Decontamination of Patients

1
Decontamination of Patients

• External
• Skin
• Wound
• Internal
• Decorporation agents

2
Patient Decontamination

• Remove and bag the patients clothing and
  personal belongings (this typically removes 80 -
  90 of contamination)
• Handle foreign objects with care until proven
  non-radioactive with survey meter
• Survey patient and collect samples
• Survey face, hands and feet
• Survey rest of body
• Note Avoid contamination of the probe.

3
External Contamination

• Radioactive material (usually in the form of dust
  particles) on the body surface and/or clothing
• Radiation dose rate from contamination is usually
  low, but while it remains on the patient it will
  continue to expose the patient and staff

4
External Contamination Remove with Showering
5
Decontamination Priorities

• Wounds
• Intact skin (areas of highest contamination
  first)
• Change outer gloves frequently to minimize spread
  of contamination

6
Decontamination of Wounds

• Contaminated wounds
• Irrigate and gently scrub with surgical sponge
• Debride surgically only as needed
• Contaminated thermal burns
• Gently rinse
• Changing dressings will remove additional
  contamination
• Avoid overly aggressive decontamination
• Change dressings frequently

7
Decontamination of Skin

• Use multiple gentle efforts
• Use a mild soap water solution
• Cut hair if necessary (do not shave)
• Promote sweating
• Plastic wrap, glove, etc.
• Use survey meter

8
Cease Patient Decontamination

• When decontamination efforts produce no
  significant reduction in contamination
• When the level of radiation of the contaminated
  area is less than twice background
• Before intact skin becomes abraded
• Consider internal contamination

9
Internal Contamination

• Radioactive material may enter the body through
• - Inhalation
• - Ingestion
• - Wounds
• Internal contamination generally does not cause
  early signs or symptoms
• Internal contamination will continue to irradiate
  the patient

10
Treatment of Internal Contamination

• Rare earths
• - Plutonium
• - Transplutonics
• - Yttrium
• Uranium
• Cesium, rubidium, thallium
• Tritium

11
Potassium Iodide (KI)

• Only helpful in blocking thyroid gland
• KI saturates the thyroid gland with stable iodine
• KI must used prior to or within hours of exposure
  to radioactive iodine
• See the FDA web site
• Decorporation agent
• Provide to Decon Team Members

www.fda.gov/cder/drugprepare/KI_QA.htm
12
Immediate Medical Management of Radiation Exposed
Patients

• Triage
• Acute Radiation Syndrome (ARS)
• localized/cutaneous
• combined injury
• Initial stabilization and treatment
• Psychological effects
• Record keeping/Dose assessment

13
Management - Priorities of Radiation Exposed
Patients

• Standard medical triage is the highest priority
• Radiation exposure and contamination are
  secondary considerations

14
Management Protocol of Radiation Exposed
Patients (Cont)

• Based on
• Injuries
• Signs and symptoms
• Patient history
• Contamination survey

15
Prenatal Radiation Exposure

• Human embryo and fetus highly sensitive to
  ionizing radiation
• At higher doses, effects depend on dose and stage
  of gestation
• Pregnant patients should receive special dose
  assessments and counseling
• Information on prenatal radiation exposure
• www.bt.cdc.gov/radiation/prenatalphysician.asp

16
Required Conditions forAcute Radiation Syndrome

• Large dose
• Penetrating
• Most of body exposed
• Acute

17
Never delay critical care because a patient is
contaminated
Acute Radiation Syndrome
18
1986 Chernobyl Accident
When workers at Chernobyl who were in the
reactor area at the time of the nuclear accident
were decontaminated, the medical personal at the
site received less than 10 mGy of
radiation. Mettler and Voelz, New England
Journal of Medicine, 2002 346 1554-61
19
Skin Effects

• Epilation
• Erythema
• Pigmentation
• Dry desquamation,
• (Shedding, flaking off)
• Moist desquamation that heals

NUREG / CR-4214, p II-68
20
Treatment of Large External Exposures

• Treat patients symptomatically
• Prevent and manage infections
• Hematopoietic growth factors, e.g., GM-CSF, G-CSF
  (24-48 hr) (Neupogen)
• Irradiated blood products
• Antibiotics/reverse isolation
• Electrolytes
• More information on ARS
• www.bt.cdc.gov/radiation/arsphysicianfactshee
  t.asp

• Treat patients symptomatically
• Prevent and manage infections
• Hematopoietic growth factors, e.g., GM-CSF, G-CSF
  (24-48 hr) (Neupogen)
• Irradiated blood products
• Antibiotics/reverse isolation
• Electrolytes
• More information on ARS
• www.bt.cdc.gov/radiation/arsphysicianfactshee
  t.asp

21
Treatment of Cutaneous Radiation Syndrome

• Lesions do not appear for days to weeks
• Perform surgical treatments within 48 hrs
• Consult Radiation Emergency Assistance Center/
  Training Site (REAC/TS) for advice for further
  treatment, 865-576-1005 or www.orau.gov/reacts/

22
Dealing With Staff Stress

• Preplanning
• Establish information center
• Train staff on radiation basics
• Post Event
• Debrief immediately after event
• Offer counseling

23
Bomb Blast - Injury Patterns

• Most survivors suffer secondary and tertiary
  blast effects
• Primary blast injury is infrequent in survivors
• 15 of survivors require hospital admission
• The remaining are treated and released from the
  emergency department

24
Staff Preparedness

• Plan for the needs of the unaffected population
• Ratios range from 5-15 to 1
• 5-15 worried well to 1 actual injured patient
• This can paralyze your ED
• Prepare to receive large numbers of casualties
• Rotate staff to avoid congestion and fatigue
• Monitor staff in chemical protective clothing
  equipment (CPCE)

25
Logistics/Supplies

• Highest priority getting the right resources to
  the right place at the right time
• Chemical protective clothing and equipment
• Medications / antidotes / vaccines
• Mechanical ventilators
• Isolation rooms remote from other patients
• Identify current inventory and augment as
  necessary
• Develop a procedure to access external assets

26
Maximal Utilization of Hospital Space

• Identify alternative medical treatment areas
• Planning for use of available space
• Open areas
• Isolated areas
• Temporary morgue
• Conference room
• Cafeteria
• Physical Therapy

27
Handling of Evidence

• Maintaining evidence is critical for an
  investigation
• Clothing
• Embedded foreign bodies
• Decontamination runoff
• Chain of Custody must be maintained

EVIDENCE
28
Table Top Exercise

• Hospital Incident Management System (HIMS)
  Hands-on Exercise - Overview

29
Table Top Exercise

• Hospital Incident Management System (HIMS)
  Hands-on Exercise - Report Out