Medical response in a nuclear or radiological emergency

National Guide JUNE 2023 MEDICAL RESPONSE IN A NUCLEAR OR RADIOLOGICAL EMERGENCY H H

MEDICAL RESPONSE IN A NUCLEAR OR RADIOLOGICAL EMERGENCY National Guide 2023 ISSUE MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 3

The 2023 issue of the national guide “Medical Response in a Nuclear or Radiological Emergency” is a fully revised version. It builds on the official reference documents and instruments: J Contingency plans such as the regional application of the governmental Chemical, Biological, Radiological or Nuclear (CBRN) plan or the Off-Site Emergency Plans; J The medical management aspects: Circular 8001 and the Major Radiological or Nuclear Accident National Response Plan activated by the Prefect. The recommended actions are to be adapted according to the situations and the available resources. The emergency treatments listed are essentially the initial first aid measures to take so that the specialists can subsequently administer the appropriate treatments. In the majority of cases these emergency treatments are carried out by the Mobile Emergency and Resuscitation Service (SMUR) and the Rapid Response Health Units (RRHU) of the Fire and Rescue Service (FRS) in the field or in hospital in the emergency or intra-hospital structures (imaging, operating theatre, etc.) or in the occupational health services. The emergency therapies proposed in this guide, particularly in the case of internal contamination, which are based on the current state of knowledge, use medicines that have a marketing authorisation (MA) or are undergoing studies with a view to obtaining this authorisation issued by the French Health Products Safety Agency (ANSM). Furthermore, stocks of some of these products have been acquired insofar as possible and distributed nationally for use in the pre-hospital and hospital environments. The update was carried out as part of the work of the Advisory Committee of Experts in Radiation Protection (GPRP) and the French Nuclear Safety Authority (Autorité de sûreté nucléaire – ASN). CONTRIBUTING EXPERTS listed in alphabetical order Members of the working group J P. Barbey (University of Caen Normandie) J Ph. Bérard (CEA) J L. Bodin (CEA) J S. Bohand (Orano) J G. Bonardel (Centre cardiologique du Nord – North Cardiological Centre) J M. Bourguignon (Paris Saclay University – UVSQ) J C. Challeton-de-Vathaire (IRSN) J J. Fogelman (Quatre Villes Hospital) J G. Gagna (SPRA) J F. Ménétrier (CEA) J JM. Philippe (General Directorate for Health – DGS and SGDSN) J Ph. Sans (SIS 31) J D. Schiedts (Cotentin Public Hospital) J C. Telion (SAMU 75) Reviewers J S. Abdelkhalek (Rouen University Hospital) J JC. Amabile (SSA) J C. Bertrand (Henri Mondor AP‑HP Hospital) J A. Bonnin-Dussaud (SSA) J A. Cazoulat (SSA) J M. Deloy (Henri Mondor Aurillac Hospital) J E. Delvecchio (General Directorate for Health – DGS) J M. Deschouvert (Rouen University Hospital) J C. Dolard (Rouen University Hospital) J F. Entine (SSA) J V. Fofana (General Directorate for Health – DGS) J L. Gabilly (Civil Hospices of Lyon) J Y. Ibanez (General Directorate for Health – DGS) J L. Lachenaud (SGDSN) J M. Lamballais-Glemot (Rennes University Hospital) J JB. Le Loch (National Civil and Military Centre for NRBC-E Instruction and Training – CNCMFE NRBC-E) J A. Raynaud-Lambinet (CNCMFE NRBC-E) J S. Supervil (SGDSN) J J. Treille (Nîmes University Hospital) J E. Vial (SGDSN) Previous issues: 1997 : Initial version produced by a working group of the Scientific Council of the Office for Protection against Ionising Radiation (OPRI) 2002 : 1st update coordinated by ASN 2008 : 2nd update coordinated by ASN 1. Circular relative to the national doctrine concerning the use of emergency and medical care resources in the event of a terrorist attack involving radioactive materials. 4 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

A PRACTICAL GUIDE FOR ALL PARTICIPANTS IN MEDICAL EMERGENCY SITUATIONS Do you work for the Emergency Medical Assistance Service (SAMU), the Mobile Emergency and Resuscitation Service (SMUR) of the Fire and Rescue Service (FRS)? Do you work for the headquarters of a defence zone or a hospital emergency department? Are you an occupational physician, a first-aid rescue worker or an instructor? This national medical response guide is intended for all health and civil security actors who could be required to respond to a nuclear or radiological emergency. It essentially covers the initial measures to take so that the specialists can subsequently apply the appropriate treatments. This third update of the national guide incorporates the organisational changes that have come about since 2008 and the new contamination treatment protocols and means. Coordinated by ASN, the French Nuclear Safety Authority, this update was carried out by a working group chiefly comprising emergency physicians and experts in radiation protection, internal dosimetry and radiotoxicology. In the context of its duties, ASN contributes to the management of nuclear or radiological emergencies and advises the Government. As such it plays a leading role in preparing for radiological emergency situations. The 2023 issue of this reference guide is based on a study of practices with professionals in the field which has enabled their expectations to be more clearly identified. The guide has been completely reorganised to meet the needs and utilisation contexts of the addressees. It takes the form of operational sheets on which the relevant information for any situation can be found quickly to ensure a fast response: treatment in the event of irradiation, action to take in the event of contamination and technical sheets (procedure for removing clothing, means of protection, etc.). It also includes the possible treatments and dosage for each radionuclide. The guide is available primarily in digital format on the ASN website. Don’t hesitate to spread the work among your colleagues! We hope you enjoy reading it! PREFACE MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 5

