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Category: EMS Operations

Topic: Multiple Casualty Incidents

Level: EMR

13 minute read

Signs and Symptoms of Biological, Nuclear, Incendiary, Chemical, and Explosives Substances (B-NICE)

When presented with a potential terrorist attack involving one of these agents, responders should look for similar signs and symptoms across many patients. Additionally, some patients may not present with a particular sign or symptom immediately depending on the agent involved.

It is impossible to know the severity of exposure or the severity of toxicity; and because you can't predict the patient's rate of deterioration, this is why prompt transport is mandated in these patients.

BIOLOGICAL AGENTS: naturally occurring bacteria or viruses that are weaponized to infect a large number of individuals.

Some of these agents include smallpox, hemorrhagic fevers, anthrax, plague, and botulinum. 

Many of these agents have an incubation period and may not present any signs or symptoms of a mass casualty incident for days or even weeks, depending on the agent involved.

The most common early signs and symptoms of biological agents are similar to those seen in severe bad cold or flu, such as:

  • Fever
  • Myalgias (muscle pains)
  • Headache
  • Nausea and vomiting
  • Abdominal pain
  • Diarrhea
  • Chest pain
  • Cough
  • Pharyngitis (sore throat)

SIGNS & SYMPTOMS of Specific Biological Agents: [SEE BELOW]

NUCLEAR AGENTS: those agents that produce ionizing radiation.

This is the result of an unstable atom that must release excess energy in the form of radiation. This radiation causes damage to human tissue at the cellular level. There are five types of radiation from nuclear agents:

  1. alpha,
  2. beta,
  3. X-ray,
  4. gamma, and
  5. neutron.

These types of radiation have different abilities to penetrate material. While the agent involved may be unknown at the time of the incident, the following list depicts the thickness of material needed to stop the radiation from penetration.

  • Alpha - Paper
  • Beta - Thin plates made of wood, aluminum, etc.
  • X-ray - Lead, iron, and thick metal plates.
  • Gamma - Lead, iron, and thick metal plates.
  • Neutron - Water, concrete, etc.

SIGNS & SYMPTOMS of Nuclear Agents:

  • Nausea and vomiting
  • Diarrhea
  • Spontaneous bleeding
  • Internal bleeding
  • Headache
  • Skin redness, blistering, and itching
  • Seizures
  • Sloughing of skin
  • Hair loss
  • Severe Fatigue
  • Mouth Ulcers

INCENDIARY and EXPLOSIVE AGENTS: comprised of materials used to create fire or explosions. Some examples of these agents may include, pipe bombs, gasoline, and gunpowder.

SIGNS & SYMPTOMS of Incendiary and Explosive Agents:

  • Blast injuries
  • Tympanic membrane rupture
  • Barotraumas
  • Pulmonary and solid organ damage
  • Alveolar hemorrhage
  • Crush injuries
  • Disorientation
  • Burns

CHEMICAL AGENTS:  comprised of chemicals weaponized to impose incapacitation or death of large numbers of people. Chemical agents are broken into five categories:

  1. Vesicants or blistering agents - Chemicals that cause burn-like blisters to the eyes, respiratory tract, and skin.
  2. Blood agents (cyanides) - Toxins that affect the body by changing blood functions such as oxygen carrying capability.
  3. Pulmonary agents - Chemicals that cause irritation or swelling of the respiratory tract.
  4. Incapacitating agents - Toxins or chemicals that cause patients to become confused or have altered mental status. Riot control agents are sometimes placed in this category.
  5. Nerve agents - Poisonous toxins that work by preventing the nervous system from working properly.

1. SIGNS & SYMPTOMS of Blister Agents (vesicants)

  • Skin irritation, burning, and reddening
  • Intense skin pain
  • Large blisters
  • Gray discoloration of skin
  • Eye irritation
  • Hoarseness and stridor
  • Severe cough
  • Hemoptysis
  • Dyspnea

2. SIGNS & SYMPTOMS of Blood Agents

  • Dyspnea
  • Gasping respiration
  • Tachypnea
  • Flushed skin color
  • Tachycardia
  • Altered mental status
  • Seizures
  • Coma
  • Apnea
  • Cardiac arrest

3. SIGNS & SYMPTOMS of Pulmonary Agents

  • Pulmonary edema
  • Choking
  • Shortness of breath
  • Dyspnea
  • Chest tightness
  • Hoarseness and stridor
  • Gasping and coughing
  • Nausea

4. SIGNS & SYMPTOMS of Incapacitating Agents

  • Restlessness, dizziness, or giddiness
  • Confused, erratic, or inappropriate behavior
  • Lack of coordination; stumbling or staggering
  • Dryness of mouth
  • Tachycardia
  • Blurred vision; pupil dilation
  • Stomach cramps; vomiting
  • Headache
  • Hallucinations
  • Dry, flushed skin
  • Fever
  • Urinary retention

5. SIGNS & SYMPTOMS of Nerve agents

Nerve agents can be identified by the acronym SLUDGEM.

  • Salivation - drooling
  • Lacrimation - tearing eyes
  • Urination - urinary incontinence
  • Defecation - diarrhea
  • Gastrointestinal - nausea
  • Emesis - vomiting
  • Miosis - pinpoint pupils


Sign and Symptoms of Specific Biologic Agents


  • High fever
  • Malaise
  • Body aches
  • Headaches
  • Blisters on skin
  • Bleeding of the skin and mucous membranes


  • Sudden onset fever
  • Weakness
  • Muscle pain
  • Headache
  • Sore throat
  • Vomiting
  • Internal and external bleeding


  • Flu-like symptoms
  • Fever
  • Respiratory distress
  • Tachycardia
  • Shock
  • Pulmonary edema
  • Respiratory Failure


  • Fever
  • Headache
  • Muscle tenderness
  • Pneumonia
  • Dyspnea
  • Extreme pain and enlargement in lymph nodes


  • Dry mouth
  • Intestinal obstruction
  • Urinary retention
  • Constipation
  • Nausea and vomiting
  • Abnormal pupil dilation
  • Blurred vision
  • Double vision
  • Drooping eyelid
  • Difficulty swallowing and speaking
  • Respiratory Failure


  • Indigestion
  • Fever
  • Chills
  • Headache
  • Muscle pain
  • Nausea and vomiting
  • Diarrhea
  • Abdominal cramping
  • Dehydration
  • Intestinal bleeding
  • Necrosis of gastrointestinal tract, liver, spleen, kidneys