Medical Response Part II

Medical Response Part II
IX. EMERGENCY EXPOSURE SITUATION IX.8.1 Medical Management of Radiation Injuries Medical Response Part II Lecture: Medical Management On-site and at Pre-hospital Levels Purpose: This lecture reviews the radiation emergencies, medical response on scene, handling of contaminated victims, and planning and preparedness of radiation emergency.

Emergency medical response off site
Treatment in reception area Priorities Life threatening injuries If internal contamination is suspected, quickly assess nature and degree Assess extent and magnitude of contamination, and decontaminate as necessary Once the patient arrives at the preplanned reception area, the trained staff determines the general condition of the patient and the severity of any associated injury. Therefore, the task of medical staff at the first off-site stage should be to identify the type, origin, severity and urgency of the cases. Treatment should be made in accordance with priorities based on patients’ condition. The basic principle is that treatment of serious or life threatening injuries must take priority over other actions. The medical team members must be capable of carrying out a preliminary assessment, conducting a careful interview and performing triage and any necessary treatment of the exposed persons. This team should include physicians, surgeons, nurses, and a physicist or technician competent in the monitoring and assessment of radiation exposure and radionuclide contamination.

First Medical Response Off-Site
Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency First Medical Response Off-Site Local hospital Located close to the scene of an emergency Provides first treatment to exposed and/or contaminated people The next stage of first medical response is implemented in the local hospital. Let’s consider the tasks. Detailed step-by-step action guide for local hospital in radiological emergency is given in the IAEA Manual for First Responders to a Radiological Emergency (Action Guide AG.9. applies to local hospitals). It is important to realize that radiological emergency (e.g., transportation accident or emergency with involvement of lost or stolen source) may happen anywhere. So, it could happen far from the designated specialised medical facility. The assumption is that victims of such radiological emergency may be hospitalised in the nearby local hospital. So, local hospital needs to have basic preparedness and procedures on how to deal with exposed/contaminated people. IAEA Training in Emergency Preparedness and Response

Tasks of Local Hospital
Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency Tasks of Local Hospital Co-ordinate activities with the IC Brief health care staff on negligible risk in treating contaminated patients if appropriate precautions are followed Have law enforcement provide a cordon area around hospital(s) to redirect worried-well to secondary location for monitoring/reassurance This slide represents tasks, deemed appropriate and practical, of the local hospital. All activities need to be coordinated with the IC. Following steps need to be taken by the leading person in the local hospital: 1. Brief health care staff that the risk from a contaminated person is negligible if they follow the general part of the response personnel protection guidelines (see Instruction 2 “Response personnel protection guidelines” starting on page 40 of the EPR-First Responders). 2. Have law enforcement provide a cordon area around the hospital(s) to redirect self-presenters (worried-well) to the secondary location for monitoring established by the resource coordinator. 3. For a security event, coordinate with law enforcement/security team and FEMT to: Provide protection/security for the hospital. Preserve evidence. Extension of actions listed above depends on the time available prior to arrival of victims. Note for lecturer: The information contained on slides can be found in AG.9. starting on page 30 of the EPR-First Responders. Ask the students to turn to AG.9. within the EPR-First Responders. IAEA Training in Emergency Preparedness and Response

Tasks of Local Hospital (cont’d)
Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency Tasks of Local Hospital (cont’d) Prepare ambulance reception area and treatment area for receiving contaminated casualties Set up a controlled area and control lines to prevent spread of contamination This slide continues reviewing tasks of the local hospital. 4. Prepare an ambulance reception area and treatment area for receiving casualties: Designate an ambulance reception area and treatment area. Set up an area large enough to handle the anticipated number of victims. Clear the area of visitors and patients. Re-route the traffic of other patients as appropriate, e.g. direct other medical emergencies to another hospital entrance. Make a path from the ambulance entrance to the hospital entrance using rolls of plastic, wrapping or butcher paper about 1 m wide. Cover the floor. Tape the covering securely to the floor. Remove or cover equipment that will not be needed. Rope off and mark the route to prevent unauthorized entry. Restrict access to the controlled treatment area. Prepare several large plastic-lined waste containers; plastic bags of varying sizes and labels for personal effects; warning labels and signs. Prepare the decontamination room of the treatment area if one has been previously designated. Otherwise, designate a decontamination room near the entrance. Establish a control line at the entrance to the decontamination room. Use wide strip tape to clearly mark the floor at the entrance to the room to differentiate the controlled (contaminated) from the non-controlled (uncontaminated) side. Check and prepare survey meters for use (if available). Prepare enough instruments and supplies (e.g. outer gloves, dressings) to change when they become contaminated. Extension of actions listed above depends on the time available prior to arrival of victims. Note for lecturer: The information contained on slides can be found in AG.9. starting on page 30 of the EPR-First Responders. Have the students turn to AG.9. within the EPR-First Responders. IAEA Training in Emergency Preparedness and Response

Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency Tasks of Local Hospital (cont’d) Prepare medical staff. Use universal precautions Assess and manage injuries (assumed to be contaminated) Medical stabilization first Radiological survey (if possible) Physical examinations and blood tests (complete blood count with differential) promptly. If internal contamination is suspected take nasal swabs This slide continues reviewing tasks of the local hospital. 5. Prepare the medical staff. Use universal precautions. Use two sets of gloves (outer gloves should be easily removable and replaced between patients). 6. Meet the victims at the established location. Request that ambulance personnel stay in their vehicle until surveyed and released by first responder monitor/radiological assessor. Survey of the ambulance may be delayed if a large number of victims must be transported. 7. Assess and treat injuries (assumed to be contaminated): First perform medical stabilization; if necessary for life saving, bypass the decontamination room. Remove the patient's clothing and wrap the patient in a sheet to limit contamination of the treatment area. Conduct a radiological survey (by the first responder monitor/radiological assessor - if he/she is available and if actions do not interfere with medical actions or adversely influence the patient's medical status); Perform physical examinations and blood tests (complete blood count with differential) promptly. IAEA Training in Emergency Preparedness and Response

Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency Tasks of Local Hospital (cont’d) If patient could not be checked for contamination, have patient take shower and change clothing as soon as possible If these actions will not adversely affect patient’s medical status If patient is contaminated proceed with general decontamination Following decontamination and surveys, transfer uncontaminated patient to clean area This slide continues reviewing tasks of the local hospital. 8. If the patient could not be checked by the first responder monitor/radiological assessor (if not available or because assessment may worsen the patient's health condition) patient(s) should shower and change into a hospital gown or other suitable clothing (if these actions will not adversely affect patient’s medical status). 9. If patient is contaminated, proceed with general decontamination: Remove clothing and place in a labelled plastic bag; Perform a radiological survey (by first responder monitor/radiological assessor); Decontaminate the skin with soap using warm water. Do not scrub too vigorously. Handle any unknown metal objects with a hemostat or forceps; Save samples and label them (smears of contamination, nasal smear, metallic objects such as buttons, buckles); If a wound is contaminated, survey, rinse, debride only for surgical reasons; If contamination persists, consider covering area or consider that contamination may be internal; Perform a final radiological survey (by the first responder monitor/radiological assessor). 10. Transfer the uncontaminated patient to the clean area. Use clean gloves to move the patient to a clean stretcher and exit the contaminated area. IAEA Training in Emergency Preparedness and Response

Module L-027 Lecture L-027: EPR-First Responders: First Medical Response to a Radiological Emergency Tasks of Local Hospital (cont’d) Control spread of contamination survey staff for possible contamination; remove contaminated clothing and shower before exiting contaminated area survey equipment before removing it from possibly contaminated area After discharging patient, clean up area in conjunction with radiation safety Hold ambulance until surveys before allowing them to return to regular service Assess needs and request additional resources This slide continues reviewing tasks of the local hospital. 11. Control the spread of contamination: Survey staff for possible contamination; remove contaminated clothing and shower before exiting contaminated area. Survey medical equipment for contamination before removing it from the contaminated area. 12. After discharging the patient, clean up the area in conjunction with radiation safety. 13. Presumptive or confirmed radiological waste should be segregated for retrospective analysis if considered necessary and in consultation with a member of the FEMT. 14. Assess needs and request additional resources if needed. Request a consultation from national experts or inform the national emergency operations centre (EOC) of the need for international assistance (if necessary). IAEA Training in Emergency Preparedness and Response

Receiving a Patient Meet patient at ambulance or other transport vehicle at emergency room entrance Instruct ambulance personnel to stay with vehicle until surveyed and released by radiation safety officer if victims are stabilized Collect information Before patients’ arrival : be prepared to receive either severely injured, heavily overexposed (vomiting) people, having combined injuries or contaminated with radioactive materials wear protective gear and personal protection as necessary - based on the information from the ambulance delivering the victims to your hospital alert your radiation safety officer (RSO), who should: - provide each member of the radiation emergency hospital team with self-reading dosimeters and also cumulative personal dosimeters (film badge or TLD) - check the functionality of the surface contamination meters and thyroid monitor (if appropriate). On the arrival of the patients: meet the radiation accident victim at the ambulance or other transporting vehicle at the emergency room entrance. instruct ambulance personnel to stay with the vehicle until they and their vehicle are surveyed and released by radiation safety officer. Photo credits: NIRS

“Medical treatment for serious conditions always take precedence
Treatment Priority “Medical treatment for serious conditions always take precedence over decontamination.” Contamination is never an immediate life-threatening condition Radiation does not usually cause acute life threatening damage. According to the result of a second trauma triage performed at the emergency department, life and limb threatening conditions must always have treatment priority over radiation injuries. Treatment of injured patients should take place according to standard guidelines. As a general criterion, the priority order may be considered as follows: First aid and resuscitation. Clinical stabilisation. Treatment of serious injuries. Management of external contamination. Treatment of internal contamination and minor injuries.