CONTENTS This guide is organised by theme and made up of numbered sheets. WHAT YOU NEED TO KNOW BEFORE TAKING ACTION Medical response strategy SHEET 01 n The 7 essential principles p. 11 SHEET 02 n General conditions of intervention p. 14 SHEET 03 n Action priorities along the medical pathway p. 15 SHEET 04 n The 3 types of victim p. 18 SHEET 05 n Questionnaire and description of the circumstances of an event p. 20 SHEET 06 n Responders’ equipment and means of protection p. 24 SHEET 07 n Decontamination and internal contamination treatment procedures p. 28 Regulatory framework SHEET 08 n Reference systems p. 30 SHEET 09 n Organisation of relief and medical care p. 34 SHEET 10 n Arrangements specific to healthcare institutions p. 37 Background SHEET 11 n Irradiation: définitions p. 40 SHEET 12 n Dosimetry: individual measurements and methods of evaluating the received dose p. 43 MANAGING THE VICTIMS Action to take in the event of external irradiation SHEET 13 n Confirming and characterising the irradiation p. 47 SHEET 14 n Guiding the diagnosis through questioning p. 49 SHEET 15 n Evaluating the dose received p. 50 SHEET 16 n Ensuring the radiation protection of the emergency response and medical teams p. 53 Action to take on the site of the event SHEET 17 n Carrying out the initial first-aid measures p. 55 SHEET 18 n Organising the medical pathway of the victims in the 3 zones p. 58 SHEET 19 n Organising the relief work p. 62 SHEET 20 n Before evacuation: stabilising and preparing the victims p. 65 SHEET 21 n Evacuating the injured: leaving the controlled zone p. 68 SHEET 22 n Protecting the responders in the exclusion zone and the controlled zone p. 70 SHEET 23 n Triaging the victims in the VAA p. 75 SHEET 24 n In the VAA: treating the absolute urgencies p. 76 SHEET 25 n In the VAA: decontaminating the relative urgencies p. 78 SHEET 26 n In the VAA: detecting external contamination of able-bodied persons p. 80 SHEET 27 n In the VAA: treating internal contamination and contaminated wounds p. 82 SHEET 28 n At the AMP: managing the victims p. 84 Action to take in a 1st line healthcare facility SHEET 29 n Preparing the premises, rehabilitating them and managing the waste p. 85 SHEET 30 n Protecting the healthcare facility personnel p. 90 SHEET 31 n Receiving and managing the victims p. 92 SHEET 32 n Detecting external contamination p. 96 SHEET 33 n Undressing the victims p. 98 01 02 6 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

SHEET 34 n Decontaminating the victims p. 102 SHEET 35 n Treating the injured persons in the operating theatre p. 104 Action to take in a 2nd or 3rd line healthcare facility SHEET 36 n Receiving the victims p. 105 Internal contamination measurements and treatments SHEET 37 n Internal contamination measurements p. 107 SHEET 38 n Internal contamination: initial treatment p. 110 SHEET 39 n Specific antidotes p. 112 SHEET 40 n Contamination of the digestive tract: non-specific treatments p. 114 RADIONUCLIDE HANDBOOK A Aluminium ............................................. RH 3 Americium ............................................. RH 4 Antimony ................................................. RH 5 Arsenic ....................................................... RH 6 B Barium ....................................................... RH 7 Bismuth .................................................... RH 8 C Cadmium ................................................ RH 9 Caesium ................................................. RH 10 Calcium ................................................... RH 11 Californium .......................................... RH 12 Cerium ..................................................... RH 13 Chromium ............................................ RH 14 Cobalt ....................................................... RH 15 Copper ..................................................... RH 16 Curium ..................................................... RH 17 E Erbium ..................................................... RH 18 Europium .............................................. RH 19 F Fluorine.................................................... RH 20 G Gallium .................................................... RH 21 Gold ............................................................ RH 22 I Indium ..................................................... RH 23 Iodine ........................................................ RH 24 Iridium ..................................................... RH 25 Iron .............................................................. RH 26 L Lanthanum .......................................... RH 27 Lead ........................................................... RH 28 Lutetium ................................................ RH 29 M Manganese .......................................... RH 30 Mixture of fission products ..... RH 31 Mercury ................................................... RH 32 N Neptunium .......................................... RH 33 Nickel ........................................................ RH 34 P Phosphorous ...................................... RH 35 Plutonium ............................................. RH 36 Polonium ............................................... RH 37 Potassium ............................................. RH 38 Praseodymium ................................. RH 39 Promethium ....................................... RH 40 R Radium .................................................... RH 41 Ruthenium ........................................... RH 42 S Samarium ............................................. RH 43 Scandium .............................................. RH 44 Silver .......................................................... RH 45 Sodium .................................................... RH 46 Strontium .............................................. RH 47 Sulphur .................................................... RH 48 T Technetium ......................................... RH 49 Tellurium ................................................ RH 50 Thallium ................................................. RH 51 Thorium .................................................. RH 52 Tritium ..................................................... RH 53 U Uranium ................................................. RH 54 Y Ytterbium .............................................. RH 55 Yttrium .................................................... RH 56 Z Zinc ............................................................. RH 57 Zirconium .............................................. RH 58 GLOSSARY p. 115 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 7

