Radiological and Nuclear Terrorism: Medical Response to Mass Casualties

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Radiological and Nuclear Terrorism: Medical Response to Mass Casualties

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About

Version

Radiological and Nuclear Terrorism: Medical Response to Mass Casualties,” in CD-ROM and Web versions, was released on April 15, 2006.

Program Purpose

The purpose of this training is to prepare clinicians in first receiver settings to: (1) Identify factors impacting immediate medical response to mass casualties following major types of radiological incidents, and (2) Demonstrate appropriate patient assessment, triage, treatment and disposition decision-making required during a radiological mass casualty incident.

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Learning Objectives

After completing this training activity, you will be able to:

  1. Describe the immediate health effects of potential radiological terrorism incidents likely to result in mass casualties.
      Discuss the major considerations impacting emergency response planning for a radiological terrorism incident involving mass casualties.
      Describe the major considerations impacting establishment of mass decontamination systems following a radiological terrorism incident.
      Identify the key principles involving triage of patients with potential radiation injury (Acute Radiation Syndrome).  
      Describe the key components of treating patients with combined injury (trauma and radiation injury).
      Describe the key components of treating patients with atraumatic irradiation (radiation without traumatic injury).
     
  2. Identify the major pharmacological agents used to treat patients with radiological injury following a mass casualty radiological terrorism incident.

Time

You should allow approximately two hours to complete this activity. The actual time you spend will depend on how much of the supplementary material, in the Resources section, you review.

Audience

The intended audience for this training are MDs and RNs in the emergency departments of first-receiver settings.

Prerequisites

As a prerequisite for this training, you should have basic knowledge of emergency preparedness and general trauma resuscitation knowledge comparable to that required to work professionally in emergency services care delivery.

In addition, some introductory knowledge regarding medical response to radiological terrorism is recommended, comparable to that provided previously by the Centers for Disease Control and Prevention in a CE approved training on Medical Response to Radiological and Nuclear Terrorism (http://www.phppo.cdc.gov/PHTN/webcast/radiation-04/default.asp)

Continuing Education Credit Information

How to Register

In order to register for this course you must complete the Self Test.

To register for the course and receive continuing education credit:

To receive continuing education credit, you must complete the entire course, take the Self Test, and provide an evaluation online.

At the time you complete the online evaluation you will be required to provide a verification code. Watch for this verification code as you complete the activity.

For assistance with the online system, call (800) 41-TRAIN or (404) 639-1292 Monday through Friday, 8:00 AM to 4:00 PM Eastern Standard Time or send an e-mail to CE@cdc.gov.

General Information

The content for this activity was finalized on March 31, 2006 and is valid for continuing education credit until March 31, 2009. We encourage you to periodically review the CDC Radiation Emergencies Web site (http://www.bt.cdc.gov/radiation/) for updated information.

Credit

CME:  The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 2.0 hours in category 1 credits towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the activity.

CNE:  This activity for 2.4 contact hours is provided by the Centers for Disease Control and Prevention, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation.

Contact Us

Send questions and comments about this training to:

Centers for Disease Control and Prevention
800-CDC-INFO
E-mail: cdcinfo@cdc.gov

Additional complimentary copies of the CD-ROM can be ordered by sending name, address, and phone number to cdcinfo@cdc.gov.

Disclosure Statements

CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Jeffrey Nemhauser’s discussion on Pharmacotherapy. He will be discussing filgrastim.

Additional Statements

This training was produced under contract number AC05-06OR23100. The producing contractors are the U.S. Department of Energy and Oak Ridge Associated Universities. The Oak Ridge Institute for Science and Education (ORISE) is a U.S. Department of Energy institute focusing on scientific initiatives to research health risks from occupational hazards, assess environmental cleanup, respond to radiation medical emergencies, support national security and emergency preparedness, and educate the next generation of scientists. ORISE is managed by Oak Ridge Associated Universities.

Portions utilize Microsoft Windows Media Technologies. Copyright© 1999-2002 Microsoft Corporation. All Rights Reserved.

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Getting Started

Welcome

Michael A. McGeehin, PhD, MSPH
Director, Division of Environmental Hazards and Health Effects
National Center for Environmental Health
Centers for Disease Control and Prevention

Welcome to the CDC’s clinician training program on Radiological Terrorism: Medical Response to Mass Casualties. I am Dr. Mike McGeehin, Director of the CDC’s Division of Environmental Hazards and Health Effects in the National Center for Environmental Health.

Over the last few years, we have all become aware of the immense challenges of responding to incidents involving mass casualties. From the events of September 11 to Hurricane Katrina, we have continued to learn from experience how we can improve the emergency response capabilities of our national healthcare system. Although this system has not been tested by a radiological terrorism, the potential is real. The purpose of this program is to provide clinician education on how to respond locally to mass casualties with potential radiological injury.

The program is designed for physicians and nurses, working in first receiver acute care environments, who have had introductory training in radiological emergency preparedness. If this topic is new to you, the CDC web site on radiation emergencies identified on the CD-ROM cover, provides sources of introductory information. This program has two parts: first, a series of lectures on potential radiological incidents, response planning, decontamination principles, triage and treatment. In Part II you have the opportunity to apply the lecture material in a series of six simulated patient case studies depicting hypothetical radiological terrorism incidents.

As new information becomes available, the CDC radiation emergencies web site will be updated. Your feedback or suggestions on our radiological terrorism preparedness initiatives would be greatly appreciated. Please send those via email to cdcinfo@cdc.gov. Thank you for your interest in this program.


Objectives

Upon completing this training, you should be able to:

  1. Describe the immediate health effects of potential radiological terrorism incidents likely to result in mass casualties.
     
  2. Discuss the major considerations impacting emergency response planning for a radiological terrorism incident involving mass casualties.
     
  3. Describe the major considerations impacting establishment of mass decontamination systems following a radiological terrorism incident.
     
  4. Identify the key principles involving triage of patients with potential radiation injury (Acute Radiation Syndrome).  
     
  5. Describe the key components of treating patients with combined injury (trauma and radiation injury).
     
  6. Describe the key components of treating patients with atraumatic irradiation (radiation without traumatic injury).
     
  7. Identify the major pharmacological agents used to treat patients with radiological injury following a mass casualty radiological terrorism incident.

Disclosure Statements

CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Jeffrey Nemhauser’s discussion on Pharmacotherapy. He will be discussing filgrastim.


Instructions

Please review the prerequisites for this training before beginning.

The training material needed to accomplish the learning objectives is organized into six lectures and six case study scenarios.

Each video lecture is 5 – 20 minutes long and is accompanied by a handout. The lectures provide information on: Potential Scenarios, Planning Response, Decontamination, Triage, Treatment and Pharmacotherapy.

You may wish to print out your handouts now so they are available as you watch each lecture. (Lecture Handout List)

Apply what you have learned from the lectures by answering questions and making decisions in each of the six case study scenarios. (See Scenario Instructions.)

