i
This guidance was developed by a Federal interagency committee with representation from 

the Executive Office of the President (Homeland Security Council and Office of Science and 

Technology Policy), the Departments of Defense, Energy, Health and Human Services, 

Homeland Security, Transportation, Veteran’s Affairs, the Environmental Protection Agency, 

the National Aeronautics and Space Administration, and the Nuclear Regulatory 

Commission. 

Please refer comments and questions to the Office of Science and Technology Policy, 

Executive Office of the President (www.ostp.gov). 
TABLE OF CONTENTS 

ACRONYM LIST............................................................................................................. 1

DEFINITIONS ................................................................................................................. 3

UNITS ............................................................................................................................. 5

REFERENCES FOR UNITS ......................................................................................................5

STRUCTURE OF THIS DOCUMENT ............................................................................. 6

INTRODUCTION ............................................................................................................ 7

REFERENCES FOR INTRODUCTION .......................................................................................10

CHAPTER 1 - NUCLEAR DETONATION EFFECTS AND IMPACTS IN AN URBAN 

ENVIRONMENT ........................................................................................................... 12

OVERVIEW..........................................................................................................................12

BLAST ................................................................................................................................13

BLAST INJURIES ..................................................................................................................18

THERMAL RADIATION (OR HEAT)..........................................................................................19

THERMAL INJURIES .............................................................................................................20

RADIATION AND FALLOUT ....................................................................................................22

RADIATION INJURIES AND FALLOUT HEALTH IMPACTS...........................................................26

COMBINED INJURIES ...........................................................................................................28

EMP ..................................................................................................................................28

REFERENCES......................................................................................................................29

CHAPTER 2 - A ZONED APPROACH TO NUCLEAR DETONATION RESPONSE... 30

OVERVIEW..........................................................................................................................31

ZONED APPROACH TO RESPONSE .......................................................................................31

RESPONSE FUNCTIONS AND PRIORITIES ..............................................................................32

RESPONSE WORKER SAFETY..............................................................................................39

REFERENCES......................................................................................................................45

CHAPTER 3 - SHELTER / EVACUATION RECOMMENDATIONS............................. 47

OVERVIEW..........................................................................................................................47

PROTECTIVE ACTIONS.........................................................................................................49

PLANNING CONSIDERATIONS...............................................................................................55

EVACUATION BIBLIOGRAPHY ...............................................................................................58

REFERENCES......................................................................................................................59

CHAPTER 4 – EARLY MEDICAL CARE ..................................................................... 61

OVERVIEW..........................................................................................................................61

INITIAL MASS CASUALTY TRIAGE (I.E., SORTING)..................................................................67

EMERGENCY CARE .............................................................................................................74

FATALITY MANAGEMENT......................................................................................................77

ADDITIONAL RESOURCES ....................................................................................................78

REFERENCES......................................................................................................................79

CHAPTER 5 – POPULATION MONITORING AND DECONTAMINATION................. 81

OVERVIEW..........................................................................................................................82
PRIMARY CONSIDERATIONS.................................................................................................83

IMPACTED POPULATION.......................................................................................................84

EXTERNAL CONTAMINATION ................................................................................................86

INTERNAL CONTAMINATION .................................................................................................87

REGISTRY – LOCATOR DATABASES......................................................................................88

VOLUNTEER RADIATION PROFESSIONALS ............................................................................88

MUTUAL AID PROGRAMS.....................................................................................................89

REFERENCES......................................................................................................................89

SUBPCC MEMBERSHIP – JANUARY 2009 ............................................................... 91
1

Acronym List 

AC Assembly Center 

AFRRI Armed Forces Radiobiology Research Institute 

ALARA As Low as Reasonably Achievable 

ARS Acute Radiation Syndrome 

ASPR Assistant Secretary for Preparedness & Response 

ATSDR Agency for Toxic Substances and Disease Registry 

CBC Complete Blood Count 

CDC Centers for Disease Control and Prevention 

CONOPS Concept of Operations 

CRCPD Conference of Radiation Control Program Directors 

DF Dangerous Fallout 

DHHS Department of Health and Human Services 

DHS Department of Homeland Security 

DIME Delayed, Immediate, Minimal or Expectant 

DOD Department of Defense 

DOE Department of Energy 

DOT Department of Transportation 

EMAC Emergency Management Assistance Compact 

EMP Electromagnetic Pulse 

EPA Environmental Protection Agency 

ESAR-VHP Emergency System for Advanced Registration of Volunteer Health Professionals 

FEMA Federal Emergency Management Agency 

FHA Federal Highway Administration 

FRMAC Federal Radiological Monitoring and Assessment Center 

Haz Mat Hazardous Materials (designating specialty emergency response team) 

HSC Homeland Security Council 

IAEA International Atomic Energy Agency 

IC Incident Command 

ICRP International Council on Radiation Protection 

IMAAC Interagency Modeling and Atmospheric Assessment Center 

IND Improvised Nuclear Device 

 

KT Kiloton 

LD Light Damage 

LD50 Median Lethal Dose 50 

LSI Life-saving Intervention 

MC Medical Care Sites 

MD Moderate Damage 

mph miles per hour 
2

MT Millions of Tons 

NCRP National Council on Radiation Protection and Measurements 

NG No-go 

NIOSH National Institute of Occupational Safety and Health 

NPS National Planning Scenario 

NRC Nuclear Regulatory Commission 

NRF National Response Framework 

OEG Operational Exposure Guidance 

OSHA Occupational Safety and Health Administration 

OSTP Office of Science and Technology Policy 

PAG Protective Action Guide 

PCC Policy Coordination Committee 

PPE Personal Protective Equipment 

psi pounds per square inch 

R&D Research and Development 

RDD Radiological Dispersal Device 

REAC/TS Radiation Emergency Assistance Center/Training Site 

REMM Radiation Event Medical Management 

REP Radiological Emergency Preparedness 

RITN Radiation Injury Treatment Network 

RN Radiological/Nuclear or Radiological and Nuclear 

RTR Radiation TRiage, TReatment, and TRansport system 

SALT Sort, Assess, Life-saving intervention, Treatment/Transport 

TEDE Total Effective Dose Equivalent 

TNT Trinitrotoluene 

US United States 

USG United States Government 
3

Definitions1

Adequate shelter – shelter that protects against acute radiation effects, and significantly 

reduces radiation dose to occupants during an extended period 

ALARA – (Acronym for “As Low As Reasonably Achievable”) –A process to control or 

manage radiation exposure to individuals and releases of radioactive material to the 

environment so that doses are as low as social, technical, economic, practical, and public 

welfare considerations permit. 

Beta burn – beta radiation induced skin damage 

Blast effects – The impacts caused by the shock wave of energy through air that is created by 

detonation of a nuclear device. The blast wave is a pulse of air in which the pressure 

increases sharply at the front, accompanied by winds. 

Combined injury – Victims of the immediate effects of a nuclear detonation are likely to 

suffer from burns and physical trauma, in addition to radiation exposure. 

Electromagnetic Pulse (EMP) – A sharp pulse of radiofrequency (long wavelength) 

electromagnetic radiation produced when an explosion occurs near the earth’s surface or at 

high altitudes. The intense electric and magnetic fields can damage unprotected electronics 

and electronic equipment over a large area. 

Emergency Management Assistance Compact (EMAC) – A Congressionally ratified 

organization that provides form and structure to interstate mutual aid. Through EMAC, a 

disaster-affected State can request and receive assistance from other member States quickly 

and efficiently, resolving two key issues up front: liability and reimbursement. 

Fallout – The process or phenomenon of the descent to the earth’s surface of particles 

contaminated with radioactive material from the radioactive cloud. The term is also applied 

in a collective sense to the contaminated particulate matter itself. 

LD50 – The amount of a radiation (or a chemical) that kills 50% of a sample population. 

Operational Exposure Guidance (OEG) – Department of Defense dose limits to US troops. 

Personal Protective Equipment (PPE) – Includes all clothing and other work accessories 

designed to create a barrier against hazards. Examples include safety goggles, blast shields, 

hard hats, hearing protectors, gloves, respirator, aprons, and work boots. 

 

1

 Where available, definitions have been adapted from Glasstone and Dolan (Glasstone and Dolan 1977) or the 

DHS Planning Guidance (DHS 2008). 
4

Radiation effects – Impacts associated with the ionizing radiation (alpha, beta, gamma, 

neutron, etc.) produced by or from a nuclear detonation. 

rad – A unit expressing the absorbed dose of ionizing radiation. Absorbed dose is the energy 

deposited per unit mass of matter. The units of rad and gray are the units in two different 

systems for expressing absorbed dose. 

1 rad = 0.01 gray (Gy); 1 Gy = 100 rad; 

 

rem – A unit of absorbed dose that accounts for the relative biological effectiveness of 

ionizing radiations in tissue (also called equivalent dose). Not all radiation produces the same 

biological effect, even for the same amount of absorbed dose; rem relates the absorbed dose 

in human tissue to the effective biological damage of the radiation. The units of rem and 

sievert are the units in two different systems for expressing equivalent dose. 1 rem = 0.01 

Sieverts (Sv); 1 Sv = 100 rem 

Roentgen (R) – A unit of gamma or x-ray exposure in air. It is the primary standard of 

measurement used in the emergency responder community in the United States. For the 

purpose of this guidance, one R of exposure is approximately equal to one rem of wholebody external dose. 

• 1,000 micro-roentgen (microR) = 1 milli-roentgen (mR) 

• 1,000 milli-roentgen (mR) = 1 Roentgen (R), thus 

• 1,000,000 microR = 1 Roentgen (R) 

Roentgen per hour (R/hour) – A unit used to express gamma or x-ray exposure in air per 

unit of time (exposure rate). 

Shelter – To take "shelter" as used in this document means going in, or staying in, any 

enclosed structure to escape direct exposure to fallout. “Shelter” may include the use of predesignated facilities or locations. It also includes locations readily available at the time of 

need, including staying inside where you are, or going immediately indoors in any readily 

available structure. 

Shelter-in-place – staying inside, or going immediately indoors in any readily available 

structure. 

Thermal effects – Impacts associated with the electromagnetic radiation emitted from the 

fireball as a consequence of its very high temperature. 

References for Definitions: 

Glasstone, Samuel and Philip J. Dolan. 1977. The Effects of Nuclear Weapons. 

Washington, DC: US Government Printing Office. 

US Department of Homeland Security. Federal Emergency Management Agency. 2008. 

Planning Guidance for Protection and Recovery Following Radiological Dispersal 

Device (RDD) and Improvised Nuclear Device (IND) Incidents, Federal Register, Vol. 

73, No. 149. http://www.fema.gov/good_guidance/download/10260. 
5

Units 

For the case of a nuclear detonation, persistent beta-gamma radiation levels will affect some 

response decisions. For the purpose of this planning guidance, the following simplifying 

assumptions about units used in measuring this radiation applies: 1 R (exposure in air) ≅ 1 

rad (adsorbed dose) ≅ 1 rem (whole-body dose) (NCRP 2005). 

For the purpose of this planning guidance, the rem unit is assumed to be equivalent to the 

sievert unit and 1 rem = 10 mSv will be applied as the basis for comparison of traditional and 

SI units. Exposure rate (R/hour) can be expressed in terms of Sv/hour. Therefore: 1 R/hour ≅

0.01 Sv/hour 

Radiation Measurement Units: 

US Common Units SI Units 

Radioactivity Curie (Ci) Becquerel (Bq) 

Absorbed dose rad Gray (Gy) 

Dose equivalent rem Sievert (Sv) 

Exposure Roentgen (R) Coulomb/Kilogram (C/kg) 

Conventional/SI Unit Conversions: 

1 Curie = 3.7 x 1010 disintegrations/second 1 Becquerel = 1 disintegration/second 

1 rad 0.01 Gray (Gy) or 1 centiGray (cGy) 

1 rem 0.01 Sieverts (Sv) 

1 Roentgen (R) 0.000258 Coulomb/kilogram (C/kg) 

1 Gray (Gy) 100 rad 

1 Sievert (Sv) 100 rem 

1 Coulomb/kilogram (C/kg) 3,876 Roentgens 

References for Units 

National Council on Radiation Protection and Measurements (NCRP). 2005. Key Elements 

of Preparing Emergency Responders for Nuclear and Radiological Terrorism, 

Commentary No. 19 (Bethesda). 
6

Background Points are in Grey Boxes 

In each chapter appropriate background or 

additional information of a technical 

nature has been included in grey boxes to 

enable those who seek supporting 

information to have access, while those 

who wish to bypass may do so. This is 

non-essential information and can be 

bypassed when using the planning 

guidance. 

Structure of this Document 

The planning guidance is organized in a stepwise manner using terminology and concepts of 

the National Planning Scenario #1, the National Response Framework, and other technical 

and policy documents. The planning guidance presents general background information that 

builds a foundation for specific planning recommendations. This is the bulk of the material 

presented in the document. Bold text is used throughout the document to emphasize 

important material or concepts. Text boxes that run the length of the page have been 

generated to summarize key information following the presentation of information in the 

context of the guidance. 

This key information has been pulled to the beginning of each chapter as a summary of KEY 

POINTS.

Relevant supporting information that may 

be useful, but is not essential for planners, 

is included throughout the planning 

guidance. This additional informational is 

useful for subject matter experts and for 

educational purposes. The information is 

captured in grey text boxes. 

KEY POINTS

1. Key points summarize important information captured throughout each 

chapter. 

2. The key points are presented at the beginning of each chapter.

Text boxes that run the length of the page have been generated following the delivery 

of key information.
7

INTRODUCTION 

One of the most catastrophic incidents that could befall the United States (US), causing 

enormous loss of life and property and severely damaging economic viability, is a nuclear 

detonation in a US city. It is incumbent upon all levels of government, as well as public and 

private parties within the US, to prepare for this incident through focused nuclear attack 

response planning. Nuclear explosions present substantial and immediate radiological threats 

to life. Local and State community preparedness to respond to a nuclear detonation could 

result in life-saving on the order of tens of thousands of lives. 

The purpose of this guidance is to provide emergency planners with nuclear detonationspecific response recommendations to maximize the preservation of life in the event of 

an urban nuclear detonation. This guidance addresses the unique effects and impacts of a 

nuclear detonation such as scale of destruction, shelter and evacuation strategies, 

unparalleled medical demands, management of nuclear casualties, and radiation dose 

management concepts. The guidance is aimed at response activities in an environment with a 

severely compromised infrastructure for the first few days (e.g., 24 – 72 hours) when it is 

likely that many Federal resources will still be en route to the incident. 

The target audiences for the guidance are response planners and their leadership. 

Emergency responders should also benefit in understanding and applying this guidance. The 

target audiences include, but are not limited to, the following at the city, county, and State 

levels: 

• Elected officials in government jurisdictions 

• Emergency managers 

• Law enforcement authority planners 

• Fire response planners 

• Emergency medical service planners 

• Hazardous material (Haz Mat) planners 

• Utility services and public works emergency planners 

• Transportation planners 

• Medical receiver planners (e.g., hospitals) 

• Other metropolitan emergency planners, planning organizations, and professional 

organizations that represent the multiple disciplines that conduct emergency response 

activities 

The planning guidance recommendations are focused on providing express consideration of 

the following topics relevant to emergency planners within the first few days of a nuclear 

detonation: 1) shelter and evacuation, 2) medical care, and 3) population monitoring and 

decontamination. Worker safety and health are briefly discussed in Chapter 2; however, 

more extensive guidance is not presently available and is expected to be the focus of future 

Federal endeavors. Additional work is also needed to support the following relevant topics: 

pre-event public education (including public alert and warning systems), establishing and 
8

maintaining infrastructure for electromagnetic pulse (EMP) proof responder 

communications, psychological impacts to the population, fatality management, and nuclear 

detonation response training. As recommendations become available on these issues, which 

are minor considerations within this planning guidance or wholly unaddressed, they will be 

incorporated into future editions of this planning guidance. 

The planning guidance summarizes recommendations based on what is currently known 

about the consequences of a nuclear detonation in an urban environment. It provides 

recommendations based on existing knowledge and existing techniques. The Federal 

government is supporting continuing studies that will inevitably provide more robust and 

comprehensive recommendations. 

Since the events of September 11, 2001, the nation has taken a series of historic steps to 

address threats against our safety and security. This guidance represents an additional step in 

this continuing effort to increase the nation’s preparedness for potential attacks against our 

nation. It was developed in response to gaps noted in the previously published Department 

of Homeland Security (DHS) “Planning Guidance for Protection and Recovery Following 

Radiological Dispersal Device (RDD) and Improvised Nuclear Device (IND) Incidents” 

(Federal Register , Vol. 73, No. 149, Friday, August 1, 2008;2

http://www.fema.gov/good_guidance/download/10260) and hereafter referred to as DHS 

Planning Guidance (DHS 2008). While the publication provides substantial guidance to 

Federal, State, and local planners for responding to such incidents, it concedes that it does not 

sufficiently prepare local and State emergency response authorities for managing the 

catastrophic consequences of a nuclear detonation as follows: 

“In addition to the issuance of this Guidance, in response to interagency 

working group discussions and public comments, further guidance will be 

provided for the consequences that would be unique to an IND attack. This 

Guidance was not written to provide specific recommendations for a nuclear 

detonation (IND), but to consider the applicability of existing PAGs3

 to RDDs 

and INDs. In particular, it does not consider very high doses or dose rate 

zones expected following a nuclear weapon detonation and other complicating 

impacts that can significantly affect life-saving outcomes, such as severely 

damaged infrastructure, loss of communications, water pressure, and 

electricity, and the prevalence of secondary hazards. Scientifically sound 

recommendations for responders are a critical component of post-incident lifesaving activities, including implementing protective orders, evacuation 

implementation, safe responder entry and operations, and urban search and 

rescue and victim extraction.” 

 

2

 By agreement with the Environmental Protection Agency (EPA), the DHS Planning Guidance (DHS 2008) 

published is final and its substance will be incorporated without change into the revision of the 1992 EPA 

Manual of Protective Actions Guides and Protective Actions for Nuclear Incidents - the PAG Manual (EPA 

1992). This notice of final guidance will therefore sunset upon publication of the new EPA PAG Manual (see, 

http://www.epa.gov/radiation/rert/pags.html) 3

 PAGs stands for Protective Action Guidelines 
9

This guidance does not replace the DHS Planning Guidance (DHS 2008); however, it does 

provide specific guidance for response in the damaged region surrounding a nuclear 

detonation (i.e., within approximately three miles of a 10 kiloton (KT) device) and the life 

threatening fallout region (i.e., where fallout is deposited within 10 – 20 miles of the 

detonation site). The DHS Planning Guidance (DHS 2008) will continue to serve planners 

who are preparing for the protection of populations beyond these immediately lifethreatening areas. The existing DHS Planning Guidance (DHS 2008), combined with this 

planning guidance, provide more comprehensive guidance for emergency response planners 

to prepare for responding to consequences of a nuclear detonation. 

This guidance was developed by a Federal interagency committee (see Appendix A for 

membership). The planning guidance was subject to two extensive reviews, a technical 

review (e.g., Federal interagency and national laboratory subject matter experts) and a 

stakeholder review (e.g., emergency response community representatives from police, fire, 

emergency medical services, medical receivers, and professional organizations such as the 

Health Physics Society, the American Public Works Association, and the International 

Association of Fire Chiefs) resulting in 1650 comments from over 70 individual reviewers 

representing nine Federal departments and national laboratories and 30 communities and 

professional organizations. 

The guidance is based upon the IND scenario, National Planning Scenario (NPS) #1, 

provided by the Homeland Security Council in partnership with DHS and the interagency 

Federal community, for use in national, Federal, State, and local homeland security 

preparedness activities. Scenario-based planning is a useful tool for Federal, State, and local 

planners, and, increasingly, departments and agencies are using the DHS NPSs to develop 

strategic, concept, and operational plans for designing response exercises and for other 

planning purposes. However, the NPSs have sometimes been applied as rigidly prescriptive 

scenarios against which planning should occur, not with the flexibility originally intended. 

This application has often been the case with NPS #1, which describes a nuclear detonation 

in Washington, DC and provides specific modeled outcomes of impacts and consequences. 

While it is impossible to predict the precise magnitude and impact of a nuclear detonation 

this scenario provides a foundation for preparedness and planning efforts, as well as for 

initial response actions in the absence of specific measurements. 

It is expected that planners and exercise designers will use this guidance, and the scenario on 

which it is based, and tailor them to their specific circumstances or to compare differing 

inputs and assumptions. Factors that planners and exercise designers may consider changing 

from parameters in NPS #1 may include target city, specific location of detonation, size and 

type of weapon, date and time of day, population features, meteorological conditions, and 

assumptions about local, regional, or national response to the incident. 

Target audiences should use this planning guidance in their preparedness efforts. They are 

encouraged to meet and work with their Federal, State, and local counterparts and partners, 

as each bring important knowledge to the design of implementation plans. Of special note 

are those planners with existing relationships with the Federal Emergency Management 

Agency (FEMA) Radiological Emergency Preparedness (REP) Program associated with 

communities in the vicinity of commercial nuclear power plants. Appropriate processes and 
10

procedures from the REP Program are expected to be an important tool in developing local 

response plans for nuclear detonations. 

Finally, critical assumptions in the development of this guidance for a nuclear detonation 

include: 

• There will be no significant Federal response at the scene for 24 hours and the 

full extent of Federal assets will not be available for up to 72 hours. Emergency 

response is principally a local function. Federal assistance will be mobilized as 

rapidly as possible; however, for purposes of this document, no significant Federal 

response is assumed for 24 – 72 hours. 

• A nominal 10 KT yield nuclear device is assumed for purposes of estimating 

impacts in high-density urban areas. Variation in the size and type of the nuclear 

device has a significant effect on the estimation of impacts, however, most homeland 

security experts agree on 10 KT as a useful assumption for planning. 

• The lessons from multi-hazard planning and response will be applicable to the 

response to a nuclear detonation. While fallout and the scale of the damage 

presented by a nuclear detonation present significantly complicating hazards, most 

aspects of multi-hazard planning and many of the response capabilities are still 

useful. Planners and responders bring a wealth of experience and expertise to nuclear 

detonation response. This guidance provides nuclear-detonation specific information 

and context to allow planners, responders, and their leaders to bring their existing 

capabilities to bear in a worst-case scenario. 

• Although based on technical analyses and modeling of the consequences of nuclear 

explosions, the recommendations are intentionally simplified to maximize their 

utility in uncertain situations where technical information is limited. 

Recommendations are intended to be practical in nature and appropriate for use by 

planners in addressing actions for the general public and emergency responders. 

• While it is recognized that the fallout from a nuclear detonation will reach across 

many jurisdictions, potentially involving multiple States, this guidance is intended 

primarily for the target audience specified above with respect to the first few 

days in the physically damaged areas and life-threatening fallout zone.

References for Introduction 

US Department of Homeland Security. 2008. Planning Guidance for Protection and 

Recovery Following Radiological Dispersal Device (RDD) and Improvised Nuclear 

Device (IND) Incidents, Federal Register, Vol. 73, No. 149. 

http://www.fema.gov/good_guidance/download/10260. 
11

US Environmental Protection Agency. Office of Radiation Programs. 1992. Manual of 

Protective Actions Guides and Protective Actions for Nuclear Incidents. 

http://www.epa.gov/radiation/docs/er/400-r-92-001.pdf. 
12

KEY POINTS 

1. There are no clear boundaries between damage zones resulting from a nuclear 

detonation, but generally, the light damage (LD) zone is characterized by broken 

windows and easily managed injuries; the moderate (MD) zone by significant 

building damage, rubble, downed utility poles, overturned automobiles, fires, and 

serious injuries; and the no-go (NG) zone by completely destroyed infrastructure 

and radiation levels resulting in unlikely survival of victims. 

2. It is anticipated that some injuries (e.g., eye injuries, blast injuries — particularly 

from flying debris and glass) can be prevented or reduced in severity if individuals 

that perceive an intense and unexpected flash of light seek immediate cover. The 

speed of light, perceived as the flash, will travel faster than the blast overpressure 

allowing a few seconds for some people to take limited protective measures. 

