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	Initial Onsite Activities Major Goals of the Initial Response Expanded Guidelines for Initial Response Radiation Control Zones and Perimeters Recommended by Various Agencies Radiation Response Worker Exposure Guidelines Personal Protective Equipment (PPE) Guidance Key Info: Notify authorities Establish perimeter security and Incident Command System (OSHA) Identify isotope(s) Ensure safety of responders Establish patient handling flow Triage patients: Perform lifesaving tasks before managing radiation problems Major Goals of the Initial Response Identify the radiation threat, which may not be apparent during the event discovery Notify appropriate (local, state, federal) authorities that a radiation event may have/has occurred Identify approximate number and location of casualties Protect the public from further injury Protect responders from being additional casualties Establish local on-site Incident Command System (OSHA) Begin triage of patients using protocols appropriate for mass casualty setting for a radiation event Alert local medical infrastructure to prepare for mass casualty transports Reference: Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19, December 2005, purchase required; see Free Overview (PDF - 219 KB)) top of page Expanded Guidelines for Initial Response Adapted from Managing Radiation Emergencies (REAC/TS) Establish Incident Command System (OSHA). Approach site with caution. Position personnel, vehicles, and command post at a safe distance upwind and uphill of the event site. Identify exposure dose rate (if any) at various distances from epicenter so safety plan for responders can be established. Ensure safety of responders. Identify all hazards (danger of fire, explosion, toxic fumes, electrical hazards, structural collapse, etc.). Identify radioactive agent by all means available: marking on shipping container, readings from radiation survey equipment, etc. Keep upwind of smoke, fumes, etc. Follow usual protocols for respiratory protection; use appropriate personal protective equipment. Monitor changing conditions that could create hazardous situations. Exclusion zone perimeter will vary with the nature of the incident. Locate victims and facilitate extrication, emergency care, and transportation of the injured following radiation event and EMS guidelines. Medical problems take priority over radiological concerns. Do not delay rescue or transport of a seriously injured, contaminated patient. If continuing exposure at event site, responder time in rescue zones may need to be regulated. Communications Notify appropriate hospitals of possible transport of contamination/exposure victims. Notify state radiological assistance centers and emergency response centers of accident conditions. Establish a control zone. Reroute traffic. Mark controlled area by use of ropes or tapes. Limit entry to rescue personnel only. Order evacuation or sheltering as needed. Prevent/fight fires as if toxic chemicals were involved. Ensure radiation protection and contamination control. Do not allow eating, drinking, smoking, or other activities within contaminated areas that might lead to intake of radioactive material. Avoid direct contact with radioactive materials where possible. Utilize protective clothing and anything available for remote handling (shovels, branches, ropes, etc.). Limit time near radioactive materials to the minimum necessary. Rotate staff as necessary. Determine radiation levels within controlled area and monitor rescue personnel with individual dosimeters, if available. Evacuate personnel from the immediate downwind area. Detain personnel who were in the accident area until they can be checked by radiological monitors. Follow instruction of radiation authority. Remove protective gear/clothing at the control line. Wrap, label, and isolate all clothing, tools, etc., used in the controlled area and retain them until they can be cleared by radiation authority. Determine if measures are needed to contain all accident debris in the control zone until cleanup is achieved. Prevent unnecessary handling of incident debris. Transport of contaminated patients needing urgent care elsewhere before decontamination procedures completed. Necessary lifesaving medical treatment should precede decontamination or other radiation management procedures. Transport personnel should wear appropriate personal protective equipment and personal dosimeters. Wear respiratory protection to limit inhalation of radiological material. Close vehicle's internal compartments before loading the patient to minimize contamination. Cover vehicle floor with disposable paper, cloth, pads, plastic, or other items to minimize contamination. Irrigate wounds distally and laterally, if possible, to limit additional contamination of patient and try to contain the runoff. Use mobile technician