Office of Emergency Coordination (OEC)

OEC Update: April 2015 (IND Detonation)

Past issues of the OEC Update are archived on the O drive at: O:\CERT\OEC Update.

Basic Concepts for Responding to the Detonation of an Improvised Nuclear Device (IND)

Of all the events that the public health and emergency response communities think about, plan for, and exercise on, probably the most serious, in terms of its immediate and long-term consequences, would be the detonation of a nuclear device in a highly populated area.

Should such an event occur, it would most likely be the result of terrorists utilizing an improvised nuclear device (IND). An IND is a small nuclear weapon using uranium or plutonium to produce a nuclear reaction (fission). Although there are conventional explosives in an IND, the majority of the energy is created by this nuclear reaction.

The detonation of such a device would result in an extraordinarily powerful explosion with intense heat and blinding light, a damaging pressure wave, very high levels of radiation, and widespread contamination of the air, water, and ground surfaces for miles around with radioactive material.

While the successful detonation of a nuclear device in a populated area would be a catastrophic event, causing an unprecedented number of injuries and lives lost, as well as economic, political, and social disruption, an effective medical response and a public prepared to protect itself from fallout could save tens of thousands of lives.1 It is important for everyone to understand that the best initial action immediately following a nuclear explosion is to take shelter in the nearest and most protective building or structure (see page 10), and then listen for instructions from authorities.2

No evacuation should be attempted until basic information is available regarding fallout distribution and radiation dose rates.4

Casualties from a nuclear detonation result from blast, heat (thermal energy), and ionizing radiation. Rescue efforts after a nuclear detonation will be complex due to potentially high radiation levels, severe infrastructural damage, the number and severity of causalities, and the inaccessibility of many victims, at least initially.3 The situation will be extremely chaotic, and for a considerable period of time, it is likely that the need for resources will greatly exceed those available. Clearly, crisis standards of medical care will have to be employed, including how injured persons are triaged.

The distribution and severity of injuries will depend on device yield, height of burst (air versus ground burst), atmospheric conditions (weather, wind pattern), protection afforded by shelter/topography of the terrain (e.g., urban landscape vs. rural open spaces, robustness of building construction).3

Rescue efforts after a nuclear detonation will be very difficult due to potentially high radiation levels, severe infrastructural damage, the number and severity of causalities, and the inaccessibility of many victims, at least initially.3

2

The following infographic, developed by CDC, contains summary information on an IND.

3

In assessing the best course of action to take following a nuclear detonation, the three major blast-damage zones and two fallout zones, illustrated in the following figure2 for a 10 kT nuclear device, can be utilized. In an actual event, the boundaries of the blast zones will be determined by observations of damage to structures. The boundaries of the fallout zones will be established initially by modeling, and later (and more precisely) by specific radiation measurements.

The distances in the figure are those associated with the ground-level detonation of a 10 kT nuclear device, whose yield is equivalent to 10,000 tons (10kT) of TNT (such a device is slightly smaller than the atomic bomb dropped on Hiroshima). Smaller, or larger, devices would have different distances associated with them. Note that the figure indicates a very large area would, at least for a time, experience dangerous levels of radioactive fallout that could well result in persons who are not properly sheltered receiving radiation exposures high enough to produce acute radiation syndrome (ARS). ARS caused by very large radiation exposures can be fatal.

Some key points:

– The goal of a zoned approach to nuclear detonation response is to save lives, while managing risks to emergency response worker life and health.4

– Most of the injuries incurred within the light damage (LD) zone are not expected to be life threatening. Most of the injuries would be associated with flying glass and debris from the blast wave and traffic accidents. The benefits of rescue of ambulatory survivors in the LD zone are low. If injured survivors are able to move on their own, emergency responder actions should focus on directing citizens to medical care or assembly shelters and proceeding towards the moderate damage (MD) zone where victim rescue will be needed most.4

