1. Natural and man-made disasters.

Throughout the history, planet earth has recorded natural and manmade disasters. Usually
the natural disasters predominant in their magnitude over the manmade ones, examples of
natural disasters can be: “The Bubonic plague” (Yersinia pestis) which believed to claim an
estimated number of 100 - 200 million victims, the fear of the impeding “Avian Influenza”
(bird flu) pandemic which may acquire a worldwide scale, earthquakes, floods, and deadly
storms (e.g. Indian ocean earthquake and subsequent tsunami in 2004).
The manmade disasters will include examples as: large scale accidents (e.g. Chernobyl
disaster), road traffic, and other means of transportation accidents, wars, terror actions,
and various political and ideological beliefs which evolve into violent actions.

“Interestingly”, in our days there is a certain merging, or cooperation, between the natural
and the manmade disasters, for example: diseases that have been eradicated (e.g. smallpox)
now have the potential to be reintroduced to the society, either accidentally from the few
remaining research sources or by intentional release. Other example of cooperation
between the natural and the manmade disasters is the advanced air transportation humans
poses that allow rapid travel to any part of the world and make disease outbreaks that were
previously controlled by natural borders, (e.g. oceans), no longer have those barriers making
the likelihood of worldwide outbreak much greater than it was hundreds of years ago.
2. Definitions of disaster. Disaster medicine

Disaster definition
The root of the word disaster ("bad star" in Greek[dus - "bad" + aster – “star”]) comes from
an astrological theme in which the ancients used to refer to the destruction or
deconstruction of a star as a disaster.

A disaster is a serious disruption of the society functioning, causing widespread human,

material or environmental losses which exceeds the ability of the affected society to
cope using only its own resources.

In terms of medical needs, an event, which accompanied by such an amount of dead and
injured, which can’t be handled by the health care system is termed a “disaster”. Therefore
an event of such magnitude is a disaster because it has overwhelmed the infrastructure of
the community in which it occurred (that’s why sometimes an event with small amount of
casualties in an underdeveloped region may fit to the definition of disaster due to the
inability to adequately respond and cope with the situation).

Disaster medicine
Disaster medicine is the prevention, reduction and mitigation of the disasters effects on
the health of communities; the provision of appropriate treatment for those affected; and
the restoration of health services and facilities to the pre-disastersituation as soon as
possible. Disaster medicine requires a different approach than that for emergency
medicineand normal public health management practices, because of the overwhelming
nature of the event and the associated disorder.
3. Mass casualties incidents

A MCI (mass casualty incident; sometimes called a multiple-casualty incident or multiple-

casualty situation) is any incident in which emergency medical services resources, such as
personnel and equipment, are overwhelmed by the number and severity of casualties. For
example, an incident where a two-person crew is responding to a motor vehicle collision with
three severely injured people could be considered a mass casualty incident.
4. Role of prehospital emergency services in Mass casualties incidents

The prehospital emergency services include all the services taking part in the rescue
organization of the people involved in the incident as well as securing the areas between
where the mass casualty incident happened and the hospital.

A mass casualty incident can involve many and various types of responders and agencies,
including (but not limited to) the ones listed here:

 Certified first responders will assist with all aspects of patient care, including triage
and treatment at the scene, and transport from the scene to the hospital.
 Paramedic and emergency medical technician (EMT) personnel will have the lead in all
aspects of patient care as assigned by the medical officer or incident commander.
 Land ambulances will be assigned to the transport sector to transport patients and
personnel to and from the incident scene, emergency departments of hospitals, and a
designated helipad.
 Air ambulances will transport patients from the scene or from designated helipads to
receiving hospitals.
 Firefighters will perform all initial rescue related operations, as well as fire suppression
and prevention. They may also provide medical care if they are trained and assigned to
do so.
 Police officers will secure the scene to ensure that only properly authorized people are
present to ensure safety and smooth operation.
 Utility Services are responsible for ensuring that utilities to the area are turned off as
necessary in order to prevent further injury or damage at the scene.
 HazMat teams are responsible for cleaning up and neutralizing any hazardous materials
at the scene. Sometimes these will be specialized CBRNE (chemical, biological,
radiological, nuclear and high-yield explosives) teams.
 The media play an important role in keeping the general public informed about the
incident and in keeping them away from the incident area.
 Non-governmental organizations(e.g. the Red Cross) will provide valuable assistance with
all aspects of a mass casualty incident including trained medical staff, vehicles, individual
registration and tracking, temporary shelter, food service, and many other important
services.
5. Effect of disaster on hospitals

A disaster may have a variety of affects on hospitals, which in turn can be affected both
bynatural disastersand/or manmade disasters.

Natural disasters can produce situation where medical stuff and pats are trapped within the
different hospital facilities, without essential services (e.g. Hurricane “Katrina”, USA,
2005). Natural disasters may also simply disrupt the hospital services (Tropic storm
“Alison”, Houston, Texas, 2001), by damaging hospitals electric supply lines, generators,
communication systems, etc…

A large scale manmade disaster (e.g. 2001 world trade center bombing), may cause the
addition of a large number of pts in a short period of time. In such conditions, despite the
great efforts, hospital may lose track of pts, run out of supplies, and face a straggle
coordinating its physicians and other medical personnel.

Hospitals are vulnerable to the stresses of disasters due to a number of inherent

characteristics:

- Complexity of cervices: hospitals provide health care, but must also function as
laundromats, hotels, office buildings, laboratories, restaurants, and storehouse.
- Dependence on lifelines: hospitals are completely dependent on basic public services:
water, sewer, power, medical gases, communication, fuel, and waste collection.
- Hazardous materials: hospital environment contains toxic agents as well as poisonous
liquids and gases.
- Dangerous objects: heavy medical equipment, storage shelves, and supplies can fall or
shift during an event such as an earthquake.
6. Hospital disaster preparedness

If hospital services fail during a disaster, the hospital will fail in it response to it,
therefore there for a hospital should form a comprehensive emergency management
program that will address a number of critical elements:

Incident commandership
An organized approach is essential to a successful hospital wide emergency response.

Emergency operation center (fully operational and well equipped)

The center will serve as the command post for operations during an event of emergency.

Exercises, drills and trainings

Only through exercise the plan is adequately stressed so that failure points can be
recognized.

Essential services and facility engineering

It is recommended that every hospital:

- Possess emergency power generating capacity for 3 – 4 days duration.

