IAEA International Atomic Energy Agency IX. EMERGENCY EXPOSURE SITUATION IX.8.1 Medical Management of Radiation Injuries Medical Response

IAEA 2 Contents Type of radiation emergency Potential of victims Flow of management on scene radiation emergency response teams Indications and notification Assessment of scene Contamination control Reception centre Field and full decontamination on scene Handling of contaminated patients

IAEA 3 “Major” World-Wide Radiation Accidents Number: ~500 Fatalities: radiation-related: ~130 not related to radiation: ~10 % Sources: IAEA, REAC/TS (1944 – 2009)

IAEA 4 External Exposure Types of Radiation Emergencies Trauma Contamination

IAEA 5 Potential of Victims Externally Exposed Externally Contaminated Internally contaminated Injured (Burn, Trauma) Combined Injury Not contaminated or injured “Worried-well”

IAEA 6 Dealing with Uninjured on the Scenario Only the injured or those in need of emergency medical treatment should be sent to local designated hospitals* Uninjured individuals should be handled in triage sites or decontamination centres away from hospitals * hospitals integrating a SYSTEM to respond to radiation emergencies

IAEA 7 Flow of Management Accident Incident Identification On Scene Triage Hospital Notification

IAEA 8 Radiation Emergency Response Teams First responder Emergency workers (police, firefighters, medical personnel, and drivers and crews of evacuation vehicles) referring to an initial response in emergency Emergency medical response team Medical transportation team Radiological assessor Decontamination team

IAEA 9 Generic Response Organization Response Initiator First official being informed of an emergency with authority to initiate a response plan Emergency Manager Appointed official in charge of overall emergency response On-scene Controller Usually senior member of First Responder team Radiological Assessor Usually senior member of a radiological assessment team sent to the scene of an accident First Responder First person or team to arrive at the scene of an accident with an official role to play in the accident response Police Facility Responder Emergency Medical Responder Fire Service

IAEA 10 Indications of a Possible Radiation Emergency Emergency exposure situation: Nuclear reactor accident Accident with radiation sources Accident outside the country with transboundary effects Nuclear powered satellites and re-entry Malicious acts involving radioactive materials

IAEA 11 Notification Get call-back number and verify accident prior to assembling radiation emergency team Assume that victim is contaminated until proven otherwise

IAEA 12 Assessment of Accident Scene What hazards present? How many people were injured (too many, many….)? When did the accident/incident occur? How was the material released into environment? Where are victims contaminated with/exposed to radioactive material?

IAEA 13 Assessment of Accident Scene Severe trauma Hazardous chemicals Radioactive materials Immediately threatens the lives of rescuers and victims? Rescuers: no Victims: possibly PossiblyNo Causes immediate visible evidence of skin injury? UsuallyPossiblyNo Causes cardiac or respiratory problems, pain, or unconsciousness? FrequentlyPossiblyRarely

IAEA 14 Radiation Incident Control on Scene Identify the substance if possible Consider all potential hazards Establish contamination control zones Protect personnel from radiation exposure Follow protective action guides for radiation exposure Time, distance, shielding Protect equipment from contamination

IAEA 15 Boundaries What should allowable boundaries be? Control point Hot Zone Warm Zone Cold Zone How large might these boundaries be? See (inter alia) TMT Handbook, IAEA’s Method for Developing Arrangements for Response to Nuclear or Radiological Emergency and IAEA’s Manual for First Responders to a Radiological Emergency

IAEA 16 Radiological Control on Scene - Zoning -

IAEA 17 Field Triage during Radiation Emergency Victims Medical Triage Not seriously injured or uninjured Seriously injured Stabilization Immediate contamination survey and decontamination (if possible) Hospital Contamination survey and decontamination Hospital Registration area Inner cordoned area Safety perimeter Outer cordoned area Security perimeter Life- threatening injury

IAEA Response Stage Basic principles of medical care of exposed persons General methods Specific methods for possible health effects of radiation and contamination Medical care On-site (on the scene of an accident) Off-site (in medical institutions) 18