3. Blast, thermal, and radiation injuries in combination will result in prognoses for 

patients worse than those for the individual injury mechanisms. 

4. EMP effects could result in extensive electronics disruptions complicating the 

function of communications, computers, and other essential electronic equipment. 

5. The most hazardous fallout particles are readily visible as fine, sand-sized grains, 

but the lack of apparent fallout should not be misrepresented to mean radiation 

isn’t present; therefore appropriate radiation monitoring should always be 

performed.. Fallout that is immediately hazardous to the public and emergency 

responders will descend to the ground within about 24 hours. 

6. The most effective life-saving opportunities for response officials in the first 60 

minutes following a nuclear explosion will be the decision to safely shelter or 

evacuate people in expected fallout areas. 

Chapter 1 - Nuclear Detonation Effects and Impacts in an 

Urban Environment 

Overview 

A nuclear detonation would produce several important effects that impact the urban 

environment and people. In this discussion, the term “nuclear effects” will mean those 

primary outputs from the nuclear explosion, namely blast, thermal, and prompt radiation. 

Important secondary effects covered here include electromagnetic pulse (EMP) and fallout. 

All of these effects have impacts on people, infrastructure, and the environment, and they 

significantly affect the ability to respond to the incident. The term “nuclear impacts” will be 
13

A nuclear detonation produces an explosion 

far surpassing that of any conventional 

explosive. An explosion occurs when an 

exothermic reaction creates a rapidly 

expanding fireball of hot gas or plasma. The 

expanding fireball produces a destructive 

shock wave. In a chemical-based explosion 

(such as dynamite or trinitrotoluene (TNT), a 

common explosive), the heat produced 

reaches several thousand degrees and creates 

a gaseous fireball on the order of a few 

meters in diameter. While energy in a 

chemical explosion derives from reactions 

between molecules, the energy released in a 

nuclear explosion derives from the splitting 

(or fission) of atomic nuclei of uranium or 

plutonium (i.e., fissile material). Pound-forpound, a nuclear explosion releases ~10 

million times more energy than a chemical 

explosive. The heat in a nuclear explosion 

reaches millions of degrees where matter 

becomes plasma. The nuclear fireball for a 

10 KT nuclear device can achieve a diameter 

of approximately 650 ft (200 meters), and the 

shock wave and degree of destruction is 

correspondingly large. 

used to describe the consequences to 

materials, people or the environment as a 

result of nuclear effects, such as structural 

damage, fire, radioactivity, and human 

health consequences. 

Generally, when considering nuclear 

explosion scenarios perpetrated by a 

terrorist, experts assume a low-yield 

nuclear device detonated at ground level.4 

Low yield in this context ranges from 

fractions of a kiloton (KT) to 10 KT. The 

descriptions and planning factors provided 

in this document are based on the 

Department of Homeland Security (DHS) 

National Planning Scenario (NPS) #1, 

which describes a nuclear device yield of 

10 KT detonated at ground level in an 

urban environment. The effects of a 

nuclear explosion less than 10 KT would 

be less; however, there is no easy or direct 

correlation factor to use for scaling of 

effects. 

Blast 

The primary effect of a nuclear explosion is the blast that it generates. Blast generation is the 

same in any kind of explosion. The blast originates from the rapidly expanding fireball of the 

explosion, which generates a pressure wave front moving rapidly away from the point of 

detonation. Blast is measured by the overpressure5 and dynamic pressure6 that it produces. 

Initially, near the point of detonation for a surface nuclear burst (also referred to as ground 

zero), the overpressure is extremely high (thousands of pounds per square inch (psi) 

expanding out in all directions from the detonation at hundreds of miles per hour). With 

increasing distance from ground zero, the overpressure and speed of the blast wave dissipate 

to where they cease to be destructive (see Table 1.1). 

 

4

 It should be noted that if a state-built weapon were available to terrorists, the presumption of low yield may no 

longer hold. 

5

 Pressure over and above atmospheric pressure, and measured in pounds per square inch (psi). 6

 Manifested as wind, dynamic pressure is a term associated with the velocity of flow and is measured in miles 

per hour (mph). 
14

The magnitude of a nuclear explosion is 

quantified in terms of the amount of 

conventional explosive it would take to 

create the same blast effect. The amount of 

explosive power from a nuclear explosion, or 

the “yield,” is measured relative to TNT, and 

is usually in the thousands of tons (kilotons, 

or KT) of TNT. A small nuclear device, for 

example, would be a 1 KT device, meaning it 

would produce an explosive yield equivalent 

to one thousand tons of TNT. Most nuclear 

weapons in the world today were designed to 

deliver less than 200 KT; but, some can 

deliver millions of tons (MT) of yield. For 

comparison the size of the Murrah Federal 

Building bombing in Oklahoma City, OK 

(1995) was 2.5 tons of TNT equivalents. 

Accompanying the overpressure wave is 

dynamic pressure that is wind generated by 

the passing pressure wave. A very high wind 

velocity is associated with a seemingly small 

amount of overpressure, as shown in Table 

1.1. The combination of overpressure and 

wind is extremely destructive to structures. 

For example, at 5 psi, the wind velocity may 

reach over 160 miles per hour. The full 

impact of overpressure and dynamic pressure 

on structures common in a modern city is not 

currently known; however, past tests and 

computer models aid in impacts estimation. 

Table 1.1: Relation of wind speed to peak overpressure and distance for a 10 KT explosion; 

adapted from Glasstone and Dolan (Glasstone and Dolan 1977)

Peak Overpressure (psi) 

Approximate Distance 

from Ground Zero (miles) 

Maximum Wind Speed 

(mph) 

50 0.18 934 

30 0.24 669 

20 0.30 502 

10 0.44 294 

5 0.6 163 

2 1.1 70 

Physical destruction of structures following an urban nuclear explosion at different 

overpressures is described as follows: 

1. Buildings sustain minor damage — damage corresponds to overpressures in the 

range of approximately 0.15 to about 2 psi 

2. Most buildings are moderately damaged — damage corresponds to overpressures 

between 2 and 5 psi 

3. Buildings are badly damaged or destroyed — damage corresponds to 

overpressures around 5 to 8 psi 

4. Only heavily reinforced buildings remain standing, but are significantly damaged 

and all other buildings are completely destroyed — damage corresponds to 10 psi 

or greater 
15

The amount of damage to structures can be used to describe zones for use in response 

planning. Each zone will have health and survival implications, although not as neatly as 

arbitrary zone delineations would indicate. The purpose of establishing zones is to help plan 

response operations and prioritize actions. The following zones are proposed for planning 

response to a 10 KT surface burst nuclear explosion in an urban environment and are 

summarized in Figure 1.1:7 

Light Damage (LD) Zone: 

 The outer boundary of the LD zone may be defined by the prevalence of broken 

windows, with approximately 25% broken. This corresponds to approximately 

0.5 psi. Shattering of windows and associated injury from flying glass will occur 

to about three miles (4.8 km) from ground zero making this distance a reasonable 

estimate of the outer boundary of the LD zone. However, window breakage may 

occur to a lesser degree out to five miles (8 km) or more from ground zero. 

 Doors and window frames may be blown in at overpressures of about two psi. 

Essentially all windows will be shattered out to one psi and perhaps 25% at 0.5 

psi. 

 As a responder moves inward, windows and doors will be blown in and gutters, 

window shutters, roofs, and light construction will have increasing damage. Litter 

and rubble will increase moving towards ground zero and there will be increasing 

numbers of stalled and crashed automobiles, making emergency vehicle passage 

difficult. 

 Blast overpressures that characterize the LD zone are calculated to be about 0.5 

psi at the outer boundary and 2–3 psi at the inner boundary. More significant 

structural damage to buildings will indicate entry into the moderate damage zone. 

Moderate Damage (MD) Zone: 

 Responders may expect they are transitioning into the MD zone when building 

damage becomes substantial. This damage may correspond to a distance of about 

one mile (1.6 km) from ground zero for a 10 KT nuclear explosion. 

 Observations in the MD zone include significant structural damage, blown out 

building interiors, blown down utility poles, overturned automobiles, some 

collapsed buildings, and fires. In the MD zone sturdier buildings (e.g., reinforced 

concrete) will remain standing, lighter commercial and multi-unit residential 

 

7

 In order to provide some basic parameters to describe the generic urban environment this document assumes a 

nominal 10 KT detonation in a modern city with a population of several million. While distances would vary 

the zone descriptions apply to any size nuclear explosion. Building types will include a mix of high rise 

commercial structures of varying ages and design, with some residential high rises, and high daytime population 

density at the ground zero location. Building heights and population density are assumed to drop off with 

distance from the ground zero location in favor of low, lighter constructed buildings, and increased residential 

structures. 
16

buildings may be fallen or structurally unstable, and most single-family houses 

would be destroyed. 

 Substantial rubble and crashed and overturned vehicles in streets are expected, 

making evacuation and passage of rescue vehicles difficult or impossible without 

street clearing. Moving towards ground zero in the MD zone, rubble will 

completely block streets and require heavy equipment to clear. 

 Within the MD zone, broken water and utility lines are expected and fires will be 

encountered. 

 Many casualties in the MD zone will survive and these survivors, in comparison 

to survivors in other zones, will benefit most from urgent medical care. 

 A number of hazards should be expected in the MD zone, including elevated 

radiation levels, potentially live, downed power lines, ruptured gas lines, sharp 

metal objects and broken glass, ruptured vehicle fuel tanks, and other hazards. 

 Visibility in much of the MD zone may be limited for an hour or more after the 

explosion because of dust raised by the shock wave and from collapsed buildings. 

Smoke from fires will also obscure visibility. 

 Blast overpressures that characterize the MD zone are: outer boundary, about 2–3 

psi, and inner boundary, about 5–8 psi. When most buildings are severely 

damaged or collapsed, responders have encountered the no-go zone. 

No-go (NG) Zone: 

 Few, if any, buildings are expected to be structurally sound or even standing in 

the NG zone, and very few people would survive; however, some people 

protected within stable structures (e.g., subterranean parking garages or subway 

tunnels) at the time of the explosion may survive the initial blast. 

 Very high radiation levels and other hazards are expected in the NG zone making 

this zone gravely dangerous to survivors and responders; therefore, the NG zone 

should be considered a no-go zone during the early days following the explosion. 

 Rubble in streets is estimated to be impassable in the NG zone making timely 

response impossible. Approaching ground zero, all buildings will be rubble and 

rubble may be 30 feet deep or more.

 The NG zone may have a radius on the order of 0.6 miles (1.0 km). Blast 

overpressure that characterizes the NG zone is 5–8 psi and greater. 
17

All approximated distances from center of detonation site

No-go (NG) Zone

Moderate Damage (MD) Zone

Light Damage (LD) Zone

No-go (NG): Buildings 

completely destroyed; radiation 

prevents entry into the area; 

lifesaving is not likely

Light Damage (LD): Windows 

mostly broken, injuries 

requiring self- or outpatientcare

~0.6 mi

~ 3 mi

Moderate Damage (MD): 

Significant building damage 

and rubble, downed utility 

poles, overturned 

automobiles, fires, many 

serious injuries; greatest 

lifesaving opportunities ~1 mi

Figure 1.1: Representative damage zones for 10 KT nuclear explosion (not to scale; circles are 

idealized here for planning purposes) 

These zone delineations are rough approximations that can assist response planners. They 

will be referred to during the remainder of Chapter 1 discussions and will be further 

developed for response planning in Chapter 2. There are no clear boundaries between the 

damage zones. Initial response units may make observations and estimates, based on 

information contained in this document, for purposes of making zone delineations at the 

scene. Some of the visual markers provided above will help to distinguish the zones. 

It is important to recognize that the zones depicted as circles in Figure 1.1 should be defined 

not by precise distances, but by the degree of observable physical damage for purposes of 

response planning. Nuclear weapon experts believe damage will be highly unpredictable; for 

example, some lighter buildings may survive closer to ground zero while robust structures 

may be destroyed under relatively low overpressure resulting from complex wave reflection 

and diffraction in the urban cityscape. Glass breakage is an important factor in assessing 

There are no clear boundaries between the representative damage zones resulting from 

a nuclear detonation, but generally, the light damage (LD) zone is characterized by 

broken windows and easily managed injuries; the moderate (MD) zone by significant 

building damage, rubble, downed utility poles, overturned automobiles, fires, and 

serious injuries; and the no-go (NG) zone by completely destroyed infrastructure and 

high radiation levels resulting in unlikely survival of victims. 
18

blast damage, but different kinds of glasses break at widely varying overpressures. Some 

modern windows may survive two psi, whereas others will shatter at 0.15 psi. The glass 

dimensions, hardening, thickness, and numerous other factors influence glass breakage. 

Zoned planning, however, will help officials estimate overall response needs and preplan the 

logistical support necessary for a response. 

Blast Injuries 

The most critical, direct overpressure blast injuries will include lung damage, eardrum 

rupture, and damage to the hollow viscera (e.g., esophagus, stomach, small and large 

intestine, rectum). When the blast wave hits the human body, rapid compression and 

decompression result in transmission of pressure waves through the tissues, resulting in 

damage primarily at junctions between different tissues (e.g., bone and muscle, at the 

interface between tissue and air spaces). Lung tissue and the gastrointestinal system, both of 

which contain air, are particularly susceptible to injury. The resulting tissue damage can lead 

to severe hemorrhage or to air emboli (i.e., incorporation of air into the bloodstream that can 

result in blockage of major arteries or the heart), either of which can be rapidly fatal. 

Perforation of the eardrums would be a common but minor blast injury. Table 1.2 provides 

an overview of impacts relative to the peak overpressure of the blast wave. 

Table 1.2: Impacts of peak overpressure of blast; adapted from Glasstone and Department of 

Defense (DOD) (Glasstone and Dolan 1977; DOD 2001) 

Peak 

Overpressure 

(psi) 

Type of Structure Degree of Damage 

0.15-1 Windows Moderate (broken) 

3-5 Apartments Moderate 

3-5 Houses Severe 

6-8 Reinforced concrete building Severe 

6-8 Massive concrete building Moderate 

100 Personnel shelters Severe (collapse) 

Type of Injury to People

5 Threshold for eardrum rupture 

15 Threshold for serious lung damage 

50 50% incidence of fatal lung damage 
19

As shown in Table 1.2, the human body is remarkably resistant to overpressure, particularly 

when compared with rigid structures such as buildings. Although many would survive the 

blast overpressure itself, they will not easily survive the crushing injuries incurred during the 

collapse of buildings (see Figure 1.2) from the blast overpressure or the impact of shrapnel 

(e.g., flying debris and glass). 

Figure 1.2: Blast wave effects on a house, indicating low survivability 

The majority of casualties from blast effects will result from wind generated from the blast 

overpressure. The velocity of the wind will lift and throw people causing serious injuries for 

a 10 KT yield within a mile of ground zero. It will also turn lighter objects into flying 

shrapnel resulting in impalement injuries. Heavier objects may present crushing hazards. 

Head injuries, damage to body extremities, and internal organ damage will result. 

The probability of penetrating injuries from flying debris increases with increasing velocity, 

particularly for small, sharp debris such as glass fragments. Single projectile injuries will be 

rare; however, multiple, varied projectile injuries will be common. Blast wave pressures 

above three to five psi can produce flying debris and glass fragments with sufficient velocity 

to cause blunt trauma or deep lacerations resulting in injuries that require professional 

medical attention. For a 10 KT detonation, the range for these effects is about 0.6 – 1 mile 

(1–1.6 km). However, broken and shattered windows will be observed at much greater 

distances. Large windows can break at blast wave pressures down to 0.15 psi and people will 

be subject to injury from the falling glass of tall buildings. For 10 KT, these lower pressure 

window breakages could range out several miles from ground zero. Although, not directly 

relevant to expectations in a modern urban environment, at Nagasaki (21 KT) and Hiroshima 

(16 KT) minor injuries from flying glass extended to two miles, serious injuries were 

prevalent out to one mile, and falling glass was not an issue for lack of tall buildings beyond 

the MD zone. 

Thermal Radiation (or Heat) 

An important effect of a nuclear detonation is the generation of an intense thermal pulse of 

energy (i.e., the nuclear flash). The potential for fire ignition in modern cities from thermal 

effects is poorly understood but remains a major concern. Fires may be started by the initial 

thermal burst igniting flammable materials in buildings, or by the ignition of gas from broken 

gas lines and ruptured fuel tanks. 

Fires destroy infrastructure, pose a direct threat to survivors and responders, and may 

threaten people taking shelter or attempting to evacuate. If fires are able to grow and 

Blast wave destroys wood 

frame house 

(16 KT, 0.6 miles away, ~6 

psi, ~200 mph) 
20

The thermal pulse of energy from a nuclear 

detonation originates from two sources. First, a 

short intense pulse of heat (the flash) occurs from 

the fission event itself, then the expanding 

fireball continues to radiate for several seconds 

as it rockets upward. The thermal pulse 

generates instantaneous direct energy in the 

infrared, visible, and ultraviolet wave bands, but 

most of the thermal radiation comes from the 

fireball itself. The thermal radiation intensity at 

any given point will depend on distance from the 

detonation and the location of the burst (e.g., 

detonation high above the ground, or detonation 

at the surface of the earth). In general, the 

thermal hazard is greatest in the case of a lowaltitude air burst. General thermal effects will be 

less for surface bursts resulting from less direct 

line-of-sight contact with the energy radiating 

from the detonation. Surface bursts result in a 

large part of the thermal energy being absorbed 

by the ground and any buildings around ground 

zero. Partial and sometimes complete shadowing 

from the thermal pulse and fireball may be 

provided to people inside or behind buildings and 

other structures. Terrain irregularities, moisture, 

and various gases in the air near the surface of 

the earth will tend to reduce the amount of 

thermal energy that is transported at distance. 

coalesce, a firestorm8 could develop that would be beyond the abilities of firefighters to 

control. 

The NG zone might be depicted as a 

large concrete rubble area (with a very 

large hole in the middle) and is not 

expected to be conducive for fueling 

fires. The MD zone is the more likely 

the area where fires will erupt and 

threaten survivors and responders 

because of the intense thermal pulse 

and the severe damage to 

infrastructure (such as gas lines and 

fuel tanks). Depending on the 

flammability of various materials, 

blast winds can either extinguish or 

fan the burning materials. The LD 

zone with minor infrastructure damage 

may also have fires but these should 

be more easily contained and 

mitigated. 

Thermal Injuries 

Close to the fireball, the thermal 

energy is so intense that infrastructure 

and humans are incinerated. 

Immediate lethality would be 100% in 

close proximity. The distance of 

lethality will vary with nuclear yield, position of the burst relative to the earth’s surface, 

weather, environment, and how soon victims can receive medical care. 

Thermal radiation emitted by a nuclear detonation causes burns in two ways; direct 

absorption of thermal energy through exposed surfaces (flash burns) or indirectly from fires 

ignited by the burst (see Figure 1.3). Thermal energy from the burst is delivered to bare skin 

or through clothing to the skin so quickly that burn patterns will be evident. The victim will 

be burned on the side facing the fireball. If people were out in the open and not protected by 

terrain, buildings, or other shadowing structures, flash burns would be the most common 

injuries among survivors. Tall city buildings between people and the burst provide 

substantial shadowing from the burst and reduce the overall flash burn impact. People within 

line of sight of the burst may be subject to burn injuries up to two miles away for a 10 KT 

 

8 A firestorm is a conflagration, which attains such intensity that it creates and sustains its own wind system that 

draws oxygen into the inferno to continue fueling the fires. 
21

Sudden exposures to high-intensity 

sources of light can cause eye injury, 

specifically to the retina. Factors that 

determine the extent of eye injury 

include pupil dilation, spectral 

transmission through the ocular media, 

spectral absorption by the retina and 

choroids, length of time of exposure, 

and the size and quality of the image. 

Eye injury is a result of not only 

thermal energy but also photochemical 

reactions that occur within the retina 

with light wavelengths in the range of 

400 to 500 nanometers. 

device. The farther away from ground zero a person is, the less severe the burn injury will 

be. Early treatment can reduce mortality rates among the severely burned victims. 

(a) (b)

Figure 1.3: Flash burn victims from (a) Hiroshima showing pattern burns (i.e., the dark colored 

material pattern on the victims clothing absorbed the thermal energy and burned the skin), 

and (b) Nagasaki showing profile burns (i.e., burns around the light colored clothing that 

reflected the thermal energy). 

Secondary fires are expected to be prevalent in the MD zone. Secondary fires will result in 

medically routine burns, but the health threat will be compounded by other injury 

mechanisms associated with a nuclear explosion.

Observation of the thermal flash can result in 

temporary or permanent eye injuries. Temporary 

flash blindness may occur in people who 

observed the flash of intense light energy with 

their peripheral vision. This blindness is a 

temporary condition that results from a depletion 

of photopigment from the retinal receptors. The 

duration of flash blindness can last several 

seconds when the exposure occurs during 

daylight. The blindness may then be followed by 

a darkened after-image that lasts for several 

minutes. At night, when one’s pupils are fully 

dilated, flash blindness may last for up to 30 

minutes and may occur up to 15 miles away from 

the detonation resulting in traffic accidents far 

removed from the damage zones. 

Direct observation of the brilliant flash of light from a nuclear detonation can also cause 

macular-retinal burns. Burns of the macula will result in permanent scarring with resultant 

loss in visual acuity, or blindness. Burns of the peripheral regions of the retina will produce 

scotomas (blind spots), but overall visual acuity will be less impaired. These burns can occur 

at distances of several miles under optimal conditions and roughly double in range at night. 
22

It is anticipated that some injuries (e.g., eye injuries, blast injuries, particularly from 

flying debris and glass) can be prevented or reduced in severity if individuals that 

perceive an intense and unexpected flash of light as described here seek immediate 

cover. The speed of light, perceived as the flash, will travel faster than the blast 

overpressure allowing a few seconds for some people to take limited protective 

measures. 

A nuclear explosion involves the splitting, or 

fission, of the nuclei of uranium or plutonium. 

During and following a nuclear explosion, 

radiation is released. This radiation includes 

both electromagnetic (e.g., ultraviolet, infrared, 

visible, gamma and x-ray) and particulate 

radiation (e.g., alpha and beta particles, and 

neutrons). The intense visible light that occurs 

is one of the hallmarks of a nuclear explosion; 

it can be seen from many kilometers away and 

can be blinding. The health threat from these 

types of radiation varies; however gamma 

radiation contributes the greatest early threat 

from the initial radiation and from radiation 

associated with fallout. 

Radiation and Fallout 

One of the primary outputs from a nuclear explosion is radiation. Intense radiation is 

generated by the nuclear fission process that creates the explosion, and it is generated from 

the decay of radioactive fission products (radionuclides) resulting from nuclear fission. 

During a nuclear explosion, fission products are created that attach to particles and debris to 

form fallout; these particles are the main source of contamination associated with a nuclear 

explosion. Fission products emit primarily gamma and beta radiation. The various fission 

products have widely differing radioactive half-lives.9

 Some have very short half-lives (e.g., 

fractions of a second), while others can continue to emit radiation for months or years. To 

help in making radiation dose assessments, radiation from a nuclear explosion is categorized 

as prompt radiation, which occurs within the first minute, and latent radiation, which occurs 

after the first minute and is largely associated with radioactive fallout. Both can deliver 

lethal radiation doses. Moderate to large radiation doses are known to increase long-term 

cancer risk as well. 

 

9

 The radioactive half-life for a given radionuclide is the time for half the radioactive nuclei in a given sample to 

undergo radioactive decay. After two half-lives, there will be one-fourth of the original sample, after three halflives one-eight of the original sample, and so forth. 
23

For low-yield detonations (e.g., 10 KT and less) prompt radiation can be an important 

contributor to casualties. The intensity of prompt radiation, however, is of short duration and 

decreases with increasing distance from ground zero. This decrease is a result of the radial 

distribution of radiation as it travels away from the point of detonation, and the absorption, 

scattering, and capture of radiation by the atmosphere and buildings. Buildings help to block 

the direct path of prompt radiation, however, even if an individual is shielded behind 

buildings, backscattered radiation from the atmosphere can still deliver a dose that could 

make people sick or even prove fatal. 

