxin from the body as quickly as possible. Patients who have inhaled ricin should be moved to an area with fresh air, clothing contaminated with the toxin should be removed, and the patient should be decontaminated.

Smallpox

1. Smallpox was declared extinct by the World Health Organization in 1980 because of near-universal vaccination. 2. Signs and symptoms of the disease include high fever, fatigue, headache, and backache. These are followed within 2 to 3 days with the smallpox rash and skin lesions. 3. Treatment a. There is no proven treatment for smallpox. However, several antiviral drugs are being studied. Patients with smallpox should receive supportive care provided by vaccinated personnel.

Explosive Threats. A. Emergency care

1. The Hartford Consensus used the THREAT acronym to describe zones of care during mass shooter and other intentional mass-casualty events. The THREAT acronym stands for Threat suppression, Hemorrhage control, Rapid Extrication, Assess patient, and Transport to the hospital 2. The consensus recommendations advocate that the traditional zones of treatment in these situations consisting of red (hot - immediate/direct threat), yellow (warm - indirect threat), and green (cold -no known threat) be compressed from that in the past. 3. In active shooter or explosive incidents, care begins with hemorrhage control. The DHS suggests the following interventions following an IED or active shooter incident: a. Tourniquets to control bleeding b. Hemostatic gauze when bleeding control by tourniquet is not possible at the site c. Nasopharyngeal airway if facial trauma is not present d. Positioning in recovery position if possible when bleeding into the airway related to facial trauma is present e. Spinal precaution if indicated and feasible for blunt trauma patients f. IV access if indicated and provider is qualified and authorized to do so. (IV access is not routinely needed in the initial phase of care.) g. Surgical airway if "sit up and lean forward" posture is not possible in patients with face or neck trauma h. IO access for medications or fluids if IV access is not possible i. IV morphine, oral transmucosal fentanyl citrate lozenges, and ketamine for analgesia

Tularemia

1. Tularemia is a serious illness caused by the bacterium F tularensis. This bacterium is found in animals (especially rodents, rabbits, and hares). The disease is highly infectious. Some strains are resistant to antibiotics. 2. Transmission of the disease from person to person does not occur. The development of signs and symptoms varies widely (from 1 day to 2 weeks). 3. Treatment a. The disease is managed with antibiotics. The patient may require airway, ventilatory, and circulatory support. Until recently, a tularemia vaccine was available for laboratory workers. The safety of the vaccine is being reviewed and is not available at this time.

Viral hemorrhagic fevers

1. Viral hemorrhagic fevers (VHFs) refer to a group of illnesses caused by several distinct families of viruses that include arenaviruses, filoviruses, bunyaviruses, paramyxoviruses, and flaviviruses. 2. Some VHFs (e.g., Ebola and Marburg) also can spread from person to person following an initial infection. This type of infection most often results from close contact with infected people through their body tissues and fluids. 3. Treatment a. Therapy for patients with VHFs is supportive. With the exception of yellow fever and Argentine hemorrhagic fever, and more recently dengue and Rift Valley virus, for which experimental vaccines have been developed, no vaccines exist that can protect against these diseases.

Explosive Threats

A. Active shooter incidents 1. Between 2000 and 2016, the United States experienced 1,486 casualties from 220 active shooter incidents. Of these, 661 people died and 825 were wounded. Almost 70% of the incidents ended in 5 minutes or less. Although they occurred in a variety of locations, all involved a single shooter (Table 57-3). 2. Some groups and organizations are advocating that the term mass-casualty attacker be used in place of active shooter. This change recognizes that a growing number of incidents involve weapons other than firearms (e.g., knives, cars, buses).

Terrorist

A. Acts of terrorism can pose significant risk to civilian populations. If airplanes were to spray chemical and biologic agents on a city on a clear, breezy night, thousands and perhaps millions of people would be killed. For example, 200 pounds (91 kg) of anthrax sprayed over a city the size of Omaha, Nebraska, would kill as many as 2.5 million people; 200 pounds of botulinum toxin would kill as many as 40,000 people in an area the size of Minnesota's Mall of America; and 200 pounds of VX sprayed over an area the size of Disneyland in California would kill about 12,500 people.

Explosive Threats

A. An explosive is a bomb. Bombs can be made from a variety of dangerous materials and can be made in a variety of sizes, weighing several ounces to several thousand pounds.

Department of Homeland Security

A. Following the terrorist attacks on the World Trade Center in New York City on September 11, 2001, the DHS was established through the Homeland Security Act of 2002. B. The missions of the DHS are to (1) prevent terrorism and enhance security, (2) ensure resilience to disasters, (3) enforce and administer immigration laws, (4) safeguard and secure cyberspace, and (5) secure and manage the borders.

