Preparing for an Unplanned Radiation Event

Niel Wald, M.D. Michael P. Kuniak, D.O., M.P.H.

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, MS Marcia 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.

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

OUTLINE

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

What is Radiation?
For the purpose of this presentation, defined as energetic emissions from unstable atoms that can result in ionizing events to target atoms Ionizing radiation is radiation capable of imparting its energy to the body and causing chemical changes Ionizing radiation is emitted by
- Radioactive material Some devices such as x-ray machines

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

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

Types of Radiation Emitted from Radioactive Material

Particulate
Charged

Alpha Radiation Beta Radiation

Uncharged

Neutron Radiation Electromagnetic Gamma Radiation

Types of Ionizing Radiation

Alpha Particles Radiation Source

Stopped by a sheet of paper

Beta Particles
Stopped by a layer of clothing or less than an inch of a substance (e.g. plastic)

Gamma Rays
Stopped by inches to feet of concrete or less than an inch of lead

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 skin layer (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

Pertinent Alpha Emitters

Neutron Radiation

Neutral particle emitted from the nucleus Can be very penetrating Requires special consideration for shielding Can induce radioactivity when absorbed by stable elements (N, Na, Al, S, Cl, P, etc.)

Electromagnetic Radiation
Energy = hf Energy expressed typically in KeV or MeV (not joules) Absorption of Electromagnetic Radiation by matter Photoelectric Compton Scattering Pair production (photon energy must exceed 1.02 MeV) Stochastic event Low energy photons more readily absorbed

The Electromagnetic Spectrum

Gamma Radiation

Electromagnetic energy emitted from the nucleus Specific energies can be analyzed to identify source Very penetrating (many meters in air) Difficult to shield, often shielded with lead

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

Radiation Units
Measure of Amount of radioactive material Ionization in air Absorbed energy per mass Absorbed dose Quantity Activity Unit curie (Ci) roentgen (R) rad rem

Exposure Absorbed Dose Dose Equivalent

weighted by type For most types of radiation 1 R 1 rad 1 rem of radiation

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

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

Example of the Effect of Half-Life

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

after 1 half-life (6 h): after 2 half-lives (12 h): after 3 half-lives (18 h): after 4 half-lives (24 h): 16 uCi 8 uCi 4 uCi 2 uCi

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

Selected Radionuclides with Radiations

Radionuclide Hydrogen-3 Cobalt-60 Strontium-90 Iodine-131 Cesium-137 Iridium-192 Radium-226

Radiation(s)

Half-Life 12 y 5.26 y 28 y 8.05 d 30 y 74 d 1602 y

Eff. Half-Life 12 d 10 d 15 y 8d 70 d 44 y

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

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

Deterministic Acute Effects

Stochastic Late Effects

Note: 1 MeV = 1.6 x 10-13 Joules

Weighting Factors

Organization Weighting factor X &Gamma Rays Beta Rays Thermal Neutrons Fast Neutrons Hi Energy Protons Alpha Particles

NRC Q 1 1 2 10 10 20

ICRU Q 1 1

NCRP Q 1 1 5

ICRP WR 1 1 5 20 5 20

25

20 1

25

20

Radiation Doses and Dose Limits

Flight from Los Angeles to London Annual public dose limit mrem Annual natural background Fetal dose limit Barium enema Annual radiation worker dose limit Heart catheterization (skin dose) 5 mrem 100 300 mrem 500 mrem 870 mrem 5,000 mrem

45,000 mrem Life saving actions guidance (NCRP-116) 50,000 mrem

Radioactive Material
Radioactive material consists of atoms with unstable nuclei The atoms spontaneously change (decay) to more stable forms and emit radiation A person who is contaminated has radioactive material on their skin or inside their body (e.g., inhalation, ingestion or wound contamination)

Examples of Radioactive Materials

Radionuclide
Cesium-137 Cobalt-60 Plutonium-239 Iridium-192 Radiography Hydrogen-3 Strontium-90 Iodine-131 Therapy Technetium-99m Americium-241 Radon-222

Physical Half-Life
30 yrs 5 yrs 24,000 yrs 74 days 12 yrs 29 yrs 8 days 6 hrs 432 yrs 4 days

Activity
1.5x106 Ci 15,000 Ci 600 Ci 100 Ci 12 Ci 0.1 Ci 0.015 Ci 0.025 Ci 0.000005 Ci 1 pCi/l