Even if a person is at a safe distance with respect to prompt radiation, radioactive fallout can 

deliver a lethal radiation dose. The intensity of latent radiation from fallout diminishes 

generally with distance from the point of detonation (depending on meteorological factors), 

and with time as the radionuclides decay away. Sheltering in a heavily constructed building 

away from windows or in a basement provides good protection (see Chapter 3). 

Although the latent radiation hazard from a nuclear explosion arises mainly from fission 

products, another source can arise when neutrons impact materials such as metal, soil, rock, 

and buildings that are in close proximity to ground zero. The absorption of neutrons in 

materials can make them radioactive, emitting beta and gamma radiation. These radioactive 

materials decay in the same manner as fission products. In addition to local radioactive 

fallout, the immediate area around ground zero, mostly within the NG zone, may be 

radioactive for several weeks or months as a result of this neutron-induced radioactivity in 

buildings, soil, metals, and other materials. 

The decay of nuclear weapons fission products follows the relationship, Rt = R1t

-1.2, where Rt

is the gamma radiation dose rate at time t after the explosion and R1 is the dose rate at unit 

time, for example one hour. However, a standard rule of thumb for the decay, called the 7–

10 rule, makes for easy approximations. This rule states that for every sevenfold increase in 

time after detonation, there is a tenfold decrease in the radiation rate. Table 1.3 summarizes 

relative dose rates at various times after a nuclear explosion. The following explanation and 

accompanying Table 1.3 are from The Effects of Nuclear Weapons, by Glasstone and Dolan 

1977 (Glasstone and Dolan 1977): 

“For example, if the radiation dose rate at 1 hour after the explosion is taken as a 

reference point, then at 7 hours after the explosion the dose rate will have decreased 

to one-tenth; at 7x7 = 49 hours (or roughly 2 days) it will be one-hundredth; and at 

7x7x7 = 343 hours (or roughly 2 weeks) the dose rate will be one-thousandth of that 

at 1 hour after the burst. Another aspect of the rule is that at the end of 1 week (7 

days), the radiation dose rate will be about one tenth of the value after 1 day. This 

rule is accurate to within about 25 percent up to 2 weeks or so and is applicable to 

within a factor of two up to roughly 6 months after the nuclear detonation.” 
24

Table 1.3: Example dose rate decay from early fallout tracked as a function of time after a 

nuclear explosion; adapted from Glasstone and Dolan (Glasstone and Dolan 1977). 

Time (hours) Dose Rate (R/hour) Time (hours) Dose Rate (R/hour) 

1 1,000 36 15 

1.5 610 48 10 

2 400 72 6.2 

3 230 100 4.0 

5 130 200 1.7 

6 100 400 0.69 

70 63 600 0.40 

15 40 800 0.31 

24 23 1,000 (~ 42 days) 0.24 

Fallout is particulate material (and larger debris) that is engulfed by or drawn up into the 

fireball. Smaller particles, below 1 mm, generally have fission products fused into or 

condensed onto them, creating radioactive fallout that could be carried a significant distance. 

As the fireball cools, the particulates are drawn back to earth by gravity. If the detonation 

occurs near the earth’s surface, the shock wave will crush and loosen thousands of tons of 

earth and urban infrastructure (e.g., buildings, roads, concrete) that can become entrained in 

the fireball. Some of this material will be vaporized by the intense heat of the fireball, some 

will be partially melted, and some will remain essentially unchanged. 

Nearly all the radioactivity in fallout comes from fission products produced during 

detonation (e.g., uranium or plutonium nuclei split apart in the fission reaction). A smaller 

contributor is the induced radioactivity (activation) of local materials by neutron capture. In 

the fireball, the fission products and neutron activation products are incorporated into or 

condensed onto the particles generated from the explosion, which then descend as fallout. In 

a fallout zone, external exposure to gamma radiation is the dominant health concern but beta 

radiation will cause severe tissue damage when the material remains in contact with 

unprotected skin resulting in “beta burns.” 

Fallout particles studied during historical weapons testing ranged in size from submicron up 

to centimeters, and they behave according to standard aerodynamic principles. As the fireball 

rises, winds shift its particle-laden column resulting in fluctuation of the fallout pattern of 

deposition as upper level winds finally convey the cooling fireball. Winds at ground level 

typically do not reflect wind speeds and directions at higher levels, and the fallout path may 

veer in unexpected ways, and carry fallout a significant distance. 

As a rule, fallout particles that are most hazardous are readily visible as fine sand-sized 

grains, but the lack of apparent fallout should not be misrepresented to mean radiation isn’t 

present; therefore appropriate radiation monitoring should always be performed. Fallout that 

is immediately hazardous to the public and emergency responders will descend to the ground 

within about 24 hours. The most significant hazard area will extend 10 to 20 miles from 

ground zero. Within a few miles of ground zero exposure rates in excess of 100 R/hour 

during the first four to six hours post-detonation may be observed. The area covered by 

fallout that impacts responder life-saving operations and/or has acute radiation injury 

potential to the population is known as the dangerous fallout (DF) zone. To the three zones 

already described (LD, MD, and NG), a fourth is added, the dangerous fallout (DF) zone. 
25

While fallout may trigger consideration of PAGs hundreds of miles away (DHS 2008), this 

DF zone pertains to near-in areas to focus on activities that maximize population survival and 

limit acute radiation injuries. Figure 1.4 illustrates the relation of the DF zone to zones LD, 

MD and NG. 

~ 10 to 20 miles

LD MDNG

DF

Figure 1.4: Representative dangerous fallout (DF) zone in which an early and direct threat from 

fallout radioactivity exists. A radiation exposure rate of 10 R/hour is used to delimit this zone. 

The DF zone is distinguished not by structural damage, but by fallout radiation levels. A 

radiation exposure rate of 10 R/hour is used to delimit this zone. This zone is a hazardous 

area and any response operations within the DF zone must be justified, optimized, and 

planned. It is important that responders refrain from undertaking missions in areas where 

radioactivity may be present until radiation levels can be accurately determined and readily 

monitored. Responder planning recommendations for the DF zone are provided in Chapter 

2. 

Rarely does fallout form easily predictable deposition patterns. Winds of varying speed and 

direction at different levels of lower and upper atmosphere push the fireball and the 

descending fallout material in directions that may not be evident from ground-level 

observation. Therefore, ground-level winds should never be used to predict the path of fallout 

deposition. Dangerous fallout may land on people who think the fallout is being blown a 

different direction, because of upper-level winds; or early evacuation could prove ineffective, 

even fatal, if planning assumes a straight line deposition pattern based on ground-level 

winds. To add to the complication of the fallout zone, there will be small areas that are 

significantly more radioactive and others that are less radioactive within the overall fallout 

field because of micro-level wind variation. 

The most hazardous fallout particles are readily visible as fine, sand-sized grains, but 

the lack of apparent fallout should not be misrepresented to mean radiation isn’t 

present; therefore appropriate radiation monitoring should always be performed.. 

Fallout that is immediately hazardous to the public and emergency responders will 

descend to the ground within about 24 hours.
26

Beyond 20 miles, the extended fallout area will still require shelter and/or evacuation orders 

to minimize radiation exposure to the population. As a general rule, the population in the 

local fallout area should immediately shelter to avoid exposure to fallout prior to any 

consideration for evacuation (see Chapter 3). 

Contamination from fallout will hinder response operations in the local fallout areas and may 

preclude some actions before sufficient radioactive decay has occurred. However, the fallout 

will be subject to rapid radioactive decay and the DF zone will immediately begin to shrink 

in size with time. The radiation exposure rate at a given location, whether in the center of the 

DF zone or at the perimeter (10 R/hour), will diminish with time resulting in a gradually 

smaller DF zone. Monitoring ground radiation levels is imperative for the response 

community. Combining the measured radiation levels with predictive plume models and/or 

aerial measurement systems can prove invaluable in determining response courses of action 

and developing protective action decisions. 

Finally, fallout travels substantial distances beyond the DF zone boundary, though levels 

beyond the DF boundary would not be lethal. However, fallout in areas 100 or more miles 

away may warrant protective actions (e.g., sheltering and/or evacuation, food collection 

prohibitions, water advisories). Fallout deposition at great distances (e.g., 100 miles) is 

dictated by the parameters of jet stream winds. Fallout of fine particle size will continue to 

move on the jet streams and have a low-level global impact. 

Radiation Injuries and Fallout Health Impacts 

A nuclear explosion will produce dangerous levels of prompt radiation, and radiation from 

fallout. Elevated radiation doses will produce clinical injuries and death. Prompt radiation 

from a 10 KT nuclear detonation can deliver a radiation dose of approximately 400 rads (4 

Gy or 400 cGy) at a distance of just over half a mile (~0.9 km) whereby ~50% of the 

population who are out in the open (unshielded) will not survive. This level of dose is called 

the LD50 dose for untreated patients. Medical care increases one’s chances of survival up to a 

dose of ~600 rads (600 cGy). Even with medical care, many victims that receive radiation 

doses over ~600 rads would not be expected to survive. The time to death for these victims 

ranges from several weeks to a few months. 

Nuclear fallout can cause acute health effects (short-term effects), including death, and longterm health risks, especially cancer. Close in to the explosion out to about 10 to 20 miles 

from ground zero, unsheltered people could receive acute and even lethal radiation doses. A 

simplified acute radiation dose chart is shown below (Table 1.4). From this chart, responders 

will note that if they are subjected to acute doses above ~200 rem (200 cGy), they will likely 

be unable to perform their jobs adequately and be at risk of becoming a casualty themselves. 

Below the range of acute effects, the risk of cancer is increased over a person’s lifetime. 
27

Table 1.4: Approximate acute death and acute symptoms estimates as a function 

of whole-body absorbed doses (for adults), for use in decision making after shortterma

 radiation exposure adapted from NCRP, AFRRI, Goans, IAEA, ICRP and 

Mettler (NCRP 2005; DOD, 2003; Goans and Wasalenko, 2005; IAEA, 1998; ICRP, 

1991; Mettler and Upton, 1995). 

Short-Term 

Whole-Body 

Dose [rad (Gy)] 

Acute Deathb

 from 

Radiation Without 

Medical Treatment 

(%) 

Acute Death from 

Radiation with 

Medical Treatment 

(%) 

Acute Symptoms 

(nausea and 

vomiting within 4 h) 

(%) 

1 (0.01) 

10 (0.1) 

50 (0.5) 

100 (1) 

150 (1.5) 

200 (2) 

300 (3) 

600 (6) 

1,000 (10) 

0 

0 

0 

<5 

<5 

5 

30 – 50 

95 – 100 

100 

0 

0 

0 

0 

<5 

<5 

15 – 30 

50 

>90 

0 

0 

0 

5 – 30 

40 

60 

75 

100 

100 

a

Short-term refers to the radiation exposure during the initial response to the incident. The acute 

effects listed are likely to be reduced by about one-half if radiation exposure occurs over weeks. b

Acute deaths are likely to occur from 30 to 180 d after exposure and few if any after that time. 

Estimates are for healthy adults. Individuals with other injuries, and children, will be at greater risk. 

In zones where acute or lethal doses may occur, attention should be directed towards 

minimizing doses to levels as low as can be achieved to maximize survival under the 

circumstances. In zones further away and where relatively low radiation doses are observed 

(i.e., from fallout), attention should be given to managing radiation exposures with the goal 

of minimizing cancer risk and other long-term effects. Chapter 3 provides more information 

on radiation dose management and protective actions. 

Perhaps the most effective life-saving opportunity for response officials in the first 60 

minutes following a nuclear explosion will be the decision to shelter or evacuate populations 

in the expected fallout areas. When individuals remain in a nuclear fallout area, the fallout 

deposited on the ground and roofs will lead to an immediate external radiation exposure from 

gamma radiation. The radiation dose from fallout is often referred to as the ground shine dose 

and it is orders of magnitude greater than internal hazards resulting from inhalation or 

ingestion of radioactive material in the DF zone. However, respiratory protection for the 

public, even ad hoc protection (e.g., holding a cloth over one’s mouth and nose), is better 

than no protection at all. Emergency responder respiratory protection recommendations are 

provided in Chapter 2, “Response Worker Safety.” 

Fallout exposure can be effectively minimized by taking shelter in a sufficiently protective 

structure. It is critical that pre-event public education address this protective action measure 

The most effective life-saving opportunities for response officials in the first 60 

minutes following a nuclear explosion will be the decision to safely shelter or 

evacuate people in expected fallout areas. 
28

directly with the public. Emergency responders should attempt to transmit shelter or evacuate 

decisions to the public. Individuals need to understand the shelter adequacy of the shelter in 

which they are located to be able to make their own decisions. Sheltering and evacuation is 

the subject of Chapter 3. 

Many people sheltering or being evacuated will need at least rudimentary decontamination. 

Effective decontamination of people from fallout is straightforward (i.e., remove clothes and 

shower). If contamination is not brushed or washed off, it can cause beta burns to the skin. If 

responders find themselves caught in an area during active fallout from the plume, they 

should brush each other off every few minutes until they can find suitable shelter or evacuate 

from the fallout area. Decontamination will place additional constraints on responder 

resources. Mass decontamination of populations can involve sending people home or to an 

alternate location to change clothes and shower. This subject is extensively addressed in 

Chapter 5. 

Combined Injuries 

Nuclear explosions produce thermal, blast, and radiation injuries that will often occur in 

combination. Research has led to the conclusion that the prognosis of patients suffering from 

both radiation and traumatic injuries (including burns) will be worse than the prognosis of 

patients suffering the same magnitude of either trauma or radiation exposure alone. For 

example, the LD50 for untreated, combined-injury casualties may be reduced from ~400 rad 

(400 cGy) to as low as 250 rad (250 cGy). Combined-injury patients who have received 

significant, but less than lethal, radiation doses (100 to 200 rads, or equivalently, 100 to 200 

cGy) will also require more support than those who have traumatic injuries alone. 

EMP 

A phenomenon associated with a nuclear detonation called electromagnetic pulse (EMP) 

poses no direct health threat, but can be very damaging to electronic equipment. EMP is an 

electromagnetic field generated from the detonation that produces a high-voltage surge. This 

voltage surge can impact electronic components that it reaches. The EMP phenomenon is a 

major effect for bursts at very high altitude, but it is not well understood how it radiates 

outward from a surface level detonation and to what degree it will damage the electronic 

systems that permeate modern society.10 Although experts have not achieved consensus 

agreement on expected effects, generally they believe that the most severe consequence of 

the pulse would not travel beyond about two miles (three km) to five miles (eight km) from a 

surface level 10 KT detonation. Stalling of vehicles and disruptions in communications, 

 

10 NPS #1 is a surface burst scenario. If the detonation were to occur at altitude, for example, if the device were 

carried up a thousand feet or more in a small plane, EMP would have a significantly larger impact on 

electronics and could seriously hamper communications and other systems locally. 

Blast, thermal, and radiation injuries in combination will result in prognoses for 

patients worse than those for the individual injury mechanisms. 
29

computer equipment, control systems, and other electronic devices could result. Another 

EMP phenomenon called source-region EMP may lead to conductance of electricity through 

conducting materials (e.g., pipes and wires) and could cause damage much further away, but 

this subject requires further research and analysis. Because the extent of the EMP effect is 

expected to occur relatively close to ground zero, other effects of the explosion (such as blast 

destruction) are expected to dominate over the EMP effect. Equipment brought in from 

unaffected areas should function normally if communications towers and repeaters remain 

functioning. 

References 

Glasstone, Samuel and Philip J. Dolan. 1977. The Effects of Nuclear Weapons. 

Washington, DC: US Government Printing Office. 

Goans, R. E., and J. K. Waselenko. 2005. Medical management of radiological casualties. 

Health Physics 89:505–12. 

International Atomic Energy Agency. 1998. Diagnosis and Treatment of Radiation Injuries. 

IAEA Safety Reports Series No. 2, STI/PUB/1040. http://wwwpub.iaea.org/MTCD/publications/PDF/P040_scr.pdf. 

International Commission on Radiological Protection. 1991. 1990 Recommendations of the 

International Commission on Radiological Protection, ICRP Publication 60, Ann. 

ICRP 21(1–3) (New York). 

Mettler, F. A., Jr. and A. C. Upton. 1995. Medical Effects of Ionizing Radiation. 2nd ed. 

Philadelphia: W.B. Saunders. 

National Council on Radiation Protection and Measurements. 2005. Key Elements of 

Preparing Emergency Responders for Nuclear and Radiological Terrorism, 

Commentary No. 19 (Bethesda). 

US Department of Defense. Armed Forces Radiobiology Research Institute. 2003. Medical 

Management of Radiological Casualties. 

http://www.afrri.usuhs.mil/www/outreach/pdf/2edmmrchandbook.pdf. 

US Department of Defense. Departments of the Army, the Navy, and the Air Force, and 

Commandant, Marine Corps. 2001. Treatment of Nuclear And Radiological 

Casualties. ARMY FM 4-02.283, NAVY NTRP 4-02.21, AIR FORCE AFMAN 44-

161(I), MARINE CORPS MCRP 4-11.1B. 

http://www.globalsecurity.org/wmd/library/policy/army/fm/4-02-283/fm4-02-

283.pdf. 

EMP effects could result in extensive electronics disruptions complicating the 

function of communications, computers, and other essential electronic equipment. 
30

KEY POINTS 

1. The goal of a zoned approach to nuclear detonation response is to save lives, while 

managing risks to emergency response worker life and health. 

2. Response to a nuclear detonation will be provided from neighboring response 

units; therefore advance planning is required to establish mutual aid agreements 

and response protocols. 

3. Radiation detection equipment should be capable of reading dose rates up to 1,000 

R/hour. 

4. Radiation safety and measurement training should be required of any workers that 

would be deployed to a radiation area. 

5. Most of the injuries incurred within the LD zone are not expected to be life 

threatening. Most of the injuries would be associated with flying glass and debris 

from the blast wave and traffic accidents. 

6. Responders should focus medical attention in the LD zone only on severe injuries 

and should encourage individuals to shelter in safe locations to expedite access to 

severely injured individuals. 

7. Response within the MD zone requires planners to prepare for elevated radiation 

levels, unstable buildings and other structures, downed power lines, ruptured gas 

lines, hazardous chemicals, sharp metal objects, broken glass, and fires. 

8. The MD zone should be the focus of early life-saving operations. Early response 

activities should focus on medical triage with constant consideration of radiation 

dose minimization. 

9. Response within the NG zone should not be attempted until radiation dose rates 

have dropped substantially in the days following a nuclear detonation, and the MD 

zone response is significantly advanced. 

10. The highest hazard from fallout occurs within the first four hours and continues to 

drop as the radioactive fission products decay. 

11. The most important mission in the DF zone is communicating protective action 

orders to the public. Effective preparedness requires public education, effective 

communication plans, messages, and means of delivery in the DF zone. 

Chapter 2 - A Zoned Approach to Nuclear Detonation 

Response 
31

Overview 

As stated in Chapter 1, defining zones can be a useful approach to planning and executing a 

response, including predicting casualties and medical needs, determining where to locate 

staging areas, determining incident management requirements, assessing potential worker 

hazards, determining how to access affected areas, and determining how to prioritize mission 

objectives especially for medical triage. While presented generically here, response planning 

must be done on a city-specific basis. The priority of saving lives is emphasized along with 

protecting emergency response workers. The zones in this recommended approach to nuclear 

explosion emergency response are based on visual indicators of physical damage and on 

radiation levels that will need to be measured in the field. The basic zones were described in 

Chapter 1 and their use is expanded here. 

Zoned Approach to Response 

The physical and radiological (fallout) impacts of nuclear explosion may be extensive 

making local response to the incident difficult. Responder units within one or two miles 

from ground zero of a surface, 10 KT nuclear explosion may be compromised or completely 

nonfunctional. However, response capabilities more than five miles away from ground zero 

are likely to be minimally affected by blast and electromagnetic pulse (EMP) and should be 

able to mobilize and respond, provided they are not impacted by dangerous levels of fallout. 

Therefore, response to a nuclear explosion may largely be provided by neighboring 

boroughs, suburbs, cities, townships, and counties through mutual aid agreements or other 

planning mechanisms. Some neighboring response capabilities, however, will be directly 

affected by fallout and advised to shelter until dose rates have fallen.11 Regional response 

planning in advance of a nuclear explosion is imperative to maximize response efficacy. 

The hazard from high radioactivity is an ever-present threat for responders and survivors in 

the early postdetonation time period. Radioactivity cannot be seen or felt; it must be detected 

and measured with specialized equipment capable of measuring high levels of radioactivity 

consistent with a nuclear detonation. Equipment should be capable of reading dose rates up 

to 1,000 R/hour. Radiation safety and measurement training should be required of any 

workers deployed to radiation areas. Response teams should not enter affected areas without 

first confirming the level of radioactivity in the area they are entering. 

 

11 In the scenario being considered here, a surface level nuclear explosion will generate a large amount of 

dangerous fallout. 

Response to a nuclear detonation will largely be provided from neighboring response 

units; therefore advance planning is required to establish mutual aid agreements and 

response protocols. 

The goal of a zoned approach to nuclear detonation response is to save lives, while 

managing risks to emergency response worker life and health. 
32

Planners and responders should remember that dose rates will be decreasing significantly in 

the first 48 hours. The level of radioactivity will need to be monitored periodically to 

properly characterize the changing hazard. Federal assets to support radiation monitoring 

will become available in the early days following a nuclear detonation, but local responders 

will be operating without substantial Federal support on the ground for approximately 24 to 

72 hours. Beginning about 30 minutes to 1 hour after a nuclear detonation, the Federal 

Interagency Modeling and Atmospheric Assessment Center (IMAAC) will be able to provide 

plume and fallout projections to State and local authorities through the Department of 

Homeland Security (DHS). The projections will be continuously updated as additional 

information becomes available from the incident location. 

Response Functions and Priorities 

Response teams that may use a zoned response approach to nuclear detonation response 

include radiation assessment support teams, police and fire fighters, emergency medical 

personnel, search and rescue teams, Haz Mat teams, engineering response teams,12 medical 

triage units, and response support functions. The main objective of early response is the 

preservation of life. While the life-saving objective is aimed at the general public, the safety 

and health of response workers is also critical. Emergency response planners and incident 

commanders must carefully weigh the decision to send response workers into situations 

where they may receive very high-radiation doses and/or physical injuries, both to protect the 

responder and to maximize responder resources. During the first hours and days after a 

nuclear attack, as many as one hundred thousand13 individuals may live or die depending on 

the ability of responders to treat injuries and protect people from lethal exposures to 

radiation. 

A number of nuclear explosion impacts (described in Chapter 1) severely hinder the lifesaving mission. Successful execution of life-saving and supporting response activities, such 

as search and rescue and fire fighting, is determined in part by the incident area conditions. 

Area access for such missions may be severely hindered by deep rubble, smoke and dust, 

stalled and crashed automobiles, and downed power lines. Fire fighting may be hampered or 

prevented by low water pressure. Worker safety concerns may affect response planning and 

 

12 The term engineering response teams is used here to include teams of workers tasked with clearing rubble and 

debris from transportation routes, repairing critical transportation infrastructure, stabilizing damaged utilities 

(e.g., gas, electric, and water), assessing structural damages to buildings, bridges, and other structures, and other 

critical engineering-related tasks. 

13 In some computer simulated high-density urban scenarios, several hundred thousand people may be at risk of 

death following a 10 KT nuclear explosion where effective planning and response actions could save many of 

them. 

Radiation safety and measurement training should be required of any workers that 

could potentially be deployed to a radiation area. 

