Disasters can cause widespread damage, loss of life, and deterioration of health services. The document discusses different types of natural and man-made disasters and their impacts, including human suffering, property damage, and disruption of daily life. It also outlines the stages of a disaster cycle, from response and relief to rehabilitation, mitigation, and preparedness. Key aspects of disaster management include classification of disasters, triage of casualties, disease prevention strategies, and the roles of organizations like the National Disaster Response Force.

1. DISASTER MANAGEMENT
-Dr.Ravikiran HM
INTRODUCTION
Disaster (WHO): Is any occurrence that causes damage, ecological disruption, loss of human life
or deterioration of health and health services on a scale sufficient to warrant an extraordinary
response from outside the affected community or area.
Disaster (Colin Grant): Is catastrophe causing ‗injury or illness simultaneously to at least 30
people‘, who will require hospital emergency treatment.
 Human sufferings (injuries and deaths). Survivors are at risk of developing infectious
diseases due to epidemics like acute gastroenteritis, measles, hepatitis A, malaria, etc.
 There is widespread panic in the community.
 Death of animals, destruction of standing crops and damage to the properties.
 Roads, rails, bridges, electrical installations, telecommunications, buildings and other
properties are damaged.
 Disruption of all the routine activities of the community.
 Acute shortage of food, clothes, shelter, etc. resulting in living problems.
 Most commonly reported disease in post-disaster phase is Gastroenteritis
 Most practical and effective strategy of disease prevention and control in post-disaster phase
is ‗supplying safe drinking water and proper disposal of excreta‘
 Foremost step for disease prevention and control in post-disaster phase is chlorination of all
water bodies
 Level of residual chlorine to be maintained in all water bodies in post-disaster phase is > 0.7
mg/l (> 0.7 ppm)
 A common micronutrient deficiency in disasters is Vitamin A deficiency: It occurs due to
deficient relief diets, measles and diarrhea (gastroenteritis)
 Other common deficiencies include scurvy (Vitamin C), anemia (iron) and pellagra (Vitamin
B4 –niacin).
CLASSIFICATION
Natural Disasters:

2. Natural Phenomena Beneath the Earth‘s Surface (Tectonic)
a. Earthquake.
b. Tsunamis.
c. Volcanic eruptions
Phenomena at the Earth‘s Surface (Topological)
a. Landslides.
b. Avalanches.
Natural Phenomena above the Earth‘s Surface
a. Meteorological (Hydrological) phenomena
i. Windstorms (Cyclone, typhoon, hurricane)
ii. Tornadoes
iii. Hailstorms (or Snow storms)
iv. Sea-surges
v. Floods
vi. Droughts.
b. Biological phenomena
i. Epidemics of diseases
ii. Locust swarms (group of insects/bees)
Man-made Disasters
• Caused by Warfare
– Conventional
– Nuclear
– Biological
– Chemical
• Caused by accidents
– Vehicular—Air crafts, train, ship, four wheelers, two wheelers.
– Drowning
– Collapse of the building
– Explosions
– Fires
– Biological

3. – Chemicals including poisoning
STAGES OF A DISASTER CYCLE
1. Disaster impact and response:
2. Stage of health and medical relief
3. Rehabilitation
4. Mitigation
5. Disaster preparedness
• Disaster impact and response:
 Search, rescue and first aid
 Field care: Food to be provided at the place of disaster. People are sheltered in tents,
schools and community halls. Health resource persons (doctors, nurses, etc.) and other
volunteers, police, home guards are deployed to the place. An enquiry center to be
established to respond to patients, friends, relatives and family members. Dead victims to
be identified and adequate mortuary space provided.
 Triage
 Tagging
 Identification of dead: The dead body is removed from the site of disaster, shifted to
mortuary, identified and bereaved family members are received. If the dead bodies
contaminate the water sources as in floods, the risk of water-borne epidemic is more.

