Disaster Med

ROSTISLAV KOSTADINOV
DISASTER MEDICINE
HIGHLIGHTS
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■■
Contents 3
TABLE OF CONTENT
REVIEW 1 .......................................................................................... 5
REVIEW 2 .......................................................................................... 7
PREFACE .......................................................................................... 9
DISASTER MEDICINE HIGHLIGHLIGHTS................................ 10
DISASTERS.........................................................................................12
DISASTER MEDICINE ................................................................... 27
AREA OF DAMAGE.......................................................................... 36
MEDICAL LOSES............................................................................. 42
DISASTERS’ RELIEF TO POPULATION........................................49
DISASTERS’ MEDICAL SUPPORT................................................. 58
MEDICAL INTELLIGENCE............................................................. 64
TRIAGE...............................................................................................69
FIRST A ID .......................................................................................... 74
MEDICAL FIRST A ID ....................................................................... 81
EVACUATION.................................................................................... 88
DISASTER MEDICAL SUPPORT PLANNING...............................96
MANAGEMENT OF DISASTER MEDICAL SUPPORT............ 101
MEDICAL TEAMS TASKS IN DISASTER MEDICAL
SUPPORT........................................................................................ 105
FORWARD (TEMPORARY) MEDICAL STATION..................... 109
EARTHQUAKE DISASTER MEDICAL SUPPORT
MANAGEMENT ............................................................................ 113
FLOODS DISASTER MEDICAL SUPPORT MANAGEMENT .. 120
WARS DISASTER MEDICAL SUPPORT MANAGEMENT......125
TERRORISM DISASTER MEDICAL SUPPORT
MANAGEMENT............................................................................. 131
FIRES DISASTER MEDICAL SUPPORT MANAGEMENT...... 135
RADIATION. IONIZING RADIATION. MEASUREMENT.
EFFECTS.......................................................................................... 142
4 Disaster Medicine Highlights
DISASTER MEDICAL SUPPORT IN CASE OF AREA OF

RADIOLOGICAL DAMAGE........................................................... 157
NUCLEAR BOMB EXPLOSION VS. NUCLEAR PLANT
FAILURE ........................................................................................... 162
ACUTE RADIATION SYNDROME.............................................. 162
RADIO-DERMATITIS.................................................................... 194
BIOLOGICAL DAMAGE............................................................... 199
SANITARY CONTROL................................................................... 203
BIOLOGICAL WEAPO S .............................................................. 206
TOXIC INDUSTRIAL MATERIALS FEATURES AND
CLASSIFICATION ......................................................................... 209
CHEMICAL DAMAGE.................................................................... 209
DMS IN CHLORINE INTOXICATION.......................................... 216
DMS IN AMMONIA INTOXICATION........................................... 223
DMS IN CYANIDE INTOXICATION.............................................228
DMS IN ORGANO-PHOSPHATE COMPOUNDS
INTOXICATION...............................................................................234
DMS IN CARBON MONOXIDE INTOXICATION....................... 239
DMS IN BLISTERING AGENTS INTOXICATION...................... 24 7
DMS IN RIOT CONTROL AGENTS INTOXICATION.................251
Differential diagnosis must be done with intoxication by:
DISASTERS PSYCHOLOGICAL DISORDERS............................ 256
DECO TAMINATION .................................................................... 270
REFERENCE .................................................................................... 282
DISASTER MEDICINE HIGHLIGHLIGHTS
1. Disasters
2. Disaster Medicine
3. Area of Damage
4. Medical Loses
5. Disasters’ Relief to population
6. Disasters’ Medical Support
7. Medical Intelligence
8. Triage
9. First Aid
10. Medical First Aid
11. Medical Evacuation
12. Disaster Medical Support Planning
13. Management of Disaster Medical Support
14. Medical Teams Tasks in Disaster Medical Support
15. Forward (Temporary) Medical Station
16. Earthquake. Disaster Medical Support Management
17. Floods. Disaster Medical Support Management
18. Wars. Disaster Medical Support Management
19. Terrorism. Disaster Medical Support Management
20. Fires. Disaster Medical Support Management
21. Radiation. Ionizing radiation. Measurement. Effects.
22. Disaster Medical Support in case of Area of Radiological Damage
23. Nuclear Bomb Explosion vs. Nuclear Plant Failure
24. Acute Radiation Syndrome
25. Radio-dermatitis
26. Disaster Medical Support in case of Area of biological damage
27. Sanitary control
28. Biological weapons
29. Toxic Industrial Materials Features and Classification
Disaster Medicine Highlighlights 11
30. Disaster Medical Support in Case ofArea of Chemical Damage

31. DMS in Chlorine Intoxication
32. DMS in Ammonia Intoxication
33. DMS in Cyanide Intoxication
34. DMS in Organo-phosphate Compounds Intoxication
35. DMS in Carbon Monoxide Intoxication
36. DMS in Blistering Agents Intoxication
37. DMS in Riot Control Agents Intoxication
38. Disasters Psychological Disorders
39. Decontamination
DISASTERS
Highlights,
1. Incident - definition, features, consequences
2. Emergency - definition, features, consequences
3. Crisis - definition, features, consequences
4. Disasters’ main features
5. Disasters definitions
6. Classifications types
7. WHO/Bulgarian classification
8. Natural disasters are
9. Man-made disasters are
10. Transport Accidents are
11. WHO classify the following disaster into the group Others
12. Disasters’ features with impact on medical support
13. Main damaging factors
14. The blast wave cause damage by
15. The casualties related to the blast wave are
16. The mechanical factor cause damage by
17. The casualties related to the mechanical factor are
18. Thermal factor cause damage by
19. The casualties related to the thermal factor are
20. Biological factor consists of
21. The casualties related to the biological factor are
22. Disasters’ developing stages are
23. When the first signs for possible disaster occurrence could be rec
ognised?
24. When the disaster medical support activities commence?
25. When the Search and Rescue operations begin?
26. What is the main medical teams’ task during the Impact phase?
27. Main medical teams’ tasks during the Intermediate/Quiescent phase
:;.: 335ters 13
are
_,!_ Main medical teams’ tasks during the Prodrome phase are
. Main medical teams’ activities during the Response phase are
■ Main medical teams’ tasks during the Recovery phase are
Disasters are devastating the Earth throughout entire geological and

--=:tan history. Great majority of researches are defining an event as dis-
^;:er only when there is an impact on society. (1, 2, 3) Moreover, some
-: :aem are stating that there are no natural disasters, disasters are re-
of the failure of society to protect itself. These two almost opposite
r^tements are proof for the difficulties scientists are facing while trying
-.: define disasters. A lot of definition have been adopted by different
...,......;,ties, therefore the first and significant topic of the disaster medicine
DM is to find out the most appropriate for the disaster medical support
DMS) definition.
World Health Organization (WHO) (4) is stating that disaster is ”sud-
ecological phenomenon of sufficient magnitude to require external
::::i:^Mce.” This definition is revealing some of the main features of the
.:._5^srrous event, but a lot of disasters are remaining out - e.g. the hurri-
drought and famine are everything, but not a sudden events. And
• - λ you could classify the wars and large-scale industrial accidents as
-!".::'_ogical by origin, when they are man-made (anthropogenic by na-
On the other hand, WHO defines some of the main features of the
=s;;..ster - phenomenon - rarity, the magnitude - power, requirement for
_ : ^ a l assistance - severe consequences and scarcity of resources to
- --.2 ge them, therefore, requirement of external assistance.
Another definition that is in use of international organization is:
A serious disruption of the functioning of a community or a society
x scale due to hazardous events interacting with conditions of expo
s e . Mlnerability and capacity, leading to one or more of the following:
n material, economic and environmental losses and impacts." (5)
There are several other events that could cause negative impact on
human health and are requiring the medical attention, but they differ
from the disasters. In order to properly classify the event and based on
it to organize and perform adequate and efficient DMS the following
categories of events have to be distinguished:
• Accident;
• Emergency;
• Crisis;
• Disaster.
Definition of incident - an unusual, out of routine activity. Its con
sequences could be with negative or positive impact on human life and
health, as well on society welbeing. The impact of the incident on socie
ty is almost negligible and on the human is requiring some extraordinary
(in sense, not performed everyday) activities for eradicating the effects
of the consequences. (6)
Definition of emergency - An incident, always with negative impact
on human life and health that is requiring extraordinary actions in order
to safe life and protect, assure health and ability of the casualty. The ef
fect of the emrgencies on society are with no or limited impact, depend
ing on the personality/duties/ role in the social life of the affected These
action has to be performed in very limited timeframe, otherwise the life
and ability of the human are under threat. The response activities are
urgent. (7)
Definition of crisis - Large scale incident that requires extraordinary
and urgent actions, in order to respond to the negative consequences for
society and a number of its members. For coping with the consequences,
mobilization of all available in the region resources of society has to be
done. The mobilized resources are sufficient for managing the negative
impact. (3, 8, 9, 10)
Disasters definitions - Sudden or with slow, prolonged beginning
event, natural or man-made, characterized with sufficient power to pro-
Disasters 15
voke property damages, casualties and injjn::ies overwhelming the capa

bilities of available resources for adequate and efficient answer, leading
to requirement for immediate intervention. All the activities have to be
broadening in scope, coordinated, prompt and focused on consequences
minimization and eradication, along with rehabilitation and reconstruc
tion commencement. Required for this activities resources are not avail
able, therefore, external assistance is required. (11, 12, 13)
Disasters’ definition main features:
1. Frequency - phenomenon, very rare.
2. Magnitude, power - great, sufficient for disturbing the daily life
3. Consequences - damage of property and threat to population life
:.nd health.
4. Disparity between required and available means and capabilities.
5. Requirement for assistance from outside to overcome the conse
quences. (14)
The difficulties regarding the definition of the disasters are found
^ d into the attempts to classify the disastrous events. Several classifi-
iztions are proposed by different entities. They are based on variety of
reamres - beginning, length, number of casualties, size of the area of
■•mage (AOD), etc.
Examples of classifications in use:
• size oftheAOD:
- local,
- regional,
- global.
• number of the casualties -
moderate (25-100),
- medium (100-1000),
- large (above 1000).
• continuance:
- short - to an hour,
- medium - to 24 hours,
- prolonged - above 24 hours. ( 15)
CIE.SSifications that are most in use are those that are classifying dis
asters in accordance to their origin. (14, 16) The WHO classification is
accepted in Bulgaria. Disasters are 3 main groups - natural, man-made,
others:
1. Natural disasters in accordance with WHO/BGR Classification
are
Meteorological: These calamities are with origin processes into
the atmosphere and are related to the climate and geography of
the area - storms, hurricanes, tomados, cyclones, extreme heat
and cold, droughts etc...;
Topological: These disasters are changing the topography of
the earth surface - catastrophic floods, landslides, avalanches
etc... ;
Tectonic: Calamities with origin bellow the earth surface - from
the tectonic layers - earthquakes, volcanoes;
Cosmic calamities are related to the objects that are coming
from outer space - asteroids, comets, meteors etc.
2. Man-made disasters in accordance with WHO/BGR Classifica
tion are
Large Industrial Failures: - Chemical; - Radiological; - Ac
cidents with blasts and or conflagrations
Social-Economics - Financial crises; Social catastrophic -
Famine; Terrorism; Social Unrest; Toxic manias;
Wars Without WMD application; Only conventional arms ap
plication; WMD and Geophysical weapons application; Com
bined damages by diverse damaging factors and affected foci
- Transport Accidents - ground (road accidents), air (plane
crush), maritime (shipwreck), railway (train accidents).
3. Others in accordance WHO/BGR classification of disasters are
Disasters 17
these disasters that are not classified into the previous two groups, e.g.:
- Collapsing and incidents in tunnels, mines, underground facili
ties etc.;
- Highly Hazardous Infections and Large-scale Epidemics;
- Mass Poisoning;
- Extreme Air, Water, Soil Pollutions;
- Mass Water Accidents;
- Ecological Disorders (11, 14)
Disasters are important for the healthcare system, because when they
occur the impact of the system is significant. Summarizing the findings
of disaster medicine and disasters' researches several calamities' fea
tures with impact on medical support provision could be listed:
1. Type of disaster, time of onset, place of occurrence and scale are
^predictable. When there is no possibility to predict the type and time
o f disaster, it is impossible to plan the proper protection. This means
±at always we have to expect casualties among the population living/
working in the AOD.
2. Unpredictable are the casualties’ number, type and severity. From
::.e unpredictability of the type and its magnitude it is obvious that no
:::e could predict the number, type and severity of the casualties. What
could be expected is that in the AOD there always will be disparity be-
r.veen the required and available resources. This follows from the nor-
sial planning of the healthcare system - the number and specialization
:: the medical facilities are based on the average morbidity of the re-
pon that is related to the demography, particular for the region health
.-c:zards, endemic diseases, enviromental pollution etc. Disasters are not
considerd into this planning, therefore the increased need of the medi
co support in case of disaster occurrence is always overwhelming the
capacities of the established healthcare system. Therefore, all medical
-=--:ilities are asked to create plans what could be their role into DMS -
they will adequately react to the disasters' challenges.
ίΟ____ ________ ____ _______ Disaster Medicine Highlights
3. C ^ :: z.::eet geographical and administrative areas of different

size, " ΐ ώ dr. erse political or economical importance. This particular
impact is enormous potential to impact the DMS. From the size
depend mnnber and size of Forward Medical Stations (FMS) required,
number and type of the sanitary transport, medical and technical equip
ment for the D MS provision, logistics and medical evacuation.
4. Damage to the critical and non-critical infrastructure that leads
to requirements regarding logistics, protection, communication etc. that
have to be provided in the very beginning of the DMS operations.
5. During the impact phase damaging factors could cause infrastruc
ture damages that are leading to secondary threats for the human life and
health. For instance, as a result of earthquake the dam wall is severely
damaged and this damage could cause a catastrophic flooding of the
nearby zone.
6. Another challenge related to the casualties that sharpen the dispar
ity of the resources is the sudden appearance of a relatively large num
ber of casualties requiring medical support.
7. Moreover, great number of the almost simultaneously appeared
casualties have sustained severe, even life-threatening injuries. The
number of the combined injuries is also relatively (to the capabilities)
high.
8. Therefore, the sharp disparity between available and required
medical means and capabilities is one of the main disasters’ medical
features.
9. Sanitary and hygiene in the affected area usually are affected by
disaster that leads to significant changes into epidemiological situation.
10. The disparity into the medical means and capabilities includes
the means for sanitary transport required for medical evacuation. As the
number of the casualties cannot be predicted, significant scarcity in the
number of medically equipped vehicles could be expected and in reality
it is recorded.
Disasters 19
11. The unexpected and unspecified munber and type of casualties

results in limited hospitals capacities to admit and treat those in need
because of lack of room for their accommodation.
12. Several of the disasters are leading to intense environment pollu
tion. This pollution has twofold negative impact on DMS:
- increase the number of the casualties by adding those injured by
the polluted air/water/soil/food etc.;
- limits the medical teams’ capacities for prompt response because
of the imperative for protection of medics - medical specialists
either not enter into the AOD that extends the time for medi
cal support provision, or limits their effectiveness because of the
effects of the individual protective equipment (IPE) impact on
medical activities (impeded fine movements, slowed movement,
heat, time limitation etc.). (14)
The results of the long-term analysis of the types of disaster situa
tions and their consequences allow DMS experts to identify seven key
factors through which disasters cause their negative impact. (14)
Damaging factor is defined as a factor by which the disaster impacts
negatively environment, infrastructure and population.
The territory on which the damaging factor/s (DF) of a disaster acts
is defined as AOD.
The DFs are as follows:
1. Thermal - Thermal DF defines the effects of extreme tempera
tures and / or temperature differences that cause heat or cold trauma. In
Great majority of these traumas are accompanied by irreversible chang
es in human tissues and organs. Thermal factor is most often present in
the following disasters:
• Fires - the temperature of the burning surfaces causes varying de
grees of burns, depending on the distance to the burning surfaces,
their size and the time of impact;
• Industrial accidents - in many industrial accidents secondary fires
2 '____________ ________ ___ ________ _Disaster Medicine Highlights
«sea- due to the leakage of certain chemicals. The temperature of

ill cC2Dbe abruptly reduced, resulting in cold traumas - e.g.
lee....^ge of liquid ammonia;
• factor is the most common factor in meteorological natu
ral disasters. Recorded climate change is associated by many au
thors with the increasing number of extreme natural phenomena
- sharp and prolonged cold waves reaching temperature records
as well as prolonged heat waves. In both situations, the popula
tion is exposed to increased risk of heart attacks in chronically
ill patients, as well as increased morbidity and mortality among
the most vulnerable groups of society - the elderly, children and
persons below the threshold of poverty;
• Military actions (with deliberate fires and destruction of criti
cal infrastructure), volcanoes (the temperature of crater and lava
eruptions), foods, are also examples of the impact of the thermal
factor on the population in the AOD.
2. Blast (Shock) wave. The blast wave is a kind of energy transfer
in an environment that moves faster than the local sound velocity. Like
a simple wave, it brings energy and can spread in the middle but is char
acterized by a sharp, almost continuous change in pressure, temperature
and density of the medium. It reports a sharp, spike-increasing / decreas
ing pressure distributed in gaseous, liquid or solid media. Because the
shock wave is a mechanical wave propagating in a material environ
ment, it causes changes in the physical parameters of the environment
in which it is spreading. (17, 18, 19)
The effect of this DF is related to the radial, in all directions, spread
of elevated / depressed pressure. Difference between the pressure at the
front of the propagating wave and the atmospheric pressure, causes tears
in the human organs and tissues, demolition of buildings and people,
secondary damage from shakes and drafts, industrial accidents involving
industrial plants. The main feature of this DF is its strong dependence
Disasters 21
on time - the pressure difference b e te e n the two media very quickly, in

parts of a second, is restored .
Most often the blast wave is DF in the following disasters:
• industrial failures in which explosions are produced in the pre
cursor;
• military action - the most frequent impact of the blast wave is
encountered in military operations, because of implementation
of various types explosives in the form of conventional, aerial
bombs, atomic bombs, vacuum bombs (in which there is an im
plosion with a pressure drop in the middle). Bombs and explo
sives are one of the preferred weapons of the terrorists.
• fires - in many cases fires near industrial plants and / or ware
houses cause explosions in them;
• Traffic accidents can also be accompanied by explosions - when
the tanks of the means of transportation and I or the transported
goods explode.
3. Chemical or toxic impact factor. These are highly toxic poison
ous substances - chemicals and compounds that have the ability to cause
;:>0 llution in the environment they fall into and in most cases cause lethal
or severe damage to the human body due to the developing intoxication.
The chemical DF can cause a different size and period of contamina
tion. Contamination depends on the type of chemical / element may be
air, water or soil, but pollution of the all three media is very common.
Chemical outbreaks occur in:
• Industrial incidents when toxic chemicals are released into the
environment. These chemical elements / substances can be a raw
material or a starting product, but can also be product of chemical
reaction between non-toxic products during a chemical accident.
• Transport accidents in which the transported toxic substances
and / elements pollute the environment, or the pollution is caused
by leakage of fuels and lubricants;
: Disaster Medicine Highlights
• m;JS: toxic contaminations were recorded, when the safety

-Uons for handling, transporting, storing and using of toxic
s u H ^ c e s were not followed and therefore they had contami
nated the environment;
• Carbon monoxide (CO) and carbon dioxide (CO2) are released
in atmosphere within burning process during all fires. Other com
ponents of the smoke may also be toxic, depending on the type of
burning substance;
• In the case of military conflicts and terrorist acts, toxic chemi
cal compounds have been used for inflicting a greater number of
casualties among the enemy (opposing forces). Despite the ban
on the use of chemical weapons, the events of recent military
conflicts and successfol terrorist acts prove the high risk of their
implementation. (20, 21)
4. Overpressure - This DF causes marked destruction of material
values and numerous injuries to the affected population due to the physi
cal impact of elevated pressure levels on exposed humans and objects.
The levels rise due to pressure, stroke, rejection. Often in literature it
is also described as mechanical, because of the emphasized physical
(mechanical) nature of the mechanism of affect. In order to cause me
chanical damage, there must be a carrier of this energy - the weight of
the water masses in floods, the pressure from fragments of demolished
buildings in earthquakes, shots from explosions, stunts from falling ob
jects in hurricanes, or lifted by the wind gust or by the blast wave body,
when it falls on the ground. As a result of its impact various localiza
tion, severity and type of injuries occur both in the locomotory system
and internal organs. The most frequent impact of the overpressure is
observed in: foods, tsunamis, hurricanes, storms when air or water pres
sure causes damages.
5. Ionizing Radiation. The damage occurs under the influence of
ionizing radiation. Depending on the activity of the source, the magni-
23
cf ionization in the environment, the distance to the radio-emitter,

::*;e of irradiation (internal or external), the type of ionizing radia
t e """'d the irradiated surface of the injured person, occur differently
=-=-vsrity and with different prognosis. Primary outbreak of radiation
—~ i z e develops in:
• Accidents in nuclear power plants - there is a continuous dis
charge into the environment of different quantities of radioactive
elements, which causes radiation pollution of the air, water, soil,
objects and objects of the infrastructure, which in tum become
secondary emitters of radioactivity. Depending on the quantity
and temperature of the radionuclides, it is possible to obtain
cross-border and even transcontinental AODs. (22, 23)
• The use of nuclear weapons in the form of atomic bombs (Hi
roshima and Nagasaki 1945) and more than 2100 nuclear tests
(1054 are US experiments only) according to official data. (24)
• Environmental pollution after radionuclide leaks in traffic acci
dents, improper operation or storage.
• Using the so-called "dirty bomb". The Dirty Bomb is an impro
vised explosive device in which radioactive elements are placed,
which, when the bomb explodes, disperse and contaminate the
environment.
Regardless of the cause of the radiation contamination and the char
acteristic of the AOD, radiation from secondary sources of ionizing ra-
iation persists years after the completion of the disaster that has caused
--eir release into the environment.
6. Biological factor - is caused by the impact of pathogenic organ-
•'■ms (viruses, bacteria, fungi, parasites) or their toxins. The penetration
of biological agents may be direct by inhalation, fecal-oral or through
,kin pathway, but often is mediated by carriers (vectors), for example,
a number of transmissible infections. Moreover, some of the infected
victims can serve as a source of infection. The most frequent impact of
_ Disaster Medicine Highlights
this fa-tor :s ^ consequence of various disasters, which lead to a severe

disndbz::ce of :l:e hygienic conditions and difficult sanitary-epidemio
logical connol of the territory damaged by the DF. Biological factor is
leading in epidemics and use of biological weapons. A secondary out
break of biological damage is most often documented after earthquakes,
floods, m ilitar conflicts, famine, and droughts.
7. Psychological factor. Each disaster has an impact on the psy
che of the victims, survivors and eyewitnesses. (25) Members of rescue
teams are also under the influence of the psychological factor during
the execution of the eradication tasks of the disaster consequences. (26)
Each one of the DFs during its impact has a negative impact on the
psyche of the population at risk. A strong psychological effect is the
observation of the perished, the destruction of the homes, the injuries
received, the impudence of the situation (especially the impact at the
beginning of the disaster, when the whole known world changes in sec
onds in front of the eyes of the people in the AOD). Different respons
es to these stressors are ranged from a strong stress response reaching
panic and / or aggressive behavior to fall into deep depression reaching
stupor and lethargy, From the point of view of the DMS, a particular
challenge is the mass panic, which can not only lead to an increase in
the number of injured persons (the impact of the mechanical factor, ba
sically), but also severely hinders the actions of the rescue and medical
teams. Another characteristic of the psychological DF is the duration of
its impact - months, even years after an experienced disaster, marked
psychological disorders are recorded, which researchers describe with
the terms anxiety or post traumatic stress disorder syndrome.
Every disaster passes through five phases in its development.
Interim (Quiescent) Phase. This is the longest phase - the phase,
when the required for the hazards negative impact risk factors are still
not sufficient. Generally speaking, this is the phase between two disas
ters. With regard to the DMS this is the most important phase. Through-
Disasters 25
out it healthcare system has to prepare itself for the better response in
case of disaster occurrence. What are the activities to be performed?
• Hazard identification. During the assessment of the general and
medical
• situation all available hazards into the region have to be discov
ered and listed.
• Risk factors identification. Along with hazards those factors that
could increase the probability of hazards to cause harm have to
be identified and listed.
• Evaluation of the health risk levels related to the identified haz
ards.
• Planning for preventive measures that could minimize the health
risk levels.
• Planning for the courses of action to be performed in case of non
sufficient prevention and disaster occurrence.
• Education and training of rescue and medical teams for disaster
relief operations.
• Resources allocation for disaster relief operations.
During the second Prodrome phase of the disaster development a
change into the situation is observed. This change is characterized by
the appearance of new and increase of the number of existing risk fac
tors. This increase changes the risk level. Required activities are:
• Identification of risk factors.
• Reevaluation of the risk level.
• Implementing of the preventive measures planned during the
quiescent phase.
• Reevaluation of the risk level.
• Planning for additional preventive measures.
• Alerting the rescue and medical teams.
• Notifying population at risk.
The only activity to be performed during the impact phase by the
meci::s their own safety and security in order to survive and

be read:· t..,. medically support affected population.
During ± e following Response phase, activities for supporting the
affected popu!ation and emergency and urgent emergency restoration
are performed. This phase is divided into two sub-phases:
• Isolation sub-phase. During this period all the activities are per
formed by the non-injured or lightly injured in the AOD. Main
activities are spontaneous evacuation, first aid, self and buddy
aid, finding shelters and collective protective installations.
• Salvation sub-phase. All the activities are performed by the
search and rescue teams that enter in the AOD for performing:
search and finding of the casualties and trapped; extracting those
in need; primay triage; first aid; organized evacuation of the
casualties, emergency and urgent emergency restoration of the
critical infrastructure.
The fifth is Recovery phase. During this phase a complex activi
ties have to be performed by various entities, in order to recover, repair,
rebuild and reconstruct the infrastructure and restore the governmental
functions and entire society life. In the beginning of this long-lasting
phase food, water and shelters are provided to all in need. External aid is
received and distributed. DMS is focused on treatment and full recovery
of the casualties. Healthcare system restoration is supported by special
ized teams and redistribution of the patients flow till medical installation
of the affected area become fully operational again. (14)
Disaster Medicine 27
DISASTER MEDICINE
Highlights
1. Disaster Medicine (DM) definition
2. DM objective
3. DM main topics
4. Main DM tasks
5. The main 5 DM principles
6. Health hazard
7. Health risk
8. Risk factor
9. Preventive measures
10. Exposure
11. Vulnerability
12. Resilience
13. Levels of health risk
14. Low is the risk level, when
15. Moderate is the risk level, when
16. High is the risk level, when
17. Health threat
18. Definition of health hazard assessment
19. Health risk management
20. Health risk assessment
DM is defined as interdisciplinary medical specialty with scientific

and practical approach to DMS to population. The specialty is constitu
ent part of Unified Rescue System (URS) established in Bulgaria, in
order to perform specific tasks in particular circumstances. To fulfill its
ultimate objective, DM apply various, complex and unusual tectoiques.
(2, 11, 14)
DM objective is to protect, secure and assure the human life, health
and abili::· in case of disastrous events.

Why DM has to apply specific, different from the everyday tech
niques and Standard Operating Procedures (SOP)? This is needed be
cause of the medical features of the disasters, mainly the sharp disparity
betveen available and required medical means and capabilities, along
with the constant threat to the life of the medics acting into the hostile
(devastated by the DFs) environment. Therefore, the first, basic objec
tive is to protect the life and health and then, if required and possible
to secure the life by life-saving procedures and to assure the health and
abilit' with first medical aid and treatment and rehabilitation in medical
installation.
In order to achieve the objective, the medical community has to be
educated, prepared and trained for DMS. The required basic knowledge
and skills required for DMS are the topics of the DM. As the disasters
are different types, as well as the DFs are different, the topics of the DM
are also several:
• Basic knowledge for natural and manmade disasters - origin,
causes, occurrence, features, development, impact on population
health. From the disasters' features analyzes the different impact
of the human health has to be noted. Disasters are characterized
with different DFs and they cause diverse damages;
• Defining the AOD and its characteristics. It is of utmost im
portance to define the AOD, because within its boundaries the
DFs are active, therefore the affected people, requiring DMS
are mainly in the AOD. Moreover, as the entire AOD is under
the DFs impact, in order medics to safeguard their own life and
health, AOD has to define very precisely;
• Types casualties in case of disasters. Already has been high
lighted that the different DFs are provoking diverse health distur
bances, traumas and injuries. DMS is organized and performed
in order affected people to receive adequate medical assistance.
The adequacy of the medical aid is directly related to type and

severity of injuries sustained;
• Injuries types related to the DFs - significant for the type and
scope of the DMS activities;
• General and specific knowledge about mass casualty events. This
is required because of the recorded data from disaster relief op
erations revealing that great majority of disasters are causing a
number of almost instantly appearing casualties;
• Required medical activities in case of disasters. As it is stated
into the definition DM is applying specific, unusual techniques
for responding to the health challenges of the disasters. These
techniques are combined along with the required resources into
DMS SOP;
• Standard Medical Operating Procedures in case of Disasters;
• Coordination and collaboration. DMS is a collaborative work
- medical tasks are performed by different medical specialists -
nurses, technicians, doctors, specialists, etc. Their efforts have to
be coordinated in order objective to be achieved. Has to be noted
that DMS is only a part of the disaster relief operations, there
fore, medical activities have to be coordinated with the activities
of the other URS elements;
• Scope of medical activities, treatment and rehabilitation of the
injured in case of disasters that are described into the DMS SOPS
and protocols have to be comprehensively taught and trained.
Objective of the DM could be achieved not only with acquiring re
quired knowledge and skills, but mainly through performing specific,
focused on the DM goal activities. These basic activities are defined into
the main DM tasks:
• Research on natural and manmade disasters medical aspects that
is required for understanding the mechanism of the recorded neg
ative disasters' impact on human and population health;
30_ Disaster Medicine Highlights
• R ^ ^ c h on disasters’ impact on human health is a rational fol-

Iov,,TOg tasks - the mechanism is causing impact and impact leads
to the specific psychological and physical traumas;
• Determine and analyze the features of disasters related types of
injuries and required treatment methods is the task where the
negative health consequences are classified in accordance to the
DFs. This gives an opportunity to plan and train specific medical
SOP for every particular calamity that is basis for the following
two task;
• Optimizing the established structures and doctrines for prompt,
adequate and efficient planning, organization and execution of
theDMS;
• Establishing Standard Operating Procedures, methodologies and
policies for prevention and treatment of the entire spectrum prob
able health injuries, diseases and epidemics related to disasters;
• Scientific tutorial and practical training of health providers for
reaction and performance in case of disasters. In order to imple
ment into the practice, the DMS SOPs and protocols, it is man
datory to educate and train the healthcare providers what is the
novel and specific in comparison to their routine practice;
• Based on existing national healthcare system, DMS structure and
efficient organization have to be established most for prompt, ad
equate medical aid provision in case of natural or man-made ca
lamity;
• The results of the tasks have to be inserted into the scientific re
searches and profound analyses that have to become a valuable
input for elaborating the DM doctrines and policies.
All the doctrines and SOPs have to be developed within a framework
of the established DM principles. These principles are the guidelines for
the DMS operations. The main DM principles are as follows:
1. The main foundation principle of the DM is to assure the medical
teams safety and security. Why the medical teams· safety and security are
of utmost importance? Why in D 1 is not followed the main principles
of medicine - Prirnum non nocere (First no to harm)? The answer could
be easily found into the disaster impact on healthcare system - DFs are
devastating everything into the AOD, medical infrastructure and person
nel included. Moreover, the number of the casualties is overwhelming
the available medical means capacities and capabilities, therefore, every
medic is an invaluable asset for the DMS. If even a single medic become
injured the negative consequence will be twofold - firstly, DMS is losing
a capability that is scarce and secondly the injured medic is becoming a
new casualty, who is increasing the demand for medical support. Some
of the forced SOP (triage, medical evacuation) within DMS are violat
ing the first principle of medicine, once again driven by the disparity
into required and available medical means and capabilities.
2. The objective is not the single injured, but providing the best for
the maximum. Once gain the requirements for medical assistance and
scarcity of medical means leads to SOP, where the objective is set on the
number of the saved lives, not on the individual in need.
3. Early hazard detection, followed by risk assessment and triage
are the basis for DMS. From the first two principles the third one is de
rived. What is needed for assuring the safety and security of the medical
teams? Identification of the hazards and evaluating the risk level associ
ated to this particular hazard. The triage is required by the second princi
ple - in order to save as much as possible casualties, all affected have to
be group in accordance to the urgency of the medical aid required. This
will prioritize the use of the limited resources - they are focused into
saving the threatened lives first.
4. Continuity of the medical support has to be assured for every
casualty. The medical assistance commences in the AOD with first aid,
followed by primary triage and organized evacuation, proceeding with
first medical aid and medical evacuation and treatment in hospital, if re-
Disaster Medicine Highlights
quirec.. AU :hese activities in their sequence are assuring constant assis

tance that depends mainly on type and severity of the sustained injury,
thus building the Treatment Evacuation System.
5. All described medical activities are in coordination with the ac
tivities of the others structures of the URS.
6. Lessons Learned from every disaster medical relief activity are
invaluable input for the constant DM development. (2, 11, 14, 27, 28,
29, 30)
DM as majority of specialties is forced to use a specific glossary
of terms for describing the required DMS activities. The knowledge of
the terminology is a base for understanding the DMS policy, doctrines,
SOPs and protocols. The most important terms in use in DM are:
1. Hazard. Hazard is a process, phenomenon or human activity that
may cause loss of life, injury or other health impacts, property damage,
social and economic disruption or environmental degradation. Hazards
may be single, sequential or combined in their origin and effects. Each
hazard is characterized by its location, intensity or magnitude, frequen
cy and probability. Hazards include (as mentioned in the Sendai Frame
work for Disaster Risk Reduction 2015-2030, and listed in alphabetical
order) biological, environmental, geological, hydrometeorological and
technological processes and phenomena. (5) It is an event or status with
potential to cause undesired consequences because of physical or psy
chological health damages.
2. Risk. Disaster risk is defined as the potential loss of life, injury, or
destroyed or damaged assets which could occur to a system, society or
a community in a specific period of time, determined probabilistically
as a function of hazard, exposure, vulnerability and capacity. (5, 31, 32)
Risk is the probability within time period a particular hazard to trigger
the negative impact on population health, assets, infrastructure, etc.
There are two types of risk - Acceptable and Residual risk. Accept
able risk is tolerable by the society and depends on existing conditions
- social, economic, political, cultural, technical and environmental. This

probability is either low and without significant consequences, or noth
ing could be done in order to prevent the possibility present hazard to
negatively impact the society as whole.
Residual risk is the disaster risk that remains even when effective
disaster risk reduction measures are implemented. This risk is the rea
son emergency response and recovery capacities (DMS included) to be
maintained. It implies a continuing requirement for continuing DM de
velopment and allocation of effective capacities and sufficient resources
for emergency services.
3. Exposure. Exposure defines anything that is potentially at risk.
This includes people, property, facilities, infrastructures located in the
risk prone areas, in the AOD or in an area where hazards are identified
.:::id are therefore subject to potential losses. (5)
4. Vulnerability. The conditions determined by physical, social,
economic and environmental factors or processes which increase the
susceptibility of an individual, a community, assets or systems to the
impacts of hazards. (5) Vulnerability can be also defined as the reduced
ability of an individual or group to predict, cope, resist, and recover
::om the effects of a natural or man-made disaster. It depends on human/
society reparedness and exposure to the hazards. (33, 34)
5. Resilience. The ability of a system, community or society exposed
:o hazards to resist, absorb, accommodate, adapt to, transform and re
cover from the effects of a hazard in a timely and efficient manner, in
cluding through the preservation and restoration of its essential basic
nuctures and functions through risk management. (5)
6. Risk factor. Factor, which existence increases the particular haz-
realization probability in certain circumstances
7. Preventive measure. Activity or capacity with potential to reduce
::ie risk level.
8. Health hazard assessment. The process of identification and anal-
yses of entire spectrum of existing hazards with potential to cause health

harm in given circumstances is defined as health hazard assessment.
9. Disaster risk assessment. A qualitative or quantitative approach to
determine the nature and extent of disaster risk by analysing potential
hazards and evaluating existing conditions of exposure and vulnerabil
ity that together could harm people, property, services, livelihoods and
the environment on which they depend. (5, 14) The process of collect
ing, analyses and evaluation of the available information about available
hazards, risks factors and their probability to cause acceptable or unac
ceptable health harm is defined as health risk assessment.
10. Disaster risk management is the application of disaster risk re
duction policies and strategies to prevent new disaster risk, reduce exist
ing disaster risk and manage residual risk, contributing to the strength
ening of resilience and reduction of disaster losses. (5) It is the process
of preventive measures evaluation and selection, in order to minimize or
eradicate assessed risks’ levels.
For DMS practice, the following 4 levels of risk for health and life
are mainly used:
1. Low risk. The level of risk is assessed as low level, when the
identified hazard can adversely affect, but a number of risk factors (ex
posure, vulnerability, etc.) that are not available at the time of assess
ment are necessary. There is a low level of risk and when no serious
consequences are expected even when the hazard realizes its potential
to cause negative impact. At low risk levels, no additional preventive
action is required.
2. Moderate risk. The risk is moderate when more than half of the
risk factors are identified for the realization of the hazard and the sever
ity of the consequences will have an impact on the population at risk. It
is necessary to take the planned preventive measures that are sufficient
to reduce the likelihood of realization of the hazard.
3. High risk. The risk is high when all necessary risk factors are
available and the consequences will have a negative impact on the popu
lation and society, as a whole. The introduction of the planned preven
tive measures reduces to a certain extent the potential of the hazard to
cause negative consequences.
4. Threat. The highest level of risk. All risk factors have been iden
tified, severe consequences are expected, and taking preventive action
can only reduce to a certain extent the severity of the consequences, but
it does not affect the likelihood of the hazard to realize its potential. In
other words, it is not possible to prevent the damage to the population,
to the environment and to the infrastructure, but it can, for example,
:nfluence the number and type of casualties, the severity of injuries sus
tained, as well as to reduce the number of perished persons. (14)
AREA OF DAMAGE
Highlights
1. Define AOD
2. AOD mainly depends on
3. What could be affected in the AOD
4. Main elements of the AOD
5. Risk factors within AOD
6. What have to be considered in AOD?
7. Where the DMS has to be performed?
8. Define casualties
9. Types of the casualties
I 0. Irreversible loses
11. Define the medical loses
12. SOP for medical support in the AOD
13. Where is located FMS?
14. What type of medical assistance is required?
15. Who is providing the required assistance in the AOD?
16. Types of AOD
17. Exceptions
Area, the territory, where the DF affects population, environment

and infrastructure is defined as AOD. (11) From the definition could be
stated that the main element of the AOD is the DF. Without DF, no AOD
could be established. The other elements that are defining the AOD are:
1. The area that has been hit by the DF. In order this area to be de
fined, boundaries of the affected territory have to been drawn. These
boundaries depends on:
• Type of the DF, e.g. different territories could be affected from
chemical and from the mechanical factors, especially, if the me
chanical damage is caused by the hurricane, or by the biological,
Area Of Damage 37
when the epidemics could affect almost entire continents. What

is more the impact of the psychological factor could be great
er and affect population in territories far from the affected by
the primary DF AOD - the fear from pandemic was with almost
global spread;
• Quantity (in case of the chemical and biological factors), power
(for the mechanical and the blast wave), activity (for the radio
logical);
• Exiting in the disaster prone area of barriers that could impede
the spread of the DF. For instance, the high mountains and hills
could stop the propagation of the toxic cloud, the sea or large
river could limit the devastated by the volcanic lava area and etc.;
• Hazards available into theAOD, different from the DF, that could
provoke additional or novel damage on health, infrastructure and
environment, e.g. dams and lakes could enlarge the flooded area;
• Risk objects. As risk object is defined an object that could be
come harmful in certain circumstances, mainly in case of crises
and disasters, when it could be affected by the DF. As conse
quence a new AOD is set, or the existing one is enlarged and the
risk for population at risk and environment raises significantly;
• Wind. The wind direction determines which area could be af
fected. The range of the affect is related to the speed of the wind,
while the type (continuous, constant or the variable, fluctuating)
defines the shape of theAOD;
• Meteorological characteristics - air temperature; temperature of
the water basins; precipitation; clouds, etc, are important for the
movement of the DF - toxic or radiological cloud, pathogenic
organisms development, flooded are range and etc.;
2. Population at risk. Population that resides in the AOD or disaster
prone area is classified as population at risk. From the number and loca
tion of the population at risk could be calculated the probable number of
3- Disaster Medicine Highlights
the people t a t could be affected by the DF. The information regarding

the age and healthy status of the population is other important indicator
for the exposure and vulnerability of the population.
3. Type of settlements and type of building are other indicators re
garding the exposure and vulnerability of the population.
4. Exposed and affected by the DF animals and plants. It is impor
tant to take into consideration the possible impact on flora and fauna,
because of the high probability polluted plants to harm the people eating
them. Animals also could cause negative effects on population, either
serving as a food or via transmission of the biological agents, or direct
contact damage.
5. Environment affected. Polluted soils, air and water could become
dangerous for the population - inhaling toxic elements or compounds
(chlorine intoxication), radioactive dust or infected by viruses air
throughout the breathing, drinking polluted water and eating vegetables
grown on contaminated soil, could increase the number of casualties far
beyond the numbers affected by the DF itself.
6. Casualties - type, number, location, severity of wounding. From
the medical point of view the casualties are the most important compo
nent of the AOD. How we a defining casualties? Part of the population
at risk could become under the impact of the DF. Those people that have
lost only property and have sustained no injury (physical or psychologi
cal) are classified as affected. All those with different types of damage
to health - from minor injuries to death, as a result of the impact of the
DFs, are classified as casualties. The group of casualties is divided into
two main subgroups:
• Irreversible (Irretrievable) losses;
• Medical Losses. (11)
The irreversible losses include those injured who does not require
medical assistance - those who died under the DF impact, the missing
persons and those who died while receiving medical care.
Area Of Damage 39
The medical losses are all those in need of medical help due to the
injuries resulting from the impact of the DF. The definition adopted and
used for medical losses in the Geneva Conventions and the additional
protocols thereto is: "Medical losses are all who, due to trauma, illness
or other somatic or mental condition, require medical assistance and
care." As an additional condition for their registration, they have sought
and / or received medical assistance (in an ambulatory or other medical
facility) and have lost their working capacity for at least 24 hours. (11,
14)
Medical losses are those for which the entire DMS is organized and
conducted in a particular disaster.
Another important characteristic of the AOD is the determination of
::s type. This determination is in accordance to the medical assistance
required by the medical losses within the AOD. AODs are divided into
five main types:
1. Mechanical (traumatic) AOD (MAOD). In this AOD, medical
.:-sses are mainly with different types of trauma and the aid required is
general surgery. The mechanical damage is result from the DFs over-
rressure, shock wave and the thermal one.
2. Chemical AOD (CAOD). In this AOD, the casualties of the toxic
(chemical) DF have different intoxications due to their type and sever
er.. The necessary help is therapeutic with the aid of a specialist in toxi-
-ology.
3. Area of Radiological Damage (RAOD). Under the influence of
ϊ -nizing radiation, irradiated patients develop different levels acute radi-
1: on syndrome and / or radio-dermatitis. They need general therapeutic
. which is enhanced by specialists in hematology.
4. Biological AOD (BAOD). Biological DF causes the development
infectious diseases that can only be within a limited number ofpopu-
^::on at risk or develop as an epidemic. In addition to providing spe
cialized medical assistance from infectious disease specialists, it is also
necessary to mobilize epidemiologists.

