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RITN Overview Presentation NMDP Basic Radiation Training Presenters name Date.

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1 RITN Overview Presentation NMDP Basic Radiation Training Presenters name Date

2 RITN Overview Presentation Why learn about radiation? Many agencies think that there will be a radiological incident in our lifetime –U.S. government –Independent nuclear watch groups (Nuclear Threat Initiative)www.NTI.org (Monterey Institute for International Studies)http://cns.miis.edu/cns/index.htm –International Atomic Energy Agency (IAEA) Every year hundreds of radiological sources are stolen worldwide

3 RITN Overview Presentation Goals of this Presentation Basics of radiation: sources, types, units of measurement Biological and clinical effects of radiation Symptoms of Acute Radiation Syndrome (ARS) Exposure and contamination Protection against radiation exposure: time, distance, shielding Preparedness planning and our role with RITN

4 RITN Overview Presentation Section 1: Radiation Basics

5 RITN Overview Presentation Types of Radiation Natural –Many more sources of natural radiation –Insignificant risk associated with typical exposure Man made –Fewer sources of exposure –BUT…potentially deadly if misused –Ionizing radiation is focus of this course

6 RITN Overview Presentation Sources of Radiation Exposure in the U.S. Population Natural (82%) –Radon –Cosmic (outer space) –Terrestrial Rocks/Soil –Internal Inside human body

7 RITN Overview Presentation Natural Background Radiation Cosmic –Sun (much of this radiation is shielded by Earth’s atmosphere) Terrestrial Sources –Materials in soil –Break down into radon gas Radioactivity in the Body –Very minute quantities

8 RITN Overview Presentation Sources of Radiation Exposure in the U.S. Population Man Made (11%) - Medical X-rays CT scans - Nuclear medicine/ radiation oncology - Consumer products - Other

9 RITN Overview Presentation Atomic Structure (a VERY basic one) Protons –Positive charge Neutrons –No charge Electrons –Negative charge

10 RITN Overview Presentation Radioactivity and Ionizing Radiation Radioactivity or radioactive decay: –Emitting excess energy from the nucleus of an unstable atom –Radioactive decay results in the decrease of radiation levels over time Ionizing radiation: Energy released from unstable (radioactive) atoms NOTE: Radioactive Atoms Emit Radiation

11 RITN Overview Presentation Three Main Types of Ionizing Radiation Emitted from Radioactive Atoms Alpha Beta Gamma

12 RITN Overview Presentation Ionizing Radiation Alpha Particles –Heaviest and most highly charged ionizing radiations –Energy is used up quickly; low penetrating ability –Cannot travel more than 4 to 7 inches –Stopped by a sheet of paper –Not a serious hazard outside the body –Can be most damaging if inside the body (e.g., ingestion, inhalation)

13 RITN Overview Presentation Ionizing Radiation Beta Particles –Smaller and travel much faster than alpha –Physically similar to electrons, but do not orbit around an atom –Travel faster with less charge than alpha and penetrate further –Major hazard when emitted by internally- deposited radioactive material

14 RITN Overview Presentation Ionizing Radiation Gamma Rays –Similar to medical x-rays –Short wavelength and high frequency –Most hazardous from sources outside the body –Can travel up to a mile in open air –All tissues and organs can be damaged by sources outside the body

15 RITN Overview Presentation Ionizing Radiation Alpha and beta radiation: both are PARTICLES Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVES

16 RITN Overview Presentation Electromagnetic Radiation Transmitted in the form of waves Generally higher in energy Originate in the nuclei of atoms

17 RITN Overview Presentation Radiation Penetration Into Skin Exposure to alpha & beta from outside body is slight hazard Long periods of exposure can cause “heat burns” Significant hazard if ingested, inhaled or contaminates a wound

18 RITN Overview Presentation Ionizing Radiation Alpha particles – hazardous internally Beta particles – internally a bit more hazardous Gamma rays - deadly

19 RITN Overview Presentation Shielding 2-1/2 inches of dense concrete will absorb approximately 50% of typical gamma rays Five inches of water is just as effective

20 RITN Overview Presentation Exposure vs. Dose When you are exposed to radiation, your body absorbs a measurable dose

21 RITN Overview Presentation Measurement of Radiation Dose What needs to be known for medical treatment Intensity of exposure Time or duration of exposure

22 RITN Overview Presentation Roentgen The Roentgen is used to express the amount of gamma radiation exposure Abbreviated with a capital “R” after the amount of gamma radiation received Independent of the time of exposure