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MEDICAL RESPONSE STRATEGY SHEET 01 n The 7 essential principles p. 11 SHEET 02 n General conditions of response p. 14 SHEET 03 n Action priorities along the medical care pathway p. 15 SHEET 04 n The 3 types of victim p. 18 SHEET 05 n Questioning and description of the circumstances of an event p. 20 SHEET 06 n Responders’ equipment and means of protection p. 24 SHEET 07 n Decontamination and internal contamination treatment procedures p. 28 REGULATORY FRAMEWORK SHEET 08 n Reference systems p. 30 SHEET 09 n Organisation of relief and medical care p. 34 SHEET 10 n Arrangements specific to healthcare facilities p. 37 BACKGROUND SHEET 11 n Irradiation: definitions p. 40 SHEET 12 n Dosimetry: individual measurements and methods of evaluating the received dose p. 43 WHAT YOU NEED TO KNOW BEFORE TAKING ACTION MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 9

10 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

12FICHE MEDICAL RESPONSE STRATEGY The 7 essential principles 01 The exposure of people to a radiological or nuclear (RN) agent can result from an accident, a terrorist attack or an act of war. The medical response aims to evaluate the severity of the condition of the victims, to define response priorities and to consider the use of antidotes after evacuation of the victims by the emergency response teams. The emergency decontamination and full decontamination measures limit the radiological risk and the transfer of contamination into the healthcare facilities outside the contaminated area. Medical-surgical urgencies take priority over the treatment of contamination and irradiation. A human being can be irradiated or contaminated by a radioactive source. Irradiation results from exposure to a source external to the organism, while contamination can be either external (skin, hair, beard, clothing) or internal. Contamination causes irradiation throughout the time the radionuclide is present. Whatever the situation, medical-surgical urgencies take priority over the treatment of contamination and irradiation. The urgent medical actions must therefore be taken using appropriate techniques before carrying out full decontamination. SEE SHEET 3 A person is contaminated if radioactive particles are deposited on their skin, skin appendages (such as hair, beard, nails) or clothing (external contamination) or if these particles enter the organism by ingestion, inhalation or further to skin puncture, or possibly penetrating injuries (internal contamination). The absence of immediate effects complicates the evaluation and the treatment of potentially exposed persons. SEE SHEET 3 Medical-surgical urgencies take priority over the treatment of contamination and irradiation Radioactive contamination does not usually have immediate effects RADIOLOGICAL OR NUCLEAR EVENTS They can be caused by: • accidents: nuclear industry, radiotherapy devices, transport of radioactive substances, laboratory accident, etc. • terrorist attacks: attack by an explosive agent with dispersion of radioactive substances (“dirty bomb”), dispersion of radionuclides into the environment, exposure to a high-activity sealed source, etc. • acts of war: utilisation of tactical nuclear weapons, etc. These RN events involve a risk of radioactive contamination and irradiation of a large number of victims. i SHEET MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 11

MEDICAL RESPONSE STRATEGY The 7 essential principles 01 SHEET Internal contamination results from the entry of radionuclides into the organism. When a radionuclide is incorporated in an organism, it irradiates the tissues for a time that varies according to the physical half-life of the radionuclide and its biological retention in the organs. This is the committed effective dose. The radioactive substances causing the exposure are incorporated in the organism by ingestion, inhalation or after skin puncture (piercing, injury, penetrating wound). The subject then becomes exposed by internal contamination. Once the substances are incorporated, they can accumulate in certain organs (such as the thyroid in the case of radioactive iodine and the bones in the case of strontium). Emergency treatment with antidotes aims to prevent storage of the contaminant in the tissues or to speed up its natural elimination. Administration of antidotes reduces the quantity of radioactivity retained in the organism and hence the dose received by the tissues/organs and the risk of radiation-induced cancer. SEE SHEETS 7 27 + 38 to 40 + radionuclides handbook In the event of internal contamination, the radioactive elements are stored in different organs depending on their chemical nature. In the event of internal contamination, antidotes must be administered as soon as possible The external contamination of a person comes from deposits on the skin, clothing and/or the skin appendages, such as hair, beard and nails). Decontamination is carried out by undressing and washing the exposed persons, in one or two steps: emergency decontamination, followed by full decontamination. Protecting the upper airways as soon as possible prevents external contamination from being transformed into internal contamination (instructions: do not drink, eat or smoke). SEE SHEET 7 The external contamination was caused by the deposition of aerosols, dust or liquids 12 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

SHEET MEDICAL RESPONSE STRATEGY The 7 essential principles “Nuclear” covers anything that concerns the properties of the nuclei of atoms and radioactive materials. “Radiological” covers aspects concerning radiographic imaging techniques and events causing exposure to ionising radiation. The nuclear or radiological emergency response teams must be suitably trained and have Personal Protective Equipment (PPE) that is appropriate for the risk and the intervention site. The exposure of responders is evaluated by personal monitoring using passive and active dosimeters and, if necessary, by bioassay measurements (in vivo analyses and in vivo measurements). SEE SHEETS 6 22 In prehospital situations, a nuclear or radiological medical emergency requires a specific response framework Irradiation results from exposure to ionising radiation: the radioactive source is situated outside the body and the radiation passes through the organism or part of it. The irradiation is said to be external. The person stops being irradiated once they are sufficiently far from the source. The person does not transport any radioactivity but suffers the effects caused by the radiation. The exposure must be confirmed and characterised, and its severity must be evaluated as quickly as possible. SEE SHEETS 5 11 The usual work dress of hospital personnel provides adequate protection: gown, gloves and surgical mask. SEE SHEETS 6 30 The risk of contamination being transferred from a decontaminated victim is negligible H IRRADIATION The radioactive substances or the ionising radiation emitter causing the exposure are/is situated outside the organism: • either at a distance from the body, leading to overall exposure of the organism; • or close to the body, leading to localised exposure. In both cases, we use the term irradiation. i An irradiated person does not irradiate others any more than a burned person burns others 01 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 13

