Code Blue Response in Radionuclide Therapy Wards: A Standard Operating Procedure for Emergency Care and Radiation Safety

First responder (ward staff, e.g., nurse)

• First responder can be anyone who sees the emergency, examines the condition, and activates the Code Blue. If the responder is alone, activate the code blue by dialling the emergency number (e.g., 2222) and/or announce on the hospital public address (PA) system as the situation permits.

• Initiates cardiopulmonary resuscitation (CPR) at 100-120 compressions per minute.

• If two people are present, one person can activate the Code Blue, and the other can initiate CPR.

Primary responders

Once the code blue is announced, the Primary responders, i.e., ward nurses, RSOs, and Nuclear Medicine Physicians, are to rush to the site as announced and perform the following:

Ward nurses

• Wear appropriate personal protective equipment (PPE):

  • Double nitrile gloves (0.1 mm thick), Tyvek gown, shoe covers, and a thermo-luminescent dosimeter (TLD) badge clipped to the chest for radiation monitoring, and if available, wear a digital pocket dosimeter.

• Assess the patient's condition:

  • Check pulse (carotid for adults/children, brachial for infants, ≤10 seconds), breathing status, and level of consciousness using the AVPU scale (Alert, Verbal, Pain, Unresponsive).

• Rapidly deploy the crash cart with requisite life-saving drugs to the code blue site, ensuring immediate availability of critical equipment, including:

  • Defibrillator: Biphasic, pre-charged to 120-200 J, with disposable pads covered in 0.1 mm plastic sheets to prevent radioactive contamination.

  • Oxygen cylinder: Portable, 10 L capacity, with a flow rate of 10-15 L/min, fitted with a disposable regulator.

  • Ambu bag: Adult and paediatric sizes, with disposable airways to minimise contamination risks.

Radiological safety officer (RSO)

• Oversees radiation protection: Ensure radiation safety protocols are adhered to and ensure that everyone involved wears all protective gear and radiation monitors. Ensures responders' exposure remains below safety limits (e.g., 5 mSv per episode for non-radiation workers, 20 mSv/year for radiation workers.^[13,14]

• Ensure intake of thyroid blockade: Coordinate with the Nuclear Medicine Physician to administer stable Potassium Iodide (KI, 130 mg tablets) to personnel handling Code Blue for I-131-treated patients.^[15] Also, ensure the availability of the thyroid blocking agent.

• Assess radiation level & radiopharmaceutical administration history: Assess the patient's administered activity (e.g., Iodine-131 [I-131], 7.4 GBq [200 mCi], 48 hours post-administration, ~2.5 mSv/hour at 1 m) to estimate radiation exposure and contamination risks.

• Monitor contamination: Use a calibrated radiation survey meter to assess ward and environmental contamination levels. The Surface Contamination Levels in Restricted Areas is to be below 33 Bq (2,000 dpm) per 100 cm² for I-131 and Lu-177 isotopes as per The United States Nuclear Regulatory Commission (USNRC) Nuclear Regulatory Commission (NUREG) technical report series - 1556(Consolidated Guidance About Materials Licenses).^[16]

• Ensures availability of radiation safety supplies: Maintain stock of absorbent sheets, radioactive waste bins, plastic sheets to cover instruments, disposal gloves, gown, shoe cover, caps, etc.

• Minimises contamination risks: Use of plastic sheets (0.1 mm thick) to cover equipment and surfaces, and places absorbent sheets under patients to contain body fluids (e.g., urine, saliva, stool).

• Supervises radioactive waste disposal, including linen: Ensure all contaminated materials (e.g., gloves, absorbent sheets, linen) are sealed in labelled waste bags ("Radioactive, I-131, [Date]") and stored in lead-lined bins until activity decays to background level. Linen is to be stored in separate bags with labels as described. Other waste is to be disposed of as per the hospital bio-medical waste management policy.

