preparing for an unplanned radiation event

8/3/2019 Preparing for an Unplanned Radiation Event

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Preparing for an UnplannedRadiation Event

Niel Wald, M.D.

Michael P. Kuniak, D.O.,

M.P.H.


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Acknowledgments

Prepared by the Radiological Emergency Medical

Preparedness & Management Subcommittee of the National

Health Physics Society

Ad Hoc Committee on Homeland Security.

Jerrold T. Bushberg, PhD, Chair

Kenneth L. Miller, MSMarcia Hartman, MS

Robert Derlet, MD

Victoria Ritter, RN, MBA

Edwin M. Leidholdt, Jr., PhD

Consultants

Fred A. Mettler, Jr., MD

Niel Wald, MD

William E. Dickerson, MD

Appreciation to Linda Kroger, MS who assisted in this effort.


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Christine Hartmann Siantar, Ph.D.

Deputy Program Leader

Nuclear and Radiological Countermeasures

Monterey Institute of International Studies

Center for Nonproliferation Studies

Resource Links CIF 2004-2005

(http://cif.miis.edu/resource.htm)

Associate Professor UC Davis
http://cif.miis.edu/resource.htmhttp://cif.miis.edu/resource.htm


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Radiation Terrorism and Response

1. Radiation Basics

2. Radiation Protection Rules

3. Radiation Threats

Nuclear device, dirty bomb

Equivalent Experiences: Chernobyl, Goiana

4. Health Management of Affected Population

OUTLINE


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What is Radiation?

For the purpose of this presentation, definedas energetic emissions from unstable atomsthat can result in ionizing events to targetatoms

Ionizing radiation is radiation capable ofimparting its energy to the body and causingchemical changes

Ionizing radiation is emitted by

- Radioactive material

Some devices such as x-ray machines


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Common Radiation Terms

Radioisotope - a generic name for a

radioactive element

Radionuclide - a specific radioisotope

such as Uranium-235

These terms are often used

interchangeably


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Radiation Physics

Ionizing Radiation

Radiation with enough energy to cause

ionization of atoms by ejecting electrons from

their atomic orbits

Types of Radiation

Electromagnetic (Photons - No Mass)

X-ray, Gamma

Particulate

Alpha (helium nucleus), Beta

(electron), Proton, Neutron


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Types of Radiation Emitted from

Radioactive Material

Particulate Charged

Alpha Radiation

Beta Radiation

Uncharged

Neutron Radiation

Electromagnetic

Gamma Radiation


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Types of Ionizing Radiation

Alpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothing

or less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concrete

or less than an inch of lead

Radiation

Source


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Alpha and Beta Radiation Alpha

Typically emitted from a heavy element

Most have energies between 4-8 MeV

Particles up to 7.5 MeV stopped by dead skinlayer (only a few microns penetration)

Can be shielded by paper

Penetrates a few cm in air

Does not penetrate the dead layer of skin

Beta

Travels about 4 meters in air per MeV

Penetrates about 0.5 cm in soft tissue per MeV

Can reach the basal cell layer of skin


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Pertinent Alpha Emitters


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Neutron Radiation

Neutral particle emitted from the nucleus

Can be very penetrating

Requires special consideration forshielding

Can induce radioactivity when absorbed

by stable elements (N, Na, Al, S, Cl, P,etc.)


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Electromagnetic Radiation

Energy = hf

Energy expressed typically in KeV or MeV (notjoules)

Absorption of Electromagnetic Radiation by matter

Photoelectric Compton Scattering

Pair production (photon energy must exceed1.02 MeV)

Stochastic event

Low energy photons more readily absorbed


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The Electromagnetic Spectrum


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Gamma Radiation

Electromagnetic energy emitted from thenucleus

Specific energies can be analyzed to identify

source

Very penetrating (many meters in air)

Difficult to shield, often shielded with lead


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X-ray Radiation

Electromagnetic energy emitted from

outside the nucleus

May be machine-produced by bombarding

high energy electrons on a target

May also be emitted from radioactive

materials

Similar shielding and penetrating powers as

gamma radiation


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Measure of

Amount of

radioactive

material

Ionization in air

Absorbed energy

per mass

Absorbed dose

weighted by type

of radiation

Radiation Units

For most types of radiation 1 R 1 rad 1 rem

Quantity

Activity

Exposure

Absorbed

Dose

Dose

Equivalent

Unit

curie (Ci)

roentgen(R)

rad

rem


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Units of Radioactivity

Quantity

1 Becquerel (Bq) = 1tps

1 Curie (Ci) = 3.7 x 1010 tps

Exposure

1 Roentgen (R) = 2.58 x 10-4 C/Kgair

87.7 ergs/gair

Exposure to Dose Relationship

1 R exposure 95 ergs/g absorption in muscle


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Half-Life

The time required for a radioactive

substance to loose 1/2 of its radioactivity

Each radionuclide has a unique half-life

Half-lives range from extremely short

(fraction of a second) to billions of years

E l f h Eff f H lf if


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Example of the Effect of Half-Life

Assume an initial amount of 32 uCi ofTC-99m with a half-life (T1/2) of 6 hours

after 1 half-life (6 h): 16 uCi

after 2 half-lives (12 h): 8 uCi



After 10 half-lives, less than 1/1000 of theoriginal activity remains


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Selected Radionuclides with Radiations