-. Area of Combined Damage (AOCD). The type of medical as
sistance n ^ ^ e d is determined by the type of concurrently affecting two
or more DFs
Based on the principles of DM the location of the FMS has to be
chosen at a safe place for the medical teams, but this place has to be as
close a s possible to the casualties, in order to provide medical aid to
maximum number of people in need. Taking into consideration these
two principles it is logical to state that the FMS has to be located out of
the AOD. In the RAOD, CAOD and AOCD (if radiological or chemi
cal DFs are present) always the FMS are outside of the AOD. In these
areas the use of proper protective equipment is mandatory. Very few,
ambulances are equipped with such equipment, therefore, most of the
teams will remained unprotected and entering into the area will become
casualties. Analyzing the MAOD, could be concluded that the DF is
not present or with decreased power at the time of the relief operations
commencement. This could allow the establishment of the FMS within
the AOD, if no imminent threat for the medical teams’ life is detected.
Example is the organization of the medical operations in the devastated
by the earthquake area. FMS and even field hospitals are established in
the zones of the light and moderate destructions.
On the contrary is the organization of DMS for BAOD. The threat
for the life of the medics is present, but if infected casualties are evacu
ated out of the AOD, this will enlarge the zone, because these type of
medical losses cannot be decontaminated, as is the SOP for the intoxi
cated and irradiated. These, the infected, casualties require treatment
and only after their definitive healing could be declared safe for the other
population. Moreover, those who was in contact with the infected, also
could be dangerous and have to be monitored for development of the in
fectious disease at least to the maximal incubation period. Considering
these, the DMS for BAOD is organized in the AOD. Medical teams are
Area Of Damage 41
operating under the constant threat for their lives and health, therefore,
a strict adherence to the prescribed into the SOPs and implemented anti
epidemic measures, is required.
MEDICAL LOSES
Highlights
1. Definition for Medical losses
2. The role of medical losses for the DMS
3. Requirement for the classification of the medical losses
4. Main criteria for classification
5. Severity of the injuries depend on
6. Based on severity are the following decisions
7. Injury type is related to
8. How many are the groups in accordance to the injury type?
9. How many are the groups in accordance to the injury location?
10. Definition of polytrauma
11. Definition of multiple trauma
12. Definition of combined trauma
13. Definition of open injury
14. Definition of blunt injury
15. How many are the groups in accordance to the severity of the in
jury?
16. Definition of life-threatening injuries
17. Definition of severe injuries
18. Definition of moderate injuries
19. Definition of light injuries
20. How many groups are the life-threatening injuries?
21. How many are the groups in accordance to the priority of medical aid?
22. Which severity group is PI?
23. Which severity group is P2?
24. Which severity group is P3?
25. How many are the groups in accordance to the evacuation criteria?
26. 26. Which severity group is El?
27. Which severity group is E2?
Medical Loses 43
The medical losses are all those in need of medical help due to the
injuries resulting from the impact of the DF. The definition adopted and
used for medical losses in the Geneva Conventions and the additional
protocols is: "Medical losses are all who, due to trauma, illness or other
somatic or mental condition, require medical assistance and care.” As
an additional condition for their registration, they have sought and / or
received medical assistance (in an ambulatory or other medical facility)
and have lost their working capacity for at least 24 hours. Medical losses
are those for which the entire DMS is organized and executed in a par
ticular disaster. (11) The objective is adequate medical assistance to be
provided to maximum number of casualties with the available insuffi
cient medical forces and resources in the highly limited time frame. The
time for medical support provision is limited by the type and severity of
the received injuries and the possibility for further negative impact from
the DFs. As the requirements for medical assistance are overwhelming
the capacities of the available medical means, it is necessary to classify
the medical losses for prioritizing their needs.
The main criterion that guides the casualties prioritization is the se
v erity of the damages and their complications. Depending on the sever
ity, a decision is made on the priority (order) of the medical care and the
subsequent evacuation, as well as the type of medical care itself. The
severity of the injury is related to the type and the location of the sus
tained injury/ies. Therefore, in order to define the severity of the health
damage is mandatory to define the type of the injury.
From the type of the injuries sustained depends also and the required
type and scope medical aid, as well as and the necessary medical de
vices - consumables, medicines, antidotes, equipment. Because medical
losses occur during the disasters under the impact of the DFs on the
_?Opulation, their classification by type will be related to the type of the
factor (s). Although the DFs are seven, the medical losses groups are
sight.
ίΐ Disaster Medicine Highlights
1. e:pressure and shock wave cause medical losses mainly with

different rypes and localization of traumatic injuries. Major health
threats include bleeding (external and internal), tearing or damage to
organs, severe pain syndrome. Resuscitation and surgical aid have to be
provided;
2. The heat injuries (bums, frosts), which also require surgical help,
are caused by the thermal factor. The thermal factor may also cause a
thermal shock, requiring resuscitation actions;
3. In addition to the mentioned two categories of medical losses, a
third category of specific, related to the water-driven disasters injuries
have to be described - the drowned and drowning. While the drowned
are in the group of irreversable losses, those rescued of drowning re
quire targeted intense therapeutic care, because of the frequent compli
cations - hypotermia, aspiration of water or vomit that cause acute res
piration distress syndrome at the beginning and pneumonias as remote
complications;
4. Specific are the medical losses caused by the the chemical / tox
ic factor. This factor causes various intoxications that threaten life and
damage health through different mechanisms, depending on the type of
toxic factor. Typical for the intoxications is their extremely rapid devel
opment. The life-saving success highly depends on the rapid administra
tion of antidotes (for part of the chemicals). A basic requirement for first
aid is to stop the contact with the DF as soon as possible. Resuscitation
activities and intensive therapy are required;
5. All injured under the impact of ionizing radiation are classified as
irradiated. Deterministic and stochastic effects are developed depend
ing on the magnitude of the absorbed dose, the type of irradiation and
the radionuclides. Medical losses are treated in therapeutic departments,
hematology clinics and wards. The rapid suppression of the both cellu
lar and humoral immunity requires measures for protecting the casualty
from being infected, therefore they have to be isolated;
Medical Loses 45
6. Biological DF causes various infectious diseases. Infected patients

should be isolated and treated in the AOD. The treatment requires doc
tors with the following specialties infectious diseases, internal diseases,
general medicine. Of particular importance is the role of epidemiolo
gists in identifying and eradicating the outbreak of biological damage;
7. Great variety of mental disorders are recorded resulting from the
impact of the psychological factor. Acute stress reactions are within the
most common one. Of great importance in the medical aid provision
for this group medical losses is the early onset of psychological sup
port. This activity is often forgotten and neglected by the DMS manag
ers. Specialized teams of psychologists, but also all medical specialists,
have to provide psychological support to all those in need in the very
beginning of the relief operations;
8. When the resulting damage is due to two or more DFs, the medical
losses are combined. Great majority of the disasters are inflicting com
bined medical losses among the population at risk. The ratio of com
bined damage varies widely depending on the type of the disaster. In
some disasters, the high percentage of combined medical losses is due
to the nature of the calamity DFs. Fires are such disasters, where two
DFs are active - the thermal and the toxic. Medical forces and means for
stabilization of intoxicated victims with different degrees bums have to
be planned and deployed. The records reveal that some of the disasters
cause the development of secondary calamities that add their DFs to
the one of the primary disaster. For example, very often as a result of
earthquakes, residential buildings are damaged and fires occur. Frequent
consequences after earthquakes are also the floods due to damages to
dam walls or tsunami waves. Combined injury is an aggravation syn
drome. Most of the sustained damages are worsen in combination with
the others resulting from the secondary DFs. This probable deteriro-
ration has to be considered, when planning, organizing and deploying
DMS. Another challenge for the medics is which damage to be choosen
as priori::"? The answer is unambiguous: life has to be saved first and

severe damage stabilized.
To s^ m a riz e the eight injury types are: traumas, burns, drowning,
infections, irradiation, psychological disorders, combined injuries.
The severity, as well as the type of medical care required, also de
pend on the localization of the damage. Depending on the location of the
damage, the following categories of medical losses are distinguished:
1. Head and neck injuy. In the case of the damage with this localiza
tion, the life and the health are threatened because of the limited spaces
and the structures that can be affected;
2. Damage in the chest area. Again, severe health consequences pre
dominate due to the possibility of damage to the organs of the respira
tory system, heart, aorta etc;
3. Damage to the abdomen. Depending on the intensity and type of
the DF, great variety ofinjuries could be observed;
4. Locomotory injuries. Predominant injuries that do not pose threat
to the life, with the exception of pelvic trauma and damage to the large-
blood vessel (a. Femoralis, and brachialis, for example).
Depending on the severity of the resulting damage, medical losses
are classified into the following four groups:
I. Life-threatening - they have suffered damage that directly threat
ens their lives. These victims should receive urgent, immediate assis
tance. Any delay can lead to a fatal outcome - death. The following
injuries are classified as life-threatening:
• First in this category are the injured without respiratory and / or
cardiac activity. Delaying cardio-pulmonary resuscitation means
sure death.
• . Any unconscious state during disaster can lead to death because
of the inability to refine the diagnosis and constant monitoring of
the victim's vital signs.
• Massive blood loss and profuse bleeding are two other conditions
Medical Loses 47
with a direct threat of death due to the \ ery limited possibilities

for rapid and adequate correction of the changes occurring in the
body.
• Changes in heart rhythm such as ventricular fibrillation, ven
tricular tachycardia, bradycardia below 40/min, atrial fibrillation
with a frequency above 180-200/min. also require immediate in
terventions to save the life.
2. Severe injury. This category classifies damage that is not a direct
:hreat to life at the present moment, but has potential for rapidly and eas
ily development of life-threatening complications.
• Any breathing difficulties - tachypnoea/tachydispnea over 30
breaths per minute, bradypnoea / bradydispinea below 10 breaths
per minute, are expected to lead to a rapid development of hy
poxemia and subsequent metabolic acidosis, and a difficulty in
the function of the organs with the highest oxygen and energy
consumption - brain, heart, liver.
• Tachycardia, tachyarrhythmias, bradycardia and bradyarrhyth-
mias are also classified as severe injuries.
• Some fractures can also lead to a life-threatening condition due
to marked blood loss (fractures of the femur in proximal third).
• Victims with inadequate behavior and responses, confusion and
disorientation also fall into this category due to the inability to di
agnose the condition and the possibility that the observed chang
es in mentality may be due to cranial brain trauma, bleeding in
various brain structures, severe intoxications, etc.
3. Moderate injury. This group classifies the damage that can lead to
complications with threat for permanent disability. These medical losses
=eed urgent help, but it may be postponed in time.
4. Light injury. All medical losses that do not require emergency
::iedical care are classified in this category. A large percentage of these
can be treated in outpatient settings.
:- Disaster Medicine Highlights
D ecoding on the severity of the damage category, medical losses

are cl^sified by priority, i.g. who should receive medical attention be
fore the others:
1. Priority 1. These are life-threatening and severely injured. In these
cases, delaying the aid may cause irreversible consequences and death
of the victim·
2. Priority 2. All moderately injured casualties receive medical as
sistance as soon as it is given to Priority 1;
3. Priority 3. Casualties with light injuries are classified into this
category.
Wien medical losses are classified for the DMS needs, the require
ment for medical evacuation has to be considered. The medical evacua
tion requirements also depend mainly on severity of the damage. Medi
cal losses are classified in accordance to the timefi’ame within which the
transportation has to be performed:
1. E 1 are those who are evacuated first, if medical transport is avail
able. They are subject to evacuation in emergency order - up to 2 hours;
2. E2 are casualties, who are evacuated in a second order from the
4th to the 6th hour;
3. E3 is the group that is evacuated last until the 12th hour.
Disasters’ Relief To Population 49
DISASTERS’ RELIEF TO POPULATION
Highlights
1. Definition of the disaster relief to population
2. Objective of the disaster relief to population
3. Define the principles of the disaster relief to population
4. Define the main activities groups
5. Define the tasks during the preparatory phase
6. Who is responsible for education activities?
7. Who is responsible for Individual Protective Equipment and Col
lective Protective Sites purchase, storage and maintenance?
8. Define the tasks during the response phase
9. Who is declaring state of the emergency?
10. Define the tasks during the recovery phase
11. Define the levels of the disasters
12. What forces and resources are required for Level 1 disasters man
agement?
agement?
agement?
15. Define the Disasters Paradigm
16. Define the structure of the National Management System
17. Define the National Management System elements tasks
18. Define the Unified Rescue System (URS) structure
19. URS tasks
20. URS main elements
_l. URS main elements responsibilities
12. Define the tasks of National Police
13. Define the tasks of Fire Safety and Population Protection
24. Define the tasks of Centers for Emergency Medical Aid
25. Define the Crisis Headquarters (CHQ) structure

26. Define the CHQ main elements responsibilities
27. \\tho is the CHQ leader?
28. Who is the Incident Commander?
Disaster relief to population (DRP) differs in every country, but the

principles are the same.
Definition - complex of specific measures aiming to decrease as
much as possible the impact of the damaging factors and to prevent
from human and material losses. That is all the activities undertaken by
different agencies in order to support the population in the AOD. (14)
The objective of the DRP is to organize and execute complex search,
rescue and recovery operations in order to minimize the impact of the
DFs - the number of the casualties and the residual disability, critical
infrastructure damage and damages to the citizens’ property. (14)
In order to achieve the set goal several tasks have to be accomplished:
• Educating and preparing the population for adequate reaction in
case of imminent disaster threat or in case of actual disaster.
• Training of the reaction forces - With regard to the urgent re
sponse required for prompt and efficient disaster management
teams with different skills are trained and maintained on high
level of readiness to enter into actions if and when required.
• Allocating the required for the DRP operations resources, pur
chasing and storing them.
• Provision of personal protective equipment
• Provision of collective protective equipment
• Relocation and evacuation of the population at risk in order to
decrease the density, thus decreasing the expected medical and
irreversible losses.
• Informing the population about hazards and the undertaken ac
tivities
The DPR activities are 3 main groups b ced on the time of their per
formance and its content:
1. Preventive - research on disasters' features and occurrence; explo
ration; analysis, evaluation and estimation of the existing hazards and
risk factors; assessment of risk level; planning the protection; imple
menting preventive measures; adopting the ational Disaster Protection
Plan; control of prevention.
2. Response - after the “state of emergency” is declared and Disaster
management plan is activated. they include - warning and alarming the
population; assessment of the impact; establishment of crisis HQ; coor
dinated activities from the parts of the Unified Rescue System (URS);
search and rescue operations; urgent rehabilitation and rebuilding; medi
cal aid and support; psychological aid; resource supply; localization and
management of the ecological emergencies; protection against explo
sives; radiological, biological and chemical protection; extinguishing
fires; evacuation and relocation; asking for external assistance. These
activities are within the first 72 hours of the disaster management.
3. Recovery- Provision of shelter, food, water and medical support
:o all in need; rehabilitation, recovery and when required rebuilding of
critical infrastructure; enhanced sanitary and hygienic control; preven
tion of epidemics; accepting and distributing the external aid; restoring
:he normal activities into the society to the pre-disaster level. (35, 36)
All the activities of the DRP are in accordance to the following main
principles:
• Every person has the right to be protected.
• Priority to life-saving activities before other protective and res
cue operations.
• Priority to preventive measures when providing the protection.
• Assuring of reliable and secured communication between all in
volved into the DRP.
• Publicity of the information about risks and preventive measures.
52 _______ Disaster Medicine Highlights
• R^ 7 3 nsibility for the execution of the DRP.

• Staged provision of means and capabilities.
• Coordination of the activities performed by the different agencies
and entities.
• All the activities are planned and performed on three levels in ac
cordance to the administrative division of the country.
• Strict subordination to the crises HQ and incident commander.
(14)
To execute these specific tasks in Republic of Bulgaria a dedicated
system is established - National Management System (NMS). It plans,
co-ordinates, and executes activities on solving crisis situations.
'The establishment of NMS is imposed by the following features of
the disaster:
• Unpredictable (as time, place, type) disaster occurrence.
• Multiple casualties and destructions that vary into the severity of
consequences.
• Damaged critical infrastructure
• Disparity between the available and the required means and ca
pabilities.
• Limited time to commence the search and rescue activities be
cause of the imperative for impact minimization and casualties
and destruction decrease.
• Necessity to relocate means and capabilities to the AOD in the
shortest time possible in order to manage properly the conse
quences.
• Risk of secondary damages.
Depending on the scale of the disaster, actions could be undertaken
on 3 levels - National (Country/Nation-wide), Regional (Province), Lo
cal (Municipality). Depending on the size of the territory affected by
the disaster the state of emergency is declared by the Mayor (for a mu
nicipality range), by the Governor (three or more municipalities of the
province affected) by the Council of ministers, based on proposal by

Minister of Internal Affairs (when two or more provinces are under the
impact of the disaster). (2, 11, 14)
NMS has 4 elements:
• Managing body.
• Headquarter.
• Communication and Information System (CIS).
• Reaction Forces.
Because of the need for immediate reaction in response to the dis-
3ter, the NMS provides - education and training of managing bodies
^ d reaction forces; analysis and estimation of the risk; support the re
action readiness; implementation of preventive measures; information
exchange; effective usage of the resources; co-ordination of the reaction
forces; localization and management of the crisis and its consequences
order disaster not to be developed.
The Managing body consists of council of ministers/prime minis-
:er and an security council for disasters and crisis management. The
council includes experts and advisors in order to support the DRP deci
sion making process. The managing body defines national politics, leads
----e DRP management, leads the National System, accepts the National
Plan and declares state of emergency on national level. Security council
evolve in National Crisis Headquarter. The security council aids
:.::e council of ministers, creates and accepts National Plan for crisis,
=-_ovides suggestions for participating in humanitarian operations. Its
---ain goal is to monitor and manage the entire spectrum of disaster relief
=?erations. It is established on administrative principle. The leader is the
idministrative head in the affected area (mayor, governor, PM)
The crisis headquarters always lead by the head of the administra-
=-on on National level consists of:
- Minister of internal affairs- Chief Directorate National Police (CD
NP) is responsible for securing the AOD, restricting the access to and
our of it. coordinating and facilitating the movement of DRP teams and
population. Chief Directorate Fire Safety and Population Protection (CD
FSPP) are the main search and rescue teams.
• Minister of infrastructure - responsible for critical infrastructure
restoration and recovery.
• Minister of health- medical teams provide medical support, sani
tary and hygienic measures.
• Minister of transport and communications - assuring the reliable
and secured CIS, as well responsible for transport routes restoring
and maintaining in operational status.
• Minister of environment and water - providing advice and mak
ing decision regarding the environmental impact of the disaster
- proposing best options for shelters and safe water provision.
• Minister of agriculture and food - food supplies and veterinary
control are main responsibilities of this ministry.
• Representative of Red Cross- non-governmental organization are
in support of the HQ, especially into the recovery phase.
• Minister of defense - ready to support the governmental activi
ties when capabilities are not present of insufficient, the armed
forces are ready to assist the civilians with their unique expertise
and means and capabilities. Elements of the armed forces are in
volved into the DRP only with the prime minister decision and
request to the minister of defense.
Population is alarmed by national awareness system, communica-
tional networks for emergency calls, mass media.
The prime minister or his/her deputy declares “state of emergency”
when 2 or more provinces/regions are affected and need external assis
tance. The mayor declares state of emergency for the municipality. If 3
or more municipalities - the governor declares state of emergency for the
province/region. State of emergency is a situation in which a government
suspends normal constitutional procedures in order to regain control.
Disasters’ ReliefTo Population 55
State of emergency is declared with order that gives the circum

stances, the reasons, the borders of the territory, the measures including
restriction in civil rights, the responsible bodies, the start and the term.
During the SE the following could be restricted:
• The sovereignty of persons and homes
• The right to use property
• Freedom of movement
• The right to perform activities
The Reaction forces form the Unified Rescue System. The URS ob
jective is to organize, co-ordinate and manage the efforts of the differ
ent units, services, structures and execute immediate population relief
operations for saving human life, repair damages and lower the impact
on environment. It has 3 basic elements, ready to receive calls, make
evaluation and react immediately 24/7.
• CDNP.
• CD FSPP.
• Centers for emergency medical help (Ambulances services -
CEMH).
• Red Cross is a part of the URS basic elements, because it has
professional and voluntary formations and established structure
for humanitarian aid.
They work according to the disaster paradigm:
• D - detect
• I - incident command
• S - scene safety and security
• A - assess hazards
• S - support needed
• T - triage/treatment
• E - evacuation
• R - recovery (repair, rehabilitation, restoration, rebuilding, sani
tary and hygienic control)
—— --------- ------------------------- -—Disaster Medicine Highlights
The URS has officers on call 24/7. It is ready to perform analysis and
assessment of the situation ins hort time and to commence immediate
activities
It has structures/units nationwide according to the administrative-
territoriaJ division. All the services keep their institutional and organi
zational appurtenance and their given functions and subject-matter. If
it is necessary, they get help from ministries, regions and municipali
ties, armed forces, hospitals, trade companies and traders, legal entities.
They work according to plans that provide co-ordination, interaction
among services and staged provision of means and capabilities depend
ing on the disaster development. The plans differ, based on the level and
volume of activities. They contain information on teams and resources,
their tasks and capabilities, the way to alarm them and their time to pre
pare. (6)
Incident commander at the site is the representative of Ministry of
internal affairs, could be from CD FSPP or CD NP He/she has the au
thority to restrict access, relocate people and rescue teams, to stop con
structions or order demolition of buildings, to ask for personal or mate
rial help, establish a local HQ, to assign managers.
Main URS elements activities include:
• CD FSPP - urgent rehabilitation, reconstruction and rebuilding,
search and rescue, primary triage, organized evacuation.
• CEMH - medical intelligence, establishment of medical stations,
medical triage, stabilization and medical evacuation.
• CD NP is responsible for securing the AOD and restricting the
access to and out of it and facilitating the DR activities (clearing
paths for the rescue teams, prevent the population and journalists
from interfering, protect the property).
Coordination and communication is through the NMS CIS. Their
tasks are:
• To receive and evaluate the information.
• To inform the parts of the URS and coordinate their actions based
on standard procedures.
• To inform the reaction forces for any changes related to the dis
aster situation.
• To include more means and capabilities according to the plan for
rescue and urgent rehabilitation and rebuilding on demand from
the incident commander, the mayor or the governor.
58 __________________________ Disaster Medicine Highlights
DISASTERS’ MEDICAL SUPPORT
High lights
1. Definition
2. Objective
3. Principles
4. Tasks
5. DMS consist of
6. Unified Medical Doctrine
7. First stage medical activities
8. Second stage medical activities
9. Third stage medical activities
10. DMS structure
11. DMS managing bodies
12. DMS means and capabilities
13. Helathcare establishments
14. Treatment and evacuation activities
15. Structures for treatment and evacuation activities
16. Hygiene and anti-epidemic activities
17. Structures for hygiene and anti-epidemic activities
18. Prehospital structures
19. Hospital structures
Disaster Medical Support (DMS) is defined as system, organization

and structures established to prepare and execute proper and adequate
medical operations in support of the affected population, as well as the
population at risk.
DMS consists of:
• Evacuation and treatment: triage, first medical aid, directed medi
cal evacuation, treatment.
• Hygienic and anti-epidemic- observation and prophylaxis, pre-
Disasters’ Medical Support 59
vention from epidemics and radiation and chemical damage, deal

ing with BAOD and CAOD.
• Medical means and capabilities- medical teams, healthcare estab
lishments, emergency medical centers.
The objective of DMS is to prevent human life and health damage
and to lessen the number of fatalities, injured and disabled in case of
disaster. (14)
In order to achieve the set objective, the DMS has to fulfill the fol
lowing tasks:
• To educate, train and maintain high level of readiness of the medi
cal staff and facilities
• Well-timed provision of first medical aid, stabilization, evacua
tion and treatment of the injured until their recovery.
• To prevent and treat the neuro-psychological and emotional ef
fects of the disaster.
• To conduct sanitary and hygiene measures in order to prevent epi
demics’ outbreaks
• To preserve health and fitness of the medical professionals work
ing in the AOD
• To perform forensic medical expertise and disability expertise of
the casualties
The following principles are guiding the DMS activities:
• The organization is based upon the administrative-territorial divi
sion of the country - (Administrative principle).
• To be prepared to act in all types of AOD (universal principle).
• Be prepared to act under the impact of the DF (preparedness prin
ciple).
• To be prepared to work independently in austere and hostile envi
ronment (principle of autonomy).
• To maintain high level ofreadiness for immediate reaction (readi
ness principle).
• To assure resources (medical and technical equipment) availabil

ity for DMS operations (principle of resources assurance).
• Unified principles and methods for prevention, diagnosis and
treatment (principle of unity).
• Efficient and prompt exchange of information (principle for
awareness).
• Providing medical help closest to the casualties (accessibility
principle).
• Coordination, cooperation, subordination (coordination princi
ple).
• Early hazard identification, early triage and rapid evacuation
(principle of sequence).
• Continuity of the medical aid from the AOD to the hospital for
definite treatment (principle of continuity).
• All the DMS medical means and capabilities are planned on
functional principle - no medical structure is established only for
DMS.
To ensure the effective DMS, the Unified Medical Doctrine is estab
lished. The basic doctrine principle is to organize the medical help in
staged system that has the objective to provide early first medical and
physician aid in sufficient volume to maximal number of casualties and
also to assure rapid evacuation to the hospitals capable for definitive
treatment.
I. First stage activities - They are performed within the AOD. Those
who have survived are providing first aid as self and buddy (mutual) aid
within the impact phase and throughout the isolation sub-phase of the
response phase. Search and rescue teams entering in the AOD during
the salvation sub-phase of the response phase after finding and extract
ing the casualties are performing primary triage, first aid (if required
and if possible) and organized evacuation to all casualties and organized
evacuation for those that which life and health were not affected by the
DFs. Medical teams trapped by the disaster in the AOD starts to provide
first and first medical aid if there is no imminent threat for their life and
health .
2. Second stage - Medical aid activities (qualified and sometimes
specialized) including medical intelligence, medical triage, treatment
.::.:nd evacuation to all in need. Life, limb and eyesight saving procedures,
control of the bleeding and shock management. Performed by mobile
medical teams in FMSs as close as possible to the AOD.
3. Third stage- Medical activities including entire scope of quali
fied and specialized medical aid to all injured (casualties). They are per
fumed in treatment facilities in the vicinity oftheAOD, if it is necessary
-.futh enhancement from mobile medical teams.
The structure of the DMS consists of constantly functioning medical
establishments and temporary establishments based on the existing ones:
A. Managing body
B. Medical means and capabilities
C. Healthcare establishments
1. The managing body on national level is the Minister of health. On

-egional level is the leader of a special institution called Regional Health
'-spection On local level there is an expert on DMS. He might not be of
—.edical background so he is consulted by the director of the local hospi-
■-•1 GPs have also to be included at the local level.
2. Medical means and capabilities:
1. Medical-sanitary formations- sanitary teams (in the large in-
e-ismal factories/plants) educated and train for enhanced first aid provi
sion. These formations are established mainly into the administration and
=.::ustrial sites processing hazardous materials - nuclear power plants,
imemical plants etc.
2. Medical formations
a. medical teams
• physician team (driver and doctor who is physician, provide phy
sician aid and triage) - ordinary CEMH ambulance team.
• specialized team (driver, nurse and paediatrician, intensivist or
cardiologist where they are needed)
• medical technician team- provide first pre-physician aid.
• transport team- provide transport - just driver and sanitay atten
dant.
• b. medical teams with high level of readiness
• military medical detachment for emergency response- they can
establish field hospital, summoned and dispatched for 2 hours on
dedicated vehicles. (37)
• anti-epidemic teams and squads for preventing epidemics
• sampling groups
• specialized medical teams - teams for medical triage, toxicologi
cal team, radiobiological team, surgical, infectious disease, inter
nal medicine, epidemiological;
• teams of specialist for enhancement treatment and diagnostic ca
pability of hospitals.
3. Healthcare establishments
1. Outpatient clinics/medical centres for diagnose and treatment
2. Hospitals - hospitals for active treatment - multiprofile, special
ized; for long-term treatment and rehabilitation (they provide additional
beds and could be transformed with mobile medical teams into hospitals
for active treatment)
3. Dispensaries/rehabilitation
D. Hygienic and anti-epidemic establishments
• sanitary-chemical labs
• toxicological labs
• radio-biological labs
• microbiological labs
E. Centres for transfusion haematology (the blood banks) they have
teams on high readiness for blood collection, when needed

F. Ambulance services.
The DMS paradigm is:
1. In accordance to the first principle ofDM - assuring medical teams
safety and security the first step is medical intelligence. The teams that
perform medical intelligence- take samples and analyse them.
2. For adhering to the second DM principle - provide maximum sup-
?)rt to a maximum number of casualties, the second step is performing
::riage.
3. Third step is stabilization of the casualties and preparing for medi
cal evacuation;
4. Fifth step is performing the medical evacuation to the nearest hos
pital capable for definite treatment;
5. The hospitals have to be prepared for prehospital triage, admit-
:_mce and treatment (urgent or delayed) of the casualties. Hospitals have
obligation to train, equip and maintain in high readiness mobile medi
cal teams for enhancement, or specialized teams. The type and number of
these teams depend on the type, level of excellence and specialists avail
able. Military medical detachment for emergency response could deploy
field diagnostic and treatment complex consisting of 3 modules and one
hospital and required diagnostic capabilities:
• Trauma centre - three surgical rooms, dressing room;
• Toxicological module;
• Radio-biological module;
• Infectious hospital;
• Diagnostic complex - clinical lab, imaging capabilities - X-ray,
CT scan, ultrasound;
• Transport unit.
6. Hygienic and anti-epidemic support. Sampling groups, teams and
squads for preventing epidemics, labs.
7. Teams for psychological aid.
MEDICAL INTELLIGENCE
Highlights
1. Definition
2. Objective
3. Data
4. Information
5. Medical Intelligence cycle
6. Main tasks
7. Questions with regard to Protectection
8. Questions with regard to medical support provision
9. Questions for facilitating the DMS planning and management
10. Medical Intelligence activities
11. Time for execution of the medical intelligence
Medical Intelligence (MEDINT) is the process of collection, analy

sis, assessment, evaluation, processing, and dissemination of every sin
gle piece of medical information It is specific medical activity aiming to
provide the Disaster Medical Planners and Managers with the required
information regarding the disaster in the shortest possible time-frame.
MEDINT is necessary for the planning and the management of the
DMS. (14)
The process of medical intelligence is to:
• Collect data - observe, ask, collect samples.
• Analyse - study in detail/what does it mean (systematic examina
tion and evaluation of data or information, by breaking it into its
component parts to uncover their interrelationships.). Also com
pare with previous information.
• Assess - is it true, is it enough for the whole picture.
• Evaluate - is it useful, is it important for the planning and deci
sion making.
Medical Intelligence 65
• Process - give the shape of official report, clear and concise, fo
cused, with proposals about prevention and security.
• Dissemination the report to whom may it concern.
Objective- to collect data, transform it into signal and transfer in
understandable way the valuable medical information.
Medical information is every data regarding factors with possible
impact or influence on human health.
Data is the raw facts, something existing. In order to transform the
raw data into information the data has to be unified in a meaningful way.
38, 39, 40) The combined in accordance to some rule or for some pur-
nose data could become information if it is:
• accurate and timely,
• specific and organized for a purpose,
• presented within a context that gives it meaning and relevance,
• can lead to an increase in understanding and decrease in uncer
tainty. (41, 42)
This processed data is a signal that has to be transferred to reach a
recipient, who could understand and utilize the signal, thus transforming
:ie data into meaningful information. Therefore in order to have infor
mation flow a an information chain has to be set up - Data-originator-
-ignal-means of communication-recipient.(43)
MEDINT is needed for DMS planning and management, that is
wav MEDINT is performed continuously throughout all the disaster de-
·■elopment phases. During the intermediate and prodrome phases the
MEDINT is responsibility of the Regional Health Inspections structures
^tablished for monitoring and assessing the medical situation and eval-
•2 -ring the health risks levels. When a disaster strikes every medic has to
rcrform MEDINT in order to safeguard him/herself, at least. (44) Every
=edical specialist has to be prepared for performing MEDINT in order
fulfil the following DMS tasks:
1. Protect his/her own life and health;
2. ?!rnide medical support to the casualties;

3. Transfer valuable information to the medical authorities, thus fa
cilitating the DMS planning and management.
In order to assure his/her own and the medical team security and
safety the following questions have to find rapid and accurate answers
(14):
1. Type of disaster.
2. Time of onset.
3. Place and location of the event.
4. AOD size and areas at risk.
5. Damaging factors- related to the type of disaster.
6. Risk factors - terrain, industrial sites, wind, rain, buildings, pipe
lines, critical infrastructure, etc.
7. Damages to the critical infrastructure
8. Protective equipment and preventive measures required.
9. Location of the collective shelters and personal protective equip
ment.
For medical support provision to the affected population the ques
tions to be answered are:
10. Population at risk.
11. Medical losses- type, number, structure and location.
12. Medical means and capabilities in the AOD- status, operability,
capability.
13. Elements of the URS active in the AOD.
The information valuable for the planners and DMS managers con
cerns the following:
14. Required medical means and capabilities for medical support to
all in need.
15. If known medical facilities capable to provide required teams
and means for enhancing the DMS capabilities.
16. Location of the FMS.
Liedical Intelligence_ 67
17. Routes for ingress.

18. Routes for egress.
19. Location of the triage area.
20. Location of the medical evacuation area.
21. Medical facilities that are ready and capable to admit casualties-
location, specialization, routes for medical evacuation, time for trans
porting casualties to the suitable hospitals.
22. Communication systems available.
23. Schedule for reports and returns.
24. Who is and where is situated the incident commander?
25. What is expected development of the situation?
In summary the MEDINT has to provide the information about what
:s happening, what is the threat, what should be done. The report should
be concise, focused, clear and should include proposals for protection/
prevention, best location, provision of support.
MEDINT activities include:
1. observation
2. questioning
3. sampling
4. comparative analysis-of different sources
5. deduction-making conclusions
6. prognosis- what is needed, how long it will take
7. overall assessment on what can be improved and/or
8. how to overcome the shortages in human and material resources.
MEDINT is planned before the disaster, when teams are selected,
:::ained and equipped. They are trained and equipped to identify the health
hazards, to assess the health risk level and required protective equip
ment; to collect, store and transport samples. They should be trained to
•.vork in austere and hostile environment with IPE; to use different com
munication systems and equipment; to report and receive orders and
guidance. The MEDINT is organized from the medical manager into the
affected region.
MEDNT is a cycle of repeating four steps (always into the described
sequence):
1. Receiving directives and guidance from the medical manager.
2. Collection of data.
3. Analysis and processing the data.
4. Dissemination of the MEDINT information product to those who
gave the orders. ( 14)
Requirements for proper MEDINT - continuity, timely provision of
information, accuracy.
Everyone in the medical community should be able to perform
MEDINT. It is done by the first medical unit that receives the signal and
the unit that arrives first to the AOD.
The intelligence activities are managed by the physician in charge
of the unit. The performers have to be medical professionals capable
to detect hazards, assess the situation, evaluate the possibilities. They
should be trained for the task and prepared to protect themselves and
also to start the DMS.
Tria e 69
TRIAGE
Highlights
1. Definition
2. Objective
.>. Time
4 Types
5. Primary triage place, actors
6. Primary triage principles
Primary triage groups
Primary triage SOP
9. Primary medical triage place, actors
10. Primary medical triage principles
: l. Primary medical triage groups
'_2. Prehospital triage place, actors
_3. Prehospital triage principles
14. Prehospital triage groups
Triage is the process of sorting. For the DMS triage is applied for
sorting, grouping the casualties based on some principles that differs
depending on the place the triage is performed.
The triage is forced medical activity. By the definition the number of
:ie casualties and the support they require are overwhelming the avail
able medical capabilities. Therefore, the casualties could not be pro
vided with the full extent of the medical care required by the sustained
mjuries.
The objective of the triage is to provide timely medical aid and evac
uation to maximal number of injured. These could be assured by rapid
evaluation of the victims and prioritizing all activities according to their
condition. (2, 11, 14)
Triage is performed as quickly as possible after the victim is located
or rescued. The person, performing the triage evaluates the condition of

the casualty and classifies them in categories. Because the triage is the
first step of the casualties’ medical management, the decision made will
impact all the following procedures. The prerequisite for success is that
triage has to be performed by educated and trained providers. (3, 27, 28)
There are three main types of the prehospital triage:
1. Primary triage.
2. Primary medical triage.
3. Prehospital medical triage.
The principles for triaging the casualties differs into the three types
because of the different place, different providers and different set objec
tive.
A. Primary triage is performed in the AOD by the search and rescue
teams. The search and rescue teams’ members are concerned mainly to
evacuate as many as possible of the casualties prior they are impacted
to death. The triage is performed in accordance to two principles - the
urgency of medical aid and evacuation priority. It is clear that the evacu
ation priority fully depends on the result of the first criterion. In accord
ance to the urgency of medical aid, there are 4 groups of casualties in
theAOD:
Tl - Immediate. Casualties triaged into this category require Imme
diate, Life-saving medical aid. They are tagged with red colour. Within
this Immediate category the following life-threatening injuries demand
ing immediate attention and rapid treatment have to be included:
• Insufficiency of the breathing and/or circulation.
• Unconsciousness.
• Disturbed mentality.
• Massive bleeding (open chest wound and fracture in the upper
third of the thigh).
• Shock.
T2 - Delayed. There is no imminent threat to life/limb/sight. They
Triage 71
definitely require professional care but immediate treatment is not an

imperative (not moving and not life-threatening). The medical aid could
be postponed. The colour of the tag is Yellow.
T3 - Minor. The casualties into this category have sustained minor
injuries or low level stress reaction. They can move independently to
the nearest medical facility. The requirement is for ambulatory medical
care. They are tagged with Green colour.
T4. Expectant/Dead. Into this category falls the casualties with ex-
:::emely severe injuries, or without life signs available. As the death could
declared only by physicians, in reality within the primary triage into
this category the search and rescue teams’ members are including only
::iose without vital signs. They are tag with the black colour. Those with
incompatible with life injuries are tagged into primary triage as Red.
The process of primary triage consists of the following steps:
After entering into the AOD the rescuer signalizes his/her presence
.:.:id summon all those who are moving and understanding. They are
*'gged as Green (T3) and if no threat is present for their life they are
requested to assist the rescue operation. If the threat is imminent the
protective measures are taken and their evacuation is organized by the
other members of the team. The triage proceeds by attending the closest
casualty - checking the consciousness. If conscious check for mental
ity disturbance by asking simple questions and assessing the adequacy
:-:the responses. No adequate answers - Red. If unconscious check for
rreathing, if breaths - Red. If not breathing is detected the upper airways
are opened and a secondary check for breading is performed. No breath-
.;:g - Black. If the breathing process is restored - Red.
In conscious casualties with adequate responsiveness the triage pro-
eeds by check of the breathing rate - below lO/min and above 30/min
- Red. If the breathing is normal, circulation is assessed by capillary
refill test. If it is above 2 minutes - Red (probably shock). If there is a
-assive bleeding. If the casualty is bleeding - Red tag and guide him/
^ Disaster Medicine Highlights
her or the supporter to compresses the wound till the search and rescue
team member arrives for controlling the bleeding.
In accordance to the evacuation principle - as El are evacuated all
Reds. If there is a need and possibility for First aid in the AOD it is pro
vided prior the evacuation. The Yellow are evacuated as E2. Those T3
that could not evacuate by themselves are evacuated as E3.
The casualties are evacuated to the FMS - triaged area, where the
primary medical triage is performed.
Primary medical triage is performed in accordance to three princi
ples:
1. Safety/Danger.
2. Urgency of medical support.
3. Evacuation.
First all the casualties are triaged for danger. All those that are con
taminated (by the chemical, radiological or biological DF) are not al
lowed to enter into the FMS. They are isolated with the support of CD
FSPP for further decontamination. As dangerous are triaged and those
casualties with aggressive stress reaction, that are also isolated with the
support of CD NP.
In accordance to the urgency of the medical support required in addi
tion to the already described Red, Yellow and Green categories, that are
the same, differences are into the Expectant category. Here are classified
all casualties with incompatible with the life injuries, or severe injuries
that require a lot of time, drugs and consumables (not available into the
FMS) and dubious prognosis for the life. As T5 are classified all dead.
E 1 are those casualties that even after the medical support received
into the FMS are with life threat, they are evacuated as priority one
with doctor on board. All those with stabilized status are evacuated as
E2. Those T3 that could not be evacuated by other means are medically
evacuated. The last evacuated the T4 that have received palliative care
till the moment of evacuation.
Tria.e
73
Pre-hospital medical triage is performed in front of the hospitals
for definitive treatment by anaesthesiologist. All are safe and no more
evacuation is foreseen, so triage is based only upon one principle the
urgency of medical assistance. The Tl here are divided into two groups
- those with imminent life-threat are directed to the shock rooms for
resuscitation procedures. Those with Severe traumas are directed to the
operating theatres or intensive care units. The others are classified as for
delayed - treatment can wait. Classification on the type of care has also
:o executed - surgical, non-surgical. T3 that are coming independently
.lre sorted by nurse with protective equipment and directed for ambula-
:o y care.
The main mistakes recorded during the triage are:
• inadequate medical capabilities.
• not enough training.
• indecisive leadership.
• time loss - triage time is about 15-30 seconds per casualty.
• treatment instead of triage.
• over-triage (T2 and T4 as Tl) and under -triage (miss Tl).
FIRST AID
Highlights
1. First A id (FA ) definition
2. \V hy FA is required?
3. W here FA is perform ed?
4. W ho is perform ing FA?
5. The first step o f the FA is
6. First step includes
7. Second step is
8. Second step includes
9. I f casualty is co n scio u s, w hat has to be controlled?
10. T he procedure o f con trollin g hem orrhage w ithin FA includes
11. I f casualty is u n con sciou s, next step o f FA is
12. W hen and how the Breathing is checked?
13. I f the casualty has breathing, w hat is the fo llo w in g FA step?
14. What the recovery step stands for?
15. W hy the recovery p osition is required?
16. D escrib e the process o f p osition in g o f the casualty into recovery
position
17. I f casualty does not breath, what is the next step?
18. D escribe the liberation (opening) o f the upper airways?
19. A fter liberation o f the upper airw ays, w hat has to be checked?
20 . W hen the pulse is checked?
21. What is CPR and w hat is its objective?
22. W here is the p lace for external cardiac m assage?
23. D escrib e the external cardiac m assage
24. T he procedure for artificial breathing is
25. H ow the CPR proceeds?
26. W hen the C PR ends?
First Aid 75
First aid are elementary medical activities that could be performed

by everyone in case of incident, emergency, disaster. (14) These elemen
tary procedures are required, because when the incident or emergency
occurs a life saving activities have to be performed at the very moment
of injury or of finding. Every delay (e.g. till the medical team arrival)
could cost the life. The brain cells start dying without oxigen within 3
minutes. Five minutes brain anoxia (no oxigen supply to brain) is be
coming a threat for the life- death is imminent, but survivals are re
corded even after 10 minutes without oxigen (a residual brain damge
could be expected). 15 minutes after stopping the brain oxigenation the
survival is almost impossible. The effectivness of the first aid is time
related - if the breathing and circulation are maintained till the medical
teams’ arrival the casuzlty life could be saved. Therefore, everyone has
to ready to perform first aid when and if required.
The ultimate objective of the first aid is to safe the life of the casu
alty. Overall objectives are defined as the rule of 3 Ps:
1. Preseve life - activities in order to minimize the threat of death;
2. Prevent further harm - these are activities for protecting the health
status of deterioration, e.g. stopping the bleeding and immobilzation of
the fractured limbs. In disasters, stopping or preventing the DFs imact
on the casualty is also part of the first ai ..-r - CAOD .c.r.
RAOD;
3. Promote recovery - in some occasion? some of the steps of the
first aid (FA) are sufficient for the recovery o fire - the rr:=-r_h:
is restored, the bleeding from minor\vou& is ten- s:__: red
In disasters theFASOP is modified in c rie r:: — . -- v - f-
fi.c challenges related to the presen re = fre DFs ~e M As
a result of the DFs impact on poprfetM^ perr rr tre tzes^rtcr t :-_c
sustain injuries that require FA provisi on ^
othewise the casualty will lose his i?ier life - : c-e “ ..
breathing and circulation.
76
The place where FA is most effec ·'· and have to be performed is
the place, where the casualty is found - AOD in the disaster. About who
has to peform it, the answer is everyone. E Λeryone has to be educat
ed and trained to perform the FA SOP, because no one knows when
these knowledge and skills will be urgently required for saving the life.
(45, 46, 47) During the disaster (impact and isolation sub-phase of the
response phase) FA is provided as self and buddy aid fr°m everyone
who is not or not severely injured, therefore capable to do it. (2, Π, 14)
Could happen that no one of the survived will be able to save the life
of the badly injured, because of the injuries sustaind. The search and
rescue teams (entering in the AOD into the sub-phase of salvation) have
to provide FA to all in need. Without any doubt all those with medical
backgroud will also provide FA, if are not impeded by the injuries or by
the threatening their own life DF.
FA is sequence of steps that have to be perfomed in a strict order for
assuring the life of the both casualty and the doer.
AOD is defined by the DF and its impact. In order not to aggravate
his own condition, the one who is finding the casualty in needfirstly has
to assure his/her own safety and safety of the scene, where the FA will
be performed. Based on this assumption the first step of the FA is to
check the scene for hazards present. This check consists of observation
(Look) and/or detecting the hazard via senses (Listen, Smell). If no haz
ard is identified the FA proceeds with the second step.
The second step - check for consciosness and responsivness is re
quired for fast orientation regarding the casualty general condition and
the possible life-threat. If casualty is conscious and responds adequately
this means that the respiratory system, heart and brain are not severely
damaged and the basic life functions are maintained. There will be no
need to check for breathing and pulse. The consciousness is checked by
trying to receive answer to the verbal and ph- sical contact. The verbal
i
contact is via shouting louder simple questions 'How are you" "Are you
First Aid 77
OK". Not receiving answer is still not evidence for unconsciousness,

because the casualty could be with impeded hearing from the DF impact
blast wave), or has lost his/her hearing apparatus, might be scarred or
not speaking your language. Therefore, after not receiving response to
he verbal contact, an attempt for psysical contact has to be done - ap
proach the casualty and gently shake the victim's shoulders and ask him:
Are you all right? What happened?” or try to determin him to follow
instructions such as: “Open your eyes!” If the victim answers or moves,
o if the victim is conscious, the check for external bleeding is per
formed. If there is a bleeding it has to be stopped - by manual pressing
on the wound, by compressive dressing of the wound and elevation of
the injured part of the body. If no bleeding the the casualty has to left the
position he/she has been found (if there is no danger).
Ask for qualified assistance. The victim's state is to be reevaluated
from time to time until the arrival of the medical unit.
If there is no response the casualty is unconscious and check for
responsivness to the pain trriger is required. Pressing on both clavicu-
las for periostal reaction is a method for it. If response to the pain is
achieved, we are following the procedure for FA for unconscious but
with preserved vital signs casualty.
The no response means that the casualty is in deep coma or is under
the threat of death - specialized support is needed, therefore the third
step is calling for help. Loudly, request for help has to be addressed to
everyone in visinity. Not loosing time, the forth step has to be performed
- check for breathing. The procedure is - bending to the casualty, placing
the ear close to the casualty nose and mouth and for 10 seconds trying
to hear and or feel the breathing, simultaneous ly obsen-ing for the chest
movements (Listen, Feel, Look).
If no respiration, the next step is t : ;n-:-ntin.- _me: λ:t■'••λ; In situa
tion different from disaster the procedure ::: r 1 _n: ut.uus casualty
is first openning the upper aiways anh ΓΓΓ r . _T;=-. In case
of disaster there is a probability for ne fu injury and this is the reason

not to increase the risk for fatal neck movement, if it is not necessary
(casualty breaths spontaneously). The procedure of openning the upper
airways is simply to tilt the head backwards lifting the chin - one of our
hands is pushing the forehead backwards and the with the other hand we
are lifting the chin.
The following step is to check for breathing again, maintaining the
position of the hands (open airways maintainance). If the casualty re
stores the breathing, but is still unconscious we are following the proce
dure for FA to the unconscious but with preserved vital signs casualty.
If breathing is not restored on a carotid artery we are checking for
pulse. Carotid artery is found easily by following the musculus ster-
nocleidomatoides from the procesus mastoideus down to the angle of
the jaw. Between the muscle and the jaw, the pulsing artery (if heart is
functioning) is felt.
If the casualty is not breathing and with no pulse the cardio-pulmo-
nary resuscitation (CPR) has to be performed.
CPR starts with external cardiac massage. With the victim placed
on his/her back against a solid surface, the compression point at the
inferior side of the breastbone has to be localized. The ring finger slides
along the edge of the ribs until the xyphoid appendix (the joining of the
ribs). At this level, next to that finger the other two fingers are placed,
the midle and the index. The palm of the other hand is put not on, over
those fingers, touching them. This is the place where the thoracic com
pressions have to be performed. The other hand (the one used to find
the spot) is placed on the wrist of the hand situated on the chestbone
without letting the fingers to press the thorax. With elbows straight, and
arms perpendicularly on the chestbone, keeping the shoulder line paral
lel to the longitudinal line of the casualty, the compression (30) starts
by pushing hard on the chest - moving it downwards 4-5 cm. This push
will be sufficient to pomp out the blood from the heart into the aorta and
First Aid 79
maintain the circulation. The required rhytm is about 80-100 per minute.
48,49, 50, 51)
After 30 compressions the CPR proceeds with artificial respiration.
Technique is - again open the upper airway; clear the neck of any tight
clothing; open the mouth by the hand lifting the chin; clear any obvious
. ause of obstruction in the mouth (these may be: broken teeth, broken
denture, saliva, blood, etc.); with the index and thumb of the hand on
forehead close the nose by pressing the nostrils; sharply deep inhale and
rapidly with force exhale the air into the casualty mouth; repeat twice.
Maintain the upper arways open all the time and while exhaling the air
he chest of the casualty is observed for chest movement upwards. If no
movement is detected this means that the artificial respiration is not per
formed properly and no effect could be expected. This 30:2 CPR is re
peated ten times and again checks for breathing and pulse is performed.
The most important for the external cardiac massage is the force applied
4-5 cm down) on the chest and for the artificial breathing is the volume
of the air exhailed into the casualty mouth.
The CPR is performed till restoring the casualty vital signs or till the
medical teams arrives.
If the casualty is unconsciuos a thoroughly examination for exteranal
bleeding is performed. If there is bleeding a pressing, dressing method
for stopping it is applyed.
If the casualty does not loose blood but is unconscious, he/she has to
be placed into recovery (lateral safe) position. The technique is:
Kneel next to the victim, make two ventilations, and then find the
mark point. Place the nearest victim s arm in a right angle and the fore
arm is bent upwards. We will slide the other ana nver the chest placing
•he back of the hand on the victim s cheek. Pull up the knee (the one op
posed to the resquer), pulling it up h heer :r._ : : ::: the ground.
With one hand grab the opposite shoui der ώ fee o±er hand the
patient's knee. Tum him laterally fee re·^-_er. λ h e sure the
80_ Disaster Medicine Highlights
victim leans on the elbow and knee· Put the head back into hyperexten
sion again and open the mouth. Check for breathing again and if the
respitaions are present the rescuer is approaching the next casualty.
If the casualties are conscious but with fractured limbs an immo-
bilzation with what could be found suitabale have to be made. The rule
is taht the immobilization always includes the the joints upper and down
of the bone
Medical First Aid 81
MEDICAL FIRST AID
Highlights
1. Definition -pre-physician and physician medical aid
Objective -pre-physician and physician medical aid
3. Place for -pre-physician and physician medical aid
-i. Pre-physician medical aid main tasks
5. SOP of pre-physician medical aid
6. Physician medical aid tasks
7. SOP for physician medical aid
Medical first aid is performed by medical specialists as a part of the