All references and Web sites cited in this training are listed in the "Resources" section.

To proceed through this training, use the "Next" button in the upper or lower right corner of your screen. You may also navigate directly to a section by using the menu on the left.


Your Instructors

The lecture portion of this training is provided by members of the Centers for Disease Control and Prevention, Radiation Studies Branch.

James Smith, PhD
Associate Director for Radiation
Division of Environmental Hazards and Health Effects (EHHE)
Radiation Studies Branch
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

Hello. I'm Dr. Jim Smith, a physicist and an Associate Director for Radiation at the Centers for Disease Control and Prevention.

Jeffrey Nemhauser, MD
Medical Officer
Radiation Studies Branch
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

Hi. I'm Commander Jeffrey Nemhauser, a Medical Officer with the Radiation Studies Branch at the Centers for Disease Control and Prevention.


CE Credits

To obtain CE credit for this training you must complete this training and take the Self Test. Upon completion you will be given the verification code.

For more information about this training and how to obtain continuing education credits, see the "About This Training" link (located on the starting page and in the Index.)

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Potential Incidents (Handout)

James Smith, PhD
Associate Director for Radiation
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

There are several unique challenges in responding to radiological or nuclear terrorism. First the medical response infrastructure in the U.S. is untested for a major radiation event involving mass casualties. Furthermore, clinicians are for the most part, inexperienced with treating radiation injuries and there is a general fear of radiation exposure often expressed not only by members of the public, but also by health care givers!

Finally, there could be an exceptionally large number of casualties, plus many more who are worried or concerned but otherwise not hurt. Combined these could readily overwhelm the local hospitals.

There are several differences between radiation and biological or chemical exposures. The effects of radiation exposure have been extensively studied since World War II. We know a lot more about the health effects of radiation than we do about most other agents. Also, unlike many biological or chemical agents, radiation is readily detectable with proper instrumentation. Fortunately, radiation detectors are widely available, they are in use, and are reliable when properly maintained. Let’s discuss some potential terrorist scenarios. Of course, there could be a targeted attack on a nuclear installation. Or, terrorists could choose to use a radiological exposure device, for example, a hidden, or covert radioactive source. Or terrorists could choose a radiological dispersal device or RDD, commonly referred to as a dirty bomb.

And finally, there could be a detonation of an improvised nuclear devise or a stolen nuclear weapon. It’s instructive to discuss the last three of these. The radiological exposure device could employ radioactive sources that are stolen from industrial facilities or from hospitals. These devices have the potential to expose people to lethal doses of radiation by hiding the source in a large public place, such as transit system. Tens to hundreds of people could present with symptoms of acute radiation syndrome. Thousands more could require medical or exposure monitoring. Let’s examine a case study to illustrate how this type of scenario might play out. This incident occurred in Goiânia, Brazil, in 1987. A radioactive source, it was actually a powered Cesium 137 source, was obtained from an abandoned medical facility. Contamination was spread throughout the community by person-to-person contact. About 250 people received significant exposures. Over 50 were hospitalized and there were 4 deaths, among them a small child who had ingested some of the highly radioactive powder. Over 100,000 people were monitored for contamination. That was greater than 10 percent of the total population. Now, can terrorists obtain radioactive sources? Consider that there are about 157,000 licensed users in the U.S. and approximately two million devices containing radioactive sources. The nuclear regulatory commission tells us that about 400 sources are lost or stolen in the U.S. every year.

The radiological dispersal device usually refers to a conventional explosive laced with radioactive material, that is, a dirty bomb. In this case, tens to hundreds could present with conventional traumatic injury, possibly significant radiation exposure, if they are near the detonation, and external or internal contamination. On the other hand, hundreds to thousands could present for radiological screening or counseling. Now, the worst case scenario would be illustrated by an improvised nuclear device or stolen nuclear weapon. This could potentially kill or injure tens of thousands of people. Thousands could present with combined blast, burn, and radiation injury. Hundreds of thousands could be displaced and require exposure and medical monitoring, decontamination, and counseling. Keep in mind, major metropolitan hospitals could be destroyed or rendered inoperable. Some examples of the immediate effects of a one kiloton improvised nuclear device include blast, thermal and radiation injuries. A one kiloton yield represents about ten percent of the yield that occurred with the Hiroshima bombing. The direct blast could result in deaths up to 200 yards away from the source of the blast. Third degree burns and radiation doses lethal to 50% of those exposed could occur out to a distance of one-half mile from the explosion.

In summary, radiation terrorist events are unique, but radiation is readily detected with proper instrumentation. A variety of scenarios exist for radiological and nuclear terrorism. These scenarios are possible and radioactive sources that might be employed are plentiful. Radiation exposures and the numbers of people requiring treatment vary widely with the different scenarios. In all cases, there is the potential for the hospitals to be overwhelmed with a combination of casualties and those who self-refer but are otherwise unhurt.

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Planning (Handout)

James Smith, PhD
Associate Director for Radiation
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

A national response plan exists for disasters, including terrorist events, that describes how the federal government will coordinate operations. It outlines the procedures, and the roles and responsibilities for federal agencies. It also defines resources most likely needed during an incident.

But remember, all emergencies are local. Federal resources will require many hours, to days, before arriving.

An example of a significant national resource is CDCs Strategic National Stockpile.  Its mission is to maintain a national repository of life-saving pharmaceuticals and medical materiel that could be delivered to the site of a terrorist event to supplement local resources.  A federal plan, however, cannot substitute for a community emergency plan. This type of planning involves a large network of partners, including not only the area hospitals and clinics, but also fire, police, EMS, health departments, the news media, and many other organizations.

Let’s look at some of the immediate response issues: facility preparation, surge capacity, health care provider safety, patient decontamination, triage and the medical management of life threatening injuries. With regard to facility preparation, first, activate the hospital disaster plan. In addition, obtain radiation survey meters and personal dosimeters for staff.

Contact, the radiation safety officer and in-house radiation  Professionals, for example, the staff in nuclear medicine and radiation oncology.  Establish triage and decontamination areas with warm and cold zones. Establish areas for patient treatment with a system for patient transportation. And it is important to establish a crowd control plan with adequate security.

In planning for triage, let’s consider how victims would arrive at the hospital.  In the Oklahoma City bombing of 1995 we found that more than half of those who arrived at the local area hospitals came by private vehicles.

In the sarin attack in Tokyo of the same year far more of those that arrived at the local hospitals came as walk-ins, by private vehicle, or were delivered by taxi.

A review of the disaster literature indicates that a majority of   patients seeking care in the immediate post event time period are self referrals. People will most likely go directly to the closest or most familiar hospitals and most who seek care will be ambulatory and minimally injured as well as those who are not hurt but understandably concerned about possible health effects. This is a natural response to mass causality incidents.

An important strategy for triage is categorizing the risk.  The medium to high risk group would include those with severe physical trauma, significant exposure or internal contamination.  They should be referred to the emergency department as their condition requires.

