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به نام خدا
دکتر زهره بیگدلیرئیس گروه مراقبتهای پزشکی مرکز نظام ایمنی هسته ای کشور
مسئول امور پزشکی پرتوی پژوهشگاه علوم و فنون هسته ای1396پائیز
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Emergency Medical management on Site
and at Prehospital Level
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Earthquake
Ship
accident
Storm
Heavy rain
Heavy snowfall
Flood
High tide
Others
(train, plane)
Tsunami
Volcano eruption
Other natural
phenomenon
Fire or wildfire
Explosion
Disasters
Release of RM
WHAT IS DIFFERENCE OF RADIATION
ACCIDENT FROM OTHERS?
3
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IN NUCLEAR EVENTS, PARADIGM SHIFTS
Radiation can not be seen, heard, smelt,
or felt & dose not cause immediate
symptoms.
Contamination complicates.
4
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FLOW OF MANAGEMENT
5
Accident
Incident
Identification
On Scene
Triage
Hospital
Notification
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6
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WHO ARE FIRST RESPONDERS?
A general team ( police, fire, EMS )
referring to an initial response in
emergency.
7
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NOTIFICATION
Get call-back number and verify
accident prior to assembling
radiological emergency team.
Assume that victim is contaminated
until proven otherwise.
8
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RADIOLOGICAL INCIDENT CONTROL
- INFORMATION -
9
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ASSESSMENT OF ACCIDENT SCENE
What hazards present?
How many people were injured (too many,
many….)?
When did the accident/incident occur?
How were the material released into environment?
Where are victims contaminated with/exposed to
radioactive material?
10
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ASSESSMENT OF ACCIDENT SCENE
Severe
trauma
Hazardous
chemicals
Radioactive
materials
Immediately threatens
the lives of rescuers
and victims?
Rescuers: no
Victims:
possibly
Possibly No
Causes immediate
visible evidence of
skin injury?
Usually Possibly No
Causes cardiac or
respiratory problems,
pain, or
unconsciousness?
Frequently Possibly Rarely
11
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RADIOLOGICAL INCIDENT CONTROL ON
SCENE
Identify the substance if possible
Consider all potential hazards
Establish contamination control zones
Protect personnel from radiation exposure
Follow EPA protective action guides for radiation
exposure
Time , distance, shielding
Protect equipment from contamination
12
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13
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RADIOLOGICAL CONTROL ON SCENE
- ZONING -
Vehiclemarshalling
areaReception
for responsepersonnel
Staging area
Medicalresponse
base
Triage
area
Decontamination
area
Inner cordoned
areaOutercordoned
area
Safety
perimeter
Security
response
base
Safety access
and
contamination
control point
Security
perimeter
Radiological
Monitoring and
Assessment
Centre
Evacuee monitoring
registration area
PublicInformation
Centre
Prevailing wind
directionFrom
Incident
command
post
Incident
commander
Procedure C2 : On Scene Emergency Medical Response
To
14EPA protective action guides for radiation exposure
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FIELD TRIAGE DURING RADIATION
EMERGENCY
15
Victims
Triage
Not seriously injured
or uninjured
Seriously injured
Stabilization
Immediate contamination survey and decontamination
(if possible)
Hospital
Contamination survey and
decontamination
HospitalRegistration
area
Inner cordoned
area
Safety perimeter
Outer
cordoned
area
Securityperimeter
Life-threatening
injury
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INITIAL ASSESSMENT AND ESTABLISHING
OF RESPONSE AREAS AND FACILITIES
After arrival on the scene of a radiological
emergency, first responders should perform an
initial assessment of the situation and radiological
hazard.
Establish a safety perimeter.
16
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ZONING
17
Inner cordoned
area
Outer cordoned
area
Safety perimeter line
Ensure safety of the area and visualize the zoning lines
by rope.
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18
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SURVEY METERS
Geiger-Muller (GM) Counters - good use for
contamination
Ion Chambers – more accurate, generally good overall
field
Scintillation Counters – very sensitive; ideal for looking for
sources or levels of radiation; not good in high radiation
field000
19
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GEIGER-MULLER (GM) COUNTERS
Detection of β and γ-radiation (/min, cpm)
Generally rugged field instruments, but window
can be damaged, and then instrument is out of
order
It can be “maxed out” and will under-respond
20
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PERSONAL DOSIMETER
21Personal dosimeter – use as an alarming dosimeter and
accumulated dose meter
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DOSIMETRY
TLD Badges
Are passive (no batteries
needed)
Clip onto front of clothing
Mandatory - Everyone wears one
Dose information is read later
Electronic Dosimeters
Must have battery inserted
to function
Are optional
Provide direct dose readout
22
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2
3
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DOSE RATE LIMIT RECOMMENDATIONS
Activities
Suggested
Turn-back
Exposure Rate
Guidelines for
Total
Accumulated
Dose
Increased cancer
Risk*
Emergency
worker dose limit
Follow Radiation
safety Officer
instructions
50 mSv 0.5%
Non-lifesaving
activities (major
critical property
protection)
100 mSv/hr 0.5 Sv** 5%
Lifesaving
activities2 Sv/hr
1 Sv**10%
24
*National Council on Radiation Protection and Measurements Report No. 138.
