Radiological terrorism is particularly
frightening because of its potential for massive destruction,
its long term effects and genetic impact.
Radiological threats can come from a variety of sources (CDC,
- Radiation Dispersal Device. This could be a conventional
explosion that scattered radioactive material such as
a dirty bomb, a truck carrying radioactive materials were
exploded, or an aerosol containing the radioactive material
can be spread over a large area. In such a situation,
there may be hundreds of injured people with many hundreds
contaminated or exposed. Generally, the radiation levels
are not sufficient to cause acute radiation sickness,
however there are immediate psychological effects and
risk of long-term health effects.
- Major event at or near a nuclear facility. This could occur if an airplane crashed into a nuclear power plant or spent nuclear fuel pool. Most recently this occurred following the earthquake and subsequent tsunami of March 15, 2011 in Japan. Significant amounts of radioactive materials would be released. Injuries are in the dozens, many experiencing symptoms related to acute radiation syndrome; there would be thousands of contaminated or exposed people in the surrounding area who would have a greater risk of long term health effects.
- Nuclear Detonation. The immediate physical devastation
could appear similar to that of the World Trade Center
following the events of September 11, 2001. However, the
dust and debris from this event will be highly radioactive.
There are thousands of people both contaminated and injured
at the scene. In addition, there will be thousands of
people in a large area potentially extending many miles
outward from the initial point of attack with serious
radiation exposures although they may have no obvious
physical injury or contamination. Radioactive fallout
with potential for long-term health effects will extend
over a large region far from ground zero. There would
likely be many persons experiencing symptoms related to
acute radiation syndrome.
In 2013, the National Security Staff Interagency Policy Coordination
Subcommittee for Preparedness and Response to Radiological
and Nuclear Threats developed Planning Guidance for Response
to a Nuclear Detonation. This document is available from http://www.usuhs.mil/afrri/outreach/pdf/planning-guidance2010.pdf
and provides detailed information aimed at response activities
in an environment with a severely compromised infrastructure
immediately after such an event (the first 24-72 hours), when
federal resources are likely to be still being mobilized.
The target audience for this document are emergency response
planners, however, first responders, healthcare providers
and others who would likely be called into service during
such an event would benefit from this information. The learner
is directed to that document for further information.
While emergency and law enforcement personnel
conduct routine radiological monitoring, an emergency situation
may not immediately be recognized as a radiological threat.
Just as with biological and chemical threats, planning has occurred for the possibility of radiological threats. The Nevada State Health Division in 2012, updated The State of Nevada Radiological Emergency Response Plan. The 24 hour emergency hotline for radiological emergencies in Nevada is 1 (877) GET RAD 1 (438-7231).
The Nevada State plan should be integrated
into the emergency plans of each healthcare organization.
Healthcare providers are urged to identify and follow the
emergency response plans in their healthcare organizations.
Such plans should be integrated into the healthcare provider's
own personal and family emergency plans.
OSHA's 2005 OSHA Best Practices for Hospital-Based
First Receivers of Victims (2005) provides guidelines
for the protection for first receivers during releases of
chemicals, radiological particles, and biological agents (overt
releases) that produce victims who may need decontamination
prior to administration of medical care. Although intended
for mass casualty incidents as they affect emergency department
personnel at fixed hospitals, the basic principles and concepts
of this guidance also apply to mobile casualty care facilities
and temporary shelters, such as would be necessary in the
event of a catastrophic incident involving tens or hundreds
of thousands of victims. These previous general guidelines
covered in the Chemical Weapons section of this course, also
apply to the Radiological threats.
Radiation cannot be detected by the
human senses. A radiological survey conducted with specialized
equipment is the only way to confirm the presence of radiation.
If a terrorist event involves the use of radioactive material,
both patient exposure and contamination must be assessed (CDC,
Exposure occurs when a person is near
a radiation source. People exposed to a source of radiation
can suffer radiation illness if their dose is high enough,
but they do not become radioactive. For example, an x-ray
machine is a source of radiation exposure. A person does not
become radioactive or pose a risk to others following a chest
x-ray (CDC, 2014e).