General Guidelines for Emergency Response

A. However, there are some significant differences: 1. Terrorists have been known to time secondary events (e.g., booby traps, additional bombs, armed resistance) to injure emergency responders. These events occur more commonly abroad (e.g., with ISIL). 2. A terrorist act is a criminal event. As such, the site becomes a crime scene, and everything is considered evidence of the crime. Fear and panic can be expected from the public, patients, and emergency responders. This makes scene safety, security, and crowd control major issues with which to contend. 3. Contingency plans for emergency responders at the scene and at destination facilities will need to be in place. These plans will help emergency responders to deal with the large numbers of upset, agitated, frightened, and injured patients. Large-scale events will likely involve local, state, and federal agencies.

Incendiary Threats

A. Incendiary devices are weapons that produce heat and fire through the chemical reaction of a flammable substance. They are often referred to as firebombs. Terrorists may choose to use an improvised incendiary device because most are inexpensive and can be easily made from materials purchased at the hardware or grocery store. B. Depending on the severity of the attack, primary concerns may include the following: 1. The possibility for large numbers of burn victims, inhalation injuries, and fatalities 2. Significant damage to buildings and the infrastructure of a community 3. Overwhelming of local resources (emergency response agencies, hospitals, mental health agencies) 4. The involvement of law enforcement at local, state, and federal levels because of the criminal nature of the event 5. The closing of workplaces and schools 6. Possible restrictions on domestic and international travel 7. The need for evacuation and extended cleanup 8. Public fear that can continue for a prolonged period

Methods of Dissemination

A. Most biologic agents used in bioterrorism are designed to enter the body through one of three ways. One way is the inhalation of small particles into the lungs. Another is through the ingestion of contaminated food or water. The third way is by contamination of the skin that allows for absorption of the toxins. A rarer type of exposure is by injection. B. Aerosols can be delivered in wet or dry form in closed or open spaces. Equipment that may be used to disseminate aerosols includes crop-dusting planes for open spaces, aerosol-generating devices for enclosed areas (e.g., subways, enclosed malls), ventilation systems in buildings, and contamination of items in the environment with fine powders that are aerosolized easily when disrupted.

Nuclear and Radiologic Threats

A. Nuclear explosions can cause deadly effects from blinding light, intense heat (thermal radiation), initial nuclear radiation, blast, fires started by the heat pulse, and secondary fires caused by destruction. A radiologic dispersion device (RDD) is also called a "dirty nuke" or "dirty bomb." B. The main type of RDD combines an explosive, such as dynamite, with a radioactive material. C. Emergency care 1. Limit the amount of time at a radiologic scene. Fallout radiation loses its intensity fairly rapidly. Use or wear radiation detection monitors. Remove clothing and shower if exposed to radioactive dust or sand (fallout). 2. Increase the distance between you and the scene. 3. Shield yourself with appropriate PPE, geographic features of the terrain (mountains, hills, depressions), or structural materials whenever possible. Your protection increases in proportion to the number of heavy, dense materials located between you and the fallout particles.

History of Biologic Weapons

A. The use of biologic agents as weapons has occurred throughout history, dating back at least as far as 184 BC when Hannibal ordered that pots filled with venomous snakes be thrown onto the decks of enemy ships B. Box 57-1: Timeline of suspected or reported use of biologic weapons 1. Early examples 2. Pre-World War II 3. World War II 4. Post-World War II 5. The Gulf War 6. The Aum Shinrikyo 7. Recent terrorist group activities 8. Recent terrorist wartime activities

Sarin

also known as BG) is a clear, colorless, and tasteless liquid that has no odor in its pure form. However, sarin can evaporate into a vapor (gas) and spread into the environment. The agent also mixes easily with water, creating a contamination risk for those who touch or drink the water.

Tabun

also known as GA) is a clear, colorless, tasteless liquid with a faint fruity odor. The chemical can vaporize if heated. Thus, people can be exposed to the nerve agent by skin or eye contact or by inhalation. The agent also mixes easily with water, allowing for possible cutaneous exposure and exposure to the gastrointestinal tract if contaminated food or water is ingested.

Soman

also known as GD) is a clear, colorless, tasteless liquid with a slight camphor odor. The odor is similar to the smell of a topical cough suppressant (e.g., Vicks VapoRub) or rotting fruit. The agent can vaporize if heated.

Treatment for exposure to nerve agents

consists of quickly removing the agent from the body and supporting the patient's vital functions. If vapor exposure has occurred, the patient should be moved quickly to an area with fresh air. b. Atropine and pralidoxime chloride are antidotes for nerve agent toxicity (Table 57-1). They are available in autoinjector kits.

VX

thick, amber-colored, odorless liquid. It resembles motor oil and is the most potent of all nerve agents. VX is considered to be much more toxic when absorbed through the skin and somewhat more toxic by inhalation than are other nerve agents. 3. Allied forces in World War II coined these nerve agents as "G" series. They were so named because they were first developed by German scientists during the war.