—Radiation Basics—

Radiation Safety
- There are 3 basic principles in radiation safety:
● Time
○ This refers to how much time you spend near the radioactive source
○ Spend as little time as possible near the radioactive source
● Distance
○ This is the distance between you and the radioactive source or radioactive area
○ Put as much distance as possible between you and the radioactive source
● Shielding
○ Shielding means putting a barrier between you and the radioactive source
○ It is difficult for first responders to shield against the radioactive source other than
wearing PPE, as they must work in the “hot” zone, so they minimize time exposure by
rotating in and out of the “hot” zone
○ PPE and respirators offer shielding for healthcare professionals when dealing with
contaminated victims
○ Items such as shrapnel, radioactive “seeds” placed in the OR, or other small sources of
radioactive material should be stored in a lead lined box

Exposure vs. Contamination

- Exposure
● This refers to being near a source and the radiation passes through and/or is absorbed in your body
● You are NOT in direct contact with the radioactive source
● Examples: sitting near a radioactive source, getting an X-ray or CT scan
- External Contamination
● This is when you come in direct contact with the radioactive source. You can carry the
contamination with you because it is on you
● Examples: debris from a dirty bomb (bomb laced with radioactive material), getting splashed with
radioactive material
● Removing External Contamination:
○ Just by removing clothing and then washing the victim with water you can remove 90% of
surface radioactive material
■ Shower is best, however you may need to wash patients in bed, you can use baby
wipes if water is not available
■ When giving a bed bath use spray bottles for the water and not a basin to avoid
cross contamination of the water
○ Clothing must be properly disposed of
■ Roll clothing so that the contamination is folded away from victim
■ Dispose of clothing by double bagging in yellow bags marked “radioactive
material”
○ Water used to wash the victim whether it is from a shower or bedside bath must be
collected and properly stored and disposed of
○ Generally water is collected in containers/barrels.
○ A Haz-Mat Team will properly dispose of water and clothing
- Internal Contamination
● The radioactive material was inhaled, ingested, or comes in contact with a wound and gets inside
your body
● Medications for Internal Contamination
○ There are limited medications for treatment of internal contamination and they have
specific targets
○ Potassium Iodide (KI)
■ Taken to protect your thyroid from absorbing radioactive iodine
 ○ Prussian Blue
■ Helps your body excrete radioactive cesium
○ DTPA
■ Helps remove radioactive plutonium and americium

Care of a Patient with External and Internal Contamination

- Treat life-threatening injuries first before decontaminating (removing clothes & washing pt)
- Use survey monitor to scan pt to obtain baseline radiation level
- Remove clothing, wash pt and re-scan. Repeat procedure until pt levels are less than 3 times background
radiation level
- Remove schrapnel with forceps and place in lead lined box
- Treat any injuries

Key Assessment Data

- It is important for the healthcare provider to determine the timing of the onset of vomiting.
- The quicker someone vomits from the time of exposure/contamination, the poorer the outcome
- See the chart on the next slide (from WISER) which can help you determine how acute their radiation
sickness will be or if they received a lethal dose.

—Triage—

What Is Triage
- Sorting or categorizing
- During a disaster, triage sorts treatable from untreatable victims
- Goal is to maximize survivors using resources available

Why Triage?
- In a perfect world, all patients could receive all the treatments they needed immediately.
- In reality, limited resources (time, personnel, treatment availability, etc.) require that some patients get
treated FIRST.
- During a disaster, this situation is even more acute, as there are many more patients and probably fewer
resources.

Triage Systems
- Many systems available
- All hospital Emergency Departments use triage routinely and have a system
● Remember that the ED will have different resources than a field unit during a disaster
- Triage system should be clear and concrete
● May go against nurses’ instincts and inclinations

