Annals of Disaster Medicine
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Updated
Oct 30, 2003
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Contents:
Volume 2, Supplement 1; October, 2003 |
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Emergency Department Response on Radiology
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Chun-Chieh Chao, MD;
Tzong-Luen Wang, MD, PhD |
From the Department of Emergency Medicine (Chao
CC, Wang TL), Shin-Kong Wu Ho-Su Memorial Hospital.
Correspondence to Dr. Tzong-Luen Wang, Department
of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95
Wen Chang Road, Taipei, Taiwan. E-mail M002183@ms.skh.org.tw
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Abstract
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Radiology incident has been a great threat to Taiwan. Any
leakage of radiation can lead to major casualties. We wonder
whether emergency department been well prepared if this situation
occurred here. Because radiation is not physically detectable, it’s difficult
for a primary physician to determine the severity of the victim.
Numbers showed on the survey meters may not be compatible with
the dosage the patient has exposed. Three ways of radiation-induced
injury may occur: external irradiation, contamination with radioactive
materials, and incorporation of radioactive material into tissues,
cells, or organs. The different causes for radiation-induced
injury may result in different modes of emergent management.
The standard emergency protocols of advanced cardiac life support
(ACLS), advanced pediatric life support (APLS), and advanced
trauma life support (ATLS) should always take care first over
treating the effects of radiation because of concomitant clinical
conditions. The medical stability of the patient should be ensured
before concentrating on the radiation-related clinical issues.
Lymphocyte count in 48 hour is very important predictor of prognosis.
We can minimize radiation exposure
through decrease the amount of time the victims spend near the
source of radiation. It is also essential to increase distance
and shielding between radioactive sources. Four
levels of response to radiation event in Taiwan. Depending how serious
the radiation has been leaked, the impact on society greatly
differs.
Key words--- Radiological Event; Emergency Department;
Disaster Response
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Introduction
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Radiology
incident has been a great threat to Taiwan. We
will have four nuclear power plants in one small island in the future.
We are also under the pressure of nuclear attack by Mainland China. Any
leakage of radiation can lead to major casualties.1
In 1979, Three Mile island accident, and worst commercial nuclear power plant
disaster in history occurred with explosion of Chernobyl No4. nuclear power plant in the Soviet Union.2-3
The Chernobyl No 4 nuclear disaster resulted 33 death at scene and
209 victims with major casualty. These two events resulted in long-term
consequences and numerous acute injuries seeking emergency department
for help. How we can minimize our exposure to radiation and take care of all the patients in such
disaster is a great challenge to primary physicians. We reviewed
several articles to summarize some initial steps in order to make
a quick and efficacious response on such disaster.
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Characteristics
of Radiation |
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Radiation can be divided into ionizing and non-ionizing.
Generally speaking, ionizing radiation is teratogenic
through atoms’ losses or gain of electrons.4Ionizing
radiation (α-radiation, β-radiation,
and γ-radiation)
can be produced by nuclear weapons and x-rays. It can travel
through space and penetrate matters of a few millimeters or many
meters in thickness depending upon the type of radiation and the
type of matter. With different severity of the exposure, one or
more radiation syndromes may develop. Efficacious and quick emergency
response to radiology event is the key to minimize impact on society.
Radiation is invisible, odorless, and not audible by human. We
can only detect the exposed dosage by radiation survey meters (eg. Geiger-Mueller (GM) Counter).4 Unfortunately,
there are many kinds of radiations, from naturally
occurring cosmic radionuclides to human-made
sources such as diagnostic X-rays, televisions, nuclear weapons.
All people and all living creatures are daily exposed to it. But
not all the radiations are harmful to human. Radiation
can be divided into ionizing and non-ionizing. Different
types and the dosage of radiation in which we are exposed to greatly
influence the side effects. (Table 1)
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Table 1. Biological effects of acute, total body
irradiation |
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Types
of Radiological Events and Possible Effects |
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We
can define radiologic incident as any event in which people or
the environment are exposed to radiation through accident. Examples
of radiologic incidents and emergencies include a traffic accident
involving a truck carrying medical radioactive isotopes, a fire
in a hospital’s radioactive waste storage facility, a spill
of radioactive liquids in a research laboratory, or an accidental
radioactive release from a nuclear power station. All these situations
can lead to radiologic incidents.6
When radiologic incidents and emergencies
occur, many patients will seek help in nearest hospital, the risk
of contamination between patients and medial personnel is great.