Triage at the Emergency Department
Medical assessment and triage at hospital First aid and resuscitation Medical stabilization Radiological assessment In radiation accident or nuclear detonation, many victims can suffer from burns and traumatic injuries in addition to radiation exposure. Hospital triage of combined radiation injury (CRI) patients based on conventional injuries. Treat related injuries first. Photo credits: NIRS

Management of Non-contaminated
Care for non-contaminated patients is like any other emergency case Victim of external exposure without contamination has no radiological hazard If exposure is known or suspected, order blood cell count in particular to determine absolute lymphocyte count and chromosome analysis. Record time blood sample taken Non-contaminated individuals can be cared for like any other emergency case. Following attention to medical needs, question the patient to determine the possibility of radiation exposure from an external source. Remember, the victim of exposure without contamination poses no radiological hazard to anyone. If exposure is known or suspected, a CBC (count of blood cells) should be ordered with particular attention to determining the absolute lymphocyte count. Be sure to record the time the blood sample is taken.

Management of Contaminated Patient
Ensure stabilization of patient Survey whether contaminated or not Ensure contaminated area Identify decontamination priority Wound Orifices (eyes, mouth, nose, ears) High level intact skin Low level intact skin Always give first priority to life support, control of haemorrhage and treatment of trauma. If possible, remove the patient’s clothing and place in labelled plastic bags. Assess the patient’s medical condition, stabilise and treat as necessary. Survey contamination and document the affected areas along with their levels of contamination. Take samples from affected areas (e.g. wounds, nose, mouth) for analysis and planning of definitive treatment. Every sample should be clearly labelled. If possible, identify the isotope/s involved with appropriate techniques. Document all the procedures and the results of monitoring on appropriate worksheets.

Acute Radiation Syndrome As a Function of The Dose
Add Module title Acute Radiation Syndrome As a Function of The Dose 6-8 Gy 4 Gy The Haematopietic Syndrome 12 Gy GASTROINTESTINAL Syndrome 30 Gy 1 Gy SUBCLINICAL NEUROVASCULAR Syndrome Three different radiation syndromes were associated with these three categories based on the latency to death: the haemopoietic syndrome after doses < 12 Gy, the gastrointestinal syndrome after doses of 12 to 30 Gy, and the neurovascular syndrome after even higher doses. 50 Gy INCREASING DOSE

Acute Radiation Syndrome As a Function of The Delay Post-irradiation
Add Module title Acute Radiation Syndrome As a Function of The Delay Post-irradiation Dose IRREVERSIBLE SINGLE ORGAN FAILURE Neurovascular Syndrome 40-50 Gy 12-30 Gy 1-10 Gy IRREVERSIBLE SINGLE ORGAN FAILURE Gastrointestinal Syndrome Haematopoietic Syndrome Increasisng the doses, the survival time gradually decreased from about 2 – 3 weeks to about 2 – 3 days. REVERSIBLE / IRREVERSIBLE SINGLE ORGAN FAILURE 2 -3 Days 7-15 Days 30 Days Survival time

Acute Radiation Syndrom: Clinical Course
Add Module title Acute Radiation Syndrom: Clinical Course Irradiation 0-48 hrs hours - 21 d hours - 30 d hours - > 60 d MANIFEST ILLNESS DEATH PRODROMAL LATENT RECOVERY? Anorexia Nausea Vomiting Diarrhoea Fever Lymphopenia Granulocytosis Prodromata absent or diminished Vascular damage Infection Bone marrow depression Leukopenia Thrombocytopenia GI symptoms clinical pattern ARS follows a similar clinical pattern that can be divided into three phases: an initial or prodromal phase occurring during the first few hours after exposure, a latent phase, which becomes shorter with increasing dose; and the manifest phase of clinical illness. The time of onset and degree of the transient incapacitation of the initial phase, the duration of the latent period, as well as the time of onset and severity of the clinical phase and ultimate outcome are all, to a variable extent, dependent upon total dose and individual radiation sensitivity. As a rule, the higher the dose, the time of onset of all three phases and their duration shortens while the prodrome and the manifest illness phase become more severe.