Radiation detection equipment should be capable of reading dose rates up to 1,000 

R/hour. 
33

mission execution. Planning for response in impacted areas according to zones (by type and 

magnitude of physical impact and level of radiation) will help planners optimize response 

asset allocation and deployment of resources to most effectively support the life-saving 

activities. For example, areas where significant street rubble is expected warrant rapid 

deployment of street clearing equipment to allow access to areas where medical triage is a 

priority, or to open critical access routes for other key missions. Likewise, engineering teams 

may be needed to stabilize structures and utilities, such as water, gas, and power lines before 

fire, search and rescue, or medical teams can enter. 

The nature and magnitude of impacts provides indicators for prioritizing search and rescue 

and medical triage missions. For example, close to ground zero the likelihood of survivors is 

very low. Other zones will have varying proportions of injured people, and varying degrees 

of injury, thus providing rough indicators where scarce resources may be best deployed. 

Planning response activities by zones based on the magnitude and type of impact and 

expected casualties will help planners set priorities to realize the greatest number of lives 

saved. 

Finally, high radiation from fallout may overlay zones with heavy physical impacts as well as 

outlying areas with no physical impact at all. Therefore, planning in these zones must 

account for heavy damage, moderate or light damage, and no damage at all, depending on the 

distance from ground zero along the path of fallout deposition. Areas of combined physical 

(trauma and burn) and radiation impacts also generate casualties with combined physical and 

radiation health impacts. These combined injuries significantly reduce survival. The ability to 

plan response around combined impact zones will help officials plan for and focus efforts 

where life-saving activities will realize the most lives saved. 

In Chapter 1, four zones were described based on the magnitude of physical damage and 

radiation levels associated with fallout. Emergency response operations can be planned 

using these four zones. They are provided again for convenience as Figure 2.1: the light 

damage (LD) zone; the moderate damage (MD) zone; and, the “no-go” (NG) zone; and, 

Figure 2.2: the dangerous fallout (DF) zone. 
34

All approximated distances from center of detonation site

No-go (NG) Zone

Moderate Damage (MD) Zone

Light Damage (LD) Zone

No-go (NG): Buildings 

completely destroyed; radiation 

prevents entry into the area; 

lifesaving is not likely

Light Damage (LD): Windows 

mostly broken, injuries 

requiring self- or outpatientcare

~0.6 mi

~ 3 mi

Moderate Damage (MD): 

Significant building damage 

and rubble, downed utility 

poles, overturned 

automobiles, fires, many 

serious injuries; greatest 

lifesaving opportunities ~1 mi

Figure 2.1: Representative damage zones for 10 KT nuclear explosion (not to scale; circles are 

idealized here for planning purposes) (Identical to Figure 1.1) 

~ 10 to 20 miles

LD MDNG

DF

Figure 2.2: Representative dangerous fallout (DF) zone for a 10 KT nuclear explosion in which 

an early and direct threat from fallout radioactivity exists. A radiation exposure rate of 10 

R/hour is used to delimit this zone. (Identical to Figure 1.4) 
35

LD Zone Response

The outer perimeter of the LD zone will become recognizable when responders consistently 

see broken windows. The outer perimeter of the LD zone is arbitrarily set at approximately 

25% observable broken windows. The LD zone will require some street clearing of small 

rubble and debris and stalled or crashed vehicles. Passage into this zone will become 

increasingly difficult and require heavy equipment and debris removal capabilities. 

Responders may encounter elevated radiation in the LD zone; however; elevated radiation 

doses would be associated predominantly with the major path of fallout deposition where the 

DF zone is overlaying. 

The severity of injuries responders will encounter in the LD zone should be relatively light, 

consisting mostly of superficial wounds. Elevated radiation doses from prompt radiation and 

burns from the detonation itself (see Chapter 1) are not expected in the LD zone because of 

the distance from ground zero and the shielding provided by buildings. Injuries are 

anticipated to result primarily from flying glass and debris, falls, and traffic accidents. Glass 

and other projectile penetrations are expected to be superficial (e.g., 1 centimeter depth) in 

the torso, limbs, and face. Eyes are particularly vulnerable. As responders proceed inward 

they will begin to observe an increasing frequency and severity of injuries from flying glass 

and debris, and crush, translation and tumbling injuries.14 Glass shards will become 

prominent in injured individuals. Glass alone, depending on where it has entered the body, 

may present a direct threat to life. In summary, the most injuries incurred within the LD zone 

are not expected to be life threatening. Injuries resulting from traffic accidents are likely to 

be the most serious injuries in the LD zone. As responders penetrate further in towards the 

MD zone, the number and severity of physical injuries will increase. 

Responders should expect LD zone survivors to be panicked and confused, and to request 

medical assistance. A small percentage of injured in the LD zone may require emergency 

care, for example, for severe blood loss or head injury from a traffic accident. But, the 

population as a whole in the LD zone is anticipated to have a good chance for survival 

without immediate medical attention. Responders should resist spending time and resources 

on minor injuries in order to maximize the use of medical resources on more critical needs 

closer in to ground zero. Response actions in this zone should be focused on encouraging 

individuals to stay safely sheltered so that responders can expedite access to MD zone 

casualties. 

 

14 Translation and tumbling injuries are those incurred when people are thrown about and into solid objects by 

the blast wave. 

Responders should focus medical attention in the LD zone only on severe injuries and 

should encourage individuals to shelter in safe locations to expedite access to severely 

injured individuals. 

Most injuries incurred within the LD zone are not expected to be life threatening. 

Most of the injuries would be associated with flying glass and debris, falls, and traffic 

accidents. 
36

As responders continue to advance into and through the LD zone, the occurrence of shattered 

windows continues to increase until all glass is shattered in buildings, and damage to roofs 

and building facades is observed. Some lighter buildings are collapsed. Injury from flying 

glass and debris will be more severe and serious injuries associated with building structural 

damage will increase. At this point, responders are entering the MD zone. 

MD Zone Response 

While no clear demarcation exists, responders may recognize the transition to the MD zone 

by the prevalence of significant building structural damage. Observations in the MD zone 

include significant structural damage, overturned vehicles, and fires. In the MD zone sturdier 

buildings (e.g., reinforced concrete) will remain standing, lighter commercial and multi-unit 

residential buildings may be structurally unstable or collapsed, and many wood framed and 

brick residential structures will have collapsed. Telephone poles and street light poles may 

be blown over. Substantial rubble in streets from damaged buildings and crashed and 

overturned vehicles should be expected, making evacuation and passage of rescue vehicles 

very difficult or impossible without street clearing. Within the MD zone, broken water and 

utility lines and numerous fires should be expected. 

A major threat to survivors may be fire. Fire was a major cause of death in the nuclear attack 

on Hiroshima; however, experts suggest that differences in modern US city design and 

construction make a raging firestorm unlikely. Fires in tall office buildings can lead to high 

concentrations of fatalities. Water pressure for firefighting is a major concern because of 

damage to the utility systems, and trained engineering teams will be required to stabilize 

them. This challenge may take many hours as deep rubble in the streets will make access by 

response vehicles very difficult or impossible without concerted street clearing and debris 

hauling efforts. 

The MD zone is expected to have a high proportion of survivors, many of whom will have 

life-threatening injuries. The greatest opportunity to effect life-saving in the MD zone is in 

areas not affected by fallout (i.e., where the DF zone is overlapping the MD zone). All early 

response activities in this zone should facilitate delivery of medical care to survivors. 

Prompt access, search and rescue, and delivery of medical attention is essential to 

maximizing lives saved, but this zone poses great challenges in access, search and rescue, 

fire, and hazards to response workers. 

Response planning must be city-specific. Targeted search and rescue missions may be 

sensible in the MD zone, such as locations with special populations (e.g., schools or 

hospitals), or in discrete locations such as tunnels and subways. As a result of the extent of 

impacts and hazards, an effective response will require well-planned, expeditious actions to 

maximize saving lives. Therefore, early response planning should focus on facilitating MD 

zone medical triage. However, responders should enter the MD zone and focus response 

efforts in areas outside the dangerous fallout (DF) zone, except to implement shelter or 

evacuation orders as appropriate. This approach will help maximize life-saving while 

preserving the viability of the responder workforce. 
37

The MD zone presents significant hazards to response workers that must be considered and 

planned for, including elevated radiation levels, unstable buildings and other structures, 

downed power lines, ruptured gas lines, hazardous chemicals, and sharp metal objects and 

broken glass. Fires fed by broken gas lines, ruptured vehicle fuel tanks, and other sources 

will be prevalent and may pose a significant danger to survivors and responders. Visibility in 

much of the MD zone may be low for an hour or more after the explosion resulting from dust 

raised by the shock wave and from collapsed buildings. Low visibility may be exacerbated 

and extended in duration because of smoke from fires. 

Radiation levels in the MD zone may be very high, especially in the first hours after the 

incident. High radiation may be a result of local deposition of fallout debris and/or from 

neutron activation of local materials. Where the primary path of fallout deposition (the DF 

zone) crosses the MD zone, radiation levels are expected to be elevated and pose an 

imminent danger for 12 hours or more. Responders advancing into a zone should always be 

led by radiation assessment teams or adequately equipped and trained Haz Mat teams to 

characterize the radiation threat. A mission into a radioactive zone should always have a 

benefit that justifies the anticipated radiation dose to response workers. 

In summary, the MD zone should be the heart of a nuclear explosion response, with the goal 

of managing the impacted scene through aggressive rubble removal and site access, fire 

suppression, and structural and utility stabilization, in order to facilitate expeditious search 

and rescue and medical triage. Response planners should develop plans for MD zone 

response that includes: 

• Establishing nuclear emergency response protocols that maximize life-saving 

potential 

• Organizing neighboring response units 

• Establishing Incident Command (IC) 

• Deploying radiation assessment teams, engineering response teams (e.g., road 

clearing, debris hauling capabilities), Haz Mat and search and rescue teams, and 

medical response teams 

NG Zone Response

Once the responder recognizes severe damage to infrastructure such as complete building 

destruction and high rubble piles completely preventing access, the chance of encountering 

survivors is minimal, and prohibitive risks to response workers should be assumed. However, 

Response within the MD zone requires planners to prepare for elevated radiation 

levels, unstable buildings and other structures, downed power lines, ruptured gas lines, 

hazardous chemicals, sharp metal objects, broken glass, and fires. 

The MD zone should be the focus of early life-saving operations. Early response 

activities should focus on facilitating medical triage with constant consideration of 

radiation dose minimization. 
38

as the overall response progresses, the Incident Commander may consider strategic rescues 

within the NG zone. Response within the NG zone should not be attempted until radiation 

dose rates have dropped substantially in the days following a nuclear detonation, and the MD 

zone response is significantly advanced. At that point, search and rescue efforts may focus on 

underground structures that could have maintained their integrity. 

DF Zone Response 

Fallout will likely be widespread longitudinally along the path of upper level winds, and 

locally fallout may also exhibit significant spread as a result of lower level winds. In the DF 

zone, fallout particles may be visible as fine sandy material, either actively falling out as the 

plume passes, or visible on clean surfaces. Visible fallout provides strong evidence of 

dangerous levels of radioactivity. But, fallout may not be noticeable on rough or dirty 

surfaces, and there is no method to reliably estimate radiation dose rates based on the 

quantity of visible fallout. Therefore, visible fallout may possibly be used as an indicator of 

a direct radiation hazard, but the lack of apparent fallout should not replace appropriate 

radiation measurements. 

High levels of radiation from fallout pose a direct threat to survivors and response workers.15 

The National Council on Radiation Protection and Measurements (NCRP) has recommended 

10 R/hour (R/hour) as a nuclear-explosion fallout zone delimiter, stating responders should,

“Establish an inner perimeter at 10 R hour-1 exposure rate (~0.1 Gy hour-1 air-kerma rate). 

Exposure and radioactivity levels within the inner perimeter have the potential to produce 

acute radiation injury and thus actions taken within this area should be restricted to timesensitive, mission-critical activities such as life-saving.”(NCRP, 2005). Thus, the perimeter 

of the DF zone is defined by an exposure rate of 10 R/hour. The 10 R/hour point would 

normally indicate that workers should return to a safe area, unless they are undertaking a 

sufficiently important mission; a mission with a benefit that justifies the anticipated radiation 

dose. This exposure rate also indicates that much higher rates may be nearby and is useful 

for making shelter/evacuation decisions (see Chapter 3). 

Fallout will also traverse the physical damage zones. Dangerous levels of fallout are 

expected in the MD and LD zones as well as areas that are otherwise unaffected, for example 

10 to 20 miles from ground zero. Lower level fallout will continue for a hundred miles or 

more (see Chapter 3 for shelter and evacuation planning recommendations). As stated in 

Chapter 1, the highest hazard from fallout occurs within the first four hours and continues to 

drop as the fission products decay. As radioactivity levels drop, the DF zone will steadily 

shrink. 

 

15 The other source of residual radioactivity after a nuclear explosion is induced radioactivity in materials (e.g., 

construction materials, rock, and soil) resulting from neutron absorption. Generally, in the scenario being 

considered here, significant neutron activation will not occur beyond the NG zone. Activation radioactivity 

decays rapidly similar to the decay rate for fallout. 

Response within the NG zone should not be attempted until radiation dose rates have 

dropped substantially in the days following a nuclear detonation, and the MD zone 

response is significantly advanced. 
39

The most important mission in the DF zone is communicating protective action orders to the 

public. Generally, the order would be to seek and remain in a robust shelter until advised 

otherwise to avoid exposure to fallout. This communication is a temporary action until the 

affected population can be evacuated in a safe and orderly fashion. Preparedness planning 

and effective communication plans, messages, and means of delivery will be the key to 

survival for many in the DF zone. 

Radiation exposure rates in high-fallout areas can reach thousands of R/hour, delivering 

doses that are fatal. Allowing time for radioactive decay of fallout significantly improves the 

ability to respond safely. When planning response in highly radioactive zones, the time for 

decay must be weighed against the urgency of saving lives. In the most critical time period, 

the first hours after the explosion, radiation is also highest. Waiting could cost survivor’s 

lives; advancing could cost responder’s lives. The 7–10 rule, described in Chapter 1, is a 

useful rule-of-thumb for estimating radiation dose rates after a nuclear explosion. Officials 

and responders should not rely on the 7–10 rule in lieu of actual measurements when sending 

responders into radioactive areas. A healthy, viable responder workforce is critical to saving 

lives after a nuclear explosion. Incident Commanders should use great discretion in sending 

workers into highly radioactive areas, and planning and training are critical to successful 

post-nuclear response. 

Response Worker Safety 

Emergency response worker safety and health is an essential consideration in response 

planning. Emergency response workers will be the primary resource for the response. For a 

nuclear attack, emergency response workers will not only include fire and police, but will 

likely include emergency medical technicians, utility workers, and other skilled support 

personnel (such as truck drivers, equipment operators and debris contractors) that provide 

immediate support services during response operations. Besides the radiation hazards, these 

responders will face widespread fires, collapsing structures, chemical exposures, smoke/dust 

inhalation, and numerous other physical and health hazards. In general, emergency 

response workers do not have substantial experience working in radioactive environments. 

Safe emergency response actions within the LD, MD, and DF zones can only be 

accomplished with appropriate planning, responder training, provision and use of personal 

protective equipment (PPE), and other mission critical equipment, including dosimetry. 

The most important mission in the DF zone is communicating protective action orders 

to the public. Effective preparedness requires public education, effective 

communication plans, messages, and means of delivery in the DF zone. 

The highest hazard from fallout occurs within the first four hours and continues to 

drop as the fission radionuclides decay. 
40

Most organizations have a safety and health management program, but no single organization 

will be able to manage the vast array of significant hazards that must be conducted in order to 

sustain resources for all of the response operations. An emergency response worker safety 

management program for this scenario will need to be integrated into overall operations, 

reviewing the tasks and occupations involved in the operations, analyzing the hazards posed 

to the workers, and establishing the necessary protection for the workers. 

An emergency responder safety management program will need to be established as early on 

in the response as possible. Local responders would need to establish a base-level program 

that would expand as more response organizations arrive. As more organizations are brought 

into the response safety representatives of these organizations will need to be integrated. The 

safety management program will also need subject matter experts on the safety precautions 

necessary for the vast array of hazards. The challenge of the safety management program 

will be the need to track and analyze dosimetry for those responders who have entered the 

impacted area and provide this information back to the Incident Commander in a timely 

manner for making future operational decisions. 

Monitoring exposures of workers is significantly different from the atmospheric and 

environmental monitoring performed by the Federal Radiological Monitoring and 

Assessment Center (FRMAC). Atmospheric and environmental monitoring supports general 

mapping and plume modeling, but worker monitoring will need to address the specific dose 

received by each individual responder. Rather than general monitoring devices, each 

individual responder will likely need a dosimeter. Preparedness activities need to address 

how response organizations will obtain the vast quantity of dosimeters that will be needed. 

Components of the emergency responder safety management program would need to include 

the following: 

• Hazard risk assessments for each operation to minimize exposure during the response 

• Worker safety and health needs assessment 

• PPE including respirators for every responder 

• Dosimetry including electronic alarming dosimeters 

• Data management to track responders and their accumulated dose should be 

performed 

• Training and communication will need to be performed 

• Preparations for a medical surveillance program will need to be performed 

The DHS Planning Guidance (DHS 2008) provided a summary of radiation emergency 

worker guidelines, similar to the EPA 1992 PAG Manual (EPA 1992). The summary table 

provided the following dose guidelines in alignment with emergency worker activities: 5 rem 

for all response actions, 10 rem for protecting valuable property necessary for public welfare 

(e.g., power plants), and 25 rem for lifesaving activities. The 25rem dose recommendation 

was footnoted as follows: 

“EPA’s 1992 PAG Manual states that “Situations may also rarely occur in 

which a dose in excess of 25 rem for emergency exposure would be 
41

unavoidable in order to carry out a lifesaving operation or avoid extensive 

exposure of large populations.” Similarly, the NCRP and ICRP raise the 

possibility that emergency responders might receive an equivalent dose that 

approaches or exceeds 50 rem (0.5 Sv) to a large portion of the body in a short 

time (NCRP 1993; ICRP 1996). If lifesaving emergency responder doses 

approach or exceed 50 rem (0.5 Sv), emergency responders must be made 

aware of both the acute and the chronic (cancer) risks of such exposure.” 

The DHS guidance document and the emergency worker guidelines were developed for a 

wide range of possible radiological scenarios, from a small radiological dispersal device 

(RDD) that may impact a single building to an improvised nuclear device (IND) that could 

potentially impact a large geographic region. The guidance does not represent strict dose or 

dose rate limits. The 5, 10, and 25 rem guidelines should not be viewed as inflexible limits 

applicable to the range of early phase emergency response actions covered by this guidance. 

The guidelines should serve as decision points for planning for the protection of emergency 

response workers as well as for making worker protection decisions during emergency 

response to a nuclear detonation. Because of the range of impacts and case-specific 

information needed, it is impossible to develop a single turn-back dose level for all 

emergency responders to use in all situations, especially those that involve life-saving 

operations. However, the guidance does provide recommendations and decision points at 

which emergency responders must have the training necessary to understand and consent to 

progressively higher radiation doses. 

Decisions regarding emergency response actions in incidents involving high-radiation 

exposures require careful consideration of the benefits to be achieved by the “rescue” or 

emergency response action (e.g., the significance of the outcome to individuals, large 

populations, general welfare, or valuable property necessary for public welfare), and the 

potential health impacts (i.e., acute and chronic) to emergency workers. The planning for a 

potential high-radiation exposure incident should provide how to weigh the potential for and 

significance of the success of the emergency response or rescue operation against the 

potential for and significance of the health and safety risks to the emergency workers 

participating in the response action. 

State and local emergency response officials should use these guidelines to develop specific 

operational plans and response protocols for protection of emergency response workers. It is 

essential to ensure that emergency workers are trained so they have full knowledge of the 

associated risks prior to initiating emergency action. Having adequate training is also 

necessary for emergency response workers to give informed consent. Indeed above 5 rem 

(the normal occupational dose limit), worker participation should proceed only on a 

voluntary basis. It is also essential that emergency responders have adequate PPE and other 

equipment for responding to the incident and are provided a medical evaluation after 

exposure. 

Incident Commanders should make every effort to employ the “as low as reasonably 

achievable” (ALARA) principle when responding to an incident. Protocols for maintaining 

ALARA doses should include the following health physics and industrial hygiene practices: 
42

• Maintain distance from sources of radiation 

• Shield the radiation source 

• Minimize the time spent in the contaminated area (e.g., rotation of emergency 

responders) 

• Use personal dosimeters (radiation badges) and alarming dosimeters to determine 

dose 

• Properly select and use respirators and other personal protective equipment (PPE), 

appropriate for minimizing dose to internally deposited radioactive materials 

(e.g., alpha and beta emitters) 

• Use prophylactic medications, when appropriate, that block the uptake or reduce 

the retention time of radioactive material in the body 

Responding to a nuclear detonation in communities will be extremely difficult and 

hazardous. Therefore, it is absolutely essential that there be detailed advance planning and 

preparation, including purchasing and prepositioning the necessary equipment for 

responders. Planning should include evaluating data (radiation survey and personal 

monitoring) and information on possible or anticipated radiation exposures from a nuclear 

explosion, developing procedures for reducing and controlling exposures of all workers 

involved in the emergency response action, and developing appropriate decision-making 

criteria for responding to the nuclear detonation. Planning should also address how to obtain 

and preposition essential equipment that includes appropriate personal protective equipment 

(e.g., respirators, clothing) for protecting emergency responders who enter contaminated 

areas, radiation detection meters or other measurement equipment, and personal dosimeters. 

Respiratory protection of emergency responders is an essential issue that will need to be 

addressed during the planning phase and also during the emergency. Initially, emergency 

responders will need respiratory protection as exposure levels are being characterized. The 

National Institute of Occupational Safety and Health (NIOSH) has prepared guidance on 

selecting appropriate PPE for response to terrorism incidents involving chemical, biological, 

and radiological events (DHHS, 2008). OSHA's web site is a resource for emergency 

response planning and action as it provides guidance on the proper use of respiratory 

protection equipment (http://www.osha.gov/). Effective advance planning will help to ensure 

that the emergency worker guidelines are correctly applied and that emergency workers are 

not exposed to radiation levels that are higher than necessary in the specific emergency 

action. 
43

Additional Guidance for State and Local 

Planners 

Additional guidance for state and local 

emergency response planners is available from 

several sources. There are a number of resources 

available that can be used to establish 

recommendations regarding emergency 

responder dose limits. The EPA’s guidance 

provides for greater than 25 rem (0.25 Sv) for 

lifesaving activities or protection of large 

populations (EPA, 1992). There is no upper limit 

provided by the EPA guidance. The newly 

published DHS Planning Guidance (DHS, 2008) 

modifies the EPA guidance (EPA 1992) slightly 

as described in Table 2.3 in the grey box that 

follows. The National Council on Radiation 

Protection and Measurement (NCRP) (NCRP 

2001b), International Commission on 

Radiological Protection (ICRP) (ICRP 1996), 

and the Conference of Radiation Control 

Program Directors (CRCPD 2006) all provide 50 

rem (0.5 Sv) for life-saving. Finally, the 

International Atomic Energy Agency (IAEA) 

(IAEA 2006) provides a recommendation of 100 

rem (1 Sv) for life-saving. 
44

NCRP’s Commentary 19 (NCRP 2005) provides additional responder guidelines that are 

applicable for consideration in planning for nuclear detonation response. These guidelines 

only address short-term (acute or deterministic) effects. Exposure at these levels can also 

result in long-term (lifetime cancer or stochastic) health effects. The NCRP guidelines are 

summarized in Table 2.3. 

Table 2.3: NCRP Emergency Responder Guidelines (Adapted from NCRP 

Commentary 19 (NCRP 2005)) 

CONCEPT VALUE EXPLANATION 

Inner 

Perimeter 

10 R/hour Responders should establish an inner perimeter (e.g., an 

operational boundary) at an exposure rate of 10 R/hour. Exposure 

and radioactivity levels within the inner perimeter have the potential 

to produce acute radiation injury and thus actions taken within this 

area should be restricted to time-sensitive, mission-critical activities 

such as life-saving. 