- Maintain the water supply and the alternative water supply in secure areas in sufficient
quantity to support all services (e.g. sanitation, hygiene, laundry) for 3 – 4 days.
- Maintain medical gases in a secure location, and have a 3 – 4 day supply for the hospital.
- Configure the heating-ventilation-air conditioning system so that it can be shut down,
and ideally, so that specific zones can be manipulated to control air flow in the building in
case of contamination.
- Maintain a fuel source for 3 – 4 days duration.

Physical security
Security is essential on daily basis but during a disaster it becomes more challenging. To
ensure that the environment remains safe, exit must be controlled.

In addition security plan should include:

- Security force with full time security responsibility.

- All entrances and exists should be controlled, monitored and capable of being locked.
- Hospital should be able to perform perimeter security protection (“lockdown”) within
minutes of notification.

Situation report
It is critical that a hospital will be able to rapidly assess the impact of a disaster on its
operations and communicate the status to leadership.
Assessment should at minimum include the following:

- Extend and magnitude of the disaster and the scope and nature of casualties.
- Status of operations and any disrupted critical services.
- Impact of disruptions on operations and the ability to sustain operations.

Staff notification
Hospital staff must be able to receive timely and accurate notifications in a disaster.
Additionally the facility must be able to receive warnings and notifications from external
agencies and be able to send warnings.

Triage system
During a disaster, triage procedures must adapt to become like what is used on the battle
field. Whatever triage system is selected, (e.g. START (simple triage and rapid treatment);
ID-ME (immediate, delayed, minimal, expectant); MASS (move, assess, sort and send)),
there must be pre-disaster training and exercises.

Alternative triage area

When casualties number overwhelms the facility an alternative area must be available to
manage the overflow.

Disaster mental health services

It is clear that every disaster creates emotional trauma victims. Hospital must plan for
providing mental health services to disaster victims.

Evidence and crime scene management

In an event of an international act that results in mass casualties the hospital also plays a
critical role in bringing the responsible to justice. Hospital staff members require training
in proper management of potential evidence (both, in collection and preservation). Law
enforcement agencies and forensic departments can provide training and guidance.

Food services
Adequacy of food supplies for the pts and staff must be evaluated. Because a hospital may
need to be self-sufficient for several days in a disaster, a 3 – 4 day supply of food products
is advisable.

Disaster supplies
Hospitals should maintain dedicated disaster supplies, to ensure stocks do not expire, and
form arrangements for rapid resupply (administrative as well as clinical) in a disaster event.
7. Role of prehospital medical services at the accident site

Emergency medical services (EMS) are services dedicated to provide“out-of-hospital”

acute medical care and/or transport to definitive care, to patients with illnesses and
injuries which the patient, or the medical practitioner, believes constitutes a medical
emergency. The use of the term emergency medical services may refer solely to the pre-
hospital element of the care, or be part of an integrated system of care, including the main
care provider, such as a hospital.

The goal of most emergency medical services is to either provide treatment to those in
need of urgent medical care, with the goal of satisfactorily treating the presenting
conditions, or arranging for timely removal of the patient to the next point of definitive
care. This is most likely an emergency department at a hospital or another place where
physicians are available. The term emergency medical service evolved to reflect a change
from a simple system of ambulances providing only transportation, to a system in which
actual medical care is given on scene and during transport.

Emergency medical services exist to fulfill the basic principles of first aid, which are to
preserve life, prevent further injury, and promote recovery.

There are six stages of high quality pre-hospital care:

1. Early detection- Members of the public, or another

agency, find the incident and understand the problem
2. Early reporting- The first persons on scene make a call to
the emergency medical services and provide details to
enable a response to be mounted
3. Early response -The first professional (EMS) rescuers
arrive on scene as quickly as possible, enabling care to
begin
4. Good on-scene care - The emergency medical service
provides appropriate and timely interventions to treat the
patient at the scene of the incident
5. Care in transit - the emergency medical service load the
patient in to suitable transport and continue to provide
appropriate medical care throughout the journey
6. Transfer to definitive care - the patient is handed over to an appropriate care setting,
such as the emergency department at a hospital, in to the care of physicians
Generally speaking, the levels of service available will fall into one of three categories; Basic
Life Support (BLS), Advanced Life Support (ALS), and care by traditional healthcare
professionals, meaning nurses and/or physicians working in the pre-hospital setting and even
on ambulances.
8. Local response to disasters. Responsibility of emergency services
9. Public welfare in disasters
10. Public health in disasters

Public health seeks to mitigate hazards such as explosions, chemical exposures, and natural
disasters (like floods, earthquakes, and infectious Mitigation --> is the process of recognizing risk and

disease), as well as reducing vulnerabilities of the vulnerabilities and then acting to both reduce the
vulnerabilities and strengthen the society’s ability to
infrastructure such as weak assets, resources, withstand an unstoppable event or to reduce the effects
from a disaster.
personnel, and science (e.g. hardening structures
against blasts; act to increase early detection of infectious diseases).

Public health program should act in the training

and development of staff, identify and classify Preparedness -->is the process of developing a
formal response program.
public health resources (including personnel,
supplies and facilities), act for the development
of standard operating procedures, emergency response plans, and communications plans and
the pre-placement of key supplies and protective equipment.

Later, (in case of an event and after the situation happened), public health agencies must
identify what resources may be available to assist in restoring the condition as well as
address the physically and emotionally affected populations (e.g. search and rescue in the
case of an earthquake, bombing or landslide; reinstitution of medical services if clinics and
hospitals are destroyed; establishment of corrupted lifelines like sanitation, electricity, and
water).
11. General principles of triage

Triage is the process of determination of the pts treatment priority, based on their
condition severity.
The term comes from the French verb “trier”, meaning to separate, sift or select.

Triage may result in determining the order and priority of emergency treatment, the order
and priority of emergency transport, or the transport destination for the patient.

Two types of triage exist: simple and advanced.

Simple triage
Simple triage is usually used in a scene of a "mass-casualty incident" (MCI), in order to sort
patients into those who need critical attention and immediate transport to the hospital and
those with less serious injuries. This step can be started before transportation becomes
available. The categorization of patients based on the severity of their injuries can be aided
with the use of printed triage tags or colored flagging.

S.T.A.R.T. model
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be
performed by lightly trained emergency personnel in emergencies.

