به نام خدا دکتر زهره بیگدلی رئیس گروه مراقبتهای پزشکی مرکز نظام ایمنی هسته ای کشور مسئول امور پزشکی پرتوی پژوهشگاه علوم و فنون هسته ای پائیز 1396

Transcription

1 به نام خدا دکتر زهره بیگدلی رئیس گروه مراقبتهای پزشکی مرکز نظام ایمنی هسته ای کشور مسئول امور پزشکی پرتوی پژوهشگاه علوم و فنون هسته ای پائیز 1396

2 Emergency Medical management on Site and at Prehospital Level

3 WHAT IS DIFFERENCE OF RADIATION ACCIDENT FROM OTHERS? High tide Flood Heavy snowfall Heavy rain Storm Release of RM Earthquake Disasters Ship accident Tsunami Volcano eruption Other natural phenomenon Fire or wildfire Explosion Others (train, plane) 3

4 IN NUCLEAR EVENTS, PARADIGM SHIFTS Radiation can not be seen, heard, smelt, or felt & dose not cause immediate symptoms. Contamination complicates. 4

5 FLOW OF MANAGEMENT Accident Incident Identification Notification On Scene Triage Hospital 5

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7 WHO ARE FIRST RESPONDERS? A general team ( police, fire, EMS ) referring to an initial response in emergency. 7

8 NOTIFICATION Get call-back number and verify accident prior to assembling radiological emergency team. Assume that victim is contaminated until proven otherwise. 8

9 RADIOLOGICAL INCIDENT CONTROL - INFORMATION - 9

10 ASSESSMENT OF ACCIDENT SCENE What hazards present? How many people were injured (too many, many.)? When did the accident/incident occur? How were the material released into environment? Where are victims contaminated with/exposed to radioactive material? 10

11 ASSESSMENT OF ACCIDENT SCENE Immediately threatens the lives of rescuers and victims? Causes immediate visible evidence of skin injury? Causes cardiac or respiratory problems, pain, or unconsciousness? Severe trauma Rescuers: no Victims: possibly Hazardous chemicals Possibly Radioactive materials No Usually Possibly No Frequently Possibly Rarely 11

12 RADIOLOGICAL INCIDENT CONTROL ON SCENE Identify the substance if possible Consider all potential hazards Establish contamination control zones Protect personnel from radiation exposure Follow EPA protective action guides for radiation exposure Time, distance, shielding Protect equipment from contamination 12

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14 RADIOLOGICAL CONTROL ON SCENE - ZONING - Procedure C2 : On Scene Emergency Medical Response To Prevailing wind direction From Staging area Vehicle marshalling area Reception for response personnel Public Information Centre Incident commander Outer cordoned area Inner cordoned area Safety perimeter Triage area Decontamination area Medical response base Security response base Incident command post Safety access and contamination control point Radiological Monitoring and Assessment Centre Security perimeter Evacuee monitoring registration area EPA protective action guides for radiation exposure 14

15 FIELD TRIAGE DURING RADIATION EMERGENCY Security perimeter Inner cordoned area Victims Safety perimeter Triage Outer cordoned area Not seriously injured or uninjured Contamination survey and decontamination Immediate contamination survey and decontamination (if possible) Seriously injured Stabilization Lifethreatening injury Registration area Hospital Hospital 15

16 INITIAL ASSESSMENT AND ESTABLISHING OF RESPONSE AREAS AND FACILITIES After arrival on the scene of a radiological emergency, first responders should perform an initial assessment of the situation and radiological hazard. Establish a safety perimeter. 16

17 ZONING Ensure safety of the area and visualize the zoning lines by rope. Outer cordoned area Inner cordoned area Safety perimeter line 17

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19 SURVEY METERS Geiger-Muller (GM) Counters - good use for contamination Ion Chambers more accurate, generally good overall field Scintillation Counters very sensitive; ideal for looking for sources or levels of radiation; not good in high radiation field000 19

20 GEIGER-MULLER (GM) COUNTERS Detection of β and γ-radiation (/min, cpm) Generally rugged field instruments, but window can be damaged, and then instrument is out of order It can be maxed out and will under-respond 20

21 PERSONAL DOSIMETER Personal dosimeter use as an alarming dosimeter and accumulated dose meter 21

22 DOSIMETRY TLD Badges Are passive (no batteries needed) Clip onto front of clothing Mandatory - Everyone wears one Dose information is read later Electronic Dosimeters Must have battery inserted to function Are optional Provide direct dose readout 22

