Decontamination of Patients  External  Skin  Wound  Internal  Decorporation agents DHS/NTC B461 Course 1

Patient Decontamination  Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of contamination)  Handle foreign objects with care until proven non radioactive with survey meter  Survey patient and collect samples Survey face, hands and feet Survey rest of body Note: Avoid contamination of the probe.

DHS/NTC B461 Course 2

External Contamination  Radioactive material (usually in the form of dust particles) on the body surface and/or clothing  Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff DHS/NTC B461 Course 3

External Contamination – Remove with Showering DHS/NTC B461 Course 4

Decontamination Priorities  Wounds  Intact skin (areas of highest contamination first)  Change outer gloves frequently to minimize spread of contamination DHS/NTC B461 Course 5

Decontamination of Wounds  Contaminated wounds:  Irrigate and gently scrub with surgical sponge  Debride surgically only as needed  Contaminated thermal burns:  Gently rinse  Changing dressings will remove additional contamination  Avoid overly aggressive decontamination  Change dressings frequently DHS/NTC B461 Course 6

Decontamination of Skin  Use multiple gentle efforts  Use a mild soap & water solution  Cut hair if necessary (do not shave)  Promote sweating:  Plastic wrap, glove, etc.  Use survey meter DHS/NTC B461 Course 7

Cease Patient Decontamination  When decontamination efforts produce no significant reduction in contamination  When the level of radiation of the contaminated area is less than twice background  Before intact skin becomes abraded  Consider internal contamination DHS/NTC B461 Course 8

Internal Contamination  Radioactive material may enter the body through: Inhalation - Ingestion - Wounds  Internal contamination generally does not cause early signs or symptoms  Internal contamination will continue to irradiate the patient DHS/NTC B461 Course 9

Treatment of Internal Contamination  Rare earths - Plutonium - Transplutonics - Yttrium  Uranium  Cesium, rubidium, thallium  Tritium DHS/NTC B461 Course 10

Potassium Iodide (KI)   Only helpful in blocking thyroid gland KI saturates the thyroid gland with stable iodine  KI must used prior to or within hours of exposure to radioactive iodine  See the FDA web site:

www.fda.gov/cder/drugprepare/KI_Q&A.htm

  Decorporation agent Provide to Decon Team Members DHS/NTC B461 Course 11

Immediate Medical Management of Radiation Exposed Patients  Triage  Acute Radiation Syndrome (ARS)   localized/cutaneous combined injury  Initial stabilization and treatment  Psychological effects  Record keeping/Dose assessment DHS/NTC B461 Course 12

Management - Priorities of Radiation Exposed Patients  Standard medical triage is the highest priority  Radiation exposure and contamination are secondary considerations DHS/NTC B461 Course 13

Management – Protocol of Radiation Exposed Patients (Cont) Based on:  Injuries  Signs and symptoms  Patient history  Contamination survey DHS/NTC B461 Course 14

Prenatal Radiation Exposure  Human embryo and fetus highly sensitive to ionizing radiation  At higher doses, effects depend on dose and stage of gestation  Pregnant patients should receive special dose assessments and counseling  Information on prenatal radiation exposure www.bt.cdc.gov/radiation/prenatalphysician.asp

DHS/NTC B461 Course 15

Required Conditions for Acute Radiation Syndrome  Large dose  Penetrating  Most of body exposed  Acute DHS/NTC B461 Course 16

DHS/NTC Acute Radiation Syndrome Never delay critical care because a patient is contaminated B461 Course 17

1986 Chernobyl Accident “When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personal at the site received less than 10 mGy of radiation.” Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61 DHS/NTC B461 Course 18

Skin Effects  Epilation  Erythema  Pigmentation  Dry desquamation, (Shedding, flaking off)  Moist desquamation that heals B461 Course

NUREG / CR-4214, p II-68

19 DHS/NTC

Treatment of Large External Exposures Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24 48 hr) (Neupogen®) DHS/NTC B461 Course 20

Treatment of Cutaneous Radiation Syndrome  Lesions do not appear for days to weeks  Perform surgical treatments within 48 hrs  Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment, 865-576-1005 or www.orau.gov/reacts/ DHS/NTC B461 Course 21

Dealing With Staff Stress  Preplanning   Establish information center Train staff on radiation basics  Post Event   Debrief immediately after event Offer counseling DHS/NTC B461 Course 22

Bomb Blast - Injury Patterns  Most survivors suffer secondary and tertiary blast effects  Primary blast injury is infrequent in survivors  15% of survivors require hospital admission  The remaining are treated and released from the emergency department DHS/NTC B461 Course 23

Staff Preparedness  Plan for the needs of the unaffected population:   Ratios range from 5-15 to 1 5 15 “worried well” to 1 actual injured patient  This can paralyze your ED   Rotate staff to avoid congestion and fatigue  Prepare to receive large numbers of casualties Monitor staff in chemical protective clothing & equipment (CPC&E) DHS/NTC B461 Course 24

Logistics/Supplies  Highest priority: getting the right resources to the right place at the right time:    Chemical protective clothing and equipment Medications / antidotes / vaccines Mechanical ventilators  Isolation rooms remote from other patients  Identify current inventory and augment as necessary  Develop a procedure to access external assets DHS/NTC B461 Course 25

Maximal Utilization of Hospital Space  Identify alternative medical treatment areas  Planning for use of available space:       Open areas Isolated areas Temporary morgue Conference room Cafeteria Physical Therapy DHS/NTC B461 Course 26

Handling of Evidence  Maintaining evidence is critical for an investigation:   Clothing Embedded foreign bodies  Decontamination runoff  Chain of Custody must be maintained DHS/NTC B461 Course 27

Table Top Exercise

Hospital Incident Management System (HIMS) Hands-on Exercise - Overview

Table Top Exercise

Hospital Incident Management System (HIMS) Hands-on Exercise - Report Out