Radionuclide Radiation(s) Half-Life Eff. Half-Life

Hydrogen-3 12 y 12 d

Cobalt-60 5.26 y 10 d

Strontium-90 28 y 15 y

Iodine-131 8.05 d 8 d

Cesium-137 30 y 70 d

Iridium-192 74 d -

Radium-226 1602 y 44 y

From Mettler, Jr., F.A. and Upton, A.C., Medical Effects of Ionizing Radiation 2nd edition


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Radiation Dose

Absorbed Dose (D)

1 Gray (Gy) = 1 J/Kg

1 rad = 100 ergs/g

100 rad = 1 Gy

Dose Equivalent (HT)

[ HT = DQ]

1 Seivert (Sv) = 1 J/Kg

1 rem = 100 ergs/g

100 rem = 1 Sv

Note: 1 MeV = 1.6 x 10-13

Joules

Deterministic Acute Effects Stochastic Late Effects


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Weighting Factors

Organization NRC ICRU NCRP ICRP

Weighting factor Q Q Q WR

X &Gamma Rays 1 1 1 1

Beta Rays 1 1 1 1

Thermal Neutrons 2 5 5

Fast Neutrons 10 25 20 20

Hi Energy Protons 10 1 5

Alpha Particles 20 25 20 20


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Radiation Doses and Dose Limits

Flight from Los Angeles to London5 mrem

Annual public dose limit 100mrem

Annual natural background300 mrem

Fetal dose limit500 mrem

Barium enema870 mrem

Annual radiation worker dose limit5,000 mrem

Heart catheterization (skin dose)45,000 mrem

Life saving actions guidance (NCRP-116)

50,000 mrem


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Radioactive materialconsists of atomswith unstable nuclei

The atoms spontaneously change

(decay) to more stable forms and emitradiation

A person who is contaminatedhasradioactive material on their skin or

inside their body (e.g., inhalation,ingestion or wound contamination)


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Physical

Radionuclide Half-Life Activity UseCesium-137 30 yrs 1.5x106 Ci Food Irradiator

Cobalt-60 5 yrs 15,000 Ci Cancer Therapy

Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon

Iridium-192 74 days 100 Ci IndustrialRadiography

Hydrogen-3 12 yrs 12 Ci Exit Signs

Strontium-90 29 yrs 0.1 Ci Eye Therapy Device

Iodine-131 8 days 0.015 Ci Nuclear MedicineTherapy

Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging

Americium-241 432 yrs 0.000005 Ci Smoke Detectors

Radon-222 4 days 1 pCi/l Environmental Level

Examples of Radioactive Materials


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Radiation vs. Radioactive Material


Any substance thatspontaneously gives offradiation

Can be in variouschemical forms

Ifnot contained(sealed source) canlead to contamination -External, Internal orBoth

Radiation

The energetic emissions ofradioactive material

Can be subatomic particles

(, , n), photons (X-ray, )or combinations

Results in ionization of the

absorbing material (if living

tissue radiation injury)


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Half-Life (HL)

Physical Half-Life

Time (in minutes, hours, days or years)required for the activity of a radioactivematerial to decrease by one half due toradioactive decay

Biological Half-Life

Time required for the body to eliminate half ofthe radioactive material (depends on thechemical form)

Effective Half-Life

The net effect of the combination of thephysical & biological half-lives in removing the

radioactive material from the body


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Criticality Incident

Operation Upshot/Knothole, a 1953 test of nuclear artillery projectile

at Nevada Test Site


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Nuclear Fission

Fissile Material


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Fissile Material

U-235

Enriched from 0.7% (Natural) to 3% > 90%

Used:

Commercial Reactors

Research Reactors

Naval Reactors

Atomic Bomb

Pu-239

Byproduct of U-235 fission

Used in Breeder Reactor

Also can be weaponized


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Radionuclides of Concern


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Causes of Radiation

Exposure/Contamination

Accidents

Nuclear reactor

Medical radiation therapy

Industrial irradiator Lost/stolen medical or industrial radioactive

sources

Transportation

Terrorist Event

Low yield nuclear weapon

Radiological dispersal device (dirty bomb)

Attack on or sabotage of a nuclear facility


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Size of Event

Event No. of Deaths Most Deaths Due to

RadiationAccident

None/Few Radiation

RadioactiveDispersalDevice

Few/Moderate(Depends on

size of explosion &proximity of persons)

Blast Trauma

Low YieldNuclearWeapon

Large(e.g. tens of thousands inan urban area even from

0.1 kT weapon)Radiation Exposure

Blast TraumaThermal Burns

Fallout(Depends on Distance)


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Dose Limits - ICRP 60

Application Occupational Public

Whole Body 20 mSv/year Effective dose averaged over

5 years, max: 50 mSv/yr

1 mSv in 1 year

Annual Equiv. Dose:

Lens of eye 150 mSv 15 mSv

Skin 500 mSv 50 mSv

Hands & Feet 500 mSv _


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Emergency Exposure Guidelines - ICRP 60

Dose Limit(Whole Body) Activity Performed Conditions

5 rems All.. .

10 rems Protecting major property Where lower dose limit notpracticable.

