- Email: [email protected]
Dealing With Radiological Disasters
Dealing With Radiological Disasters j Deborah S. Adelman, PhD, RN, NE-BC; Mary Anne Theiss, PhD, JD, MS, RN, CNE; and Joan Goudounis, MS, RN ABSTRACT: Dealing with the victims of a radiological disaster can be daunting for nurses who have little experience in this area. Knowing how to set up a response area that protects the hospital and staff from radiation exposure coupled with treatment of victims is the goal. Accomplishment of these goals requires a knowledge base of the different types of exposure and the treatment of each. (J Radiol Nurs 2014;33:100-104.) KEYWORDS: Radiological disaster; Contamination; Decontamination; Radiation exposure; Acute radiation syndrome.
INTRODUCTION There has been much in the media about radiological disasters for at least 20 years. From Three Mile Island (World Nuclear Association, 2012) to the tsunami that destroyed the Fukushima power plant in Japan (International Atomic Energy Agency, 1998-2013), radiological disasters and terrorist attacks are infrequent but an area of nursing that must be explored and understood. The reality becomes greater for nurses working in hospitals with victims arriving that may possibly result in hospital contamination. Nurses in the emergency department (ED) caring for patients who are exposed to radiation must be skilled, experienced, and fully understand their role (Yin et al., 2012). This article will discuss the role of the hospitalbased nurse in responding to such situations. Radiological disasters are complex and usually fall into one of six categories (Adelstein, 2005, as cited in Arizona Department of Health Services, 2012, p. 3; DeLuca & Adelman, 2009): 1. Detonation of explosives with dirty bombs containing radiological materials,
Deborah S. Adelman, PhD, RN, NE-BC, is a Professor in Graduate Programs at Kaplan University School of Nursing; Mary Anne Theiss, PhD, JD, MS, RN, CNE, is a Professor in Graduate Programs at Kaplan University School of Nursing; Joan Goudounis, MS, RN, is an Adjunct Professor in Graduate Programs at Kaplan University School of Nursing, 550 West Van Buren Street, Chicago, IL 60607. No grants or financial assistance was received for this article. Corresponding author: Deborah S. Adelman, 1532 Seven Pines Road, Apt. B, Springfield, IL 62704-6605. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2014 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2014.03.006
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2. Placement of radiation materials in public places, 3. Attacks on nuclear sites or release of radiation from a power plant, 4. Accidents involving vehicles transporting radioactive isotopes, 5. Contamination of water or food supplies, and 6. Detonation of a nuclear explosive device. Staff at the institution receiving radiological disaster victims may have to deal with two types of victims: those decontaminated at the scene and untreated victims arriving without prior care who maybe contaminated, so it is important for staff to understand the possible types of contamination that they may encounter. The first is radiation in the form of dust, solid particles, or liquid that attaches to the victim’s skin or clothing. This can be detected by monitoring and may consist of alpha, beta, or gamma emitters. The second is inhalation, contamination of wounds, or digestion of dust, solid particles, or liquids. This is a true emergency because the contact with internal organs can result in tissue destruction. Finally, the patient may experience acute radiation syndrome, which is high exposure to gamma rays, such as an X-ray. The patient will not be radioactive and offers no danger to the staff (Downstate Medical Center, 2008). ED RESPONSE The Radiation Emergency Assistance Center [REAC/ TS] (n.d.) has steps that must be followed when the ED receives a call about a radiation accident. The first step is to check the credibility of the call. If the call is not received through the usual emergency notification channels, then verification of the accident must be made through those proper channels. If the call is
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credible, then information must be gathered for proper preparation and determination of the number of victims.