4. • Stage of health and medical relief: Disaster containment
 Primary phase (0-6 hours): First aid, medical care
 Secondary follow-up (6-24 hours): Transportation, sanitation and immunization
 Tertiary clean up (1-60 days): Food, clothing, shelter assistance, social service,
employment, rehabilitation
• Rehabilitation:
 Water supply
 Sanitation and personal hygiene
 Food safety
 Vector control
• Mitigation: Measures designed to either prevent hazards from causing emergency or to lessen
the effects of emergency. For example, improving the structural qualities of schools, houses and
such other buildings so that medical casualties can be minimized. Similarly, ensuring the safety
of health facilities and public health services including water supply and sewerage system
reduces the cost of rehabilitation and reconstruction. This mitigation compliments the disaster
preparedness and disaster response activities.
• Disaster preparedness: This consists of strengthening the capacity of a country to manage
efficiently all types of emergencies, so that the resources should be able to provide assistance to
the victims and bring back the life to normal.
Preparedness should be in the form of money, manpower and materials.
Disaster preparedness is a continuous, on-going multisectoral activity.
It also consists of the following measures:
• Evaluation, from past experiences about the risk, the area has
• Location of disaster prone areas
• Adoption of a standard operating procedure
• Organization of communication, information and warning systems
• Ensuring co-ordination and response mechanisms
• Development of public education program

5. • Co-ordination with news-media
• National and international relations
• Organization of disaster simulation exercises that test response mechanisms
• Keeping stock of foods, drugs and other essential commodities.
The preparedness should be active and energetic when it is forecasted before it really strikes, a
few hours before in case of cyclones and a week before in case of floods.
TRIAGE
• Triage: Consists of rapidly classifying the injured ‘on the basis of severity of their injuries and
likelihood of their survival’ with prompt medical intervention
–– First come first serve is NOT followed in emergencies
–– Triage yields best results when carried out at the site of disaster
• Triage sieve: Quick survey to separate the dead and the walking from the injured
• Triage sort: Remaining casualties are assessed and allocated to categories
• Triage system: Most commonly uses FOUR color code system:
–– Red (Highest Priority): Immediate resuscitation or limb/life saving surgery in next 6
hours
–– Yellow (High Priority): Possible resuscitation or limb/life saving surgery in next 24
hours
–– Green (Low Priority): Minor illness/AMBULATORY patients
–– Black (Least Priority): Dead and moribund patients
• Tagging: Is the procedure where identification, age, place of origin, triage category, diagnosis
and initial treatment are tagged on to every victim of disaster through a Colour Coding.
Types of Triage
• Triage is of two types:
Simple triage: Simple triage is used in a scene of mass casualty, in order to sort patients into
those who need critical attention and immediate transport to the hospital and those with less
serious injuries
- T his step is required before transportation becomes available

6. - T he categorization of patients based on the severity of their injuries can be aided with
the use of printed triage tags or colored flagging
Rapid triage: S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can
be performed by lightly-trained lay and emergency personnel in emergencies
- I t is not intended to supersede or instruct medical personnel or techniques
- I t may serve as an instructive example
- It has been field-proven in mass casualty incidents such as train wrecks and bus
accidents
Reverse Triage: In addition to the standard practices of triage as mentioned above, there are
conditions where sometimes the less wounded are treated in preference to the more severely
wounded. This may arise in,
–– A situation such as war where the military setting may require soldiers be returned to
combat as quickly as possible
–– Disaster situations where medical resources are limited in order to conserve resources
for those likely to survive but requiring advanced medical care.
National Institute for Disaster Management (NIDM)
• Established: 1995 (under Indian institute of Public Administration)
• Ministry In-charge: Ministry of Home Affairs
• Head: Union Home Minister
• Purpose:
–– To work as a think tank for Government by providing assistance in policy formulation
–– To facilitate in reducing the impact of disasters
National Disaster Response Force and Civil Defence (NDRF)
• Established: 2006
• Composition: 10 battalions from CRPF, BSF, ITBP, CISF
• Purpose:

7. –– Civil defence: To safeguard the life and property of the civilian population and also to
maintain the continuity of productive and economic activity of the nation during war time
crisis
–– Home guards: To assist the police in controlling civil disturbance and communal riots
(maintenance of internal security)
–– Fire cell: To organize Fire prevention and Fire fighting services, and to render
technical advice on Fire Protection, Fire Prevention and Fire Legislation

