Essential Elements #1-7
Essential Element #1
Initial Recognition and Notification of the Accident
Question 1-1: What types of radiation accidents are likely to occur in this country or neighboring countries?
Background: Types of radiation accidents include:
- Inadvertent exposure to radioisotopes during production, transportation, handling, storage or industrial use. These mishaps can occur in an industrial, scientific, medical or military setting. Criminal or terrorist use of radioisotopes is also possible
- Reactor accidents
Question 1-2: Who is likely to be the first to become aware of an accident involving radiation exposure?
Background: Nuclear power plan personnel, radiation physicists, nuclear medicine
personnel and individuals involved in the extraction or production of radioisotopes are likely to be the first to become aware of an accident involving radiation exposure. They should wear dosimeters, be subjected to screening and be trained in detecting evidence of radiation exposure. In addition, emergency medical personnel, police, fire and military professionals are another group of professionals likely to come into awareness in the early stage of an accident. They too should receive education about the risks of exposure to radiation as they do for other hazardous materials and biological agents. Since victims of radiation exposure may be unaware of the origin of their medical problem(s), and may not present themselves for medical care for hours or days after the exposure, emergency medical response personnel should suspect that a radiation exposure has occurred when the common signs and symptoms of radiation exposure are present at the time of the patient’s request for medical assistance.
Question 1-3: Will the individuals who observe or suspect an accident know whom to contact?
Background: Communication cascades should be established in advance of an accident
with emergency medical personnel, radiation surveillance personnel and public health officials. In certain cases it may be necessary to contact other agencies such as the military or law enforcement personnel to help manage the accident scene.
Question 1-4: What communication network will be used to notify the appropriate individuals?
Background: In most instances patient care issues will be managed by the existing
emergency medical system communications network. Key individuals listed in the communication cascade protocol should carry cellular phones or electronic pagers when they are away from their residence. Backup systems that do not rely on the standard telephone network are advisable.
Question 1-5: What information should be transmitted?
Background: First responders and dispatchers should be trained to identify the location
of the accident, the nature of the accident and the nature of the traumatic injuries to the victims as well as any radiation exposure that has been suspected. Information concerning potential threats to rescuers (such as a second explosive device) or suggestions regarding the best route to access victims will be helpful. After the initial report, comments on needed resources and a possible location for field command setup should be solicited. Once field command is established, communication should be based at the command site. First responders should remain and brief arriving medical units.
Essential Element #1
Initial Recognition and Notification of the Accident
Timeline
Essential Element #1
Planning Worksheet
Planning Activities
- Identify types of accidents that involve radiation exposure
- Identify and train individuals likely to observe or suspect such accidents
- Identify and test existing communication systems
- Identify those individuals who should be contacted in your system when a radiation accident is suspected or has occurred
- Develop a communication cascade that tests the order in which critical individuals are to be contacted and their contact numbers
Essential Element #2
Activation of the Radiation Accident Response Plan
Question 2-1: What are the criteria for activation of the Response Plan and who has the authority to activate the Plan?
Background: In most situations any radiation exposure beyond prescribed levels
associated with industrial and medical applications should prompt an assessment by emergency response personnel. In some cases it may be necessary to estimate the radiation dose based on the clinical signs and symptoms that are observed in the hours following the radiation exposure. In some countries, existing laws or public health regulations may have an impact on the planning process. The fire, police officer or the power plant supervisor may activate the plan. The radiation response plan should be integrated with the plan for response to accidents that do not involve radiation release.
Question 2-2: Who are the members of the Radiation Accident Response Team?
Background: Responders to a radiation accident should be divided into the On-site Medical Response Team and the Emergency Department Radiation Accident Response Team. In some circumstances certain individuals will serve on both teams, however the roles may vary slightly depending on where the individual is serving.
On-site Medical Response Team (see Background Supplement)
Emergency Department Radiation Accident Response Team (see Background Supplement)
Question 2-3: Are there more than one level of Plan activation/response?
Background: Levels of response are determined by the type of radiation exposure, amount of radiation involved, and whether victims have associated injuries. Early photographic documentation is helpful when structural damage has occurred at a facility where radiation is in use.
Essential Element #2: Background Supplement
On-site Medical Response Team
The On-site Medical Response Team will assemble shortly after an observer or first responder has reported an accident involving injury and exposure to ionizing radiation.