Nuclear medicine physicians

• Supervise medical interventions: Arrive within five minutes to lead and oversee all life support procedures, including defibrillation (120-200 J biphasic for adults, 2-4 J/kg for paediatrics), airway management (10-12 breaths/min), and intubation (endotracheal tube, 7.5-8.0 mm for adults), ensuring compliance with AHA 2020 guidelines until the Hospital Code Blue Team assumes control.

• Prescribe thyroid blockade: Prescribe Super Saturated Potassium Iodide (SSKI) to responders as soon as possible and within 24 hours pre-exposure or ≤2 hours post-exposure for I-131 patients to reduce thyroid uptake by ~80% (WHO, 2018^[15]). Details are mentioned in section 3.5.3.

• Review radiopharmaceutical history: Coordinate with the RSO to review the patient's radiopharmaceutical administration records. Estimate the residual activity and potential external and internal exposure risks to caregivers and staff, facilitating appropriate radiation protection measures.

• Assist Hospital Code Blue: Upon arrival of the Code Blue team, provide a clear and structured handover summarising all interventions performed and the patient's radioactive status. Ensure seamless transition of care while continuing to adhere to radiation safety aspects as needed.

Hospital code blue team (secondary responders)

For effective in-hospital resuscitation (Code Blue events), a team comprising at least four trained personnel is essential, with optimal performance achieved with five to six members, with each assigned clearly defined roles.^[17] The resuscitation team is typically interdisciplinary, including one to two attending physicians, resident doctors, two nurses, and one to two paramedics, depending on patient volume.^[18] All team members must be certified in Advanced Cardiac Life Support (ACLS). This team structure ensures a high chest compression fraction, efficient administration of advanced life support (ALS), and coordinated response during critical events. A designated team leader may be a senior physician, intensivist, or anaesthesiologist; however, other specialists, including emergency medicine physicians or cardiologists, may also serve effectively in this capacity, depending on institutional protocols and clinical context. Additionally, the Radiological Safety Officer (RSO) should remain an integral part of the team in the high-dose therapy ward to supervise and ensure adherence to radiation safety measures.

Exclusion criteria

As far as possible, pregnant staff are not to be part of the Code Blue Team unless the situation necessitates them to be an integral part of the team and no other option is available. In this situation, the Time, Distance, and Shielding principles of radiation protection are also to be followed. In case she is part of the code blue team, an additional abdominal pocket dosimeter is to be issued (dose limit: 1 mSv), and abdominal doses are to be recorded.

The roles and responsibilities of each member are as follows:

Team leader (senior physician, intensivist, anaesthesiologist, emergency medicine physicians, or cardiologists):

An effective team leader plays an important role in code blue management. This becomes more critical when the resuscitation team is formed ad hoc, a common scenario during off-hours or in resource-limited settings^[5] The responsibilities of a team leader include

• Initiates and oversees the Code Blue response immediately upon arrival.

• Assigns and clarifies team roles based on members' competencies.

• Maintains situational awareness and minimises confusion.

• Directs the flow of clinical interventions, ensuring timely defibrillation, airway management, and medication administration.

• Supervises resuscitation progress in collaboration with other team members.

• Determines the decision to terminate resuscitation, particularly if no Return of Spontaneous Circulation (ROSC) is achieved after a reasonable period (commonly ~20 minutes without reversible causes).

Compressor:

He/she is responsible for delivering high-quality chest compressions at a rate of 100-120 per minute and plays a very important role in resuscitation. The definition of high-quality chest compression is mentioned in the AHA 2020 guidelines, part 3,^[1],4^[19] and 7^[20] and suggest that the majority of resuscitation success is achieved by application of high-quality CPR and defibrillation. High-quality chest compressions consist of delivering compressions at an adequate depth, maintaining an optimal rate, minimising interruptions, allowing full chest recoil, and avoiding excessive ventilation. As per AHA guidelines, the role of the compressor is as follows:

• Deliver chest compressions at a rate of 100-120 per minute, with a depth of at least one-third the anterior-posterior diameter of the chest i.e. approximately 1.5 inches (4 cm) in infants, 2 inches (5 cm) in children and adults, while avoiding excessive depth greater than 6 cm, as deeper compressions may increase the risk of internal injuries without additional circulatory benefit.