Radiopathology of The Skin Early (Acute) Effects
After a single dose, high dose-rate: ERYTHEMA SWELLING & OEDEMA DRY DESQUAMATION BLISTERING EPIDERMAL DENUDATION (Moist Desquamation) DUSKY MAUVE ERYTHEMA NECROSIS HAIR LOSS ONYCHOLYSIS Essentially depend on the epidermis layer and the microvasculature The latent period for the manifestation of a specific pathology is dependent on the characteristics of the target cells responsible for the development of that lesion and the dose of radiation delivered to those target cells. The intensity and duration of the lesions are also dose dependent. Since the depth dose distribution of a radiation source is dependent on the radiation quality, the development of a specific lesion, its intensity and its duration will also vary with radiation quality. The CS may appear as an isolated lesion or as a number of lesions occurring simultaneously or over different time scales. In dealing with the cutaneous tissues the concept of dose is meaningless unless it is associated with a reference depth dose distribution to indicate the level of injury to specific target cells. 18

Radiopathology of The Skin Early (Acute) Effects Versus Dose
After a single dose, high dose-rate: 4- 5 Gy: Simple and transitory hair loss 6-12 Gy: Erythema , then pigmentation 12-15 Gy: Dry epithelitis, with erythema and desquamation 15-25 Gy: Moist epithelitis ( nude dermis ) Above 25 Gy: Skin radionecrosis Clinical features of acute skin effects can be related to single radiation exposure as follows: 4- 5 Gy : Simple and transitory hair loss 6-12 Gy : Erythema , then pigmentation 12-15 Gy : Dry epithelitis, with erythema and desquamation 15-25 Gy : Moist epithelitis ( nude dermis ) Above 25 Gy : Skin radionecrosis. This correlation between skin dose and clinical features has been observed after single high dose rate exposures. The influence of the dose rate in CRS is not clearly documented and data concerning skin effects after protracted doses (dose delivered over a longer time period) or chronic exposures are very poor. 19

Dry Desquamation dose 12 to 15 Gy dry epithelitis, with desquamation
compensation of epidermis leakage: protection of the cutaneous barrier absence of serum exudation absence of skin crust formation epidermis thickening: rough, dry, pigmented aspect

Moist Desquamation Dose 15 to 25 Gy Epidermis leakage sufficient for:
- serum exudation - skin crust formation 3 to 4 weeks for epidermis leakage, blistering, apparition of dripping, pink skin area which dry and form skin crust Stripped area covered by fibrin

Radionecrosis Dose > 25 Gy
Endothelium loss, drop of capillary density, drop of blood perfusion Huge dermal inflammatory response Stripped area covered by fibrin Intense and long-lasting moist desquamation induced secondary dermal lesion

Identify radionuclide
Samples Easy to assess possibility of internal contamination Nasal swabs Contaminated wound swabs Contaminated wound dressing Identify radionuclide Take these samples from externally contaminated patient

Laboratory Studies Full Blood Count Cytogenetic analysis
Urine and stool samples for later evaluation of radionuclide content Other laboratory studies for diagnosis and medical treatment if necessary Diagnose and Dose assessment for whole body irradiation Diagnose and Dose assessment for internal contamination

Dose Assessment (1) Initial (Primary Assessment)
Prodromal symptoms; frequency, severity Blood cell count foccussing lymphocyte count Level of amylase (for exposure of head/neck) Whole body counting (for neutrons) Urine, stool Intermediate Assessment Chromosome analysis Count of blood cells (neutrophils, platelets) Full Assessment Above Reconstruction of accident (mathematical)

Dose Assessment (2) Symptoms Clinical findings Type of symptoms
Time of onset Severity and frequency Clinical findings Count of blood cells (CBC) with differential Repeat in 4-6 hours, then every 6 to 8 hours for 24 to 48 hours Chromosome analysis: use heparinised syringe

Clinical Dosimetry A crude estimate of absorbed dose can be obtained from clinical signs / symptoms Prodromal symptoms Onset: 2 h after exposure or later Onset: 1-2 h after exposure or later Onset: earlier than 1 h after exposure Onset: Earlier than 30 min after exposure MILD ARS (1-2 Gy) MODERATE ARS (2-4 Gy) SEVERE ARS (4-6 Gy) A crude estimate of absorbed dose can be obtained from the clinical presentation. Most symptom based clinical systems for dose estimates are well established. Uncertainties in dose estimates arise largely from the high variability between individuals and other factors. Generally, the sensitivity of these bioindicators is poor; and given the transient nature of the signs and symptoms in sublethal doses, their clinical usefulness is limited. Biological dosimetry is recommended in cases where medical treatment decisions are warranted. VERY SEVERE ARS (6-8 Gy) 27

