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Annals of Disaster Medicine

ISSN:1684-193X

Updated Oct 30, 2003
Contents:
Volume 2, Supplement 1; October, 2003
Emergency Department Response on Radiology Event
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

 

Abstract

   
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

 

Introduction

 
   
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.
 
Characteristics of Radiation
 

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)


  
Table 1. Biological effects of acute, total body irradiation
 
Types of Radiological Events and Possible Effects  
   
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.

 
 
Emergency Resonse  
   
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
 
   
Table 2.The onset of symptoms as predictor for the dosage exposed
 
 
Conclusion  
 

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.

  
 
References  
   
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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