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Scenario 1
| 1) |
In this RDD (dirty bomb) scenario, which of the following statements most accurately describes the casualties that might be expected? |
| a) |
Hundreds of patients with combined injuries from significant radiation exposure and traumatic injury may present to hospitals. |
| b) |
Since EMS follows strict protocols requiring patient decontamination prior to transport, few patients will need hospital decontamination. |
| c) |
The majority of patients will arrive by taxi or in private vehicles rather than waiting at the scene as directed by first responders. |
| d) |
Decontamination will be mandatory for all patients arriving at the hospital due to wide dispersal of radioactive dust particles. |
| e) |
None of the above. |
| 2) |
Which of the following statements regarding medical response to radiological mass casualties is true? |
| a) |
Clinicians are more likely to respond to chemical incidents than radiological. |
| b) |
Treating radiologically contaminated patients poses far greater risk to caregivers than treating chemically contaminated patients. |
| c) |
Limited knowledge regarding treatment of patients with radiation injury is available in the literature. |
| d) |
Hospitals typically do not have in-house staff with expertise in radiation. |
| e) |
All of the above. |
Scenario 2 - Part A
| 1) |
Critique the scenario you just saw by indicating which of the following statements is/are true. |
| a) |
Radiologically contaminated patients should never be allowed to enter the hospital. |
| b) |
Health care workers treating radiologically contaminated patients must wear chemical suits. |
| c) |
This patient should have been immediately decontaminated upon arrival at the hospital. |
| d) |
A purpose of this “quick look” radiological survey was to assess caregiver risk. |
| e) |
All of the above. |
| 2) |
Although standardized triage algorithms for mass casualties following radiological events are not currently available, triage should be based on: |
| a) |
Traumatic injury and medical condition assessment |
| b) |
Clinical assessment of signs and symptoms of radiation exposure |
| c) |
Exposure history |
| d) |
Contamination survey |
| e) |
All of the above. |
Scenario 2 - Part B
| 1) |
This scenario includes portions of the major components of irradiation screening, including signs and symptoms of radiation exposure, the exposure history, and the contamination survey. Which of the findings is the most helpful in evaluating the radiation dose received by the patient? |
| a) |
1200 counts per minute (cpm) of contamination in wound. |
| b) |
Patient's response "No, I wasn’t ever nauseated." |
| c) |
Patient's response "I was outside." |
| d) |
Patient's response "Yes" to the question "Do you remember when the bomb exploded?" |
| e) |
Background radiation in the room is 35 cpm. |
| 2) |
Which of the following conclusions can be drawn from the radiological survey in this scenario? |
| a) |
The patient has external contamination. |
| b) |
The patient received a significant dose of radiation. |
| c) |
The patient will develop symptoms of acute radiation syndrome. |
| d) |
The patient is a hazard to the surrounding health care providers. |
| e) |
All of the above. |
| 3) |
Radiological triage assessment findings for this patient are indicative of: |
| a) |
External contamination |
| b) |
Internal contamination |
| c) |
Exposure |
| d) |
A and B |
| e) |
A, B, and C |
| 4) |
If contamination levels are not reduced by multiple cleansing attempts, it may indicate: |
| a) |
Internal contamination. |
| b) |
Aggressive scrubbing with Betadine® is needed. |
| c) |
Recent nuclear medicine testing. |
| d) |
The patient was exposed to a high dose of radiation at a rapid rate. |
| e) |
A, C |
Scenario 3
| 1) |
Which of the following statements most accurately describes expected psychosocial responses to mass casualty radiological events? |
| a) |
Widespread panic is expected due to fear of radiation. |
| b) |
Severe, recurrent vomiting may manifest as a response to stress and mimic radiation-induced prodromal symptoms. |
| c) |
Post-Traumatic Stress Disorder (PTSD) will immediately manifest in up to 30% of patients. |
| d) |
Bystanders typically initiate rescue and response efforts. |
| e) |
The most seriously injured casualties, triaged as immediate, arrive first at the hospital. |
| 2) |
Principles of psychological first aid include: |
| a) |
Provision of good medical care is of primary importance. |
| b) |
Promote debriefing by providing reminders of the traumatic event. |
| c) |
Separate families according to gender. |
| d) |
Understand that primarily victims with a previous history of psychiatric illness are vulnerable. |
| e) |
All of the above. |
| 3) |
If this dirty bomb was laced with an alpha emitting radioisotope, then: |
| a) |
Radiation burns are more likely. |
| b) |
Skin and clothing will not protect from physical injury. |
| c) |
Rotating care givers may be necessary. |
| d) |
Injury due to inhalation is more likely since alpha particles travel extensive distances in air. |
| e) |
None of the above. |
| 4) |