25 rems Lifesaving or protection of large

populations

Where lower dose limit not

practicable

>25 rems Lifesaving or protection of largepopulations

Only on a voluntary basis topersonnel fully aware of therisks involved


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Radiography Source


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Sealed Source Accident

13 Curie Cs-137 RadiographySource

Found by a man at an Argentina

construction site

Carried in front pockets for 18

hours


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Accident Dose Calculation

Cs-137 Gamma Constant = 0.323 R-m2/hr-Ci

0.323 R-m2 x (18hr)(13Ci) = 755,820 R

hr-Ci (0.01m)2


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Accident Isodose Curves

B i R di bi l


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Basic Radiobiology

Atom Ionization in Water or Cell Molecules

Molecule Chemical Damage

Bond Breakage

DNA Chromosomal Aberration

Cell Death Mutation


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Radiosensitivity(most to least):

Lymphocytes

Erythroblasts

Myeloblasts

Epithelial Cells

Intestinal crypts

Testis

Ovary

Skin

Secretory glands

Lungs and bile ducts

Endothelial Cells

Connective Tissue Cells

Tubular Cells of Kidneys

Bone Cells

Nerve Cells

Brain Cells

Muscle Cells

19-A


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Classification of Medical Radiation Problems

Anxiety

Acute Radiation Syndrome

Local Radiation Injury

External Radionuclide Contamination

Local Trauma with Radionuclide Contamination

Internal Radionuclide Contamination


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Radiation Injuries

External exposure to penetrating radiation Criticality Incident (,N)

Sealed Source (,)

External Contamination (, )

Beam Generator (,N)

Internal contamination with radionuclides

Wound Contamination (, , )

Injection (, , )

Inhalation (, , )

Ingestion (, , )


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Late Health Effects from Radiation

Radiation is a weak carcinogen at low doses No unique effects (type, latency, pathology)

Natural incidence of cancer~ 40%; mortality ~

25% Risk of fatal cancer is estimated as ~ 4% per

100 rem

A dose of 5 rem increases the risk of fatal

cancer by ~ 0.2% A dose of 25 rem increases the risk of fatal

cancer by ~ 1%


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What are the Risks to Future Children?

Hereditary Effects

Magnitude of hereditary risk per rem is 10%that of fatal cancer risk

Risk to caregivers who would likely receivelow doses is very small - 5 rem increasesthe risk of severe hereditary effects by ~0.02%

Risk of severe hereditary effects to a patientpopulation receiving high doses is estimatedas ~ 0.4% per 100 rem

Fetal Irradiation


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Fetal IrradiationNo significant risk of adverse

developmental effects below 10 rem

Little chance of

malformation.Most probable effect, if any,

is death of embryo.Reduced lethal effects.Teratogenic effects.Growth retardation.

Impaired mental ability.Growth retardation with

higher doses.Increased childhood cancer

risk. (~ 0.6% per 10 rem)


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Types of Radiation Hazards

External Exposure -

whole-body or partial-body (no radiation

hazard to EMS staff) Contaminated-

external radioactivematerial: on the skin

internal radioactivematerial: inhaled,swallowed, absorbedthrough skin orwounds

External

Exposure

InternalContamination

External

Contamination


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Radioactive Contamination

Contamination is simply the presence of

radioactive material where it is not wanted

Persons may be contaminated eitherexternally, internally or both

Exposure does not necessarily imply

contamination

In order to limit the amount of radiation you are


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yexposed to, think about:

SHIELDING, DISTANCE and TIME

Shielding: If you

have a thick shield

between yourself andthe radioactive

materials more of the

radiation will be

absorbed, and you

will be exposed to

less.

Distance: The farther

away from the blast

and the fallout thelower your exposure.

Time: Minimizing

time spent exposed

will also reduce yourrisk.

ALARA Techniques


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ALARA Techniques

Work quickly and efficiently (TIME)

Rotate personnel if qualified replacements are available (TIME)

When not involved in patient care, remain a few feet away from thepatient (DISTANCE)

Use long-handled forceps to remove contaminated particles,contaminated dressings, etc. (DISTANCE)

Remove contaminated materials from the treatment area (DISTANCE& QUANTITY)

Put contaminated metal or glass in lead in lead pigs obtained fromnuclear medicine department (SHIELDING)

R di ti P t ti


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TimeMinimize time spent near radiation

sources

Radiation Protection:

Reducing Radiation Exposure

Distance

Maintain maximal practicaldistance from radiationsource

Shielding

Place radioactive sources ina lead container

To Limit Caregiver Dose to 5

rem

Distance Rate Stay

time

1 ft 12.5 R/hr 24 min

2 ft 3.1 R/hr 1.6 hr

5 ft 0.5 R/hr 10 hr

8 ft 0.2 R/hr 25 hr

Risk to Contaminated Patient


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Risk to Contaminated Patient

ARS, local radiation injury or contamination (both internal &

external) never demands immediate medical attention. Priority 1: True medical emergencies

ABCs

Bleeding assessment

Trauma assessment

Wound assessment

Remove contaminated clothing as soon as reasonably

possible (removes 80% of external contamination)

Proceed with decontamination procedures after patient

stabilized

Risk to Healthcare Provider


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Risk to Healthcare Provider

Minimal if using proper precautions

Remember ALARA techniques

Worst case - 15 mSv/hr close to contaminated wound

At 1 foot ( 30 cm) - 0.02 mSv/hr

NCRP public monthly equivalent dose to embryo/fetus:0.5 mSv

H lth P id C t lli th


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Healthcare Provider - Controlling the

