The ABCs of Disaster Medical Response
Manual for Providers
2nd Edition

Susan M. Briggs, MD, MPH, FACS, Editor Michael Cronin, MPH, Associate Editor


The ABCs of Disaster Medical Response


The ABCs of Disaster Medical Response
Manual for Providers 2nd Edition

Director, International Trauma and Disaster Institute, Massachusetts General Hospital Associate Professor of Surgery, Harvard Medical School

Editor Susan M. Briggs, MD, MPH, FACS

Senior Editor, International Trauma and Disaster Institute, Massachusetts General Hospital

Associate Editor Michael Cronin, MPH


The ABCs of Disaster Medical Response

This manual was made possible through an educational grant from Z-Medica and On Site Gas Systems.

Copyright © 2006 , International Trauma and Disaster Institute, All rights reserved. All photos in this publication are courtesy of the authors unless otherwise noted.

............................................................................................ 22 Chemical Agents ...............9 Evacuation ................ 18 Biological Agents ..........................................................7 Definitive Medical Care ..................................................................................6 Search and Rescue.................... 34 Psychological Response to Disasters ............................................ 16 Crush Injuries .. 26 Radioactive Agents.... 36 ........................................2 Chapter 2: Incident Command System ................................................... 12 The Threat of Terrorism and Weapons of Mass Destruction .i Table of Contents Introduction .................................... 30 Chapter 6: Chapter 7: Decontamination........... 10 Chapter 4: Chapter 5: Public Health Response to Disasters .......6 Triage...............1 Chapter 1: Mass Casualty Incident Management .................................... 14 Blast Injuries....4 Chapter 3: Medical Response to Disasters....................................................................................................................................................

1 The ABCs of Disaster Medical Response .

not surprisingly. especially those involving terrorism. All medical responders need to incorporate the key principles of the MCI response in their training given the complexity of today’s disasters. based on an understanding of their common features and the response expertise they require. MCI response has the primary objective of reducing the morbidity (injury/disease) and mortality (death) associated with the disaster. medical providers have held the erroneous belief that all disasters are different. have similar medical and public health consequences. No one can predict the complexity. regardless of etiology. Traditionally. man-made disasters and terrorism encompass the spectrum of possible disaster threats. Terrorism. The key principle of disaster medical care is to do the greatest good for the greatest number of patients. . A consistent approach to disasters. is the most challenging for medical providers. is becoming the accepted practice throughout the world. while the objective of conventional medical care is to do the greatest good for the individual patient. time. or location of the next disaster. This strategy is called the Mass Casualty Incident (MCI) Response.1 INTRODUCTION D isasters follow no rules. All disasters. Natural disasters. Disasters differ in the degree to which these consequences occur and the degree to which they disrupt the medical and public health infrastructure of the disaster scene. Weapons of mass destruction creating “contaminated environments” will be the greatest challenge of all.

political. will be major factors in determining whether a mass casualty incident requires resources from outside of the community. especially those disasters involving terrorism and weapons of mass destruction (chemical. The severity and diversity of injuries.2 The ABCs of Disaster Medical Response CHAPTER 1: Mass Casualty Incident Management M ass casualty incidents (MCIs) are events that cause casualties large enough to overwhelm the medical and public health services of the affected community. biological. transportation. social. Similar to the ABCs of trauma care. or nuclear). in addition to the number of victims. and other aspects of the physical. or economic environments impose severe constraints on the availability and adequacy of immediate care for the population in need. Today’s complex disasters. Medical concerns related to MCIs include four elements: ♦ ♦ ♦ ♦ Search and rescue Triage and initial stabilization Definitive medical care Evacuation . and the degree to which outside assistance is needed to perform the ABCs of disaster care. An austere environment is a setting where resources. may result in an austere environment. disaster response includes basic medical and public health concerns that are similar in all disasters. The difference is the degree to which these responses are utilized in a specific disaster.

New York (2001) . the Incident Command System. World Trade Center.Chapter 1: Mass Casualty Incident Management 3 Public health concerns related to MCIs include: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Water Food Shelter Sanitation Safety and Security Transportation Communication Disease surveillance Endemic and epidemic diseases Both medical and public health disaster response activities are coordinated through one organizational structure. Ground Zero.