Clinical Dosimetry Using Early Changes in Lymphocyte Counts
Curve(1)-3.1 Gy Curve(2)-4.4 Gy Curve(3)-5.6 Gy Curve(4)-7.1 Gy (1) (2) (3) The peripheral lymphocyte count is the earliest of exposure. However, the individual error in estimated made from this alone is often in the ± 1.5 Gy. The haemopoietic system is one of the most radiosensitive tissues in the body. Therefore, radiation-induced depletion of haematopoietic cells in the bone marrow and peripheral blood can be easily observed and this character used in dose approximation. Doses of Gy obtained as single exposures induce observable changes in blood cell frequencies.In many cases of overexposure an early approximation of dose is required for efficient medical intervention. This can be achieved by counting the decrease in frequency of lymphocytes, as these are very radiosensitive. Nadir values for lymphocytes are attaned much earlier than for other cell types, and the decrease may be recognized within hours of exposure, rendering lymphocyte counts as the most sensitive of haematological dosimeters. From: Andrews GA, Auxier JA, Lushbaugh CC. The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In: Personnel Dosimetry for Radiation Accidents. Vienna: International Atomic Energy Agency; 1965. (4) (Adapted from Andrews, 1980) 28

Cytogenetic Dosimetry
The analysis of chromosomal aberrations in peripheral blood lymphocytes is a biological dosimetry method that is widely used to assess radiation dose “Gold Standard” Chromosome aberration analysis is recognized as a valuable dose assessment method which fills a gap in dosimetric technology, particularly when there are difficulties in interpreting the data, in cases where there is reason to believe that persons not wearing dosimeters have been exposed to radiation, in cases of claims for compensation for radiation injuries that are not supported by unequivocal dosimetric evidence, or in cases of exposure over an individual’s working lifetime. Biological dosimetry, based on the analysis of solid stained dicentric chromosomes, has been used since the mid- 1960s. The intervening years have seen great improvements bringing the technique to a point where dicentric analysis has become a routine component of the radiological protection programmes of many countries. Experience of its application in many thousands of cases of actual or suspected overexposures has proved the value of the method and also helped to define its limitations. It should be emphasized that chromosomal aberrations are used as a dosemeter and provide one input, frequently a very important input, into the compendium of information that needs to be collected and considered when a radiation accident is investigated. In the investigation of radiation accidents it is important to estimate the dose to exposed persons for several reasons. In the case of high exposures (> 1Gy acute), information on doses assists in the planning of treatment and in alerting physicians of likely deterministic health consequences that could arise in the following weeks and months. For exposures below the level where treatment is needed, dosimetric information is important for the physician in counselling irradiated persons on the risk of their developing late stochastic diseases- i.e. cancer.

Calibration Curves Application of the dicentric yields for dose estimation requires knowledge of the radiation type during exposure. Dose estimation is then based on the specific dose-effect relationship of the particular radiation source. The statistical accuracy of the dose estimate and the lowest detection limit are dependent on the number of metaphases analysed. A dose of about 100mGy gamma rays can be detected by scoring 500 cells, but increasing the number of cells analysed decreases the statistical errors of estimate. It is possible to observe doses of less than 100 mGy X rays and mGy fission neutrons with this method. After very high doses of several Gy, lymphocyte growth may be slowed down and there may not be many metaphases to score. However, in such cases the highly elevated frequency of dicentrics enables a reliable estimate to be obtained from less than 100 cells. The reliability of the dose estimate is usually expressed as the 95% confidence interval (CI), which limits the true dose in 95% of cases with the same dicentric frequency. From EPR-MEDICAL/T 2002, IAEA, 2002, Module X 30

Use of Dicentric Assay The most accurate method for dose estimation
The threshold of sensitivity: about 0.1 Gy for whole body low LET radiation Especially useful in cases where a dosimeter was not used, like in a radiation accident to support physical dosimetry results in radiation protection and safety practice to determine partial body exposure (but limited), not detected by a locally placed dosimeter Dicentric analysis is generally performed to support the dosimetric data obtained from personal thermo luminescence dosimeters and other physical dosimetry. It is also possible that partial body exposure not detected by a locally placed dosimeter can be observed by this method. More importantly, the dicentric assay is the most accurate method for dose estimation in cases where a dosimeter has not been used, such as in radiation accidents. A reliable dose estimate is of major value when decisions are to be made on the medical treatment of individuals exposed to ionising radiation. 31

