IAEAInternational Atomic Energy Agency

IX. EMERGENCY EXPOSURE SITUATION

IX.8.1 Medical Management of Radiation Injuries

Medical Response

Part II

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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

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First Medical Response Off-Site

• Local hospital

• Located close to the scene of an emergency

• Provides first treatment to exposed and/or contaminated people

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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

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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

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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

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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

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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

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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

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“Medical treatment for serious conditions always take precedence

over decontamination.”

Contamination is never an immediatelife-threatening condition

Treatment Priority

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“Medical treatment for serious conditions always take precedence

over decontamination.”

Contamination is never an immediatelife-threatening condition

Treatment Priority

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Triage at the Emergency Department

• Medical assessment and triage at hospital

• First aid and resuscitation

• Medical stabilization

• Radiological assessmentPhoto credits: NIRS

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Management of Non-contaminated

• Care for non-contaminated patients is like any other emergency case

• Victim of external exposure without contamination has no radiological hazard

• If exposure is known or suspected, order blood cell count in particular to determine absolute lymphocyte count and chromosome analysis.

• Record time blood sample taken

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Management of Contaminated Patient

• Ensure stabilization of patient

• Survey whether contaminated or not

• Ensure contaminated area

• Identify decontamination priority1. Wound

2. Orifices (eyes, mouth, nose, ears)

3. High level intact skin

4. Low level intact skin

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INCREASING DOSE

SUBCLINICAL

The Haematopietic

Syndrome

NEUROVASCULAR

Syndrome

GASTROINTESTINAL

Syndrome

1 Gy

50 Gy

30 Gy

6-8 Gy

4 Gy

12 Gy

Acute Radiation SyndromeAs a Function of The Dose

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Acute Radiation SyndromeAs a Function of The Delay Post-irradiation

Gastrointestinal Syndrome

Haematopoietic Syndrome

40-50 Gy

12-30 Gy

1-10 Gy

2 -3 Days 7-15 Days 30 Days

Dose

Survival time

Neurovascular Syndrome

IRREVERSIBLE SINGLE ORGAN FAILURE

IRREVERSIBLE SINGLE ORGAN FAILURE

REVERSIBLE / IRREVERSIBLE SINGLE ORGAN FAILURE

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Acute Radiation Syndrom: Clinical Course

Irradiation

0-48 hrs. hours - 21 d hours - 30 d hours - > 60 d

PRODROMAL LATENT MANIFESTILLNESS

DEATH

RECOVERY?

Time of Onset

Severity of Effect

Time of Onset

Severity of Effect

• Anorexia• Nausea• Vomiting• Diarrhoea• Fever• Lymphopenia• Granulocytosis

• Prodromata absent or diminished

• Vascular damage• Infection• Bone marrow depression• Leukopenia• Thrombocytopenia• GI symptoms

clinicalpattern

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Radiopathology of The Skin Early (Acute) Effects

After a single dose, high dose-rate:

ERYTHEMASWELLING & OEDEMADRY DESQUAMATIONBLISTERINGEPIDERMAL DENUDATION (Moist Desquamation)DUSKY MAUVE ERYTHEMANECROSISHAIR LOSSONYCHOLYSIS

Essentially depend on the epidermis layer and the microvasculature

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Radiopathology of The SkinEarly (Acute) Effects Versus Dose

• After a single dose, high dose-rate:

4- 5 Gy: Simple and transitory hair loss

6-12 Gy: Erythema , then pigmentation

12-15 Gy: Dry epithelitis, with erythema and desquamation

15-25 Gy: Moist epithelitis ( nude dermis )

Above 25 Gy: Skin radionecrosis

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Dry Desquamation

• dose 12 to 15 Gy

• dry epithelitis, with desquamation

• compensation of epidermis leakage: protection of the cutaneous barrier • absence of serum exudation• absence of skin crust formation

• epidermis thickening: rough, dry, pigmented aspect

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• Dose 15 to 25 Gy

• Epidermis leakage sufficient for: - serum exudation

- skin crust formation• 3 to 4 weeks for epidermis leakage, blistering, apparition of dripping,

pink skin area which dry and form skin crust• Stripped area covered by fibrin

Moist Desquamation

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Radionecrosis

• Dose > 25 Gy

• Endothelium loss, drop of capillary density, drop of blood perfusion

• Huge dermal inflammatory response

• Stripped area covered by fibrin

• Intense and long-lasting moist desquamation induced secondary dermal lesion

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Samples

• Nasal swabs

• Contaminated wound swabs

• Contaminated wound dressing

Easy to assess possibility of internal contamination

Identify radionuclide

Take these samples from externally contaminated patient

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Laboratory Studies

• Full Blood Count

• Cytogenetic analysis

• Urine and stool samples for later evaluation of radionuclide content

• Other laboratory studies for diagnosis and medical treatment if necessary

Diagnose and Dose assessment for whole body irradiation

Diagnose and Dose assessment for internal contamination

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Dose Assessment (1)

• Initial (Primary Assessment)• Prodromal symptoms; frequency, severity• Blood cell count foccussing lymphocyte count• Level of amylase (for exposure of head/neck)• Whole body counting (for neutrons)• Urine, stool

• Intermediate Assessment• Chromosome analysis• Count of blood cells (neutrophils, platelets)

• Full Assessment• Above• Reconstruction of accident (mathematical)

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Dose Assessment (2)

