Authors: Somayeh Yadollahifar, Mohsen Aminizadeh, Khadijeh Nasiriani, Abbas Ali Dehghani Tafti, Reyhane Sefidkar, Samaneh Mirzaei
Categories: Research, Medical emergency services, Preparedness, Nuclear, Radiological
Source: BMC Emergency Medicine
Authors: Somayeh Yadollahifar, Mohsen Aminizadeh, Khadijeh Nasiriani, Abbas Ali Dehghani Tafti, Reyhane Sefidkar, Samaneh Mirzaei
Despite the low probability of radiological and nuclear (RN) incidents, they can have severe consequences and require immediate response. Therefore, preparedness for them is important. In this regard, prehospital emergencies are important in reducing injuries and deaths from these accidents.
This study aimed to identify the factors affecting prehospital emergency preparedness in RN incidents.
The study was conducted using a scoping review methodology. The research protocol followed the 2020 PRISMA-P checklist for systematic reviews and meta-analysis protocols. A search was conducted from 1970 to 2024 across PubMed, Scopus, Web of Science, ProQuest, Google Scholar, and Persian databases such as SID and Magiran using “Medical Emergency Services,” “EMS,” “Preparedness,” “nuclear,” and “radiological” as keywords. Of the 9,330 articles, 39 were selected according to the inclusion and exclusion criteria.
The study identified three main categories, 18 subcategories, and 125 codes for prehospital emergency preparedness in RN incidents. These include medical and non-medical care at the scene (triage, treatment surveillance, monitoring, decontamination, Psychosocial Support, and safety & Security), scene management aspects (command system & management, information & data management, documentation, communication, coordination, cooperation & collaboration, risk Assessment, evacuation, and surge capacity), resources and education (staff, equipment & stuff, finances, and training & exercises).
The preparedness of the prehospital system in RN incidents is important in various aspects and includes various components addressed in this study. Paying attention to them can play a significant role in reducing the health effects of the mentioned accidents. These components include planning, resource provision, training and practice, and internal and external organizational coordination.
The online version contains supplementary material available at 10.1186/s12873-025-01258-0.
Major incidents and disasters disrupt community functioning and cause human, economic, and environmental losses. They can also overwhelm local resources and necessitate a sudden increase in healthcare provision [1–3]. In the meantime, causing damage to infrastructure and the environment, chemical, biological, radiological, nuclear, and explosive(CBRNe) incidents can pose significant risks to human health and life, leading to challenges and uncertainties and creating unique barriers to the provision of health services [1, 4–6]. Although radiological and nuclear (RN) incidents are unlikely, their consequences can be severe [7]. Besides their applications in industry, research, and medicine, RN sources also pose a risk of incidents, including potential use in terrorist attacks. In these attacks, the public’s fear of contamination and radiation exposure extends far beyond the physical impact, leading to widespread disruption and panic. Therefore, it should be considered a serious threat [8–13]. These incidents can occur at any time and place, creating an urgent need for response, so countries must prepare for effective emergency management [14, 15]. A radiation emergency occurs when radioactive materials or radiation are released into the environment, potentially leading to hazardous conditions that could contaminate people and the environment or expose them to high doses of radiation [16]. Therefore, preparedness for these incidents is of particular importance.
Preparedness is crucial for effectively managing incidents and disasters; therefore, proper planning is essential [17]. Preparedness refers to the knowledge and skills that governments, response organizations, communities, and individuals acquire to effectively anticipate, respond to, and recover from potential impacts [18]. Identifying the factors that enhance readiness will improve relief capacities in response to CBRNe incidents [19].
Emergency medical services (EMS) are crucial in healthcare delivery as they provide essential care in emergencies, life-threatening situations, and disasters. EMS is a gateway to specialized care and treatment in many countries [20–23]. EMS is crucial for saving lives by providing immediate medical assistance before patients arrive at the hospital. Timely and effective management, including quick referral of trauma patients, can minimize secondary damage and enhance the patient’s condition during transfer [20, 24]. While emergency medical organizations worldwide may differ in structure and function, many principles are universally applicable in the general plan for managing RN incidents [25]. Staff in this system must be prepared to respond to these incidents.
Responding to an RN emergency of any scale requires responders with expertise in this field [7]. In these incidents, EMS personnel are responsible for tasks such as triage, stabilization of patients, and, if necessary, decontamination of victims. The inability to perform these tasks may contaminate hospitals [7, 26, 27]. The safety and security approach and purposeful activities should be considered in prehospital measures [28]. EMS employees may feel unprepared to respond to such incidents; however, they must be able to quickly think and make decisions for safe and effective action in these situations [29]. While experts recognize that these incidents are unavoidable, the healthcare community still lacks the knowledge and preparation to handle infected or exposed individuals [30].
Despite the importance of the topic due to the wide consequences of these accidents, little research has been done on EMS preparedness in the field of RN incidents [7, 14, 30–41], including staff training, required competencies, and specific measures such as triage. However, based on the search, no study examined various aspects of EMS readiness in RN incidents and described all practical components. Therefore, this study used a scoping review approach to identify the elements necessary for prehospital emergency preparedness in RN incidents. The results of this study will help identify the facilities and assess the conditions for EMS readiness in RN incidents, as well as provide an appropriate response to such incidents.
This scoping review examined the literature on EMS preparedness for RN incidents from 1970 to 2024. Given the extensive scope of the topic and the need to review all pertinent articles, including high-quality originals and other studies, this approach was chosen.
The scoping protocol was developed following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols 2020 (PRISMA-P 2020) checklist. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) provides a reporting guideline with 20 essential items and two optional ones for scoping reviews [42]. The PRISMA-ScR checklist for this study has been completed and is available in Supplementary 1.