DMS. With regard to the medical background of the specialist two types
of medical aid are distinguished - medical pre-physician and medical
physician aid. (11, 14, 27, 28)
Medical Pre-physician First Aid (MPPH FA) is define as medical
activities performed by non physician during the DMS to affected by
the DFs population.
The objectve of this aid is to maintain the vital functions and to
prevent the development of severe acute complications. MPPH FA is
performed into FMS, ambulances throughout the medical evacuation,
hospitals. It could be performed even into AOD, ifthere is no imminent
threat for the life and health of the medics. FA procedures are included
and the following additional acti ■ities ha, e to be made, when and if
required by the type and severity of the inj sustained and type of the
AOD:
A. Maintaining the vital function. In :rde. " t ■ maintain the breath
ing, circulation and central nervous system several physiological signs
have to be monitored via constant ' e;.'_:e:~ ire :: r ere i :
be supported. Monitored are:
Respiratory rate ( 12 - 16 20 per mmere If reehypnea --owe --
min) or bradipnea (below 10/min ) or dyspnea (abnormal rhytm of re-

piration) are recorded the intervention is required. Depending on the
injury an oxigen supply could be pro ) ided ' ia nasal catheter, oxigen gas
mask, or an AMBU could be applyed in order to maintain the oxigena-
tion of the blood (brain and heart, respectively). Bronchodilatators (with
inhalers or Intramuscular) could be also applied, as well as the glucor-
ticoides (if a bronchoconstriction or laryngeal oedema are suspected).
Heart rate or pulse - 60 - 90 beats per minute - (bpm) Cardiac func
tion could be disturbed by various reasons. During the disaster an in
crease beats to be measured (tachycardia 100 and above bpm) it is a nor
mal reaction to the stress and impact survived. Every tachycardia above
120 bpm, bardicardia (below 60 bpm) or arrhytmia (disturbed cardia
rhytm) are alarming signal for more detailed check for the origin of this
disturbance - e.g. bleeding, shock development, cardiac failure etc.
Blood pressure - 100 - 140/60-90 mm. The blood pressure is anoth
er sign providing significant information regarding the cardio-vascular
system status. Both pulse and blood pressure could give information
about exacerbation of a chronic sickness or for acute complications de
velopment.
Body temperature. Every hyperpirexia (temperature above 37.4 de
grees Celsius) or hypotermia (below 360 Celsius) are alarming signal.
The most frequent acute severe complication that have to be consid
ered during DMS are:
Shock development. Shock could have diverse origins - traumatic
(most frequent one) triggered by the intense pain caused by the sustained
traumas; hypovolemic, caused by the fluids loss (it is hemorrhagic when
the blood is lost via extensive or prolonged bleeding), toxic (from tox
ins) ets. Shock management has to be initiated at the first possibility,
therefore it is important part of the MPPH FA. The following procedures
(depending on the type of the shock) are aplyed:
1. Placing casualty into anti-shock position. Elevating the limbs,
while the body and head remain down will centralize the blood stream
to the vital organs.
2. Warming the casualty will decrease the demand for extra energy
production trrigered by the feeling of cold. This feeling is due to pe-
ripherial vasoconstriction (constriction of the small vessels into the pe
riphery of the body) into the initian of the shock. The vasospasm is a
protective reaction - the blood stream is redirected to heart, brain, liver,
kidneys etc. Every energy production requires more oxigen that could
trriger extra efforts from heart and respiratory system (a lot of energy)
thus entering into the vicious circle - for the production of the missing
energy an increase of the consumption of energy is required.
3. Administation of pain killers per mouth or via intramuscular in
jection. By decreasind the pain the traumatic shock could be avoided.
Morphin and other opioid drugs are not allowed for administration at
this type of medical aid because of the risk of breating centre suppre-
sion. The opioids could be administrated only by person who is trained
and allowed by the law to intubate (prevention of the imminent brain
anoxia) - the physician (medical doctor).
4. Pain management is also achieved with immobilization of the
fractured limbs. The difference with the FA is that the medics are sup
posed the immobilize the neighboring joints into physiological position.
5. Efficient control of the bleeding is an anti-shock measure, but also
it is and the life saving procedure. The FA dressings are controlled and
if not efficient the secondary over dressing is perfrmed. Into MPPH FA
in addition to the compressive dressings (part of the FA) the medics are
supposed to aplly tourniquet - it is their task to stop the bleeding. (52)
Turning stick to
6. In case ofhypovolemic or even hemorrhagic shock a fluid resusci

tation per mouth will be plausible. Advise casualties to drink more water
(if no limitations of the water intake are present)
Next severe complication that has to be prevented is the infections
development. The medics are supposed to irrigate the wounded areas
with antiseptic solutions or simply with water, if solution are not avail
able. After irrigation the surface around the wound is cleaned and a ster
ile (asseptic) dressing is applied. Broad spectrum antibiotics that are in
the medics bag also are administrated per mouth, because the time for
arrival of the ambulance and for medical evacuation are unknown durin
DMS. These antibiotics are carefurely selected to be both broad spec
trum and with lowest possible alergic side effects.
MPPH FA when needed includes initionor continuation of the anti
dotes administration.
Performing Biological dosimetry in case of irradiation.
Administrating antiemetics (Intra muscular) in case of radiological
damage.
Administrating symptomatic drugs as antitussiva (to reduce the
.ough), antipyretics (to decrease the temperature) and sedatives (if casu
alty is agitated)
Depending on the type of injurie and general status of the casual
ties, in physician abscence, the medics are supposed to request medi-
.. .l support - defining the required specialties and to organize and strat
:::ie medical evacuation, deciding the type of transportation and the end
- int/destination.
Medical Physician First Aid (MPH FA) are the activities performed
ry medical doctors during the DMS. (14)
The objective of the MPH FA is to minimize the negative impact of
:._e DF on human life and health.
The aid is performed into FMS, ambulances throughout the medical
r. a·;uation, hospitals. It could be performed even into AOD, if there is
- _■imminent threat for the life and health of the medics. FA and MPPH
procedures are included and the following additional activities have
«ο be made, when and if required by the type and severity of the injury
_ --:-ained and type of the AOD:
1. Erradicating all types of asphycsias. Every doctor has to be pre
y e d to perform intubation, when required, in order to safe the casusalty
fe. If no equipment is available, a chricothyrotomy is the life-saving
::: tedure for liberating the upper airways. (53)
CricothyrotOITly
Thyroid cartilage
Incision site
Crcoid cartilage
*AD AM
Figure 2. Place for chricothyrotomy (53)
2. Agressive intra venous fluid resuscitation and if needed (and pos

sible - blood available) blood transfusion for corection of the extensive
fluid (blood) loss, thus preventing further development and starting the
treatment of the hypovolemic (hemorrhagic) shock.
3. Definitive control of the bleeding. The source of the bleeding has
to be faund and stop with instrument. If there is time and need a tempo
rary ligature of the damaged vessel could be applied. When an abodo-
men trauma with massive bleeding and damage of organs is present it is
required to performe a damage control surgery technique:
• Control of hemorrhage.
• Exploration to determine extent of injury.
• Control of contamination.
• Therapeutic packing.
• Temporary abdominal closure.
In case of open fracture with vascular injunyor large soft tissue dam
age, the damage control orthopedic surgen' demands application of an
external fixators for prevention of further harm to the bones and serious
infectious complications are applied. If there is no need : r soft tisuue

control a cast or splint could be applied for transport immobilization.
These immobilizations are decreasing the pain and the traumatic shock
development.
4. For pain reduction the doctors are allowed to administrate mor-
phin and opioids, always considering the possibility for acute respira
tory failure because of the suppressive effect on the breathing (respira
tory) brain center.
5. Starting cardio supportive therapy - e.g. vasopressors - adrenalin,
dopamin for cardiac function maintaince.
6. Inition of the treatment of pulmonary edema - glucorticoides, Ca
gluconicum, Solutio Glucose 40%, diuretics (Furosemide).
7. Inition of broadspectrum antibiotic therapy when reuired via Intra
venous administration.
8. During disasters, CAOD in particular, it is doctors decision
whether to perform a stomach cleaning via inducing vomiting or not to
perform. The risk of rupture of esophagus in some of the intoxications
ingested chlorine, ammonia) has to be precisely evaluated.
9. Evacuation of the urine in case of urine retention via catheteri-
_.:ion or puncuture of the urine bladder are also part of the MPH FA.
10. One of the main physicians' tasks during the DMS is the proper
organization and prompt execution of the medical evacuation. The de-
ision regarding necessity, prority, type of transportation, medical as-
s:stanse and psychological support to the evacuee are doctor's responsi-
rility.
EVACUATION
Highlights
1. Define evacuation
2. Requirement for evacuation
3. Objective of the evacuation
4. Preventive evacuation:
• When is performed (the phase of disaster)?
• Who is evacuated?
• What is the objective of the preventive evacuation?
• The preventive evacuation stars from,
• The preventive evacuation end point
• Who is organizing and managing?
5. Spontaneous evacuation
• What is the objective of the spontaneous evacuation?
• The spontaneous evacuation stars from,
• The spontaneous evacuation end point
6. Organized evacuation
7. Directed evacuation
• What is the objective of the pre enti e e acuation?
Evacuation 89

8. Medical evacuation
9. What is required for medical evacuation?
10. The six topics for consideration
Evacuation is defined in Cambridge dictionary as process of moving

people from dangerous place to somewhere safe, or removing some
thing from one place and moving it to another. (54)
When disaster strikes or when it is imminent there is a need for per
forming Emergency evacuation. This means urgent immediate move
ment of people away from an AOD that contains an imminent threat, an
ongoing threat or a hazard to lives or property. If people remain in the
area, we could expect impact on their health. The damaging factors im
pact on human health could lead to severe consequences and even dead.
Therefore, the evacuation is forced activity in population disaster relief
operations, in order to provide the population ■ ith safe for their health
and life place. (14) From medical point of '. iew. the evacuation is also
forced activity of moving casualties. The medical teams hav e to evacu
ate the casualties not only for assuring s i ' ‘.hem. but also
because the scarcity of the medical means and capabilitie s to provide
them with more adequate, best possible ■;*
Analyzing the aforementioned could be s—:ed f r : evo:_Ltkr: :s
part, to be more precise, significant md e-::-emeb- eze.__. e of
preventive measures.
Process of movement in order not to permit impact has to be organ
ized and execute even prior the disaster occurrence. Some of the disas
ters, mainly the natural one (hurricanes, storms, blizzards, floods etc.)
could be foreseen with regard to the time they could affect particular
area. For eradicating the negative impact on population, the preventive
evacuation is ordered. Throughout preventive evacuation entire popula
tion at risk is moved away from the disaster prone area. They are evacu
ated to the specific, preplanned safe areas, where the damaging factors
of the disaster would not affect their lives and health. This evacuation
is performed during the prodrome phase of the disaster development,
when sufficient data regarding the imminent threat is collected, analyzed
and processed. The decision and management of the preventive evacu
ation is crisis headquarters' responsibility. All the available means of
transportation are utilized and routes for the egress of the population are
secured by the law enforcement agencies. The main agency involved
into the preventive evacuation is the Chief Directorate "Fire safety and
population protection".
Unfortunately, greater part of the disasters could not be forecasted
and their beginning surprises population in the AOD. During the impact
phase of the disaster without any organization, all those how are still not
affected physically by the disaster's damaging factors are trying to es
cape as rapidly and as far as possible from the AOD. They are perform
ing spontaneous evacuation - everyone who is capable run away from
the damaging factors’ impact (from the area of damage). As this type of
evacuation is not organized sometimes a lot undesirable events occur:
• Some people are not orientated to the extent of the AOD and its
boundaries, therefore, they could not escape;
• The crowd fleeing frenetically, occasionally trample and tread
people, mainly children and elderl -;
• Running away from the hazard the people could face other unex-
Evacuation 91
pected one. For instance, trying to escape from the faeues of the
forest fire, tourists reached the bench of the river and were forced
to dive into the cold, chilling waters, where the fast current lead
them to dead - their bodies crushed by the riverbed rocks.
There are a lot of population at risk in the AOD who could not spon
taneously evacuate during throughout the impact phase - those that have
sustained different types injuries, as well as those that were not capable
to do it. All the casualties with life threatening, severe and part of those
with moderate injuries cannot move themselves and require assistance
for evacuation, therefore they are remaining in the AOD. The second
group are people that are without any damage sustained but were not
able to evacuate, because of impeded movement (disabled, elderly, tod
dlers etc.) or because of psychological reason (disorientated, patients
with dementia, children). Into this group are classified and all those that
were trapped into the AOD, because of the damaging factor impact, e.g.
after the earthquake, family remained buried in the basement of their
house, under the debris of the ruined building.
These two groups could be evacuated only during the response phase,
v. hen search and rescue teams are entering into the AOD (sub-phase of
salvation). After finding and extraction, both casualties and non-injured
""eople have to be evacuated. This evacuation is organized and executed
H the search and rescue teams. From the AOD the two groups have dif-
rerent end points:
• Casualties are brought and directed (depending on their capabil
ity to walk alone) tot the Forward Medical Stations for receiving
medical care.
• The non-injured people are directed and guided to the nearest to
their location safe place.
From the FMSs casualties are moved to the highest level healthcare
facility, in order to receive definiti ■·.e trea ur.er.:. Due :o ±e curer.:
-:.e required and available medical means : eerabLki eS
ter medical primary triage are directed to the most appropriate for their
injuries and condition medical installation. (11) This directed evacuation
is managed by the medical teams and the categories of the evacuees are:
• All that require only ambulatory care (T3) are directed to the
nearest available medical facility (general practitioner, medical
center, ambulatory etc.).
• All that require further treatment (T1, T2, T4) are evacuated with
sanitary transport to the nearest hospital with capabilities (spe
cialists and equipment) for definitive treatment of the casualty.
When medical team is performing evacuation of the casualty on
board of the vehicle with medical equipment and medical personnel for
provision of medical assistance during the transportation is defined as
medical evacuation. This means that the medical evacuation is part of
the directed evacuation.
Organization and the management of the medical evacuation are
part of the physician first aid. Therefore, every doctor has to be prepared
for managing the process of casualties’ movement, when required. Six
basic topics have to be considered for taking the adequate and efficient
decision:
1. The most important is to decide whether the casualty require
medical evacuation. If the injury sustained does not imply necessity for
medical assistance throughout the transportation, the casualty does not
require medical evacuation - he/she are just directed to find the nearest
place for receiving ambulatory care.
2. If the casualty requires medical evacuation the next step is to spec
ify the priority - who to be evacuated first, second and etc. The decision
regarding the priority depends on the urgency of the next level medical
aid needed. All T1 after stabilization are priority 1 (E1) for evacuation.
Depending on the stability of the casualty status some of the severe
wounded could be prioritized as E2 along with the T2s. As E3 are clas
sified the T4s.
Evacuation 93
3. Next topic that has to be considered relates to the mode of trans

portations. What type of movement is required? The most ancient one
that is with limited potential for medical support and it is really slow,
but on the other hand is less traumatizing, is evacuation by human force.
Sometimes, especially when medical facility has to be evacuated this is
the only mode of transportation.
If available stretchers, litters, borrows could be used. Once again
the speed of evacuation is quite low and in most circumstances not an
appropriate one.
Different type of vehicle could be equipped with medical appara
tuses and be used as sanitary transport. The fastest possible is the air
medical evacuation, but this evacuation is limited because of the re
quirements for flying conditions (wind, visibility) places for landing and
takeoff (airports, helipads) and type of sustained injury (increasing risk,
when blunt traumas are sustained, with hemorrhage in particular). (55)
More suitable could be different cars, microbuses and buses (especially,
when large number of casualties have to be evacuated) - ground medi
cal evacuation. Sometimes, the most convenient, rapid and appropriate
mode of transporting the casualties to use the water routes, therefore
evacuating casualties on board of boats and even ships Some of the
ships are constructed especially for provision of medical, specialized
physician aid on board, during military and disaster relief operations -
ship hospitals. In such a mass casualty e \ents the medical evacuation
could be performed and by sanitary trains - railroad e -■acuations.
4. Under consideration has to be taken and the required by the type of
injury and functional status position of the eva ._uee. ithout any doubt
the T4s and the T 1s have to be e\ acuate e. _ fa militate the
medical procedures during the transp, rm: :: r.:v.: nmc rfuhe vi
tal systems. Some of the T2s could be evacoated 5=:.==--: v·. hen there
is a need to evacuate T3s (mass casuafu e-. en:s - * = disas
ters) some of them, in order to spare space could be =· ^ :ei ^ dm=.
5. One of the most important decisions is to related to the medical

assistance needed during the evacuation. The following four categories
of casualties could be classified in accordance to the medical assistance
required:
• Fully dependant on medical assistance - the casualties require
constant monitoring of their status and performance of medical
procedures during the entire evacuation. As it is expected dete
rioration and aggravation with life threat that could not be speci
fied, these casualties require physician's presence on board of the
vehicle.
• Semi-dependant - requirement for monitoring of the patient sta
tus and performance of medical procedures during the evacua
tion, but serious deterioration is not expected, therefore, the pro
cedures needed - administration of drugs, maintaining the fluids
administration could be done by the non doctors - here we need
pre-physician medical support and what is more, several casual
ties could be managed by one medic.
• Under observation - requirement for monitoring of the patient
condition for possible, but not probable (not expected) changes
e.g. adjusting the applied dressings, immobilizations, pain killers
etc.
• No requirement for constant monitoring of the patient condition
6. Because of the psychological impact on the casualties the require
ment for psychological support throughout the transport has to be con
sidered. With regard this support three categories casualties are distin
guished:
• Fully dependant on psychological support. These casualties re
quire constant psychological support - those with deep depres
sion or aggressive stress reactions. Sometimes it is recommend
able straitjackets or other immobilizing measures to be applied.
• Under observation - These casualties do not require constant
Evacuation 95
support, but are extremely psychologically vulnerable, therefore

significant changes in their psychological status are foreseeable,
when appropriate measures have to be implemented .
• No requirement for psychological support. (14)
DISASTER MEDICAL SUPPORT PLANNING
Higlights
1. Definition of planning
2. Definition of plan
3. Objective
4. Time for planning
5. DMS Planning priniciples
6. Types planning
7. Types of DMS Plans
8. Planning process
9. Main elements
10. Textual body
11. Maps
12. Annexes
DMS Planning is a process of preparing a sequence of action steps

to achieve the specific goal of DMS - to prevent human life and health
damage and lessen the number of victims, injured and disabled in case
of disaster. This process is focused on assuring the most effective and
efficient course of actions with the available resources for responding to
the most likely to occur into the given region natural and man-made dis
asters. This means that planning includes forecasting different scenarios
and preparing the required resources for effective management of the
predicted negative impacts on the population life and health. (56, 57, 58)
The main tasks in front of the DMS planning are:
1. To increase the efficiency of DMS organization.
2. To reduce risks.
3. To utilizes with maximum efficiency the available time and re
sources.
The DMMS Plan is a document v. here all activities of the medical
Disaster Medical Support Planning ----------- 97
means in case of disaster occurrence are described.

Objective of the DMS planning is:
• To optimize the established DMS organization preparedness and
training;
• To prepare sufficient amount of human, medical and technical
resources;
• To establish medical teams of different level of readiness;
• To provide means for rapid medical reaction in case of disaster.
In order to achieve the set objective, the planning process has to
include the establishment of goals, policies, and procedures. The princi
ples of DMS planning are:
• Particularity - DMS plan describes the medical operations for
the particular type of disaster in particular administrative area
and for particular actors - ambulance services, prehospital and
hospital medical entities. This principle requires every healthcare
provider (medical center, hospital, regional healthcare inspec
tion) to prepare its own plan;
• Unity. The DMS plan has to be linked with all disaster manage
ment plans - different level, ministries etc. Moreover, the region
al plan is including the local plans, as the national DMS plan
includes the all the regional.
• Operability - the DMS plan has to consider only the available
means and capabilities for planning and organizing the disaster
medical response.
• Continuity of development and re ' ision - Because of the highly
variability of the general and medical situation the D '' ‘S plans
are living documents. All the changes *n xê resources’ in the
hazards, vulnerability, exposure ha 'e t ‘re eriress -.vhh::: the
plan immediately after they are re^ n e ^ ‘ Tr =, , re...uireu for as-
• · · o r
suring the operability of the MS pl...
Depending on the time when the pla..... - ess =·-_ :.::ere __
two types of planning - long-term and crisis. The long-term planning is

performed prior the disaster, while the crisis planning starts in the im
pact phase.
Long-term planning is planning for the possible, but still unreal sit
uation. Based on the medical intelligence data the possible disastrous
events scenarios are addressed with the available in the administrative
territory means and capabilities. The probable number and type of casu
alties is estimated, as well as the most probable medical infrastructure
damages and shortfalls for the DMS. Organization of the DMS provi
sion and required external assistance are estimated and the best possible
option is written into the plan. After implementing the plan into training
event the plan is approved as a Contingency. When the disaster strikes,
in great majority of the recorded events the situation is quite different
from the one described into the contingency plan. (59, 60) This requires
adjustment into the plan in accordance to the actual, real situation. Into
the crisis planning the actual situation is compared to the predicted one
and based on the differences medical operations are changed, in order to
correspond to the real challenges. The new organization, objectives and
tasks to the operational (not affected by the disaster) medical structures
are included and an Operational plan is created and presented for ap
proval by the DMS manager.
The planning process follows the sequence of steps:
• Receiving the superior level instructions and guidance.
• Receiving medical intelligence information regarding actual
medical situation and available medical means and capabilities,
regarding risk levels for particular disaster occurrence, regarding
vulnerability and required preventive measures.
• Describing executive bodies tasks and responsibilities.
• Assessing the readiness status of available means and capabili
ties. -
• Assessing the Disaster probability based on
Disaster Medical Support Planning 99
• Hazardous objects identification,

• Risk factors identification,
• Hazards and risks assessment.
• Setting the DMS objective and tasks
• Designing the DMS organization and structure.
• Allocating tasks to the elements of the DMS structure.
• Noting the possible shortfalls and feasible reactions.
• Providing comprehensive list of the all the means and capabili
ties involved into the DMS operations.
Every DMS plan consist of three main elements:
• Textual body.
• Maps.
• Annexes.
The text describes the following:
Description of the physical and economic geography of the admin
istration unit.
• Evaluation of the prognosis medical situation in case of particu
lar disaster.
• DMS Objective and tasks.
• Organization of the DMS - planning, management and execu
tions - means and capabilities. (61)
• Medical Intelligence assessment of the region - health hazards
and risk factors - in daily life and in case of particular disaster.
• Population at risk.
• Medical means and capabilities a ailable.
• Transport and communication n eto rk s.
• Organization of the Medical Intelligence.
• Organization of duty and call roasters.
• Individual and collective protective me^-.:-es requirement and
implementation.
• Reports and returns.
• Coordination with the others elements of the URS.

• SOP for key personnel.
All aforementioned information is provided on maps for faster situa
tion awareness and decision making. The following maps are mandatory
for every DMS plan:
• Area - administrative boundaries.
• Physical map.
• Industrial map.
• Meteorological maps.
• Medical means and capabilities location.
• Forward medical stations location.
• Routes for medical evacuation, for egress and ingress.
• Executive bodies locations.
• Warehouses locations.
• Endemic and epidemic diseases spread.
• Environmental Pollution.
• Objects with potential to cause secondary AOD in case of the
disaster.
• Most vulnerable objects and villages.
• Population density.
Into the annexes the most valuable for rapid decision making infor
mation is concisely provided. The annexes are describing information
about:
• Available capabilities.
• Required capabilities in case of disaster.
• Sources for enhancement.
• Available means.
• Required means in case of disaster.
• Sources for enhancement.
Management Of Disaster Medical Support 101
MANAGEMENT OF DISASTER MEDICAL SUPPORT
Highlights
1. Definition
2. Objective
3. Prerequisite
4. Activities
5. Principle
6. SOP
DMS management is defined as complex decision making process.

This process is performed by the medical managers in order to react ad
equately with available means and capabilities in case of disaster. ((62)
The prerequisite for efficient and adequate reaction are:
1. Awareness of the available medical resources - medical special
ists - doctors, nurses, medical technicians, sanitary attendants and para
medics; technical equipment - ambulances with the required drivers/
pilots; mobile systems for assisted and guided respiration; Diagnostic
imaging techniques include X-rays, computed tomography (CT) scans,
_trasound, magnetic resonance imaging (MRI); laboratories; drugs and
: nsumables; blood banks; available intensive care units beds and its
; . ssible extension; hospitals capabilities to admit and treat particular
nmes of health damages related to the possible disasters in the region
tic.
2. Awareness of the Unified Rescue Si stem elements into the re

m. n - their point of contacts, their capabilities and deployment readi
ness time.
3. Assured communication with the medi cal installations in the re-
_ .' and with URS commanding structures!
4. Reliable and secured communication wich regional and national
- ·· th authorities; (63, 64)
5. Awareness of the contingency plan;

6. Cognition about the disaster management process. (65)
The decision making process includes the following activities:
• Evaluation of the situation - What, when, where event has hap
pened, the immediate damages and the forecasted situation de
velopment.
• Evaluations of the required and available assets - This evalua
tion requires information about the type, number, severity of the
casualties, their location and the available and still operational
medical means and capabilities. If the present into the affected
area medical resources are insufficient to meet the demands for
medical support the missing capabilities have to be requested.
• Risk Assessment - Based on the received information regarding
the type of disaster, the DFs, risk factors, casualties and the most
probable situation development, the medical manager is evaluat
ing the risk level for the population at risk, casualties, response
teams.
• Risk Management - The assessed health risk level is managed by
planning and implementation of preventive activities and meas
ures.
• Decision on what has to performed, who to do it, when and
where and how the medical operations and activities have to be
executed.
• Execution - Once the decision is made orders and directives to
the reaction forces are given and the medical system starts the
DMS.
• Evaluation of the situation - A continuous monitoring on the re
sults of the performed activities is required.
• Decision revision has to be performed if the results are not achiev
ing the set objective.
• Means and capabilities maneuver - In accordance to the new de-
Management Of Disaster Medical Support 103
cision medical reaction forces could receive new tasks or could

be relocated to the place where more medical means and capa
bilities are required.
All the managerial activities are based on the following five princi
ples:
• Preplanned - Managers are making their decisions in accordance
to the aforementioned standard operating procedure and based
on the resources listed in the contingency plan.
• Operability - All the activities ordered by the manager have to be
feasible.
• Flexibility - one of the main principle. The manager has to be
ready to revise his/her decision if the ordered courses of action
are not achieving the required outcome. (66)
• Continuity - the decision making process is a cycle, starting with
the signal for disaster occurrence and could be completed, when
the recovery activities have ended.
• Centralization means that the decision is made only by the one
person, who is authorized for such activity.
• Autonomy - Every single medical specialist on charge has an
autonomy to choose how to fulfill the received orders and what
course of action to follow in achieving the required results.
The standard operating procedure for decision making process in
:: udes the following activities:
• Adequate reaction after signal for disaster receiving - It is re
quired validation ofthe received signal . ifit is not coming through
the URS communication system. E ■ef) signal is validated from
the officers on duty of the 'National Management St stem. After
the signal is validated the medi cal manager s^ rn the decision
making process by ordering the prezlc:—e;:: activities execution.
• CONOPS activation is the second s:e--. As :=,e fusaster situation
requires immediate focused actio ns. the rrefu a—ad course of a<t-
tions for the type of the reported disaster are ordered. This is the
first reaction to the disaster's challenges.
• Medical Intelligence regarding the particular disaster devastating
the particular AOD has to be executed as rapidly as possible in
order information about the actual general and medical situation
to be received.
• OPLAN Creation - The received information regarding the ac
tual disaster's impact is used for adjusting the contingency plan
to the real situation.
• Decision - When operational plan has described the possible
reactions to the occurring disaster with the available resources,
the medical manager choose the most suitable for the situation
course of actions to be executed.
• Orders - In accordance to the approved operational plan orders,
directives and guidance are issued to the all medical structures
involved into the DMS.
• Receiving feedback and assessment of the situation.
In summary the DMS Management consist of:
• Signal validation;
• General situation assessment;
• Medical situation assessment;
• Casualties - type, structure, number, location;
• Available and required medical means and capabilities;
• Hygiene and sanitary conditions assessment;
• Required activities;
• Protection;
• Order to teams;
• Feedback receiving;
• Reassessment;
• Maneuver - new orders, directives and guidance. (67)
Medical Teams Tasks In Disaster Medical Support 105
MEDICAL TEAMS TASKS IN DISASTER MEDICAL SUPPORT
Highlights
1. The scenarios
2. Activities after receiving a signal
3. Activities during transport
4. SOP if first team
5. SOP if first medical team
6. SOP if team for enhancement
Debrief
Teams engaged in DMS have different tasks depending on time,

place and the role into the DMS. Six possible scenarios have to be con
sidered (11):
A. Activities, performed when the signal for a disaster has been re
ceived. It happens in the communication and information centers. The
::-erson responsible there alarms the URS and the DMS manager. The
:' llowing steps have to been followed:
1. Collection of information regarding the location of the event -
exact area, size of the AOD; terrain; population at risk, population den-
q ; infrastructure, constructions, industrial sites, etc.
2. Collection of planning information- type of disaster and its
=-gnitude; DFs; Risk factors; casualties - number, type, structure, loca-
· protection required; damages to the critical infrastructure; medical
=-eans and capabilities present; medical infrastructure damage; oper-
* :lity of the healthcare system in the AOD.
3. Healthcare facilities close to the \OD - as s ^ edi cal e cacuation
• -tination or source for resources.
4. Collecting information regarding the task- what medical opera-
:.s have to be performed (medical intelligence; se~fa_ = e r-iS : ^*-
;ge. stabilization or only medical evacuati on); medici' :earr compost-
tion; medical team leader; resources; transportation.

5. Collecting information regarding the coordination and subordi
nation - who is active in the AOD; who and where is situated the Inci
dent Commander, point of contact with the Incident Commander; time
and means for medical information exchange - to whom, how, when and
what data/information have to be sent. Collecting information regarding
the transportation - route for ingress, secondary routes, possible police
support.
B. Second scenario is regarding the activities during movement to
the AOD. Steps:
1. Brief the medical team regarding the tasks and objective.
2. Highlight the hazards and required preventive and protective
measures.
3. Allocation of the specific tasks for every member of the team
what, when, how, why, with what means.
4. Checking the resources.
5. Maintaining constant communication with the medical manag
er and incident commander regarding any change into the general and
medical situation (e.g. traffic congestions, arrival of new forces on the
spot, changing into mission or particular task, changed location for ar
rival, or for the Incident Commander, etc)
C. When the medical team arrives first at the scene, the following
activities have to be performed:
1. Medical intelligence tries to find answer to entire medical intel
ligence questionnaire.
2. Report the results of the medical intelligence to the medical
manager and request directives and guidance if the actual situation dif
fers from the briefed one.
3. Indicate the AOD.
4. Indicate the medical presence with lights or sounds according
to SOP.
Medical Teams Tasks In Disaster Medical Support 107
5. FMS establishment - settle triage, treatment, monitoring and

evacuation areas, etc.
6. Start triage of the casualties exiting form the AOD;
7. Medical officer in charge has to give a brief report to the offic
ers from CD FSPP or CD NP with their arrival, in order to transfer the
authority over the disaster site management to the representative of the
ministry of internal affairs.
8. Triage, treat, stabilize and prepare casualties for evacuation. ac
cording to the SOP.
9. Monitor the situation and report any change.
10. Medical team do not enter in the AOD, if a threat is identified
and special protective gear is required.
D. When medical team arrives as the first medical team at the AOD:
1. The medical officer in charge reports to the incident commander
.rnd introduces his/her team, the capabilities of the team and the IPE
mailable.
2. Receives briefing on the situation and directives and guidance
on the tasks, deployment area,
3. Performs medical intelligence (identify hazards, evaluate the
:'sks, explore ingress and egress routes, evacuation and communication
.slans). If the risk is evaluated as unacceptable, reports to the medical
manager, proposes course of action and requests directives and guid-
mce. Compare the collected and the gi \ en data and report to the DMS
manager. If the location is suitable -
4. Set the FMS.
5. Triage, treat, stabilize and prepare casualties for ev acuation.
6. Report to the DMS manager regarding the required medical
m eans and capabilities and development . . . . . . - edi . al situ-
on.
E. When the team arrives as enhan ..em.em.:: mm ._ -·------:
1. The medical officer in charge -H
commander and reports on the number and capabilities of his team and
the available IPE.
2. Gathers information on the general and medical situation.
3. Receives tasks.
4. Initiates medical support according to the tasks and SOP.
F. Activities on DMS termination:
1. Debrief to the team - Expressing appreciation of the activities
and results, sharing some observation regarding the sequence of the
events and medical response to the unplanned challenges.
2. Request every team member for impressions and lessons identi
fied (what went wrong, why, could similar challenges to be forecasted
and its impact decreased into the future missions, overall assessment).
3. Report to the medical commander on the performed activities
and overall outcome of the medical mission.
4. Report lessons identified.
5. Provide proposals for DMS improvement.
Forward (Temporary) Medical Station 109
FORWARD (TEMPORARY) MEDICAL STATION
Highlights
1. Definition
2. Purpose
3. Considerations
4. Areas
5. Activities within the areas
6. Casualties flow
7. Medical aid within the areas
Forward medical station (FMS) is the area, where medical activities

are performed.
In accordance to the DMS principle of accessibility the FMS has to
'e located in a place that is closest possible to the casualties. The first
principle of DM states that assuring the medical teams safety and secu
rity is priority one. Therefore, the location of the FMS has to be closest
m possible to the casualties but on a safe distance from the DFs. There
is only one exception of this rule - the BAOD. FMS is located into the
BAOD, where threat for the life and health of the medical staff exists.
m order to find such a place medical intelligence has to be performed.
Medical intelligence should provide the information about the best loca
tion according to (safety, accessibility, proximity). The main issues that
have to be taken into consideration into choosing the location are:
• DFs (hazards related to the disaster ■:
• Localization of the casualties·
• Critical infrastructure - electricity, water supply;
• RF- avoid industrial sites, ware : mas. mremms. electricity and
water distribution systems . nm A me m ' em. lm.es. cams, Al
ways consider the direction smm aa _ m . m am am >con
stant, changing);
• Terrain - terra firma (firm ground), avoid swamps, flooded areas;
• Essential for FMS operability is the transportation route. With
out road, port, helipad, airport close to the medical site, first the
approaching will be impeded or slowed, secondly the medical
evacuation will be significantly delayed.
It is best if FMS is situated in hospital building but it is rarely pos
sible. Other suitable buildings could be used - schools, theatres, their
yards in particular. Water supply is essential.
The medical operations to be executed into the FMS are triage, stabi
lization, preparation for and medical evacuation. In accordance to these
activities the FMS has the following areas (Fig. 3):
MORTUARY
t--------------------- s t --------------------- )
EVACUATION AREA PARKING AREA
J l J
Figure 3. Forw ard Medical Station
1. Triage Area - This area is set as an entry point to the FMS. It is

closest to the AOD and the admittance part is situated out of the main
complex. This is required because all the casualties are first seen here.
Forward (Temporary) Medical Station 111
From the AOD a lot of casualties and survives will spontaneousl v evac
uate themselves and will seek the medical aid. Part of these casualties
could be contaminated and/or aggressive. Both categories are triaged as
dangerous and not allowed to enter into the FMS. They are isolated - the
contaminated by the CD FSPP for decontamination and the aggressive
by the CD NP for imposing sedative procedures. This means that the tri
age area has to be close to the two isolation areas. Moreover, when a Tl
casualties have to be isolated a medical specialist in protective clothing
has to maintain the life signs in the isolation areas. After the decontami
nation the injured once again are admitted into the Triage Area. Into the
Triage Area a physician and pre-physician aid is provided. The most
experienced physician is performing the triage tagging, nurses/techni-
cians are keeping records, sanitary attendants or stretcher bearers are
transporting the casualties to the respective areas for DMS continuation.
From the AOD the search and rescue teams are bringing to the Tri
age Area T l, T2 and T4. The T3 are directed by the CD FSPP and are
; oming on their own.
2. Those Tl that are medically triaged as Tl require life saving ur
gent medical aid. They are carried to the Active Treatment Area. Into
this area life saving and stabilization of the casualties are performed.
Tl are treated by physicians, nurses, technicians. Areas for surgical and
therapeutic aid and resuscitation should be established. When Tl are
stabilized to T2 they are transferred to the Active Monitoring Area. A
nu rse keeps records.
3. Active Monitoring Area - All T2 are directed to this area, where
i have to wait to be evacuated. Into this area their life signs and gen
eral status is closely monitored. If a sign of deieri orati on is present they
::=e transferred to the Active Treatmen vAr..., ■.·. I - n ®>:e brought to Ac
tiv e Monitoring Area. If someone fro v . : e 7 - .:_·. es. e e is transferred
bo the Mortuary. In this area a pre-physietan a:d is provt ied.
Part of the Tls in spite of the acm e trea-=-entrr;-:ed_'e; :: .7d re
m ain in life-threatening condition, therefore, th ey h ave to be rapidly
prepared for m ed ica l evacuation. From the A ctiv e Treatm ent A rea, th ey
are d irected to the E vacuation Area.
4. E vacuation A rea - p h ysician considers all criteria for evacuation,
nurse is k eep in g records and w h en a v eh icle is available the T l are m ed
ica lly evacuated w ith p h ysician on board.
5. A rea for L ight Injuries - A ll the T 3s are directed to this area, w here
they are w aitin g for the m eans for their evacuation.
6. Parking A rea - In this area am bulances and other veh icles are
arriving. A t this area an organization for dow nloading and u p load in g
eq u ip m en t and co n su m a b les is set. W hen a casu alty appears into the
E vacu ation A rea an am bulance from Parking A rea lea v es for E vacu a
tion A rea for transporting the injured. P o lice clears the routes for ev a cu
ation.
Earthquake Disaster Medical Support Management 113
EARTHQUAKE DISASTER MEDICAL SUPPORT

MANAGEMENT
Highlights
1. Definition
2. Origin
3. Classification
4. Main DF
5. Secondary DFs
6. Risk factors
7. Scales for measurement
8. AOD
9. AOD zones
10. Types of casualties
11. Prevention required
12. Medical assitance required
13. Particularities into the medical assisstance
An earthquake is the movement (shaking) of the surface of the Earth,

resulting from the sudden release of energy in the Earth lithosphere.
This energy release is due to movement of the tectonic layers. ^faen
released the energy irradiates as seismic waves. They are two types -
ransversal and longitudinal. Energy radiates in all directions. ^faen the
-.vaves reach the Earth surface, the earthquake is felt.
There is always some movement in the Earth ' s crust. Every year
:::ere are approximately 500 000 earthquakes w orldwide, ofwhich only
-rproximately 20% are perceptible.
Earthquake is a natural, tectonic dis '.srer. - n '~rra geologi
cal process. But rarely earthquake could be result of ma:::i-niade a advi
c e - underground nuclear tests, minmg. 1. T 1" I ; rw- r e a r !
asters could also cause underground move—.ear : f the re; ΐ m r faj■ers.
114________________________________________ Disaster Medicine Highlights
e.g. volcanic eruptions. Several secondary disasters have' been recorded

after the earthquake - tsunami, landslides . avalanches.
The main damaging factor is related to the consequences of the Earth
surface shaking. Casualties are result from the mechanical DF impact
on population. Those trapped under the debris of collapsing buildings,
threes, rockfalls or landslides are traumatized by the overpressure.
Several secondary DFs could be present - biological, thermal, (high
or low temperatures), toxic, radiological, psychological - posttraumatic
stress disorder (PTSD) and depression. Toxic and radiological are pre
sent when due to the mechanical factor an industrial failure is caused,
or warehouses containing toxic or radiological materials are damaged.
Biological is very likely because of the impact on critical infrastructure,
disturbed water supply, deterioration of the logistics, because of the
damaged road infrastructure, deterioration of the sanitary and hygienic
supplies/condition, buried under the debris corpses of rodents, insects
are becoming a source of infections, jeopardized healthcare (damages
on medical infrastructure, on communication), increased population
density due to the damaged homes people are accommodated in centers,
where the hygiene, malnutrition, sleep deprivation, possible hypother
mia are increasing the risk for epidemics.
As the main DF is the overpressure, the AOD is pure mechanical
(traumatic) or combined if some of the secondary DFs are present and
secondary AOD has been created. The main type of injuries sustained is
due to the damages of the infrastructure, therefore the AOD has 4 zones
related to the destruction and shape of circle, because of the irradiation
of the released energy in all direction:
1. Zone of complete destruction - on or close to the epicenter. Eve
rything is ruined, no roads, no shelter, no solid ground. There is an el
evated risk of aftershocks or secondary earthquake.
2. Zone of severe destructions - the sustained damage is beyond re
pair. Walls or roofs may stay still erected, but they are unstable, danger-
ous.
3. Zone of moderate destructions - damages could be repaired, roads
might be preserved.
4. Zone of light destructions - only cracks on the buildings. (2, 3, 68)
The risk factors for an earthquake are:
1. The amount of energy released. This is one of the main risk fac
tors, because the damages on the Earth surface are result from the por
tion of the energy reached the surface. Bigger the energy released is
bigger damages could be expected. The. amount of energy is measured
by the Richter scale. It is a magnitude scale and each grade is 10 times
stronger than the previous and the energy released is 31,6 times high
er. Hypocenter is the place, where the energy is released. Minor earth
quakes occur every day and hour. On the other hand, great earthquakes
ccur once a year, on average. The largest recorded earthquake was the
Great Chilean earthquake of May 22, 1960, which had a magnitude of
.5 on the moment magnitude scale. The larger the magnitude, the less
frequently the earthquake happens. Beyond 9.5, while extremely strong
earthquakes are theoretically possible, the energies involved rapidly
::}ake such earthquakes on Earth effectively impossible without an ex-
remely destructive source of external energy. For example, the asteroid
—pact that created the Chicxulub crater and caused the mass extinction
-'-at may have killed the dinosaurs has been estimated as causing a mag
nitude 13 earthquake, while a magnitude 15 earthquake could destroy
=e Earth completely.
_- The depth. - Every earthquake along v. hh the hypocenter is char
. ;:erized and with epicenter. Epicenter is the projection of the hypo-
eater on the surface of the Earth. The depth is the distance between
~e hypo - and the epicenter. There are three tyres of earthquakes based
:r the depth-shallow (0-60km), medium (60- 3 0 0 ^ >^ d deep (over
As deeper is the hypocenter as much energy .-.dU be lost till its
_~.. al to the surface and less damag es ?ê e^re.te
3. Type of construction-in Japan a shallow earthquake of 8,5M

caused just scratches on the buildings , while almost with the same depth
earthquake in Turkey of 5,5M destroyed almost completely two villages.
Wooden constructions are more stable.
4. Density and height of buildings.
5. Population at risk.
6. Water basins-river, dam, lake, sea, ocean.
7. Critical infrastructure.
8. Industrial sites.
9. Time-day/night.
10. Damages sustained. As this is the main origin for human threat, a
scale for measuring the impact of the earthquake on the surface is used -
the Mercalli scale. Scale of Medvedev-Sponheuer-Kamik measures the
impact. In reality it is a modified Mercalli scale. It has 12 grades and
from 1 to 12, every grade is two times more powerfal than the previ
ous. We feel shakes between 4-th and 5-th. Damages happen at the 6-th.
Casualties are possible at 7-th.
11. Preventive measures: Structural preparations and engineering and
design issues intended to strengthen and improve buildings to decrease
the likelihood of massive destruction in the face of an earthquake event.
These engineering decisions may also focus on the positioning, strength
ening, and layout of utility pipes, roadways, and power plants and the
relative proximity of potentially dangerous structures, such as factories
producing or storing toxic materials and fuel storage facilities, to fault
lines and potential earthquake epicenters.
Development and implementation of a disaster response plan should
include training medical providers and stockpiling equipment to facili
tate rapid action in the event of an earthquake.
Most earthquakes strike with little or no warning, and they can oc
cur at any time. Despite constant monitoring of seismic and geologic
activity, the ability to predict or detect a significant earthquake in time to
Earthquake Disaster Medical Support Management _____________'! 7
mitigate its effects on the community is limited. At this mome m . how

ever, educating the community, updating building codes, and impro··. ing
land-use legislation remains the most viable way to mitigate the impact
of earthquakes.
Due to the main DF are expected mainly casualties with diverse types
of traumas. There are two studies from Japan and Taiwan suggesting that
serious injuries are most common among the very young and elderly also
people with preexisting disabilities. Casualties are higher in areas close
to the earthquake epicenter with fewer physicians and hospitals. Col
lapsing buildings, falling rubble, fire, and dust inhalation are negatively
affecting the population at risk.
Some of those trapped have body parts pinned under extremely heavy
loads, timbers, or stone. Even when rescued, they will often have crush
syndrome and acute renal failure. Others are caught up in the flash fires
that accompany the rupture of natural gas pipes and suffer extensive body
bums or smoke inhalation, leading to severe morbidity and mortality.
A third group of patients suffers acute and chronic respiratory disease
from the inhalation of the large amount of particulate matter that is aero
solized by the collapse of concrete and stone buildings and mixed with
smoke from the generalized fires throughout a region.
Depending on climatic conditions, hypothermia can also be a consid
eration.
Illness in the subacute phase includes exacerbation of chronic medical
_roblems no longer being treated with appropriate medications or equip
ment destroyed during the disaster. These illnesses ma., include diabetes,
hypertension, coronary artery disease . a n piilrao" ary disease. \sthma
2d
:1. chronic obstructive pulmonaI} dise:2Se. ore:-: rn response to de
teriorating air quality and the rapid sore-id of aeure res;:tccto.:;r ^ ess
through a population weakened bv comprzmsed re:-r::::r_. seer ie r _ -
vation, lack of clothing, housing, anp rp-o:... s::--ess
Other infectious disease entities cst : e:-
from the consumption of spoiled food when refrigeration is not available
and contaminated water from ruptured water mains and surface water
that is contaminated.
Crash syndrome- Severe systemic manifestation of trauma and is
chemia involving soft tissues, principally skeletal muscle, due to pro
longed severe crushing. Lysis of skeletal muscles and release of cellular
contents (K, P04, myoglobin). Mechanical stress opens Ca channels with
an influx in Na, Ca, fluid and neutrophils. Main issue is muscle reperfu
sion with systemic effects of the toxins. (fig. 4)
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Compression longer than 1h is likely to result in crush syndrome.