Decision 

Dose 

50 rad The cumulative absorbed dose that triggers a decision on whether 

to withdraw an emergency responder from within or near (but 

outside) the inner perimeter is 50 rad (50 cGy). 

Responder 

Acute 

Radiation 

Sickness 

>100 rad Nausea and vomiting are among the earliest clinical signs of acute 

radiation sickness. Nausea and vomiting are symptoms that occur 

as whole-body absorbed doses become high [i.e., >100 rad (>1 

Gy)]. If these symptoms occur during the conduct of activities 

within a radiation area, the affected individual(s) should be 

removed from the area, and provided appropriate medical care. 

ALARA for 

Terrorism 

Incidents 

n/a In a nuclear terrorism emergency, it may be neither practical nor 

appropriate for radiation protection considerations to automatically 

be governed by guidelines applied in more routine scenarios. While 

the fundamental concept of keeping all radiation exposures as low 

as reasonably achievable (ALARA) should still apply, it may not be 

realistic to apply other traditional radiation protection guidelines for 

limitation of radiation dose. The traditional guidelines are based on 

an assumption of low-level exposure over long periods, and govern 

activities and situations that are more controllable and are not as 

critical as those associated with responding to a nuclear terrorism 

incident. 

Radiation 

Control for 

Terrorism 

Incidents 

n/a The approach to worker radiation protection in a terrorism incident 

is based on two considerations: (1) the identification of radiation 

control zones, and (2) the control of the absorbed dose to 

individual emergency responders. The radiation control zones 

segment the site into areas of differing levels of radiation risk by 

using observed exposure rates. The absorbed dose to an individual 

emergency responder governs decisions regarding duration (stay 

time) for various emergency response activities. 

 
45

 

References 

Conference of Radiation Control Program Directors, Inc. 2006. Handbook for Responding 

to a Radiological Dispersal Device. First Responder’s Guide— the First 12 Hours. 

http://www.crcpd.org/RDD_Handbook/RDD-Handbook-ForWeb.pdf. 

International Atomic Energy Agency (IAEA). 2006. Manual for First Responders to a 

Radiological Emergency. http://wwwpub.iaea.org/MTCD/publications/PDF/EPR_FirstResponder_web.pdf. 

International Commission on Radiological Protection (ICRP). 2005. ICRP Publication 96: 

Protecting People Against Radiation Exposure In The Event Of A Radiological 

Attack, Report 96 (Ottawa). 

National Council on Radiation Protection and Measurements (NCRP). 1993. Limitation of 

Exposure to Ionizing Radiation, National Council on Radiation Protection and 

Measures, Report 116 (Bethesda). 

NCRP. 2001a. Management of Terrorist Events Involving Radioactive Material, Report No. 

138 (Bethesda). 

NCRP. 2001b. Limitation of Exposure to Ionizing Radiation. Report No. 116 (Bethesda). 

NCRP. 2005. Key Elements of Preparing Emergency Responders for Nuclear and 

Radiological Terrorism, Commentary No. 19 (Bethesda). 

US Department of Defense. Departments of the Army, the Navy, and the Air Force, and 

Commandant, Marine Corps. 2001. Treatment of Nuclear and Radiological 

Casualties. ARMY FM 4-02.283, NAVY NTRP 4-02.21, AIR FORCE AFMAN 44-

161(I), MARINE CORPS MCRP 4-11.1B. 

http://www.globalsecurity.org/wmd/library/policy/army/fm/4-02-283/fm4-02-

283.pdf. 

US Military Planning 

The US Military has established a system for mission-specific risk-based dose limits that 

includes life-saving activities. In current doctrine, US military personnel become 

restricted from ever again engaging in operational radiological/nuclear missions once they 

have exceeded 125 rad (125 cGy) dose accumulation. Whereas military commanders set 

their Operational Exposure Guidance (OEG) (i.e., dose limits to US troops) at any level in 

nuclear war, the risk analysis for extremely high-priority missions, to include life-saving, 

yields a maximum OEG of 125 rad (125 cGy). For operations other than war and also 

based on mission priorities and risk analysis, military commanders limit OEG levels to 75 

rad (75 cGy) and below. (DOD 2008; DOD 2001) 
46

US Department of Defense. Departments of the Army, the Navy, and the Air Force, and 

Coast Guard. 2008 Operations in Chemical, Biological, Radiological, and Nuclear 

(CBRN) Environments, Joint Publication 3-11. 

http://www.dtic.mil/doctrine/jel/new_pubs/jp3_11.pdf. 

US Department of Health and Human Services. Centers for Disease Control. 2008. 

Guidance on Emergency Responder Personal Protective Equipment (PPE) for 

Response to CBRN Terrorism Incidents. http://www.cdc.gov/niosh/docs/2008-

132/pdfs/2008-132.pdf. 

US Department of Homeland Security. Federal Emergency Management Agency. 2008. 

Planning Guidance for Protection and Recovery Following Radiological Dispersal 

Device (RDD) and Improvised Nuclear Device (IND) Incidents, Federal Register, 

Vol. 73, No. 149. http://www.fema.gov/good_guidance/download/10260. 

US Environmental Protection Agency. Office of Radiation Programs. 1992. Manual of 

Protective Actions Guides and Protective Actions for Nuclear Incidents. 

http://www.epa.gov/radiation/docs/er/400-r-92-001.pdf. 
47

Chapter 3 - Shelter / Evacuation Recommendations 

Overview 

One of the greatest threats to the life and health of people in the vicinity of a nuclear 

explosion is exposure to radioactive fallout. People may be exposed to dangerous levels of 

fallout in the moderate damage (MD) and light damage (LD) zones, and further out to 10 or 

20 miles in the dangerous fallout (DF) zone. There are two principle actions that may be 

taken to protect the public from fallout: taking shelter and evacuation. These protective 

actions may be self-executed by informed members of the public, or they may be 

KEY POINTS 

1. There are two principle actions that may be taken to protect the public from 

fallout: taking shelter and evacuation. 

2. The best initial action immediately following a nuclear explosion is to take 

shelter in the nearest building or structure and listen for instructions from 

authorities. 

3. Shelters such as houses with basements, large multi-story structures, and 

underground spaces (e.g., parking garages and tunnels), can generally reduce 

doses from fallout by a factor of 10, or more. These structures would generally 

provide shelter defined as “adequate.” 

4. Single-story wood frame houses without basements provide only minimal 

shelter. These structures may not provide adequate shelter for extended 

periods in the DF zone. 

5. Evacuations should be prioritized based on the fallout pattern and radiation 

intensity, adequacy of shelter, impending hazards (e.g., fire and structural 

collapse), fallout pattern and density, medical and special population needs, 

sustenance resources (e.g. food and water), and response operational and 

logistical considerations. 

6. When evacuations are executed, travel should be at right angles to the fallout 

path (to the extent possible) and away from the plume centerline, sometimes 

referred to as “lateral evacuation.” 

7. No evacuation should be attempted until basic information is available 

regarding fallout distribution and radiation dose rates. 

8. Decontamination of persons is generally not a lifesaving issue. Simply 

brushing off outer garments will be useful until more thorough 

decontamination can be accomplished. 
48

communicated and orchestrated by response officials during the incident. Timely decisions 

about shelter and evacuation are critical to saving lives and reducing radiation injuries. The 

effective implementation of protective actions during an incident is largely dependent on preevent preparedness and dissemination of guidance to the public. This section provides an 

overview of sheltering and evacuation and describes the protective actions and planning 

considerations for the decision-maker. 

Given the large uncertainties involved, recommendations presented here are necessarily 

general in nature and should be used to inform city-specific response planning and 

preparedness. In addition, both responders and the public will need to consider their own 

specific circumstances (physical condition, ease of egress, access to evacuation routes, and 

access to adequate shelter) in deciding the best course of action. 

The standard ways to reduce radiation exposure are as follows: reduce time in the zone, 

increase distance from the source of radiation (the fallout), and/or use of dense materials (like 

concrete, brick, or earth) as shielding against the radiation. In the case of widespread fallout, 

the primary protective actions are to take shelter and to evacuate. Evacuation reduces time 

spent exposed to radiation; the goal, of course, is to avoid exposure. Sheltering protects 

people by (a) providing shielding, and (b) increasing distance from fallout, especially in the 

center of a large building. To take "shelter" as used in this document means going in, or 

staying in, any enclosed structure to escape direct exposure to fallout. “Shelter” may include 

the use of pre-designated facilities or locations. It also includes locations readily available at 

the time of need, including staying inside where you are, or going immediately indoors in 

any readily available structure. “Adequate” shelter is shelter that protects against acute 

radiation effects, and significantly reduces radiation dose to occupants during an extended 

period. 

The objectives of guidance in this chapter are as follows: 

• Protect the public from the acute effects of high radiation exposure associated with 

fallout in the initial 72 hours after a nuclear explosion. Generally, symptoms will 

occur with radiation doses approaching 100 rad. The potential for acute radiation 

effects increases with higher radiation doses, and above 200 rad medical treatment 

will likely be needed. 

• Reduce long-term risks from radiation exposure associated with fallout from a 

nuclear explosion. 

• Ensure that actions taken result in more benefit than harm to both individuals and the 

public. 

There are two principle actions that may be taken to protect the public from fallout: 

taking shelter and evacuation. 
49

Protective Actions 

Protective Action Recommendations 

The Environmental Protection Agency (EPA) publishes protective actions guides (PAGs)16

for nuclear incidents. The Department of Homeland Security “Planning Guidance for 

Protection and Recovery Following Radiological Dispersal Device (RDD) and Improvised 

Nuclear Device (IND) Incidents” (DHS 2008) affirms the applicability of existing EPA 

guidance for radiological dispersal device (RDD) and improvised nuclear device (IND) 

incidents in areas beyond those subject to the elevated radiation dose rates and other impacts 

associated with a nuclear explosion. The radiation protection principles, however, are the 

same regardless of the potential dose or circumstances. The difference in the case of a 

nuclear explosion is that priority must be given to the radiation protection principle that 

acute-level radiation exposures should be prevented. Existing PAGs could be applied in 

areas outside the DF zone, which could be below the radiation level of acute health effects. 

They should also be applied during the intermediate phase of the incident, when relocation 

would be considered as a protective action. 

As stated earlier, the primary means of protecting the public from radiation associated with 

fallout following a nuclear explosion is to shelter and/or to evacuate. Secondary protective 

actions include removal of fallout particles from one’s clothing and body (decontamination), 

and avoiding inhaling and ingesting fallout particles. Planners should consider what actions 

are to be recommended to the public, where those actions would apply, how they would be 

communicated, how they would be supported and implemented by responders, and what 

resources are needed for successful implementation. 

Nuclear explosion impacts are complex and extensive (see Chapter 1). No single protective 

action will be adequate for all locations and times; therefore planners should consider the 

following three tiers of protective action recommendations: 

1. Generic recommendations issued in advance of an incident that are coupled with 

public education and outreach. Pre-designated public shelters may be part of this 

strategy for communities that do not have abundant, adequate shelter options. 

2. Initial recommendations issued as soon as possible after an incident, which are 

based on little or no incident data. Generally, the recommendation would be for 

the public to take shelter immediately in the most adequate, readily available 

shelter. 

3. Follow-up recommendations issued once additional data and information become 

available. These recommendations may include continued shelter for a set period 

of time followed by evacuation, and specific evacuation instructions for selected 

areas or populations, such as heavily impacted areas or for vulnerable 

populations. The most important information influencing these recommendations 

will be the local distribution and extent of the fallout, the intensity of fallout 

radiation, and the available shelter and evacuation options. 

 

16 A protective action guide (PAG) is the projected dose to a reference individual, from an accidental or 

deliberate release of radioactive material, at which a specific protective action to reduce or avoid that dose is 

recommended. 
50

Shelter Recommendations 

Sheltering in the most accessible building or structure is the best initial action immediately 

following a nuclear explosion. This includes "Shelter-in-place", which means staying 

inside, or going immediately indoors in any readily available structure. People should 

remain sheltered and listen for instructions from authorities. Even in areas where fallout has 

not yet arrived, sheltering is advised until it is clear where the fallout areas are. Otherwise, 

evacuees could be caught outside when the fallout arrives or flee unaffected areas and 

unknowingly enter into a fallout area. 

“Adequate shelter” is defined as shelter that protects against acute radiation effects, 

and significantly reduces radiation dose to occupants during an extended period. The 

adequacy of shelter is a function of initial radiation dose rates when fallout arrives, and the 

dose rate reduction afforded by the structure. A shelter far from the DF zone may be 

adequate even if it provides little shielding, whereas the same shelter close into the DF zone 

may not be adequate. The primary risk from nuclear fallout is penetrating radiation that 

needs to be reduced as much as possible by shielding using dense building material, and 

increased distance from deposited fallout, including on roofs, that may be afforded by large 

buildings. Good shielding materials include concrete, brick, stone and earth, while wood, 

drywall, and sheet metal provide minimal shielding. Basements and large concrete structures 

are good examples of adequate shelter. Large buildings often have thick walls of concrete or 

other refractory material, but also provide the benefit of increased distance from deposited 

fallout materials when people gather away from exterior walls. This distance from exterior 

walls and roofs can substantially reduce radiation dose to those sheltering. 

Shelters such as houses with basements, large multi-story structures, and underground spaces 

(e.g., parking garages, and tunnels), can generally reduce doses from fallout by a factor of 10, 

or more. These structures would generally provide adequate shelter, and individuals with 

ready access to these structures would protect themselves effectively even where initial 

unshielded fallout dose rates would result in lethal radiation dose levels. 

Some structures offer limited fallout protection, particularly single-story wood frame 

structures without basements. These structures may not provide adequate shelter for extended 

periods in the DF zone. Emergency managers may have to issue supplemental orders to 

those sheltering in wood frame structures (e.g., stay in the center of the structure at ground 

level) in order to minimize dose while sheltering. Because shelter in these and similar light 

structures may not be adequate for extended periods, consideration should be given to 

expedited evacuation of people sheltered in them, especially in the DF zone. Figure 3.1 

Shelters such as houses with basements, large multi-story structures, and 

underground spaces (e.g., parking garages and tunnels), can generally reduce doses 

from fallout by a factor of 10, or more. These structures would generally provide 

shelter defined as “adequate.”

The best initial action immediately following a nuclear explosion is to take shelter in 

the nearest building or structure and listen for instructions from authorities. 
51

provides a summary of the radiation exposure reduction factors as a function of building type 

and location within the building. Table 3.1 presents a tabular summary of radiation reduction 

factors for buildings. 

 

Single-story wood frame houses without basements provide only minimal shelter. 

These structures may not provide adequate shelter for extended periods in the DF 

zone. 

Figure 3.1 a: Building as shielding – 

numbers represent a dose reduction 

factor". A dose reduction factor of 10 

indicates that a person in that area 

would receive 1/10th of the dose of a 

person in the open.

Figure 3.1 b: Building as shielding: 

numbers represent a dose reduction 

factor. A dose reduction factor of 

200 indicates that a person in that 

area would receive 1/200th of the 

dose of a person out in the open.
52

Radiation Reduction Factors of Buildings and Structures 

Structure Gamma Reduction Factor 

3-feet Underground 5000 

Frame House 2-3 

Basement 10-20 

Vehicle 1-2 

Multi-story Buildings 

Apartment 

 Upper stories 100 

 Lower stories 10 

Concrete Blockhouse Shelter 

 9-inch walls 11-140 

 12-inch walls 30-1000 

 24-inch walls 500-10,000 

Table 3.1: Radiation reduction factors for various structures; adapted from Glasstone and 

Dolan (Glasstone and Dolan 1977). A reduction factor of 1 indicates no reduction. A factor of 

10 is presumed adequate shelter. 

Sheltering is implicitly short term; everyone sheltering should be evacuated at some point 

until the safety of the area can be confirmed by officials. The duration of time spent in 

shelter may range from short, on the order of hours, to several days, depending on the fallout 

dose rates, adequacy of shelter, local factors and operational factors, and individual 

circumstances. 

Evacuation

Sheltering should be followed by staged, facilitated evacuation for those in fallout-impacted 

areas. Evacuations should be prioritized based on the fallout pattern and radiation intensity, 

adequacy of shelter, impending hazards (e.g., fire and structural collapse), medical and 

special population needs, sustenance resources (e.g., food and water), and response 

operational and logistical considerations. Evacuations should be planned so as not to 

obstruct access to transportation routes that are critical for ongoing life-saving missions. 

In far downwind areas, officials may be able to implement an orderly evacuation before the 

arrival of fallout, and should develop plans to communicate and carry out a rapid, orderly 

Evacuations should be prioritized based on the fallout pattern and radiation intensity, 

adequacy of shelter, impending hazards (e.g., fire and structural collapse), medical and 

special population needs, sustenance resources (e.g. food and water), and response 

operational and logistical considerations. 
53

evacuation. For areas closer in (including the DF zone), where fallout arrives quickly, 

evacuations should take place after a period of sheltering. 

Staged or Phased Evacuation 

Early evacuation may be needed to protect some people shortly following sheltering. The 

staging of evacuations should be driven by the hazard to members of the public and logistical 

considerations. Early evacuation should be considered for individuals who (1) are close to 

the detonation (generally within 10 miles), (2) are in the fallout area, (3) who do not have 

adequate shelter, and (4) who have special vulnerabilities, such as children or the elderly. 

In undamaged areas beyond the LD zone, evacuation should only be critical within the DF 

zone, but may be considered outside the DF zone as long as it does not hinder DF zone 

evacuation or other response operations. For some people in the LD, MD, and DF zones that 

are not adequately sheltered, are critically injured, or threatened by building collapse or fire, 

early evacuation may be required for their survival. Prioritization of early evacuation of at 

risk populations should be balanced against responder risk, modes of transport, ease of access 

and egress, control of fires in the area the ability to communicate with them, etc. 

Uninjured individuals with adequate shelter conditions may not be the highest priority for 

early evacuation. Similarly, priority evacuation should not be considered beyond twenty 

miles from the detonation as long as people have access to minimally protective shelter, 

including single-story frame houses without basements. 

Rapidly defining populations or areas that need early evacuation is a high priority. But, no 

evacuation should be attempted until basic information is available regarding fallout 

distribution and radiation dose rates. Evacuation strategies must take into account the 

dimensions and distribution of the fallout pattern and radiation dose rates. When evacuations 

are executed, travel should be at right angles to the fallout path (to the extent possible) and 

away from the plume centerline, sometimes referred to as “lateral evacuation.” This strategy 

maximizes dose reduction during the course of the evacuation. The fallout direction and 

deposition pattern may be difficult to ascertain without substantial field measurement of 

radioactivity, therefore, determining the deposition pattern is a high priority in the early 

hours after a nuclear explosion. Once the hazard area is defined and has been communicated 

to responders and the public, evacuations may proceed. Many people in the LD zone and 

beyond may be able to reach safety on their own, if they receive basic instructions. 

In issuing evacuation recommendations responders must consider route conditions such as 

rubble and debris in streets, traffic gridlock, uncontrolled fires, collapsed bridges, other 

No evacuation should be attempted until basic information is available regarding 

fallout distribution and radiation dose rates. 

When evacuations are executed, travel should be at right angles to the fallout path (to 

the extent possible) and away from the plume centerline, sometimes referred to as 

“lateral evacuation.” 
54

obstacles to mobility, and natural or manmade barriers (e.g., rivers and fenced areas). 

Attempting to evacuate everyone in too large an area could divert key resources from the 

zones of highest dose close to the detonation where radiation exposure control is most 

essential. Responders should assess the status of the transportation infrastructure as one of 

the top priorities in the first hours after a nuclear explosion. A poorly planned evacuation 

could result in unnecessary fatalities from radiation exposure, or other hazards that were not 

foreseen. 

If radiation measurement equipment is not available, and data and modeled projections are 

not available in a timely fashion, responders may need to rely on visual observations. Fallout 

particles may be visible as fine sandy material, either actively falling out as the plume passes, 

or visible on clean surfaces. Visible fallout is strong evidence of dangerous levels of 

radioactivity. But, fallout may not be noticeable on rough or dirty surfaces, and there is no 

method to reliably estimate radiation dose rates based on the quantity of visible fallout. 

Therefore, visible fallout may possibly be used as an indicator of a direct radiation hazard, 

but the lack of apparent fallout should not replace appropriate radiation measurements. 

 

It is also possible that the direction of the fallout plume may be estimated by some observers 

several miles away in unaffected areas. Such information would be of great value to the 

Incident Commander in making early protective action decisions. However, confirming and 

communicating fallout observation information in a timely fashion poses a significant 

challenge. 

In those areas subject to fallout, internal exposure (inhalation or ingestion) will be a 

secondary radiation protection concern. For evacuees, use of respiratory protection should 

not interfere with the primary objective of avoiding excessive external radiation exposure. 

Using even crude respiratory protection (e.g., breathing through a cloth mask) while in 

fallout areas can further reduce this concern. Responders, however, should maintain 

respiratory protection at all times during operations in contaminated areas. Responders 

should consider other potential critical needs of evacuees, such as critical medical care, and 

how those needs can be met in a timely manner. Decontamination of persons, however, is 

generally not a lifesaving issue. Simply brushing off outer garments in the course of 

evacuation will be useful until more thorough decontamination can be accomplished. 

Decontamination of persons is generally not a lifesaving issue. Simply brushing off 

outer garments will be useful until more thorough decontamination can be 

accomplished. 
55

Self Evacuations 

There may be circumstances where planned 

evacuation efforts are not practical given 

circumstances and time constraints. For 

instance, physical damage, impassible streets, 

and very high dose rates in the NG and MD 

zones will limit the ability of responders to 

access areas in standard ways to support an 

evacuation. In such cases, consideration should 

be given to supporting those who are able to 

self-evacuate. It is recognized that some selfevacuation will spontaneously occur following a 

nuclear explosion. Planners should anticipate self-evacuations and be prepared to assist 

those who self-evacuate to the extent possible. Assistance could include providing 

information to self-evacuees, including instructions about how best to leave the area, what 

direction to travel, and when to go. Support may also be provided to evacuees as they leave 

(e.g., public reception centers, medical treatment, transportation, self-decontamination 

instructions, etc.). Self-evacuation may also present a significant obstacle to emergency 

responder life-saving operations. Unnecessary evacuations can complicate those that are 

necessary. Public messaging and communication should clearly instruct self-evacuees what 

to do for their safety and protection, and to avoid hindering critical operations. 

No Evacuation 

For people who were initially sheltered but who are in areas where there is no fallout (or 

negligible fallout), evacuation based on radiation hazard will not be necessary (EPA 1992). 

It is possible, however, that non-radiological hazards may warrant protective actions. Once 

an area has been determined to be without significant fallout or other hazards from the 

incident, protective actions are no longer necessary. 

Decontaminating Vehicles 

The public may attempt to self-evacuate in either official or personal vehicles that may be 

contaminated. Although this may result in some spread of contamination, concern over 

spread of minor contamination should not hinder time-sensitive evacuations. The public 

should simply be directed to rinse or wash down vehicles as soon as practical once they are 

out of danger. More detailed instructions should be provided at a later time. When possible, 

official transit vehicles that are used to evacuate individuals from contaminated areas, should 

be surveyed and controlled (e.g., simple washing or rinsing in a common area) so as to 

minimize the potential for spreading contamination; however as in the case of personal 

vehicles, these actions should be implemented in a manner that does not restrict or inhibit 

necessary evacuations. If there is potential that these simple protective actions will slow 

down evacuations then they should be avoided. 

