Notes

Outline

Possible Scenarios Nuclear power plant incident Hidden source “Dirty bomb” Improvised nuclear device Nuclear weapon

Hypothetical Suitcase Bomb

What is Radiation?

Penetration Abilities of Different Types of Radiation

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Radiation vs. Radioactive Material Radiation: energy transported in the form of particles or waves (alpha, beta, gamma, neutrons) Radioactive Material: material that contains atoms that emit radiation spontaneously

Exposure vs. Contamination Exposure: irradiation of the body à absorbed dose (Gray, rad) Contamination: radioactive material on patient (external)or within patient (internal)

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Consult with Radiation Experts Radiation Safety Officer Health Physicist Medical Physicist Conference of Radiation Control Program Directors (www.crcpd.org)

Consult with Radiation Experts Determining/documenting presence of radioactivity, activity levels, and radiation dose Collecting samples to document contamination Assisting in decontamination procedures Disposing of radioactive waste

Injuries Associated with Radiological Incidents Acute Radiation Syndrome (ARS) Localized radiation injuries/ cutaneous radiation syndrome Internal or external contamination Combined radiation injuries with    - Trauma    - Burns Fetal effects

Psychological Casualties Terrorist acts perceived as very threatening Large numbers of concerned with no apparent injuries Mental health professionals should be included For more information on radiation exposure and pregnancy www.bt.cdc.gov/radiation/prenatalphysician.asp

Radiation Protection  for Clinical Staff Fundamental Principles     - Time     - Distance     - Shielding Personnel Protective Equipment Contamination Control

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Pregnant Staff NRC limit for pregnant workers is 5 mGy (0.5 rad) Pregnant staff should be reassigned CDC prenatal radiation exposure fact sheet:

Dealing With Staff Stress Preplanning Establish information center Train staff on radiation basics Post Event Debrief immediately after event Offer Counseling

1986 Chernobyl Accident

Never delay critical care because a patient is contaminated

Immediate Medical Management Triage ARS localized/ cutaneous combined injury Initial stabilization and treatment Psychological effects Record keeping/ Dose assessment

Patient Management - Priorities Standard medical triage is the highest priority Radiation exposure and contamination                   are secondary considerations

Patient Management - Protocol Based on: Injuries Signs and symptoms Patient history Contamination survey

Prenatal Radiation Exposure Human embryo and fetus highly sensitive to ionizing radiation At higher doses, effects depend on dose and stage of gestation Pregnant patients should receive special dose assessments and counseling Information on prenatal radiation exposure www.bt.cdc.gov/radiation/prenatalphysician.asp

Required Conditions for Acute Radiation Syndrome Large dose Penetrating Most of body exposed Acute

Acute Radiation Syndrome (A Spectrum of Disease)

Biodosimetry Assessment Tool Armed Forces Radiobiology Research Institute www.afrri.usuhs.mil/

Andrews Lymphocyte Nomogram

Phases of Acute Radiation Syndrome

Special Considerations High radiation dose and trauma interact synergistically to increase mortality Close wounds on patients with doses > 1 Gy (100 rad) Perform wound/burn care and surgery in first 48 hours or delayed for 2 to 3 months when dose is > 1 Gy (100 rad)

Skin Effects

"Treat patients symptomatically" Treat patients symptomatically Prevent and manage infections Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®) Irradiated blood products Antibiotics/reverse isolation Electrolytes More information on ARS: www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

Treatment of Cutaneous Radiation Syndrome Lesions do not appear for days to weeks Perform surgical treatments within 48 hrs Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment, 865-576-1005 or www.orau.gov/reacts/

Decontamination of Patients External Skin Wound Internal Decorporation agents

Patient Decontamination

External Contamination Radioactive material (usually in the form of dust particles) on the body surface and/or clothing Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff

Decontamination Priorities Wounds Intact skin (areas of highest contamination first) Change outer gloves frequently to minimize spread of contamination

Decontamination of Wounds Contaminated wounds: Irrigate and gently scrub with surgical sponge Debride surgically only as needed Contaminated thermal burns: Gently rinse Changing dressings will remove additional contamination Avoid overly aggressive decontamination Change dressings frequently

Decontamination of Skin Use multiple gentle efforts Use soap & water Cut hair if necessary (do not shave) Promote sweating Use survey meter

Cease Patient Decontamination When decontamination efforts produce no significant reduction in contamination When the level of radiation of the contaminated area is less than twice background Before intact skin becomes abraded Consider internal contamination

Internal Contamination Radioactive material may enter the body through - Inhalation - Ingestion - Wounds Internal contamination generally does not cause early signs or symptoms Internal contamination will continue to irradiate the patient

Treatment of Internal Contamination

Potassium Iodide (KI) Only helpful in special cases KI saturates the thyroid gland with stable iodine KI must used prior to or within hours of exposure to radioactive iodine See the FDA web site:

Longer Term Considerations Following Radiation Injury Neutropenia Pain management Necrosis Plastic/reconstructive surgery Psychological effects (PTSD) Counseling Dose assessments Possible increased risk of cancer Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment: www.orau.gov/reacts/, 865-576-1005.

Key Points Stabilization is the highest priority Radiation experts should be consulted Training and drills should be offered Adequate supplies and survey instruments should be stocked Standard precautions (N95 mask if available) reduce contamination Early symptoms and their intensity indicate the severity of the radiation injury First 24 hours are the most critical

More Incident Assistance The Radiation Emergency Assistance Center/ Training Site (REAC/TS) - www.orau.gov/reacts/ - Phone: (865) 576-1005 The Armed Forces Radiobiology Research Institute, Medical Radiobiology Advisory Team (MRAT) - www.afrri.usuhs.mil/ - Phone: (301) 295-0530 The American Association of Poison Control Centers - www.aapcc.org/ - Phone: (800) 222-1222

Other Resources Books: - Disaster Medicine; Hogan and Burnstein, 2002. - Medical Management of Radiation Accidents; Gusev, Guskova, Mettler, 2001. - The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference, 2002. - National Council on Radiation Protection and Measurement Report No. 65: Management of Persons Accidentally Contaminated With Radionuclides, 1980. - National Council on Radiation Protection and Measurement Report No. 138: Management of Terrorist Events Involving Radioactive Material, 2001. AFRRI Publications: Medical Management of Radiological Casualties Handbook; Jarrett, 2003, and Terrorism with Ionizing Radiation Pocket Guide

Other Resources Article: “Major Radiation Exposure - What to Expect and How to Respond,” Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61. Web Sites: - www.va.gov/emshg/ - Department of Homeland Security Working Group on Radiological Dispersal Device Preparedness, Medical Treatment of Radiological Casualties - www.crcpd.org – Conference of Radiation Control Program Directors - www.bt.cdc.gov/radiation/index.asp - Centers for Disease Control and Prevention Radiation Emergencies Page - www.acr.org/flash.html - Disaster Preparedness for Radiology Professionals - www.hps.org/ - The Health Physics Society - www.fda.gov/ - The Food and Drug Administration