ICS Structure and Hierarchy The organizational structure of ICS is built around five major management activities. emergency medical services). NOT TITLES. The ICS uses a common organizational structure and language to achieve this goal. Incident Commander (IC) Maintains overall responsibility for disaster response Public Information Officer (PIO) Communicates with press and public Liaison Officer Coordinates the efforts of all responding agencies Safety Officer Responsible for safety of responders Operations Planning Logistics Finance . ♦ Incident command ♦ Operations ♦ Planning ♦ Logistics ♦ Financial/Administrative FUNCTIONAL REQUIREMENTS. and/or multiple jurisdictions of similar agencies to work together effectively in response to a disaster. DETERMINE ICS HIERARCHY. Note: Not all activities are used for every disaster.4 The ABCs of Disaster Medical Response CHAPTER 2: Incident Command System M any different organizations participate in the response to a disaster. police. The Incident Command System (ICS) was created to allow different kinds of agencies (fire.

the safety officer varies by the type of disaster: ♦ ♦ ♦ Biological incident = Infection control expert Chemical incident = Hazardous material expert Radiation incident = Radiation detection expert. 3. before an incident gets out of control. An important part of disaster planning is the identification of the incident commander and other key positions BEFORE a disaster occurs. must adhere to the structure of the ICS in order to avoid potentially negative consequences. The only difference is in the particular experience of key personnel and the extent of the ICS utilized in a particular disaster. For example. 2. The structure of the ICS is the same regardless of the nature of the disaster. often used to working independently. ICS allows the integration of local EMS.Chapter 2: Incident Command System 5 Important Principles 1. Medical and public health responders. fire. and police assets . ICS must be started early. including: ♦ ♦ ♦ Death of personnel due to lack of training Lack of adequate supplies to provide care Staff working beyond their training or certification 4.

structural engineering. Bam. e. heavy equipment operation. and even wooden planks that can be used as stretchers at the disaster site.g. listening equipment.6 The ABCs of Disaster Medical Response CHAPTER 3: Medical Response to Disasters 1. Many countries have developed specialized search-and-rescue teams as an integral part of their national disaster plans. tools. remote cameras Trained canines and their handlers Field Tip Local construction companies may be valuable search and rescue assets by providing equipment.” Search-and-rescue units generally include: A cadre of medical specialists Technical specialists knowledgeable in hazardous materials. and technical search-and-rescue methods. Iran (2003) . Members of these teams receive specialized training in “confined space environments. Local residents search earthquake ruins for survivors. SEARCH AND RESCUE T ♦ ♦ ♦ he local population near any disaster site is the immediate search-and-rescue resource..

Field medical triage must be conducted at three levels: ♦ ♦ ♦ On-site Triage (Level 1) Medical Triage (Level 2) Evacuation Triage (Level 3) Color coding used at casualty collection site ♦ ♦ ♦ ♦ Rapid categorization of victims with potentially severe injuries needing immediate medical care “where they are lying” or at a triage site Personnel are typically first responders from the local population or local emergency medical personnel Patients characterized as “acute” or “non-acute” Simplified color coding may be done if resources permit: On-Site Triage (Level 1) ACUTE = RED NON-ACUTE = GREEN . The objective of conventional triage is to do the greatest good for the individual patient. TRIAGE Triage is the most important mission of any disaster medical response. Important features are: ♦ ♦ ♦ ♦ ♦ Proximity to the disaster site Safety from hazards and upwind location from contaminated environments Protection from climatic conditions Easy visibility for disaster victims Convenient exit routes for air and land evacuation 2. The objective of disaster triage (field triage) is to do the greatest good for the greatest number of people. regardless of the nature of the mass casualty incident.Chapter 3: Medical Response to Disasters 7 Casualty Collection Site Casualty collection sites for Level 1 and 2 triage should be located close enough to the disaster site to offer rapid treatment but far enough away to be safe.

8 The ABCs of Disaster Medical Response Medical Triage (Level 2) ♦ Rapid categorization of victims at a casualty site by the most experienced medical personnel available to identify the level of medical care needed “The greatest good for the greatest number of people” Knowledge of the medical consequences of various injuries (e. or nuclear weapons) is critical Color coding may be used: RED ♦ ♦ ♦ URGENT Casualties who require immediate lifesaving interventions (airway. biological. breathing. ♦ . circulation) Casualties who do not require immediate life-saving interventions and for whom treatment can be delayed Casualties who are not expected to survive due to the severity of injuries complicated by the conditions and lack of resources Individuals who require minimal or no medical care DELAYED YELLOW or EXPECTANT GREEN MINOR BLACK DECEASED Evacuation Triage (Level 3) ♦ ♦ Level 3 triage assigns priorities to disaster victims for transfer to medical facilities Goal is appropriate evacuation (by land or air) of victims according to severity of injury and available resources Same medical personnel as in Level 2 triage.g. blast. burn. or crush injuries or exposure to chemical..

