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1 Medical Response to Nuclear and Radiological Terrorism Stevan Cordas DO MPH Clinical Associate Professor TCOM/UNTHSC.

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Presentation on theme: "1 Medical Response to Nuclear and Radiological Terrorism Stevan Cordas DO MPH Clinical Associate Professor TCOM/UNTHSC."— Presentation transcript:

1 1 Medical Response to Nuclear and Radiological Terrorism Stevan Cordas DO MPH Clinical Associate Professor TCOM/UNTHSC

2 2 Consultant Texas Department of Health - WMD Education Consultant American Osteopathic Association – Washington Bureau – WMD Certified Occupational Medicine (Toxicology) Trained in Cleveland Institute of Nuclear Medicine Former U.S. Army Medical Corps Steering Committee - Medical Reserve Corps (Dallas, Tarrant, Denton and Collins County) Author of WMD – AOA DO-online for CME

3 3 What Is Radiation? Radiation is energy transported in the form of particles or waves.

4 4 Exposure Vs. Contamination Exposure: irradiation of the body absorbed dose (Gray, rad) Contamination: radioactive material on patient (external)or within patient (internal)

5 5

6 6 Penetration Abilities of Different Types of Radiation Alpha Particles 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 Radiation Source Neutrons Stopped by a few feet of concrete CDC

7 7 Measure of Amount of radioactive material Ionization in air Absorbed energy per mass Absorbed dose weighted by type of radiation Radiation Units Quantity Activity Exposure Absorbed Dose Dose Equivalent Unit curie (Ci) roentgen (R) rad rem

8 8 A Gray (Gy) The Gray (Gy) is a unit of absorbed dose and reflects an amount of energy deposited into a mass of tissue (1 Gy = 100 rads). In this lecture, the absorbed dose we are referring to is that dose inside the patient's body (i.e., the dose which is normally measured with personal dosimeters). For most purposes, one rem equal one rad. One mrem is one thousandth of one rem and is a common means of expressing radiation.

9 9 Radiation Doses and Dose Limits Flight from Los Angeles to London 5 mrem Annual public dose limit 100 mrem Annual natural background 300 mrem Fetal dose limit 500 mrem Barium enema 870 mrem Annual radiation worker dose limit5,000 mrem Heart catheterization (skin dose) 45,000 mrem Life saving actions guidance (NCRP-116) 50,000 mrem Mild acute radiation syndrome 200,000 mrem LD 50/60 for humans (bone marrow dose) 350,000 mrem Radiation therapy (localized & fractionated) 6,000,000 mrem

10 10 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)

11 11 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)

12 12 Effective Half-life The net effect of the combination of the physical & biological half- lives in removing the radioactive material from the body Half-lives range from fractions of seconds to millions of years 1 HL = 50%2 HL = 25% 3 HL = 12.5%

13 13 Potential Types of Weapons Stolen nuclear material from a hospital, industry, university, power plant or disposal facility Creation of a dirty bomb Generally thought to be the most likely scenario. Nuclear detonation from a device. Nuclear reactor sabotage

14 14 Hypothetical Suitcase Bomb Chairman Dan Burton Committee – Demonstration of example suitcase nuke made from US nuclear shell CDC

15 15 Radionuclide Half-Life Activity Use Cesium yrs 1.5x10 6 Ci Food Irradiator Cobalt-60 5 yrs 15,000 Ci Cancer Therapy Plutonium-23924,000 yrs 600 CiNuclear Weapon Iridium days 100 Ci Industrial Radiography Hydrogen-3 12 yrs 12 Ci Exit Signs Strontium-9029 yrs 0.1 CiEye Therapy Device Examples of Radioactive Materials

16 16 Examples of Radioactive Materials Iodine days Ci Nuclear Medicine Therapy Technetium-99m 6 hrs Ci Diagnostic Imaging Americium yrs Ci Smoke Detectors Radon days 1 pCi/l Environmental Level

17 17 Trinity Site N.M. 5:29 AM July 16 th 1945

18 18 Types of Radiation Hazards External Exposure - whole-body or partial- body (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