START Triage
- Simple Triage and Rapid Treatment (START)
- This is intended as field triage but provides a framework that is easy to learn and use.
- Victims may require repeated triage as they move through the system, as their conditions may change.
Triage Tags
- Triage tags are used to sort the patients and help the Triage Officer determine where to send the patients for
treatment according to their injuries and beds available at the hospitals.
● They are not only used to "tag" a patient as "minor, delayed, immediate, or expectant/deceased",
but they provide vital information for EMS and hospital personnel.
● A patient's condition may deteriorate and this initial baseline information is essential.
● You may have discovered your patient is allergic to PCN, and prior to transport to a hospital, they
became unconscious. Recording this information on the triage tag may save someone's life.
- Triage not only includes "tagging" the pts with the appropriate color, it includes a quick assessment of the
victim and recording this information on the triage tag.
- After all patients are tagged, while waiting for transport for the patients, Go back and re-assess your victims.
● You may find that a "minor" has turned into an "immediate"
● Some pts need to be re-tagged and is discovered during a secondary assessment.
- After all patients are tagged, you may also provide first-aid as you are able. Remember you may have little to
no equipment with you, resources on scene are limited.
- Another essential activity in triage is calming the victims and assuring them that help is on the way.
- Expect confusion and chaos at the scene, especially if families are separated or one member is determined to
be expectant/deceased.
- ON Card Front:
● 1. Fill out RPM and orientation sections which helps in the "tagging" process
● 2. Circle contamination information if known
● 3. Fill out vital sign information (may not have BP, but should be able to get pulse and respirations)
● 4. Fill out if any medications were given on scene
● 5. Identify major injuries
● 6. THE DESTINATION section may not be known on initial triage
- On Card Back:
● 1. Fill out allergies
● 2. Fill out meds
● 3. Fill out personal information
● 4. Pictures can be used to identify place of injuries
● 5. Fill in any other information gathered under NOTES
section
- Once filled out and pt is identified as Minor, Delayed, Immediate, or
Deceased tear off small barcode tag to give to Triage Officer.
 —Smallpox: The disease—

Smallpox Facts
- Contagious
- Serious
- Sometimes fatal

Transmission of Smallpox
- Humans -only natural host of smallpox
- Not transmitted by insects or animals (no animal reservoir)
- Transmission - direct and fairly prolonged face-to-face contact (droplet) OR Direct contact with infected
bodily fluids or contaminated objects (i.e. Bedding and clothing)

Pathogenesis of Smallpox
- Portal of entry is the respiratory tract or inoculation on the skin
- Excretions from the mouth and nose, rather than scabs, are the most important source of infectious virus

Stages of Smallpox
- Incubation period
● Average 12 – 14 days
● Range 7 – 17 days
- Prodrome or Pre-eruptive stage
● Initial, non-specific symptoms
● Abrupt onset fever, malaise, headache, muscle aches, prostration, and often nausea and vomiting
● T = 101°F +
● Lasts 2 – 4 days, may be contagious
● This severe febrile prodrome before rash onset is characteristic of smallpox
- Rash Phase
● Fever rises again and stays elevated until scabs form
● Day 6-7 of rash pustules
○ Sharply raised
○ Typically round
○ Umbilicated
○ Tense, firm to touch (some say like BB under skin)
● Day 10 of rash – begin to form crust
● ~ Day 14 most crusted, some begin to separate
● By 3 weeks most have separated, leaving scars

When is a person contagious?

- Contagious with the onset of fever (the prodrome phase)
- Most contagious with the onset of the rash
- Luckily (?), by the time a person gets the rash they are so sick they can’t likely move around the community
- Contagious until the last smallpox scab falls off

Treatment of Smallpox: After exposure

- Vaccine
● Administered up to 4 days after exposure to the virus and before the rash appears,
● Can prevent infection or ameliorate the severity of the disease
- No effective treatment, other than the management of the symptoms
● Adequate fluid intake (difficult)
● Alleviation of pain and fever
 ● Keeping skin lesions clean to prevent bacterial infection

Outcome of Infection
- Those who survive usually have noticeable scars
- If eye involvement then blindness could occur
- Recovery results in long lasting immunity to reinfection with variola virus; no evidence of chronic or
recurrent infection with variola virus
- In fatal cases death usually occurs b/w the 10th and 16th days of illness
- The cause of death from smallpox is not exactly clear since the infection involves multiple organs; perhaps
uncontrolled immune response as well as overwhelming viremia and soluble variola antigens

Treatment for Smallpox

- No Cure
- Prevention
- Vaccination

History of Smallpox
- Has been known since antiquity
- In the 15th century, the English used the prefix “small” to distinguish Variola, the smallpox, from syphilis,
the great pox.
- Spread by travelers

Smallpox IN History
- The Spanish inadvertently owe success in conquering the Aztec and Incas in Mexico to smallpox.
● Europeans had been around variola for centuries, some degree of immunity
● Aztecs, Inca, and other indigenous American populations had no immunity at all, highly lethal
- During the French and Indian War (1754-1763) British forces used blankets (smallpox blankets) coated with
smallpox dust as germ warfare to wipe out the Native American population.