• Allow complete chest recoil after each compression to maximise venous return to the heart.

• To avoid fatigue and maintain effective compressions, the role should be rotated every 2 minutes.^[1] with another trained team member, such as an emergency technician or the monitor/defibrillator operator. Minimise interruptions in compressions to maintain coronary and cerebral perfusion pressure.

• Avoid excessive ventilation, as it can increase intrathoracic pressure and compromise venous return.

• If an advanced airway is not in place, maintain a compression-to-ventilation ratio of 30:2.

• Reassess CPR quality if Partial Pressure of End-Tidal Carbon Dioxide (PETCO₂) levels are low or decreasing. The PETCO2 is a measure of CO₂ in exhaled air and is a primary indicator of perfusion. It is typically measured in waveform by a capnograph connected to the airway (via mask or endotracheal tube) and depicts low chances of survival or failure to achieve return of spontaneous circulation (ROSC) if its value is <10 mmHg after 20 minutes of CPR.

Airway manager:

• He/she is responsible for securing and maintaining a patent airway to ensure effective oxygenation and ventilation during resuscitation. Proper airway management enhances gas exchange and supports perfusion and neurological outcomes.

• Airway management during resuscitation involves manual and advanced techniques. The manual technique involves head tilt, chin lift or jaw thrust, and may include suctioning, whereas advanced techniques involve supraglottic airways (e.g., laryngeal mask airway) and endotracheal tubes, with supraglottic devices showing strong safety and efficacy in paediatrics^[1,21]

• Confirm and monitor airway placement with waveform capnography, the gold standard for verifying endotracheal tube positioning and monitoring CPR effectiveness.^[22]

• For adults, provide 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions and each breath over 1 second.

• In infants and children, ventilate at 20-30 breaths/min (1 breath every 2-3 seconds), adjusted for age and clinical conditions. Avoid hyperventilation to prevent reduced venous return and cardiac output.

• For adults receiving bag-valve-mask ventilations during CPR, deliver tidal volumes of approximately 500-600 mL (or just enough to produce a visible chest rise) with each breath given over about 1 second to minimise the risk of gastric insufflation and aspiration.^{[1, 23]}

• When administering oxygen via bag-valve-mask (BVM) connected to an oxygen cylinder, set the flow regulator to at least 10-15 L/min to ensure adequate oxygen delivery with a reservoir-equipped BVM.^[24]

• Coordinate with the team leader and compressor to synchronise ventilation, especially during rhythm checks and team transitions.

Medication nurse:

He/she is responsible for preparing and administering emergency medications during resuscitation, following:

• Administer Inj. epinephrine 1 mg intravenous (IV)/Intraosseous (IO) every 3-5 minutes for adults and 0.01 mg/kg with a max dose of 1 mg and repeat with the same every 3-5 minutes.

• For non-shockable rhythms (asystole/PEA), give epinephrine as soon as feasible.

• For persistent VF/pVT (ventricular fibrillation or pulseless ventricular tachycardia), epinephrine (1 mg IV/IO) may be given every 3-5 minutes starting after the second defibrillation attempt, while continuing CPR and rhythm checks.^[25]

• IV access is preferred; if unsuccessful or delayed, establish intraosseous (IO) access promptly.

• In cases where IV/IO access is not possible, consider endotracheal (ET) drug administration as an alternative route.

• For refractory VF/pVT, consider:

  • Amiodarone IV/IO: First dose 300 mg bolus; second dose 150 mg for adults and 5 mg/kg for paediatric patients, and repeat up to 3 doses for Refractory VF/pVT.

  • or Lidocaine IV/IO: First dose 1-1.5 mg/kg; subsequent doses 0.5-0.75 mg/kg for adults and 1 mg/kg for paediatrics.

• Coordinate closely with the team leader for drug timing, avoid duplication, and document all doses administered accurately.

