University of Pennsylvania
Radiation Safety Office
Children's Hospital of Philadelphia

Emergency Treatment of
Patients Contaminated with Radioactive Materials

---

Outline

A. Notification

1. Instructions for Emergency Department Attending Physicians
2. Instructions for Emergency Department Charge Nurse

B. Facility/Personnel Preparation

1. Emergency Department Charge Nurse
2. Emergency Department (Attending) Physician (or designee)
3. Security
4. Environmental Services
5. Nuclear Medicine
6. Radiation Safety

C. Patient Transport and Arrival

1. Patient Transportation

a. CHOP
b. Off Campus

2. Patient Arrival

A. Initial Evaluation

1. Instructions for Emergency (Attending) Physician (or designee)
2. Instructions for Health Physicist or Nuclear Medicine Physician

B. Establishment of Containment Control Lines

C. Contamination

1. Instructions for Emergency Physician (with the assistance of a health physicist or nuclear medicine physician if needed)
2. Instructions for Health Physicist or Nuclear Medicine Physician

D. Patient Decontamination and Treatment

E. Personnel Decontamination

A. Equipment/Supplies

B. In-Services

C. Drills

The Hospital will be prepared to provide appropriate care of the patients contaminated with radioactive material in a manner which will minimize risk to staff and other patients.

To outline the procedure to be followed in the event that emergency medical care is required for persons injured in any incident which involved radioactive contamination. Every emergency department faces the potential problem of handling one or more victims of a radiation accident. This policy provides a step-by-step protocol for handling, receiving, and treating radioactively contaminated patients.

This policy applies to all hospital employees and medical staff who will be involved in the care of these patients.

A. Notification

As soon as it has been established that a patient must be transported to, or arrive at, the Hospital for treatment, the Emergency Department Attending physician must be notified.

1. Instructions for Emergency Department Attending Physicians

When the call is received, the Emergency Department Attending Physician will take the following steps:

a. Interview the individual reporting the incident regarding the nature of the injuries and possible radioactive contamination, completing the attached information sheet (Appendix 1).

b. Instruct the caller to wait, if possible, for a return call from the Radiation Safety Officer. Instruct the caller to bring the patient to the Emergency Department entrance, and to wait in the ambulance for assessment.

c. Call the Radiation Safety Office at 898-7187 (days) or beeper 215-980-0035 (after hours or weekends) and take the following steps:

i. State that you have a radiation emergency.

ii. Provide the information obtained from the individual.

iii. Provide the number where the caller can be reached (if applicable).

d. Share the information with Charge Nurse and Head Nurse/Nursing Supervisor.

2. Instructions for Emergency Department Charge Nurse

After notification, the Emergency Department Charge Nurse will take the following steps:

a. Instruct the hospital operator to notify the RSO and Security. Security will notify the departments and individuals specified in the Radiation Emergency Telephone Directory (Appendix 2) that a child contaminated with radioactive material is coming into the Emergency Department.

b. Assign nursing personnel to assist the attending physician in the radiation emergency treatment area. Ensure that no pregnant personnel are assigned to the area.

c. Assign a buffer zone (step-off pad) nurse.

d. Ensure that the Emergency Department decontamination room is prepared to receive patients.

e. Ensure that appropriate and sufficient medical supplies are available in the Emergency Department decontamination room.

f. Coordinate all activities in the treatment area and at the step-off pad.

B. Facility/Personnel Preparation

1. Emergency Department Charge Nurse

The Emergency Department Charge Nurse must take the following steps:

a. Ensure that appropriate personnel don protective clothing (caps, surgical masks, disposable water-repellent gowns, shoe covers and surgical gloves) and dosimeters.

b. Ensure that a nurse has been assigned to the step off area until it can be staffed by radiation safety or a radiology person. This nurse should ensure that air flow is on negative pressure.

c. Assign a nurse to set up the facility. The nurse will also place equipment/supply kits in their designated areas and will unlock the shower hose cabinet (key in medication room) and adjust the water temperature to lukewarm.

d. Ensure that appropriate specialists have been notified.