9. Figure 1: SALT: Sort, Assess, Life saving intervention, Treatment/Transport

10. Figure 2 START then SAVE: Simple triage and rapid treatment, Secondary assessment of victim end point

11. NATURAL DISASTERS
Introduction: a major adverse event resulting from natural processes of earth.
Examples: Earth quake, Tornado, Tsunami, Floods
Definitions:
A mass casualty event is one that overwhelms the hospital or the community‘s
healthcare system.
Natural disaster in which the hospital is damaged or loses electricity or water
Disaster (natural/industrial/terrorist) in which care is provided on site
Disasters and mass casualty events are not something in which we participate on a daily basis so
therefore education and training for these situations is critically important, beginning with
preparation to respond to the most likely disasters to occur in our respective geographic location.
Role of Anesthetist: Becoz of their combined knowledge
1. Emergency Room : resuscitation, Triage
2. Oprating room: anesthesia for emergency surgery
3. Recovery room
4. ICU
5. Pain management
Other places anesthesia providers can assist during a disaster include:
1. to assist in triage outside the hospital (who better to manage the pain or labored
respiration of the expectant patient?),
2. to assist in decontamination (who better to evaluate for the presenc of anticholinesterase
(nerve) agents or cyanide toxicity),
3. to assist with vascular access or airway management (made more difficult if wearing a
HAZMAT suit and even more difficult if one has never worn such a suit), or
4. to assist in ventilator management in the ICU or in overflow areas of the hospital such as
the PACU of patients with respiratory failure caused by a nerve agent or biologic agent.
Features:

12. 1. Resource rich place to resource poor place
2. From one country to another: language & cultural changes
3. Lack of food, water, O2, fuel, electricity, telecommunication, transport, blood, fluids,
drugs, lab, paramedics, hospital infrastructure
4. New working place Ex: ships, trains
5. Emergency cases: life and limb saving procedure
6. Lack of familiarity with 3rd
world infectious disease Ex. Tetanus
7. Opportunistic infection: Ex. Necrotizing cutaneous mucormycosis during Joplin Tornado
8. Communicable diseases becoz of poor hygiene and sanitary facility Ex: cholera,
dysentery-Tsunami
9. Damage to education institute –medical students-clinical practice and exams. Ex: Katrina
hurricane
10. Psychological stress
Physical: long working hours, inadequate rest
Mental: witness pain, suffering, death
Operating room management

14. PREPARATION—PERSONAL PREPAREDNESS
Family Plan
Government Plan
NGO‘s Plans
Family Plan and Personal plan
The former is important whether one is single or lives alone. Whether or not one has a
pet, family, or friends living with them, or has legal responsibility for a loved one (elderly

15. parents, disabled person) one must have a plan for these individuals that provides care for
and information to loved ones.
Plans might include situations such as
 what to do if there is a fire,
 what to do if parents do not make it home,
 the location of second copies of all important documents,
 where to meet if the house or neighborhood is destroyed or not accessible.
 Many assume that they will be able to communicate with loved ones during a
disaster but often cell phone towers are damaged or so many people are trying to
use the system that the network is overwhelmed. Plan in advance so that you are
prepared for these contingencies.
 And just as service members have a duffel bag or sea bag packed with toiletries,
bedding, change of clothes, money, flash lights, and battery operated radio, those
with such important roles as ours ideally should have a packed duffel bag as well.
Government plan
 Disaster Medical Assistance Team (DMAT)—a team that supposedly can rapidly
mobilize and whose goal is to set up and staff with physicians, nurses and other
support personnel emergency facilities and pharmaceutical dispensaries
geographically as close as possible to a disaster. The teams are supposed to be
selfsustaining for at least 72 hours before they require outside logistics. Just as the
reserve military forces do, a DMAT is supposed to train 1 week-end a month.
 Disaster Mortuary Team (DMORT) as the name implies is a team that would
manage large numbers of dead following a mass casualty event with capacity to
conduct forensic examinations.
 National Veterinary Response Team (NVRT) is a team established to provide
veterinary services as well as zoonotic disease surveillance.
 Medical Specialty Enhancement Teams (MSETs). MSETsare going to consist of a
group of precredentialed anesthesiologists and surgeons (30 of each), along with a
few pediatricians. The concept is that there would be a pool of specialists who would
be activated during a crisis, whether domestic or international, and would have

16. sufficient logistic support that the team could deploy to either a fixed facility or a
field site. Once activated MSET members would be federal employees during their
deployments for a minimum of 2 weeks and would be protected by workers‘
compensation laws
NGO plan
Three major areas:
I. Enlisting the community to develop the local response.
II. Focusing on the key aspects of the system that prepares the community to mobilize to
care for patients, protect its staff, and serve the public.
III. Establishing the accountabilities, oversight, leadership, and sustainment of a
community-preparedness system.
ACTS OF TERRORISM