Use
Food Irradiator Cancer Therapy Nuclear Weapon Industrial Exit Signs Eye Therapy Device Nuclear Medicine Diagnostic Imaging Smoke Detectors Environmental Level

Radiation vs. Radioactive Material

Radioactive Material
Any substance that spontaneously gives off radiation Can be in various chemical forms If not contained (sealed source) can lead to contamination External, Internal or Both

Radiation
The energetic emissions of radioactive material Can be subatomic particles (, , n), photons (X-ray, ) or combinations Results in ionization of the absorbing material (if living tissue radiation injury)

Half-Life (HL)
Physical Half-Life

Time (in minutes, hours, days or years) required for the activity of a radioactive material to decrease by one half due to radioactive decay
Biological Half-Life

Time required for the body to eliminate half of the radioactive material (depends on the chemical form)
Effective Half-Life

The net effect of the combination of the physical & biological half-lives in removing the radioactive material from the body

Criticality Incident

Operation Upshot/Knothole, a 1953 test of nuclear artillery projectile at Nevada Test Site

Nuclear Fission

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

Radionuclides of Concern

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

Size of Event
Event
Radiation Accident Radioactive Dispersal Device

No. of Deaths
None/Few Few/Moderate
(Depends on size of explosion & proximity of persons)

Most Deaths Due to

Radiation Blast Trauma

Low Yield Large Nuclear Weapon (e.g. tens of thousands in

an urban area even from 0.1 kT weapon)

Blast Trauma Thermal Burns Radiation Exposure Fallout

(Depends on Distance)

Dose Limits - ICRP 60

Application
Whole Body

Occupational
20 mSv/year Effective dose averaged over 5 years, max: 50 mSv/yr

Public
1 mSv in 1 year

Annual Equiv. Dose: Lens of eye Skin Hands & Feet 150 mSv 500 mSv 500 mSv 15 mSv 50 mSv

Emergency Exposure Guidelines - ICRP 60

Dose Limit (Whole Body)

Activity Performed

Conditions

5 rems 10 rems 25 rems

All.. Protecting major property Lifesaving or protection of large populations Lifesaving or protection of large populations

. Where lower dose limit not practicable. Where lower dose limit not practicable Only on a voluntary basis to personnel fully aware of the risks involved

>25 rems

Radiography Source

Sealed Source Accident

13 Curie Cs-137 Radiography Source Found by a man at an Argentina construction site Carried in front pockets for 18 hours

Accident Dose Calculation

Cs-137 Gamma Constant = 0.323 R-m2/hr-Ci 0.323 R-m2 hr-Ci (18hr)(13Ci) (0.01m)2 755,820 R

Accident Isodose Curves

Basic Radiobiology

Atom Molecule

Ionization in Water or Cell Molecules Chemical Damage Bond Breakage

DNA

Chromosomal Aberration

Cell Death

Mutation

Radiosensitivity (most to least):

Lymphocytes Erythroblasts Myeloblasts Epithelial Cells Intestinal crypts Testis Ovary Skin Secretory glands Lungs and bile ducts 19-A Endothelial Cells Connective Tissue Cells Tubular Cells of Kidneys Bone Cells Nerve Cells Brain Cells Muscle Cells

Classification of Medical Radiation Problems

Anxiety Acute Radiation Syndrome Local Radiation Injury External Radionuclide Contamination Local Trauma with Radionuclide Contamination Internal Radionuclide Contamination

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 (, , )

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%

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 receive low doses is very small - 5 rem increases the risk of severe hereditary effects by ~ 0.02% Risk of severe hereditary effects to a patient population receiving high doses is estimated as ~ 0.4% per 100 rem

Fetal Irradiation
No significant risk of adverse developmental effects below 10 rem Weeks After Period of Fertilization Development Effects <2 Pre-implantation Little chance of malformation. Most probable effect, if any, is death of embryo. Reduced lethal effects. 2-7 Organogenesis Teratogenic effects. Fetal Growth retardation. 7-40 Impaired mental ability. Growth retardation with higher doses. All Increased childhood cancer risk. (~ 0.6% per 10 rem)

Types of Radiation Hazards

External Exposure whole-body or partialbody (no radiation hazard to EMS staff) Contaminated external radioactive material: on the skin internal radioactive material: inhaled, swallowed, absorbed through skin or wounds
External Exposure Internal Contamination External Contamination

Radioactive Contamination
Contamination is simply the presence of radioactive material where it is not wanted Persons may be contaminated either externally, internally or both Exposure does not necessarily imply contamination

In order to limit the amount of radiation you are exposed to, think about: SHIELDING, DISTANCE and TIME

Shielding: If you have a thick shield between yourself and the 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 the lower your exposure.