the ED by nurses who are not trained to be on the response team. INPATIENT CARE FOR THE RADIATION VICTIM
Unknown Exposure Versus Known Exposure When there is doubt about a person’s contamination status, the person is assumed contaminated on arrival for treatment in the decontamination room. The United States Nuclear Regulatory Commission (United States Nuclear Regulatory Commission [USNRC], 2013) recommends that, if possible, clothing from the patient be removed and placed in a bag before entering the ED. Because this may not always be the case, patients with known exposure are taken directly to the decontamination room, undressed, and their clothing bagged. Because contamination can be present on the skin or in an orifice or wound from ingestion or inhalation, emergent care is provided first. This may take the form of washing the patient, lavage of the stomach, or oral chelating agents (DeLuca & Adelman, 2009). The main goal of decontamination of the victim is to prevent radioactive materials from being further inhaled by the victim or ingested. Once the patient is stabilized, the radiation status of the patient is determined. Patients who enter the ED and deemed no longer contaminated receive standard basic care with no special precautions need to be taken. Setting Up Triage and Decontamination Preparing to receive victims of radiological disasters and protecting the hospital staff and building from further contamination are also important. The Radiological Emergency Response team is notified and dresses appropriately. A team may consist of the following personnel: a radiological physicist, physician, nurse, and radiology technologist. A decontamination room, preferably with a separate ventilation system, should be set up close to the entrance. Without such a separate system, the ventilation should be turned off from the ED to the rest of the hospital. Security should be available for control of family members, media, and onlookers. Equipment is brought into the decontamination area and plastic placed on the floor to prevent transfer of radiation into clean areas of the ED via shoes, stretchers, and wheelchairs, as well as other equipment being moved from one area to the next (USNRC, 2013). During transport, the patient, stretcher, and pillow should be covered with a blanket (Downstate Medical Center, 2008). The ED nurse who is trained as part of the response team will assist with procedures, collect specimens, perform physical assessments, provide direct patient care, and monitor radiation contamination levels. Care of patients who are not contaminated continues throughout the rest of VOLUME 33 ISSUE 3
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The number of incoming casualties, severity of injuries, and causes of injuries may influence how much patient management is needed and the focus of medical treatment (DeLuca & Adelman, 2009). In general, healthcare personnel in the hospital are not familiar with the standards of care for the treatment of patients who were exposed to different types of radiation (Veenema & Toke, 2007; Williams & Williams, 2010). Understanding what is involved and the potential risks associated with caring for such patients must be made clear to the receiving units. It is also important for nurses to understand that caring for mass casualties without increasing harm often entails changing accepted nursing standards of practice (Veenema & Toke, 2007). With an influx of patients admitted with radiation exposure and lack of qualified personnel, duties may expand beyond the normal scope of practice for nurses in a radiological disaster. However, there is nothing in the extant literature on exactly how the role of the nurse changes in the hospital setting (Yin et al., 2012). These changes may also occur in the role a hospital unit may normally have, such as when an intensive care unit is used as an operating room (Veenema & Toke, 2007). Caring for a patient with a radiation exposure and determining the prognosis requires specific nursing interventions. One must look at the patient’s laboratory values, diagnostics, clinical manifestations, and type of radiological exposure. A Geiger counter, which detects particles from a radioactive substance (Shampo, Kyle, & Steensma, 2011), may be used to detect if the patient has been adequately decontaminated. The Geiger counter is moved directly over the patient and throughout the room to detect whether any radioactive materials were inadvertently transported into the unit. The complete blood count results can be used as an indicator of patient prognosis because radiation lowers lymphocyte production that indicates a high exposure and poor prognosis (Pae, 2006). The first CBC should be obtained as soon as possible while in the ED so comparisons can be made after transfer to the receiving unit. Physical assessment findings may reveal alterations such as changes in mental status, cardiac dysrhythmias, respiratory distress, and/or impaired tissue and skin integrity (Iroquois Memorial Hospital, 2003). Potassium iodide is the treatment of choice when a patient has been exposed to radioactive iodine as it inhibits the uptake into the thyroid gland (Centers for Disease Control and Prevention, n.d.;
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Food and Drug Administration, 2002; Murray, 2011). Contraindications to this treatment are a history of thyroid disease or known allergy to potassium iodide (AHRQ, n.d.b). Acute Radiation Syndrome and Radiation Burns When a body is exposed to large amounts of radiation, the resulting pathophysiology is a process called acute radiation syndrome (ARS) (Pae, 2006). The prognosis from such an intense level of exposure is death. Clinical manifestation of the syndrome depends on the amount of radiation exposure. The symptoms consisting of nausea, vomiting, diarrhea, abdominal cramping, dehydration, listlessness, and weight loss that may occur as early as 5 min or 12 hr after exposure. The gastrointestinal tract provides a good indication of the amount of radiation the patient is exposed to with anorexia and nausea indicators of low levels of radiation. Vomiting within an hour may be a sign of near lethal dose and up to 5 hr may have serious sequelae (Downstate Medical Center, 2008; Pae, 2006; Waselenko et al., 2004), making it important to note the time of onset. Cerebrovascular syndrome (ie, cerebral edema and hypotension), another manifestation of acute radiation syndrome, is fatal and can occur within hours to days (Koenig et al., 2005). When treating victims with acute radiation syndrome, nursing care would consist of palliative comfort measures such as controlling pain, nausea, vomiting, and