Triage separates the injured into four groups:

a) The expectant who are beyond help

b) The injured who can be helped by immediate transportation
c) The injured whose transport can be delayed
d) Those with minor injuries, who need help less urgently

Advanced triage
In advanced triage, doctors may decide that some seriously injured people should not
receive advanced care because they are unlikely to survive. Advanced care will be used on
patients with less severe injuries. It is used to divert scarce resources away from patients
with little chance of survival in order to increase the chances of survival of others who are
more likely to survive.

In Western Europe, the criterion used for this category of patient is a trauma score of
consistently at or below 3. This can be determined by using the Triage Revised Trauma
Score (TRTS), a medically-validated scoring system incorporated in some triage cards.

Another example of a trauma scoring system is the Injury Severity Score (ISS). This
assigns a score from 0 to 75 based on severity of injury to the human body divided into
three categories: A (face/neck/head), B (thorax/abdomen), C (extremities/external/skin).
Each category is scored from 0 to 5 using the Abbreviated Injury Scale, from uninjured to
critically injured, which is then squared and summed to create the ISS. A score of 6, for
"unsurvivable", can also be used for any of the three categories, and automatically sets the
score to 75 regardless of other scores.

The use of advanced triage may become necessary when medical professionals decide that
the medical resources available are not sufficient to treat all the people who need help. The
treatment being prioritized can include the time spent on medical care, or drugs or other
limited resources.

Triage should be a continuous process and categories should be checked regularly to ensure
that the priority remains correct.
12. Triage at the accident site

During the early stages of an incident, first responders may be overwhelmed by the scope
of patients and injuries. One valuable technique is the Patient Assist Method (PAM); the
responders quickly establish a casualty collection point (CCP) and advise; either by yelling, or
over a loudspeaker, that "anyone requiring assistance should move to the selected area
(CCP)". This does several things at once, it identifies the not so severely injured, those
who need immediate help, it physically clears the scene, and provides possibleassistants
to the responders. As those who can move, do so, the responders then ask, "Anyone who still
needs assistance, yell out or raise your hands"; this further identifies patients who are
responsive, yet maybe unable to move. Now the responders can rapidly assess the remaining
patients who are either expectant, or are in need of immediate aid. From that point the
first responder is quickly able to identify those in need of immediate attention, while not
being distracted or overwhelmed by the magnitude of the situation.

Using this method assumes the ability to hear. Deaf, partially deaf or victims of a large
blast injury may not be able to hear these instructions.
13. Principles of hospital triage

In the USA, within the hospital system, the first stage on arrival at the emergency room is
assessment by the hospital triage nurse. This nurse will evaluate the patient's condition, as
well as any changes, and will determine their priority for admission to the Emergency Room
and also for treatment. Once emergency assessment and treatment are complete, the
patient may need to be referred to the hospital's internal triage system.

For a typical inpatient hospital triage system, a triage physician will either field requests
for admission from the ER physician on patients needing admission or from physicians taking
care of patients from other floors who can be transferred because they no longer need
that level of care (i.e. intensive care unit patient is stable for the medical floor). This helps
keep patients moving through the hospital in an efficient and effective manner.

A major factor contributing to the triage decision is available hospital bed space. The triage
hospitalist must determine, in conjunction with a hospital's "bed control" and admitting
team, what beds are available for optimal utilization of resources in order to provide safe
care to all patients.

A typical surgical team will have their own system of triage for trauma and general surgery
patients. This is also true for neurology and neurosurgical services.

The overall goal of triage, in this system, is to both determine if a patient is appropriate for
a given level of care and to ensure that hospital resources are utilized effectively.
14. Main causes of HazMat incidents

HazMat (Hazardous materials) are solids, liquids, or gases that can harm people, other

living organisms, property, or the environment.

The causes of HazMat incidents are classified regarding the location (WHERE?) of the
place where the incident can occur, the HazMat behavior (WHY IT HAPPENS?) as well as
the way they harm (HOW?)

Where
The more a hazardous material is handled or manipulated, the higher chances for an incident
to occur.

Places are as listed:

- Research and development: one of the most dangerous and is generally undertaken only
under extreme safety procedures
- Site of manufacture: the manufacturing process presents the greatest bulk hazard
because materials are stored, handled, and mixed at the facility throughout the process.
Billions of dollars are spent by the chemical industry to prevent incidents or to limit the
incident effects if such to occur
- Storage (at site of manufacture):a complete understanding of the stored products
nature and the associated storage systems is necessary for emergency response forces
- Transportation:during transportation, the chemical industry has less control and
oversight (because of road, weather, and other conditions), the incident may occur at any
point of the transportation phase.
- Storage (at site of use):the risks at this point are wholly dependent on the quantity of
materials stored and how they are stored
- Site of use:the element of human error predominates
- Disposal of waste product:the disposal phase has an increased potential fora serious
incident. With some materials the breakdown products may be more hazardous than the
original product itself.

HazMat behavior
Hazardous materials are chemicals that follow the laws of physics and have generally easily
predictable properties.

Accidental HazMat incidents occur because of one or more of the following initiation
events:
- Human error
- Environmental conditions
- Container failure
- Equipment failure
15. Routes of exposure of hazardous chemicals

The three main mechanisms of harm in the case of chemical emergencies are as follows:

- Flammability - Causing thermal injury (such as burns and scalds)

- Reactivity - Causing a rapid release of energy when a chemical reaction occurs
- Healtheffects - Causing the disruption of normal bodily functions

These injuries are often complicated by the toxic properties of the chemical.

Hazardous chemicals can interact with the human body through four routes of exposure:

- Inhalation
- Absorption
- Ingestion
- Injection
16. Principles of decontamination

Decontamination is the process of reducing and preventing the spread of contaminants from
a hazardous materials scene.