This patient, and many of the others standing in the ambulatory lines for radiological screening and/or decontamination, are requesting potassium iodide (KI) administration. KI is most beneficial when: |
| a) |
Administered to patients over the age of 50. |
| b) |
Used specifically to treat victims contaminated by a RDD explosion. |
| c) |
Contraindications such as pregnancy are considered. |
| d) |
Administered to patients with thyroid disease. |
| e) |
None of the above. |
Scenario 4
| 1) |
Given this exposure history and clinical presentation, what special precautions should be taken by the staff? |
| a) |
Standard precautions PPE with N-95. |
| b) |
Handling excretions in accordance with radioactive hazard protocols. |
| c) |
Double-bagging and labeling clothing as radioactive. |
| d) |
If the patient expires, the body should be decontaminated. |
| e) |
None of the above. |
| 2) |
In this scenario, which of the following will be most helpful in assessing radiation dose in the Emergency Department (ED)? |
| a) |
Presence of nausea and vomiting. |
| b) |
Lymphocyte depletion kinetics. |
| c) |
Chromosomal aberration biodosimetry. |
| d) |
Bioassay samples of urine, stool. |
| e) |
Gamma cameras or whole body counters. |
| 3) |
Drawn three hours post ED admission, the results of this patient’s CBC and differential indicate normal counts for all values. Which of the following conclusions can be drawn from these results? |
| a) |
A low dose of radiation was received. |
| b) |
Nausea did not result from radiation exposure. |
| c) |
The patient may be discharged with outpatient follow-up. |
| d) |
This patient does not have systemic radiation injury. |
| e) |
None of the above. |
Scenario 5
| 1) |
In this scenario, which of the following resources could be used for 24/7 diagnostic and treatment consultation? |
| a) |
Poison Control resources |
| b) |
In-house physicians with radiation expertise |
| c) |
Hospital-based health physicists |
| d) |
REAC/TS (Radiation Emergency Assistance Center/Training Site) |
| e) |
All of the above |
| 2) |
In this scenario, the following actions should be taken: |
| a) |
Standard precautions PPE should be worn by the caregivers. |
| b) |
Excretions should be labeled as radioactive waste. |
| c) |
Patient clothing should be double-bagged and labeled as radioactive. |
| d) |
A survey of the patient’s body should be conducted with a survey meter. |
| e) |
All of the above |
| 3) |
Which of the following drugs would be appropriate for use in this scenario? |
| a) |
Prussian Blue (Radiogardase®) |
| b) |
Ca-DTPA or Zn-DTPA |
| c) |
Potassium Iodide |
| d) |
Granulocyte Colony-stimulating Factors (such as filgrastim) |
| e) |
A and D |
Scenario 6
| 1) |
Which statement regarding the immediate effects of a 1 kiloton burst of an improvised nuclear device is not true? |
| a) |
Radiation energy is released in greater percentages than blast and heat. |
| b) |
People located greater than one mile from ground zero are likely to have no immediate health effects from radiation. |
| c) |
An electromagnetic pulse (EMP) could disrupt function of electronic devices. |
| d) |
Fallout will result if the IND is a ground surface burst, as opposed to an air burst. |
| e) |
Third degree burns may result within an approximate radius of one-half mile. |
| 2) |
Which of the following statements regarding the potential health effects of an IND are true? |
| a) |
The highest percentage of injuries will be combined injuries from thermal burns and radiation. |
| b) |
Both flash (temporary) and retinal (permanent) blindness may result. |
| c) |
Beta skin surface burns to the face and neck may result from fallout. |
| d) |
Radiation exposure results in significant immune system compromise and delayed wound healing. |
| e) |
All of the above. |
Answers to Scenario Questions
Scenario 1
| 1) |
Correct answer: |
c) |
| |
Explanation: |
Disaster research indicates the majority of patients will self-refer. Hundreds may indeed seek care, particularly given the fear associated with radiation exposure. Many will need decontamination. Many will need screening for radiological contamination, but will not be contaminated. Many will simply seek reassurance. Psychological assessment, counseling services, and patient information regarding radiation exposure, contamination and potential long-term health effects will be needed. Systemic radiation injury, or acute radiation syndrome (ARS), is not expected to occur in significant numbers. Emergency response planning, preferably done in concert with local response systems, should include scaleable surge capacity plans for high volume radiological screening, ambulatory and non-ambulatory decontamination, and counseling. |
| 1) |
Correct answer: |
a) |
| |
Explanation: |
A 2002 study [Lanzilotti, et al. Hawaii Med J. 2002; 61(8): 162-73] indicated 59% of RNs expressed commitment to help following a chemical incident, versus 45% following a radiological incident. It is highly unlikely that radioactivity associated with a contaminated patient would pose a significant risk to care providers. Significant knowledge of radiation injury is present in the literature, although most ED clinicians do not have radiation injury treatment experience. In-house radiation expertise exists in most hospitals with nuclear medicine and radiation oncology services. |