Time: Minimizing time spent exposed will also reduce your risk.

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 the patient (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 from nuclear medicine department (SHIELDING)

Radiation Protection: Reducing Radiation Exposure

Time
Minimize time spent near radiation sources
To Limit Caregiver Dose to 5 rem Distance time 1 ft 2 ft 5 ft 8 ft Rate 12.5 R/hr 3.1 R/hr 0.5 R/hr 0.2 R/hr Stay 24 min 1.6 hr 10 hr 25 hr

Distance
Maintain maximal practical distance from radiation source

Shielding
Place radioactive sources in a lead container

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

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

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 necessary personnel only

Putting It All Together

OUTLINE
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

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 Nuclear Device Detonation

Terrorist 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 Penetrating Ionizing Radiation

A nuclear weapon is expected to cause many deaths and injuries: radiation is not the primary hazard Blast and thermal effect comprise of the majority of effects/casualties
Radiation lethality out-distances thermal and blast damage only in low yield weapons ( 1 kiloton)

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

Retinal burn: visual capacity is permanently lost in the burned area. Retinal burns can be produced at great distances from the nuclear detonation because the probability of occurrence does not follow the inverse square law as is true of many other types of nuclear radiation.

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

Fallout: important for surface bursts

A nuclear detonation results in a fireball with a temperature estimated to be several tens of millions of degrees. The radioactive particles resulting from nuclear fission and activation of surrounding materials are carried up by the fireball and then drift downwind to later settle on the ground.

Real-World Example Similar to Russian Suitcase Nukes

Same type of nuclear warhead was used in a small artillery round, called Davy Crockett.

Davy Crockett Fallout NYC

FOR TRAINING PURPOSES ONLY

Results from Davy Crockett overlaid on New York City map Building that houses detonation device is destroyed Adjoining buildings damaged People within 1200 feet receive lethal dose of radiation (650,000 mrem or higher) from blast (not fallout) 1~50,000 fatalities in estimation 1~200,000 casualties
Lethal Dose Area

10,000 mrem/hr

1,000 mrem/hr

10,000 mrem/hr

Point of Detonation

Atomic Weapon NuclideYields

Approximate Yields of the Principal Nuclides per Megaton of Fission Nuclide Half-life MCi Sr 90 Sr 95 Zr 103 Ru 106 Ru 131 I 137 Cs 131 Ce 144 Ce
89
b

53 d 28 y 65 d 40 d 1y 8d 30 y 1y 33 d

20.0b 0.1b 25.0b 18.5b 0.29b 125.0c 0.16b 39.0b 3.7b

From Klement (1965) c From Knapp (1963)

Environmental Radioactivity 4th Ed., Eisenbud M (1997)

The Chernobyl Accident

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)

Chernobyl: Healthcare Procedures

Medical Examinations Dosimetric & lab tests Inpatient care 1,000,000 persons 700,000 (216,000 children) 32,000 persons (12,000 children) Iodine prophylaxis 5,400,000 persons (1,700,000 children)

Chernobyl: 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 out to 30 km from plant Dose to public (3-15 km zone): estimate 43 rem (50 year commited dose)

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
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

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 exposed to, think about shielding, distance and time.

Local authorities may not be able to immediately provide information on what is happening and what you should do. However, you should watch TV, listen to the radio, or check the Internet often for official news and information as it becomes available.

