Healthcare Response to Weapons of Mass Destruction: Biological, Chemical and Radiological

Radiological Terrorism

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, 2003):

  • 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 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, 2014e).

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 (CDC, 2014e).

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 is different.

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 (CDC, 2014e).

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.

Medical Management Principles

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.

Staff Protection Guidelines

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 plans.

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 contamination.
  • 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, 2003).
  • Survey hands and clothing at frequent intervals with a radiation meter.
  • 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 treatment.
  • Under the triage process for patients with non-life threatening conditions: When possible, trained staff should survey all patients for radioactive contamination

Decontamination Guidelines

Survey the patient with a radiation meter (CDC, 2014e; CDC, 2003).

  • Perform surveys using consistent technique and trained personnel.
  • Note exceptionally large amounts of surface or imbedded radioactive material.
  • Handle radioactive objects with forceps and store in lead containers.
  • 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 the process.
  • 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 the individual.
  • 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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