Grand Rounds Recap 5.2.18

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Disaster Day WITH DR. CALHOUN

Radiation Injuries and Nuclear Incidents

These injuries are often the one exception to the rule that "all contaminated patients need to be decontaminated prior to entering the ED.” This is due to the fact that radiation is easily measurable, containable and presents a lower risk to the ED at large.

Unintentional release: research facilities, power plants, etc.

  • There are approximately 104 Nuclear reactors in the US, about half have reported a leak at some point. On the West Coast and parts of the Midwest some of these reactors correspond with areas of high seismic activity

Intentional Release: dirty bomb (difficult to injure a large number of people with the radiologic damage, most of the damage is caused by the explosives itself), nuclear bomb, non-explosive release (poisoning water or food supply, hidden sources in public places, etc.)

Types of Radiation

  • Non-ionizing radiation: UV, visible lights, infrared, microwaves, radio waves, heat
  • Ionizing: UV, x-ray, alpha/beta/gamma
    • Alpha: rays do not travel nor penetrate well, skin provides a barrier, usually only causes issues if ingested leading to prolonged exposure
    • Beta: large variability in potential for damage, can penetrate skin and can cause "cancer-like” changes
    • Gamma: photons that emits energy, potential to penetrate most normal objects, highly dangerous and carcinogenic

Measurements
Rem: the dose of radiation absorbed corrected for the biological hazard of the type of radiation, most useful when it comes to affect of radiation on the body
Sievert = 100 rem 

  • 6-10 Sv whole body dose = lethal to almost 100% of patients
  • 2.5-5 Sv whole body dose = lethal to about 50% of patients

Acute Radiation Syndrome

  1. Prodrome: onset in minutes to days and lasts for minutes to days, symptoms include nausea, vomiting diarrhea, anorexia,
  2. Latent stage: onset is hours to weeks, less likely to report symptoms at this time producing a possible public health risk as these patients may not present to the health care system but the source of the exposure is still at large
  3. Manifest illness: variable viral like symptoms, lasts for hours to months, treatment is largely supportive care
    • Higher doses lead to more rapid onset of manifest illness and shorter latent period
  4. Recovery/death

Irradiation: patient was exposed to radiation but is not currently carrying radioactive particles on their person, patient is not harmful to the health care worker
Contamination: continued threat to those around them, clothing removal takes care of 90% of the decon, use PPE for spread prevention

Treatment

  • PPE/physical barriers to prevent spread including masks to prevent inhalational injury
  • Decon: undress patient, wash with soap and water, irrigate wounds
  • Stay indoors unless evacuation is ordered
  • Potassium iodide: Completely inhibits iodine uptake and reduces the risk of thyroid cancer only, provides no protection to other organs, must be given within 12 hours of inhalation and usually unnecessary if over 40 years of age 

Hazmat Preparations 

Difference between first responder and the first receiver of a contaminated patient

  • Ensure provider safety, even when may lead to significant delays in patient care or worsening of their condition 
  • Keep contamination out of the ED, we must protect the function of the department before all else
  • Self-referral patients pose a unique issue due to the lack of pre-notification 

Webwiser.nlm.nih.gov

  • Free website and app to help identify what symptoms to look for and PPE needed for each exposure
  • Also has a feature by which you can enter the symptamatology and it will provide you with a list of potential agents
  • Be sure to use filters in the upper right corner to find the most applicable information to your setting

What HazMat incidents do hospitals see?

  • Low toxicity flammable hydrocarbon 70%
  • Highly toxic: mercury, pesticides 7%
  • A literature review of healthcare worker injuries due to secondary exposure from patients shows a low overall risk
    • Highest risk to healthcare workers are organophosphates which are is usually related to lack of appropriate PPE