kits instead of compartments in and on the vehicle if possible, because contaminated mobile equipment can be removed more easily from the vehicle. Wrap patient in at least a double layer of sheeting to limit contamination from patient to personnel, vehicle, or equipment but preserve ability to monitor and access the patient adequately. (Adapted from: Emergency Response Plan, Addendum 4: Radiological Operations, New York City Fire Department Guidelines, February 2, 2006) Documentation of those involved in event (register patient/responders in post-event surveillance cohort study). Record the names and addresses of all persons involved, including Those who insist on leaving the area Rescuers Those removed for medical attention Ambulance personnel All responding personnel. Make detailed records of the incident. Delay cleanup pending instruction from radiation authority. Coordinate cleanup activities at site with public officials. top of page Radiation Control Zones and Perimeters Recommended by Various Agencies Agency Zone Designation Perimeter Designation Exposure Levels Activities and Guidelines IAEA† (See diagram) --- --- >10,000 mR/hr (>10 R/hr) Only lifesaving actions should be performed Limit staying time to <30 minutes Inner Cordoned Area Safety Perimeter >10 mR/hr - OR - 1000 Bq/cm2 β, γ surface contamination - OR - 100 Bq/cm2 a surface contamination Inner cordoned area: area around dangerous radioactive source where precautions should be taken to protect the responders and the public from potential external exposure and contamination. "Forensic evidence management area" should be located in the inner cordoned area, adjacent to the "safety access" and "contamination control area". "Response contamination control area" should be located at the boundary of the inner cordoned area and away from the public processing area. Outer Cordoned Area Security Perimeter --- Outer cordoned area: secured area around the inner cordoned area. Ambient dose rates in this area need to be at levels close to background levels. The "public processing area" should be located within the outer cordoned area with access for medical transport. The "temporary morgue area" may be located in a tent or existing facility that is secured within the outer cordoned area away froma the view of the general public. The "waste storage area" should be located within the outer cordoned area preferably in a structure that is secured and positioned to prevent the spread of contamination (e.g., by wind or rain). The "Incident Command Post" should be established outside the outer cordoned area. NCRP‡ (See diagram) --- Inner Perimeter 10,000 mR/hr (10 R/hr) Actions taken in this area should be restricted to time sensitive, mission critical activities such as life saving. --- Outer Perimeter 10 mR/hr - OR - 1000 Bq/cm2 β, γ surface contamination - OR - 100 Bq/cm2 a surface contamination Appropriate actions are to Evacuate members of the public Isolate the area Minimize time each emergency worker spends inside the area Ensure that workers follow appropriate personal protection guidelines. --- --- --- The area outside the outer perimeter is where the command post and other support functions are located. To implement the ALARA principle, the selection of locations for decontamination as well as for staging equipment and support personnel should be made carefully, and if possible, these functions should be established in areas without elevated exposure rates. CRCPD§ (See diagram) Extreme Caution Radiation Zone Extreme Caution Radiation Boundary ≥10,000 mR/hr (10 R/hr) Activities restricted to saving lives. Total accumulated stay time for first 12 hours: minutes to hours High Radiation Zone High Radiation Boundary 1000 mR/hr Access restricted to authorized personnel performing critical tasks: Firefighting Medical assistance Rescue Extrication Other time-sensitive activities Medium Radiation Zone Medium Radiation Boundary 100 mR/hr Access restricted to authorized personnel entering the "High Radiation Zone" to perform critical tasks such as saving of lives and property. Serves as a buffer zone/transition area between the "High Radiation Zone" and "Low Radiation Zones" Low Radiation Zone Low Radiation Boundary ≤10 mR/hr Access restricted to essential individuals. Initial decontamination of first responders should occur near the "outer boundary" (i.e., "Low Radiation Boundary") of this area. † Manual for First Responders to a Radiological Emergency (PDF - 2.2 MB) (CTIF, IAEA, PAHO, WHO, October 2006) ‡ Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19, December 2005, purchase required; see Free Overview (PDF - 219 KB)) § 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). Conference of Radiation Control Program Directors, Inc. Frankfort, Kentucky, 2006. Abbreviations: mR/hour: milliRoentgens per hour R/hour: Roentgens per hour Bq/cm2: Becquerels per square centimeter