12FICHE MEDICAL RESPONSE STRATEGY General conditions of response Medical-surgical urgencies take priority over the treatment of contamination and irradiation: this principle applies whenever responding to a radiological or nuclear (RN) emergency, whether it involves one or more victims. As for the medical response strategy, it must comply with the criteria set out below. Mutual exchange of information between emergency services The information must be exchanged mutually between the emergency response and the emergency medical services (there are four different emergency service phone numbers in France: 15 (SAMU), 17 (Police/Gendarmerie), 18 (Fire Brigade) and 112 (European emergency number). These services trigger their respective response means according to pre-established contingency and emergency care plans (defining of a First Destination Area (FDA) and a Resources Assembly Area (RAA). Sending of a trained and equipped medical team After medical regulation and confirmation of the nature of the event (explosion, chemical accident, etc.), sending a trained and equipped medical team enables urgent medical and resuscitation treatments to be ensured without delay. This team has active dosimeters for the persons potentially exposed to radiation. Medical monitoring of the response actions The regulating physician of the regionally competent Emergency Medical Assistance Service (SAMU) ensures the medical monitoring of the response. He or she refers in particular to this “Medical Response Guide for Nuclear or Radiological Emergencies”. Depending on the scale of the event, a physician capable of fulfilling the functions of Medical Operational Coordinator (MOC) may be sent to the site to manage the event in collaboration with the zone SAMU. Intervention of a SMUR team trained for the RN risk A team from the Mobile Emergency and Resuscitation Service (SMUR) or the Rapid Response Health Unit (RRHU) trained for the RN risk intervenes, assisted if necessary by a specialist in nuclear medicine and a Radiation Protection Expert (RPE) from the same facility or, if necessary, a person from the Regional Reference Hospital for the RN risk (RRH RN). Inter-personnel collaboration It the intervention takes place on an industrial site classified as representing a “radiological or nuclear risk” (such as the nuclear power plants), there must be effective collaboration between the medical team and the personnel present on the site, especially the occupational medicine and radiation protection personnel. Scaling up the response organisation Scaling up of the response organisation must be considered on the basis of the situation assessment established by the first medical team on the site in collaboration with the zone SAMU and the RRHH RN. 15 17 18 112 02 SHEET 14 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

Only suitably trained and physically prepared rescue service or emergency medical teams can respond in radiological emergency situations. They must be protected against the risk of external and internal contamination by protective equipment that is appropriate for the zone concerned and they must wear active and/or passive dosimeters. SEE SHEET 16 • The following people are trained and equipped to intervene in the controlled zone in the VAA: the personnel of the Mobile Emergency and Resuscitation Services (SMUR), the fire brigade personnel of the Fire and Rescue Services (FRS), including the Rapid Response Health Unit (RRHU) and the personnel of the Mobile Radiological Response Units (MRRU), and the Internal Security Forces (ISF). • The following people are trained and equipped to intervene in the exclusion zone: the fire brigade personnel of the FRS’s, particularly the MRRU personnel. In situations of lifethreatening emergency, the SMUR and FRS RRHU personnel can also intervene in exclusion zones if they have appropriate Personal Protective Equipment (PPE). The personnel of healthcare facilities taking in victims that have not yet been decontaminated (Extreme Urgency – EU – medicalised or self-presenting contaminated persons) must be protected by appropriate PPE to prevent the risk of contamination (Hospital Victim Assembly Area – HVAA, hospital decontamination unit, imaging, operating theatre, etc.). SEE SHEETS 6 22 30 Protection of responders Appropriate resuscitation measures and emergency techniques must always be applied immediately on the site of the event. Protection against internal contamination Protecting the victims against internal contamination is a reflex action, in the same way as the resuscitation actions. The aim is to protect the airways without delay (wipe the face with a damp compress and put a medical face mask on the victim). Resuscitation actions and transfer to a safe place The resuscitation actions are performed on reaching the Victim Assembly Area (VAA), in the controlled area, without delaying transfer of the most critical victims (medical regulation). SEE SHEET 17 Vital actions and protection of injured persons against radioactive exposure 1 2 Action priorities along the medical care pathway MEDICAL RESPONSE STRATEGY The radiological or nuclear (RN) emergency is likely to lead to irradiation and/or external and/or internal contamination. Whatever the extent of any such contamination and the stage of treatment, medical-surgical urgencies take priority over contamination and irradiation management once medical care is provided on the site of the event. 03 SHEET MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 15

