TCCC IN A RADIOLOGICAL/NUCLEAR EVENT (MARCHE)

Casualty care in a radiological/nuclear event should proceed according to the basic principles outlined in the (MARCHE)2 sequence as described in JTS CBRN CPG Part I. However, there are some nuances to the application of (MARCHE)2 in a radiological/nuclear scenario that are outlined in each phase of casualty care in the following sections (highlighted in blue). It is important to note that irradiation or contamination plus trauma, also described as combined injury, adds complexity to casualty care. The (MARCHE)2 sequence integrates the assessment and response to both trauma and radiologic/nuclear casualties.

In isolated irradiation, the most reliable early clinical indicators of whole-body radiation injury are the time-to-emesis and/or elevated body temperature, which can be seen in the early hours following exposure.

CARE UNDER FIRE/EXTREME HOT ZONE

It is important to seek cover at the first indication of a radiological or nuclear event. Even a layer of cloth can protect from large particles, so every attempt should be made to completely cover exposed areas including the eyes and mouth. There are no radiation specific treatments required at point of injury and all efforts should be made towards addressing life-threatening hemorrhage and extricating to a safe area. Medical responders need to understand the importance of minimizing personal exposure time and maximizing distance from a source when responding to casualties. If the tactical situation dictates that some casualty care must occur in the Extreme Hot Zone or Hot Zone, utilization of shielding will lower dose rates, but will increase exposure time. Dragging a casualty a few feet from a source can provide benefit while reducing risk to responders.

Table 5. Radiological threat in zones of care
Table 6. Point of Injury (Extreme Hot Zone / Hot Zone Response - (MAR)

TACTICAL FIELD CARE / WARM ZONE

Care in this phase should be rendered with consideration to “as low as reasonably achievable” principles in order to minimize further exposure or contamination once extracted from the Hot Zone. Moving to the basement of a building would be an ideal example. Ensure that medical equipment and supplies are covered. Ideally all but immediate life-saving interventions would be deferred until the patient reaches the Cold Zone where risk of further contamination is minimal. In the event that the radiation field is so large, or evacuation movement is restricted, these considerations may necessitate the transition to prolonged field care while still in the Warm Zone.

Initial Evaluation

- Assess for COMBINED injuries causing immediate loss of life (e.g. exsanguination)
- Decontaminate AFTER stabilization
- Traumatic injuries are more acutely life threatening than radiation injuries
- Removal of clothing and washing of patient >90% effective
- Requirement for some medical providers to work in a ‘radiation environment’
- Risk to providers is very low***Don’t delay resuscitation for decon***

Table 7. Assessment at the Dirty CCP (Warm Zone)– (M A R C H E)

TACTICAL EVACUATION CARE

Triage principles in this CPG should be heavily emphasized to support efficient use of CASEVAC and MEDEVAC resources. Role 1 to Role 3 evacuation priority should be based on trauma in combined injury casualties. Retriage for evacuation priority is crucial. If a casualty starts exhibiting signs and symptoms of significant exposure, the provider may need to change the triage category depending on evacuation capability, time to surgery and other “non-clinical” risk assessments by the triage person in charge. Evacuation out of theater for those with exposures likely to cause Acute Radiation Syndrome are described below. Additional guidance on evacuation operations in contaminated environments can be found in JP3-11. The decision to use ground and air transport platforms to transport contaminated casualties lies with Commanders after calculating acceptable risk, informed by medical personnel with expertise in this area. Risks include but are not limited to:

- contaminated casualty or retained radioactive material.
- cumulative exposure to transport and medical crew while transiting the contaminated environment.
- cross contamination of the transportation platform.

Although aircraft can safely fly through fallout (ATP 3-05.11) and the risk of ingestion and inhalation is small with PPE, rotor wash from helicopters can disrupt/spread settling radiological dust particles, liquids, and solids and can increase risk. Ground personnel and aircraft crews conducting CASEVAC/MEDEVAC operations should use PPE guidelines in this CPG if the aircraft is picking up patients in a Warm Zone. The use of protective masks (military or Level C) may provide some protection initially, but the canister or filters of the masks can accumulate radiological particles during prolonged use.

When preparing to execute a CASEVAC/MEDEVAC for a radiation casualty, medical providers should account for ensuring decontamination, isolating immunocompromised patients, and access to an appropriate receiving medical facility. Those who still have embedded shrapnel may require shielding. Portable shielding devices such as lead rolls are not currently issued as common equipment and unlikely to be necessary. Not all patients require shielding, only patients with retained radioactive material which is highly unlikely. The shielding device only needs to be large enough to cover the radioactive hazard, not the whole patient.

PROLONGED FIELD CARE / ROLE I-3 - CARE / COLD ZONE

Patient management during this phase should address both contamination and exposure. Patients with internal contamination require specific countermeasures based on the relevant radionuclide as discussed below and referenced in Table 10. Patients with exposure require a dose estimate (see Appendix C for details on biodosimetry) to determine appropriate level of monitoring and treatment. Developing dose estimates or using qualitative factors to categorize patients according to risk is a necessary secondary triage to appropriately determine disposition and allocate resources.

Clinical impacts are divided into deterministic and stochastic effects. Deterministic effects are dose dependent and consist of the ARS sub-syndromes and CRS. ARS and CRS are discussed below. Stochastic effects are probability driven and are most focused on long-term cancer risk.