Role of a Radiologic Technologist During Radiologic Crisis
As radiologic technologists, we are uniquely qualified to participate in the medical response to radiologic accidents and radiologic terrorist attacks. Should such incidents occur in our area, our colleagues and the public at large will have the expectation that we will know how to deal with radiation safely since we work with it every day. This article offers information to help you feel comfortable that you can safely help others during such a horrible crisis.
In order to safely work during a radiologic disaster, you need to understand 3 basic things.
- Understand what radiation is and know the different types of radioactive materials.
- Know what types of incidents are likely to release those types of materials.
- Know how to deal with patients, decedents, and materials that may be contaminated
Understanding Ionizing Radiation
As radiologic technologists, we understand this more than most people, but it’s always a good idea to keep our knowlege current since this is not usually a subject that comes up in daily discussions. Also, there are many types of radioactive materials that are outside our scope of clinical practice. Our course of the same name ‘Understanding Ionizing Radiation‘ offers a good refresher and offers 12 ARRT CE Credits. There are also some good videos on the subject at the CDC website.
Radiation emergencies may be intentional (e.g., caused by terrorists) or unintentional.
Improvised Nuclear Device and Nuclear Weapons
A nuclear weapon is a device that uses a nuclear reaction to create an explosion.
An Improvised Nuclear Device (IND) is a type of nuclear weapon.
When an IND explodes, it gives off four types of energy: a blast wave, intense heat, light, and radiation.
Nuclear explosions produce fallout (radioactive materials that can be carried long distances by the wind).
Dirty Bomb or Radiological Dispersal Device (RDD)
A dirty bomb (also known as a Radiological Dispersal Device or RDD) is a mix of explosives such as dynamite, with radioactive powder or pellets.
A dirty bomb cannot create an atomic blast.
When the explosives are set off, the blast carries radioactive material into the surrounding area.
Radiological Exposure Device (RED)
A Radiological Exposure Device or RED (also called a hidden sealed source) is made of or contains radioactive material.
REDs are hidden from sight to expose people to radiation without their knowledge.
Nuclear Power Plant Accident
An accident at a nuclear power plant could release radiation over an area.
Nuclear power plants have many safety and security procedures in place and are closely monitored by the Nuclear Regulatory Commission (NRC).
This video discusses the difference between nuclear and radiologic incidents.
Radiologic Incident Response
Radiation cannot be detected by the human senses. A radiological survey conducted with specialized equipment is the only way to confirm the presence of radiation. If a terrorist event involves the use of radioactive material, both patient exposure and contamination must be assessed.
Exposure occurs when a person is near a radiation source. People exposed to a source of radiation can suffer radiation illness if their dose is high enough, but they do not become radioactive. For example, an x-ray machine is a source of radiation exposure. A person does not become radioactive or pose a risk to others following a chest x-ray.
Contamination occurs externally when loose particles of radioactive material are deposited on surfaces, skin, or clothing. Internal contamination occurs when radioactive particles are inhaled, ingested, or lodged in an open wound.
Contaminated patients should be decontaminated as soon as possible, without delaying critical care. Patients who have been exposed to radiation, but are not contaminated with radioactive material, do not need to be decontaminated.
MEDICAL MANAGEMENT PRINCIPLES
Addressing contamination issues should not delay treatment of life-threatening injuries.
It is highly unlikely that the levels of radioactivity associated with a contaminated patient would pose a significant health risk to care providers.
In certain rare instances, the presence of imbedded radioactive fragments or large amounts of external contamination may require expedited decontamination.
Include in-house radiation professionals on the response team.
STAFF PROTECTION GUIDELINES
Establish an ad hoc triage area.
- Base the location on your hospital’s disaster plan and the anticipated number of casualties.
- Establish a contaminated area and clean area separated by a buffer zone.
- Remove your contaminated outer garments when leaving the contaminated area.
- Have your body surveyed with a radiation meter when exiting a contaminated area.
Use standard precautions to protect staff.
- Follow standard guidelines for protection from microbiological contamination.
- Surgical masks should be adequate.
- N95 masks, if available, are recommended.
- Survey hands and clothing at frequent intervals with a radiation meter.
- Due to fetal sensitivity to radiation, assign pregnant staff to other duties.
Survey the patient with a radiation meter.
- Perform surveys using consistent technique and trained personnel.
- Note exceptionally large amounts of surface or imbedded radioactive material.