17. Twin tower attack or September 11th attacks: deadliest act of terrorism in recorded history-
3000death.
Hospital phone lines were non-functional-use mobiles/radio/satellite communications
Medical students were employed as runners and assigned to attending physicians. All
workers were encouraged to wear a label on their shirt with name, specialty, and title, to
expedite face-to-face communication.
Triage
Mass shooting
No region appears to be safe from these events, as they have occurred in schools,
churches, offices, and military bases in all parts of the country.
The lethality of these attacks appears to be increasing with each passing year, in part
because more and more of these shootings are carried out with military-style semiau-
tomatic rifles as opposed to conventional guns.
With a normal gunshot wound, the radiologist can trace a laceration through affected
organs that is roughly the same width as the bullet itself. Following the Parkland shooting
with an AR-15, radiologists and trauma surgeons observed that tissue had been destroyed
in wide swaths near the pathway of bullets. Organs were found to be ―smashed‖ and
―shredded,‖ where traditionally they are found to be merely lacerated following handgun
injuries. This extensive damage to surrounding structures occurs as a result of the much
higher bullet velocities and thus higher energy levels transmitted by assault rifles as
compared with typical handguns.
Requesting additional blood products prior to losing the tamponade effect following the
opening of the abdomen or the chest.
BOSTON MARATHON BOMBING
Use of tourniquet to decrease bleeding
CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR WARFARE

18. Introduction:
In today‘s global political environment the threat of a chemical, biological, radiological, or
nuclear (CBRN) attack combined with massive casualties cannot be disregarded.
Understanding the toxic effects and pathophysiologic effects of CBRN agents can help reduce
the collateral damage to first responders. Anesthesia providers are essential in resuscitation
efforts at the scene of an attack and with continued life support measures during sustained CBRN
and terrorist attacks.
World War I as the ―Chemist‘s War.‖
Biological weapons being considered weapons of mass destruction by the British government,
because they led to catastrophic and painful loss of life.
Risk of these weapons being transferred to terrorist groups
Risk of utilizing different combinations of chemical, biological, and/or nerve agents.
The massive release of chemical, biological, or nerve agents among a very large population is
possible in theory, but this would require a delivery modality such as a missile, rocket, or violent
explosive vehicle.

19. Figure 3 U.S. Dept. of Defense CBRN Response table.

20. Figure 4 Lesion learnt from past incidence
CHEMICAL AGENTS
The main categories:
Blistering agents (vesicants)—
 Generally affect the eyes and mucous membranes.
 In addition, they damage the respiratory epithelium.
 Airway management in these patients can be cumbersome for anesthesia providers
because of sloughing off epithelium and necrotic tissue occluding the glottic view and
anatomy.
 Overall, the effect and toxicity depend on the type of agent, the concentration of the
agent, the weather/weather patterns, and exposure time.
Blood agents (nerve agents)—
 Generally inhibit oxygen transfer from blood or hemoglobin to the cells of the body, or in
another way causes tissue hypoxemia.

21.  Overall, the higher the concentration of blood agents, the more rapidly fatal these agents
are.
 Most blood agents inhibit acetylcholinesterase activity, increasing the concentration of
acetylcholine at the muscarinic and nicotinic receptors, causing cholinergic toxicity.
 This excessive acetylcholine in the body can cause a myriad of symptoms, but for the
anesthesiologist airway interventions can be hindered because of significant airway
occlusion from secretions and profound bronchospasm, which is why atropine should be
administered prior to any airway intervention
 Higher concentrations of agent lead to more rapid physiologic decline proceeding to
cardiopulmonary arrest.
Choking agents (pulmonary agents)—
 Generally cause a shift of fluid into the small airways at lower doses, while at higher
doses all the major airways become irritated and dried out, causing choking, poor gas
exchange, and ultimately, death.
 Rapid, shallow breathing, painful cough, and cyanotic skin are indicative of fluid filling
the lungs and preventing oxygenation.
 Commonly, these patients will present with pulmonary physiology that mimics acute
respiratory distress syndrome because of the fluid shifts, airway irritation, and
inflammation.
Riot control agents—
 Generally cause lacrimation or vomiting.
 Unlike the choking agents, they are irritants that are used to cause a brief period of
misery and harassment to subdue or incapacitate a threat or aggressive persons.
 Most of these agents inhibit multiple different enzymes and invariably increase
bradykinin release.
 Overall, these agents do not require significant medical attention except flushing of
the eyes and removal from the environment.

