EMS World

JUL 2018

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EMSWORLD.com | JULY 2018 35 SDZ because the destruction of buildings and infrastructure would be so complete as to deny fires the fuel to burn. Given that there would be no people or property to save and because of the extreme levels of radiation near ground zero, emergency per- sonnel would never need to enter the SDZ. Moderate damage zone—About a half- mile from ground zero, the landscape would begin to shift from total devastation to one that contained both survivors and damaged structures. This is the moderate damage zone (MDZ). The degree and number of injuries would largely depend upon the dis- tance of survivors from ground zero. People who were closer would sustain more injuries and more severe injuries—from blast, burn, and radiation. Structures closer to the SDZ would be more severely damaged. The MDZ is where emergency services agencies will be able to save the most lives; however, conditions will be austere. Road- ways will likely be blocked by large piles of debris. Navigation will be difficult because street signs and landmarks will have been lost. Critical infrastructure such as commu- nications equipment, water for fire suppres- sion, and gas and electric lines will likely have been disrupted. There will be many fatalities in the MDZ, but there will also be numerous survivors—some entrapped, some not. Survivors will require rescue, decontamination, medical treatment, evacuation to fallout shelters and medical facilities, and other care (e.g., food). Injuries within the MDZ will range from minor to life-threatening and include burns, barotrauma, blunt and penetrating multi - system trauma from people being thrown against objects and vice versa, and heart attacks, as well as the normal spectrum of medical conditions seen in any popula- tion during noncatastrophic conditions. Additionally, many people will suffer from temporary (or longer-term) flash blindness due to the intense brilliant light associated with a nucdet. Responders should focus their lifesaving efforts on the MDZ, as this is where the salvageable patients with the greatest need for care will be found. Light damage zone—Outside the MDZ, effects on people, structures, and infra- structure will be more limited. Buildings may suffer light damage such as broken glass, cracks in walls, and door frames being forced out of alignment; however, most structures should sur vive intact. People may suffer minor, non-life-threat- ening injuries. Most injuries will come from flying glass and debris. Additionally, the stress and shock of a nuclear attack may precipitate heart attacks, and flash blind- ness among drivers will likely cause vehicle crashes with accompanying injuries. Emergency responders will likely see a surge in call volume in the LDZ, both for emergencies and because panicked peo- ple call 9-1-1 not knowing what else to do. Public safety answering points may need to implement more rigorous triaging of calls in order to direct resources to incidents where there is an actual opportunity (and need) to save lives. In all likelihood, however, there will be a much greater need for emergency services in the MDZ than the LDZ. Treatment Principle s The great overpressures and wind associ- ated with a nucdet will produce blunt and penetrating trauma, but most patients in the MDZ will likely suffer from combined injuries (i.e., trauma and radiation injuries). As radiation passes through the body, it kills blood cells, disrupts DNA, and causes burns. People who receive large doses of radiation over short periods of time often develop acute radiation syndrome (ARS), which can result in death within hours (for extremely high doses of radiation) or over a more prolonged period. Survivors who receive cytokine therapy within 24 hours of irradiation may be saved, especially if other life threats (i.e., trauma) are addressed. 3 Therefore, the care philosophy follow- ing a nucdet should be to treat immediate life threats first. Patients will present with trauma, medical, and radiological insults, but the standard life threats are going to kill patients before any radiological condition will. EMS personnel should treat conditions that will prevent a physician from dealing with the effects of irradiation; however, they will need to triage patients in a manner that takes into account the likelihood of survival if the patient has been irradiated. Standard EMS triage approaches (e.g., START) will not properly identify salvage- able patients as they do not account for the effects of irradiation and ARS. Properly triaging patients requires factoring in the likelihood of survival as a function of the total body dose of radiation received. Fig- ure 2 depicts a triage protocol that reflects the greater mortality associated with higher doses of radiation. The key feature of this system is that patient expectancy is driven by the time of onset of nausea and vomiting. Patient Decon and PPE All survivors (whether patients or not) should undergo decontamination. The longer radioactive particles sit on skin, Figure 2: Modified Triage System for Irradiated Patients. "Vomit" refers to onset of nausea; "Gy" refers to ionizing radiation. *Source: Armed Forces Radiobiology Research Institute. Medical Management of Radiological Casualties, 4th ed., 2013.

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