Hospital Preparation for a Radiation Patient

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  • Causes of Radiation Exposure and Contamination
    Accidents—There are several settings or scenarios in which radiation accidents may occur: nuclear reactor accidents; medical radiation therapy accidents or errors in treatment dose; accidental overexposures from industrial irradiators; lost, stolen, or misused medical or industrial radioactive sources; and accidents during the transportation of radioactive material.
    Terrorist Use of Nuclear Materials—The use of radioactive materials in an RDD or a nuclear weapon by a terrorist is a remote but plausible threat. The medical consequences depend on the type of device used in a terrorist event. An attack on or sabotage of a nuclear facility, such as an irradiation facility or a nuclear power plant, could result in the release of very large amounts of radioactive material.
    Radiological Dispersal Device (RDD)—An RDD disperses radioactive material for the purpose of terrorism. An RDD that uses a conventional explosive (e.g., TNT or a plastic explosive) to disperse the radioactive material is called a “dirty bomb.” A dirty bomb is NOT an atomic bomb. The initial explosion may kill or injure those closest to the bomb, while the radioactive material remains to expose and contaminate survivors and emergency responders.
    Low-Yield Nuclear Weapon—A low-yield nuclear weapon or partial failure of a high-yield weapon could cause a low-yield nuclear detonation. For example, if one considers the consequences of a 0.1 kiloton-yield nuclear detonation (less than 1/100 the size of the weapon used on Hiroshima), then the following would occur within one minute surrounding ground zero. The effects listed below do not take into account that multiple injuries caused by the interaction of the various types of injury will increase the probability of fatality. (NCRP Report No. 138)
    -The range for 50 percent mortality from trauma from the blast is approximately 150 yards.
    -The range for 50 percent mortality from thermal burns is approximately 220 yards.
    -The range for 400 rad from gamma and neutron radiation would be approximately 1/3 mile.
    -The range for 400 rad in the first hour from radioactive fallout would be almost 2 miles in the downwind direction.
    -As the size of the weapon increases, the effects encompass a greater distance. This will result in the release of widespread contamination and substantial air blast and heat.
  • Scope of Event
    428 major radiation accidents have been reported worldwide in the years 1944 to 2002. These accidents caused 126 deaths due to radiation. Their effects were dependent on exposure, contamination, and the number of people involved. There were an additional eight nonradiation deaths that would likely have resulted in eventual death due to the radiation. (REAC/TS Registry, 2002)
    There have been no uses of radioactive dispersal devices. The outcome of such an event would depend on the size of the explosion, the radioactive material involved, the activity (amount) of the radioactive material, the number of people in the vicinity, and the effectiveness of the emergency response.
    There have been no low-yield nuclear weapon detonations by terrorists. The outcome from such an event would depend on the yield, the location of the detonation, and the number of people in the vicinity.
  • Mass Casualties, Contaminated but Uninjured People, and Worried Well
    A mass-casualty incident resulting from nuclear terrorism is likely to generate large numbers of frightened people who may not require decontamination or trauma care. It may also generate people who are contaminated, but not injured or whose injuries do not require care in the emergency department. It is important to take measures to prevent these people from overwhelming the emergency department.
    A triage site should be established outside the ED. Security personnel will be needed to directed people to the triage site and prevent them avoiding the triage site and reached the emergency department.
  • Decontamination Center
    A decontamination center should be established to monitor people who may be contaminated and to provide facilities for decontamination.
    Ideally, it should provide showers. In a crisis, hoses could be used.
    A decontamination center should be staffed by physicians with a radiological background, health physicists or other staff familiar with decontamination procedures and the use of radiation survey meters, and psychological counselors.
    Towels and replacement clothing should be available. Provisions, especially in inclement weather, may be needed to shelter people or to transport them elsewhere after decontamination.
  • This slide and the previous one provide information from the CDC document “Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident,” found on the CDC Web site at http://www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf.
  • Facility Preparation
    The hospital should activate its radiological emergency medical response plan.
    A triage area should be identified for accepting patients and the worried well.
    The plan should address contamination control for staff and facilities. There should be a call-out list to obtain additional staff and equipment.
    Staff protects themselves from contamination by using universal precautions and double gloving.
    Staff should know where to obtain radiation survey meters and personnel to operate them.
    Environmental Services should establish multiple receptacles for contaminated waste.
    Call for additional support from hospital staff: Nuclear Medicine, Radiation Oncology, Radiation Safety/Health Physics.
    Plan for the decontamination of uninjured persons away from the ED.
    Protect the floor with covering if time allows.

  • Facility Preparation
    The hospital should activate its radiological emergency medical response plan.
    A triage area should be identified for accepting patients and the worried well.
    The plan should address contamination control for staff and facilities. There should be a call-out list to obtain additional staff and equipment.
    Staff protects themselves from contamination by using universal precautions and double gloving.
    Staff should know where to obtain radiation survey meters and personnel to operate them.
    Environmental Services should establish multiple receptacles for contaminated waste.
    Call for additional support from hospital staff: Nuclear Medicine, Radiation Oncology, Radiation Safety/Health Physics.
    Plan for the decontamination of uninjured persons away from the ED.
    Protect the floor with covering if time allows.

