1.

Disasters – Definition, Classification, Principles

A rare event with sufficient magnitude to create severe damage

and many casualties that overcomes our own ability to cope with
the consequences therefore, we require external help.

WHO definition: Sudden ecological phenomenon of sufficient

magnitude to require external assistance.

WHO Classification: Natural, Man-made, Transport and other.

Natural: Meteorological (storms, hurricanes, tornadoes, cyclones,

extreme heat and cold, drought), topological (floods, landslides,
avalanches), tectonic (earthquakes and volcanoes) and cosmic

Manmade: Large industrial accidents (chemical, radiological,

blasts), transport accidents (road, railway, aeronautical, naval),
social economical (financial crisis, famine, terrorism, social unrest,
social manias), war (WMD, geophysical weapons). Others include
Epidemic like aids or ecological disaster (mass poisining, mass
water accidents), collapsing of tunnels, mines, buildings.

Principles

1. All medical activities are coordinated with all other rescue teams
in the unified rescue teams/

2. Provide as much help to as many people which is the main

objective.

3. Medical teams safety and security is of utmost importance.

4. Early hazard detection followed by risk assessment and triage

are basics for disaster medical management and support.

5. Treatment commences in the affected area nearby, continues

during the medical evacuation and finalises in particular medical
facilities, depending on type and severity of the sufferers injuries
(treatment evacuation system).

6. Lessons learnt are an invaluable input for the ongoing disaster

medicine development.

2. Disasters – Definition, Development Stages, Response Types

Definition: A rare event with sufficient magnitude to create severe

damage and many casualties that overcomes our own ability to
cope with the consequences therefore, we require external help

WHO definition: Sudden ecological phenomenon of sufficient

magnitude to require external assistance.

Development stages (5)

1. Interim/Quiescent phase/ inter-disaster period

-Identify the hazard

-Based on the observation however may not be obvious. Risk

factor identification and risk level assessment.

-Then plan the preventive methods in order to decrease the risk

-We have to plan our activities in case a disaster occurs. Includes

education and training.

2. Prodromal phase

-Increase of the risk factors with new hazards.

-That leads us to requirement to renovate the health phase and

reassess risk level.

-Implementing the preventing measures

-Variable time limit.

3. Impact phase – When the damaging factor is causing an impact.

Can be short like an earthquake or long like in a famine. This is a
tough stage if no prep is done.

-Survive

-Life of the casualties is in your hands

4. Response phase

Isolation
- All resources provided by self body

Salvation via immediate assistance

- Rescue team are entering

-They are providing First aid

-bystanders are also helping

Recovery phase
-All efforts are to return the health care system to normal.
Stabalise, rebuild, reconstruct and reorganise.

3. Disasters – Definition, Damaging Factors, Impact on Medical

Support

Definition: A rare event with sufficient magnitude to create severe

damage and many casualties that overcomes our own ability to
cope with the consequences therefore, we require external help

WHO definition: Sudden ecological phenomenon of sufficient

magnitude to require external assistance.

7 Damaging factors:

-Thermal- extreme temperatures cause injuries that lead to

irreversible changes in human tissues and organs. Wildfires,
industrial accidents, wars, natural disasters.

-Toxic – Chemical compound (CO). Pollute the area and harm

humans. Industrial accidents and fires.

-Overpressure- Falling debris. excessive property damage and

mass casualties. Floods, hurricanes, tornadoes, tsunamis.

-Blastwave – The difference in pressure in the blast front and the

environment. causes human tissue and organ tearing, building

damages and secondary injuries.

-Biological – Virus, bacteria toxins. Damages sanitary and hygiene.

-Radiological (ionizing). can be accidental or when weapons are

applies. Depends on dose. Can be long term.

- Stress and panic. Not just during the disaster but could be due
to the consequences of the disaster.

Impact on medical support

- Scale and type of casualties unpredictable

- Could affect geographical and demographical areas which is of

political and economical importance.

- Disparities between available and required medical means

- Sanitary and hygiene

- Sanitary transport is required for medical evacuation and hospital

room

insufficiency

- Could lead to environmental pollution

- Secondary injuries

- Time of onset, place of occurrence and scale are unpredictable.

- Damage of buildings

- Communication and transport may be destroyed.

4. Disaster Medicine – Definition, Objective, Tasks

Definition: Interdisciplinary medical specialty with scientific and

practical approach to disaster medical management and support
to population. Constituent of unified rescue system.

Disaster objective: Protect, secure and assure human life, health

and ability in case of disastrous events.

8 Main tasks

-Research on natural and manmade disasters

-Research on disasters impact on human health

-Determine and analyze the features of disaster related to types of

injuries. Required treatment methods.

-Optimising the established and doctrines for efficient planning,

organisation and execution of disaster medical management and
support

-Establishing standard operating services and procedures,

methodologies and policies for prevention and treatment of the
entire spectrum of probable health injuries, diseases and
epidemics related to disasters.

- Scientific tutorial and practical training in case of disasters

- On the basis of existing national healthcare. Establishing the most

efficient organisation for medical management and support
provisions.

- Scientific researches, analysis, doctrines and policies –

development of disaster medicine.

5. Disaster Medicine – Definition, Principles, Terminology

Definition: Interdisciplinary medical specialty with scientific and

practical approach to disaster medical management and support
to population.

Principles

1.All medical activities are coordinated with all other activities of

unified rescue teams structures.

2. Provide as much help to as many people not just to the single

injured.

3. Medical teams safety and security is of utmost importance.

4. Early identification of the hazard.

5. Stabilisation and rapid evacuation of the causalities followed by

risk assessment and triage. Management of the casualties in the
affected area continues during evacuation and finalises in particular
medical facilities.

6. Lessons learnt are invaluable input for ongoing disaster medicine

development.

Terminology

Hazard -Something, which could have a negative impact on

population, society and environment.

Risk -The probability of the hazard occurring and severity of

consequences.

Risk factors –Factors which increase the probability

Preventive measure - Factors which decrease the probability

Incident – An event, which is extraordinary, breaks routine, diverts

your attention.

Emergency- A sudden incident that requires emergency attention

Crisis – An emergency that requires mobilization of all available

resources

Disaster – A rare event with sufficient magnitude to create severe

damage and many casualties that overcomes our own ability to
cope with the consequences therefore, we require external help

WHO definition: Sudden ecological phenomenon of sufficient

magnitude to require external assistance.

Health hazard- event or status with potential to cause undesired

consequences because of [physical or psychological health
damages.

Health hazard assesment- identification and analysis of entire

spectrum of existing hazards with potential to cause health harm in
given circumstances.

Health risk assesment- process of collecting, analysing, and

evaluation of the available information about available hazards, risk
factors, and their probability to cause acceptable or unacceptable
health harm.

Risk management- process of preventative measures, evaluation

and selection, in order to minimise or eradicate asses risk levels.

Negligible risk- hazard identified, minimal probability of -ve impact.

Low risk- hazard identified, probability to inflict limited damaging

effects. No risk factors.

Moderate risk- hazard identified, probability to inflict harm that will

impact on common society lifestyle. Few risk factors.

High risk - hazard identified with probability to cause distinguishing

-ve impact on population and society. All risk factors are available.

Health threat- all preconditions available. Prevention will only

moderate.

6. Area of Damage – Definition, Types, Elements,

Characteristics

Area of damage: Area (land, air, water) where the damaging factors
of a disaster could harm the population and cause infrastructural
damage.

Type of AOD – Biological (infectious disease), chemical

(intoxication), radiological, mechanical (trauma, overpressure,
shock wave) and area of combined damage (2 or more damaging
factors).

Elements of Area of Damage

-Area, size and extent of damage. Depends on type of damaging

factors.

-Health hazard – type of AOD

-Secondary hazard -Could these damaging factors lead to new

hazard within

the area of damage?

- Individual and collective protective measures

-Type, number, location and structure of casualties (irreversible

losses or medical losses).

-Available medical means

-Required medical means

-Medical activities required

-Related to Area of Contamination * Only in Chemical and

Radiological & Biological. Environmental effect and ecological
effect.

-Quantity, power, activity of damaging factors (wind speed,

physical barriers).

-Population at risk and types of settlements and buildings

Characteristics

-What happened? Where? When?

-Damaging factors

-Number of casualties and damaged structures

-Crisis HQ and organisation of aid

-Available medical means

-Medical evacuation

-Where to place forward medical station. Is threat still present.

7. Medical Loses - Definition, Classification

Definition- all humans suffered in relation to the disaster due

trauma illness or other somatic or mental condition. They require
medical assistance and care which they may or may not have
received. 2 types: medical losses and irreversible losses.Medical
loses are casualties and irreversible losses are dead or missing.

Medical casualties classified into:

-The main injury type

- Injury location

-Severity to determine priority

- Emergency

-Evacuation

Depending on the injury type: to identify require type of aid

-Mechanical (overpressure, trauma)

-Intoxication (chemical)

-Thermal (burns, frosts)

-Drowns (can lead to hypothermia)

-Radiation

-Infection (biological)

-Stress (psychological)

-Combined (fire, earthquakes followed by floods)

Depending on the localization of the injury:

-Head and neck injuries

-Body injuries – thorax and abdomen

-Upper and lower extremities

- Eye injury

-Multiple injuries

-Polytrauma

-Closed Injuries

-Penetrating injuries

-combines

Groups into severity

-Life threatening. Should receive urgent, immediate assistance.
(respiratory failure, unconscious, blood loss, arrhythmia).

-Severe. Residual disability. (Tachypnoea, tachycardia, fractures

that cause blood loss, delirious patients)

-Moderate. Postponable.

-Light. Outpatients

-Possibility for full recovery

Emergency points
Priority 1 – life, limb, eyesight. Life threatening and severely injured.
Can lead to death

Priority 2 – complications. Moderate.

Priority 3 – Delayed treatment. Light.

Priority 4 – No requirement for treatment

In terms of required evacuation

- E1 Immediate – life, limb, sight. P1. Up to 2 hours.

- E2 Evacuation with delay. P2. 4th to 6th hour

- E3 No requirement. P3. 12th hour.

8. Disasters’ Relief to population – Definition, Objective, Tasks

Definition: complex of specific measures aiming to decrease as

much as possible the impact of the damaging factors and to
prevent human and material loss.

Objective: To organize search, rescue and recovery operations in

order to minimize the impact of the damaging factors, number of
casualties and infrastructure damage. Every member of society has
to be equally supported. Life saving activities have priority.