Compartment syndrome is another possible complication of pro
longed pressure. When fluid is introduced into a ixed-volume compart
ment, tissue pressure increases and venous pressure rises. When the in
terstitial pressure exceeds the CPP (a narrowed arteriovenous perfusion
gradient), capillary collapse and muscle and tissue ischemia occur. Skel
etal muscle responds to ischemia by releasing histaminelike substances
that increase vascular permeability. Plasma leaks out of the capillaries,
and relative blood sludging in the small capillaries occurs, worsening the
ischemia. The myocytes begin to lyse, and the myofibrillar proteins de
compose into osmotically active particles that attract water from arterial
blood. When tissue blood flow is diminished further, muscle ischemia
and subsequent cell edema worsen. This vicious cycle of worsening tis
sue perfusion continues to propagate.
FMS - sometimes we enter the third zone, if it is safe and away from
buildings and roads are preserved. Most often TMS is in the fourth zone.
First aid - search and rescue team enter the AOD, look for the casual
ties, find and extract them, perform triage, provide first aid, CPR, evacu
ate to FMS. For casualties pinned under heavy loads, prior to releasing
the rescuers have to apply tourniquet. In the FMS the devitalized and ne
crotic tissues are removed surgically to prevent endogenic intoxication.
The most common injuries in an earthquake are traumatic injuries to
the head and body, including closed head injury and orthopedic injuries .
Disaster medical response teams must be prepared to handle these neu
rosurgical, orthopedic, and soft tissue injuries. Crush syndrome is more
c ommon in earthquakes than in any other disaster. The response team
should have appropriate intravenous solutions and the equipment and
skills to evaluate tissue compartment syndromes, perform fasciectomies,
and treat crush syndrome. Laboratory capacity is necessary to monitor
:"'nal function and provide dialysis, if necessary.
1. First pre-physician medical aid consists of stopping the bleeding,
painkillers, cleaning the wounds, aseptic dressing. temporary immobili
zation, 02 mask and ventilation wit mask-bag de, ice.
2. Medical teams should include gener .Ί s .r= - ons . anesthetists, epi
demiologist, hemodialysis specialist and equipment. No orthopedic sur
geon needed. Capabilities for fascio''ot h y = i- - ~ e ~ : - ... ' « i i ; tartment
^ndrome, necrectomy and amputation furpres eni:=n of era, ':!-_·r.drorne.,,

evaluation of renal function .
3. Medical evacuation is to hospital with .'■= rare sniS
^ d hemodialysis wards. (2, 3, 68)
FLOODS DISASTER MEDICAL SUPPORT MANAGEMENT
Highlights
1. Definition
2. Origin
3. Classification
4. Main DF
5. Secondary DFs
6. Risk factors
7. AOD
8. AOD zones
A flood is defined as an overflow of an expanse of water that sub

merges land. The European Union (EU) Floods Directive defines a flood
as a covering by water of land not normally covered by water. (69)
Floods are classified in accordance to different criteria:
• By the origin.
• By the range.
• By the intensity and repeatability.
By the origin floods are divided into:
• Natural, caused:
- By the precipitations.
-Riverine.
- By the snow melting; snow-rain precipitations.
- By the rivers barrage (mud, v·■oods . ice).
- By costal or estuary tidal overflow s.
-Tsunami.
Floods Disaster Medical Support Management VM
• Man-made floods are following:

- Dam or other hydro-ameliorative failure.
- Deliberate river flows barrage or dam’s water reL.n-:
By range floods are grouped into:
• Local - flooded area is surrounding particular river, streams or
hydro-ameliorative channels.
• Mid range - flooded region includes several rivers.
• Large range - extended territories are flooded, including several
administrative entities.
• Great range - flood extends on great majority or entire country or
even is affecting trans-boundaries territories.
By intensity and repeatability floods are classified as:
• Slight - Occurring every 10-20 years and cause minor to moder
ate damages.
• Dangerous - Occurring every 20-40 years. Large territories are
submerged by the water causing threat to animal and human life.
• Very Dangerous - Recorded every 40-80 years with depth abo ■e
1 m, speed 5km/h - significant impact on the infrastructure . envi
ronment and population.
• Devastating - Observed every 80-150 years, with depth above
2 m, speed above 10 km/h resulting in gre vt material loses and
significant number of casualties, m f m n endfe : : : n en n d .
• Catastrophic -ab o v e 100 e .m. men n eer. nan v·. n e. gre v
depth and great number of ca_tialties. is well as enormous mate
rial damages. (11)
The main DF of the flood is re latec ie me r r m : of water and its
speed. The water is pressing the humrn bodies rm ’.dmgs and environ
ment causing damages by the ove=:-re?v—e e x -e r=: - re of rnj
ries are different types of traumas c:.::.:: mr—nmn - s m ease : : n:od
the secondary DFs are present:
• Thermal -cooling to free7m/ of -be :·:■_ n r* ; nm lerena-
ing on the time spent in the waters.

• Biological, depending on the infrastructure damages and the time
water remains on the area.
• Psychological - always present stress and panic. They are caused
not only because of the terrifying view of the approaching dev
astating waters, but also from the instant lost of your lifespan
material gains.
The main type medical loses caused by the aforementioned DF are:
• Saved by drowning.
• Traumatized - multiple traumas and polytraumas
• Hypothermia, colds and frosts.
• Infected by various bio-agents.
In order to analyze the flood impact, an overview of its features is
required. The flood main features are:
• TF - time for first wave arrival - minutes or hours.
• TC - time for waters disappearing - minutes, hours, days or even
weeks.
• V - speed of the flood wave.
• H - depth of the flood.
• L - length of the affected territory - meters or kilometers.
Depending on the expression of the aforementioned features four
zones into the flood AOD could be defined:
• I - Tidal wave
• II - Rapid Current
• II - Mid Current
• I V - Low Current - Spill
Zone of the tidal wave is the most dangerous for the population,
because it is:
• Closest to the origin;
• L - till 10 km;
• V- above 30km/h;
Floods Disaster Medical Support Management 123
• TF - minutes;
• TC - less than 30 min;
• Casualties - drowned, severe traumas, thermal, 100% are psy
chologically affected
• Number - if the tidal wave arrives at night 90% of the population
at risk are expected to be affected with prevalence of the irrevers
ible loses - records are describing fatalities up to - 75%. During
the daytime, only 40% of the population at risk are affected with
up to - 40% irreversible loses.
Zone of the rapid current features are:
• L -till 20 km.
• V- average 20km/h.
• T F-above 30 minutes.
• T C -6 0 min.
• Casualties - drowned, traumas, thermal injuries, psychological
disorders
• The number of casualties is dramatically decreased becaused of
the sufficient time for preventive evacuation - night time up to
20% of the population is affected with some - 5% irreversible
loses and 10% during day time with - 1% irreversible. Here the
medical loses outnumber the irreversible.
Zone of the mid (low) current is characterized by:
• L -till 50 km.
• V- around 10km/h.
• TF-hours.
• TC - 2-3 hours.
• Casualties are mainly due to the ev:e_ ft,.;::.: e s r ent in the wa
ters - hypothermia and p s y : -: - - - ; - aa: es because of
the material loses.
• Number - occasional light ini un;:5_. grea: =-— ‘~er o f psychologi
cally affected and secondary · re ------ological
impact.
Zone of the spill:
• L - till 70 km
• V- slow
• TF - hours, days
• TC - days, weeks
• Casualties - psychological impact and high risk for BAOD de
velopment with epidemics.
• Number - depends on preparedness and infrastructure. (11,27)
The first aid is provided by the search and rescue teams entering into
the rapid current zone, always bind to the firm object on the land. The
FMS is located outside of the AOD, closer to the rapid and mid current
zones. The required medical specialists for the medical support provi
sion are general practitioners, internal medicine, emergency medicine.
The specialist that are of utmost importance are the epidemiologists.
(70)
The particularity of the DMS is related to the medical evacuation -
all those who have survived the drowning have to be admitted at least
for monitoring in internal medicine departments. This is required be
cause of the long term effects of the hypothermia and the possible com
plication - acute distress respiratory syndrome or pneumonias due to
inhaled drops of water.
Wars Disaster Medical Support Management 125
WARS DISASTER MEDICAL SUPPORT MANAGE IE \ T
Highlights
1. Definition
2. Origin/theories
3. Classification
4. Main DF
5. Secondary DFs
6. Risk factors
7. AOD
8. AOD zones
War is a man-made disaster. From the very beginning of the human

society development the war activities started. Throughout thousands
years the wars are part of the human world. The ancient Greek philoso
pher Plato stated that "only the dead men have seen the end of war" and
unfortunately his words are still correct - even nowadays the war con
flicts are devastating several countries.
Throughout its long h isto r v. ar was defined b’ various philoso
phers, rulers, agencies, organizations · military and non military lead
ers - thousands and thousands definit ions. One of the most famous and
widely used is the definition of the Gen:: an General Carl von Clause-
witz, who in his book "On W ar ' de ·'kaecme yâr 1nr .5 ar'ar an act of
force to compel our enemy to d · : ar : ar r ~ ar-ar. ar.-; : :arar na
tion of policy by other means’'. Λ-o —ar ar—- ar ar-ar- — -- ar-- ^ from
the Brecht Courage Model Book. where be arar-ar i '■ ar ar rnother
profit venture by Europe's great leaders “1
As a comprehensive definition for war could be used the following

- Actual, intentional and widespread armed conflict between political
communities, and therefore is defined as a form of (collective) political
violence.
Why the war is defined as disaster? The following war features are
covering the disasters characteristics:
• Number of casualties - The war activities are implementing the
most advanced technologies available in order to cause the great
est possible harm to the opposing forces - fatalities and injured
among the ranks are one of objectives to be achieved.
• Material Damages - In order to impede the opponent forces free
dom of movement and supplies needed for continuation of their
resistance the critical infrastructure is targeted into the first hours
of the military activities - roads, bridges, communications, in
dustrial sites, power and distribution systems, agriculture crop
fields, etc.
• Disparity between required and available means and capabilities
Notwithstanding the sophisticated and elaborating planning for
medical support to the military operations, always on the battle
field, there is a disparity between the available and required for
treatment of the wounded medical means and capabilities. No
one military commander will place his/her valuable medical as
sets under the direct fire. The Field medical stations are always,
as a rule, located behind the front lines. A system for evacuation
of the wounded on the battlefield to the medical station and from
them to the field military hospitals has to be established.
• Requirement for external assistance - As on the front line there
are not medical capabilities the assistance is required.
• Requirement for urgent measures towards the consequences - The
urgency of the medical support chain establishment is related to
the severity of the sustained injuries. As the objective is to cause
maximum possible fatalities, the expected type and gra \ ity of

injures could vary, but always there is a threat for the life, health
and ability of the soldiers and officers. (11)
There different theories regarding the origin of the war:
• Social - that states that every society has to gain its existence by
defeating the others;
• Psychological - that declares a war as normal state of the psycho
logical, mental development - there is a duty of the most pow
erful to lead and punish, when disobey, the less powerful. An
evidence from the nature are given as a proofs for these theories.
• Malthus and his followers are describing wars as a necessity for
reduction of the constantly growing population for saving the
world from the coming famine.
• Hunger of the youngsters - Wars are presenting as a natural con
sequences of the young and potent population strive for conquer
ing the power.
• Prevalence of foreign policy and Prevalence of domestic policy
are two theories describing wars as a consequence of the policy
driven by the desire to prove your superiority over the others, or
as a attempt to solve internal security issues (financial, social in
security) by starting a war, thus shifting the population attention
from the domestic problems to the perfidious and treacherous en
emy beyond the borders.
Depending on the weapons used by the forces a great variety of
DFs could be present into the war AOD. Even into the conventional
weapons use only the AOD is combined due :o the mechanical and blast
wave DFs affect on the fighting forces. Fi ..._ c-e ::e t : consequences
of the bombings. Chemical and radiologic.:. DFs c.oufu be present in
.....se of chemical and/or nuclear/radit ·
Because of the jeopardized supplies f:::e:'..;, ;.
density the BAOD is always present dun...=_ -— ϊ _is —.r —
ity of the irreversible and medical loses during wars are related to the
epidemics among the military forces, but mainly among the civilians.
(11, 27, 28)
Based on the aforementioned the DMS in case war has the following
particularities:
1. All the operation in wartime are lead by the military commanders.
Therefore, the location and tasks during the war DMS are ordered by the
military commander (he is the incident commander).
2. The commander's orders are not subject for discussions - the loca
tion is set, because of the safety, but and military considerations.
3. On the battlefield, where the casualties are expected the search
and rescue operations are carried out by trained and equipped for en
hanced first aid provision soldiers - combat saviors.
4. The first aid provided by them has several particularities - the first
step is to localize the wounded. Second step is to reach the injured under
the constant threat of being targeted. Third step is to stop the bleeding
and forth to extract the casualty (to evacuate) to the safer place. As a fifth
is starting the assessment of responsiveness, breathing ad circulation. If
casualty is alive an external help for evacuation out of the battlefield is
requested and the casualty is transported to the Field medical station.
5. The first medical activity is related to the triage - Casualties are
triaged for contamination only, not for the psychological impact. Only
the contaminated are isolated, in order to safeguard the medical staff and
the other injured from contamination.
6. In accordance to the urgency criterion the injured are receiving
the medical aid.
7. First pre-physician medical aid is limited to maintaining the
breathing, hemorrhage control, wound surface cleaning and wound ir
rigation, wound dressing and immobilizations.
8. First physician aid is limited to the Damage Control Surgery
(DCS) - dictates an abbreviated surgical approach in patients with ex-
tensive injuries directed at control of hemorrhage and contamination,

followed by resuscitation to normal physiology with definiti ne repair in
a delayed fashion. This approach is designed to restore normal physiol
ogy prior to normal anatomy. It is well established that patients who
develop the lethal triad of coagulopathy, acidosis, and hypothermia have
significantly increased mortality. DCS is designed to prevent or lim
it the triad through rapid control of bleeding and shortened operative
time. First step is to stop the bleeding in abdomen and thorax cavity;
in case of head/neck injury or bone fractures. The second is to control
the contamination and the third step is temporary stabilization - abdo-
men/thorax closure, fracture immobilization, sufficient for transferring
to the next level of military medical support - the field hospital. Chang
ing patterns of warfare coupled with improvements in protective body
armor have combined synergistically to decrease truncal and abdominal
trauma in contrast to previous conflicts. Despite the many advances in
protective body armor, penetrating abdominal trauma remains an inev
itable component of war surgery. Rapid recognition and treatment of
intraabdominal injuries are necessary to ensure maximal survival with
the minimum amount of morbidity. Trauma to the abdomen, both blunt
and penetrating, can lead to occult injury that can be devastating or fatal
if not recognized and treated in a timely manner. In an unstable patient
who presents with an abdominal injury, the decision to operate is usually
straightforward. In this circumstance, exploratory laparotomy should be
performed as soon as the diagnosis is made. In a few rapidly hemorrhag
ing patients with thoracoabdominal injuries a rapid decision must be
made as to which cavity to enter first. DCS in ·:■ase of abdomen/thoracic
trauma could be summarized in Control of hemorrhage - Exploration
to determine extent of injury - Control of eonîm atioo - Therapeutic
packing - Temporary abdominal 1n>s ,.-e.
Damage Control Orthopedics s e e , : : ___ g .1 se, ere
inflammatory response, and confines i , e ’: : : more = - d e : goals: suf-
ficient stabilization of fractures to prevent further tissue damage and
the possibility of compartment s drome, and allowing the patient to
be mobilized for tests and impro ed pulmonary care. For most upper
extremity injuries, simple external stabilization with splints or a sling
will suffice. For closed fractures below the knee, splinting is usually the
best option, though an application of temporary external fixation has to
be considered as option. Both of these methods are acceptable for initial
treatment of a casualty who will be evacuated out of theater. The choice
of initial fracture stabilization must be made on a case-by-case basis by
the treating surgeon. In general, indications for external fixator use in
clude when the soft tissues need to be evaluated while en route, such as
with a vascular injury; when other injuries make use of casting impracti
cal, such as with a femur fracture and abdominal injury; or when the pa
tients have extensive bums. The advantages of external fixation are that
it allows for soft-tissue access, can be used for polytrauma patients, and
has a minimal impact on the patient. A splint and bulky dressing may be
added for better soft-tissue support.
9. The last war DMS particularity is related to the evacuation - First
are evacuated the stabilized and prepared for evacuation casualties. First
stabilized - first evacuated. The primary medical triage evacuation crite
rion is violated. (73)
10. All these particularities are due to the impossibility safety and
security of the Field medical station to be assured/guaranteed - it could
be targeted, it could be captured by the opposing forces, no one could
assure the next delivery of supplies and next arrival of vehicles for evac
uation.
Terrorism Disaster Medical Support Management_______________________ 131
TERRORISM DISASTER MEDICAL SUPPORT

MANAGEMENT
Highlights
1. Definition
2. Origin
3. Classification
4. Objective, target, means
5. Main DF
6. Secondary DFs
7. Risk factors
8. AOD
9. AOD zones
No one could predict when, where and with what means the terror
ists will attack. The success of the terrorists’ attack is in its unpredict
ability. If the place, time, type of attack, number and type of casualties
are unknown it is impossible to plan and organize medical teams at the
place of the incident to support the casualties, therefore, when a success
ful terrorist attack is performed, alv a \ s at the spot there is a disparity
between the available and required medical resources and external as
sistance is required - a DMS has to be organized. ' l ·: i
Defining the terrorism is still « « es . ~■-e,d challenge. Thousands of
definition are used by different c o n n e c ven by the agencies and
services into the countries, but there r_ er.e fufir.iti, >n fut' is interna
tionally approved and accepted. Tne ..ifu er.gr ii -e 'e terrorist.
As it was said " One man’s terrorist ti n m a n ', freed.om fighter"
- the fighter for freedom for one is a terrorist for another. Even more dur
ing the years one movement was seen as fighting for liberty and against
aggression and within a year time was recognized ad terrorists’ organi
zation.
The definition accepted by the academia is proposed by Schmid and
Jongman (1988): "Terrorism is an anxiety-inspiring method of repeated
violent action, employed by (semi-) clandestine individual, group or
state actors, for idiosyncratic, criminal or political reasons, whereby - in
contrast to assassination - the direct targets of violence are not the main
targets. The immediate human victims of violence are generally chosen
randomly (targets of opportunity) or selectively (representative or sym
bolic targets) from a target population, and serve as message generators.
Threat- and violence-based communication processes between terrorist
(organization), (imperilled) victims, and main targets are used to ma
nipulate the main target (audience(s)), turning it into a target of terror, a
target of demands, or a target of attention, depending on whether intimi
dation, coercion, or propaganda is primarily sought." (74)
There are three main basic features of the terrorism that could be
found in the majority of the definitions: Use or threat for use of vio
lence in order to intimidate society (inflict fear among the population)
for achieving clearly declared political or ideological objectives.
Based on these features the main DF in case of terrorist attack could
be easily defined - the psychological one. The main target of the ter
rorists are not those dying or injured by their weapons. Terrorist are
not interested who was killed and injured, they goal is to intimidate the
population. The fear of the population is their weapon for targeting the
principal objective - the government, the authorities, the leaders of the
country. Terrorists by their actions (fear among society and social un
rest) are compelling, coercing the authorities to react in favor of their
demands.
To summarize, terrorists' objective are the authorities, their means to
Terrorism Disaster Medical Support Management 133
reach the authorities is the affected society, the damages caused b y the
terrorists' activities are mere the messages to the population, caring the
demand for political or ideological change.
From disaster medicine point of view, the required DMS is related to
the medical aid provision to those who are actual casualties on the spot
of the attack (to those who serve as message).
The AOD depends on the weapons used by the terrorists - area of
trauma caused by the use of conventional weapons - bombs, improvised
explosive devices, guns, rifles, or by the contemporary "trendy terrorist
mean” causing traffic accidents among mass gathering. Of course sev
eral attempts for implementation of chemical weapons were registered,
as well as the biological ones.
The particularities of terrorists' attack DMS are related to the general
situation and incident management:
1. The incident commander is not from the Fire Safety and Popula
tion Protection, but form the police, because the main threat is related to
the possibility of secondary attacks.
2. Related to the main security concern the second particularity is
that the place ofFMS or area for medical teams’ operations is chosen by
the incident commander and it is a definith e one - medical command
er is not aware of the entire aspects of security situation development,
therefore, has to obey the orders gi\ en.
3. In the actual AOD, because of securif uncertainty . are entering
the special police forces. They main o .ycciUve s :.·. ' calize and eradi
cate the terrorist hazard and to clean the area. As a secondary task they
are finding the casualties and sur\ iv rs crc ere ry c m . Sec
tion in a previously cleared, safe areas. call·ed r e sts The cal sup
, ort provided is only related to bl ■;*w-g . rro ~ ·
e ■acuation of the casualties is exe .Med.
4. In the FMS the triage is p e r c c c m m cc.
: f the medical support required.
1 3 4 _______________________________________ Disaster Medicine Highlights
5. The medical team task is to stabilize and evacuate in the most
rapid and efficient manner all the casualties. This requirement is due to
the extremely variable and changeable security situation. No one could
grant the security even for the medical station, as it could be targeted
from the terrorists in a secondary terrorist attack.
6. The evacuation organization is based on only one principle - first
evacuated is the first casualty stabilized and prepared for evacuation.
The triage evacuation principle is violated.
7. For the evacuation are not expected the medically equipped vehi
cles - even those requiring medical assistance throughout the transporta
tion are transported by the available vehicles with medic on board.
8. It is recommendable into the per hospital triage a screening for
contamination to be performed, due to the limitation of the triage into
the FMS.
9. The security concerns should be taken into consideration into the
prehospital triage, as it is possible within the casualties aninjured terror
ists to be transported to the hospital. That pose risk for hospital targeting.
10. The last particularity is related to the media coverage of the ter
rorist attack. All the medical staff has to be informed that all information
regarding the management of situation are given by the police, because
the media could become an ally of the terrorist by inflicting more fear
among the population spreading data regarding the attack. Providing
information regarding the undergoing activities also could be plausible
for the terrorist - how to escape or where and what to be targeted.
Fires Disaster Medical Support Management 135
FIRES DISASTER MEDICAL SUPPORT MANAGEMENT
Highlights
1. Definition
2. Origin
3. Classification
4. Main DF
5. Secondary DFs
6. Risk factors
7. AOD
8. AOD zones
Definition-uncontrolled process of burning. The three elements a

fire needs to ignite: heat, fuel and oxidizing agent (usually oxygen). A
fire naturally occurs when the elements are present and combined in the
right mixture, meaning that fire is actually an event. Intensity and dura
tion of burning depends on the 02 and the amount of the burning mater.
When 02 decreases to 14-15% the burning stops. (11, 27, 28)
Origin of the fires could be manmade (explosions, motor vehicle
collisions, industrial accidents, negligence-cigarettes, burning garden
debris, camp fires, the use of fault)' machinery releasing sparks) or natu
ral (thunderstorms, volcanoes, sparks from rtc kfalis, spontaneous com
bustion of hay, oil seeds, coal).
In case of fire always at least two DFs are present-thermal, toxic
(CO, CO2, HCN, Nitrogen and s tήfur : v. ran ' ■ΗΓ-. ~ 71. a :r: for
maldehyde, phosgene, saturated and non- n r -- ranor-nynrogens.
cot.).
Fire could cause great variety of secondary damages-explosions,

chemical and radiological accidents and collapsing of structures that
lead to secondary DF-overpressure, blast wave, radiological, psycho
logical.
There are plenty of risk factors that are increasing the risk level:
• Meteorological. The most important from them is the wind. Wind
direction guides the propagation of the AOD, thus determines the
location of the FMS). The speed of the wind is related to size
and the time for preventive measures implementation (stronger
winds enlarge the AOD). The type of the wind is also with signif
icant impact on the form, size of the AOD, but most important is
its significance for assessment of the population and areas at risk.
The precipitations, or it is better said the lack of precipitation are
prerequisite for the natural fires. In dry weather and moderate to
strong wind, the fire spreads with 40-70km/h.
• Landscape - dry grass and forests promote the spreading; water
basins stop the fire but obstruct the evacuation.
• Industrial sites dealing with flammable or explosive materials
can cause secondary damage or be the source of the fire.
• Gas/petrol stations.
• Structural safety/constructions’ fire resistance.
• Density of constructions-the distance between buildings and the
width of the streets could be obstacle or could assure the fire
spreading.
• The density of the population.
• Time of the day - always the disasters occurring during the night
time are accompanied by more severe consequences.
In case of fire always at least two DFs are always present, therefore
the AOD is combined. Three zones within the combined AOD are pre
sent, but with swiftly changing boundaries - zone of burning, zone of
thermal damage, zone of smoke CAOD
Fires Disaster Medical Support Management ________________137
Preparedness for responding to the threat of fire. In disaster prepar

edness the mitigation has significant role. Into preventing the fire oc
currence, a lot has been done - creation and implementation of impor
tant aalrming systems, planning and training for appropriate responses,
preparations, and buiding infrastructure designed to lessen the impact
of a deleterious event. Perhaps in no other area of disaster, science has
such an positive effect on human mortality rate and property protec
tion, than in the area of fire mitigation and prevention. The significant
reduction in deaths has been recorded due to the increased use of home
smoke alarm devices, better building codes (marked, lighted exits, fire
doors, and automatic alarms), implementation of fire-resistant materials
for building (concrete and cement), as well as upholstery and mattress
materials, sprinkler systems, improved safety of household appliances,
better firefighting equipment and tactics, and certainly better care for
injured patients.
Emergency clinicians and prehospital personnel can expect to en
counter victims from a fire- or bum-related event relatively frequently
in their clinical practice. Preplanning is essential to effective incident
management and the use of available specialty resources. (75)
Another preventive measure is the proper management of forest re
sources - controlled bums should be carried out in lower hazard peri
ods, setting up firebreaks around housing and other buildings. Setting up
warning systems is a technique used for fire prevention from the ancient
times.
There are two main types of injuries that could be found into the
combined casualties - bum and inhalation in:"ury are expected in case of
fires. Depending on the depth of the thermal ::.auma and the tissues that
are affected, bums are classified info ur ce es:
Degree Depth description Wound description
Superficial, red, wet ap

Partial thickness, pearance, painful. Not gen
First degree
Epidermis is damaged erally used in the calcula
tion of burned surface area
Partial thickness,
Red, blisters, swollen,
Second degree Epidermis and Dermis are
painful
damaged
Full thickness, Epidermis
Whitish, charred, trans
and dermis are destructed,
Third degree lucent, lacking sensation,
subcutaneous fat is dam
cherry red, nonblanching
aged
Muscle, bone, and tendon
Fourth degree Full thickness involvement, insensate
areas, charred tissues
According to the surface area that is affected, three categories of
bums are distinguished:
• Major bums-more than 20%;
• Moderate bums-10-20%;
• Minor-less than 10%.
Even though total body surface area (TBSA) can be calculated by
the rule of nines, it is not as accurate as the rule of palms or the Lund
and Browder chart is. Clinicians are notoriously poor at estimating bum
depth accurately at the initial time of injury. Bum depth assessment has
been found to have more than 60% variation among experts in the field.
Unfortunately, clinicians are also often poor at estimating the actual size
of the bum area on the patient, as well.
Bums could cause two types of shock - hypovolemic from the ex
travasation and traumatic from the pain and cell damage.
Of the ambulatory victims outside the structure the majority of pa
tients are likely to have respiratory complaints secondary to inhalation
of fumes, plus or minus bums. Inhalation injuries are caused by-thermic
trauma, hypoxia (lack of 02), acute inflammation from the irritating
Fires DisasterMedicai s upport Management _________________139
components, systemic toxicity from toxic components of the smoke.

Smoke inhalation is the leading cause of fire-related deaths . according
to death certificate analysis - the smoke inhalation to bums ratio was 2 to
1. Smoke itself is composed of particulate matter, heated gases, irritants
(such as hydrochloric acid, sulfur dioxide, and ammonia), asphyxiates
(such as carbon dioxide), and toxins (such as hydrogen sulfide, carbon
monoxide, and hydrogen cyanide). Victims of structure fires should be
assessed for signs of potential inhalational injury on scene (respiratory
distress, facial bums, and soot in nasopharynx).
Thermal insult to the upper airways may produce edema, bronchos-
pasm, airway occlusion, decreased chest wall compliance, and intrapul
monary shunting. Patients with inhalational injuries may present with
singed nasal hairs, carbonaceous sputum, a cough, hoarseness, stridor,
retractions, or the presence of soot or facial bums.
Systemic toxicity may occur following the inhalation of toxic gases,
such as hydrogen cyanide and carbon monoxide, which are produced in
the combustion of certain fuels and plastics. Bum patients with a his
tory of being enclosed in a confined space should undergo testing for
carboxyhemoglobin and lactic acidosis.
Protection required - Rescuers should use autonomous gas mask be
cause it’s difficult to know what is burning. Full protective equipment
with thermal protective properties is also required.
First aid in the AOD consists of:
1. Casualties are found and extracted from the fire.
2. The initial priority in bum patient management is to stop the burn
ing process. This strategy may require the extingishing of flames by
covering with blanket or wetting the l. d ies.
3. Primary triage is performed.
4. Once the risk of immediate and : :ir ire : :r :s crcressed,
providers should undertake a systematic approach:: racier.: assessment
airway support, assurance of adequate nhenhw.r a—- —c_.acc— --nh-
tenance of adequate core bod temperature. As with all cases in emer

gency medical care, the patient assessment begins with a primary survey
that is focused on airway patency, breathing, and circulation (ABC).
5. On scene the burn care should consist of wound coverage with
sterile gauze, hypothermia countermeasures because damaged skin can
not take part in thermoregulation.
6. Then organized evacuation to the TMS, where medical triage is
performed and casualties are decontaminated by removal of clothes and
partial decontamination of the face.
The FMS is set out of the combined AOD. Its location is related
to the wind direction. The FMS has to locate far from the risk objects
as petrol/gas stations; pipelines, flammable and explosive materials and
constructions, etc.
First pre-physician medical aid in case of fire includes:
1. Patient treatment begins with the administration of high-flow oxy
gen. Oxygen may mitigate the effects of airway edema, and it addresses
potential lethal gas exposures such as carbon monoxide and hydrogen
cyanide.
2. As a burn trauma is caused by extreme heat a cooling of the body
is recommended - with wet tissue covering.
3. Rehydration with fluids orally;
4. Pain relief and antibiotic might be given.
5. Immobilization of the injured body part to reduce the pain. Nurses
don’t manage the burns, just a wet dressing is applied.
First physician aid finalizes the medical support into the FMS:
Although patients may present with initial hemodynamic stability,
bum patients warrant continuous reassessment of airway, breathing, and
circulation because of the potential volatility of their illness.
1. Patients who have evidence of a in a burn injury, such as a hoarse
or raspy voice, stridor, indications of inhalation injury such as soot in
the nares or mouth, altered mentatio or signs of respiratory distress,
Fires Disaster Medical Support Management 141
should receive early and swift airway management. Patients requiring

intubation should be evaluated and supported by the most experienced
airway clinician, as rapid decompensation is possible. Potential for pro
gressive airway edema and sloughing of the airway mucosa.
2. Intravenous or interosseous access should be obtained, ideally in
a nonbumed area if possible and fluid resuscitation with crystalloid so
lutions should begin. Bum patients may experience massive interstitial
fluid shifts and are at risk for intravascular hypovolemia, which in tum,
reduces cardiac output and causes an increase in systemic vascular re
sistance. Aggressive fluid resuscitation is generally indicated to maintain
end organ perfusion. Several formulas exist to guide the administration
of intravenous fluids within the first 24 hours of a massive bum injury.
If they do not accurately predict the patient’s actual fluid requirements,
the resuscitation should be goal directed. Parameters such as mean arte
rial pressure and urine output may inform lifesaving efforts and prevent
complications such as pulmonary edema, compartment syndrome, and
hypothermia.
3. Initial wound management involves covering affected areas with
greasy and sterile dressings, with deflamol or panthenol if available.
4. Surgical treatment is not attempted in the FMS, because of the
risk of excessive bleeding.
5. Clinicians should assess accurateli and treat adequately burn-re
lated pain with opioids if necessary
6. The most severe injury is treated fir&-intoxication or burn.
7. Evacuation-to hospital well e c „ :r r d : tensi\ ■e
:are treatment. For 3rd and 4th de^ ee _- - : .rn.tre
might be required.
RADIATION. IONIZING RWIATION.

MEASUREMENT. EFFECTS.
Highlights
1. Definition of radiation
2. Energy is transferred as
3. Definition of ionizing radiation
4. What is radioactive decay?
5. Types of ionizing radiation
6. Alpha radiation characteristics
7. Beta radiation characteristics
8. Gamma radiation characteristics
9. Neutron radiation characteristics
10. Protection required
11. Alpha radiation could cause damage to human in case of
12. Types of effects under ionizing radiation impact
13. Cause of Deterministic effects
14. Deterministic effects are related to
15. Examples of deterministic effects
16. Cause of the Stochastic effects
17. Examples of stochastic effects
18. Ionizing radiation measurement
19. Physics Electrical Method for measurement
20. Chemical method for measurement
21. Scintillation method for measurement
22. Measurement units for ionizing radiation
23. Becquerel stands for
24. Coulomb per kilogram is unit measuring
25. Gray stands for
26. Equivalent dose stands for
27. Sievert is unit for measurement of
Radiation. Ionizing Radiation. Measurement. Effects. 1 ;3
28. Unit Roentgen measures

29. What the unit Curie is measuring?
30. Effective dose depends on
Radiation is the process in which energy travels through a medium

or through space, ultimately to be absorbed by another body. The en
ergy could be emitted and travel in form of particles of electromagnetic
waves. When the energy that radiates is capable to change the medium
and causing formation/emission of charged or non charged particles and
rays this radiation is defined as ionizing radiation. (11, 27, 28)
There are several sources of ionizing radiation:
1. Natural background ionizing radiation. The principal types and
sources of such radiation are:
• cosmic rays, which impinge on the Earth from outer space, main
ly the solar flare containing protons and hellium;
• terrestrial radiations, which are released by the disintegration of
radium, thorium, uranium, and other radioactive minerals in the
Earth’s crust - with the highest activity are the monazide sands in
Kerala, India and monazid alluvial deposits in Brazil, as well as
the granites in France;
• internal radiations, which are emitted by the disintegration of
potassium-40, carbon-14, and other radioactive isotopes (radium
and daughters, radon and daughters), that are normally present
within living tissues.
2. Artificial sources. From the artificial sources most significant
::re the X-ray examination, that are reaching the le, els of natural back-
?"ound radiation. Less important as a so srne are Ofise crushed rocks used
ruilding materials, phosphate fertilizers. n.:c’.e= p l a * e-""",.....isi nu-
;'era tests etc.
The ability of atomic nuclei of chemi... "-:= :--:?es
spontaneously tum into nuclei of o fter eiera^Ls. : j e~:>
ting energy in the form of electr magnetic radiation (gamma rays) or

particles (alpha particles, beta-panicles or neutrons).
The decaying nucleus is called the parent radionuclide (or parent
radioisotop), and the process produces at least one daughter nuclide.
Except for gamma decay or internal conversion from a nuclear excited
state, the decay is a nuclear transmutation resulting in a daughter con
taining a different number of protons or neutrons (or both). When the
number of protons changes, an atom of a different chemical element is
created.
Four types of radiactive decay processes are most frequent:
1. Alfa decay occurs when the nucleus ejects an alpha particle (2
protons and 2 neutrons - helium nucleus).
2. Beta decay is the process of change of the neutron to proton - be
ta-minus, the nucleus emits an electron and an antineutrino in a process
that changes, or when a proton is changed to neutron by beta-plus decay
- nucleus emits a positron and a neutrino.
3. Neutron decay - neutron-rich nuclei, could emit neutrons for los
ing energy - the results is change from one isotope to another of the
same element.
4. Gamma decay - energy of nucleus may is emitted as a gamma ray
without nuclear transmutation.
Spontaneous fission is another type of radioactive decay when a large
unstable nucleus spontaneously splits into two/three smaller daughter
nuclei, and generally leads to the emission of gamma rays, neutrons, or
other particles.
As summary for the ionizing radiation there are 28 natural chemi
cal elements that are radioactive, consisting of 33 radionuclides (5 ele
ments have 2 different radionuclides) - known as primordial nuclides.
Another 50 radionuclides, (radium and radon, etc.) are the products of
decay chains that began with the primordial nuclides, or are the product
of ongoing cosmogenic processes, car on-1 from nitrogen-14) in the
Radiation. Ionizina Radiation. Measurement. Effects. 1 -
atmosphere by cosmic rays.
Alfa particles are emitted mainly in the decay in large nuclei. An
alpha particle is with relatively high positive charge. The . are large,
heavy with low range (up to 10 centimeters) and extremely low pen
etration. Alpha particles can be stopped with a sheet of paper (or skin).
The ionizing capacity of these particles is enormous -within 1 cm range
they could ionize up to 30 000 atoms. Therefore, the alfa particles are
extremely dangerous if ingested and inhaled, but because of their low
penetrating ability, effective protection could be achieved by wearing a
normal mask to protect mouth and nose.
Beta radiation are positively or negatively charged particles. It con
sists either of electron or positron. Their mass is timely manner smaller
in comparison with the alfa particles, therefore they could travel longer
distances - the range of beta particles is several meters. The velocity is
also higher, as well as their penetration ability. A metal (aluminium or
plastic) shields are required for our protection. (fig. 5) Beta particles as
the alfa cause direct ionization of the medium but their ionizing capacity
is just up to 150 atoms per 1 cm range.
a, Alpha Radiation
. Beta Radiation
X-Rays
V, Gamma Rays
n°, Neutrons
Paper A lu m in u m
Figure 5. Protection against iooizxss r i :

G am m a rays are w ith n eg lig ib le m ass (they are electrom agnetic

w a v es) w ith the v elo city o f the light and range o f kilom eters. M oreover,
the penetration ability is an enorm ous one - alm ost nothing could stop
them . The h eavy lead shields and antinuclear shelters (at least 1 m eter o f
concrete w all) are decreasing their activity for every 15 cm the activity
drops w ith one half, but alw ays at the end the is som e residual activity.
Gam m a rays do not p o sses enough energy for direct ionization, but their
n eg ative effects are due to the undirected one - w hen absorbed b y the
atom this type o f radiation p rovokes energy instability and the atom s
cou ld em it particles or rays in order to b eco m e stable again. Ion izin g
capability is low er n com parison to the beta particles several atom s on ly
for 1 cm range.
N eutron radiation is flo w o f non-charged particles. Their range is
k ilom eters, sim ilar to the gam m a rays, as w e ll as their h igh penetration
ability and h igh speed. O pposite to the gam m a rays their io n izin g capa
bility is extrem ely potent - several thousand o f atom s re io n ized for 1
cm range. The lead sh ield s are not efficinet barrier against the neutrons,
therefore a concrete shelters w ith thick w a lls (m eter and ab ove) are re
quired for protection.
W hen cells are exp osed to io n izin g radiation, there is energy d ep osi
tion in the c e ll nucleus. (77, 78, 7 9 ) The principal target for all b io lo g ica l
effects o f io n izin g radiations is the D N A . T he dam age can occur either
by direct or indirect action. D irect action occurs w hen alpha particles,
beta particles or x-rays create ions w h ich p h y sica lly break one or both
o f the sugar phosphate backbones or break the base pairs, dam age bases
or affects the bonding o f the b ase pairs o f the D N A . (80, 81, 82) (fig. 5)
The b ase pairs adenine, thym ine guanine and cy to sin e are h eld together
b y w eak hyd rogen bonds. A d en in e alw a s pairs w ith thym ine (ex cep t in
R N A w here thym ine is substituted b uracil and guanine alw ays pairs
w ith cytosin e. D irect radiation dam age is initiated w ith the breaking o f
bonds (S H , O H , N - H , and C -H ). 1
Radiation. Ionizins Radiation. Measurement. Effects. 147
Figure 6. Direct ionization impact (78)
Alfa, heavy charged, particles have a greater probability of caus

ing direct damage compared to low charged particles. Gamma and X-
rays cause most of their damage by indirect effects. Alpha particles and
beta particles could break the “backbone” of the DNA and the hydrogen
bonds. These effects on the DNA structure are significant for the cell,
because the DNA base pairs form sequences called nucleotides which
in tum form genes. Genes are managing the cell production of proteins
which determine cell type and regulate cell inaction. Two types of breaks
in the sugar phosphate backbone can . in 'ey ionizing radia-
.’on. (fig. 6) A single strand break u:-r. .Tin. ::.e of the sugar
phosphate backbones is broken. Single 5":-=..: rreiks ..:e e in y repaired
using the opposite strand as a tempin.u- H'w r. :::-. rin- ^,„in:1tions
2nd. frameshift mutations can still u.; - I : -
ietrimental lesions produced in chre-== =: = ^ in. O cjzm z radiation.
Because such breaks are difficult t. repair, they can cause mutations
and cell death. Unrejoined double strand breaks are cytotoxic (they kill
cells). Double strand breaks can al o result in the loss ofDNA fragments
which, during the repair process, can cause the joining of non-homolo
gous chromosomes (chromosomes not of the same pair) leading to the
loss or amplification of chromosomal material.
DNA has a capability to repair such a breaks through a process exci
sion. This process consists of three steps:
1. Endonucleases (cutting out the damaged part of the DNA);
2. Resynthesis of the original DNA by DNA polymerase;
3. Ligation of the sugar phosphate backbone damages.
These repair processes are continuous and highly efficient. lncase
of ionizing radiation impact the process is impaired or hampered or the
DNA is incorrectly repaired and the wrong nucleotide is inserted which
can lead to cell death or a mutation. The mutations are basicly two types:
• Substitutions — this is the replacement of one base by another.
For example, if a DNA molecule usually contains guanine at a
certain position, but adenine takes the place of the guanine, then
a base substitution has occurred. There are two types of base sub
stitutions:
1. Replacement of the bases
• transitions — replacement of adenine with thyamine or vice
verse (purine replaced with purine), or of cytosine with guanine
and viceverse (one pyrimidine with the other pyrimidine)
• transversions — replacement of a purine with a pyrimidine or
vice versa
2. Frameshift Mutations — these change the reading frame of a gene
(the triplet code):
• insertions — insertion of one or more extra nucleotides into a
DNA chain;
• deletions — these result from the loss of one or more nucleotides
Radiation. Ionizins Radiation. Measurement. Effects. 149
from a D' ‘ A chain.