Medical-surgical urgencies take priority over the treatment of contamination and irradiation. The treatment of external and internal contaminations is most effective when applied as early as possible, as soon as the potential contaminating radionuclide(s) has/have been identified. • In the event of dispersion of radionuclides in the environment, the victim is removed from the contaminated environment and placed in safety. • In the event of external contamination, the treatment is based on undressing (emergency decontamination) and showering (full decontamination) with protection of the airways. SEE SHEETS 7 + 24 to 26 + 34 • In the event of internal contamination, antidotes are administered. SEE SHEETS 7 27 34 + 37 to 40 + radionuclides handbook Treatment of contamination cases as rapidly as possible Any exposure to a source of irradiation must be confirmed and characterised (total or partial irradiation of the body). The irradiation severity must be assessed as quickly as possible because it determines the appropriate medical pathway and treatment. Questioning the victim is an urgent priority in this assessment which leads to the filling out of a radiological risk assessment sheet for each victim. The investigative elements (circumstances of the event, dosimetric survey) are to be looked for on the scene of the accident, otherwise they risk being lost definitively. SEE SHEETS 5 7 11 Treatment of an irradiated victim IN PRACTICE Action to take in the case of irradiated or contaminated lesions When acute irradiation and/or contamination are associated with traumatic lesions (fractures, injuries, wounds, burns), the prognosis of the lesions is aggravated: the injury potentiates the effects of the irradiation and vice versa. Whole-body irradiation increases the risk of cardiovascular shock, infection and haemorrhage, and slows down the healing of wounds and consolidation of fractures. The first aid measures consist in controlling any severe bleeding (if necessary, take a blood sample for HLA tissue typing before transfusing), maintaining the circulatory function and freeing the airways to ensure satisfactory ventilation. After this, decontamination and/or internal contamination treatment must be started. SEE SHEET 17 4 3 MEDICAL RESPONSE STRATEGY Action priorities along the response pathway 03 SHEET 16 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

DIAGRAM No. 1 Victims’ pathway (simplified diagram) 1. Circular relative to the national doctrine concerning the use of emergency and medical care resources in the event of a terrorist attack involving radioactive materials. IN PRACTICE What are the action priorities in emergencies involving a large number of victims? In situations with large numbers of victims, the civil security and urgent medical aid response is organised on the site of the event in order to treat as many victims as possible. The on-site response organisation is governed by Interministerial Circular No. 800/SGDSN/PSE/PPS of 18 February 20111. It is divided into three separate zones: an exclusion zone, a controlled zone and a support zone. The victims must be prioritised by triage. • Front-end triage, before going to the Victim Assembly Area for Chemical, Radiological and Nuclear risks (VAA CRN). If many people are involved, triage is vital in order to rapidly assess the condition of each victim and determine decontamination and initial treatment priorities. An Advanced Medical Post (AMP) may be set up, depending on the severity, the number of victims and the scaling of the emergency response services. • Organisation of victim transfers: the medical regulation by the Emergency Medical Assistance Service (SAMU) organises the transfers to the healthcare facilities capable of continuing the resuscitation strategy initiated in the field (1st line healthcare facilities, and notably the Regional Reference Hospital for the RN risk (RRH RN), or even the National Reference Hospital (NRH RN). Only the casualties identified as EU are evacuated to a 1st line healthcare facility without full decontamination, subject to the approval of the SAMU and the receiving facility. SEE SHEET 18 Once the victims are in a safe place, the appropriate treatments must be provided at each stage of the care process: symptomatic treatments, (assisting a vital function, complementary therapies, etc.), specific treatments (chelating agents). Provide appropriate treatment as quickly as possible 5 + - - - - - - + Victims in Extreme Urgency condition MEDICAL AND RADIOLOGICAL TRIAGE RECEPTION CENTRE FOR UNINJURED PERSONS (RCUP) HEALTHCARE FACILITIES VICTIM ASSEMBLY AREA (VAA) DECONTAMINATION LINE Event ADVANCED MEDICAL POST (AMP) 1 2 3 EVACUATION Exclusion zone (contaminated zone) Controlled zone (triage, stabilisation, decontamination) Support zone (clean zone) Non-contaminated victims Contaminated victims MEDICAL RESPONSE STRATEGY Action priorities along the response pathway SHEET 03 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 17

MEDICAL RESPONSE STRATEGY The 3 types of victim In the event of a voluntary act or an accident of radiological or nuclear (RN) origin involving a risk of radioactive contamination and irradiation affecting a large number of victims, the emergency medical care organisation must be appropriate for the management of all the victims, distinguishing the following three types. The injured persons are potentially contaminated and/or irradiated. Casualties can be divided into Absolute Urgencies (AU), which includes the Extreme Urgencies (EU), and Relative Urgencies (RU). This categorisation of the casualties is carried out on site by the medical teams of the Mobile Emergency and Resuscitation Service (SMUR) and/or the Rapid Response Health Unit (RRHU) of the Fire and Rescue Services (FRS). Another medical triage is carried out at the reception of 1st line healthcare facilities, particularly with self-presenting victims. The management of these casualties complies with the usual response principles in disaster or accident situations involving a large number of victims: whatever the circumstances, medical-surgical urgencies take priority over the treatment of contamination and irradiation. The urgent medical actions must therefore be taken before carrying out any decontamination procedures. The AUs must receive medical care and be evacuated rapidly. Among them, the EUs must receive medical or possibly surgical treatment without delay. They are likely to be evacuated directly after stabilisation without full decontamination, subject to agreement between the Emergency Operations Commander (EOC), the Medical Operational Coordinator (MOC) and the regulating physician of the Emergency Medical Assistance Service (SAMU), supported if necessary by the medical consultant of the Regional Reference Hospital for the RN risk (RRH RN). The RUs undergo prehospital decontamination (emergency decontamination and full decontamination), before being evacuated to a healthcare facility. A residual contamination check must be carried out using a detector equipped with a suitable probe. SEE SHEET 25 PAEDIATRIC VICTIMS The principles applied to adults also apply to children. If a child is unaccompanied or is incapacitated, provisions must be made to accompany them. If a child goes through the able-bodied persons’ line, they must be accompanied by a relative or someone they know whenever possible. Casualties present on the site of the event 04SHEET 18 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