Applicability of Stable Chromosome Aberration Analysis for Biological Dosimetry
This method is based on scoring stable chromosome aberrations (translocations and insertions) detected with fluorescent in situ Requires complex procedures and technical equipment May be use decades after exposure The threshold of sensitivity is a few cGy but this method is not feasible for doses less than 0.2 Gy because of the expense and time needed for analyses The spontaneously occuring level of stable chromosome aberrations is not well established Dose assesment of victims in radiation accidents that are recognized within a month or two is most reliably achieved using routine dicentric analysis. If a considerable time has passed since the accident, dose estimation can be achieved using translocation analysis by means of FISH chromosome painting. From EPR-MEDICAL/T 2002, IAEA, 2002, Module X 32 32

Reception Centre (RC) The primary objectives of a reception centre
Triage of incoming victims Forwarding patients with life threatening injuries to the emergency department Providing minimum first aid Contamination survey Decontamination The best way to handle complex situations is through planning the response, taking into account a number of factors, like possible scenarios, training, infrastructure, etc. A response plan will never be “perfect”, but the more elaborated it is, the les the chance to have to improvise during a response. A completely improvised response will surely aggravate the different impacts of a disaster (medical, psychosocial, etc). Reception centres play a pivotal role in the response to mass casualty events.

Ideal Requirements for RC
Away from the disaster zone Easy access for emergency vehicles Controlled access and exit Space to house a large number of victims Protection from natural elements Lots of shower facilities (depending on countries) Working utilities (including phones) Easy to secured If a reception center is to be located next to the hospital’s emergency department, precautions must be taken for people not to avoid the reception centre. If it is located away from the hospital, emergency personnel and ambulance drivers must know to route individuals through the centre rather than the emergency department of the hospital (obviously injured patients would be excepted). Wherever the center is located, it must provide easy access for ambulances and parking space for other vehicles. Space must be sufficient to house a number of individuals according to the impact of the disaster. Showering capabilities are highly desirable for decontaminating individuals. The facility should lend itself to security and control of patient flow through it.

Establishment of RC Prior arrangements and consent for specific use, as handling of contaminated individuals No delay in occupying (keys in advance) Agreement on use of existing furnishings and areas Plan for control of radioactive waste Plan for security control Approval will be needed from the owners of the property or facility before using it as a reception centre. Such approval should be agreed upon before any disaster occurs. There should be prior agreement on who assumes responsibility for decontamination of the facility and for decontamination or replacement of any contaminated equipment that cannot be decontaminated. If there are areas of the facility that cannot be used (e.g., office areas), these should be known in advance. Emergency occupiers should have keys or otherwise, ready access to the facility. There should be plans in place for control of people through the facility and for the control of radiation, contamination, contamination removal and control of radioactive waste.

Staffing RC Triage physicians Triage nurses and assistants
Health Physicists or other qualified technicians Security staff Psychologists Social assistants Administrator/Coordinator Individuals with prior training in dealing with medical radiation emergencies will be needed to staff the reception center: Physicians with experience and training in triage and medical radiation emergency procedures Nurses with training and experience in handling medical radiation emergency cases Nurses’ assistants who can assist released patients to exit the facility or move to designated rooms. Health physicists, medical physicists, nuclear medicine technologists, nuclear medicine physicians, radioisotopes researchers or others with training in measuring and interpreting radiation exposure levels or finding and measuring contamination levels. Security staff who can assist with controlling the flow of people through the facility, assure security for the facility and individual’s valuables and maintain general control. Social assistants who can address the concerns of individuals and provide reassurance and answers to their questions. Psychologists to deal with psychological trauma caused by the disaster. Administrator/Coordinator (this could be the triage physician, the head nurse or a hospital administrator) who can make decisions, make things happen and, commit funds, if necessary.

Contamination Survey Survey with GM survey meters
A head-to-toe radiation survey technique photo credits: REAC/TS Probe held ~ 1 cm from surface Move at a rate of 2,5 to 5 cm per second Follow logical pattern Document readings in counts per minute (cpm) A head-to-toe radiation survey Surveys of individuals should be done in a systematic manner. The survey should begin at the top of the head and progress downward is a raster pattern to assure coverage of all areas of the body. Once the front is finished, the survey should be repeated on the back. During the survey, the radiation detector probe should be held roughly 1 cm from the surface, making sure not to touch the surface and contaminate the probe. The probe should be moved at a controlled rate (1 to 2 cm per second) to allow adequate time for the detector to respond to and contamination found. Any contamination found should be recorded on an anatomical survey form as seem in the next slide. A head-to-toe radiation survey technique is standard radiation protection work practice, followed by full documentation of survey findings. This is not a recommended survey methodology for the first few hours after a mass casualty incident, for any unnecessary delay can potentially increase the radiation dose to people waiting. If a large population must be surveyed, performing a screening survey of only the head, face, shoulders, and hands is acceptable, rather than performing a more detailed survey, because these are the most likely locations of contamination.

