and welcome to chapter 41 terrorism response and disaster management of emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will be able to describe what constitutes terrorism and the emt's response to terrorism and you will be able to apply this knowledge additionally you'll be able to demonstrate an understanding of weapons of mass destruction agents and countermeasures as well as a fundamental knowledge of disaster management safety okay so let's get started it is possible that you may be called on to respond to a terrorist event during your career the question is not will terrorists strike again but rather when and where they will strike you must be mentally and physically prepared for the possibility of a terrorist event it is difficult to plan and anticipate a response to many terrorist events yet there are several key principles that apply to every response so let's start off with what is terrorism terrorist forces have been at work since early civilizations the u.s department of justice defines both international terrorism and domestic terrorism with these points they involve violent acts or acts dangerous to human life that violate federal or state law and they appear to be intended to in intimidate or coerce a civilian population to influence the policy of a government by intimidating or coercion or to affect the conduct of a government by mass destruction assassination or kidnapping one difference between the two is location okay so international terrorism occurs primarily outside the the jurisdiction of the united states and domestic terrorism occurs primarily within the jurisdiction of the united states modern-day terrorism is common in the middle east where terrorist groups frequently attack civilian populations in the united states domestic terrorists have carried out multiple attacks only a small prevent percentage of groups actually turn towards terrorism as a means to achieve their goals so religious excrement extremist groups or doomsday cults are example of terrorism and extremist political groups they include violent supremacy groups and those who seek political religious economic and social freedoms also cyber terrorists and single-issue groups next we're going to talk about active shooter events and an alarming new trend in domestic terrorism involves the concept of a lone wolf terrorist attack this has become a frequent threat in the united states the national security critical issue task force defines lone wolf terrorism as the deliberate creation and exploitation of fear through violence or threat of violence by a single actor who pursues political change linked to a formulative ideology whether his own or that of a large organization and who does not receive orders direction or material support from outside sources the motives of a lone wolf terrorists are not always clear attacks may be targeted at schools music festivals or shopping centers and are difficult to predict many lone wolf terrorist attacks involve firearms and not explosives this type of event is classified as an active shooter event these attacks are have prompted discussion of gun laws mental health and education of the public and first responders on how to treat the casualties of active shooter events the hartford consensus recommends that a response plan for active shooter response should include the acronym threat threat stands for the t is threat suppression hemorrhage control is the hr rapid extrication to safety a is assessment by medical providers and finally transport to definitive care ems crews may be equipped with ballistic vests and helmets so that they can potentially be prepared with law enforcement to assist with threat and evacuation of injured people from the active scene a key component to safely uh incorporating ems crews with law enforcement teams who are moving forward into an active shooter scene is interagency training next we're going to talk about weapons of mass destruction so a weapon of mass destruction or a wmd or a weapon of mass casualty a wmc is any agent designed to bring about mass death casualties or massive damage to property and infrastructure such as a bridge of bridges or tunnels airports ores and or seaports we use the acronym be nice or c-b-r-n-e and these are mnemonics to remember the kinds of weapons of mass destruction okay so be nice is biologic nuclear incinerary chemical and explosive and then the c b r and e is chemical biologic radiologic nuclear and explosive to date the preferred weapons of mass destruction for terrorists have been explosives weapons of mass destruction are relatively easy to obtain or create and are specifically geared towards killing large numbers of people chemical terrorism warfare so chemical agents are manufactured substances that can have devastating effects on living organisms they can be produced in liquid powder or vapor form depending on the desired route and of exposure and dissemination technique so these agents consist of the following type so we have first vesicans these are blister agents next are respiratory agents and those are choking agents nerve agents and then metabolic agents so cyanides so let's talk about biologic terrorism and warfare a little bit more so biologic agents are organisms that can cause disease they're generally found in nature for terrorist use however they can be cultivated synthesized and mutated in a laboratory so weaponization of a biologic agent is performed to artificially maximize the target population's exposure to the germ so the primary types are viruses they can be bacteria or toxins next we're going to talk