1. Emergency Department: Management of Radiation Exposed/Contaminated Patients CAUTION

2. This presentation, "Emergency Department: Management of Radiation Exposed/Contaminated Patients, was prepared as a public service by the Health Physics Society for hospital staff training. The presentation includes talking points on the Notes pages, which can be viewed if you go to the File Menu and "Save As" a PowerPoint file to your computer. The talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points will be presented during the training. The presentation can be edited to fit the needs of the user. The authors request that that appropriate attribution be given for this material and would like to know who is presenting it and to what groups. That information and comments may be sent to Jerrold T. Bushberg, PhD, UC Davis Health System, at jtbushberg@ucdavis.edu.

3. Key Points Contamination is easy to detect and most of it can be removed. It is very unlikely that medical staff will receive large radiation doses from treating contaminated patients. Protecting Staff from Contamination Follow universal precautions. Survey hands and clothing with a radiation meter. Replace contaminated gloves or clothing. Keep the work area free of contamination.

4. Time Minimize time spent near radiation sources. Reducing Radiation Exposure Distance Maintain maximal practical distance from radiation source. Shielding Place radioactive sources in a lead container. To Limit Caregiver Dose to 5 rem Distance Rate Stay time 1 ft 12.5 R/hr 24 min 2 ft 3.1 R/hr 1.6 hr 5 ft 0.5 R/hr 10 hr 8 ft 0.2 R/hr 25 hr

5. Detecting and Measuring Radiation Instruments Locate contamination - GM Survey Meter (Geiger counter) Measure exposure rate - Ion Chamber Personal Dosimeters - Measure doses to staff Radiation Badge - Film/TLD Self-reading dosimeter (analog and digital)

6. Patient Management - Priorities Triage Medical triage is the highest priority. Radiation exposure and contamination are secondary considerations. Degree of decontamination is dictated by number of and capacity to treat other injured patients.

7. Patient Management - Triage Triage based on: Injuries Signs and symptoms - nausea, vomiting, fatigue, diarrhea History - Where were you when the incident occurred, i.e. how far from the actual event site? Contamination survey

8. Contamination Surveys Survey with GM survey meters. Those familiar with the use of radiation detection instruments should operate them. Goal is <5 times background. Prepare protocol for survey and documentation. Hold probe ~1/2 inch from surface. Move at a rate of 1 to 2 inches per second. Follow logical pattern. Document readings in counts per minute (cpm). photo credits: REAC/TS

9. Directions Clear directions (in appropriate languages) are necessary to help individuals understand what is expected of them.

10. Surveying After Each Decontamination Provisions must be provided for repeat surveying of individuals after each decontamination procedure to determine success of efforts and when individuals can be routed out of the decontamination center. photo credits: REAC/TS

11. Mass Decontamination Facilities Where possible, the decontamination of many contaminated individuals should be carried out in existing shower facilities (e.g., at a fire house, school locker room, or public campground). When such facilities are not immediately available, field decontamination capabilities may have to be implemented.

12. Mass Decontamination

13. Runoff Responders should closely monitor the direction of runoff to prevent cross contamination between lanes and between zones. If possible, the decontamination area should contain a storm water drain or be on a slope that allows control of water runoff. EPA and Runoff The Environmental Protection Agency has stated that it will not hold responders liable for runoff in a chemical or biological incident caused by a terrorist event. (EPA letter dated 17 September 2000) Protection of human life and health is primary goal. Mass Decontamination

14. Second-Stage Decontamination When surveying shows that preliminary decontamination of individuals has not been complete, they should be sent to a second- stage decontamination facility (e.g., specialized decontamination tent). Ambulatory Patients

15. Second-Stage Decontamination Some specialized decontamination tents permit capabilities for decontamination of nonambulatory patients as well as those who can walk. Nonambulatory Patients

16. Clothing for Decontaminated Individuals Supplies of clean clothing (sheets, blankets, scrub suits, etc.) should be available for individuals exiting decontamination stations. Provide plastic bags for personal items, wallets, jewelry.

17. Gowning Capabilities Patients exiting second-stage decontamination facilities need to be provided with clean clothes (hospital gowns, coveralls, sheets or blankets).

18. Resurveying Individuals exiting the second- stage decontamination facility should be surveyed again to determine the effectiveness of decontamination. Individuals found to still be contaminated can be rerouted through the second- stage decontamination effort.

19. Patient Management - Decontamination Carefully remove and bag patients clothing and personal belongings (typically removes 95 percent of contamination). Survey patient and, if practical, collect samples. Handle foreign objects with care until proven nonradioactive with survey meter. Decontamination priorities: Decontaminate wounds first, then intact skin. Start with highest levels of contamination. Change outer gloves frequently to minimize spread of contamination. Protect uncontaminated wounds with waterproof dressings.

20. Patient Management - Decontamination Contaminated wounds: Irrigate and gently scrub with surgical sponge. Extend wound debridement for removal of contamination only in extreme cases and upon expert advice. Avoid overly aggressive decontamination. Change dressings frequently. Decontaminate intact skin and hair by washing with soap & water. Remove stubborn contamination on hair by cutting with scissors or electric clippers. Promote sweating. Use survey meter to monitor progress of decontamination.