22. BIOLOGICAL
Biological hazards are relatively easy to produce, especially since production facilities have very
little environmental signature.
Production of these microbes or organisms can pose a significant threat to human and animal
welfare.
Biological agents differ from chemical agents in that the agents are living organisms, viruses,
toxins and/or microtoxins utilized to disable, disrupt, or kill other human beings or other
organisms.
While most biological agents are small, they have tremendous potential for lethality and applica-
tion to a large-scale attack.

23. Most biological agents are accessible throughout the world and are relatively inexpensive to
produce compared to weaponization of chemical, radiological, or nuclear agents.
Limitation:they can be degraded by changes in the environmental conditions such as ultraviolet
light, temperature, and humidity.
Initial symptoms: are vague and nonspecific. However, in the event there is high index of
suspicion for a biological attack, steps must be taken to protect first responders and medical
personnel.
Physical protective barriers and personal protective equipment (PPE) are essential primary
preventive measures. In addition, for other hazard responders and personnel there are
vaccinations and immunizations for certain biological agents. By protecting our primary
responders and healthcare providers during biological attacks, they are more apt and readily able
to care for those directly and immediately in danger.
BIOTERRORISM
With the advancement in techniques, genetic manipulations, delivery systems, the threat of
biological warfare is more eminent today, not only aiming at human enemies but also towards
live stocks and crops to produce economic loss.
Biological weapons: are defined as microorganisms that infect and grow in target hosts to
produce a clinical disease.
Such microbes can be natural, wild type strains or genetically engineered organisms. They
produce their effects in humans, livestock and crops.
Biological weapons (BW) are aptly called as ‗Poor man’s atomic bomb’, as their production cost
is low.
An ideal BW is the one, which:
• Can be produced in large quantities
• Can infect large number of individuals
• Can be stable when stored
• Retains the virulence after aerosol dissemination.

24. History:
 Biological warfare seems to have been existing since 600 BC when Roman Generals
poisoned water used by the enemy, by dumping rotting animal carcasses.
 In Scythia (400 BC) arrows were used dipped in blood, manure or decomposing bodies
and targeted at water supply of the enemy.
 Hanibal in 190 BC hurled venomous snakes in Roman ships.
 The tartars of Ukrain (1346) catapulted bodies of plague victims into the city of Kaffa.
 Blankets infested with smallpox were distributed to American Indians during the French
and Indian War which raged between 1954 through 1967.
 The Japanese (1932) experimented on Chinese by using Anthrax, Cholera and
Shigellosis.
 Members of religious cult (1984) in Dalas, Oregon, contaminated salads in restaurants
with Salmonella typhimurium in an attempt to influence the results of elections.
 In 1995, the Japanese Cult-Ann Shimrikyo, released nerve gas in a Tokyo sub-way.
 In the recent past Anthrax contaminated letters were posted to politicians.
Merits
 Low cost—‗Poor man‘s atomic bomb‘.
 Large quantities can be produced in short time with small facilities.
 Nondetection by routine security system (biosensor), access to a wide range of agents and
their dispersal can be made silently.
 Very toxic, hence small quantities will kill large number of persons.
 Destroys the enemy leaving his infrastructure intact as booty for the winter.
Demerits
 Difficulty of protecting workers during production, transportation and delivery.
 Difficulty in maintaining quality control, contamination during growth and harvesting.
 Effective delivery system.
 May be destroyed after delivery.
 May disperse in unexpected ways aided by the wind.
 Need specific conditions for storage; hence difficult to maintain in weapons.
 Difficult to control once released.

