Treat a Nuclear Exposed Casualty

INTRODUCTION

When a nuclear device is detonated in space, in the atmosphere, or at or below the surface of the earth or ocean, many characteristic effects are produced. Some effects, such as nuclear radiation and expanding debris, are common to all of these environments, though varying in degree. Other effects, such as crating, blast, and water shock, are peculiar to certain environments.

Effects such as light and heat are visible or tangible. Others, like nuclear radiation, are not directly apparent and can only be discerned by instruments or secondary effects. Some effects occur in and last only microseconds, whereas others occur in microseconds but linger for days, months, or even years. Meteorological conditions such as atmospheric pressure, temperature, humidity, winds, and precipitation can affect some of the observed phenomena. All nuclear detonations, however, produce effects that can damage equipment and injure personnel.

Describe Nuclear Effects

Describe nuclear blast effects

(1) Initial blast wave

(2) Secondary–Projectiles debris

(3) Tertiary–Impact of being thrown. Wind drag can displace large objects and collapse buildings.

Medical effects from a nuclear detonation

Blast Injuries

(1) Two types of blast forces that occur in a nuclear detonation blast wave

(a) Direct blast wave overpressure forces

(b) Indirect blast wind drag forces

(2) Types of injuries

(a) Primary injuries due to overpressures such as ruptured eardrums and lungs

(b) Secondary injuries such as lacerations and puncture wounds can occur from primary and secondary missiles and falls and crush from debris

Blunt injuries

(1) Foreign body impact - heavy, blunt missiles may not penetrate, but can result in significant injury, particularly fractures

(2) Acceleration and deceleration injuries

Thermal Injuries

Flash burns

(1) Thermal radiation travels outward from the fireball in a straight line

(2) Thermal intensity decrease with distance

(3) Close to the fireball, all objects will be incinerated

Indirect (flame) burns

(1) Result from exposure to fires caused by the thermal effects in the environment, particularly from ignition of clothing

(2) Could be the predominant cause of burns depending on the number of and characteristics of flammable objects in the environment

(3) Eye injury: the intense light of a nuclear fireball can cause flash blindness

Radiation Injury

(1) Casualties produced by ionizing radiation alone or with other injuries will be common

(2) Acute Radiation Injury on the Battlefield:

(a) Dose delivered quickly, usually over several minutes

(b) High doses are required for clinically observable effects

(d) Exposure MUST be from gamma or neutrons

(e) Effects appear quickly usually within hours

(3) Acute Radiation Injury experience in man:

(a) Survivors of Hiroshima and Nagasaki

(b) Operation Castle (1954)

(d) Clinical radiotherapy

(e) Chernobyl

Assessment findings of exposure

Radiation Exposure

(1) Whole-body irradiation

(a) Absorbed doses are high and acquired over short periods of time

(b) Results in acute radiation sickness

(2) Three characteristic syndromes that occur with increasing doses

(a) Hematopoietic syndrome

(i) Low to mid range -lethal dose of radiation

(ii) Depression of bone-marrow function causing anemia

(b) Gastrointestinal syndrome

(i) Very serious prognosis - almost always accompanied by non-recoverable loss of bone marrow

(ii) Short latent period of a few days to a week – characterized by severe fluid loss, hemorrhage, and diarrhea

(i) Associated with absorbed doses in the lethal range

(ii) Rarely seen since heat and blast effect could cause immediate death

(iii) Latent period is very short - varying from several hours to 1 to 3 days

Mechanism of damage

(1) Cellular sensitivity determines organ and whole body response to a dose of radiation

(2) Cells are listed from MOST radiosensitive to least radiosensitive

(a) Lymphocytes

(b) Epidermal epithelium

(d) Nerve cells

(3) Radiation effects at each level of biological organization depend on the killing of cells. As a result, the most sensitive organ system is the blood forming system followed by the gastrointestinal system.

Terminate exposure

Physically remove casualty from contaminated environment

(1) Evacuation removes casualties from the dangers associated with radioactive fallout

(2) Move the casualties perpendicular to the wind direction

(a) This moves the casualties most quickly to a safe zone

(b) Be aware that wind directions change frequently

(3) If evacuation is not possible, shelter personnel from fallout and radioactive contamination

Time, distance, and shielding

(1) Time or duration of exposure

(a) Short duration can still be intense

(b) The longer the period of exposure the more damage will be done

(2) Distance

(a) The further away from the epicenter, the less intense the exposure

(b) Move yourself and the casualty as far away from the epicenter as possible

(3) Shielding is best accomplished by placing as much distance and substance between you and the accumulating radioactive material

(a) Two inches of steel, 6 inches of concrete, 8 inches of earth and 22 inches of wood will each reduce gamma radiation exposure by 50%

(b) If fallout is, or you expect it to become, a significant exposure threat, locate or construct a shelter

Provide assessment/treatment for specific exposure

Clinical Course of Radiation Sickness

(1) Initial Stage (before rash and fever)