– Responders should focus medical attention in the LD zone only on severe injuries and should encourage and direct individuals to shelter in safe locations to expedite access to severely injured individuals.4

– Response within the moderate damage (MD) zone requires planners to prepare for elevated radiation levels, unstable buildings and other structures, downed power lines, ruptured gas lines, hazardous (perhaps airborne) chemicals, sharp metal objects, broken glass, and fires.4

– The MD zone should be the focus of early life-saving operations. Early response activities should focus on medical triage with constant consideration of radiation dose minimization.4

Miles Miles Miles

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– Response within the severe damage (SD) zone should not be attempted until radiation dose rates have dropped substantially in the days following a nuclear detonation, and the MD zone response is significantly advanced. All response missions must be justified to minimize responder risks based on risk/benefit considerations built into worker safety.4

– In physical locations where the dangerous fallout (DF) zone overlaps the LD or MD zones, response activities should be guided by the potentially lethal radiation hazard of the DF zone.4 [Note the DF zone is referred to as the DFZ in the above figure.]

– The most important mission in the DF zone is communicating protective action orders to the public. Effective preparedness requires public education, effective communication plans, messages, and means of delivery in the DF zone.4

To repeat, the response to an IND detonation will be extremely complex and difficult, and it will also be very lengthy. More detailed information is available below in the documents listed in the References section, and in the Appendix beginning on the next page. Comprehensive information and guidance on all types of radiation emergencies are available at http://health.mo.gov/emergencies/ert/nucmed.php.

References

1. Medical Planning and Response Manual for a Nuclear Detonation Incident: A Practical Guide (HHS, 2012). http://www.phe.gov/Preparedness/planning/nuclearresponsemanual/Documents/medplanresmannucdet-guide-final.pdf

2. National Capital Region: Key Response Planning Factors for the Aftermath of Nuclear Terrorism (FENA, DHS, 2011) http://fas.org/irp/agency/dhs/fema/ncr.pdf

3. State and Local Planners Playbook for Medical Response to a Nuclear Detonation (HHS/ASPR, 2012) http://www.phe.gov/Preparedness/planning/playbooks/stateandlocal/nuclear/Pages/default.aspx

4. Planning Guidance for Response to a Nuclear Detonation (National Security Staff Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats, 2010). http://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdf

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Appendix

Effects of the Detonation of an Improvised Nuclear Device (IND): The First 72 Hours

0-1 Hour (ET)

WHAT'S HAPPENING NOW?

Immediate effects of a 10kT IND include:

▪ complete destruction to severe damage in an approximate 0.5 mile radius from ground zero (severe

damage zone);

▪ severe to moderate damage in the 0.5 mile - 1.5 mile radius (moderate damage zone); and moderate

to light damage (light damage zone) in the 1.5 - 3.0 mile radius.

Effects of the IND detonation that will occur during the first hour are:

Acute Radiation Syndrome: Early Effects - Prodromal Symptoms of Acute Radiation Syndrome (ARS)

begin in victims who have received very high (unsurvivable) radiation doses.

Air Blast / Shockwave - The shock wave from the IND causes severe damage on an enormous scale,

completely destroying all but the most sturdy buildings within 0.5 miles of ground zero.

Blackouts - Regional blackouts are caused by a combination of direct damage to electrical power

systems, the electromagnetic pulse (EMP), and the sudden loss of electrical load on the grid.

Communication Impairment - Communication is impaired or disrupted entirely by a combination of

direct damage to communication equipment by the air blast, electrical damage from the electromagnetic

pulse (EMP), and loss of electrical power.

Contamination/Exposure - Radioactive contamination of wide areas is caused by the early fallout.

People outdoors are in extreme danger of radioactive exposure and should seek shelter immediately.

Electromagnetic Pulse (EMP) - The Electromagnetic Pulse (EMP) damages electrical equipment within

several miles of ground zero. While most electronics may function if restarted, others, particularly

sensitive equipment, may be destroyed.