25. Delivery of Biological Weapon
 Scud missiles
 Motor vehicles with a spray
 Handpump sprayers
 By an individual
 Book or letter
 Guns
 Remote control devices
 Robotic delivery.
At Risk Group
The first responders are physicians, infectious disease specialists, epidemiologists, hospital and
public health administrators and laboratory experts.
Steps to be Taken
 Detection: A microbiologic confirmation is needed.
 Case definition: To be formulated by health care personnel.
 Notification: To proper civilian and military authorities.
 Differentiation between natural and terrorist warfare:
– Natural: Gradual rise in cases.
– Terrorist: Sudden rise in cases, in hours or days.
 Investigation: A quick identification of the source and consequence of the outbreak.
 Medical intervention: Diagnosis, isolation and treatment.
 Prophylaxis: Immunization of health care professionals and contacts—actively or
passively.
 Public awareness: It needs to be created to ensure that the incident does not turn into
public hysteria.
Prevention and Control Measures
 To create awareness among the public and doctors.
 To stock pile drugs and vaccine.

26.  Allocation of separate funds.
 Preparedness: This is not a cause for panic—It is a cause for serious, deliberate long-
term concern.
 International collaboration is required as BW do not respect ‗boundaries, culture,
language or territory‘, hence solution has to be global.
 Microbiologists are the main focal point of action, because the BW are the products of
their specialty.
Anthrax
 has additional appeal to bioterrorists because inhalation anthrax is hard to detect.

27.  It manifests as an influenza-like disease with fever, myalgias, malaise, and a
nonproductive cough with or without chest pain. After a few days, the patient appears to
get better, but then a couple days later the patient becomes much sicker with dyspnea,
cyanosis, hemoptysis, stridor, and chest pain.
 The most notable finding on physical examination and laboratory testing is a widened
mediastinum.
 Usually when a patient develops profound dyspnea, death ensues within 1 to 2 days.
 In the past, penicillin G was the treatment of choice, but since weaponized anthrax has
been engineered to be resistant to penicillin G, ciprofloxacin or doxacycline is more
commonly used. In the outbreaks in Florida, Washington, D.C. and New Jersey contacts
of infected patients or people exposed to the spores were treated with ciprofloxacin or
doxacycline.
 A recent study concluded 8 years later that this drug regimen is the best strategy for
managing a small-scale attack as occurred in 2001
Plague:
Two types: Bubonic and pneumonic.
 With bubonic plague, after a fleabite, there is a 2- to 6-day incubation period at which
time there is the sudden onset of fever, chills, weakness, and headache. Intense painful
swelling occurs in the lymph nodes, usually in the groin, axilla, or neck. This swelling or
buboes are typically oval in nature, 1 to 10 cm in diameter and extremely tender. Up to
25% of patients will have pustules, papules, or skin lesions near these buboes. Without
treatment, patients become septic, develop septic shock with cyanosis and gangrene in
peripheral tissues, leading to the ―black death‖ descriptor that was used during the
epidemics in Europe. As mentioned, material from these buboes is infective only if
inoculated into human tissue.
 However, patients who have bubonic plague can seed their lungs in which case they
develop pneumonic plague. During coughing, they aerosolize Y. pestis which is highly
contagious. Mortality for either form of the disease is over 50%.
Diagnosis is made with a Gram stain or culture of organisms from blood, sputum, or buboes.

28. The treatment of choice
 is streptomycin, but chloramphenicol and tetracycline are acceptable alternatives.
 These patients with pneumonic plague should be managed as one would manage a patient
with drug resistance to tuberculosis as the respiratory secretions are highly infectious.
 There is currently no vaccine against Y. pestis.
The treatment of choice for tularemia
 is streptomycin, though gentamicin, tetracycline, and chloramphenicol have been
used.
 There is a concern that the former Soviet Union, perhaps the United States, and
perhaps terrorists have engineered F. tularenis to be resistant to a number of agents.
 Prophylaxis with streptomycin, ciprofloxacin, or doxycycline has been recommended
in the past for individuals exposed to the organism.
 There was a vaccine available that comprised of an attenuated whole organism strain,
but it is not available.
Treatment of botulism:
 Toxins can be removed through gastric lavage, use of cathartics, and with enemas.
 The treatment of patients includes the use of a trivalent antitoxin.
 Patients with profound respiratory embarrassment should have their airways protected
and mechanical ventilation initiated.
 Without the use of antitoxin, it takes the patient 2 to 8 weeks to recover.