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24 DOSE RATE LIMIT RECOMMENDATIONS Activities Emergency worker dose limit Non-lifesaving activities (major critical property protection) Suggested Turn-back Exposure Rate Follow Radiation safety Officer instructions Guidelines for Total Accumulated Dose Increased cancer Risk* 50 msv 0.5% 100 msv/hr 0.5 Sv** 5% Lifesaving activities 2 Sv/hr 1 Sv** 10% *National Council on Radiation Protection and Measurements Report No ** International Atomic Energy Agency EPR-First Responders

25 EMERGENCY WORKER TURN BACK DOSE GUIDANCE* Tasks Do not exceed unless Approved by incident commander Actions to avert a large collective dose, such as: Environmental sample collection and analysis for environmental monitoring of populated areas; Localized decontamination if required to protect the public. 50 msv *IAEA EPR-First Responders

26 EMERGENCY WORKER TURN BACK DOSE GUIDANCE* Tasks Do not exceed unless Approved by incident commander Actions to prevent severe health effects or injuries, such as: evacuation/protection of the public; environmental monitoring of populated areas to identify where evacuation, sheltering or food restrictions are warranted; Rescue from potential threats of serious injury; Immediate treatment of serious injuries; Urgent decontamination of people Prevention or mitigation of fires; Apprehension of terrorist suspects. 500 msv *IAEA EPR-First Responders

27 EMERGENCY WORKER TURN BACK DOSE GUIDANCE* Tasks Do not exceed unless Approved by incident commander Life saving actions, such as: Rescue from immediate threats to life; Provision of first aid for life threatening injuries; Prevention /mitigation of conditions that could be life threatening msv *IAEA EPR-First Responders

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29 RADIOACTIVE MATERIALS Can be in the form of : Solid (Powder, dust, metal) Liquid Gas Others 29

30 WHAT IS CONTAMINATION? Radioactive material in the form of smokes, dust or liquids is called contamination and if such material gets on a surface, object or person, they become contaminated. 30

31 INTERNAL VS. EXTERNAL CONTAMINATION Ingestion Inhalation Radioactive Material Radioactive Material 0 Wound Wound Internal contamination External Contamination 31

32 BASIC PRINCIPLES FOR HANDLING CONTAMINATED PATIENTS 1. Treat life-threatening conditions first without regard to radiation or contamination 2. Isolate patient and restrict access to the treatment/evaluation area Maintain contamination control 3. Internal contamination is never immediate lifethreatening 32

33 RADIATION DOES NOT CAUSE : Immediate death Immediate symptoms ( burns, wounds ) Contaminations alone : Not immediate threat to victim Not threat to responders or others 33

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35 TRIAGE OF RADIATION CASUALTIES (1) Triage first task for multiple casualties : Sorting of victims depending on condition, urgent needs and number Decision on prompt FIRST medical intervention life saving immobilization of fractures urgent investigations 35

36 TRIAGE OF RADIATION CASUALTIES (2) Always employ standard medical triage principle Decontamination can be done before, during, or after initial stabilization, depending on the severity The most important decontamination is to remove all clothes at the site 36

37 CONTAMINATION CONTROL : AT THE SITE Remove contaminated clothing Cover patient and secure Transfer patient by cold team 37

38 PROTECTIVE CLOTHING (1) Effective in stopping α and some β particles Not effective for γ-rays Lead aprons are not recommended since they will not stop most 38

39 PROTECTIVE CLOTHING (2) Use water proof materials Place clothing and any accompanying sheets, blankets, and others in a plastic bag Change instruments, outer gloves, and drapes after handling clothing or other potentially contaminated items 39

40 DO NOT CONTAMINATE PERSONAL DOSIMETER Personal dosimeter Not to contaminate, it should be put inner the personal protective clothing. 40

41 TYPICAL PROTECTIVE CLOTHING Eye protection Mask Tape gloves Personal dosimetry Name Seal up with the tape Water proof shoe covers Tape 41

42 RESPIRATORY PROTECTION Respiratory protection if necessary Breath filtered air It protect from inhalation of radioactive materials. Seal up with the tape 42

43 PROTECTIVE EQUIPMENT FROM CONTAMINATION 43

44 CONTAMINATION CONTROL DURING RESCUE OPERATIONS Use personal protective measures and means Do not eat, drink, smoke, rub eyes, or apply make-up in contaminated area Use good work practices Appropriate equipment Control lines Assume contamination when in doubt 44

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46 RECOMMENDED PROCEDURES FOR ON-SCENE RESPONDERS (1) 1. Personal protective gears with a personal dosimeter 2. Transport medically unstable patients. A survey, decon may be performed in the ambulance. 3. Move the stable patients to a low background area, remove the other clothing and wrap in a sheet or a blanket. 4. Treat injuries. 46