The protocol was registered in the Open Science Framework (OSF) on December 19, 2024 (registration 10.17605/OSF.IO/Y8TMX).
The study used Arksey and O’Malley’s methodological framework [46], which includes five steps (Fig. 1).
Fig. 1stages of the scoping review process
The question addressed by this scoping review “What are the EMS preparedness components for radiological and nuclear incidents?”
This study used the Population-Concept-Context (PCC) mnemonic, as recommended by JBI [43]. Table 1 outlines the key elements of the research question based on the JBI PCC framework.
Table 1The main elements of the study’s research question, according to the PCC mnemonic P PapulationCConcept(interventions, phenomena of interest, and outcomes)CContext• Medical Emergency Services• Prehospital Emergency Care• Emergicenters• EMS• Preparedness for radiological and nuclear incidents• Research publications within the last 54 years (1970–2024)PCC: Papulation, Concept, and Context
On June 15, 2024, a search of PubMed, Scopus, Web of Science, and ProQuest databases was conducted to extract articles from 1970 to that date. Keywords were selected based on the research question, MeSH terms, expert input, and keywords from related articles. Each database’s search strategy was specifically defined, with the PubMed strategy detailed in Table 2.
Following database searches, the reference lists of included articles were reviewed, including sources from Google Scholar and Persian databases like Scientific Information Database (SID) and Magiran. A hand search was then performed to find additional studies not identified through the databases.
Inclusion criteria included studies with available full texts, no language restrictions, review articles, reports, and gray literature. The final search for recent findings was conducted on October 12, 2024. Exclusion criteria included letters to the editor, unavailable original articles, instructions, and research findings typically shared at conferences and published in proceedings.
The database search results were entered into EndNote 7 software, and after removing duplicates, the titles, abstracts, and full texts of the remaining articles were reviewed in order. Articles irrelevant to our study objectives that did not meet the inclusion criteria were excluded. Two team members handled all screening and selection stages, resolving disagreements through discussion and consulting a third expert when necessary. A download of the full text of the selected articles has been completed, and the reference list of related articles has also been reviewed based on the inclusion criteria. The PRISMA 2020 [44, 45] flowchart shows the article selection process. (Fig. 2)
As suggested by Arksey and O’Malley, the charting approach should use a unified analytical framework across all the selected articles while taking a broader perspective. For this reason, a descriptive-analytical method was utilized for this study [46].
The research team created a data extraction form using Word 2020 that collected key items from selected articles, including the first author’s name, year of publication, country, purpose, and study results.
In the last stage, data was analyzed using content analysis, with two researchers handling the data coding [47–50]. Upon completing the previous phases and considering the research team’s extracted results and opinions, guidance and suggestions were discussed.
Table 2The search strategy in the pubmed database(‘Emergency Medical Services’[MeSH] OR ‘Emergency Medical Service*’[tiab] OR Ambulance*[MeSH] OR Ambulance*[tiab] OR ‘Medical Service*’[tiab] OR ‘Emergency Medical’ [tiab] OR ‘Emergency Service*’[tiab] OR ‘Emergency service*’[tiab] OR ‘Medical Emergency Service*’[tiab] OR Emergicenter*[tiab] OR ‘Prehospital Emergency Care’[tiab] OR ‘Emergency Medicine Technician’[tiab] OR ‘Emergency Care’[tiab] OR Prehospital[tiab] OR pre-hospital[tiab] OR ‘Emergency Health Service*’[tiab] OR ‘Emergency Health’[tiab] OR ‘Emergency Mobile Unit’ [tiab] OR EMS[tiab] OR ‘Emergency Medical Technician*’[tiab] OR ‘prehospital rapid response teams’[tiab] OR ‘prehospital care’[tiab] OR ‘emergency medicine’[tiab] OR ‘first responder*’ [tiab] OR ‘medical first responder’[tiab] OR ‘emergency medical services providers’[tiab] OR Paramedic*[tiab] OR ‘Emergency medical technicians’[tiab] OR ‘Medical Technician*’[tiab] OR ‘Emergency Paramedic’[tiab] OR EMTs[tiab]) AND (‘Radioactive Hazard Release’[MeSH] OR ‘Radioactive Hazard Release’[tiab] OR ‘Nuclear Reactor*’[MeSH] OR ‘Nuclear Reactor*’[tiab] OR ‘Radiation Injuries’[MeSH] OR ‘Radiation Injuries’[tiab] OR ‘Nuclear Warfare’[MeSH] OR ‘Nuclear Warfare’[tiab] OR Bombs[MeSH] OR Bombs[tiab] OR ‘Nuclear Weapons’[MeSH] OR ‘Nuclear Weapons’[tiab] OR ‘Hazardous Substances’[MeSH] OR ‘Hazardous Substances’[tiab] OR ‘radiation Hazard’[tiab] OR ‘Nuclear Accident*’[tiab] OR ‘radiological accident*’[tiab] OR ‘radioactive accident*’[tiab] OR ‘radiation accident*’[tiab] OR ‘Nuclear Reactor Accident*’[tiab] OR ‘Reactor Accident*’[tiab] OR uranium[MeSH] OR uranium[tiab] OR ‘Gamma Rays’[MeSH] OR ‘Gamma Rays’[tiab] OR terrorism[MeSH] OR terrorism[tiab] OR ‘Nuclear Industry’[tiab] OR ‘radiation exposure’[MeSH] OR ‘radiation exposure’[tiab] OR ‘radiation emergency’[tiab] OR radiological[tiab] OR ‘radioactive material’[tiab] OR ‘radiological material’[tiab] OR ‘nuclear material’[tiab] OR ‘radiation material’[tiab] OR ‘Radioactive pollution’[tiab] OR ‘Dirty bomb’[tiab] OR ‘radiological agent’[tiab] OR ‘radioactive agent’[tiab] OR ‘nuclear agent’[tiab] OR ‘radiation agent’[tiab] OR ‘Accidents Radiation’[tiab] OR ‘radiological event’[tiab] OR ‘radiological disaster’ Q1 Q2 [tiab] OR ‘nuclear disaster’[tiab] OR ‘radiation disaster’[tiab] OR radioactive disaster[tiab] OR ‘radiation casualties’[tiab] OR ‘radiation event’[tiab] OR ‘nuclear event’[tiab] OR radioactive event[tiab] OR ‘radiation emergency’[tiab] OR ‘Mass Casualty Incidents’[tiab] OR ‘nuclear Terrorism’[tiab] OR ‘radioactive Terrorism’[tiab] OR ‘radiological Terrorism’[tiab] OR ‘Radiological emergency’[tiab] OR radioactive emergency[tiab] OR ‘radiological hazard*’[tiab] OR ‘nuclear hazard*’[tiab] OR ‘Radioactive hazard*’[tiab] OR ‘Radiological threat’[tiab] OR radioactive threat[tiab] OR ‘nuclear threat’[tiab] OR ‘CBRN emergencies’[tiab] OR ‘nuclear incident*’[tiab] OR ‘radioactive incident*’[tiab] OR ‘radiological incident’[tiab] OR ‘HazMat‐CBRN’ [tiab] OR nuclear and radiation accident[tiab] OR ‘radiological exposure’[tiab] OR ‘radiation exposure’[tiab] OR ‘radioactive exposure’[tiab] OR ‘nuclear exposure’[tiab] OR ‘radiation contamination’[tiab] OR ‘radioactive contamination’[tiab] OR ‘nuclear contamination’[tiab] OR ‘radiological contamination’[tiab] OR ‘Hazard* material’[tiab] OR ‘CBRN events’[tiab] OR ‘Chemical, biological, radiological, nuclear, and explosive’[tiab] OR CBRN*[tiab] OR ‘Chemical, biological, radiological and nuclear’[tiab] OR CBRN* incident[tiab] OR CBRN* accident[tiab] OR ‘Nuclear emergency’[tiab] OR nuclear injures[tiab] OR ‘radioactive injuries’[tiab] OR ‘radiological injuries’[tiab] OR Radioactive[tiab] OR radiological[tiab] OR Radiation[tiab] OR Radiation[MeSH] OR nuclear[tiab]) AND (preparedness [Title/Abstract] OR readiness [Title/Abstract] OR ‘disaster preparedness’[Title/Abstract] OR ‘emergency preparedness’[Title/Abstract] OR ‘Emergency response’[Title/Abstract] OR ‘EMS Management’[Title/Abstract] OR ‘EMS Response’ [Title/Abstract] OR medical facilities preparedness[Title/Abstract] OR ‘Surge Capacity’ [Title/Abstract] OR ‘operational preparedness’[Title/Abstract] OR vigilance [Title/Abstract] OR ‘Disaster Planning’[MESH] OR ‘Disaster Planning’[Title/Abstract] OR ‘Disaster Management’ [Title/Abstract] OR ‘Disaster Relief Planning’[Title/Abstract] OR ‘Emergency Care’[Title/Abstract] OR ‘medical countermeasures’[Title/Abstract] OR ‘emergency planning’[Title/Abstract] OR ‘victim management’[Title/Abstract] OR response[Title/Abstract] OR ‘Prehospital care’ [Title/Abstract] OR ‘Radiation protection’[Title/Abstract] OR Resilience [Title/Abstract] OR ‘disaster risk reduction’[Title/Abstract] OR ‘DRR’[Title/Abstract]) AND (1970.01.01:2024.09.12[dp]))\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ [Title/Abstract] OR "DRR" [Title/Abstract]) AND (1970/01/2024/09/12[dp]))
## Results The total number of articles extracted from the identified databases was 9,330. Following this, 4,593 articles were removed due to being duplicates. In the remaining 4,737 articles, the title and abstract were reviewed, and 52 articles were selected for full-text review. Finally, 48 articles were chosen for inclusion in the study, while the others were excluded due to not meeting the necessary criteria or being irrelevant. In addition, other articles obtained from their reference review were included in the study. In total, 39 articles were analyzed. At the first level, the extracted information included authors’ names, countries of origin, publication years, study objectives, and conclusions. The results are presented in Table 3. Evaluation of articles by content analysis led to 3 main categories, 18 subcategories, and 125 codes. The identified categories were On-site Medical Care, On-site Non-Medical Care, On-site Management Aspects, and Resources and Education. In the categories of On-site Medical and Non-Medical Care, the subcategories include triage, treatment and surveillance, monitoring, decontamination, psychosocial support, and safety and Security. In the On-site Management Aspects category, the subcategories included incident command system and management, information and data management, documentation, communication, coordination, cooperation and collaboration, risk assessment, evacuation, and surge capacity. Finally, in the Resources and Education category, the subcategories were as staff, equipment and stuff, finances, and training and exercises (Fig. 3). Table 4 presents the results based on the categories provided for the components of preparedness for RN incidents. Fig. 2Flowchart to present the article selection process Table 3An overview of the characteristics of selected articlesFirst author.YearSettingsResearch purposeConclusionSouchkevitch G. 1997 [51].WHOIt aims to strengthen international cooperation between the WHO and specialists in the field of radiation emergency medical preparedness and response and to call attention to the unsolved problems in the fieldEstablishing an international infrastructure for better preparedness, response, and assistance in case of a radiological disaster by the WHO in three areas of great medical actions, public health actions, and follow-up studies of affected populationsLevy K. 1999 [52].U.S.Report of a Training ProgramBeing necessary training programs that prepare medical personnel for radiation accident responsePorrovecchio J. 2005 [53].U.S.Outlining some of the critical components of the situational awareness and actions necessary to save lives and minimize radiation contamination and exposure.Being aware and training in basic radiation protection for first responders coupled with guidance on appropriate protective actions and augmenting with practical experience and rehearsalCone DC. 2005 [35].U.S.Proposing chemical, biological, radiological, or nuclear-compatible trauma triage algorithmsA common, simplified triage template for three protocols (chemical, radiation/nuclear, biological) that focuses on assessments that can be carried out quickly and easily by field personnelPassetti WA. 2007 [54].U.S.Examining current roles and looking for other areas where the Bureau of Radiation Control’s expertise can be used to train, advise, and support local emergency respondersPaying attention to the decontamination issues and working to help provide the appropriate level of training to the different emergency responders and to expand the number of radiation protection professionals available immediately to advise and consultLiu Y. 2010 [55].ChinaTo introduce the work of strengthening radiation emergency preparedness and share the experience obtained while preparing and organizing the 2008 Olympic Games in ChinaTo make a series of preparations for the Olympic Games including review and update of plans, medical response team, laboratory, equipment and supplies, hospital, training, exercise, and technical support to Olympic seriesYusof MA. 2011 [15].MalaysiaDiscussing Malaysian preparedness for, and response to, any potential radiological emergencyNot enough preparedness for nuclear or radiological emergencies, and to enhance its capabilities under international standards and requirementsDalnoki-Veress F. 2014 [56].U.S.Testing the Analytical Hierarchy Process tool for its use in public health to identify potential gaps in emergency preparedness by local health departments (LHDs) in