(a) Symptoms: Relatively rapid onset of nausea, vomiting, and malaise

(b) Short duration - generally a few hours

(2) Latent Phase

(a) Relatively symptom-free

(b) Duration varies with the dose

Symptoms

Frequently occur in the whole-body-irradiated casualties within the first few hours of post exposure

(1) Nausea and vomiting occur with increasing frequency as the radiation exceeds 100-200 cGy

(a) Onset may be as long as 6-12 hours post exposure

(b) Vomiting within the first hours is associated with fatal doses

(2) Hyperthermia

(a) Significant rise in body temperature within the first few hours of potentially lethal radiation injury

(b) Fever and chills are associated with severe and life-threatening radiation dose

(3) Erythema - redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries

(a) Developed within the first day of post exposure if casualty received a whole-body dose of more than 1000-2000 cGy

(b) Erythema is restricted to the affected area

(4) Hypotension

(a) A noticeable decline in systemic blood pressure if received lethal dose of whole-body radiation

(b) Severe hypotension after irradiation is associated with a poor prognosis

(5) Neurologic Dysfunction

(a) Almost all person who demonstrate obvious signs of damage to the central nervous system within the first hours post exposure have received a lethal dose

(b) Symptoms include mental convulsion, convulsions, and coma

Triage

A mass casualty situation is developed by a nuclear attack

(1) Immediate treatment group (T1). Those requiring immediate lifesaving surgery. Procedures should not be time-consuming and should concern only those with a high chance of survival, such as respiratory obstruction and accessible hemorrhage.

(2) Delayed treatment group (T2). Those needing surgery, but whose conditions permit delay without unduly endangering safety. Life-sustaining treatment such as intravenous fluids, antibiotics, splinting, catheterization, and relief of pain may be required in this group. Examples are fractured limbs, spinal injuries, and uncomplicated burns.

(3) Minimal treatment group (T3). Those with relatively minor injuries who can be helped by untrained personnel, or who can look after themselves, such as minor fractures or lacerations. Buddy care is particularly important in this situation.

(4) Expectant treatment group (T4). Those with serious or multiple injuries requiring intensive treatment, or with a poor chance of survival. These patients receive appropriate supportive treatment compatible with resources, which will include large doses of analgesics as applicable. Examples are severe head and spinal injuries, widespread burns, or high doses of radiation; this is a temporary category.

EXAMPLES: One combat medic has two patients requiring immediate lifesaving procedures; s/he can only provide needed procedures for one. Thus, correct triage and evacuation procedures are essential. Triage and care of any life-threatening injuries should be rendered without regard for the probability of radiation injury or contamination.

The physician should make a preliminary diagnosis of radiation injury only for those casualties for whom radiation is the sole source of the problem

This is based on:

(1) Appearance of nausea

(2) Vomiting

(3) Diarrhea

(4) Hyperthermia

(5) Hypotension

(6) Neurologic dysfunction

Provide emergency medical care

Decontamination

(1) Soldiers from fallout areas may have fallout on their skin and clothing

(2) Soldier will not be radioactive, but may suffer radiation injury from the contamination

(3) Removal of the contamination

(a) Should be accomplished as soon as possible, definitely before admission into a clean treatment area

(b) Decontaminate the casualty's hood

(d) Decontaminate the casualty's mask and exposed skin

(e) Remove the casualty's Field Medical Card (FMC)

(f) Remove gross contamination on the overgarment by wiping all visible contamination spots with a sponge soaked in 5% solution

(g) Remove the casualty's protective overgarment jacket

(h) Remove the casualty's protective overgarment trousers

(i) Remove the casualty's butyl rubber gloves

(j) Remove the casualty's protective overboots

(k) Remove and secure the casualty's personal effects

(l) Remove the combat boots following the same procedures as for removing the protective overboots

(m) Cut off the casualty's battle dress uniform (BDU)

(n) Cut off the casualty's undergarments

(o) Remove the casualty's glove inner liners

(p) Remove the casualty's socks

(q) Decontaminate the casualty's ID tags

(i) Decontaminate your butyl rubber gloves in the 5% solution

(ii) Wipe the ID tags with the 0.5% solution

(r) Move the casualty to the skin decontamination area

(s) Perform spot skin decontamination

(i) Spot decontaminate potential areas of contamination with the M258A1 or M291 Skin Decontaminating Kit or the 0.5% solution

(ii) Pay particular attention to areas where gaps exist in the MOPP gear, such as the neck, lower part of the face, waistline, wrists, and ankles

(iii) Briefly wash or brush exposed skin (this will reduce 99 percent of contamination)

(t) Remove field dressings and bandages

(u) Decontaminate any splints

(v) Transfer the casualty to the shuffle pit

Treatment for Radiation Injury

(1) Start IV

(2) Administer antibiotics where appropriate

(3) Management of infection

Management of soldiers injured from the immediate effects of nuclear weapons

Flash, blast, thermal are the same as for conventional battlefield injuries - severity may be increased

(1) A burn is a burn regardless of whether it is caused by a nuclear explosion or by napalm and its management remains the same

(2) True of fractures, lacerations, mechanical injuries, and shock

(3) For most of the conventional injuries, standard first-aid procedures should be followed.