Ionizing radiation can also impair or damage cells indirectiy : se
ating free radicals. (fig. 7)
O H -h y d ro x id e
H+ hydrogen ion
Ho hydrogen
' HOO neural hydroxide
Figure 7. Inderect ionization (78)
Free radicals are molecules that are highly reactive due to the pres
ence of unpaired electrons on the molecule. Free radicals may form
compounds, such as hydrogen peroxide, which could initiate harm
ful chemical reactions within the cells . mainl r an oxidative damage to
DNA, lipids, proteins, and many metabolites.
As a result of these chemical changes, cells may undergo a variety
of structural changes which lead to altered function or cell death. The
indirect effects of ionization are d ie :::e re . ».i r i:y ■f ize high-energy
species originating from the water 'a;:: ' ; “ -■ ‘ rea anon im
pacts the cellular water rapidly reach, = osy 5 -e::es ^ e generated
- hydroxyl radical (OH-) and ionized i s H- G - . =:ger. radical
<Ή+) and hydrated electrons (eaq-). A sa s =-: -- - s~er s_r-er :-\:d=- <0 2-)
and hydrogen peroxide (H20_ ; are formed. They initiate a subsequent

chemical cascades generating additional cell-damaging molecules:
Intracellular ferrous and/or cuprous ions catalyse the convertion of
02- and H202 with result additional amounts of OH-.
0 2 - couples with endogenous nitric oxide (NO), forming perox-
ynitrite anion (ONOO-). It along with peroxynitrous acid (ONOOH),
nitrogen dioxide (NO2·), dinitrogen trioxide (N2O3) are highly reactive
nitrogen species.
This increased formation of reactive substances are particularly
harmful to the cell, as the reaction products are in many cases more re
active than their precursors. (fig. 8)
Oxidative Stress
H20 +
Lipid
damage
Protein oxidation
DNA damage
Figure 8. Ionizing radiation generates the potent intracellular oxidants (78)

Radiation. Ionizina Radiation. m
easurement. Effects. 151
Ionizing radiation causes two types of negative effects in the hu man

body - deterministic and stochastic. (83, 84, 85)
Deterministic effects are linked to the ammonut of dead 'ells re suit
ing from the impact of the ionizing radiation. These effects of ionizing
radiation lead to a functional loss of the irradiated organ or tissue, v.hen
sufficient cells are killed or prevented from reproducing or functioning
due to radiation. The severity of the loss of organ function is directly
proportional to the number of cells affected. Certain amount of cells has
to die in order the function to be jeopardised - a threshold dose exists.
This dose has to be exceeded for deterministic radiation effects to oc
cur. The deterministic effects of ionizing radiation is dierctly dependent
on the ionizing radiation that has irradiated the body and was aborbed.
Therefore, if the absorbed by body dose is above of the threshold the
symptoms will be present. Moreover, with increase of the dose more
symptoms will be developed. As the tissues are with different vulner
ability to the ionizing radiation, if the absorbed dose is known, the or
gans and systems damaged could be easily foreseen, along with symp
toms related to their loss of function. In summary, detenninistic effects
describe a cause and effect relationship between the power of radiation
energy and certain side-effects. They posses threshold below which the
effect does not occur. This threshold ma. v a r from person to person.
The severity of deterministic effects increases ' ith dose. (84)
Examples of deterministic effects and the threshold doses (as ab
s: ■rbed dose) are:
• skin erythema (skin reddening : 2-5 2y.
• irreversible skin damage: 20- - G .
• hair loss: 2-5 Gy
• sterility: 2-3 Gy
• cataracts (opacity of the eye le::s n: .= :: 10 i .. Gy
• lethality (whole body): 3-5 Gy 2
• fetal abnormality: 0.1-0.5 Gy
Stochastic effects of ionising radiation are chance events. Their oc

currence and the type of the side effect are not known and are not related
to the absorbed dose or type and po er of the radiation. The probability
of the effects is increasing with the dose, but the severity, time of onset
and the type of the effect are independent of the dose received. It is as
sumed that stochastic effects have no threshold. These effects are link
mainly to the mutation in the cells, induced by the radiation. If mutated
cells are not recognised and eliminated as foreighn by the immunity
system, they could result in uncontrolled growth (increased primarily
neoplasm risk) or in malfunction of a tissue. Germline mutations in
duced by radiation could be transmitted to the offspring and may result
in congenital anomalies or increased risk of common multifactorial dis
ease - hereditary disorders. The DNA double strand breaks plays a criti
cal role in the carcinogenesis process. This damage induce further DNA
damage and chromosome breaks resulting in chromosomal aberrations
represent one of the earliest detectable biological changes.
Humans do not posses any receptors for ionizing radiation. As the
radiation could be extremely harmful three different methods for detect
ing ionizing radiation are implemented into the practice. Prior to define
the methods it is necessary to discuss what has to be measured, in order
the prevent health harm or to start appropriate treatment. The following
measurements (86) are basic for the prevention and treatment:
1. Activity - Activity defines what is the potential of the radiactive
element to emit ionizing radiation. The ionizing radiation is product of
the emission of energy during the radiactive decay. Therefore, in order
to measure the activity, it is required to mesure how many nuclei de
cayed for a certain period. The SI unit is Becquirel (Bq) The activity is
1 Bq when one nucleus decays per one second.
2. When the energy is emited, it starts to ionize the environment. The
exposure dose is measuring the amount , f energ' that is ionizing the air.
The SI unit is Coulomb (Energy) per kg mass of the affected air).
Radiation. Ionizina---------------------------------------------------------------------------------------------------------
------------------- Radiation. Measurement. Effects. TA
3. Absorbed dose (AD) measures the energy deposite ■i m λ ::\e:
(human body) by ionising radiation. It is equal to the energy deposited
per unit mass of a medium, and so has the unit joules (J) per kil ogram
(kg), with the adopted name of gray (Gy) where AD 1 Gy = l J. per kg.
4. For measuring the biological effect of the ionizing radiation an
other units are required, because 1 Gy of alpha radiation would be in
timely manner more damaging than 1 Gy of gamma radiation, for exam
ple. Appropriate coefficients/konstants or weighting factors are applied
to reflect the different relative biological effects of the particular ioniz
ing radiation type and from the tissue affected (upon its radiosensitivity).
The biological effects related to the type of radiation are measured by
the equivalent dose. The equivalent dose (EqD) is measured in Sievert.
The EqD = AD x Kir, where Kir is the coefficient, specifying the type of
the ionized radiation - alfa, beta, gamma, neutrons.
5. To measure the biological damage on a particular tissue is neces
sary to take into consideration how vulnerable the tissue is. This radio-
sensitivy or successability is measured by the Effective dose (EflD).
EflD in Si = EqD x Kt, where Kt is the coefficient related to type of
the tissue irradiated.
All the instruments that are created for detection and measurement
of the ionizing radiation are based on its capability to induce ioniza
tion in the medium and changes of the atomic number of the affected
elements. The most used instruments are measuring changes into elec
tricity, colourmetry and scintalaion. One of the world's best-known ra-
dioation detection instruments is the Geiger c ■1U I ter. -8“ ) It consusts of
the Geiger-Muller tube where the ionizing r at l f a; , is detected and elec
tronics for measurement. (fig. S) Geiger Muiler mbe is an outer metal
cylinder (the cathode), with a thin wire — = -1:=g i:s Eris. The anode
is insulated, and maintained at l 0 ■1 : /.5 r : f ' = Tr.e ;: .:r.:er is filled
with an argon-alcohol mixture. T ie ==.-::es through a
thin mica window and charged pc....-::ieie5 v — '_re g", Tie produced
154________________________________________ DisasterMedicineHighlights
electrons are accelerated by the applied potential difference towards an

ode. The free eletrons are attarcted to the positive electrod completing
the circuit and generating a current. By arrival at the anode they collide
with the gas molecules and ionize the gas even further, producing more
electrons. The electrical signal so produced can be amplified to operate
mechanical counters, or to give a click on a loudspeaker. The instrument
is detecting the present radioactivity. The Geiger counter is cheap and
reliable instrument but has some limitation:
Geiger Counter
Figure 9. Geiger counter (87)
• Inability to differentiate between different types of ionizing ra

diations.
• Inability to measure high amounts of radiation due to “dead”
time of the Geiger Muller tube. (86)
Second method that is widely used in the peronal dosimeters is the
colourmetric. When a film covered b - the chemcal compound with spe
cific colour is affected by the ionizing radiation, change in the colour
Radiation. Ionizing Radiation. Measurement. Effects. ::
occurs, because of the changes into the chemical structure . The extent of
the change is measured by colouremetry. The dosimetres
the aborbed by the instrument dose ionizing radiation.
Third method is using the scintallation of the medium. S .-mmlation
counters are used to measure the radioactivity present in an ^. radioac
tive sample or any biological sample which is radiolabelled. It v;orks on
the principle of excitation of the Fluorescent chemicals in the presence
of any radiations such as alfa- particle emission, beta-particle emission
or gama rays. When the emissions strike the chemical, their electrons
reache the excited state. When the electrons from the excited states reach
back the ground state, it emits light with a longer wavelength, and there
fore lower energy, than the absorbed radiation. This light is converted
to electric signal by photomultiplier present in the photomultiplier tube
and analysed by Pulse Height analyser.
Figure 10. Scinttillaa: ' l

156
To summarize, scintillation counter as a spectrometer. The spec
trometer consists of a suitable scintillator (transparent crystal, usually a
phosphor, plastic or organic liquid) which generates photons in response
to incident radiation a sensitive photomultiplier tube which converts the
light to an electrical signal and electronics to process this signal - a cir
cuit for measuring the height of the pulses produced by the photomul
tiplier. When an ionizing particle passes into the scintillator material,
atoms are ionized along a track. The photon from the scintillation strikes
a photocathode and emits an electron which accelerated by a pulse and
produce a voltage that is amplified and recorded by an electronic coun
ter. (88, 89) (fig. 10)
Disaster Medical Support In Case OfArea Of Radiological D!nn?.=

RADIOLOGICAL DAMAGE
Highlights
1. Definition.
2. Sources.
3. Risk factors.
4. Zones.
5. Type of the casualties.
6. Protection required.
7. Location of the FMS.
8. First aid in the ÂOD.
9. Primary medical triage of the casualties.
10. Define the biological dosimetry.
11. Symptoms to be checked during Biological dosimetry.
12. Relation between the vomiting and the absorbed dose.
13. Relation between the skin reaction and the triage categories.
14. ’What is the significance of the body temperature and blood pres
sure?
15. Medical evacuation end point.
16. Relation between the biological dosimetry and treatment required.
17. First pre-physician medical aid in the FMS.
18. First physician medical Aid in the l-MS.
Radiological area of damage (RAOD ) is de::u:ed as temtoI)' that is

under the impact of the radiological DF. Radiolle^ c a l g factor
is the ionizing radiation. ( 11, 2 ", 2 e
The origin of the ionizing radian on .. o be fa:= d=er en: sources:
1. The most famous events creat=aa. 7~ -- = lend
nuclear power plants. The Chernobyl and _s r_^_i I s . * ire in·: - ~
all over the world. Explosions of theτ reicr ;re : i _ e r trir.erxi·'
spread of the radioactive element- and RAOD covering immense ter

ritories.
2. Implementation of the nuclear weapons is also notorious source
for RAOD. Apart of the Hiroshima and Nagasaki bombings, using the
impoverished uranium (depleted uranium) in armaments and military
equipment has to be considered as source for RAOD. (91, 92, 93) In the
armed conflicts of the last decades wide use of armour-piercing means
with elements consisted of impoverished uranium has led to the appear
ance of some health concerns among the veterans and population. For
instance during the Gulf War some 320 tons of depleted uranium sub
stances were used. (fig. I 0)
WIien macltl—
wete ususlCI during tlle (Gulf War
JIIA O
S toeM kK io
dc^boQnc U on t.r.o ^
— .......
* " ' ' i Mdt i M . . . . . . . . . . .
Area in which DU bullets and rounds Rate per 1,000 births of congenital malformations
were used in the Gulf W ar at Basra University Hospital, Iraq
Figure 10. Depleted uranium and birt malformation (94)
Following year, a sharp increase of congenital malformations was

recorded in Basra, region heavily bombed with this armament. (94, 95)
Other usage of these weapons is during 1991 war in former Yugoslavia
- I 0-15 tons of depleted uranium was used during the 1999 bombing.
More than 1000 tons of depleted uranium munitions were used during
conflict in Iraq 2003.
Disaster Medical Support In Case Of Area Of Radiological Da : ... _ :
Nuclear tests are also sources for radiological contamination.

3. Improper use, storage or radioactive waste manag .m e rt and dis
posal. The Goiainia accident in Brazil (1987) is example of how the
improper radioactive waste governance could endanger the socie :
4. Radioactive and nuclear terrorism. The public execution of ex
KGB agent Litvinenko in London (2006) is a classic example of use of
violence for threat and it is the first confirmed victim oflethal polonium-
210-induced acute radiation syndrome. Possible, but still not recorded is
a scenario of successful terrorist attack against the nuclear power plant
- but throughout the years several unsuccessful attempts are recorded.
Nuclear plants are highly sensitive target and were military targeted
in a several local military conflicts in Iran, Iraq, Syria etc.
Summarizing the information regarding the sources could be stated
that as a hazards with potential for ÂOD emergence are all facilities
that are operating, or storing radioactive materials.
RAOD consists of 5 zones:
1. Zone of radiological threat;
2. Zone of moderate radiological contamination;
3. Zone ofhigh radiological contamination
4. Zone of dangerous radiological contamination;
5. Zone of extremely dangerous radiological contamination
Notwithstanding the levels of activity and exposure dose all these
zones are posing threat to the life and health of medical staff (a full
protective equipment is required for operating within the contaminated
area), therefore the FMS has to be located outside of the RAOD on a
safe distance, opposite t the wind directio ::
The vicinity, wind and precipitation cl oset o the RA OD _ e:::e main
risk factors for enlargement of the contaminated err .: r·
There are several specifics regarding the relie a;:::-. e r: .
ties’ management in the RAOD.
First, it is medical duty to remind seainfi :::--
that no protective clothing could as sure and maintain the protections

against all types of ionizing radiation, therefore the time of operating in
the AOD is limited. The time limitation is related to the activity and the
exposure dose measured.
After finding the casualties into the area, the first step of the man
agement is to stop the contact with the DF - partial decontamination of
the bared skin surfaces, brushing the radioactive dust off the clothes and
then applying barrier between ionizing radiation and the casualty via
covering the entire body. After primary triage a fast organized evacua
tion is performed, followed by decontamination.
If not decontaminated, all the casualties exiting from the RAOD
have to be considered as dangerous and isolated, not allowed to enter
into FMS.
For performing the primary medical triage, it is important to ob
tained data regarding the absorbed by the casualty dose. A practical SOP
for rapid, field orientation regarding the absorbed dose is the Biological
dosimetry. It is part of the both first pre-physician and physician aid.
Biological dosimetry is based on the expected visible and easily measur
able changes due to negative effect of the ionizing radiation:
As the most vulnerable are the crypts into small intestines (villi in-
testinalis) the first symptom into Biological dosimetry is the vomiting.
Casualties are questioned about the time of the onset of the vomiting and
its character - number, frequency etc. If the vomiting has started within
first 30 minutes the probable absorbed dose is extremely high and a fall
spectrum manifest acute radiation syndrome (ARS) is expected with se
vere, often lethal outcome - triage as T4. Full spectrum ARS is expected
and when the vomiting starts between 30 min. and 1 hour after the ir
radiation, but the casualty might enter into the recovery phase - triage
as Tl. Evacuation has to be directed to the hematological wards/clinics.
When vomiting has started between the first and second hour after the
incident, a mild ARS is expected (T2) and casualties are hospitalized
Disaster Medical Support In Case OfArea Of Radiological Du-u^-- 161
in internal medicine departments with hematologist for :r.c:t λ f-e

treatment. When casualty reports no vomiting or the vomiting c art ■n o
and above hours after the accident, the casualties requires obseration
that could be done into the internal medicine departments - rarel ■ ·. they
develop ARS.
Second visible change that has to be detected is the skin reaction to
the ionizing radiation. The erythema of the skin is indicating ionizing
radiation impact, but almost no ARS development is expected. The red,
edematous, sore skin indicates higher absorbed dose and ARS develop
ment - T2. Blisters and ulcers are indicators for great amount of radia
tion absorbed and full spectrum ARS - Tl.
Third and fourth changes are related to the involvement of the cen
tral nervous system into the damaged structures - that requires extreme
ly high doses.
Hyperpyrexia above 39 degrees Celsius and hypotonia below 100
mm. per systolic blood pressure are associated with poor survival prog
nosis.
After performing the Biological dosimetry first pre-physician aid
proceed with activities for preventing the complications:
Administrating antiemetic drugs for controlling and stopping the
, omiting and starting rehydration via giving fluids (water) per mouth.
Affected by the radiological bums (radiodermatitis) skin areas are irri
gated, cleaned and covered with sterile dressing. Ps s chological support
has also to be provided.
Physician first aid into the FMS also is limited. Starting aggressive
fluid resuscitation intravenously, alongwith initi ation of prophylaxis of
the infectious complications by admini iHSxve Miislt the most
broaden in its spectrum of activity antibiotic available. Casualties has
:o be evacuated with no delay because of me eloping suppression of
the immunity due to ionizing radiatioη ~ r i : t oc haarncpoetic tissue.
NUCLEAR BOMB EXPLOSION VS. NUCLEAR PLANT

FAILURE
ACUTE RADIATION Sn"l)R O M E
Highlights
1. Acute Radiation Syndrom (ARS) Definition
2. What could cause ARS development?
3. ARS Phases
4. ARS pathophysiology
5. Initial (Prodrome) phase general symptoms
6. Latent phase
7. Manifest phase - general symptoms
8. ARS Complications
9. Diagnose
10. ARS main treatment challenges
11. First step of the hospital treatment
12. Why isolation is needed?
13. Treatment of the infectious complications
14. Adrressing the endogenous infections' threat
15. Treatment of the haemoptoic syndrome
16. Treatment of the hemorrhagic syndrome
17. Treatment of the gastrointestinal syndrome
18. Nuclear bomb explosion
19. Nuclear bomb explosion DFs
20. Nuclear power plants accidents
21. Nuclear power plants DF
22. Comparison between the Nuclear bomb explosion AOD and the
AOD due to nuclear plant accident
23. SOP for relief operations in case of nuclear bomb explosion
24. SOP for DMS in case of nuclear plant accident
Nuclear Bomb Explosion vs. Nuclear Plant Failure 163
Acute radiation syndrome (ARS) is defined as a combination of

clinical syndromes occuring in stages during a period ofh ..un; o week:',
after exposure, as injury to various tissue and organs is ex. : e,-;. . 11 ,
14, 27, 28)
In every RAOD, ARS could be developed. Therefore, all hazards
and risk factors are the same - nuclear plants accidents (e.g. Explosion
of the vapour at the Chernobyl Nuclear Power Plant in April 1986 re
sulted in the hospitalization of 237 patients identified as overexposed
persons. 134 of them developed ARS. Of these 134 exposed persons,
28 eventually died of ARS associated injury with extensive radiation
bums), improper storage or waste disposal of radioactive materials (e.g.
In September 1987, a shielded radioactive caesium-137 source 50.9
TBq) was removed from the protective housing of an abandoned tele
therapy machine in Goiania, Brazil. Subsequently, the source was rup
tured. As a result, many people incurred large doses of radiation by both
external and internal contamination. Four of the casualties ultimately
died, and 28 people developed local radiation injuries. Example for im
proper use is from Salvador - In 1989, a radiological accident occurred
at an industrial sterilization facility in San Salvador, El Salvador. The
accident occurred when the cobalt-60 source became stuck in the open
position. Three workers were exposed to high radiation doses and de-
. eloped ARS.
Other sources are nuclear weapons implementation . nuclear tests
and terrorists’ activity (the execution o fL in n e nko. 2006. London, UK).
Humans could be irradiated from the emited ionizing radiation in
case of the above mentioned radiologi is mainly
three types: (fig.11) - Whole bod . irra .;:i -=--_duti::: and
internal irradiation. Early symptoms for. λτ ' ; ..re:: E
body radiation are related to the most \ ru·n e t tle :e .issîc rnr hade:
• gastrointestinal: nausea, v o m · ;· ; _- i-:: - r .e ^ λ- :r=
• neuromuscular: easy fatigabilif:.
AH the effects are dose dependent - the ARS is an example for the
deterministic effects of ionizin!l radiati0n.
Contamination types
Irradiation External Internal
Contamination Contamination
Figure 11. Irradiation types (96)
The effects vary in time of onset, severity and duration. The effects
could be combined in three syndroms, which manifestations are dose
dependent:
1. Hematopoietic syndrome:
• Cause of death at doses <8 Gy.
• Peak incidence of death occurs at about 30 days post-irradiation,
and continues for up to 60 days.
• Suppresses normal bone marrow and spleen functions.
• Symptoms associated with hematopoietic syndrome are: chill,
fatigue, hemorrhages, ulceration, infection and anemia. Death
usually result unless receive bone marrow transplant.
2. Gastrointestinal syndrome:
• Occurs at dose> 10 Gy of gamma-ra ·, s or its equivalence.
Nuclear Bomb Explosion vs. Nuclear Plant Failure 16 ;
• Death usually occurs within 3 to 10 days.

• Symptoms due largely to depopulation of the epithelial lining of
the GI tract by radiation.
• No human has survived radiation dose > 10 Gy.
• Clinical symptoms include nausea, vomiting, and prolong di
arrhea, dehydration, loss of weight, complete exhaustion, and
eventually death.
3. Cerebrovascular syndrome:
• Identified at doses >30 Gy.
• Death occurs within hours from cardiovascular and neuromuscu
lar complications.
• Clinical manifestations include severe nausea, vomiting within
minutes of exposure, disorientation, loss of muscular co-ordina
tion, respiratory distress, seizures, coma and death
ARS has been broken down into three subsyndromes (briefly de
scribed), which are dose and time profile dependent. The three syn
dromes described follow a similar clinical pattern that can be divided
into four phases: an initial or prodromal phase occurring during the first
few hours after exposure, a latent phase, which becomes shorter with
increasing dose; and the manifest phase of clinical illness. The time of
nset and degree of the transient incapacitation of the initial phase, the
duration of the latent period, as well as the time of onset and severity of
*lie manifest phase and ultimate outcome are all dependent upon total
2bsorbed
- dose and individual radiation sensitivi The outcome of the
manifest stage is either death or recovery, that consists the fourth phase
. the ARS development.
Acute radiation syndrome (ARS ) is a complex of acute injury mani
festations that occur after a sufficiently '.mg; r :m : ■ ::fe mm :r. s r my
:s exposed to a high dose of ionizing rastiatiion. _ _ n vradisfioo initially
mures all organs to some extent, but : m mmm m m m m mm .r
manifestations depend upon the type , pen- s
that is injured and dose of radiation re cei ved. Different ranges of whole
body doses produce different manifestations of injury.
The three main ranges that produce the most characteristic manifes
tations are referred to as the haematopoetic, gastrointestinal, and neuro
vascular syndromes. These syndromes are, as a rule, produced only with
total-body or nearly total-body irradiation by photon or mixed photon/
neutron radiation. High-dose injuries to smaller percentages of the body
produce local injury effects (e.g. radiodermatities) but may not cause
ARS.
Patients who have received doses of radiation in the potentially low
to mid-lethal range (2-6 Gy) will have depression of bone-marrow func
tion with cessation of blood-cell production leading to pancytopenia.
Bone marrow contains three cell renewal systems whose time cycles,
cellular distribution patterns and post-irradiation responses are quite
different: the erythropoietic (red cell), the myelopoietic (white cell),
and the thrombopoietic (platelet). A pluripotential stem cell gives rise
to these three cell lines in the bone marrow. Each cell renewal system
consists of a stem cell compartment for the production of erythrocytes,
leukocytes (lymphocytes, granulocytes, monocytes, etc.), or platelets,
a dividing and differentiating compartment, a maturing (non-dividing)
compartment, and a compartment containing mature functional cells.
The stem cell lines of the bone marrow are among the most radio
sensitive tissue of the body. This is because of their high mitotic rate
and their high nuclear-to-cytoplasmic ratio. Cytogenetic injury to bone
marrow cells and nucleated blood cells can occur at ionizing radiation
doses as low as 0.25 Gy, but clinical depression of cell counts is usually
not noted until a dose of 0.5 Gy.
Platelets. After exposure to ionizing radiation, platelet counts gen
erally drop in concert with neutrophil counts, but an abortive count rise
is not usually observed. Platelet counts drop to zero or near zero with
doses that exceed 5 Gy.
Nuclear Bomb Explosion s. Nuclear Plant Failure 167
With the changes in blood counts, the patient suffers damage to the
immune and haematostatic systems. In the week preceding a: at: during
the neutrophil and platelet count lowest level, the function of remaining
cells is altered. Not only are few neutrophils and platelets left but the
remaining cells may not function since they are at the end of their life
span due to either senescence or radiation damage.
If, during the 15-day recovery period from the lowest level of neu
tropenia, the patient survives neutropenic fever, complications of sepsis,
and uncontrollable haemorrhage, recovery can be expected. Thus, the
therapeutic goal in the management of such a patient is to lessen the
severity of thrombocytopenia and neutropenia while minimizing and
treating infectious damages.
Red blood cells. After exposure to ionizing radiation, there is usu
ally no depression or only a very mild depression of red blood cells un
less there is concomitant haemorrhage.
Granulocytes. Doses greater than 2 Gy cause an initial paradoxical
rise in counts, a rise that lasts only hours or days and is followed by a
precipitous drop. This is caused by prompt demargination of white cells
into the circulation. Any blood cell count taken during this paradoxi
cal rise may be misinterpreted as evidence of infection. Doses of 2 to 5
Gy cause a second abortive rise, which interrupts the precipitous drop
in counts for several days and possibl > as long as a v eek. This second
abortive rise is caused by the products of final differentiation and entry
into circulation of marrow polymorphi : ::...leatee cell precursor cells.
v,hich do not need to undergo further nuttu: c uutr.s. The extent and
duration of this second rise varies: rut f t— ta.a . :t lasts far annroxi-
nately a week with a rise from about 51 t ' :mtil 1 ten
the neutrophil count continues dropping :c .=■·efe :: zero io 0%
f normal at around 25-35 days after ex:'
General Symptoms of the haemopo :.ti 3S) —
Patients injured with doses in the haem i::;*:.;-; . r
rience prodromal symptoms of nausea and vomiting which, compared

with those for the other syndromes . are less severe and easier to control.
They last only a few hours, with time of onset from later than an hour to
about 24 hours after exposure. There is usually a lack of central nervous
system syndrome signs, very little change in blood pressure, and only
mild watery diarrhoea.
Fatigue, malaise, anorexia, and drowsiness may be observed but are
not consistently correlated to dose received as are the onset and severity
of nausea and vomiting.
The prodromal phase is followed by the latent phase that lasts up to
a month and is relatively asymptomatic except for some tiredness and
weakness.
The latent phase is followed by the manifest illness phase, charac
terized by neutropenic fevers, systemic and localized infections, sepsis,
and hemorrhage.
General symptom of the gatrointestinal syndrome
Generally, exposure to a dose range of 8-30 Gy is fatal since that
dose range causes reproductive death of the mucosal crypt stem cell.
Loss of these cells eliminates the bowel's ability to replenish the short
lived mucosal cells that normally slough off during routine GI function.
Since the rate of cell turnover is highest in the small intestine, radiation
injury is usually most severe in that part of the tract. Additionally, there
is, to a degree, disruption of neural control of the gut, abnormal release
of intestinal neurohormonal peptides, oedema of the submucosa, and
engorgement and stasis of the submucosal blood vessels. Denuding of
sections of bowel, in tum, causes a host of pathophysiological sequelae.
They include invasion of lumenal bacteria into the circulation, loss of
fluid and electrolytes, loss of absorptive capability, significant gastroin
testinal haemorrhage and loss of blood and d 1■sfunctional bowel motil
ity, resulting in severe bloody diarrhoea, anaemia, ileus, severe electro
lyte disturbances, and malnutrition.
In summary, depletion of the epithelial cells lining lumen of gastro

intestinal tract is reulting in:
• Intestinal bacteria gaining free access to body;
• Haemorrhage through denuded areas;
• Loss of absorptive capacity.
Prodromal period. Within 30 minutes to 2 hours of exposure, pa
tients receiving radiation doses of 8-30 Gy may experience severe pro
dromal symptoms of anorexia, nausea, vomiting, and occasionally wa
tery diarrhoea with abdominal cramps, which increase in intensity for
4-8 hours and may be difficult to control with antiemetic medications.
These symptoms are usually accompanied by listlessness, drowsiness,
and fatigue. Occasionally, prodromal symptoms include parotid gland
pain, metallic taste sensation, mild hypotension, and tachycardia. The
prodromal symptoms continue but diminish over the first 48 hours after
exposure.
Latent (subacute) phase: Patient is asymptomatic for hours to days
but is markedly tired and weak.
Manifest illness: return of severe diarrhoea, vomiting and diarrhoea
v ith fever, progressing to bloody diarrhoea, shock, and death. The com
.;■lications intothe manifest phase are:
• The simultaneous invasion of an endogenous potentially path
ological bacteria into the bloodstream quickly overwhelms the
victim's ability to fight such infections, resulting in sepsis devel
opment, septic shock, and eventuallv death.
• Malabsorption (loss of absorbtive capacity) caused by the deple
tion of the crypts leads to maln u. "' . rcouung in less energy
production.
• Paralytic ileus (impaired bowe Is mo* emeu: causes vomiting
and abdominal distension;
• Fluid and electrolyte shifts r i u u r n ;u ' u Nr -
ure, and cardiovascular collapse.
• Gastrointestinal bleeding leads to anaemia.
• Radiation doses in the "--30 G range usually cause death from
the gastrointestinal (GI) syndrome. However, such doses also
produce potentially life threatening pulmonary effects of respir
atory insufficiency and pneumonitis, which will be seen 14-30
days after exposure. Pneumonitis is likely caused by a complex
of factors, including breakdown of vascular permeability, fluid
imbalance, free radical tissue interactions, infectious agent, bio
logical and chemical toxin damage, and inhalation injury from
heat, smoke, and fumes. The patient injured by fatal whole body
radiation may die of the GI syndrome before the pulmonary ef
fects become manifest. However, a patient spared the GI effects
by partial body shielding or dose inhomogeneities may succumb
to the pulmonary effects.
General symptoms of the Neurovascular syndrome
Acute radiation doses of 30 Gy and above cause death within 72
hours and usually between 24 and 48 hours, well before the damage to
the gastrointestinal or bone marrow systems becomes clinically appar
ent. Doses in this range cause significant direct effects, as well as, free
radical overload of the cells and basement membranes of the microcir
culation system. This leads to, among other damage, massive loss of
serum and electrolytes through leakage into the extravascular space, cir
culatory collapse, oedema, increased intracranial pressure, and cerebral
anoxia.
The prodromal period starts in less than an hour and possibly within
minutes of exposure, patients receiving these doses begin experiencing
prodromal symptoms: a burning sensation within minutes and severe
nausea and usually projectile vomiting within an hour. The symptoms,
which are severe and may last more than 24 hours, also include diar
rhoea that is occasionally bloody, cutaneous oedema and erythema, hy
potension, hyperpyrexia, disorientation, prostration, loss of co-ordina-
Nuclear Bomb Explosion ■s. Nuclear Plant Failure 1"* 1
1/1
tion, and possibly seizures.
The latent phase is brief with apparent clinical improvement; but
this will last only for hours to days.
The manfest ohase is characterized with:
• Rapid onset
• Watery diarrhoea
• Respiratory distress
• Gross central nervous systme signs
• Wide pulse pressure and Hypotension
The gross central nervous system dysfunction and total cardiovascu
lar collapse lead to a relatively prompt and inevitable death.
Radiation doses in this range are uniformly fatal regardless of thera
py attempted (T4), therefore, aggressive medical support with vasopres
sors, fluids, steroids could bring only temporary improvement and may
only serve to prolong suffering. Thus, therapy should be palliative in
nature - such as opiates, tranquillizers, antiemetics and antidepressants
administration is encouraged.
In order to start the adequate and efficient treatment it is required
estimation of the degree of radiation damage and exposure that is ex
tremely difficult. Sequential diagnosis and reassessment is mandatory
throughout the patient's clinical course. Prodromal symptoms begin
within hours of exposure. They are characterized by gastrointestinal,
skin and neurovascular signs and symptoms, which can include nausea,
\ omiting, diarrhoea, erythema or other skin changes . fatigue, weakness,
fever, and headache (Biological dosimetry has to be pergormed). The
prodromal gastrointestinal symptoms ge i erally sN : : last longer than
_4-48 hours after exposure, but a v a g e persist k r an un
determined length of time. The time : :
these signs are dose dependent and N: se-rie i - r - - :. : - Ί s.:: - ι “r
used in conjunction with early biologi---. pi:--=-==:rrs- ^ g ■_eeik*
cyte and lymphocyte levels, to deteimine far presence m i severity of
the acute radiation syndrome.

The rate and degree of decrease in blood cells are dose dependent.
An initial baseline sample should be obtained as early as possible after
irradiation. Blood samples should be taken at least daily during the first
2 weeks. The records have defined "If lymphocytes have decreased by
50 per cent and are less than 1000^L within 24-48 hours, the patient has
received at least a moderate dose of radiation".
The clinical experience has led to defining and the Fatal irradiation
signs:
1. Nausea and Vomiting. Vomiting within the first hour, especially
if accompanied by explosive diarrhoea, is associated with fatal doses.
Vomiting within the first 2 hours is usually associated with a severe
radiation dose. Due to the transient nature of these symptoms, it is pos
sible that the patient will have already passed through the initial phase
of gastrointestinal distress before being seen.
2. Hyperthermia. Casualties who have received a potentially lethal
radiation injury show a significant rise in body temperature within the
first few hours post-exposure. The occurrence of a fever (above 39o
Celsius) and chills within the first day postexposure is associated with
a severe and life threatening radiation dose. Hyperthermia may occur
in patients who receive lower but still serious radiation doses (2 Gy or
more).
3. Erythema. A person who received a whole-body dose of more
than 10 Gy will develop erythema within the first day postexposure.
This is also true for those who received comparable doses to local body
regions. In this case, the erythema is restricted to the affected area. With
whole-body doses lower but still in the potentially fatal range, erythema
is less frequently seen.
4. Hypotension. A noticeable decline in systemic blood pressure
has been recorded in victims who recei \ ed a lethal whole body radia
tion dose. Severe hypotension after irradiation is associated with a poor
Nuclear Bomb Explosion ■
·.s. Nuclear Plant Failure
prognosis.
5. Neurological dysfunction. Experience indicated tfej; afetnaei; all
persons who demonstrate obvious signs of damage to the c=n--,-c:l nerv
ous system within the first hour post-exposure have received a lethal
dose. Symptoms include mental confusion, convulsion . and •-i-ma. hi-
tractable hypotension will probably accompany these symptoms. D e*
spite vascular support, these partients succumb within 48 hours.
The practice provides also fast and easily performed orientation re
garding the probability of ARS development:
The patient with unlikely ARS demonstrates no more than episodes
of nausea and vomiting and usually retains lymphocyte counts abo ■ ·.e
1500/mm3 in 48 hours .
By contrast, the patient with probable ARS has prodromal symp
toms of more severe and sustained nausea and vomiting that commence
within 1 hour to 1 day of exposure and last for hours. This patient has
a lymphocyte drop to around 1000 to 1500 lymphocytes/mm3 but no
\ ascular or central nervous system symptoms.
The patient who has severe, potentially fatal radiation injury and
who may have to be categorized as expectant in a triage situation (T4),
presents with uncontrollable nausea and vomiting within 1 hour after
exposure. Those symptoms are frequentl ■ associated with prompt, ex
plosive, bloody diarrhoea, hypotension . a burning skin sensation, and
gross central nervous system signs.
The early clinical symptoms are the basis for sorting persons ex
posed to radiation and deciding upon proper medi cal care at an individ-
::al level. The most important prodromal early clinical signs are nausea,
vo miting, diarrhoea, skin and mucosa e=:1hema. Upon the dec i-
sion on hospitalization, in cases of wh<t : d;. ex;: s _ e w :er.
Patients in the emergency room m r
should be treated symptomatically andshould =-= daily
=-jood counts. Victims who have received doses _ : - = a. na:.ar
of less than 1 Gy might be followe ... up as outpatients if the laboratory
test (absolute lymphocyte count ' results and dose estimate seem appro
priate.
Lymphocyte counts are usuall y the first blood counts to drop af
ter exposure to ionizing radiation. A drop in lymphocytes occurs 24-48
hours after the injury. The speed and extent of the lymphocyte drop is
linearly proportional to the severity of the dose to the bone marrow. A
minor drop is noted after doses of0.25-1 Gy. At about 1.5 Gy, the drop is
around 50 %. At 3 Gy, the count drops to 1000/mm3; at 4-5 Gy, it drops
to less than 500/mm3. A drop to zero implies a dose of greater than 6
Gy. Thus, the drop in lymphocyte count is a crude but simple and sen
sitive, and therefore important, estimation of severity of injury within
48 hours of exposure. For example, a patient whose lymphocyte count
stays above 1500/mm3 after 48 hours may have received a clinically
significant dose, but the overall prognosis is quite good. On the other
hand, a patient whose count drops to less than 500/mm3 in 24 hours
demonstrates a profound life threatening injury.
Management of a radiation casualty involves simultaneously man
aging severe immune system compromise and resulting infectious
complications, and preventing haemorrhage and severe anaemia due
to thrombocytopenia. Doses in the haematopoietic syndrome range are
survivable. The therapeutic goal is to lessen the severity of neutropenia
and thrombocytopenia while minimizing and treating infection.
The medical management starts with activities towards infectious
complication. They could be devided into two groups:
1. Prophylaxis
• Barrier/isolation
• Gut decontamination
• Antiviral agents
• Antifungal agents
• Pneumocystis prophylaxis
Nuclear Bomb Explosion ·. s. Nuclear Plant Failure
• Early cytokine therapy

• Close wounds
• Avoid invasive procedures
2. Direct therapy for infections
• Culture specific antibiotics
• Therapy for leukopenia
• Cytokine administration
Patients exposed to radiation doses exceeding 2 Gy should be treated
in isolated wards. For moderate degree ARS patients (absorbed dose 2-4
Gy), isolation is necessary from days 10-20 and patients whose estimated
absorbed dose exceeds 4 Gy should be isolated from the beginning (as
early as possible). Initial care of medical casualties with moderate and
severe radiation exposure has to include early institution of measures to
reduce pathogen acquisition, with emphasis on low-microbial-content
food, acceptable water supplies, frequent hand washing (or wearing of
gloves), and air filtration. When possible, an early oral immuno-incom-
petent diet is preferred to intravenous feeding to maintain the immuno
logical and physiological integrity of the gut. Surgical implantation of a
subcutaneously tunnelled central venous catheter can be considered to
allow frequent venous access, but meticulous attention to proper care is
necessary to prevent disastrous catheter-associated infections.
Gut decontamination. In a situation of severe immunocompromise,
as ARS, a significant source of infection may be pathogenic bacteria that
normally inhabit the human colon. The pathoph ■siological changes that
ccur during radiation injury, combined "ith use of antibiotic therapy,
significantly alter the normal gut flora an c y gastrointestinal
pathogens to gain access to the patie nfs uistion - sepsiv dev elop-
ment. The usual strategy to comba v : :: - ; : . =.■:/ >e'edti\e
decontamination of the gut using r : :: d : - - : d . d^ddd.:^:.;'
drugs. Quinolones eliminate potentially pathc5==-:.: aerotk _::.am-neg-
ative bacilli, prevent colonization am.· i_rs=_ :~:e:
anaerobic bacteria, they assist to mainmm digestion of overexposed per

sons developing gastro intestinal syndrome. Other groups medicaments
for gut decontamination include Ciprofloxacin, Polymixin B, and Tri-
methoprim-Sulfamethoxizole or other sulphur-based oral medications.
Antiviral drugs (e.g. Acyclo ■ir) should also be considered.
Maintenance of gastric acidity (avoidance of antacids and H2 block
ers) may prevent bacteria from colonizing and invading the gastric mu
cosa and may reduce the frequency of nosocomial pneumonia due to
aspiration of these organisms. The use of Sucralfate or prostaglandin
analogues may prevent gastric haemorrhage without decreasing gastric
activity. When possible, an early oral immuno-incompetent diet is pre
ferred to intravenous feeding to maintain the immunological and physi
ological integrity of the gut.
Passive intravenous administration of immunoglobulins (IgG)
following acute radiation injury is a therapeutic measure employed to
counter the suppressive effects of irradiation on the immune system and
to diminish susceptibility to infection or its pathological consequences.
The more commonly applied strategy involves periodic blood infusions
in an attempt to bolster the diminished IgG blood plasma levels that are
critical in combating a variety of infections.
Broad spectrum Anibiotic coverage: Empirical/specific therapy
should be maintained until granulocytes exceed 800/mm3. If antibiotics
fail to control the fever, or if specific fungal or viral pathogens are sus
pected on clinical grounds, aggressive use of antifungal and antiviral
agents should be considered.
First, an empirical regimen of antibiotics should be selected, based
on the pattern of bacterial susceptibility and nosocomial infections in
the particular institution and the degree of neutropenia. Broad spectrum
empirical therapy with high doses of one or more antibiotics, avoiding
aminoglycosides whenever feasible due to associated toxicities, should
be used. Broad spectrum antibiotic co . erage includes double beta-
Nuclear Bomb Explosion vs. Nuclear Plant Failure "7'J
lactam antibiotics such as a third-generation cephalosporin and

ureidopenicillin, monotherapy with imipenem or a third-generation
cephalosporin, and vancomycin plus a third-generation cephalo
sporin.
If there is evidence of resistant gram-positive infection, Vancomycin
should be added. If diarrhoea is present, stool cultures should be ex
amined for salmonella, shigella, campylobacter and yersinia. Oral and
pharyngeal mucositis and esophagitis suggest herpes simplex infection
or candidiasis. Empiric antiviral and/or antifungal therapy should be
considered.
Surveillance cultures may be useful for monitoring acquisition of
resistant bacteria during prophylaxis and emergence of fungi. A once or
twice weekly sampling of surveillance cultures from natural orifices and
skin folds (e.g. axillae, groin) would be reasonable, but should be modi
fied according to the institutional patterns of nosocomial infections. A
chest radiograph should be considered at initiation of empirical therapy.
This may aid in definitive diagnosis of a new pulmonary infiltrate ob
tained during the course of neutropenia.
Antifungal coverage with Amphotericin B should be added, if in
dicated, for patients who remain persistently febrile for 7 days or more
on antibiotic therapy in association with clinical evidence of infection,
or if they have new fever on or after day 7 of treatment with antibiotics .
In radiation casualty management one area of potential debate con
cerns the relative merits and indications o ' total parenteral nutrition
versus an elemental diet delivered orally ata :: thttttgi'. a feeding tube.
Paenteral feeding has the advantage of deli vering large am ounts of care
fully tailored nutrition on a real time busts to- :: pare-- whose gastro
intestinal function may be compro -Tjisec F _ the— :re. futoitage
to the gastrointestinal tract is especially s;:-. ere :: m the e^ e of sev ere
vomiting, ileus, or obstruction, it is the only crttatt a a..a - .e
Cytokines administration Granul oc yte - tl-rct. Frm - at~g Factor
(G-CSF) and Granulocyte -Macrophage Stimulating Factor (GM-CSF)

increase rate of hemopoietic recovery in patients after radiation expo
sure, when stem cells are still iable. Interleukins (IL-1 and IL-3) act in
synergism with GM-CSF. These combinations were successfully used
for radiation victims after Goiania, San Salvador, Israel and Belarus and
Istanbul accidents.
A benchmark absolute lymphocyte count of less than 500/ml may be
considered a threshold for beginning cytokine therapy in the first 2 days.
The therapeutic goal of cytokine application is to minimize the extent
and duration of radiation induced neutropenia, and hence minimize the
subsequent risk of infection.
In order to achieve maximum clinical response, G-CSF or GM-CSF
should be started 24-72 hours after exposure. This provides the oppor
tunity for maximum recovery. Cytokine administration should continue,
with daily consecutive injections, to reach the desired effect of an lym
phocyte count of 1000/ml.
Bone marrow transplantation The timing of marrow grafting is
crucial. Experimental data suggest that the marrow should be infused
within the first 3-5 days of radiation exposure. This coincides with the
peak period of immunosuppression, therefore the graft rejection will be
less likely. The Chernobyl (1986) and Soreq (Israel, 1990) experiences
strongly suggest that bone marrow transplantation has a limited role for
the treatment of victims of radiation accidents and would be of benefit
to only a very small number of exposed individuals.
The effects of radiation on the gastrointestinal tract and the associ
ated symptomatology can be categorized into three major phases that
correspond to the elapsed time from exposure to manifestation.
Fluid and electrolytes administration Tausea and vomiting asso
ciated with the prodromal effects of radiation exposure leads to dehydra
tion. Therfore, tow activities are reuired - administration of antiemetics
(Metoclopramide) Im, or the new generation of 5-HT3-receptor antag-
Nuclear Bomb Explosion s. xuclear Plant Failure 179
onists such as ondansetron and granisetron. During the subacute and

acute phases, fluids and electrolytes have to be agressive .
to prevent or correct dehydration.
Treatment of radiation induced diarrhoea A number o t fa. tors
may contribute to radiation-induced diarrhoea. Diarrhoea as -ociated
with the prodromal and subacute phases of gastrointestinal injur' is most
likely related to neurohumoral factors affecting gastrointestinal motility
and transport. Loss of the epithelial cell lining is not observed until later
during the acute phase of gastrointestinal injury. As a result, treatment
for postirradiation diarrhoea will require several different approaches.
For the early prodromal and subacute phases of diarrhoea, agents
directed against or counteracting the effects of neurohumoral factors
on gastrointestinal cells should be considered. These include antidiar-
rhoeal/antisecretory agents such as anticholinergics, metamucil, am-
phogel, and loperamide. Loperamide may offer distinct advantages as
this drug affects both intestinal cell transport and motility, each of which
may contribute to diarrhoea. Antisecretory agents, however, will be of
limited effectiveness against the acute phase of gastrointestinal injury,
curing which the loss of epithelial cell lining has progressed to denuda
tion of the intestine.
Loss of the mucosal crypt stem cells eliminates the bowel's ability
: ■replenish the short lived mucosal cells. Currently, the processes in
v olved in stimulating proliferation an J or maintaining the intestinal cell
lining following radiation exposure are not folly described, therefore,
specific therapies for the acute phase of gastrointestinal injur7are still
:.::.ider development.
Cytokines that have proven efficacy in pro—utmg re-covery of hae-
= itopoietic injury may be beneficial ::: ir.'.es.me ^ .··.. si-ffoier.i
.:2ta concerning the efficacy of these a g e n t s a - . -:-- i~>. in spite
considerable advances in the treatment o: nion in;_τ·. n: patient
n th foll-scale gastrointestinal syndroneh^s=--· - - Tr_s r· ste- and
180
possibly the lungs are the organs ftiat can limit survival probability, as
suming the patient survives the : ne marrow damage as well.
Correction of the peripheral blood changes. In order t0 treat
haemorrhage, imunnity inj'u r · and the anemia a compensatory admin
iStration of blood cellular masses (Lymphocytes mass, Thrombocytes
mass and Erythrocyte mass) has to be considered. The blood transfu
sions is extremely dangerous becuse of the high risk of graft versus host
reactions. Therefore, the whole blood are administered only if the blood
is irradiated to erradicate the proteins from the plasma.
Atomic_bomb_explosion vs
Nuclear power_plant_accident_DMS challenges
The great majority of casualties with ARS were affected during the
nuclear power plant accidents and nuclear weapons (atomic bombs etc)
implementation. Both of the events are leading to the RAOD development,
but the AOD have several variations that are with significant impact on the
DMS organization and management.
Both - atomic bomb and nuclear power plant reactor are constructed on
the nuclear fission. Fission can occur when a nucleus of a heavy atom cap
tures a neutron, or it can happen spontaneously (radiactive decay). (fig. 12)
Figure 12. Nuclear fission (97)