** International Atomic Energy Agency EPR-First Responders 2006.
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EMERGENCY WORKER TURN BACK DOSE
GUIDANCE*
25
Tasks
Do not exceed unless
Approved by incident
commander
Actions to avert a large collective dose, such as:
•Environmental sample collection and analysis for
environmental monitoring of populated areas;
•Localized decontamination if required to protect
the public.
50 mSv
*IAEA EPR-First Responders 2006.
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EMERGENCY WORKER TURN BACK DOSE GUIDANCE*
26
Tasks
Do not exceed unless
Approved by incident
commander
Actions to prevent severe health effects or injuries,
such as:
•evacuation/protection of the public;
•environmental monitoring of populated areas to
identify where evacuation, sheltering or food
restrictions are warranted;
•Rescue from potential threats of serious injury;
•Immediate treatment of serious injuries;
•Urgent decontamination of people
•Prevention or mitigation of fires;
•Apprehension of terrorist suspects.
500 mSv
*IAEA EPR-First Responders 2006.
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EMERGENCY WORKER TURN BACK DOSE
GUIDANCE*
27
Tasks
Do not exceed unless
Approved by incident
commander
Life saving actions, such as:
•Rescue from immediate threats to life;
•Provision of first aid for life threatening injuries;
•Prevention /mitigation of conditions that could
be life threatening.
1000 mSv
*IAEA EPR-First Responders 2006.
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2
8
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RADIOACTIVE MATERIALS
Can be in the form of :
Solid (Powder, dust, metal)
Liquid
Gas
Others
29
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WHAT IS CONTAMINATION?
Radioactive material in the form
of smokes, dust or liquids is
called contamination and if such
material gets on a surface,
object or person, they become
contaminated.
30
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INTERNAL VS. EXTERNAL
CONTAMINATION
31
Radioactive
Material
Wound
Ingestion
Inhalation
Internal
contamination
0
Wound
External
Contamination
Radioactive
Material
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BASIC PRINCIPLES FOR
HANDLING CONTAMINATED PATIENTS
1. Treat life-threatening conditions first without regard
to radiation or contamination
2. Isolate patient and restrict access to the
treatment/evaluation area
Maintain contamination control
3. Internal contamination is never immediate life-
threatening
32
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RADIATION DOES NOT CAUSE :
Immediate death
Immediate symptoms ( burns, wounds )
Contaminations alone :
Not immediate threat to victim
Not threat to responders or others33
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34
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TRIAGE OF RADIATION CASUALTIES (1)
Triage – first task for multiple casualties :
• Sorting of victims depending on condition,
urgent needs and number
• Decision on prompt FIRST medical intervention
– life saving immobilization of fractures urgent
investigations
35
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TRIAGE OF RADIATION CASUALTIES (2)
Always employ standard medical triage principle
Decontamination can be done before, during,
or after initial stabilization, depending on the
severity
36
The most important decontamination is to remove all clothes at the site
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CONTAMINATION CONTROL : AT THE SITE
Remove contaminated clothing
Cover patient and secure
Transfer patient by cold team
37
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PROTECTIVE CLOTHING (1)
Effective in stopping α and some βparticles
Not effective for γ-rays
Lead aprons are not recommended
since they will not stop most
38
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PROTECTIVE CLOTHING (2)
Use water proof materials
Place clothing and any accompanying
sheets, blankets, and others in a plastic
bag
Change instruments, outer gloves, and
drapes after handling clothing or other
potentially contaminated items
39
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DO NOT CONTAMINATE PERSONAL DOSIMETER
40
Personal dosimeter
Not to contaminate, it
should be put inner the
personal protective
clothing.
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TYPICAL PROTECTIVE CLOTHING
41
Eye protection Mask
Personal dosimetry
Water proof shoe covers
gloves
Name
Tape
Tape
Seal up with the tape
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RESPIRATORY PROTECTION
Respiratory protection
if necessary
Breath filtered air
It protect from
inhalation of
radioactive materials.
42
Seal up with the tape
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PROTECTIVE EQUIPMENT FROM CONTAMINATION
43
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CONTAMINATION CONTROL DURING RESCUE
OPERATIONS
Use personal protective measures and means
Do not eat, drink, smoke, rub eyes, or apply make-up in
contaminated area
Use good work practices
Appropriate equipment
Control lines
Assume contamination when in
doubt 44
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45
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RECOMMENDED PROCEDURES FOR ON-SCENE
RESPONDERS (1)
1. Personal protective gears with a personal dosimeter
2. Transport medically unstable patients. A survey,
decon may be performed in the ambulance.
46
3. Move the stable patients
to a low background
area, remove the other
clothing and wrap in a
sheet or a blanket.