Spread of Contamination

Goal: Minimize and control contamination

Use proper protective clothing

Do not eat drink or smoke in contamination areas Check yourself for contamination prior to leaving a

potentially contaminated area

Limit access to treatment area to necessarypersonnel only

P tti It All T th


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Putting It All Together

OUTLINE


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OUTLINE


1. Radiation Basics






Mass Exposure Events


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Mass Exposure Events

Criticality Events

Improvised Nuclear Device (IND)

Reactor Release

Nuclide Contamination

Radiological Dispersal Device (RDD) aka: Dirty Bomb

Intentional Contamination of Resources

External Radiation Source

-- Industrial or Medical Source

Injury Sources From


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j y

Nuclear Device DetonationTerrorist Event

Low yield nuclear weapon

Energy Distribution

50% Blast

35% Thermal Radiation

15% Ionizing Radiation

Health Consequences

Injury

Burns

Penetrating Ionizing Radiation

Prompt (1/3)

Delayed (2/3)

Fallout

Contamination

Penetratin Ionizin Radiation

A nuclear weapon is expected to


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cause many deaths and injuries:

radiation is not the primary hazard

Blast and thermaleffect comprise of

the majority of

effects/casualties

Radiation lethality

out-distances

thermal and blast

damage only in low

yield weapons ( 1

kiloton)


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Thermal: 35% of the energy

1st flash Pulse 2nd pulse (99% of the energy)

The pattern is from the dark

colored areas on her kimono

Long distance visual effects


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g

Flash Blindness, also referred to as "dazzle," is a

temporary impairment of vision. Victim does not have to

be looking directly at the source for this to occur.Nighttime greatly increases distance of effect

Retinal burn: visual capacity is permanently lost in the burned area.

Retinal burns can be produced at great distances from the nucleardetonation because the probability of occurrence does not follow

the inverse square law as is true of many other types of nuclear

radiation.

Fallout: important for surface bursts


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Fallout: important for surface bursts

A nuclear detonationresults in a fireball with atemperature estimated tobe several tens ofmillions of degrees.

The radioactive particlesresulting from nuclearfission and activation ofsurrounding materials

are carried up by thefireball and then driftdownwind to later settleon the ground.

Real-World Example Similar to Russian


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Same type of nuclear

warhead was used in

a small artillery

round, called Davy

Crockett.

Real-World Example Similar to Russian

Suitcase Nukes

Da Crockett Fallo t NYC


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Davy Crockett Fallout NYC

Results from Davy Crockett overlaid onNew York City map

Building that houses detonation deviceis destroyed

Adjoining buildings damaged

People within 1200 feet receive lethal

dose of radiation (650,000 mrem orhigher) from blast (not fallout)

1~50,000 fatalities in estimation

1~200,000 casualties

10,000 mrem/hr

Point of

Detonation

10,000

mrem/hr

FOR TRAINING PURPOSES

ONLY

1,000

mrem/hr

Lethal Dose

Area

Atomic Weapon NuclideYields


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Nuclide Half-life MCi

89Sr90Sr95Zr

103Ru106Ru

131I137Cs131Ce144Ce

53 d

28 y

65 d

40 d1 y

8 d

30 y

1 y

33 d

20.0b

0.1b

25.0b

18.5b

0.29b

125.0c

0.16b

39.0b

3.7b

Approximate Yields of the PrincipalNuclides per Megaton of Fission

bFrom Klement (1965)cFrom Knapp (1963) Environmental Radioactivity 4

th

Ed., Eisenbud M (1997)

The Chernobyl Accident


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Chernobyl:

Healthcare Resources Used

Local medical facilities

400 special medical brigades

M.D., H.P., etc.

15,000 health workers

2,000 M.D.s, 4,000 nurses, med

students, etc

213 mobile laboratories

Special hospitals (Kiev, Moscow)


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Chernobyl:

Healthcare Procedures

MedicalExaminations

1,000,000 persons

Dosimetric & labtests

700,000

(216,000 children)

Inpatient care 32,000 persons

(12,000 children)

Iodine prophylaxis 5,400,000 persons(1,700,000

children)

Chernobyl:


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Aftermath

31 deaths

1 from roof collapse

1 severe burns

21 of 22 with ARS and skin burns (400-1600 r)

7 of 23 (200-400 r)

Estimate additional 300 cases of thyroid cancer in

exposed children and 100 cases in exposed adults.

135,000 persons from 176 communities evacuated outto 30 km from plant

Dose to public (3-15 km zone): estimate 43 rem (50

year commited dose)


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Lessons Learned

In the USSR highly organized Civil Defense,

Health system, Military and other government

resources were quickly mobilized.

In the US less centralized resources might

currently have more difficulties, although the

maturation of the Homeland Security Agency

should facilitate such a response.

OUTLINE


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OUTLINE


1. Radiation Basics






What Is a Radiation Threat?


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What Is a Radiation Threat?

A radiation threat or

"Dirty Bomb" is the

use of common

explosives to spread

radioactive materials.

It is not a nuclear blast. The

force of the explosion and

radioactive contamination

will be more localized. In

order to limit the amount of

radiation you are exposedto, think about shielding,

distance and time.

Local authorities maynot be able toimmediately provideinformation on what ishappening and what

you should do.However, you shouldwatch TV, listen to theradio, or check theInternet often forofficial news andinformation as itbecomes available.