  • Treatment Area Layout
    The layout for the handling of a contaminated radiation accident victim should be established to control the spread of contamination by using universal precautions.
    Control of individuals and materials going into the area.
    Control and survey of materials and personnel coming out of the area.
    Use appropriate steps to prevent the spread of contamination (e.g., monitor gloves and change as necessary, monitor shoes when leaving, etc.).
    Monitoring of the patient and the trauma room to detect, control, and remove contamination.
    Contaminated waste water need not be contained if it will unduly complicate the treatment of the patient or it is otherwise determined to be impractical. Release of wastewater can be justified in almost all situations.
  • Hospital Preparation for a Radiation Patient

    1. 1. Emergency Department Preparation for Receiving Radiation Exposed/Contaminated Patients
    2. 2. Radiation Exposure/Contamination • Accidents • Nuclear reactor • Medical radiation therapy • Industrial irradiator • Lost/stolen radioactive sources • Transportation • Terrorist Event • Radiological dispersal device (dirty bomb) • Attack on or sabotage of a nuclear facility • Low-yield nuclear weapon
    3. 3. Scope of Event Event Number of Deaths Most Deaths Due to Radiation Accident None/Few Radiation Radioactive Dispersal Device Few/Moderate (Depends on size of explosion and proximity of persons) Blast Trauma Low-Yield Nuclear Weapon Large (e.g., tens of thousands in an urban area even from 0.1 kT weapon) Radiation Exposure Blast Trauma Thermal Burns (Depends on Distance)
    4. 4. Emergency Preparedness  Medical stabilization is the highest priority.  Contamination control should not delay critical medical care.  Be prepared for multiple hazards, including chemical, radiological, and biological.  Be prepared for multiple events, e.g., a 1st event followed by 2nd event used to take out first responders if terrorists are involved.  Be prepared for:  Large numbers of potentially contaminated individuals.  Large numbers of uninjured and uncontaminated but concerned and frightened individuals.
    5. 5. Emergency Preparedness  Triage Goals for Mass Casualty  Evaluate and sort patients by immediacy of treatment.  Do the greatest good for the most people.  In mass casualty event, may need to deal with thousands of persons in need of contamination and exposure assessment.  Pre-plan to ensure adequate supplies and survey instruments are available.  Training and drills are essential to competence and confidence.
    6. 6. Systematic Approach • A systematic approach to handling large numbers of potentially contaminated individuals is necessary. • Such an approach should provide for surveying, mass decontamination, resurveying, advanced decontamination (if necessary), resurveying, and additional decontamination or medical care as indicated. • Depending on weather, decontamination sites may have to be established indoors or in a temporary shelter.
    7. 7. Contaminated but Uninjured and Worried Well • An incident caused by nuclear terrorism may create large numbers of contaminated people who are not injured and worried people who may not be injured or contaminated. • Measures must be taken to prevent these people from overwhelming the emergency department.
    8. 8. Controlled Triage Site • A controlled triage site should be established away from the emergency department to intercept the large numbers of contaminated people who are not injured and people who are uncontaminated but worried and divert them to appropriate locations.
    9. 9. Triage Site Control • Control of movement through the site is necessary to minimize the potential for contaminating clean areas of the site. • The triage site should be staffed with medical staff, radiation monitors, and security personnel. • Precautions should be taken so that people cannot avoid the triage center and go directly to the emergency department.
    10. 10. Decontamination Center • Establish a decontamination center for people who are contaminated, but not significantly injured. • Center should provide showers for many people. • Replacement clothing must be available. • Provisions to transport or shelter people after decontamination may be necessary. • Staff the center with medical staff with a radiological background, health physicists or other staff trained in decontamination and use of radiation survey meters. • Psychological counselors available
    11. 11. Movement Through the Triage/Decontamination Areas • The path through the triage/decontamination area must be clearly marked and individuals assigned to keep traffic moving in the right direction and to prevent potentially contaminated individuals from walking into clean areas, except by the designated route. photo credits: M. Meehan
    12. 12. Directions • Clear directions (in appropriate languages) are necessary to help individuals understand what is expected of them.
    13. 13. Handling of Mass Casualties Near Emergency Department Community Controlled Triage Site Triage for Injury & Contamination Emergency Department • Perform first aid • Perform decontamination Ambulance Traffic Only Area for deceased Admit patients or treat & discharge Access for Self- referred patients Access for Staff, Press, Officials Main Hospital Serious Injury/Illness
    14. 14. Facility Preparation • Activate hospital plan: • Obtain radiation survey meters. • Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics). • Establish area for decontamination of uninjured persons. • Establish triage area.
    15. 15. Facility Preparation • Plan to control contamination: • Instruct staff to use universal precautions and double glove. • Establish multiple receptacles for contaminated waste. • Protect floor with covering if time allows. • For transport of contaminated patients into the emergency department, designate separate entrance, designate one side of corridor, or transfer to clean gurney before entering, if time allows.
    16. 16. Contaminated Waste Waste Treatment Area Layout Radiation Survey HOT LINE STEP OFF PAD CONTAMINATED AREA BUFFER ZONE CLEAN AREA Radiation Survey & Charting ED Staff Clean Gloves, Masks, Gowns, Booties Separate Entrance Trauma Room
    17. 17. Additional Considerations • Develop prepared information packets with Media Relations in advance with message for incidents involving radiation. • CDC Web site (www.cdc.gov) has Emergency Instructions for Individuals and Families Available in English Español Deutsch Français Tagalog Chinese photo credits: CDC
    18. 18. © 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.

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