Physical decontaminationinvolves physically removing contaminant from the contaminated

person or object.Physical decontamination techniques include:

- Dilution
- Brushing or scraping
- Absorption

Chemical decontaminationis the process of removing or reducing the threat from a specific
contaminant by making it less harmful through a chemical change.
Chemical decontamination techniques include:

- Chemical degradation – application of a degradation agent to alter the chemical

structure of hazardous material [Note: degrading agents should never be applied
directly to skin!]. (Examples: bleach, drain cleaner, washing soda, lime, detergent,
isopropyl alcohol)
- Neutralization – application of either an acid or caustic to a corrosive liquid spill to bring
the pH of the spill towards neutral (pH=7)
- Solidification – application of a material which chemically bonds thecontaminant to
another object or encapsulates it
- Disinfection – application of materials which will inactivate or killpathogenic
microorganisms [Note: you can never assume that fielddisinfection will be 100%
effective in killing all traces of an organism]
- Sterilization – destroys all microorganisms in or on an object(examples: steam,
concentrated chemical agents, ultraviolet lightradiation)

The decontamination process is executed at the so called

decontamination corridor. The decontamination
corridor is created as a sole communication between
the “hot zone” (area immediatelycontaining, or within the
effect of, an uncontained hazardous material) and the “cold zone” (absence of
contaminants) and it is passed through a territory between those two which is called the
“warm zone” (designated as a barrier to trafficin order to protect people from getting into
the hot zone as well as minimize the migration of hazardous material outside of the hot
zone).The decontamination corridor can be tightlycontrolled to prevent the spread of
contaminants.

All decontamination takes place within the Decontaminationcorridor.

The near end of the Decon Corridor (which opens into the Cold Zone) isoften referred to as
the “clean end” of the corridor, while the opposite endis known as the “dirty end.” People
and equipment passing outboundthrough the corridor will be subjected to the appropriate
decontaminationprocesses to insure that they are “clean” or free from contaminant
beforethey exit the clean end.

Various pieces of special equipment can greatly assist the process of decontamination. Some
may be mobile and erected as needed, while others may be permanent in places where
hazardous materials are frequently stored and handled. Examples:

- Positive and Negative Pressure Rooms – positive air pressure outside and negative
pressure inside to prevent contaminants from spreading beyond containment room
- Fixed Ventilation Systems – primarily found in research or manufacturing facilities
engaged in the use of hazardous materials
- Safety Showers – deliver water at 30-50 gallons/minute.
- Eyewash Fountains – often combined with emergency showers, these devices are
designed to deliver a continual low-pressure stream of water to flush out the eyes.

Health care considerations

• Patient should be fully decontaminated prior to transportation to a medical facility

• Receiving medical staff should be notified when handling a contaminated patient
• Patient should be wrapped in disposable fabric bags to prevent spread of any remaining
contaminants
• Fatalities should be handled with same decontamination procedures
17. Radiation accidents. Principles of medical management

Radiation accidents
Radiation accidents can occur in situationswhere there are problems with nuclear reactors
aswell as industrial and medical sources of radiation. From1946 to 2000, there have been
more than 120 documentedfatalities resulting from radiation accidentsworldwide.

There are two categories of radiation accidents.

- The first category is an external exposure accident, that is, external irradiation from a
source distant to or in close proximity to the body. Once a person has been removed
from the source of radiation or the radiation-producing machine has been turned off,
the irradiation stops. This exposed person does not become radioactive and there are no
hazards to other people.
- The second category is a contamination accident. A person contaminated with
radioactive material will continue to be irradiated until theradioactive material is
removed,eliminated,or decays away.Contamination may occur in the form of radioactive
gases,liquids, or particles. The contamination can be spread toother parts of the victim’s
body as well as to others.
- Thereis a third category of accident—a combination of the two.

Principles of medical management

Conventional injuries should be treated first, since radiationcontamination is not a life-
threatening medicalemergency. Patients with traumatic blast and radiationinjury should be
resuscitated and stabilized. Airway,breathing, and circulation always take priority.
Thesepatients require more specialized treatment. Decontaminationof patients should be
carried out according toaccepted standards of radiation decontamination. Specialists in
hematology,oncology, radiation, and infectious disease should beconsulted. Effective
treatment of internally contaminatedpatients requires knowledge of both the radioactive
isotopeand its physical form. Treatment should be institutedquickly to ensure
effectiveness. Several general approaches maybe used to treat internal radiation
contamination, includingreduction of absorption (Prussian blue),dilution
(forcefluids),blockage (potassium iodide),displacementby nonradioactivematerials (oral
phosphate), mobilization as ameans of elimination from tissue (ammonium chloride),and
chelation (Ca-DTPA and Zn-DTPA).

Patients who have received a low whole-body radiationdose may develop GI distresswithin
the first 2 days. Antiemetics may be effective inreducing the GI symptoms. If ineffective,
parenteral fluids shouldbe considered.

The prognosis for patients who have suffered traumaticblast, burn, and radiation injury is
worse than forpatients with radiation injury alone. A wound that iscontaminated with
radioactive materials should berinsed with saline and treated using conventional
aseptictechniques. Alpha-emitting radioactive isotopes, forexample, that contaminate
wounds are usually excised.In patients who receive whole-body doses of radiationgreater
than 100 cGy, the wound should be closed assoon as possible to prevent it from becoming an
entryfor lethal infection.

In spite of the wide availability of antibiotics, infectionsfrom opportunistic pathogens are a

major problemamong patients exposed to intermediate and high dosesof radiation. In these
cases the primary determinants ofsurvival are treatment of microbial infections and
aggressiveresuscitation of the bone marrow.

Specific management:  Symptomatic treatment is given as needed and includes managing

shock and hypoxia, relieving pain and anxiety, and giving sedatives (lorazepam1 to 2 mg IV
prn (prn = as needed)) to control seizures, antiemetics (metoclopramide10 to 20 mg IV q 4
to 6 h; prochlorperazine5 to 10 mg IV q 4 to 6 h; ondansetron4 to 8 mg IV q 8 to 12 h) to
control vomiting, and antidiarrheal agents (kaolin/pectin 30 to 60 mL po with each loose
stool; loperamide4 mg po initially, then 2 mg po with each loose stool) for diarrhea.

There is no specific treatment for the cerebrovascular syndrome. It is universally fatal;

care should address patient comfort.

The GI syndrome is treated with aggressive fluid resuscitation and electrolyte replacement.
Parenteral nutrition should be initiated to promote bowel rest. In febrile patients, broad-
spectrum antibiotics (eg, imipenem 500 mg IV q 6 h) should be initiated immediately.

Management of the hematopoietic syndrome is similar to that of bone marrow hypoplasia

and pancytopenia of any cause. Blood products should be transfused to treat anemia and
thrombocytopenia, and hematopoietic growth factors (GCSF & GMCSF) and broad-spectrum
antibiotics should be given to treat neutropenia and neutropenic fever, respectively.
Patients with neutropenia should also be placed in reverse isolation. With a whole-body
radiation dose > 4 Gy, the probability of bone marrow recovery is poor, and hematopoietic
growth factors should be given as soon as possible. Stem cell transplantation has had limited
success but should be considered for exposure > 7 to 10 Gy.