California and Hawaii during a radiological emergencyNeed to a clear, coherent communication strategy that uses a common language and is understandable by all response teams, in addition to a well-planned communication plan to and from the relevant agenciesYasui S. 2014 [57].JapanFocusing on the duties and responsibilities of the medical and health care management and administrationTo modify its “Nuclear Disaster Response Manual” and undertake consultation concerning amending the “Basic Nuclear Disaster Prevention Plan”Stenke L. 2016 [58].JapanIn order to further evaluate Japanese experiences of the disaster, and to bring home ‘lessons-learnt’ of relevance for continued emergency preparedness planningRunning extensive preparedness plans for serious incidents within the radio-nuclear area in JapanDallas CE. 2017 [30].U.S. and JapanTo evaluate the relative knowledge, willingness to respond, and familiarity with nuclear/ radiological contamination risks among U.S. and Japanese emergency medical personnelBeing the health-care community uncomfortable with and unaware how to respond to a radiological/nuclear eventAshley SF. 2017 [34].UKTo detail the various stages of a nuclear accident and the corresponding aspects of an emergency preparedness plan that are relevant to these stages, both from a UK and international perspectiveTo consider societal effects, economic effects, and non-radiological health effects in addition to radiological harmIngram RJ. 2017 [59].U.S.Addressing aspects communicated effectively to the first responder communities to prepare them to safely manage radiological releasesNeed to communicate radiation facts to the public and emergency response communities to effectively manage the fear of radiation, emergency responder and community training about emergency responseMoghadam Azadi H. 2017 [32].IranDeveloping triage clinical guidelines in nuclear_ and radiological events that are all things consideredUsing triage operational guidelines in nuclear-radiological events with a large number of casualties to manage casualties in a more organized mannerRiccobono D. 2018 [38].FranceDescribing the main French principles of mass victim management in a nuclear/radiological context from the victims’ extraction from the unsafe environment to arrival at the hospitalTo require specific facilities for the management of CBRN casualties but also regular training of all the staff working in emergency organizationsHu X. 2020 [60].ChinaTo define and delineate specific non-technical competencies for first-line public health responders in Chemical, Biological, Radiological, and Nuclear (CBRN) emergencies in ChinaBeing necessary for the non-technical competencies for the health workers to respond effectively in CBRN emergencies and useful to develop a workforceRojas-Palma C. 2020 [61].Czech RepublicTo derive CATO guidelines a proof-of-concept experimentNeed to appropriate training in trauma triage, carrying out rescue operations in full protective gear, considering a conservative safety perimeterBeyramijam M. 2021 [62].IranTo evaluate the current disaster preparedness status of the EMS agenciesNot adequately preparing the EMS agencies for response to various emergencies and disastersYan T. 2021 [63].UKTo construct a discrete event simulation system to analyze the medical response process based on a serious subway dirty bomb attack scenario and to propose in preparationUse of a simulation system to explore the medical response preparation strategies for subway terrorist dirty bomb explosion especially obtained the prediction method of staff and equipment resources for specific disaster backgroundDiCarlo AL. 2021 [14].U.S.To revisit aspects of radiation preparedness, and leverage those lessons learned to enhance readiness for a possible future radiation public health emergencyNeed to identify accurate biomarkers and design bio dosimetry devices to triage large numbers of civilians and develop decorporation agents that are more amenable for mass casualty useLiutsko L. 2021 [40].SpainAn overview of the SHAMISEN Recommendations for Preparedness and Health Surveillance of Populations Affected by a Radiation AccidentUse of the SHAMISEN Recommendations to optimize decision-making processes in case of an emergency due to a nuclear accident, and to improve emergency preparedness in planningRump A. 2021 [39].GermanyReducing antidote requirements by using radioactivity screening equipment and determining the most efficient mix of screening units and antidote daily dosesA high daily screening capacity to substantially decrease the required amount of antidote doses to achieve economic efficiencyColeman CN. 2022 [41].U.S.To describe steps for civilian medical and public health response planning for a nuclear detonationNeed to detailed planning, preparedness, and scripting for an immediate operational response, addressing clinical manifestations of evolving radiation illness, and flexibility to adapt to a rapidly changing situationFarhat H. 2022 [6].QatarTo explore a satisfaction survey, by Specialized Emergency Management personnel from a “Hazardous Material Incident Management” course and seek their opinion about personnel needs for training topicsContinuously improving the created training packages regarding increasing risks of HazMat-CBRN incidentsFarhat H. 2022 [64].QatarTo determine whether the Hamad Medical Corporation Ambulance Service personnel fulfil the pre-hospital readiness requirements for HazMat-CBRN incidentsTo emphasize the importance of establishing a well-structured continuous training programTsegmed U. 2022 [65].MongoliaTo identify and share the key challenges facing Mongolia regarding the ability to introduce and establish an effective system for radiation emergency medicineImportance to develop human resources, regularly train the assigned medical and emergency personnel of the designated institutions and steadily enhance capacity building in radiation emergency medicineLorenzini G. 2023 [66].ItalyTo explore the state of the art in human factors applied to emergency situations and to develop a new tool to support healthcare professionals in conducting evidence-based briefings and debriefingsDeserving of human factors applied to great attention in emergency situationsNazari S. 2023 [17].IranDetermining effective factors in the formation of pre-hospital rapid response teams in the field of health in