DEPARTMENT OF VETERANS AFFAIRS

MEDICAL CENTER

(LOCATION)

EMERGENCY MANAGEMENT PROGRAM (DATE)

STANDARD OPERATING PROCEDURE NO. ( )

**SUBJECT: Patients with Radiation Exposure or Radioactive
Contamination**

1.  ***Description of the Threat/Event.*** Persons may be exposed to
    ionizing radiation in a variety of ways. The degree of exposure (low
    to high dose), type of exposure (internal or external), and number
    of patients involved all must be considered in implementing specific
    components of this plan. For example, a single employee may become
    externally contaminated from handling radionuclides in a research
    experiment. At the other extreme, a large group of potential
    patients could result from a radionuclide dispersal event such as
    detonation of a nuclear weapon or an explosive containing a large
    radioactive source ("dirty bomb"). The latter events could be
    catastrophic and tax the community and the VA Medical Center's
    resources for handling such events. As an aid to classifying the
    type of radiation emergency, see Section 4.5 of NCRP Report No. 111.

2.  ***Impact on Mission Critical Systems.*** Patients who have received
    only an external dose and/or who are only internally contaminated
    (e.g., have inhaled or ingested radioactive material) will require
    medical evaluation for immediate or late effects. Those patients who
    may have contamination on skin or clothes should be evaluated and
    decontaminated to the extent possible prior to treatment.

**Note:** Treatment of life-threatening injuries always takes precedence
over measure to address radioactive contamination or exposure**.**

This decontamination effort should primarily consist of removal of
clothes and washing the patient with water. Generally, water may be
released into the sewer without restriction. Contaminated items must be
collected and isolated in order to prevent cross-contamination.
Universal precautions will usually be adequate. Airborne contaminants
will rarely be present and can be assessed by a qualified expert. For
additional details on contamination control, see *Attachment A*.

3.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.*** A Radiological Emergency Response Team should
    be designated as described below.

-   **Radiological Emergency Response Team.**

  -------------------------------- --------------------------------------
  **Role**                         **Function**

  Team Coordinator                 Leads, advises, and coordinates.

  Emergency Physician              Diagnoses, treats, and provides
                                   emergency medical care; can also
                                   function as team coordinator or triage
                                   officer.

  Triage Officer                   Performs triage.

  Nurse                            Assists physician with medical
                                   procedures, collection of specimens,
                                   and decontamination; assesses
                                   patient\'s needs and intervenes
                                   appropriately.

  Technical Recorder               Records and documents medical and
                                   radiological data.

  Radiation Safety Officer         Supervises all aspects of monitoring
                                   and contamination control.

  Radiation Safety Staff           Monitors patient and area and advises
                                   on contamination and exposure control;
                                   maintains survey equipment.

  Public Information Officer       Releases accident information to
                                   public media.

  Medical Center Director          Coordinates Medical Center response
                                   and assures normal Medical Center
                                   operations.

  Security Personnel               Secures the radiation emergency area
                                   and controls crowds.

  Maintenance Personnel            Aids in preparation of the Radiation
                                   Emergency Area for contamination
                                   control.

  Laboratory Technician            Provides routine clinical analysis of
                                   biological samples.
  -------------------------------- --------------------------------------

4.  ***Mitigation/Preparedness Activities of the Threat/Event***.

*a. Notification and Accident Verification.*

-   When the hospital receives a call that a radiation accident victim
    is to be admitted, a planned course of action should be followed.
    The individual receiving the call should get as much information as
    possible, including the following:

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-   Number of accident victims.

-   Each victim\'s medical status and mechanism of injury.

-   If victims have been surveyed for contamination.

-   Radiological status of victims (exposed vs. contaminated).

-   Identity of contaminant, if known.

-   Estimated time of arrival.

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-   If any doubt about contamination exists, assume the victim is
    contaminated until proven otherwise. Advise ambulance personnel of
    any special entrance to the emergency department for the radiation
    accident victim. If the accident notification comes from a source
    other than usual emergency communications, get a call-back number
    and verify the accident prior to assembling the Radiological
    Emergency Response Team and preparing for patient admission.