Radiation-induced sores or ulcers that fail to heal satisfactorily may be repaired by skin
grafting or other surgical procedures.

Aside from regular monitoring for signs of certain disorders (eg, ophthalmic examination
for cataracts, thyroid function studies for thyroid disorders), there is no specific
monitoring, screening, or treatment for specific organ injury or cancer.
18. Acute radiation syndrome

Ionizing radiation interacts with living cells by producingcharged water molecules (i.e., free
hydroxyl radicals) orby direct ionization of deoxyribonucleic acid. Clinicalsymptoms (acute
radiation syndrome) occur if enoughcells are damaged and die, or if the killed cells are
essentialfor human survival. Rapidly dividing cells, such asbone marrow cells or the intestinal
mucosa, are the mostsensitive to radiation, whereas slowly dividing cells (e.g.,central
nervous system) are the most radio-resistant.Nonlethal radiation doses may cause some
cells toundergo malignant transformation, leading to radiationinducedcancers years or
decades after exposure

External irradiation --> is the exposure of the entire bodyor a part of it to an external
source of penetratingradiation.

Acute radiation syndrome (ARS) is the primary threatto life after exposure to major doses
of radiation.ARS occurs when theentire body is exposed to a large dose of
penetratingexternal radiation over a short period. There are threeclassic acute radiation
syndromes.

- Bone marrow, or hematopoietic, syndromeusuallyoccurs with doses higher than 2 Sv

(200 rem), depending on the premorbid state of health. Destruction ordepression of the
bone marrow produces a pancytopenia,resulting in increased susceptibility to infection
andclotting abnormalities. As long as the bone marrow isnot completely destroyed,
granulocyte stimulating factorsmay enhance regeneration.
- Gastrointestinal syndrome occurs with doses greater than 6 Sv (600 rem). Cell death
and sloughing of theintestinal mucosa result initially in nausea, vomiting, anddiarrhea.
Since gastrointestinal symptoms coincide withhematologic abnormalities, dehydration,
electrolyteimbalances, and sepsis are part of the natural diseasecourse. Severe bloody
diarrhea is an ominous sign.
- Cardiovascular (CV)/central nervous system (CNS)syndromeoccurs with doses
exceeding 20 Sv (2000rem). The almost immediate nausea, vomiting, ataxia,and
convulsions are the result of diffuse microvascularleaks in the central nervous system,
causing edema andincreased intracranial pressure. Cardiovascular collapsefrom a
transient post-irradiation vasodilation has beenobserved.

ARS progresses through the following four clinicalphases:

1. The prodromal phaseoccurs within hours of exposureand may last for up to 2 days.
Symptoms are afunction of the total radiation absorbed dose andinclude anorexia,
nausea, vomiting, diarrhea, fatigue,fever, respiratory distress, and agitation.
Treatmentshould be symptomatic.
 2. The latent phaseis a transitional period in which thepatient is asymptomatic. This may
last as long as3 weeks, but is much shorter with higher radiationexposures.
3. The illness phaseproduces overt clinical manifestations,including infection as a result
of leukopenia,bleeding from thrombocytopenia, diarrhea, electrolyteimbalances, altered
mental status, and shock.
4. The death or recovery phaseoften occurs over weeksor months.

The clinical phases of ARS are related to cell reproduction,with the fastest-dividing cells
affected earliest. Thetime of onset after exposure of general signs and symptomsrelated
to the hematopoietic and gastrointestinalsystems are good markers for prognosis. After
exposure,a shorter time until symptom onset is associated with apoorer prognosis.
19. Chemical accidents. Principles of medical management

Chemical exposures may come from environmental,industrial, warfare, or terrorism sources.

Any chemical release has the potential to produce masscasualties. The safe and effective
management of thescene, patients, and environment depends on prioritizingscene safety
and staff protection for emergency respondersand hospital personnel.

Industrial chemical disasters

An industrial chemical disasteris defined as the release or spill of a toxic chemical that
results in an abrupt and serious disruption of the functioning of a society, causing
widespread human, material, or environmental losses that exceed the ability of the affected
society to cope using only its own resources.

Detection and management of the consequences of industrial chemical disasters

• Rapid assessment
• Scene control and establishment of a perimeter
• Product identification and information gathering
• Pre-entry examination and characterization of site
• Selection and donning of appropriate personal protective clothing and equipment
• Establishment of a decontamination area
• Entry planning and preparation of equipment and supplies
• Victim rescue from release area
• Containment of spill
• Neutralization of spill/release
• Decontamination of victims and responders
• Triage of injured
• Consultation with toxicologist/emergency department/Poison Control Center
• Medical care, including antidotes
• Transport of patients
• Post-entry evaluation of rescuers and equipment
• Delegation of final clean-up to responsible party
• Record-keeping and after-action reporting

Medical treatment of casualties

There are certain generalizationsthat can be made to simplify disaster medicalresponse.
Toxic chemicals can be categorized by theirknown health effects. For ease of case and
incidentmanagement, a broad variety of hazardous chemicals can be divided into 13 basic
categories(Metals and metallic compounds, Incendiaries, Irritant gases, etc…)

Aside from an extremely limited number of antidote therapies, medical management of

nearly all toxic chemical exposures involves mostly supportive therapy. Even if there may be
an antidote available for a specific exposure, many times the clinician may not be able to
identify the offending agent in enough time to guide effective therapy.