Planning Considerations 

Planning considerations are key factors to consider in planning for and ultimately 

implementing public shelter and evacuations. The planning considerations provided below 

Examination of the New York and 

Washington, D.C. events on 9/11 

showed that when numerous people 

evacuate a downtown business district, 

they are often on foot and headed 

toward public transit stations. A large 

proportion of the evacuees will have 

their residence as their intended 

destination, even if it is far beyond the 

distance they need to travel to be safe.
56

are not in priority order and the list is not exhaustive. Additional factors unique to each 

community should be considered during the planning process. 

Situation Assessment 

The path of fallout transport and deposition and the delineation of the DF zone are key pieces 

of information for early shelter and evacuation decision making. Planners should anticipate 

the need for this information and consider what resources and means they will use to obtain 

initial fallout projections. Weather information, computer models, visual observations, and 

access to early federally developed17 data and fallout projections will all be useful. Standard 

emergency response tools, including radiation detection instrumentation, used in other highhazard emergency situations will also be necessary. Planners should continuously assess 

information and be looking to fold in new resources as time passes and new information 

becomes available. It is recommended that state and local response officials immediately 

request federally produced fallout projections and recommendations on protective actions. 

Response officials will also need to quickly assess the status of infrastructure and the general 

impacted environment. Within a few hours, responders will need a basic assessment of the 

status of transportation systems (i.e., roads, bridges, rails, subways/tunnels, airports, and 

harbors); communications infrastructure; the electric power grid; water, sewer, and gas 

infrastructure; the number, location, and severity of fires; and building structural damages. 

These factors have a major influence on shelter and evacuation decisions. Prior to an 

incident, models and simulations can help estimate planning needs and constraints. 

Adequacy of Shelter 

Because the radiation protection properties of potential shelter structures are of significant 

importance, planners should evaluate the types of shelter commonly available in their 

planning area (e.g., basements and other below-ground structures, concrete structures, and 

multi-story structures) that can generally provide adequate shelter. Planners should 

specifically evaluate the occurrence and general locations of single-story, wood frame 

structures without basements. These structures provide limited protection against fallout 

radiation and may not be adequate for shelter. Planners should consider areas where 

adequate shelter is not readily available and develop options for protection of the public, 

including information and awareness messaging, evacuation plans, and self-protection 

measures the public may take. Planners in communities that generally lack adequate shelters 

should consider implementing a public shelter program that would meet the needs of the 

community. For example, cities in regions of the country where residential basements are 

uncommon should consider pre-designating large buildings as public shelters in which 

people nearby can quickly find adequate shelter. 

 

People occupying inadequate shelter may need to be selectively evacuated early to avoid 

acute exposures and minimize overall dose. Other factors that would warrant early selective 

evacuation include stability of the structure, critical medical needs, lack of basic resources 

such as water (especially after 24 hours), occurrence of fire, and other hazards that may 

threaten people’s lives. 

 

17 The Interagency Modeling and Atmospheric Assessment Center (IMAAC) is the official federal center for 

making fallout projections. 
57

Time 

For all protective actions, but especially for the immediate actions after a nuclear explosion 

has occurred, the speed with which protective action recommendations are issued and 

implemented is of primary importance. Delays in issuing and implementing 

recommendations (or orders) could result in a large number of unnecessary fatalities. 

Planners can expedite these early messages by preparing messages in advance and by 

planning how they will be communicated in an emergency. 

The following guidelines are designed to help planners. It is recognized that conditions may 

limit the ability of responders to meet these guidelines. They are provided for planning 

purposes only and as a basis for identifying planning and resource needs. 

• Initial projections of fallout deposition should be communicated to responders as 

rapidly as possible; at most within the first hour and updated every hour. 

• Initial self-protection recommendations should be communicated to the public as 

rapidly as possible, at most within the first hour. 

• Early evacuations, if appropriate, should begin as soon as possible and be completed 

within four hours. 

• Staged or phased evacuations (or relocations following sheltering-in-place) should 

begin, where appropriate, within 48 hours, depending on estimated radiation exposure 

of the subject population, and logistical and other factors. 

Communications 

The effectiveness of protective action recommendations depends on the ability to 

communicate with responders and the public. Planners should specifically consider 

communications problems that will be caused by a nuclear detonation (i.e., EMP and 

infrastructure damage) and recognize in their planning that normal means of communication 

may not be available. Mass communication methods and public guidance on stocking of 

battery powered radios may be appropriate. 

Transportation Planning 

A nuclear explosion will create particularly challenging circumstances for carrying out an 

evacuation. In a preplanned evacuation, information is available during the readiness phase 

of the incident and the factors that necessitate an evacuation. When no advance warning is 

given, incomplete, imperfect, and, at times, contradictory information about the incident is 

likely, at the same time decisions need to be made. Decision makers have little or no time to 

wait for additional or better information in a no-notice scenario because any delay will likely 

have a significant effect on the safety of their citizens; they must make decisions with the 

information available at the time. 

Because of the central role of evacuation in a response, transportation planners should be an 

integral element of the planning effort. Transportation and other planners should consider 

the full range of planning elements associated with a nuclear explosion. These may include 

the following: 
58

• Priority areas for evacuation and how to identify them 

• Access to the impacted zones 

• Transportation resources (vehicles, public transit, air, rail and water routes of egress) 

• Massive infrastructure damage (roads, bridges, tunnels, electricity), and 

• Evacuation routes, impediments to evacuation, and evacuation time estimates 

Further information may be found in the references listed at the end of this chapter in the 

Evacuation Bibliography. 

Long-Term Planning 

It should be anticipated that many people will be relocated for a lengthy period (months to 

years), even at great distances downwind, to avoid unnecessary exposure to fallout radiation. 

The EPA PAG for relocation in the intermediate phase is 2 rem in the first year. This should 

be taken into consideration when planning how far to extend recommendations for shelter 

during the first 72 hours. 

Evacuation Bibliography 

Nuclear Regulatory Commission (NRC). 2004. Effective Risk Communication (NUREG/BR0308): The Nuclear Regulatory Commission's Guideline for External Risk 

Communication. http://www.nrc.gov/reading-rm/doccollections/nuregs/brochures/br0308/index.html. 

NRC. 2005a. Identification and Analysis of Factors Affecting Emergency Evacuations - 

Main Report (NUREG/CR-6864, Vol. 1). http://www.nrc.gov/reading-rm/doccollections/nuregs/contract/cr6864/v1/. 

NRC. 2005b Identification and Analysis of Factors Affecting Emergency Evacuations - 

Appendices (NUREG/CR-6864, Vol. 2). http://www.nrc.gov/reading-rm/doccollections/nuregs/contract/cr6864/v2/. 

NRC. 2005c Development of Evacuation Time Estimate Studies for Nuclear Power Plants 

(NUREG/CR-6863). http://www.nrc.gov/reading-rm/doccollections/nuregs/contract/cr6863/index.html. 

U.S. Department of Transportation (DOT). Federal Highway Administration (FHA). 2006a. 

Operational Concept – Assessment of the State of the Practice and the State of the Art 

in Evacuation Transportation Management, FHWA-HOP-08-020. 

http://ops.fhwa.dot.gov/publications/fhwahop08020/fhwahop08020.pdf. 

U.S. DOT. FHA. 2006b. Interview and Survey Results: Assessment of the State of the 

Practice and the State of the Art in Evacuation Transportation Management, FHWAHOP-08-106. 

http://ops.fhwa.dot.gov/publications/fhwahop08016/fhwahop08016.pdf. 

U.S. DOT. FHA 2006c. Literature Search for Federal Highway Administration – 

Assessment of the State of the Practice and State of the Art in Evacuation 
59

Transportation Management, FHWA-HOP-08-015. 

http://ops.fhwa.dot.gov/publications/fhwahop08015/fhwahop08015.pdf. 

U.S. DOT. FHA 2006d. Technical Memorandum for Federal Highway Administration on 

Case Studies – Assessment of the State of the Practice and State of the Art in 

Evacuation Transportation Management, FHWA-HOP-08-014. 

http://ops.fhwa.dot.gov/publications/fhwahop08014/task3_case.pdf. 

U.S. DOT. FHA 2006e. Routes to Effective Evacuation Planning Primer Series: Using 

Highways during Evacuation Operations for Events with Advance Notice, FHWAHOP-06-109. http://ops.fhwa.dot.gov/publications/evac_primer/primer.pdf. 

U.S. DOT. FHA 2007a. Using Highways for No-Notice Evacuations: Routes to Effective 

Evacuation Primers Planning Series, FHWA-HOP-08-003. 

http://ops.fhwa.dot.gov/publications/evac_primer_nn/primer.pdf. 

U.S. DOT. FHA 2007b. Common Issues in Emergency Transportation Operations 

Preparedness and Response: Results of the FHWA Workshop Series, FHWA-HOP07-090. 

http://ops.fhwa.dot.gov/publications/etopr/common_issues/etopr_common_issues.pdf

. 

U.S. DOT. FHA 2007c. Best Practices in Emergency Transportation Operations 

Preparedness and Response: Results of the FHWA Workshop Series, FHWA-HOP07-076. 

http://ops.fhwa.dot.gov/publications/etopr/best_practices/etopr_best_practices.pdf. 

U.S. DOT. FHA 2007d Communicating with the Public Using ATIS during Disasters: A 

Guide for Practitioners, FHWA-HOP-07-068. 

http://ops.fhwa.dot.gov/publications/atis/atis_guidance.pdf. 

U.S. DOT. FHA 2007e. Managing Pedestrians during Evacuation of Metropolitan Areas, 

FHWA-HOP-07-066. 

http://ops.fhwa.dot.gov/publications/pedevac/ped_evac_final_mar07.pdf. 

References 

U.S. Department of Homeland Security (DHS). 2008. Planning Guidance for Protection 

and Recovery Following Radiological Dispersal Device (RDD) and Improvised 

Nuclear Device (IND) Incidents, Federal Register, Vol. 73, No. 149. 

http://www.fema.gov/good_guidance/download/10260. 
60

U.S. Environmental Protection Agency. Office of Radiation Programs. 1992. Manual of 

Protective Actions Guides and Protective Actions for Nuclear Incidents, EPA-400-R92-001, May 1992. 

http://www.epa.gov/radiation/docs/er/400-r-92-001.pdf. 

Glasstone, Samuel and Philip J. Dolan. 1977. The Effects of Nuclear Weapons. 

Washington, DC: U.S. Government Printing Office. 
61

Chapter 4 – Early Medical Care 

KEY POINTS 

1. There will be a spectrum of casualties including one or more of blast, radiation, and 

thermal injury. Initial triage and management will be based in part on victim’s postdetonation location history, physical examination, dosimetry predictions from initial 

models and real-time physical dosimetry (dose measurements), and from available 

clinical laboratory studies. 

2. To maximize overall preservation of life with insufficient resources to manage mass 

casualties, severely injured victims may be placed into an “expectant” (expected to 

die) category early on although the criteria for “expectant” will vary depending on 

resources available. Although expectant, palliation (treatment of symptoms) should 

be performed when possible. 

3. Because of the damage to the infrastructure, the limited availability of resources, and 

presence of radiation paramedics and clinicians will have to bypass conventional 

clinical standards of care, preferably using predetermined criteria, in order to 

maximize the overall preservation of life. Such conditions are to be expected until 

medical staffing, logistical support, and infrastructure can be restored. 

4. Management of serious injury takes precedent over decontamination. 

Decontamination of personnel and patients from fallout or visible debris involves 

brushing off, shaking, washing or wiping off the radioactive dust and dirt and should 

not be a limiting factor in providing medical care. 

5. Initial mass casualty triage, also known as sorting, should not be confused with 

follow-on clinical triage for more specific medical management. 

6. There is no established USG interagency medical triage system specifically validated 

for an urban nuclear detonation; therefore, existing emergency triage algorithms are 

used with modification for the impact of radiation. 

7. For the time frame covered by this guidance processing of the deceased will likely not 

be a priority in lieu of saving lives; however, fatality management will be one of the 

most demanding aspects of the nuclear detonation response and should be planned for 

as early as possible. 

Overview 

The human injury consequences of a nuclear detonation in a modern urban area will impact 

the medical system well beyond any disaster previously experienced by the nation. Large 

numbers of casualties with traumatic, thermal, and radiation injuries, in all possible 
62

combinations, will be generated. The death toll will be high, but there is an opportunity to 

save tens or hundreds of thousands of injured victims with appropriate mitigation (before 

symptoms develop) and treatment strategies. Increased survival will necessitate deployment 

of medical, surgical, burn, and other treatment assets to the location of the mass casualties for 

several weeks while evacuation to distant care facilities around the entire nation will be 

necessary to distribute the large number of injured. Assets for evacuation of burn and trauma 

patients will be very limited. Currently, the majority of clinicians, including emergency 

medicine physicians and nurses, are not familiar with triage or treatment methods for nuclear 

casualties. 

Maximizing the overall preservation of life will force many paramedics and clinicians to adjust 

clinical standards of care to the disaster situation. Mass casualty care will be resource limited 

and require that the response be optimized for the circumstances. Such conditions are to be 

expected until medical staffing, logistical support, and infrastructure can be restored. Planners 

can use hospital surge models (e.g. http://www.hospitalsurgemodel.org/) to estimate casualty 

arrival patterns, number of expected hospitalizations, number of deceased, and the resources that 

would be consumed to care for the patients (Department of Health and Human Services (DHHS) 

2008a). 

 

Initially, the nature of mass casualties will invoke a patient sorting system (i.e., initial triage) 

to maximize care to the most people. Initial triage and management will be based in part on 

victim’s location history post-detonation, physical examination, dosimetry predictions from 

initial models and real-time physical dosimetry (dose measurements), and from available 

clinical laboratory studies. It must be recognized that extremely difficult decisions and 

actions will be required of responders and clinicians regarding who will receive early 

treatment, who will not, and who will be classified as expectant.18 To maximize overall 

preservation of life with insufficient resources to manage mass casualties, severely injured 

victims may be placed into an “expectant” (expected to die) category early on although the 

criteria for “expectant” will vary depending on resources available. Although expectant, 

palliation (i.e., treatment of symptoms) should be done when possible. The skill and moral 

courage to designate severely injured victims into the expectant category in the first day 

following a detonation can serve to maximize overall preservation of life taking into account 

the lack of resources on hand to manage mass casualties. Implementing broad use of rapid 

“grab and drag” techniques will allow earlier rescue and treatment of more casualties than 

will traditional rescue methods. Local and regional preplanning is required to modify 

emergency response procedures (e.g., when to use or not use backboards and neck braces, 

etc.) for a mass casualty response. In fallout areas, such techniques will also minimize 

responder doses during the first hours or days into the response. Consideration should be 

given to concentrate medical personnel in treatment facilities with plans to avoid using them 

for first aid type duties. Instead, volunteers, support personnel and possibly minimally 

injured ambulatory victims can be asked and/or directed to help with a range of tasks 

including limited first aid, assisting the more severely injured, etc. 

 

18 Patients that will die regardless of medical intervention, but should be afforded palliative or comfort care. 
63

From the medical intervention perspective, survival rates will increase with rapid evacuation 

of individuals in the damage zone following a nuclear explosion to mass medical triage and 

staging areas for subsequent transport of stabilized and decontaminated patients to care 

facilities around the nation. Survival rates will decrease if transportation is constrained by 

policies imposed by EMS and ambulance providers and medical facilities that will not 

transport and/or accept potentially contaminated patients. Because typical evacuation assets 

(e.g., buses, aircraft) will be heavily tasked, additional assets such as rail or water 

transportation should be included in medical evacuation planning. 

Decontamination of personnel and patients from fall out is easy. Brushing off, shaking, 

washing or wiping off the radioactive dust and dirt is an effective decontamination technique 

in the field. Removing clothing and appropriately storing it away from people in collection 

bags, for example, and showers are an exceptionally good way to decontaminate individuals. 

Internal contamination of people is not a priority concern following a nuclear detonation and 

should not be considered a priority in medical care for the first few days of response. 

Acute Radiation Syndrome (ARS) 

The essential feature distinguishing a nuclear detonation from other types of mass casualty 

events is the presence of radiation. Radiation produces its own medical effects (called the 

Management of serious injury takes precedent over decontamination. 

Decontamination of personnel and patients from fallout or contaminated debris 

involves brushing off, shaking, washing or wiping off the radioactive dust and dirt and 

should not be a limiting factor in providing medical care. 

Because of the damage to the infrastructure, the limited availability of resources, and 

presence of radiation paramedics and clinicians will have to bypass conventional 

clinical standards of care, preferably using predetermined criteria, in order to 

maximize the overall preservation of life. Such conditions are to be expected until 

medical staffing, logistical support, and infrastructure can be restored. 

To maximize overall preservation of life with insufficient resources to manage mass 

casualties, severely injured victims may be placed into an “expectant” (expected to 

die) category early on although the criteria for “expectant” will vary depending on 

resources available. Although expectant, palliation (treatment of symptoms) should be 

performed when possible. 

There will be a spectrum of casualties including one or more of blast, radiation, and 

thermal injury. Initial triage and management will be based in part on victim’s 

location history post-detonation, physical examination, dosimetry predictions from 

initial models and real-time physical dosimetry (dose measurements), and from 
64

Acute Radiation Syndrome, or ARS) and worsens an individual’s survival from other injuries 

(called “combined injury”). The presence of radiation limits the amount of time responders 

can spend taking care of victims. 

Acute radiation sickness is generally seen at whole body doses above approximately one Gy. 

Temporally, ARS presents in phases. The first phase shows prodromal symptoms (these are 

general symptoms that indicate a more serious process may follow later on) that may be 

useful during early triage (e.g., nausea, vomiting, heavy fatigue); second with a lethargic but 

otherwise asymptomatic latent period; and third by a manifest illness phase that results in 

either recovery or death. More information on ARS is provided in the grey box below. 

Acute Radiation Sickness - General Considerations 

(Details available in REMM at www.remm.nlm.gov and AFRRI at www.afrri.usuhs.mil) 

Phases: Radiation victims may have some initial symptoms, such as nausea or vomiting in 

the prodromal phase that may then clear for a few days or weeks (the latent phase) followed 

by the eventual onset of ARS possibly 3-4 weeks later (the manifest illness phase). 

Classical Subsyndromes: Hematopoietic (blood and immune system), Gastrointestinal 

(digestive tract), Dermatological (skin), Cerebrovascular (spinal system and brain) 

These are dose related in ascending order with mitigation and treatment of the hematopoietic 

syndrome being considered at a whole body dose of > 2 Gy. 

Good Prognosis: 

• Vomiting starts > 4 hours after incident 

• No significant change in serial lymphocyte counts within 48 hours after an incident 

• Erythema (reddened skin) absent in first 24 hours 

• No other significant injuries

Poor Prognosis: 

• Central Nervous System (CNS) syndrome (e.g., Coma, Seizures) 

• Severe erythema (reddened skin) within 2-3 h of exposure indicates dose of >10 Gy 

• Vomiting less than 1 hour after incident 

• Serial lymphocyte counts drop more than 50% within 48 hours 

• Gastrointestinal syndrome (e.g., bloody vomitus or stool) (> 6 Gray) 

• Other serious injuries (so called, combined injury)

LD50/60: The radiation dose at which half the victims will die without intensive treatment by 

60 days (called the Lethal Dose 50, or LD50/60) is approximately 400 rem (4 Gy) (Anno and 

coauthors 2003)). Vigorous medical management, which would be available for victims of a 

small-sized radiation emergency can increase the LD50 possibly to 600 – 700 rem (6 – 7 Gy), 

but the capacity to provide this level of care will be limited in a mass casualty nuclear 

detonation. 
65

Radiation Exposure Risks Years 

after the Nuclear Detonation 

The precise relationship between 

radiation dose and cancer risk is the 

subject of debate. There is a relative 

long latency between exposure to 

radiation and development of a 

radiation-induced cancer, often 5-10 

years for leukemia and decades for 

“solid tumors.” As a general estimate, 

5 rem, the annual limit for a radiation 

worker but not necessarily the limit to 

be used for an event such as this, 

would increase the lifetime risk of 

cancer by <0.5%. The average 

lifetime risk is around 25% so this 

dose would add <0.5% to that risk. 

For 25 rem the increased risk is 

approximately 2%, and for 100 rem, 

approximately 6-8%. 

DHHS Concept of Operations 

A Concept of Operations (CONOPS) model recently developed by DHHS is presented here. The 

intent of providing this concept is to provide standardized terminology for local and State 

consideration, and to provide more detailed perspective on the impact of radiation on traditional 

response. 

This CONOPS is for consideration at the State 

and local level to help organize their response and 

to best plan for receiving federal medical assets as 

they arrive in the hours and days that follow a 

detonation. Familiarity with DHHS CONOPS 

terminology could prove useful in planning and 

perhaps provide an opportunity to standardize 

medical response CONOPS terminology. State 

and local medical response planners may choose 

to consider evaluating the DHHS CONOPS for 

nuclear detonation response as a possible template 

for State and local plans. The DHHS CONOPS 

was developed with emergency medical 

physicians with the idea that this operational 

theory could be readily used in the community 

(Hrdina and coauthors 2009). 

The DHHS CONOPS includes consideration of 

the zones that account for damage and radiation 

introduced in Chapters 1 and 2. It makes sense 

for planners to account for staging areas designed 

to receive federal medical response resources that 

may start to arrive within hours but certainly 

within days of a nuclear detonation, the following text describes a model for the Emergency 

Support Function #8 of the National Response Framework: Public Health and Medical Services. 

Federal CONOPS for Nuclear Detonation Response – the RTR System. RTR is a 

function-oriented care system and not an individual medical triage system (Hrdina and 

coauthors 2009). It stands for Radiation TRiage, TRansport, and TReatment and is 

illustrated in Figure 4.1. Following a nuclear explosion there will be three types of sites that 

form spontaneously as follows: 

• RTR1 – sites will have victims with major trauma coupled with radiation that limits 

operational response time and exacerbates victim injuries; many victims may be 

expectant; the location will be near the no-go (NG) boundary and/or in the moderate 

damage (MD) zone; rubble may prevent entry into this zone 

• RTR2 – sites will be for triaging victims with radiation exposure only or possibly 

with minor trauma; the location will be along the outer edges of the dangerous fallout 

(DF) zone and the light damage (LD) zone and may have ambient radiation; most 

victims are anticipated to be ambulatory 
66

• RTR3 – sites are collection points where radiation is not present and will allow for 

occupation for many hours or more; victims are anticipated to have limited trauma 

injuries such as glass injury; most victims ambulatory, including people displaced by 

the explosion without any injury or exposure; extensive self-evacuation is likely to be 

observed at these sites; these may occur in the LD zone and beyond 

The locations of the RTR sites will be compatible with the infrastructure damage, as outlined 

in Chapters 1 and 2 and are summarized in Figure 4.1. 

MC

AC

RTR2

RTR3

RTR1

Prevailing Upper Winds

MC

AC

MC

AC

RTR1

Dangerous Fallout Zone (DF) 

Light Damage Zone (LD) 

Moderate Damage Zone (MD) 

No Go Zone (NG) 

RTR2

RTR3

RTR3

EC

EC

RTR1

Outside Facilities &

Expert Centers

Assembly Centers AC

Medical Centers MC

Tiered Triage Sites RTR

Evacuation Centers EC

Self Evacuation

Critical Care Patients

Ambulatory, Possible ARS

Assembly Centers AC

Medical Centers MC

Tiered Triage Sites RTR

Evacuation Centers EC

Self Evacuation

Critical Care Patients

Ambulatory, Possible ARS

Self Evacuation

Critical Care Patients

Ambulatory, Possible ARS

Figure 4.1: The RTR system for a nuclear detonation response; theoretical zones in a 10 KT 

nuclear explosion at surface level 

From the RTR sites victims will be directed and/or transported to appropriate secondary sites 

as follows: medical care (MC) sites, including hospitals, healthcare facilities and alternative 

care sites for those who need immediate medical care and assembly centers (AC) as 

collection points for displaced persons or those who do not need immediate medical 

attention. Locations for MC and AC sites will have been largely predetermined as much as 

possible by an ongoing project at DHHS called MedMap and by the local responders in 

planning. RTR3 sites will have formed in various locations spontaneously or by direction of 

the Incident Commander as opposed to preplanned AC sites. From MC sites victims 

requiring medical care may be sent to medical treatment centers and hospitals nationwide, 

including the Radiation Injury Treatment Network (RITN - 

http://www.nmdp.org/RITN/index.html), National Disaster Medical System, Veteran’s 

Administration Hospitals, etc., or to temporary housing using predetermined transportation 

hubs. Major transportation hubs may include airports, seaports, railroad stations, and 
67

designated highway and other road routes. Victim flow will be mainly away from the 

incident although many people not too far from the incident should remain safely in their 

buildings. At all RTR, MC and AC sites, efforts will be made to track victims and evacuees 

as they are moved to MC or AC sites nearby or transported to appropriate destinations 

regionally and nationally. 