• Symptoms• Type of symptoms

• Time of onset

• Severity and frequency

• Clinical findings• Count of blood cells (CBC) with differential

• Repeat in 4-6 hours, then every 6 to 8 hours for 24 to 48 hours

• Chromosome analysis: use heparinised syringe

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A crude estimate of absorbed dose can be obtained from clinical signs / symptoms

Prodromal symptoms

Onset: 2 h after exposure or later

Onset: 1-2 h after exposure or later

Onset: earlier than 1 h after exposure

Onset: Earlier than 30 min after exposure

VERY SEVERE ARS (6-8 Gy)

SEVERE ARS (4-6 Gy)

MODERATE ARS (2-4 Gy)

MILD ARS (1-2 Gy)

Clinical Dosimetry

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Curve(1)-3.1 Gy Curve(2)-4.4 Gy Curve(3)-5.6 Gy

Curve(4)-7.1 Gy (1)

(2)

(3)

(4)

Clinical Dosimetry Using Early Changes in Lymphocyte Counts

(Adapted from Andrews, 1980)

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Cytogenetic Dosimetry

• The analysis of chromosomal aberrations in peripheral blood lymphocytes is a biological dosimetry method that is widely used to assess radiation dose

“Gold Standard”

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Calibration Curves

From EPR-MEDICAL/T 2002, IAEA, 2002, Module X

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Use of Dicentric Assay

• The most accurate method for dose estimation

• The threshold of sensitivity: about 0.1 Gy for whole body low LET radiation

• Especially useful• in cases where a dosimeter was not used, like in a

radiation accident

• to support physical dosimetry results in radiation protection and safety practice

• to determine partial body exposure (but limited), not detected by a locally placed dosimeter

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Applicability of Stable Chromosome Aberration Analysis for Biological Dosimetry

• This method is based on scoring stable chromosome aberrations (translocations and insertions) detected with fluorescent in situ

• Requires complex procedures and technical equipment

• May be use decades after exposure• The threshold of sensitivity is a few

cGy but this method is not feasible for doses less than 0.2 Gy because of the expense and time needed for analyses

• The spontaneously occuring level of stable chromosome aberrations is not well established

From EPR-MEDICAL/T 2002, IAEA, 2002, Module X

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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

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Ideal Requirements for RC

• 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

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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

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Staffing RC

• Triage physicians

• Triage nurses and assistants

• Health Physicists or other qualified technicians

• Security staff

• Psychologists

• Social assistants

• Administrator/Coordinator

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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

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Radiation Portals

Photo credits: REACTS /Oak Ridge Associated Universities(ORAU)

*2

*1

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Whole Body Counter (1)

Photo credits: NIRS

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Whole Body Counter (2)

Photo credits: NIRS

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Lung Counter

Photos credit: NIRS

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Radiation Does Not Cause

• Immediate death

• Immediate symptoms (burns, wounds)

• Contaminations alone:• Not immediate threat to victim

• Not threat to responders or others

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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

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Rescue

• Remove injured person from the hazard area into the triage area as soon as possible

Photo credits: NIRS

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Life Saving

• Medical triage

• Assess and treat life-threatening injuries immediately

• Life-threatening injured victim should transport into hospital immediately, even if contamination survey has not been done

Photo credits: NIRS

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Remove Contaminated Clothing at the Accident Scene

Photos credit: NIRS

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Contamination Survey

• It is possible to perform radiation survey during stabilization of victim if monitoring procedures do not interfere with medical actions at scene

Photos credit: NIRS

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Cover Contaminated Wounds

• Cover contaminated wounds with sterile dressings before transport to hospital emergency room

Photos credit: NIRS

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Transport of Contaminated Victims (1)

• Victims are to be transported by medical or paramedical personnel who have not entered the controlled area on scene

• Assume all victims are contaminated until proven otherwise

• Continue medical assessment and treatment during transport when necessary

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Transport of Contaminated Victims (2)

• Place the ambulance stretcher on the clean side of the outer cordoned line and pass the victims across the outer cordoned line to the prepared stretcher

• Cover victim by folding a sheet or blanket

Photo credits: NIRS

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Contamination Control on Transportation

Photos credit: NIRS

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Management of Radioactive Waste

• Collect radioactive waste in plastic bags.

• Survey bags periodically to prevent high radiation levels in the work area

• Use distance to protect against radiation from radioactive waste

• Use walls, dirt mounds, hills, etc. as shielding for radioactive waste

Photo credits: REACTS /Oak Ridge Associated Universities(ORAU)

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Contamination Control

• Before leaving the inner cordoned area, first responder should be checked contamination and change clothing if needed

Photos credit: NIRS

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Protective Measures

• Self• PPEs (Personal protective

clothing)• Personal dosimeter

• Scene• Radiation detector• Distance, Time, Shield

• Survivor (Victim)• Contamination• External exposure

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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)

• http://www-pub.iaea.org/MTCD/publications/PDF/Pub1133_scr.pdf

• 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)

• http://www-pub.iaea.org/MTCD/publications/PDF/Pub1265_web.pdf

• INTERNATIONAL ATOMIC ENERGY AGENCY, Method for Developing Arrangements for Response to a Nuclear or Radiological Emergency, EPR-METHOD, IAEA, Vienna (2003)

• http://www-pub.iaea.org/MTCD/publications/PDF/Method2003_web.pdf

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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, 2005.

• 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)