The low risk group would include those with limited trauma, exposure and contamination. They should be decontaminated, treated and observed.  The negligible risk group includes those with minimal or no trauma, exposure, or contamination. They may require decontamination, but   will certainly require information and reassurance.

An exceptionally important triage strategy is that of establishing a secondary assessment center physically separate from the hospital. This is a basic step toward protecting the hospital from becoming overwhelmed. It is also useful for pre-clinical screening, assessing exposure and contamination, and conducting triage and decontamination as well as reuniting families.

The secondary assessment center should be established in the planning stages by working with communities and local and state agencies.  These centers could be community facilities, such as schools and churches, and they could involve non-traditional personnel such as allied health professionals, retired health care workers, and community nurses.

Let’s summarize: Remember, all emergencies are local.   The initial hours of response will be managed by the local emergency response system and the local hospitals.

The majority of patients seeking care in the immediate post-event time period are self-referrals.

In addition to clinical personnel, have available radiation experts, radiation survey meters and personal dosimeters.

And finally, plan for establishing secondary assessment centers, physically separate from the hospital.

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Decontamination (Handout)

James Smith, PhD
Associate Director for Radiation
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

Let’s review a few key principles of decontamination.

First, radioactive contamination is easy to detect and most of it can be readily removed. It is also highly unlikely that this contamination poses a significant risk to health care providers.

An important principle to keep in mind is that provision of life-saving treatment should take priority over radiological decontamination. For these cases, hospitals should have a policy and procedure for performing decontamination inside the facility. On the other hand, patients without life-threatening injuries should be decontaminated prior to treatment.

Segmentation of patients during the decontamination process is an important consideration. For example, dealing with those who are ambulatory vs. non-ambulatory, segregating male and female, and having a procedure to keep families together as much as possible throughout the process.

In protecting staff from contamination use standard precaution personal protective equipment and, if available, N95 masks. Change outer gloves frequently. It’s recommended to have personal dosimeters for keeping track of radiation exposures to individual staff due to contamination on patients or in the facility. Also, it is recommended to have a full-body radiological survey when exiting any warm zone.

Although highly unlikely, for those scenarios where an explosion has occurred, metallic shrapnel from a radioactive source may become embedded in wounds. In those cases, a radiation survey can identify highly radioactive fragments present. These fragments should be removed with forceps and sealed in a lead container. This is another instance when cooperation with the radiation safety officer or other radiation experts is very important.

Where practical, use additional protective measures in dealing with any highly radioactive fragment or source. Think of it in terms of time, distance, and shielding. That is, decrease the time spent near the radioactive source. And where practical, increase the distance and the amount of physical shielding between you and the source.

Finally, it is important to decontaminate the facility in the recovery phase of the emergency.  Always coordinate this with the radiation safety officer. Remove waste from the emergency department and triage area. And survey the facility for contamination and decontaminate as necessary.

Now, let’s summarize. Radioactive contamination is easy to detect and most of it can be readily removed. Provision of life-saving treatment should take priority over decontamination.  Complete a radiation survey to rule out highly radioactive fragments that may be embedded in the patient  for those scenarios involving explosions.

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Triage (Handout)

Jeffrey Nemhauser, MD
Medical Officer
Radiation Studies Branch
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

In the aftermath of a radiological or nuclear incident, clinicians should expect large numbers of both physically and psychologically injured individuals to present to hospital emergency departments – this may include people not in close physical proximity to the event.

For the purposes of triage following such a disaster, individuals can be divided into 1 of 4 categories:

Since we assume that clinicians are already well-trained to handle patients that fall into the latter 2 categories – that is, those not exposed to radiation – this lecture will focus on the management of persons who have suspected or confirmed radiation exposure.

Radiation exposure – also referred to as “irradiation” – can cause serious or life-threatening illness.

At sufficiently high doses, irradiation by itself may precipitate the onset of early, life-threatening adverse health effects.

This occurs, however, only at levels of exposure likely to be seen in instances like the detonation of a nuclear bomb or an improvised nuclear device.

Individuals who have been exposed to radiation and who have sustained physical trauma are said to have combined injury.

Combined injury is defined as physical, thermal, and/or chemical trauma combined with radiation exposure at a dose sufficient to threaten overall survival or recovery.

Thus, management of any traumatic, thermal, or chemical injury can be complicated by the added presence of radiation exposure and triage and treatment decisions must include consideration of the health effects of radiation exposure.

Treatment decisions for individuals with combined injury should be based on the following four criteria:

Combined, these 4 factors can help guide the emergency clinician in the proper management and treatment of a patient in a mass casualty situation, especially when resources may be limited.

I’m now going to spend a little time discussing how the presence of characteristic adverse health effects and certain laboratory test results can assist the clinician in the mass casualty management of victims of radiation exposure.

“Adverse health effects due to radiation exposure” form one important set of clinical clues that the emergency clinician can use to assist in triage of the Radiation Mass Casualty victim.

These initial adverse health effects form one part of an illness known as Acute Radiation Syndrome or ARS.

ARS is caused by irradiation of the whole body – or significant portions of it – over a relatively short period of time.

The type and severity of ARS health effects and the timing of their onset depend on the total amount of energy deposited in – or absorbed by – the body.

This is known as the radiation dose.

All cases of ARS may be divided into 3 Stages:

The prodrome is the stage most likely to be seen by the emergency clinician and is the stage during which early triage and management decisions will be made.

Depending on the dose of exposure, clinicians in the emergency department may – or may not – witness the onset of the latent period and the manifest illness stages of ARS.

The prodrome stage of ARS is the first stage of this illness.

Onset is usually rapid – and, for most radiation exposures, lasts approximately 24–48 hours.

Adverse health effects most commonly seen during the prodromal stage include nausea and vomiting, possibly diarrhea, fatigue, headache, salivary gland inflammation, erythema or redness to the skin, and fever.

By themselves, none of these adverse health effects should be considered life-threatening although fluid and electrolyte loss due to vomiting and diarrhea may become problematic.

The prodrome of ARS is particularly helpful in the triage of patients with acute radiation exposure.

During this stage, the onset of adverse health effects occurs more rapidly with more severe forms of ARS than with the more mild forms.

Nausea and vomiting, in particular, are reliable indicators of acute radiation sickness.

The time to emesis following an exposure is roughly correlated to the absorbed dose – as we shall see on the next slide.

The rapid onset of vomiting following a radiological or nuclear incident indicates a high dose of exposure and an increasingly poor prognosis.

Conversely, vomiting occurring more than 2 hours after a possible exposure is indicative of a lower dose of exposure, a milder course of ARS, and a better overall prognosis.

Another useful clinical sign of high dose radiation exposure is a rise in core body temperature.

As seen in this table, a rise in core body temperature can be used – like nausea and vomiting – as a marker for exposure and a rough estimate of dose and outcome.