Scene Commander: generally the senior-most fire service or police service officers take charge of the scene initially. This individual should wear a vest or other distinguishing markings.
Radiation Safety Officer: This individual must determine the radiation risk to victims and rescue personnel. Reports to scene commander.
Chief Medical Officer and Medical Care Providers: Once the scene is safe for rescuers these individuals oversee triage and victim stabilization.
Communications Officer: establishes vital linkage to the emergency communication network and to public health officials. Works closely with commander.
Logistic/Transportation/Equipment Personnel: This individual obtains necessary equipment for extrication, medical care and transport. Also arranges for trained individuals who can complete specific tasks identified by the commander.
Public Relations: This individual communicates with the media based on information cleared by the commander.
Administrative Liaisons: These individuals work closely with military, civilian and international units that respond to the disaster.
Security Office and Staff: These individuals protect the lives and property of the victims, rescuers and local population.
Essential Element #2: Background Supplement
Emergency Department Radiation Accident Response Team
The Emergency Department Radiation Accident Response Team should be organized in advance and given well-defined assignments, such as the following:
Team Leader: an individual trained in radiation accident management (e.g., an emergency
physician, radiologist or nuclear medicine specialist or other person as deemed appropriate) and in administration.
Emergency Physicians: diagnose and treat emergency conditions. Must be familiar with the decontamination protocols.
Triage Officer (may also be team captain): a physician or nurse who is familiar with medical triage. Directs patients to appropriate personnel for decontamination and emergency treatment.
Nurse(s): preferably three or more nurses [in the United States, Registered Nurses (RNs) or Licensed Practical Nurses (LPNs)] familiar with decontamination, area isolation and control, and radiation monitoring. At least two will assist in direct patient care, another will serve in the “buffer zone.” Assist with specimen collection.
Administrator: coordinates with other hospital departments to acquire needed resources.
Technical recorder: someone who is familiar with medical and health physics terminology and documentation. Records medical and radiological data.
Health or medical physicist: This person functions as the radiation safety officer (RSO) and is trained in and responsible for monitoring radiation, maintaining the survey equipment, controlling contamination, determining personnel exposures and training the team. The hospital’s staff radiologist may serve as the RSO if the services of a health or medical physicist are not available.
Public Information Officer: releases accident information to public media.
Security Officer: serves to control crowds, guard the emergency vehicle(s) and secure the area.
Laboratory technician: A person who is proficient in the collection and analysis of radiological and biological samples. Analyses should be sent to a qualified physician.
Maintenance personnel: aid in the preparation of the radiation emergency area for contamination control. Help move victims within the area.
Essential Element #2
Activation of the Radiation Accident Response Plan
Timeline
Essential Element #2
Planning Worksheet
Planning Activities
1. Identify criteria to be used to activate the Radiation Accident Response Plan.
2. Determine who has the authority to activate the plan.
3. Describe the members of the Radiation Accident Response Team at the scene of the accident and in the emergency department.
4. Describe the levels of Radiation Accident Response Team activation and response.
Essential Element #3
Establishment of the Medical Command Structure
Question 3-1: Who is responsible for establishing the Medical Command Structure at the scene of an accident involving radiation?
Background: When the situation does not involve external injury and emergency personnel are not summoned to the scene, the supervising personnel at the site should arrange for medical evaluation of exposed victims. When external injuries are involved and rescue/medical personnel are called, the senior officer of the first-arriving emergency medical team should assume command of medical operations at the scene. Command duties include the establishment of safe and secure perimeters of operation, communications, assignments of individuals to specific roles, and assessment of the needs of the victims.
Responsibility for medical command should be clearly laid out by preexisting protocol. In the absence of protocol definition, responders should quickly identify the most experienced individual to serve as medical scene commander before undertaking medical care efforts. The commander should be clearly identifiable (for example, by vest or hat). Changes in command should be announced to the medical response team in a formal manner.
Question 3-2: How shall the medical command group function during a radiation
accident?
Background: When a radiation accident involves injury and radiation exposure to a large number of victims, a command structure should be set up to manage medical operations until all victims and medical personnel have left the area. Some of the functions performed by the medical command team include preparing requests for specific equipment, assignment of medical personnel to needed treatment areas, coordination of patient radiation surveillance efforts, coordination of victims and rescue movement and communications with public officials and the media. During a response the commander should hold regular meetings (for example, at 12 or 24-hour intervals) of the command group and key staff members so that efforts proceed in a coordinated fashion.