a casualty’s condition. definitive care must be provided outside traditional medical facilities.g. flexible response to the need for definitive medical care in disasters are key to a successful disaster response. DEFINITIVE MEDICAL CARE Definitive medical care generally refers to care that will improve. rather than simply stabilize. Requirements for definitive medical care will vary widely depending on the magnitude and epidemiology of the disaster. transportation to medical facilities might not be feasible. Hospital teams with mobile equipment that can provide a graded. local hospitals may be destroyed. or the environment may be contaminated. surgery or other care provided in a hospital. El Salvador earthquake (1987) . In these situations.Chapter 3: Medical Response to Disasters 9 3. Definitive medical care in field tents. In some disasters. e..

etc. cabin pressure decreases and gas trapped in organs expands. These include: ♦ ♦ ♦ Contaminated casualties Casualties with transmissible diseases Unstable casualties Modes of evacuation include: ♦ ♦ ♦ Ground transport Transport by helicopters or small fixed wing aircraft Transport by large fixed wing aircraft Patient Stresses of Flight ♦ Hypobaric environment. such as those with burns and crush injuries There are also several reasons to delay or defer evacuation of some casualties. There are several indications for evacuation in a disaster: ♦ ♦ ♦ To decompress the disaster area To improve care for most critical casualties by removal to off-site medical facilities To provide specialized care for specific casualties. At altitude. Casualties with impaired gas exchange will usually experience hypoxia. possibly causing pneumothorax.10 The ABCs of Disaster Medical Response 4. Medical equipment can shift in flight or during take off and landing. Decreased partial pressure of oxygen. ♦ ♦ ♦ . are at greatest risk. Temperature and Humidity. Turbulence and Vibration. Patients with unstable fractures. Varying temperatures and low humidity are the norm. Monitor patients’ temperatures and use humidified O2 whenever possible. ileus. EVACUATION Evacuation can be useful in a disaster. especially spinal.

Thomas.Chapter 3: Medical Response to Disasters 11 Interior of a military transport plane converted for medical evacuation. V. (1991) . El Salvador earthquake (1987) Orange crate doubles as a pediatric evacuation stretcher.I. El Salvador earthquake (1987) Helicopter used for evacuation after hurricane in St.

Planning the response will be based. particularly in the area of greatest impact. The challenges related to this task are twofold: The needs assessment must be performed concurrently with the provision of medical services. ASSESSING THE MAGNITUDE OF A DISASTER Media reports can provide valuable information regarding the magnitude of a disaster. The three specific elements of the Rapid Needs Assessment are described below. 1. on limited assessment information.12 The ABCs of Disaster Medical Response CHAPTER 4: Public Health Response to Disasters M ♦ ♦ edical providers must understand the impact of disasters on the public health infrastructure in order to have an efficient medical response. Aerial reconnaissance over areas devastated by Supertyphoon Pongsona in Guam (2002) . The Rapid Needs Assessment provides a timely evaluation of the impact of the disaster on the affected population. The ability of reporters to gain firsthand observational information through helicopter and fixed wing aircraft reconnaissance can provide visual information that can be used to estimate damage caused by the disaster. of necessity.

Is the local community able to respond? 3. food supply. shelter. Are there current or future infrastructure problems? ♦ Health and medical issues: ◊ ◊ ◊ immediate life-threatening injury/illness epidemic and endemic diseases disrupted/overwhelmed services ♦ ♦ ♦ ♦ Potable water: quality and quantity Food: quality and quantity Shelter Sanitation 2. sanitation capacity.900 kcal/person/day (Increase by 500 kcal/day for pregnant/lactating females) Children: varies by age Food ♦ ♦ Emergency/Temporary Shelter ♦ 3.5 m2/person 3. including potable water supply. Is the appropriate assistance being provided? . ASSESSING THE LOCAL RESPONSE Cardinal questions in assessing local response are: 1.Chapter 4: Public Health Response to Disasters 13 2. ASSESSING LIFELINE SERVICES Determining the disruption of lifeline services. Water ♦ ♦ Lifeline Services: Minimum Requirements Potable: 20 L/day/person (Increase by 20% for increased temperature or physical exertion) Sanitation: 5 L/day/person Adult: 1. Any disruption of the community’s medical infrastructure should be examined as well. and electricity is critical to the relief effort. Is outside assistance needed? 4.

” generating massive destruction of life and property.000 were suffering from the physical effects of the sarin gas with the remaining suffering psychological stress. 5. . No longer will emergency responders be able to bring victims into hospitals for fear of contaminating medical facilities. and possibly definitive care. biological. at staging areas outside traditional hospital facilities. fewer than 1. Medical responders must be equipped to provide triage and initial stabilization. One of the unique features of a terrorist threat. Terrorists are not limited by conventional technology or weaponry. ranging from suicide bombers. In the World Trade Center bombings on September 11. Terrorist events have the greatest potential of all man-made disasters to generate large numbers of casualties and fatalities.14 The ABCs of Disaster Medical Response CHAPTER 5: T The Threat of Terrorism errorism is the most challenging mass casualty incident for emergency responders. terrorists used fully fueled jumbo jets as “flying bombs. 2001. conventional explosives. The recent anthrax incidents in the United States also dramatically increased the number of individuals presenting to emergency departments with non-specific respiratory symptoms. Of these.000 casualties were referred to hospitals. is that psychogenic casualties usually predominate. In the March 1995 sarin attacks in Tokyo. and military weapons to weapons of mass destruction (nuclear. especially involving weapons of mass destruction. or chemical). Terrorists do not have to kill people to achieve their goals: they just have to create a climate of fear and panic to overwhelm the medical infrastructure. Weapons of mass destruction creating “contaminated environments” are the greatest disaster challenge of all. The spectrum of terrorist threats is limitless.

