Welcome to Boone County Hospital

Radioactive Emergency

GENERAL INFORMATION ON CLINICAL MANAGEMENT OF RADIATION ACCIDENT PATIENTS:

Types of radiation injuries to be covered range from external radiation; internal radiation from ingested or inhaled radioactivity; and surface radioactivity contamination by liquids and dust, both with and without surface wounds.

This will include the immediate care (what to do first) and special care needed that is unique to this type accident.  The definition of lethal dose and description of the acute radiation syndrome, care of the same will be described.

AXIOMS OF CARE:
The medical needs of the victim always take precedence over radioactive contamination.

Three basic principles allow you to limit the radiation exposure to attending personnel and victims:

Time

Distance

Shielding (in the form of protective gowns, gloves, masks, hats, shoe covers).

Standards and Objectives:

Definition:  Decontamination of patients refers to those techniques used to remove radioactive materials from on or in the body of a patient.

The level of radioactive contamination that is acceptable on patients ideally is zero or "no radioactivity above ground."  However, in emergency situations it may be necessary to postpone any or complete decontamination in order to execute operations that are life saving.

It may happen that decontamination of skin surfaces will become ineffective at radiation levels two or three times background. In these cases, rather than risk skin injury by continuing active decontamination, wait 24 hours and resurvey.  Usually the radiation level will have dropped to background levels.

General Consideration:

Evaluation of extent and degree of contamination must be done initially and recurrently in order to guide personnel in decontamination procedures.  This is even more important where there is possibility of internal deposition of radionuclide within the body of the patient.

Adequate records of contamination and decontamination must be kept.

Major efforts shall be made to prevent body absorption of radioactive materials.  The prime barrier minimizing body absorption of radioactive material is the skin.  Do not injure the skin.

Skin breaks, abrasions, lacerations etc. shall be kept free of radioactive materials.  If already contaminated, skin breaks shall receive priority decontamination.

In decontamination, with the exception of contaminated skin breaks, start to decontaminate the areas where higher levels of contamination are present.

Localization of contaminated areas with drapes and tape shall be done to prevent spread of radioactive nuclides to "clear" areas or areas of lesser contamination.  Cover and protect areas not being immediately decontaminated.

Repeatedly check degree of contamination of those reagents and equipment used in decontamination.  You cannot clean up a "low level" area with a highly contaminated brush or detergent.

Patients can be categorized in the following way:

No Contamination:

A patient involved in a radiation incident who does not become contaminated or exposed to radiation, but is transported to a hospital as a precautionary measure.

Radiation Exposure:

The individual who has received whole or partial body external radiation exposure, regardless of dose is no contamination hazard to personnel, other patients, or the environment.  The management of this patient depends upon the absorbed dose of radiation and could be similar to the management of a radiation therapy or chemotherapy patient.

Internal Contamination:

Such contamination results from inhalation or ingestion of radioactive material.  (Inhalation and ingestion almost always occur together).  This patient is usually no hazard to personnel, other patients or the environment.  Following cleansing of minor amounts of contaminated material deposited on the body from an exposure to airborne radioactivity, this person could be handled similar to a case involving exposure to a chemical poison such as lead.

External Contamination:

External contamination of the body surface and/or clothing by radioactive material presents problems similar to cases of vermin infestation.  Surgical isolation and decontamination techniques, to protect other patients and the Hospital environment, must be employed in order to confine and control any potential hazard.

If possible external contamination is involved, save all clothing and bedding from ambulance, blood, urine, stool, vomitus and all metal objects (i.e., jewelry, belt buckle, dental plates, etc.).  Label with name, body location, time and date.  Save each in appropriate containers marked clearly ... "RADIOACTIVE ...DO NOT DISCARD."

Note: Careful removal of patient's clothing will remove most of the external contamination.  If clothing is grossly contaminated, it might be a good idea to moisten the clothing before removal.

Contaminated Wounds:

When a wound is complicated by radioactive contamination, care must be taken not to cross-contaminate surfaces surrounding the wound.

Cover the wound with self-adhering disposable surgical drapes.  Cleanse neighboring surfaces of skin.  Seal off cleansed areas with self-adhering disposable surgical drapes.  Remove wound covering and irrigate wound with sterile water, catching irrigation fluid in a basin to be marked and handled.

If the wound is grossly contaminated with dirt particles and crushed tissue, the physician shall do a preliminary simple wet debridement using disposable instruments.

Contaminated Corpses:

Contaminated corpses must be wrapped in plastic and put on ice in a large container.