Scenario 2 - Part A
| 1) |
Correct answer: |
d) |
| |
Explanation: |
Again, it is highly unlikely that radioactivity associated with a contaminated patient would pose a significant risk to caregivers. Standard precautions PPE, with N-95 mask if available, is adequate when radiation is the sole contaminant. The “quick look” survey not only confirmed the presence of contamination, but ruled out the presence of imbedded radioactive shrapnel, a rare event that would require special precautions such as rotating care providers. Provision of life-saving treatment should take priority over radiological decontamination. Removal of this patient’s clothes likely removed as much as 90% of the contamination. To allow for provision of life-saving treatment, hospitals should have a policy and procedure for performing radiological decontamination inside the facility. |
| 2) |
Correct answer: |
e) |
| |
Explanation: |
Each of these are factors in determining triage priority. Following an RDD explosion, routine trauma triage protocols will prevail, as radiation exposure levels alone are unlikely to generate an emergent condition. Combined injury (significant mechanical trauma or burns combined with systemic radiation injury) is not likely with an RDD unless patients are trapped near sources of gamma radiation. |
Scenario 2 - Part B
| 1) |
Correct answer: |
b) |
| |
Explanation: |
The time of onset of prodromal symptoms, particularly time to emesis post radiation exposure, can be used as a rough dose estimate. Increasing radiation dose results in progressively rapid onset of prodromal symptoms. Onset within 1 - 2 hours or less may indicate significant exposure. |
| 2) |
Correct answer: |
a) |
| |
Explanation: |
This survey quantified the amount of external contamination and identified specific areas that require further decontamination. No conclusions regarding patient dose or potential for developing ARS symptoms can be drawn from the survey. The results of this survey, as well as the “quick look” survey upon arrival, ruled out any appreciable health risk to health care workers, provided appropriate PPE is worn. |
| 3) |
Correct answer: |
e) |
| |
Explanation: |
The exposure history and the radiological survey confirm external contamination and exposure to radioactive dust particles occurred. The potential for inhalation and/or ingestion of radioactive particles is also evident with these findings. This patient in particular, given the presence of external contamination near facial orifices and in the wound, is at increased risk for internal contamination. |
| 4) |
Correct answer: |
e) |
| |
Explanation: |
Both A and C are correct answer choices. Persistent high readings in the thorax area may indicate internal contamination. Certain nuclear medicine tests may induce higher than normal radiation survey readings for up to two weeks post testing. The skin serves as a barrier to most radionuclides. Since aggressive scrubbing may break the skin, this decontamination technique should be avoided. If a patient is exposed to a high dose of radiation at a rapid rate, ARS may occur but the patient will not be contaminated. |
Scenario 3
| 1) |
Correct answer: |
d) |
| |
Explanation: |
Disaster research indicates that even in the midst of confusion and fear, disaster survivors do not panic unless routes of escape are blocked. Bystanders typically initiate improvised rescue and response efforts. Stress-induced vomiting is typically episodic rather than recurrent. PTSD manifests approximately 30 days post event. The majority of those who seek care in the immediate post-event time period are not seriously injured, but evade scene triage for the nearest hospital, arriving prior to the more serious casualties. This highlights the need for separate, large areas to accommodate ambulatory patients who are at minimal risk for physical injury or radiation exposure. |
| 2) |
Correct answer: |
a) |
| |
Explanation: |
Provision of good medical care is one of the most important principles of psychological first aid. For many, the management of acute psychological responses will be just as important as treatment of physical injury. Psychological trauma may be the primary health effect for the majority of casualties. Avoid providing reminders of the traumatic event and separating families. High numbers of PTSD victims (40% after the Oklahoma City bombing) may have no prior history of psychiatric illness. |
| 3) |
Correct answer: |
e) |
| |
Explanation: |
Alpha particles cannot penetrate skin or clothing, do not cause skin damage, and can only travel a few inches in the air. If allowed to re-aerosolize, which may occur when clothing is shaken, alpha particles may be inhaled or ingested, causing localized damage in internal organs. The major danger of external contamination on clothing and skin, from both alpha and beta particles, is the potential for incorporation in the internal organs of the body. |
| 4) |
Correct answer: |
e) |
| |
Explanation: |