World Trade Center attack (2001) EMS providers at the scene of a suicide bombing .Chapter 5: The Threat of Terrorism 15 New York.

16 The ABCs of Disaster Medical Response 1. or moving vehicles. the respiratory tract. but to the subsequent structural damage that leads to collapse of buildings. a common phenomenon in large explosions. when strategically placed in buildings. The magnitude of the wave depends on the size of the explosion and the environment in which it occurs: the more powerful the blast. Casualties often sustain mixed types of injuries. The effects of the blast wave are increased in a closed space such as a building or bus and underwater. and the GI tract. secondary blast injury. The majority of terrorist bombings consist of relatively small explosives that produce low casualty rates. . The high morbidity and mortality is related not only to the intensity of the blast. PRIMARY BLAST INJURY (PBI) Blasts produce a pressure wave that moves out from the center of the explosion at supersonic speed. However. Treatment Alert! Tympanic membrane (eardrum) rupture is a useful marker for significant PBI. BLAST INJURIES Explosions and bombings related to terrorism continue to be a frequent cause of mass casualties in disasters. the greater the damage. Injuries caused by explosives and bombings can be divided into four categories: primary blast injury. Terrorists have also begun to use larger devices that traditionally have been confined to military operations. pipelines. Casualties with a mechanism of injury that suggests blast injury should be observed for 12-24 hours. and miscellaneous injuries. tertiary blast injury. their impact can be much greater. Primary blast injury is due solely to the direct effect of the pressure wave on the body. Primary blast injury occurs almost exclusively in gas-containing organs: the ear.

crush injuries . It is caused by flying debris. Summary: Mechanism of Blast Injuries CATEGORY Primary Blast Injury Secondary Blast Injury Tertiary Blast Injury Miscellaneous Injuries M ECHANISM OF I NJURY Blast Wave Victim struck by flying debris Victim impacted against stationary object Burns. MISCELLANEOUS BLAST INJURIES Exposure to the intense heat generated by the blast can cause thermal and inhalation burns. metal and glass. Traumatic amputations. Head. Secondary blast injury from land mine TERTIARY BLAST INJURY Tertiary blast injury is caused by propulsion of the body by the shock wave into solid objects. spine and extremity injuries are common. Structural collapse can cause crush injury with secondary complications such as crush syndrome and compartment syndrome.Chapter 5: The Threat of Terrorism 17 SECONDARY BLAST INJURY Secondary blast injury is the most common cause of death in blast casualties. fractures and soft tissue injuries are common. inhalation injuries.

18 The ABCs of Disaster Medical Response 2. CRUSH INJURY AND CRUSH SYNDROME Crush Injury is defined as compression of extremities and body parts that causes muscle swelling and/or neurological disturbances in the affected parts of the body. and trunk (9%). new hemostatic products. such as QuikClot powder (QC). and fibrin sealant dressing (FSD) are being field tested in disaster situations. upper extremities (10%). QuikClot. the HemCon Bandage. In addition to standard therapeutic modalities such as gauze dressings and tourniquets. Non-compressible hemorrhage in crush injured extremities continues to be a major source of mortality and morbidity. one example of a hemostatic agent . Typically affected body parts include lower extremities (74%).

Crush syndrome can cause local tissue injury. Previous experience with earthquakes that caused major structural damage demonstrated that: ♦ ♦ ♦ ♦ The incidence of crush syndrome was 2%—15% Approximately half of those with crush syndrome developed acute renal failure Approximately half of those with acute renal failure needed dialysis A significant number of patients with crush syndrome (>50%) needed fasciotomy . organ dysfunction. hyperkalemia (high potassium levels). and metabolic abnormalities such as acidosis (low blood pH levels). These systemic effects are caused by traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulation.Chapter 5: The Threat of Terrorism 19 Clotting agent (QC) used to stop bleeding in a wounded soldier Crush Syndrome is localized crush injury with systemic manifestations. and hypocalcemia (low calcium levels).