Vital signs should therefore be checked on presentation and as often as staff resources will allow.

This slide – and the one that follows – summarizes the clinical findings characteristic of the final stage of ARS – and the prognosis for recovery – based on the ARS prodrome.

Simply put, as the time to disease onset shortens and severity of prodromal health effects worsen, the worse the prognosis becomes.

I’m not going to take the time to fully discuss these slides now but I encourage you to use them as references.

In this slide, we see the worsening spectrum of disease.

In each case, vomiting occurs within the first 2 hours after exposure and possibly even sooner.

In the bottom row, for example, a severe prodrome – characterized by the onset of vomiting (within minutes) and diarrhea – combined with CNS injury, fever, and shock – is indicative of certain death, usually within days.

Using these clinical clues can help to give clinicians an estimate of radiation-induced injury and an indication of how best to allocate limited resources in the face of a mass casualty event.

Lymphocytes are among the most radiosensitive cells in the body and clinicians can use that fact to help aid their triage decisions.

A progressive decline in absolute lymphocyte counts provides an early estimate of injury caused by acute radiation exposure – if within the first two days of exposure, lymphocytes have decreased by 50% and are less than 1000 cells per μL, the patient has received at least a moderate dose of radiation.

This is seen in the graph on this slide – the Andrews nomogram.

We recommend that victims of acute radiation exposure should have – as part of their workup – a complete blood count drawn at baseline.

This should be repeated in 4–6 hours and then every 6–8 hours thereafter for 24–48 hours.

Results should be plotted and compared to the curves on this nomogram – significant, rapid declines in absolute lymphocyte count during the first 2 days indicate both a higher dose of radiation exposure and a poorer likelihood for recovery.

This slide now reintroduces the concept of Combined Injury discussed earlier.

Radiation Mass Casualty events in which there are large numbers of patients having combined injury will test limited health care resources significantly and triage decisions will need to be made that consider long-term prognosis.

Mass casualty patients following a radiological or nuclear incident may be triaged as either exposed or not exposed to radiation.

Trauma victims having radiation exposure have what is referred to as “Combined Injury” and, in general, will have a worse prognosis.

Trauma victims not having radiation exposure will be managed by emergency teams as usual.

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Treatment (Handout )

Jeffrey Nemhauser, MD
Medical Officer
Radiation Studies Branch
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

In the triage module, I described how victims of a mass casualty radiological or nuclear incident may present to the hospital with combined injuries – that is, physical, thermal, and/or chemical trauma combined with an exposure to radiation at doses sufficient to threaten overall survival or recovery.

Treatment decisions for victims of radiation exposure may be based on the characteristic physical findings of the prodromal phase of Acute Radiation Syndrome – nausea and vomiting and fever – and also on complete blood count results.

I’m now going to continue the discussion of Combined Injury Management by emphasizing the importance of:

Your ability to perform some – or all – of these activities may be limited by the numbers of victims and the depletion of available resources and health care infrastructure during a mass casualty event.

Despite the added burden of injury caused by radiation exposure, resuscitation and stabilization remain the primary objectives of patient management.

Several factors distinguish thermal or chemical burns from cutaneous radiation injury or CRI.

Unlike severe thermal or chemical burns, the initial skin damage caused by CRI may begin to show signs of healing after several weeks.

This may then be followed months later by ulceration.

Like severe thermal and chemical burns, CRI lesions can be debilitating and life threatening and medical follow-up is essential.

In addition, victims should be cautioned to avoid additional trauma to involved areas.
The outcome of these injuries is dependent on the total dose of radiation received and the total body surface area irradiated.

Another key aspect to the management of a combined injury patient – as it is with nearly all patient evaluations – involves obtaining an exposure history .

If available, information about

This information can help to establish the likelihood of exposure, and the potential that internal and/or external contamination may have occurred.

A contamination assessment – where possible – can provide the clinician with additional important information about victims of radiation exposure.   However, as I noted earlier, patient stabilization should not be delayed in favor of conducting contamination surveys and decontamination.

If readily available, screening for contamination should be completed as part of the survey of a patient presenting with combined injury.

In their absence, clinicians should assume that the victim of a combined injury is externally contaminated and provide initial decontamination through a careful removal of clothing.

Any further attempts at decontamination should be delayed until after the patient has been adequately stabilized and resuscitated as per Advanced Trauma Life Support protocols.
In my lecture dealing with victim triage, I discussed the importance of establishing a baseline lymphocyte count and tracking that count over time.

Doing so can provide an estimation of the dose of radiation absorbed by a patient and this will allow clinicians to better predict outcome and allocate resources.

In a mass casualty situation involving hundreds or even thousands of victims, tracking lymphocyte counts may be the best – and most readily available – means for assessing the dose of radiation to which individuals have been exposed.

In the face of such an event, however, the availability of laboratory staff and resources may be significantly compromised.

The sheer volume of specimens generated following such an event is likely to tax hospital laboratory capabilities even if infrastructure and staffing remain fully in place.

Planning for a radiation or nuclear mass casualty event therefore must include discussions about how to appropriately collect and label numerous specimens to facilitate their timely and correct analysis.

Other tests that clinicians may consider obtaining include:

Where possible, additional blood samples should be drawn into heparinized tubes and refrigerated.

Another laboratory study that can aid in proper patient management is the analysis of urine for radioactivity.

A 24-hour collection of urine should be initiated in the emergency department – the presence of radioactivity in the urine is highly suggestive of internal contamination and can indicate an urgent need for decontamination.

In terms of treatment priorities in a combined injury patient, traumatic injuries must be assessed and managed first.

In the first part of this lecture, I emphasized the importance of assessing and managing the ABCs and conducting a complete and thorough trauma survey – proper early trauma management can help ensure the long-term survival of a victim, early decontamination cannot.

That having been said, all open wounds identified during a trauma survey should be considered contaminated with radioactivity – timely decontamination of open wounds is a necessary part of the management of these patients.

In addition – in order to protect the hospital staff – all visible pieces of shrapnel should be assumed to be radioactive and removed and stored in shielded containers.
 
Current guidelines call for early surgery – within the first 36–48 hours in patients with combined injury – before the effects of bone marrow injury occur and platelet and white cell counts begin to fall.

Even when indicated surgery is completed within the recommended time frame, patients with combined injuries are at risk for:

Having spent the last little while talking about the emergency management of combined injuries, I would now like to briefly discuss the early management of victims of atraumatic irradiation injury.

The absence of trauma makes the management of victims of atraumatic irradiation somewhat less complicated than that of combined injury patients.

The key concepts in taking care of a patient with atraumatic irradiation are essentially the same as those for a combined injury patient:

First, obtain a focused history – including a medical history – and details about the individual’s exposure to the radiation:

Next, use physical examination findings just as you would for assessing an individual with combined injury.

After completing a history and physical examination – if personnel and equipment are available – emergency staff should conduct a contamination assessment to identify contamination.