2. Emergency Department (Attending) Physician (or designee)

The Emergency Department (Attending) Physician (or designee) must don protective clothing and dosimeters.

3. Security

Security keep patient arrival area clear.

4. Environmental Services

Environmental Services must take the following steps:

a. Clear decontamination room of non-stationary supplies and equipment.

b. Hang a magenta and yellow rope between the covered and uncovered areas to delineate them.

c. Hang several "Caution, Radioactive Materials" signs from the rope.

d. Cover the floor of the decontamination room with plastic.

e. Cover the floor outside the entrance to the decontamination room with plastic.

f. Place water receptacle under drain.

g. Remove sheet from stretcher and place decontamination tub on top of stretcher.

h. Position tubing over drain (cut off receptacle bag and discard).

i. Place back board in decontamination tub.

5. Nuclear Medicine

Nuclear Medicine must take the following steps:

a. Don protective clothing.

b. Check meters for proper operation.

c. Review radiation safety procedures with staff.

d. Assist with and evaluate facility preparation.

6. Radiation Safety

Radiation Safety must take the following steps:

a. Don protective clothing.

b. Check meters for proper operation.

c. Review radiation safety procedures with staff.

d. Evaluate and assist with facility preparation.

C. Patient Transport and Arrival

1. Patient Transportation

a. CHOP

i. Escort/transport individuals at CHOP contaminated with radioactive materials and requiring emergency treatment to the Emergency Department with Nuclear Medicine personnel when possible. Stable adults should be transported to the Hospital of the University of Pennsylvania.

ii. If a wheel chair or stretcher is used for transport, make an effort to limit the spread of radioactive contamination by covering the vehicle with absorbent pads or linens. In addition, wrap the patient in a sheet to help prevent the spread of contamination.

iii. Personnel handling the patient must be aware of the potential for radioactive contamination and wear the appropriate protective clothing. Remove potentially contaminated articles and store them in a plastic bag before moving throughout the hospital.

iv. Hold the vehicle in the Emergency Department until it has been checked for contamination.

v. Check transport personnel radioactive contamination before they leave the Emergency Department.

b. Off Campus

i. Transport individuals contaminated with radioactive material and requiring emergency treatment to the Emergency Department by ambulance, helicopter, or other emergency vehicle. Admit the patient through the outside door to the decontamination room. If time allows, cover the area from the ambulance to the door with plastic.

ii. Follow the steps in section a.

2. Patient Arrival

a. Transport the patient immediately to the Emergency Department decontamination room via the outside entrance, which must be unlocked by security prior to the patient's arrival.

b. Have security hold any transport vehicles until they are determined to be free of radioactive contamination.

c. Check all personnel involved in the transport of the patient for radioactive contamination before they leave the Emergency Department.

A. Initial Evaluation

1. Emergency (Attending) Physician (or designee)

a. Meet the emergency vehicle as it arrives.

b. Determine the extent of any injuries.

i. If immediate medical attention is required, take the patient directly to the Emergency Department decontamination room.

ii. If the patient's condition permits, remove the patient's clothing (if it is still on) and wrap the patient in a sheet or blanket before transport to the Emergency Department decontamination room. Handle clothing as radioactive and place it in a plastic bag.

iii. When a choice must be made, the care of life threatening conditions must always take priority over containment of contamination.

c. Stabilize the patient as required by his medical condition.

i. If the condition is life-threatening, begin medical therapy without delay.

ii. If the condition is serious but not life-threatening, begin medical therapy after covering radioactively contaminated areas of the patient's body with plastic or other water proof material.

iii. If the condition is not serious, carry out decontamination procedures prior to medical treatment.

iv. Carry out decontamination procedures only when the patient's condition is stable.