Nuclear Bomb Explosion vs. Nuclear Plant Failure ISI
When a nucleus fissions, it splits into several smaller that

are about equal to half the original mass. Two or three neutrons are also
emitted and always the sum of the masses of the fragments is less than
the mas of the atom, because part of the mass (0.1 % in accordance to the
Einstain) is converted into the energy released. If the neutrons released
in fission produce an additional fission in at least one further nucleus
the reaction is named chain reaction, because the secondary affected
nucleus in turn produces neutrons, and the process repeats. The process
may be controlled (nuclear power) or uncontrolled (nuclear weapons).
Although two to three neutrons are produced for every fission, not
all of these neutrons are available for continuing the fission reaction. If
the conditions are such that the neutrons are lost at a faster rate than they
are formed by fission, the chain reaction will not be self-sustaining. At
he point where the chain reaction can become self-sustaining, this is
referred to as critical mass.
In an atomic bomb, a mass of fissile material greater than the critical
mass must be assembled instantaneously and held together for about a
millionth of a second to permit the chain reaction to propagate before
the bomb explodes. The amount of a fissionable material's critical mass
depends on several factors; the shape of the material, its composition
and density, and the level of purity.
A sphere has the minimum possible surface area for a given mass,
and hence minimizes the leakage of neutrons. B > surrounding the fis-
s.:enable material with a suitable neutron "refle rtor' ', the loss of neutrons
:an be reduced and the critical mass can Ne re iu red. ' 9 >
In the nuclear power plant reactions , a 5N5:a::-.ea T rolled chain
.ction is applied. To maintain a susta: : 4 ... . riled nuc .... :. t reaction,
r every 2 or 3 neutrons released, oni. yore ro®t allo--;,;e d to strike
arother uranium nucleus. If this ratio ·r lez> ------ --=' ----==- ----eraa::::r
die out; if it is greater than one it wI —cae=oMed an atomic
ex-rlosion). A neutron absorbing eleme . . . - -
amount of free neutrons in the reaction space. Most reactors are con
trolled by means of control rods that are made of a strongly neutron-
absorbent material such as boron or cadmium. (fig. 13)
N uclear P ow er P lant S chem atic

Cooling Tower
Figure 13. Nuclear power Plant
In addition to the need to capture neturons, the neutrons often have

too much kinetic energy. These fast neutrons are slowed through the use
of a moderator such as heavy water and ordinary water. Some reactors
use graphite as a moderator, but this design has several problems. Once
the fast neutrons have been slowed, they are more likely to produce fur
ther nuclear fissions or be absorbed by the control rod. (fig. 14)
Nuclear Bomb Explosion s. Nuclear Plant Failure 183
M o d e ra te d , c o n tro lle d fiss io n o f u ra n iu m -2 3 5 moderate-

moderator nuclei 1.
fast neutron
neutron r-Q
slow
neutron 742
slow neutron
neutron _
-. Q- i f Q V'
' fast ^
neutron
neutron
moderator nuclei
fast
slow neutron neutron
neutron Γ Ίί slow
92Q neutron
w tifsy a - slow
/
uranium-235
nucleus
fast
neutron fast
neutron
neutron
moderator
© 2 0 1 2 Encyclopedia Britannica, Inc.
Figure 14. Slowing the neutrons (98)
The spontaneous nuclear fission rate is the probability per second

that a given atom will fission spontaneously--that is, without any exter
nal intervention. If a spontaneous fission occurs before the bomb is folly
ready, it could fizzle. Therefore, the critical mass in the atomic bombs
has to be obtained a part of the seond prior the explosion. In the first
bomb - "the Little Boy" this was achie i ed b i specific design consisted
of a gun that fired one mass of uranium 23 5 at another mass of uranium
_35, thus creating a supercritical mass. \ cmdal requirement was that
the pieces be brought together in a time shorter than the time betveen
spontaneous fissions. Once the tv. o pieces :::: .rarn^n are Drought to
gether, the initiator introduces a burst : : r . u : r s m :'.-.e . .v: re Action
begins, continuing until the energy re leasee becomes so great that the
bomb simply blows itself apart. (fig. . 5
U ranium 235
Detonator
Conventional Charge
£’ atomtsarciwa.eofn
Figure 15. The Little boy (97)
As the plutonium used in the second bomb "Fat man" contained

plutonium 240, an isotope with a rapid spontaneous fission rate, a new
design design was applied - the fissile material was surrouded by ex
plosives. These explosives when detonated form a shock wave pushing
the two parts of fission material one to another and creates a significant
pressure - the mass becomes critical, and then supercritical (where the
chain reactions grow exponentially). At this moment the initiator is re
leased, producing many neutrons, so that many early generations are
bypassed. Started chain reaction continues until the energy generated
inside the bomb becomes so great that the internal pressure due to the
energy of the fission fragments exceed the implosion pressure due to the
shock wave and the bomb disassembles, the energy released in the fis
sion process is transferred to the surroundings. (fig.16)
Nuclear Bomb Explosion \ s. Nuclear Plant Failure 185
Uranium 238
Hollow Plutonium Sphere
Conventional Explosives
Polonium-Beryllium Initiator
Ο a t o ^ ^ ^ iv e . c o m
Figure 16. The Fat man (98)

When an atomic bomb explodes there are several DFs released.
(fig.17)
Lethal l)fompt (initial) radiation
Severe shockwave damage ^Sevee thermal damage
Prevailing Wind
radtoariive fanout pattern
^wbsfte
Figure 17. Atomic bomb A O D s 99,
One of the fundamental differe ■.: 5 -e:-., -er.::. :^ ' a conven

tional explosion is that nuclear e i V": <or
millions) of times more po\.\■erful ' :ir : . r.N. ra
tions. Both types of weapons re .' i r^ - —. = ::::: = of th^ bSsst
wave. However, the temperatures reached in a nuclear explosion are

very much higher than in a conve t. ·■nal explosion, and a large propor
tion of the energy in a nuclear explosion is emitted in the form of light
and heat, generally referred to as thermal energy. This energy is capa
ble of causing skin burns and of starting fires at considerable distances.
Nuclear explosions are also accompanied by various forms of radiation,
lasting a few seconds, or remaining dangerous over an extended period
of time. (fig. 18)
Figure 18. Energy released in atomic bomb blast (97)
Approximately 85 percent of the energy of a nuclear weapon pro

duces air blast (and shock), thermal energy (heat). The remaining 15
percent of the energy is released as various type of nuclear radiation.
Of this, 5 percent constitutes the initial nuclear radiation, defined as that
produced within a minute or so of the explosion - mostly gamma rays
and neutrons. The final 10 percent of the total fission energy represents
that of the residual (or delayed) nuclear radiation, which is emitted over
a period of time. This is largely due to the radioactivity of the fission
products present in the weapon residues, or debris, and fallout after the
explosion.
Nuclear Bomb Explosion s. Nuclear Plant Failure
_______________________________________________________ 187
From this brief overview of the DFs associated :th line :r e

bomb explosion could be concluded taht the AOD is a combined one.
The DFs present into this combined area are the blast wa ■ . e . the thermal,
overpressure and the ionizing radiation. Th electromagnetic impulse re
leased into the explosion has also to be considered.
Nuclear explosions produce both immediate and delayed destructive
effects. Blast, thermal radiation, and prompt ionizing radiation cause
significant destruction within seconds or minutes of a nuclear detona
tion. The delayed effects, such as radioactive fallout and other possible
environmental effects, inflict damage over an extended period ranging
from hours to years.
The first and most important from medical point of view is the AOD
caused by both the balst wave and overpressure. The blast wave pro
duced the time of explosion (50 % of the bomb energy) radiates out
ward, producing sudden changes in air pressure that can crush objects,
destruct and knock objects down. A fraction of a second after a nuclear
explosion, the heat produced by the released during the nuclei fission
energy causes a high-pressure wave to develop and move outward pro
ducing the blast effect. The front of the blast wa ce, irradiates at all direc
tions rapidly - an extremely fast moving , . all of highly compressed air.
Moreover, the air immediately behind the shock front is accelerated to
high velocities and creates a powerful wind. These winds in tum create
dynamic pressure against all the objects facing the bias:. Theblas: V!·ave
causes a virtually instantaneous jump :: r ess ee : : :: . e . re
combination of the pressure jump s e e s : e e : :e i -
namic pressure causes blast damage. The = --. —_g pres e e simpiy de
creases for a tenth of a second and .ee : e s-_ _ .
vanishes into the air.
Blast damage is caused by the isiwil^sl ft© tay»si «**§§«§£ b f
the nuclear explosion. Humans are aetÛy _ _.:=- s t i : ' e e e e ; -
effect of overpressure. Pressures of over 40 ;r . e rer __ e ~ e-
ter) are required before lethal e :jfects are noted. The real threat from
overpressure comes from the collapsing buildings. The buildings de
pending on the material and construction could resist from 3 to maxi
mum 8 psi. The collapsing of the structure could bary under the debris
and can crush or suffocate those caught inside.
Population is under the impact of the projectiles from the bomb, soil,
destructed objects that travel with high velocity along with the winds
following the blast wave.
Serious injury or death can also occur from impact after the casualty
being thrown through the air and is fallen on the ground.
In general, large buildings are destroyed by the change in air pres
sure, while people and objects such as trees and utility are more resist
ant. This AOD has four different zones and they are related to the de
structions caused:
1. Zone of complete destruction;
2. Zone of severe (beyond) destruction;
3. Zone of moderate (repaireble) destruction;
4. Zones of light destruction.
All the casualties within this AOD sustained diverse types of trau
mas, as the poly and combined traumas are predominant.
Thermal radiation effects (approximately 35 percent of the energy
from a nuclear explosion) are caused by an intense burst of thermal ra
diation (heat). It is the primary form of energy from a nuclear explosion.
In the beginning of the explosion, most of this energy goes into heating
the bomb materials and the air in the vicinity of the blast. Tempera
tures of a nuclear explosion reach those in the interior of the sun, about
100,000,000° Celsius, and produce a brilliant fireball. Thermal radiation
emerges from the fireball as radiation in the ultraviolet region (lasting
about a tenth of a second) and a second puke that last for several sec
onds and carries about 99 percent of the total thermal radiation energy.
This second pulce is the main cause of skin bums and eye injuries suf-
fered by exposed individuals and causes combustible mate ri als to break
into flames.
Thermal radiation travels almost with the speed of light . therefore
the first DF that impacts the population and the invironment is the ther
mal one. The flash of light and heat precedes the blast wave by se r eral
seconds.
Thermal radiation damage depends very strongly on weather condi
tions. Clouds or smoke decrease considerably the damage.
Thermal radiation also affects humans both directly - by flash bums
on exposed skin - and indirectly - by fires started by the explosion. Skin
bums result from higher intensities of light, and therefore take place
closer to the point of explosion. The thermal radiation from a nuclear
explosion can directly ignite materials. In general, enough combusti
ble material to generate a self-sustaining fire is found within the houses
(furniture) or the inderect fires when fuel into cars, gas lines, stores, sta
tion is affected by the thermal factor.
Related to the bums degrees 4 zones could be distinguished within
the thermal AOD:
1. Zone of the 4-th degree bums - necrosis of full-thickness skin and
the undrlaying layers;
2. Zone of the severe bums - 3-rd degree (ulcers within the skin lay
ers);
3. Zone of moderate bums - 2-nd degree ■edema and blisters);
4. Zone of the erythema.
A 1-megaton explosion can cause erythe ma first-degree bums) at a
distance of about 12 km., second-degree ai distanres of about 9
km. miles, and third-degree bums up to - ·— m il«. and fourth-degree
bums (with direct life threat) up to 5 ^ - int of explosion.
The third-degree bums over 24 percen: c f fire rocy. or second-degree
bums over 30 percent, have to ·..e 7 ;:;?=-=- ^ ' n■fir be .:a. : e
result in serious shock (both traumatic ar.d r/o :
Regarding the significance of : e thermal injury after the atomic

bomb explosion the records of the deaths at Hiroshima and Nagasaki
present data that burns caused some 50 percent of them.
Flash and residual blindness are also caused by the initial brilliant
flash of light produced by the nuclear detonation. Great majority of the
casualties received amount of light on the retina less than required for
irreversible injury. The retina is particularly susceptible to visible and
short wavelength infrared light. The result is a bleaching of visual pig
ment and temporary blindness. Vision is completely recovered as the
pigment is regenerated. Rarely a residual blidness occurs in cse of inten
sive energy impact that results in permanent retinal burn.
A I-megaton explosion can cause flash blindness at distances as
great as 22 km. on a clear day, or above 85 km. on a clear night (pupils
are wider during night time). Retinal injury is the most far-reaching in
jury effect of nuclear explosions, but it is relatively rare since the eye
must be looking directly at the detonation.
Direct (Initial) nuclear radiation occurs at the time of the explosion.
Initial nuclear radiation is defined as the radiation that arrives during
the first minute after an explosion, and is mostly gamma radiation and
neutron radiation. The level of initial nuclear radiation decreases rap
idly with distance from the fireball. The initial radiation lasts only as
long as nuclear fission occurs in the fireball. It represents only about 3
percent of the total energy in a nuclear explosion. The initial radiation
can be very intense, but its range is limited. For large nuclear weapons,
the range of intense direct radiation is less than the range of lethal blast
and thermal radiation effects. However, in the case of smaller weapons,
direct radiation may be the lethal effect with the greatest range. Direct
radiation did substantial damage deterministic and stochastic effects to
the residents of Hiroshima and Nagasaki.
Fallout (Secondary) radiation contains about 60 percent of the total
radioactivity of a nuclear explosion. Fallout is emited by the particles
Nuclear Bomb Explosion . s. Nuclear Plant Failure
that are made radioactive by the effects of the explosi ja (fluey are pol
luted form the initial radiation), and subsequently di stribuied a: \ ary-
ing distances from the site of the blast. This radiation dbiwcs fro«i me
weapon debris, fission products, and, in the case of a gro .md foimt, (radi
ated soil. There are over 300 different fission products mm /
from a fission reaction. Much of this products vary in size an in lb di
rectly back down close to place of the explosion within several minute s
after the explosion (early fallout, within the first 24 hours) . but some
travels high into the atmosphere and fall down days or years later (de
layed fallout). The radioactive particles that rise only a short distance,
the heaviests, will fall back to earth within a matter of minutes, landing
close to the center of the explosion. They do not cause many deaths,
because fall in areas where most people have already been killed by the
blast wave and the thermal DF. The radioactive particles that rise higher
will be carried some distance by the winds before falling down on Earth.
Depending on the temperature at time of explosion (defining the height
of raise), the particles weight, speed and direction of the wind, prob
ability of precipitations, is the lenght of the formed RAOD. Majority of
the material is simply blown downwind in a long plume or falls with the
rainfall. The soil, vegetation, living creatures receiving such contami
nation are becoming emiters of ionizing radiat'on - hot spots, ' with
greater radiation intensity than their s r o u a ding 5-
Great variety in the lenght of their decay- ii oirser. e. but me pri ncipal
mode of decay is by the emission of beta policies g ^ . —a radiation.
Most of the ionizing radiation comes t o rn sh:-:-:-=.:--*»e a r a mammesex
ternal to the body with half-li ses of seconds m a re- rnrcmi- arm mrm
soil and other materials in the , isabaftLym ate f a u n a s w jShui »aim . fey
the intense neutron flux. Most of ife piracies decty rrojiL; mr mere
are and areas contaminated from lons-fived naaka.-. ; ~- ;
strontium 90 or cesium 137. Their etfects me m a amm_ * a _*r.
population and complicating efforts ^ sfaspe i t *. 4
The most hazardous radioa . rive elements are as follows:
1. Strontium 90 is very long-lived with a half-life of 28 years. It is
chemically similar to calcium . therefore accumulates in growing bones.
This radiation can cause tumors, leukemia, and other blood abnormali
ties.
2. Iodine 131 has a half-life of 8.1 days. Ingestion of it concentrates
in the thyroid gland destroying it. Potassium iodide can reduce the ef
fects.
3. The amount of tritium released varies by bomb design. It has a
half-life of 12.3 years and can be easily ingested, since it can replace a
hydrogen in water. The beta radiation can cause lung cancer.
4. Cesium 137 has a half-life of 30 years. It is similar to potassium,
therefore is distributed uniformly thoughout the body. Contributes to
gonadal irradiation and genetic damage.
5. When a plutonium weapon is exploded, not all of the plutonium
is fissioned. Plutonium 239 has a half-life of 24,400 years. Ingestion of
as little as 1 microgram of plutonium, a barely visible speck, is a serious
health hazard causing the formation of bone and lung tumors.
Electromagnetic pulse is an electromagnetic wave similar to radio
waves. It derives from secondary reactions, when the gamma radiation
is absorbed in the air or ground. It creates much higher electric field than
radio signals and as a single pulse of energy disappears completely in
a small fraction of a second. There is no evidence that this impulse is a
physical threat to humans, but electrical or electronic systems are dam
aged within hundreds of kilometers. Example of the leght of the dam
age is the nuclear test from 1962, the "Starfish Prime" test (1.4 Mt) that
turned off 300 streetlights in Oahu, Hawaii (1300 km. away)
The AOD after the nuclear power plant explosion is combined only
within the surroundings of the reactor, where a very modest area of blast
wave and thermal DF (from the explosion) could be observed. The main
health threat is related to the initial and secondary, in particular, ionizing
radiation.
Comparing both AOD the following differences ha \ e to be consid
ered:
1. More DFs in case of atomic bomb explosion - main damages re
lated to the blast wave and thermal one. Mainly radiological threat in
case of nuclear power planr accident.
2. Higher temperature at the spot of explosion, in case of bomb ex
plosion, that leads to higher rise of the radiactive materials than into
plant accident.
3. Larger mass of nuclear fuel as a source of contamination in the
plant accident.
4. Longer disposal of radioactive substances in case of power plant
failure in comparison with the bomb explosion.
5. Because of the longer disposal, the fallout cloud and trace from
the failed reator are uneven, mutable, variable and erratic.
6. Lower temperature - emission of larger particles on lower height
into the nuclear plant accident.
7. Greater variety of radionucleids for nuclear power plant accident.
This great variety defines and the longer pollution form the elemnts with
extremely long period of half decay.
All these defines the different challenges towards the DMS for the
affected and population at risk in these AOD.
RADIO-DERMATITIS
Highlights
1. Definition
2. Pathophysiology of the changes
3. The most vulnerable to the ionoizing radion skin structures
4. General symptoms
5. Forms of radiodermatitis
6. Degress of the acute dermatitis
7. Ionizing radiation doses leading to the different degrees
8. First degree - pathophysiology and symptoms
9. Second degree symptoms
10. Third degree symptoms
11. Fourth degree symptoms - skin and general
12. Treatment of the acute radiodermatitis
13. Chronic radiodermatitis symptoms
14. Chronic radiodermatitis complications
Radio-dermatitis is a cutaneous inflammatory reaction to exposure

to biologically effective levels of ionizing radiation. (100, 101). The
changes observed could range from erythema to wet desquamation of
the skin and ulcers development in acute form; tissue atrophy, fibrosis,
and permanent scarring in chronic form. Permanent changes in skin pig
mentation can also occur (102, 103)
The radiation dermatitis is caused by the impact of the radioactive
elements, alpha-, beta- and gamma particles and X-rays on skin. Each
type of ionizing radiation has an energetic characteristic that determines
changes in the skin and the body as a whole. The most vulnerable is
the fraction of rapidly proliferating cells in the basal layer of the skin.
They are affected by the radiation, injured or destroyed. This leads to
precipitating a decrease in the population of differentiated epidermal
Radio-Dermatitis I95
keratinocytes and can result in desquamation, (peeling an ·: ::
the epidermis) depending on the total dose of radiation delive red. (104)
Loosing the epidermis affects the main function of the skin. Im r aim ent
of the skin barrier function incrases the risks of wounding and infer-
tions.
Radiation could also affect and damage the microvascular s vstem,
increasing the risk of tissue hypoxia and fibrosis. These processes are
activating an inflammatory cascade, leading to acute and chronic skin
changes. Hair follicles and sebaceous glands can also be affected in the
early stages of the radiodermatitis deveopment.
Skin changes depend on the dose, location and area of the irradi
ated skin area. Radiation dermatitis is recorded among the professions
related to radioactive radiation - radiologists, radiologists, laboratory
workers, industrial workers, miners in radioactive mines and patients on
radiotherapy.
The skin changes occur in two forms:
1. Acute radiodermatitis.
2. Chronic radiodermatitis.
Skin changes characterizing the acute dermatities depends on the ab
sorbed dose and are example of the deterministic effects of the ionizing
radiation. General symptoms of radiation bums include:
1. redness;
2. itching;
3. flaking;
4. peeling;
5. soreness;
6. moistness;
7. blistering:
8. pigmentation changes;
9. fibrosis, or scarring of co· iiti.ee.__-. =
10. development of ulcers·
Depending on the absorbed i%se there are four degrees of radiation

deramatitis.
First degree occurs after single a single exposure dose of 0.15 C/kg.
Changes are expressed in initial faint erythema (redness) and swelling
of the skin. The initial mild erythema that is visible within hours after
the irradiation is transient. It is likely due to capillary dilation shortly
after the exposure to radiation. The more conventional erythema and
sustained hyperpigmentation appeared 2 - 4 weeks after the irradiation.
Affected hair follicles and sebaceous glands lead to dry skin and hair
loss. The erythema is associated with edema, pruritus, tenderness, and a
burning sensation. Dry desquamation, which manifests as pruritus and
flaking of the skin, starts from the 3-th to 6 weeks after the irradiation,
at cumulative doses above 20 Gy. First degree skin chage (erythema) is
associated with epillation, the scaly skin (dry desquamtion), decreased
sweating and temporarily pigmentation.
The second degree occurs after irradiation with a single exposure
dose of 0.26 C/kg, with a strong swelling and reddening of the skin - the
erythema is tender and bright, 1-2 weeks after the exposure. A moist
patchy desquamation is following. Has to be noted that the moist des
quamation is predominantly confined into the skin folds and creases.
Subsequently, a permanent epillation occurs in the irradiated area. Skin
changes are accompanied by burning sensation and pain.
A third stage occurs after a single exposure dose of 0.31 C/kg. After
a hidden period of 5-6 days, intense blushing of the skin with multi
ple bubbles full with clear or purulent, pyogenic fluid occurs. Bubbles
spontaneously, rapidly burst. The blisters are replaced by hard-to-heal
to non-healing ulcers are formed at their place. Moist confluent desqua
mation of the irradiated skin, even outer of the skin folds. The edema
is pitting one. Skin bleeds with minor truma - touch only. changes are
accompanied by burning and pain.
The fourth degree occurs after a single exposure dose of 0.39 C/kg.
Radio-Dermatitis
In addition to third-degree changes, areas with necroti t -.

here. Skin changes are full-thickness necrosis, ulceration m$l,
ous bleeding (haemorrhage). The patients have impaired general
tion, fatigue, increased body temperature, vomiting, adeno :na,, I... jkiMry-
topenia. Later, the skin in the irradiated areas is thinner an ·.: r i
as the hairs fall off.
Typical of all grades for acute radiodermatitis is the sharp belint -
tion of the affected irradiated areas of the surrounding health\ s : ·r„
The treatment is performed with epithelial and anti-inflamma :
agents, vitamins, biogenic stimulants. It is difficult and prolonged. Dam
aged skin areas are incomplete and easily susceptible to inflammation
and infection.
Chronic radiodermatitis. Skin changes occur after repeated exposure
to low doses of radioactive rays, sometimes after decades, but not less
than 90 days after the exposure to the ionizing radiation.
Chronic skin changes may result from aberrant or dysregulated al
terations in proinflammatory and profibrotic cytokines. (105, 106, 107)
The changes vary - may include hypopigmented or hyperpigmented
skin that persists after or develops after the acute phase of dermatitis. A
lot of skin structures could be lost - sebaceous glands, hair follicles, and
nails. Textural changes to the skin are also recorded. (108, 109) Changes
are observed in the epidermis and dermis - they could be thinny or even
atrofic, or induration and thickening of the dermis could be observed.
As a result of blood vessel dilation telangiectasia are frequently pre
sent. Damage to the blood vessels results in tissue hypoxia that could
facilitate the development of skin uIcerati on and or chronic hard-to-heal
wounds. (ll0) One of the most significant consequences is the dev el-
opment of the radiation-induced fibrosis. Tbs bfrosrs ooobi r a s e skin
retraction that may lead to joint · ,: i; r O o s o r r m re:s:s:e:'.:
hyperpigmentation. (111, 112 : 1i· S: e r r . · es ;: -. r
burst into dirty-gray ulcers with u n d e _ _ b l u i s h
edges. These changes are considered precancerous.

Treatment of chronic radioderrnatitis is generally the same as in
acute radiodermatitis. Especiall heavy changes occur in a thermonu
clear blast. Then, in addition to distorted injuries and bums, under the
influence of gamma rays, the acute or chronic radiation syndrome devel
ops. The treatment of acute or chronic radiation syndrome is complex
and is carried out by specialized doctors' teams - hematologists, reani
mators, infectious diseases specialists, gastroenterologists, general and
plastic surgeons.
Disaster Medical Support In Case OfArea Of Biological Damage 199
DISASTER MEDICAL SUPPORT IN CASE OF AREA

OF BIOLOGICAL DAMAGE
Highlights
I. Definition
2 . DF
3. DF characteristics
4. AOD
5. AOD Zones
6. Casualties
8. Medical activities required
9. Medical activities particularities
10. Observation
II. Quarantine
Biological area of damage (BAOD) could be defined as the area

where the environment and the living organisms are affected by the bio
logical damaging factor.
Biological DF are viruses, bacteria, protozoa, prions, or fungi and
their toxins. Each of them has specific characteristics that will determine
the epidemic process in the BAOD. These characteristics are:
1. Contagiousness (or Infectivitv <refers to the proportion of exposed
persons (those entering into contact with the bio-agent) who become in
fected. Pathogenicity (or Morbidity ■refers ^ i&e proportion of infected
individuals who develop clinically a vparer: disease.
2. Virulence refers to the s e v e r .. .. _ manifestation and
the course of disease.
3. Mortality refers to the perce::::cage .:=== tnfeoed who are dying
due to the infection.
4. Resistance of the bio-agent imo err-.t := = ^ : This enacacteristic
is of utmost importance for the jread of infection and the size of the
BAOD, respectively.
5. Drug resistance refers to the ability of the microorganism to re
duce the effectiveness of the medication applied during the treatment of
the disease.
6. The stage of subclinical disease, extending from the time of ex
posure to onset of disease symptoms, is usually called the incubation
period for infectious diseases. During this phase the casualties are una
ware of their infection, therefore are spreading the biological agent and
increasing the risk for disease occurrence.
BAOD could be caused by an epidemic or be a result of the delib
erate usage of biological weapons or be a secondary damaging factor
in different disasters, because of the impaired sanitation and hygiene.
(2, 3, 11, 27, 28) The reasons for the last are impaired waste manage
ment, contamination of the environment, high density of the population
in health centers and lack of hygienic supplies and jeopardized primary
healthcare.
The casualties in the BAOD are two types:
• Primary - infected directly from the source or vector of the dis
ease.
• Secondary - infected by the primary casualties. (11)
Disaster medical support in case of BAOD has specific features.
This is the only area of damage where search and rescue teams don’t
enter. Efforts on disaster management are performed primarily by the
medical teams, assisted by police and armed forces. Casualties are not
evacuated out of the BAOD. Care is provided inside and measures are
taken to control the spread of the biological agent. (11, 26, 27)
Medical standard operating procedure is:
1. Active search of infected casualties and casualties that have had a
contact with infected ones.
2. Isolation and treatment of the info ted and monitoring of the ones
Disaster Medical Support In Case OfArea Of Biological Dam . ge : a
that had a contact (during isolation);

3. Isolation and treatment of the infected, isolation an. m omtonng
of the ones that had contacts (during quarantine);
4. Health education activities;
5. Passive immunization;
6. Strict sanitary control;
7. Active immunization.
Restrictive measures are necessary to limit the spread of the disease.
They are observation and quarantine.
Observation - Observation is used to separate ill persons who ha ■e a
communicable disease from those who are healthy. BAOD is circled by
two cordons - outer, guarded by the police, and inner - operated by anti
epidemic teams and squads that make checkpoints for going in and out
of the area. Exiting the area is possible after isolation for a period equal
to one maximal incubation period -if the person shows no symptoms
of the illness. Entering the guarded zone is possible if demanded by ur
gent needs. Anti-epidemic teams visit all homes to look for people with
symptoms, check temperature and perform sanitary education. Those
with symptoms are isolated in infectious disease departments or tempo
rary hospitals established in schools, theaters or other public buildings.
People in contact are advised to stay at home and are observed. People
are advised to limit contacts outside family members. All mass gather
ings are prohibited. Public administration is functioning. People can go
out of their homes to get food, goods and sa n ita, materials.
Quarantine - Quarantine is used t o sep_ aie and restrict the move
ment of well persons who may have been exposed to a communicable
disease to see if they become ill. I=p'e—e.::.:ed ft: - BAOD caused by
extremely dangerous infectious agents. Outer : is guarded by the
armed forces. Only teams engage . in êe. ore allowed
oenter.They wear protecti : e ee.r.rrte-: e r - ftsaue.aoa
before exiting the area. Every o ::e , t_r , ------ . - ·--____ :::s are
202 Disaster Medicine Highlis*_
not allowed. Food is pro\ ided in specific places and timetable is estab
lished for taking it in order to a\ oid contact. Those who are infected
isolated away from all other patients and receive appropriate medic^
care. Those who were in contact -v ith the infected are also isolated in in
fectious disease department, but separate entirely form the ward, where
the casualties with symptoms are treated, and observed for symptoms.
Measures to control the disease include passive immunization o:
the population at risk with the objective to increase individual and col
lective immunity using immune stimulators - gamma globulins. Entire
population at risk, but those with symptoms, are the object of this im
munization. The passive immunization starts when BAOD is declared.
After identification of biological agent, active immunization with spe
cific vaccines is performed to everyone with two exceptions - those with
symptoms and those that were into contact with them.
Medical specialists that are required are - infectious diseases spe
cialists, specialists internal medicine, general practitioners. Significant
is the role of the epidemiologists.
Sanitary education aims to inform the population about the epidem
ic, to explain the measures that are undertaken, to educate them on the
risk factors and required prevention. Most common symptoms are dis
cussed, so that people can actively seek help if they experience them or
such a symptoms are identified on another person.
Strict and enhanced sanitary control in the BAOD is performed.
BAOD is eradicated when no new infectious cases are presented for
one maximal incubation period of the disease. Then additional active
medical intelligence is performed for 3 more weeks.
Sanitary Control
SANITARY CO \TROL
Highlights
1. Definition
2. Objective
3. Time for execution
4. Structures
5. Types
6. Steps
Sanitary control is defined as complex of measures performed to

prevent from any harm coming from the environment.
The objective is to protect the population and environment from
possible health threats. This is achieved by eradication of the damaging
factors. If sanitary control is not performed, DFs could affect population
long after the end of the disaster.
Sanitary control is performed constantly. (11, 27) Anti-epidemic
teams from Regional Health Inspection are constantly monitoring the
environment and checking the quality of air, water, as well as the soil pol
lution. Checks are performed by groups educated, trained and equipped
for taking samples from different surfaces. After samples are taken they
have to be inserted into specific for every sample container, labeled
and transported within particular time frame to laboratories (sanitary-
chemical, radiological, microbiological and toxicological) for qualita
tive (for presence of contaminants ) and quantitative (what is the extent
of the pollution) analyses. With regard to the lab results decontamina
tion measures are taken or awareners regarding prohibition of use could
be issued. This process is called ifaiifii -xvous Sanitary control. In case
of disasters the capabilities of the srni etures involved are enhanced by
the police, FSPP and veterinan se.r :-..es. Bigger amount of samples is
analyzed and the frequency of tesrir ineveased. Main focus is set on
the DFs and their possible impact by polluting environment - enhanced

sanitary control.
Main tasks of sanitary control include:
• To detect available and potential health hazards.
• To measure the level of contamination.
• To make decision regarding the safety of the environment.
• To plan and implement preventive measures that assures popula
tion health.
• To plan and execute eradication activities.
The steps that are compulsory in sanitary control are:
1. Observation of the environment to choose the most appropriate
source for taking samples and inflict more probes.
2. Sampling - taking samples, labeling and transporting them to the
specific for the DF or contaminant laboratory.
3. Indication - into the laboratory the type of the contaminant and
the level of pollution are analyzed.
4. Sanitary expertise - evaluation of the potential of the detected
pollution to cause harm and the risk level for the population health.
5. Decision regarding utilization - based on the result of the sanitary
expertise is decided if a product is safe to be used or it poses danger/
threat to the population.
6. Decision regarding decontamination or eradication. All contami
nated areas that are considered dangerous undergo either decontamina
tion or eradication.
7. Eradication is executed when the risk level is high and poses real
threat for life or residual disability. These products are eradicated by
burning or burying. All biologically contaminated are burned. Radio
logical and chemically contaminated are first decontaminated and after
wards are buried into specific locations. These places (dumps for toxic
and radiological waste) for storing and eradication of dangerous goods
are labeled and access is restricted until measurements show no residual
Sanitary Control 205
contamination.
8. Decontamination is a process of cleaning by ph —
physicochemical or biological methods. After completion of the decon
tamination, a new cycle of sampling, indication, sanitan ^ e ha·
to be performed (Repeated sanitary control) in order the effe ctiVeness of
the applied decontamination to be proven.
9. Water basins (rivers, lakes, dams, springs, etc) could not be eradi
cated. They undergo a rigorous decontamination and are prohibited for
use till the levels of pollution reaches the acceptable levels.
10. All the food products contaminated are to be eradicated. Excep
tion some of the canned foods, only if the surface of the can is intact and
there is no radioactivity measured.
206
BIOLOGICAL WEAPONS
Highlights
1. Definition
2. Biological weapons particularities
3. Biological weapons AOD particularities
4. Classes
Biological weapons are defined as biological agents modified to

cause widespread damage and inflict more casualties and the devices
for their spreading. (2, 3, 11,27, 28)
Microorganisms are modified in order to:
1. Increase the virulence.
2. Increase the infectivity.
3. Increase the pathogenicity.
4. Increase the antibiotic resistance.
5. Increase the resistance in the environment.
6. Modifi.ed incubation period could be shortened or prolonged de
pending on what exacfiy are the military objectives - to cause rapid harm
to the opposing ranks, or to inflict more casualties among military and
civilians.
Mechanisms to spread biological weapons include by contaminating
food, water, dispersing with shells of aerosolized germs. One possible
and dreadly mechanism is by infected people.
BAOD caused by BW differ from normal epidemics in:
1. Mosaic distribution of the affected.
2. No link between casualties.
3. Several epidemics divided into space but with almost simultane
ous initial date.
4. Simultaneously and sudden commencement among large group of
the population not linked between them.
Biological Weapons
5. Extremely high morbidity.

6. Full manifestation.
7. Difficult to treat.
8. Resistance to ordinary treatment protocols.
9. Extraordinary (exotic) infections that are not specifi : fi r like e-
gion.
10. Sudden break out of the disease.
11. Unexpected mortality rates.
Biological weapons are three classes - class A, class B and class C.
Class A are high-priority agents include organisms that pose a risk to
national security because they have the following characteristics:
1 . can be easily disseminated or transmitted from person to person.
2 . result in high mortality rates and have the potential for major pub
lic health impact.
3. might cause public panic and social disruption.
4. require special action for public health preparedness.
Disease/Bio-agent
• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers . including Filo wruses (Ebola, Mar
burg), Arenaviruses (Lassa, Machupo)
Class B bio weapons are v..hh the fi jk. wing characteristics:
• are moderately easy to dis :-e:r.:r.a:e.
• result in moderate morbidi cy rate? -=dlow m ortality rates; and
• require specific enhance :riee5: . = : capacity and en
hanced disease surveillan .e.
Disease/Bio-agent
• Brucellosis (Brucella spcfres
• Epsilon toxin of Clostri perfringens

• Food safety threats ■Salmonella species, Escherichia coli
O157:H7, Shigella)
• Glanders (Burkholderia mallei)
• Melioidosis (Burkholderia pseudomallei)
• Psittacosis (Chlamydia psittaci)
• Q fever (Coxiella burnetii)
• Ricin toxin from Ricinus communis (castor beans)
• Staphylococcal enterotoxin B
• Typhus fever (Rickettsia prowazekii)
• Viral encephalitis (alphaviruses, such as eastern equine enceph
alitis, Venezuelan equine encephalitis, and western equine en
cephalitis)
• Water safety threats (Vibrio cholerae, Cryptosporidium parvum)
Class C Bio-weapons are emerging pathogens that could be engi
neered for mass dissemination in the future because of their:
• availability.
• ease of production and dissemination.
• potential for high morbidity and mortality rates and major health
impact.
Most probable are the Nipah virus and hantavirus as they are nowa
days emergent infections. (114)
When bio-weapon implementation is suspected, quarantine is en
forced immediately.
Toxic Industrial Materials Features And Classification
TOXIC INDUSTRIAL MATERIALS FEATURES AND

CLASSIFICATION
DISASTER MEDICAL SUPPORT IN CASE OF AREA
OF CHEMICAL DAMAGE
Highlights
1. Definition of chemical DF
2. Definition of CAOD
3. Factors realted to the CAOD
4. Origin
5. Risk factors
6. AOD zones
8. First aid SOP
9. Medical activities particularities
10. Classification of the toxic chemicals
Chemical Area of Damage (CAOD) is the territory (environment

and living creatures) affected by the chemical (toxic) DF. In order to de
fine the boundaries of the CAOD several factors have to be considered.
1. The state of the matter of the chemical DF. The size of the AOD is
considerably different in case of gasses . liquids and solid chemicals. It is
expected gasses to cover larger territo r in comparison with the liquids,
while the solid will affect the smallest area.
2. Boiling and freezing points of the toxic material. Changes into the
state of matter will affect the size o f the AOD in certain circumstances.
3. Type of the chemical eleme ntcomMtmd. Related to the type are
the expected damages on the air, soiL w■ate:.. :::...,imals. plants and popula
tion at risk. Depending on the iype _ e ± e ■__5 of exposure and the
pathological changes into the h1- ^ — or r ?.ns or activities (the
type of poisoning).
210_______________________________________ DisasterMedicineHighlights
4. The quantity of the release :: toxic material into the environment