Finally, just as with victims of combined injury, obtaining a CBC with differential at baseline is key.

In summary, then, victims of acute radiation exposure may – or may not – have additional traumatic injury.

Those persons having penetrating and/or blunt trauma and/or burns – in addition to acute radiation exposure – are said to have combined injury.

For these patients, management of traumatic injury takes precedence over radiological decontamination.

In patients with thermal or chemical burns, these should be distinguished from cutaneous radiation injury – the appropriate treatment differs for each.

Whether dealing with a victim of combined injury or a victim of atraumatic irradiation, obtaining an exposure history, identifying the time to onset of specific adverse health effects, conducting a contamination survey, and appropriate use of laboratory resources are the keys to proper triage, diagnosis, and management.

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Pharmacotherapy (Handout)

Jeffrey Nemhauser, MD
Medical Officer
Radiation Studies Branch
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)

The deposition of radioactive materials in the body – or internal contamination – is a time-dependent phenomenon related to both the physical and chemical properties of the contaminant. Once internal contamination has occurred, the rate of radionuclide incorporation into target tissues can occur rapidly. Thus, time to treatment is critical. For treatment to be effective, it must be administered quickly in order to have the best chance at mitigating adverse health effects.

Clinicians will need to rely on the basic tools of diagnosis – history, physical examination, and a couple of confirmatory laboratory studies – to make a presumptive diagnosis of internal contamination. An exposure history can help identify the likelihood or potential for inhalation or ingestion of radionuclides following a radiation mass casualty event.  These clues can help increase the clinician’s index of suspicion that internal contamination may have occurred. On physical examination, the presence of open wounds containing shrapnel should suggest the possibilities of internal contamination. Finally, a laboratory assessment can provide clues as to the likelihood of internal contamination. If present, measured levels of radioactivity in a victim’s urine are strongly suggestive of internal contamination.

Once internal contamination has occurred, a goal of treatment is to prevent incorporation of radionuclides in internal organs. Gastric lavage and catharsis are methods familiar to most physicians that can be used shortly after ingestion of a radionuclide to help facilitate rapid excretion from the body. Recommended treatment for cobalt 60, phosphorus 32, and radium 226, for example, includes the use of Gastric Lavage.  In the case of Radium 226 ingestion, this should be accomplished using a 10% magnesium sulfate solution. Whether attempting gastric lavage on large numbers of patients is feasible or practical will be determined by the size of the event. An additional point I would like to make concerns the use of activated charcoal. Activated charcoal is widely available in most emergency departments for use as a GI decontaminant, and most clinicians are well acquainted with its use. Based on current information, however, the efficacy of activated charcoal may be limited. While there is no obvious downside to its use, it may not be a useful adjunct for gastrointestinal decontamination of radionuclides. The effects of radiation exposure, such as nausea and vomiting, should also be treated. Drugs to treat nausea, vomiting, and diarrhea should be used as necessary and fluid and electrolyte balance should be carefully monitored and aggressively treated.

Ultimately, treatment decisions may be based on a history that is only suggestive for exposure or on incomplete laboratory data. Nonetheless, for treatment to be most effective it should be initiated early following radiation exposure and clinicians may be required to make decisions about whom to treat in the absence of complete or compelling evidence. Some treatment modalities for internal contamination are currently available – the most sophisticated of which are directed at preventing incorporation or removing radioactive isotopes from the body.

I would now like to introduce the discussion of the pharmacotherapy of internal contamination and acute radiation illness.  In the event of a radiological or nuclear event, four drugs are available for use from the Strategic National Stockpile.  Three drugs: Potassium Iodide, Prussian Blue, and DTPA may be used to treat internal contamination.  The fourth, the granulocyte colony stimulating factor, filgrastim is used in the treatment of the hematopoietic syndrome. In a mass casualty situation, demand for these drugs may exceed initial supplies. Although some states already have stores of KI, the other drugs on this list will likely only be available in quantities sufficient to treat large numbers of casualties from the Strategic National Stockpile. A deliberate and careful use of these agents will necessitate an understanding and application of radiological mass casualty triage principles since not all individuals exposed to radiation or internally contaminated with radiation will be candidates for drug therapy.  Pharmacotherapy may not be indicated in patients with low levels of exposure or internal contamination.  Furthermore, assuming that resources will be limited following a radiation mass casualty event, it may be appropriate to withhold definitive care from those identified by triage criteria as having high levels of exposure and, consequently, a poor prognosis; such individuals should, however, receive adequate pain management, antiemetics, and antidiarrheals.

Potassium iodide – or KI – is an orally administered radioactive iodine blocking agent. KI is available as a variety of preparations, including an FDA-approved solution – for administration to children.  KI acts by blocking the incorporation of radioactive iodine into the thyroid gland by competing with the radioisotope for uptake binding sites. This agent should be administered as quickly as possible following a radiation mass casualty event in which there is a high likelihood of exposure to radioactive iodine. Radiation mass casualty events in which the release of radioactive iodine is most likely include: Nuclear power plant incidents – for example, significant levels of radioactive iodine were released following the Chernobyl nuclear power plant explosion in 1986. Also, the detonation of an improvised nuclear device or a nuclear bomb could serve as sources of radioactive iodine. So-called “dirty bombs” – more formally referred to as radiation dispersal devices or RDDs – in which a conventional explosive is laced with radioactivity – represent an unlikely source of exposure to radioactive iodine. Therefore – victims of a “dirty bomb” attack – are unlikely to need treatment with KI. As I said earlier, KI must be administered within hours following a radiological mass casualty event. As seen in the graph on this slide, the effectiveness of KI is highly time-dependent.   Taken as early as 24 hours in advance of an exposure to radioactive iodine, KI can provide near total blockade of radioactive iodine uptake. As soon as exposure has occurred, however, the effectiveness of this drug falls rapidly. At 2 hours post-exposure, KI is 80% effective in blocking radioactive iodine uptake, At 8 hours, it is 40% effective, and By 24 hours, KI provides little effective blockade and radioactive iodine has been incorporated into the thyroid gland. The populations most sensitive to the effects of radioactive iodine exposure – cancer of the thyroid – are among the youngest. During the years following the Chernobyl nuclear power plant disaster, it was discovered that children developed cancer of the thyroid at rates much greater than adults having similar levels of exposure. Thus, according to current treatment recommendations, the threshold for initiating treatment with KI in children and in pregnant mothers after a radiation mass casualty event is lower than it is for non-pregnant adults. Additional guidance concerning the administration of KI – including dosages and dosing schedules – is available from the US Food and Drug Administration and may be found on their website.