Emergency technician:

The emergency technician plays a vital role in supporting the resuscitation team by ensuring the rapid and efficient setup and operation of critical life-saving equipment. Responsibilities include the correct placement and functioning of defibrillator pads, suction apparatus, bag-valve-mask devices, and various oxygen delivery systems. The technician actively assists in maintaining equipment readiness, troubleshooting device malfunctions, and ensuring seamless transitions between interventions. Additionally, the technician facilitates timely patient transport when indicated and may assume alternate roles within the resuscitation team as required, adapting flexibly to the dynamic needs of the clinical scenario.

Recorder: He/she documents all critical details, including:

• Time of cardiac arrest (e.g., 16:30).

• Initial cardiac rhythm (e.g., ventricular fibrillation).

• Interventions performed (e.g., defibrillation at 200 J at 16:33).

RSO during code blue

• Supervises the entire procedure with respect to radiation safety protocols and ensures all measures are followed to contain the spillage, overexposure to the staff, while ensuring no compromise on patient care.

• Conducts radiation contamination checks to ensure surface readings remain below 50 counts per second (cps) for unrestricted handling of instruments.

• Supervises decontamination procedures, ensuring the availability of decontamination supplies (e.g., 10 litres of prepared soap solution, decontamination sprays).

• Records estimated radiation exposure to responders (e.g., Responder 1: 0.3 mSv).

• Record cumulative radiation dose to the entire team.

Patient and environment assessment

Equipment check

Internal communication

• Announce for Code Blue on the hospital's Public Address (PA) system and or

• Dial Code Blue Help line number, e.g., 2222, and state, e.g.:

  • "Code Blue, High-Dose Therapy Ward, Room 19, radioactive patient."

• Notify the RSO & Nuclear Medicine Physician:

  • Primary contact (e.g., xxxxx: 00000- 00000).

  • Secondary contact (e.g., yyyyy: 00000-00000).

External team coordination

• Pre-action briefing: The Hospital Code Blue Team is to be briefed about:

  • "Patient given radioiodine solution (I-131), 7.4 GBq, 24 hr post-dose; PPE required & Thyroid protection required."

  • Ensure stable iodine is administered as per the doses mentioned in the next section

Eligibility, contraindications, and institutional discretion

KI prophylaxis should not be administered indiscriminately. Authoritative guidance identifies known contraindications, including iodine hypersensitivity, active thyroid disease (e.g., Graves' disease or thyroiditis), dermatitis herpetiformis, and certain autoimmune conditions.^[15,29] Routine KI administration is generally recommended for children, pregnant and lactating women, and younger adults (<40 years). In comparison, its use in older adults requires careful consideration because of reduced benefit and higher risk of adverse effects.^[29] Pregnant and lactating staff require special consideration due to potential foetal and neonatal thyroid effects, and KI use in these groups should be carefully justified and documented.^[15,29] In addition, institutions may define eligibility criteria and documentation requirements in accordance with national regulations and occupational health policies.^[14]

Table 1] summarises the thyroid dose thresholds for different population groups at which intervention is recommended only when internal contamination with radioactive iodine is expected to exceed these levels.

Administration protocol

• Who: Ward sister-in-charge dispenses from stock.

• How:

  • Provide 1 potassium iodide (KI) tablet (130 mg) dissolved in water. If using SSKI ( 50 mg per drop), administer 2 drops diluted in water. If using 5% Lugol's iodine (5% solution; 20 drops = 100 mg iodine), administer 20 drops in water. Prepare the dilution using 100-150 ml of water in a disposable paper cup.

  • Log administration details (e.g., "14:30, Nurse A").

Inventory management

• Stock: 50 KI tablets (130 mg each) or 2 bottles (10 mL each) of SSKI liquid, stored in a locked cabinet.

• Expiry Check: Monthly audit; replenish near-expiry stock and discard expired medicines.

Implementation note

• Label cabinet: "Stable Iodine - Emergency Use Only".