4. Treat injuries.
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RECOMMENDED PROCEDURES FOR ON-
SCENE RESPONDERS (2)
5. Do not release stable patients to ambulance
before radiological survey. Perform preliminary
decontamination.
6. Decontaminate gently.
7. Save everything (clothing, bedding, watch, coins,
buckles, jewelry, cellular phone, vomitus, etc.),
tag each item.
8. Transport the patient to medical facility. 47
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CONTAMINATION CONTROL FOR
AMBULANCE PERSONNEL
Remove protective gear at control line and get
surveyed
Clean team can transport patient to hospital
or
Put on clean gloves and gown, and transport patient
At hospital, transfer patient to clean treatment
table in contaminated patient area
Await survey for contamination
48
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REMOVE VICTIMS FROM HAZARDOUS AREA
If there is immediate life-
threatening hazard in the area,
remove victim first.
Hazardous area :
Fire
Smoke
Steam
Chemicals
Electrical
Radioactive contamination
high air dose rate 49
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RESCUE
Remove injured
person from the
hazard area into
the triage area as
soon as possible.
50
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LIFE SAVING
Medical triage
Assess and treat life-
threatening injuries
immediately
Life-threatening injured
victim should transport
into hospital immediately,
even if contamination
survey has not been done.
51
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52
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EXTERNAL CONTAMINATION REMOVAL
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REMOVE CONTAMINATED CLOTHING AT
THE ACCIDENT SCENE
54
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CONTAMINATION SURVEY
55
It is possible to perform radiological survey during
stabilization of victim if monitoring procedures do not
interfere with medical actions at scene.
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COVER CONTAMINATED WOUNDS
56
Cover contaminated wounds with sterile dressings before
transport into hospital emergency room.
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PATIENT MANAGEMENT
-DECONTAMINATION-
Carefully remove and bag patient’s clothing and
personal belongings
(Typically removes 95% of contamination)
Decontamination priorities:
Decontaminate wounds first, then intact skin
Start with highest levels of contamination
Change outer gloves frequently to minimize spread of
contamination
Do not delay surgery or other necessary medical
procedures or exam…residual contamination can be
controlled 57
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58
PERFORM GROSS
DECONTAMINATION
If needed and also
If it will not interfere with critical care
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TRANSPORT OF CONTAMINATED
VICTIMS (1)
Victims are to be transported by medical or
paramedical personnel who have not
entered the controlled area on scene.
Assume all victims are contaminated until
proven otherwise.
Continue medical assessment and treatment
during transport when necessary.
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TRANSPORT OF CONTAMINATED VICTIMS (2)
Place the ambulance
stretcher on the clean
side of the outer
cordoned line and pass
the victims across the
outer cordoned line to
the prepared stretcher.
Cover victim by folding a
sheet or blanket.
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CONTAMINATION CONTROL ON
TRANSPORTATION
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USE CAUTION AROUND CONTAMINATION
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CONTAMINATION CONTROL
Use universal precautions
Frequently survey hands
and clothing with radiation
meter
Replace gloves or clothing
that is contaminated
Keep the work area free of
contamination and
radiation sources
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PROTECTION AGAINST CONTAMINATION
Protection can be improved
by performing frequent
measurements for
contamination, dealing with
it as it is found and
controlling the
accumulation of radioactive
waste.
65
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CONTAMINATION CONTROL
Contamination that
cannot be cleaned
can be controlled by
taping over it with an
impervious covering.
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6
7
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Compared to chemical and
biological hazards, radiation and
radioactive materials are easy to
detect and measure.
DETECTING RADIATION
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RADIOLOGICAL INCIDENT CONTROL
- PREVENTION OF CROSS CONTAMINATION -
69
Hot area marked off with
tape and stanchions
Contamination check
Tool drop before
leaving hot zone
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CONTAMINATION CONTROL
70
Before leaving the inner cordoned area, first
responder should be checked contamination
and change clothing if needed.
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MANAGEMENT OF RADIOACTIVE WASTE
Collect radioactive waste in
plastic bags.
Survey bags periodically to
prevent high radiation levels
in the work area.
Use distance to protect
against radiation from
radioactive waste.
Use walls, dirt mounds, hills,
etc. as shielding for
radioactive waste.
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RULES OF THUMB
Removing outer clothing
will remove majority of
contamination.
Washing hands and
heads can remove most
of the remaining
contamination.
For large incidents,
containment of runoff is
not necessary.
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RULES OF THUMB
Most of the airborne radioactive dust from an
outdoor explosion will settle to the ground within
10 minutes.
Without better information, evacuate away from
plume settling to at least 500 meters.
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SUMMARY
1. Rescue, resuscitation, emergency aid
2. Medical stabilization of general condition of
victim and of serious injuries
3. Removal of patients from contaminated area
4. Assessment of external contamination
5. Decontamination and DE corporation -
preventing internal contamination of patient and
contamination of staff 74
Actions of Primary Significance in Pre-hospital
Medical Management of Radiation Accidents
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Thank you for your
attention