The people not present on the site of the event but situated nearby (permanent or occasional residents) are potentially concerned. They are also grouped in an RCUP. These people may be effectively impacted by the event, feel potentially directly involved or worry that they might have been exposed or contaminated. A medical examination and body contamination check are carried out at the RCUP. An information and support unit associated with medical-psychological care provided by the Emergency Psycho-Medical Units (EPMU) may be put in place in order to identify people requiring medical follow-up. The uninjured persons are assembled in a Reception Centre for Uninjured Persons (RCUP). Persons who have not undergone a contamination check2 on the site of the event, shall be checked for contamination just before they enter the RCUP. If necessary, decontamination will then be organised by the authorities. This procedure starts with questioning of the victims, by which they can be classified in one of three categories (contaminated, irradiated, contaminated and irradiated). The victims are then directed to the appropriate care structures according to their category. NATURE OR TYPOLOGY OF VICTIMS ACCORDING TO THE TYPE OF ACCIDENT The victim typology depends on the nature of the event or its modus operandi for terrorist attacks (e.g. use of explosives for the dispersion of RN agents resulting in complex casualties: injured, burned, blasted, contaminated irradiated). These victims will require appropriate care in the pre-identified 1st line healthcare facilities and in the RRHH RN facilities which have specialised resources and skills. The National Reference Hospital for the RN risk (NRH RN) is mobilised to treat the most serious victims in priority (examples: severe contaminations, paediatric care, etc.) and to provide their expertise to the other facilities. SEE SHEETS 3 7 Uninjured persons present on the site of the event The people situated near the site of the event 2. Hand-held radiological contamination meter. SEE SHEET 32 MEDICAL RESPONSE STRATEGY The 3 types of victim SHEET 04 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 19

12FICHE Questioning and description of the circumstances of an event MEDICAL RESPONSE STRATEGY The anamnesis must be based on specific questionnaires presented in several stages: during the triage of the victims, at the Advanced Medical Post (AMP) or in the healthcare facility if irradiation is suspected, when the patient is taken into medical care by a physician or, if applicable, a nurse. Victim triage stage The triage questionnaire is filled out for all conscious victims in order to rapidly identify the most exposed persons: persons who were closest to the event or are showing early signs of irradiation. The questionnaire is analysed locally following the indications of the referring physicians: nuclear physicians, radiologists, radiation oncologists, physicians with expertise in radiation protection. If a victim is unconscious, the information is obtained from witnesses (people who were close to the victim). Triage questionnaire (fill out three columns: “yes” / “no” / “details” on the Word file) 1 • Where were you at the time of the event? 2 • Roughly how far were you from the site of the event? 3 • Were you in a room? Which room? 4 • Were you outside a building? 5 • How long did you remain on the site of the event? 6 • Do you have any digestive problems (nausea, vomiting, diarrhoea)? 7 • At what time did you vomit? 8 • Do you feel very tired? 9 • Do you have a headache? Download the triage questionnaire Word file Early vomiting is a sign of severity in acute radiation syndrome. It is vital to determine whether vomiting has occurred. 05 SHEET IN PRACTICE For all the questionnaires Each questionnaire must be completed as quickly as possible. A sheet must be filled out for each victim giving a precise description of the circumstances of the event and all the necessary listed information. The questionnaires indicate the victim’s identification data (including the AMP patient number and the SINUS, SI‑VIC tag), the name of the physician or nurse who administered the questionnaire and the date and time it was filled out. 20 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

MEDICAL RESPONSE STRATEGY Questioning and description of the circumstances of an event If irradiation is suspected The detailed questionnaire and the medical examination questionnaire supplement the triage questionnaire. They concern all victims identified as being exposed to a risk of irradiation. Detailed questionnaire The detailed questionnaire serves to evaluate the received dose if irradiation is suspected. Part 1: The circumstances of the accident 1 • Were you in a building? Which building? 2 • Were other people present and close to you? How many people? Who were they? (Names) 3 • Can you estimate how far away from you they were? How long did they remain beside you? What were their respective positions? Standing, sitting, lying down, other? 4 • Describe precisely what you were doing at the time of the accident. What was the duration of each task you did following the accident? 5 • What route did you take to reach the assembly area ? How long did you take to reach the assembly area? 6 • Describe your near environment. Distance and position with respect to the source and the shielding: were you close to structures situated between yourself and the site of the incident? Made of concrete? Another material? Can you indicate their size and approximate thickness? 7 • What position were you in? Standing, sitting, lying down, other? 8 • Do you have a telephone or any other electronic object on your person? Do you have a watch, spectacles, a packet of cigarettes, sweets, medication, sugar or sweeteners? Indicate their location at the time of the accident (for example, in which pocket). These objects can be useful for the dosimetric reconstruction. 9 • For the workers: do you know the nature and activity of the radioactive source? The type of radiation, the dose, the dose rate? Were you wearing a dosimeter? Active or passive? The questionnaire is supplemented by an accurate diagram: illustrate the places where the victim was situated at the time of the event, locate their position on the ground, in the area and with respect to the initial point of the event, and the position of any people present around the victim (markings on the ground). To position the various elements as accurately as possible, while observing the proper distances, you can for example use the grid shown below (1 square = 0.50 metres x 0.50 metres). SHEET 05 Download the detailed questionnaire Word file MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 21

