Decontamination Procedures
Cautionary Notes in Mass Casualty Events
- REMM Contamination Algorithm guidelines are appropriate for events small enough to permit individualized evaluation and decontamination of each patient/victim.
- Limited resource availability in mass casualty events (e.g., insufficient water, personnel, equipment, medical facilities, laboratories) may necessitate major modification of Contamination Algorithm guidelines.
- Large numbers of victims seeking decontamination and reassurance may overwhelm the emergency response infrastructure, at least initially.
- Modifications to both the Contamination Algorithm and Decontamination Procedures Guidelines in a mass casualty event may include
- Self-decontamination at home by large numbers of ambulatory victims
(Instructions for decontamination at home)
- Limiting radiation surveys to simple screenings rather than comprehensive and repeated evaluations
- Altering decontamination methods
- Altering target decontamination levels (i.e., accepting decontamination levels in excess of 2 times background)
- Eliminating or curtailing early collection of biological specimens (e.g. radioisotope assays, nasal swabs) if logistical barriers to timely collection, transport, analysis, and reporting results limit their utility
- Initiating isotope decorporation therapy in highly selected, life-threatening circumstances prior to receiving diagnostic test results normally required
- This algorithm and supporting material provide guidelines not mandates.
top of page
Photos and Illustrations
top of page
Protecting Responding Personnel
- Use appropriate Personal Protective Equipment (PPE) when evaluating and treating patients/victims known or suspected to be contaminated with radioactive material
- Pregnant healthcare providers should not be permitted to work in
- Pre-decontamination areas
- Decontamination areas
- Areas where internally contaminated patients are cared for or domiciled
- Areas where there are elevated levels of environmental radiation
- All first responders and first receivers responding to a radiation emergency should wear a personal radiation dosimeter to monitor dose
- Consult with hospital radiation safety officer (RSO) about type(s) and proper wearing of personal radiation dosimeters
- Dose rate meters (with or without alarms)
- Accumulated dose meters (with or without alarms)
- Finger ring dosimeters if the dose to hands or fingers is likely to be higher than the dose to the torso where the main dosimeter is worn
- Ensure that all personal radiation dosimeters are collected by the proper official, usually the radiation safety officer.
- Health care providers responsible for debridement of potentially radioactive foreign bodies (e.g., radioactive shrapnel) should wear a finger ring dosimeter on their dominant hand or on both hands in addition to the one worn on the torso.
- Many finger ring dosimeters are not read locally, so actual radiation dose to fingers/hands will not be available in real time.
- Radiation safety officer may be able to estimate dose to fingers based on body dosimeter readings if ring is not used, but finger ring use is preferred.
- Personal dosimeters providing real-time readings may be taped to the forearm.
top of page
Goals of Skin Decontamination
- Decrease the risk of acute dermal injury
- Lower the risk of internal contamination
- Reduce the potential of contaminating medical personnel and the environment
top of page
Gross Whole-Body Contamination
- Begin by carefully removing all of patient's/victim's clothing or have patients/victims undress themselves, working from head to toe.
- Removal of shoes and clothing can reduce contamination by as much as 90%.
- Place all property of each patient/victim in a single, airtight container e.g., property bag.
- Label property bag with
- Patient/victim name
- Date and time of collection
- Location of collection
- Radiation warning label
- Barcode (if one has been assigned)
- Store property bags in secure location designated by RSO for later forensic evaluation1 (as necessary) and appropriate disposal.
- Separate property bags from one another to avoid creating high radiation areas within contamination zone, as instructed by RSO.
- Perform whole body radiation survey.
- Mark on patient's/victim's skin, using waterproof felt tip marker, any areas of high level contamination found by radiation survey.
- Ensure that meter-to-skin distance is consistent in all surveys to minimize inter-survey errors.
- Record initial and all follow-up survey results for an individual patient/victim on a body diagram (PDF - 49 KB); include name, and time and date of initial and all follow-up radiation surveys.
- Update body diagram after each decontamination cycle or use new body diagram for each cycle.
- Conduct decontamination in the following order
- Whole body
- Radioactive shrapnel
- Open wounds
- Body entrance cavities: nose, mouth, ears
- Localized contaminated skin starting with area of highest contamination noted on radiation body survey
- Consider general guidance
- Goal of whole body external decontamination is to decrease external contamination to a level of no more than 2 times background radiation level.