The presence of radiation will limit the time that responders can spend at various RTR 1 and 

2 locations. A radiation event differs substantially from a non-radiation mass casualty event 

because of the presence of radiation and the time limit for responders to be within radiation 

areas. The Department of Homeland Security (DHS) Planning Guidance (DHS 2008) 

includes time limitations based on the lifetime risk of an exposed person developing a 

radiation induced cancer, but the decision to enter the zone will be made by the Incident 

Commander and responders. Planning for response in elevated radiation environments is 

strongly suggested. 

Initial Mass Casualty Triage (i.e., Sorting) 

Initial mass casualty triage, also known as sorting, should not be confused with follow-on 

clinical triage for more specific medical management. There are several established triage 

systems for a mass casualty events, typically related to trauma, but there are, at present, no USG 

or internationally agreed upon medical triage systems overlaying radiation issues onto mass 

casualty trauma categories expected from a nuclear detonation. The Department of Defense 

(DOD) has done extensive triage planning, some of which is accessible in various documents. 

The DOD effort serves as an important underpinning for developing a civilian response and has 

been used by Waselenko and coauthors to assess how radiation may affect the triage of trauma 

victims (Waselenko and coauthors 2004). 

Recently, a major consensus meeting on mass casualty triage in the US resulted in the 

publication: “Mass casualty triage: an evaluation of the data and a proposed national guideline”

(Lerner and coauthors 2008). Based on extensive review of the various systems, this committee 

proposed a new five-category mass casualty triage system called SALT (Sort, Assess, LifeSaving Intervention (LSI), Treatment and/or Transport). This new system was quickly endorsed 

by several major US professional societies with expertise in emergency medicine. It must be 

emphasized that a modified SALT algorithm (or any of the other standard triage algorithms) 

would be necessary for a nuclear detonation because it may be the ambulatory and responsive 

There is as yet no established USG interagency medical triage system specifically 

validated for an urban nuclear detonation; therefore, existing emergency triage 

algorithms are used with modification for the impact of radiation. 

Initial mass casualty triage, also known as sorting, should not be confused with 

follow-on clinical triage for more specific medical management. 
68

victims that would take priority over those with more obvious serious injury because of scarce 

resources. 

The military has traditionally used a mass casualty triage system entitled DIME: Delayed, 

Immediate, Minimal and Expectant, which includes four of the categories of the SALT (DOD 

2003). DOD has developed a triage system for a nuclear detonation such that a future mass 

casualty triage and treatment approach for an nuclear detonation that is under development 

would include structure and content from both SALT and DIME. 

A landmark series of papers recently addressed how mass casualty planning and resource 

allocations must address scarcities of “staff, space and stuff” (Chest series and Kaji and 

coauthors 2006) for pandemic flu. The papers addressed exactly how “optimal care algorithms” 

would change when resources become progressively more scarce. Similar issues surely need to 

be addressed for a nuclear detonation as well. 

To address the extraordinary complexity of triage and treatment of potentially hundreds of 

thousands of patients following a nuclear detonation, DHHS is convening a multi-specialty 

expert group in 2009 with the goal of creating recommendations for national medical planning. 

Any new or modified triage system suggested will need to account for complexities related to 

ranges of severity for the following: 

• Conventional injury categories (trauma and burns) 

• Radiation (alone and/or as part of combined injury) 

• Scare resources [staff, stuff, and space (Kaji and coauthors 2006)] and how resource 

availability and treatment effect triage 

• Importance of life-saving interventions including mitigation for acute radiation syndrome 

that will impact the triage category 

• Co-morbidities and special needs in the civilian population 

Any new mass casualty radiation triage system must be flexible enough to reflect new medical 

countermeasures and deployed field technologies and procedures. Optimally any new system 

should provide responders with easily understood and implementable algorithms that would be 

available and adaptable on REMM. 

The following discussion provides planners with a sense of the current state of the art and 

science of radiation mass-casualty triage, including information from SALT, scarce resources, 

and the DOD. The medical care chapter of this first edition planning guidance will be modified 

significantly over the next year as a result of the progress being made in the following: 

• Establishing standard terminology, victim coding, and a response algorithm (such as 

SALT) for a mass casualty event 

• Developing guidance and linking medical response to availability of resources 

• Access to a nuclear detonation triage and casualty planning systems developed by the 

DOD that have potential application to a civilian event. 
69

SALT Color Codes 

The logic for this specific system and for 

the use of the grey color for expectant is: 

“Unlike the other triage categories (i.e., 

immediate = red, delayed = yellow, 

minimal = green, and dead = black), the 

color designation for expectant patients 

is not common among the existing mass 

casualty triage systems. Some systems 

use the color blue; however, that may 

potentially lead to confusion because 

blue also has been used to designate 

patients who need decontamination. In 

an effort to reflect the fluid nature of this 

category and to have a distinct color 

associated with it, the committee selected 

grey” (Lerner and coauthors, 2008)

The SALT system (Figure 4.2) refers to mass 

casualty triage in general (i.e., mostly trauma). It 

uses common terminology for triage categories and 

places them in a five category and color system, 

adding grey for expectant (Lerner and coauthors 

2008). 

Figure 4.2 below is included to only illustrate the 

general organization of mass casualty triage. The 

nuclear detonation algorithm to be developed in 

future work will use the general concepts behind 

SALT (Lerner and coauthors 2008), DIME (DOD 

2003) and the DHHS 2009 effort previously 

described. In Figure 4.2, S is for initial sorting; A is 

for individual assessment in that the initial sorting 

may misclassify a person; and LSI is for life-saving 

intervention (if appropriate). The LSI for a nuclear 

detonation response could include mitigation of 

hematopoietic ARS. A triage category is then assigned to one of the 5 categories- Minimal, 

Delayed, Immediate, Expectant or Dead. Patients then undergo treatment and transport 

(represented by T). This is presented only as an example of how SALT is used for mass casualty 

events. A nuclear detonation-related SALT system will have radiation specific interventions and 

the sorting and triage will depend on the scarcity of resources. 
70

Figure 4.2: Illustrates the steps in the SALT system for mass casualty triage (Lerner and 

coauthors 2008). 

Data on the impact combined injuries have on survivability are limited. However, because of 

the detrimental effect on the hematological systems (blood cells and immune systems) it is 

likely that whole body radiation doses above 200 rad (2 Gy) will have a substantial negative 

impact on survival of patients with significant burn or blast injuries. Additionally, the size of 

a nuclear detonation and availability of resources and expert care would dictate what 

treatment would be administered and who might move into the palliative or expectant 

category (Waselenko and coauthors 2004). Medical management for radiation effects 

includes drugs for both mitigation of subsequent medical deterioration and treatment. 

Effective mitigation for ARS that would make fatal injuries survivable by preventing or 

reducing the serious deterioration in the hematological and immune systems would become a 

LSI. Similar advances may be possible for the dermatological and gastrointestinal syndromes 

using drugs or cell-based therapies under investigation. Standard supportive care is perhaps 

the most important medical intervention and the degree of scarcity of resources will certainly 

be a critical factor in supportive care decision-making. The scarcity of resources will be 

extraordinarily variable as one moves away from the zones immediately surrounding ground 

zero to facilities miles away and then further to facilities around the nation. Therefore, a 

given set of medical circumstances for a victim would lead to a different triage category, 

which must be considered as SALT or any other system is applied. 
71

The military DIME system (DOD 2003) includes Delayed, Immediate, Minimal and 

Expectant categories, SALT adds a fifth category, “Dead”, and includes “Individual 

Assessment”. Because the civilian population has a much wider range of individuals 

including co-morbidity and special populations, the individual assessment will be more 

complex. Additionally, the spectrum of injuries will likely differ between a tactical nuclear 

explosion in a battlefield situation compared to a nuclear explosion within a city. 

The DIME categories for a nuclear explosion are defined in the following grey box material 

for the DOD (courtesy of AFRRI). As noted, the DOD nuclear casualty planning factors are 

based on a young healthy adult population. The more detailed triage system to be developed 

by the consensus group to be convened by DHHS in 2009 will include specifics such as 

percentage of burns, radiation dose, and medical countermeasures and will take into account 

the scarcity of resources. Note that enhanced availability of resources may remove victims 

from the expectant category. 
72

DoD DIME Triage for Early Nuclear Casualty Assessments and Planning (Adapted 

from FM 4-02.283 (DOD 2001) and unpublished DoD reports courtesy of AFRRI) 

(NOTE: The DoD text below was not designed for use by civilian clinicians. Future 

work by the USG Interagency is expected to yield civilian-specific information on 

nuclear casualty planning factors and early nuclear triage assessments) 

DIME: D = Delayed, I = Immediate, M = Minimal, and E = Expectant 

Triage decisions and classifications for nuclear victims differ from conventionally injured 

patients and must consider physical injury and radiation exposure. The first step in triage is 

based primarily on the presentation of conventional injuries and is then modified by radiation 

injury level. That is, triage and care of any life-threatening injuries should be rendered without 

regard for the probability of radiation exposure or contamination. Medical personnel must also 

make a preliminary diagnosis of radiation injury based on those who display the appropriate 

radiation exposure symptoms, such as nausea, vomiting, diarrhea, hyperthermia, and so forth 

but also on assessment of their potential exposure based on history, physical location during 

the event and initial laboratory assessment when possible because early intervention for 

those at risk for ARS can effect their ultimate triage category and outcome. Many of the 

victims that can benefit from early ARS mitigation will come from the Dangerous Fallout 

Zone and may have no or only very minor physical injury. Understanding the types of 

casualties that will receive early triage is also useful in response planning. So both casualty 

assessments and planning factors are provided for the DIME method of triage codes with the 

very important caveats that the DoD uses nuclear casualty planning factors designed for 

young healthy adults and that the spectrum of injuries for civilian IND events is not yet fully 

determined. 

Delayed group (D). 

Early Casualty Assessment: Those needing surgery, but whose conditions permit 

delay without unduly endangering safety. Life-sustaining treatment such as intravenous fluids, 

antibiotics, splinting, catheterization, and relief of pain may be required in this group. 

Examples are fractured limbs, spinal injuries, and uncomplicated burns, and all casualties with 

only radiation injury who do not exhibit gross neurological symptoms. NOTE: Early wound 

closure for patients with doses above 100-200 rads (1-2 Gy) will improve outcomes. 

Consequently, combined injury patients become the highest priority immediately after those 

requiring life or limb-saving surgery. 

Casualty Planning Factors: Nuclear casualties in this group are generally those 

suffering injury that requires professional medical treatment but that is not immediately 

threatening to life, limb or sight. These injuries include lacerations without extensive 

hemorrhage, closed fractures, first degree burns covering a moderate to large Body Surface 

Area (BSA), second degree burns covering a small BSA (perhaps in the 5 to 15% BSA range), 

and third degree burns covering a very small BSA (perhaps in the 1 to 5% BSA range). Also 

in this category are patients with moderate to high radiation dose in the 200-600 rads (2-6 Gy) 

range that have either minimal or no other injuries. 
73

DoD DIME Triage for Early Nuclear Casualty Assessments and Planning (Adapted 

from FM 4-02.283 and unpublished DoD reports; Courtesy of AFRRI) - continued 

DIME: D = Delayed, I = Immediate, M = Minimal, and E = Expectant 

Immediate group (I). 

Early Casualty Assessment: Those requiring immediate lifesaving surgery. 

Procedures should not be time-consuming and should concern only those with a high chance 

of survival, such as respiratory obstruction and accessible hemorrhage. Pure radiation injury is 

not acutely life-threatening unless the irradiation is massive. If a massive dose has been 

received, then the patient is classified as expectant (E). NOTE: Early wound closure for 

patients with doses above 100-200 rads (1-2 Gy) will improve outcomes. 

Casualty Planning Factors: Nuclear casualties in this group are generally those 

suffering serious injury that requires prompt professional medical treatment to save life, limb 

or sight. These injuries include hemorrhage to a readily accessible site, multiple lacerations, 

correctable mechanical respiratory defects, fractures of long bones, crushed extremities, 

incomplete amputations, fractured skull or spine, ruptured internal organ, second degree burns 

covering a moderate BSA (perhaps in the 15 to 50 % BSA range), and third degree burns 

covering a small to moderate BSA (perhaps in the 5-25% BSA range). 

Minimal group (M). 

Early Casualty Assessment: Those with relatively minor injuries who can be helped 

by untrained personnel, or who can look after themselves, such those who have minor 

fractures or lacerations. Buddy care is particularly important in this situation. Patients with 

radiological injury should have all wounds and lacerations cleaned meticulously and then 

closed. 

Casualty Planning Factors: Nuclear casualties in this group are generally those that 

suffer nonincapacitating injury that requires some kind of medical treatment. 

Nonincapacitating injuries imply limited lacerations, contusions, concussions, eardrum 

rupture, first degree burns to a moderate to large BSA (perhaps less than 50% BSA), second 

degree burns covering a small BSA (perhaps less than 5% BSA), very small third degree 

burns (perhaps less than 1% BSA), or mild to moderate radiation exposure (roughly 75 to 200 

rads or 0.75 to 2 Gy) that may result in mild nausea, anorexia or fatigue four or more hours 

after being exposed. This initial triage category aligns with the early "treat-and-release" 

patient load. 

Expectant group (E). 

Early Casualty Assessment: Those with serious or multiple injuries requiring 

intensive treatment, or with a poor chance of survival. These patients receive appropriate 

supportive treatment compatible with resources, which will include large doses of analgesics 

as applicable. Examples are severe head and spinal injuries, widespread burns, or neurological 

symptoms from massive doses of radiation. These casualties may be removed from this 

category as additional medical assets become available. 

Casualty Planning Factors: Nuclear casualties in this group are generally those that 

suffer from obvious injuries to the respiratory and central nervous system, significant 

penetrating abdominal wounds, multiple severe injuries, second degree burns covering a large 

BSA (perhaps more than 50 % BSA), and third degree burns covering a moderate BSA 

(perhaps in more than 25% BSA), high radiation doses that result in obvious cerebrovascular 

dysfunction or vomiting within one hour of being exposed. 
74

Figure 4.3 below illustrates the following concepts: 

• How radiation can impact triage categories 

• Importance of appropriate early intervention for radiation mitigation of ARS 

Figure 4.3: Illustrates how radiation can impact triage category and the importance of appropriate 

early intervention for radiation mitigation of ARS (courtesy of AFRRI). 

Emergency Care

For managing mass nuclear casualties with blast and thermal injuries, the focus is first to 

provide only emergency medical care and essential surgical procedures. Expect a setting of 

resource constraints to extend for several days. Time consuming procedures must be 

deferred initially in order to direct attention to many others that can be saved. Current 

recommendations are that all wounds should be closed within 36 to 48 hours for 

patients with doses above 1-2 Gy. If this is not possible, wound closure should be delayed 

until hematopoietic recovery is evident although newer approaches to care of 

immunosuppressed patients may alter this recommendation. 

Although doses in the higher ranges [500-800 rad (5-8 Gy)] are most often fatal within six 

weeks, nearly all of these patients will exhibit a latency (asymptomatic) period of days to 

weeks immediately following their initial symptoms. Finding opportunities to provide 

definitive care, to include treatment during the latency period, will improve survival rates 

among these patients. Currently available data indicate that to mitigate the acute 
75

hematological syndrome, drug treatment with cytokines is recommended for the >2 Gy dose 

range and should be administered within 24 hours. In general, experts in hematology and 

oncology are involved in medical management as the cause of morbidity and death is usually 

a result of sepsis and bleeding days to weeks following exposure, similar to that seen in 

cancer treatment. Note that cytokines are not of benefit to people with lower doses (<2Gy) 

and would take resources from those who need it. Thus, cytokines must not be used without 

clinical indication. Also, regardless of whether or not cytokines are available, supportive care 

alone will increase survivability to as much as 50% for patients with ARS. Supportive care 

includes fluids, cytokines, antibiotics when needed. Overall supportive care is the most 

important aspect of victim management. Additional details are on the REMM website 

(http://www.remm.nlm.gov). 

The currently used US follow-on clinical triage and medical management system is dose-based, 

recognizing that there will be heterogeneity in exposure, dose-rate, combined injuries and special 

populations (e.g., age, co-morbid diseases, etc). To estimate dose, the use of medical history, 

physical dose reconstruction (location during the event), dose-plots such as those from 

Interagency Modeling and Atmospheric Assessment Center (IMAAC) and on-site measurement, 

and blood studies will be used. The latter includes complete blood counts (CBCs) and 

cytogenetic biodosimetry. Research is being done to develop technologies for high throughput 

screening. 

Referral to Expert Centers

Following the initial sorting and the subsequent identification of those either already with 

manifestations of ARS or at risk for developing it over days to weeks, medical management 

will require highly specialized expertise. The medical specialties most familiar with diseases 

that require similar treatment to ARS are hematology, medical oncology, and radiation 

oncology. The Radiation Injury Treatment Network (http://www.nmdp.org/RITN/) is 

working with DHHS and also with international partners to develop medical management 

protocols (REMM - http://www.remm.nlm.gov.). As noted above, the current US clinical 

triage and medical management system at tertiary care centers (e.g., bone marrow transplant 

and cancer centers) for managing radiation patients is dose-based. While specific organ 

syndromes are usually noted (e.g., hematological, gastrointestinal, dermatological and central 

nervous system), victims will have some degree of multi-system injury so that medical 

management will be both algorithm-based and individualized. Tertiary care may be done 

with international partners. In Europe, a tertiary triage and management system has been 

developed based on organ system dysfunction, which is presented here as an example for 

consideration by planners (Fliedner and coauthors 2001). Aspects of both dose-based and 

organ-dysfunction are mutually compatible and subject matter experts are working to further 

harmonize the medical management approaches. 
76

METREPOL: This approach is an example of the European system (Medical Treatment 

Protocols) for radiation casualty triage at tertiary care centers. The METREPOL system for 

radiation management depends on medical signs and symptoms and requires serial analysis to 

determine the ultimate response category (1-4) for each of the four systems (H for 

hematological, G for gastrointestinal, N for neurovascular, and C for cutaneous); see Figure 

4.4). This current system is not based on radiation dose but on clinical manifestations. Figure 

4.4 illustrates how the METREPOL response category based system could be used for triage. 

It is emphasized that this system is intended for limited size events such as industrial accidents 

and the applicability to the initial triage at a nuclear detonation is limited. However, once 

victims are under the care of medical experts, the METREPOL system could be employed to 

refine the initial triage category and treatment plans 

Degree of Cutaneous, Gastrointestinal, and 

Neurovascular Symptoms

1 2 3 4

Ambulatory 

Monitoring

Hospitalization

Hematologic Degree

2 3 4

Routine

Care Floor

Critical

Care Unit

. 

Figure 4.4: METREPOL response category based system (Fliedner and coauthors 2001) 
77

Fatality Management 

In a nuclear detonation, fatality management may be one of the most demanding aspects of 

the incident response, and the way it is executed will have a direct impact on the recovery of 

the community and the nation. The catastrophic significance of a nuclear detonation is 

quickly understood through the number of casualties it produces, including fatalities. 

Fatalities from the detonation can come about in essentially two ways: (1) those who are 

promptly killed by the blast, and possibly vaporized; and (2) those who die from mortal 

wounds later, either in the field or in the care of emergency personnel. This second group 

includes the “walking dead” and its effect should not be underestimated because it is likely 

that large numbers of people directly affected by the blast or fallout who would seemingly 

benefit from medical intervention are in fact expectant resulting from their combined injuries 

or radiation exposure. The quantity and phenomenon of “walking-dead” were not 

understood in the Hiroshima atomic bomb attack because large numbers of people died after 

varying latency periods following the detonation. Because of the potentially high number 

of deceased persons produced by a nuclear detonation, there is a complexity that stems from 

the overwhelming numbers of bodies versus the scarce resources available to manage them 

and our national values that lead us to respect the traditions of the deceased. This dichotomy 

means fatality management has the potential to become one of the most demanding aspects 

of the nuclear detonation response because of the concerns of respect for the deceased versus 

capability limitations to provide these gestures. Incident commanders must consider means 

to fairly accommodate public expectations while efficiently and appropriately handling 

human remains in a way that is consistent with their capabilities. 

 

While fatality management is a very significant concern, it is also important to note that in 

the first 72 hours of the response, which is the time frame covered by this guidance, the 

processing of the deceased will likely not be a priority in lieu of saving lives. However, 

personnel in the field and in definitive care centers, assembly centers, etc. must have an 

option for handling persons who die in their care. Because bodies in the field do not pose a 

significant biohazardous threat to response personnel (Morgan 2004), it is not necessary to 

immediately begin fatality management operations. The main priority should be saving lives. 

When fatality management becomes a feasible operational capability, a few days after the 

response, incident commanders should consider the following: 

1. Determine capabilities (e.g., personnel, equipment, supplies) 

2. Develop a strategy for proper identification and respectful handling of the deceased 

victims including transport, storage, and disposition in the context of the available 

capabilities 

3. Strive to keep cross-contamination to a minimum including the use of radiation 

monitors (DHHS 2008b) 

4. Develop and disseminate a public communications strategy that outlines the efforts to 

respect the bodies and discusses the outcomes of the body handling, especially where 

survivors will not be able to recover family members who are deceased and 

contaminated, or unidentifiable 
78

The Centers for Disease Control Guidelines for Handling Decedents Contaminated with 

Radioactive Materials (Centers for Disease Control) details points for consideration to 

appropriately manage remains. Additionally the Mass Fatality Management for Incidents 

Involving Weapons of Mass Destruction (DOD 2005) and Joint Publication 4-06, Mortuary 

Affairs in Joint Operations, (DOD 2006), provide guidance that primarily focuses on 

chemical, biological, and nuclear detonations, and may be useful for planners as well. 

However, DOD doctrine may not always be applicable to civilian planning and should be 

considered appropriately. 

In summary, fatality management will be one of the most demanding aspects of the nuclear 

detonation response, because: 

• There will be an overwhelming need for immediate care for those who can be treated 

• Many people who are expectant will live for a period of time and then die 

• Concerns of respect for the deceased versus limited capability to provide these 

gestures 

Additional Resources 

REMM: A comprehensive set of medical management guidelines is available at the 

Radiation Event Medical Management (REMM) website (http://www.remm.nlm.gov). 

Emergency Room and other medical response assets should download REMM and join 

the Listserve. The REMM system was created in collaboration between the National Library 

of Medicine and DHHS, with input from subject matter experts worldwide. REMM provides 

radiation, algorithms for medical evaluation and management. Detailed support information 

can be readily updated as new information becomes available, assuring just-in-time and upto-date information for medical personnel. REMM is available online as a download to a 

laptop or other computer, and as a PDA. 

In addition to REMM, the AFRRI Medical Management of Radiological Casualties Handbook, 

the AFRRI Emergency Radiation Medicine Pocket Guide (DOD 2008), the AFRRI 

Biodosimetry Assessment Tool and a few other useful and free products are available for 

download at www.afrri.usuhs.mil. As well, the Centers for Disease Control and Prevention 

(CDC) (http://www.bt.cdc.gov/radiation) and the Radiation Emergency Assistance 

Center/Training Site (REAC/TS) (http://orise.orau.gov/reacts) websites address several key 

aspects of radiological emergencies. 