Russian Nuclear SuitcaseDevices


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84 of 132 devices are missing

We do not know what the status of

the other devices is, we just could not

locate them

Russian General Lebed, 1998

No direct evidence that any have

been stolen.

US Assistant Sec of Defense of Nuclear

Chemical Biological Programs, January 2003

Black Market Smuggling


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Total Number of Material

Seizures

(April 2001)

217 low-grade nuclear

material 14 weapons usable

material 299 Radioactive

Sources

Sophisticated RDD


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May not be

recognized

before it is

exploded

Probability of RDD


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Simple to build

Widely available materials Ease of building simple explosives

More than 200 naturally-occurring and man-made

radionuclides can be potentially used for RDD

Terrorist Event Radiological dispersal device(dirty bomb)

Health Consequences:

InjuryBurnsSingle Nuclide Contamination(?)

Much higher probability than the use of a nuclear

weapon:


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Background

After the 1991 Gulf War Iraqis disclosed they had

worked on an RDD made of iron bombs packed

with zirconium oxide irradiated in a research

reactor. (USAF SAB, 1998 and IAEA

documentation)

~ 200 of the 2 million regulated radioactive sources

and devices are lost, stolen, or abandoned each

year in the USA.

Cesium-137, the most commonly lost radiation

source has a 33 year half-life emits Beta (0.510,

1.17 MeV), and Gamma (~0.662 KeV) and

substitutes for Potassium in the body.

Radiation exposure from most RDDs inurban areas would expose many kill few


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The principal type of dirty bomb, or Radiological Dispersal Device (RDD),combines a conventional explosive, such as dynamite, with radioactive

material. In most instances, the conventional explosive itself would havemore immediate lethality than the radioactive material. At the levelscreated by most probable sources, not enough radiation would be presentin a dirty bomb to kill people or cause severe illness. However, certainother radioactive materials, dispersed in the air, could contaminate up toseveral city blocks, creating fear and possibly panic and requiring

potentially costly cleanup. Prompt, accurate, non-emotional publicinformation might prevent the panic sought by terrorists.

A second type of RDD might involve a powerful radioactive source hiddenin a public place, such as a trash receptacle in a busy train or subwaystation, where people passing close to the source might get a significant

dose of radiation.

A dirty bomb is in no way similar to a nuclear weapon. The presumedpurpose of its use would be therefore not as a Weapon of MassDestruction but rather as aWeapon of Mass Disruption.

urban areas would expose many, kill few

Good reference:

http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/dirty-bombs.html


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Concerns

Immediate radiation injuryvery few

Cancersmall (if any) increase on overall

25% probability of dying from cancerExceptions: iodine and childrens thyroid cancer

Birth defectsonly a concern for a few (ifany), has been dramatically overestimated

in the past

Goiania Contamination Accident


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Go a a Co ta at o cc de t

454-2

Location of Goiania Brazil


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Location of Goiania, Brazil

451-1

Goiania Accident Source


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Goiania Accident Source

137Cs teletherapy source capsule:

Physical form: CsCl hygroscopic

powder with blue fluorescence as itabsorbed moisture.

Radioactivity: 50.9 TBq (1375Ci)

Dose rate @1 m: 4.56 Gy/hr (456rad/hr)

Goiania Event Sequence


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Goiania Event Sequence

451-3

Goiania Medical Disposition


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p

580-9

Goiania Casualty Burial


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Goiania Local Injury


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454-5

Goiania Contaminated Areas


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451-2

Goiania Population Screening


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55-3

Goiania Accident Magnitude


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People monitored: 112,000

Chromosome analyses: 110

Roads monitored: 2,000 Km

Remediation workers: 755

Above DL: 38 (Highest:10 mSv CDE)

Homes contaminated: 85

Demolished: 7

Vehicles contaminated: 50

Radwaste created: 3,800 - 200L drums


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Lessons Learned

Lack of awareness of the detrimental healtheffects of radiation exposure can impede its

recognition on the part of patients and medical

practitioners until much damage is done.

The alert M.D. who faces an unusual public

health problem must find a collaborating H.P. to

evaluate its possible radiogenic origin and if

confirmed, to help deal with it.

Shelter if you cantevacuate


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evacuate

Use the Shelter toShield and Distance

yourself from the falloutcontamination.

Particle Filtering Factors


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Particle Filtering Factors

Filtration Efficiencies

Mans cotton handkerchief, 16 thick. 94%

Mans cotton handkerchief, 8 thick. 88%

Toilet paper, 3 thick. 91%

Bath towel, 2 thick. 85%

Cotton Shirt, 2 thick. 65%

Turn off ventilation

Recommended Accumulated Dose Levels at which toConsider Evacuation and/or Relocation


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Fallout: The 7-10 Rule of Thumb


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Time (hours) Relative FalloutDose Rates

H + 1* 100%

H + 7 (17) 10 %

H+49 (77) 1%

H+343 (777)

~14 Days

0.1%

H+2401 (74)

~100 Days

0.01%

*Prior to H+1, the dose rates from fall out is significantly higher

Shelter as long aspossible before

evacuating acrossfallout contamination.Waiting 2 days willreduce exposure by afactor of 100!