a: alpha particles β: beta particles γ: gamma radiation top of page Radiation Response Worker Exposure Guidelines 1, 2, 3 Total Effective Dose Equivalent (TEDE) Guideline Activity Condition 5 rem All occupational exposures Dose limit to emergency workers: 5 rem Use all reasonable measures to minimize dose For most Radiological Dispersal Devices, radiation control measures will maintain exposures below 5 rem Some rescues may involve exposures > 5 rem When 5 rem limit is exceeded, worker monitoring must be made available and volunteers for such activities should be made fully aware of the risks 10 rem Protecting valuable property necessary for public welfare (e.g., a power plant) Exposures to emergency workers protecting valuable property necessary for public welfare may exceed 5 rem Use all reasonable measures to minimize dose When 5 rem limit is exceeded, worker monitoring must be made available and volunteers for such activities should be made fully aware of the risks For potential doses > 10 rem, special medical monitoring programs should be employed, and exposure should be tracked in terms of the unit of absorbed dose (rad) rather than TEDE (rem). 25 rem Lifesaving or protection of large populations During large incidents (e.g., Improvised Nuclear Devices) exposures to emergency workers may exceed 5 rem Emergency response activities may include: lifesaving, protection of large populations, prevention of mass spread of destruction Use all reasonable measures to minimize dose When 5 rem limit is exceeded, worker monitoring must be made available and volunteers for such activities should be made fully aware of the risks For potential doses > 10 rem, special medical monitoring programs should be employed, and exposure should be tracked in terms of the unit of absorbed dose (rad) rather than TEDE (rem). 1 Adapted from Planning Guidance for Protection and Recovery Following Radiological Dispersal Device (RDD) and Improvised Nuclear Device (IND) Incidents (PDF - 394 KB) (DHS/FEMA, published in Federal Register, August 1, 2008, Z-RIN 1660-ZA02) 2 Emergency response decisions resulting in worker exposure doses greater than 5 rem Made by on-scene Incident Commander during incident when exceeding 5 rem is unavoidable Reflect actual incident circumstances/worker activity (e.g., need to save lives or critical infrastructure) Require informed consent from responding worker 3 Decision points for restricting response workers' activities have been recommended by various other agencies. Agency Summary Information Original Document National Council on Radiation Protection and Measurement (NCRP) NCRP Radiation Protection Guidelines: Control of Radiation Dose in the Control Zones Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19, December 2005, page 19, purchase required; see Free Overview (PDF - 219 KB)) International Atomic Energy Agency (IAEA) IAEA Emergency Worker Turn-back Dose Guidance Manual for First Responders to a Radiological Emergency (PDF - 2.2 MB) (CTIF, IAEA, PAHO, WHO, October 2006, page 41) Conference of Radiation Control Program Directors, Inc. (CRCPD) CRCPD Turn-back Exposure Rates and Dose Guidelines 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), page 28. Conference of Radiation Control Program Directors, Inc. Frankfort, Kentucky, 2006. International Commission on Radiological Protection (ICRP) ICRP Guidance for Occupational Exposure Protecting People Against Radiation Exposure in the Event of a Radiological Attack (International Commission on Radiological Protection, ICRP Publication 96, 2005, page 51) See also: Personal Protective Equipment (PPE) top of page Personal Protective Equipment (PPE) Guidance PPE for First Responders when exposure hazard is unknown or uncharacterized 1, 2 Bunker gear (aka turnout gear, firefighter protective clothing, PPE Level B) Standard bunker gear Flame- and water-retardant pants and overcoat Helmet, gloves, footwear, and hood Protects against external contamination from alpha and most beta radiation, but not against exposure from high energy x-rays/gamma rays. Contaminated gear/clothing should not be worn for extended periods of time and should be disposed of per RSO guidance. Reviews of civilian PPE Levels A, B, C, D are available. 