about nuclear or rheologic terrorism so there have been only two publicly known incidents involving the use of a nuclear device hiroshima and nagasaki it is possible for a terrorist to secure radioactive material or waste to um use one of these as a an act of terror so these materials are far easier for a determined terrorist to acquire and require less expertise to use they're called dirty bombs and they can be they can cause widespread panic and civil disturbances all right so we've talked a little bit about the different types of terrorisms and so now we're going to talk about emt response to this so the basic foundation of patient care remain the same the treatment can and will vary slightly so always remember situational awareness and recognize a terrorist event or indicators so the planning of most acts of terror is covert which means that the public safety community generally has no prior knowledge of the time location or nature of the attack so you must be constantly aware of your surroundings and understand the possible risks for terrorism you must know the current threat level issued by the government through the department of homeland security or dhs on april 2011 the color-coded homeland security advisory system was placed by was replaced by the national terrorism advisory system or ntas this alerts from the ntas contain a summary of the threat and actions that first responders government agencies and the public can take to maintain safety make sure you are aware of the information sent out by that advisory system at the start of your work day so on every call make the following observations and this is what we mean by the situational awareness so what type of call are you responding to where's the location what are the number of patients do you what about the victim statements or any pre-incident indicators all right so when we respond we have to remember scene safety and remember to stage your vehicle a safe distance from this incident we need to wait for law enforcement personnel to advise us if the scene has been secured so if you have any doubt that it may not be safe do not enter the best location for staging is upwind and uphill from the incident remember the following rules so we're going to failure to park your vehicle at a safe location can place you and your partner in danger if your vehicle is blocked by another emergency vehicle or damaged by a secondary device you will be unable to provide victims with transportation or escape yourself all right so let's talk about a secondary device and this is an additional explosive that are set to explode after the initial bomb it's intended primarily to injure those responders and to secure media coverage may include various types of electronic equipment such as cell phones or pagers and so the figure on this slide shows an example of the safely staging an ambulance all right so responder safety or personal protective equipment when we're responding so the best form of protection from a weapons of mass destruction is preventing yourself from even coming in contact with that agent the greatest threats are contamination and cross-contamination so what we want to do is as soon as we realize there's the terrorist attack we need to make those notification procedures we have to notify the dispatcher when we suspect that terrorist attack or weapons of mass destruction and what we're going to tell dispatch is the nature of the event any additional resources that we need and the estimated number of patients the upwind route of approach or an additional or optimal approach it is important to establish a staging area and this is where other units are going to converge train responders and the proper protective equipment are the only people to handle the weapons of mass destruction event okay so keep in mind that there may be more than one event or one device next we need to establish command so as the first provider on scene the emt may need to establish command until additional personnel arrive you and other emts may function as a medical branch triage supervisor treatment supervisor transport supervisor logistics officers or command and general staff and if the incident command system is already in place immediately seek out the medical staging officer to receive your assignment okay so then we need to reassess scene safety we're constantly assessing and reassessing scene safety important component of situational awareness all right so if there's chemical agents such as liquid or gases that are dispersed to kill or injure the characteristics of of an agent can be described as liquid gas or solid material and it could be persistent or non-volatile asian and it can remain on the surface for long periods of time usually longer than 24 hours a non-persistent or volatile agents evaporate quickly when left on the surface in an optimal temperature range okay so persistent stays for longer than 24 hours sometimes and non-persistent agents can evaporate almost immediately so routes of exposure is how is how the agent most effectively enters the body okay so agents with a vapor hazard those are going to enter the body through the respiratory tract in agents with a contact hazard of course you get they give off very little vapor or no vapors and they enter the body through the skin okay next we're going to talk about vesicans so vesicans are blister agents the primary route of exposure of blister agents or vesicans is skin so that's a skin contact however if vesicans are left on the skin or clothing too long they produce vapors that can enter in through the respiratory