19 19 Scope of Event Event Number of Deaths Most Deaths Due to Radiation Accident None/Few Radiation Radioactive Dispersal Device Few/Moderate (Depends on size of explosion & proximity of persons) Blast Trauma Low Yield Nuclear Weapon Large (e.g. tens of thousands in an urban area even from 0.1 kT weapon) Radiation Exposure Blast Trauma Thermal Burns Fallout (Depends on Distance)

20 20 Map of Our Nuclear Power Plants

21 21 Facility Preparation Activate hospital plan –Obtain radiation survey meters –Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics) –Plan for decontamination of uninjured persons –Establish triage area

22 22 Develop Radiological Response Team Team Coordinator (leader) Emergency physician(s) Nurse (s) Triage Officer Administrator Radiation Safety Officer Maintenance Public Information Officer Security Laboratory Personnel Technical Recorder

23 23 Consult With Radiation Experts Radiation Safety Officer Health Physicist Medical Physicist Conference of Radiation Control Program Directors ( CDC

24 24 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

25 25 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)

26 26 Biodosimetry Assessment Tool Armed Forces Radiobiology Research Institute

27 27 Facility Preparation 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

28 28 Contaminated Waste Treatment Area Layout Radiation Survey HOT LINE STEP OFF PAD CONTAMINATED AREA BUFFER ZONE CLEAN AREA Radiation Survey & Charting ED Staff Clean Gloves, Masks, Gowns, Booties Separat e Entranc e Trauma Room

29 29 Immediate Medical Management Triage –ARS –localized/ cutaneous –combined injury Initial stabilization and treatment Psychological effects Record keeping/ Dose assessment

30 30 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 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

31 31 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

32 32 Patient Management - Triage Triage based on: Injuries Signs and symptoms - nausea, vomiting, fatigue, diarrhea History - Where were you when the bomb exploded or incident occurred? Contamination survey

33 33 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

34 34 Psychological Casualties Provide psychological support to patients and set up a center in the hospital for staff Establish triage (monitoring and counseling) centers to prevent psychological casualties from overwhelming health care facilities –Staff counseling centers with physicians with a radiological background, health physicists with instrumentation and psychological counselors

35 35 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

36 36 Patient Management - Decontamination Decontamination priorities: –Decontaminate wounds first, then intact skin –Start with highest levels of contamination Change outer gloves frequently to minimize spread of contamination

37 37

38 38

39 39 Patient Management - Decontamination (Cont.) 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

40 40 Patient Management - Decontamination (Cont.) 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

41 41 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 exams…residual contamination can be controlled.

42 42 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

43 43 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 background…higher levels may be acceptable

44 44 Data Management

45 45 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 CDC

46 46 Occurs only in patients who have received very high radiation doses (greater than approximately 100 rem or rads (1 Gy)) to most of the body Dose ~ 15 rem –no symptoms, possible chromosomal aberrations Dose ~ 50 rem –no symptoms, minor decreases in white cells and platelets Radiation Sickness Acute Radiation Syndrome

47 47 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 Manifest Illness Stage –Hematopoietic –Gastrointestinal –CNS Acute Radiation Syndrome (Cont.) For Doses > 100 rem Time of Onset Severity of Effect

48 48 Acute Radiation Syndrome (ARS) Radiation must be of penetrating type (X-rays, gamma rays or neutrons) Most or all of body must be exposed. The dose must be from an external source. Dose must be delivered in a short time. Not fractionated.

49 49 The Three ARS Syndromes Hematopoetic – Between 0.7 Gy and 10 Gy –Mortality rate is proportional to dosage. –Death from hemorrhage and infection –Absence of stem cells with leukopenia and thrombocytopenia. If they survive, anemia later.

