Chad Hrdina, MS, EMT, GC-WMD Chief, Medical Countermeasure Utilization and Response Integration

1. Division of Medical Countermeasure Strategy and Requirements Mass Casualty Emergency Medical Response to a Nuclear Detonation:Utilization of Oxygen Transporters Chad Hrdina, MS, EMT, GC-WMD Chief, Medical Countermeasure Utilization and Response Integration Given at Oxygen Carrier State of the Science Meeting Fort Detrick, MD 6 February 2017

2. Bottom line up front • Following a nuclear detonation there will be hundreds of thousands of casualties that could benefit from intervention with oxygen transporters. With efficient response to a mass casualty incident, and early application of hemostats, many lives can be saved with oxygen transporters later in the care paradigm.

3. Nuclear detonationresponse considerations • Nuclear detonation will result in • Infrastructure damage (response will require flexibility and adaptability) • Complex spectrum of injuries (treatment will require polypharmacy approaches) • Radiation exposure • Mechanical trauma: blunt force, fractures, lacerations, penetrations • Thermal burns • Combined injuries of acute radiation exposure, • Spectrum of injuries changes with different scenarios • Resource limitations • Medical management will require complex coordination

4. Potential casualties resulting from a nuclear detonation in a major city 1 injury severity score 2 % total body surface area, partial- and full-thickness burns 3 centigray *Adapted from Knebel, et al., DMPHP (S1), March 2011: http://jnls.cup.org/pdftext.do?componentId=8848885&jid=DMP&freeFlag=OA †http://www.childstats.gov

5. Nuclear detonation = scarce resources situation • Resource adequacy will vary greatly across the response areas by time and location (local and region, possibly nationally) • Response resources will be overwhelmed by casualty numbers and needs and concerned citizens requesting assistance • Limited access to interventions, (e.g., IV, transfusions, MCMs, conventional care) • To achieve fairness in resource allocation, a common triage approach is important • Possible change from "conventional" to "contingency" or "crisis" standards of care (treating those "most likely to survive" first approach) • Clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves.  • Bottom line: MCMs that provide benefit in lieu of extensive medical interventions (e.g., transfusion therapy) provide greatest effectiveness in response

6. CONOPS for responseRadiation TRiage, TRansport, TReatment RTR Sites (Field evacuation RTR1 – combined injuries (trauma, burn, radiation) RTR2 – radiation exposure RTR3 – limited injuries AC – assembly centers (screening, initial intervention) MC – medical centers (triage, screening, intervention) 1Hrdina, et al. Prehospital Disaster Medicine, 2009 May-Jun; 24(3); 167-78 2Planning Guidance for Response to a Nuclear Detonation / 2nd Edition / June 2010

7. CONOPS for response: activities Field stabilization (initial triage) ASPR/PHEMCE objective is to develop a flexible, adaptable, coordinated armamentarium – we must understand the limitations and capabilities of each MCM to help coordinate a cohesive response. Screening/assessment Stabilization / resuscitation some initial definitive care Definitive care

8. Response: MCM considerations Response timeline (transition of care) Stabilization and Resuscitation field care / ER and early intervention Definitive Care inpatient/outpatient therapy • Activities • Triage and radiation assessment • Decontamination • Biodosimetry if possible • Stabilize mechanical trauma injuries • Initial burn management and covering • Initial hemodynamic stabilization • Pain control • Initiate anti-neutropenic therapy • Control nausea and vomiting • Activities • Provide specialized care • Surgical interventions • Burn debridement and management • Long-term inpatient/outpatient care • Pain control • Biodosimetry • Neutropenia therapy / bone marrow transplant • Transfusion therapy for hemodynamic maintenance and late hemostatic risks Medical countermeasure considerations • Immediate to early access needed • Ease of administration, use, application • Topical, intramuscular, oral, etc. • High therapeutic index required • Poor diagnostics, concerned but healthy casualties • Robust storage, easy deployment • Room temperature, lightweight, pre-formulated, etc. • Delayed access ok timed as patients arrive • Expertise required to administer is ok • Surgical grafting, expert assessment, etc. • Low therapeutic index acceptable • Better diagnostics, expert assessment • Limiting storage requirements may be ok • Frozen, cryopreservation, etc.

9. Role of oxygen transporters • Hemostats are needed in the field • Must be • Easy to use • Effective • Universal • Oxygen transporters may be used in the emergency room and definitive care settings • Nonspecific products are easily administered without compatibility testing • Oxygen transporters/substrates are more beneficial if they behave somewhat like whole blood: maintain hemodynamic stability • They increase volume • Transport oxygen, carbon dioxide, wastes, etc • Hemostatic (if safe)

10. Bottom line • Field stabilization will be about • splinting, • hemostasis, and • addressing other medical issues that present impedance of progression through care system • To be most effective, oxygen transporters must be easy to use. • Universal products are easier to use • Easily administered products are preferred • Will be administered in the emergency room and definitive care settings