Triage is an important initial step (Figure 1). No matter where or how an accident
involving radiation occurs, three ways of radiation-induced injury
may occur: external irradiation, contamination with radioactive
materials, and incorporation of radioactive material into tissues,
cells, or organs. The different causes for radiation-induced injury
require different modes of emergent management.
External irradiation occurs when a person is exposed to penetrating
radiation from an external source. During exposure, this radiation
can be absorbed by any part of the body or it can pass completely
through. A similar thing occurs during an ordinary chest x-ray.
Following external exposure, an individual is not radioactive
and can be treated like any other patient.
The second type of radiation injury involves patient being contaminated
with radioactive materials. Contamination means that radioactive
materials in the form of gases, liquids, or solids are released
into the environment and people are externally, internally, or
both contaminated. An external surface of the body, such as the
skin, can become contaminated, and if radioactive materials get
inside the body through the lungs, gut, or wounds, the contaminant
can become deposited internally. We should decontaminate the patient
if no immediate life threatening event.
The third type of radiation injury that can occur is incorporation
of radioactive material. Incorporation refers to the radioactive
materials are uptaked by body cells, tissues, and target organs such thyroid,
or bone marrow etc. Generally speaking, radioactive materials
are distributed throughout the body based upon their chemical
properties. Incorporation cannot occur unless contamination has
occurred. This process can cause teratogenecity
and malignancy.
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Emergency
Resonse |
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In the past, emergency response personnel have, at times, hesitated to approach
the scene of a radiologic incident, according
to Ricks’ guideline for Pre-hospital Management of Radiation
Accidents.1 Regardless the route of contamination,
there are some principles for emergent personnel to follow in the
field and in the emergency department:1,6,7
At the field:
1. universal precaution--look for evidence
of hazardous materials.
2. If radiation hazard is suspected, set personnel, vehicles, and
command post at a safe distance (approximately 150 feet away) and
upwind and uphill of the site.
3. Make sure that proper authorities and hospital have been activated.
4. Put on protective gear and use dosimeters and survey meters if
immediately available. 5. Search and give first aid if injured victims are present.
6. Assess and treat life-threatening injuries immediately. Do not
withhold advanced life support if victims cannot be moved or to evaluate
contamination status. Perform routine emergency care during extrication
procedures. (Figure 1)
7. Move victims away from the radiation hazard area (hot zone), using
proper patient transfer procedure to prevent further injury. Stay
within the controlled zone if contamination is suspected.
8. Totally expose patient then look for wounds and cover with sterile
dressings.
9. Victims should be monitored at the control line for possible contamination
only after they are medically stable. Radiation levels above background
indicate the presence of contamination. Remove the contaminated accident
victims' clothing, provided removal can be accomplished without causing
further injury. Remember to collect all the stuff for evidence.
10. Move the ambulance
to the clean side of the control line. Place the victim on the covered
cot and package for transport. Do not remove the backboard if one
has been used.
11. Package the victim by folding the stretcher sheet or blanket over
and securing them in the appropriate manner.
12. Before leaving the controlled area, rescuers should remove protective
gear at the control line site. If possible, the victim should be transported
by personnel who have not entered the controlled area. Ambulance personnel
touching victims should wear gloves. 13. Transport the victims to the hospital emergency department.
The hospital should be given appropriate information, and the ambulance crew should ask
for any special instructions the hospital may have.
14. Follow the hospital's radiological protocol upon arrival.
15. The ambulance and crew
should not return to regular service until the crew, vehicle, and
equipment have undergone monitoring and necessary decontamination
by the radiation safety officer.
16. Personnel should not eat drink, smoke, etc., at the accident site,
in the ambu lance, or at
the hospital until they have been released by the radiation safety
officer.
After arriving in the emergency department:
1. Triage: The radiation accident victim should be approached with universal
precautions. The standard emergency protocols of advanced cardiac
life support (ACLS), advanced pediatric
life support (APLS), and advanced trauma life support (ATLS) should
always take care first over treating the effects of radiation. The
medical stability of the patient should be ensured before concentrating
on the radiation-related clinical issues.
2.The nurse, working with other health care providers, should determine whether
the possible mode of exposure presents a contamination hazard and
whether the patient is likely to be locally or systemically affected.
If such concern exists, patients who were exposed to radiation should
first be assessed by emergent physics or a radiation safety technician.
If the patient is contaminated, emergency personnel should collect
samples from the orifices and the contaminated areas and document
the sample collection, as in a physical assault examination for
evidence.
