dhs/ntcb461 course1 decontamination of patients external skin wound internal decorporation...

DHS/NTCDHS/NTC B461 CourseB461 Course 11

Decontamination of Patients Decontamination of Patients

ExternalExternal SkinSkin WoundWound

InternalInternal Decorporation agentsDecorporation agents


Patient DecontaminationPatient Decontamination

Remove and bag the patient’s clothing and personal Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of belongings (this typically removes 80 - 90% of contamination)contamination)

Handle foreign objects with care until proven non-Handle foreign objects with care until proven non-radioactive with survey meterradioactive with survey meter

Survey patient and collect samplesSurvey patient and collect samples- Survey face, hands and feetSurvey face, hands and feet- Survey rest of bodySurvey rest of body

Note: Avoid contamination of the probe.Note: Avoid contamination of the probe.


External Contamination External Contamination

Radioactive material (usually in the form of dust Radioactive material (usually in the form of dust particles) on the body surface and/or clothingparticles) on the body surface and/or clothing

Radiation dose rate from contamination is usually Radiation dose rate from contamination is usually low, but while it remains on the patient it will low, but while it remains on the patient it will continue to expose the patient and staffcontinue to expose the patient and staff


External Contamination – Remove External Contamination – Remove with Showeringwith Showering


Decontamination PrioritiesDecontamination Priorities

WoundsWounds

Intact skin (areas of highest contamination first)Intact skin (areas of highest contamination first)

Change outer gloves frequently to minimize Change outer gloves frequently to minimize spread of contaminationspread of contamination


Decontamination of WoundsDecontamination of Wounds

Contaminated wounds:Contaminated wounds: Irrigate and gently scrub with surgical spongeIrrigate and gently scrub with surgical sponge Debride surgically only as neededDebride surgically only as needed

Contaminated thermal burns:Contaminated thermal burns: Gently rinse Gently rinse Changing dressings will remove additional contaminationChanging dressings will remove additional contamination

Avoid overly aggressive decontaminationAvoid overly aggressive decontamination Change dressings frequentlyChange dressings frequently


Decontamination of SkinDecontamination of Skin

Use multiple gentle effortsUse multiple gentle efforts

Use a mild soap & water solutionUse a mild soap & water solution

Cut hair if necessary (do not shave)Cut hair if necessary (do not shave)

Promote sweating:Promote sweating: Plastic wrap, glove, etc. Plastic wrap, glove, etc.

Use survey meterUse survey meter


Cease Patient DecontaminationCease Patient Decontamination

When decontamination efforts produce no significant When decontamination efforts produce no significant reduction in contaminationreduction in contamination

When the level of radiation of the contaminated area is When the level of radiation of the contaminated area is less than twice backgroundless than twice background

Before intact skin becomes abradedBefore intact skin becomes abraded Consider internal contaminationConsider internal contamination


Internal ContaminationInternal Contamination

Radioactive material may enter the body through:Radioactive material may enter the body through:

- - InhalationInhalation

- Ingestion- Ingestion

- Wounds- Wounds Internal contamination generally does not cause Internal contamination generally does not cause

early signs or symptomsearly signs or symptoms Internal contamination will continue to irradiate the Internal contamination will continue to irradiate the

patientpatient


Treatment of Internal ContaminationTreatment of Internal Contamination

Rare earths Rare earths

- Plutonium- Plutonium

- Transplutonics- Transplutonics

- Yttrium- Yttrium UraniumUranium Cesium, rubidium, thallium Cesium, rubidium, thallium TritiumTritium


Potassium Iodide (KI)Potassium Iodide (KI)

Only helpful in blocking thyroid glandOnly helpful in blocking thyroid gland KI saturates the thyroid gland with stable KI saturates the thyroid gland with stable

iodineiodine KI must used prior to or within hours of KI must used prior to or within hours of

exposure to radioactive iodineexposure to radioactive iodine See the FDA web site:See the FDA web site:

Decorporation agentDecorporation agent Provide to Decon Team MembersProvide to Decon Team Members

www.fda.gov/cder/drugprepare/KI_Q&A.htmwww.fda.gov/cder/drugprepare/KI_Q&A.htm


Immediate Medical Management of Immediate Medical Management of Radiation Exposed PatientsRadiation Exposed Patients

TriageTriage Acute Radiation Syndrome (ARS)Acute Radiation Syndrome (ARS) localized/cutaneouslocalized/cutaneous combined injurycombined injury

Initial stabilization and treatmentInitial stabilization and treatment

Psychological effectsPsychological effects

Record keeping/Dose assessmentRecord keeping/Dose assessment


Management - Priorities of Radiation Management - Priorities of Radiation Exposed PatientsExposed Patients

Standard medical triage is the Standard medical triage is the highest priorityhighest priority

Radiation exposure and Radiation exposure and contamination are secondary contamination are secondary considerations considerations


Management – Protocol of Radiation Management – Protocol of Radiation Exposed Patients (Cont)Exposed Patients (Cont)

Based on:Based on: InjuriesInjuries

Signs and symptomsSigns and symptoms

Patient history Patient history

Contamination surveyContamination survey


Prenatal Radiation ExposurePrenatal Radiation Exposure

Human embryo and fetus highly sensitive to ionizing Human embryo and fetus highly sensitive to ionizing radiationradiation

At higher doses, effects depend on dose and stage of At higher doses, effects depend on dose and stage of gestationgestation

Pregnant patients should receive special dose Pregnant patients should receive special dose assessments and counselingassessments and counseling

Information on prenatal radiation exposureInformation on prenatal radiation exposure

www.bt.cdc.gov/radiation/prenatalphysician.aspwww.bt.cdc.gov/radiation/prenatalphysician.asp


Required Conditions forRequired Conditions forAcute Radiation SyndromeAcute Radiation Syndrome

Large doseLarge dose

PenetratingPenetrating

Most of body exposedMost of body exposed

AcuteAcute


Never delay critical care Never delay critical care because a patient is because a patient is

contaminatedcontaminated

Acute Radiation SyndromeAcute Radiation Syndrome


1986 Chernobyl Accident1986 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


Skin EffectsSkin EffectsSkin EffectsSkin Effects

NUREG / CR-4214, p II-68NUREG / CR-4214, p II-68

EpilationEpilation ErythemaErythema PigmentationPigmentation Dry desquamation,Dry desquamation,

(Shedding, flaking off)(Shedding, flaking off) Moist desquamation that Moist desquamation that

healsheals

EpilationEpilation ErythemaErythema PigmentationPigmentation Dry desquamation,Dry desquamation,

(Shedding, flaking off)(Shedding, flaking off) Moist desquamation that Moist desquamation that

healsheals


Treatment of Large External Treatment of Large External ExposuresExposures

Treat patients symptomaticallyTreat patients symptomatically Prevent and manage infections:Prevent and manage infections:

Hematopoietic growth factors, e.g., GM-CSF, G-CSF Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®)(24-48 hr) (Neupogen®)

Irradiated blood productsIrradiated blood products Antibiotics/reverse isolationAntibiotics/reverse isolation ElectrolytesElectrolytes

More information on ARS:More information on ARS: www.bt.cdc.gov/radiation/arsphysicianfactsheet.aspwww.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

Treat patients symptomaticallyTreat patients symptomatically Prevent and manage infections:Prevent and manage infections:

Hematopoietic growth factors, e.g., GM-CSF, G-CSF Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®)(24-48 hr) (Neupogen®)

Irradiated blood productsIrradiated blood products Antibiotics/reverse isolationAntibiotics/reverse isolation ElectrolytesElectrolytes

More information on ARS:More information on ARS: www.bt.cdc.gov/radiation/arsphysicianfactsheet.aspwww.bt.cdc.gov/radiation/arsphysicianfactsheet.asp