The table below represents four main basic medical conditions that can be expected to
occur as major short-term sequelae following severe exposures to any of these chemical
hazards. It then also identifies a mere eight categories of emergency medical therapeutics
that would become necessary to treat these four syndrome complexes.
EMERGENCY MEDICAL CONDITIONS AND NEEDS ASSOCIATED WITH CHEMICAL
EXPOSURE
Syndromes and causative agents Medical therapeutic needs
Burns and trauma
Corrosives, vesicants, explosives, oxidants, Intravenous fluid and supplies
incendiaries, radiologics Pain medications
Pulmonary products
Splints and bandages
Respiratory Failure
Corrosives, military agents, explosives, Pulmonary products
oxidants, incendiaries, asphyxiants, irritants, Ventilators and supplies
pharmaceuticals, metals Antidotes (when available)
Tranquilizing medications
Cardiovascular Shock
Pesticides, asphyxiants,pharmaceuticals Intravenous fluids and supplies
Cardiovascular products
Antidotes (when available)
Neurologic Toxicity
Pesticides, pharmaceuticals, radiologics Antidotes (when available)
20. Biohazards. Principles of medical management
21. Chemical decontamination

Decontaminationis defined as the reduction or removal of chemical (or biologic) agents by

physical means or by chemical neutralization (detoxification) so agents are no longer
hazardous.The major objective of decontamination of victims exposed to a hazardous
chemical is the prevention of further harm and the optimization of the chance for full
clinical recovery.An important secondary objective is to avoid spreading contamination to
others and the healthcare facility (HCF).

Chemical agents exist in liquid, solid, or vapor form, with inhalation of vapors being the most
likely route of exposure.

Decontamination is generally the task of first responders (e.g., firefighters and hazardous
materials teams) trained to use PPE (Personal Protective Equipment) and to process victims
through decontamination units at the site of the chemical release.

Over 95% of surface contaminants can be eliminated by removing clothing and showering.

The three primary types of decontamination important to the healthcare provider are:

• Personal decontamination (i.e., self- or buddy decontamination when one is exposed)

• Casualty decontamination (i.e., decontamination of casualties)
• Personnel decontamination (generally,decontamination of non-casualties as medical
personnel).

The most common problems with decontamination solutionsare skin irritation, toxicity,
ineffectiveness, and high cost, so washing the skin with copious amounts of soap andwater
and irrigating the eyes with clean water is commonly done.

Because of the potential for secondary contamination, it is essential that medical personnel
understand the need for and undergo training in the actual use of PPE.

Common features of most stations include separate lines for ambulatory and non-ambulatory
patients.

Ambulatory patients should be instructed to remove all clothing and to bag personal
effects. The patient should then shower with copious amounts of soap and water from the
head down, leaning the head back to reduce the chance of residue contacting the eyes, nose,
or mouth followed by a thorough overall rinse with clean water.Once decontaminated,
patients should pot on clean clothing (e.g. scrubs). Patients then receive a standardized
wrist-band indicating that decontamination has been completed and move to the next zone
for screening and medical treatment.
In non-ambulatory patient a rapid decontamination is engaged, involving removal of clothing
and a quick, high-volume shower focusing on exposed areas: skin and hair. The peculiarity of
non-ambulatory decontamination is that the patients cannot decontaminate themselves due
to their immobility, so this decontamination must be done by members of the staff (2 - 4
persons involved)

Alternatively, victims may be decontaminated in one or more groups; this is called mass
decontamination.
22. Radiation decontamination

4 categories of decontamination are generally recognized:

1. Personal decontamination (decontamination of oneself)

2. Casualty decontamination (decontamination of patient casualties)
3. Personnel decontamination (decontamination of workers who are not pts)
4. Mechanical decontamination (procedures of physical removal of the radioactive
particles)

Radiation decontamination is not an emergency! (It requires time-consuming dedicated

actions and large amount of resources).

Pts decontamination performed by emergency responders should be brief. The goal should
be to remove all gross radioactive dust or debris from the body surfaces. If clothing and
shoes are also contaminated they should be removed. These actions will benefit pts by
eliminating the radiation emitting source and will reduce the cumulative absorbed dose the
pt would have received.

Hospital Decontamination
To prevent or minimize radiologiccontamination of the hospital facility and hospital staff,a
decontamination area should be established outside thehospital, preferably downwind from
the clean treatmentarea or hospital entrance. A patient arrival/triage areashould be
downwind from the decontamination area.

Control of patient and staff movementis critical to ensure that contaminated

ambulatorypatients and staff do not accidentally contaminate cleanareas. A hotline should
be established and secured. Anypeople or equipment leaving a contaminated area
mustundergo radiologic monitoring to make sure that radioactivecontaminants do not enter
clean areas.

In addition, a location for indoor decontaminationshould be part of the radiation emergency

plansin the event that patients contaminate the hospital.

Patient Decontamination
Removal of outer clothing and rapid washing of exposedskin and hair removes 95% of
contamination. Standardpatient decontamination is normally performed underthe supervision
of medical personnel. Moist cottonswabs of the nasal mucosa from both sides of the
noseshould be obtained, labeled, and sealed in separate bags.These swabs can be used as
evidence for inhalation ofradioactive particles. A 0.5% sodium hypochlorite solutioncan be
used to remove radioactive contaminationfrom intact skin. Radioactive material removed
from thepatient should be preserved for later analysis to identifythe specific radioisotope.
Surgical irrigating solutions, such as normal saline or lactatedRinger’s solution should be
used liberally inwounds, the abdomen, and the chest. These solutionsshould be removed
using suction instead of wiping orsponging. For the eyes,only abundant amounts of
water,normal saline, or eye wash solutions are recommended.If feasible, skin wash water
should be contained and heldfor disposal. Contaminated tourniquets are changedwith clean
ones. Wounds should be covered after adjacentskin is decontaminated to prevent skin
contaminantsfrom entering the wound.

Wound Decontamination
During initial decontamination in the receiving/triagearea, bandages should be removed and
all wounds flushed.Particulate mattercontaminating a wound should be removed ifpossible.
After adequatedecontamination of the wound is achieved, it should becopiously irrigated
with saline or some other physiologicsolution. Partial-thickness burnsshould be extensively
irrigated and cleaned with mildsolutions to prevent irritation of burned skin. In full-
thicknessburns, the presence of radioactive contaminants requires specialized surgical
treatment.

Mechanical decontamination
Examples of mechanical decontamination (depending of the contamination type) include:

- Washing/rinsing by water.
- Vacuuming.
- Washing with detergent solution.
- Applying protective coating of paint over inanimate contaminated objects/surfaces.
- Removing the top layer of contaminated soil and its disposal as radioactive waste.
- Applying a complexing agent solution.
- Or any combination of the above.
23. Explosives. Principles of medical management

Explosives
An explosive blast is essentially an intense exothermic reaction generated by triggering a
rapid chemical conversion of a solid or a liquid into a gas. The resultingcompressed energy
release leads to detonationand a massive increase in local pressure. As a consequence a
“pressure pulse” rapidly expands into thesurrounding medium at speeds exceeding the speed
ofsound. This expanding pressure pulse moves, as a blastwave, in all directions. When the
blast front (the leading edge of the blast wave) encounters an object, it causes
“overpressure”(a virtually instantaneous rise in the atmospheric pressure). With continued
expansion of gases from their point of origin, the pressure at a fixed point subsequently and
exponentially drops below predetonation levels, temporarily creating a relative vacuum
known as “underpressure”. Eventually, the blast wave deteriorates and forms acoustic
waves.