Further. which may cause renal failure if untreated. the sudden release of toxins from necrotic muscle into the circulation leads to myoglobinuria (excretion of myoglobin in the urine).20 The ABCs of Disaster Medical Response Clinical Manifestations of Crush Syndrome Sudden release of a crushed extremity may result in acute hypovolemia and metabolic abnormalities (reperfusion syndrome). Muscle Ischemia and Necrosis from Prolonged Exposure (Local Effects) CRUSH INJURY CRUSH SYNDROME Third Spacing: Fluid Retention in Extremities Myoglobinuria Electrolyte Abnormalities Secondary Complications Crush injury of pelvis with secondary crush syndrome . This may cause lethal cardiac arrhythmias and sudden death.

21 Definitive Management of Crush Syndrome Pretreat casualties with prolonged crush (>4 hours). as well as those who demonstrate abnormal neurological or vascular exam. apply a tourniquet to the crushed limbs and maintain until initiation of IV fluids. Renal Failure: ♦ Prevent renal failure through appropriate IV fluid hydration. Cardiac Arrhythmias: Monitor for cardiac arrhythmias and arrest. ♦ ♦ Hyperkalemia/Hypocalcemia: Administer calcium. Initiate (or continue) IV hydration—up to 1. Monitor for Vascular Compromise: The Five P’s ♦ ♦ ♦ ♦ ♦ TREATMENT ALERT! Prevention of crush syndrome through early treatment is key to reducing morbidity and mortality in crush injuries. Pain Pallor Paresthesias Pain with passive movement Pulselessness . sodium bicarbonate. and treat accordingly. Secondary Complications: ♦ Monitor casualties for compartment syndrome.5 L/hour. insulin/D50. Metabolic Abnormalities: ♦ Acidosis: Administer IV sodium bicarbonate until urine pH reaches 6. consider kayexalate.5 to prevent myoglobin deposits in kidneys. with 1—2 liters of normal saline before releasing the crushing object whenever possible. If pretreatment is not possible. Hypotension: ♦ Crush syndrome can cause massive fluid-shifts in casualties.

22 The ABCs of Disaster Medical Response 3. or plants. BIOLOGICAL AGENTS Biological terrorism is the use of microorganisms or toxins derived from living organisms to produce death or disease in humans. courtesy of the WHO . Recent events have demonstrated the vulnerability of civilian populations to the threat of biological agents. animals. The following disease agents are believed to have the greatest potential for bioterrorism: ♦ ♦ ♦ ♦ ♦ ♦ ♦ Anthrax (bacteria) Tularemia (bacteria) Plague (bacteria) Smallpox (virus) Viral hemorrhagic fevers (virus) Botulinum (toxin) Ricin (toxin) Cutaneous Anthrax Smallpox .

biological agents. Contamination may occur directly or secondarily after an aerosol attack and may represent a hazard for infection or intoxication by ingestion. Dermal Intact skin provides the most effective barrier for many. Mucous membranes and abraded or otherwise damaged skin can allow passage of some bacteria and viruses: these areas should be protected in the event of an attack. In an attack. but are still significant. and invisible due to its small particle size. The aerosol could be odorless.Chapter 5: The Threat of Terrorism 23 Routes of Exposure Inhalation The route of exposure of greatest concern with biological terrorist attacks is inhalation of the agent. which would produce particles of the right size and diameter to be inhaled deeply into the lungs where they would begin to cause illness. Ensuring that the food and water supply is free of contamination is an important function of public health and should be done as soon as possible after a biological attack. colorless. a terrorist might attempt to generate aerosols of the biological agent. Cutaneous anthrax caused by dermal exposure . Oral Oral routes of exposure for biological agents are believed to be less important. but not all.

A full-face respirator prevents exposure of the respiratory tract and mucous membranes.e. Physical protection is essential when dealing with unknown agents . including conjunctivae. Decontamination Any dermal exposure should be treated immediately by washing with soap and water. theoretically obviating the need for additional measures.24 The ABCs of Disaster Medical Response RESPONDING TO A BIOLOGICAL ATTACK Physical Protection The most effective and important prophylaxis against biological agents is physical protection. medical responders must guard against secondary contamination (i. In addition. Treatment options vary from agent to agent and include a variety of antibiotics such as ciprofloxacin and doxycycline for bacterial agents. and supportive therapy for viruses and toxins. Prophylaxis and Treatment Medical defenses against some biological agents are limited. to infectious or toxic exposure. contamination passed from the clothing of affected individuals) through the use of appropriate physical protection until decontamination is complete.

or combinations of unusual disease entities in the same patient population Suspected aerosol route of exposure Data suggesting a massive point-source outbreak Sentinel dead animals of multiple species High morbidity and mortality ♦ ♦ ♦ ♦ .Chapter 5: The Threat of Terrorism 25 Indications of a Possible Biological Attack ♦ A disease entity that is unusual or that does not occur naturally in a given geographic area.