response to CBRN accidentsProviding a general and specialized composition of pre-hospital rapid response teams to deal with the health effects of nuclear and radiation accidents and proposing separate teams based on risk assessments for different regions of the countryNovack Z. 2023 [67].CanadaTo determine factors associated with increased response readiness to CBRN threats of paramedics in Ontario, CanadaLooking at occupational, dispositional, and demographic factors that affect paramedic response readiness and highlighting the importance of maintaining awareness, increasing knowledge, and exploring first responders’ attitudesVentzke MM. 2023 [68].GermanyAddressing emergency medical services in radiation incidents in road transportationTo impart the necessary principles and to demonstrate the safe approach at the scene of the accident and the handling and transfer of the patient to the hospitalNazari S. 2024 [69].IranTo extract the effective components and factors in the dynamic On-site health management and Emergency on-the-scene systemsPlanning and preparation for nuclear and radiological event response at three technological, organizational, and personalKouvalainen J. 2024 [33].FinlandExploring advanced-level paramedic perspectives on competence requirements for responding to radiological/nuclear incidentsTo identify several competence requirements for advanced-level paramedics for responding to RN incidentsStevens G. 2010 [29].AustraliaInvestigate the factors underpinning paramedics’ readiness to respond to CBRNE incidentsTo associate paramedic CBRNE training with higher perceived readiness to respond to CBRNE terrorism and related incidentsRamesh AC. 2010 [36].IndiaConsidering issues related to triage systems that can be applied to CBRN casualtiesDeploying a triage and decontamination system that is easy to follow and flexible to the available medical resources, casualty number, and severity of injury in CBRN eventsNazari S. 2023 [70].IranTo investigate the factors influencing the formation of rapid response teams in the field of health in response to CBRN incidentsConsidering factors including team requirements, population distribution, type of incident, level of team activity and training, and equipment required by the team after the incident to design and establish the structure of CBRN EDMRT by each country/organizationLinney AC. 2011 [71].UKTo find consensus amongst multi-agency CBRNe experts on the factors that must be included in future National Health Service CBRNe competenciesNeed to standardize national planning, training, and evaluation of NHS staff who are expected to respond to CRBNe and other emergenciesWaeckerle JF. 2001 [72].U.S.Assessing the needs, demands, feasibility, and content of training for US civilian emergency medical responders for NBC terrorismDeveloping training programs and materials need and incorporating NBC training into standard training programs for emergency medical professionalsColeman CN. 2015 [37].U.S.Use of the components of NIME to support planning for, response to, and recovery from the effects of a nuclear incidentEnhance the effectiveness and capability of planners, responders, and researchers and provide some assurance to members of the public by the NIME systematic approach and enhanced models under developmentHomer MJ. 2016 [73].U.S.Launching and managing a multi-agency, comprehensive effort to develop and operationalize medical countermeasures by HHS Through the Public Health Emergency Medical Countermeasures EnterpriseDeveloping and implementing the HHS Radiological and Nuclear Countermeasure Development programs to ensure that appropriate MCMs are available to counter nuclear or radiological threats Fig. 3Main categories & subcategories of EMS preparedness ***i****n radiological and nuclear incidents based on Content Analysis* Table 4Categories and subcategories of EMS preparedness in radiological and nuclear incidents Based on Content Analysis. (included studies of the Final Articles Reviewed Systematically in 2024categoriesSubcategoriescodesOn-sitemedical and non-medical careTriage• Radiological triage protocols, guidelines and principles [14, 32, 35, 69]• Primary and secondary triage [38, 63]• Levels of Field medical triage [36]• Contamination triage [57, 63]Treatment& Surveillance• Medical treatment protocol and guidelines [41, 57]• System for radiation emergency medicine [40, 57, 65]• Medical-decision management [37]• Medical assessment [33, 61]• Special populations [14, 58]• Paying attention to injured and uninjured persons on-site [63, 69]• Medical assistance team [65]• Specific medications [14, 38, 39, 55]• Transferring patients [17, 38, 57]• Treatment of various injuries (burn, trauma care and ARS) [30, 33, 34]• Health surveillance [40]• Health care of workers [36, 57]• Ethical consideration [40]Monitoring• The surveying of possible contaminated individuals [51, 54, 69]• Radioactivity screening equipment [14, 17, 30, 34, 39, 54]Decontamination• Principles of decontamination [36, 54]• Decontamination team [36, 54]• Decontamination kits and facilities [6, 55, 57]• Types of decontamination [30, 38]• Decontamination corridors [38]• Mass decontamination [54]• Selecting and defining joint decontamination operations sites [36]• Decontamination of patient, responder, and equipment [35, 38, 61]• Categories of contaminated people [69]Psychosocial support• Psychological support program [33, 51]• The psychological burden on society [32]• General worry and fear in victims and rescue workers [38, 59, 68]• Stress & fatigue management in workers [66]• Resilience and flexibility [29, 33, 41]• Family concerns [67]Safety & Security• Protective action guideline [14, 32, 36, 37, 57]• Planning for safety measures [58]• Hazardous agent identification [38, 64]• Principles to reduce or eliminate the exposure [36]• Basis rules for safety at the scene [68]• Rules of radiation protection [68]• Occupational safety [33, 35, 57, 67]• Selection of and proper use of PPE [30, 32, 33, 35, 36, 61]• Patient safety [33]• Food banning [34]• Waste management [33, 68]• Iodine distribution &Consumption [14, 34, 39, 40, 51, 55, 58]On-site management aspectsIncident Command system & management• Procedures for establishing command and control [34]• Incident Command Structure [65]• Chain of command [56]• Scene management [36, 67, 69]• Fatality management [41]• Mass casualty management [6, 14, 33, 35, 38, 60, 69]Information &data gathering• Information program [34, 58, 59]• Information sharing and dissemination [33, 51, 58, 59]• Information transfer [56]• Information tools [56]• Pre-distributed information [34]• Clarity, accurate and reliable information [40, 56, 66]• Review of background information [41]• Collecting information from affected populations [33]Documentation• Documentation, including emergency plans and procedures [15, 55]• Documentation, including Compiled records of information, actions, and occurrences [41, 51, 55, 56, 58]• Systems for storing and accessing patient records [38, 40, 51, 58]• Questionnaires and consent forms [40]Communication• Communication plan, protocols and strategies [34, 40, 41, 56, 58, 59, 64]• Communication devices and methods [33, 53, 55, 59]• Communication staff [33, 58, 60, 64]• Communications with the general public, media and other organization [14, 40, 58]• Pre-scripted public messaging [58, 59]• Communication infrastructure [17]Coordination, cooperation & collaboration• Interagency partners-planning [15, 37, 40]• Internal and external coordination [17, 56, 68]• Mutual aid agreements [56]• Collaboration with other agencies and organizations [14, 33, 41, 59, 69]• Collaboration with colleagues [14, 33, 66]• Cooperation with other response organizations [33, 37, 41, 66]Risk assessment• Risk-based preparedness plan [6]• Hazard identification [56]• Hazard mitigation [56]• Awareness of local and national hazards [71]• Rules for risk reduction [68]• Risk identification [6]• Multiple incidents [41]• Scenarios and concept of operations [37, 39, 41]• Environmental factors [6, 34, 53, 61]• Early warning system [62]• Extrinsic factors affecting risk management [6]Evacuation• Sheltering and evacuation protocols [40, 58]• Types of evacuation [34, 53, 54, 59]• Evacuation zone [57]• Evacuation patterns [58]• Public service announcements [53]• Monitoring and supporting dislocated populations [37]• Patient safe transport [63]Surge capacity• Additional staff and equipment [38, 54, 62]• First-aid groups added [63]• Decontamination groups added [63]• Increasing the screening capacity [39]• MCM requirements and measures [14, 35, 37, 38, 69]resources and educationStaff• Human assets, including Personnel and volunteers [54, 56]• Being available to all staff 24 h a day, 7 days a week [55, 65]• Explicit allocations of responsibilities, authorities, and arrangements [15, 17, 39, 55–57, 60, 66]• Consideration of the rotation needs of staff [63]• Support and responder teams [15, 17, 51, 55, 63, 64, 67, 68]• Specialists [14, 37, 41, 65]• To report to duty [33, 67]• Formation and composition of the team [6, 17, 69, 70]• Task force team [36]• Personnel skills [6, 33, 41, 53–56, 60, 64–67, 69]Equipment & stuff• Logistic planning [34]• Resource management [34, 60]• Medical and non-medical resources [6, 17, 30, 38, 54–56, 65, 69]• Resource allocation [55, 56]• Professional rescue equipment [63]• Vehicles [6, 38, 55, 56, 74]• Emergency medical helicopters [57]• Food stocks [57]• Stockpiling supplies [14, 55, 70]Finances• Financial support [17, 56, 62]• Evaluation of costs [39, 58]Training & exercises• EMS personal training [6, 29, 30, 38–40, 52–55, 57–59, 61, 62, 66, 67, 70–72]• Drill & exercises [14,15, 17, 32, 38, 40, 41, 52–54, 56–58, 64, 65, 71, 72]• Lesson learned [15, 34, 41, 56]• Theoretical & operational understanding of RN incidents [33]• Public awareness [40, 56, 59] ## Discussion This study used a scoping review method to identify the factors influencing prehospital emergency preparedness for RN incidents. Key components were extracted from the findings, which included medical and non-medical care at the incident scene, aspects of scene management, resource availability, and the importance of education. The review of studies, triage, treatment, surveillance, radiation monitoring, decontamination, psychological support, and safety and Security identified the effective factors in medical and non-medical care at the scene for RN incidents. In the preparedness phase for an effective response to radiological incidents, forming a medical assistance team that includes relevant specialists can effectively manage a radiation emergency and provide an appropriate response [65]. According to the study by Riccobono et al., in these incidents, one of the important aspects of medical care is how emergency medical personnel triage patients at the scene and transport them to medical centers. In RN incidents, triage is conducted in two first, after patients have been moved to a safe environment, and second, after they have undergone decontamination [38]. The triage algorithm used in these cases is based on the START triage [35]. The International Energy Agency (IAE) considers related RN triage activities to assess common injuries, determine treatment priorities, conduct initial patient resuscitation, evaluate radiation damage, and check for external and internal radiation contamination [75, 76]. Detailing the clinical manifestations and symptoms of radiation sickness during emergency response requires careful planning and the flexibility to adapt to changing situations [41]. Kippnich et al. stated that some individuals at the scene were uninjured. Prioritizing the management and care of these individuals at a specialized triage site is important [77]. Thus, their buildup in advanced medical care centers and disruption of their operations is avoided [78–84]. Other studies have emphasized that the basic needs and conditions of the affected population, especially vulnerable groups including children, the elderly, pregnant women, individuals with weakened immune systems, and those with chronic or underlying medical conditions, should be considered in medical care preparedness planning [14, 58]. Radiation monitoring and decontamination are crucial for prehospital emergency personnel’s preparedness to respond effectively and safely to RN incidents. According to a study by Passetti et al., proper radiation monitoring can differentiate contaminated individuals from those who are worried well [54]. The standard method for radiation monitoring involves conducting a comprehensive survey of the entire body, from head to toe [84, 85]. However, based on the results of other studies, examining the head, face, shoulders, and hands in the early hours following a mass casualty incident is