preventing the spread of infection and dehydration. Pain medications, antibiotics, burn creams, prophylaxis against ulceration of the gastrointestinal tract, and IV fluids would be provided (Arizona Department of Health Services, 2012; Pae, 2006; Waselenko et al., 2004). When a radiation burn is severe, vasodilator therapy, grafts, and amputation may be the only options available (Dendass, 2012). Care for radiation burns and wounds that may be related to other trauma at the disaster scene is focused on preventing absorption of radiation particles that may still be present in the wound. Rubbing and irritating wounds must be avoided as this accelerates absorption (Dendass, 2012; Williams & Williams, 2010). Open wounds should be cleaned separately from the rest of the body and covered with a dressing and wrapped with a bandage to secure it, avoiding the use of tape on the fragile skin (Dendass, 2012). Blast Injury Care There is a possibility that the radiological disaster occurred as a result of an explosion, whether from a terrorist’s dirty bomb or from an industrial accident where radiation is used. How the patient was positioned at the time of the blast dictates where injury will occur and the type of care needed on the inpatient 102
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unit. More severe injuries such as damage to the lungs occur if there is anterior exposure to the blast, whereas less severe injuries may occur if the exposure is posterior (Taylor & Daywood, 2005). The most common injuries from blast explosions are lacerations; open and closed fractures to the face, hands, arms, legs, and spine; foreign body embedment; pneumothorax; flail chest; ruptured spleen; smoke inhalation; burns; and tympanic perforations (Goh, 2009; Williams & Williams, 2010). The provider must be alert for signs of abdominal pain, nausea, vomiting, hematemesis, and hypovolemia as this is indicative of intra-abdominal injury requiring immediate surgical intervention. Ensuring that the patient remains hydrated with oral and IV liquids as appropriate and frequent abdominal assessment are required to identify possible signs of intestinal perforation and developing peritonitis (DeLuca & Adelman, 2009). Further Care for Victims of Radiation Exposures Although the victim of a radiological exposure generally poses no threat of radiation exposure to health-care personnel or the receiving facility, exposure to radioactive isotopes does pose a risk. Such contamination can be caused by contaminated victims and clothing. The skin should be decontaminated carefully by cleaning small areas at a time and discarding the sterile gauze after each use. Open wounds are irrigated with large amounts of normal saline for at least 3 min or until radiation detection devices show no danger. Tissues removed from wound debridement are discarded in the same manner as hazardous waste (Downstate Medical Center, 2008). Eyes, ear canals, nares, and mouth should be washed gently. Care should be taken that contaminated water is not ingested by the victim when washing the mouth. The stomach is lavaged with normal saline until clear of contamination. The hair is washed and may be cut, but skin should not be shaved or washed with soap as these may irritate the skin (Chan et al., 2014). If the victim has been decontaminated and does not need further medical treatment, he or she may be discharged. The goal of treatment of victims who have ingested, inhaled, or incorporated radioactive materials into their bodies is to reduce the absorption or enhance elimination or excretion of the materials. The key to effective treatment is the proper drug for the radioactive material and quick administration after exposure. Mobilizing or chelating agents are used, and the risks are weighed in relationship to the benefits when administering these agents. Mobilizing agents increase the body’s release of isotopes and enhance the rate of excretion. Urinary excretion rate and half-life of the radionuclide are considerations that are weighted
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against the use of mobilizing or chelating agents (Downstate Medical Center, 2008). Chelating agents enhance the elimination of metals by forming bonds and thus eliminate the hazardous material from being a free ion with destructive capabilities (Fukuda, 2005). Significant exposures necessitate greater risks with drugs. PROTECTING STAFF CARING FOR VICTIMS OF RADIOLOGICAL DISASTERS No matter how the injury occurred, nursing staff caring for patients who are victims of a radiological disaster must maintain strict isolation precautions and wear protective clothing that can be easily discarded to prevent the spread of contamination until decontamination is established. This generally will occur in the field at the disaster site, but it may also occur in a decontamination room in the ED as noted previously. In the case where decontamination has not occurred before the patient being transferred to the hospital or when there is any question of safety, protective clothing should be worn. The clothing includes surgical gowns and gloves, protective eye cover, waterproof shoe covers, and waterproof aprons. Furthermore, a radiation dosimeter must be worn on the outside the surgical gown and, if possible, under the surgical gown (Radiation Emergency Assistant Center [REAC/TS], n.d.). Surprisingly, there are no cases in the extant literature that show health-care workers, whether first responders or hospital personnel, suffering from radiation exposure and becoming ill after caring for patients involved in a radiological disaster (Kitchen, Hendee, & Orton, 2008; REAC/TS, n.d.). CONCLUSION The care for victims exposed to radiation depends on how the victims were exposed to the radiation and if they were superficially contaminated with radioactive isotopes or ingested, inhaled, or incorporated radioactive materials into the body. Dealing with victims of radiation disasters is a challenge for first responders and hospital personnel. The safest route to take is to assume contamination unless documentation arrives with the victim from a credible source. As with all radiation exposure, time, distance, and shielding will help to protect those caring for the victim and decrease exposure for the victim. References Agency of Healthcare Research and Quality (AHRQ). (n.d.a). Altered standards of care in mass casualty events. Retrieved from http://archive.ahrq.gov/research/altstand/altstand2. htm#Changes. April 19, 2014. AHRQ, (n.d.b.). Altered standards of care in mass casualty events. Retrieved from http://archive.ahrq.gov/research/ altstand/altstand4.htm#Protection. April 19, 2014.