MEDICAL RESPONSE STRATEGY Questioning and description of the circumstances of an event Detailed questionnaire (cont’d) Part 2: The reported disorders 10 • Are you experiencing nausea? Since when? Slight or severe? 11 • Do you have abdominal pains? Since when? Slight or severe? 12 • Have you experienced loss of consciousness? When? How many times? 13 • Do you have difficulty swallowing? 14 • Have you experienced dizziness? Since when? Slight or severe? 15 • Have you vomited since the accident? How many times? At what time? 16 • Have you had diarrhoea since the accident? How many times? 17 • Do you feel tired? Exhausted? Since when? 18 • Do you have a headache? Since when? Slight or severe? 19 • Have you eaten since the accident? Part 3: The observed disorders 20 • Does the subject display redness of the skin? Since when? Indicate the exact location: face, hands, other. 21 • Did the subject vomit during the questioning? Note scrupulously: number of times, time and duration of vomiting. 22 • Did the subject have diarrhoea during the questioning? Note: number of times, time and visual aspect. 23 • Does the subject seem to have difficulty in answering the questions? If the answer to even just one of the preceding questions is “yes”, the following medical examination questionnaire must be filled out in the field (Advanced Medical Post – AMP). Medical examination questionnaire The medical examination questionnaire is filled out by the medical personnel in the AMP or the healthcare facility, in addition to the usual medical examination of any victim. Does the subject present: 11 • An erythema, a burn, a wound? Since when? Indicate its exact location (diagram or photo). 12 • Asthenia? Since when? Moderate, severe? 13 • Periods of nausea since the event? Moderate, severe? 14 • Abdominal pains? Since when? Moderate, severe? 15 • Vomiting? Note the times. 16 • Diarrhoea? Since when? Moderate, severe? How many stools since the accident? Liquid or solid appearance? Note the times. 17 • Difficulties in swallowing? Appearance of the oro-pharyngeal mucosa: normal, inflamed? 18 • Headaches? Since when? Moderate, severe? Characterise them. 19 • Dizzy spells? Since when? Moderate, severe? Characterise them. 10 • Loss of consciousness? How many times? Characterise them. 11 • Spatio-temporal disorientation? Moderate, severe? Specify. 12 • Ataxia? Moderate, severe? Specify. 05 SHEET Download the medical examination questionnaire Word file 22 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

Medical management by a physician or nurse Medical management questionnaire (preparation of the medical record) Part 1: General medical management 11 • Pathology and treatment: Glasgow Coma Score – Dominant pathologies (Absolute Urgencies – AU / Relative Urgencies – RU): skull, thorax, abdomen, burned, poisoned, blast, fracture, polytraumatised, spine, other chemical, biological, radiological, nuclear (CBRN) risk? Diagnosis and treatment (peripheral venous catheter, intraosteal route, tourniquet, intubated). Development: improvement, stabilisation, aggravation (AU / RU / DECD)? 12 • Transport and destination: medicalised, non-medicalised, destination, service, means of transport, time, follower card (Victim Assembly Area – VAA / Advanced Medical Post – AMP / triage)? 13 • Medical surveillance and development: clinical, samples, therapeutic. Part 2: Radiological management (radiological evaluation sheet) Required information list: 14 • Acute radiation: yes/no, date and time, type of radiation (gamma/X-ray, neutrons), whole body and/or localised (part of body), estimated dose in gray (Gy) and diagram showing positioning with respect to the source. 15 • Headaches and/or impaired consciousness: yes/no, date and time. 16 • Early erythema: yes/no, location, date and time. 17 • Nausea and/or vomiting and/or diarrhoea: yes/no, date and time. 18 • Hyperthermia: yes/no, date and time. 19 • Guidance: total estimated dose (gamma/X-ray + neutrons) < 1 Gy (monitoring by) / total estimated dose (gamma/X-ray + neutrons) > 1 Gy Hospital 10 • Associated chemical risk: yes/no. Chemical agents concerned. 11 • External contamination: yes/no (if yes, indicate the contaminated zone). 12 • Emergency decontamination: yes/no, date and time. 13 • Full decontamination performed: yes/no, date and time. 14 • Residual external contamination: yes/no, detected or suspected radionuclides. Diagram of the residual contamination 15 • Internal contamination suspected: yes/no. 16 • Internal contamination: measured by in-vivo radiation measurement (yes/non), radionuclides and activities measured, suspected (yes/no), radionuclides. 17 • Contaminated wound: yes/no, location. 18 • Measurements – samples: in-vivo radiation measurement – urine radiotoxicology – nostril sampling – skin appendage sampling indicating location (or time-stamped) – time-stamped blood samples: Complete Blood Count (CBC), platelets, reticulocytes / haemostasis biochemistry enzymology / sodium-24 / phenotyping of the erythrocytes (red blood cells) / HLA class I and II typing / chromosomal aberrations. 19 • Internal contamination treatment: Potassium iodide (yes/no, time). This treatment is administered as quickly as possible in cases of internal contamination by radioactive iodine – Radiogardase® (yes/no, time, dosage) – Ca‑DTPA administered by slow IV injection or perfusion (yes/no, time, dosage) – Ca‑DTPA by inhalation (yes/no, time) – DTPA on contaminated wound: one or more vials (yes/no, time). 08 MEDICAL RESPONSE STRATEGY Questioning and description of the circumstances of an event SHEET 05 Download the medical management questionnaire Word file MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 23