acceptable, as these areas are the most likely to be contaminated [79, 86, 87]. Patient decontamination must follow the appropriate principles, procedures, and methods [36]. It is crucial to prioritize treating infected patients’ wounds over decontamination [38, 54]. Decontamination is generally conducted in two stages. According to the study by Arora et al., the first stage, dry decontamination, focuses on airway protection with a mask, followed by decontamination and removing the first layer of clothing. Removing this clothing eliminates approximately 90% of external contamination [88]. Riccobono et al. stated that wet decontamination should always be conducted for any radionuclide exposure, except in surgical emergencies where the immediate aim is to prevent the spread and internalization of residual contamination, particularly in cases of hair contamination. Two separate decontamination corridors must be established for ambulatory and non-ambulatory victims to ensure safety. Additionally, a corridor should be designated for all individuals involved in care and protection [38]. In this study, the safety and Security of personnel and their families are important factors in managing these incidents. Other studies have identified concerns about personal health and safety, as well as that of their family and friends, as factors that influence paramedics’ willingness of rescue staff to work during disasters [19, 89, 90]. Worry and fear can impact both victims and relief workers [38]. According to a study by Sedlár et al., when these incidents occur, understanding the situation and improving resilience will reduce stress and fatigue, thus decreasing unsafe behaviors by care teams [91]. Healthcare organizations need to enhance the flexibility and resilience of their staff [92]. In this study, scene management is the second main component of preparedness for these incidents. When managing incidents, staff should prioritize safety measures at all before arriving at the incident scene, while attending the scene, and after completing the mission [33]. Ventzke et al. have considered compliance with five rules, including maintaining distance, shielding, staying in the danger zone, turning off the radiation source (when applicable to technical systems), and preventing the absorption of hazardous substances, to be mandatory for effective risk reduction for emergency services on the scene [68]. As Haslam et al. have stated, following strict PPE requirements and using cover-and-wipe techniques ensures that first responders are not exposed to the agent [93]. Rescuers’ awareness of occupational safety and readiness for predicting radiological threats will impact their health, as well as that of civilians and other first responders [33]. Other findings of the study on prehospital emergency preparedness in RN incidents include attention to management and incident command system components, information and data collection, documentation, communication, coordination, cooperation and collaboration, risk management, evacuation, and surge capacity for effective scene management. According to the study of Ramesh et al., effective scene management is essential for controlling access to the incident scene, managing the movement of contaminated victims, ensuring safe work methods for responders, and containing any material release [36]. When incidents occur, command and control are swiftly established at the site [69]. Based on other studies, emergency medical management during CBRN incidents can be more complex than other emergencies. It is essential to focus on the spread of nuclear contamination and its various conditions. Key considerations include preventing the spread of contamination to other victims, caregivers, or healthcare facilities and ensuring effective decontamination [94, 95]. The study by Tsujiguchi et al. showed that personnel preparedness for information collection and management is crucial for a timely response. Because it will lead to timely treatment and thus increase the chance of survival of the injured [96]. According to a study by Dalnoki-Veress et al., receiving information on time is very important. Therefore, communication must be considered. Communication involves successfully transferring information within and between organizations, jurisdictions, and the public [56]. Communicating with the public and media requires a specific plan [58]. A clear, effective strategy that uses a common language for all response teams is crucial [56]. Stenke et al. stated that planning these strategies before incidents occur is important. Prepared statements need to be made in advance and updated based on the specific circumstances of each incident so they are ready for immediate release. Furthermore, it is necessary to make arrangements for access to skilled spokespersons [58]. Smith and colleagues considered thorough and accurate documentation of information, actions, and events in an incident essential for maintaining situational awareness and ensuring access to critical information [51]. Before the incident, questionnaires, checklists, and consent forms for health monitoring, as well as suitable databases, must be prepared, and ethical approvals for data collection must be obtained immediately after the incident [63]. Since many organizations do not interact and confront each other before incidents, participating before incidents provides a unique opportunity to create efficient networks [82, 97]. According to a study by Liutsko et al., the participation of communities and stakeholders involves them in emergency preparedness and decision-making processes [40]. Coleman et al. stated that successfully responding to a mass casualty incident necessitates a clear understanding of the fundamental scientific principles and the importance of preparedness across different authorities. It involves sequential and transparent response planning, including formal operational exercises, logistics management, interagency coordination, public-private collaboration, adaptability, and continuous improvement based on lessons learned and new insights [41]. In a large-scale mass casualty emergency, effective and rapid public health interventions are required [98]. In such a situation, there is a need to surge capacity, which includes staff, stuff, and structure(62). Based on the study of Cone et al., time and complexity may be more critical