Flash Blindness - The bright flash of visible light caused by the explosion temporarily blinds drivers

causing accidents on freeways and surface streets alike, paralyzing car traffic and blocking roads.

High Velocity Winds - Powerful winds in excess of 100 mph blow down utility poles, trees, and

mailboxes within several miles of ground zero. Shattered glass is turned into deadly shrapnel.

Infrastructure Impairment - Roads are blocked by car accidents and debris, airports are paralyzed as all

flights are grounded.

Mass Casualties - Tens of thousands of people are killed in an instant. Structural damage to buildings

(including collapse), car accidents, shrapnel, and radiological effects, amongst others, injure hundreds

of thousands more.

Radioactive Fallout - Fallout begins almost immediately. The large radioactive plume - which may or

may not be mushroom shaped - begins to deposit radioactive ash or sand particles nearby. Suspended

radioactive particles pose a dangerous inhalation hazard as the plume passes.

Super Fires/Mass Fires - Spot fires begin as the heat of the fireball causes flammables to burst into

flames. Broken gas lines and damaged electrical equipment may contribute to the blaze.

Thermal Burns - The nuclear fireball causes severe thermal burns to people caught outside. The

thermal radiation is so powerful, many receive burns through clothing. Others may be burned by the

fires that erupt across the city.

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1-6 Hour (ET)

WHAT'S HAPPENING NOW?

Although the initial effects of the detonation are now over, many of the initial effects still linger. As the

shocked population finally begins to understand the scope of the disaster, public mayhem will begin. People

will self-evacuate and the worried well (low-risk patients) will overwhelm local medical centers.

Effects of the IND detonation that will occur during the one to six hour period are:

Acute Radiation Syndrome - People who have received potentially dangerous but survivable doses of

radiation will begin to show prodromal symptoms like vomiting or diarrhea.

Delayed Structural Collapse - Buildings damaged in the detonation may still be at risk for collapse.

Food and Water Contamination - Fallout particles land in surface waters and on food, contaminating

them. Sealed food and water, like bottled water, will still be safe to drink but care should be taken to

clean containers.

Public Mayhem - Scared or opportunistic people may riot or engage in survival-motivated appropriation.

Radiation Burns - Painful burns caused by skin contamination by radioactive fallout begin to itch or turn

red (erythema).

Worried Well - Fearful of the effects of radiation, unexposed or low-risk patients will flood towards

hospitals and medical centers. While it is impossible to treat all of these people and resources must be

focused on those that need treatment to survive, care should be taken not to dismiss or invalidate fears

as they can make psychological injuries more severe.

Effects that will change during the one to six hour period are:

Contamination / Exposure - The expanding dangerous fallout zone and hot zone put larger

communities at risk.

Radioactive Fallout - Although the dangerous fallout zone reaches its maximum in the first hour, the hot

zone continues to expand downwind. The cloud also poses an exposure hazard as it passes overhead.

Super Fires/Mass Fires - Fires continue. If not controlled, these fires may combine into a firestorm.

Effects that will not change during the one to six hour period are:

Blackouts - Regional blackouts continue..

Communication Impairment - Communication is still difficult. The air in the moderate damage zone may

be thick with smoke and dust for several hours following the detonation. Combined with damaged

communications equipment, situational awareness is compromised.

Infrastructure Impairment - Roads are blocked by car accidents and debris, airports are paralyzed as all

flights are grounded.

6-24 Hour (ET)

WHAT'S HAPPENING NOW?

While few new nuclear effects occur past six hours post detonation, many of the initial effects continue. The

Hot Zone (HZ) reaches its maximum size during this period, affecting communities hundreds of miles from

ground zero. Blackouts, communications and infrastructure impairment, and radioactive contamination

continue to impede the response.

The effect of the IND detonation that will begin to be important during the 6-24 hour period is:

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Involuntary Family Separation - As people evacuate from the city, families are separated. Some are

separated in the chaos, others are separated as schools or work places are evacuated into different

areas.