Disasters classified into 3 levels

Level 1

- Only local resources

- Escalated emergency medical system (EMS)

- Municipal resouces

- Community agencies

Level 2

- Regional resources

- State level coordination

- Mutual aid agreements

- Specialized equipment (cranes)

Level 3

- Widespread

- State level and international resources

- National disaster medicine system and disaster medical

assistance teams

3 main groups of population relief activities: Preventative,

response, and recovery

General tasks
-educating and preparing the population for adequate reaction in
case of disaster

-training of the reaction forces

-allocating the required resources

-provision of personal/collective protective equipment

-relocation and evacuation

-providing information about hazards

Tasks in relation to prevention

- Prior to disaster

- Preventative character

- Research of disaster features

- Analyzing the available hazards and risk factors

- Assessing risk level

- Planning activities in case of disaster

- Adopting national disaster protection plan

Tasks in relation to response -within 72 hours

- After emergency declaration

- Impact assessment

- Crises HQ established

- Unified rescue system (URS). Coordinated activities.

- Search and rescue

- Medical aid and support

- Warn and alarm population

- Rehabilitation

- Psychological aid

- Protection against secondary disasters

Tasks in relation to recovery

- Planning and implementing recovery activities

- Shelter, food, medical support

- Recovery of infrastructure

- Epidemic prevention

- Rehabilitation

9. Disasters’ Relief to population - Organization, Actors,

Unified Rescue System, Crisis HQ

Organisation: National management system

-managing body

-headquarters

-communication and information system

-reaction forces

-provides education and training

-analyses and estimates risk

-implements preventative measures

-exchanges information and coordinates resources and forces

Who's is declaring state of Disaster?

National – Prime minister

Local – Mayor

Regional - Governor. If 2 or more regions are affected it is a state of

emergency.

Unified rescue system – from ministry of internal affairs and

ministry of health. Tasks of URS – 24/h officers on call

- Analyse situation

- Commencement of required activities

- has structures and units nationwide

- Red cross. Detect. Incident command. Scene safety and

security. Assess hazards. Give support. Triage and treatment.
Evacuation. Recovery.

Who enters the Crisis HQ

-Minister of internal affairs. In contact with head of police and fire

service.

-Minister of health

Minister of Transport

-Minister of water and environment

-Minister of food and agriculture

-Veterinary sanitary service

-Possible Armed forces so minister of defense

-representative of red cross

-director of telecommunications

-minister of infrastructure

10. Disasters’ Medical Support – Definition, Objective,

Principles, Tasks

DMMS (Disaster medical management and support) consists of

evacuation and treatment. Hygiene. Medical means and
capabilites.– Organization and structures established for
preparation and execution of proper adequate medical operation in
support of population. Complex of medical activities in order to
protect life and prevent casualties.

Objective: Preserve assure and protect human life and treat

casualties.

Tasks 6

- Train and educate medical staff

- Duly provision of first medical aid, stabilization, evacuation, and

treatment of injured until their recovery

- To conduct preventative and treatment activities of

neuropsychological and emotion defects.

- To conduct sanitary and hygienic methods. Decontamination,

disinfection, deradictaion, disactivation and degasation.

- To preserve health and fitness of medical professionals in AOD

- To record irreversible casualties. Peform forensic medical

expertise and disability expertise on the casualties.

Principles 11

- To be prepared to act in all types of disasters and AODS with

different damaging factors.

- Organization is according to division of country

- To be prepared for independent activities

- Maintain high level of readiness for immediate action

- Maintain high level of readiness of equipment/resources

- Unified principles and methods for prevention, diagnosis and

treatment.

- Effective DMMS. Educate and train. Plan on functional principle.

- Provide medical help to closest casualties

- Close coordination with teams associated with AOD. Efficient and

prompt exchange of information. Coordination , cooperation and
subordination.

- Early triage, early hazard identification and rapid evacuation.

- Continuity of medical aid

First stage -performed AOD

Second stage – Medical aid – temporary medical station

Third stage – Full scope qualified and specialized medical aid

11. Disaster Medical Support - Organization, Stages, Levels,

Actors

Organisation: Unified medical doctrine. Principle is to organise the

medical help in staged system that has the objective to provide
early first medical and physician aid. Minister of health manages
DMMS, ministry of defence coordinates DMMS. At a national level
the prime minister is chief, mayor at a local level and governor at a
regional level. Medical support is provided by the medical teams. it
consists of medical aid and evacuation. Medical triage, medical
aid, directed medical evacuation and hospital treatment are
performed.

Stages

First stage is performed in AOD. Everyone is treated. Survivors

help. Search and rescue teams enter. Primary triage. First aid.
Maybe first medical aid. Second stage is performed in the
temporary (forward) medical station. Medical aid is performed to
casualties by a trained specialised team. Medical intelligence,
medical triage, treatment and evacuation. Third stage is Full scope
qualified and specialized medical aid provided at treatment
facilities in the vicinity of the AOD. It is enhanced by the mobile
medical team.

Levels

Managing body-Nationally minister of health, regionally regional

health inspector and local DMS specialist and GPs.

Medical means and capabilities- sanitary teams. Medical formation

includes medical teams, physician team, medical technicians,
transport team, anti-epidemic and samplers.

Healthcare establishments- outpatient clinics, hospitals.

Hygiene and anti epidemic establishments- lab technicians

Centres for transfusion/haematology

Ambulance services

Actors

Medical intelligence teams (occurs throughout entire disaster).

Sample takers. Lab technicians (microbiological, toxicological,
radiological, sanitary, chemical). Anti-epidemics. Blood collectors.
12. Medical Intelligence

Process of collection, analysis, assessment, evaluation and

processing of every single piece of medical information. Specific
medical activity focused on providing disaster medical planners
and manager in the shortest time frame with information

regarding the disaster. It is a cycle. Objective is to collect data,

transform it into a signal and transfer it into an understandable way.
It is done to protect ones own life and health, provide medical
support to casualties and to transfer valuable information to
medical authorities.

The information is unified in accordance to a specific feature

- To collect data and reach a medical condition

- Must be collected by an educated individual throughout all

phases

- Must be translated to universal terms understood by all

- Recipient who receives info

- Medical manager organises medical intelligence – consists of

incident commander, medical officer in charge, DMMS manager

Gathering medical intelligence – differs from the book checked by

professor

1) Type of disaster

2) Time of onset

3) Place and localisation

4) AOD size and areas of risk

5) Damaging factors

6) Risk factors

7) Damages to critical infrastructure

8) Protective equipment and preventative measurements required

9) Localisation of protective equipment and preventative

measurements

10) Population at risk

11) Type, number, location and structure of medical losses

12) Medical means and capabilities in AOD

13) Elements of URS active in AOD

14) Required medical means and capabilities

15) Known medical teams/facilities available to help

16) Location of forward medical station

17) Routes for ingress

18) Routes for egress

19) Location of triage area

20) Location of medical evacuation area

21) Medical facilities ready to admit casualties

22) Communication systems available

23) Schedule for reports and returns

24) Who and where is situation commander

25) What is expected development of situation

13. Triage

Definitione: Process of sorting and grouping casualties. It occurs as

quickly as possible after casualty is located/rescued. It is a forced
medical activity. Performed by educated and trained providers.

Two types of casualties in terms of safety – safe and dangerous

The dangerous – psychologically stress/aggressive or

contaminated via radiological substances.

1) Safety first. Contaminated not allowed to enter 2) Treatment and

urgency of medical support 3) Evacuation (E1, E2, E3)

Classification of casualties

T1 – immediate – life threatening – code RED. Insufficiency of

breathing, unconsciousness, disturbed mentality, massive
bleeding, shock.

T2 – Delayed immediate treatment not required – Yellow

T3 – Minor – Green. Can move independently.

T4 – Expectant Violet/Dark blue

T5 – Dead - black

There are 3 types of triage: Medical triage, Primary triage (In the
area of damage by search and rescue teams. As many as possible.
Done according to urgency of medical aid and evacuation priority),
pre hospital triage (Done by anaesthetist. Only based on urgency.
T1 are resuscitated or admitted to surgery. T3 are sorted by
nurses). Types of medical triage 2.

Standard operating procedures of the triage:

-Stop look listen and think

- Conduct voice triage for T3

- Follow a systematic route. Attend to closest casualty. Check

consciousness, mental state. No answer then red. If no breathing
even after clearing obstruction then black.

- Conduct status evacuation. E1, E2, E3 to FMS.

- Treat category 1 casualties immediately

- Document results

14. First Aid

Definition: Elementary medical activity, that provides temporary

relief and save life until medical treatment can be provided.
Performed by everyone in case of incident, emergency and
disaster. Also stop contact with damaging factor. Performed in
order to save lives. Performed where casualty is found.

Objectives: preserve life, prevent further harm and promote

recovery.

Steps – incorrect in the book

1. Check for danger – assess the situation. Look, listen and smell.
Assure you own safety.

2. Check for Consciousness and responsiveness. “How are you?”

“Are you okay?”

a. The person responds

i. Check for breathing, Pulse

ii. Check for mental disturbance

b. If the person does not respond, then lightly shake them on

clavicles and ask them to open their eyes.

i. See if they respond to pain

3. Call HELP as you may require qualified assistance.

4. Breathing. Do it in 10 seconds

a. Ear close to mouth

b. Chest movement

c. Muscle relaxation

5. Open the airways

a. Tilt the chest and forehead

b. Check tongue

i. Be blocking

ii. Since it is relaxed

6. Check breathing again

a. After you Open the airways

i. Tilting the chin and forehead

b. Tongue may be relaxed

7. Check for pulse

a. Tell them to find the muscle

b. Then move to the oft place

i. In stressful position - may feel your own pulse

c. DO NOT use the radial pulse however you can check for
capillary refill of the hand

8. CPR

a. Performing artificial heart circulation

b. External cardiac massage

c. On xiphoid process. Find it by locating the last rib.

d. Manubrium

e. 30 compression

i. 80-100 compression per minute

f. 2 breathes

i. Artificial Ventilation

ii. Look for obvious obstacles

1. Remove them

iii. Take deep but rapid

iv. Then expire rapid

v. 10 cycles of 30 - 2

1. Recheck breathing, circulation, pulse

vi. Continue until help arrives. Make sure elbows are straight and
perpendicular to the patient. Push 4-5 cm deep.