(4) Thermal Burns: (See Treat a Casualty with a Burn Injury

(a) Dressings for wounds and burns should follow a closed-dressed principle, with application of an adequate sterile dressing using aseptic techniques

(b) DO NOT close the wound, regardless of its size, unless authorized by a physician

(d) Overwhelming infection can develop rapidly from a burn caused by radiation

(e) Good nursing care and aseptic control of all procedures is a must; casualties should get plenty of rest, light sedation if they are restless or anxious, and a bland, nonresidue diet

(5) Penetrating injuries

(a) Fractured limbs Refer to Treat a Casualty with a Musculoskeletal Injury

(b) (b) Possible spinal injury Refer to Treat a Casualty with a Spine Injury

(6) Pressure Trauma

(a) Breathing difficulty

(i) Edema

(ii) Fluid accumulation

(iii) If pulmonary embolus suspected place casualty head down on left side

(iv) Watch for developing dyspnea and possible tension pneumothorax: Consider plural decompression

NOTE: If any lung pressure injury signs are present consider the administration of 100% oxygen. (If available)

(b) Ear and bowel Injury

(i) Require supportive care only

(ii) Ear pain/hearing loss keep ear canals clean and suspect lung damage

NOTE: Hollow organs and open air spaces are more susceptible to barotrauma.

(iii) Bowel injuries present as abdominal pain

(iv) Consider limited duty of casualties with diminished hearing loss

(7) Radiation exposure considerations

(a) Consider antibiotic therapy and rehydration

(b) Keep other wounds clean

(d) Apply sterile dressing if required

(8) Flash Injury

NOTE: When administering Morphine Sulfate, be aware of the indications and contraindications of this drug as they relate to burns. Indications: Severe acute or chronic pain, relieved dyspnea of acute left ventricular failure, pulmonary edema, and pain of a Myocardial Infarction (MI). Contraindications: Hypersensitivity to opiates, increased intracranial pressure, convulsive disorders, bronchial asthma, and respiratory depression, diarrhea caused by poisoning until the toxic material has been eliminated.

NOTE: Changes in fluid volume and tissue blood flow make absorption of any drug given intramuscularly or subcutaneously unpredictable. The intramuscular or subcutaneous routes should not be used and narcotics should only be given intravenously and in doses no larger than those needed to control pain.

Depleted Uranium (DU) Awareness

NOTE: Show DU Awareness Video (20 min). Introduce the video as an introductory/informational presentation. After the videotape has ended, review the subject matter contained below. Be prepared to answer questions concerning DU.

Characteristics

(1) DU is a heavy metal, that is 60% as radioactive as natural uranium found in the soil.

(2) Nuclear Fuel Cycle and Enrichment. It is termed „depleted„ because it is the waste that is left from the enrichment process of natural uranium. Natural uranium has three major isotopes (U-234, U-235, and U-238). The U-234 and U-235 are extracted from natural uranium ore to be used a nuclear of fission based fuel. The U-238 can not be used for reactor fuel or weapons grade uranium, thus is considered waste. About 99% of uranium ore is U-238, the other 1% is the most radioactive component of the ore.

(3) DU is very dense metal, about 1.6 times greater than lead.

(4) DU can be easily machined or working into different shapes. This allows it to be "molded" and fabricated for many industrial situations that require a very dense material.

Properties

(1) Chemically, DU is the same as natural uranium. It is a heavy metal, just like mercury, lead, or tungsten.

(2) DU is pyrophoric. DU will readily ignite when it strikes a target. This property is what eyewitness accounts of DU hits described as the enemy vehicle being engulfed in flame.

NOTE: DU is NOT fissionable material. It will no go critical regardless of the quantity or its configuration. All fissionable material (U-234/235 has been removed). DU rounds are not explosive, nor will they create a nuclear explosion when they hit a vehicle. They use their mass, properties, and high rate of velocity to penetrate vehicle’s armored skins (punches through).

Identification

Spent Penetrator:

(a) Rod shaped. If the penetrator is intact and has not impacted with a hard target, it may retain its original shape.

(b) Color may be silver, green-black, black, or black-gold

NOTE: Original penetrator is dart-shaped with a nose cone (point) and a tail fin section. It is approximately 1.5 feet in length and weighs 10-15 pounds.

(c) Tungsten or other metals may be used as penetrators. These may look the same as the depleted uranium penetrator. The only way to POSITIVELY identify a DU penetrator is with a RADIAC meter. ASSUME ALL PENETRATORS FOUND TO BE DU.

Burning Vehicles

(a) M1A1 Abrams MBT may have depleted uranium in their armor plating. When penetrated, there may be DU in the smoke. Of course, DU will be in the air on the inside of the tank when it is hit and penetrated.

(b) Any vehicle hit and penetrated with DU munitions may have the same conditions as above.

SUMMARY

As a soldier medic, you will be confronted with the realities of the modern battlefield. When faced with casualties that are the result of an individual being exposed to nuclear elements. Of primary concern will always be basic life saving and preservation steps required to assure the airway, breathing, and circulation of the casualty. The conventional injuries should be treated first by following standard first-aid procedures.