Overpressure is the major force generating primary blast injury (PBI), underpressure
forces are the principle mechanisms involved in producing secondary and tertiary blast
injury.

The blast effect is strongly affected by specific characteristics of the environment in

which it occurs (e.g. the effect of an explosion in an open space is much smaller than that of
one that occurs in a closed, confined environment; the lethal radius around an explosion in
water is ~ 3 times the one it would be in air).

The clinical spectrum of blast injuries is usually described as involving primary, secondary,
tertiary and miscellaneous blast injuries.

- Primary blast injuries are a direct result of blast overpressure forces. Overpressure
forces tend to damage various internal organs by direct conduction of forces derived
from the blast wave which come in contact with external body surfaces.
- Secondary blast injuries are caused by accelerated object due to the explosion (pieces
of glass, wood, stones etc…), which may cause blunt and/or penetrating injuries.
- Tertiary blast injuries result from deceleration forces after the victim’s body is set in
motion by the pressure and the high winds of an explosion (e.g. striking various
stationary objects).
- Miscellaneous blast injuries refer to a broad category of injuries which include thermal
and chemical burns, inhalation exposure, and crush related trauma.

Principles of medical management

As with any trauma patient, initial management beginswith conventional priorities outlined in
the advancedtrauma life support protocols (ABCDE).

Auditory Injury
The ear is the organ most frequently injured by an explosion.Auditory PBI rarely requires
emergent intervention,and the important considerations involve recognitionand appropriate
referral to reduce long-termmorbidity. All survivors of blast should have an
otologicassessment and audiometry at some time in their aftercare.

The complication of perilymph fistula shouldis the only component of auditory PBI
requiringprompt surgical treatment (i.e., emergent tympanotomyand fistula repair).
Cholesteatoma may be a late complication(12 to 48 months) of TM perforation. 80% of TM
perforations heal spontaneously,and nonoperative management is appropriate for
mostcases.Large perforations may warrant surgicalrepair, but elective tympanoplasty can
safely be delayedfor up to 12 months with good outcomes.

Thoracic Injury
PBI involving the respiratory system can leadto a constellation of findings known as “blast
lung.”Blast lung injury (BLI) involves pulmonary hemorrhage,edema,and associated disruption
of alveolar architectureleading to air embolism.

Recent studies showthat the prognosis from BLI (blast lung injury) is significantly
improvedwith aggressive treatment.

BLI lead tosubsequent hemorrhage into the distalbranches of the respiratory tree. These
changescause a ventilation-perfusion mismatch and reducedcompliance resulting in hypoxia
and increased work ofbreathing.Traumatic alveolar-capillary fistulae may form, and airmay
be introduced into blood vessels leading to airembolism.

Chest radiography is required for all patients exposedto blast forces to gauge the initial
severity of injury andto monitor progression.

Although the general management of BLI is similar tothat of pulmonary contusion and
ARDS, the relativelyhigher risk of significant barotrauma (i.e., alveolar rupture,systemic air
emboli, and pneumothorax) in patientsincurring BLI is a critically important
feature.Persistent observations show that the use of positivepressure ventilation, especially
high levels of positiveend-expiratory pressure, increases the risk of and/or
theexacerbation of pulmonary barotrauma and shouldtherefore be avoided whenever
possible.Furthermore, patients with BLI may be at increased riskof pulmonary complication
related to overly aggressivefluid resuscitation.Various strategies aimed at ameliorating
these riskshave shown some success, including (1) permissivehypercapnia with a reduction
of tidal volume and peakinspiratory pressure, (2) use of intermittent
mechanicalventilation and continuous positive airway pressure tofacilitate reversion to
spontaneous breathing as soon aspossible, and (3) prophylactic insertion of chesttubes.

Cardiovascular Injury
In addition to conventional causes of hemodynamicinstability seen in trauma patients, there
are special factorsparticular to the management of victims with suspectedblast injury.
Given theimportance of wise fluid administration (includingblood products) for appropriate
cardiorespiratory resuscitation,in the context of potentially exacerbating softtissue injury
with suboptimal fluid resuscitation, invasivemonitoring to guide therapy is often
necessary.Colloid solutions are generally the resuscitation fluid ofchoice.

Abdominal Injury
Initial evaluation may be complicatedby the overall acuity of a multiply injured patientor
prior administration of pain-control medication.
Abdominal CT, ultrasound, and diagnostic peritoneallavage have been shown to be useful
modalities for theevaluation of intestinal PBI. Colonoscopy has beensuggested for the
surveillance of large bowel contusions.
But given the potential for iatrogenic perforation,colonoscopy may be ill advised in the post-
blast period. Indications for urgent laparotomy are similar to thoseestablished for blunt
abdominal trauma.

Musculoskeletal/Extremity Injury
Most blast injuries involving the musculoskeletal systemare due to secondary and tertiary
blast injury. There arenumerous reports of traumatic amputation in blast victimsthat are
thought to be due to PBI, but these injuriesare rare among survivors.
The conventional military approach to small fragmentwounds has involved treating
penetrating wounds in anaggressive fashion with early exploration, debridement,and delayed
primary closure. However, recent evidencesuggests that a more conservative approach
maybe appropriate provided that bacterial colonization isprevented with appropriate
antibiotic coverage.Appropriateantimicrobial coverage should be administeredand tetanus
immunization addressed. Primary closure ofblast wounds greatly increases the risk of
infection;therefore delayed primary closure is performed oncethe wound is clean and
granulation tissue hasappeared.

CNS Injury
Signs and symptoms of CNS PBI include headache,vertigo,ataxia, seizures, altered mental
status, retinal arteryemboli, tongue blanching, and anterograde or retrogradeamnesia. If
any of these findings are present, immediateadministration of adequate oxygen therapy is
appropriate.Expeditious administration of hyperbaric oxygenmay be helpful for suspected
CNS PBI. Placing the patient in the left lateral decubitus position with the head down is
recommended to avoid complications of arterial air emboli.