For the time frame covered by this guidance processing of the deceased will likely not 

be a priority in lieu of saving lives; however, fatality management will be one of the 

most demanding aspects of the nuclear detonation response and should be planned for 

as early as possible. 
79

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81

Chapter 5 – Population Monitoring and Decontamination 

KEY POINTS 

1. Radiation survey methods, screening criteria used for radiation screenings, and 

decontamination guidance or services offered or recommended should be adjusted to 

reflect the prioritized needs of individuals and availability of resources at any given 

location. 

2. Identification of individuals whose health is in immediate danger and require urgent 

care is the immediate priority of any population monitoring activity. 

3. The primary purpose of population monitoring, following a nuclear detonation, is 

detection and removal of external contamination. In most cases external 

decontamination can be self performed, if straightforward instructions are provided. 

4. Prevention of acute radiation health effects should be the primary concern when 

monitoring for radioactive contamination. 

5. Population monitoring and decontamination activities should remain flexible and 

scalable to reflect the available resources and competing priorities. 

6. Radioactive contamination is not immediately life threatening. 

7. Self-evacuating individuals will require decontamination instructions to be 

communicated to them in advance of the event (e.g., public education campaign) or 

through post-event public outreach mechanisms. Instructions should be provided with 

consideration of languages appropriate for the affected community. 

8. Planning must provide for consideration of concerned populations because it is 

anticipated that a significant number of individuals, who should remain safely 

sheltered, will begin to request population monitoring to confirm that they have not 

been exposed to radiation. 

9. Use of contaminated vehicles (e.g., personal or mass transit) for evacuation should not 

be discouraged in the initial days following a nuclear detonation; however, simple 

instructions for rinsing or washing vehicles once decontamination can be achieved 

without impeding evacuation should be provided. 

10. There is no universally accepted threshold of radioactivity (external or internal) above 

which a person is considered contaminated and below which a person is considered 

uncontaminated. 

11. State and local agencies should establish survivor registry and locator databases as 

early as possible. Initially, the most basic and critical information to collect from each 

person is his or her name, address, telephone number, and contact information. 

12. Planners should identify radiation protection professionals in their community and 

encourage them to volunteer and register in any one of the Citizen Corps or similar 

programs in their community. 
82

Overview 

Population monitoring is the process of identifying, screening, and monitoring people for 

exposure to radiation or contamination with radioactive materials. Decontamination is the 

process of washing or removing radioactive materials on the outside of the body or clothing 

and, if necessary, facilitating removal of contamination from inside the body. 

The population monitoring process begins soon after a nuclear emergency and continues until 

all potentially affected people have been monitored and evaluated as appropriate for the 

following: 

• Needed medical treatment 

• Presence of radioactive contamination on the body or clothing 

• Intake of radioactive materials into the body 

• Removal of external or internal contamination (decontamination) 

• Radiation dose received and the resulting health risk from the exposure 

• Long-term health effects 

 

Assessment of the first five elements listed above should be accomplished as soon as 

practical. However, long-term health effects are usually determined through a population 

registry and an epidemiologic investigation that will likely span several decades, and are 

beyond the scope of this guidance. 

It is important to recognize that early decisions by emergency responders and response 

authorities related to monitoring for radioactivity and decontamination should be made in the 

context of the overall response operations. For example, as stated in Chapter 4, survival rates 

will decrease if evacuation is constrained by policies for nontransportation or acceptance of 

potentially contaminated patients imposed by ambulance providers and medical facilities. 

Furthermore, the needs of a displaced population and concerned citizens hundreds of miles 

away are different from those of the immediate victims near the site of detonation. 

Therefore, radiation survey methods, screening criteria used for radiation screenings, and 

decontamination guidance or services offered or recommended should be adjusted to reflect 

the prioritized needs of individuals and availability of resources at any given location. 

The recommendations in this chapter are derived from the Department of Health and Human 

Services (DHHS) Centers for Disease Control and Prevention (CDC) publication 

“Population Monitoring in Radiation Emergencies: A Guide for State and Local Public 

Health Planners” (http://emergency.cdc.gov/radiation/pdf/population-monitoring-guide.pdf) 

(DHHS 2007). The relevant portions of the CDC guidance are summarized here; however, 

readers are referred to that document in its entirety for more information. 

Radiation survey methods, screening criteria used for radiation screenings, and 

decontamination guidance or services offered or recommended should be adjusted to 

reflect the prioritized needs of individuals and availability of resources at any given 

location. 
83

Primary Considerations 

There are several priority considerations that should be applied in any radiation emergency, 

especially in a nuclear emergency where life-threatening conditions exist for a potentially 

large number of individuals. 

1. Identification of individuals whose health is in immediate danger and require 

urgent care is the immediate priority of any population monitoring activity. 

Near the incident scene, this monitoring need is accomplished as part of the medical 

triage already described in Chapter 4. Management of serious injury takes 

precedence over radiological decontamination. 

2. The primary purpose of population monitoring, following a nuclear detonation, 

is detection and removal of external contamination. In most cases external 

decontamination can be self performed, if straightforward instructions are 

provided. There are two types of decontamination. External decontamination 

removes fallout particles and other radioactive debris from clothes and external 

surface of the body. Internal decontamination, if needed, requires medical treatment 

to reduce the amount of radioactivity in the body. 

3. Prevention of acute radiation health effects should be the primary concern when 

monitoring for radioactive contamination. Population monitoring personnel 

should offer or recommend gross external decontamination, such as brushing away 

dust or removal of outer clothing. Cross-contamination issues (e.g., from transport 

vehicles) are of secondary concern, especially in a nuclear emergency where the 

contaminated area and the potentially impacted population are large. 

4. Population monitoring and decontamination activities should remain flexible 

and scalable to reflect the available resources and competing priorities. For 

example, if water is a scarce commodity or is needed to fight fires, dry methods can 

be used for decontamination. Moist wipes can be used to wipe the face and hands in 

addition to a change of outer clothing. Instead of pouring water as in a shower, small 

amounts of water can be used to wet paper towels and clean the skin. 

5. Radioactive contamination is not immediately life threatening. Individuals who 

are self evacuating may be advised to self decontaminate. Suggestions for monitoring 

and decontamination in this chapter assume radioactivity is the only contaminant, and 

that there are no chemical or contagious biological agents present. 

Identification of individuals whose health is in immediate danger and require urgent 

care is the immediate priority of any population monitoring activity. 
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Impacted Population 

 

Victims who may be suffering from severe burn and trauma injuries are addressed in Chapter 

4. Evacuating those critical patients away from the scene should not be hindered by lengthy 

or restrictive decontamination and transport policies. People who are not critically injured 

may fall into four broad categories that can be linked with general decontamination 

considerations as follows: 

1. Individuals who self evacuate from the affected and surrounding areas and who 

are not under the direction of emergency response officials — These are 

individuals who self evacuate before emergency responders arrive. Even after 

responders arrive, there may not be sufficient responders to direct all of the 

individuals who may continue to self evacuate. For this group of individuals, 

responders will not have an opportunity to provide on-the-scene decontamination 

assistance before they leave the area. Decontamination instructions will need to be 

communicated to these individuals in advance of a nuclear detonation (e.g., public 

education campaign) or through post-event public outreach mechanisms. Some of 

these individuals may go directly to hospitals or seek care in public shelters. 

2. Individuals who leave the affected areas under the direction of emergency 

response officials — These are people leaving the immediate impact zone (e.g., 

moderate damage (MD) or light damage (LD) zones) of the incident may require 

assistance from responders to evacuate (e.g., search and rescue, emergency medical 

service). Some people may be able to leave unassisted but will be part of an 

organized immediate evacuation. Responders will need to make decontamination 

decisions regarding these individuals. As stated earlier, these decisions must be made 

in the context of the overall response effort and reflect the prioritized needs of the 

evacuating individuals and available resources. 

Radioactive contamination is not immediately life threatening. 

Population monitoring and decontamination activities should remain flexible and 

scalable to reflect the available resources and competing priorities. 

Prevention of acute radiation health effects should be the primary concern when 

monitoring for radioactive contamination. 

The primary purpose of population monitoring, following a nuclear detonation, is 

detection and removal of external contamination. In most cases external 

decontamination can be self performed, if straightforward instructions are provided. 
85

3. Individuals who initially sheltered, both in the immediate impact area as well as 

in the fallout zone, then evacuate as part of an organized evacuation — As in the 

previous category, these individuals will be dependent on responders to make and 

communicate decontamination decisions. 

4. Individuals who are in the surrounding area of the detonation, have not received 

an evacuation notice, but who are concerned about possible contamination and 

seek screening from public officials to confirm that they have not been exposed

— These individuals may report to hospitals or public shelters. This group could 

represent a significant number of individuals and planners will need to ensure they 

adequately address this group’s concerns. Community reception centers, as described 

in CDC’s publication “Population Monitoring in Radiation Emergencies: A Guide for 

State and Local Public Health Planners,” recommend an infrastructure to address the 

needs of this population, as well as those of the displaced population reporting to 

reception centers (DHHS 2007). 

The public may self evacuate using personal vehicles that may be contaminated. Although 

this evacuation may result in the spread of some contamination, such actions should not be 

discouraged during the initial days following a nuclear detonation. Simple rinsing or 

washing of vehicles in a common location before or after use should be considered; however, 

these actions should be implemented so that they do not restrict or inhibit necessary 

evacuations. The public should be directed to rinse or wash down vehicles as soon as 

practical once they are out of danger. In communities where people do not speak English as 

their primary language, instructions should be provided in languages appropriate for the 

affected community. At later times following the detonation, more detailed instructions 

should be provided along with protective action guidance basing mitigation measures on 

potential for contamination, dose, and residual risk. 

If public mass transportation (e.g., rail, bus) is used to evacuate individuals from 

contaminated areas, the vehicles should be surveyed and controlled, to the extent practical, to 

minimize the potential for contaminating land and people. During the early phase, simple 

rinsing or washing of mass transit equipment in a common location before or after use should 

be considered; however, these actions should be implemented in a manner so they do not 

restrict or inhibit necessary evacuations. If there is a potential that these simple protective 

actions will inhibit needed evacuations then they should be delayed. 

Planning must provide for the consideration of concerned populations because it is 

anticipated that a significant number of individuals, who should remain safely 

sheltered, will begin to request population monitoring to confirm that they have not 

been exposed to radiation or contaminated with radioactive materials. 

Self-evacuating individuals will require decontamination instructions to be 

communicated to them in advance of the event (e.g., public education campaign) or 

through post-event public outreach mechanisms. 
86

External Contamination 

The first step in external monitoring is to check people for radioactive contamination on their 

bodies and clothing. Note that detailed radiological surveys are not necessary and initial 

screenings for external contamination can be done in a matter of seconds by trained 

professionals using proper radiation detection instruments. Depending on the situation, and 

if adequate staff and decontamination resources are available, more restrictive radiological 

screening criteria may be used. 

There is no universally accepted level of radioactivity (external or internal) above which a 

person is contaminated and below which a person is uncontaminated at a ‘safe’ level. A 

discussion of key considerations in a selecting a contamination screening criterion and a 

number of benchmark screening criteria are described and referenced in Appendix C of the 

CDC population monitoring guide (DHHS 2007). Screening values may also be found in 

other agency documents such as Federal Emergency Management Agency (FEMA)-REP-21 

(1995) and FEMA-REP-22 (2002), National Council on Radiation Protection (NCRP) 

Commentary 19 (2005), International Atomic Energy Agency (IAEA) (2006), and 

Conference of Radiation Control Program Directors (CRCPD) (2006) (DHS 1995; DHS 

2002; NCRP 2005; IAEA 2006; CRCPD 2006), as well as military manuals. 

As uncontaminated people are referred to discharge stations and contaminated people to 

washing (decontamination) stations, care must be taken not to co-mingle contaminated and 

uncontaminated people while making sure families are not separated. Wrist bands or similar 

tools can be used to distinguish people who have been cleared through decontamination. 

It would be prudent to assume that most people will be able to self decontaminate, but 

provisions for those who cannot, such as people using wheelchairs or people with other 

disabilities, must also be made. A best practice during the decontamination process would be 

to determine if parents can assist their children with washing. For people who do not have 

wounds, direct them to perform the following actions: 

• Remove contaminated clothes and place them in a bag 

• Wash with warm water 

There is no universally accepted threshold of radioactivity (external or internal) above 

which a person is considered contaminated and below which a person is considered 

decontaminated. 

Use of contaminated vehicles (e.g., personal or mass transit) for evacuation should not 

be discouraged in the initial days following a nuclear detonation; however, simple 

instructions for rinsing or washing vehicles once this can be achieved without 

impeding evacuation should be provided. 
87

• Use the mechanical action of flushing or friction of cloth, sponge, or soft brush 

• Begin with the least aggressive techniques and mildest agents (e.g., soap and 

water) 

• When showering, begin with the head and proceed to the feet 

• Keep materials out of eyes, nose, mouth, and wounds; use waterproof draping to 

limit the spread of contamination 

• Avoid causing mechanical, chemical, or thermal damage to skin 

Use of pumper fire truck systems for mass decontamination (Capitol Region Metropolitan 

Medical Response System 2003), although effective in decontaminating large numbers of 

people at a hazardous materials scene, is not necessary and may not be even advisable when 

other decontamination methods are considered. If water resources are scarce or not 

available, a change of outer clothing or carefully brushing off the fallout dust can 

significantly reduce exposure. When cold temperatures or poor weather conditions exist, the 

use of water-based decontamination techniques may not be advisable. Furthermore, 

firefighting resources may be more urgently needed to fight fires or to conduct search and 

rescue operations. 

To the extent possible, responders should take reasonable measures to control the spread of 

contamination from runoff or solid waste generated by decontamination activities. However, 

these control measures should not slow down or delay the processing of contaminated 

individuals or contaminated vehicles leaving the impacted area to address imminent threats to 

human life or health. Addressing people’s needs and facilitating their decontamination or 

evacuation to protect human life or health takes priority (EPA 2000).

People with wounds must be directed to a medical treatment facility or to a designated 

medical triage station, if established. Supporting response organizations should be prepared 

to provide for the security of the designated monitoring, decontamination, and staging areas 

as well as items of personal value. 

Internal Contamination 

Internal contamination is radioactive material that has entered the body through, for example, 

ingestion or inhalation, or through a wound. In a nuclear detonation scenario, a radiation 

dose received from internal contamination will not be a major concern relative to burn and 

traumatic injuries received or relative to potentially large external radiation doses from 

prompt radiation or nuclear fallout. However, there is potential for internal contamination 

and regardless of how significant or insignificant it may be, internal contamination can be a 

source of anxiety and concern for the public. After all, while people can self decontaminate 

themselves from external contamination, any internal contamination stays with them and 

does not go away quickly. 

While certainly not an immediate priority, following a nuclear detonation, having accurate 

information about the levels of internal contamination is important in deciding whether 
88

medical intervention is warranted (see www.remm.nlm.gov for more information). The 

methods and equipment needed for assessing internal contamination are more advanced than 

the equipment required to conduct external monitoring. Collectively, internal contamination 

monitoring procedures are referred to as “bioassays,” and in general these bioassays require 

off-site analysis by a clinically certified commercial laboratory or hospital. Although some 

results will be available quickly, monitored individuals should be advised that depending on 

the size of the population monitored and the radionuclides involved, it may be some time, 

perhaps weeks or months, before all results are available. Knowledge of the physical location 

of the individuals during the incident or the extent of external contamination on their bodies 

prior to washing can be helpful indicators of the likelihood and magnitude of internal 

contamination. However, laboratory results can provide definitive information, especially in 

the case of alpha-emitting radionuclides. 

Registry – Locator Databases 

State and local agencies should establish a registry system as early as possible. This registry 

will be used to contact people in the affected population who require short-term medical 

follow-up or long-term health monitoring. Initially, the most basic and critical information to 

collect from each person is his or her name, address, telephone number, and contact 

information. If time permits, other information can be recorded, including the person’s 

location at time of the incident and immediately afterwards and other epidemiological 

information, but this is not essential and should not become a bottleneck in the registration 

process. Additional information can be collected later as individuals are processed and 

evacuated out of the area, sent to shelters or when they report to community reception 

centers. Extensive resources will be required, and federal agencies, specifically CDC and the 

Agency for Toxic Substances and Disease Registry (ATSDR), will provide assistance in 

establishing, coordinating and maintaining this registry. Emergency responders should be 

registered and monitored through a mechanism provided by their respective employers. 

State and local authorities must work with Emergency Support Function #6 (Mass Care, 

Emergency Assistance, Housing, and Human Services) and the American Red Cross to 

establish an evacuee tracking database system. This system will assist in promptly locating 

evacuees, patients, fatalities and any other survivors or displaced persons. Extensive 

experience from response to hurricanes can be used to meet this need. 

Volunteer Radiation Professionals 

As stated in the National Response Framework, population decontamination activities are 

accomplished locally and are the responsibility of local and State authorities (DHS 2008). 

Federal resources to assist with population monitoring and decontamination are limited and 

State and local agencies should establish a survivor registry and locator databases as 

early as possible. Initially, the most basic and critical information to collect from each 

person is his or her name, address, telephone number, and contact information. 
89

will take some time to arrive. Radiation control staff, employed by local and State 

governments, are few in number. However, there are tens of thousands of radiation 

protection professionals across the country that can be tapped into and encouraged to 

volunteer and register in any one of the Citizen Corps programs in their community 

(www.citizencorps.gov). Specifically, the Medical Reserve Corps 

(www.medicalreservecorps.gov) offers a mechanism to recruit and train radiation 

professionals already in the community who can assist public health and emergency 

management agencies in population monitoring or shelter support operations. The 

Emergency System for Advance Registration of Volunteer Health Professionals (ESARVHP) is a program to establish and implement guidelines and standards for the registration, 

credentialing, and deployment of medical professionals in the event of a large scale national 

emergency. The same infrastructure can be used to recruit and register radiological health 

professionals (health physicists, medical physicists, radiation protection technologists, 

nuclear medicine technologists, etc.) for response to a potential nuclear emergency. The 

ESAR-VHP program is administered under the Assistant Secretary for Preparedness & 

Response (ASPR) within the Office of Preparedness and Emergency Operations of the 

Department of Health and Human Services (www.hhs.gov/aspr/). 

Mutual Aid Programs 

Many States, especially those with nuclear power plants, have established mutual aid 

agreements with their neighboring and other States to provide assistance in case of a 

radiation emergency. The Emergency Management Assistance Compact (EMAC) is a 

Congressionally ratified organization that provides form and structure to interstate mutual aid 

and addresses key issues such as liability and reimbursement (www.emacweb.org). Through 

EMAC, a disaster impacted State can request and receive assistance from other member 

States quickly and efficiently. EMAC has been used effectively to respond to natural 

disasters, but resources specific to nuclear emergency response has not yet been incorporated 

into EMAC. 

References 

Capitol Region Metropolitan Medical Response System. 2003. Rapid Access Mass 

Decontamination Protocol for the Capitol Region Metropolitan Medical Response 

System. www.au.af.mil/au/awc/awcgate/mmrs/mass_decon.pdf. 

Conference of Radiation Control Program Directors, Inc. 2006. Handbook for Responding 

to a Radiological Dispersal Device. First Responder’s Guide— the First 12 Hours. 

http://www.crcpd.org/RDD_Handbook/RDD-Handbook-ForWeb.pdf. 

Planners should identify radiation protection professionals in their community and 

encourage them to volunteer and register in any one of the Citizen Corps or similar 

programs in their community. 
90

International Atomic Energy Agency. 2006. Manual for First Responders to a Radiological 

Emergency. http://wwwpub.iaea.org/MTCD/publications/PDF/EPR_FirstResponder_web.pdf. 

National Council on Radiation Protection and Measurements. 2005. Key Elements of 

Preparing Emergency Responders for Nuclear and Radiological Terrorism, 

Commentary No. 19 (Bethesda). 

US Department of Health and Human Services (DHHS). Centers for Disease Control 

(CDC). 2007. Population Monitoring in Radiation Emergencies: A Guide for State 

and Local Public Health Planners. 

http://emergency.cdc.gov/radiation/pdf/population-monitoring-guide.pdf. 

US Department of Homeland Security (DHS). Federal Emergency Management Agency 

(FEMA). 1995. Contamination Monitoring Standard for a Portal Monitor Used for 

Radiological Emergency Response, FEMA-Report-21 (Washington, D.C.). 

US DHS. FEMA 2002. Contamination Monitoring Guidance for Portable Instruments 

Used for Radiological Emergency Response to Nuclear Power Plant Accidents.

FEMA-REP-22. https://www.rkb.us/contentdetail.cfm?content_id=140772. 

US DHS. FEMA. 2008 Nuclear/Radiological Incident Annex of the National Response 

Framework 

www.fema.gov/pdf/emergency/nrf/nrf_nuclearradiologicalincidentannex.pdf. 

US Environmental Protection Agency. Office of Emergency Management. 2000 First 

Responders’ Environmental Liability Due to Mass Decontamination Runoff. EPA550-F-00-009. www.epa.gov/OEM/docs/chem/onepage.pdf. 
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SubPCC Membership – January 2009 

Interagency Members Department or Agency 

Korey Jackson, CoChair Homeland Security Council, Executive Office of the President 

Tammy Taylor, CoChairOffice of Science and Technology Policy (OSTP), Executive 

Office of the President 

Armin Ansari Centers for Disease Control & Prevention, Radiation Studies 

Branch, National Center for Environmental Health 

Manuel Aponte Department of Defense, Office of the Assistant Secretary of 

Defense for Homeland Defense & Americas' Security Affairs 

Julie Bentz Department of Defense, Office of the Deputy Assistant to the 

Secretary of Defense for Nuclear Matters 

David Bowman Department Of Energy, National Nuclear Security 

Administration, Office of Emergency Response 

Norman Coleman 

Department of Health & Human Services, Office of Planning and 

Emergency Operations, Office of the Assistant Secretary for 

Preparedness and Response 

Donald Daigler Department of Homeland Security, Federal Emergency 

Management Agency, Disaster Operations Directorate 

Sara DeCair Environmental Protection Agency, Office of Radiation and 

Indoor Air, Office of Air and Radiation 

John Dixon Centers for Disease Control & Prevention, Radiation Studies 

Branch, National Center for Environmental Health 

Michael Fea Department of Defense, Joint Chiefs of Staff 

Larry Flesh Department of Veteran’s Affairs 

Chad Hrdina Department of Health & Human Services, Office of the Assistant 

Secretary for Preparedness and Response 

John MacKinney 

Department of Homeland Security, 

Radiological/Nuclear/Chemical Threats and Science and 

Technology Policy Development, Policy Directorate 

John Mercier Department of Defense, Armed Forces Radiobiology Research 

Institute 

Patricia Milligan Nuclear Regulatory Commission, Office of Nuclear Security and 

Incident Response 
92

Rick Poeton Environmental Protection Agency, Region 10 

Peter Prassinos National Aeronautics and Space Administration, Office of Safety 

and Mission Assurance 

Laurel Radow 

Department of Transportation, Emergency Transportation 

Operations Team, Office of Operations, Federal Highway 

Administration 

Alan Remick Department of Energy, National Nuclear Security Administration, 

Office of Emergency Response 

Jean Schumann Environmental Protection Agency, Office of Emergency 

Management 

Emily Snyder Environmental Protection Agency, National Homeland Security 

Research Center 

Colby Stanton Environmental Protection Agency, Office of Radiation and 

Indoor Air, Office of Air and Radiation 

Thomas Strother 

Department of Homeland Security, Federal Emergency 

Management Agency, Radiological Emergency Preparedness 

Program 

Andrew Wallo Department of Energy, Office of Nuclear Safety, Quality 

Assurance and Environment 

Robert Whitcomb Centers for Disease Control & Prevention, Radiation Studies 

Branch, National Center for Environmental Health 

Michael Zanker Department of Homeland Security, Office of Health Affairs 
93

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