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Arizona Department of Health Services. (2012). Arizona Department of Health Services radiological emergency response plan. Retrieved from http://www.azdhs.gov/phs/emergencypreparedness/documents/response-plans/radiological-emergencyresponse-plan.pdf. April 19, 2014. Centers for Disease Control and Prevention. (n.d.). Emergency preparedness and response. Retrieved from http:// emergency.cdc.gov/radiation/ki.asp. April 19, 2014. Chan, R.J., Webster, J., Chung, B., Marquart, L., Ahmed, M., & Garantziotis, S. (2014). Prevention and treatment of acute radiation-induced skin reactions: A systematic review and meta-analysis of randomized control trials. BMC Cancer, 14(1), 1-42. http://dx.doi.org/10.1186/1471-2407-14-53. DeLuca, D.A., & Adelman, D.S. (2009). Upscaling burn management: The mass burn casualty incident application: CBRN. Adelman, D.S., Legg, T.J. Disaster nursing: A handbook for practice. Sudbury, MA: Jones and Bartlett, pp. 265-294. Dendass, N. (2012). Toward evidence and theory-based skin care in radiation oncology. Clinical Journal of Oncology Nursing, 16(5), 520-525. http://dx.doi.org/10.1188/12CJON.520-525. Downstate Medical Center. (2008). Hazardous materials, chemical, and radiation exposure decontamination protocol. Retrieved from http://www.downstate.edu/emergency_ medicine/pdf/KCHCSection05.pdf. April 19, 2014. Food and Drug Administration. (2002). Guidance for industry. KI in radiation emergencies-questions and answers. Retrieved from http://www.fda.gov/downloads/Drugs/GuidanceCompliance RegulatoryInformation/Guidances/ucm080546.pdf. April 19, 2014. Fukuda, S. (2005). Chelating agents used for plutonium and uranium removal in radiation emergency medicine. Current Medicinal Chemistry, 12(23), 2765-2770. http://dx.doi.org/10. 2174/092986705774463012. Goh, S.H. (2009). Bomb blast injuries: Initial triage and management of injuries. Singapore Medical Journal, 50(1), 101-106. International Atomic Energy Agency. (1998-2013). Fukushima nuclear accident. Retrieved from http://www.iaea.org/newscenter/ focus/fukushima/. April 19, 2014. Iroquois Memorial Hospital (2003). Emergency department patient care standard for major burns. Watseka, IL: Author. Kitchen, R.H., Hendee, E.G., & Orton, C.G. (2008). Exposure limits for emergency responders should be the same as the prevailing limits for occupational radiation workers. Medical Physics, 35(1), 1-3. http://dx.doi.org/10.1118/1.2815355. Koenig, K.L., Goans, R.E., Hatchett, R.J., Mettler, F.A., Schumacher, T.A., & Noji, E.K., et al. (2005). Medical treatment of radiological casualties: Current concepts. Annals of Emergency Medicine, 45(6), 643-652. http://dx.doi.org/10.1016/j. annemergmed.2005.01.020. Murray, J.S. (2011). Caring for children following radiation disaster. Journal for Specialists in Pediatric Nursing, 16(4), 313-319. http://dx.doi.org/10.1111/j.1744-6155.2011.00294.x. Pae, J.S. (2006). CBRNE: Radiation emergencies. eMedicine Journal. Retrieved from http://emedicine.medscape.com/ article/834015-overview#aw2aab6c11. April 19, 2014. Radiation Emergency Assistant Center/Training Site. (n.d.). Managing radiation emergencies. Retrieved from http:// orise.orau.gov/reacts/guide/care.htm. April 19, 2014. Shampo, M.A., Kyle, R.A., & Steensma, D.P. (2011). Hans Geiger-German physicist and the Geiger counter. Mayo Clinic Proceedings, 86(12), e54. http://dx.doi.org/10.4065/ mcp.2011.0638. Taylor, I., & Dawood, M. (2005). Terrorism: The reality of blast injuries. Emergency Nurse, 13(8), 22-25. ISSN:1354e5752.
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United States Nuclear Regulatory Commission. (2013). Managing radiation emergencies. Retrieved from http://orise.orau. gov/reacts/guide/emergency.htm. April 19, 2014. Veenema, T.G., & Toke, J. (2007). When standards of care change in mass-casualty events. American Journal of Nursing, 107(9). 72A-72H. http://dx.doi.org/10.1097/01.NAJ. 0000287515.53876.03. Waselenko, J.K., MacVittie, T.J., Blakely, W.F., Peski, N., Wiley, A.L., & Dickerson, W.E., et al. (2004). Medical management of the acute radiation syndrome: Recommendations of the strategic national stockpile radiation working group. Annals of Internal Medicine, 140(12), 1037-1051. PMID: 15197022.