23 RITN Overview Presentation Rad (radiation absorbed dose) Relates different types of radiation (alpha, beta, gamma and neutron) to the energy they impart Basic unit of absorbed dose of radiation One roentgen of gamma radiation exposure results in about one rad of absorbed dose

24 RITN Overview Presentation Rem (roentgen equivalent man) Relates the dose of any radiation to the biological effect of that dose For gamma rays and beta particles, 1 rad of exposure results in 1 rem of dose For alpha particles, 1 rad of exposure results in ~20 rem of dose

25 RITN Overview Presentation Exposure Rate The rate at which an individual is exposed to radiation Expressed in terms of roentgen or milliroentgen per hour

26 RITN Overview Presentation International System of Units (SI) SI uses gray (Gy) instead of rad - 1 Gy = 100 rad SI uses sievert (Sv) instead of rem - 1 Sv = 100 rem SI units must be used on labels to identify radioactive materials during transport

27 RITN Overview Presentation Section 2: Biological Effects of Radiation

28 RITN Overview Presentation Biological Effects Dependent upon type of exposure (duration of exposure) –Acute (limited time of exposure) –Chronic (extended or repetitive exposure) Level of exposure (intensity) Certain biological factors

29 RITN Overview Presentation Ionizing Radiation Radiation is a form of energy in motion When alpha, beta and gamma radiation enter the body, some or all of their energy is lost in collisions with the body’s cells Collisions strip away electrons from atoms in the body ionizationRemoval of electrons is called ionization

30 RITN Overview Presentation Biologic Effects Damage DNA and other structures inside cells Could result in cell death Incorrect repair, resulting in mutations that could cause cancer

31 RITN Overview Presentation Biological Effects Acute Exposure –Significant dose of radiation over a short period of time –Radiation sickness or death shortly after exposure –Long-term effects (possibly cancer years later) Chronic Exposure –Small dose of radiation continuously or over many years –No immediate observable effects –May result in long-term effects

32 RITN Overview Presentation Biological Factors Each person differs in their biological response to a given dose of radiation –Age –Sex –Diet –Body temperature –Overall medical health

33 RITN Overview Presentation Acute Radiation Sickness Occurs when an individual is exposed to a large amount of radiation in a short period of time Occurs at doses greater than 100 rem (1 Sv), which would be 100 rad (1 Gy) for gamma rays

34 RITN Overview Presentation Acute Radiation Sickness Manifestations –Changes in blood cells (lymphocytes decrease first) –Vascular changes –Skin irritation –GI effects (nausea, vomiting, diarrhea) –Fever –Non specific “flu”-like symptoms –Hair loss

35 RITN Overview Presentation Acute Radiation Sickness Severity and course depends on –How much total dose is received –How much of the body is exposed –Sensitivity of exposed individual to radiation May appear shortly after exposure, then disappear for a few days only to reappear in a much more serious form in a week or more (related to amount of exposure)

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37 RITN Overview Presentation Four Stages of ARS Prodromal phase (within 48 hours) Latent Phase (days to weeks) Manifest Illness (weeks to months) Recovery or Death

38 RITN Overview Presentation Four Stages of ARS Prodromal phase (within 48 hours) –Nausea/vomiting –Headache –Fatigue –Fever, diarrhea –Anorexia –Fluid shifts –Electrolyte imbalance Latent Phase (days to weeks) –Temporary improvement

39 RITN Overview Presentation Four Stages of ARS Manifest Illness (weeks to months) –Intense immunocompromise and symptoms specific to 4 major organ systems (heme, GI, skin, neurovascular) Recovery or Death Note: After lethal dose, victims may go through these phases in a period of hours resulting in early death

40 RITN Overview Presentation Severity Levels Delayed effects after sublethal dose (<250 rem*) may be non-specific  Malaise  Fatigue  Drowsiness  Weight loss  Fever  Abdominal pain  Insomnia  Restlessness  Blisters * For gamma and beta radiation, 1 rem = 1 rad

41 RITN Overview Presentation Severity Levels Delayed effects after potentially lethal dose (250 to 650 rem*) Significant reduction in production of blood cells Nausea/vomiting which appears to get better in 3 days WBC greatly reduced After two weeks: chills, fatigue, ulceration of the mouth * For gamma and beta radiation, 1 rem = 1 rad