Question 3-3: How will international responders and expert consultants be integrated into the ongoing incident operations?
Background: Command personnel should be responsible for identifying the need for international assistance. Requests for international assistance may be directed through the national health ministry to the International Atomic Energy Agency (IAEA) which brokers requests for medical assistance to the World Health Organization (WHO), as specified in the “Convention on Assistance in the Case of a Nuclear Accident or Radiological Emergency,” to which IAEA member states are signatory. International responders and consultants should be briefed upon arrival (after presentation of their credentials). Appendix 9 provides current listings of national coordinators from Armenia, Estonia, Moldova, Russian Federation, and Ukraine.
Command personnel should identify the specific tasks or advice that is being requested of the individuals providing international assistance.
Essential Element #3
Establishment of the Medical Command Structure
Timeline
Essential Element #3
Planning Worksheet
Planning Activities
1.Write a protocol for establishing medical command.
2. Identify members of the medical command team and principle functions for each member.
3. Write a protocol that describes the Medical Command Structure that will be implemented at the scene.
4. Describe how international assistance will be requested and how international consultants will be integrated into the response team.
Essential Element #4
Initial Survey of the Accident Site by Emergency Response Personnel
Question 4-1: How should emergency response personnel proceed into the victim area?
Background: Ideally the accident scene should be surveyed for radiation at the same time that victims are being assessed for injury. Detection devices should be immediately available if the accident occurs at a power plant or in a location where radionuclides are normally kept. If radiation is suspected and the presence of radiation in the environment and on the injured victims cannot be monitored, emergency responders should dress themselves in protective clothing and proceed to care for victims. If the victims appear to be in an area with ongoing exposure, they should be unclothed quickly and moved to a safer location. As soon as possible rescuers should be given radiation detection devices to wear and should be evaluated by the radiation safety officer. The radiation officer, once at the site, should attempt to identify sources of radiation to further assess the risk to those at the site. Responder safety should be of great concern to all.
Question 4-2: How will movement of rescue personnel in and out of site be managed?
Background: When radiation is present at the accident site, responders should establish three distinct areas around the victims. These zones are referred to as “hot,” “warm,” and “cold” zones . Only rescue personnel wearing protective clothing should be allowed in the “hot zone.” Victims should be quickly moved away from the “hot zone” through the “warm zone” and on to the “cold zone”. Field documentation should be started at the “warm zone” and completed in the “cold zone.” Only immediately life saving medical care should be provided before the patient has been moved from the “hot zone” and fully decontaminated. Access past the outer perimeter of the “cold zone” should be restricted to members of the response team. Once stabilized, victims can be moved to the outer perimeter of the “cold zone” for staging and transport to medical care. Security personnel must maintain the integrity of the safety zone borders in addition to controlling traffic flow to and from the site.
4From reference 12 (Exhibit I-11).
Exhibit I-11
chart – NIOSH/OSHA/USCG/EPA Recommended Zones
Question 4-3: How will extrication and evacuation problems be handled?
Background: Victim extrication at the site of a radiation release may be very difficult. Responding personnel should know how to access extrication equipment that may be necessary if the accident has involved the collapse of a building. Medical personnel should be prepared to assist with the evacuation of hospitals and facilities housing the chronically ill.
Essential Element #4
Initial Survey of the Accident Site by Emergency Response Personnel
Timeline
Planning Guidelines
1. Identify how victim assessment is going to occur. Assessment will include injury and radiation considerations.
2. Identify how rescuers will protect themselves from physical harm or radiation exposure.
3. Design a protocol for the flow of individuals and vehicles in and around the incident site.
4. Describe how victims who are trapped or in need of evacuation will be handled.
Essential Element #5
Triage, Resuscitation and Decontamination of Victims
Question 5-1: What protocol will be used for victim decontamination at the site? Who will perform decontamination?
Background: Victims who have been exposed to radioactive fluids or particulate matter should have their clothing removed and skin washed soon after exposure. However, lifesaving intervention must take priority over decontamination.
Medical response team members who may be responsible for victim decontamination should receive training, including drill experience, in preparation for radiation accident management.
Question 5-2: How is medical triage at the site of an accident affected by radiation exposure?