tract this can cause burn-like blisters to form on the victim's skin and in the respiratory tract and the agents can consist of so we could have sulfur sulfur mustard leucite or phosgene gases the vesican usually can cause the most damage to damp or moist areas of the body such as armpits groin or respiratory tract signs of vesican's exposure on the skin include the following so you're going to have skin irritation burning and reddening immediate intense skin pain formation of large burst blisters or a gray discoloration of the skin swollen and closed or irritated eyes permanent eye injury including blindness and signs and symptoms of vapors if they're inhaled they could cause hoarseness and strider or severe cough or hematosis or severe dipsnia all right so let's go through these vesicans sulfur mustard is a brown yellow oily substance that is generally considered very persistent okay so it stays around a long time as the agent is absorbed into the skin it begins an irreversible process of damage to our cells so this mustard is considered a mutant gin and which means that it mutates it changes and causes the struc changes the structure of cells the patient will experience a progressive redlining of that area which will generally develop large blisters so mustard also attacks vulnerable cells within the bone marrow and depletes the body's ability to reproduce white cells so sulfur mustard vapors can be inhaled creating upper and lower airway compromise okay leucisite and phase gene gas produce blister wounds very similar to those caused by mustard they produce immediate intense pain and discomfort when contact is made the patient may have a gray discoloration at the contaminated site so vesicant treatment so how are we going to treat these um there are no antibodies for mustard or cx exposure so british anti-leucite um is an antidote for agent l ensure that the patient has been decon before you initiate any treatment if agency has been inhaled the patient may require prompt airway support so soon as decon is complete generally burn centers are the best equipped to handle wounds and in subsequent infections from these vesicans all right so pulmonary agents and these are choking agents and gases that can immediately calm or harm a person if when they're exposed to them so this includes chlorine and phosgene and they produce respiratory related symptoms such as dipsnia and tachypnea the role of exposure is through the respiratory tract which makes them an inhalant and a vapor hazard so place inside the lungs they damage the lung tissue and fluid leaks into the lungs pulmonary edema develops and this results in difficulty breathing because of the severely impaired gas exchange right so let's talk about chlorine chlorine was the first chemical agent ever used in warfare it has a distinct odor of bleach and creates a green haze so initially it produces upper airway irritation and a choking sensation the signs and symptoms are shortness of breath tightness in the chest hoarseness and strider and gasps gasping and coughing with serious exposure patients may experience pulmonary edema and complete airway obstruction or even death next we're going to talk about fosgene so phosgene has been produced in chemical warfare and is a product of the combustion such as might be produced in a fire okay so it's a very potent agent that has developed a delayed onset of symptoms usually hours the odor produced by the chemical is similar to that of freshly mown grass or hay all right so fosgene is smell it smells like freshly mown grass or hay okay the chlorine chlorine smells like what did we say chlorine smelt like chlorine smelt like um bleach and it's green haze okay so back to phosgene um the result is that much more of a the gas may enter the body unnoticed okay so initially a mild exposure may include the signs and symptoms of nausea chest tightness severe coughs dipnia on exertion and pulmonary edema may be severe that the patient continues to cough up white or pink tinged fluid okay and so a severe exposure produces large amounts of fluid in the lungs that may that's going to cause the patient to be eventually become hypovolemic and then of course hypotension tensive all right so pulmonary agent treatment that's what we're just been discussing is the pulmonary agent so we're going to remove the patient from that atmosphere and we need to do aggressive management of the abcs okay so do not allow the patient to be active we want them to rest and there are no antidotes to counteract pulmonary agents so primary goals are to perform abc's allow the patient to rest in a position of comfort with the head elevated and initiate proper transport if the patient's condition does not improve with basic airway support we need to consider requesting our advanced life support intercept and continuous positive airway pressure or cpap may benefit some patients others will require advanced airway management all right so now let's talk about nerve agents so nerve agents are among the most deadly chemicals developed and they're classified as weapons of mass destruction they're not readily available to the general public public they're extremely toxic and rapidly fatal with any route of exposure so weapons of mass destruction can cause cardiac arrest within seconds to minutes after exposure a class of chemical agents are organophosphates these are the nerve agents which are found in household bug sprays agricultural pesticides and some industrial chemicals at much higher or lower strengths than a weaponized form so organophosphates what they do is they block