Hostname: page-component-78c5997874-j824f Total loading time: 0 Render date: 2024-11-19T00:41:45.679Z Has data issue: false hasContentIssue false
  • English
  • Français

Symptom-Based, Algorithmic Approach for Handling the Initial Encounter with Victims of a Potential Terrorist Attack

Published online by Cambridge University Press:  28 June 2012

Italo Subbarao ,
Christopher Johnson ,
William F. Bond ,
Howard A. Schwid ,
Thomas E. Wasser ,
Greg A. Deye  and
Keith K. Burkhart
Italo Subbarao*
Affiliation:
Department of Emergency Medicine, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania, USA
Christopher Johnson
Affiliation:
Department of Emergency Medicine, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania, USA
William F. Bond
Affiliation:
Department of Emergency Medicine, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania, USA
Howard A. Schwid
Affiliation:
Department of Anesthesiology, University of Washington, Seattle, Washington, USA
Thomas E. Wasser
Affiliation:
Department of Health Studies, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania, USA
Greg A. Deye
Affiliation:
Division of Infectious Disease, Department of Internal Medicine, Landstuh Regional Medical Center, Germany
Keith K. Burkhart
Affiliation:
Agency for Toxic Substances and Disease Registry, Harrisburg, Pennsylvania, USA
*
Johns Hopkins Center for Critical Event Preparedness and Response201 North Charles StreetSuite 1400Baltimore, MD 21201USA E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives:

This study intended to create symptom-based triage algorithms for the initial encounter with terror-attack victims. The goals of the triage algorithms include: (1) early recognition; (2) avoiding contamination; (3) early use of antidotes; (4) appropriate handling of unstable, contaminated victims; and (5) provisions of force protection. The algorithms also address industrial accidents and emerging infections, which have similar clinical presentations and risks for contamination as weapons of mass destruction (WMD).

Methods:

The algorithms were developed using references from military and civilian sources. They were tested and adjusted using a series of theoretical patients from a CD-ROM chemical, biological, radiological/nuclear, and explosive victim simulator. Then, the algorithms were placed into a card format and sent to experts in relevant fields for academic review.

Results:

Six inter-connected algorithms were created, described, and presented in figure form. The “attack” algorithm, for example, begins by differentiating between overt and covert attack victims (A covert attack is defined by epidemiological criteria adapted from the Centers for Disease Control and Prevention (CDC) recommendations). The attack algorithm then categorizes patients either as stable or unstable. Unstable patients flow to the “Dirty Resuscitation” algorithm, whereas, stable patients flow to the “Chemical Agent” and “Biological Agent” algorithms. The two remaining algorithms include the “Suicide Bomb/Blast/Explosion” and the “Radiation Dispersal Device” algorithms, which are inter-connected through the overt pathway in the “Attack” algorithm.

Conclusion:

A civilian, symptom-based, algorithmic approach to the initial encounter with victims of terrorist attacks, industrial accidents, or emerging infections was created. Future studies will address the usability of the algorithms with theoretical cases and utility in prospective, announced and unannounced, field drills. Additionally, future studies will assess the effectiveness of teaching modalities used to reinforce the algorithmic approach.

Keywords

algorithmbiological agentschemical agentscontaminationdirty radiationdispersal devicesresuscitationterrorist attackvictimsweapons of mass destruction (WMD)
Type
Theoretical Discussion
Information
Prehospital and Disaster Medicine , Volume 20 , Issue 5 , October 2005 , pp. 301 - 308
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2005