Background: Since exposure to radiation alone is never immediately life threatening, field triage should be based on the external or internal injuries suspected when the victim is examined. Traumatic injuries, observed or suspected, hould be classified using the Red, Yellow, Green or Black coding system. Radiation accident patient tags may be useful in determining the order in which victims should be evacuated from the accident scene .
Question 5-3: How should triage be conducted when a large number of victims are spread over a large area?
Background: In situations where numerous victims are widely scattered, it will be necessary to establish more than one triage team and casualty collection site. The Medical Scene Commander should make the decision about the number of triage teams and the quantity and location of casualty collection sites after assessing available resources and victim data.
RADIATION ACCIDENT PATIENT TAG
(from Reference 9,IAEA/WHO Safety Reports Series #2 p 36)
Essential Element #5: Background Supplement
The presence of ionizing radiation is not detectable by the human senses but only by special radiation equipment. Keep in mind that the three most basic means of reducing the harm caused by a source of radiation are related to the time spent near the source, distance from the source, and shielding between one’s self and the source.
Triage Categories For Victims with Traumatic Injuries
RED Patients (immediate) – Priority 1
Synopsis:
1. Injuries are life threatening and risk of asphyxiation and shock is present or imminent.
2. Patient has a high probability of survival if treated and transported immediately.
3. Patient can be stabilized without requiring constant care or elaborate treatment.
Injuries:
- Airway compromise and severe breathing difficulties
- Uncontrolled external bleeding or suspected severe internal bleeding
- Head injuries (not catastrophic) with altered level of consciousness
- Open chest or abdominal wounds (sucking chest wounds or evisceration)
- Shock
- Severe medical problems: poisoning, insulin shock, and cardiac emergencies
- Burns involving the respiratory tract
- 3rd degree burns covering from 25 to 50 percent of surface area
- Unconsciousness with no obvious head injury
YELLOW Patients (delayed) – Priority 2
Synopsis:
1. Patients with potentially life threatening or severely debilitating injuries who are not yet in shock and who can accept a delay of two hours or less for delivery to hospital treatment.
2. A YELLOW patient may deteriorate over time into a RED patient. Therefore, these patients require reassessment on a regular schedule.
Injuries:
- Multiple fractures
- Back injuries with or without spinal cord damage
- 3rd degree burns over less than 25 percent of surface area
- Eye injuries
GREEN Patients (minor) – Priority 3
Synopsis:
1. Patients with non-life threatening injuries who require a minimum of care and who are not expected to deteriorate.
2. For secondary triage, the ability to walk should not be used as a classification factor.
Injuries:
- Minor fractures
- Minor burns
- Abrasions, lacerations and other soft tissue injuries without significant blood loss
- General sickness or weakness uncomplicated by other injuries or illness
BLACK Patients (catastrophically injured patients)
Synopsis:
1. Patients are classified as BLACK if they are not breathing and do not breathe when the airway is opened. However, if resources permit, a catastrophically injured dying patient may be included for treatment and transportation. In small accidents it may be possible to treat and transport after other RED patients are cleared. In large accidents with a large number of YELLOW patients, the catastrophically injured may have to be deferred until the YELLOWs are moved.
2. The decision to treat and transport is made by the treatment officer and transportation officer in conjunction with the command hospital physician.
Injuries:
- Unresponsive with severe head injury
- 3rd degree burns greater than 50% of the body surface
- Open skull fracture with extruded brain material
- Crushed chest injury and traumatic asphyxia
Essential Element #5
Triage, Resuscitation and Decontamination of Victims
Timeline
Planning Guidelines
1. Develop a protocol for victim decontamination at the site.
2. Adjust plans for medical care according to amount of radiation exposure.
3. Review triage criteria and show how they may vary according to the number of victims involved.
Essential Element #6
Medical Stabilization at the Accident Site and Victim Transport to Emergency Departments
Question 6-1: What stabilization procedures should be performed in the field on the traumatized victim who has been exposed to ionizing radiation?
Background: Stabilization of a traumatized victim who has been exposed to ionizing radiation should be identical to the treatment of victims without such exposure. The medical care provider must protect himself/herself from aerosolized and particulate radioactive material by wearing protective clothing and, if necessary, a self-contained breathing apparatus. Prior to victim decontamination, only life-saving intervention such as airway and breathing management, defibrillation, control of hemorrhage and spinal immobilization should be performed. Fluid resuscitation, definitive wound management, and fracture stabilization can be completed when the victim has been moved to a safer environment.