PTSD may also have an organic basis linked to CNSPBI. Mental healthreferral for blast
victims is indicated for general counselingand surveillance of serious postincident morbidity.
24. Common psychological responses to disasters

Researchers describe multiple phases of response:

Phase one, “preimpact phase” -this phase occurs before the eventtakes place; the stressor
of this phase is worry.Response to this stress ranges but normally includesdenial and
anxiety.
Phasetwo, “impact phase” - in which the disaster is actively occurring. According to studies
during these phase a small percentage of individuals (12-25%) remain calm andhigh
functioning, whereas an equal percentage demonstratedisorganization, confusion, and other
serious copingdifficulty. The majority of individuals during theimpact phase are found to
temporarily have a bluntedresponse, demonstrate a lack of emotion, and
evidencebewilderment.
Phase three, “postimpact phase” - emotional reactionsvary widely and range from relief at
personal survival tosurvivor guilt, feelings of self-consciousness, emotional lability, and
numbness.

Victims of disaster can be classified into three groups.Primary casualties suffer physical
injury and acute psychologicalsequela as a consequence or may experiencepsychological harm
alone. Secondary casualties includeaffected relatives and friends of primary casualties
andwitnesses of the event who were not directly affected.Tertiary victims are rescue
workers and healthcare providers.

There is a spectrum of psychopathology associated with trauma.Victim responses vary, and

one victim may manifest a wide range of illness. Most victims manifest only mild symptoms
that often resolve without intervention.

A list of common symptoms:

- Apathy - Inappropriate - Overinvolvement in

- Anxiety joking survival activities
- Denial - Insomnia - Restlessness
- Helplessness - Mild confusion - Terror
- Mood swings

A list ofcommonly associated psychopathological featuresrelated to trauma:

- PTSD(by far the most notable psychological consequence of trauma)

- Substance abuse
- Anxiety disorders
- Depression
25. Diagnostic criteria for posttraumatic stress disorder

PTSD is a response to a catastrophic (life-threatening) life experience in which the patient

reexperiences the trauma, avoids reminders of the event, and experiences emotional
numbing or hyperarousal.

Diagnosis and DSM-IV criteria

 Having experienced or witnessed a traumatic event (e.g., war, rape, ornatural disaster).
The event was potentially harmful or fatal, and theinitial reaction was intense fear or
horror.

 Persistent reexperiencing of the event (e.g., in dreams, flashbacks, or

recurrentrecollections)

 Avoidance of stimuli associated with the trauma (e.g., avoiding a locationthat will remind
him or her of the event or having difficulty recallingdetails of the event).

 Numbing of responsiveness (limited range of affect, feelings of detachmentor

estrangement from others, etc.)

 Persistent symptoms of increased arousal (e.g., difficulty sleeping, outburstsof anger,

exaggerated startle response, or difficulty concentrating)

 Symptoms must be present for at least 1 month and cause significant impairment or
stress.
26. Principles of critical incident stress management

The most commonly used element of CISM is critical incident stressdebriefing (CISD).
CISD is commonly used as an intervention after an unusually traumatizing event. Even
though there are many variations of CISD, a debriefing is generally a group session
facilitated by a mental health professional and a group member who was not part of the
traumatizing event. During the session, participants recount their experiences and express
fears and concerns while facilitators acknowledge victim experiences and discuss coping
strategies.

The goal of CISD is to normalize the crisis experience,prevent the development of poor
coping mechanisms,and assess the need for follow-up.

The CISD session generally lasts1.5 to 3 hours and is recommended 2 - 14 days after
acritical incident. In cases of mass disaster,CISD is not recommended until 3 weeks after
theevent. CISD is not intended to be a stand-aloneintervention or a replacement for
psychotherapy. Rather,CISD is intended to be a single component in the CISMsystem.

There are eight core components of the CISMsystem:

 The first component of CISM is precrisis intervention.The goal of this component is to

identify those at risk ofpsychological trauma/crisis and to provide informationto them.
It also consists of stress management education,stress resistance training, and crisis
mitigation for teammembers and management.
 The second component of CISM consists of crisis interventionprograms.Examples
include demobilization, staffconsultation, and crisis management briefings (CMBs).The
goal of these sessions is to allow for psychologicaldecompression and provide opportunity
for stress management.Decompressions are intended for emergencymedical services
personnel and should occur immediatelyafter a shift when there has been exposure to a
criticalevent. Staff consultation is intended to provideadvice for command staff.
Examples of staff advisementrecipients include disaster response team leaders,
nursingsupervisors, and fire captains. CMBs are similar todecompressions but are
intended for use with civilians.Examples of groups needing a CMB might include
teachersafter a particularly violent school event or storeworkers after a robbery.
 The third component of CISM is defusing. The goal ofdefusing is to allow for symptom
mitigation and to giveopportunity for closure. It also serves as an opportunityto triage
those needing greater assistance. Defusing is asmall-group discussion held within 12
hours of the criticalincident in which group members are encouraged todiscuss events
that have just occurred. Defusing has threephases: (1) introduction of the debriefing
team, (2) explorationof the experience, and (3) providing informationabout expected
emotions and availability of resources.
 The fourth component of CISM is the aforementionedCISD. It is a seven-phase
smallgroupdiscussion:

1. Phase one is introduction of the team.

2. Phase two is a fact phase, in which members describetheir role in the event.
3. Phase three is the thought phase, when participantsexplore their thoughts that
occurred during the event.
4. Phase four, the reaction phase, allows individuals to express their emotional
reactions or feelings.
5. Phase five, the symptoms phase, in which participants explore the physical,
emotional, and behavior symptoms since the event.
6. The sixth phase is a teaching phase. During this phase the debriefing team helps to
normalize participants’ feelings and provides information about expected reactions.
7. The seventh phase is the re-entry phase, in which the meeting is summarized and
questions are answered.

CISD typically takes two hours and should occur 1 - 14 days after the crisis.However, it
should be delayed further in the setting of mass disasters.As with defusing sessions, its
goal is also to allow for symptom mitigation,closure, and triage.
Other components of CISM are available in an as-needed basis, and include:

 Individual crisis intervention(5th component)

 pastoral crisis intervention (6th component)
 family/organizational CISM (7th component)
 Follow-up/referral (8th component)