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An integrated, interactive human body map permits convenient documentation of the location of a personnel dosimeter (if worn by the individual at the time of exposure), radiation-induced erythema, and radioactivity detected by an appropriate radiation detection device. Radioactivity counting and bioassay. In the case of suspected internal radioactive contamination, the following processes are typically performed concurrently: • Decontamination to minimize the local radiation dose to the potential wound site. • Removal and collection of metallic (or other) fragments for isotope identification. • Biological sample collection for determination of committed dose. Monitoring/sampling of wounds (i.e., wound swabs or wound cleansing wipes), body orifices (i.e., nasal swabs, oral swabs), and skin surfaces (i.e., wipes) should be performed for confirmation of internal contamination. Although not strictly considered biological samples, metal fragments, bandages/dressings, and clothing should be retained for isotope identification. Biological specimens should also be collected to determine possible internal radionuclide deposition. Urinalysis and fecal sample analysis are the primary in vitro methods for determining internal dose. Urine is generally a high priority for bioassay, and therefore, “spot” urine as well as 24-hour urine specimens should be collected from accident victims. In the special case of an improvised nuclear device or any event involving nuclear fission, there is also a need to collect whole blood specimens for biodosimetry. The blood specimens should be labeled, packaged, and shipped to the network of radionuclide bioassay laboratories for neutron activation analysis to estimate individual neutron doses for the casualties. Prodromal signs, symptoms, and erythema. The pattern of biological responses associated with acute radiation sickness (ARS) can provide initial diagnostic indices and help with triage of potentially exposed individuals. The early clinical responses associated with the radiation prodromal phase include the following: • Nausea. • Vomiting. • Headache. • Fever. • Tachycardia. • Fatigue. • Weakness. • Abdominal pain. • Parotid pain. • Erythema. For the dose-dependent signs and symptoms associated with the prodromal phase of whole-body exposure to photon-equivalent radiation, see Table 6.2. An increase in the 159
exposure dose is associated with a parallel increase in both the constellation of prodromal signs and symptoms and the percentage of exposed individuals affected. For example, only 50% of individuals exposed to 2-Gy acute photon radiation will exhibit emesis. Radiation doses above 2 Gy will result in a progressive increase in the percentage of individuals who vomit and also express the broad range of prodromal symptoms. Hematology. Radiation exposure produces a predictable pattern of changes in bloodforming tissues. A crude estimate of absorbed dose can be obtained by serial measurement of peripheral lymphocyte blood counts. Therefore, a CBC with WBC differential should be obtained immediately after exposure, three times a day for the next 2–3 days, and then twice a day for the next 3–6 days. Lymphocyte cell counts and lymphocyte depletion kinetics can be used to estimate exposures between 1 and 10 Gy photon equivalent dose range. This biodosimeter is useful only for a few days (
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Bioterrorism and Other Public Healt
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Contents Chapter 1. Introduction ..
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Q Fever............................
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Basic Principles...................
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Chapter 9. Integrating Terrorism an
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Table 5.4 Nerve agent triage and do
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There are many gaps in knowledge, e
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injured or killed (see also Chapter
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Head injury is common in children.
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In situations of disaster, caregive
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maintaining and securing the airway
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• Schonfeld DJ. In times of crisi
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Types of Disasters Chapter 2. Syste
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problems noted above for flooding,
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Federal Response The United States
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The scope of ESF #8 is broad and in
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• Centers for Disease Control and
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Table 2.1 Types of disasters, hazar
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Medical staffs need to know what wi
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information, health and safety educ
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y private physicians. Approximately
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even required (particularly if a pe
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ICS structure is hierarchical. For
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• Provide community education so
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• Provide for crisis counseling.
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incident command officer is most of
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Figure 3.1 National Response Plan D
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Background History of Bioterrorism
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Epidemiology of a Terrorist Attack
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and may be watery, purulent, or blo
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fluid in these vesicles. A painless
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determined to be due to an agent of
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cared for using standard precaution
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may be providing longer term and mo
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The vaccine has a number of common
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Vaccination Large-scale vaccination
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cutaneous lesions; however, previou
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common food source is identified du
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treated people experience some degr
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treatment for plague meningitis. An
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Smallpox is spread most commonly in
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focal, intensely suppurative necros
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Control measures. Some viruses that
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Control measures. Person-to-person
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Signs and symptoms. The incubation
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currently used for individuals trav
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Accessed July 12, 2006. • Centers
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• Roffey R, Tegnell A, Elg HF. Bi
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Figure 4.2. Neurological signs, bot
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Figure 4.4. Physical distribution o
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Figure 4.6. Varicella lesions Note:
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Figure 4.8a. Febrile rash illness a
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Table 4.1. Early clinical signs and
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Table 4.2. Infection control transm
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Table 4.3. Diagnostic procedures, i
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Table 4.4a. Diagnostic tests for an
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Table 4.6. Treatment recommendation
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Introduction Chapter 5. Chemical Te
Page 120 and 121: likely manifest as an acute onset o