Effects that will change during the 6-24 hour period are:

Acute Radiation Syndrome - Those with prodromal symptoms may or may not be experiencing them.

Towards the later part of this time window, some of the more mild cases of ARS will enter into the

'latent period' in which they are asymptomatic (no symptoms).

Contamination/Exposure - Contamination continues to impede the response effort. Evacuees out of

contaminated areas need to be decontaminated to prevent radiological injury and the spread of

contamination. Luckily, contamination on a person poses little threat to those around them.

Food and Water Contamination - Fallout stretching hundreds of miles from ground zero continues to

pose an ingestion hazard.

Radioactive Fallout - The hot zone (HZ) reaches its maximum size, potentially reaching hundreds of

miles downwind. The dangerous fallout zone (DFZ) continues to shrink.

Radiation Burns - The risk of radiation burns continues. Care should be taken to keep fallout off of the

skin.

Effects that will not change during the 6-24 hour period are:

Blackouts - The regional blackouts continue...

Communication Impairment - Communication continues to be difficult due to blackouts and local

damage.

Delayed Structural Collapse - Buildings damaged by the explosion or ensuing fires are at risk for

collapse.

Infrastructure Impairment - By this point, responders will hopefully have made great strides in clearing

roads into the moderate damage zone and preparing airports to receive the surge of regional and

federal assets into the area. Blocked or impassable roads will continue to be a problem.

Public Mayhem - Public Mayhem continues...

Super Fires / Mass Fires - Fires in the severe damage zone (SDZ) or in contaminated areas continue to

burn out of control. Fire fighting efforts in the uncontaminated moderate damage zone (MDZ) continue...

Worried Well - Low-Risk patients continue to overwhelm medical centers and hospitals.

24-48 Hour (ET)

WHAT'S HAPPENING NOW?

As evacuations continue, farmers may be forced to abandon their livestock and families arrive at shelters

and community reception centers (CRCs) with their service or companion animals.

The effects of the IND detonation that will begin to be important during the 24-48 hour period are:

Abandoned Livestock - Evacuating farmers may leave livestock behind, with or without the intention of

ever returning for them. Livestock may need food and water and some animals may need special care

(like milking dairy cows).

Pet & Service Animal Care - Evacuees will arrive at medical centers, assembly centers, community

reception centers, and shelters with their service and companion animals with them. These animals will

need to be decontaminated and provided food and water.

Effects that will change during the 24-48 hour period are:

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Acute Radiation Syndrome - Most of the survivable cases of acute radiation syndrome will be in the

latent phase during this time, showing no symptoms. People with extreme exposures may already be

showing the manifest illness stage.

Contamination/Exposure - Contamination continues to impede the response effort. Evacuees out of

contaminated areas need to be decontaminated to prevent radiological injury and the spread of

contamination.

Food and Water Contamination - Fallout stretching hundreds of miles from ground zero continues to

pose an ingestion hazard.

Radioactive Fallout - Both the Hot Zone (HZ) and Dangerous Fallout Zone (DFZ) are shrinking as the

radioactive material decays.

Radiation Burns - The risk of radiation burns continues. Those who received skin doses early on are

experiencing a latent period where erythema (red skin) and other symptoms disappear. Those who

received an extremely large skin dose may already begin show symptoms of the manifest illness

(blisters, severe pain, edema, ulceration, etc.).

Effects that will not change during the 24-48 hour period are:

Blackouts - The regional blackouts continue...

Communication Impairment - Communication continues to be difficult due to blackouts and local

damage.

Delayed Structural Collapse - Buildings damaged by the explosion or ensuing fires are at risk for

collapse.

Infrastructure Impairment - Blocked or impassable roads will continue to be a problem.

Involuntary Family Separation - As people evacuate from the city, families are separated. Some are

separated in the chaos, others are separated as schools or work places are evacuated into different

areas.

Public Mayhem - Public Mayhem continues...