9. Wounds

a. Compressive

b. If on trunk

i. Just cover do not compress,

c. Look for mental disturbance

i. Try to calm him

10. Recovery position - place victim’s nearest arm at right angle

and forearm is bent upwards. Slide other arm over chest placing
back of hand on cheek. Pull up opposite knee with foot on ground.
Grab opposite shoulder and knee and turn. Head in hyper
extensive position. Check breathing again and if possible
immobilise fractures.

15. Medical First Aid

Types of assistance in medical aid

- Pre physician

- Physician

Pre physician aid: medical activities performed by non-physician

during DMS to affected population. Objective is to maintain vital
functions and to prevent the development of severe acute
complications. It occurs in the FMS, ambulances, evacuation sites,
hospitals and AOD. It is normal first aid plus monitoring and
supporting physiological signs (respiratory rate, heart rate, blood
pressure, temperature). You have to prevent shock (pain, volemic,
toxic) by placing them in the anti shock position. Warm casualties.
Administer pain killers (not opiates). Immobilisation of fractures on
limbs. Control bleeding. Fluid resuscitation. Tourniquet. Irrigate
wound area to prevent infections. Clean with antiseptics.Administer
broad spectrum antibiotics, sedatives and antiemetics.

Physician medical aid is activities performed by medical doctors

during DMS. Objective is is to minimise negative impact of
damaging factors on human life and health. Performed in the
temporary medical station, hospital and other treatment facilities. It
is the same as pre physician aid plus eradicating asphyxias (maybe
cricothyrotomy), aggressive intravenous fluid resuscitation (blood
transfusions). Definitive control of bleeding maybe through surgery
and controlling contamination. Maybe external fixators on fractures
to prevent loss of blood. Doctors are allowed to administer opiates
(however must be careful of the depressing effect it has on
breathing). Cardio-supportive therapies. Start treatment of
pulmonary oedema. Antibiotics via intravenous method. May
induce vomiting. Catheterisation. Medical evacuation.

16. Medical Evacuation

Definition: Combined activities in order to evacuate from FMS to

hospital. The injured thus providing them with a higher level of
treatment. Its described as forced medical activity in order to
provide required but unavailable efficiency of medical care

Time for performance – Spontaneous (performed during the

isolation phase by all survivors. They are trying to escape out of
AOD by all available capabilites), organised (performed during
search and rescue teams and direct those who need medical
assistance to the FMS), directed (process of transporting casualties
to medical treatment facilities, according to medical triage and first
medical aid for receiving the required level of medical assistance)
and preventative (entire population at risk is moved away from the
disaster prone area to pre planned safe areas).

Direction of MEDVAC – to a temporary medical station, to medical

treatment facilities.

Step 1: Does injured require medical evacuation or can they be

directed.

Step 2: MEDVAC classification in accordance to the casualty

injuries. Priority (P)

P1 – Life, limb and sight danger. T1

P2 – Sever injuries but without immediate threat. T2

P3 – Injuries that could lead to delayed complication T3

Step 3: Means for transportation –Ground, air (fast but limited

resources), maritime (military and disaster relief), river, and rail
(mass casualties).

Step 4: Casualties are classified in terms of position – Laying (T4,

T1), sitting (T2), and standing (T3 if need to be evacuated).

Step 5: Medical assistance criterion

Type 1 – constant monitoring and performance of medical

procedures during entire MEDVAC. Fully dependent. Can
deteriorate. Require physician on board.

Type 2 - monitoring and performance of medical procedures during

entire MEDVAC. Semi dependent. Serious deterioration not
expected. Require pre-physician medical support. Many casualties
by one person.

Type 3- Monitoring patient. Under observation. Possible but not

probable changes.

Type 4 – no requirement to monitor

Step 6: Psychological support: Fully dependable (deep depression

or aggressive stress reactions), partly dependable 9under
observation as psychological state may change), undependable.

17. Planning for Disaster Medical Support

Definition: process of preparing a sequence of steps to achieve

goal of DMMS. Organise, reduce risks and minimise time and
resource insufficiency. The disaster plan is a document where all
activities of medical means in case of a disaster occurrence are
described.

Objectives of the DMS plan

- To optimize the established DMMS

- To prepare sufficient amount of medical and technical equipment

- Establish medical teams of different level of readiness

- To provide means for rapid medical reaction in case of disaster

Planning process

- Receiving the superior levels instructions or guidance

- Receiving medical intelligence information

- Describing executive body’s tasks and responsibilities

- Assessing the readiness of available means and capabilities

- Disaster probability based on hazards and risk factors

- DMS objective and tasks

- Designing DMS organisation and structure

- Allocating tasks

- Noting shortfalls and feasible reactions

Principles of the DMS plan

- Unity of all disaster management plans, levels, ministers

- Particularity – different disaster different plan for different actors.

Every healthcare provider prepares his/her own plan

- Related to available means and capabilities. Operability

- Continuity of development and revision. Changes in resources,

hazards, vulnerability, exposure

Types of plan

- Long term plan. Possible but unreal situation. Based on medical

intelligence. Estimation of number and type of casualties.
Approved as a contingency plan but it is not realistic.

- Crisis plan. Starts in impact phase. Actual compared to predicted.

Medical operations are changed. Operational plan is created and
presented for approval by DMS manager.

Elements of DMS Plan

- Textual body

- Maps

- Annexes

In the textual body of the DMS plan you include

- description of physical and economical geography of

administration unit

- evacuation of the prognosis of medical situation in case of

particular disaster

- DMMS objective and task

- Organization of DMS

- Medical intelligence assessment of the region

- Population at risk

- Medical means and capabilities

- Transport and communication networks

- What kind of reports and to who

- Coordination with unified rescue system

- SOP for key personnel

What kind of maps?

- Area map

- Physical

- Industrial

- Meteorological

- Temporary medical station location

- medical means and capabilities location

- routes for medical evacuation

- executive bodies location

- warehouses location

Types of annexes

- Available capabilities

- Required capabilities

- Sources of enhancement

- Available means

- Required means

- Sources for enhancement

18. Management of Disaster Medical Support

DMS management: complex decision-making process performed

by medical managers in order to react adequately with available
means and capabilities in case of disaster. Objective: Providing
population affected by disaster with the best medical support by

effective utilization of the available medical means and capabilities.

Principles 6

1) Preplanned. Managers make their decision in accordance to

SOP and resources available

2) Operability. Have to be feasible

3) Flexibility. Be ready to revise his/her decision

4) Continuity. Its a cycle

5) Centralisation. Only one authority.

6) Autonomy. Every single medical specialist on charge has

autonomy to choose how to fulfil the received orders and what
course of action to follow in order to achieve results.

Elements- standard operating procedure

- Adequate reaction after signal for disaster receiving. Require

validation of the received signals so manager starts decision
making process.

- Contingency of plan activation. Preplanned actions ordered.

- Medical intelligence about AOD and general and medical situation

- Operational plan creation. Adjust contingency plan.

- Decision by medical manager

- Orders based on decisions

- Receiving feedback and assessment

Sequence of DMS management process

- Evaluation of the situation. What, when, where. Immediate and

forecasted damages.

- Evaluation of required and available assets. Types, location and

number of casualties.

- Risk assessment

- Risk management. Usually of health risks.

- Decision. When, where and how to execute it.

- Execution. Start DMS.

- Evaluation of the situation. Constant monitoring on the results of

performed activities.

- Decision revision. If results don’t meet objective.

- Means and capabilities manoeuvre in accordance to new decision

and tasks.

Prerequisite

- awareness of available medical resources, medical specialists,

technical equipment

- awareness of URS into the region

- Assured communication. Regionally and nationally.

- Awareness of contingency plan

- Cognition about the disaster management process.

19. Medical Teams Tasks in Disaster Medical Support

The medical team provides medical aid in the temporary medical

station.

Medical teams’ responsibility

-to provide medical support to all injured

-in order to preserve their life, limb and sight

Medics responsible for:

-Sanitary and hygiene measures

-In order to prevent epidemic outbreaks in AOD

- Medical managers undergo complex decision making process to

react adequately

with available means and capabilities in disaster

Steps for Medical Team

-General situation assessment

-Medical situation assessment

-Casualties – structure, number

-Available and required medical means and capabilities

-Hygiene and sanitary conditions assessment

-Required activities

-Protections

-Order to teams

-Reassessment

-Manoeuvre

Objectives

-To optimise established DMMS organisation and training

-To prepare sufficient amount of medical and technical equipment

-To establish medical teams of different level of readiness

-To provide means for rapid medical reaction in case of disaster

Principles

-Unity with all disaster management plans

-Plan for particular type of disaster and actors – every hospital has
own plan,

as well as regional healthcare

-Response related to available means and capabilities

-Continue to develop and revise

A) Activities performed when the signal for a disaster has been

received.

- collection of information

- collection of planning information

- health care facilities close to the AOD

- collecting information regarding the task

- collecting information regarding the coordination & subordination

B) Activities during movement to AOD

- brief medical team regarding tasks and objectives

- highlight hazards and required protective measures

- allocation of specific tasks

- checking the resources

- maintaining constant communication with the medical manager

and incident commander regarding any change into the general
and medical situation

C) The activities required when the medical team Is arriving as a

first rescue team

- To perform medical intelligence

- Medical intelligence assessment report

- To indicate AOD and medical team presence with lights or sounds

accordingly

standard operating procedures

- To settle triage, treatment and evacuation areas. Establish FMS

- Medical officer in charge has to give brief report in situation to

arrived officers. Transfer authority.

- Triage, treat stabilise and prepare casualties for evacuation.

These actions are

routine for standard operating procedures

- To monitor background and report any change

- Do not enter AOD if any hazards are detected.

D) Activities requires when the medical team is the first medical

team arrived for DMS

- Medical officer in charge represents himself and report to

emergency HQ in charge

- Receives commanding officer brief

- Indicated medical team presence with lights or sounds

- Reports observed medical situation

- Reports on acquired medical means and capabilities

-Medical triage, treats, stabilises, and prepares causalities for

evacuation according to SOPs

E) Team arrives as enhancement to the DMS

- medical officer in charge introduces himself to the medical

commander and reports on the number and capabilities of his
team

- gathers information on the general and medical situation

- receive tasks

- initiate medical support

F) Activities on DMS termination

- debrief to the team. Appreciation then complaints

- ask each member for impressions and lessons learnt

- report to medical commander

- report lessons identified

- provide proposals for DMS improvement.