The next drug I will discuss is Prussian Blue or Ferric hexacyanoferrate. In January, 2003, the Food and Drug Administration determined that Prussian blue had been shown to be safe and effective in treating people exposed to radioactive elements such as Cesium 137 and also to thallium. Once absorbed into the body, cesium and thallium are removed by the liver, passed into the intestine and then re-absorbed into the bloodstream from the intestinal lumen – a process known as entero-hepatic circulation. Prussian Blue, an orally administered decorporation agent acts by adsorbing radioactive cesium and thallium within the gastrointestinal tract and promoting the excretion of these isotopes into the stool. Prussian blue does not, however, treat the complications of radiation exposure – supportive care will undoubtedly be required. This means the use of antibiotics, antiemetics, nutritional support, intravenous fluids, and irradiated blood products and platelet transfusions as necessary. Administration of Prussian Blue is indicated when internal contamination with radioactive cesium occurs at doses in excess of 10 times the annual limit of intake.  The decision to treat therefore requires an assessment of the patient by a qualified health physicist who will determine the amount of internal contamination. The health physicist is also needed to help monitor the patient’s course since current recommendations are that Prussian Blue should be discontinued once the total body burden is estimated to be less than 1 annual limit of intake. Treatment is not generally recommended for persons who are internally contaminated with a dose less than 1 annual limit of intake and the need for treatment of internal contamination between 1 and 10 times the annual limit of intake remains controversial. Ideally, treatment with Prussian Blue should begin as soon as possible. Even when treatment cannot be started right away, treatment with Prussian Blue is effective and should not be withheld – it should be administered as soon as it does become available. Additional sources of guidance for Prussian Blue administration are included here.

Calcium and zinc DTPA – diethylenetriaminepentaacetate – are chelating agents that effectively bind the transuranic, radioactive elements plutonium, americium, and curium. DTPA acts by exchanging cations for these specific radioisotopes which, in turn, form stable, water-soluble complexes with the DTPA ligand. The radioisotope-DTPA complex is then excreted in the urine. Although DTPA is an effective chelator for some transuranic radioisotopes it is important to remember that internal contamination with uranium and neptunium should not be treated with DTPA. It is believed that DTPA forms unstable complexes with uranium and neptunium that may result in increased deposition of these radioisotopes into bones. Current recommendations for treating uranium call for alkalinizing the urine with bicarbonate in order to promote renal excretion. As with the other agents we have been discussing, the effectiveness of DTPA administration – particularly calcium DTPA – is time-dependent. When administered within the first 6 hours of exposure, calcium DTPA is maximally effective as a chelating agent, even exceeding the binding of zinc DTPA by as much as 10x. By 24 hours post-exposure, however, calcium and zinc DTPA have approximately equal efficacy. In addition, over time, calcium DTPA is associated with more complications than is zinc DTPA. Because zinc DTPA does not deplete zinc and magnesium from the body like calcium DTPA does, it has a better safety profile over the long term. Therefore, current guidance recommends initiating chelation with calcium DTPA in the first 24 hours and then suspending its use – to be followed by zinc DTPA. The use of zinc DTPA is also preferable to calcium DTPA among children, pregnant women, in people with serious kidney disease, and in those who have a suppressed bone marrow. Clinicians should remember to check a patient’s renal function prior to each administration of the drug since it is known itself to be toxic to the kidneys. The use of DTPA should be discontinued if proteinuria, hematuria, or renal casts develop during its use. Further guidance concerning the use, contraindications, and adverse side affects associated with the use of DTPA may be found at these web sites.

The last agent I would like to discuss differs somewhat from the previous three in that it is neither a blocking agent nor is it a drug that promotes decorporation after internal contamination. Instead, this drug is used to treat one of the more serious adverse effects of acute radiation syndrome: bone marrow suppression. Drugs of this class are known as colony stimulating factors. In fact, colony stimulating factors occur naturally within the body where they act to induce hematopoietic progenitor cells of the bone marrow to proliferate and differentiate into specific mature blood cell types. One drug of this class – filgrastim – has been genetically engineered to stimulate the proliferation and maturation of granulocytes. Filgrastim specifically activates the neutrophil progenitor cells and its effect on stimulating the proliferation of other hematopoietic precursor cells – other than neutrophils – is minimal. Filgrastim has been used now for several years with FDA approval, and with good effect, in the treatment of cancer patients receiving myelosuppressive therapies. Although filgrastim has not been approved by the FDA for the treatment of bone marrow suppression following acute radiation exposure, studies involving irradiated animals receiving colony stimulating factors in the first 24 hours post-exposure indicate improved rates of survival compared to untreated controls. In addition, these drugs have been used with some success in victims of unintentional radiological exposures, such as have occurred in workplace settings.

Following a radiation mass casualty event, it is anticipated that filgrastim would be administered to victims suffering from bone marrow suppression secondary to acute radiation syndrome. Administration of colony stimulating factors is recommended for any adult having whole body or significant partial-body radiation exposures resulting in a moderate to severe Acute Radiation Syndrome prodrome. Short-term therapy with colony stimulating factors is appropriate when exposure doses following a radiological or nuclear incident are relatively low. For victims with high exposure doses, a more prolonged course of therapy may be appropriate. The use of these drugs may be discontinued when the absolute neutrophil count has rebounded to 1000 cells per microliter or greater. Since victims of combined injury have an overall worse prognosis, it may be appropriate in a mass casualty situation to withhold use of filgrastim in favor of children and adults with atraumatic irradiation. Overall the safety profile of the colony stimulating factors is largely good but they are not without potential adverse side effects. Allergic reactions have been reported in less than 1 in 4000 patients and the reactions all respond well to conventional therapies such as antihistamines and steroids.  Less commonly there have been reports of fatal and non-fatal splenic rupture in patients receiving colony stimulating factors – patients receiving these drugs must be cautioned about reporting immediately any abdominal pain, left upper quadrant pain, or any left shoulder pain. Finally, in patients with sickle cell disease, the colony stimulating factors have induced severe sickle cell crises requiring hospitalization, IV hydration and aggressive pain management. Additional guidance information concerning the appropriate use of colony stimulating factors and filgrastim may be found at the web sites listed here. Oncology specialists in your own institution may also be able to provide you with information and answers to questions concerning the use of these drugs.

In most cases – in order to maximize efficacy available pharmacotherapy for the treatment of internal contamination and acute radiation exposure should occur in a timely fashion.

Some drugs may have limited or no efficacy when administered too long after a radiation exposure.  This means that clinicians may need to begin some treatments in the absence of a definitive diagnosis. Treatment should be appropriate to the exposure.  For example, administering KI to a population exposed to a “dirty bomb” detonation may not be appropriate and use of DTPA to treat internal contamination with uranium is contraindicated. Guidance concerning the use of these agents – many of which may be novel to you – is available from the US Food and Drug Administration and from the Centers for Disease Control and Prevention.

To conclude, I would like to quote a recent article published in the Annals of Internal Medicine, entitled “Medical Management of the Acute Radiation Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group”.  This paragraph succinctly summarizes some of the most important points I have tried to make in this series of lectures. I highly recommend this reference to any of you who may be looking for additional, in-depth information on the topics I have discussed.