at least until the ventilation system removes it—or possibly disperses it even further. the vapor will remain and the concentration will build.500 people to seek medical attention. terrorists used a chemical agent against a civilian population.26 The ABCs of Disaster Medical Response 4. a vapor will not remain in place—even a light wind will dilute and carry it away. terrorism changed. This can be done in three general ways: ♦ ♦ ♦ Aerosolizing it with an aerial sprayer (such as done with pesticides) Aerosolizing it in an explosion Allowing it to evaporate and dispersing the vapor When used outside. CHEMICAL AGENTS On March 20. However. There are five principal classes of chemical agents: ♦ ♦ ♦ ♦ ♦ Nerve agents Vesicants (blistering agents) Cyanide Pulmonary agents Riot control agents . when dispersed inside a structure where no wind is present. For the first time. causing over 5. chemical agents in liquid form must be dispersed in order to be maximally effective. 1995. Most chemical warfare agents are liquids. However. The nerve agent sarin (GB) was released in the Tokyo subway system by the Aum Shinrikyo cult. Chemical agents are now a terrorist weapon.

Chapter 5: The Threat of Terrorism 27 NERVE AGENTS Nerve agents cause biological effects by disrupting the normal mechanisms by which nerves communicate with muscles. Nerve agents enter the body either through the skin or by inhalation through the lungs. and VX. GB (Sarin). and other nerves. This causes hyperactivity in these structures before they fatigue and stop functioning. VESICANTS Vesicants are substances that cause erythema (redness) and vesicles (blisters) on the skin as well as injury to the eyes. Vesicant (blistering agent) . GF. lewisite. There are three types of vesicants that are considered chemical agents: sulfur mustard. and phosgene oxime. The important nerve agents are GA (Tabun). the airways and other organs. glands. GD (Soman).

or mustard. cyanide evaporates quickly to form poisonous gas or vapor. and lacrimators. Lewisite has the scent of geraniums. The forms of cyanide most likely to be used in a terrorist attack are hydrogen cyanide or cyanide chloride. Cyanide has the scent of bitter almonds and causes cherry red skin in its victims. RIOT CONTROL AGENTS Riot control agents. The best known of these is phosgene. are usually dispersed as a fine powder suspended in a liquid. PULMONARY AGENTS This class of compounds includes agents that cause pulmonary edema. Field Observations ♦ ♦ ♦ Sulfur mustard has the scent of onions. irritants. Under temperate conditions. a liquid that evaporates very quickly and enters the body through the airways. also known as tear gas. ♦ . Most signs and symptoms from cyanide poisoning are of central nervous system origin. Injuries from riot control agents are generally not serious and medical assistance is not usually sought after exposure to these agents.28 The ABCs of Disaster Medical Response CYANIDE Cyanide has a long history as a deadly poison because it causes death within minutes of exposure. Phosgene has the scent of freshly cut grass or hay. garlic.

suit. while the contaminated area is called the hot zone. one of the first things responders should do is establish a clean treatment area at least 300 yards upwind of the contaminated area..Chapter 5: The Threat of Terrorism 29 RESPONDING TO A CHEMICAL ATTACK When responding to a chemical accident. including mask. as described in Chapter 6. All responders must leave the hot zone via specially designated pathways into the warm zone where they will be decontaminated. such as atropine. one to triage and one to administer emergency care. two medical care responders should work in the contaminated area. The warm zone should be several hundred yards upwind from the contamination. These responders must be in full protective equipment. If there are multiple casualties who have severe. HOT ZONE Contaminated Area (Decontamination) WARM ZONE 50+ yards COLD ZONE (Clean Treatment Area) at least 300 yards WIND . Separating the hot and cold zones is the warm zone where decontamination occurs. life-threatening injuries. The clean treatment area is referred to as the cold zone. including the possible intramuscular administration of nerve agent antidotes. gloves. and at least 50 yards from the cold zone.

. Everyone is continuously exposed to a small amount of ionizing radiation. ♦ ♦ Detonation of a nuclear device: nuclear explosion Meltdown of a nuclear reactor: melting of the nuclear fuel within a reactor with limited release of radioactive materials into the environment if there is also a failure of the reactor containment structure Dispersal of material though use of conventional explosives: a radiation dispersal device (RDD) or “dirty bomb” Non-explosive dispersal of nuclear material: placing radioactive materials in public places ♦ ♦ Nuclear Detonation Reactor Meltdown RDD “Dirty Bomb” Simple Dispersal Least Likely Most Harmful Most Likely Least Harmful Principles of Radiation Radiation is everywhere. called background radiation. RADIOACTIVE AGENTS Use of nuclear material by terrorists would likely involve one of four scenarios below. as are television and radio signals. Fortunately. Sources of background radiation are both natural and man-made. Ionizing radiation is radiation that can injure living tissue by transferring energy to vital cell components. Visible sunlight and radar are forms of non-ionizing radiation.30 The ABCs of Disaster Medical Response 5. Cell phones use non-ionizing radiation to transmit our conversations. the most devastating scenarios are the least likely. Ionizing radiation is a natural part of our environment.