20. Temporary Medical Station

Temporary medical station: Mobile medical station where medical

activities are performed. Temporary medical station in the vicinity
(closest as possible to casualties whilst securing safety of medical
teams) of area of damage(AOD) – one exception biological disaster
is in the AOD. It’s known as the second stage. To find the correct
location, MEDINT is done to assess DF, localisation of casualties,
critical structure, risk factors, terrain and transporting routes.

Medical casualties/loses will come to the temporary medical

station to be sorted, given medical treatment according to
priorities, then sent to facilities according to priority – high priority
transported to hospital first

Main Functions of medical teams in the temporary medical station

- Triage and treatment of life preserver

- Initiation of medical documentation for victims

- Receiving, evaluating and sending information to hospitals

6 members of temporary medical station: General surgeon, nurse

for surgeon, anaesthetist and a nurse for them, psychologist and
sanitary inspector.

Where- hospitals, schools, theatres. Water supply is essential.

Firstly all casualties go to the triage area. If contaminated/

dangerous then they are not allowed to enter the FMS (isolation). In
the triage area we have physician and pre physician aid with nurses
and doctors. T3 are moved to light injuries. T! to active treatment
where there are doctors, nurses and technicians. They are
evacuated first along with doctors, nurses and a driver. T2 and T4
are sent to active monitoring where there are nurses providing pre-
physician aid. From here T5 are moved to the mortuary. There is
also designated parking spots which are cleaned by the police.
Organisation for downloading and uploading equipment and
consumables is set.

21. Earthquake. Disaster Medical Support Management

Earthquake is defined as underground movement of the earth

layers – can be longitudinal or transverse. As a result of these
movements a huge amount of energy is released which radiates as
seismic waves and can lead to secondary disasters. Can be man
made due to mining or nuclear test. The result of seismic waves –
During the released, a deformation and rupture of earth layers with
different levels of destruction. Energy is the damaging factor.

Phases for the Earthquake: Foreshock, shock, Aftershock.

Risk factors: 1) Epicenter – On the surface but the energy is not

released on the surface.

Hypocenter – Where the energy is released.

Depth – Distance between the hypocenter and the epicenter.

Types of earthquake depending on depth: close to surface (0-60m),

medial (60-300m), deep (300m+).

2) Richter scale or mercalli scale measures destruction

Richter scale measures the energy released in the hypocenter in

magnitude units. There are 2 levels of the Richter scale the different
between the two levels is there’s 10 times more energy. 3) type of
construction. 4) density and height of buildings. 5) population at
risk. 6) water basins. 7) critical infrastructure. 8) industrial sites 9)
time of day. 10) The modified Mercalli scale has 12 levels it
measures the effects of the earthquake on the ground surface. 11)
preventative measures.

Impact factors of the earthquake: depth, distance from epicenter

and energy. The main damaging factor is overpressure due to
being trapped under debris.

Secondary damaging factors we could expect in earthquake AOD

- Thermal, stress and panic, radiological, toxic (industrial),

biological (sleep deprivation and sanitation).

Risk factors the rescue and medical teams could face: collapsing
buildings and hostile environment.

Zones of earthquake:

Zone 4 – light destructions. Only cracks on buildings.

Zone 3 - zone of moderate destruction. Reopairable damage.

Preserved roads. FMS is usually located here.

Zone 2 Zone of severe destruction. Damage is beyond repair.

Unstable walls and roofs.

Zone 1 – Zone of complete destruction. Close to epicentre.

Aftershocks.

SOP for earthquake AOD DMS to affected population

1) Removal and rescue of the victims to safe place –search and

rescue

team

2) First triage performed by search and rescue teams

3) ABC and CPR performed by search and rescue

4) Stop bleeding via tourniquets.

5) Evacuation to temporary medical station

6) Medical triage. Be prepared for neurosurgical, orthopaedic and

soft tissue injuries. Require surgeons, anaesthetists,
epidemiologists, nephrologists.

7) Pain killers

8) Shock management

9) Wound debridement and aseptic dressing

10)Immobilsation

11) Stabilization of general condition

12) Evacuation to surfical, ICU, nephrology.

Earthquake related particularities

1) Great majority of casualties have different trauma

2) Damage to infrastructure

3) TMS established and first and 2nd zone

4) All teams prepared for autonomous work

5) Neuropsychiatric disturbance

6) Pediatric and obstetric help needed

7) Risk of epidemic

8) Medical teams require special protective measures

9) Flash fires due to ruptured gas pipes

10) Respiratory problems due to dust

11)Chronic problems affected due to lack of medicines

12) Compression longer than one hour is likely to lead to crush

syndrome. Compartment syndrome (oedema and ischaemia) can
also develop.

22. Floods. Disaster Medical Support Management

A Flood is an overflow of an expanse of water that submerges land

not usually covered by water. Origin can be natural (precipitation,
riverine, snow, tidal overflow, tsunami) and man made (dam, river
flow barrage). Range can be local, mid range, large range, great
range.

First medical activity is medical intelligence

5 groups of floods dependent on intensity and repeatability

- Slight 10-20 years- small damages

- Dangerous – 20-40. Threat to animal and human life.

- Very dangerous – 30-80 years. Depth above 1m. 5km/h.

Significant impact on infrastructure, environment and population.

- Devastating – 80-150 years. Depth above 2m. 10km/h. Casualties

and material loss.

- Catastrophic – over 100 years. Great speed, tidal wave, great

depth and number of casualties. Enormous material damage.

Signs specific for flood AOD

TF – time for first wave arrival. Mins/hours.

TC – time for water disappearing. Mins/hrs/days/weeks

V – speed of flood wave

H – depth of flood

L – Length of affected territory m/km

Main damaging factors Overpressure and thermal

Secondary damaging factors: overpressure, thermal, biological,

stress and panic and drowns.

Different types of injuries: Drowned, trauma, frosts and infectious

outbreaks

Zones AOD flood 4

1) Tidal waves. Closest to origin. 10km. 30km/h. TF=mins. TC is

less than 30 mins. Drowned casualties, severe traumas,, thermal
casualties. If at night then 90% death and during the day 40%.

2) Rapid current. 20km. 20km/h. TF=30 mins. TC=60 mins. Drown,

trauma, thermal and psychological casualties. 20% death at night.

3) Mid current. 50km. 10km/h. TF=hrs. TC=2-3hrs. Psychological

and thermal casualties.

4) Low current. 70km. Slow. TF=hrs/days. TC=days/weeks.

Casualties are psychological and biological.

Specialists: GP, psychiatrists and epidemiologist

23. Wars. Disaster Medical Support Management

Definition: Man made disaster. An act of force to compel our

enemy to do our will. An actual, intentional and widespread armed
conflict between political communities. Therefore is defined as a
form of political violence. It is a disaster because of the number of
casualties, material damages, disparity between required and
available means and capabilities, requirement for external
assistance and requirement for urgent measures towards the
consequences.

Theories of war

- Social – war seen as product of domestic conditions – targeting

aggression in war

- Psychological-duty of most powerful to lead and punish.

- Malthus – expanding population and scarce resources = source

of violent conflict

- Hunger of the youngsters – youths with lack of regular

employment opportunities =

risk of violence due to frustration

- Prevalence of foreign and domestic policy. Desire to prove

superiority over others or as an attempt to solve internal security
isssue.

Classification

- Conventional – war using conventional weapons not chemical,

biological or nuclear

weapons

- Global/local - world war/in one country

- Civil/international - syrian civil war

- Environmental – war over land, desert, space

- Cause

- Legitimacy – war against foreign intervention

-
Damaging Factors

- Mechanical-blast wave

- Thermal – from fire

- Chemical – from chemicals in weapons, toxic fumes

- Biological- jeopardised supplies

- Stress and Panic – people with minimal injuries will be panicked

and erratic

- Blast Wave

- Radiological in case of WMD

- Fires, floods, epidemics, crops

Main trauma types

- Blast injuries – main cause of injuries – 4 types

o Closest – difference between the pressure

o Thermal

o Over pressure – body moved into space

o Secondary partial

Pecularities

- DMS manager is military leader

- No discussion about orders

- Search and rescue by trained first aiders

- Different first aid

- Triage only on contamination

- Medical aid according to urgency

- Pre physician aid limited to maintaining breathing

- Physician aid is damage control surgery

- Medical Support-Surgeons – general/orthopaedic, damage

control surgeons – to control haemorrhage, contamination then
resuscitation. Surgical requirements: stop bleeding in abdomen
and thorax, control contamination, temporary stabilisation. GPs
for general medical treatment/triage. Anaesthesiologists for
surgery. Internal med Dr – for general medical treatment/triage.
Psychologist for psychological effects occurring immediately like
shock. Orthopedics for stabilisation to avoid further tissue injury
and avoid inflammation.

- Evacuation once stabilised

- Impossible assurance of safety in forward medical station.

24. Terrorism. Disaster Medical Support Management

Definition: The calculated used of unlawful violence or threat of

unlawful violence to create fear/anxeity from an individual, group or
state. Intended to coerce or intimidate governments or societies in
pursuit of goals that are generally political, religious or ideological.

Teacher definition: Use of violence or threat in order to change the

political system. Clear defined objective. Target = public opinion.
Modified Public Opinion = the mean. *one man’s terrorist is another
man’s freedom fighter*. *actual victims are not the target – they do
not care who the victim is*. Damaging factor is psychological
because population is intimidated.

Types of Terrorism

- Separatists – group of people who believe attempts at integration

with dominant groups compromise their identity and ability to
pursue greater self-determination

- Ethnic

- Nationalistic

- Revolutionary

- Political

- Religious – acts are religious in character or influence – increase

since 1980s – use religious scripts to justify/explain their violent
acts or gain recruits - ISIS

- Social

- International

- Trans-national – jihadist groups

Direct Targets

- Critical infrastructure

- Political or national symbols

- Hospitals or schools – e.g. Beslan school siege 2004

- Government Buildings/Buildings of Law Enforcement – e.g. 911

- Places with mass people gathering – e.g. Nice, Paris

Why is it a disaster?

- Unpredictable – cannot be prepared for

- Instant mass casualty events

- Material damages – the building or area the terrorist attack takes

place

- Disparity between required and available means and capabilities

- Requirement for external assistance

- Requirement for urgent measures towards consequences

Three perspectives of terrorism: the terrorists’, the victim’s and the

general public.