- Perform two decontamination cycles if feasible, with a whole body radiation survey after each cycle.
- Use tepid decontamination water.
- Avoid cold water which tends to close skin pores, trapping radioactive contamination. Cold water may also cause hypothermia.
- Avoid hot water which tends to enhance absorption of radioactive material through vasodilation and increased skin blood flow. Hot water may also cause thermal burns.
- Add mild soap (neutral pH) to water to emulsify and dissolve contamination.
- Direct contaminated waste water away from patient, rather than over the rest of the body.
- Stop whole body external decontamination efforts after 2 decontamination cycles and handle patient with standard precautions if the second whole body radiation survey shows:
- External contamination in excess of 2 times background radiation level
- Additional whole body external decontamination efforts do not further reduce contamination levels by more than 10%.
- Consider that attempts to remove all contamination from skin may not be feasible or desirable.
- Some radioactivity may be trapped in outermost layer of skin (stratum corneum) and will remain until normal sloughing occurs (12-15 days).
- Attempts at vigorous decontamination may result in loss of normal intact skin barrier and an increased risk of internal contamination.
- Cover areas of residual radiation contamination with waterproof dressings/drapes in order to limit spread of contamination to other body sites, immediate environment, and others.
- Persistently elevated levels of external contamination after adequate decontamination efforts may also be due to internal contamination, retained radioactive foreign bodies (shrapnel), contaminated wounds, or contaminated body orifices.
top of page
Radioactive Shrapnel
- Consider all open wound/s contaminated until proven otherwise.
- Use appropriate radiation survey meter to evaluate and monitor the medical management of radioactive shrapnel in order to protect medical team
- Assume embedded foreign bodies will produce uptake (internal contamination).
- Attempt to prevent or minimize further uptake of radioactive material into the body.
- Manage patients/victims with embedded foreign bodies as outlined in Management of Persons Contaminated with Radionuclides: Handbook (NCRP Report No. 161, Vol. I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008, Contamination Screening of Individuals (p. 103), External Contamination Assessment Procedures (pp. 107-109), Decontamination of Persons (pp. 115-117); and Management of Persons Contaminated with Radionuclides: Scientific and Technical Bases (NCRP Report No. 161, Vol. II), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010, Direct (In Vivo) Measurements of Body or Organ Content (pp. 461-465).2, 3
- Cover skin surrounding open wound/s (with or without foreign bodies) with waterproof dressings or drapes, to limit the spread of radioactivity by water run-off during wound irrigation/decontamination.
- Irrigate wound/s gently with copious amounts of water or saline.
- Multiple irrigation attempts are usually necessary.
- Remove visible radioactive foreign bodies (e.g., metallic fragments or shrapnel) using forceps or water-pik.
- While removing radioactive shrapnel, use long surgical instruments that
maximize distance between the operator and the shrapnel.
- Removed foreign bodies and any instruments used to handle foreign bodies should be properly stored in lead containers and labeled by RSO for forensic evaluation1 and proper disposal.
- Organize health care provider decontamination teams to minimize exposures to team members.
- Frequently monitor individual team member radiation doses.
- Frequently rotate teams and team members away from high radiation dose fields.
- If contamination levels remain high after primary decontamination attempts, consider conventional surgical debridement of wound/s.
- Obtain expert medical and health physics advice before excision of vital tissue.
- Surgically removed tissue and all surgical supplies should be properly stored and labeled by RSO for forensic evaluation1 and proper disposal.
- Cover decontaminated wound/s with a waterproof dressing to prevent further contamination.
- Decontaminate skin around wound/s as thoroughly as possible before suturing or other treatment.
- Decontaminate intact skin as described below.
top of page
Open Wounds
- Consider all open wounds contaminated until proven otherwise.
- Assume significant wound contamination will produce uptake (internal contamination).
- Attempt to prevent or minimize further uptake of radioactive material into the body.
- Manage patients/victims with open wounds as outlined in Management of Persons Contaminated with Radionuclides: Handbook (NCRP Report No. 161, Vol. I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008, Contamination Screening of Individuals (p. 103), External Contamination Assessment Procedures (pp. 107-109), Decontamination of Persons (pp. 115-117), Initial Treatment Decisions (pp. 132-133), Bioassay (pp. 150-151); and Management of Persons Contaminated with Radionuclides: Scientific and Technical Bases (NCRP Report No. 161, Vol. II), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010, Direct (In Vivo) Measurements of Body or Organ Content (pp. 461-465).2, 3
- Cover skin surrounding open wound/s (with or without foreign bodies) with waterproof dressings or drapes, to limit the spread of radioactivity by water run-off during wound irrigation/decontamination.