Page 122 and 123: exposures (Table 5.3). For an in-de
Page 124 and 125: Neuromuscular effects. At the neuro
Page 126 and 127: children. Finally, routine administ
Page 128 and 129: Treatment Management of cyanide poi
Page 130 and 131: Sulfur mustard is stockpiled both i
Page 132 and 133: decontamination is therefore extrem
Page 134 and 135: Pulmonary Agents Toxic industrial c
Page 136 and 137: Type I agents, the significance of
Page 138 and 139: After dispersal of riot control age
Page 140 and 141: • Kales SN, Christiani DC. Acute
Page 142 and 143: • Gray EA, Love JW, Arnold JL. CB
Page 144 and 145: Table 5.2. Chemical weapons - Summa
Page 146 and 147: Table 5.3 Representative classes of
Page 148 and 149: Table 5.4. Nerve agent triage and d
Page 150 and 151: Table 5.5. Clinical effects from su
Page 152 and 153: Table 5.7. Medical treatment of rio
Page 154 and 155: Chapter 6. Radiological and Nuclear
Page 156 and 157: from ground zero. For weapons large
Page 158 and 159: (1000 rem), resulting in four fatal
Page 160 and 161: cooling systems at Mayak exploded,
Page 162 and 163: pediatric practices. This put infan
Page 164 and 165: energy, releasing two photons of ex
Page 166 and 167: need to be shielded, although the a
Page 168 and 169: adioactive isotope of potassium. Ba
Page 172 and 173: Biodosimetry and Radiological Terro
Page 174 and 175: primitive/progenitor cells and othe
Page 176 and 177: permits bacterial translocation and
Page 178 and 179: To assess radiation dose, a researc
Page 180 and 181: status? 4. Conduct an initial surve
Page 182 and 183: explosion, when it is concentrated
Page 184 and 185: Skin pathway. Although intact skin
Page 186 and 187: personnel should also take a wipe s
Page 188 and 189: • Geiger-Mueller or G-M counters
Page 190 and 191: • Protective clothing— Disposab
Page 192 and 193: Decontamination priorities are as f
Page 194 and 195: These effects can occur anywhere fr
Page 196 and 197: manifestations of ARS may range fro
Page 198 and 199: Neutropenia: Viral and Fungal Infec
Page 200 and 201: The main reason for targeting pregn
Page 202 and 203: No significant side effects from it
Page 204 and 205: axilla, groin, and skin folds. Radi
Page 206 and 207: Followup Care, Including Risk of Ca
Page 208 and 209: artificial because followup in almo
Page 210 and 211: adioactive material in an accident.
Page 212 and 213: 131, canned milk or other milk prod
Page 214 and 215: home immediately after the incident
Page 216 and 217: • National Council on Radiation P
Page 218 and 219: • U.S. Nuclear Regulatory Commiss
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Radiation Detection, PPE, Monitorin
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• National Council on Radiation P
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• Peter RU, Gottlober P. Manageme
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Recommendations for State and Local
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Figure 6.2. Environmental exposure
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Figure 6.4. Bone marrow irradiated
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Figure 6.6. Classic Andrews diagram
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Figure 6.8. Examples of radiation s
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Figure 6.10. Localized radiation ef
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Table 6.2. Biodosimetry based on ac
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Table 6.4. Diagnostic steps in acut
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Table 6.6. Dose assessment summary
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Table 6.8. Antibiotics for treatmen
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Table 6.10. Radionuclide specific t
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Introduction Chapter 7. Blast Terro
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Spalling effect. When a blast wave
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Clinical findings and diagnosis. Cl
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highest position. Because of the pr
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perilymph in the membranous labyrin
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• Hemoptysis. • Subcutaneous em
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management and immediately involve
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considered (see Chapter 4, Biologic
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• Circumstances (weather conditio
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Bibliography Explosives, Incendiary
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Trauma Systems and Planning/Mitigat
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Table 7.2 Spectrum of primary blast
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Table 7.3 Principles of Advanced Tr
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Determine the severity of the burn
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Chapter 8. Mental Health Issues Men
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• Amnesia for important parts of
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Treatment. Treatment should be guid
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• Before notifying the family, br
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• Be conscious of nonverbal commu
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sadness, anger, guilt, or a sense o
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was mean to my father yesterday and
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these roles, they should work close
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• Lack of availability of trauma-
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The structure provided by a preexis
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necessarily meet the children’s n
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Make Psychological Contact Tune in
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A communications goal of “educati
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• Schonfeld D. Crisis interventio
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Chapter 9. Integrating Terrorism an
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Chain of command. A chain of comman
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The chain of command established by
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Advice for families of children wit
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Quarantine procedures. Quarantine p
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Chapter 10. Working with Government
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need under the 12 Emergency Service
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ecognizes that community clinicians
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Chapter 11. Conclusion This report
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Planning for special medical needs
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Table 11.1 Environmental constraint
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Table 11.2 Pediatric medical compla
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• The post-storm environment is h
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Acronyms AAP American Academy of Pe
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RIA RTG SCIWORA SEB SI SNS SSRI STA
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Appendix A. Pediatric Terrorism and
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1. List which biological agents (mi
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19. Identify chemical terrorism tox
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39. Provide followup care, being mi
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Learning Objectives: At the end of
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Lead Editors Appendix B. List of Co
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James Tsung, MD, FAAP Attending Phy
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Gerald S. Braley, PhD Major, United
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Kobi Peleg, PhD Michael Stein, MD J
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Lou E. Romig MD, FAAP, FACEP Childr
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Maternal & Child Health Bureau Dan
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