Greater the amount is, larger territory will be affected.
5. Topography of the affected area. All elevated above the earth sur
face elements could impede the spread of the chemical and confine the
CAOD. The high hills and mountains are natural physical barriers shel
tering the territories behind. Lowlands and valleys on the opposite are
more vulnerable to great majority of chemical DFs (the highly volatile
excluded).
6. Water basins could be a natural barrier for spreading the chemical
by diluting it into the waters, or could enlarge the AOD by transporting
the toxic materials by the water flow.
7. Weather related factors. Depending on the boiling and freezing
point of the released chemicals, the air, water and soil temperature could
have impact on its state of matter and size of the contaminated territory.
Other element of the weather is the wind. Wind facilitates spreading of
the chemicals. Following the wind direction, the CAOD track for en
largement could be traced. Moreover, the speed of the wind provides a
clue regarding the velocity of the CAOD spreading. From the wind type
(a constant or changing its directions) depends the shape of the affected
area. When the wind is a constant one the affected area is with conical
shape expanding in the wind direction. Changing winds are creating
monstrous shapes and it is extremely difficult to predict the territory,
respectively population at risk.
8. Different types of soil differs with regard to the possibility for
being contaminated. The time for absorption significantly impacts the
contamination of the environment.
9. Types of the vegetation is also a factor that could increase or de
crease the environmental pollution. Some of the plants could absorb
the toxic material from the soil via routes, or from the air by the leaves.
Some of the chemicals could penetrate into the plants, other will remain
on their surface. All these possibilities have to be considered while as-
Toxic Industrial Materials Features And Classification 211
sessing the health risk related to the to the chemical poll i.:;:; ;: e .:
10. From the medical point of view the most importarn : 5 v.e
population density and its exposure to the toxic material.
11. Protective measures required for preventing the heal ih harm . ;e
also part of the CAOD assessment. These measures are mainly rela ■ed
to the type of the chemical.
12. Type, number and location of the casualties. These are the most
significant for the DMS elements of the CAOD. All the medical activi
ties are focused on saving the affected population life and presering
their health and ability. (11, 27, 28)
In order to define the required DMS activities data regarding the
type of the chemical released is important. Chemicals are classified into
various hazard classifications in accordance with their physiochemical
properties and health hazards.
PHYSIOCHEMICAL
Explosive Chemicals (E) These are chemicals or mixtures capable
of producing an explosive or pyrotechnic effect with substantial release
of heat and gases under the right conditions. Explosions can be initi
ated by heat, shock, friction etc. Explosives which are shock sensitive
are particularly dangerous as they can be detonated merely by touching
their container - functional groups such as azides, acetylides, diazo, ni-
toso, haloamine, ozonides are sensiti ■ ·.e to shock and heat and can ex
plode violently.
Oxidising Chemicals (0) These are substances that can readily re
lease oxygen thus intensifying a fire. F ie or explosions can occur when
strong oxidising substances come · ti o \vi.th easily oxidisiable
substances such as metals, metal hy drides c:: organics. Examples of oxi
dising chemicals include Hydrogen Peroxide. Hypochlorites (bleach)
and concentrated Nitric Acid.
Flammable Chemicals (F = Highly le and F+ = Extremely
Flammable)
212_ Disaster MedicineJHighlights
Flammable chemicals ignite e.::s :.v. They are divided into extremely
flammable, highly flammable and yyammable and this classification de
pends mainly on their “flashpoin _". Flashpoint is defined as the lowest
temperature at which the vapour on the surface of the liquid will ignite.
The lower the flashpoint, the easier it is to ignite a material.
HEALTH
Toxic_Chemicals (T+ = Very toxic and T= Toxic) Toxic agents can
cause serious damage to health if they are allowed to enter the body.
The classification of toxic agents is based on their LD50 values (me
dial lethal dose). The LD50 is the average exposure to a single dose of
a chemical agent which causes at least 50% of test subjects (rats, mice
etc.) to die. There are LD50 values for ingestion, skin exposure and
inhalation of chemicals. Very toxic agents can cause damage to health
at very low levels. Toxic chemicals also cause damage at low levels.
Examples include phosgene, hydrogen cyanide and nicotine.
Harmful_Chemicals (Xn) cause damage to the health of persons ex
posed to them but do not present as serious a health risk as toxic chemi
cals.
Irritant Chemicals (Xi) cause inflammation of the skin and mucous
membranes.
Sensitising Chemicals (Xn or Xi)
• Respiratory sensitiser: is a substance which when breathed in can
trigger an irreversible allergic reaction in the respiratory system.
Once this sensitisation has taken place, further exposure to the
substance, even to the tiniest trace, will produce symptoms.
• Skin sensitiser: is a substance capable of causing an allergic reac
tion in the skin. Once this sensitisation has taken place, further
exposure to the substance, even to the tiniest trace, will produce
symptoms of dermatitis.
Note: Sensitisation does not necessarily take place right away, it may
happen after several months or even years of contact with the sensitiser.
Toxic Industrial Material: Features And Classification
Corrosive Chemicals (C) destroy living tissue on con _ . '.'.'λχχ ex

posure is through inhalation or ingestion, then the damag ,. s x
within the respiratory or alimentary tracts. Examples include a<_x x a d
caustic soda.
Carcinogens
• Category 1: substances known to cause cancer in humans , Clas
sified as Toxic
• Category 2: substances that should be regarded as if the _ are car
cinogenic to humans - sufficient evidence based on long-temi
animal studies and other information that human exposure ma>
result in cancer. Classified as toxic.
• Category 3: substances that cause concern owing to possible car
cinogenic effects. Classified as harmful.
Teratogens/Reproductive_toxins
• Category 1: substances that produce or increase the incidence of
non-heritable effects. Classified as Toxic
• Caregory 2: substances that should be regarded as if they are
reproductive toxins to humans - sufficient evidence that human
exposure may result in development of genetic mutations. Clas
sified as Toxic.
• Category 3: substances that cause concern owing to possible re
productive toxin effects. Classified as Harmful.
Mutagens
• Category 1: substances knowra :: produce heritable genetic de
fects. Classified as Toxic.
• Category 2: substances that 5:J. :-e r-::;arded as if they are mu
tagenic to humans - suffi cien: ec idenc e :'.::-"t human exposure may
result in development o r-::s. Classified as Toxic.
• Category 3: substance s casual****τ>»«m , irig to possible mu
tagenic effects. Classifies s — 3 '
Other classification in use is de,·-z—z :oxt... chemicals into six
groups:
1. Suffocating:
• With manifest suffocating acti ity - chlorine, etc.
• With moderate suffocating activity (fosgen, sulfuric chloride)
2. General toxicity
• Blood poisons - hydrogen arsenic, carbon monoxide
• Tissue poisons - cyanide, dinitrophenol, etc.
3. Suffocating and general toxicity:
• With manifest suffocating activity - (nitric acid, acrylonitrile).
• With moderate suffocating activity (sulfur anhydride, nitrous ox
ide, hydrogen sulphide, etc.)
4. Neurotoxic poisonous substances (FOS, carbon, tetraethylol, etc.)
5. Toxic substances with suffocating and neurotoxic action (ammo
nia, hydrazine, etc.)
6 . Metabolic poisonous substances
• With alkylating activity - methyl bromide, ethylene oxide
• Influencing metabolism - dioxins, benzofurans. (11)
It is also important to predict the possible sources for CAOD devel
opment. The following events could lead to CAOD:
1. Improper use, storage or transporting of toxic chemicals;
2. Industrial failure; ( 116)
3. Transport accidents;
4. Fires and explosions;
5. Chemical weapons usage.
The CAOD consists of three zones related to the concentration of the
chemical and its effect on the population:
1. Zone of the chemical spill. This zone is small in size, but with
concentration that are causing death among the unprotected population. ·
Almost all of the unprotected population is affected. The majority of
casualties are irreversible loses.
2. Zone of lethal concentration. In this zone the concentration of the
Toxic Industrial Material·· Features And Classification 215
chemical is lower than the previous, but the size is large: The majority
of unprotected population is affected. The medical loses :tre o u m ^ ; er-
ing the irreversible.
3. Zone of damaging concentration. The dose is lower than inio the
zone of lethal concentration and do not cause irreversible loses - onli
few of the population will sustain health damage. ( 11 )
Required disaster medical support for the CAOD casualties has to
be provided within minutes to hour. Search and rescue teams ha, e to
wear full protective equipment with autonomous respirator. After find
ing the casualty is of utmost importance to stop the contact \ ith the
toxic chemical. This is performed within two steps - first is perform
ing partial decontamination and placing a barrier between the chemical
DF and the casualty - gas mask, protective clothing, blanket, foil etc.
If there is antidote against the chemical it has to be administrated. The
third step is primary triage and rapid organized evacuation. In case of
pollution with persistent contaminants full spectrum decontamination
is performed prior admitting them into the FMS. First medical aid is
limited to maintaining of the vital signs, intravenous fluids administra
tion and antidotal therapy continuation or initiation. If the chemical was
ingested a stomach has to be emptied, or active charcoal is given. All the
chemical burns are meticulously irrigated in order to clean the wound
surface from the chemical. After removing the toxic agent, the damaged
area is covered by dressing wetted in neutralizing solution, antiseptic
solution or only water. Rigorous monitoring of the breathing and cardiac
function and supporting therapy if requi red. The medical evacuation has
to be directed to the internal medi ■·,' ::e die · anments with intensive care
units and toxicological wards. If no toxic·dogistis available, a consult
ant or toxicological team will be req„e5: e : ·.: enhancement of the hos
pital care.
DMS IN CHLORINE INTOXICATION
Highlights
1. Type of the toxic elemen compound
2. State of matter (Physics)
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
7. Where can be found (Spread)
8. Routes of exposure
9. Target
10. Pathophysiology (Mechanism) of intoxication
11. Main symptoms
12. Why intoxicated are dying, when impacted with lethal concentra
tion
13. Degrees of poisoning
14. Differential diagnosis
16. First aid
17. Antidote
18. First aid particularities
19. First pre-physician aid
20. First physician aid
21. Delayed effects
Chlorine is part of the suffocating (choking) toxic chemicals. It is the

most aggressive toxic industrial material.
Chlorine is yellow- green gas, with distinctive odor. Heavier than
air, accumulates at the bottom of poorl entilated spaces. It is a toxic
gas that irritates the respiratory system. From the chemical characteris-
Dms In Chlorine Intoxication
tics the most important is its intermittent solubility and . . a

tion with the water. Chlorine is moderately soluble in v ate : :
combination to form hypochlorous (HOCl) and hydrochlo ric (HCl) ac
ids. Elemental chlorine and its derivatives, hydrochloric and hypochlor
ous acids, may cause biological injury.
Cl2 + H20 = HCl (hydrochloric acid) + HOCL (hypochloro : a :id '
or
Cl2 + H20 = 2HC1 + [0-] (nascent oxygen)
HOCl = HCl + [0-]
As strong oxidizer may react with flammable materials.
Chlorine gas is one of the most common single, irritant. Inhalation
exposures could occur occupationally and environmentally. Sources of
exposure with chlorine are:
• Industrial bleaching operations - Chlorine gas, when mixed with
ammonia, reacts to form chloramine gas. In the presence of wa
ter, chloramines decompose to ammonia and hypochlorous acid
or hydrochloric acid;
• Sewage treatment;
• Household accidents involving the inappropriate mixing of hy
pochlorite cleaning solutions with acidic agents;
• Transportation releases;
• Swimming pool chlorination tablet accidents;
• Storage tank failure;
• Chemical warfare - Chlorine was firstly used as chemical weap
on during the First World War at Vpres, France, in 1915. The last
chemical attack with chlorine ■;u ,u:rred in Syria, 2016.
The early response to chlorine eApo_,,....e depends on the:
• concentration of chlorine _. s.
• duration of exposure,
• water content of the tis e:··.::
• individual susceptibilif
Pathophysiology of the chl ;rme irr oxication is related to the reac

tion of chlorine with the v·.ater o the mucosa in eyes, nose, mouth and
respiratory tract. Hydration of chlorine ^ H C l ^ acid injury.
However, chlorine 35x more toxic than HCl fumes in mice. The
more recent theory regarding the chlorine toxicity includes the “Oxida
tive injury” - nonspecfic chemical/mechanism reaction:
Cl2 + H20 ^ OC1- + 2H+ + 2C1-^ HOCl + HCl
Cellular injury is believed to result from the oxidation of functional
groups in cell components, from reactions with tissue water to form
hypochlorous and hydrochloric acid, and from the generation of free
oxygen radicals. (28)
In summary the pathophysiology of the chlorine is twofold - first a
necrosis occurs from the direct effects of the formed acid. This necrosis
progresses very rapidly, because of the cellular injuries due to the nitra
tion and oxidative injuries from the highly reactive OH and O radicals
Because of its intermediate water solubility and deeper penetration,
elemental chlorine frequently causes acute damage throughout the res
piratory tract.
Immediate effects that occurs after exposure to chlorine could in
clude:
• Acute inflammation of the conjunctivae, nose, pharynx, larynx,
trachea, and bronchi.
• Irritation of the airway mucosa leads to local edema secondary to
active arterial and capillary hyperemia.
• Plasma exudation results in filling the alveoli with edema fluid,
resulting in pulmonary congestion.
Pathologic findings are nonspecific:
•· Severe pulmonary edema;
• Pneumonia;
• Hyaline membrane formation;
• Multiple pulmonary thromboses·
Dms In Chlorine Intoxication 219
• Ulcerative tracheobronchitis.
• The eye seldom is damaged severely - burns and comeal abra
sions have occurred. Acids formed by the chlorine ga ■ rea . tion
with the conjunctival mucous membranes are buffered, in part
by the tear film and the proteins present in tears.
• Consequently, acid burns to the eye typically cause epithelial
and basement membrane damage but rarely damage deep en
dothelial cells.
• Acid burns to the periphery of the cornea and conjunctiva often
heal uneventfully, while burns to the center of the cornea may
lead to corneal ulcer formation and subsequent scarring.
Noncardiogenic pulmonary edema is thought to occur when there is
a loss of pulmonary capillary integrity, and subsequent transudation of
fluid into the alveolus is present. The onset can occur within minutes or
hours, depending upon severity of exposure and it is manifested as hy
poxia. Persistent hypoxemia is associated with a higher mortality rate.
Clinical symptoms of the chlorine intoxication include:
• Cough (up to 80%) with abundant expectoration with foamy yel
low green sputum;
• Shortness of breath (up to 50%)·
• Chest pain (up to 35%);
• Burning sensation in the throat and -ubstemal area (up to 10%);
• Nausea or vomiting (up to 10%·
• Ocular and nasal irritation 1ur : : :;
• Choking;
• Muscle weakness;
• Dizziness;
• Abdominal discomfort.
Physical findings could incl - e:
• Decreased breath sounds·
• Tachypnea;
• Tachycardia;
• Wheezing;
• Nasal flaring;
• Intercostal and subcostal retractions;
• Cyanosis;
• Rhinorrhea;
• Lacrimation;
• Hoarseness of the voice or stridor;
• Rales (acute respiratory distress syndrome (ARDS)/noncardio-
genic pulmonary edema);
• Crepitus (associated with pneumomediastinum).
Differential diagnosis is with the:
• Acute Respiratory Distress Syndrome
• Asthma
• Chronic Obstructive Pulmonary Disease and Emphysema
• Intoxication with Ammonia
• Intoxication with Carbon Monoxide
• Intoxication with Caustic Ingestions
• Intoxication with Cyanide
Casualty instant death is provoked by high concentration of the
chlorine that cause a generalized constriction (spasms) of the bronchial
three. (11, 14, 27, 28)
Prevention during the first aid requires the use of a chemical (indus
trial) cartridge respirator or self-contained breathing apparatus with full
face mask should protect against the effects of chlorine gas. When the
intoxicated with chlorine is found partial decontamination is performed
with the 2% sodium bicarboate solution and a barrier to the gas is ap
plied. Following the primary triage an organized evacuation (removing
the individual from the toxic environment and directing, bringing him/
her to the FMS) is performed.
Dms In Chlorine Intoxication
Prehospital care:
• The most important rule is not to perform artificial reep......,li on due
to the risk of rupture of the necrotic trachea, bronchi . w .w.-. the
pressure is elevated during the inhalation to the casualty mouth.
• Commence primary decontamination of the eye and skin, if nec
essary.
• Real-time measurement of chlorine gas, both quantitative and
qualitative, is possible through the use of mobile equipment.
• Chlorine gas is denser than air and accumulates close to the
ground. Therefore, during chlorine-related accidents, people
should be instructed to seek higher altitudes to avoid excessive
exposure.
• Decontamination
• Eye and skin exposures require copious irrigation with saline.
Continue irrigation with 0.9% saline until the pH returns to
7.4. For skin a 2% sodium bicarbonate solution also could be
used.
• Topical anesthetics help limit pain and improve patient coop
eration.
• Following irrigation . perform slit lamp examination, includ
ing fluorescein staining.
• Measure ocular pressures.
• Treat corneal abrasions " '^ ^ ^ T ^ ti ; ointment.
• Supplemental oxygen
• Maintain a PaO2 of 60 rig or greater.
• Long-term (>24 h i e_e. tion of inspired oxygen
(FIO2) greater than 50% — =. resul: oxygen toxicity.
• Fluid restriction in patient n itfe AR£‘=
• Treatment of broncho<r^r
• Bronchodilators (d ia led :r ::.erbeta-agonists ) Li-
docaine (1 % soluti results in
both analgesic and :.·: ugh-suppressant actions.

• Intubation for laryngospasm
• Fiberoptic aid may be required if significant edema is present.
• Consider using the largest size endotracheal tube possible to
optimize pulmonary toilet.
• Hypoxemic respiratory failure
• Treat with positive-pressure ventilation.
• High positive end-expiratory pressure (PEEP) (8-10 mm Hg)
and inverse ratio ventilation may be beneficial in ARDS. (27,
28)
• Treatment of the pulmonary edema. The most important is to re
direct the fluids from lungs to the vessels. This is achieved by in
creasing the osmolarity of the blood by administrating Sol. Glu
cose 40% 10ml/kg Afterwards the changed permeability of the
vessels is addressed by Iv administration of glucocorticoides and
Sol. Calcium Gluconicum 10% 10ml. Administration of furo-
semide is required for eliminating the extra fluids with the urine.
A lot of cases of ingestions occur every year due to drinking house
hold cleaning solutions, instead of water. The casualties complain in
clude burning sensation and extremely severe pain along the esophagus
and the stomach. This pain is due to the rapidly developing necrosis.
The medical management of this incidents includes inducing vom
iting only into the first 30 minutes, because afterwards the rupture of
the necrotic esophagus could occur. If the time from the incident is not
clear is better not to induce vomiting. A considerable amount of active
charcoal is administrated per mouth for absorption part of the acids pro
duced. In order to dilute and neutralized the acids sodium bicarbonate
2% solution is recommended for drinking. For the so called protein
dressing a protein water (if not available - milk) is also applied. Pain
killers, even morphine and opioids could be administrated, for reducing
the severity and intensity of the pain. ( 11 , 2 ' 2 8 )
Dms In Ammonia Intoxication
DMS IN AMMONIA INTOXICATION
Highlights
1. Type of the toxic element/compound
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
tion
16. First aid
17. Antidote
21. Delayed effects
Ammonia is a chemical compound. :: nitrogen and hydrogen with

the formula NH3. The simplest nitrogen hr· drtde. ammm ia is a col
ourless gas with a characteristi c pungent sued It .5 a ; r m a nitrog
enous waste, particularly among aquatic r-ga--.—>. anc M c i nm r _tes
significantly to the nutritional needs in te r.-—: t_ se-m g
as a precursor to food and it \v ceiy used in agriculture as different

varieties of fertilizers. Ammoni·. either directly or indirectly, is also a
building block for the synthesis of many pharmaceutical products and is
used in many commercial cleaning products.
Amonnia is the most widespread toxic industrial material. It is a suf
focating poision.
Ammonia is gas, colorless, with suffocating, pungent odor (sensed
when concentration is over 0,37mg/l), lighter than air (0,59), highly sol
uble in water, flammable, mixed with air forms air-ammonia mixture
that is heavier than air and explosive. Ammonia reacts with the organic
acids and forms ammonia acetates.
NH 3+ CH3COOH ^ c h 3c o o n h 4
Sources for intoxication are various -widespread in chemical, phar
maceutical, oil and other industries. Ammonia is stored and transported
in a liquid form under 2 atm. negative pressure and low temperature -33.
60 Celsius. Therefore, intoxication could occur in case of an improper
use or storage, transport accidents, but largely the intoxication are due
to industrial failures. (11, 27)
The Routes for exposure - ammonia could be inhaled, ingested, or
through damaged skin. When liquid ammonia enters into contact with
the skin cold injuries from second, even third levels are reported.
The target of the ammonia is respiratory system.
Pathogenesis- ammonia chemically reacts with water in mucous
membranes and gives ammonium NH4+ and Hydroxide OH- ions. They
cause corrosive damage and liquefied necrosis (or colliquative necrosis)
thoughout entire route of exposure (eyes, nose, mouth, pharynx, lar
ynx, trachea, esophagus, lungs. It swiftly enlarges in depth and penetra
tion of the trachea or oesophagus is possible. The pathognomic for the
ammonia poisoning is that the necrosis is surrounded by irritative and
toxic-allergic oedema. When great amount of ammonia is inhaled the
toxico-allergic oedema of the vocal hords cause the immediate death
Dms In Ammonia Intoxi nation
because of stopping the air intake. When less ammonia is in a l ed the de
veloping necrosis is triggering the reaction of the bod v - 5::m.. m: ' :
the glands function in order to wash out the irritant - lacrimat · . mom
nose (rhinorrhea) hyper salivation, bronchorea. When ammonia rea . hes
the lungs, because of the irritating stimuli from the developing necrosis ,
an extravasation of fluid into the alveoli and interstitial tissues starts.
This extravasation results into pulmonary edema development.
Main pathologic findings-necrosis, perforation, toxic-allergic ede
ma.
The clinical symptoms of ammonia intoxication include:
When inhaled:
• copious lacrimation and pain in the eyes due to the necrosis de
velopment;
• cough due to the bronchorrhea and pulmonary edema. When pul
monary edema is manifest the cough is a productive - produces
frothy sputum that may be tinged with blood (pinky);
• acute tracheobronchitis;
• laryngospasm;
• vocal cords edema;
• pulmonary edema;
• bronchopneumonia;
• Central Nervous System stimulati n-possible seizures.
When ingested ammonia cause:
• intensive retrosternal pain:
• epigastric pain;
• salivation;
• dysphagia;
• vomiting;
• esophageal perforation-
• hemorrhage with blood) de-jews—
On the skin ammonia cause fu rap idly
226 D isa ster M e d icin e H ig h lig h ts
forms blisters. From the blisters e sions and ulcers could be formed. In
lower concentration only irritation and itching on the skin are reported.
(11,27)
When a liquefied ammonia is released into the environment due to
its low temperature it attracts the warmer air and forms an ammonia
cloud. The particles of the cloud are formed by ammonia, drops of wa
ter, oxygen, nitrogen, NH40H. These macromolecules are heavier than
air, therefore, the ammonia cloud stays close to the earth surface and it is
moving with wind. As it is named as cloud, it is visible, but not because
of any specific color, but from the optical density. The temperature in
the cloud is around two - three degrees lower than into the surrounding
environment. The ammonia cloud is the zone of the spill, therefore, it
is extremely dangerous - there is a threat for the life of all that are not
protected.
Prevention - a full protective equipment is required when entering
into the ammonia cloud. In case of industrial accidents the operators
have to put a gas mask with a specific industrial respirators. Population
could protect themselves with mask of whatsoever fabric wetted, mois
ten with 50% water solution of organic acid - vinegar or lemon juice.
First Aid consists of stopping the contact with gas mask with indus
trial respirator. As the ammonia is highly volatile the mask is sufficient
for protecting the life. There is no antidote for the ammonia intoxica
tion. After exiting the CAOD the full decontamination is performed. It
is important to note that artificial respiration is prohibited because of the
risk for trachea rupture due to the developing necrosis. (11,27, 28)
Into the FMS the pre-physician medical aid starts with warming up
the casualty. The breathing is maintained via assisted ventilation. Intra
muscular administration of glucorticoides is preventing the peri-necrot
ic edema growth. Bronchodilators have also to be given for elevating the
bronchoconstriction.
First physician aid includes pulmonaT) edema treatment. Pulmonary
Dms In Ammonia Intoxication
edema standard Intravenous treatment is:

• Sol. Ca gluconici 10% 10ml, every 4 hours 3x
• Glucocorticoides in large dose - Urbason 50-75mg or h ; d r ror-
tison 100 mg every 2 hours 3x,
• Sol. Glucose 40% 100 ml iv;
• Diuretics - Furosimide.
Symptomatic treatment includes antitussives, antibiotics, painkill
ers.
When ammonia is swallowed
• Inducing vomiting is allowed only into first 15 minutes after the
ingestion. Afterwards the risk for perforation of the esophagus
increases;
• A lot of water intake with 1-2% organic acids or vinegar, lemon
jmce;
• Protein water per mouth
• Carbo medicinalis (active charcoal);
• Olive oil per mouth;
• Active surgeon monitoring for complications is required.
Ammonia into the eyes has to be washed out with irrigating eyes
with clean water for at least 10 minutes.
Ammonia on the skin has to be remo \ ed with soft tissue wetted with
water and vinegar acid (2%).
228 Disaster Medicine H ighligb
DMS IN CYANIDE INTOXICATION
1. Type of the toxic element compound

3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
tion
16. First aid
17. Antidote
21. Delayed effects
In 1782 cyanide liquid was isolated by chemist Karl Wilhelm Scheele

through the action of sulfuric acid and Prussian Blue. Four years after
his discovery he died from inhaling hydrogen cyanide gas. Cyanides
are widely found. There are over 360 plant species that contain the sub
stance amygdalin - the seeds from plums, peaches, pears, apples, apri
cots, cherries, bitter almonds, elderberries. The amygdalin is broken
Dms In Cyanide Intoxication 229
down to produce hydrogen cyanide when the seed is cru w w . _ w w.
or acted on by enzyme.
Cyanide is found in our environment, in other living or_.U 11.J.3L
.. LL->. .. d
in our bodies in small amounts. Our blood can contain u p to 0. mi
crograms per milliliter of cyanide. Larger concentrations are tv picaliv
found in the blood of smokers, fire fighters, and operators in indus c->
with cyanide containing products. We all have the ability to detoxi p- a
certain amount of additional cyanide on a daily basis and excrete it in
our urme.
Cyanide is used in the production of nitriles and cyanohydrins pre
cursors of many plastics. When plastics are burned the cyanide is liber
ated and found in the smoke. Cyanide is released from the combustion
of organic-nitrogen containing polymers, both natural, such as wood
and silk, and synthetic, such as polyurethanes, which are found in home
furnishings.
It is also used as a fumigant to kill rodents and insects in a vapor
form. Cyanide compounds are widely applied into agriculture, industry,
chemistry, as well as chemical weapons - as hydrogen cyanide (AC) and
cyanogen chloride (CK).
Cyanide is also a popular chemical agent for terrorist use considera
tion. It was used in executions by the ancient Greeks, Egyptians and
Romans and many of the Nazi leaders committed suicide by biting on
cyanide filled glass capsules at the en i ωί'ίΐϊ e second world war. Napo
leon urged his soldiers to dip their c w ~.c-:s ; cyanide during the Fran-
co-Prussian War. The French used hydrocyanic acid, a combination of
potassium cyanide with sulfuri .. ww. w ~ w w : w ' \\ 'W 1. The \azis
used cyanide to kill millions in w.e w w . w c ^ : : : .ty ; w Europe dur
ing the period of the second wor Id v?ir. rode-nt led ler Zyk 1on B \cras
used which release hydrogen w w __ · ;c . w en closed
room. Japan used cyanide againsr the Chocse w ^ offu e second
world war.
230 _ Disaster Medicine Highlights
Cyanide can exist in se ■-e :v. : .m s: - liquid, gas, or a salt. The salt
is activated, to become a gas, by rd :mrre with a dilute mineral acid. The
boiling point for cyanide is 1o\-. and because it evaporates quickly for
several minutes it is considered a non-persistent agent. It is most effec
tive in a gas form when used in an enclosed space. Cyanide has a musty
smell ofbitter almonds, but cyanogen chloride has the smell of chlorine
and is heavier than air. Important characteristic is that cyanide has a very
strong affinity for metals, especially the ferric (Fe3+) form of iron. This
form of iron is found in various parts of body’s cells into Cytochrome
oxidase (Fe3+), as well as into the Methemoglobin (Fe3+)
As a gas it is colorless, dissipates rapidly - hydrogen cyanide (HCN)
and cyanogen chloride (CNCl). As a liquid: ranges from blue to color
less, stable hydrocyanic acid; an aqueous solution ofHCN. As a solid it
is white granular powder, stable - sodium, potassium, or calcium. (11,
27, 28)
Cyanide is a tissue poison.
The target of the cyanide are the mitochondria of the cells. Inside
each mitochondrion there is an enzyme (hemoprotein) cytochrome oxi
dase. It is responsible for the cell oxygen utilization and energy pro
duction, throughout process oxidative phosphorylation. Cytochrome
oxidase contains the ferric form of iron (FeH) that cyanide is strongly at
tracted to. When cyanide enters the cell it combines with the cytochrome
oxidase and interferes with the oxidative phosphorylation process. Cya
nide blocks aerobic metabolism and energy production causing cellular
hypoxia, leading to the cell death. There is almost no extraction of oxy
gen from the blood so the venous blood oxygen levels increase to near
arterial levels. There is no aerobic metabolism and it instead shifts to
anaerobic metabolism which causes a rapid lactic acidosis.
The lack of energy production primary targets the organs with great
energy consumption - brain and heart. The presentation depends on the
dose and route of exposure. When inhaled the rapid death (within 6-8
Dms In Cyanide Intoxication
minutes occurs). Additional signs include metallic taste in the mouth,

burning sensation into the gastro-intestinal tract and respiramry system.
The onset is seconds to minutes.
When ingest a delayed onset (15 to 30 minutes) with additio nal
symptoms the aforementioned plus sore throat and diarrhea.
In case of skin contact the onset is delayed from 15 to 30 minutes
with additional signs - erythema and pain at site of contact.
For the all types of exposure a rapid onset of symptoms (less than
hour), “Cherry red” skin; odor of bitter almonds and respiratory depres
sion are recorded. From the most vulnerable organs the symptoms are:
1. From Central Nervous System:
• dizziness;
• nausea and vomiting;
• drowsiness;
• tetany;
• trismus
• hallucinations.
2. From Cardio-vascular system:
• tachicardia;
• hypertension;
• arrhythmia;
• hypotension.
3. From the Respiratory system:
• dyspnea;
• hyperventilation;
• hypoventilation
• pulmonary edema.
Normally body metabolizes ivytw-"-..: - r a tion mediat
ed by mitochondrial enzyme rh oc anese = frse h ==. This reaction forms
thiocyanate which is excreted in the The :: \ : : hese ovenvhelms
the normal metabolic processes. C~. hr
232 __ Disaster Medicine Highlights
SOP for FA: Search and rescue teams have to wear protective equip
ment - there is a specific industrial respirator for the cyanide. Because
of the time limitation with the industrial respirators it is better an au
tonomous respirator gas mask to be used. For casualties - partial decon
tamination and application of a gas mask with amyl nitrite in front of the
respirator. Rapid evacuation out of the AOD. Following is the removal
of the toxic agent - decontamination (soap and water).
Performing CPR if required, decontamination required prior the arti
ficial respiration. Into the FMS the general supportive therapy incorpo
rating oxygen is critical. Afterwards starts the specific antidotal therapy.
The antidote therapy has started with the application of the amyl ni
trate. On the next stage the sodium nitrate is administrated intravenously.
Amyl and sodium nitrate bind with hemoglobin to form methemoglob-
in. The methemoglobin has the ferric form of iron that attracts the free
cyanide and even pulls the cyanide away from the cytochrome oxidase.
Could be said that methemoglobin competes with cytochrome oxidase
for cyanides. But methemoglobin does not carry oxygen, it binds with
cyanides to form cyanmethemoglobin. If normal levels of circulating
hemoglobin are assumed in the adult, the intravenously infusion of a 10
ml. ampule of a solution containing 30mg/ml of sodium nitrite (300 mg
total dose; for children the dosage is from 0.12 to 0.33 mg/kg) over a
period of 5 to 15 minutes should produce a level of 20 to 30 % methe
moglobinemia. Normal concentrations of methemoglobin range from
1% to 2 %. Concentrations below 30% are rarely symptomatic but may
produce feelings of fatigue, lightheadedness, or headache. Concentra
tions above 35% to 40% are associated with oxygen carrying deficits
caused by the methemoglobin itself and can result in cardiovascular and
central nervous system effects that can be life threatening. The blood
pressure can drop markedly, therefore must be monitored. Several ad
verse reactions are reported - hypotension associated with rapid infu
sion, tachycardia, syncope, cyanosis due to methemoglobin formation,
Dms In Cyanide Intoxi ..«.vksi 23 .
^ Λ
headache, dizziness, nause vomitmg.

The second antidote is sodium tiosulphate - it is sulfur donor tha .
helps cellular rhodanase enzymes in the liver to metabolize cyanide an .
form thiocyanate. The thiocyanate is excreted through the kidneys. This
antidote mechanism (enhancing normal metabolism capability) is too
slow for first line treatment.
The second part of the antidotal therapy involves the administration
of thiosulfate which acts as a sulfur donor. The required dose for adults
is 12.5g intravenously (children: 412.5mg per kg) over 10-20 minute -.
This administration is following administration of sodium nitrite. Some
adverse reactions are also reported - hypotension, central nervous sys
tem depression and coma due to thiocyanate intoxication, psychosis .
confusion, weakness, tinnitus, contact dermatitis.
The third antidote is the Hydroxocobalamin. It is a direct binding
agent that chelates cyanide The dose is 4 to 5 g intravenously.
Gastric lavage with activated charcoal, 5% sodium thiosulfate, 0.1%
potassium permanganate, or 1.5% hydrogen peroxide (ingestion) has to
be also considered into the therapy, as well as administration of 100%
oxygen. The metabolic acidosis has to be corrected and the seizures
managed. Follow up observation for at least 24 to 48 hours is required.
(11)
DMS IN ORGANO-PHOSPHATE COMPOUNDS

INTOXICATION
Highlights
1. Type of the toxic elemen i compound
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
tion
16. First aid
17. Antidote
21. Delayed effects
Organophosphates (OPs) are neuro-paralytic toxic materials. They.

are widely used into agriculture as insecticides (parathion, malathion,
azinphosmethyl etc). OPs are used and as chemical weapons - nerve
agents. First they were discovered b i the French scientists Lassaigne
Dms In Organo-Phospha :e Compounds Intoxication 235
and de Clermon in mid 19 century. After the discovery of the OPs 1.IIl-
pact on cholinergic nero u s system by the German chemist .- Lange and
von Krueger in 30-s of XX century Schrader starts to work on o thesis
of insecticides. Forced by the German government he also created and
the first G series of the chemical weapons nerve agents - Tabun . Zoman,
Zarin into the eve of the WW II. Germans produced enormous stock of
these weapons but never used them for warfare (they were used into the
gas cameras of the concentration camps). Nowadays more than 50% of
the pesticides used in agriculture are OPs.
OPs could be solid, liquid or gases. Always heavier than air. Dif
ferent colors from colorless to slight yellow. The odor is also with little
help for detection - either are odorless or with non specific smell.
Organophosphosphate pesticides can be absorbed by all routes, in
cluding inhalation, ingestion, and dermal absorption. They inhibit the
activity of an enzyme acetylcholinesterase (cholinesterase) into the syn
apses of the nervous system. This inhibition is due to irreversible bind
between the active centers of the enzyme and the OPs. Cholinesterase
has two active centers and acetylcholine is binding with both of them
(fig. 1) and the result is dissociation into acetyl and choline. Chemically
active are the following structural features of the OPs:
• A terminal oxygen connected to phosphorus by a double bond,
i.e. a phosphoryl group;
• Two lipophilic groups bonded to the phosphorus;
• A leaving group bonded to :b.e r r or t : r_:s, often a halid (halogen
binary compound - fluori ..:e. o h : riZe. :: A::;:- .
Most of OPs binds with the re t ; r : t > . ^ it the creat
ed in UK Vx gases are bindingwish the both tenters, thus reaching more
inhibiting effect. Inhibition of e r a ~ e ie a^ :: a ; h :g t .. ex . es: of
acetylcholine in the body.
Figure 19. Binding between the enzyme and acetylcholine and Zarin (11)
The second pathological effect of the OPs into the synapses is their
direct effect on the Muscarin and Nicotin receptors. Both fthe receptors
are sensibilized to the Acetylcholine. As a result of these two mecha
nisms when OPs are inhaled/ingested or penetrated via skin, the excess
ofAcetylcholine is formed and great majority ofthe M and N receptors
are blocked. This blockage ofthe receptors leads to impairment ofnerv-
ous signal transmission, because of scarcity to lack ofavailable free re
ceptors to bind with the secreted due to the signal arrival acetylcholine.
(11, 28)
The clinical picture of the OPs intoxication is dominated by two
syndromes:
• Muscarin syndrome;
• Nicotin syndrome.
Depending on the dose the symptoms of these syndromes could be
differently expressed.
Repeated or prolonged exposure to organophosphates may result in
the same effects as acute exposure including the delayed symptoms.
The muscarin syndrome includes:
• m10s1s;
• visual disturbances jeopardized (abnormal) accommodation;
• bradycardia;
Dms In Organo-Phospha'. e Compounds Intoxication
• cardiodepression·
• vasodilation;
• tightness in chest, wheezing due to bronchoconstric::; v:
• increased activity of glands - bronchorea (increased r
secretions) increased salivation, lacrimation, sweating (dia pho
resis);
• pain into gastro-intestinal tract due to increased bo el motili:.
(peristalsis) and diarrhea;
• increased urination (due to contraction of detrusor and dilation of
the urinary sphincter);
• excitation.
Nicotin syndrome includes:
• anxiety;
• headache;
• general weakness;
• convulsions;
• ataxia;
• depression of respiration and circulation;
• tremor;
• tetany;
• coma.
In the beginning of the intoxication the casualties are excited, hectic
with hypermobility - they are trin g to find oh) gen as the breathing is
impaired (bronchoconstriction, bron ore ineffective and discoordi-
nated muscle contraction (d iap faa ^ mm ·ever . ostals muscles). With
the time due to the hypoxia they fuel ex:.:-eme weakness. ataxia, tremor,
tetany and coma.
The death is due to the ineffective breaking c ^ diodepression. If
casualty survives or is exposed co1---- - -..' - -=- y to lower doses
a long-term effects are reported:
• impaired memory and c . -:=-
• disorientation;
• severe depressions;
• irritability;
• confusion;
• headache;
• speech difficulties;
• nightmares, sleepwalking or insomnia;
• an influenza-like condition with headache, nausea, weakness,
loss of appetite, and malaise. (11, 27, 28)
Prevention requires usage of gas mask and full protective equipment
- gloves, boots and protective costume.
First aid consists of partial decontamination of the phase and open
skin surfaces with 2%o solution of backing soda and application of bar
rier to stop the contact with the poison - gas mask, bare skin protection.
( 11)
Administration of the antidote - Atropine via auto injectors, intra
muscular injection. The first aid proceeds with rapid evacuation out of
the CAOD. Artificial respiration and cardiac massage if required. De
contamination is required. First prephysian aid - administrating atro
pine every 15-20 minutes till mydriasis. For the excitation - Diazepam
intramuscular. Assisted ventilation. The physician first aid consists of
administration of cholinesterase reactivators - oximes (toxocogonin,
obidoxim, polidoxim) intravenously.
Initiation of the cardiosupportive therapy and fluid intravenously ad
ministration are also part of the first physician aid.
Medical evacuation to the internal departments with intensive care
units that if required could be enhanced with toxicologists.
Dms In Carbon Mono 'ide Intoxication 239
DMS IN CARBON MONOXIDE INTOXICATION
Highlights
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
tion
16. First aid
17. Antidote
21. Delayed effects
Carbon Monoxide (CO) is colorless. odorless and tasteless gas

slightly lither than air (0.967). The CO :s toxic compound with actisi-
ties into the human blood cells, therefore. :t :s e mood poison. Other
important characteristics of the = :=-: __:oe ._:.e:
• Non solubility in water:
• It is flammable - bluest flame·

• Oxidize to CO2;
• Penetrates easily through materials and travels long distances;
• Its compounds with air in normal temperature are combustible;
• With chlorine are entering into chemical reaction resulting in one
of the most toxic compounds- fosgen;
• CO intoxication is on the fourth place within the intoxications -
after the alcohol, drugs and narcotics.
It is widespread, distributed everywhere, where not folly completed
burning process occurs. Example for CO production are the processes
where fuels as gas, coal, wood are burning not completely - burning
charcoal for heating, running cars, smoke of the cigarettes. Sources of
pollution with CO are many household appliances, including:
• boilers
• gas fires
• central heating systems
• water heaters
• cookers
• open fires
When the aforementioned appliances are incorrectly installed or
poorly frequently CO is produced and could cause accidental exposure
leading to carbon monoxide intoxication. The risk of exposure increases
when portable heating/cooking devices are used in narrow rooms as car
avans, boats and mobile homes. Blocked flues and chimneys are imped
ing the carbon monoxide escaping, thus increasing it levels to dangerous
heights. Burning fuel in an enclosed or unventilated space (running a car
engine inside a garage), a faulty or blocked car exhausts a leak or block
age in the exhaust pipe, also could lead to a build-up of carbon monox
ide. Cleaning fluids and paint removers containing methylene chloride
(dichloromethane) are causing carbon monoxide poisoning if inhaled
for long period of time. The trendy smoking shisha pipes (shisha pipes
Dms In Carbon Monoxide Intoxication 241
bum charcoal and tobacco) also can lead to a build-up of mon

oxide in enclosed or unventilated rooms.
CO is found also in the following:
• Gunpowder gases up to 50-60%;
• Cars’ gases up to-15%;
• Blast furnace gases up to 30%;
• Generators up to 27%.
In the atmosphere CO could be build up form natural processes as:
• Volcanoes eruption;
• Forrest fires.
To summarize any source of heat and carbon could emit CO:
Carbon Heat Oxygen
co CO""'
Figure. 20.
The only route for exposure is vi inhalation. Target is the blood. Into
the blood are the red cells - the Hemoglobin. After being inhaled CO
rapidly penetrates alveolar-vesse . me = erane. Entering into the blood
directly goes to the erythrocytes c.::d steady binds with the Fe2+ of Hb
to form carboxyhemoglobin (COfU >. I: is important to be noted that CO
reacts with both redox and oxv HB replacing 02), because CO is with
250-300x higher affinity to Fe::- in comparison with 02· Moreover, the
dissociation ofCOHB is 3600x slower than ofOHb. The speed ofCOHB
creation is related to CO concentration in the air. This data is of utmost
importance for the treatment of the CO poisoning.
CO also reacts with enzymes v ith Fe2+ - cytochrom A3 (cytochro-
moxydase) h cytochrom P450 resulting in block of oxidative phospho-
rylating process in the mitochondria. With myoglobin CO forms - car-
boxymyoglobin. (11, 27)
The pathophysiology of the poisoning is related to the impeded oxy
gen utilization. Transforming the Hb into COHb does not allow the ex
traction of the oxygen from the alveoli. This results into decreased level
of the 0 2 into the blood - hypoxemia. This hypoxemia cause hypoxia
into the vital organs - brain, heart, liver etc. As result of the hypoxia
the breathing centre activates the respiration - tachypnea, and the car
diovascular centre triggers an increased heart rate - tachyarrhythmia.
Increased breathing is supplying more oxygen, but it can't be transferred
to the blood. Along with increased input of oxygen, a lot of carbon di
oxide (CO2) is exhaled that leads to low levels of the CO2 (hypocapnia).
As the main trigger for breathing centre is the level of the CO2 in the
blood, the breathing centre is decreasing the breathing activity - bradyp-
nea and could lead to apnea. The low oxygen supply leads to decreasing
energy production and the brain starts to adjust its activities to the low
est energy and oxygen levels by decreasing the central nervous system
activity - tiredness, weakness, somnolence and coma. From the heart
the hypoxemia of the working hard muscle results into ECG changes
similar to the infarctus myocardii - elevation and afterwards depression
of the ST segment. These changes are accompanied with the feeling of
chest heaviness and pain.
The lab tests record initial respiratory alkalosis (due to the loss of
acids - CO2, followed by the metabolic acidosis (due to anaerobic pro-
Dms In Carbon Monoxide Intoxication
duction of energy, because of the oxygen scarcity). Hypergly t ^ i a is

also recorded from the impact on pancreas and the liyer react·on to the
homeostasis stress. (11, 27, 28)
Poisoning is developing rapidly without latent period. The following
syndromes are developed through the CO poisoning:
• Nervous - psychotic;
• Cerebral;
• Cardio-vascular;
• Tiredness and weakness;
• Hyperpyrexia;
• Changes in consciousness and pupils’ reactions.
Depending on the levels of COHb four levels could be distinguished:
• Light -20-30% COHb;
• Moderate 30-40% COHb;
• Heavy above 50% COHb;
• Instant death occurs with levels of 60-70% COHb.
The clinical symptoms of the light level of intoxications are:
• Conscious - no disturbances into the central nervous system ac
tivity;
• Acceptable general status;
• Extreme pulsing headache, vertigo, temporal pulsing, tinnitus;
• Eye - sight disturbances;
• Nausea, vomiting;
• Weakness, muscle and joints ' pams;
• Pink colour of the skin and mucosa;
• Hyperthermia - 38°C;
• With increasing the time of exposure a nervous and psychotic
symptoms are developed-euphoria, disorientation, memory loss;
• Tachycardia, tachypne ti. disturbanees in speaking and writing.
• The heavy level of the ·c-*gx : .. . is manifested with:
*■ Coma from toxic brain c m ; : ncc.mse of COHb - from hours
to days. If the coma lasts ~ m·; i:han day, the prognosis is dubia;
• Cerebral syndrome mm:, mm’ties -th e toxic cerebral edema pro
vokes changes into the m mle tonus - contractions and relaxa
tion;
• Mydriasis till no pupil reaction;
• Hyperpyrexia 41°C;
• Hemorrhages in the cerebrum are manifested clinically with pa
resis and paralysis;
• Breathing changes into shallow type Chain Stokes or apnea;
• Bronchopneumonia could be recorded;
• Cardiovascular symptoms - tachycardia with pulse filliformis
and ECG changes as myocardial infarcts, because of the hypox
emia of the heart muscle;
• Arrhythmia because of metabolic acidosis.
If casualty survives the acute intoxication a distinct long-term ef
fects are frequently observed:
• Persistent Headache;
• Hypotonia;
• Muscle pains;
• Tiredness physical and psychological;
• Heart pain;
• ECG disturbances rhythm and conductive;
• Hepatomegalia;
• Hallucination etc.
Differential diagnosis has to be made with all types comas. (11, 27,
28)
First aid in case of CO pollution and intoxication requires search
and rescue team members to wear autonomous respirator or application
of the common gas mask but with hopcalith bullet (40% CUO h 60%
M N02). This "bullet" transforms the CO from the air into CO2thus pro
tecting from intoxication. With this enhanced respirator around twenty
Dms In Carbon Monoxide Intoxication
minutes of activity in the CAOD is assured.