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Williams, G., & Williams, E. (2010). A nursing guide to surviving a radiological dispersal device. British Journal of Nursing, 19(1), 24-27. ISSN:0966e0461. World Nuclear Association. (2012). Three Mile Island accident. Retrieved from http://www.world-nuclear.org/info/Safetyand-Security/Safety-of-Plants/Three-Mile-Island-accident/. April 19, 2014. Yin, H., He, H., Arbon, H., Zhu, J., Tan, J., & Zhang, L. (2012). Optimal qualifications, staffing and scope of practice for first responder nurses in disaster. Journal of Clinical Nursing, 21(1/2), 264-271. http://dx.doi.org/10.1111/j.1365-2702.2011. 03790x.
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INTRODUCTION There has been much in the media about radiological disasters for at least 20 years. From Three Mile Island (World Nuclear Association, 2012) to the tsunami that destroyed the Fukushima power plant in Japan (International Atomic Energy Agency, 1998-2013), radiological disasters and terrorist attacks are infrequent but an area of nursing that must be explored and understood. The reality becomes greater for nurses working in hospitals with victims arriving that may possibly result in hospital contamination. Nurses in the emergency department (ED) caring for patients who are exposed to radiation must be skilled, experienced, and fully understand their role (Yin et al., 2012). This article will discuss the role of the hospitalbased nurse in responding to such situations. Radiological disasters are complex and usually fall into one of six categories (Adelstein, 2005, as cited in Arizona Department of Health Services, 2012, p. 3; DeLuca & Adelman, 2009): 1. Detonation of explosives with dirty bombs containing radiological materials,
Deborah S. Adelman, PhD, RN, NE-BC, is a Professor in Graduate Programs at Kaplan University School of Nursing; Mary Anne Theiss, PhD, JD, MS, RN, CNE, is a Professor in Graduate Programs at Kaplan University School of Nursing; Joan Goudounis, MS, RN, is an Adjunct Professor in Graduate Programs at Kaplan University School of Nursing, 550 West Van Buren Street, Chicago, IL 60607. No grants or financial assistance was received for this article. Corresponding author: Deborah S. Adelman, 1532 Seven Pines Road, Apt. B, Springfield, IL 62704-6605. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2014 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2014.03.006
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2. Placement of radiation materials in public places, 3. Attacks on nuclear sites or release of radiation from a power plant, 4. Accidents involving vehicles transporting radioactive isotopes, 5. Contamination of water or food supplies, and 6. Detonation of a nuclear explosive device. Staff at the institution receiving radiological disaster victims may have to deal with two types of victims: those decontaminated at the scene and untreated victims arriving without prior care who maybe contaminated, so it is important for staff to understand the possible types of contamination that they may encounter. The first is radiation in the form of dust, solid particles, or liquid that attaches to the victim’s skin or clothing. This can be detected by monitoring and may consist of alpha, beta, or gamma emitters. The second is inhalation, contamination of wounds, or digestion of dust, solid particles, or liquids. This is a true emergency because the contact with internal organs can result in tissue destruction. Finally, the patient may experience acute radiation syndrome, which is high exposure to gamma rays, such as an X-ray. The patient will not be radioactive and offers no danger to the staff (Downstate Medical Center, 2008). ED RESPONSE The Radiation Emergency Assistance Center [REAC/ TS] (n.d.) has steps that must be followed when the ED receives a call about a radiation accident. The first step is to check the credibility of the call. If the call is not received through the usual emergency notification channels, then verification of the accident must be made through those proper channels. If the call is
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credible, then information must be gathered for proper preparation and determination of the number of victims.
the ED by nurses who are not trained to be on the response team. INPATIENT CARE FOR THE RADIATION VICTIM
Unknown Exposure Versus Known Exposure When there is doubt about a person’s contamination status, the person is assumed contaminated on arrival for treatment in the decontamination room. The United States Nuclear Regulatory Commission (United States Nuclear Regulatory Commission [USNRC], 2013) recommends that, if possible, clothing from the patient be removed and placed in a bag before entering the ED. Because this may not always be the case, patients with known exposure are taken directly to the decontamination room, undressed, and their clothing bagged. Because contamination can be present on the skin or in an orifice or wound from ingestion or inhalation, emergent care is provided first. This may take the form of washing the patient, lavage of the stomach, or oral chelating agents (DeLuca & Adelman, 2009). The main goal of decontamination of the victim is to prevent radioactive materials from being further inhaled by the victim or ingested. Once the patient is stabilized, the radiation status of the patient is determined. Patients who enter the ED and deemed no longer contaminated receive standard basic care with no special precautions need to be taken. Setting Up Triage and Decontamination Preparing to receive victims of radiological disasters and protecting the hospital staff and building from further contamination are also important. The Radiological Emergency Response team is notified and dresses appropriately. A team may consist of the following personnel: a radiological