How to prepare yourself as a physician? Follow guidance from the

police and do not enter the area of damage without guidance from
the police!

Specialist needed;

➢ Emergency medicine-ambulance

➢ General surgeons

➢Psychologists-to manage stress and panic.

Pecularities

- incident commander is the police due to risk of secondary attack

- FMS chosen by incident commander

- police enter AOD to localise and eradicate hazard. They find

casualties and survivors and collect people to safe areas. Only
give bleeding support.

- in FMS, triage is performed on urgency of medical support

- medical team stabilise and evacuate in rapid and efficient

manner due to security concerns

- first casualty stabilised is first evacuated

- all vehicles have medics on board

- screening for contamination at pre hospital stage

- still require security at pre hospital stage

- all information should come from police as media could become

allies of the terrorists.

25. Mass Humans Movement. Disaster Medical Support

Management

Mass movement: movement of people exceeding 2% of

population.

The causes of mass movements are;

➢ From prehistorically time

➢ Anthropogenic (Man made)

➢ Social-economic cause (poverty, famine, wars!international or

civil)

➢ Limited movement because of natural disaster

➢ 26. Fires. Disaster Medical Support.

Migrants are grouped into 5;

1. Pure migrants: people that are escaping from their original

country for a better life (6%

to 7% are males in the middle age). For example economic

migrants.

2. Escaping from man made or natural disasters and there are 2

groups:

o Refugees! concentrating in neighbouring countries (Jordan vs

Syria)

o Status of refugees: concentrating in countries far away from the

original

countries.

3. Escaping from a man made disasters and concentrating in other

places in their countries

(intermedially displaced people).

4. Escaping from political oppression.

5. This point is missing but it could be seasonal migrants!labourers

that come during the

summer periods.

Main damaging factors;

➢ Psychological-stress and panic

➢ Biological factors and these are classified into 2: new exotic

environment and

deteriorated (immunity is decreased and the vaccination calendar

is not followed strictly)

➢ Thermal- (weather conditions for example refugees affected by

harsh weather conditions

such as snow!causes ilnesses)

➢ Traumas (IDP and migrants are in constant movement)

Medical specialists in refugee camps:

➢ General practitioners

➢ Mid wives nurses

➢ Paediatricians

➢ Social workers (cultural and health education)

➢ Psychologists epidemiologists

26. Fires. Disaster Medical Support Management

Definition: Uncontrolled process of burning. Can be man made

(explosions, RTC, cigarettes) or natural (thunderstorms, volcanoes).
Damaging factors are thermal and toxic. And these two damaging
factors are usually found in the combined area of damage. Zone of
burning, thermal damage and smoke.

Things to consider;

▪ What is the nature of the environment where is the fire occurring?

-Vegetation surrounded by rocks or forest without any boundaries.

▪ Take weather in consideration, the speed and direction of wind,

rain. When it is windy, warm/hot, precipitation fire will be greater
risk factors.

▪ Risk factors: industrial facilities- most fire can cause technical

damage to warehouse for

example if petrol is stored in the warehouse we could expect and

explosion (flammable), blast waves. Warehouse of pesticides!risk
factor!fire can release toxic fumes!organophosphate in the air!when
inhaled can cause neuroparalytic effects such as acetylcholine
drunkiness (uncoordinated movement), disturbed respiratory
muscle coordination!death due to hypoxia follows. These risk
factors are causing a threat for the operators that are working
inside. Time of day. Population density.

1. Explosion where the damaging factor is considered to be the

blast waves and the injuries are grouped into 4 types such as wars
and these are : head and neck injuries, thorax

injuries, abdomen injuries and extremity injuries.

2. Casualties are intoxicated by fumes and burns and the burns are
grouped into 4 Grades;

➢ 1st Grade: Burn only in epidermis!there is change in color

(hyperaemia) and a pain but not an intensive pain.

➢ 2nd Grade: When the thermal effects are entering into the derma
(small nerves and vessels) there is an intensive hperemia, pain,
edema and blisters (filled with opaque fluid). There is an intensive
burning pain because of the edema which presses the nerves in
the derma. Less than 10% casualties.

➢ 3rd Grade: Entire layer of the derma is affected!hyperemia,

blisters (filled with opaque non transparent liquid, necrotic area,
some of the tissues under the derma are visible. There is an area
with anaesthesia and area with extensive pain- why? because the
necrotic area is affecting the nerves. 10-20% of casualties.

➢ 4th Grade: When does the necrotic processes affect the tissues
below the derma(muscles and bones) the pain is spreading to the
surrounding area because there is an edema, hyperaemia and its
pressing the nerves. Hyopvolemic shock. +20% casualties

3. Injury can occur when the casualty is inhaling the chemical toxic
and this will cause intoxication, necrotic pneumonitis, atelactasis
and emphysema.

1st medical step in medical disaster support?

= medical intelligence

First medical step for disaster medical support to casualties is?

=triage (the objective of this is to provide treatment to those that

require biggest need of medical support).

The medical support consists of: treatment and evacuation,

hygiene and anti-epidemic support and medical means and
capabilities. Disaster medicine management and support main
principles is? Providing medical help closest to the casualties in the
area of damage. Rescuers should use autonomous gas make. Full
protective equipment.

First aid: Find and extract from fire. Stop burning. Primary triage.
Systemic approach. Wound covering with sterile gauze.
Evacuation. FMS far from possible fires against wind direction.

First pre physician aid: Administration of high flow O2. Cooling

body with wet tissue covering. Rehydration with fluids orally. Pain
relief and antibiotics. Immobilisation of injured body part.

First physician aid: Early and swift airway management.

Intravenous or per os access for fluid resuscitation. Covering
affected areas with greasy and sterile dressings. No surgical
treatment. Opiates if necessary. Intoxication or burns treated first.
Evacuation to surgical, ICU or burns centre for 3rd/4th degree
burns.

27. Radiology. Radiation – Definition, Emissions’ Types,

Characteristics

Radiation – Any process in which energy travels through a medium

or through space, ultimately to be absorbed by another body.
Could be particles or EM waves. Radiation becomes ionising once
it can change the medium and cause formation/emission of
charged particles. Sources can be natural (cosmic rays,
terrestrialnradiations, internal radiations) or artificial (X-ray
examination, crushed rocks, fertilisers, nuclear plants).

Types of radiation

Alpha - Charged particle – ionise directly

Beta - Charged particle - ionise directly

Gamma

Neutrons – non-charged – ionise indirectly. Change in isotope of

the element. Range of km. High speed. High penetration. 1000s
atoms per cm. Concrete shelters block them.

Characteristics

Alpha – positively charged – 2 neutrons and two protons emitted

Relatively high charge =charge so heavily ionising. Will cause a lot

of damage if ingested. 30000 atoms per cm.

It has a high mass and little energy and low range (10cm) –stopped
with sheet of paper. Alpha decays in large nuclei.

Beta minus – change of neutron to proton Either electron or

positron emitted. Negatively charged ionisation. It is less ionising
than alpha but more than gamma. Electrons can be stopped with a
few cm of metal. It occurs when neutrons decay into the proton in
a nucleus releasing beta particle and antineutrino. Range is several
metres. High velocity. 150 atoms per cm.

Gamma – neutral ionizing radiation – Gamma radiation consists of

photons with a frequency of 1019Hz. Causes instability in atoms.
Very pentrative. Activity half every 15cm.

Gamma radiation occurs to rid the decaying nucleus of excess

energy after it’s emitted either alpha or beta radiation. – Stopped
by lead or concrete – 1m. No nuclear transmutation. Negligable
mass.

Spontaneous fission is when a large unstable nucleus

spontaneously splits into 2/3 smaller daughter nuclei and generally
leads to the emission of gamma rays, neutrons or other particles.

28. Radiology. Ionizing radiation – Measurement, Units, Effects

– Determinative, Stochastic

Ionising radiation – Some types of radiation have enough energy to

ionize particles. Change medium and cause formation/emission of
charged or non charged particles. Involves an electron or other
particle being “knocked out” of an atom.

Radioactive decay is process of spontaneously generating ionising

radiation from a certain element. They develop other elements
during this process.

Ionisation radiation measured by an instrument called a gas filled

radiation detector or geiger counter. It is cheap and reliable. Gas is
argon. It is attached to a speaker. Doesn’t differentiate between
different types and enable to measure high amounts.

These are measured in order to describe the ionizing radiation

power and effect on humans:

Activity- what is the potential of the radioactive element to emit

ionising radiation. How many nuclei decay for a certain period of
time.

-N/S = Bq (Becquerel)

Exposure dose- amount of energy that is ionising the air.

-E/M = C/Kg (Coulomb per kilogram)

Absorbed dose – amount deposited in the body by IR

-Grey= J/KG

Equivalent dose – measures biological effect of ionising radiation.

As 1 Gy of alpha is more damaging than 1 Gy of gamma.

-What is the impact of a specific ionisation radiation

-Absorbed dose x Coefficient (Kir) = Sv - sievert

Effective dose – Total of equivalent doses. How vulnerable the

tissue is.

*-Equivalent dose x tissue Factor (Kt) = Sv

Weighting factor: Represents the relative biological effectiveness of

the radiation in

particular tissue. It’s different for different tissue.

There is a direct relationship between absorbed and equivalent

dose:

Equivalent dose = absorbed dose x weighting factor

The unit curie measures the radioactivity. Scintillation detector uses

excitation of fluorescent chemicals in the presence of any
radiations. The excitation then fall and causes light to be emitted.
Photomultiplier present. They can also form free radicals.

Effects observed in the cell when it’s under ionising radiation

impact: Cellular death (due to unrefined double strands) and DNA
mutations (substitutions, transitions, transversions, insertions,
deletions).

The determinative effect is observed when the effects of the

damage are directly related and proportional to the ionising
radiation activity, exposure, and absorbed and equivalent doses.
The determinative effects are predictable as types and scopes. It is
linked to the amount of dead cells resulting from the impact of
ionising radiation. Certain amount of cells have to die in order for
the function to be jeopardised. There is a threshold.

The stochastic effect of ionizing radiation is observed when the

effects of the damage are not related to the ionizing radiation
activity, exposure, absorbed and equivalent doses. Stochastic
effects can not be predicted. It is a chance event. Occurrence and
effect is not related to the absorbed type or dose and power of the
radiation. Severity increased with dose. No threshold. Linked
mainly to the mutations in cells, induced by radiation. Mutations
can lead to increase risk of neoplasm. Germline mutations could be
transmitted to offspring.