Treatment of Cutaneous Radiation Treatment of Cutaneous Radiation SyndromeSyndrome

Lesions do not appear for days to weeksLesions do not appear for days to weeks Perform surgical treatments within 48 hrs Perform surgical treatments within 48 hrs Consult Radiation Emergency Assistance Center/ Consult Radiation Emergency Assistance Center/

Training Site (REAC/TS) for advice for further Training Site (REAC/TS) for advice for further treatment, 865-576-1005 or treatment, 865-576-1005 or www.orau.gov/reacts/www.orau.gov/reacts/


Dealing With Staff StressDealing With Staff Stress

PreplanningPreplanning

Establish information centerEstablish information center Train staff on radiation basicsTrain staff on radiation basics

Post EventPost Event

Debrief immediately after eventDebrief immediately after event Offer counselingOffer counseling


Bomb Blast - Injury PatternsBomb Blast - Injury Patterns

Most survivors suffer Most survivors suffer secondary and tertiary blast secondary and tertiary blast effectseffects

Primary blast injury is Primary blast injury is infrequent in survivorsinfrequent in survivors

15% of survivors require 15% of survivors require hospital admission hospital admission

The remaining are treated The remaining are treated and released from the and released from the emergency departmentemergency department


Staff PreparednessStaff Preparedness

Plan for the needs of the Plan for the needs of the unaffected population:unaffected population: Ratios range from 5-15 to 1Ratios range from 5-15 to 1 5-15 “worried well” to 1 5-15 “worried well” to 1

actual injured patientactual injured patient This can paralyze your EDThis can paralyze your ED

Prepare to receive large Prepare to receive large numbers of casualtiesnumbers of casualties

Rotate staff to avoid Rotate staff to avoid congestion and fatiguecongestion and fatigue

Monitor staff in chemical Monitor staff in chemical protective clothing & protective clothing & equipment (CPC&E)equipment (CPC&E)


Logistics/SuppliesLogistics/Supplies

Highest priority: getting the right resources to the Highest priority: getting the right resources to the right place at the right time:right place at the right time: Chemical protective clothing and equipmentChemical protective clothing and equipment Medications / antidotes / vaccinesMedications / antidotes / vaccines Mechanical ventilatorsMechanical ventilators Isolation rooms remote from other patientsIsolation rooms remote from other patients

Identify current inventory and augment as Identify current inventory and augment as necessarynecessary

Develop a procedure to access external assetsDevelop a procedure to access external assets


Maximal Utilization of Maximal Utilization of Hospital SpaceHospital Space

Identify alternative medical Identify alternative medical treatment areastreatment areas

Planning for use of Planning for use of available space:available space: Open areasOpen areas Isolated areasIsolated areas Temporary morgueTemporary morgue Conference roomConference room CafeteriaCafeteria Physical TherapyPhysical Therapy


Handling of EvidenceHandling of Evidence

Maintaining evidence is Maintaining evidence is critical for an critical for an investigation:investigation: ClothingClothing Embedded foreign Embedded foreign

bodiesbodies Decontamination Decontamination

runoffrunoff Chain of Custody must Chain of Custody must

be maintainedbe maintained

EVIDENCE

EVIDENCE

Table Top ExerciseTable Top Exercise

Hospital Incident Hospital Incident Management System Management System

(HIMS) Hands-on (HIMS) Hands-on Exercise - OverviewExercise - Overview

Table Top ExerciseTable Top Exercise

Hospital Incident Hospital Incident Management System Management System

(HIMS) Hands-on (HIMS) Hands-on Exercise - Report OutExercise - Report Out

dhs/ntcb461 course1 decontamination of patients external skin wound internal decorporation...

Documents

woundsinternal contamination

symptomsinternal contamination

level of radiation

survey metersurvey patient

radioactive iodinesee

hours of exposure

special dose assessments

b461 courserequired