5.  ***Response/Recovery from the Event/Threat*.**

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a.  *Response Team Preparation*

-   **Protective Clothing** -- The purpose of protective clothing is to
    keep bare skin and personal clothing free of contaminants. Members
    of the radiological emergency response teams should dress in
    surgical clothing (scrub suit, gown, mask, cap, eye protection, and
    gloves). Waterproof shoe covers also should be used. All open seams
    and cuffs should be taped using masking or adhesive tape. Fold-over
    tabs at the end of each taped area will aid removal. Two pairs of
    surgical gloves should be worn. The first pair of gloves should be
    under the arm cuff and secured by tape. The second pair of gloves
    should be easily removable and replaced if they become contaminated.
    A radiation dosimeter should be assigned to each team member and
    attached to the outside of the surgical gown at the neck where it
    can be easily removed and read. If available, a film badge or other
    type of dosimeter can be worn under the surgical gown. A waterproof
    apron can also be worn by any member of the team using liquids for
    decontamination purposes.

This protective clothing is effective in stopping alpha and some beta
particles but not gamma rays. Lead aprons, such as those used in the
X-ray Department, are not recommended since they give a false sense of
security -- they will not stop most gamma rays.

b.  *Preparing the Treatment Area for Contamination Control**.***

-   **Treatment Room** -- If possible, select a treatment room near an
    outside entrance. Clear the area of visitors and patients. Remove or
    cover equipment that will not be needed during emergency care of the
    radiation accident victim.

1)  Several large plastic-lined waste containers will be needed. The
    treatment table should be covered with several layers of waterproof,
    disposable sheeting. Plastic bags in all sizes will be needed and
    should be readily available.

2)  Survey instruments should be checked and ready for use before the
    patient arrives. Background radiation levels should be documented.

3)  The treatment team should be prepared to meet the patient at the
    ambulance where the patient can be transferred to the prepared
    treatment gurney.

-   **Covering Floor Areas** -- Rolls of brown wrapping paper or butcher
    paper three to four feet wide can be unrolled to make a path from
    the ambulance entrance to the decontamination room. Ordinary cloth
    sheets or square absorbent pads can be used if paper is unavailable.
    Whatever the floor covering*, it should be taped securely to the
    floor*. This route should then be roped off and marked to prevent
    unauthorized entry. The floor of the decontamination room or
    treatment area should be covered in a similar way if time allows.
    This will make cleanup of the area easier.

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-   **Control Line** -- A control line should be established at the
    entrance to the decontamination room. A wide strip of tape on the
    floor at the entrance to the room should be marked clearly to
    differentiate the controlled (contaminated) from the non-controlled
    (uncontaminated) side.

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-   **Control Ventilation** -- While it may be desirable that the room,
    or rooms, have either a ventilation system that is separate from the
    rest of the hospital or a means of preventing the unfiltered exhaust
    air of the Radiation Emergency Area from mixing with the air that is
    distributed to the rest of the Medical Center, there is very little
    likelihood that contaminants will become suspended in air and enter
    the ventilation system. Hence, no special precautions are advised.
    (Ref.: AMA. "A Guide to the Hospital Management of Injuries Arising
    from Exposure to or Involving Ionizing Radiation", 1984).

c.  *On Scene Triage.*

-   Treatment of life-threatening injuries always takes precedence over
    measure to address radioactive contamination or exposure.

d.  *Patient Medical Management.*

-   **General** -- The general objectives in approximate order of
    importance for the management of contaminated, injured patients are
    as follows.

1)  First aid and resuscitation

2)  Medical stabilization

3)  Definitive treatment of serious injuries

4)  Prevention/minimization of serious injuries

5)  Assessment of external contamination and decontamination

6)  Treatment of other minor injuries

7)  Containment of contamination to treatment area

8)  Minimization of external radiation to treatment personnel

9)  Assessment of internal contamination

10) Treatment of internal contamination

11) Assessment of local radiation injuries/radiation burns

12) Long-term follow-up of patients

13) Counseling of patients and family members about long-term effects
    and risks (Ref: NCRP 138)

-   **Radiation Injury** -- Exposure to high levels of penetrating
    radiation can involve the whole body (uniformly or nonuniformly), a
    significant portion of the body, or a small, localized part. The
    exposure can be acute, protracted, or fractionated over time.

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-   *Local Injury* -- Most radiation injuries are \"local\"
    injuries**,** frequently involving the hands. These local injuries
    seldom cause the classical signs and symptoms of the acute radiation
    syndrome.