“Barriers to the provision of optimal care [in a radiation mass casualty event] include limitations of resources, loss of infrastructure, a high volume of victims, and presence of combined injury. Allocation of potentially limited resources should be determined by the number of victims and their long-term prognosis. Estimation of individual radiation dose is recommended for determining survivability of patients in a range of doses that indicate predisposition to the acute radiation syndrome. Treatment recommendations are based on this dose range, which becomes increasingly narrower as the number of casualties increases and with the occurrence of combined injuries.” 

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Scenario Instructions

You are about to embark on a practice exercise that will take you through a series of fictitious scenarios depicting hypothetical radiological terrorism incidents.

You will be asked to answer questions that test your ability to provide appropriate medical response. These questions are drawn from the series of lectures in this training, as well the introductory material provided in the CDC training program Medical Response to Radiological and Nuclear Terrorism.

Do not be concerned about getting all the questions correct in this practice exercise. The answers are not scored. These scenarios are designed to teach, not test. Thorough explanations of the correct answer are provided as immediate feedback.

A printable version of all scenario questions is available.

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Scenario 1

RN: “Dr. Mike, come listen to this. They’re talking about the explosion.”

TELEVISION BROADCAST: “Once again in case you are just joining us.  A large explosion has occurred in the southwest area of the city.  Firefighters and police officers are on the scene and it appears to be quite chaotic. If you will bear with us we are getting information in as we speak.  Also reports now…many people appear to be injured. Others are fleeing the scene at this moment.  There are reports of a large black cloud over the area. Excuse me. Ok, we’re getting reports that debris and dust are spread over several blocks, and it has been confirmed.  One moment, yes it has been confirmed that radiation has been detected in this area.  Again radiation has been detected. Steve Meyers is our actual eyes and ears on the scene. We’re going to bring you the latest, I can assure you. We ask everyone to please remain calm.”

DR. MIKE: “Ok, notify administration we’re implementing the emergency response plan for mass casualties. Notify the decon team and let’s get set up for unknown hazards, now.”

Scenario 1 Questions

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Scenario 2 - Part A

MEDICAL STAFF: “Yeah, looks like it’s a dirty bomb. We’ve gotten 30 patients so far, all self-referred, mostly walking wounded. They were all contaminated with radiation, no sign of any chemical use. HAZMAT just contacted us to confirm there’s radiation at the site but no chemical agent was detected. EMS just radio’d in about a critical contaminated patient with a pneumothorax. Ok, out.”

EMS: “This is the patient we called you about with the sucking chest wound. The needle decompression worked for a while, but now he’s not responding very well.”

SECOND REPONSER: “We’ve got contamination here, looks fairly low levels.”

EMS: BP’s 90/60. “Respirations 30 per minute and shallow with retractions. He was maybe 50 feet from the dirty bomb explosion. He’s got a deep wound on the right calf. Sinus tachycardia around 130.”

MEDICAL STAFF: “We’ve need to treat this chest wound stat. Get his clothes off before we get him to trauma.”

MEDICAL STAFF: “Let’s go, let’s go.”

Scenario 2 - Part A Questions

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Scenario 2 - Part B

RN: “Mr. Jones, are you breathing better?” (Patient shakes his head, yes) “The bomb was laced with radioactive material. Now we got most of the contamination off when we removed your clothes. We’re going to take a close look all over and if there is any contamination we’re going to wash it off.”
           
RN: “Sir…sir, I have some important questions I need to ask you. What time did this happen?”

Patient: “About 11:00.”

RN: “Where were you?”

Patient: “I was outside, I was walking up Main and turned…just turned on 7th.

RN: “Did you lose consciousness?”

Patient: “No.”

RN: “And you remember when the bomb exploded?”

Patient: “Yes.”

RN: “Did you every feel nauseated?”

Patient: “No.”

RN: “No vomiting or diarrhea?” (Patient shakes head no). “No, Ok, sir it is important that you let me know if you feel nauseated.”

HP: “Ok, background radiation in the room is 35 cpm. We’ve got 200 cpm from face, 700 cpm from right hand, 600 cpm from left hand, 1200 cpm from this wound and the right lower leg. Did you write all that down?”

RN: “Yes, got it.”

Scenario 2 - Part B Questions

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Scenario 3

MAN: “Help me, I’m covered with radiation! Someone help me please!”

RN: “Sir, calm down. You’re going to be alright. But we have to help you so you going have to calm down first, so we can help.”

RN: “Come with me. We need to wash this dust off, ok. Come on…are you hurting anywhere?”

Patient: “No, I was inside during the explosion. But afterwards I came out and walked through this cloud of dust. Then everybody was saying it is radiation! I’ve been breathing this stuff in! Please help me I’m really scared!”

RN: We will, we will.

RN: “We’re going to get the contamination off and you’ll be fine.”

RN: “Ok, sir please put your valuables in this red bag. Then take this white gown and put it over your clothes.  I going to have you undress underneath the gown and put your clothes in this orange bag.  Then you’re going to go through the shower.  I want you to scrub well especially where you had no clothes covering your body. Someone will help you on the other side.”

Patient: “Ok, ok.”

RN: “Are you ok Sir?”

Patient: “I worried you know there’s radiation in this stuff isn’t there.”

RN: “You are going to be alright.  I know this is very upsetting.  We need you to walk over to our staff member over here.  They going to survey you body and make sure the contamination is gone.  Then they are going to take you to another area where other staff members will talk to you about all of this and about radiation.”

Scenario 3 Questions

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Scenario 4

EMS: “This patient was on the subway where they found the bag with the radioactive source inside. The bag was hidden under a seat. She was sitting next to the bag. They haven’t found any contamination at the scene. She’s homeless and she been riding the subway all day, maybe six hours, in the same car. She’s been complaining of nausea. Vital signs are stable.”

HP: “Looks like the levels are just normal background.”

RN: “It just hit the news that a radioactive source was found. We’re expecting to get flooded with patients from that subway.”

RN: “Let get her into room three.”

Scenario 4 Questions

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Scenario 5

RN: “Doctor we just got another one. This makes 10 patients we’ve gotten in from that PTA meeting at the middle school. Similar symptoms, something must be going on.”

MD: “Another one? Alright, I’ll be right there.”

MD: “Hi Mrs. Block, I’m Dr. Castline. I’m going to take a look at your daughter. Correct me if any of this is wrong. You were at the PTA meeting last night at around 7:00 and your daughter got sick after that?”

MOM: (nods)

MD: “When exactly did she first throw up?”

MOM: “ It was around midnight. She’s felt bad all night. She also had some diarrhea.”

MD: “Are there any other complaints?”

MOM: She’s been complaining of a headache.

MD: “Angie, how many times last night did you have diarrhea?”

Daughter: “ Uh, dunno. My belly hurts.”

MD: “Ok, we’ll look at your belly in a minute, ok? (To Mom) What did she have to eat and when?”