Lethal Dose:

May occur in patient who has received full or partial body external radiation exposure.

LD 100 in man approximately 800 REM.

LD 50 in man approximately 400 REM.

Definition of LD 50 - dose which will produce an acute illness (ARS) followed by death in 30 - 60 days in 50% of the people thus exposed.

Triage will be necessary if widespread accident such as in a major nuclear disaster or war attack to segregate patients and keep those exposed to an LD 100 comfortable but save supplies and manpower for persons in which there is some hope for recovery.

Lower doses (LD 30, LD 10)

Effect of lower dose is proportionately less:

At 100 REM only 15% of people develop any symptoms.

At 25 - 50 REM no clinical findings are present and the syndrome is only diagnosable by laboratory tests (blood count changes).

Acute Radiation Syndrome:

Assume a dose of 400 REM (LD 50).  This dose almost invariably would be from external radiation.

Smaller doses would show an attenuated ARS both in time and severity of symptoms.

Early Phase:  (1 hour to 2 days)

Nausea plus or minus vomiting

Malaise plus or minus hyperexcitability of reflexes

Asymptomatic Phase:  (2 hours to 2 days)

Patient feels well but tissue damage is progressing.

WBC drops during first day, first lymphocytes then granulocytes to the range of 1000 cells per cc.  This is followed by a drop in RBCs and platelets.

Internal bleeding:

GI

Skin

Height of Disease:  (2 to 3 weeks)

Elevated temperature in the range of 103 to 104 degrees

Exhaustion

Weight loss

Reddened skin

Loss of hair

Hemorrhages in skin

Ulcerated mucous membrane

GI hemorrhages

Infection, may be ultimate cause of death

Fluid imbalance

Delayed effects in survivors:

Hair loss

Cataracts

Anemia

Leukopenia, may go on to Leukemia

Impaired spermatogenesis

Premature aging, shortens life span

Internal contamination:

The total body dose will be lower.

No acute radiation syndrome is ordinarily seen.

The disease tends to be a chronic matter with toxicity and damage from the agent:

Bone seekers

Thyroid seekers, etc.

Treatment is mainly directed to eliminate the isotope from the body as quickly as possible and particularly in bone seekers to use the well known treatments for heavy metal poisoning.

EMERGENCY DEPARTMENT MANAGEMENT OF RADIATION ACCIDENT VICTIM(S):

When a known or suspected patient with radiation exposure is called or brought into the Emergency Department:

Contact the Boone County Emergency Management for available resources.

The Emergency Department charge nurse/delegate notifies the following of the potential radiation incident:

Chief Executive Officer/Designee

Nursing Supervisor

Environmental Services

Security Services

Engineering Department

While awaiting the Boone County Emergency Management response, the Emergency Department nurse requests the ambulance personnel to remove and "bag" the clothing the patient is wearing and place him/her in two (2) clean sheets or blankets.  (This can reduce the radioactive contamination by 70%).  This is especially important if the incident is called in from the scene that this be done right away.

Emergency Department Preparations:

Evacuation of Emergency Department:

All patients or others near the route from the ambulance entrance to the decontamination room will be moved to other areas.

Patients with non-critical problems will be moved to waiting rooms or other suitable areas.

Preparation for arrival of victims:

Floors of rooms will be prepared by placing tape on the floor at the entrance to the decontamination side from the non-contaminated side.

Route from ambulance entrance to decontamination room will be covered with a roll of plastic, paper, or with sheets.  Covering will be secured to floor with tape.

Above route will be marked off with ropes, if necessary, and marked radioactive until cleared by the representative from Boone County Emergency Management.

Decontamination rooms will be prepared:

Rooms shall have separate ventilation systems.  If they do not, have the ventilation system turned off by the hospital Engineering Department personnel.

Floor will be covered smoothly with plastic, paper floor covering, or sheets and secured to the floor with tape.

Nonessential equipment will be removed from the room or covered with plastic.

Light switches and handles on cabinets and doors will be covered with tape.

The charge nurse will designate an individual to stand outside and receive supplies for medical and decontamination teams.

A trough will be made on the decontamination table with plastic sheeting.

Large plastic or metal containers with plastic bags shall be provided to receive discarded contaminated clothes, gauze, supplies, etc.

Environmental Services Role:

They, along with the Emergency Department's staff, will begin setting up either or both of the Decontamination Areas.  Additional help can be obtained by contacting the Nursing Supervisor.  Depending on the information received prior to the arrival of the victim(s), have necessary life-support equipment on hand if necessary.