Decontamination: important for nuclear weapons and


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Decontamination: important for nuclear weapons andradiation dispersal devices

Evacuate the Fallout Path


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Althoughdose ratesare highestwithin the firstfew hours,this only

represents arelativelysmall area

Evacuating

the falloutarea beforefallout arrivalwill save themost lives

If there is a radiation or adirty bomb threat


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dirty bomb threat

1. If you are outside and there is an explosion orauthorities warn of a radiation release nearby, coveryour nose and mouth and quickly go inside abuilding that has not been damaged. If you are

already inside check to see if your building hasbeen damaged. If your building is stable, staywhere you are. Close windows and doors; turn offair conditioners, heaters or other ventilationsystems.

If there is a radiation or adirty bomb threat


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dirty bomb threat

1. If you are inside and there is an explosion near where you areor you are warned of a radiation release inside, cover noseand mouth and go outside immediately. Look for a building orother shelter that has not been damaged and quickly getinside.

2. Once you are inside, close windows and doors; turn off airconditioners, heaters or other ventilation systems.

3. If you think you have been exposed to radiation, take off yourclothes and wash as soon as possible.

4. Stay where you are, watch TV, listen to the radio, or check theInternet for official news as it becomes available.

If there is a nuclear blast


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If there is advance warning:

Take cover immediately, as far below ground as possible, though any

shield or shelter will help protect you from the immediate effects of theblast and the pressure wave.

If there is no warning:

1. Quickly assess the situation.

2. Consider if you can get out of the area or if it would be better to go inside

a building to limit the amount of radioactive material you are exposed to.3. If you take shelter go as far below ground as possible, close windows and

doors, turn off air conditioners, heaters or other ventilation systems. Staywhere you are, watch TV, listen to the radio, or check the Internet forofficial news as it becomes available.

To limit the amount of radiation you are exposed to, think about shielding,distance and time.

Use available information to assess the situation. If there is a significantradioactive contamination threat, health care authorities may advise youto take potassium iodide. It may protect your thyroid gland, which isparticularly vulnerable, from radioactive iodine exposure. Plan to speakwith your health care provider in advance about what makes sense foryour family.

Conclusions


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Radiation dispersal devices could cause significant

contamination with low levels of radiation, but would result infew if any radiation casualties.

Much of the radiation dispersal devices impact willdepend on how much we over-react to the dangers ofradiation.

A nuclear weapon would result in substantial casualties andconfusion from many effects, with radiation injury being thedominant one in the fallout region.

In a fallout scenario, wise actions onsheltering/evacuation will save thousands of lives.

You can prepare by knowing (and teaching) the facts aboutradiation, and having a plan about what to do in a radiationemergencya good place to start is www.ready.gov.

OUTLINE
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1. Radiation Basics






The Real Medical Radiation Problems
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Fear

Communication Failure

Uncertainty

Inaction

Chaos

Key Points for Emergency Responders
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Responders

Lifesaving first aid is the First Priority Familiarize yourself with work area

Survey instrumentation, protective clothing, respiratoryprotection suitable to accident conditions

Evacuate personnel to safe areas Assessment of radiological hazard

Public

Prevention is key as therapeutic measures are limited

Shelter vs Evacuation

Contamination

Rule of thumb: 80 - 90% contamination removed withclothing

Showering will remove an additional 7%

Facility Preparation
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Facility Preparation

Activate hospital plan Obtain radiation survey meters

Call for additional support: Staff from Nuclear Medicine,Radiation Oncology, Radiation Safety (Health Physics)

Establish area for decontamination of uninjured persons

Establish triage area

Plan to control contamination

Instruct staff to use universal precautions and double glove

Establish multiple receptacles for contaminated waste

Protect floor with covering if time allows

For transport of contaminated patients into ED, designateseparate entrance, designate one side of corridor, or transferto clean gurney before entering, if time allows

Decontamination Center
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Establish a decontamination center for peoplewho are contaminated, but not significantlyinjured.

Center should provide showers for many people.

Replacement clothing must be available.

Provisions to transport or shelter people afterdecontamination may be necessary.

Staff decontamination center with medical staff with aradiological background, health physicists or otherstaff trained in decontamination and use of radiationsurvey meters, and psychological counselors

Protecting Staff from Contamination
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Key Points

Contamination is easy to detect and most of itcan be removed

It is very unlikely that ED staff will receive large

radiation doses from treating contaminated

patients

Protecting Staff from Contamination Universal precautions

Survey hands and clothingwith radiation meter

Replace gloves or clothing

that is contaminated

Keep the work area free ofcontamination

Treatment Area LayoutSeparate
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Contaminated

Waste

WasteRadiation

Survey

HOTLINE

STEP

OFF

PAD

CONTAMINA

TED

AREA

BUFFER

ZONE

CLEAN

AREA

Radiation

Survey&

Charting

ED

Staff

Clean

Gloves, Masks,

Gowns, Booties

Separate

Entrance

Trauma Room

Detecting and Measuring Radiation
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g g

Instruments

Locate contamination - GM Survey Meter (Geiger counter)

Measure exposure rate - Ion Chamber

Personal Dosimeters - measure doses to staff

Radiation Badge - Film/TLD Self reading dosimeter

(analog & digital)

Patient Management - Priorities
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Patient Management Priorities

Triage

Medical triage is the highestpriority

Radiation exposure andcontamination aresecondary considerations

Degree of decontaminationdictated by number of andcapacity to treat other injuredpatients

Patient Management - Triage
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Patient Management Triage

Triage based on:

Injuries

Signs and symptoms -nausea, vomiting, fatigue,diarrhea

History - Where were you

when the bombexploded?