- Irrigate wound/s gently with copious amounts of saline or water.
- Monitor wound/s with radiation survey meter after each irrigation attempt and record results.
- Gently swab wound/s with sterile cotton-tipped applicator and survey the cotton tip for levels of radioactivity.
- If monitoring wound/s directly with a survey meter, remove contaminated drapes, dressings, etc., before conducting survey.
- If contamination levels remain high after primary irrigation attempts, consider conventional surgical debridement of wound/s.
- Obtain expert medical and health physics advice before excision of vital tissue.
- Surgically removed tissue and all surgical supplies should be properly stored and labeled by RSO for forensic evaluation1 and proper disposal.
- Cover decontaminated wounds with a waterproof dressing to prevent further contamination.
- Decontaminate skin around wounds as thoroughly as possible before suturing or other treatment.
- Decontaminate intact skin as described below.
top of page
Body Cavity Entrance Sites: Ear, Nose, Mouth
- Uptake of radioactive material may be faster through body orifices and mucous membranes than through intact skin.
- Decontaminate contaminated body orifices before decontaminating intact skin but after decontaminating open wounds.
- Manage patients/victims with a nasal swab positive for radioactivity as outlined in Management of Persons Contaminated with Radionuclides: Handbook (NCRP Report No. 161, Vol. I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008, Radiation Exposures from Internal Depositions of Radionuclides (pp. 54-55), Information about the Contaminating Incident (pp. 144-146); and Management of Persons Contaminated with Radionuclides: Scientific and Technical Bases (NCRP Report No. 161, Vol. II), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010, Routes of Entry into the Body (pp. 300-308), Indirect (In Vitro) Measurements of Body or Organ Content (p. 467).2, 3
- Use of nasal swabs in large mass casualty incident may not be feasible
- Assess carefully that the body cavity is actually contaminated and not the surrounding area.
- Perform whole body radiation survey to assess orifice contamination.
- Gently swab orifices (ears, nose, mouth) with moistened sterile cotton-tipped applicator and survey swab for levels of radioactivity. See nasal swab information about correlation between nasal swab radioactivity and inhaled lung activity.
- For alpha-emitting radioisotopes, swabs must be allowed to dry before assessing for presence of radioactivity.
- Localize areas of contamination as determined by radiation survey.
- Record initial and follow-up survey results for an individual patient/victim on a body diagram (PDF - 49 KB); include name, and time and date of initial and all follow-up radiation surveys.
- Update body diagram (PDF - 49 KB) after each decontamination cycle or use new body diagram for each cycle.
- Ear decontamination
- Ensure integrity of tympanic membrane (TM) prior to decontamination.
- Use ear syringe to rinse external auditory canal only if TM intact.
- Sample collected irrigation fluid at frequent intervals for residual radioactivity.
- Properly collect, store, and label irrigation fluid for forensic evaluation1 and proper disposal.
- Oral cavity decontamination
- Encourage tooth brushing with toothpaste and frequent mouth rinsing.
- Encourage gargling with 3% hydrogen peroxide solution for pharyngeal contamination.
- Sample collected irrigation fluid at frequent intervals for residual radioactivity.
- Properly collect, store, and label irrigation fluid for forensic evaluation1 and proper disposal.
top of page
Eyes
- Use x-rays to rule out presence of shrapnel in globe.
- Irrigate eyes gently with copious amounts of saline or water if corneal contamination is present and globe is intact.
- Do not irrigate a ruptured globe.
- Direct irrigation stream away from inner canthus and toward outer canthus to avoid contamination of nasolacrimal duct.
- Observe for conjunctivitis after decontamination.
- Sample collected irrigation fluid at frequent intervals for residual radioactivity.
- Properly collect, store, and label irrigation fluid for forensic evaluation1 and proper disposal.
top of page
Hairy Areas
- Wrap or position patient/victim to avoid spread of contamination from run-off water.
- Wash hair (or have patient/victim wash their own hair) with tepid water and mild soap or shampoo without conditioner.