Security's Role:

They shall clear the area outside around the Decontamination Areas, and plan for alternate placement of cars and traffic.

Engineering Department's Role:

They will obtain supplies, such as rope, etc., and assist with the set-up and security as determined by other priorities and needs at the time.

Decontamination:

The staff who will be monitoring/decontaminating the patient shall begin to gown and glove up.  (This is usually performed by the Radiologist, qualified medical radiation physicist and/or the Nuclear Medicine Technologist.)

Physician, nurse, Radiology personnel and/or monitors shall wear the following:  gown, gloves, mask, hat, plastic boots with tape around the ankles and wrists.  They will proceed to the Decontamination Triage Area to evaluate the degree of physical injury and the level of radioactivity of the arriving victims.

Check the ABC's:  Airway, Breathing, Circulation and if necessary, stabilize the patient first.

Note: If emergency life saving equipment/procedures are required, delay the radiation monitoring; place the patient on a clean, covered gurney, and proceed into the ER where emergency equipment will be available.

If the patient is stable, but injured, place him/her on a covered gurney and monitor him/her behind the "hot line" at the entrance.  If the patient is uninjured and able to stand; have him/her stand on the "hot pad."

MONITORING THE PATIENT:
Begin with the hands; then work from the head down; front of the patient, then the back, having the patient turn around.  Perform the assessment as quickly as possible, passing the probe 1 inch above the skin (cover the probe with a plastic glove to prevent skin contamination of the probe rendering it useless).  List the levels of radiation obtained over the various parts of the patient's body.

After the initial monitoring of the uninjured patient(s), transport them to the uninjured victim decontamination area located in the West Ambulance garage (Patient shall be transported by the ambulance to another entrance i.e., morgue.)

If the patient is not radioactive, he/she may be taken to the regular Emergency Department.

Once the patient has been stabilized (if necessary) and evaluated, the personnel involved in the transportation of the victims shall be monitored for contamination, and shall not leave the area until this is done and they are released.

The vehicle/ambulance and its contents shall be thoroughly monitored and decontaminated if required.

The personnel who will be involved in the monitoring of the victims or the actual decontamination process shall be dressed as follows:

Gown

Two to three (2-3) pairs of light gloves, taped with masking tape at the wrist

Cap

Plastic, waterproof shoe covers taped at the ankles with masking tape

An X-ray film badge or a dosimeter

DECONTAMINATION TECHNIQUE:  SKIN:
Step I - Evaluation:

Read radiation marking tag.

Determine which areas that will be decontaminated and in what order giving priority to skin breaks and highest levels of contamination.

Remove covering of contaminated area to be cleaned.

Survey area with "smear," "swab" or GM Counter.

Record survey results.

Step II - Decontamination:  Intact Surface:

Localize area of contamination with plastic sheet and tape to prevent further contamination of patient.

Gently wipe off loose contamination with gauze moistened with soap and warm water.

Discard contaminated gauze into waste disposal bag.

Repeat cleansing using cotton balls or cotton tipped applicators moistened with soap and warm water.  Rub skin gently to produce good detergent action.  Do not produce skin redness.

Resurvey area and soap container.

Repeat cleansing until contamination is removed or until level of contamination does not decrease appreciably.

In case where contamination is still present skip to Step III.

Where contamination has been removed apply cream, cover area and proceed to next area for decontamination.

Note: Surveys between cleansings shall be done every 2 or 3 minutes and recorded.  Never dip cleansing instrument into soap.  Pour the soap into the gauze or brush.

Step III - If Second Cleansing is Needed:

Repeat Step II using another detergent such as Tide, Dreft, Oxydol, etc., and soft skin brush.  Do not use Lava soap.

If contamination is still present go to Step IV.

Step IV - If Contamination is Still Present:

Prepare 4% Potassium Permanganate solution.

Prepare 4% Sodium Bisulfite solution.

Paint contaminated area with Potassium Permanganate.

Allow solution to dry on skin.

Repeat painting procedure until skin is almost black using new applicators each time.

Rub the darkened skin area with Sodium Bisulfite solution discarding applicators after each use.

Repeat above step until skin has just a light brown coloration.

Remove Sodium Bisulfite with water moistened gauze or cotton.

Cleanse area with soap and warm water.

Survey.

If contamination remains, repeat items 3 to 10 once more.

If contamination persists, repeat items 3 to 10 but substituting Hydrogen Peroxide for soap in first Step I.

After removal of contamination apply cream and cover area.