Damages to human tissue when they’re exposed to equal ionizing

radiation doses but from different types cause different amounts of
damage to living tissue.

29. Radiology. Radiological Incident – Damaging Factors

Disaster Medical Support Management

Definition: RAOD is the area under impact of the ionising radiation

DF. The Damaging factor in RAOD is the IR. Sorces can be nuclear
plants (covers immense territories), nuclear weapons (as well as
nuclear tests), improper use storage or radioactive waste
management, radioactive and nuclear terrorism.

Elements of ROAD

1) Type of disaster

2) What magnitude

3) During of the exposure

4) Main DF – ionization radiation

5) Damaging factor – list the 7

6) Secondary DF

7) Types of casualties – acute radiation syndrome

8) Number and distribution of casualties

9) Protective measures requires

10) First medical activities – medical intelligence – location and

zones. Direction of radioactivity distribution, personal and
collective. Protective measures available and required, routes of
ingress, egress

11)Medical teams available and required

12) TMS location

13) Treatment facilities available and required

How many zones you could distinguish in RAOD. All zones require
protective equipment so the FMS is situated outside AOD opposite
win direction. Time of operating in AOD is limited.

1. Zone of radiological threat.

2. Zone of moderate contamination

3. Zone of high contamination

4. Zone of dangerous contamination

5. Zone of extremely dangerous contamination

Prior to being admitted into the TMS all casualties need to be

decontaminated otherwise they are considered dangerous and
isolated.

The specialists needed: Internal diseases, hematologist, burn or

plastic surgeon

Origin for ROAD NON MILITARY

- Accidents due to negligent handling or transportation or

radioactive material

- Accident due to technical failure in industry

- Breakdown in nuclear power station

- Radioactive terrorism due to terrorism

Military

- Nuclear power station disasters caused by military operations

- Detonation of nuclear weapons

Pre physician aid: drugs for controlling vomiting, rehydration

therapy, irrigate, clean and cover with sterile dressing.
Psychological support. Do biological dosimetry by assessing for
vomiting. Within 30 mins they are T4 with extremely high doses.
30-60 mins they are T1 and are admitted to haematological ward.
60-120 mins they are T2 and admitted to internal medicine
department. 120+ mins they are T3 and are observed in internal
medicine department. Also asses for CNS changes which is in
extremely high doses.

Physician aid: aggressive fluid resuscitation intravenously, along

with initiation of prophylaxis of the infectious complications by
administrating IV. Evacuation with no delay.

30. Radiology. Nuclear Bomb Damaging Factors. Disaster

Medical Support Management

This disaster happens after detonation of nuclear bomb.

Overpressure has an effect due to collapsing buildings (crushing
and suffocation). Population is under threat from projectiles.

Pie chart (Blast 50%, Thermal 35% (light and heat. 1000000
degrees. There are two pusles. Second pulse causes skin burns
and eye injuries), Initial radiation 5% within a minute and residual
10%) – Types of bomb explosion damaging factors. Combined
AOD.

Blast wave cases different levels of destruction the levels of

destruction are directly related to

- The power if the bomb

- The distance of the explosion

- Types of construction

- The terrain – stretch of land

Zone related to blast wave

1) Complete destruction-severe

2) Destruction beyond repair – highest level of medical casualties

3) Major repairs-moderate

4) Light destruction – First impact – 3 +4 level burns, blisters and

sunburn

Sequence of the damaging factor impact

1) Light-flash burns and sudden fires. Residual blindness

2) Electromagnetic impulse

3) Blast wave

4) Initial radiation- first minute

5) Residual radiation- weapon debris, fission products and radiated

soil.

Different between initial and residual radiation is that initial is

created by the radiation released in the decay of the elements in
the bomb. The residual is created from the secondary
contaminated air, water and soil.

Residual radiation zones

M – zone of radiological danger - smallest radiation level – TMS

outside M zone and opposite direction to wind

A – Zone of moderate contamination

B – Zone of high contamination

C – Zone of dangerous contamination

D – zone of extremely dangerous contamination

Zone according to burns

- 4th degree: necrosis of full thickness of skin and underlying

layers

- 3rd degree: ulcers

- 2nd degree: oedema and blisters

- 1st degree: erythema

Hazardous radioactive elements: Strotium 90 (half life of 28 years),

iodine 131 (half life of 8.1 days), tritium (half life of 12.3 years),
celsius 137 (half life of 30 years), plutonium 239 (half life of 24400
years).

AODs

1. bomb site with 50% of bomb energy

2. severe shockwave damage

3. lethal prompt (initial) radiation

4. severe thermal damage

5. general radioactive fallout pattern

31. Acute Radiation Syndrome - Definition, Stages, Clinical

Features

Acute Radiation: Combination of clinical syndromes occurring in

stages hours to weeks after exposure as injury to various tissue
and organs is expressed. Can be developed in every RAOD.

Phases of ARS

-Initial/prodromal- first few hrs

-Latent- shorter with increasing dose

-Manifest illness phase

-Recovery phase

3 main syndromes of ARS

- Haematopoietic – symptoms – suppressed immunity (due to bone

marrow and spleen dysfunction), anaemia, and haemorrhage.
Causes death at 8Gy. Peak death at 30 days post radiation.

- Gastrointestinal – cause is damage of epithelial cells – damages

that lead to this are depletion of epithelial cells, intestinal bacteria,
haaemorrhage and loss of absorptive capacity. Death at 10Gy
within 3-10 days. Nausea, vomiting, diarrhoea and annorhexia.

- Neurovascular – Symptoms – burning sensation , nausea and

fatigue. Death at more than 30Gy. Death occurs within hours from
CV and neuromuscular complications.

Phases of hematopoietic syndrome

Prodromal phase – nausea and vomiting lasts a few hours. Not

severe and easy to control.

Latent – Up to a month. Asymptomatic.

Manifest illness phase – neutropenia fevers. Systemic and local

infections. Sepsis and haemorrhage. Platelet count drop to 0.
Neutropenia. No effect on RBC. Granulocytopenia.

Phases of gastrointestinal syndrome

Prodromal: sever nausea and vomiting, watery diarrhea and

cramps. 30-120 mins. Annorexia, abdominal cramps, parotid
gland, hypotension, tachycardia, fatigue.

Latent: Asymptomatic for hours to days.

Manifest illness – return of severe diarrhea – can lead to shock and

death without treatment. Vomiting, shock, bloody poo, infection via
bacteria results in sepsis, effects crypts in small intestine.

Symptomatic effects of gastrointestinal syndrome: Malabsorption !

malnutrition, GI bleeding ! anemia, Sepsis

The symptoms during the neurovascular manifestation stage is

watery diarrhoea, respiratory distress, Wide pulse pressure (wtf) ,
hypotension.

Prodromal- less than an hour. Burning sensation, severe nausea,

projectile vomiting. In 24 hours, bloody diarrhoea, cutaneous
oedema, erythema, hypotension, hyperpyrexia, disorientation,
prostration, coordination.

Latent- hours to days. Clinical improvement

Manifest- rapid onset. Water diarrhoea, respiratory distress, wide

pulse pressure and hypotension.

Deterministic effects:

0.1Gy – whole body – no detectable difference

0.1-0.2 Gy –whole body – detectable increases in chromosome

aberrations. No clinical signs

0.1-1.12 – whole body – sperm count decreases

0.5Gy Detectable bone marrow depression with lymphopenia

How severity of radiation injury is assessed

Prodromal effects: degree of symptoms

Hematological changes : lymphocyte count

Physical dosimeter – attendant readable

Symptoms of fatal radiation injury:

On the first day : Explosive bloody diarrhea (melena),

Hyperthermia, hypotension, erythema and neurological signs

Lymphocyte drop: 0.25-1Gy slight drop. 1.5Gy 50% drop. 3Gy

1000/mm3. 4-5Gy less than 500/mm3. +6Gy leaves 0.

32. Acute Radiation Syndrome - Treatment, Complications.

Radio-dermatitis

How severity of radiation injury is assessed

Prodromal effects: degree of symptoms

Haematological changes : lymphocyte count. Constantly check.

Physical dosimeter – attendant readable

Milestones in medical management of ARS patient

Simultaneously managing severe immune system compromises

and preventing hemorrhage and sever anemia due to
thrombocytopenia

General principles in gastrointestinal syndrome management

Prophylaxis

- Barrier/isolation

- Gut decontamination. Quinolones, ciprofloxacin, maintenance of

acidity

- Antifungal agents/ antiviral agents

- Early cytokine therapy

- Close wounds

- pneumocytosis prophylaxis

- avoid invasive procedures

Direct therapy for infections

– culture specific antibiotics

- Therapy leukopenia

- cytokine administration

- IV administration of IgG

- broad spectrum antibiotic coverage should exceed 800/mm3

Main therapeutic approach to the hematopoietic syndrome is bone

marrow transplant within 3-5 days of exposure

Advantages of the cytokine therapy

Bone marrow – increase production of white cells

- Stimulate production of colony forming units

- Decrease maturation

Mature – increase viability, prime neutrophils, stimulate additional

Cytokine release

For GI syndrome we use fluid and electrolyte administration,

treatment of radiation induced diarrhoea with anti diarrhoea agents
and cytokine therapy. We also correct peripheral blood changes.

Radio dermatitis

Definition: cutaneous inflammatory reaction due to exposure to

biologically effective levels of ionising radiation. You can get
erythema to wet desquamination of the skin, ulcer development,
tissue atrophy, fibrosis, permanent scarring. Can be acute or
chronic.

Cause: impact of radioactive elements. Proliferating basal layer

most vulnerable.

Types: 1st degree 0.15 C/KG. 2nd degree 0.26 C/KG. 3rd degree
0.31 C/KG. 4th degree 0.39 C/KG.

Treatment: epithelial and anti inflammatory agents, vitamins,

biogenic stimulants. Difficult and prolonged. Patients who have had
more than 2GY are placed in isolated wards. Between 2-4Gy then
isolated for 10-20 days.

33. Area of radiation damage management. Radiation injured

patient management

Severity of radiation injury is assessed by the following criteria:

- Prodromal Effects: Time of onset and degree of symptoms

- Haematological changes: Lymphocyte counts, biological

dosimetry

- Physical Dosimetry: Attendant readable

Management of casualties affected by radiation damage involves:

- “managing” severely compromised immune systems and

resulting infections - Contact control; food, water, air (filtered) with
low microbe content.