Russian Nuclear SuitcaseDevices

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

Total Number of Material Seizures (April 2001)

217 low-grade nuclear material 14 weapons usable material 299 Radioactive Sources

Sophisticated RDD

May not be recognized before it is exploded

Probability of RDD
Terrorist Event Radiological dispersal device (dirty bomb) Health Consequences: Injury Burns Single Nuclide Contamination(?) Much higher probability than the use of a nuclear weapon: 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

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 in urban areas would expose many, kill few
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 have more immediate lethality than the radioactive material. At the levels created by most probable sources, not enough radiation would be present in a dirty bomb to kill people or cause severe illness. However, certain other radioactive materials, dispersed in the air, could contaminate up to several city blocks, creating fear and possibly panic and requiring potentially costly cleanup. Prompt, accurate, non-emotional public information might prevent the panic sought by terrorists. A second type of RDD might involve a powerful radioactive source hidden in a public place, such as a trash receptacle in a busy train or subway station, 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 presumed purpose of its use would be therefore not as a Weapon of Mass Destruction but rather as a Weapon of Mass Disruption.
Good reference: http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/dirty-bombs.html

Concerns
Immediate radiation injuryvery few Cancersmall (if any) increase on overall 25% probability of dying from cancer

Exceptions:

iodine and childrens thyroid cancer

Birth defectsonly a concern for a few (if any), has been dramatically overestimated in the past

Goiania Contamination Accident

454-2

Location of Goiania, Brazil

451-1

Goiania Accident Source

137

Cs teletherapy source capsule:

Physical form: CsCl hygroscopic powder with blue fluorescence as it absorbed moisture. Radioactivity: 50.9 TBq (1375Ci) Dose rate @1 m: 4.56 Gy/hr (456 rad/hr)

Goiania Event Sequence

451-3

Goiania Medical Disposition

580-9

Goiania Casualty Burial

Goiania Local Injury

454-5

Goiania Contaminated Areas

451-2

Goiania Population Screening

55-3

Goiania Accident Magnitude

People monitored: Chromosome analyses: Roads monitored: Remediation workers: Above DL: 10 mSv CDE) Homes contaminated: Demolished: Vehicles contaminated: Radwaste created: 112,000 110 2,000 Km 755 38 (Highest: 85 7 50 3,800 - 200L drums

Lessons Learned
Lack of awareness of the detrimental health effects 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 cant evacuate

Use the Shelter to Shield and Distance yourself from the fallout contamination.

Particle Filtering Factors Filtration Efficiencies

Mans cotton handkerchief, 16 thick. Mans cotton handkerchief, 8 thick. 88% Toilet paper, 3 thick. Bath towel, 2 thick. Cotton Shirt, 2 thick. 65% 91% 85% 94%

Turn off ventilation

Recommended Accumulated Dose Levels at which to Consider Evacuation and/or Relocation

Fallout: The 7-10 Rule of Thumb

Time (hours) H + 1* H + 7 (17) H+49 (77) H+343 (777) ~14 Days H+2401 (74) ~100 Days

Relative Fallout Dose Rates

100% 10 % 1% 0.1%

0.01%

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

Shelter as long as possible before evacuating across fallout contamination. Waiting 2 days will reduce exposure by a factor of 100!

Decontamination: important for nuclear weapons and radiation dispersal devices

Evacuate the Fallout Path

Although dose rates are highest within the first few hours, this only represents a relatively small area Evacuating the fallout area before fallout arrival will save the most lives

If there is a radiation or a dirty bomb threat

1. If you are outside and there is an explosion or authorities warn of a radiation release nearby, cover your nose and mouth and quickly go inside a building that has not been damaged. If you are already inside check to see if your building has been damaged. If your building is stable, stay where you are. Close windows and doors; turn off air conditioners, heaters or other ventilation systems.

If there is a radiation or a dirty bomb threat

1. If you are inside and there is an explosion near where you are or you are warned of a radiation release inside, cover nose and mouth and go outside immediately. Look for a building or other shelter that has not been damaged and quickly get inside. Once you are inside, close windows and doors; turn off air conditioners, heaters or other ventilation systems. If you think you have been exposed to radiation, take off your clothes and wash as soon as possible. Stay where you are, watch TV, listen to the radio, or check the Internet for official news as it becomes available.

2.

3.

4.

If there is a nuclear blast

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 the blast and the pressure wave. If there is no warning: 1. 2. 3. Quickly assess the situation. 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. If you take shelter go as far below ground as possible, close windows and doors, turn off air conditioners, heaters or other ventilation systems. Stay where you are, watch TV, listen to the radio, or check the Internet for official 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 significant radioactive contamination threat, health care authorities may advise you to take potassium iodide. It may protect your thyroid gland, which is particularly vulnerable, from radioactive iodine exposure. Plan to speak with your health care provider in advance about what makes sense for your family.