Super Fires / Mass Fires - Fires in the severe damage zone (SDZ) or in contaminated areas continue to

burn out of control. Fire fighting efforts in the uncontaminated moderate damage zone (MDZ) continue...

Worried Well - Low-Risk patients continue to overwhelm medical centers and hospitals.

48-72 Hour (ET)

WHAT'S HAPPENING NOW?

The response is now transitioning into the 'Sustained Response' phase. Many of the collateral effects of the

IND detonation continue, as well as the radiological effects and related health concerns. In the years to

come, survivors will see a measurable increase cancer risk due to radiation exposure.

The effect of the IND detonation that will begin to be important during the 48-72 hour period and

beyond is:

Increased Cancer Risk - Cancer risk among survivors who were exposed to radiation will rise slightly.

Effects that will change during the 48-72 hour period are:

Acute Radiation Syndrome - Most survivable patients are in the latent period during this period. After

one to three weeks, manifest illness will begin.

Contamination/Exposure - People continue to arrive at assembly centers, medical centers, and shelters

contaminated with radioactive fallout. By this time, these locations are likely to have large amounts of

contaminated water (from showers), clothing, and other material that needs to be disposed of.

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Food and Water Contamination - Deposition of fallout onto food and water continues to pose an

ingestion hazard both inside the fallout zones and outside of them.

Radioactive Fallout - Both the hot zone (HZ) and the dangerous fallout zone (DFZ) continue to shrink as

the radioactive material decays. After about one week, the HZ will be the size of the DFZ's maximum,

stretching 10-20 miles from ground zero.

Radiation Burns - Individuals with extremely mild burns will begin to experience erythema (skin

redness) and itchiness. Individuals with very extreme burns will be well into the manifest illness stage of

cutaneous radiation syndrome and experience blisters, edema, ulcers, and severe pain.

Super Fires / Mass Fires - Fires in areas unreachable by responders, particularly those in contaminated

areas, will die as they run out of fuel.

Effects that will not change during the 48-72 hour period are:

Abandoned Livestock - Evacuating farmers may leave livestock behind, with or without the intention of

ever returning for them. Livestock may need food and water and some animals may need special care

(like milking dairy cows).

Blackouts - The regional blackouts continue...

Communication Impairment - Communication continues to be difficult due to blackouts and local

damage.

Delayed Structural Collapse - Buildings damaged by the explosion or ensuing fires are at risk for

collapse.

Infrastructure Impairment - Most roads are still blocked with debris. Water, power, and gas

infrastructure is completely destroyed close to ground zero.

Involuntary Family Separation - As people evacuate from the city, families are separated. Some are

separated in the chaos, others are separated as schools or work places are evacuated into different

areas.

Pet Care - Evacuees will arrive at medical centers, assembly centers, community reception centers,

and shelters with their service and companion animals with them. These animals will need to be

decontaminated and provided food and water.

Public Mayhem - Public Mayhem continues..

Worried Well - Low-Risk patients continue to overwhelm medical centers and hospitals. Increased Cancer Risk DESCRIPTION: Radiation is a known cause of cancer. Even at low levels, which may have no other visible effects, ionizing radiation is carcinogenic. Unlike acute radiation syndrome, increased radiation exposure increases the chances of radiation-induced cancer occurring but does not increase the severity of that cancer. The resulting cancers may not appear for decades after exposure and there is no definite way to tell whether or not you will eventually develop a cancer. While there is some disagreement of the exact risks of radiation at very small doses, there is a roughly 5% increase in cancer risk for each Sievert (100 rem) of radiation exposure for chronic exposures.

EXAMPLE:

Leukemia (starting 2-5 years following exposure for children)

Thyroid cancer (particularly following ingestion of I-131)

Nuclear/Radiological Incident & Exercise Planner (FEMA, 2015)

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The best initial action immediately following a nuclear explosion is to take shelter in the nearest and most protective building or structure and listen for instructions from authorities.