Radiation Portals *1 Radiation portals can be, if set up correctly, very useful for rapid assessment of populations walk-thought to be contaminated with gamma emitters, but they will not be of help in monitoring people who are contaminated with many alpha and beta emitters. These people will generally require urine/faeces bioassay. Photo *1: Photo *2: *2 Photo credits: REACTS /Oak Ridge Associated Universities(ORAU)

Whole Body Counter (1) Lung and whole body counters, when available, are also helpful for the monitoring and quantising the internal contamination levels. People with external contamination must be externally decontaminated before whole body counting. Photo credits: NIRS

Whole Body Counter (2) Lung and whole body counters, when available, are also helpful for the monitoring and quantising the internal contamination levels. People with external contamination must be externally decontaminated before whole body counting. Photo credits: NIRS

Lung Counter Lung and whole body counters, when available, are also helpful for the monitoring and quantising the internal contamination levels. People with external contamination must be externally decontaminated before whole body counting. Photos credit: NIRS

Radiation Does Not Cause
Immediate death Immediate symptoms (burns, wounds) Contaminations alone: Not immediate threat to victim Not threat to responders or others Do not delay surgery or other necessary medical procedures or exam…residual contamination can be controlled.

Handling Contaminated Patients
Treat life-threatening conditions first without regard to radiation or contamination Isolate patient and restrict access to the treatment/evaluation area Maintain contamination control Internal contamination is never immediate life-threatening

Rescue Remove injured person from the hazard area into the triage area as soon as possible Perform search and rescue for injured persons as soon as possible. Remove injured person from the hazard area into the triage area as soon as possible. If victim is life-threatening injured, victim on backboard is handed across outer cordon line to Medical Transport Team. If necessary, request additional medical help. Photo credits: NIRS

Life Saving Medical triage
Assess and treat life-threatening injuries immediately Life-threatening injured victim should transport into hospital immediately, even if contamination survey has not been done Assess and treat life-threatening injury immediately. Transport such patients into the hospital immediately, even if contamination survey has not been done. Photo credits: NIRS

Remove Contaminated Clothing at the Accident Scene
Removing a patient’s outer clothing will remove up to 90% or more of their external contamination. Following clothing removal, contamination efforts will usually be focused on the head and hands. Contaminated clothing should be immediately placed into plastic bags as it is removed from the patient to assure that it does not contaminate the work area and so it can be removed from the area as indicated. Also, any dampened wipes used to remove skin contamination from the patient should be bagged immediately for contamination control purposes. Use the following steps in removing the clothing: Cut the clothing from head to toe and down the sleeves Fold cut parts of the material back under itself as it is cut Roll up the material. By removing the clothing in such a way, it will be turned inside out. This will reduce the possibility of spreading contamination. Photos credit: NIRS

Contamination Survey It is possible to perform radiation survey during stabilization of victim if monitoring procedures do not interfere with medical actions at scene Initiate radiological survey of patients left on the scene. Require assistance from Radiological Assessor. Perform radiological triage on the basis of radiological survey. Use the results of radiological survey and triage for appropriate medical and other actions. It is possible to perform radiological survey during stabilization of victim if monitoring procedures do not interfere with medical actions. Photos credit: NIRS

Cover Contaminated Wounds
Cover wounds with sterile dressings. Prepare injured person for transport to the hospital. Cover contaminated wounds with sterile dressings before transport to hospital emergency room Photos credit: NIRS

Transport of Contaminated Victims (1)
Victims are to be transported by medical or paramedical personnel who have not entered the controlled area on scene Assume all victims are contaminated until proven otherwise Continue medical assessment and treatment during transport when necessary If possible, victims are to be transported by qualified medical or paramedical personnel who have not entered the controlled area on scene. Exposed victims require no special handling while contaminated victims are handled and transported using contamination control procedures. If there is any doubt, assume all victims are contaminated until proven otherwise. Continue medical assessment and treatment during transport when necessary.