Conclusions
Radiation dispersal devices could cause significant contamination with low levels of radiation, but would result in few if any radiation casualties.

Much of the radiation dispersal devices impact will

depend on how much we over-react to the dangers of radiation.

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

In a fallout scenario, wise actions on

sheltering/evacuation will save thousands of lives.

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

OUTLINE
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

The Real Medical Radiation Problems

Fear Communication Failure Uncertainty Inaction Chaos

Key Points for Emergency Responders

Responders
Lifesaving first aid is the First Priority Familiarize yourself with work area Survey instrumentation, protective clothing, respiratory protection 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 with clothing Showering will remove an additional 7%

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, designate separate entrance, designate one side of corridor, or transfer to clean gurney before entering, if time allows

Decontamination Center
Establish a decontamination center for people who are contaminated, but not significantly injured.
Center should provide showers for many people. Replacement clothing must be available. Provisions to transport or shelter people after decontamination may be necessary. Staff decontamination center with medical staff with a radiological background, health physicists or other staff trained in decontamination and use of radiation survey meters, and psychological counselors

Protecting Staff from Contamination

Universal precautions Survey hands and clothing with radiation meter Replace gloves or clothing that is contaminated Keep the work area free of contamination

Key Points

Contamination is easy to detect and most of it can be removed It is very unlikely that ED staff will receive large radiation doses from treating contaminated patients

Treatment Area Layout

CONTAMINATED AREA
Radiation Survey & Charting ED Staff

Separate Entrance

Contaminated Waste

Trauma Room HOT LINE

CLEAN AREA

BUFFER ZONE

Waste

STEP OFF PAD

Radiation Survey

Clean Gloves, Masks, Gowns, Booties

Detecting and Measuring Radiation

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

Triage Medical triage is the highest priority Radiation exposure and contamination are secondary considerations Degree of decontamination dictated by number of and capacity to treat other injured patients

Patient Management - Triage

Triage based on: Injuries Signs and symptoms nausea, vomiting, fatigue, diarrhea History - Where were you when the bomb exploded? Contamination survey

Classification of Medical Radiation Problems

Anxiety Acute Radiation Syndrome 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

An incident caused by nuclear terrorism may create large numbers of contaminated people who are not injured and worried people who may not be injured or contaminated 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 appropriate locations. Triage site should be staffed with medical staff and security personnel Precautions should be taken so that people cannot avoid the triage center and reach the ED

Radiation Anxiety
In the event of a nuclear or radiological weapon detonation, thousands of victims will be concerned about their possible exposure to ionizing radiation. Accurate knowledge of radiation dose can dramatically affect the assignment of triage category, BUT accepted methods for accurate post-exposure dosimetry take days to measure. Thus, clinical signs, symptoms and blood counts are best early indicators of radiation injury.

Psychological Casualties
Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening Mass casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated Establish a center to provide psychological support to such people Set up a center in the hospital to provide psychological support for staff

Acute Radiation Syndrome

Depending on the magnitude of the exposure, the hematopoietic system, the gastrointestinal tract, the cardiovascular and central nervous systems may be involved in damage. There are three major forms (in order of severity):
Hematological form Gastrointestinal form Neurovascular form

Thoma/Wald Prognostic Categories

Group 1: 0.5 to 1.5 Gy; mostly asymptomatic with occasional 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 GI complications Group 5: >50Gy; manifested by marked early neurovascular changes

Acute Radiation Syndrome (Cont.) For Doses > 100 rem

Prodromal stage
nausea, vomiting, diarrhea and fatigue higher doses produce more rapid onset and greater severity

Latent period (Interval)

patient appears to recover decreases with increasing dose
Time of Onset

Manifest Illness Stage

Hematopoietic Gastrointestinal CNS
Severity of Effect

Prodromal Appearance Time

39-J

Clinical Effects of ARS

Acute Local Radiation Injury

Effect Time of Appearance (days) Threshold Dose (cGy)

Erythema

minutes to weeks (dose dependant) at threshold 8-17

600

Epilation Dry desquamation Moist desquamation

17-21 21 14-21

300 1000-1500 1800-3000

Localized Radiation Effects - Organ System Threshold Effects

Skin - No visible injuries < 100 rem
Main erythema, epilation Moist desquamation Ulceration/Necrosis >500 rem >1,800 rem >2,400 rem