42 RITN Overview Presentation Severity Levels Delayed effects after supralethal dose (>650 rem*) Damage to the stomach lining and/or intestine –Causing decreased absorption, ulceration and dehydration Seven Days After Exposure –Severe infection, fluid loss, blood loss or collapse of the circulatory system and may result in death * For gamma and beta radiation, 1 rem = 1 rad

43 RITN Overview Presentation Severity Levels Acute Doses over 1000 rem* Irreparable damage to the brain and spinal cord Symptoms –Agitation –Lack of coordination –Breathing difficulty –Occasional periods of disorientation –Death occurs within hours to days * For gamma and beta radiation, 1 rem = 1 rad

44 RITN Overview Presentation Key Symptoms of ARS  Nausea  Vomiting  Anorexia  Reduced number of white blood cells (lymphocytes, granulocytes)  Reduced number of platelets  Itching or altered sensation in the skin  Swelling and Edema  Diarrhea  Fatigue

45 Severity of Radiation Injury Dose Range (Gy)*ProdromeManifest - IllnessPrognosis (without therapy) MildSlight decrease in blood cell counts Almost certain survival Mild to ModerateEarly signs of BM damage Highly probable survival (>90% of victims) ModerateModerate-severe BM damage Probable survival SevereSevere BM damage; mild GI damage Death within weeks (50% of victims) SeverePancytopenia and moderate GI damage Death probable within 2-3 weeks SevereMarked GI and BM damage; hypotension Death probable within weeks SevereSevere GI damage, pneumonitis, altered mental status Death certain within 5-12 days SevereCV collapse; fever; shock Death certain within 2-5 days Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI). Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko * 1 Gy = 100 rad

46 RITN Overview Presentation What is the standard dose of irradiation used for total body irradiation (TBI) in clinical BMT?

47 Severity of Radiation Injury Dose Range (Gy)ProdromeManifest - IllnessPrognosis (without therapy) MildSlight decrease in blood cell counts Almost certain survival Mild to ModerateEarly signs of BM damage Highly probable survival (>90% of victims) ModerateModerate-severe BM damage Probable survival SevereSevere BM damage; mild GI damage Death within weeks (50% of victims) SeverePancytopenia and moderate GI damage Death probable within 2-3 weeks SevereMarked GI and BM damage; hypotension Death probable within weeks SevereSevere GI damage, pneumonitis, altered mental status Death certain within 5-12 days SevereCV collapse; fever; shock Death certain within 2-5 days Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI). Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko 12 Gy: TBI dose for clinical BMT

48 RITN Overview Presentation The standard dose of irradiation used for total body irradiation (TBI) in clinical BMT is 12 Gy (1200 rad), but…. - this total dose is administered in multiple fractions over several days to allow repair of normal cells and tissues - the lungs are usually given a lower total exposure (e.g., 9 Gy) to reduce risks of pulmonary toxicity

49 RITN Overview PresentationTreatments Exposure results in a full range of injuries, from changes in the blood cells to skin burns to serious radiation sickness Analysis of peripheral blood may diagnose exposure before other effects appear Treatment depends upon the nature and severity of the injury

50 RITN Overview Presentation Long-Term Effects Probability increases as level of exposure increases Three most notable effects –Cancer –Cataracts Acute exposure of 200 rads (2 Gy) Chronic exposure (months) of 1,000 rads (10 Gy) –Shortening of lifespan

51 RITN Overview Presentation Long-Term Effects Animal experiments –Same disease, earlier age Data from populations of Hiroshima and Nagasaki –Very slight risk (i.e., <1 years per 100 R)

52 RITN Overview Presentation Long-Term Effects

53 RITN Overview Presentation Section 3: Exposure versus Contamination

54 RITN Overview Presentation Contamination versus Radiation Contamination: the deposition of radioactive material in undesired locations NOTE: one can be exposed to radiation without becoming contaminated (e.g., radiation therapy treatments) Radioactive contamination on a surface does not make the surface itself radioactive - Remember that radioactive materials emit radiation - Once the contaminated surface is cleaned of the radioactive material, there is no longer a threat of radiation

55 RITN Overview Presentation Sources of Radioactive Exposure and Contamination Direct radiation Inhalation Skin contamination Direct ingestion Radiation from contaminated surfaces Secondary ingestion (e.g., food, water, milk)

56 RITN Overview Presentation Control of Radiation Exposure Protective Measures –Time Less time = less exposure –Distance Further away = less exposure –Shielding Intensity is reduced by absorption and scattering by the material between you and the source