3.Taking a detailed radiation-exposure history. The exact mechanism should
be confirmed in order to determine whether an actual exposure took
place and whether it involved irradiation, external contamination,
internal contamination, or a combination of these. And the onset
time of symptoms is a significant predictor for the dosage the patient
exposed. (Table 2)
4.Collection of specimens. All cases after radiation exposure require the collection
of samples (including blood, urine, and stool) and radiologic assays conducted in a health physics laboratory
to confirm the level of exposure and to help determine a treatment
plan.
5. Although patients are not radioactive, specimens must be treated as potentially
contaminated until proved otherwise. Areas of the facility used
to collect specimens should be uncontaminated or must be decontaminated
to minimize the chance of inadvertent specimen contamination. Because
patients might contaminate specimens that they collect themselves
(for example, urine and stool samples), they should wear latex gloves
to minimize that possibility. Gloves and other possibly contaminated
material should be disposed of in radioactive waste cans or assessed
by radiation safety personnel.
6. Lymphocyte count in 48 hour is very important predictor of prognosis, and
less than 1000 indicate severe bone marrow suppression.
Patients exposed to moderately high levels of radiation (100
rem or less) usually do not exhibit
immediate symptoms of radiation sickness (prodromal syndrome). Laboratory work shows a decrease in the
number of RBC and WBC, but this may not appear for several days
after exposure.
Some patients may be exposed to high levels of radiation but only
affects a part of their bodies. For example, a scientist who places
her fingers into the beam of an X-ray diffractometer may have very severe burns on the exposed fingers
but no other symptoms. In such cases, it may be necessary to perform
skin grafts or even to amputate the fingers, but the rest of the
body will remain unaffected. Similarly, people may receive radiation
burns in very small areas from radioactive particles that fall onto
the skin. These patients must be decontaminated and the burns dressed,
and skin grafts may be necessary.
The three basic ways to reduce radiation exposure are through:
1.TIME: Decrease the amount of time you are
near the source of radiation.
2.DISTANCE: Increase your distance from a radiation
source.
3.SHIELDING: Increase the shielding between
you and the radiation source. Shielding could be anything that:
build a barrier between people and the radiation source. Depending
on the type of radiation, the shielding can range from something
as thin as a plate of window glass or as thick as several feet of
concrete. Being inside a building or a vehicle can provide shielding
from some kinds of radiation.
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Figure 1.Flow chart of emergency care during extrication |
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Table 2.The onset of symptoms as predictor for
the dosage exposed |
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Conclusion |
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Radiation events worldwide from 1944 to 2001 showed that, 417 incidents that
led to significant overexposure of at least one person, approximately
3,000 people were affected and 127 died. (Long-term effects of
radiation exposure are not included in these statistics.) Such
accidents have become more frequent since 1970, reaching 40 to
45 incidents per five-year. While such incidents have been relatively
rare, current fears of a terrorist attack on a nuclear power plant
or spent-fuel storage facility, or one involving the detonation
of a nuclear weapon, have caused many clinicians to question whether
their facilities are prepared. And we develop 3 levels of response
to radiation event in Taiwan. First degree response denotes no leakage
of radiation outside the power plant, and only medical office
within the plant is activated. Second
degree response consists of whole area medical system being
activated, and third degree response involves the whole
country. The impact on society greatly differs depending upon
the severity the radiation has been leaked. |
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References |
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1. |
Ricks RC. Prehospital
Management of Radiation Accidents, ORAU 223, Oak
Ridge Associated Universities, Oak Ridge, TN, 1984. |
2. |
Castronovo JFP, Teratogen update: radiation and Chernobyl. Teratology 1999;60:100–6 |
3. |
Veenema TG, Karam PA. Radiation: clinical responses to radiologic incidents and emergencies. Am J Nursing 2003;103:32-40 |
4. |
Turai
I, Veress K. Radiation accidents: occurrence,
types, consequences, medical management and the lessons to be learned.
Central European Journal of Occupational and Environmental Medicine
2001;7:3–14 |
5. |
Fong F. Medical management of radiation accidents.
In: Hogan D, Burstein J, editors. Disaster medicine. Philadelphia: Lippincott Williams & Wilkins; 2002;
237–57. |
6. |
Hall E. Radiobiology for the radiologist. Philadelphia: Lippincott Williams & Wilkins; 2000 |
7. |
Jarrett D. Medical management of radiological
casualties handbook. Bethesda, MD: Armed Forces Radiobiology Research Institute;
1999. |
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