Exposure to radiation can cause two kinds
of health effects. Deterministic effects are observable
health effects that occur soon after receipt of large doses.
These may include hair loss, skin burns, nausea, or death.
Stochastic effects are long-term effects, such as cancer.
The radiation dose determines the severity of a deterministic
effect and the probability of a stochastic effect. The object
of any radiation control program is to prevent any deterministic
effects and minimize the risk for stochastic effects. When
a person inhales or ingests a radionuclide, the body will
absorb different amounts of that radionuclide in different
organs, so each organ will receive a different organ dose
A person can receive an external dose
by standing near a gamma or high-energy beta-emitting source.
A person can receive an internal dose by ingesting
or inhaling radioactive material. The external exposure stops
when the person leaves the area of the source. The internal
exposure continues until the radioactive material is flushed
from the body by natural processes or decays. A person who
has ingested a radioactive material receives an internal dose
to several different organs. The absorbed dose to each organ
is different, and the sensitivity of each organ to radiation
Contamination occurs externally when
loose particles of radioactive material are deposited on surfaces,
skin, or clothing. Internal contamination occurs when radioactive
particles are inhaled, ingested, or lodged in an open wound
Contaminated patients should be decontaminated
as soon as possible, without delaying critical care. Patients
who have been exposed to radiation, but are not contaminated
with radioactive material, do not need to be decontaminated.
Internal contamination should be considered
if persistently high survey readings are noted following decontamination.
Internal contamination generally does not cause early symptoms.
Addressing contamination issues should not
delay treatment of life-threatening injuries. It is unlikely
that the levels of radioactivity associated with a contaminated
patient would pose a significant health risk to care providers.
In certain rare instances, the presence of imbedded radioactive
fragments or large amounts of external contamination may require
expedited decontamination. In-house radiation professionals
should be included in the response team.
||The symbol above is called a tri-foil
and it is the international symbol for radiation. The
symbol can be magenta or black, on a yellow background.
This sign is posted where radioactive materials are handled,
or where radiation-producing equipment is used. This sign
is used as a warning to protect people from being exposed
to radioactivity. Courtesy of US EPA.
Knowing how to protect oneself from potential
exposure and contamination is critical for healthcare providers.
Know and follow your organization's emergency plans for radiological
emergencies. However, some general guidelines pervade most
Upon initial notification of a potential radiological incident, it will be prudent to obtain as much information as possible about the affected patient and impacted site from first responders (CDC, 2003).
The first step in protecting staff is to
establish an assessment center removed from the emergency
department to rapidly screen victims for injury and contamination
and to provide for decontamination. Radiation control zones,
where potential radioactive contamination exists, should be
established within the hospital and the administration should
ensure that there is someone in charge of access to/from the
control zones, and that they have a law enforcement representative
present (CDC, 2003).
The assessment center should be used for
observation, decontamination, limited treatment and evaluation
and reuniting with family members where possible (CDC, 2003).
Suggested personnel protection equipment
that also facilitates the ease of clean-up includes (CDC,
2014e; CDC, 2003):
- Follow standard guidelines for protection from microbiological
- Surgical masks should be adequate.
- N95 masks, if available, are recommended.
- Goggles, gowns, double-gloves with inner one taped and
outer glove removed after each contact).
- Plastic wrap (e.g., disposable trash bags, Saran Wrap™,
ZipLoc™ bags, etc.) to cover and protect instruments and
equipment (CDC, 2003).
- Disposable shoe coverings (CDC, 2003).
- Butcher paper or equivalent on floor (CDC, 2003).
- If possible, personal dosimeters for staff members who
might have frequent contact with contaminated patients (CDC,
- Survey hands and clothing at frequent intervals with a
- Due to fetal sensitivity to radiation, assign pregnant
staff to other duties.
Establish an assessment center/ad
hoc triage area
In most mass casualty incidents a large majority of people
will self-triage and go directly to the closest and most familiar
hospitals; they will probably bypass field triage and treatment
whether contaminated or not (CDC, 2003) so hospitals often
have little, if any, advance notification of incoming patients.