57 RITN Overview Presentation Section 4: Preparedness Planning

58 RITN Overview Presentation Types of Radiological Incidents Orphaned source –Lost/stolen radiation source that exposes people –Can be purposely placed to injure Radiological Dispersal Device –a.k.a. “dirty bomb” Improvised Nuclear Device (IND) – a.k.a. “terrorist nuke” – could fit into a suitcase

59 RITN Overview Presentation Orphaned Source Case Study

60 RITN Overview Presentation Dirty Bombs Conventional bomb attached to a source of radioactivity (e.g., Cobalt-60) Explosion spreads radioactivity resulting in widespread contamination Result in few casualties Public panic is greatest danger Economic impact is far reaching when compared to INDs or military weapons

61 RITN Overview Presentation Radiological Dispersal Device Case Study

62 RITN Overview Presentation Improvised Nuclear Device (IND) Estimates based on a 1 kiloton or 10 kiloton IND Worst case scenario: Victims will outnumber BMT community resources

63 RITN Overview Presentation Improvised Nuclear Device (IND)

64 RITN Overview Presentation Contingency Planning The Radiation Injury Treatment Network SM (RITN) provides comprehensive evaluation and treatment for victims of radiation exposure or other marrow toxic injuries. RITN develops treatment guidelines, educates health care professionals, works to expand the network, and coordinates situation response. RITN is a cooperative effort of the National Marrow Donor Program® (NMDP) and The American Society for Blood and Marrow Transplantation (ASBMT).

65 RITN Overview Presentation RITN Centers RITN provides: –Existing facilities with practicing specialists for intensive supportive care and treatment Infrastructure and process for transplant if needed –Training of physicians and other health care workers –Assistance during an emergency –Donor search support –IRB - approved data collection plan –Increases transplant community awareness about potential need of their services in time of crisis –Involves transplant community in emergency preparedness

66 RITN Overview Presentation Available through RITN Website RITN Acute Radiation Syndrome treatment guidelines RITN center standard operating procedure templates Donor selection criteria NMDP data collection protocol Training resources Pertinent publications

67 RITN Overview Presentation What is RITN Doing to Prepare? Standard Operating Procedures Basic radiation training completed by staff Grand rounds presentation in development Additional training resources provided on RITN Web site Conduct an annual tabletop exercise Emergency communications tests GETS cards and satellite telephones Coordinating with government (DHHS-ASPR)

68 RITN Overview Presentation RITN Distribution Across USA UMC

69 RITN Overview Presentation What if there is a disaster? If an improvised nuclear device (terrorist nuclear bomb) is detonated, what will happen? The federal government will: –Setup outside the hazard area –Receive, decontaminate and triage victims –Forward them on for appropriate care Any victim with trauma or burns would be treated for that before being evaluated for treatment due to marrow toxicity This leaves a smaller subset for marrow reconstitution

70 RITN Overview Presentation Possible Casualty Levels The U.S. government is planning to respond to a 10 kiloton improvised nuclear device (terrorist nuclear bomb)

71 RITN Overview Presentation Timelines for Activity - Transplants

72 RITN Overview Presentation RITN Centers Admission to RITN several days after event (unless hospital is in the vicinity of the event) –Initial triage and decontamination is completed by first responders –Identifying a destination for each victim Health & Human Services working with RITN –Initial treatment and diagnosis Conducted by RITN, NCI and NDMS centers

73 RITN Overview Presentation Urgent BMT Small subset of patients will require transplantation Expediting the evaluation of donor(s) is key Housing needs for donors and patients Expect that altered standards of care will be implemented by the Dept. of Health and Human Services during this time to facilitate treatment

74 RITN Overview Presentation Contingency Planning “By failing to prepare you are preparing to fail.” Benjamin Franklin

75 RITN Overview Presentation Some Online References RITN: HHS Radiation Event Medical Management (REMM): CDC: –Radiological Terrorism: Medical Response to Mass Casualties: –Radiological Terrorism: Just in Time Training for Hospital Clinicians: –Medical Response to Nuclear and Radiological Terrorism: –The Role of Public Health in a Nuclear or Radiological Terrorist Incident: National Planning Scenarios: srv/nation/nationalsecurity/ earlywarning/NationalPlanningScenariosApril2005.pdf srv/nation/nationalsecurity/ earlywarning/NationalPlanningScenariosApril2005.pdf


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