• Annual training: Staff must attend iodine administration workshops.

CPR protocol and radiation safety

• Primary responders:

  • CPR: Start within 1 min (e.g., 14:33); 100-120/min, 5 cm depth (adult), 4 cm in infants and children.

  • Continue: Until Hospital Code Blue Team arrives (target: ≤5 min).

• Team arrival:

  • PPE provision: Supply 5 extra sets (gowns, gloves, TLDs) from ward stock.

  • Briefing: "Patient on I-131, 7.4 GBq, 48 hr post-dose; risks: thyroid uptake, fluid contamination."

  • KI: Offer 130 mg KI to team; log administration.

• Containment:

  • Fluids: Collect vomit/urine with absorbent pads; seal in 3-6 mm thick waste bags (label: "Radioactive, I-131, 03/03/2025").

  • Check: Use contamination monitor.

• CPR guidelines (AHA, 2020):

• Adult (puberty and older):

  • Pulse: Carotid, ≤10 sec; if absent, begin compressions.

  • Rate: 100-120/min (use metronome app if available).

  • Depth: 5-6 cm (place backboard if bed is soft).

  • Airway: Head tilt-chin lift (jaw thrust if neck injury); Ambu bag (500-600 mL tidal volume per breath).

  • Compression-Ventilation Ratio: 30:2 (single or two rescuers)

  • Switching compressor: every 2 minutes or ~200 compressions

• Child (1-8 years):

  • Pulse: Carotid or femoral.

  • Technique: 1 or 2 hands depending on size (e.g., ~10 kg: 1 hand).

  • Depth: About 5 cm.

  • Compression-Ventilation Ratio:

  • - Single rescuer: 30:2

  • - Two rescuers: 15:2

• Infant (<1 year):

  • Pulse: Brachial.

  • Technique:

  • - Single rescuer: 2-finger chest compression.

  • - Two rescuers: 2-thumb encircling technique.

  • Depth: About 4 cm (1.5 inches).

  • Compression-Ventilation Ratio:

  • - Single rescuer: 30:2

  • - Two rescuers: 15:2

• Documentation:

• Recorder uses pre-printed form:

  • "Arrest noted at 16:30."

  • "Initial rhythm: VF via monitor."

  • "CPR started at 16:31."

  • "Epinephrine 1 mg IV push at 16:32."

  • "200 J biphasic defibrillation at 16:33."

  • "ROSC achieved at 16:43" or "Resuscitation terminated at 16:50."

  • "Exposure: 0.3 mSv at 1 m (noted at 16:33).

Advanced life support integration

Airway

• Tools: Adult ET tube size 7.0-8.0; paediatric size 3.5-5.0; laryngoscope (e.g. Mac 3 blade).

• Technique: Continue chest compressions; pause <10 seconds for intubation; once an advanced airway is placed, ventilate at one breath every 6 seconds (10/min).

• Confirmation: Waveform capnography and/or visible chest rise.

Quality metrics

• Compression fraction: Target ≥60%, ideally >80% of time compressing in each 2-minute cycle.

• Rate: 100-120 compressions per minute; use an audible metronome if available.

• Depth: Adults: 5 cm (not >6 cm), Paediatric: 4 cm

• Recoil: Ensure complete chest recoil; avoid leaning between compressions

Post-resuscitation care

Monitoring & vital signs

• Vital signs: Continuously monitor and maintain target values:

  • Systolic BP: > 90 mmHg in adults, age-specific targets in paediatrics (e.g., avoiding values below the 5th percentile).

  • Heart rate and Peripheral Oxygen Saturation SpO₂: Maintain SpO₂ between 92-98%; HR per age norms.

• Electrocardiogram (ECG): Obtain a 12-lead ECG within 10 minutes post-ROSC to identify ST-segment Elevation Myocardial Infarction EMI or other acute cardiac events.

Hemodynamic stabilization

• Adults: Maintain systolic BP > 90 mmHg or mean arterial pressure (MAP) >65 mmHg using fluids or vasopressors as needed.