Question 6-2: What treatment can be provided in the staging area where victims are waiting for transport?
Background: The staging area where victims are re-triaged (reassessed) and prepared for transport should be safely away from sources of radioactive contamination.
Almost all of the victim decontamination should be completed before the victim is brought to this area. The patient can receive further spinal or skeletal immobilization, fluid administration, temperature control, sterile bandaging, etc. When distances to medical care facilities are great and vehicles are in short supply, the staging area may resemble a field hospital.
Essential Element #6
Medical Stabilization at the Accident Site and Victim Transport to Emergency Departments
Timeline
Planning Guidelines
1. Write protocols for field stabilization (identify problems that will be treated).
2. Consider how victims will be moved to a staging area.
Essential Element #7
Emergency Department Reception of Radiation Exposure Victims
Question 7-1: What preparations should be made in the reception area prior to the arrival of victims?
Background: Existing protocols must specify where victims who may have been exposed to radiation will be received. The protocols may call for one entrance to be used for severely injured trauma patients and another for those with minor injuries. The number of victims may also determine which entrance and processing area will be used to care for the victims. Floor covering should be laid down to minimize the amount of contamination in the receiving area.
Members of the Emergency Department Radiation Response Team should be assembled. Team members should put on proper attire: surgical gowns or scrub suits, headgear, and shoe covers. All garment seams should be taped.
The composition of the Emergency Department Response Team (EDRT) has been covered in Essential Element #2 (Background Supplement).
Question 7-2: How will the safety of the EDRT be monitored?
Background: The health physicist is expected to assess the victims as they arrive. In addition each member of the EDRT should be fitted with a dosimeter. Responders in the Emergency Department “hot zone” should be reassessed after each decontamination.
Question 7-3: What security measures will be in place?
Background: Security personnel should not allow any unauthorized entry into the contamination and treatment area. All responders must have on protective clothing before entering the “hot zone” and remove protective clothing (with proper disposal) when they exit.
Question 7-4: What type of treatment will victims receive in the emergency decontamination treatment area?
Background: Life saving treatment of traumatic injuries should not be withheld because of victim contamination. If the patient does not have immediate life threatening conditions, decontamination should be completed and then necessary treatment provided.
Essential Element #7: Background Supplement
Life Saving Interventions
- Removal of airway obstructions
- Maintenance of a patient airway
- Assisted ventilation
- Chest decompression
- Treatment of dysarrthymias that impair perfusion (asystole, severe bradycardia, ventricular tachycardia, ventricular fibrillation, etc.)
- Control of severe hemorrhage (external or internal)
- Restore intravascular volume following blood or fluid loss via the gastrointestinal tract
- Assess for intracranial and spinal trauma
- Manage wounds, amputations, fractures and burns for infectious contamination
Essential Element #7: Background Supplement (cont.)
Emergency Department Care of the Radiation Accident Victim
Patient Arrival and Triage
Meet the radiation accident victim at the ambulance or other transporting vehicle. Instruct ambulance personnel to stay with the vehicle until they and their vehicle are surveyed and released by a radiation safety officer.
Immediate assessment of the victim’s airway, breathing and circulation should be made and any lifesaving measures performed. The critically injured patient should be taken immediately into the prepared emergency area. If the victim’s condition allows, an initial brief radiological survey can be performed to determine if the victim is contaminated. Any radiation survey meter reading above background radiation levels indicates the possibility of a contamination. A more thorough survey will be performed in the decontamination room. If the victim’s contaminated clothing has not been removed, remove it in or near the ambulance and place it in a plastic bag. Personal belongings and items used in patient care should be bagged, labeled and saved for examination by the radiation safety officer.
A triage area should be established near the treatment area. During triage, consideration is given to medical and radiological problems. Serious medical problems always have priority over radiological concerns, and immediate attention is directed to life-threatening problems. Radiation injury rarely causes unconsciousness or immediate visible signs of injury and is not immediately life threatening; therefore, other causes of injury or illness must be considered. Non-contaminated patients are admitted to the usual treatment area while contaminated patients must be admitted to the specially prepared area.