2. Health Physicist or-Nuclear Medicine Physician

a. Meet the emergency vehicle as it arrives (if possible).

b. Make preliminary radiation measurements if they do not interfere with medical treatment.

c. Assist medical staff in removing the patient's clothing and in wrapping the patient in a sheet or blanket if time allows.

B. Establishment of Containment Control Lines

The following rules will be followed at the entrance to the treatment area under the control of the health physicist or nuclear medicine physician:

1. Only personnel wearing appropriate attire will enter the treatment area.

2. Only personnel wearing personnel dosimeter will enter the treatment area.

3. No one may leave the treatment area before removing gloves and booties and being checked for contamination.

4. No equipment may be removed from the treatment area until it is checked for contamination.

C. Contamination

1. Emergency Physician (with the assistance of a health physicist or nuclear medicine physician if needed)

a. Remove patient's clothing (if applicable) and seal it in a labeled plastic bag.

b. Obtain moistened samples of the ear canals, nostrils, mouth and open wounds.

c. Place samples in a container labeled with the patient's name, sample site, time and label with radioactive tape.

d. Take blood sample for complete blood count with differential and platelet count. The blood should be monitored for radioactivity prior to being sent to the lab. If the blood is radioactive, the sample should be placed in an impervious plastic bag and labeled with radioactive tape. The appropriate lab supervisor should be notified of the type and amount of radioactivity. The laboratory will follow their policy on handling radioactive specimens.

2. Health Physicist or Nuclear Medicine Physician:

a. Take exposure rate readings at one foot and one meter from the patient; record the results and the item.

b. Interview the patient and/or accompanying personnel in order to establish the nature of the accident and the potential for radioactive contamination.

c. Use a portable survey meter to determine contaminated areas and the record results. If a portable survey meter is not appropriate for the radionuclide(s) involved, take wipes of the body and have them counted.

d. If internal contamination is suspected, collect urine, feces, and emesis in containers and record the time of collection.

e. If neutron exposure is suspected, remove any metal objects (jewelry, belt buckles, etc.) for counting.

D. Patient Decontamination and Treatment

Decontamination is typically performed from the highest level of contamination to the lowest. The priorities are as follows: (1) deep or extensive open wounds and adjacent skin, (2) body orifices and adjacent skin, (3) superficial wounds and adjacent skin, (4) upper body skin, (5) lower body skin.

1. Wound contamination

a. If the radioactive material is small in quantity and composed of beta or gamma emitters, only mild measures to remove the activity are warranted. The presence of alpha emitters or large quantities of radioactivity may require more drastic action.

b. Handle the contaminated patient and wound as one would a surgical procedure; i.e., use gown, gloves, cap, surgical mask, etc.

c. You may use a magnetic probe to remove radioactive metal particles from wounds.

d. Flush any open wound with sterile saline.

2. Skin or hair contamination

Most contaminants can be removed by using soap and tepid water and gently scrubbing with a washcloth, paper towel, or 4-by-4's. Remove the contamination by lifting it off the skin with a towel. The skin should never be reddened or irritated with hot water or harsh scrubbing.

3. Mouth or nose contamination

a. Turn the patient's head to the side or downwards and rinse the mouth and/or nose with small amounts of water, and suctioning frequently.

b. Gently irrigate nasal passages with saline through a catheter with the head bent over a basin and the mouth open.

c. Prevent water from entering the stomach, and do not permit the patient to swallow.

d. Administer an expectorant and spray the nasal passages with a vasoconstrictor.

e. Potentially hazardous procedures, such as bronchial lavage for pulmonary contamination, should not be attempted by anyone other than the appropriate medical or surgical specialist.