Contamination survey

Classification of Medical Radiation

P bl
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Problems

Anxiety


Local Radiation Injury

External Radionuclide Contamination

Local Trauma with Radionuclide

Contamination Internal Radionuclide Contamination

82-A

Mass Casualties, Contaminated but

Uninjured People and Worried Well
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Uninjured People, and Worried Well

An incident caused by nuclear terrorism may createlarge numbers of contaminated people who are notinjured and worried people who may not be injured orcontaminated

Measures must be taken to prevent these people from

overwhelming the emergency department A triage site should be established outside the ED to

intercept such people and divert them to appropriatelocations.

Triage site should be staffed with medical staff andsecurity personnel

Precautions should be taken sothat people cannot avoid the triage

center and reach the ED

Radiation Anxiety In the event of a nuclear or
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In the event of a nuclear orradiological weapon detonation,thousands of victims will be

concerned about their possibleexposure to ionizing radiation.

Accurate knowledge of radiationdose can dramatically affect the

assignment of triage category,BUT

accepted methods for accuratepost-exposure dosimetry take

days to measure. Thus, clinical signs, symptoms

and blood counts are best earlyindicators of radiation injury.

Psychological Casualties
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Terrorist acts involving toxic agents (especially radiation)are perceived as very threatening

Mass casualty incidents caused by nuclear terrorism willcreate large numbers of worried people who may not beinjured or contaminated

Establish a center to provide psychological support tosuch people

Set up a center in the hospital to provide psychologicalsupport for staff

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Depending on the magnitude of theexposure, the hematopoietic system, thegastrointestinal tract, the cardiovascular andcentral nervous systems may be involved indamage. There are three major forms (inorder of severity):

Hematological formHematological form

Gastrointestinal formGastrointestinal form Neurovascular formNeurovascular form

Thoma/Wald

Prognostic Categories
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Prognostic Categories

Group 1: 0.5 to 1.5 Gy; mostly asymptomatic withoccasional minimal prodromal symptoms

Group 2: 1.5 to 4 Gy; clinically manifested by transient

N/V and mild hemotopoietic changes

Group 3: 4 to 6 Gy; clinically manifested by severe

hematopoietic changes with some GI symptoms

Group 4: 6 to 14 Gy; clinically manifested by severe

hematopoietic complications dominated by GIcomplications

Group 5: >50Gy; manifested by marked early neuro-

vascular changes

Acute Radiation Syndrome (Cont.)


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Prodromal stage

nausea, vomiting, diarrhea and fatigue

higher doses produce more rapid onset and greaterseverity

Latent period (Interval)

patient appears to recover

decreases with increasing dose

Manifest Illness Stage

Hematopoietic

Gastrointestinal

CNS

y ( )

For Doses > 100 rem

Time of Onset

Severity of Effect

Prodromal Appearance Time
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39-J

Clinical Effects of ARS
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Acute Local Radiation Injury
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Effect Time of Appearance(days) Threshold Dose (cGy)

Erythema minutes to weeks (dosedependant)

at threshold 8-17

600

Epilation 17-21 300

Dry desquamation 21 1000-1500

Moist desquamation 14-21 1800-3000

Localized Radiation Effects - Organ System

Th h ld Eff
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Skin - No visible injuries < 100 rem

Main erythema, epilation >500 rem

Moist desquamation >1,800 rem

Ulceration/Necrosis >2,400 rem

Cataracts

Acute exposure >200 rem

Chronic exposure >600 rem

Permanent Sterility

Female >250 rem

Male >350 rem

Threshold Effects

Special Considerations High radiation dose and trauma interact
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High radiation dose and trauma interactsynergistically to increase mortality

Close wounds on patients with doses > 100rem

Wound, burn care and surgery should bedone in the first 48 hours or delayed for 2 to 3months (> 100 rem)

24 - 48

Hours~3 Months

Emergency

Surgery

Hematologic Recovery

No Surgery

After adequate

hematopoietic recovery

Surgery

Permitted

OUTLINE


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1. Radiation Basics






Emergency Department

Management
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Management

of Radiation Casualties

CAUTION

Patient Management - Decontamination
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Carefully remove and bag patients clothingand personal belongings (typically removes95% of contamination)

Survey patient and, if practical, collect

samples Handle foreign objects with care until proven

non-radioactive with survey meter

Decontamination priorities:

Decontaminate wounds first, then intact skin

Start with highest levels of contamination

Change outer gloves frequently to minimize

spread of contamination

Patient Management - Decontamination(Cont.)

Protect non contaminated wounds with waterproof dressings
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Protect non-contaminated wounds with waterproof dressings

Contaminated wounds:

Irrigate and gently scrub with surgical sponge

Extend wound debridement for removal of contaminationonlyin extreme cases and upon expert advice

Avoid overly aggressive decontamination Change dressings frequently

Decontaminate intact skin and hair by washing with soap &water

Remove stubborn contamination on hair bycutting with scissors or electric clippers

Promote sweating

Use survey meter to monitor progress of

decontamination

Patient Management - Decontamination

(Cont.)


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(Cont.)

Cease decontamination of skin and wounds When the area is less than twice background, or

When there is no significant reduction between deconefforts, and

Before intact skin becomes abraded. Contaminated thermal burns

Gently rinse. Washing may increase severity of injury.

Additional contamination will be removed when

dressings are changed.

Do not delay surgery or other necessarymedical procedures or examsresidualcontamination can be controlled.