Assessment and Treatment of the Non-Contaminated Patient
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 that the victim of exposure without contamination poses no radiological hazard to anyone. If exposure is known or suspected, a complete blood count should be ordered with particular attention given to determining the absolute lymphocyte count. Be sure to record the time the blood sample is taken.
Assessment and Treatment of the Contaminated Patient
Contaminated patients can have radioactive materials deposited on skin surfaces, in wounds, or internally (ingested, inhaled or absorbed). Reassessment of the contaminated
patient’s airway, breathing and circulation are done in the decontamination room prior to attention to the patient’s radiological status. It is unlikely that cardiopulmonary resuscitation will be required on a victim whose only problem is inhalation or ingestion of radioactive materials. However, the emergency physician or nurse might be concerned with becoming contaminated (lips, mouth, lungs or gut) when performing mouth-to-mouth resuscitation. In the absence of a bag mask, ambu-bag or positive pressure ventilator, mouth-to-mouth resuscitation may be considered.
As in other cases of emergency medical care, many procedures are accomplished simultaneously when time is at a premium. Level of consciousness and vital signs are assessed promptly and the patient’s condition is stabilized. After examining the entire patient and identifying all injuries, a complete radiological survey should be done.
The patient should be questioned about allergies, currently used medications, any history of chronic or recent illness and recent nuclear medicine tests. The patient’s level of anxiety should be noted, and psychological support offered. A complete and detailed medical, occupational and accident history should be taken, and a physical examination completed. Sample forms have been developed by IAEA and WHO .
Certain clinical and radiological laboratory analyses are essential to the care of the radiation accident patient. These laboratory tests are done to assess the biological effects of radiation injury; to identify abnormalities that might complicate treatment; to locate, identify and quantify radionuclide contamination and to provide information useful in accident analysis. The biological and physical samples needed, why are they taken and how they are handled are reviewed in the accompanying Table .
Decontamination of the Contaminated Patient
Good judgment is essential in determining decontamination priorities. Since some radioactive materials are corrosive or toxic because of their chemical properties, medical attention might have to be directed first to a non-radiological problem if radioactive materials were shipped as acids, fluorides (uranium hexaflouride – UF6), mercury, or lead compounds.
In general, contaminated wounds and body orifices are decontaminated first, followed by areas of highest contamination levels on the intact skin. The purpose of decontamination is to prevent or reduce incorporation of the material (internal contamination), to reduce the radiation dose from the contaminated site to the rest of the body, to contain the contamination, and prevent its spread.
External Contamination
Decontamination of the intact skin is a relatively simple procedure. Complete decontamination, which returns the area to a background survey reading, is not always possible because some radioactive material can remain fixed on the skin surface. Decontamination should be only as thorough as practical.
Decontamination should begin with the least aggressive method and progress to more aggressive ones. Whatever the procedure, take care to limit mechanical or chemical irritation of the skin. The simplest procedure is to wash the contaminated area gently under a stream of water (do not splash) and scrub at the same time using a soft brush or surgical sponge. Warm, never hot, tap water is used. Cold water tends to close the pores, trapping the radioactive material within them. Hot water causes vasodilation with increased area blood flow, opens pores and enhances the chance of absorption of the radioactive material through the skin. Aggressive rubbing tends to cause abrasion and erythema and should be avoided.
If washing with plain water is ineffective, a mild soap (neutral pH) or surgical scrub soap can be used. The area should be scrubbed for 3 – 4 minutes, then rinsed for 2-3 minutes and dried, repeating if necessary. Between each scrub and rinse, check the contaminated area to see if radiation levels are decreasing. Sodium hypochlorite, diluted 1 to 10 with water, is an effective decontamination agent. A mildly abrasive soap; a 1 to 1 mixture of powdered detergent and cornmeal mixed with water into a paste; a paste of sawdust and water; or a mixture of 65 percent NaPO4, 5 percent carboxylmethycellulose, and 30 percent detergent as a 5 percent solution in water can be used.
More aggressive measures for decontamination include procedures that remove cornified epithelium. Very fine sandpaper can be used on hands or feet. Potassium permanganate (4 percent) followed by sodium bisulfate (4 percent) also can be used with caution. The decontamination procedure stops when the radioactivity level cannot be reduced to a lower level. Expert advice might be needed to determine an appropriate stopping point. Contaminated hairy areas can be shampooed several times and then rinsed in a 3 percent citric acid solution. Contaminated hair can be clipped if shampooing is ineffective. Shaving should be avoided since small nicks or abrasions can lead to internal contamination. When shampooing the head, avoid getting any fluids into the ears, eyes, nose and mouth.