physicist, physician, nurse, and radiology technologist. A decontamination room, preferably with a separate ventilation system, should be set up close to the entrance. Without such a separate system, the ventilation should be turned off from the ED to the rest of the hospital. Security should be available for control of family members, media, and onlookers. Equipment is brought into the decontamination area and plastic placed on the floor to prevent transfer of radiation into clean areas of the ED via shoes, stretchers, and wheelchairs, as well as other equipment being moved from one area to the next (USNRC, 2013). During transport, the patient, stretcher, and pillow should be covered with a blanket (Downstate Medical Center, 2008). The ED nurse who is trained as part of the response team will assist with procedures, collect specimens, perform physical assessments, provide direct patient care, and monitor radiation contamination levels. Care of patients who are not contaminated continues throughout the rest of VOLUME 33 ISSUE 3
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The number of incoming casualties, severity of injuries, and causes of injuries may influence how much patient management is needed and the focus of medical treatment (DeLuca & Adelman, 2009). In general, healthcare personnel in the hospital are not familiar with the standards of care for the treatment of patients who were exposed to different types of radiation (Veenema & Toke, 2007; Williams & Williams, 2010). Understanding what is involved and the potential risks associated with caring for such patients must be made clear to the receiving units. It is also important for nurses to understand that caring for mass casualties without increasing harm often entails changing accepted nursing standards of practice (Veenema & Toke, 2007). With an influx of patients admitted with radiation exposure and lack of qualified personnel, duties may expand beyond the normal scope of practice for nurses in a radiological disaster. However, there is nothing in the extant literature on exactly how the role of the nurse changes in the hospital setting (Yin et al., 2012). These changes may also occur in the role a hospital unit may normally have, such as when an intensive care unit is used as an operating room (Veenema & Toke, 2007). Caring for a patient with a radiation exposure and determining the prognosis requires specific nursing interventions. One must look at the patient’s laboratory values, diagnostics, clinical manifestations, and type of radiological exposure. A Geiger counter, which detects particles from a radioactive substance (Shampo, Kyle, & Steensma, 2011), may be used to detect if the patient has been adequately decontaminated. The Geiger counter is moved directly over the patient and throughout the room to detect whether any radioactive materials were inadvertently transported into the unit. The complete blood count results can be used as an indicator of patient prognosis because radiation lowers lymphocyte production that indicates a high exposure and poor prognosis (Pae, 2006). The first CBC should be obtained as soon as possible while in the ED so comparisons can be made after transfer to the receiving unit. Physical assessment findings may reveal alterations such as changes in mental status, cardiac dysrhythmias, respiratory distress, and/or impaired tissue and skin integrity (Iroquois Memorial Hospital, 2003). Potassium iodide is the treatment of choice when a patient has been exposed to radioactive iodine as it inhibits the uptake into the thyroid gland (Centers for Disease Control and Prevention, n.d.;
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Food and Drug Administration, 2002; Murray, 2011). Contraindications to this treatment are a history of thyroid disease or known allergy to potassium iodide (AHRQ, n.d.b). Acute Radiation Syndrome and Radiation Burns When a body is exposed to large amounts of radiation, the resulting pathophysiology is a process called acute radiation syndrome (ARS) (Pae, 2006). The prognosis from such an intense level of exposure is death. Clinical manifestation of the syndrome depends on the amount of radiation exposure. The symptoms consisting of nausea, vomiting, diarrhea, abdominal cramping, dehydration, listlessness, and weight loss that may occur as early as 5 min or 12 hr after exposure. The gastrointestinal tract provides a good indication of the amount of radiation the patient is exposed to with anorexia and nausea indicators of low levels of radiation. Vomiting within an hour may be a sign of near lethal dose and up to 5 hr may have serious sequelae (Downstate Medical Center, 2008; Pae, 2006; Waselenko et al., 2004), making it important to note the time of onset. Cerebrovascular syndrome (ie, cerebral edema and hypotension), another manifestation of acute radiation syndrome, is fatal and can occur within hours to days (Koenig et al., 2005). When treating victims with acute radiation syndrome, nursing care would consist of palliative comfort measures such as controlling pain, nausea, vomiting, and preventing the spread of infection and dehydration. Pain medications, antibiotics, burn creams, prophylaxis against ulceration of the gastrointestinal tract, and IV fluids would be provided (Arizona Department of Health Services, 2012; Pae, 2006; Waselenko et al., 2004). When a radiation burn is severe, vasodilator therapy, grafts, and amputation may be the only options available (Dendass, 2012). Care for radiation burns and wounds that may be related to other trauma at the disaster scene is focused on preventing absorption of radiation particles that may still be present in the wound. Rubbing and irritating wounds must be avoided as this accelerates absorption (Dendass, 2012; Williams & Williams, 2010). Open wounds should be cleaned separately from the rest of the body and covered with a dressing and wrapped with a bandage to secure it, avoiding the use of tape on the fragile skin (Dendass, 2012). Blast Injury Care There is a possibility that the radiological disaster occurred as a result of an explosion, whether from a terrorist’s dirty bomb or from an industrial accident where radiation is used. How the patient was positioned at the time of the blast dictates where injury will occur and the type of care needed on the inpatient 102
