The prospect of a mass casualty incident from a terrorist release of biologic or chemical agents is more likely now than ever before Although the impact of such an event is almost unimaginable, at the same time, efforts must be made to prepare for this possibility Such preparedness requires highly coordinated responses involving local and regional EMS systems, HAZMAT teams, police and fire departments, hospital EDs, local and federal public health agencies, and civilian and military medical specialists In particular, EDs must consider important issues, including (i) the early recognition, triage, stabilization, decontamination, treatment, and disposition of multiple casualties of such an attack; (ii) protection of healthcare workers and existing patients; and (iii) the integrity of the ED itself to provide ongoing care to later-arriving casualties and to continue to meet normal patient demands Fortunately, our pediatric emergency care providers, academic medical centers, regional health departments, and several federal agencies, including the U.S Departments of Health and Human Services, Homeland Security, and Defense, are actively engaged in confronting these vital public health and national security challenges Suggested Readings and Key References General American Academy of Pediatrics Chemical and biological terrorism and its impact on children: a subject review Pediatrics 2000;105:662–670 Henretig F Biological and chemical terrorism defense: a view from the “front lines” of public health Am J Public Health 2001;91:718–720 Henretig FM, Cieslak TJ, Eitzen EM Jr Biological and chemical terrorism J Pediatr 2002;141:311–326 Henretig FM, McKee MR Preparedness for acts of nuclear, biological and chemical terrorism In: Gausche Hill M, Fuchs S, Yamamoto L, eds APLS: The Pediatric Emergency Medicine Resource Sudbury, MA: Jones and Bartlett, American Academy of Pediatrics and American College of Emergency Physicians; 2004:568–591 Macintyre AG, Christopher GW, Eitzen E Jr, et al Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities JAMA 2002;83:242–249 Biologic Terrorism Breman JG, Henderson DA Diagnosis and treatment of smallpox N Engl J Med 2002;346:1300–1308