47 RECOMMENDED PROCEDURES FOR ON- SCENE RESPONDERS (2) 5. Do not release stable patients to ambulance before radiological survey. Perform preliminary decontamination. 6. Decontaminate gently. 7. Save everything (clothing, bedding, watch, coins, buckles, jewelry, cellular phone, vomitus, etc.), tag each item. 8. Transport the patient to medical facility. 47

48 CONTAMINATION CONTROL FOR AMBULANCE PERSONNEL Remove protective gear at control line and get surveyed Clean team can transport patient to hospital or Put on clean gloves and gown, and transport patient At hospital, transfer patient to clean treatment table in contaminated patient area Await survey for contamination 48

49 REMOVE VICTIMS FROM HAZARDOUS AREA If there is immediate lifethreatening hazard in the area, remove victim first. Hazardous area : Fire Smoke Steam Chemicals Electrical Radioactive contamination high air dose rate 49

50 RESCUE Remove injured person from the hazard area into the triage area as soon as possible. 50

51 LIFE SAVING Medical triage Assess and treat lifethreatening injuries immediately Life-threatening injured victim should transport into hospital immediately, even if contamination survey has not been done. 51

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53 EXTERNAL CONTAMINATION REMOVAL 53

54 REMOVE CONTAMINATED CLOTHING AT THE ACCIDENT SCENE 54

55 CONTAMINATION SURVEY It is possible to perform radiological survey during stabilization of victim if monitoring procedures do not 55 interfere with medical actions at scene.

56 COVER CONTAMINATED WOUNDS Cover contaminated wounds with sterile dressings before transport into hospital emergency room. 56

57 PATIENT MANAGEMENT -DECONTAMINATION- Carefully remove and bag patient s clothing and personal belongings (Typically removes 95% of contamination) Decontamination priorities: Decontaminate wounds first, then intact skin Start with highest levels of contamination Change outer gloves frequently to minimize spread of contamination Do not delay surgery or other necessary medical procedures or exam residual contamination can be controlled 57

58 PERFORM GROSS DECONTAMINATION If needed and also If it will not interfere with critical care 58 58

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60 TRANSPORT OF CONTAMINATED VICTIMS (1) Victims are to be transported by medical or paramedical personnel who have not entered the controlled area on scene. Assume all victims are contaminated until proven otherwise. Continue medical assessment and treatment during transport when necessary. 60

61 TRANSPORT OF CONTAMINATED VICTIMS (2) Place the ambulance stretcher on the clean side of the outer cordoned line and pass the victims across the outer cordoned line to the prepared stretcher. Cover victim by folding a sheet or blanket. 61

62 CONTAMINATION CONTROL ON TRANSPORTATION 62

63 USE CAUTION AROUND CONTAMINATION 63

64 CONTAMINATION CONTROL Use universal precautions Frequently survey hands and clothing with radiation meter Replace gloves or clothing that is contaminated Keep the work area free of contamination and radiation sources 64

65 PROTECTION AGAINST CONTAMINATION Protection can be improved by performing frequent measurements for contamination, dealing with it as it is found and controlling the accumulation of radioactive waste. 65

66 CONTAMINATION CONTROL Contamination that cannot be cleaned can be controlled by taping over it with an impervious covering. 66

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68 DETECTING RADIATION Compared to chemical and biological hazards, radiation and radioactive materials are easy to detect and measure. 68

69 RADIOLOGICAL INCIDENT CONTROL - PREVENTION OF CROSS CONTAMINATION - Tool drop before leaving hot zone Contamination check Hot area marked off with tape and stanchions 69

70 CONTAMINATION CONTROL Before leaving the inner cordoned area, first responder should be checked contamination and change clothing if needed. 70

71 MANAGEMENT OF RADIOACTIVE WASTE Collect radioactive waste in plastic bags. Survey bags periodically to prevent high radiation levels in the work area. Use distance to protect against radiation from radioactive waste. Use walls, dirt mounds, hills, etc. as shielding for radioactive waste. 71

72 RULES OF THUMB Removing outer clothing will remove majority of contamination. Washing hands and heads can remove most of the remaining contamination. For large incidents, containment of runoff is not necessary. 72

73 RULES OF THUMB Most of the airborne radioactive dust from an outdoor explosion will settle to the ground within 10 minutes. Without better information, evacuate away from plume settling to at least 500 meters. 73

74 SUMMARY Actions of Primary Significance in Pre-hospital Medical Management of Radiation Accidents 1. Rescue, resuscitation, emergency aid 2. Medical stabilization of general condition of victim and of serious injuries 3. Removal of patients from contaminated area 4. Assessment of external contamination 5. Decontamination and DE corporation - preventing internal contamination of patient and contamination of staff 74

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76 Thank you for your attention