29. Radiological and Nuclear Weapons and Effects
Radiological hazards include electromagnetic or particulate radiation capable of causing damage,
injury, or destruction through ionizing effects of neutrons, γ rays, α particles, or β particles.
Radiological damage can be dispersed in many ways, but ultimately causes destruction, damage,
or injury to a large population of people, while exposing an even larger population to the
lingering effects of ionizing radiation.
Nuclear weapons are a complete assembly of weapons capable of independently being armed,
fired, fused, and detonated to release a large-scale nuclear explosion capable of significant
destruction to the land, environment, people, and animals within a large area.
The intensity of nuclear weapons is greater than that of chemical and biological weapons, and the
deployment of a nuclear weapon will cause significantly more death and destruction from the
point of detonation, outward.
Short- and long-term devastation can be attributed to nuclear fallout, which is the residual
radioactive material that is propelled into the atmosphere following a nuclear detonation. Thus,
nuclear and radioactive material is literally falling from the sky and is moved miles and miles
away by winds within the atmosphere.
Unlike chemical attacks or biological attacks, nuclear/ radiological attacks rarely induce the need
for immediate airway intervention, even in the harshest of exposed patients.
While nuclear warfare can devastate a large area, the immediate impact can be considered
similar to a high-grade explosive device.
The main difference between nuclear weapons and conventional explosives is that a nuclear
weapon will do greater damage by orders of magnitude. Overall, acute management of the
effects of high radiation doses is prudent.
Most commonly, supportive care of the hematological, gastrointestinal, neurologic,
cardiovascular, and integumentary systems are required. Following a major radiological or
nuclear attack, patients with significant nausea and vomiting may require intubation for airway
protection.
Three basic reasons why CBRN situations occur:

30. 1. Intentional—This is a deliberate action to induce harm in the form of toxic agents,
release of radiological agents, or the detonation of explosive material in an attempt to
cause terror for political, religious, or ideological purposes.
2. Accidental—A human error–induced release of toxic agents, release of radiological
agents into the environment, or detonation of explosive material.
3. Natural—Caused directly by or in response to a natural disaster, which leads to the
release of toxic agents, release of radiological agents into the environment, or detonation
of explosive material.
Unfortunately, because of the possibility of blast, thermal, and crush injuries, along with the
radiation injury, the care of the injured may require the care of patients who have multiple
combined injuries.
The initial response should be as per the advanced trauma life support (ATLS) guidelines, which
include an assessment of the airway, breathing, and circulation, and extent of trauma and then
decontamination of the patient after which the patient is stabilized and further evaluated.
Wounds must be considered contaminated. ―Dirty wounds‖ should not be closed, but cleaned
and debrided, excised, and observed.

31. Management of CBRN:
Currently the ASA has several suggested protocols for CBRN attacks, but to make these
protocols most useful will require extensive and ongoing training.
Disaster preparedness and coordination is not simply an ED problem to manage.
For anesthesia providers, it is critically important to reinforce clinical skills and practices so that,
in the event of a massive casualty event, during a natural disaster, or during a potential CBRN
attack they are prepared to respond immediately and appropriately.
Population control, situational control, and on-scene containment are essential to maintaining
order and functionality of the civilian emergency disaster system.
As anesthesiologists, the main responsibility is to be present for operating room needs, but their
advanced medical knowledge, advanced pharmacology knowledge, and advanced trauma-
stabilization training makes them ideal to aid and support emergency triage physicians.
An anesthesiologist‘s primary role is to stabilize and ensure safe operating conditions for
casualties of any CBRN attack, terrorist attack, or natural disaster.
However, this is not limited to preoperative assessment and intraoperative management of
CBRN victims. During times of crisis, anesthesiologists cannot remain sequestered in the
operating room awaiting the arrival of injured patients. They must be proactive within the
hospital system or emergency response system, providing triage and management of patients
prior to arrival at the operating room or the ICU.