Initial Management of Externally Contaminated Patient

Gross Decontamination


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Gross Decontamination

Removal of Contaminated Clothing

Washing and removal of Contaminated Hair

Removal of Gross Wound Contamination

Intermediate Stage (at clean location,if necessary)

Removal of Contaminated Clothing

Further Local Decontamination, Swabs of Body Orifices

Supportive Measures, First Aid

Final Stage

Patient Discharged with Fresh Clothing

More Definitive Decontamination (surgical) and OtherTherapy at Dispensary or Hospital

Handling contaminated patients


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Patient decontamination
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Monitor to determine ifdecontamination is needed

Remove outer clothing

Wash exposed skin surfaces

Flush wounds with water

Do not scrub or abrade skin! Lowlevels of contamination are not ahealth hazard and can be left inplace if not easily removed

(they will decay quickly).

Early Treatment For Radionuclide Contaminated Wounds


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Irrigate Wound Saline

Water

Decontaminate Skin (But Do Not Injure)

Detergent

Continue Wound Irrigation Until Radiation Level Is

Zero or Constant

Treat Wound as Usual

Consider Excision of Embedded Long-Lived High- HazardContaminants

Therapy For Isotope Decorporation


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Dilution

3H: Water

32P: Phosphorus (Neutraphos)

Blocking

137Cs: Prussian Blue

131I, 99Tc: KI (Lugols)

90Sr, 85Sr: Na-Alginate (Gaviscon), Al-Phosphate or Hydroxide Gel (Phosphajel orAmphojel)

Therapy For Isotope Decorporation (cont.)


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Mobilization

86Rb: Chlorthalidone (Hygroton)

Chelation

252

Cf,

242

Cm,

241

Am,

239

Pu,

144

Ce, Rare Earths,143Pm, 140La, 90Y, 65Zn, 46Sc: DTPA

210Pb: EDTA, Penicilamine

210

Po: Dimercaprol (BAL) 203Hg, 60Co: Penicilamine

Radionuclide specificTreatment of Internal Contamination
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Radionuclide-specific

Most effective when administered early May need to act on preliminary information

NCRP Report No. 65, Management ofPersons Accidentally Contaminated with

Radionuclides

Radionuclide Treatment Route

Cesium-137 Prussian blue Oral

Iodine-125/131 Potassium iodide Oral

Strontium-90 Aluminum phosphate Oral

Americium-241/ Ca- and Zn-DTPA IV /orPlutonium-239/ nebulizer

Cobalt-60

Treatment of Internal Contamination:

Treatment Options
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Treatment Options

Reduce G.I. Absorption

Hasten Excretion

Use Blocking and Diluting Agents WhenAppropriate

Use Mobilizing Agents

Use Chelating Agents If Available

Patient Management - Patient Transfer
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Transport injured, contaminatedpatient into or from the ED:

Clean gurney covered with2 sheets

Lift patient onto clean gurney

Wrap sheets over patient

Roll gurney into ED or out oftreatment room

Facility Recovery
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Remove waste from the Emergency Department

and triage area Survey facility for contamination

Decontaminate as necessary

Normal cleaning routines (mop, strip waxed floors)typically very effective

Periodically reassess contamination levels

Replace furniture, floor tiles, etc. that cannot

be adequately decontaminated Decontamination Goal: Less than twice normal

backgroundhigher levels may be acceptable

Key Points


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Medical stabilization is the highest priority

Train/drill to ensure competence andconfidence

Pre-plan to ensure adequate supplies and

survey instruments are available Universal precautions and decontaminating

patients minimizes exposure andcontamination risk

Early symptoms and their intensity are anindication of the severity of the radiation injury

The first 24 hours are the worst; then you will

likely have many additional resources

Resources Radiation Emergency Assistance Center/ Training Site

(REAC/TS) (865) 576-1005 www orau gov/reacts


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(REAC/TS) (865) 576 1005 www.orau.gov/reacts

Medical Radiobiology Advisory Team (MRAT) Armed ForcesRadiobiology Research Institute (AFRRI) (301) 295-0530www.afrri.usuhs.mil

Medical Management of Radiological Casualties Handbook, 2003;and Terrorism with Ionizing Radiation Pocket Guide

Websites:

www.bt.cdc.gov/radiation - Response to RadiationEmergencies by the Center for Disease Control

www.acr.org - Disaster Preparedness for RadiologyProfessionals by American College of Radiology

www.va.gov/emshg - Medical Treatment of RadiologicalCasualties

Resources Books:

Medical Management of Radiation Accidents; Gusev, Guskova,


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Medical Management of Radiation Accidents; Gusev, Guskova,Mettler, 2001.

Medical Effects of Ionizing Radiation; Mettler and Upton, 1995. The Medical Basis for Radiation-Accident Preparedness; REAC/TS

Conference, 2002.

National Council on Radiation Protection Reports No. 65(Contaminated Patient Care) and No. 138 (Radiation Injury Care).

Articles: Major Radiation Exposure - What to Expect and How to Respond,

Mettler and Voelz, New England Journal of Medicine, 2002, 346: 1554-61.

Medical Management of the Acute Radiation Syndrome:

Recommendations of the Strategic National Stockpile RadiationWorking Group, Waselenko, et.al., Annals of Internal Medicine, 2004,140: 1037-1051.

preparing for an unplanned radiation event

Documents