- Soap or shampoo emulsifies and dissolves contamination.
- Conditioners should not be used because they can bind radioactive material to hair protein, making decontamination more difficult.
- Direct contaminated waste water away from patient, rather than over the rest of the body.
- Avoid getting contaminated waste water into eyes, ears, nose, or mouth.
- Dry hair with clean, uncontaminated towels.
- Place all towels used by a patient/victim into a single, airtight container (e.g., property bag).
- Label property bag with
- Patient/victim name
- Date and time of collection
- Location of collection
- Radiation warning label
- Barcode (if one has been assigned)
- Store property bags in secure location designated by RSO for later forensic evaluation1 (as necessary) and appropriate disposal.
- Goal of decontamination: to decrease contamination to a level of no more than 2 times background radiation level.
- Understand that it may be difficult to remove all contamination.
- Shampoo contaminated hairy areas several times (as necessary) followed by a radiation survey recorded on a
body diagram (PDF - 49 KB)
after each washing.
- Contaminated hair can be clipped if shampooing is ineffective.
- Do not shave hair; avoid creating nicks, abrasions, breaks in skin.
top of page
Localized Skin
- Perform whole body radiation survey.
- Mark on patient's/victim's skin, using waterproof felt tip marker, any areas of high level contamination found by radiation survey.
- Ensure that meter-to-skin distance is consistent in all surveys to minimize inter-survey errors.
- Record initial and follow-up survey results for an individual patient/victim on a body diagram (PDF - 49 KB); include name, and time and date of initial and all follow-up radiation surveys.
- Update body diagram after each decontamination cycle or use new body diagram for each cycle.
- Begin decontamination with areas of highest contamination.
- In a water deficient environment, gently brush skin surface to remove a portion of the stratum corneum layer and dislodge contamination held by skin proteins.
- In a water sufficient environment, wash patients/victims (or have patients/victims wash themselves) with tepid water and soap, without damaging or abrading the skin.
- Add mild soap (neutral pH) to water to emulsify and dissolve contamination.
- Direct contaminated waste water away from patient/victim rather than over the rest of the body.
- Use serial washcloths, gauze pads or surgical sponges to avoid recontamination.
- Place all cloths, pads, or sponges used by a patient/victim into a single, airtight container e.g., property bag.
- Label property bag with
- Patient/Victim name
- Date and time of collection
- Location of collection
- Radiation warning label
- Barcode (if one has been assigned)
- Store property bags in secure location designated by RSO for later forensic evaluation1 (as necessary) and appropriate disposal.
- Goal of localized skin decontamination: to decrease external contamination to a level of no more than 2 times background radiation level.
- Perform two decontamination cycles if feasible, with a radiation survey after each cycle.
- Use tepid decontamination water.
- Add mild soap (neutral pH) to water to emulsify and dissolve contamination.
- Direct contaminated waste water away from patient, rather than over the rest of the body.
- Stop localized skin decontamination efforts after 2 decontamination cycles and handle patient with standard precautions if the second radiation survey shows:
- External contamination in excess of 2 times background radiation level
- Additional external decontamination efforts do not further reduce contamination levels by more than 10%.
- Attempts to remove all contamination from skin may not be feasible or desirable.
- Some radioactivity may be trapped in outermost layer of skin (stratum corneum) and will remain until normal sloughing occurs (12-15 days).
- Attempts at vigorous decontamination may result in loss of normal intact skin barrier and an increased risk of internal contamination.
- Cover areas of residual radiation contamination with waterproof dressings/drapes in order to limit spread of contamination to other body sites, immediate environment, and others.
- Treat focal hand contamination not removed after washing by promoting sweating, e.g., put a hand in a surgical glove for a few hours.
- Remember that persistently elevated levels of external contamination after adequate decontamination efforts may also be due to any or all of the following
- Internal contamination
- Retained radioactive foreign bodies (radioactive shrapnel)
- Contaminated wounds
- Contaminated body orifices
top of page
Transport of Victims
- Remember that if patient/victim transport is needed before decontamination can be completed, ensure that transport personnel wear proper PPE, including personal dosimeters.
- Wrap contaminated areas or whole patient/victim in two layers of full-body sheets.
- Preserve ability to observe and monitor patient fully during transport even though patient is wrapped.
- Avoid hypothermia.