an essential enzyme in that nervous system and it causes the body's organs to become over stimulated and burn out and so that what they do so we're going to talk about some of the organophosphates okay so first we have or the g agents and they came from the early nerve agents the g series okay so we have sarin sarin is a gb and is highly volatile it's colorless and odorless okay and basically um the standard measurement that represents the amount that would kill 50 of the population exposed to this level it's about one drop okay so especially dangerous and enclosed environments when it comes into contact with the skin it's quickly absorbed and then evaporates so when it's on the clothing it has the effect of off-gassing right so that was sarin now we have salmon so s-o-m-a-n that's a g agent it's a g-d agent okay and it's twice as persistent as sarin and five times more lethal so som a n someone it has a fruity odor and generally has no color this agent is in contact and an inhalation hazard okay so the next agent we're going to talk about is tubbin so it's a ga agent t-a-b-u-m toubon and it's approximately half as lethal as sarin and 36 times more persistent okay so it stays around a very long time this is another one that has a fruity smell and an appearance similar to sarin it is a contact inhalation hazard next we have a v agent v x is what you'll see how you'll see it written and it's clear oily agent has no color and looks like baby oil it is more than 100 times more lethal than sarin and extremely persistent it is usually absorbed into the skin and the oily residue remains in extremely difficult to decontaminate so this is going to show you guys um the this table shows the slide of um which compares nerve agents and so you could see the names of those agents on the left side and then the comparison of the the different types of special features the onset volatility and the exposures okay all right so nerve agents are produce similar symptoms but have varying routes of entry so symptoms are described using the military mnemonic sludge m okay or you could use the medical mnemonic dumbbells and that's what we use okay all right and so um basically how you treat these is you're going to use a duo dot auto injector okay and so let's talk a little bit more about what the what these nerve agents do so they cause meiosis and it's most common symptom of a nerve agent exposure and can remain for days and weeks and so what happens is um scenes quickly in vapor exposure and may occur after an isolated skin exposure and so the patient may have some form of exposure to both sometimes so seizures can continue until the patient dies or until treatment is given with an antidote kit and that's that duodo auto injector okay so nerve agent treatments so you can greatly increase the number of chances of survivability by providing o2 and ventilative support so i want to talk about the duode auto injector and what that is it contains 2.1 milligrams of atropine and 600 milligrams of poloxidine chloride and that it's called two pam so 600 milligrams of 2 pam all right so now we're going to talk about metabolic agents and these are cyanides cyanides are metabolic agents okay hydrogen cyanide and cyanide chlorine affect the body's ability to use oxygen and so cyanide is a colorless gas with an odor similar to almonds okay so when you see almonds think of cyanide all right so effects of cyanide begin on the cellular level and are very rapidly seen in the organ and system levels they're commonly found in many industrial settings such as gold and silver mining photography and plastic processing and often present in fires associated with textile and plastic factories so in low doses these chemicals are associated with dizziness lightheadedness headache and vomiting okay all right so high doses will produce symptoms which include shortness of breath respiratory distress to kidney flesh skin and tachycardia alter mental status seizures coma apnea and cardiac arrest so cyanide how do we treat cyanide exposures okay so all the patient's clothes must be removed and this presents off-gassing in the ambulance so we want to decontaminate any patients who may have been exposed to liquid contamination prior to initiating treatment of course we have to support the abcs okay so now we're going to talk about biologic agents okay so biologic agents pose many difficult issues when used as a weapons of mass destruction biologic agents can be almost completely undetectable and most disease causing by these agents will be similar to that of a minor illness so biologic agents are grouped as viruses bacteria and neurotoxins and may be spread in various ways so dissemination is the means by which the terrorists will spread the agent okay so a disease vector is an animal that once infected spreads that disease to another animal how easily the disease can spread from one human to another human it's called communicability communicability in instance when communicability is high such as smallpox the person is considered contagious so incubation is the period of time between the person becoming exposed to the agent and the appearance of the first symptoms all right so the first one we're going to talk about is virus viruses it seems we're living this right now so germs that require a living host to multiply and survive and once in the body the virus invades healthy cells replicates itself and spreads throughout the host so it moves from host to host by direct methods such as respiratory droplets and through vectors and some viral agents do have vaccines however there