Smallpox in Biologic Warfare

- Lord Jeffrey Amherst, Commanding General of British Forces in North America during the French and
Indian War. (1754-1763)

Smallpox (Variola) vs. Chickenpox (Varicella)

- SMALLPOX
● Centrifugal distribution
● Palms of hands and soles of feet involved
● Umbilicated lesions (dent in center)
● All in same stage of development on that part of body
- CHICKENPOX
● Trunk more involved
● Palms and soles spared
● No umbilication
● Lesions in different stages

Clinical Diagnosis
- Use the following risk algorithm from CDC if there is NO KNOWN SMALLPOX RELEASE or circulation:
●

Reportable
- Even a single case of smallpox must be reported to Public Health Authorities
 - Will be presumed to be bioterrorism
- Will involve Law Enforcement, probably FBI

—Smallpox: The Vaccination—

Key
- VARIOLA = virus responsible for Smallpox
- VACCINIA = virus used in Smallpox vaccine
- VARICELLA = virus responsible for Chickenpox

History of Variolation and Vaccination

- Known that smallpox survivors became immune to the disease.
- Physicians began to intentionally infect healthy persons with smallpox organisms.
- Variolation is the act of taking samples (pus from pustules or ground scabs) from patients whose disease
had been benign, and introducing it into others through the nose or skin.

Survival Rate with Variolation

- 2-3% of variolated persons
● Died of smallpox,
● Became the source of a new epidemic, or
● Developed other illnesses from the lymph of the donor such as tuberculosis or syphilis.
- Fatality rates were still 10X lower than from smallpox
- Side effects of variolation
● the appearance of smallpox itself would disappear after a week or so.

Cows, Milkmaids, and the Pox

- In rural areas of Europe it was known that milkmaids became immune to smallpox after developing cowpox
- 1774, farmer Benjamin Jesty was the first to vaccinate his wife and children with material taken from the
udders of cows.

Edward Jenner
- In 1801 Jenner said:
● “The annihilation of the smallpox, the most dreadful scourge of the human species, must be the
final result of this practice [vaccination].”

Eradication
- Compulsory vaccinations began in the following years:
● 1807 in Bavaria
● 1810 in Denmark
● 1835 in Prussia
● 1853 in Britain
- Even after vaccination:
● Outbreaks due to the virus imported by travelers where smallpox was still endemic.
- After WWI - most of Europe become smallpox free
- After WWII transmission was stopped throughout Europe and North America.
- In less developed countries smallpox largely unabated until mid-20th century
- 1958: WHO introduced global smallpox eradication program
- Based on a two fold strategy.
● 1) Mass vaccination campaigns in each country using a vaccine of ensured potency and stability that
would reach at least 80% of the population.
● 2)Development of a system to detect and contain cases and outbreaks.
 - 26 October 1977 the last naturally occurring case of smallpox was recorded in Merka, Somalia.
- In 1978 two cases were reported. These were both from people working in labs with smallpox in England.
- 1980: WHO formally declared that smallpox was dead.
- The eradication of smallpox was one of the most important achievements of modern medicine.
- Jenner has been acknowledged as the father of immunology

Note
- Every Healthcare Worker administering Smallpox Vaccine MUST be vaccinated against Smallpox

Vaccination
- The vaccine provides a high level of immunity for 3-5 years and decreasing immunity thereafter
- If a person is re-vaccinated the immunity lasts even longer
- Studies show that even 30 years after a vaccination, while a person may not be protected against smallpox
they have a less severe disease
- The vaccine has been effective in preventing smallpox in 95% of people vaccinated
- Vaccinations Now
● Routine vaccination in the U.S ended in 1972 for children and 1976 for healthcare workers
● On December 13, 2002, President Bush announced the following US policy:
○ Required for military personnel
○ Recommended for smallpox response teams comprised of public health staff and
healthcare workers
○ Offered to other healthcare workers and to first-responders (including police officers,
firefighters, and emergency medical technicians).
○ Smallpox Response Teams: Department of Health and Human Services will work with
state and local governments to form volunteer smallpox response teams who can provide
critical services in the event of a smallpox outbreak
- Contraindications & Precautions
● Pre-Event (if routine vaccination reinstated)
○ Immunosuppression caused by diseases, conditions, or medications
○ Allergies - antibiotics polymyxin B, streptomycin, tetracycline, or neomycin
○ Eczema
○ Pregnancy
○ Acute or chronic skin conditions
● Post-Event (if outbreak or exposure)
○ Potentially NO contraindications;
○ May need MD decision: Weigh the risk -benefits of vaccine upon exposure