The procedures described above also apply to the decontamination of uninjured accident victims. Decontamination of an uninjured patient can be accomplished on a treatment table if necessary. Small areas (hands, feet, etc.) can be decontaminated using a sink or basin. If the extensive body areas are contaminated, the patient can be showered under the direction or with the assistance of a radiation safety officer. Caution the patient to avoid splashing water into the eyes, nose, mouth, or ears. Repeated showers might be necessary, and clean towels should be provided for drying after each shower. Again, decontamination should be as thorough as practical. Contaminated water can be released directly into the hospital sanitary drain system. No special storage or holding tanks are recommended.
Treatment of Contaminated Wounds
In a contamination accident, any wound must be considered contaminated until proven otherwise and should be decontaminated prior to decontaminating intact skin. When wounds are contaminated, the physician must assume that uptake (internal contamination) has occurred. Appropriate action is based on half-life, radiotoxicity, and maximum permissible body burden of the radioactive material. It is important to consult experts as soon as possible and to initiate measures that prevent or minimize uptake to the radioactive material into body cells or tissues.
Contaminated wounds are first draped, preferably with a waterproof material, to limit the spread of radioactivity. Wound decontamination is accomplished by gently irrigating with saline, water, or a 3 percent hydrogen peroxide solution. Irrigation fluid should be collected and checked with a radiation monitor to judge the effectiveness of decontamination. More than one irrigation is usually necessary. The wound should be monitored after each irrigation. Contaminated drapes, dressings, etc., should be removed before each monitoring for accurate results. When monitoring contaminated wounds or irrigation fluids, gamma radiation is easily detected while beta radiation may prove more difficult to detect. Without special, highly sophisticated wound probes, alpha contamination will not be detected. Following irrigation, the wound is treated like any other wound. If the preceding decontamination procedures are not successful, apply a constriction band to increase blood flow and to help remove contamination from the wound. If this is unsuccessful and the contamination level is still seriously high, surgical decontamination, which is identical to conventional debridement of a wound, must be considered. Debridement should not be initiated until expert medical or health physics advice is obtained. Debrided or excised tissue should be retained for health physics assessment.
Embedded radioactive particles, if visible, can be removed with forceps or by using a water-pik. Puncture wounds containing radioactive particles, especially in the fingers, can be decontaminated by using an “en bloc” full thickness skin biopsy using a punch biopsy instrument.
After the wound has been decontaminated, it should be covered with a waterproof dressing. The area around the wound is decontaminated as thoroughly as possible before suturing or other treatment.
Contaminated burns (chemical, thermal) are treated like any other burn. Contaminants will slough off with the burn eschar. However, dressings and bed linens can become contaminated and should be handled appropriately.
Decontamination of Body Orifices
Contaminated body orifices, such as the mouth, nose, eyes, and ears need special attention because absorption of radioactive material is likely to be much more rapid in these areas than through the skin.
If radioactive material has entered the oral cavity, encourage brushing the teeth with toothpaste and frequent rinsing of the mouth with a 3 percent citric acid solution. If the pharyngeal region is also contaminated, gargling with a 3 percent H2O2 solution might be helpful. Gastric lavage can be used if radioactive materials were swallowed. Rinsing the nose with tap water or physiological saline should be tried if the nose is contaminated. Likewise, contaminated eyes should be rinsed by directing a stream of water from the inner canthus to the outer canthus of the eye while avoiding contamination of the nasolacrimal duct. Contaminated ears require external rinsing, and a ear syringe can be used to rinse the auditory canal, provided the tympanic membrane is intact.
Reference 11
SAMPLE FORMS
from IAEA/WHO Safety Reports Series #2 p 35 and 37-40
Reference 11
RADIOLOGICAL AND CLINICAL LABORATORY ASSESSMENTS from REACTS course
Essential Element #7:
Emergency Department Reception of Radiation Exposure Victim
Timeline
Planning Guidelines
1. Decide where radiation victims will be processed.
2. Identify how radioactivity will be contained.
3. Write protocols for patient flow and care in the area.