Chapter 5: The Threat of Terrorism 31 Ionizing radiation transfers energy to cells in the body. predispose to development of cancer). They transfer kinetic energy to tissue as they pass through it. and neutrons. These waves have no mass or charge and can pass through tissue easily.. irradiating casualties but leaving no radioactivity behind. Less severe radiation exposure and damage may exceed the cell’s ability to repair itself or leave permanent alteration in the cells functioning or genetic material (e. Particle radiation consists of alpha particles. damaging the atoms that make up cells. There are two types of ionizing radiation: ♦ ♦ Electromagnetic (wave) radiation Particle radiation Ionizing electromagnetic radiation consists of gamma rays and x-rays. . Alpha and beta particles do not travel very far from their source and cannot penetrate skin effectively. If the radiation is strong enough. the cell will be killed. beta particles.g.

DISTANCE: SHIELDING: Increasing the shielding around a radiation source. Internal Contamination occurs when radioactive materials are inhaled. ingested. Dose = Exposure Time X Exposure Rate. Generally. The farther away you are from a radiation source. external contamination is not a serious medical problem as long as contaminated clothing is removed and the material is washed off of the body quickly. and SHIELDING. or around you. which may occur alone or simultaneously: external irradiation (whole body irradiation or localized irradiation). Protection From Ionizing Radiation The cardinal rule of protection against radiation is TIME. The degree of injury depends upon the dose of radiation received. DISTANCE. External Contamination occurs when radioactive material or debris (sometimes referred to as fallout) is deposited on the body and clothing. The assessment and management of internal contamination is more difficult than for external contamination but is not an urgent condition. . or absorbed through open wounds.32 The ABCs of Disaster Medical Response Types of Ionizing Radiation Exposure There are two general types of radiation exposure. decreases exposure. TIME: The shorter the amount of time you spend near the radiation source. and contamination (external or internal). External Irradiation occurs when all or part of the body is exposed to electromagnetic radiation (gamma rays or x-rays) from an external source. the less radiation exposure you receive. the less exposure you receive.

but early closure of simple wounds is mandatory in irradiated casualties. All responders must be equipped with direct-reading individual dosimeters. decontamination can be done before. that responder must leave the site immediately and cannot return until the site has been decontaminated and is opened to the general public. Depending on the severity of the casualty’s condition and triage status. ♦ Normal trauma triage procedures should be employed. during. Scene Control and Responder Protection ♦ The incident commander will determine how much radiation exposure will be allowable for individual responders and will set the maximum allowable cumulative dose. ♦ ♦ Triage of Radiation Casualties Since the clinical effects of all but the most severe radiation exposures are delayed. the clinical presentation of exposed casualties will be primarily related to conventional injuries. or after initial stabilization. When any responder’s total dose exposure reaches the maximum allowable dose as set by the incident commander. ♦ Treatment Alert! Never delay major trauma care for radiologic decontamination! .Chapter 5: The Threat of Terrorism 33 Treatment Alert! Casualties who have been irradiated are not radioactive themselves unless radioactive material (source material or fallout) has been deposited on or in their bodies. There are no exceptions to this rule.

Level A protection is required for entry into an unknown hazardous environment. Respiratory protection is a self-contained breathing apparatus. Personal Protective Equipment (PPE) Level A PPE denotes fully encapsulated suit. Level B PPE denotes a hooded suit. There are two main goals in setting up decontamination at a medical facility: To protect the facility and its personnel from becoming contaminated. and large numbers of “worried well. Terrorist events. but uses an air-purifying respirator instead of a self-contained breathing apparatus. and a self-contained breathing apparatus and may be used for decontamination procedures for an unknown substance. with their larger number of patients. over-boots. Decontamination is an important part of all disasters involving hazardous materials and weapons of mass destruction. with over-gloves and over-boots integrated into the suit.” increase the possibility of casualties arriving at a facility contaminated or potentially contaminated. vapor. and upon verification of adequate oxygen in the environment. double gloves. Field Tip . and thus further casualties To facilitate the treatment and triage of contaminated patients as rapidly as possible Analysis of hazardous materials accidents has shown that up to 85% of the victims arrive at a healthcare facility without prehospital treatment or decontamination. unknown substances. Level C PPE is similar to Level B. the environment. and liquid materials are safely removed from an exposed person without further contaminating the casualty.34 The ABCs of Disaster Medical Response CHAPTER 6: Decontamination D ♦ ♦ econtamination is the process by which particulate. Showering with soap and water is among the most effective means of decontamination. or rescuers. Level C PPE can be used only after the hazardous substance has been identified. and entry into hot zones where the agent is not caustic. Removal of outer layers of clothing may reduce contamination by up to 85%.