When casualty with signs of intoxication is found the r equired steps
are:
• The contact with the CO has to be interrupted b e aonficati^ x A '
barrier in front the respiratory system;
• Primary triage and performing organized evacuation to iffe
that is located outside of the area - to fresh air
• Outside of the contaminated area, if required CPR is performed
The first pre-physician aid starts with assisting the impeded t read
ing with oxygen. Antipyretics are also part of the aid on this level. As
sisting the breathing by oxygen therapy with 100% oxygen via ■_
started and continued throughout the medical evacuation. In the hospital
the oxygen therapy continues till the level of COHb downt to l 0%. In
order to increase the efficacy and the speed of the treatment the ■asual-
ties undergo hyperbaric therapy in hyperbaric chambers. This the ■x:\·
floods the body with pure oxygen and helps the overcoming of the oxy
gen shortage into the tissues. The hyperbaric therap y is absolutely re e-
ommended in the cases with intense intoxication and suspecte c r.er. e
damages. For brain recovery antidotes fi ■r intracellular h; v.:.
ment are administrated - noothroping dru0 -:
• Vitapiracen - 12 fl/ 24 h
• Orocetam 30 amp/ 24 h
• Pyramem 30g I 24 h
In the heavy levels of intoxication, free Hr for — im —on of the οχλ-
gen is supplied by blood transtusion- A := the :.::_e le\ e·- of
the COHb are dawned and a re tpiran oin :s -=-—
In case of developing or already de. e.rrea :ere'r~ii eaena a:_re:-
ics, Sol. Ca Gluconici, concen. ated as—a : : I- :>e - are
administrated, along with cardi .Monies zr<d sxffrj.rccs. Hrrerrey ag
gressive correction of the Ph has .. - -- ■ " -
the treatment.
Notwithstanding the centra 1 nervous system symptoms, in case of

CO intoxication it is prohibited administration of opiates, because of
their effect on the breathing center.
In summary for the treatment: The decisive in the treatment are inha
lation therapy with oxygen/pulmonar' resuscitation and blood transfu
sion! Others are only supplementary!
Dms In Blistering Agents Intoxication
DMS IN BLISTERING AGENTS INTOXICATION
Highlights
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
12. Why intoxicated are dying, when impacted with lethal concentration
16. First aid
17. Antidote
21. Delayed effects
Blistering agents are chemical compounds created as chemical weap

ons. They mainly affect the skin . but because of their solubility in organic
fats are rapidly absorbed and cause systemati c damage. Main representa
tives of this group are the sulfur j ... lewisite . phosgene oxime.
Sulfur Mustard gas is oily liqui d with low volatility at cool tempera
tures, but vaporizes rapidly in hot e■"dxm&tes <at 14 Degrees Celsius).
The smell of the weapon is simil r o the garlic. Mustard is with yellow
color - the technical one. It is well dissolved in organic solvents such
as alcohol, ether, benzene, as well as \ egetable and animal fats. Has to
be noted that all symptoms of mustard exposure are with delayed com
mencement.
The Lewisite is oily, colorless liquid with characteristic odor of gera
nium. It is more volatile and persistent at cooler temperatures than sulfar
mustard. The lethal dose is 2 grams.
Unlike mustard, the lewisite symptoms occur within minutes of ex
posure.
The Phosgene oxime is a yellowish-brown liquid. It does not produce
vesicles on the skin (as mustard and lewisite). It is an urticant or nettle
agent. It is important to highlight that it is able to penetrate garments and
rubber. As the lewisite the symptoms are occurring immediately.
The blistering agents could intoxicate human entering via all routes
of exposure. Into the patophysilogy the extremely fast absorption has to
be noted. They are intracellular poisons (because of their high solubil
ity in fats they easily penetrate the cellular membranes). In the cells the
agents undergo cyclization process, thus acquiring high reaction capabil
ity. The emerging onium compounds react with active groups of proteins,
nucleoproteins and others cellular organelles. The result is damaging im
pact on several enzymes and the cellular metabolism. The main damag
ing affect is link to the induced by the blistering agents depolymerization
of DNA that results in distortions into mitosis and determine pronounced
effect on the tissues with high regeneratory activity. (11, 27, 28)
The initial symptoms depend on the route of exposure. In case of
dermal exposure, the following symptoms are developed:
• 4-8 hours after exposure a visible erythema begins;
• The erythema is followed by development of vesicles within 12
18 hours;
• Vesicles coalesce into blisters o '■er days.
Dms In Blistering Agen > Intoxication 249
• Blisters are replaced by superficial, translucent lesions (from 0.5

to 5 cm.).
Lewisite exposures cause immediate pain and central blistsring
In case of Ocular exposure symptoms are:
• Tearing, conjunctivitis, eyelid edema, and blepharospasm.
• Corneal edema and sloughing can occur hours later v. ith large
exposures.
Ocular damages from lewisite are less severe because of severe
blepharospasm which prevents the further exposure. (28)
If inhaled blistering agents leads to respiratory symptoms such as
sore throat, hoarseness, cough. Bronchospasm, dyspnea, and hemor
rhagic bronchitis are also common symptoms.
Pulmonary edema may occur after lewisite or phosgene oxime ex
posure.
After ingestion the symptom that may occur is the vomiting but is
not usually a prominent symptom.
Systemic effects include development of leukopenia and pancytope
nia several days after sulfur mustard exposure.
Lewisite can cause capillary leak with shock.
General toxicity includes symptoms related to disorders of the nerv
ous system as disturbed thermoregulation. In some cases, are observed
mental motor excitement, memory impairment and sleep occurrence of
hallucinations. In case of intoxication w ith higher doses blistering agents
nervous system is damaged and convulsions and loss of consciousness
are the outcome. Suppressing the haematopoesis and different changes
into metabolism and functioning of the respiratory and cardiovascular
systems are also recorded. (11 . 2 ■
First aid and first medical aid in case of intoxication.
Immediately the AOD has to be abandoned, because no efficient
protection is available as clothing and these is no antidote against sulfur
mustard. As the sulfur mustard is ^--<=-vier 1’iian air and will settle in low-
lying areas the higher ground is iule safe place to be found. If sulfur mus
tard exposure has occurred the most important is to rapidly remove the
sulfur mustard from the bod' ,. Getting the sulfur mustard off as soon as
possible after exposure is the onl \ effective way to prevent or decrease
tissue damage to the body. Quickly remove any clothing that has liquid
sulfur mustard on it. Any exposed part of the body (eyes, skin, etc.) has
to be immediately washed thoroughly with plain, clean water. Eyes need
to be flushed with water for 5 to 10 minutes and protect them with dark
glasses or goggles. Dry powder, soap and water, or resin decontaminants
could also be used.
No specific antidotes exist for sulfur mustard or phosgene oxime
exposure.
Povidone iodine ointment may help protect the skin if applied within
20 minutes of sulfur mustard exposure.
British Anti-Lewisite (BAL, dimercaprol) binds arsenic and may
decrease symptoms oflewisite exposure. It is administered intramuscu
larly and should be given within 15 minutes of exposure.
In case of ingestion of sulfur mustard, inducing of vomiting is not al
lowed. If the casualty can swallow some water or milk have to be given.
The supportive care is the mainstay of treatment. Additional physi
cian aid includes:
• Management of bums with analgesics, cleaning and irrigation,
infection control, aseptic dressings;
• Infection control;
• Fluid replacement;
• Eyes should be irrigated thoroughly, followed by antibiotics and
steroids.
• Bronchodilators and humidified air for management of bron-
chospasm and wheezing.
• Patients with ocular or airway symptoms and those with moder
ate to severe skin exposure ha i e to be hospitalized.
Dms In Riot Control Agents Intoxication
DMS IN RIOT CONTROL AGENTS INTOXICATIO_-
Highlights
3. Specific gravity
4. Colour
5. Odor
6. Reactivity
9. Target
11. Main symptoms
12. Why intoxicated are dying, when impacted with lethal concentration
16. First aid
17. Antidote
21. Delayed effects
Riot Control Agents includes mainb lachrymators, stemitis and

pepper spray.
Chloroacetophenone (CN)» QhlOrobenzylidenemalononitrile (CS),
chloropicrin (PS), bromobenzy ,A>. dibenzoxazepine (CR),
and combinations of these che mieau 1 own also as lachrymators) are
irritant chemical agents that "e. :: a class of agents collectively
252_______ ________________________________ Disaster Medicine Highlights
known as riot control agents o : "tear gas”. They belong to the incapaci
tating toxic materials and are used mainly by the law enforcement forces
for managing hostile activities of c t o \ \ ds. All the lachrymators are solid,
crystal compound, majority of them without odor. Most used into the
police practice are the CN an CS.
CS is a white crystalline solid compound that is burnt to create a
colorless gas with an acrid pepperlike smell. It is insoluble in water
and ethanol. First synthesized in 1928, USA, by Ben Corson and Roger
Stoughton. The first letters of their surnames gives the name of the com
pound. For becoming weapon CS undergo several tests and modifica
tions at Porton Down, UK, in the 1950s and 1960s.
As a solid form at room temperature CS and other lachrymators are
difficult to enter in use from the police - a high dispersal is required for
achieving the objective, therefore variety of techniques have been used
to make this solid usable as an aerosol:
• The solid from is melted and afterwards sprayed in the molten
form.
• The solid compounds are dissolved in organic solvent.
• Micro-pulverized form in a silicone solvent.
• The solid forms are dispersed as a hot gas from thermal grenades.
All tear gases are "reflex" toxic compounds. They rapidly reach
very high concentration on mucous membranes of the upper respiratory
tract and eyes, thus causing severe irritation of the corresponding nerve
endings. The intense impulses of these nerve endings are transmitted
through the branches of n. trigeminus (n. olfactorius) and n. vagus to the
central nervous system that triggers reflex response. The reflex response
is hyper stimulation of the normal functions and is manifested by uncon
trollable sneezing andlacrimation.
The time of symptom onset is within seconds. Duration is typically
10 minutes to one hour. Both the time of onset and duration depend on
the dose, route of the exposure to tear gas and the premorbid condition
of the person. It is immediately dangero jts i© life Susa t h m, Ά cma-

centration of 2 mg/m. The tear gases are no: accumcfa::*. e igerts in the
human body, although they could ac^= n m ^ . . v . :
is the most persistent of the tear agents a m o due ■: r :. ,..s
surfaces including soil and plaster. Most freque nt routes o f exposure are
inhalational, ocular, or dermal. (11,2 7)
Primarily the tear gases affect the skin and mucus membranes, eyes,
and lungs, but systemic effects can occur as well. It is immediately irri
tating to the eyes and upper respiratory tract - cause a burning sensation
to the eyes, nose, and mouth. Erythema (conjunctivitis) and pain in the
eyes, lacrimation, erythema of the eyelids, runny nose, burning throat,
hacking coughing and suffocation or choking sensation, dyspnea are the
effects which will occur immediately and will persist 5 to 20 minutes
after removal from the contaminated area.
The high-dose exposures in an enclosed space may lead to the de
velopment of airway edema, non-cardiogenic pulmonary edema, and
possibly respiratory arrest.
The main signs and symptoms that may be encountered in a person
exposed to tear gas are the following:
1. Respiratory signs and symptoms:
• Chest tightness;
• Cough;
• Cyanosis;
• Dyspnea;
• Hoarseness;
• Hypoxemia;
• Non-cardiogenic pulrnonaf) edema;
• Sensation of suffocation:
• Tachypnea;
• Wheezing or rales;
2. Skin and mucous membranes
254 ______ __ Disaster Medicine Highlight
• Skin: redness, pain, blistering . and burns.
• Ocular: lacrimation, ocular irritation and redness, blurred vision.
corneal bums.
• Nasal: rhinorrhea, burning, irritation, edema.
• Oropharynx: oral burns and irritation, sore throat, hoarseness,
dysphagia, salivation.
All these symptoms are dose dependable that could cause great vari
ety into the clinical manifestation.
Differential diagnosis must be done with intoxication by:
• Ammonia;
• Chlorine;
• Hydrogen chloride;
• Hydrogen sulfide;
• Phosgene.(11,27,28)
A group of the tear gases provokes more intense sensation of pain
(into the sternum area) and they are known as Stemitis.
The first signs of irritation appear after a few seconds to 1-2 min
utes of their falling on the mucous membranes of the upper respiratory
tract. Poisoning starts with a tickle in the nose, uncontrolled burning and
sneezing. Later into the intoxication development a significant burning
and pain behind the sternum is felt, along with headache, coughing and
lacrimation. Typical is the pain along n. trigeminus and especially in the
teeth.
At higher concentration or prolonged exposure sipmtoms of arsenic
resorption could be observed - fatigue, dizziness, nausea and vomiting.
In case of use of the tear gases the protection of the skin, eyes and
respiratory tract is required - any wet fabric could be plausible preven
tive measure. To the affected into the AOD it is recommendable as a first
aid to start inhalation of antismoke mixture (consisting of chloroform
and alcohol in 40 parts of ethyl ether and 20 parts of a few drops of am
monia - 5 drops per 100 ml.). After lea ■. ing the AOD a thoroughly rins-
ing the mouth and eyes v. ith water or 2% sodium bicaroo_ _ *. on

has to be performed. For the eyes is recommended local d"'-....._._ii^ ranon
in eyestrain of analgesics - 1% solution of dikain or 2% aovreaine solu
tion. (28)
Analgesics are in use for the cases of headache, pain in fr.e eeth and
behind the sternum.
The general toxicity effects require administration of an ant idote
unitiol - 1 ml/kg.
Another incapacitating, lachrymatory, widely used chemical agent
is the Pepper spray. It is also known as capsicum spray and irritates the
eyes to cause tears, pain, and temporary blindness. This spray is used
by the police, but also for self-defense. The particularity in its action is
the immense inflammatory effects that force the eyes to close, causing
emporary blindness. The active ingredient in pepper spray is capsaicin,
which is a chemical derived from the fruit of plants in the genus Capsi
cum (e.g. chili peppers). From them an oleoresin capsaicin is extracted
in a form of waxlike resin. An emulsifier is used to suspend it in water,
and under pressure becomes an aerosol in pepper spray.
Pepper spray inflames the mucous membranes in the eyes, nose,
throat and lungs, causing immediate closing of the eyes, difficulty
breathing, runny nose, and coughing lasting from 20 to 90 minutes.
As capsaicin is not soluble in water, even large volumes of water
will not wash it off. The most effective removal from the eyes is by vig
orous blinking that force lacrimation thus flushing out the irritant with
the tears.
Most effective removing of the pepper spray from the skin (decon
tamination) is by application of bab t shampoo (used by many ambu
lance services) There are also wipes for decontamination.
An antidotes capsazepine, mthem . red and other transient recep
tor potential cation channel subfamily V member 1 (TrpV 1) antagonists
are effective in the pepper spra. · ·a fa '^ ^ fo n.
256 DisasterMedicineHighlights
DISASTERS PSYCHOLOGICAL DISORDERS
Highlights
1. Defining the psychological effects of the disasters
2. Stress sourses in disasters
3. Definining the stress as biological syndrome
4. Stages of the stress reaction (the General adaptative syndrome, ac
cording the Selye)
5. Hormone chain in case of stress
6. Pathophysiologiacal effects
7. Physical effects of the stress
8. Responses to the stressors
9. Types of the stress
10. Definition of Acute stress
11. Defining Chronic stress
12. The four types acute stress effects
13. Acute stress reaction with risk for severe psychological impact
14. PTSD sourses in disasters
15. PTSD risk factors related to the disaster s and the person affected
16. PTSD risk factors related to the Acute stress management
17. Arousal symptoms
18. Other PTSD symptoms
19. PTSD long term effects
20. PTSD mitigation
Psychological effects could be defined as a physical, chemical, or

emotional factor that causes bodily or mental tension, and may be a fac
tor in disease causation.
In accordance to the Claude Bernard concept of dynamic equilib
rium (or steady state), organisms, even individual cells within organ
isms, are subject to never-ending changes into conditions. But in order
Disasters Psychological Disorders
to survive and maintain optimal function, built-in mech'-"-"s'--'-'-'-K r^cS:JOnd

to altered conditions (stresses) by making adjustments tha : a:·;- acs:
to re-establish equilibrium.
In 1946, Hans Selye first started to describe the stress reac tion a: a
biologic phenomenon. He found that three structural changes o·■burred
after rats’ exposure to noxious stimuli, such as cold, surgical injury and
restraint:
• enlargement of the cortex of the adrenal gland,
• atrophy of the thymus gland and other lymphoid structures,
• development of bleeding ulcers in the stomach and duodenal lin
ing.
These stimuli Selye called stressors. He concluded that the afore
mentioned triad (or biological syndrome) of manifestations represented
a nonspecific response to noxious stimuli, naming it the General Adap
tation Syndrome (GAS). GAS consists of three successive stages:
1. Alarm stage or reaction:
• Antishock phase: When the threat or stressor is identified or re
alized, the body starts to respond and is in a state of alarm - the
defied central nervous system releases hormons for mobilizing
the body’s defenses.
Activation of the locus coeruleus/sympathetic nervous system
Release of catecholamines such as adrenaline are being pro
duced, hence the fight-or-flight response.
Increased muscular tonus.
Increased blood pressure due to peripheral vasoconstriction and
tachycardia,
Increased glucose in blm>iL
Shock phase: The bod\ . e::: Mre changes such as hypovolemia,
hypoosmolarity, hyponaêmia. hypochloremia, hypoglycemia—
the stressor effect.
2. Stage of resistance or aaar'..i'..::
• Resistance is the increase d secretion of glucocorticoids

• Plays a major role _ intensifying the systemic response—they
have lipolytic,_catabolic_and_antianabolic_effects:_increased_glu-
cose, fat and amino aci d protein concentration in blood.
• Cause lymphocytopenia._ eosinopenia,_ neutrophilia_ and_ poly
cythemia.
• If the stressor persists, it becomes necessary to attempt some
means of coping with the stress. Although the body begins to try
to adapt to the strains or demands of the environment, the body
cannot keep this up indefinitely, so its resources are gradually
depleted.
3. Stage of recovery or exhaustion
• Recovery stage follows when the system's compensation mecha
nisms have successfully overcome the stressor effect (or have
completely eliminated, the factor which caused the stress). The
high glucose, fat and amino acid levels in blood prove useful for
anabolic_reactions,_restoration of homeostasis_and_regeneration
of cells.
• Exhaustion is the alternative third. At this point, all of the
body’s resources are eventually depleted and the body is unable
to maintain normal function. The initial autonomic nervous sys
tem symptoms may reappear (sweating, raised heart rate, etc.). If
stage three is extended, long-term damage may result (prolonged
vasoconstriction results in ischemia which in turn leads to cell
necrosis), as the body's immune system becomes exhausted, and
bodily functions become impaired, resulting in decompensation.
(117, 118)
The pathophysiology of the stress is related to the secretion of pow
erful neurotransmitters:
• Stimuli from the brain cause the hypothalamus to release cortico-
trophin releasing factor (CRF).
Disasters_ Psychological Disorders
• CRF then causes the secretion of adrenocorticor:

(ACTH) from the pituitary gland.
• ACTH stimulates the release of cortisol, epinephrine. mwi ϋΚ&:-
epinephrine from adrenal glands. (119) (fig.21)
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sc*xt
igs&sets m ay m # e « 3 W m m &tmiist w r,m £ m i naty** o* tt*
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APM Ν * λ *&λ * : ΑζΠΉ. »& ΐ**Χβη<& ?ϋί>< haiWOftO
Figure 21. Stress reaction - Hormone release (119)
The immediate effects of the chain activation are:

Norepinephrine and epinephrine rapidly ready the organism for
"fight or flight" by increasing heart rate . blood pressure, sweating, me
tabolism, breathing, and le - el of alertness.
They also constrict blood , esse -s to reduce bleeding if attacked, and
divert energy from (at the time) unnecessary organ systems, such as the
stomach and intestines, by inhib:tm0 mfutility and digestion.
Cortisol which breaks down protein from muscles, takes fatty acids
from fatty tissues, increases o - esis, and decreases the bod - 's
nonessential uses of glucose.

Cortisol and other glucocorticoids are also potent inhibitors of the
immune system and lower sensitivity to pain. (120, 121, 122, 123, 124)
The physiological reactions into the body are listed in table 1.
QRfiAMmssts is o a s s a tn s ix T
Eras-. h iS tS itz i bk< 4 Sc*- «creased giasc·,·. cftascass·.
‘k to stsm d tgeductic·
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tfM * m S ez sS zm i
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ters·**! p e o s p s sipis
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J te iS5#sSie4s<s4%I&5S4
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laaaBHed m m s tm p s .
fe»®
w i ib z s m m m u tm M m m d * isssg m & f, $ tm m & gs s t e sjin r H iM g t Φ s
W i i e s M s aaasgfeip sds%
B ep rsIm atsM fc «£is-pel*;p m Siâ,ks~r r^-t:kr« pi$®cs sr *%ssncsd: sstsgssk sfesscsiL md petapfeersls^r% 5w «-îi2jsa| lesmsaE >|€EKj
Table 1. Processes triggered by the stress (119)
Great variety of symptoms are observed s reactions to stressors.

Mainly they are effects from the hyper-stimulation of the sympathetic
nervous system, (fig.22)
The physical symptoms of the stress
• Headaches, neck pain, insomnia, tremors, confusion, fatigue, loss
of sexual desire, reduced work productivity, nightmares, difficul-
Disasters Psychological Disorders 61
ty concentrating or learning new information, racing thoughts,

forgetfulness, and disorganization .
• Feelings of frustration . loneliness, or isolation.
• It can illicit crying spells or suicidal thoughts, imtability . a ..
panic attacks.
• Might include increased use of tobacco, alcohol, and drug abuse.
• Contributing factor to depression, anxiety, heat! attacks, strok ..
hypertension, and immune system disturbances.
P a ra sy m p a t h e t ic Sympathetic ganglia S y m p a th e tic

Constricts pupil Dilates pupd
Stimulates salivation Inhibits

salvation
Inhibits heart
Relaxes bronc'
Accelerates
Constricts bronchi heart
Inhibits digestive actMty

Stimulates digestive W-
activity_______ £ 2 s Stimulates glucose
release by Sver
Stimulates
Secretion of epinephrine and
gallbladder
norepinephrine from kidney
Contracts
bladder Relaxes bladder
Relaxes rectum Contracts rectum
Figure 22. Sympathetic and parasympathetic nervous system (125)
Different responses to the stressors:

• Fight - feel agitated and aggressi ■.e towards others; this can be
due to our bodies’ natural reaction .
• Flight - avoid our stres tors . remo . ing ourselves from the situa
tion instead of tackling ::
• Freeze - stage for ‘deregul^ p f . Holding our breath and shallow
breathing are both for:::> :: freeze. The occasional deep sigh i .
the nervous system ca:cr.:r.g .r ;r. its oxygen intake.
262 Disaster Medicine Highlight
Types of the stress:

• Normal Stress (Eustress) - minimal amount of stress which pass
es quickly. It might pro ■- ide a burst of energy that helps you ge:
things done or a stimulus that helps you focus and improves you:
performance.
• Distress - more severe stress that causes significant disruption.
but occurs for a relatively short period. The effects are signifi
cant, but temporary, and the individual typically returns to a nor
mal state.
• TraumatiC)Stress - result of a profound event that alters one’s
beliefs and assumptions. Affected individuals recover over time
but they are forever changed.
• Stresses that are profound or unrelenting may exceed our capaci
ty to cope, eventually causing fatigue, exhaustion, or breakdown.
The two most common types of the stress are - acute stress and
chronic stress.
• - The most common form is the Acute Stress. It comes from de
mands and pressures of the recent past and near future. Acute
stress is thrilling and exciting in small doses, but too much is ex
hausting. Episodic Acute Stress is observed when the acute stress
episodes are frequent - many simultaneous demands of their time
and attention and their inability to organize them leads to epi
sodic acute stress. - short-tempered, irritable, anxious, and tense
-always be in a rush, yet are always late. They tend to be abrupt
and irritable. Interpersonal relationships deteriorate.
• Chronic stress could be defined as the grinding stress that wears
people down a little at a time over a long period of time. It comes
when a person cannot see a way out of a miserable situation. It
can be unrelenting demands and pressures for seemingly inter
minable periods of time. Losing hope, the individual gives up
searching for solutions. The worst aspect of chronic stress is that
Disasters Psychological Disorders_______________ 263
people often get used to it. They may forget it is there. Because
physical and mental resources are depleted through long-term at
trition, the symptoms of chronic stress are difficult to treat and
may require extended medical, as well as behavioral treatment
and stress management.
(Adapted from P. Nixon: Practitioner, 1979)
Figure. 23
During disaster's impact, response and recovery phase the acute

stress reactions and their consequences and the so called post traumatic
stress disorder syndrome could be recorded among affected population
and relief workers. The origin for these reactions are various:
• The unexpected event occurrence .
• Helplessness feeling in front of the devastating power of the DFs.
• Loss of parents, close relatives, friends and/or loss of the prop
erty and all built throughout the life.
• Grief for irretrievable losses
• Encounter with the death is always and everywhere one of the
most powerful stressors.
The reactions observed into the acute stress syndrome (from 2 days
to 4 weeks) could be grouped infou.r categories.
• Emotional effects;
• Cognitive effects;
• Physical effects;
• Interpersonal effects.
Emotional effects are various:
• Shock;
• Terror;
• Irritability;
• Blame;
• Anger;
• Guilt;
• Grief or sadness;
• Emotional numbing;
• Helplessness;
• Loss of pleasure derived from familiar activities;
• Difficulty feeling happy;
• Difficulty experiencing loving feelings.
The cognitive effects are also several:
• Impaired concentration;
• Impaired decision making ability;
• Memory impairment;
• Disbelief;
• Confusion;
• Nightmares;
• Decreased self-esteem;
• Decreased self-efficacy;
• Self-blame;
• Intrusive thoughts/memories;
• Worry;
• Dissociation (e.g., tunnel vision, dreamlike or "spacey" feeling).
Great variety physical effects are also recorded:
Disasters Psychological Disorders _ 6 ·
• Fatigue, exhaustion;
• Insomnia;
• Cardiovascular strain;
• Startle response;
• Hyperarousal;
• Increased physical pain;
• Reduced immune response;
• Headaches;
• Gastrointestinal upset;
• Decreased appetite;
• Decreased libido;
• Increased vulnerability to illness.
The interpersonal effects are manifested from the beginning by:
• Increased relational conflicts;
• Social withdrawal;
• Reduced relational intimacy;
• Alienation;
• Impaired work/school performance;
• Decreased satisfaction;
• Distrust;
• Externalization of blame;
• Externalization of vulnerability·
• Feeling abandoned/rejected;
• Overprotectiveness. (25 , 26, 126)
In the acute stress sometimes :.s are ob
served. The following responses are less i-uicat e faat the
individual will likely need assi stan e e :.·:^ a medical —er._.:.:-health
professional:
• Severe dissociation (feeling as if the - _ * =-&L - . :
connected to one's own body, ' - - - r :: ienrty or
taking on a new identity a:v.v.e.' :
266 Disaster Medicine Highlight
• Severe intrusive re-expe en .ins (flashbacks, terrifying screen

memories or nightmares . repetitive automatic reenactment)
• Extreme. avoidance (agoraphobic-like social or vocational with
drawal, compulsive avoidance)
• Severe.hyperarousal (panic episodes, terrifying nightmares, dif
ficulty controlling violent impulses, inability to concentrate)
• Debilitating anxiety (ruminative worry, severe phobias, unshake-
able obsessions, paralyzing nervousness, fear of losing control
going crazy)
• Severe.depression (lack of pleasure in life, feelings of worthless
ness, self-blame, dependency, early wakening)
• Problematic. substance. use (abuse or dependency, self-medica
tion)
• Psychotic.symptoms (delusions, hallucinations, bizarre thoughts
or images) ( 126)
If the reactions to the stressors are available above one month, most
probably a posttraumatic stress disorder syndrome (PTSD) is in devel
opment. It could be caused by:
• Exposure to a traumatic stressor;
• Re-experiencing symptoms;
• Avoidance and numbing symptoms;
• Symptoms of increased arousal;
• Duration of at least one-month exposure;
• Significant distress or impairment of functioning
The percentage of PTSD can vary depending on the nature of the
trauma. At the time of a traumatic event, many people feel overwhelmed
with fear; others feel numb or disconnected. Most trauma survivors
will be upset for several weeks following an event but will recover
to a variable degree without treatment. The percentage ofPTSD will
depend on many factors, including the severity of trauma exposure.
Highest is the risk for development ofPTSD when there is an expo-
Disasters Psychological Di -orders 262
sure to:
• Mass destruction or death;
• Toxic contamination;
• Sudden or violent death of a loved one;
• Loss of home or community.
The risk factors for PTSD development could be either related to the
disaster and the personal characteristics of the affected or due to aspects
of acute stress. Related to the disaster or the person affected are the fol
lowing risk factors;
• Magnitude, duration, and type of traumatic exposure;
• Earlier age and a lower level of education;
• Severity of initial reaction;
• Peri-traumatic dissociation (i.e., feeling numb and having a sense
of unreality during and shortly following a trauma);
• Early conduct problems; childhood adversity; family h isto r of
psychiatric disorder; poor social support after a trauma; and per
sonality traits such as hypersensitivity, pessimism, and negati, e
reactions to stressors;
• Women are more likely to develop PTSD than men, and a h isto r
of depression in women increases the vulnerability for develop-
ing PTSD.
Risk factors related to the phase o : : e saittfe s .ess are:
• Lack of emotional and soci: sarr ar
• Presence of other stressor f_ar - f e : a r ar. arar-ar. fear,
uncertainty, loss, dislocatiar. are ar : - --f; ;'ararf
experiences;
• Difficulties at the scene·
• Lack of information abou ibe
• Lack of, or interference wife. seif-- v - - — - - n o - ra r se '-narar
agement;
• Treatment [given] in an artf <jgiaes«giD*ii< wmwmr^
• Lack of follow-up suppor:: in the '.veeks following the exposure.

The symptoms of the increased arousal may include:
• Difficulty falling or stay ing asleep,
• Irritability or outbursts of anger,
• Difficulty concentrating, hypervigilant watchfulness, and an ex
aggerated startle response.
• Heightened physiological activation, which may occur in a gen
eral way even while at rest. More typically, this activation is evi
dent as excessive reactions to specific stressors that are directly
or symbolically reminiscent of the trauma.
• Sleep disturbance may be caused by nightmares, intrusive mem
ories may interfere with concentration, and excessive watchful
ness may reflect concerns about preventing the occurrence of a
traumatic event similar to the previous trauma.
Other symptoms related to the PTSD are:
• Recurring nightmares and flashbacks to traumatic events
• Chronic physical ailments (i.e., gastrointestinal problems);
• Apathy, sadness, and loss of interest in pleasurable activities;
• Difficulty concentrating;
• Mental and physical fatigue;
• Sense of dread;
• Excessive blaming of others.
The PTSD could lead to:
• Depression;
• Substance abuse;
• Panic Disorder;
• Obsessive-Compulsive Disorder;
• Sexual dysfunction;
• Eating disorders. (126)
Disasters Psychological Disorders _69
The PTSD risk could be mitigated by some of the following meas

ures:
• Social support;
• Higher income and education;
• Successful mastery of past disasters and traumatic events;
• Limitation or reduction of exposure to any of the aggravating
factors listed above;
• Provision of information about expectations and availability of
recovery services;
• Care, concern and understanding on the part of the recovery ser
vices personnel;
• Provision of regular and appropriate information concerning the
emergency and reasons for action.
Every medical team member has to consider the possibility for acute
stress reaction and to be ready to provide the psychological contro ! :
the casualty till psychologist group arrives. This psychologic il OTgpKi
is the first step of PTSD prevention. Also it will benefit itae ϊΜΐίκαηΜ©of
the DMS into the acute reaction phase. (25, 26)
DECONTAMINATION
Highlights
1. Defining decontamination
2. Different decontamination processes
3. Types of decontamination
4. Human decontamination
5. Human decontamination in case of radiological pollution
6. Human decontamination in case of biological pollution
7. Human decontamination in case of chemical pollution
8. Decontamination of polluted environment
9. Decontamination ofCAOD
10. Decontamination of RAOD
11. Decontamination ofBAOD
12. Disinsection
13. Deratization
Decontamination is a term that includes all activities performed for

eradicating the contaminants with potential to cause harm to an individ
ual human and society as a whole. Throughout disasters population and
environment could be contaminated by different agents with chemical,
biological or radiological origin. Some of the AOD are caused by the
aforementioned agents that become DFs. In both of the cases as primary
or secondary DFs these agents are posing significant threat to the life
and health of the population. (27, 28)
Decontamination could be also defined as the process of remov
ing or neutralizing contaminants that have accumulated on personnel
and equipment, so that they no longer pose a hazard. The process is
performed by using different methods - mechanical, physical, physico
chemical, chemical, etc. Decontamination, depending on what contami
nant has to be removed is three types:
Decontamination i
• disinfection,
• digassation,
• disactivation. (127)
Disinfection are all the processes of eradicating the Di
gassation are the process for neutralizing and remov ing the chemical
pollutant. With the term disactivation the procedures for e:e,:.:mmr me
radioactive threat are described.
As the biohazard could threat the population not onl y m: m me ■;
luted surfaces but also by the infected insects and rodenm. mm_ me
disinfection of the environment procedures for eradicating me mmmm
(disinsection) and rodents (deratization) are included into the biohaard
prevention. (128)
The specialized services of the General Directorate "Fire Safety and
Population Protection are organizing and executing the decontamina
tion activities and procedures. Within the directorate a sector dedicated
to the decontamination is established - "Protection against Chemical,
Biological, Radiation and Nuclear Threats". Specialized services and
units for decontamination are established also within several other insti
tutions - the Ministry of Environment and Water, the Ministry of Health,
the Ministry of Agriculture and Food, the Ministry of Defense.
Decontamination can also be classified in accordance to what has to
be decontaminated - humans or environment.
The human decontamination (HUDECONT) is the process of re
moving hazardous materials from the human body, including chemicals,
radioactive substances, and infectious bio-agents. The HUDECONT is
subdivided into partial and complete depending on the human body's
treated areas. When determining the type of decontamination, the fol
lowing factors should be taken into consideration:
1. The place of performance. Depending on the location (in or ouside
of the AOD) a decision is made on the amount of decontamination per
formed;
2. The time of contamination. The time period from the onset of

contamination is also important for deciding on the amount and type of
treatment required;
3. The number, preparedness and equipment of the rescuers who
have entered into the AOD;
4. Of utmost importance is the type of pollution (radioactive, chemi
cal, biological or combined).
Partial HUDECONT in case with radiological pollution

It consists of the mechanical removal of radioactive substances from
the exposed parts of the body, hands, face, neck, eyes, nose and mouth.
Partial HUDECONT has to be performed as soon as possible, immedi
ately after irradiation (or after finding the casualty into the AOD). It is
the first step of the casualty maangement in the AOD and has to be re
peated immediately after leaving the contaminated area in specially des
ignated for the decontamination places. When partial decontamination
takes place outside the AOD (casualties have spontaneously evacuated
themselves), it precedes, (it is the first stage) of the complete decontami
nation.
Partial decontamination is either performed the population itself (as
self-aid or/and buddy-aid, mutual assistance), or by the search and res
cue teams.
Partial HUDECONT of the exposed parts of the body contaminated
with radioactive substances is performed in a strictly order:
• Brushing the radioactive dust covering the skin;
• Washing hands, face and neck with clean water (if available the
cleaning detergent should also be used);
• Removing the dirt under the nails;
• Rinsing mouth, nose and eyes several times with clean water;
• Wiping the treated areas with a dry cloth or gauze.
When partial decontamination occurs in the AOD, and deficiency or
Decontamination
lack of clean water are present, the degassing solutions from the indi
vidual protective package may be used. Degassing solution should not
enter into eyes. In extreme circumstances (absence of clean water) the
exposed pails of the body can be wiped with damp tampons, to i'els or
other clean fabrics. (127) In some countries wet wipes that are watered
with decontaminant solutions are produced and sold. (Fig.24)
Figure 24. Decontaminating wipes (129)
The removal of the radioactive contaminant is always done from top

to bottom (from head to extremities) and from the center of the body to
the outside (from medial to lateral). The material used is replaced with
clean one with each subsequent cleaning.
When partial decontamination takes place outside the AOD, the
cleaning begins from the outside. Dust removal and washing the face of
the gas mask, followed by decontamination of the outer garments (by
tapping and / or brushing the adhering dust). The radioactive elements
adhering to the shoes are removed ~y we i rubbing. The decontamination
proceeds with stripping of the outer garments, which takes place from
the inside out. Contaminated c lothing should be carefully uncovered, if
it is impossible, they are cut, in order not t o allow contamination of the
undergarments or body. The - ’ ; : _ .^ is intended not to touch the
outer surfaces of the garment. After removing the radioactive substanc

es adhering to the outervear . the process of decontamination proceeds
through carefully wash of all exposed parts of the face, neck and hands
with water and soap and completes by rinsing the nose and mouth with
water.
Partial HUDECONT for contamination with liquid chemicals..,

It is done in the AOD, immediately after drops of toxic chemicals
(THB) on the exposed parts of the body, clothing and or shoes are real
ized. These events are also mandatory in case of contact with chemically
polluted objects, even without visible signs of body/dress contamina
tion.
The contaminated or suspected places on the exposed parts of the
body are treated with the help of degassing solutions from the individual
protective package. Decontamination is done by wetting the gauze with
the liquid into the plastic container. The polluted sites are treated starting
from the periphery to the center of pollution, in order not to pollute other
not polluted (clean) areas. During processing, it is necessary to keep the
eyes from getting degassing solutions in them. In the case of absence of
individual protective package, the drops are carefully wiped with dry
cotton, gauze or any kind soft tissue. After treatment of the exposed
parts of the body with the degassing solutions, the treated areas have to
be washed with water and soap. If the liquid chemical has entered into
the eyes, nose and/or mouth, they are washedwith clean water or with a
suitable neutralizing solution (particular for the chemical contaminant):
• 2% sodium bicarbonate solution (soda bicarbonate) for contami
nation with suffocating and nerve agents;
• 0.2% solution of chloramine or 0.05% potassium permanganate
solution for eye mucous lavage and 0.5% and 0.1% for other
mucous membranes for contamination with blister agents (vesi
cants);
Decontamination
• 5-10% syntomycin or Unitol creme as a post-treaune~;: e

eyes when damaged by blister agents;
• 3.5% dimercaptol oinment or 0.5% solution of chloramine on
ulcerative lesion due to vesicant lewisite. After the partial decon
tamination all have to undergo a complete decontamination into
the designated sites. (127)
Decontamination_in case_of biological pollution

HUDECONT in case of possible biological contamination is per
formed by carefully application of antiseptic solutions on the affected
skin. The clothes undergo physical decontamination - brush the surface
(mouth and nose covered by gauze mask), stripping off the clothing and
or burning them (recommendable) or washing them into boiling water.
The partial disinfection completes with new application of the antiseptic
solution on the bare skin surfaces.
Decontamination_of_the_environment
Decontamination of radioactive substances on objects, equipment
and foodstuffs to acceptable contamination standards. The vehicles,
roads, buildings, and sometimes large areas of the environment are sub
ject to decontamination in case of radiological pollution. According to
the specific situation it could be partial or complete. Partial decontami
nation decontaminates those parts "here people could come in contact
with the contaminated with radioactive substances, only. Upon total de
contamination, the infected site, facility and / or site must reach a level
of pollution that is safe for humans for unlimited time.
There are two main ways to perfom decontamination:
• Mechanical means. It is : the removal of radioactive dust
from the surface o finfetteti objeets. It is done by sweeping, tap
ping, wiping, brushing. removing the contaminated layer (in case
of soil decontamination . .·. with a stream of pure water.
• Physico-chemical method. Applied in partial and complete de

contamination. It is ba -ed on various physico-chemical processes
for washing the radioactive substances from the polluted surface.
It is mainly done with solutions of detergents. The use of deter
gents in water improves the wetting of particles of radioactive
powder and the surface. This helps for removal the particles from
the contaminated surface and pass them into the solution.
The physico-chemical method achieves the most complete removal
of the radioactive substances from the contaminated surface.
Decontamination of radiological contaminant from water. De

contamination of water is an extremely important event, which aims to
reduce the possibility of people being radioactively contaminated. Water
is deactivated only, if there is no clean water or in case of extreme water
scarcity. The decontamination of water could be achieved by distilla
tion, by filtration, by application of ion-exchange resins. The most ac
cessible way to decontaminate water is sedimentation and filtration. The
contaminated water is poured into large vessels where it is precipitated
for 10-15 hours - the solid radioactive particles fall to the bottom of the
vessel. The precipitation can be done more quickly by adding chemicals
to the contaminated water with coagulating action, and then passing the
water through ordinary filters.
The springs and wells are deactivated by scraping 10-15 cm from
the bottom and the repeatedly scraped water is discarded and collected
in special containers.
Decontamination_of chemically polluted_environment

Full degassing is a set of events that take place as soon as possible
after a chemical attack outside of the AOD. It aims to remove the chemi
cal contaminant from the entire surface of poluted objects, equipment
and equipment.
Decontamination
Methods of degassing are several:

1. Mechanical method - the chemical substances that are deposited
on the surface of the poluted objects are mechanically removed. This is
done in a simple mechanical way (method) by brushing and wiping with
tampons, gauzes, towels, rags, grass, straw, etc. Washing with a heavy
stream of water can also be used. After mechanical removal, the means
used, including water, must be decontaminated and then destroyed (by
baring).
2. Physical method - chemical substances are removed from con
taminated sites using some of their physical properties (solubility, melt
ing temperature, boiling temperature, volatility, swallowing, etc.).
• Chemical contaminated sites by chemicals with good water sol
ubility (hydrogen cyanide, chlorine) can be quickly and easily
degassed by thoroughly washing with water and / or water and
detergents.
• Contaminated objects whith poorly soluble or insoluble in w a-
ter chemicals (phosgene, FOS, iprit) but well soluble in : r am^
solvents (alcohol, benzene, ether, chlorobenzene- choroform. di-
chloroethane, etc.) are degassed by the solvent or rinsed v.: h i-;;._
solvent. Disintegration with solvent is possible if e , ubjaet
a smooth surface. On porous surfaces degas?: - -
blowing hot air.
3. Thermal degassing - combustion, com:::.'·.:"· - _ ■-
liquids, incineration, heating in suitable faci lit ie s, dry-er?. f_r-
naces, etc.) can also be applied. For therm J1 degassing, nrrejc-r*: -
thermal machines have been de a elope -a :::: _.. · .
by a constant reduction in the densi·.-· «sf jaAfikia gad « m b s ia scraps
with different process speeds. Therm a. .::_ ·-· - - *
minutes at temperatures above l 200C. ilt is necesser. ϋ Esse ζζή usp
ing the mechanical and physical degassin= = e f a : ■-
removed continue to some extent to be ' ■ _er: ^ :: - —-a:-...;..,.
4. Chemical method - based on the chemical interaction of degassing

substances with toxic chemicals . producing nontoxic or slightly toxic
products that do not have a negative effects on the human health. The
most commonly used methods for chemical degassing of equipment,
buildings and contaminated surfaces are: chlorination, oxidation, alka
line hydrolysis, the combination between them, and the use of organic-
based polydegative formulas.
Ways_of disinfection.^
The following methods are used for disinfection: biological, physi
cal and chemical.
The biological method is based on naturally occurring biological
processes in the external environment. For example, the biological way
to disinfect waste (garbage) is to throw it into special chambers where
waste is decomposed (mineralization). As a result of the decomposition,
the temperature rises to plus 600-800 C and all the germs die.
The mechanical way of disinfection is to remove the bio-agent by a
purely mechanical pathway. Washing with clean water or with water and
washing solutions; cleaning with a vacuum cleaner; often whitening of
the walls; ventilation and more. In the mechanical way of disinfection
microbes are not destroyed but only removed.
The physical way of disinfection includes:
• Hot air and steam disinfection;
• Burning;
• Boiling;
• Effects of direct sun rays.
Hot water as a disinfectant is distinguished by its high performance
and ease of use. For example, when boiled for 2-3 minutes, all non
invasive forms of microbes are killed; in the presence of spore forms,
the boiling time is increased up to 2 hours (for botulism spores up to
6 hours). It takes a maximum of 30 minutes to destroy the toxins. The
Decontamination Z~9
bactericidal action of boiling increases when soda, soap or lve

to the water.
The chemical way of disinfection is destruction of the biological
agents by chemicals that kill the germs.
For disinfection of premises, furniture and miscellaneous items,
3-5% solution of carbolic acid, as well as soap-carbolic solution (2%
green soap, 3% carbolic acid and 95% water) are used. The solutions
quickly kill the microbes, but almost do not work on spore forms.
For the disinfection of premises, clothing, soft objects and equip
ment infected with vegetative forms of microbes 3-5% aqueous formal
dehyde solution is used. It is prepared by mixing one volume of forma
lin with 6-12 volumes of water. For disinfection of premises, clothing,
soft objects and equipment contaminated with microbial spore forms,
the most effective is 17-20% aqueous formaldehyde solution containing
10% by weight monochloramine. The solution is prepared by prepara
tion of a 20% solution of monochloramine (20 kg monochloramine in
50 liters of water). The mixture is stirred until complete dissolution of
the monochloramine. Then equal volumes of the resulting solution and
formalin are mixed.
In addition to these chemicals, chlorine lime, calcium :h cline dkb>·
ride salts, monochloramines, dichloramines and sodium hvc :: v m .vn-
used as disinfectants. These chemicals have high bacterid dal properties.
They can be used for disinfection of the area, various objects of me ftooe.
industry, household objects, etc., contaminated \v :: ru n - : : raa ;
and sporadic forms of microbes and toxins. Depe^di-; on the resistance
of the bio-agent and the nature of the decontaminated z r ecn the con
centration of these chemical solutions , ■o n ^ :: ο 1 -
a 50% sulphuryl chloride solution in di chloroethane can de _scc for sne
disinfection.
First, disinfected are:
• passages for rescue operations·
280 Disaster Medicine Highlit:'.
• passageways for e - acuation of the people;

• passages to medical facilities.
The area and sites are treatedw ith available disinfectants using v c -
ous utensils and machines. (128)
Disinsection
In the BAOD a special role is devoted to the activities of destro ; _
insects and arthropods as carriers/vectors ofbio-agents. Arthropods c-=..
be destroyed in two basic ways: physical and chemical.
1. Physical ways are based on the effects of high temperatures. He:
water, hot air, water vapor and fire ensures the destruction of insects ar:.:
their eggs after 15-20 minutes. Ironing with a hot iron causes the spore
forms to be destroyed for about 50 seconds, and non spore forms fi :
5-10 seconds.
2. The chemical way is based on the use of insecticide formulas.
A number of disinfectants are currently being developed. They can be
used in the form of powders, emulsions, solutions, suspensions, sprays
and soaps. The simplest and most convenient way is to dust the surface--
where the insects are found. When using solutions, the spots are smearec
with a brush dipped in the solution. To combat insects in the BAOD
is also used and the barrier method. With disinfectants are treated the
edges of the area at least at 200 meters lenght. In the city at least two
neighborhoods have to be treated. Most of the insects in the premises are
destroyed with insecticidal aerosols.
Deratization
In the BAOD measures against rodents as carriers and sources of
infectious diseases are also implemented. Eradication of the rodents'
threat occurs in two ways: mechanical and physical.
• The mechanical way of deratization involves the use of differ
ent kinds of traps that can easily be prepared by the population,
Decontamination 281
even with hand ■ materials. The captured rodents are killed, their
carcasses are burned, and the used traps are to be decontaminated
with 3% chlorine solution or by boiling in 1% soda solution.
• The chemical way of deratization is the use of poisonous food
baits, spraying rodent holes with poisons, poisoning rodents in
their holes using poisonous gases. (130)

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ROSTISLAV KOSTADINOV

DISASTER MEDICAL SUPPORT IN CASE OF AREA OF

DISASTER MEDICINE HIGHLIGHLIGHTS

30. Disaster Medical Support in Case ofArea of Chemical Damage

Disasters are devastating the Earth throughout entire geological and

voke property damages, casualties and injjn::ies overwhelming the capa­

3. C ^ :: z.::eet geographical and administrative areas of different

11. The unexpected and unspecified munber and type of casualties

«sea- due to the leakage of certain chemicals. The temperature of

on time - the pressure difference b e te e n the two media very quickly, in

• m;JS: toxic contaminations were recorded, when the safety

cf ionization in the environment, the distance to the radio-emitter,

this fa-tor :s ^ consequence of various disasters, which lead to a severe

meci::s their own safety and security in order to survive and

DM is defined as interdisciplinary medical specialty with scientific

and abili::· in case of disastrous events.

The adequacy of the medical aid is directly related to type and

• R ^ ^ c h on disasters’ impact on human health is a rational fol-

quirec.. AU :hese activities in their sequence are assuring constant assis­

- social, economic, political, cultural, technical and environmental. This

yses of entire spectrum of existing hazards with potential to cause health

Area, the territory, where the DF affects population, environment

when the epidemics could affect almost entire continents. What

the people t a t could be affected by the DF. The information regarding

necessary to mobilize epidemiologists.

1. e:pressure and shock wave cause medical losses mainly with

6. Biological DF causes various infectious diseases. Infected patients

as priori::"? The answer is unambiguous: life has to be saved first and

with a direct threat of death due to the \ ery limited possibilities

D ecoding on the severity of the damage category, medical losses

DISASTERS’ RELIEF TO POPULATION

25. Define the Crisis Headquarters (CHQ) structure

Disaster relief to population (DRP) differs in every country, but the

• R^ 7 3 nsibility for the execution of the DRP.

province affected) by the Council of ministers, based on proposal by

State of emergency is declared with order that gives the circum­

DISASTERS’ MEDICAL SUPPORT

Disaster Medical Support (DMS) is defined as system, organization

vention from epidemics and radiation and chemical damage, deal­

• To assure resources (medical and technical equipment) availabil­

1. The managing body on national level is the Minister of health. On

teams on high readiness for blood collection, when needed

Medical Intelligence (MEDINT) is the process of collection, analy­

2. ?!rnide medical support to the casualties;

17. Routes for ingress.

or rescued. The person, performing the triage evaluates the condition of

definitely require professional care but immediate treatment is not an

First aid are elementary medical activities that could be performed

OK". Not receiving answer is still not evidence for unconsciousness,

of disaster there is a probability for ne fu injury and this is the reason

MEDICAL FIRST AID

Medical first aid is performed by medical specialists as a part of the

min) or bradipnea (below 10/min ) or dyspnea (abnormal rhytm of re-

6. In case ofhypovolemic or even hemorrhagic shock a fluid resusci­

Figure 2. Place for chricothyrotomy (53)

2. Agressive intra venous fluid resuscitation and if needed (and pos­

infectious complications are applied. If there is no need : r soft tisuue

• The preventive evacuation stars from,

Evacuation is defined in Cambridge dictionary as process of moving

voke property damages, casualties and injjn::ies overwhelming the capa

quirec.. AU :hese activities in their sequence are assuring constant assis

State of emergency is declared with order that gives the circum

vention from epidemics and radiation and chemical damage, deal

• To assure resources (medical and technical equipment) availabil

Medical Intelligence (MEDINT) is the process of collection, analy

6. In case ofhypovolemic or even hemorrhagic shock a fluid resusci

2. Agressive intra venous fluid resuscitation and if needed (and pos

3. Next topic that has to be considered relates to the mode of trans

2. Awareness of the Unified Rescue Si stem elements into the re

mitigate its effects on the community is limited. At this mome m . how

A flood is defined as an overflow of an expanse of water that sub

Preparedness for responding to the threat of fire. In disaster prepar

Superficial, red, wet ap

tenance of adequate core bod temperature. As with all cases in emer

Alfa, heavy charged, particles have a greater probability of caus

Stochastic effects of ionising radiation are chance events. Their oc

electrons are accelerated by the applied potential difference towards an

• Inability to differentiate between different types of ionizing ra

spread of the radioactive element- and RAOD covering immense ter