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unit. More severe injuries such as damage to the lungs occur if there is anterior exposure to the blast, whereas less severe injuries may occur if the exposure is posterior (Taylor & Daywood, 2005). The most common injuries from blast explosions are lacerations; open and closed fractures to the face, hands, arms, legs, and spine; foreign body embedment; pneumothorax; flail chest; ruptured spleen; smoke inhalation; burns; and tympanic perforations (Goh, 2009; Williams & Williams, 2010). The provider must be alert for signs of abdominal pain, nausea, vomiting, hematemesis, and hypovolemia as this is indicative of intra-abdominal injury requiring immediate surgical intervention. Ensuring that the patient remains hydrated with oral and IV liquids as appropriate and frequent abdominal assessment are required to identify possible signs of intestinal perforation and developing peritonitis (DeLuca & Adelman, 2009). Further Care for Victims of Radiation Exposures Although the victim of a radiological exposure generally poses no threat of radiation exposure to health-care personnel or the receiving facility, exposure to radioactive isotopes does pose a risk. Such contamination can be caused by contaminated victims and clothing. The skin should be decontaminated carefully by cleaning small areas at a time and discarding the sterile gauze after each use. Open wounds are irrigated with large amounts of normal saline for at least 3 min or until radiation detection devices show no danger. Tissues removed from wound debridement are discarded in the same manner as hazardous waste (Downstate Medical Center, 2008). Eyes, ear canals, nares, and mouth should be washed gently. Care should be taken that contaminated water is not ingested by the victim when washing the mouth. The stomach is lavaged with normal saline until clear of contamination. The hair is washed and may be cut, but skin should not be shaved or washed with soap as these may irritate the skin (Chan et al., 2014). If the victim has been decontaminated and does not need further medical treatment, he or she may be discharged. The goal of treatment of victims who have ingested, inhaled, or incorporated radioactive materials into their bodies is to reduce the absorption or enhance elimination or excretion of the materials. The key to effective treatment is the proper drug for the radioactive material and quick administration after exposure. Mobilizing or chelating agents are used, and the risks are weighed in relationship to the benefits when administering these agents. Mobilizing agents increase the body’s release of isotopes and enhance the rate of excretion. Urinary excretion rate and half-life of the radionuclide are considerations that are weighted
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against the use of mobilizing or chelating agents (Downstate Medical Center, 2008). Chelating agents enhance the elimination of metals by forming bonds and thus eliminate the hazardous material from being a free ion with destructive capabilities (Fukuda, 2005). Significant exposures necessitate greater risks with drugs. PROTECTING STAFF CARING FOR VICTIMS OF RADIOLOGICAL DISASTERS No matter how the injury occurred, nursing staff caring for patients who are victims of a radiological disaster must maintain strict isolation precautions and wear protective clothing that can be easily discarded to prevent the spread of contamination until decontamination is established. This generally will occur in the field at the disaster site, but it may also occur in a decontamination room in the ED as noted previously. In the case where decontamination has not occurred before the patient being transferred to the hospital or when there is any question of safety, protective clothing should be worn. The clothing includes surgical gowns and gloves, protective eye cover, waterproof shoe covers, and waterproof aprons. Furthermore, a radiation dosimeter must be worn on the outside the surgical gown and, if possible, under the surgical gown (Radiation Emergency Assistant Center [REAC/TS], n.d.). Surprisingly, there are no cases in the extant literature that show health-care workers, whether first responders or hospital personnel, suffering from radiation exposure and becoming ill after caring for patients involved in a radiological disaster (Kitchen, Hendee, & Orton, 2008; REAC/TS, n.d.). CONCLUSION The care for victims exposed to radiation depends on how the victims were exposed to the radiation and if they were superficially contaminated with radioactive isotopes or ingested, inhaled, or incorporated radioactive materials into the body. Dealing with victims of radiation disasters is a challenge for first responders and hospital personnel. The safest route to take is to assume contamination unless documentation arrives with the victim from a credible source. As with all radiation exposure, time, distance, and shielding will help to protect those caring for the victim and decrease exposure for the victim. References Agency of Healthcare Research and Quality (AHRQ). (n.d.a). Altered standards of care in mass casualty events. Retrieved from http://archive.ahrq.gov/research/altstand/altstand2. htm#Changes. April 19, 2014. AHRQ, (n.d.b.). Altered standards of care in mass casualty events. Retrieved from http://archive.ahrq.gov/research/ altstand/altstand4.htm#Protection. April 19, 2014.