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Dhara, VR, Dhara, R: The Union Carbide Disaster in Bhopal: A review of health effects. Arch Environ Health 2002;57:391–404.Google Scholar
2.Dhara, VR, Gassert, TH: The Bhopal Syndrome: Persistent questions about acute toxicity and management of gas victims. Int J Occup Environ Health 2002;8:380–386.Google Scholar
3.Okumura, T, Suzuki, K, Fukuda, A et al. : The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med 1998;5:613–617.CrossRefGoogle ScholarPubMed
4. Centers for Disease Control and Prevention: Cluster of severe acute respiratory syndrome cases among protected health-care workers—Toronto, Canada: April 2003. MMWR 2003;52:433–436.Google Scholar
5.Morita, H, Yanagisawa, N, Nakajima, T: Sarin posioning in Matsumoto, Japan. Lancet 1995;346:290–292.Google Scholar
6.Okumura, T, Suzuki, K, Fukada, A et al. : The Tokyo subway sarin attack: Disaster management, Part 2: Healthcare facility response. Acad Emerg Med 1998;5:618–624.Google Scholar
7.Kulling, PE, Lorin, H: KAMEDO: Report 69: Ebola virus epidemic in Zaire, 1995. Prehosp Disast Med 1999;14:18–26.Google Scholar
8.Nozaki, H, Hori, S, Shinozama, Y et al. : Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med 1995;21:1032–1035.CrossRefGoogle ScholarPubMed
9.Greenberg, MI, Hendrickson, RG: Report of the National Bioterrorism Civilian ResponseCenter/Drexel University Emergency Department Terrorism Preparedness Consensus Panel. Acad Emerg Med 2003;10:783–7881.Google ScholarPubMed
10. Terrorism Response Task Force of the American College of Emergency Physicians: Positioning America's Emergency Health Care System to Respond To Acts of Terrorism. ACEP: Dallas, Texas. 2002.Google Scholar
11. Centers for Disease Control and Prevention: Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR 2000;49(RR-4):1–14.Google Scholar
12.Macintyre, AG, Christopher, GW, Eitzen, E et al. : Weapons of mass destruction events with contaminated casualties: Effective planning for healthcare facilities. JAMA 2000;4:261–269.Google Scholar
13.Waeckerle, JF: Disaster planning and response. N Engl J Med 1991;324:815–821.Google Scholar
14. Centers for Disease Control and Prevention: Recognition of illness associated with the intentional release of a biologic agent. MMWR 2001;50:893–897.Google Scholar
15. Centers for Disease Control and Prevention: Outbreak of severe acute respiratory syndrome—Worldwide, 2003. MMWR 2003;52:226–228.Google Scholar
16. Centers for Disease Control and Prevention: Update: Multistate outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. MMWR 2003;52:561–565.Google Scholar
17.Arnon, S, Schecter, R, Ingelsby, TV et al. : Botulinum toxin as biological weapon. Medical and public health management. JAMA 2001;285:1059–1070.Google Scholar
18.Henderson, DA, Inglesby, TV, Bartlett, JG et al. : Smallpox as a biological weapon: Medical and public health management. JAMA 1999;281:2127–2137.Google Scholar
19.Inglesby, TV, O'Toole, T, Henderson, DA et al. : Anthrax as a biological weapon, 2002 updated recommendations and management. JAMA 2002;287:2236–2252.Google Scholar
20.Dennis, DT, Inglesby, TV, Henderson, DA et al. : Tularemia asa biological weapon: Medical and public health management. JAMA 2001;285:2763–2773.Google Scholar
21.Inglesby, TV, Dennis, DT, Henderson, DA et al. : Plague as a biological weapon: Medical and public health management. JAMA 2000;283:2281–2290.Google Scholar
22.Sidell, F, Takafuji, E, Franz, D, (eds): Textbook of Military Medicine: Part I, Medical Aspects of Chemical and Biological Warfare. Washington DC: Office of theSurgeon General, Borden Institute, Walter Reed Army Medical Center; 1997.Google Scholar
23.Newmark, J: The birth of nerve agent warfare: Lessons from Syed Abbas Foroutan. Neurology 2004;62:1590–1596.Google Scholar
24.Newmark, J: Acute chemical emergencies. (Comment) N Engl J Med 2004;350:2102–2104.Google Scholar
25. Centers for Disease Control and Prevention: Recognition of illness associated with exposure to chemical agents—United States, 2003. MMWR 2003;52:938–940.Google Scholar
26. Armed Forces Radiobiology Research Institute, US Department of Defense: Medical Effects of Ionizing Radiation, Course Handbook. Washington DC: Walter Reed Army Medical Center 2001.Google Scholar
27.Hogan, DE, Waeckerle, JF, Dire, DJ, Lillibridge, SR: Emergency department impact of the Oklahoma City terrorist bombing. Ann Emerg Med 1999;34:160–167.CrossRefGoogle ScholarPubMed
28.Mallonee, S, Shariat, S, Stennies, G et al. : Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA 1996;276:382–387.Google Scholar
29.Frykberg, ER, Tepas, JJ: Terrorist bombings: Lessons learned from Belfast to Beirut. Ann Surg 1988;208:569–576.CrossRefGoogle ScholarPubMed
30.Almogy, G, Belzberg, H, Mintz, Y et al. : Suicide bombing attacks: Update and modifications to the protocol. Ann Surg 2004;239:295–303.Google Scholar
31.Rignault, DP, Deligny, MC: The 1986 terrorist bombing experience in Paris. Ann Surg 1989;209:368–373.CrossRefGoogle ScholarPubMed
32.Biancolini, CA, Del Bosco, CG, Jorge, MA: Argentine Jewish community institution bomb explosion. J Trauma 1999;47:728–732.Google Scholar
33. Departments of the Army, the Navy, and the Air Force, and Commandant, Marine Corps: Field Manual: Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. Army Ref No. FM8-285. Released 17 July 2000.Google Scholar
34. [US] Occupational Safety and Health Administration: Hazardous Waste Operations Emergency Response. Washington, DC: Occupational Safety and Health Administration 29 CFR 1910.120. 01 July 2002.Google Scholar
35.Henretig, FM, Cieslak, TJ, Kortepeter, MG, Fleisher, GR: Medical management of the suspected victim of bioterrorism: An algorithmic approach to the undifferentiated patient. Emerg Med Clin North Am 2002;20:351–364.Google Scholar
36.Hick, JL, Hanfling, D, Burstein, JL et al. : Protective equipment for health care facility decontamination personnel: Regulations, risks, and recommendations. Ann Emerg Med 2003;42:370–380.Google Scholar
37.Cox, RD: Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med 1994;23:761–770.Google Scholar
38.Burgess, JL, Kirk, MA, Borron, SW, Cisek, J: Emergency departmenthazardous materials protocol for contaminated patients. Ann Emerg Med 1999;34:205–212.CrossRefGoogle ScholarPubMed
39.Koenig, KL: Strip and Shower: The duck and cover for the 21st Century. Ann EmergMed 2003;42(3):391–394.Google Scholar
40.Torok, TJ, Tauxe, RV, Wise, RP et al. : A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. JAMA 1997;278:389–395.CrossRefGoogle ScholarPubMed