are not often treatment for viral infections all right and so we're going to talk about smallpox so smallpox is highly contagious all forms of standard precaution must be used to prevent cross-contamination we're going to wear exam gloves hepa filters and eye protection and before the rash and blisters show the illness will start with high fever body aches and headaches and it's easily easy quick way to differentiate between small pox rash and other skin disorders is to observe the size shape and location of these lesions okay so in smallpox all the lesions are going to be identical in their den in their development okay they're small blisters and they begin on the face and extremities and eventually grow towards the chest abdomen that's smallpox the disease is in its most contagious phase when the blisters begin to form here's a table and on this table it shows a list of characteristics of smallpox okay then we have vhf so viral hemorrhagic fevers and this group of diseases causes it's caused by viruses and it includes ebola risk valley murberg and yellow fever viruses among others so it causes the blood in the body to seep out of the tissues and blood vessels eventually the patients will have flu-like symptoms progress to more serious symptoms such as internal and external hemorrhaging all standard precautions must be taken when treating this illness okay so on this table it shows a slide of characteristics of viral hemorrhagic fevers vhf and then next we're going to have the bacteria so bacteria they do not require hosts to multiply and live they bacteria are complex and larger and can grow up to 100 times larger than a virus so bacteria infections can be fought with antibiotics but most bacterial infections will generally become flu-like symptoms okay so inhalation or cutaneous anthrax okay so this is caused by deadly bacteria that lays dormant in a spur spore and when exposed to at the optimal temperature and moisture the germ will be released from the spore so the routes of our inhalation cutaneous and gi and the inhalation form or pulmonary anthrax is the deadliest and often persist as a severe cold and then pulmonary and flax is associated with about 90 death rate if it's not treated antibiotics can be used to treat anthrax successfully and a vaccine is available in this table on the slide is going to show you some characteristics of the anthrax right now we have the plague and you have a bubonic plague or mnemonic plague okay so the plagues natural vectors are infected uh usually rodents and fleas and the bubonic plague infects the lymphatic system okay so the patient's lymph nodes become infected and they grow and the glands of the nodes become large and round forming um big huge um large round lymph nodes and if you're untreated the infection may spread through the body leading to sepsis and then death so pneumonic plague though it's a lung infection and so it's also um plague also known as plague pneumonia that results from inhalation of that plague bacteria this form of disease is contagious and has much higher death rate than the bubonic form all right and so this figure slide shows the plague swollen lymph nodes and so that bubo at the lymph under the underarm and then a plague bugo at the lymph node in the neck the table on this slide shows characteristics of the plague okay so botulinum toxin this is the most potent neurotoxin and it's a botulum in which it's produced by bacteria so when introduced into the body this neurotoxin affects the nervous system's ability to function and so the voluntary muscle diminishes as the toxin spreads eventually the toxin causes muscle paralysis leading to respiratory rest okay so this table on the slide lists the characteristics of the botulinum toxin next we have of the neurotoxins is ricin so this is derived from mash that is left from the castor bean okay so it causes pulmonary edema respiratory and circulatory failure which leads to death it's quite stable and extremely toxic by many routes of exposure including inhalation signs and symptoms of rice and ingestion is fever chills headache muscle aches nausea vomiting diarrhea severe abdominal cramping dehydration gastrointestinal bleeding necrosis of the liver spleen kidneys and gi tract so signs and symptoms of rice and inhalation are fever chills nausea local irritation of the eyes nose and throat sweating headache muscle aches productive cough chest pain dips near pulmonary edema severe lung infections cyanosis seizures and respiratory failure okay yikes and this table on the slide lists the characteristics of ricin okay so other emt roles so you could be doing syndromic surveillance and so what this is is you might be called to monitor the patients presenting in an emergency department and alternate care facilities you may need to record ems call volume so it may also be for monitoring the use of over-the-counter medicines okay so patients with signs and symptoms that resemble influenza are particularly important quality measurement and dispatch operations need to be aware of the an unusual number of calls from patient and unexplainable symptom clusters coming from the particular region or community so points of disruption disruption this is this strategic national stockpile and they have it's a pod of distribution sorry so an existing facilities that are established in a time of need for mass disrupt distribution of antibiotics antidotes vaccines and other medical and supplies so medications and supplies so these medications can be released in deliveries called pushbacks by the center for disease control and