21. Patient Management - Decontamination Cease decontamination of skin and wounds: When the area is less than twice background, or When there is no significant reduction between decon efforts, and Before intact skin becomes abraded. Contaminated thermal burns Gently rinse. Washing may increase severity of injury. Additional contamination will be removed when dressings are changed. Do not delay surgery or other necessary medical procedures or exams... residual contamination can be controlled.

22. Radionuclide-specific Most effective when administered early May need to act on preliminary information NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides Treatment of Internal Contamination RadionuclideTreatmentRoute Cesium-137Prussian blueOral Iodine-125/131Potassium iodideOral Strontium-90Aluminum phosphateOral Americium-241/Ca- and Zn-DTPAIV infusion, Plutonium-239/nebulizer Cobalt-60

23. Estimating the severity of radiation injury is difficult. Signs and symptoms (N,V,D,F): Rapid onset and greater severity indicate higher doses. Can be psychosomatic. CBC with absolute lymphocyte count Chromosomal analysis of lymphocytes (requires special lab) Treat symptomatically. Prevention and management of infection is the primary objective. Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hours) Irradiated blood products Antibiotics/reverse isolation Electrolytes Seek the guidance of experts. Radiation Emergency Assistance Center/Training Site (REAC/TS) Medical Radiobiology Advisory Team (MRAT) Treatment of Large External Exposures

24. Patient Management - Patient Transfer Transport injured, contaminated patient into or out of the emergency department: Cover clean gurney with two sheets. Lift patient onto clean gurney. Wrap sheets over patient. Roll gurney into emergency department or out of treatment room.

25. Facility Recovery Remove waste from the emergency department and triage area. Survey facility for contamination. Decontaminate as necessary : Normal cleaning routines (mop, strip waxed floors) typically very effective. Periodically reassess contamination levels. Replace furniture, floor tiles, etc., that cannot be adequately decontaminated. Decontamination goal: Less than twice normal background... higher levels may be acceptable.

26. Special Considerations High radiation dose and trauma interact synergistically to increase mortality. For patients who received doses >100 rad: Close wounds, attend to any infection, look out for infections Wound care, burn care, and surgery should be done in the first 48 hours or delayed for 2 to 3 months 24-48 Hours ~3 Months Emergency Surgery Hematopoietic Recovery No Surgery After adequate hematopoietic recovery Surgery Permitted

27. Other Considerations Victims may include the terrorist(s) (if this is a dirty bomb situation). In most cases, following universal precautions is all that is necessary to protect the staff. Risk to caregivers, who would likely receive low doses, is very small. Hospital staff doses at Chernobyl <1 rem. 10 rem increases the risk of fatal cancer by ~1 percent. 25 rem increases the risk of severe hereditary effects by ~0.1 percent. Preplan who will be given radiation dosimeters

28. Other Considerations Larger hospitals or large metropolitan areas should consider stocking decorporation agents. Dose rates to first responders 20 cm from patient with uniform surface contamination: Cesium-137, 100 µCi/cm 2 – 1 rem/hr Cobalt-60, 100 µCi/cm 2 – 3.9 rem/hr Dose rates to surgeon standing 20 cm from patient with radioactive fragment (0.2 mm long, 0.2 mm radius, embedded 20 cm deep) Cobalt-60, 1 Ci – 2.5 rem/hr

29. Psychological Casualties Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening. Mass-casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated. Establish a center to provide psychological support to such people. Set up a center in the hospital to provide psychological support for staff.

30. Psychological Casualties Affected by fear of radiation and misunderstanding of consequences. Long-term psychological effects could arise hours or days after an incident. Counsel on acute and potential long-term physical and psychological effects. Psychological effects include: Anxiety disorders Post traumatic stress disorder Depression Insomnia Traumatic neurosis Acute stress disorder

31. Psychological Casualties Provide psychological counseling to staff, victims, and their families. High-risk groups include emergency workers, children, mothers with small children, cleanup workers. Provide exposed patients with a sense of control of their health. Resources: http://www.madison.va.gov/PTSD http://www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf

32. Contaminated Corpses Disaster Mortuary Operational Response Teams (DMORT) Restrict autopsies of highly radioactive corpses. No embalming or cremation. Health physics assistance for autopsies: Use contamination control. Wear protective clothing.

33. Key Points Medical stabilization is the highest priority. Train/drill to ensure competence and confidence. Preplan to ensure adequate supplies and survey instruments are available. Universal precautions and decontaminating patients minimize exposure and contamination risk for staff. Early symptoms and their intensity are an indication of the severity of the radiation injury. The first 24 hours are the worst; then you will likely have many additional resources.

34. Acknowledgments Prepared by the Medical Response Subcommittee of the National Health Physics Society Homeland Security Committee. Jerrold T. Bushberg, PhD, Chair Kenneth L. Miller, MS Marcia Hartman, MS Robert Derlet, MD Victoria Ritter, RN, MBA Edwin M. Leidholdt, Jr., PhD Consultants Fred A. Mettler, Jr., MD Niel Wald, MD William E. Dickerson, MD Appreciation to Linda Kroger, MS, who assisted in this effort.

35. Health Physics Society Disclaimer: The information contained herein was current as of 13 Aug 2008 and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. The Health Physics Society is a nonprofit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the Department of Defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; fax: 703-790-2672; email: HPS@BurkInc.com.