32. In the face of a mass casualty event from a CBRN attack, panic and chaos are to be expected.
Successful response to a CBRN attack requires command and control personnel and the medical
providers to prioritize the following: personnel safety, personnel protection, command
establishment, and site-wide communication. Similar to the U.S. military, the civilian sector has
command control entities in the form of local, state, and federal response systems.
Protection
At any time during intubation, exposure to bodily fluids, and/or airborne infection the
minimum protection level should be C.
Protection is the key feature of incident management, and anesthesia providers should be
familiar with several levels of PPE suits and masks, and the techniques of decon-
tamination

33. Basic investigation

34. Decontamination
In most situations the initial hazards are unknown, however protecting oneself is one of the
major keys to on-scene and in-hospital care of the afflicted patients.
Many hazards are short-lived or transient, but it should be assumed that the hazard released is
persistent and transmissible through the on-scene decontamination zones.
Immediately establishing the level of personal protection required for medical staff, paramedics,
and ancillary search and research personnel by the on-scene commander is vital to preventing an
increased number of casualties among medical and rescue personnel.
To safely work on search and rescue and decontamination many on-scene commanders
immediately place a level C minimum for PPE for medical staff and paramedics, and upgrade or
downgrade based on situational changes onsite.
In most situations, people in contact with chemical agents or radioactive materials are
decontaminated by those with proper training—the decontamination is normally performed first
and then patients are evaluated and triaged.

35. The process is usually fairly straightforward;
 clothes are removed and individuals are washed with copious amounts of water (the
contaminated water and apparel can present quite a challenge!);
 if individuals have been exposed to a chemical agent, a dilute solution of sodium
hypochlorite 0.5% (household bleach) can be used.
 However, if the patient presents with life-threatening injury, the patient is treated first
and decontaminated afterward.
 Patients with severe chemical agent poisoning may present with acute respiratory
failure requiring emergency tracheal intubation.
In this scenario, an anesthesiologist would be assigned to the decontamination station.
For obvious reasons the intubation would have to be performed with the anesthesiologist wearing
a hazard material (HAZMAT) or a biohazard suit with multiple-layered gloves and a gas mask.
The suits are not insulated and if the decontamination is performed outside the hospital the
extremes of temperature can significantly hinder performance, as does the decreased manual
dexterity because of the gloves and the impairment in vision from the face hoods.
Ideally individuals with prior training would manage the airway intubation but depending on
circumstances that may not happen. As many have learned from the past experience, it is best to
anticipate the unexpected, and to be flexible if the maximum numbers of patients are to be saved.
Preparation of equipment and drugs before the arrival of contaminated patients decreases the
difficulties with manual dexterity that are encountered while wearing the multiple-layered or
rubber gloves.
Consider securing the airway with a laryngeal mask airway, when indicated, rather than with a
tracheal tube.
Triage personnel and medical personnel are vital to providing immediate:
(1) triage,

36. (2) life-support measures (TOXALS—toxicology advanced life support), and
(3) antidote and other pharmacologic support.
A unique perspective to CBRN on-scene decontamination and resuscitation was introduced in
1996, and was uniquely termed TOXALS (Toxicology Advanced Life Support) to be used in
conjunction with ACLS, ATLS, and BLS in the setting of chemical, biological, and/or
radiological attacks.
TOXALS protocol expands the on-scene and in-hospital resuscitation efforts of trained medical
personnel and incorporates principles of ACLS, ATLS, and BLS, which can be expanded to the
pneumonic ABCDDEE: airway, breathing, circulation, disability, drugs, exposure, and
environment.
EPIDEMIC AND PANDEMIC INFECTIOUS OUTBREAKS
Lifesaving application of positive pressure ventilation by Danish anesthesiologist Dr. Bjorn
Ibsen probably saved hundreds if not thousands of lives during the Copenhagen polio epidemic
of 1952.
Knowledge of the disease, management options, and importantly, infection-control measures
necessary to protect oneself, are all critical for anesthesiologists to contribute maximally and
mitigate personal vulnerability during the next epidemic or pandemic.
Smallpox is the deadliest pandemic in human history. In the 20th century alone, estimates of
deaths due to smallpox exceeded 300 million people with 30% of all persons infected succumb-
ing to the disease.
Unfortunately, unlike viruses that have a human reservoir such as smallpox, polio, and measles,
and hence are targets for eradication, the next pandemic is more likely to be the result of
zoonotic transmission.
Anesthesiologists routinely perform medical procedures that are aerosol-generating in patients
with highly contagious pathogens

37. We should only perform procedures on patients with suspected or confirmed disease that are
critical to optimizing care.

39. Reference:

40. 1. Millers 9th
ed
2. Barasch 7th
ed & 8th
ed
3. Review of Preventive and Social Medicine-Vivek Jain-7th
ed
4. PSM text book by Suryakantha