1. Division of Medical Countermeasure Strategy and Requirements
Mass Casualty Emergency Medical Response to a Nuclear Detonation: Utilization of Oxygen Transporters
Chad Hrdina, MS, EMT, GC-WMD
Chief, Medical Countermeasure Utilization and Response Integration
Given at Oxygen Carrier State of the Science Meeting
Fort Detrick, MD
6 February 2017

2. Bottom line up front
Following a nuclear detonation there will be hundreds of thousands of casualties that could benefit from intervention with oxygen transporters. With efficient response to a mass casualty incident, and early application of hemostats, many lives can be saved with oxygen transporters later in the care paradigm.

3. Nuclear detonation response considerations
Nuclear detonation will result in
Infrastructure damage (response will require flexibility and adaptability)
Complex spectrum of injuries (treatment will require polypharmacy approaches)
Radiation exposure
Mechanical trauma: blunt force, fractures, lacerations, penetrations
Thermal burns
Combined injuries of acute radiation exposure,
Spectrum of injuries changes with different scenarios
Resource limitations
Medical management will require complex coordination
Spectrum: hence the need for multiple models. drug development on the other hand, should be prioritized to address symptoms most common to all scenarios to those least common

4. Potential casualties resulting from a nuclear detonation in a major city
Distribution of casualties from nuclear detonation modeling*
Injury type
Category
95%ile
air / ground scenarios
Pediatric population
estimate (23.3 %)†
Mechanical trauma (ISS1)
Mild (1-9)
80 000
19 000
Moderate (10-14)
29 000
Severe (≥ 15)
34 000
Thermal burn (% TBSA2)
Mild
Moderate
1 000 – 3 000
700
Severe
Ionizing radiation (cGy3)
Mild (75-150)
72 000
17 000
Moderate ( )
41 000
10 000
Severe ( )
12 000
3 000
Expectant (>830)
47 000
11 000
Combined Injury
Radiation: > 150 cGy; trauma/burn: mild-sev
45 000
1 injury severity score
2 % total body surface area, partial- and full-thickness burns
3 centigray
*Adapted from Knebel, et al., DMPHP (S1), March 2011: †

5. Nuclear detonation = scarce resources situation
Resource adequacy will vary greatly across the response areas by time and location (local and region, possibly nationally)
Response resources will be overwhelmed by casualty numbers and needs and concerned citizens requesting assistance
Limited access to interventions, (e.g., IV, transfusions, MCMs, conventional care)
To achieve fairness in resource allocation, a common triage approach is important
Possible change from "conventional" to "contingency" or "crisis" standards of care (treating those "most likely to survive" first approach)
Clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves. 
Bottom line: MCMs that provide benefit in lieu of extensive medical interventions (e.g., transfusion therapy) provide greatest effectiveness in response

6. CONOPS for response Radiation TRiage, TRansport, TReatment
RTR Sites (Field evacuation
RTR1 – combined injuries (trauma, burn, radiation)
RTR2 – radiation exposure
RTR3 – limited injuries
AC – assembly centers (screening, initial intervention)
MC – medical centers (triage, screening, intervention)
1Hrdina, et al. Prehospital Disaster Medicine, 2009 May-Jun; 24(3);
2Planning Guidance for Response to a Nuclear Detonation / 2nd Edition / June 2010

7. CONOPS for response: activities
Field stabilization
(initial triage)
ASPR/PHEMCE objective is to develop a flexible, adaptable, coordinated armamentarium – we must understand the limitations and capabilities of each MCM to help coordinate a cohesive response.
Screening/assessment
Stabilization / resuscitation
some initial definitive care
Definitive
care

8. Response: MCM considerations
Response timeline (transition of care)
Stabilization and Resuscitation
field care / ER and early intervention
Definitive Care
inpatient/outpatient therapy
Activities
Triage and radiation assessment
Decontamination
Biodosimetry if possible
Stabilize mechanical trauma injuries
Initial burn management and covering
Initial hemodynamic stabilization
Pain control
Initiate anti-neutropenic therapy
Control nausea and vomiting
Activities
Provide specialized care
Surgical interventions
Burn debridement and management
Long-term inpatient/outpatient care
Pain control
Biodosimetry
Neutropenia therapy / bone marrow transplant
Transfusion therapy for hemodynamic maintenance and late hemostatic risks
Medical countermeasure considerations
Immediate to early access needed
Ease of administration, use, application
Topical, intramuscular, oral, etc.
High therapeutic index required
Poor diagnostics, concerned but healthy casualties
Robust storage, easy deployment
Room temperature, lightweight, pre-formulated, etc.
Delayed access ok timed as patients arrive
Expertise required to administer is ok
Surgical grafting, expert assessment, etc.
Low therapeutic index acceptable
Better diagnostics, expert assessment
Limiting storage requirements may be ok
Frozen, cryopreservation, etc.

9. Role of oxygen transporters
Hemostats are needed in the field
Must be
Easy to use
Effective
Universal
Oxygen transporters may be used in the emergency room and definitive care settings
Nonspecific products are easily administered without compatibility testing
Oxygen transporters/substrates are more beneficial if they behave somewhat like whole blood: maintain hemodynamic stability
They increase volume
Transport oxygen, carbon dioxide, wastes, etc
Hemostatic (if safe)

10. Bottom line Field stabilization will be about
splinting,
hemostasis, and
addressing other medical issues that present impedance of progression through care system
To be most effective, oxygen transporters must be easy to use.
Universal products are easier to use
Easily administered products are preferred
Will be administered in the emergency room and definitive care settings