National Capital Region: Key Response Planning Factors for the Aftermath of Nuclear Terrorism (November 2011)

Radiation TRiage, TRansport, and Treatment (RTR) System

RTR is a conceptual system for the settings at which various levels of medical care are likely to be delivered after a nuclear detonation. Multiple RTR sites are expected to form spontaneously in such a situation. The major functions of these sites are, in general, the following: 1) identification, 2) triage, 3) medical stabilization (or provision of palliative care), and 4) transport of victims to medical care (MC) sites and assembly center (AC) sites.

MC sites include hospitals, healthcare facilities, and alternative care sites for those who need immediate medical care. AC sites are collection points for displaced persons or those who do not need immediate medical attention. Evacuation centers (EC) are hubs for major victim and evacuee transport.

The following figure illustrates how the RTR System might operate following a nuclear explosion:

A more complete description of the RTR System is provided on the next 3 pages.

Radiation TRiage, TReatment, and TRansport (RTR) Medical Response System For Nuclear and Mass-Casualty Explosive RDD Incidents

RTR (Radiation-specific TRiage, TReatment, TRansport) System (or Model) – general comments:

Developed by a Federal interagency medical response-planning group to facilitate planning for the medical and public health response to a nuclear incident* or mass-casualty RDD** incident.

Such a response will require: 1) collocating medical personnel and supplies as close as safely possible to victims, 2) transporting victims to appropriate aid locations, and 3) protecting responders and victims from radiation exposure to the extent possible.

The Model outlines the major components of a response and configures them so that a medical and logistics management system can be overlaid for planning purposes.

The RTR model is designed specifically for radiation-related mass-casualty events based on the following considerations: 1. Threat of potential radiation hazards for responders and victims; 2. Abruptness of a nuclear or explosive RDD incident, and the enormity of a nuclear incident; 3. Need for medical care and resources to be collocated and matched to the requirements; 4. Need to predetermine as much of the detail of the response as possible; and 5. Need for responders to rapidly communicate conditions on the ground

Given that nuclear or mass-casualty radiological incidents will result in large numbers of people being injured, exposed to radiation, and/or contaminated with radioactive materials, RTR sites for out-of-hospital management of victims will be established to maximize the effective handling of these persons by limited numbers of field personnel while they await transport to definitive care. Concentrating affected individuals at discrete locations in the field will also increase the efficiency of the transportation process.

The RTR System derives its name from the fact that the location of usable RTR sites depends on the potential exposure to radiation (“R”) and the site-specific activities and requirements for TRiage, TReatment, and TRansport (“TR”) of the associated victim populations.

At the RTR sites, as well as the Medical Care (MC) and Assembly Center (AC) sites, full victim tracking is required,

The RTR System is designed to be scalable.

A diagram of the RTR System (for an explosive RDD) is shown on page 2. Included in this System are the following:

1. RTR1, RTR2, and RTR3 sites, whose primary goals are 1) triage, 2) treatment, and 3) transport. Three distinct types of RTR field sites – RTR1, RTR2, and RTR3 – are needed In the context of a nuclear or mass-casualty explosive RDD incident in order to accommodate the victim population types and the environmental conditions in which the responders are working;

2. MC sites where definitive medical care will be provided;

3. AC sites for evacuating/displaced persons; and

4. Distant hospitals and medical/specialty centers, which may be located in other parts of the state or in other states

RTR sites

The major functions at RTR sites are 1) identification, 2) triage, 3) medical stabilization (or provision of palliative care), and 4) transport of victims to MC and AC sites.

Gross decontamination also may be performed at these sites as permitted, though stabilizing serious injuries takes precedent over decontamination.