Cataracts
Acute exposure Chronic exposure >200 rem >600 rem

Permanent Sterility
Female Male >250 rem >350 rem

Special Considerations
High radiation dose and trauma interact synergistically to increase mortality Close wounds on patients with doses > 100 rem Wound, burn care and surgery should be done in the first 48 hours or delayed for 2 to 3 months (> 100 rem)
Emergency Surgery

Hematologic Recovery
No Surgery

Surgery Permitted

24 - 48 Hours

~3 Months

After adequate hematopoietic recovery

OUTLINE
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

Emergency Department Management of Radiation Casualties

CAUTION

Patient Management - Decontamination

Carefully remove and bag patients clothing and personal belongings (typically removes 95% 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

 Protect non-contaminated wounds with waterproof dressings Contaminated wounds: Irrigate and gently scrub with surgical sponge Extend wound debridement for removal of contamination only in 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 by cutting with scissors or electric clippers Promote sweating Use survey meter to monitor progress of decontamination

Patient Management - Decontamination (Cont.)

Patient Management - Decontamination (Cont.)

Cease decontamination of skin and wounds
When the area is less than twice background, or When there is no significant reduction between decon efforts, 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 necessary medical procedures or examsresidual contamination can be controlled.

Initial Management of Externally Contaminated Patient

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 Other Therapy at Dispensary or Hospital

Handling contaminated patients

Patient decontamination
Monitor to determine if decontamination is needed Remove outer clothing Wash exposed skin surfaces Flush wounds with water Do not scrub or abrade skin! Low levels of contamination are not a health hazard and can be left in place if not easily removed (they will decay quickly).

Early Treatment For Radionuclide Contaminated Wounds 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- Hazard Contaminants

Therapy For Isotope Decorporation

Dilution 3H: Water

32

P: Phosphorus (Neutraphos)

Blocking
137 131 90

Cs: Prussian Blue I, 99Tc: KI (Lugols)

Sr, 85Sr: Na-Alginate (Gaviscon), AlPhosphate or Hydroxide Gel (Phosphajel or Amphojel)

Therapy For Isotope Decorporation (cont.)

Mobilization
86

Rb: Chlorthalidone (Hygroton)

Chelation Cf, 242Cm, 241Am, 239Pu, 144Ce, Rare Earths, 143 Pm, 140La, 90Y, 65Zn, 46Sc: DTPA
252 210 210 203

Pb: EDTA, Penicilamine Po: Dimercaprol (BAL) Hg, 60Co: Penicilamine

 Radionuclide-specific

Treatment of Internal Contamination

Most effective when administered early May need to act on preliminary information NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides
Radionuclide Cesium-137 Iodine-125/131 Strontium-90 Americium-241/ Plutonium-239/ Cobalt-60 Treatment Route Prussian blue Oral Potassium iodide Oral Aluminum phosphate Oral Ca- and Zn-DTPA IV /or
nebulizer

Treatment of Internal Contamination: Treatment Options

Reduce G.I. Absorption Hasten Excretion Use Blocking and Diluting Agents When Appropriate Use Mobilizing Agents Use Chelating Agents If Available

Patient Management - Patient Transfer

Transport injured, contaminated patient into or from the ED: Clean gurney covered with 2 sheets Lift patient onto clean gurney Wrap sheets over patient Roll gurney into ED or out of treatment room

Facility Recovery
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
Medical stabilization is the highest priority Train/drill to ensure competence and confidence Pre-plan to ensure adequate supplies and survey instruments are available Universal precautions and decontaminating patients minimizes exposure and contamination risk Early symptoms and their intensity are an indication 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 Medical Radiobiology Advisory Team (MRAT) Armed Forces Radiobiology Research Institute (AFRRI) (301) 295-0530 www.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 Radiation Emergencies by the Center for Disease Control www.acr.org - Disaster Preparedness for Radiology Professionals by American College of Radiology www.va.gov/emshg - Medical Treatment of Radiological Casualties

 Books:

Resources

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: 155461. Medical Management of the Acute Radiation Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group, Waselenko, et.al., Annals of Internal Medicine, 2004, 140: 1037-1051. Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers; Gerber, Thomas RG (eds), Radiation Protection Dosimetry, 1992.