• Paediatrics: Target at least the 5th percentile for systolic BP by age (higher thresholds like >10th percentile may offer better outcomes).

Targeted temperature management (TTM)

• For comatose adult survivors of cardiac arrest, initiate TTM to maintain core body temperature between 32-36 °C for at least 24 hours. Prevent subsequent fever.

Patient transport (if necessary)

• Preparation:

  • Stretcher: Cover with a 0.1 mm plastic sheet.

  • Monitor: Portable pulse oximeter, BP cuff.

• Destination:

  • Intensive Care Unit (ICU): Corner bed (e.g., Bed 1, minimal exposure to others).

  • Ward Option: Convert room to ICU (e.g., add ventilator, monitor within 15 min).

  • Safety:

  • Path: Clear corridor (e.g., "Radiation Route - No Entry" signs).

  • Survey: Check stretcher post-move (e.g., <100 cpm).

Definition of radiation workers

According to the International Commission on Radiological Protection (ICRP, Publication 103) and Atomic Energy (Radiation Protection) Rules, 2004 under the Atomic Energy Act, 1962 (India,^[34,4] A radiation worker (also referred to as an occupationally exposed worker) is:

• "Any person who is occupationally exposed to radiation" [Radiation Protection Rules, 2004]; and

• A person incurring exposure in the course of their work, excluding natural background and exempt practices [ICRP 103].

These workers are distinguished from the general public by the higher annual effective dose limits permitted (typically 20 mSv/year averaged over 5 years, with no more than 50 mSv (30 mSv in India) in any single year), as compared to the 1 mSv/year limit for the public.

In the context of the nuclear medicine and high-dose therapy settings, radiation workers include, but are not limited to:

• Nuclear Medicine Physicians

• Medical Physicists

• Nuclear Medicine Technologists

• Nurses whose primary duty station is in nuclear medicine wards or high-dose therapy units

• Housekeeping staff, porters, or other auxiliary staff assigned regularly to work in controlled areas (e.g., radiopharmaceutical handling zones, therapy isolation rooms)

These personnel are subject to occupational dose limits and require individual dosimetry monitoring (e.g., Thermoluminescent Dosimeter (TLD), Optically Stimulated Luminescence (OSL), or electronic dosimeters), appropriate training, and inclusion in the institution's radiation protection program.

In contrast, staff whose primary assignment lies outside of nuclear medicine, such as emergency physicians, anaesthesiologists, or general ward nurses, who enter the department only occasionally (e.g., during a Code Blue response or to assist with a specific patient procedure), are not categorised as radiation workers. For such personnel, the dose constraints applicable are those for carers and comforters, typically set at 5 mSv per episode, as per ICRP Publication 103 and IAEA General Safety Requirements (GSR) Part 3, may be applied.

Dose limits for radiation workers

In alignment with IAEA GSR Part 3 and Part 7, dose limits are given in [Table 3]:

Dosimetry monitoring:

• TLD/OSL badges (typically read monthly or quarterly)

• Real-time survey meters or pocket dosimeters for high-risk or emergency situations

Dose limit/constraints for code clue team

Though the IAEA GSR Part 3 and Part 7 set a dose limit of 500 mSv for emergency workers,^[14,35] The authors recommend that, for rotation purposes, the dose constraints recommended for comforters and carers can also be applied to Hospital Code Blue Team members. Using a 5 mSv dose constraint can help balance patient care demands with staff safety. However, this should not be treated as a strict rule for team replacement. Life-saving actions must always take priority.

Understanding Dose Constraints vs Dose Limits

It is important to distinguish between dose constraints and dose limits:

• Dose limits are legally enforceable upper bounds applied to occupational exposure in classified radiation workers, designed to protect individuals from excessive exposure over time.

• Dose constraints, on the other hand, are guidelines or reference levels applied in special cases such as voluntary exposure or infrequent exposure, such as emergency events in a high-dose therapy facility. They are not strict legal limits but are established to keep radiation exposure as low as reasonably achievable (ALARA), particularly when individuals do not routinely work with radiation.