Most of the individuals who come to the hospital are ambulatory,
minimally injured, or those who are concerned about potential
contamination. The general community medical needs to continue
despite the occurrence of a disaster (CDC, 2014e; CDC, 2003).
- Base the location on your hospital's disaster plan and
the anticipated number of casualties.
- Establish a contaminated area and clean area separated
by a buffer zone.
- Remove your contaminated outer garments when leaving
the contaminated area.
- Have your body surveyed with a radiation meter when exiting
a contaminated area.
- Under the triage process for patients with life-threatening
conditions, emergency department staff should stabilize
and treat physical symptoms according to standard procedures.
The threat of contamination should not preclude patient
- Under the triage process for patients with non-life
threatening conditions: When possible, trained staff
should survey all patients for radioactive contamination
Survey the patient with a radiation meter (CDC, 2014e;
- Perform surveys using consistent technique and trained
- Note exceptionally large amounts of surface or imbedded
- Handle radioactive objects with forceps and store in lead
- Record location and level of any contamination found.
Remove patient clothing (CDC, 2014e; CDC, 2003).
- Carefully cut and roll clothing away from the face to
contain the contamination.
- Removing the clothing from the patient should remove 70
to 90% of the contamination. Staff or responders should
bag and tag clothing, dressings, etc., for future evaluation
and potential use as criminal evidence and small personal
belongings (jewelry, wallet, etc.) should be surveyed for
contamination. If the personal belongings are not contaminated
they can be returned to the patient. Otherwise, steps must
be taken to decontaminate the items before giving them back
to the patient. If the patient is medically able to remove
his/her own clothing and wash, then the patient should do
so; however, providers should maintain communication during
- Repeat patient survey and record levels.
- Staff should address privacy concerns of patients who
are undressing. Disposable dressing gowns should be provided
for patients concerned about modesty and to ensure that
the environment is appropriate to remove clothing (e.g.,
not too cold, etc.).
Cleanse contaminated areas (CDC, 2014e; CDC, 2003):
- For mass casualties, consider establishing separate shower
areas for ambulatory and non-ambulatory patients.
- Responders should attempt as much decontamination as possible
either at the designated assessment center or outside the
hospital. Minimize the amount of contamination that actually
enters the emergency department or the hospital. Decontamination
areas should be separated from the hospital.
- Wash wounds first with saline or water. Care should be
taken with the washing procedure, ensuring that radioactive
materials are not incorporated into a wound.
- If facial contamination is present, flush eyes, nose,
and ears, and rinse mouth.
- Gently cleanse intact skin with soap and water, starting
outside the contaminated area and washing inward. Do not
irritate or abrade the skin.
- Ambulatory patients can be washed easily; however, nonambulatory
patients must be on gurneys that can be washed.
- Localized contamination can be rinsed off with pre-moistened
wipes or washed with soap and water as opposed to showering
- Resurvey and note levels.
- Repeat washing until survey indicates radiation level
is no more than twice background or the level remains unchanged.
- Cover wounds with waterproof/bio-occlusive dressing.
- Care should be taken with the washing procedure, ensuring
that radioactive materials are not incorporated into a wound.
- If a patient has both wounds and very high, localized
levels of internal contamination, this may indicate that
the patient has a radioactive fragment or fragments internally.
The physician, in consultation with the hospital radiation
safety officer if possible, should consider surgically removing
the fragment(s) using forceps to avoid potential local radiation
injury to the hands of the provider.
- Dispose of waste water through normal channels. In a mass
casualty emergency, staff should dispose of the water used
to decontaminate patients via the sewer system. It is unlikely
hospitals will have an effective water-holding system for
any mass casualty event.
- Hospitals should decontaminate the facility and staff
who had contact with contaminated patients to prevent the
spread of contamination. Staff should consult their radiation
safety officer for step-by-step procedures.
- If the patient does not show any signs of contamination
or meet hospital admittance criteria, providers should recommend
that the patient take a thorough shower as soon as possible.
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