MOM: “Punch and cookies at the school, at 6:45. Dinner was frozen lasagna and some milk.”

MD: “And you had the same thing she did?”

MOM: “For dinner I did; I didn’t have anything at the school. But, I also saw a couple of her friends outside (referring to the ER waiting room) – is there some kind of food poisoning going on?”

MD: “We’re trying to figure that out. Angie, I’m just going to take a look at you now.”

MD: “Mitch, get the health department on the line.”

RN: “Alright.”

RN: “The health department is on the line. It’s urgent. Line 4”

MD: “Hello, Dr. Castline here.”

HD: “Amy, it’s Stephanie.

"Look, we’re at the school; we’ve been here all night. It was definitely the source. We got worried with 30 patients showing up so sick at the two hospitals, but we got lucky. One of our guys had a radiation detection meter and the punch was contaminated. We got a radiation specialist out here and he says it was loaded with Cesium 137 – he said specifically to tell you that.”

“Police are here; they’ve shut down the school. The state radiation control folks are on their way, and they’ve called in the feds. We got TV crews in the parking lot. (Gets interrupted) Yeah, I’m sorry, I need to go.”

MD: “Stephanie, how many people were there last night?”

HD: “About 400. Look, I’ll call back in a few minutes.”

MD: (to RN) “Mitch…. Get administration on the phone; we may have a disaster on our hands. Get Dr. Berger from Radiation Oncology, the Medical Director of Nuclear Medicine, and the Radiation Safety Officer down here stat. There was a radioactive substance – Cesium – in the punch.”

Scenario 5 Questions

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Scenario 6

NEWS BROADCAST: “Once again a quick recap perhaps you have heard. But…a large explosion has occurred in the city followed by a visible mushroom cloud. We have confirmed reports right now that high levels of radiation have…one moment please. Yes, high levels of radiation have been detected in the area. The destruction of course appears to be quit extensive. We have unconfirmed reports.  And I do emphasize unconfirmed at this time that this may be some type of nuclear device, just based on the magnitude of the explosion itself. The windows at our station of course are blown out. Visible fires are raging in the buildings that are left standing in the area. Again, this information coming in I’m pasting it along to you as soon as we get it.  But it is confirmed radiation on the scene has been detected.”

EMS: “We’re 30 miles upwind off the interstate; I bet people will head here.”

HUSBAND: “She was outside the house when it happened. I was in the basement and ran out after the blast and found her like this. Seem like she can’t see me. I put her right in the car and drove upwind as fast as I could. I was in the military, but I never thought I’d actually see something like this!”

RN: “Sir, the decontamination team surveyed these and there’s no contamination, so we wanted to get these back to you.”

RN: “How far from the blast were you?”

HUSBAND: “Uh, I dunno. Looking at the television reports, maybe, two miles or so.”

Scenario 6 Questions

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NOTE: The verification code for this self-study is RADMASSCAS.

To received Continuing Education (CE) credit, you will be required to provide this verification code. Be sure to write down this code for later reference. For more information about CE credits, see "About This Training."


Self Test

You are about to take a Self Test on the material presented in this activity. Answer all of the questions then press the "Check Answer" button at the bottom of the page to grade your test.

You will be given a verification code for this self-study after you complete the test. You will be asked for the code when you register online for continuing education (CE) credit. Although completion of the Self Test is required for CE credit, a minimum passing score is not required.

1. The majority of self-referred patients arriving at hospitals following a Radiological Dispersal Device (dirty bomb) incident will most likely need medical attention for:

A. Acute radiation syndrome (ARS)
B. Internal contamination
C. Psychological trauma
D. Major trauma

Check Answer

2. Following an incident involving a Radiological Exposure Device, or hidden radioactive source, thousands could feasibly require:

A. Treatment for thermal burns
B. Post mortem decontamination
C. Treatment for ARS
D. Radiation exposure screening

Check Answer

3. Hospital emergency response planning for mass casualties should include consideration of:

A. Individual hospital surge capacity
B. Local government emergency response plans
C. State resources for equipment and supplies
D. All of the above

Check Answer

4. Establishing immediate medical response to a radiological event with mass casualties should include:

A. Obtaining radiation meters
B. Contacting in-house radiation professionals
C. Establishing areas for decontamination
D. All of the above

Check Answer

5. Which of the following statements about the process of radiological decontamination is true?

A. The decontamination process can cease when all visible particles are removed.
B. Chemical suits with N-95 masks are required for staff protection.
C. Patients with life-threatening injury must be decontaminated before treatment.
D. Hospitals should have policies that include performing radiological decontamination inside the facility.

Check Answer

6. The first step in radiological decontamination is:

A. Removing the patient’s clothes
B. Cleansing wounds
C. Gently cleaning the skin
D. Cleansing facial orifices

Check Answer

7. Hospital triage of mass casualties following a radiological event should take into account the expectation that:

A. Most patients will arrive as self-referrals to the nearest hospital
B. The majority of patients arriving at the hospital will be decontaminated at the scene
C. External contamination will be difficult to detect
D. Conventional triage for traumatic injury will not be used

Check Answer

8. Time to emesis following exposure to a radiological source can be used to measure:

A. External contamination
B. Internal contamination
C. Radiation dose
D. Effectiveness of decontamination

Check Answer

9. A contamination survey with a radiation meter can:

A. Be easily performed without training
B. Quantify the radiation dose received by the patient
C. Produce readings in counts per minute (cpm)
D. Only detect large amounts of contamination

Check Answer

10. The most useful diagnostic test in determining significant radiation injury in the first 24 hours post radiation exposure is:

A. Sequential CBCs with differential
B. Bioassay testing of urine samples
C. Bioassay testing of fecal samples
D. Chromosomal aberration biodosimetry

Check Answer

11. Acute radiation syndrome (ARS) may cause which of the following symptoms:

A. Vomiting
B. Headache
C. Diarrhea
D. All of the above

Check Answer

12. Following ingestion of cesium137, which of the following drugs would assist in eliminating the cesium from the body?

A. Potassium Iodide
B. Prussian Blue
C. DTPA
D. Filgrastim

Check Answer

13. A patient arrives following exposure to a hidden radiation source. A radiological survey indicates normal background readings. Which of the following statements are accurate?

A. In this situation, standard precautions PPE must be worn in order to protect caregivers from contamination.
B. A surgical mask may be worn in this situation, but an N-95 mask is preferred.
C. Patient clothes should be removed immediately and double bagged.
D. None of the above

Check Answer

14. Which of the following injuries may result following explosion of an improvised nuclear device?

A. Blindness
B. Radiation burns
C. Thermal burns
D. All of the above

Check Answer

15. Which of the following actions would be appropriate in treating patients who are experiencing psychological trauma following a radiological event:

A. Counseling patients on long-term health effects
B. Having trained counselors on site
C. Providing information on radiological exposure
D. All of the above

Check Answer

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