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Arizona Department of Health Services. (2012). Arizona Department of Health Services radiological emergency response plan. Retrieved from http://www.azdhs.gov/phs/emergencypreparedness/documents/response-plans/radiological-emergencyresponse-plan.pdf. April 19, 2014. Centers for Disease Control and Prevention. (n.d.). Emergency preparedness and response. Retrieved from http:// emergency.cdc.gov/radiation/ki.asp. April 19, 2014. Chan, R.J., Webster, J., Chung, B., Marquart, L., Ahmed, M., & Garantziotis, S. (2014). Prevention and treatment of acute radiation-induced skin reactions: A systematic review and meta-analysis of randomized control trials. BMC Cancer, 14(1), 1-42. http://dx.doi.org/10.1186/1471-2407-14-53. DeLuca, D.A., & Adelman, D.S. (2009). Upscaling burn management: The mass burn casualty incident application: CBRN. Adelman, D.S., Legg, T.J. Disaster nursing: A handbook for practice. Sudbury, MA: Jones and Bartlett, pp. 265-294. Dendass, N. (2012). Toward evidence and theory-based skin care in radiation oncology. Clinical Journal of Oncology Nursing, 16(5), 520-525. http://dx.doi.org/10.1188/12CJON.520-525. Downstate Medical Center. (2008). Hazardous materials, chemical, and radiation exposure decontamination protocol. Retrieved from http://www.downstate.edu/emergency_ medicine/pdf/KCHCSection05.pdf. April 19, 2014. Food and Drug Administration. (2002). Guidance for industry. KI in radiation emergencies-questions and answers. Retrieved from http://www.fda.gov/downloads/Drugs/GuidanceCompliance RegulatoryInformation/Guidances/ucm080546.pdf. April 19, 2014. Fukuda, S. (2005). Chelating agents used for plutonium and uranium removal in radiation emergency medicine. Current Medicinal Chemistry, 12(23), 2765-2770. http://dx.doi.org/10. 2174/092986705774463012. Goh, S.H. (2009). Bomb blast injuries: Initial triage and management of injuries. Singapore Medical Journal, 50(1), 101-106. International Atomic Energy Agency. (1998-2013). Fukushima nuclear accident. Retrieved from http://www.iaea.org/newscenter/ focus/fukushima/. April 19, 2014. Iroquois Memorial Hospital (2003). Emergency department patient care standard for major burns. Watseka, IL: Author. Kitchen, R.H., Hendee, E.G., & Orton, C.G. (2008). Exposure limits for emergency responders should be the same as the prevailing limits for occupational radiation workers. Medical Physics, 35(1), 1-3. http://dx.doi.org/10.1118/1.2815355. Koenig, K.L., Goans, R.E., Hatchett, R.J., Mettler, F.A., Schumacher, T.A., & Noji, E.K., et al. (2005). Medical treatment of radiological casualties: Current concepts. Annals of Emergency Medicine, 45(6), 643-652. http://dx.doi.org/10.1016/j. annemergmed.2005.01.020. Murray, J.S. (2011). Caring for children following radiation disaster. Journal for Specialists in Pediatric Nursing, 16(4), 313-319. http://dx.doi.org/10.1111/j.1744-6155.2011.00294.x. Pae, J.S. (2006). CBRNE: Radiation emergencies. eMedicine Journal. Retrieved from http://emedicine.medscape.com/ article/834015-overview#aw2aab6c11. April 19, 2014. Radiation Emergency Assistant Center/Training Site. (n.d.). Managing radiation emergencies. Retrieved from http:// orise.orau.gov/reacts/guide/care.htm. April 19, 2014. Shampo, M.A., Kyle, R.A., & Steensma, D.P. (2011). Hans Geiger-German physicist and the Geiger counter. Mayo Clinic Proceedings, 86(12), e54. http://dx.doi.org/10.4065/ mcp.2011.0638. Taylor, I., & Dawood, M. (2005). Terrorism: The reality of blast injuries. Emergency Nurse, 13(8), 22-25. ISSN:1354e5752.
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United States Nuclear Regulatory Commission. (2013). Managing radiation emergencies. Retrieved from http://orise.orau. gov/reacts/guide/emergency.htm. April 19, 2014. Veenema, T.G., & Toke, J. (2007). When standards of care change in mass-casualty events. American Journal of Nursing, 107(9). 72A-72H. http://dx.doi.org/10.1097/01.NAJ. 0000287515.53876.03. Waselenko, J.K., MacVittie, T.J., Blakely, W.F., Peski, N., Wiley, A.L., & Dickerson, W.E., et al. (2004). Medical management of the acute radiation syndrome: Recommendations of the strategic national stockpile radiation working group. Annals of Internal Medicine, 140(12), 1037-1051. PMID: 15197022.
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Williams, G., & Williams, E. (2010). A nursing guide to surviving a radiological dispersal device. British Journal of Nursing, 19(1), 24-27. ISSN:0966e0461. World Nuclear Association. (2012). Three Mile Island accident. Retrieved from http://www.world-nuclear.org/info/Safetyand-Security/Safety-of-Plants/Three-Mile-Island-accident/. April 19, 2014. Yin, H., He, H., Arbon, H., Zhu, J., Tan, J., & Zhang, L. (2012). Optimal qualifications, staffing and scope of practice for first responder nurses in disaster. Journal of Clinical Nursing, 21(1/2), 264-271. http://dx.doi.org/10.1111/j.1365-2702.2011. 03790x.
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