Smallpox Vaccine Administration

- The smallpox vaccine is generally administered on the deltoid area of the upper arm.
● In a real vaccination situation, the patients will NOT have silicone pads on their arms, and you will
administer the vaccine directly to the patient. Remember, the vaccine is administered using
multiple punctures within the circumscribed area, as indicated on this silicone pad. Real-life
patients won’t have this circle, either.
- Remember that the vaccine consists of live cowpox virus which enters the body through tiny punctures in the
skin. Using alcohol to prep the site will kill the virus and render the vaccine useless. DO NOT PREP WITH
ALCOHOL!
- The reconstituted vaccine is in a vial with a rubber cap.
● Usually we puncture the cap with our sterile needle in order to draw up the vaccine.
○ NOT IN THIS CASE! After a few uses, the cap would be shredded from the bifurcated
needle
● Instead, carefully remove the cap, opening it away from you just in case there’s a splash.
● Then dip the end of the needle into the vaccine. One dip is all you need.
 ● Then support the patient’s arm with your non-dominant hand and place the heel of your dominant
hand on the patient’s arm to reduce movement and increase your accuracy in administration.
● Carefully but quickly administer 15 shallow punctures within the administration area. A tiny
amount of capillary blood in an actual patient (not available in the silicone pads) will tell you you
have punctured the skin correctly.
● Cover the site with a 2 X 2 pad and some tape and make sure the patient understands how to care
for the site. You’re done!

—Personal Protective Equipment (PPE)—

Personal Protective Equipment (PPE)

- Many occupations use different types of PPE
- For our purposes, we will use “PPE” to refer to gear designed to protect wearer from disaster-related
hazards.
● Refer to those items designed to keep first responders, first receivers, and clinical personnel safe in
the event of a disaster with release of a hazardous substance.
○ The respiratory equipment, garments, and barrier materials used to protect rescuers and
medical personnel from exposure to biological, chemical, and radioactive hazards.
The goal of PPE → is to prevent the transfer of hazardous material from victims or the
environment to rescue or health care workers.
○ Different types of PPE may be used depending on the hazard present. The types of hazards
addressed here include biological warfare agents, chemical warfare agents, and radioactive
agents.
- Prefer to prevent need for PPE using:
● Engineering Controls
● Administrative Controls
- Sometimes PPE needed anyway.

Keeps Responders/Receivers Safe

- First responder: Emergency personnel first on scene
● Firefighters, EMS teams, police, and/ or HazMat teams who are first on the scene of a scene where
a substance has been released.
- First receiver: Hospital personnel receiving casualties
● Who may not have been fully decontaminated or who may be receiving casualties before the
substance has been identified.
○ They will be performing triage and further decontamination as well as essential life-saving
measures in a designated location that is SEPARATE from the general hospital Emergency
Department, so other patients do not become contaminated.
- Responders/Receivers may be exposed via:
● Inhalation
○ Breathing, from the air
○ The greatest chemical hazard to an unprotected responder is exposure via inhalation
● Ingestion
○ Eating or drinking
● Absorption
○ Skin contact
● [Injection or secondary contamination]