Transport of Contaminated Victims (2)
Place the ambulance stretcher on the clean side of the outer cordoned line and pass the victims across the outer cordoned line to the prepared stretcher Cover victim by folding a sheet or blanket Place the ambulance stretcher on the clean side of the outer cordoned line and unfold a clean sheet or blanket over it. Members of an Emergency Medical Response Team inside the cordoned area need to place the victims on a backboard and pass the victims across the outer cordoned line to the prepared stretcher of the Medical Transport Team. And cover victim by folding a sheet or blanket over him/her and securing it in place. Assess victims’ vital status during transport and intervene appropriately. Check status of intravenous lines started in the controlled area. Advise the receiving hospital of any change in the victims’ medical status. Photo credits: NIRS

Contamination Control on Transportation
Use contamination control during transport. Cover equipments on the ambulance or transportation vehicle. If using helicopter, cover equipments same as ambulance. Do not return to regular service until you, the vehicle, and equipment have been monitored and decontaminated (if necessary) by the appropriate service of the hospital (Radiation Protection Support Group) or other qualified dosimetry service. Photos credit: NIRS

Management of Radioactive Waste
Add Module title Management of Radioactive Waste Collect radioactive waste in plastic bags. Survey bags periodically to prevent high radiation levels in the work area Use distance to protect against radiation from radioactive waste Use walls, dirt mounds, hills, etc. as shielding for radioactive waste Radioactive waste can be handle effectively using plastic bags. Since the bags do not provide any shielding they will need to be monitored frequently to make sure they do not become a source of radiation exposure for emergency workers. The use of time, distance and shielding can be used to protect emergency personnel from radiation coming from radioactive waste bags. Buildings, automobiles, equipment, etc. can provide both distance and shielding. A hill, a pile of bricks or concrete blocks, or even a dirt mound could provide appreciable shielding. Protecting from the increasing radiation level as waste accumulates should be a minimal problem. Photo credits: REACTS /Oak Ridge Associated Universities(ORAU)

Contamination Control
Before leaving the inner cordoned area, first responder should be checked contamination and change clothing if needed Leaving the inner cordoned area, remove outer protective clothing, wash hands and face, and get monitored (if monitoring is available). Submit personal dosimeters to responsible person or organization for evaluation of personal doses. Photos credit: NIRS

Protective Measures Self Scene Survivor (Victim)
PPEs (Personal protective clothing) Personal dosimeter Scene Radiation detector Distance, Time, Shield Survivor (Victim) Contamination External exposure On the medical response at the accident scene, there are three radiological safeties which should be ensured by the medical responders or radiological assessor. Self Protection from contamination and external exposure; Use protective clothing to prevent skin contamination and surgical mask or respiratory protective equipment to prevent inhalation of radioactive materials. Use alarming personal dosimeter to prevent high dose external exposure. Scene safety for responders and victims; Observe from a distance and assess the situation. Check gamma dose rate at the scene. Do not enter areas with ambient dose rates > 100 mSv/h. Ensure all response time not to exceed the dose guidance for emergency workers. Safety for survivors (victims); Survey external contamination and, if necessary, decontaminate not to intake radioactive materials and reduce internal contamination. Triage the victims who are potentially external exposure and/or internal contamination.

Where to Get More Information
Module L-007 Lecture L-007: The Goals of Emergency Preparedness and Response Where to Get More Information INTERNATIONAL ATOMIC ENERGY AGENCY,WORLD HEALTH ORGANIZATION, Preparedness and Response for a Nuclear or Radiological Emergency, Safety Requirements, Safety Standards Series No. GS-R-2, IAEA, Vienna (2002) INTERNATIONAL ATOMIC ENERGY AGENCY,WORLD HEALTH ORGANIZATION, Arrangements for Preparedness for a Nuclear or Radiological Emergency, Safety Guide, Safety Standards Series No. GS-G-2.1, IAEA, Vienna (2007) INTERNATIONAL ATOMIC ENERGY AGENCY, Method for Developing Arrangements for Response to a Nuclear or Radiological Emergency, EPR-METHOD, IAEA, Vienna (2003) IAEA Training in Emergency Preparedness and Response

Where to Get More Information
Module L-007 Lecture L-007: The Goals of Emergency Preparedness and Response Where to Get More Information INTERNATIONAL ATOMIC ENERGY AGENCY, Generic Procedures for Medical Response during a Nuclear or Radiological Emergency, EPR-MEDICAL, IAEA, Vienna (2005). INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Application of the Commission’s Recommendations for the Protection of People in Emergency Exposure Situations, ICRP Publication 109, Ann. ICRP 39 (1), Elsevier (2009). INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Protecting people against STATES NATIONAL COUNCIL ON RADIATION PROTECTION AND MEASUREMENTS radiation exposure in the event of radiological attack, ICRP No. 96, 2005. INTERNATIONAL ATOMIC ENERGY AGENCY, Manual for First Responders to a Radiological Emergency, EPR-FIRST RESPONDER, IAEA, Vienna (2006). INTERNATIONAL ATOMIC ENERGY AGENCY, Development of extended framework for emergency response criteria. Interim report for comments, TECDOC-1432, IAEA, Vienna (2005) IAEA Training in Emergency Preparedness and Response

Medical Response Part II

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Medical Response Part II

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