- prevention of haemorrhaging and severe anaemic caused by

thrombocytopenia.

GIT Syndrome management:

- Prophylaxis

- Decontamination of gut

- Antiviral and anti fungal agents

- early cytokine therapy

- wound closure (avoid invasive procedures)

- Active immunisation for infection with specific antibodies

Haematopoietic syndrome therapeutic support aims at reducing

the depth and duration of leucopenia. Most effectively treated by
bone marrow transplant after radiation.

34. Area of biological damage – Characteristics, Medical

Activities for Localization and Eradication

Definition: It is the area where the biological damaging factor has

impact on environment and living organisms.

Biological Damaging factor consists of viruses, bacteria, toxins,

and venoms.

Characteristics

- contagiousness- proportion of those who become infected

- pathogenicity- those who show clinical symptoms

- virulence- severity

- mortality

- resistance plus drug resistance

- incubation period

What could cause BAOD?

- Development of epidemic process

- As a secondary DF due to hygiene conditions

- Deliberate use of biological DF as a biological weapon

How many types of casualties in BAOD

- Primary –Infected by the damaging factor itself

- Secondary – Casualties that were infected by the contact with the

primary ones

DMS activities for managing the BAOD

-Medical intelligence

-Where it’s happened

-When

-What is the DF?

-What protection is needed?

- How the affected could be detected

- Population at risk

- Routes of egress and ingress

- Restrictive and preventative measures

- Available means and required means and capabilities

-Affected people

- Immunization

-Antibiotic prophylaxis

-checkpoints are placed. Limited contact. No mass gatherings.

Can only leave houses to get food that is delivered.

- No evacuation

Types of immunization: Passive and active

Passive: performed to all population as risk with objective to

increase the individual and

collective immunity to the population.

Active: Specific vaccines against the DF

Injury types:

- Infectious and communicable disease

- Stress

Medical specialists

- Infectious disease specialist

- Preventative medicine specialist

- Epidemiologist

In BAOD those infected are separated to protect survivors and

victims. The search and rescue is performed by anti-epidemic
group which are part of the medical teams. There is an active
search for those that are infected or been contacted. Try to use
passive immunisation, with strict sanitary control followed by active
immunisation.

Observation: no one is permitted to exit the biological area of

damage until they past their

maximum incubation period time. Those without symptoms are

allowed to leave.

Quarantine: Those who are infected are isolated in hospital, those

with symptoms isolated in the house. No one is allowed to enter,
only those that are there to eradicate like medical teams and
specialised biological teams but they are not allowed to leave.

35. Sanitary control

Definition: a complex of measures performed to prevent from any

harm coming from the environment. The objectives of sanitary
control is to protect population and environment of possible health

threats in specific regions. Sanitary control is performed constantly

by the preventative medicine teams (anti-epidemics) and
laboratories. Their activities are supported by the teams of the civil
protection and police.

The type of decisions that could be taken according the safeness

levels are;

1. Danger for population health-for eradication.

2. Danger for population health-for decontamination

3. Safe for population health-for utilisation

There are two types of eradication!burning and burying. These

places have to be marked and secured till the measurement
indicates that the places are safer for humans, animal and plants.

The process after decontamination of the danger food, water and

soil! new measurements is performed and new decisions about
their safeness has to be taken

Sanitary control consists of staged and interrelated activities. The

activities are listed in the required for their execution order:

• Detection of health hazards

• Measurement of health hazards

• Health risk evaluation

• Decision on safety of products and environment

• Decision on required preventative measures

• Clearing

• Storage

• Protection of the warehouses

• Eradication

The main tasks of sanitary control are 5;

➢ To detect via specific activities the available and potential health

hazards

➢ To measure the level of contamination of the population and

environment

➢ To take decision regarding the safeness of the environment

➢ In accordance with the safeness decision to plan and implement

preventative measures in order to assure the population health

➢To plan and execute the adequate and appropriate eradication

activities to all detected health hazards.

Compulsory steps in sanitary control

- observation- choose most appropriate source

- sampling- labelling and transporting

- indication- type of contaminant and level of pollution

- sanitary expertise- potential to cause harm

- decision regarding utilisation/ decontamination/ eradication.

36. Area of Chemical Damage – Characteristics, Medical

Activities for Localization and Eradication

CAOD is where the toxic damaging factors is affecting the

environment (air, land, water) and all living creatures. The questions
need to be asked in the area of damage:

- state of matter

- boiling and freezing points

- the tope of chemical- will it damage air, water, soil

- the amount of the chemical

- the environment and terrain

- water basins which can dilute or transport

- the direction and speed of the wind

- soil type

- vegetation

- protective measures

- population at risk

- type, number and location of casualties

-
The zones of chemical CAOD are;

• Zone of chemical spill!where the agent is released. There is 100%

of casualty, 80% irreversible loss and 20% medical loses. Small
area

• Zone of lethal concentration! 50% casualties and 30% irreversible

loss and 20% medical losses. Larger size

• Zone of damaging factors. Only a few of the population will

sustain health damages.

The temporary medical station for disaster medical support are

located 1,5 to 2km out of the CAOD opposite to the wind direction.
No medical teams can be found in CAOD. All routes of

evacuation should be opposite to the wind direction. Perform

medical intelligence to detect the TIM and other hazards. The
casualty types are intoxicated. Types of specialists needed are

internal diseases and toxicologists.

Medical activities: within minutes to hours. Search and rescue team

have to wear protective clothing.

➢ Stop the contact

➢ Place barrier against the poison-Use protective clothing

according to the type of

chemical. If the chemical is unknown wear class 4 protective

equipment -autonomous gas

apparatus, protective clothes, shoes and gloves.

➢ Partial decontamination

➢ Perform primary triage and perform full spectrum

decontamination before they enter FMS.

➢ Evacuation out of CAOD to internal med, ICU and toxicological

➢ Antidote administration. Maintain vital signs. Administer IV and

active charcoal if necessary to induce vomiting

➢ Search and rescue team will perform first aid. Damaged area is
covered in wet sterile dressing. Rigorous monitoring of breathing
and cardiac function.

37. Toxic Industrial Materials -Ammonia - Characteristics,

Medical Activities

Ammonia is a suffocating gas. lighter than air, colourless with

distinct smelI. It’s a common industrial toxic chemical from
nitrogenous waste, fertilisers and commercial cleaning products. It
is soluble in water, flammable and can form acetates. It is the most
widespread poison. It suffocates the individual.

Enters body via inhalation, ingestion as well as skin contact, it

primarily targets the lungs. Ammonia readily reacts with water to
form ammonium base and OH- which causes liquefied necrosis
within in the respiratory tract. Also causes toxic oedema and
perforation.

Symptoms include Runny nose, watery eyes as a reflex, cough and

dyspnea. You also get pulmonary oedema. Death is caused by
suffocation. If inhaled you get pain in eyes, cough, pulmonary
oedema, copious lacrimation, tracheobronchitis, laryngospasm and
bronchopneumonia. If ingested you get retrosternal pain, bloody
vomit and diarrhoea, pain in epigastrium, salvation and dysphagia.
If contacted with skin then erythema, ulcers and blisters.

Medical activities:

- stop contact

- use of gas mask with ammonia respirator in Damaging factor

zone autonomous respirators in zone of lethal concentration.

- if no gas mask use of cloth with 1:1 ratio of water and vinegar

- protective clothing required in AOD

- No artificial breathing due to necrosis

- application og glucocorticoids and diuretics.

- pulmonary resuscitation with oxygen flow

- rapid exit out of AOD

Prevention: full protective equipment, gas masks and if not

available then wet fabric.

First aid: full decontamination outside of the CAOD. No artificial

resuscitation. Pre-physician duties is to warm up casualty, assist
ventilation, bronchodilator and administer glucocorticoids. If
ingested then induce vomiting and drink water. if in eyes then
irrigate with warm water for 10 minutes.

38. Toxic Industrial Materials - Chlorine - Toxicology,

Characteristics, Medical Activities

Chlorine is the most aggressive suffocating gas commonly found in

most household detergents, bleach and sewage. Transported in
storage tanks and can be used in chemical warfare. It is denser
than air. Yellow/green in colour. Posses a distinct strong order and
readily soluble where it forms HCl.

Entry via inhalation or ingestion predominately targets the

respiratory system and GIT if swallowed with acute inflammatory
reaction. It causes necrosis when it reacts with water as it forms
HCl and HOCl an oxygen radical that causes cell damage. Also
causes acute inflammation of pharynx and larynx resulting in local
oedema and plasma exudation.

Symptoms include a productive cough with green sputum and air.

Retrosternal pain is also associated with hoarseness. initially
vomiting can occur followed by pulmonary oedema. Death via
suffocation. Causes hyalinosis. Short of breath. Chest pain. Ocular
and nasal irritation. Nasal flaring, cyanosis and lacrimation.
Tachycardia, wheezing and tachypnoea.

Medical activities:

- stop contact

- protection with isolating equipment using industrial breathing

apparatus.

- Use of 2% NaHCO3 for neutralisation.

- partial decontamination. Primary triage and organised

evacuation.

- due not reform artificial breathing in AOD as you will rupture the
necrotic trachea. Just supplement oxygen

- Administer glucocorticoids, diuretics, milk and protein for GIT.

- Decontaminate eyes and skin.

- apply topical anaesthetics

- incubate for laryngospasms to prevent hypoxemic respiratory

failure.

39. Cyanides - Toxicology. Characteristics, Medical Activities

Cyanide is a chemical compound. It presents as either a gas,

colourless liquid or white granular powder (stable form which is
activated into gas form by mixing with mineral acid). It is a cellular
poison with a distinct bitter almond odour. It is found in the
environment (combustion of nitrogen containing compounds), living
organisms (cherries, pears, apricots) and humans (smokers and fire
fighters). It is used to produce nitrites and plastics. Also used by
terrorists. It is most efficient in an enclosed space.