RTR sites are divided into three types depending on their physical/situational relationship to the incident:

1. RTR1—near the blast with persistent radiation

2. RTR2— near the plume with some persistent radiation, and

3. RTR3—collection points with minimal to no radiation risk

The location of these sites will be determined after an incident is characterized and safe radiation perimeter zones are established, and should be based on factors such as the following: 1) extent of destruction, 2) proximity to the blast location, 3) environmental factors, 4) residual radiation, 5) available infrastructure, and 6) accessibility to transportation.

The incident commander will generally designate the RTR sites with input from emergency responders, although some (?? many) sites will likely be defined spontaneously in real time as victims collect or are brought to specific locations. These may be places that are perceived by victims as providing shelter and/or sites of opportunity established by responders.

Medical Care (MC) and Assembly Center (AC) sites will be largely pre-determined based on available facilities in the area.

A diagram of the RTR Model for a nuclear incident is shown on page 3. ____________________________

*Nuclear incident: the explosion of an improvised nuclear device (IND) or a nuclear weapon. **RDD = radiological dispersal device. The type of RDD most commonly discussed is an explosive RDD (i.e., a dirty bomb).

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RTR1 Sites Near the epicenter of the event (near the Inner Perimeter).

Develop as spontaneous gathering points for victims or aid stations established by responders.

Most austere of all the types of RTR sites; pose greatest challenges for providing medical care. Not for sustained care.

Many non-ambulatory victims (IND).

Many victims were lethally irradiated and primarily require comfort care (IND).

Transportation will be delayed and response assets likely will have difficulty reaching these sites (IND).

Highest levels of ambient radiation; limited time for responders because of radiation levels.

RTR2 Sites Near the Outer Perimeter, and in or near the path of the plume/fallout.

Develop as spontaneous gathering points for victims or aid stations established by responders.

More supplies and responders available than at RTR1 sites.

Identification, triage, treatment, and transport are the ultimate goals.

Victims will be treated for survivability rather than palliation, contingent on resources.

Most victims ambulatory, but with an IND may have significant rad exposure.

Might be possible to initiate some treatment for mitigation of ARS, plus symptomatic treatment.

Transportation to these sites may be delayed, or routes may be choked.

Likely more stay time for responders than at RTR1 sites, but must monitor.

RTR3 Sites Away from immediate blast zone and plume. Almost all victims ambulatory; many may have

minor to no injuries, and no significant radiation exposure.

Symptomatic treatment can be administered if appropriate, prior to transportation.

After triage and initiation of minor treatment, available transportation assets will evacuate victims to MC or AC sites as appropriate.

Radiation monitoring and decontamination capabilities should be available (this will help ensure that contamination of health and shelter facilities to which persons will be transported, as well as of transport vehicles, will be minimized).

Road conditions and logistics should not impose serious limitations on the capabilities at these sites.

Time constraints for responders at these sites will reflect regular disaster shift schedules and are not limited by ambient radiation. If an RTR3 site becomes contaminated, the site may move to a clean location, or it may convert to RTR2 operations, using dose-rate information.

MC (Medical Care) Sites Locations where definitive medical care will be provided

(e.g., hospitals, clinics, healthcare facilities such as nursing homes, and alternate care facilities such as Federal Medical Stations).

Sites such as outpatient clinics and nursing homes may become incident-specific hospitals.

Should be identified before an incident.

A bed-count would be done at the time of an incident and at regular intervals.

Victims with immediate medical needs will be transport-ed or directed from RTR1, 2, and 3 sites to MC sites.

People with medical needs, displacement, and socio-behavioral needs will likely self-evacuate to MC sites.

Persons who do not need immediate medical care will be directed to an AC site or to their homes.

Triage, and radiation monitoring and decontamination, will have to be provided.

To provide necessary space for those severely injured, MC sites nearest the epicenter may discharge or trans-fer patients to home care, if possible, or to other facilities.

Alternate care facilities, such as Federal Medical Stations, will be set up as rapidly as possible, usually within 24-72 hours, to care for less severely ill medical needs populations.

AC (Assembly Centers)

Evacuee receiving and registry centers as well as temporary shelters where evacuating/displaced persons may receive food and shelter and/or check in with authorities so that they can be accounted for.