- Handle radioactive objects with forceps and store in lead containers.
- Record location and level of any contamination found.
Remove patient clothing.
Carefully cut and roll clothing away from the face to contain the contamination.
Double-bag clothing using radioactive hazardous waste guidelines, label, and save as evidence.
Repeat patient survey and record levels.
Cleanse contaminated areas.
- Wash wounds first with saline or water.
- If facial contamination is present, flush eyes, nose, and ears, and rinse mouth.
- Gently cleanse intact skin with soap and water, starting outside the contaminated area and washing inward.
- Do not irritate or abrade the skin.
- Resurvey and note levels.
- Repeat washing until survey indicates radiation level is no more than twice background or the level remains unchanged.
- Cover wounds with waterproof dressing.
- Dispose of waste water through normal channels.
- For mass casualties, consider establishing separate shower areas for ambulatory and non-ambulatory patients.
Acute radiation syndrome (ARS)
- ARS is caused by high doses of radiation being rapidly delivered to large portions of the body. The most probable terrorist events, such as the use of a dirty bomb, will likely generate low levels of radiation exposure. If ARS cases are seen, small casualty numbers are likely.
- Time of exposure, distance from radioactive source, and duration of exposure should be noted.
- Patients can present individually if exposed to radioactive sources hidden in the community.
- Symptoms can be immediate or delayed, mild or severe, based on radiation dose.
- Nausea, vomiting may occur minutes to days after exposure. Time of onset of vomiting is a major factor in diagnosis and dose estimation (See Table 1).
- Early onset of vomiting followed by symptoms of bone marrow suppression, gastrointestinal destruction, and/or cardiovascular/central nervous system effects is indicative of acute illness.
- Depending on the stage of illness, a patient may be asymptomatic.
Diagnosis and treatment
- Perform sequential CBCs with differential to assess progressive declines in lymphocyte levels (See Andrews Lymphocyte Nomogram).
- Monitor for fluid and electrolyte balance and evidence of hemodynamic instability.
- Treat symptomatically with focus on prevention of infection, including antibiotics.
- Consider cytokines, e.g. Neupogen®, and hematopoietic growth factors.
- Perform surgical interventions within the first 48 hours or delay until after hematopoietic recovery.
- Consider use of biodosimetry dose assessment software from www.afrri.usuhs.mil.
Cutaneous radiation injury (CRI)
- CRI is acute radiation injury to the skin.
- Skin damage can manifest within hours, days, or weeks after radiation exposure.
- Transient itching, tingling, erythema, or edema may be seen within hours or days after exposure, and is usually followed by a latent period.
- Lesions may not be seen for weeks to months post exposure, but then can be debilitating or even life-threatening.
- Delayed occurrence of lesions is a differentiating factor from thermal burns.
- Note time of occurrence of signs and symptoms and progressive changes in appearance.
- Treat localized injuries symptomatically, focusing on pain and infection control.
- Internal contamination should be considered if persistently high survey readings are noted following decontamination. Internal contamination generally does not cause early symptoms.
- Nose or mouth contamination may indicate inhalation or ingestion.
- Assessment may include analysis of urine, blood, and fecal samples or whole body counts. Consult with radiation experts.
- Radiation experts may recommend early administration of radionuclide-specific decorporation agents such as Prussian Blue, DTPA, or Bicarbonate.
- Gastric lavage, antacids, and cathartics assist in clearing ingested contaminants.
- In urban areas, hundreds to thousands may seek care. The majority will self-refer to the nearest hospital. Many will need decontamination. Many may seek radiological screening, but will not be contaminated. Many will simply seek reassurance.
- Psychogenic illness symptoms, such as nausea or vomiting, may manifest.
- Vomiting due to radiation exposure is usually recurrent rather than episodic.
- Include mental health professionals on the response team.
- Have radiation exposure fact sheets available for patients and families.
- Pregnant patients require special counseling.
- Separate areas for radiation screening and counseling could be needed for patients with minimal risk of exposure or injury.
MANAGEMENT OF DECEASED
If exposed to a lethal dose of radiation without contamination, a patient is not radioactive and no special precautions are needed.
Special precautions may be necessary for contaminated deceased.
This video by the CDC is a good overview and outlines the basics of clinicians response to radiological incidents.
How to use a geiger counter to screen patients.
More information is available from the CDC at https://emergency.cdc.gov/radiation/resourcelibrary/all.asp