1)  Consider local radiation injury in the differential diagnosis if the
    patient presents with a skin lesion without a history of chemical or
    thermal burn, insect bite, or history of skin disease or allergy. If
    the patient gives a history of possible radiation exposure (such as
    from a radiography source, X-ray device, or accelerator) or a
    history of finding and handling an unknown metallic object, note the
    presence of any of the following: erythema, blistering, dry or wet
    desquamation, epilation, ulceration. Local injuries to the skin
    evolve very slowly over time and symptoms may not manifest for days
    to weeks after exposure.

2)  Conventional wound management is usually ineffective in these cases.
    *Consultation with experts regarding definitive diagnosis, tissue
    dose, treatment, and prognosis is recommended.*

-   *Internal Contamination* --

*Treatment of Internal Contamination* -- Once radioactive materials
cross cell membranes, they are said to be incorporated. Incorporation is
a time-dependent, physiological phenomenon related to both the physical
and chemical natures of the contaminant. Incorporation can be quite
rapid, occurring in minutes, or it can take days to months. Thus, time
can be critical and prevention of uptake is urgent. Several methods of
preventing uptake (e.g., catharsis, gastric lavage) might be applicable
and can be prescribed by a physician. Some of the medications or
preparations used in decorporation might not be available locally and
should be stocked when a decontamination station is being planned and
equipped. Examples of specific agents used for selected radionuclides
are given in *Attachment B*. Expert guidance is available from NCRP 65,
Poison Control Centers, or call REAC/TS (865-576-3131) or the 24-hour
emergency number (865-576-1005).

If internal contamination is suspected or has occurred, the physician or
Radiation Safety Officer should request samples of urine, feces,
vomitus, wound secretion, etc. Whole-body counting and radioassay can
help evaluate the magnitude of the problem and the effect of any
treatment. The contaminated patient admitted with an airway or
endotracheal tube must be considered to be internally contaminated.

-   *Acute Radiation Syndrome* -- Acute radiation syndrome (ARS) is an
    acute illness caused by irradiation of the whole body (or a
    significant portion of it). It follows a somewhat predictable course
    and is characterized by signs and symptoms that are manifestations
    of cellular deficiencies and the reactions of various cells,
    tissues, and organ systems to ionizing radiation.

Immediate, overt manifestations of the acute radiation syndrome require
a large (i.e., hundreds of rem, usually whole-body) dose of penetrating
radiation delivered over a short period of time. Penetrating radiation
comes from a radioactive source or machine that emits gamma rays,
X-rays, or neutrons. The signs and symptoms of this syndrome are
non-specific and may be indistinguishable from those of other injuries
or illness.

The ARS is characterized by four distinct phases: a prodromal period, a
latent period, a period of illness, and one of recovery or death. During
the prodromal period patients might experience loss of appetite, nausea,
vomiting, fatigue, and diarrhea; after extremely high doses, additional
symptoms such as fever, prostration, respiratory distress, and
hyperexcitability can occur. However, all of these symptoms usually
disappear in a day or two, and a symptom-free, latent period follows,
varying in length depending upon the size of the radiation dose. A
period of overt illness follows, and can be characterized by infection,
electrolyte imbalance, diarrhea, bleeding, cardiovascular collapse, and
sometimes short periods of unconsciousness. Death or a period of
recovery follows the period of overt illness.

In general, the higher the dose the greater the severity of early
effects and the greater the possibility of late effects.

Depending on dose, the following syndromes can be manifest:

-   Hematopoietic Syndrome − characterized by deficiencies of WBC,
    lymphocytes and platelets, with immunodeficiency, increased
    infectious complications, bleeding, anemia, and impaired wound
    healing.

-   Gastrointestinal Syndrome − characterized by loss of cells lining
    intestinal crypts and loss of mucosal barrier, with alterations in
    intestinal motility, fluid and electrolyte loss with vomiting and
    diarrhea, loss of normal intestinal bacteria, sepsis, and damage to
    the intestinal microcirculation, along with the hematopoietic
    syndrome.

-   Cerebrovascular/Central Nervous System Syndrome − primarily
    associated with effects on the vasculature and resultant fluid
    shifts. Signs and symptoms include vomiting and diarrhea within
    minutes of exposure, confusion, disorientation, cerebral edema,
    hypotension, and hyperpyrexia. Fatal in short time.

-   Skin Syndrome − can occur with other syndromes; characterized by
    loss of epidermis (and possibly dermis) with \"radiation burns.\"

-   For further details on management of ARS, see *Attachment C.*

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-   *Initial Emergency Management*

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-   If trauma is present, treat.