Outside the perimeter of the incident.(i.e., outside the blast zone and the plume).

Staffing may include non-medical personnel or those with limited medical expertise.

Can be designated in advance as much as possible (e.g., major public facilities, highway rest stops, schools, auditoriums, sports facilities, shopping centers, etc). Some will form spontaneously, especially along evacuation routes.

Nearly all people will be ambulatory.

Assistance with sheltering, transportation, and other human services will be facilitated. Decontamination will be an important consideration.

Very limited or no medical care will be available or needed, although some medical history and blood testing may be done for radiation screening of victims.

Persons requiring medical care or biodosimetry studies based on their injuries or location during the event will be referred to appropriate sites.

Registries will be initiated containing information on where persons were at the onset of the event and thereafter, and on their planned destinations.

Evacuation Centers and Drop Zones Hubs for major victim and evacuee transport

Some hubs may be designated for incoming supplies and personnel and others for outgoing, while others may transport persons or goods both in and out.

Victim Movement Arrows in the figure indicate the three general categories of victim

movement: 1) self-evacuation; 2) ambulatory requiring medical care; and 3) non-ambulatory.

Many of the non-ambulatory will require definitive care, but some (e.g., at-risk populations) only may require transport to AC sites.

In general, victims/people will flow away from the incident epicenter and into the surrounding area, with some lateral

movement of individuals who do not evacuate the region (e.g., to relatives’ homes or MC sites) and some sheltering-in-place.

Medical transport from the RTR1 sites will be severely limited, especially during the first hours and days (IND).

Self-evacuation will be a major source of victim movement, with vic-tims likely going to MC and AC sites Those not needing immediate medical care will be directed to AC sites and told to avoid MC sites.

Diagram of the RTR Medical Response System for an Explosive RDD Incident

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Explosive RDD Incident

An incident involving an explosive RDD would be significantly smaller than an incident involving a nuclear detonation (the latter is illustrated in the figures below). Unlike a nuclear blast, in which a large amount of radiation is discharged by the detonation (and immediately dissipates with the blast), and is broadly deposited in the fallout, an explosive RDD is a very much smaller device that disperses radioactive material.

Radiation exposure depends on the duration of a person’s proximity to the radioactive material. For most victims of an RDD, radiological exposure is from external contamination, but some victims may have internalized radiological material from inhalation, ingestion, contaminated shrapnel, or wound contamination.

While a large incident is possible, most RDD incidents will probably involve a limited section of a city, will likely have a radius of a few hundred meters, and will involve far fewer victims than a nuclear detonation.

The RDD plume is short-lived, settling or diffusing within minutes to a half-hour, and is confined largely to surface and urban winds. Distribution of radioactivity would be

determined by an urban canyon effect, and depending on prevailing winds and city layout, can be limited or broadly contaminating.

While some re-suspension and spread of radioactive material may occur during response operations and ground movements, the ambient radiation zone is largely determined by the footprint of where the material initially landed.

The high-level winds displayed by modeling maps will show the direction and distance that only very small amounts of buoyant radiological particles (likely not enough for health effects) will be carried. While long-range deposition of RDD fallout is worth noting for possible interdiction of food supply and eventual clean-up, radiological material carried beyond the local site is unlikely to cause acute radiation syndrome because of its limited quantity.

The RTR Medical Response System for an explosive RDD is shown above in the figure on page 2. The functions of RTR1–3, MC, and AC sites are the same for an explosive RDD as for a nuclear detonation.

Nuclear Detonation

Source: ASPR Playbook: Radiological Dispersal Device (HHS)

Sources: 1) Hrdina, CM, et al. Prehosp and Disast Med 2009;24(3):167-178, 2) ASPR Playbook: Radiological Dispersal Device (HHS), 3) State and Local Planners Playbook For Medical Response to a Nuclear Detonation (HHS)

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