4. Ingested contamination

a. If the ingestion of radioactive materials is suspected, collect and save urine and feces for counting.

b. To remove ingested material from the stomach, lavage the stomach or induce vomiting; save all the materials for counting.

c. Minimize absorption with absorbers such as activated charcoal, antacids such as aluminum hydroxide for acid soluble materials, or precipitating agents to form poorly soluble precipitates.

d. Cathartics (magnesium sulfate 15 grams) may be given to hasten elimination; all fecal material should be saved for counting.

e. The use of chelating agents is usually not indicated; however, if long-lived radioactive materials in soluble form appreciably above the maximum permissible body burden gain access to the body, then the use of chelating agents may be considered. DTPA, when given in several intravenous treatment(s), can appreciably increase the excretion rate of a number of radionuclides.

f. If ingested materials are in the form of "hot" particles (e.g., Co-60, Mn-54, or Fe-59 complexes), the material can assumed to be insoluble and will not be absorbed in any significant amount. If these materials are ingested in a soluble form, try to precipitate them with aluminum hydroxide.

g. If iodine contamination occurs, potassium iodide (SSKI) can be given orally to minimize damage to the thyroid (available in pharmacy).

5. Removal of patient from treatment area

a. Dry patient thoroughly.

b. Re-wipe all previously contaminated areas of body.

c. Place new covering over the old covering on the floor in the hallway step-off area.

d. Move the patient into the hallway on the stretcher. The stretcher must stay on the covering. Move the "clean" stretcher alongside the patient's stretcher and transfer the patient to it. Handle the patient only with clean gloves, and do not let the patient come into contact with potentially contaminated items.

e. Monitor the stretcher with meters as it leaves the step-off area.

f. If injured and decontaminated, the patient should be admitted to a nursing floor.

g. If injured and having residual contamination, or having been externally irradiated, the patient should be admitted to the oncology service.

h. If decontaminated and not injured, the patient should be discharged.

E. Personnel Decontamination

1. Make a list of all staff who have had contact with the patient.

2. Check all individuals involved with patient transport for radioactive contamination prior to leaving the Emergency Department.

3. All individuals leaving the Emergency Department (decontamination room) must remove shoe covers and gloves be checked for radioactive contamination. Handle shoe covers and gloves as radioactive.

4. Personnel performing decontamination duties must wear appropriate protective clothing.

5. Personnel must be checked for contamination using the appropriate means of detection: a G-M probe for high energy (>250 kev) beta and gamma emitters; a low energy scintillation probe for soft x-ray emitters; liquid scintillation counting for soft beta emitters.

6. Removable contamination levels must be less than 200 dpm.

7. Place all possible contaminated cleaning supplies (towels, absorbent pads, etc.) in a labeled plastic bag.

8. "Radioactive" labels should be removed after clean-up is complete.

9. Place radioactive waste in storage in nuclear medicine until delivery to the Radiation Safety Office can be arranged.

A. Equipment/Supplies

1. The equipment and supplies (See Appendix 3) will be inventoried on a quarterly basis by the Radiation Safety Office in conjunction with the Emergency Department Nursing staff. The following tasks must be performed:

a. Ensure that all equipment and supplies are present and in good condition.

b. Replace yearly TLD dosimeters.

c. Check the expiration date on all chemicals.

d. Check the batteries and calibration dates on all survey meters.

e. Check the operation of survey meters using a check source.

2. On an annual basis, calibrate all survey meters.

3. Every five years, replace all disposable material.

B. In-Services

1. All personnel involved with the Radiation Emergency Plan are required to attend an annual in-service to be conducted by the Radiation Safety Office. Attendees will include individuals from the following departments:

Radiation Safety
Emergency Department Attending/Fellows
Emergency Department Nursing Staff
Nuclear Medicine
Environmental Services
Laboratory
Nursing Supervisors
Security
Communications

2. In-service education will be arranged by the Director of Radiation Safety in conjunction with the Medical Director of the Emergency Department.

C. Drills

1. Drills will be conducted periodically in order to evaluate the effectiveness of this protocol.

2. The Director of the Radiation Safety Office and the Medical Director of the Emergency Department are the only individuals authorized to conduct drills.