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-   If external contaminants are present, decontaminate.

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-   **Diagnosis.**

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-   History of exposure -- consider acute radiation syndrome in the
    differential diagnosis if there is:

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-   A history of a known or possible radiation exposure (for example,
    entering an irradiation chamber when the source is unshielded).

-   A history of proximity to an unknown (usually metallic) object with
    a history of nausea and vomiting, especially if nausea/vomiting are
    unexplained by other causes.

-   A tendency to bleed (epistaxis, gingival bleeding, petechiae) and/or
    respiratory infection with neutropenia, lymphopenia, and
    thrombocytopenia, with history of nausea and vomiting two to three
    weeks previously.

-   Epilation, with a history of nausea and vomiting two to three weeks
    previously.

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-   Symptom − type of symptom, time of onset, severity, and frequency.

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-   Clinical Lab − STAT CBC with differential. Repeat in 4-6 hours, then
    every 6 to 8 hours for 24 to 48 hours. Look for a drop in the
    absolute lymphocyte count if the exposure was recent (see
    *Attachment C*). If the initial WBC and platelet counts are
    abnormally low, consider the possibility of exposure a few days to
    weeks earlier.

6.  ***External Notification Procedures.***

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a.  *Within VA.* All emergencies requiring activation of the Emergency
    Plan must be reported to:

-   VISN

-   VHA National Health Physics Program (NHPP). NHPP will make or advise
    on appropriate other federal agency (e.g., NRC) contacts (see
    below).

b.  *Other Federal Agencies.* Certain events require notification of the
    following agencies for assistance in medical management of radiation
    casualties.

-   NRC

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-   OSHA - Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

c.  *Community Entities.* If the nature of the event could affect the
    community, contact:

-   State/Local OES.

-   State/local Health Department (or entity assigned responsibility for
    radiation control).

7.  ***Specialized Staff Training.***

Each member of this team should be familiar with the hospital\'s written
plan and be required to participate in scheduled drills. More frequent
drills (quarterly or semiannually) should be considered by subgroups
such as decontamination, triage, or radiological monitoring. Special
training must be instituted to accommodate staff turnover.

The training should include demonstrations and actual hands-on use of
equipment, as well as classroom instruction. Technical staff should be
aware of the additional resources and current information as described
in paragraph 8 of this SOP. The emergency plan training program should
also include training, as needed, for those outside agencies which may
be required to respond to an emergency, such as police, fire, ambulance
and emergency medical personnel. This training should include specific
instruction in the institution\'s procedures for notification, basic
radiation protection, site access and the expected role(s) of the
trainees.

8.  ***References and Further Assistance.***

-   VHA Emergency Management Guidebook.

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-   *VHA Office of Quality and Performance, Pocket Card, Radiological
    Terrorism,* <http://www.oqp.med.va.gov/cpg/uploads/bcr/RadCard9.pdf>

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-   NCRP 65

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-   NCRP 111

-   NCRP 138

-   Many other federal agencies and entities have resources for current
    advice and assistance. Two prominent agencies for peacetime response
    are:

> Oak Ridge Institute for Science and Education
>
> REAC/TS
>
> Attn: Pat Cooley
>
> P.O. Box 117, MS 39
>
> Oak Ridge, TN 37831-0117
>
> Phone: (865) 576 3131

FAX: (865) 576 9522

> Medical Radiobiology Advisory Team (MRAT)
>
> Armed Forces Radiobiology Research Institute
>
> National Naval Medical Center
>
> 8901 Wisconsin Avenue, Building 42
>
> Bethesda, MD 20889-5603

\(301\) 295-0316

-   For further information on national emergencies and a listing of
    federal assets, see Defense Threat Reduction Agency (DTRA), under
    the authority of the Department of Defense (DoD) Directive (DoDD)
    3150.8, *DoD Response to Radiological Accidents*, June 13, 1996,
    <http://www.dtra.mil/cs/cs_narp.html>.

-   Much of the material in this SOP is taken from
    <http://www.orau.gov/reacts/guidance.htm>.

9.  ***Review Date.***

(NAME)

Chief, (SERVICE NAME)

Attachments:

A − Goals of Contamination Control

B − Treatment for Selected Internal Contaminants

C − Acute Radiation Syndrome