in a CBRN environment than in conventional mass casualty incidents [35]. Emergency evacuation from a hospital or assisted living facility may be necessary, presenting significant medical and logistical challenges [58]. According to a study by Liutsko et al., protocols should be established for sheltering, evacuation, sustainable iodine distribution, and optimizing time and support during these processes [40]. Additionally, plans must include canceling evacuation orders, long-term evacuation procedures, and health considerations, such as mental health [40]. Also, Dalnoki-Veress et al. stated that risk assessment should be conducted to identify vulnerabilities and analyze the potential consequences of threats, taking into account the demographic characteristics of the population, as well as the existing infrastructure and physical environment [56]. This study emphasizes the importance of resource allocation and personnel training as key aspects of prehospital emergency preparedness in RN incidents, including staff, equipment, stuff, training, and exercises. Establishing prehospital emergency response teams for CBRN incidents is a key responsibility of health system managers. Their goal is to enhance the capacity and capabilities of the health system. One of the most critical aspects of designing and forming these teams is determining the appropriate team structure(17). Nazari et al. pointed out that the composition of prehospital response team members and the duration of their involvement in the response area primarily depend on the tasks and service conditions [69]. Also, according to a study by Passetti et al., volunteers can serve in various roles in medical centers or monitoring and decontamination stations, providing guidance and support to first responders and medical staff [54]. The events of the past two decades in disaster preparedness and response have underscored the necessity of including subject matter experts as vital members of operational response teams [41]. In a major incident, there will be resource limitations [69]. Personnel must have the skills to use resources [33]. Based on the study by Nazari et al., all levels of the prehospital system should be equipped with specialized CBRN incident response equipment and devices such as Geiger-Muller detectors, clinical sampling devices, personal dosimeters, Global Positioning System (GPS), and telephone/wireless/satellite lines [17]. Acquisition, distribution, and coordination of any additional radiological resources needed for an appropriate response should be considered [54]. Stenke et al. considered one of the challenges to be finding the optimal balance between risk and cost efficiency [58]. One fundamental financing aspect is allocating a budget line to address these incidents and their effective management [17]. Improving capability is one of the most essential components of a quick and effective response to CBRN incidents. Nazari et al. stated that implementing continuous training programs for all prehospital staff will increase their knowledge and awareness about these incidents [17]. Other studies showed the importance of having technical and non-technical skills for staff to respond to an incident [60, 66]. According to the survey by Kouvalainen et al., paramedics are expected to possess a comprehensive understanding of the distinctive features of RN incidents and knowledge of emergency care guidelines. They should have the clinical and technical skills to assess patients’ conditions and ensure their safety. Additionally, working effectively within a team and establishing clear communication are essential [33]. Training employees in these techniques should be a priority. When incidents occur, it is necessary to check for potentially contaminated individuals using the appropriate methods of trained personnel [54]. Oriot et al. stated that risk-based preparedness is crucial for a successful emergency plan for CBRN incidents aimed at reducing risks during emergency response through ongoing training and simulations [99]. Based on the study by Kouvalainen. et al., exercises organized by multi-authority agencies help develop awareness and improve response to disasters and hazards [33]. Regular exercise and training will enhance resilience and lead to a more effective response [100, 101]. ## Conclusion As the use of RN agents grows, the chances of incidents occurring in diverse locations and on various scales have increased, and the lack of planning for an appropriate response can have serious consequences. Since the prehospital system is one of the first responders during an incident, it is essential to identify the factors influencing their preparedness for a timely response. Scene management, medical and non-medical aspects, resources, and training are among the issues for which careful planning ensures optimal readiness. Adequate training according to needs and conducting exercises helps to improve a timely and appropriate response. Also, since other organizations also play a role in the response, planning should be done with their coordination and participation. Intra-organizational coordination can also lead to optimal use of capacities. In high-risk locations, general training will help reduce risk and increase preparedness. More research on various aspects and components of preparedness, including defining training curricula, determining quantitative and qualitative details of required resources, specifying communication and coordination disruptors, and integrating readiness policies in RN incidents into general EMS policies, is suggested to improve the response process. ### Limitations A comprehensive study has not been conducted on all aspects of prehospital emergency preparedness in RN incidents. Therefore, this research represents a practical step in this field by examining the relevant components across various areas of preparedness. Researchers encountered several limitations while conducting this study on prehospital emergency preparedness in nuclear and radiation incidents. These challenges included limited access to the full text of particular articles, a scarcity of studies in this specific field, and the multi-dimensional nature of preparedness, which complicated the overall scope of the research. ## Electronic Supplementary Material Below is the link to the electronic supplementary material. Supplementary Material 1