prevention strategic natural stockpile so these push packages have a delivery time of about 12 hours wherever or anywhere in the country so emts amts and paramedics may be called upon to assist in delivery of medications to the public your role may include triage treatment and transport all right so what is radiation does anybody know and it's a ionizing radiation is imminent from rays or particles it's in in the form of rays okay so this energy can be found in radioactive material such as rocks or and or metals so radioactive material is any material that emits radiation this material is unstable and it attempts to stabilize itself by changing its structure in a natural process called decay so the energy that is emitted from a strong radiologic source is alpha beta gamma or neutron radiation alpha is the least harmful penetrating type and cannot move through most objects beta radiation is slightly more penetrating than alpha and requires a layer of clothing to stop it then you have gamma rays and they're far faster and stronger than alpha and beta rays these rays can easily penetrate through the human body and require lead or several inches of concrete to prevent penetration and then you have those neutron particles and those are among the most powerful forms of radiation so neutrons easily penetrate through lead and require several feet of concrete to stop them this figure on the slide shows what can deflect the four types of radiation alpha beta gamma neutron okay so sources of this radiological material include and they're generally used for purposes that benefit humankind such as medicine or killing germs or construction and once rheologic material has been used for that purpose the material remaining in the radiologic is waste and so these materials can be found in hospitals healthcare facilities colleges and or universities north power plants or nuclear power plants and chemical and industrial sites all right so rdds these are radiologic dispersal devices and so any container that is designed to disperse radioactive material all right so a dirty bomb carries the potential to injure victims with not only the radioactive material but also the explosion material used to deliver it okay the explosive material and so the destruction capability of a dirty bomb is limited to the explosives that are attached to it so the jury bomb is an ineffective wmd okay all right then you have nuclear energy so artificially made by altering or splitting radioactive atoms they the result is an immense amount of energy that usually takes a form of heat and so nuclear material is used when uh in medicines weapons naval vessels and power plants and nuclear material gives off all forms of radiation including neutrons all right so nuclear weapons keep only the they're kept only in secure facilities around the world the likelihood of a nuclear attack is extremely remote and since the cause of the formal the collapse of the formal soviet union the whereabouts of many small nuclear devices are still unknown though okay so these small suitcase size nuclear weapons are called special atomic demolition mutant muntunes or s-a-d-m sands these are believed to be missing all right so symptomology so patients exposed to known or suspected source of excessive radiation are considered victims of acute radiation toxicity the effect of radiation exposure will vary depending on the amount of radiation and to that person and the rod of entry so radiation can be introduced to the body by all routes of entry as well as through the through the body so irradiation right and so this table on the slide lists the common signs of acute radiation toxicity so how are we going to manage it so being exposed to a radiation source does not make a patient contaminated or radioactive however when the patients have a radioactive radioactive source on their body they are contaminated and must be initially cared for by hazmat responder so once a person is deconned you may be able to treat them and you're going to start with the abcs and treat the patient for any burns or trauma we have to wear appropriate pre-pe and we're going to secure plastic bags with body fluids obtained from the patient place all body fluids and containers and properly dispose of them with other potentially radioactive waste okay protective measures we're gonna um there are no good suits or protective gear designed to completely shield from radiation but the best way to protect yourself from the effects of the radiation is time distance and shielding all right so explosive devices we're going to talk about next and these are incendiary devices and they are weapons used to start fires terrorists use the flamethrowers chemicals multi cocktails and other explosive devices so it's important for you to be able to identify the objects you've become or you and any object you believe is a potential device notify the proper authorities and safely evacuate the area so remember that their possibility of secondary devices when you are responding to the scene all right so mechanisms of injury the type of injury of wounds primarily depend on the patient's distance from the epicenter of the explosion so blast explosions are usually current a number of ways so we have a primary blast and a secondary blast so the primary blast is due solely to the direct effects of the pressure on the body the injury is seen almost exclusive in the hollow organs and then the secondary you have in that persists of non-patented traded injury and it results from being struck by flying debris so objects are propelled by force and blood