- Following transport of contaminated patient/victim:
- Ensure complete survey and decontamination of transport vehicle and equipment.
- Ensure proper disposal of all contaminated equipment.
- Arrange for survey and decontamination of responders, as needed.
top of page
Waste Water Disposal
- In small radiation events, collection and containment of contaminated effluent water in appropriate containers (e.g., large bladders for tent decontamination and plastic bags for individuals with small areas of contamination) may be feasible.
- Sampling and appropriate disposal of contaminated water may be performed later.
- In large mass casualty events, collection of waste effluent may not be feasible.
- EPA guidance on this issue has been provided. 4
top of page
|
References |
- Sullivan MK, Donnelly B. Evidence Collection and Documentation: Are You Prepared to Be a Medical Detective?. Top Emerg Med. 2005; 27(1):50-77. (See "Forensic processes and actions," pages 59-60.) (Subscription required)
- Management of Persons Contaminated with Radionuclides: Handbook (NCRP Report No. 161, Vol. I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008.
- Management of Persons Contaminated with Radionuclides: Scientific and Technical Bases (NCRP Report No. 161, Vol. II), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010.
- First Responders' Environmental Liability Due to Mass Decontamination Runoff (PDF - 1240 KB) (EPA, July 2000)
- Carter H, Drury J, Rubin GJ, Williams R, Amlot R. Public experiences of mass casualty decontamination. Biosecur Bioterror. 2012 Sep;10(3):280-9. [PubMed Citation]
Additional References:
- Dainiak N, Delli Carpini D, Bohan M, Werdmann M, Wilds E, Barlow A, Beck C, Cheng D, Daly N, Glazer P, Mas P, Nath R, Piontek G, Price K, Albanese J, Roberts K, Salner AL, Rockwell S. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]
- Procedures for Medical Emergencies Involving Radiation (PDF - 19 KB) (Health Physics Society)
- Waselenko JK, et al., Treatment of Radiation Injury in the Adult. www.UpToDate.com Version 14.2, December 2005 (subscription required)
- Patient Decontamination: Recommendations for Hospitals (PDF - 124 KB) (The Hospital and Healthcare System Disaster Interest Group and the California Emergency Medical Services Authority, July 2005, EMSA #233, Radiological Contamination, pages 11-16)
- Guide for the Selection of Chemical, Biological, Radiological, and Nuclear Decontamination Equipment for Emergency First Responders (PDF - 6.5 MB) (DHS, Draft, March 2007)
- Handbook for Responding to a Radiological Dispersal Device (Dirty Bomb): First Responder's Guide: The First 12 Hours (CRCPD Publication 06-6) (PDF - 4.26 MB). See pages 35-38 and page 52. (Conference of Radiation Control Program Directors, Inc. Frankfort, Kentucky, 2006)
- Radiation Decontamination: 6 part audio-video demonstration (REAC/TS)
- Advanced Personal Protective Equipment (PPE) and Standard Precautions
(PowerPoint® - 10 MB) (The New York City Department of Health and Mental Hygiene)
Resources from National Council on Radiation Protection and Measurements (NCRP):
- Responding to a Radiological or Nuclear Terrorism Incident: A Guide for Decision Makers (NCRP Report No. 165), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010.
- Population Monitoring and Radionuclide Decorporation Following a Radiological or Nuclear Incident, (NCRP Report No. 166), National Council on Radiation Protection and Measurements, Bethesda, MD, 2011.
- Management of Persons Contaminated with Radionuclides: Scientific and Technical Bases (NCRP Report No. 161, Vol. II), National Council on Radiation Protection and Measurements, Bethesda, MD, 2010.
- Management of Persons Contaminated with Radionuclides: Handbook (NCRP Report No. 161, Vol. I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008.
- Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19), National Council on Radiation Protection and Measurements, Bethesda, MD, December 2005, Section 6, pages 32-39. Purchase required; see Free Overview (PDF - 219 KB).
- Management of Terrorist Events Involving Radioactive Material (NCRP Report No. 138), National Council on Radiation Protection and Measurements, Bethesda, MD, 2001. (See Section 4.3: Medical Management of Radiation Casualties, page 43.)
- Management of Persons Accidentally Contaminated with Radionuclides (NCRP Report No. 65), Bethesda, MD, 1980. [NCRP 65 has been superseded by NCRP 161.]
|
|
 |
|