IAEA Medical personnels On-site – Emergency medical responders Off- site - Medical specialists in general hospitals and specialized medical centres 19

IAEA Medical assistance in radiation emergencies: interfaces and activities 20

IAEA Tasks of emergency medical responders on site Step 1: If you are first at the scene assume the role of on-scene controller until relieved If not, get briefed by on-scene controller Step 2: If you have personal dosimeters wear them Wear protective clothing as required 21

IAEA Tasks of medical responders: search and rescue Step 3: Search for and rescue injured people as soon as possible Perform medical triage. Assess and treat life-threatening injuries immediately DO NOT DELAY LIFE SAVING ACTIONS DUE TO THE PRESENCE OF RADIATION Provide routine emergency care during extrication procedures Remove injured people from the hazard area as soon as possible If necessary, request additional medical help 22

IAEA Tasks of medical responders: establish contacts Step 5: Establish contact with police to obtain names and addresses of the involved population for further interview Step 6: Inform receiving hospital about nature of conventional injuries and any known or suspected radioactive exposure or contamination Identify radioactive material if known If not known, ask radiological assessor to identify radioactive materials involved 23

IAEA Tasks of medical responders: checking contamination Step 7: With support of decontamination team, check personal and equipment for contamination or request assistance from radiological assessor When medical conditions do not require urgent hospitalization, DO NOT leave the scene of accident before being checked for personal contamination 24

IAEA Step 7 (cont’d) DO NOT take any equipment out of area before having it checked for contamination If you have to leave the scene urgently, contamination control procedures should be carried out as soon as reasonable 25

IAEA 26 First Medical Response On-Site Emergency medical service Does not delay care Provides on-site medical response Advises medical transport and local receiving hospital on risks and appropriate protective actions Establishes a temporary morgue area

IAEA 27 Categories of Public On-Scene Involved in Emergency Victims with conventional trauma/illness Externally exposed victims Externally exposed and injured victims Externally contaminated victims Externally contaminated and injured victims Not injured and not contaminated persons

IAEA 28 Field Triage Rapid method utilizing simple procedures to sort persons into groups based on their injury and/or disease for the purpose of expediting clinical care and maximizing the use of the available clinical services and facilities

IAEA 29 Population Monitoring The presence of radioactive contamination on the body or clothing The uptake of radioactive contamination into the body The total radiation dose received (external + internal) and the resulting risk from the exposure Combined injuries A medical determination of whether treatment can and should be administered Long-term health-monitoring of the population (population registry) Evaluating impacted population for:

IAEA 30 On-site activity - Conclusion On-site management has two target Population monitoring Injured patient The major goals of the response are to protect the public and emergency personnel Life-saving and immediate transport to hospital are the first priority at pre-hospital level medical management

IAEA 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 31

IAEA 32 First Medical Response Off-Site Local hospital Located close to the scene of an emergency Provides first treatment to exposed and/or contaminated people

IAEA 33 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

IAEA 34 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

IAEA 35 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

IAEA 36 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

IAEA 37 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

IAEA 38 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

IAEA 39 Ideal Requirements for RC Away from the ED 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

IAEA 40 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

IAEA 41 Staffing RC Triage physicians Triage nurses and assistants Health Physicists or other qualified technicians Security staff Psychologists Social assistants Administrator/Coordinator

IAEA 42 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 Photo credits: NIRS

IAEA 43 Contamination Survey Survey with GM survey meters A head-to-toe radiation survey technique 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) photo credits: REAC/TS

IAEA 44 “Medical treatment for serious conditions always take precedence over decontamination.” Contamination is never an immediate life-threatening condition Treatment Priority

IAEA 45 Radiation Does Not Cause Immediate death Immediate symptoms (burns, wounds) Contaminations alone: Not immediate threat to victim Not threat to responders or others

IAEA 46 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

IAEA 47 Conclusion On-site management has two target Population monitoring Injured patient The major goals of the response are to protect the public and emergency personnel Life-saving and immediate transport to hospital are the first priority at pre-hospital level medical management

IAEA 48 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 49 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, 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)