12FICHE Responders’ equipment and means of protection MEDICAL RESPONSE STRATEGY If there is any uncertainty about the nature of the event, the rule is that the first responders3 must have maximum protection. It is only after any doubt has been removed, particularly regarding whether an associated chemical component is involved, that the protective garments can be adapted. Emergency response and emergency medical aid teams 3. National recommendations concerning protective clothing for RN risks (see INRS sheet “Personal Protective Equipment “ED 6077: https://www.inrs.fr/media.html?refINRS=ED%206077 and “Protective clothing”, sheet, ED 995: https://www.inrs.fr/media.html?refINRS=ED%20995). 4. Within the meaning of the SGDSN guide of 8 March 2021 – Good practices for deploying a Victim Assembly Area in the event of a chemical, biological, radiological or nuclear incident. 06SHEET The teams must protect themselves to avoid being exposed to the radiological and nuclear (RN) risk, or to ensure that any such exposure is kept as low as possible. If there is any uncertainty about the nature of the event, the rule is to choose Personal Protective Equipment (PPE) that provides the first responders with maximum protection. After dispelling any doubt and eliminating an associated chemical (C) risk, the PPE used can be adapted accordingly. First-line PPE pending confirmation that there is only a radiological risk: garment permeable to air for the Chemical, Biological, Radiological, Nuclear (CBRN) risk and CBRN mask with filter cartridge The professionals who are required to approach the closest to the site of the event wear appropriate garments for intervention in a hostile environment according to the zone in which they are situated and the nature of the risk (vapour, gas, dust). • The SMUR personnel, the Fire Brigade (FB) personnel of the Fire and Rescue Services (FRS), including the Rapid Response Health Unit (RRHU) and the Mobile Radiological Response Units (MRRU) personnel, and the Internal Security Forces (ISF) are trained to intervene in controlled zones at the Victim Assembly Area (VAA). They are all equipped with PPE that is appropriate for chemical and radiological risks and masks with a broad spectrum cartridge providing P3 filtration effectiveness (ABEK 2 P3 NBC standard) which must be kept constantly operational by the healthcare facilities concerned (through the general interest mission funding delegated by the General Directorate for Health (DGS). The Regional Health Agencies check that the healthcare facilities keep the PPE operational. • The FB personnel of the FRS, and the MRRU personnel in particular, are trained to intervene in exclusion zones4. They are equipped with appropriate protective garments that are permeable to air, in accordance with the equipment policy of each FRS. Respiratory protection is ensured by broad-spectrum CBRN cartridge filter masks with P3 filtration effectiveness. In situations of life-threatening emergency, the SMUR and the FRS RRHU personnel can also intervene in exclusion zones if they have appropriate PPE. Second-line PPE once the chemical risk has been excluded The means of protection are not bulky, are rapidly donned and do not unduly hamper the technical actions. Once the chemical risk has been excluded, the SMUR and FB personnel, including the RRHUs, can use PPE that is appropriate for the RN risk (non-woven coverall + FFP3 mask or, failing this, FFP2 + safety glasses + overboots + gloves). SEE SHEET 22 © ASN/P. Beuf © M. Deschouvert 24 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY

MEDICAL RESPONSE STRATEGY Responders’ equipment and means of protection Healthcare facility personnel Equipment to use according to the level of contamination of the victims There are two possible cases: 1. Medical management of a non-decontaminated victim (self-presentation or Absolute Urgency – AU not decontaminated on the site of the event): the personnel dons appropriate PPE (non-woven coverall, + FFP3 mask or, failing this, FFP2 mask + active dosimeter). 2. Medical management of victims decontaminated on the site of the event: the personnel dons the usual work clothing. A check for residual contamination may be envisaged; this is the role of the Radiation Protection Expert (RPE). SEE SHEET 30 PROPER DRESSING PROCEDURE Getting dressed properly means above all being able to get undressed properly and cleanly. Mastering the PPE dressing and undressing techniques is vital for the teams concerned. It is part of the initial and continuous training (at least once a year). If the dressing/undressing procedure is not practised regularly, and given the inevitable stress in a radiological emergency situation, supervision by experienced personnel (supervisor) must be envisaged. Respiratory protection • Available deviceS: from the complete mask with ABEK 2 P3 NBC cartridge to the disposable half-mask. The International Atomic Energy Agency (IAEA) recommends P3 filtration effectiveness for dust and aerosols. • Disposable FFP3 mask or, failing this, FFP2. • Medical (surgical) masks: these masks provide very limited protection. Gloves: 2 pairs per person • Three selection criteria: protection, dexterity, ergonomics. • The gloves must be suited to the size of the hand and fingers and guarantee good sealing. • Double pair of gloves required: change the outer pair of gloves if they get soiled. • RN risks: favour nitrile or, failing this, latex surgical gloves (good protection and dexterity) with long cuffs. • Chemical risks: if there is any doubt concerning an associated chemical agent, it is recommended to use butyl gloves with under gloves. Nitrile surgical gloves and latex gloves do not provide protection against certain substances, on the contrary. Shoes: 3 possible solutions • Rubber boots. • Butyl boots or overboots: recommended if there are associated chemical risks. • Light protective overboots in non-woven material, with non-slip soles. It is advised as a minimum to wear high-topped shoes or disposable clogs (for healthcare facilities), with protective overboots in all cases. Other equipment • Safety goggles. • Surgical caps, if the coveralls do not have a hood. 08 SHEET 06 CASE 1 CASE 2 MEDICAL RESPONSE IN NUCLEAR OR RADIOLOGICAL EMERGENCY 25

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