the blast and strike the victim causing injury and then you have tertiary so we talked about primary secondary blasts now tertiary blast okay and this results from the whole body displacement and the impact with the environment and so other indirect effects include crush injury or because of the collapse of a structure and then we have the quad quadranery blast so the number four blast injury and uh any other injury caused by the blast including toxic inhalation of that gas burns medical emergency sustained while fleeing the scene of an explosion so even metal a mental health disorder that develops immediately after or days to weeks after that definition of the explosive device so what happens with the physics of that explosion all right so when the substance is detonated a solid or liquid uh chemical is converted into large volumes of gas under pressure which results in explosive energy release this generates a pressure wave in the shape of a basically a spherical blast wave and it extends in all directions from the point of explosion so flying debris and high winds commonly cause conventional blunt and penetrating traumas so tissues are at risk when we have these explosive devices and so the hollow organs such as the middle ear or lungs or gi tract are susceptible to pressure changes the junction between these tissues of very different densities and exposed tissues such as head and neck are prone to injury as well so the ear is an organ that is sensory sensitive to blast injuries and the patient may report tingling or pain in the ears or some type of hearing loss primary blast injuries occur as contusions and hemorrhages and solid organs are relatively protected from the shock wave but may be injured by a secondary missile okay and hollow organs may be injured by similarity mechanisms as lung tissue the tqi to large hematomas are the most visible sign and according to the cdc blast lung is the most common cause of death okay so neurologic injuries and head trauma are also common causes of fatal fatality from the blast injury all right so extremity injuries include traumatic amputations are also common and patients may die of massive hemorrhage without the rapid application of a tourniquet okay so uh that concludes the lecture portion now we're going to do a little bit of review questions okay so let's see how much we've learned what type of terrorist group would most likely bomb an abortion clinic all right so what did we learn we know that this is a domestic terrorist attack and we're going to say it's a single incident terrorist attack okay the term weaponization is defined as right so is it a method is it a period of time is it a cultivation or synthesization of mutant mutation of an agent let's see or the definition of an explosive item what do we think so we're going to say weaponization is a creation of a weapon from a biologic event or agent generally found in the nature that causes disease all right so that was c and that's the correct answer okay the department of homeland security posts a daily advisory system to help the public aware of the current terrorist level so what does orange indicate we didn't really talk much about the colors but let's see what does orange indicate what do you guys think i bet it is it's b so b the orange color indicates a high risk of terrace the red is the highest okay all right so we're dispatch a balm along with 15 other ambulances on arrival where should we stage the ambulance and we know we want to be upwind and uphill right so we always want to be up when oh no downwind we want the hazmat we want to make sure that we're upwind from the and uphill yep up went up hill all right so that is the answer b up went uphill all right a terrorist would most likely use a secondary explosive device why did they use this why would they use this i bet it's to injure the rescuers and to gain that maximum public attention and we were right yep secondary is to get the rescue workers and to get caught on camera all right so when assessing a patient who was exposed to a vesican agent uh oh we should expect to encounter i bet some blistering blistering yep primary exposure route of vesicans also called blister agents is the skin okay all right number seven what does sulfur mustard do to those cells does it make it retain water does it cause it to release does it cause it to mutate or does it cause all the fluids and it causes severe high dehydration what do you guys think and it's c so it also it causes cells to mutate pinpoint pupils vomiting bradycardia and excessive salivation are signs of what do you guys think they're signs of i betcha it is uh the gd nerve agent so this is going to cause death within seconds and it's you could use the pneumonic dumbbells all right you respond to plastic factory where numerous people present with shortness of breath flesh skin and altered mental status one of the patient tells you he smelled almonds uh oh what do we know about almonds right away cyanide right so cyanide is that almond smell very good okay factors that have the greatest impact on the severity of radiation exposure include what do you think i think it's time distance and shielding you think yep the best way to protect yourself is time distance and shielding so we want to reduce the time increase the distance and the shielding okay all right so this concludes chapter 41 lecture if you enjoyed this lecture go ahead and subscribe to the channel and like it and we're going to uh and stand by for multiple more lectures i will be producing the 41 chapters of this book okay all right and thank you