3, 4, 5 Respiratory protection Protects against inhalation of airborne toxins, including radioactive materials Basic overviews of respiratory protection equipment are available 4, 6, 7, 8, 9 Radiation monitoring equipment Survey meters Used by radiation safety team to monitor environmental radiation levels Personal dosimeters Monitors individual radiation exposure Personal dosimeter types Records cumulative dose ± preset alarm parameters Records dose rate ± preset alarm parameters Incident Managers follow Protective Active Guidelines regarding allowable exposure dose limits to responders. PPE for medical facility staff when hazard is known to be radioactive contamination only 10, 11 Outer wear for working in areas contaminated with radiation: PPE Level D (2, 3, 4) plus respiratory protection 3, 4, 5, 6, 7, 8 Chemical-resistant body suit (e.g., Tyvek® suit) Double layer protective gloves with inner pair and outer pair of two different colors (if possible) and gloves taped to body suit Head covering and eye/face protection (if not part of the respirator) Shoe covers or booties taped to body suit Step by step procedures for putting gear on and off 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) Contaminated gear/clothing should not be worn for extended periods of time and should be disposed of per RSO guidance. Respiratory Protection Non-powered (negative pressure) air purifying respirator 3, 4, 6, 7, 8 When no formal respiratory protection equipment is available, a dry handkerchief or bandana may be used until appropriate equipment can be located. 12, 13, 14 Radiation monitoring equipment Survey meters Used by radiation safety team to monitor environmental radiation levels Personal dosimeters Monitors individual radiation exposure Personal dosimeter types Records cumulative dose ± preset alarm parameters Records dose rate ± preset alarm parameters Incident Managers follow Protective Active Guidelines regarding allowable exposure dose limits to responders. General guidance Removal of contaminated clothing from patients/victims reduces quantity of external contamination by about 75% - 90%. (See REMM suggested decontamination procedures.) Decontamination of patients/victims can greatly minimize first receivers' need for PPE. Even without PPE, first receivers have a low risk of significant injury from radioactive contamination. Pregnant women should be excluded from the care of radioactively contaminated victims, regardless of use of PPE. At the completion of each work period and any time a first responder or healthcare worker leaves the contaminated area, he/she must carefully remove personal contaminated garments, ensure that their personal dosimeter is returned to the RSO, undergo a personal radiation survey, and undergo personal decontamination if needed. PPE is not required when treating victims of radiation exposure only, as they are not contaminated. However, victims with significant radiation exposure are at increased risk of infection due to the Hematopoietic Subsyndrome of the Acute Radiation Syndrome. Universal Precautions (NYU Medical Center), usually with reverse isolation, are required to care for these patients, when they have low white counts. OSHA also provides PPE workplace guidance 15 Related REMM Information: Diagnosis and treatment of radiation contamination Decontamination Procedures Decontamination facilities Hospital zones used for decontamination Hospital zone access during a mass casualty event Radiation control zones and perimeters recommended by various agencies How to perform a Radiation survey Radiation survey equipment References from PPE Section: Protecting Emergency Responders, Volume 2: Community Views of Safety and Health Risks and Personal Protection Needs. LaTourrette T, Peterson DJ, Bartis JT, Jackson BA, Houser A. Prepared for the National Institute for Occupational Safety and Health. Rand Science and Technology Policy Institute, Santa Monica, California, 2003. Protecting Emergency Responders (HHS/CDC/NIOSH) General Description and Discussion of the Levels of Protection and Protective Gear. - 1910.120 App B (OSHA) Heubner KD, Lavonas E, Arnold JL, CBRNE - Personal Protective Equipment (eMedicine, May 23, 2006) Defining Personal Protective Equipment Levels A to D — OSHA and EPA regulations compared (Department of Veterans Affairs) Respirator Fact Sheet (HHS/CDC/NIOSH) NIOSH-Approved Disposable Particulate Respirators (Filtering Facepieces) (HHS/CDC/NIOSH) NIOSH Respirator Selection Logic 2004, NIOSH Publication No. 2005-100 (HHS/CDC/NIOSH) CBRNE Standards Development, Self Contained Breathing Apparatus (SCBA) — To Protect Emergency Responders Against CBRN Agents in Terrorist Attacks (HHS/CDC/NIOSH) Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19, December 2005, purchase required; see Free Overview (PDF - 219 KB)) Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving Release of Hazardous Substances (OSHA) Guyton HG, Decker HM, Anton GT. Emergency respiratory protection against radiological and biological aerosols. AMA Archives of Industrial Health 1959;20:10-92. Cooper DW, Hinds WC, Price JM. Emergency respiratory protection with common materials. Am Ind Hyg Assoc J. 1983 Oct;44(1):1-6. Musolino SV, Harper FT. Emergency Response Guidance for the First 48 Hours after the Outdoor Detonation of an Explosive Radiological Device. Health Physics 2006 Apr;90(4):377-85. [PubMed Citation] Safety and Health Topics: Personal Protective Equipment (PPE) (OSHA) top of page

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