The distinction between a carer and a comforter has been clearly defined when comparing two clinical settings.^[36] A nurse assisting with a radiology procedure while wearing protective gear does so as part of her professional responsibility and is therefore a Carer. A child's mother who stays in the imaging room to reduce the child's anxiety participates voluntarily and is classified as a comforter.

In a similar way, the Code Blue team receives radiation exposure as part of their professional responsibility to resuscitate a patient and applying comforter-and-carer dose constraints becomes reasonable. A dose constraint of 5 mSv per intervention, recommended by the ICRP, can serve as a practical guide for planning team rotation and maintaining psychological reassurance. This value is advisory and may be exceeded, when necessary, as the emergency worker dose limit of up to 500 mSv may apply in life-saving situations. Such exposures are expected to be rare and justified by the clinical context.

Note: The 5 mSv constraint should not be interpreted as a rigid upper limit. In critical, life-threatening events, exceeding this value may be acceptable, provided the exposure is documented, justified, and reviewed by the institution's radiation safety committee.^[37]

Recommended management actions

• Rotation: If the anticipated exposure could approach or exceed 5 mSv, rotate team members during the intervention to reduce individual doses.

• Documentation: Always record exposure using personal dosimeters, preferably with real-time readout.

Containment of the deceased body

Inventory and equipment maintenance:

• 10 radioactive warning labels

• 10 containment kits

• 5 lead aprons or vests

• 1 calibrated survey meter

• 1 lead-lined storage tray or screen

Personal decontamination

• Monitoring:

  • Dosimeter: Check TLD/pocket dosimeter (e.g., 0.5 mSv total).

  • Survey: Hands, face, shoes (<100 cpm goal).

• Procedure:

  • Remove PPE: Into waste bag (e.g., 50 L capacity, double-lined).

  • Wash: Soap + lukewarm water (10 L bucket, 5 min scrub); 95% removal expected.

  • Persistent: Repeat x2; if >100 cpm, use 0.5% hypochlorite (not for I-131, eyes, wounds; rinse with 1 L saline).

  • Hair: Shampoo rinse (e.g., 500 mL water).

  • Airborne: Nasal swab (blow into tissue); if >100 cpm, refer to physician.

• Medical:

  • Injuries: Report cuts/burns immediately (e.g., "14:50, Nurse C, hand laceration").

  • KI: If not given earlier, administer 130 mg for I-131 exposure.

Ward decontamination

• Waste:

  • Collect: Pads, gloves, sheets into 50 L bins (label: "Radioactive, 03/03/2025").

  • RSO: Supervises transfer to decay storage (e.g., 90 days for I-131).

• Survey:

  • Tools: Survey meter (e.g., 0-50 mSv/hour), contamination monitor (e.g., 0-10000 cpm).

  • Goal: <0.05 mSv/hour, <100 cpm on surfaces.

• Cleaning:

  • Step 1: Soap + water (10 L, 1% solution); wipe with 20 swabs (discard each use).

  • Step 2: If >100 cpm, use 1% acetic acid (5 L); avoid metal corrosion.

  • Step 3: Dry surfaces; final swab (<50 cpm).

  • Glassware: Chromic acid (1% solution, 1 L).

  • Electronics: Isopropyl alcohol (70%, 500 mL).

  • Stainless Steel: Inhibited phosphoric acid (0.1%, 2 L), then 0.1% nitric acid if needed.

Restocking and maintenance

• Replace:

  • PPE: 20 gowns, 40 gloves, 10 masks.

  • KI: 50 tablets (130 mg).

  • Supplies: 10 pads, 5 waste bags, 5 plastic sheets.

• Equipment:

  • Decontaminate: Defibrillator (alcohol wipe, <50 cpm).

  • Test: Charge to 200 J, verify Ambu bag seal.

Implementation note: Assign restocking to ward manager (e.g., checklist completed by 16:00); calibrate monitors annually.