Potassium Iodide, although promoted to the lay public as a “radiation pill,” provides protection only for the thyroid following uptake of radioactive iodine. It has no impact on the uptake of other radioactive materials. It is highly unlikely that a dirty bomb would contain radioidodine. Exposure is more likely during a nuclear power plant event or after detonation of a nuclear bomb. The risk of thyroid cancer from radioiodine exposure in people over the age of 20 is small. A fetus, neonate or child is most susceptible and of most urgent consideration for administration. Possible morbidities include thyroid function alterations. |
Scenario 4
| 1) |
Correct answer: |
e) |
| |
Explanation: |
This patient was exposed to a radioactive source but was not contaminated. No special precautions are needed. Radioprotective PPE was utilized until the hospital staff confirmed the absence of contamination. |
| 2) |
Correct answer: |
b) |
| |
Explanation: |
Monitoring for progressive declines in absolute lymphocyte count will provide the most definitive estimate of radiation dose. The time to first emesis post exposure provides a rough dose estimate. The gold standard for dose estimation is a count of the number of dicentric chromosomes in peripheral blood lymphocytes. Processing, which requires 48 - 72 hours, is done in a specially equipped laboratory utilizing federal assistance. Excreta analysis, which also requires 48 - 72 hours for processing, assists in assessing for internal contamination. Whole body counters, which are not readily accessible, and gamma cameras, available in nuclear medicine or radiology departments, may also be used to assess for internal contamination. However, this patient was not contaminated. |
| 3) |
Correct answer: |
e) |
| |
Explanation: |
Although lymphocytes are the most radiosensitive cells within the body, the absolute lymphocyte count will not typically show significant declines until 12 hours post exposure. In this scenario, radiological triage indicates prolonged exposure that will likely result in the development of ARS. |
Scenario 5
| 1) |
Correct answer: |
e) |
| |
Explanation: |
Each of these resources could provide pertinent information and assistance. Contact information should be kept in a readily accessible location. Internal ingestion of significant quantities of radionuclides is exceptionally rare. Consultative resources for this type of scenario will be critical. REAC/TS physicians are consulted internationally in situations requiring highly specialized, state-of-the-art knowledge in treating patients with radiation illness. Contact information is provided in the CDC publication Radiological Terrorism: Emergency Management Pocket Guide for Clinicians. Consider storing this pocket guide in a convenient location in emergency services. |
| 2) |
Correct answer: |
e) |
| |
Explanation: |
Since possibly high levels of radioactive material may have been ingested by many of these patients, and the internal contamination may be severe, each of these actions may be appropriate. In-house radiation experts will be needed to assess this situation and assist in decision-making. |
| 3) |
Correct answer: |
e) |
| |
Explanation: |
Prussian Blue, ferric hexacyanoferrate, is FDA-approved to treat internal contamination with cesium or thallium. Administered orally, it binds to cesium ions in the gastrointestinal tract to accelerate cesium elimination and reduce the radiation dose. Calcium and Zinc salts of Diethylenetriaminepentaacetate (DTPA) are chelating agents for plutonium and other transuranic elements such as americium, californium and curium. Potassium Iodide use is limited to prevention of radioactive iodine uptake by the thyroid. Cytokines such as filgrastim, are FDA-approved for treatment of neutropenia resulting from myelosuppressive cancer therapy. Although not approved by the FDA for use in radiation emergencies, cytokines have been used to treat patients who suffered ARS following accidental uptake of radioactive cesium in Goiania, Brazil. |
Scenario 6
| 1) |
Correct answer: |
a) |
| |
Explanation: |
An IND will release energy in three ways: radiation (15%), heat (35%) and blast (50%). The other statements are true. Given her location from ground zero and her husband’s immediate evacuation 30 miles upwind to avoid fallout, this patient is at minimal risk for health effects from radiation. Traumatic injury (presence of penetrating and/or blast injuries with percentage of burns) will determine triage and prognosis. |
| 2) |
Correct answer: |
e) |
| |
Explanation: |
Each of these is true. Mass casualties with high volumes of patients with combined injury will test limited health care resources significantly, requiring difficult triage decisions that consider long-term prognosis. Patients with combined injury syndrome due to significant physical trauma and radiation exposure with a dose greater than 4.5 gray may be considered as expectant [Waselenko, et al. Medical Management of ARS: Recommendations of the Strategic National Stockpile Radiation Working Group. Ann Internal Med. 2004; 140(12): 1037-1051]. |
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