It enters the body via inhalation, ingestion or through, wet/moist

skin. It targets the enzyme system of cells causing hyperaemia.
Ferric ion inhibition of cytochrome oxidase This results in metabolic
acidosis. Symptoms include an almond odour, red/violet spots and
shiny blood. Death is result of tissue hypoxia brought by metabolic
acidosis. Causes low blood pressure. It is a tissue poison. Main
targets are brain and heart. If inhaled symptoms appear with 6-8
mins. Gives a metallic taste in the mouth. Causes burning
sensation in the GIT and respiratory tract. If ingested there is a
delayed onset of 15-30 mins and you get a sore throat and
diarrhoea. If skin is contacted then erythema and pain at site of
contact. Specific symptoms include dizzyness, nausea, vomiting,
hallucinations, drowsiness, tetany, trisms, arrythmia, hypertension,
tachycardia, dyspnoea, hyperventilation followed by
hypoventilation.

Medical activities:

- Stop contact

- use of normal gas mask with 2 ampules of amyl nitrate which is

an antidote. This forms methaemoglobin.

- intravenous injection of sodium thiosulphate which metabolises

cyanide in the liver and thiocyanate gets excreted through the
kidneys. Assess for hypotension, CNS depression and coma.

- administer the antidote hydroxocobalamin which chelates the

cyanide.

- first partial decontaminated plus gas mask for casualties.

- perform CPR outside of the CAOD. Supplement oxygen. Before

artifice breathing make sure the casualty is decontaminated with
soap and water.

40. Organophosphorus compounds - Toxicology.

Characteristics, Medical Activities

Organophosphates are neuro-paralytic toxic compounds sourced

from most pesticides/insecticides. Majority of them are both
odourless and colourless and come in solid, liquid or aerosol form.
Some are slightly yellow. They are used for chemical weapons.

They are typically ingested, inhaled or enter the body cutaneously,

targeting the enzyme acetylcholine esterase synapses. It slops
transmission of neurone impulses and causes paralysis of
transmission, leading to stimulation of all elementary receptors.
Acetyl and choline are dissociated.

Burning red face is often associated with casualties with

organophosphate poisoning as well as lack of coordination. Other
symptoms include Blurred vision and contraction of all muscle
groups. Death is via suffocation due to fluid build up in lungs. M
and N chemoreceptors become blocked because they become
sensibilised to acetylcholine. You get muscranic syndrome (miosis,
abnormal accommodation, bradycardia, cyrdiodepresseion,
vasodilation, tight chest, pain in GIT and polyuria) and nicotinic
syndrome (anxeity, headache, malaise, convulsions, tremors,
coma). Long term you get impaired memory, disorientation, severe
depression, irritability, confusion and nightmares.

Medical Activities:

- Assess Hazard - determine type and quantity of

organophosphate.

- Use full protective equipment (can enter skin) normal gas masks
are sufficient. Gloves, boots and protective costume.

- Apply antidote -Atropine 5ml intramuscularly every 15 min. and

mydriasis for pupil dilation in first pre physician aid

- clean wounds with baking soda and clean face with water. First
aid.

- Administer Ach esterase activator in first physician aid

- stop contact

- artificial breathing

- decontamination

- evacuation out of CAOD to internal medicine department.

41 . Carbon Monoxide - Characteristics, Toxicology, Medical

Activities

CO is a toxic colourless, tasteless and odourless gas with similar

density to air. It is a blood poison that competes with oxygen by
binding to the ferrous (FE2+) ions in haemoglobin forming
carboxyhaemoglobin. It is not soluble in water. It is flammable and
very penetrative. It is sourced from boilers, gas fires, central
heating systems, water heaters, cookers, open fires, gunpowder,
cars, generators, volcanoes, forest fires.

It enters the body via inhalation and targets the brain, heart and
liver. CO has a greater affinity than oxygen to haemoglobin in
blood. it leads to cell hypoxia resulting in tachypnoea and
tachycardia as well as respiratory and metabolic alkalosis. It also
binds to myoglobin to form carboxymyoglobin. It also reacts with
the ferrous ion in cytochrome and cytochrome p450 resulting in
blockage of oxidative phosphorylation in mitochondria.

Attributed symptoms include feeling of weakness, dizziness and

sleepiness. A strobing headache is the predominant symptom of
CO poisoning. Hyperexia is also an associated symptom. In light
poisoning you get headache, eyesight disturbance, nausea,
vomiting, arthralgia, scarlet red skin, hepatomegalia, hyperthermia,
tachycardia, hypoxia, hypoxemia, hypercapnia. in heavy poisoning
death can result.

Medical Activities:

I. Stop contact with agent using hopcalith which converts CO into

CO2. This will assure at least 20 minutes of activity.

II. Use of gas mask with Hop Copper bullet

Ill. Use of hyperbaric oxygen therapy to increase saturation of free

Hb. This is first pre physician aid. Also assisted breathing and
administer antipyretics.

IV. Application of analeptics for CNS stimulation

V. Blood transfusion to boost Hb. This is first physician aid. Also

administer noothroping drugs and diuretics for cerebral oedema.
DO not give opiates as they will suppress breathing.

VI. Place the FMS out of the contaminated area. Perform primary
triage and organised evacuation.

42. Blistering Agents. Characteristics, Toxicology, Medical

Activities

Blister agents or vesicants are chemical compounds/weapons that

cause severe skin, eye and mucosal pain and irritation. They're
named for their abilty to cause severe chemical burns, resulting in
painful water blisters on the affected areas. Its commonly source
from chemical spills and chemical warfare agent but also occurs
naturally (cantharidin). They are soluble in fats so can be used as
intracellular poisons.They are denser than air. It is typically in liquid,
gas or aerosol form.

Most blister agents fall into the following groups: Sulphur mustards
(a gas in an oily liquid. Low volatility. Garlic smell), lewsites (oily,
colourless liquid that smells like geranoium. It can be lethal within
minutes of exposure) and phosgene oxide (nettle agent which is
yellowish brown liquid. Symptoms occur immediately and it passes
through clothing).

Routes for exposure are the eyes, inhalation and ingestion. They
primarily target the respiratory system and skin causing
bronchospasms, blistering of the skin, etc. Through dermal
exposure, symptoms appear 4-8 hours after. You get visible
erythema followed by vesicles within 12-18 hours and they become
blisters over days. These blisters will be replaced with superficial,
translucent lesions. Through ocular exposure, you get tearing,
conjunctivitis, eyelid oedema, blepharospasm. If inhaled you get
bronchospasm, dyspnoea, haemorrhagic bronchitis and pulmonary
oedema. If ingested then vomiting. System symptoms include
leukopenia, pancytopenia, hallucinations and memory
impairement.

Medical activities include stopping contact with the chemical agent

by abandoning AOD as they are no efficient antidotes. Go to higher
ground and remove clothing. Decontamination either with dry
powder or soapy water, application of glucocorticoids to alleviate
bronchospasms and irrigation of the eyes. Manage burns with
analgesics. infection control. Fluid replacement. Bronchodilators

43. Riot Control Agents. Characteristics, Toxicology, Medical

Activities

Chemical Compounds that temporarily make people unable to

function. They're typically used by law enforcement officials for
crowd control or for personal protection. Typically forms as a dense
vapour cloud. They can be lachrymators (chloroacetophenone,
chlorobenzylidenemalononitrile, cloropicrin. Collectively tear gas.
Solid crystals that are podourless. Used in molten spray, or
dissolved in organic solvent, or micro pulverised), sternitis, pepper
spray (causes temporary blindness. Wears off in 20-90 mins.
Removal by vigorous blinking or shampoo on skin).

Depending on the compound riot control agents can be irritants,

dye markers, malodorous substance, etc. Their main route for
exposure are via ocular exposure and/or skin. They target the
respiratory system, skin and GI tract. Irritates nerve endings
especially CNV and CNX. Results in hyperreflexia.

Symptoms include the formation of blisters, diarrhoea and

abdominal pain (nausea/vomiting) as well as irritation to the eyes
(tearing, burning, redness, blurry vision, conjunctivits, erythema of
the eyelids), mouth, throat (sore throat, hoarsenss), lungs (chest
tightness, couch, wheezing, dyspnea) and skin (burns and rashes).

Prolonged exposure or large doses of riot control agent can lead to

severe effects such as blindness, glaucoma, respiratory failure
through pulmonary oedema and severe chemical

burns both leading to death. Additional symptoms are cyanosis,

runny nose, hypoxemia, burning throat, tachypnoea. 10 mins to an
hour duration. Onset within seconds however depends on dose,
route of exposure and premorbid condition. Begins in upper
respiratory tract usually and can give pain in teeth.

Medical activities include stopping contact with agent,

decontamination with cold water, administration of glucocorticoids
(bronchodilator) and antihistamines. Wet cloth over eyes. inhale
antismoke mixture. Leave AOD. Rinse mouth and eyes with 2%
sodium bicarbonate. Analgesics. Unitol antidote.

44. Disasters Psychological Disorders

• Even when you’re not hurt physically, disasters can take an

emotional toll.

• Normal reactions may include intense, unpredictable feelings;

trouble concentrating or making decisions; disrupted eating and
sleeping patterns; emotional upsets on anniversaries or other
reminders; strained personal relationships; and physical

symptoms such as headaches, nausea or chest pain

Post-traumatic stress disorders (PTSD)

• a condition of persistent mental and emotional stress

• occurring as a result of injury or severe psychological shock

of war, fire, terrorism, earthquakes

• typically involving disturbance of sleep and constant vivid recall of

the experience, with dulled responses to others and to the outside
world

• Rx = therapy, counseling

Depression

• state of low mood and aversion to activity or apathy that can

affect a person’s thoughts, behavior, feelings, and sense of well-
being

• Risk factors include:

o Personal or family history of depression

o Major life changes, trauma, or stress

o Certain physical illnesses and medications

Schizophrenia

• genetic and environmental factors play a role in the development

of schizophrenia

• Other factors that play an important role include social isolation

and immigration related to social adversity, racial discrimination,
family dysfunction, unemployment, and poor housing conditions

Adjustment disorder

• short-term condition

• Umbrella term for stress disorders, feeling sad or hopeless, and

physical symptoms that can occur after you go through a stressful
life event

• Your reaction is stronger than expected for the type of event that
occurred.

Grief

• Learning to deal with the loss of loved ones in a disaster

• Would involve therapy with psychologist to learn coping

strategies to deal with the loss

• May even be learning to deal with the loss of your home, and
changes in circumstances – e.g. in earthquake the whole
neighbourhood would be destroyed and you would need to
relocate – children in new schools, new people in a different
neighbourhood, you may have lost your job etc...