DECONTAMINATION TECHNIQUE:  SKIN BREAKS:
Step I - Initial Procedures:

Survey and record findings using a moistened cotton applicator.

Irrigate wound with copious amounts of water making sure no contamination is washed into the wound.

Carefully decontaminate intact skin surface around wound.

Resurvey wound and record.

Continue irrigation with water and survey until no radioactivity is detectable.

Treat wound in usual medical fashion.

Cover wound and seal with plastic and tape - make sure covering is waterproof.

Do not flush with antiseptics unless this is part of your usual medical treatment.  Do not flush wound with chelating agents.

If wound contamination persists, continue to Step II.

Step II - If Contamination is Still Present:

Be certain irrigation is no longer effective in decontaminating the wound.

Have the Health Physicist evaluate the internal body burden expected from the residual contamination.

The Health Physicist in conjunction with a surgeon determines the feasibility and necessity of removing contaminated tissue.

If surgery is decided upon, the area around the wound is decontaminated completely.

If possible a "block dissection" of the wound is done.

All tissue is closed and covered.

The wound is closed and covered.

Note: At times it has been necessary to close the contaminated wound and return at later date for excision.

DECONTAMINATION TECHNIQUE:  GENERAL BODY:
Step I - Initial Procedures:

Survey entire body and record.

Mark with lipstick very high level areas to receive priority.

Contaminated persons shall shower using soap preparation.

Make effort not to contaminate hairy areas if free of radioactivity initially.

Use precautions to prevent contamination from entering body openings.

Survey entire body again marking highest levels found.

Repeat the first four steps.

Repeat the fifth step until contamination is removed or continue to Step II.

Step II - If Contamination is Still Present:

For general body contamination with high levels of radioactivity, localized areas of contamination usually remain.  When showering becomes ineffective and localized areas of contamination remain, shift to localized skin decontamination technique.

Repeat surveys and record results frequently.

DECONTAMINATION TECHNIQUE:  EYES:
Step I - General Procedures:

Irrigate with copious amounts of water.  Shift to normal saline as soon as possible.

Survey irrigation fluid at frequent intervals and record results.

After decontamination treat irrigation induced conjunctivitis as usual.

DECONTAMINATION TECHNIQUE:  BODY ENTRANCE CAVITIES:
Step I - General Procedures:

Survey and record results.

Make sure that cavity is really contaminated and not surrounding area.

Evaluate and decontaminate surrounding area.

Irrigate with copious amounts of water or normal saline.

Gently swab with moistened cotton tipped applicator.

Resurvey.

Repeat the irrigation and swabbing.

Transfer the Patient:

If hospital admission is required, place the patient on a clean gurney.

Transfer him/her through the buffer zone during which he/she is resurveyed.

Have a "clean" staff person receive the patient outside the buffer zone and transport to his/her room.

Waste Disposal:

Contaminated water will be flushed into the ordinary drains. Faucets will be left open to ensure adequate dilution.

Contaminated disposable supplies will be put into plastic bags for disposition.

Contaminated equipment will remain in the control area until decontaminated.

Personnel Disposition:

All persons entering the control area will be dressed and equipped.

All persons in the control area will shower and change clothing before leaving the control area.

All persons upon leaving the control area will present themselves at the control point for pre-exit survey.

In case showering facilities outside of the radiation control area are utilized, these secondary showers will be considered a control area.

In the case where secondary showering facilities are utilized, persons in the radiation control area will still change clothes and present themselves for survey They will then be escorted singly or in groups to the secondary showering facility.

All personnel when dressed in their street clothes will again report to a control point for a final survey which will be recorded.

Limits of Personnel External Radiation Exposure:

All practical efforts will be made to reduce personnel exposure to less than 300 mrem.

In those instances when the situation demands the allowance of greater personnel exposures, hospital personnel will be considered in the same category as industrial radiation workers and the quarterly radiation limit set by the National Committee on Radiation Protection of 1250 mrem will pertain.

The Security Officer restricts access to the area and to the possibly contaminated ambulance.

Waste Disposal:

Contaminated waste will be flushed into the ordinary drains. Faucets will be left open to ensure adequate dilution.

Contaminated disposable supplies will be put into plastic bags and labeled "Radioactive Material" for disposition.

Contaminated equipment will remain in the Control Area until decontaminated.

Personnel in Control Area:

All persons in the Control Area will shower and change clothing before leaving the Control Area.

All persons upon leaving the Control Area, will present themselves at the Control Point for a pre-exit survey.

US Patent Numbers 7,720,998 B2, 7,836,207