PPE Equipment Components

- Skin Protection (‘splash protection’)
● Wide range of protection possible
 ● Greatest protection provided by completely encapsulated suits (like moon suits, but without
anti-gravity and insulation.)
● Lowest level of protection is general work clothes, with infection control wear as appropriate
- Respiratory Protection
● Two categories:
○ ASR = Atmosphere Supplying Respirator
■ Air SUPPLYING respirators provide all the air needed to breathe: there is NO
connection with the surrounding air
■ ASR includes Self-Contained Breathing Apparatus (SCBA): like scuba, but not
underwater
○ APR = Air Purifying respirator
■ Air PURIFYING respirators consist of a tightly fitting mask or a hood with filters
that can be changed according to the characteristics of the hazardous material
involved.
■ APR includes tightly fitting mask with appropriate filters
● Some APRs that look similar to surgical masks– NOT interchangeable
● Surgical masks may have gaps around the edges where air (and thus
contaminants) can be drawn in when you inhale (do not fit tightly)
● Respirators fit tightly, so when you inhale the air must go through the
filter.
- Monitoring Devices (Protection from radiation)
● Radiation dosimeters in addition to PPE
● Monitor exposure of individuals
● Usually badges or rings
○ Rings are preferred in situations where the hands may be exposed to higher levels of
radiation
● When maximum recommended exposure is reached, individual must leave the contaminated area
○ When the safe level of exposure has been reached, the First Responder or First Receiver
rotates out of the contaminated area.

Four Levels of PPE (‘ensembles of equipment’)

- Each has advantages and disadvantages
- NO ONE LEVEL IS APPROPRIATE IN ALL CIRCUMSTANCES!
- THESE “ENSEMBLES” DO NOT PROTECT AGAINST FIRE OR EXPLOSION!
- These levels were not developed with healthcare in mind [focus was on needs “in the field”]
- What Level of PPE is needed?
● If the hazard is unknown:
○ Use highest level of PPE (Level A)
○ No matter what…Level B is the lowest level recommended to use in the field
○ In healthcare, for first receivers, usually Level C is sufficient.

SKIN RESPIRATORY COMMENTS

Level A (EPA) Vapor Protective (also Atmosphere Supplying Respirator (Self Highest level of skin and respiratory
known as gas tight or Contained Breathing Apparatus [SCBA] or protection. Bulky, heavy, and
fully encapsulating) Supplied Air Respirator [SAR]) greater potential of heat stress and
STF* injuries

Level B (OSHA) Liquid Splash Atmosphere Supplying Respirator (Self Lower level of skin protection with
Protection contained breathing apparatus [SCBA] or highest level of respiratory
Supplied Air Respirator [SAR] protection

Level C Liquid Splash Air Purifying Respirator [APR] Lower level of skin and respiratory
*currently the standard
recom for health care Protection protection
providers in health
settings*

Level D No chemical No respiratory protection Examples include: work uniforms,

protection street clothes, scrubs, and
Standard/Universal Precautions
(provides minor chemical
protection)

Hospital Mass Casualty Receiving

- Emergency plan will set up Hospital Incident Command System (HICS)
- Includes:
● “Hot Zone”
○ The “hot zone” is where there will be the greatest risk of exposure to dangerous substances
from the event.
○ Staffed by first receivers wearing [most likely] Level C PPE.
○ Incoming patients have had field decontamination only
○ Victims who are self-referring may have had no decontamination
■ “Walking wounded”
○ All victims will be triaged and sent through decontamination procedure
● Decontamination zone (“warm”)
○ Is where patients are decontaminated before entering the hospital proper.
○ Includes showers
○ Receptacles for personal belongings
○ Supervising hospital staff wearing appropriate PPE
○ Area for removing [“doffing”] PPE for first receivers
● Post- decontamination (“cold”)
○ Decontamination has been completed
○ Level D PPE is adequate
○ Includes whatever infection control PPE is appropriate (gowns, gloves, masks, etc.)

Procedure for Donning Level C PPE

- Inner gloves.
● Consider loosely securing with masking tape to facilitate removal of outer gloves without removing
inner ones
- Suit: zip to just above beltline
- Chemical protective boots
- Respirator belt or vest, turn on battery
- Respirator hood
- Zip suit to neck with hood inner collar inside, adhesive over zipper, outer collar over shoulders
- Outer gloves, seal with tape

Procedure for Removing “Do ng” Level C PPE

- Pass through Decontamination
- Stand in large plastic bag. Remove outer gloves, drop into bag
- Remove respiratory apparatus (not hood) with assistance, unzip suit
- Step out of suit, step out of bag
- Remove hood, drop into bag
- Remove inner gloves
- Shower and change to clean clothes
Level D PPE with Infection Control
- In areas after patients have been decontaminated, hospital personnel will wear routine uniforms with
whatever infection control protection is appropriate
- Refer to poster from N-200 for procedure for donning and doffing infection-control protective clothing