HOT ZONE at least 300 yards WIND The area separating the hot and cold zones where decontamination occurs is the warm zone.Chapter 6: Decontamination 35 The contaminated area is called the hot zone. COLD ZONE (Clean Treatment Area) Decontamination should always take place upwind and uphill from any potential contamination! Decontamination of casualties in the warm zone by personnel in Level B PPE . (Decontamination) WARM ZONE 50+ yards The clean treatment area is referred to as the cold zone.

Characteristics of Disasters that Affect Mental Health Not all disasters have the same level of psychological impact. With terrorism. They are important not only in the care of disaster victims. It does mean. is affected by it. It is important that planners. that all individuals will have some type of psychological or emotional response to the event. but also in all aspects of the medical and public health response. vulnerabilities. Disaster characteristics that seem to have the most significant mental health impact are the following: ♦ ♦ ♦ ♦ ♦ ♦ Little or no warning Serious threat to personal safety Potential unknown health effects Uncertain duration of the event Human error and/or malicious intent Symbolism related to terrorist target Factors Impacting Psychological Response Everyone who experiences a disaster. this does not mean that most will develop a mental health disorder. and fears. the objective is to inflict psychological pain. trauma. Similarly. Planners and providers must consider their own denial. whether as a victim or as a responder. These issues are also important in assuring that responders do not become victims themselves. Fortunately. and disequilibrium. there are both individual and collective reactions that interact as individuals and communities recover from these extraordinary events. providers. and policy makers understand the importance of psychosocial issues. however.36 The ABCs of Disaster Medical Response CHAPTER 7: P Psychological Response to Disasters sychological trauma and other adverse psychological sequellae are frequently the side effects of events such as natural disasters and unintentional disasters caused by humans. .

Interventions ♦ In cases where there is no diagnosed mental disorder. educational materials that help people understand what they and their families are experiencing is helpful. from mild stress responses to full blown post-traumatic stress disorder (PTSD). Brief crisis counseling should be provided. followed by referral when treatment is indicated. While many people may exhibit signs of psychological stress. or acute stress disorder.Chapter 7: Psychological Aspects of Disasters 37 Factors affecting individual response to disasters include: ♦ ♦ ♦ ♦ ♦ Physical and psychological proximity to the event Exposure to gruesome or grotesque situations Diminished health status prior to or as a result of the disaster Magnitude of loss Trauma history Degree of community disruption Pre-disaster family and community stability Community leadership Cultural sensitivity of recovery efforts Factors impacting collective response to trauma include: ♦ ♦ ♦ ♦ Psychological Sequelae of Disasters Post-disaster responses are wide-ranging. major depression. relatively few (typically 15%–25%) of those most directly impacted will subsequently develop a diagnosable mental disorder. ♦ . Field Tip Most reactions to disasters are normal responses to severely abnormal situations.

It can also adversely impact their personal well-being as well as their family and work relationships. Signs of Stress in Workers Some common signs of stress in workers include the following: Physiological signs of stress such as: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Fatigue. but can also become secondary victims of stress and other psychological sequellae.38 The ABCs of Disaster Medical Response Worker Stress Disaster workers who choose to be involved in this type of work gain great reward and satisfaction. even after rest Nausea Fine motor tremors Tics Paresthesias Dizziness GI upset Heart palpitations Choking or smothering sensations Anxiety Irritability Feeling overwhelmed Unrealistic anticipation of harm to self or others Memory loss Decision-making difficulties Anomia (the inability to name common objects or familiar people) Concentration problems or distractibility Reduced attention span Calculation difficulties Emotional signs of stress such as: ♦ ♦ ♦ ♦ Cognitive signs of stress such as: ♦ ♦ ♦ ♦ ♦ ♦ . This can adversely affect their functioning during and after an event.

Chapter 7: Psychological Aspects of Disasters 39 Behavioral signs of stress such as: ♦ ♦ ♦ ♦ ♦ Insomnia Hypervigilance Crying easily Inappropriate humor Ritualistic behavior Limited exposure to traumatic stimuli Reasonable hours Adequate rest/sleep Reasonable diet Regular exercise program Private time Talking to somebody who understands Monitoring signs of stress Identifiable endpoint for involvement Managing Worker Stress On-Site ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Fatigue contributes greatly to worker stress. .

40 The ABCs of Disaster Medical Response © International Trauma and Disaster Institute .

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