3. An evaluation of the performance during these drills or any actual incidents shall be the subject of a written report which shall be submitted to the Safety Committee and the Chief Operating Officer. These reports will be maintained for a period of at least three (3) years.

Radiation Emergency Information Sheet

Obtain the following information from the caller:
Date call received:
Time call received:

Name & Affiliation of Caller:
Telephone number:

Description of victim(s):
Name (if known) or description of patient #1:

Age:
Extent and type of injuries:

Location of contamination:
Radionuclide or isotope: Activity:
List decon. measures taken on site:

Est. time of arrival:

Name (if known) or description of patient #2:

Age:
Extent and type of injuries:

Location of contamination:
Radionuclide or isotope: Activity:
List decon. measures taken on site:

Est. time of arrival:

Name (if known) or description of patient #3:

Age:
Extent and type of injuries:

Location of contamination:
Radionuclide or isotope: Activity:
List decon. measures taken on site:

Est. time of arrival:

Radiation Emergency Telephone Directory

·Emergency Services

Head Nurse/Assistant Head Nurse/Charge Nurse --- 3488
Medical Director/Attending Physician --- 3488


·Radiology Department Resident on Call/
Nuclear Medicine staff on call --- Call Hospital Operator to page


·Administrator On Call --- Page Beeper# 10900


·Nursing Supervisor --- Page Beeper# 10224 (Evenings/Nights/Weekends)


·Environmental Services Director/Supervisor --- Page Beeper# 10057


·Radiation Safety Officer, University of Pennsylvania --- 898-7187


·Evenings/Nights/Weekends/Holidays page via beeper --- 215-980-0035
(When you hear the tone, enter your phone number including area code)

Equipment

The equipment/supplies Inventory will be placed Into three kits as follows:

I. Facility preparation and protective clothing kit

2 sections of plastic (10' x 10')
1 case of absorbent pads (chux)
2 boxes of 1 Inch surgical tape
1 pair of scissors and 1 pair of trauma scissors
1 roll of caution tape
4 Caution, Radioactive Materials- signs
2 dear plastic bags
2 biohazard bags
10 compete sets of the following:
shoe covers
Tyvek suit (one piece with hood and booties)
2 pairs surgical gloves
mask with eye shield
self reading dosimeter
10 TLD dosimeters

II. Patient decontamination kit

1 portable survey meter
1 GM probe
1 scintillation probe
1 ionization chamber - (Nuclear Medicine Dept. or Radiation Safety Office) 1 box of 2 x 2 alcohol preps
1 box of cotton swabs (Q-tips)
10 eye droppers
20 test tubes
100 glycene envelopes - (supplied by Radiation Safety office)
1 pair of scissors
1 nail clipper
1 pen
1 marking pen
1 pad of paper
1 bottle liquid hand soap
10 1000cc containers of normal saline
1 bottle of betadine
1 container of liquid detergent
1 bottle of shampoo
1 disposable razor and bar of soap
2 20cc syringes and 2 splash guards
2 sterile bowls
1 box of 4 x 4 gauze (unsterile)
10 absorbent pads (chux)
5 clear plastic bags
2 biohazard bags
1 roll of radioactive material tape
1 box of latex gloves
1 roll of 1 Inch surgical tape
1 disposable suture kit
4 empty 1000ml containers


Ill. Step off pad kit

1 portable well counter - (Radiation Safety office brings this)
1 portable survey meter - (Radiation Safety office brings this)
1 GM probe - (Radiation Safety office brings this)
1 scintillation probe - (Radiation Safety office brings this)
5 plastic bags
10 absorbent pads (chux)
20 pairs of shoe covers
1 box of latex gloves
2 rolls of 1 Inch surgical tape
1 roll of radioactive material tape
1 pen & paper
5 water resistant gowns
paper towels