50 50 Dose ~ 100 rem –~10% exhibit nausea and vomiting within 48 hr –mildly depressed blood counts Dose ~ 350 rem –~90% exhibit nausea/vomiting within 12 hr, 10% exhibit diarrhea within 8 hr –severe bone marrow depression –~50% mortality without supportive care Acute Radiation Syndrome (Cont.) Hematopoietic Component - latent period from weeks to days

51 51 Acute Radiation Syndrome (Cont.) Hematopoetic Component - Latent Period From Weeks to Days Dose ~ 500 rem –~50% mortality with supportive care Dose ~ 1000 rem –90-100% mortality despite supportive care

52 52 Andrews Lymphocyte Nomogram From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp Vienna, International Atomic Energy Agency, 1965, pp From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp Vienna, International Atomic Energy Agency, 1965, pp n Confirms suspected radiation exposure n Determines significant hematological involvement n Serial CBCs every hours n Confirms suspected radiation exposure n Determines significant hematological involvement n Serial CBCs every hours

53 53 The Three ARS Syndromes Gastrointestinal – –Usually occurs with exposure to 10 and 100 Gy (1000 to 10,000 rads) – –Nausea, vomiting and diarrhea. –Death within two weeks with complications of infection (always have the hematopoetic syndrome as well), electrolyte imbalance, dehydration, hemorrhage. –Survival uncommon.

54 54 Dose > 1000 rem - damage to GI system –severe nausea, vomiting and diarrhea (within minutes) –short latent period (days to hours) –usually fatal in weeks to days Dose > 3,000 rem - damage to CNS –vomiting, diarrhea, confusion, severe hypotension within minutes –collapse of cardiovascular and CNS –fatal within 24 to 72 hours Acute Radiation Syndrome (Cont.) Gastrointestinal and CNS Components

55 55 The Three ARS Syndromes Cardiovascular Syndrome –Usually with extremely high dosage. > 50 Gy or 5000 rads. Some symptoms possible at 20 Gy. –Cerebral edema, vasculitis, meningitis with convulsions, coma and death –Cardiovascular collapse –Death in 3 days or less

56 56 Estimating the severity of radiation injury is difficult. –Signs and symptoms (N,V,D,F): Rapid onset and greater severity indicate higher doses. Can be psychosomatic. –CBC with absolute lymphocyte count –Chromosomal analysis of lymphocytes (requires special lab) Treatment of Large External Exposures

57 57 Treatment of Large External Exposures Treat symptomatically. Prevention and management of infection is the primary objective. –Hematopoetic growth factors, e.g., GM-CSF, G- CSF (24-48 hr) –Irradiated blood products –Antibiotics/reverse isolation –Electrolytes Seek the guidance of experts. –Radiation Emergency Assistance Center/ Training Site (REAC/TS) –Medical Radiobiology Advisory Team (MRAT)

58 58 Other Treatment Methods Minimize intake. Reduce and/or inhibit absorption. Block uptake. Use isotopic dilution. Promote excretion. Alter chemistry of the substance. Displace isotope from receptors. Chelate.

59 59 Radionuclide-specific Most effective when administered early May need to act on preliminary information NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides Treatment of Internal Contamination RadionuclideTreatmentRoute Cesium-137Prussian blueOral Iodine-125/131Potassium iodideOral Strontium-90Aluminum phosphateOral Americium-241/Ca- and Zn-DTPAIV infusion, Plutonium-239/nebulizer Cobalt-60

60 60 Blocking Radioactive Iodine The dominant initial internal contaminant after a reactor accident, nuclear weapons test, or any incident involving fresh fission products is likely to be 131I. Block thyroid if radioactive iodine is a factor or if you are unsure. Give potassium Iodide 130 mg immediately to an adult then continue for 7 days.

61 61 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) Hours ~3 Months Emergency Surgery Hematopoietic Recovery No Surgery After adequate hematopoietic recovery Surgery Permitted

62 62 Cutaneous Radiation Syndrome May occur as part of the ARS May occur from beta rays or X-rays without ARS May be due to contamination of patients skin or clothing from radioactive particles.

63 63 Cutaneous Radiation Syndrome Inflammation Erythema usually with itching at first Dry desquamation, epilation, Moist desquamation Ulceration, blisters, Basal cell layer damaged, sebaceous and sweat glands destroyed. Hyperpigmentation later Delayed onset of about days to weeks.

64 64 Biological Effects of Ionizing Radiation Deterministic effects: n occur when the dose is above a given threshold (characteristic for the given effect); n severity increases with the dose; n many cells must die or have their function altered examples: erythema, fibrosis, marrow depletion, cataract. examples: erythema, fibrosis, marrow depletion, cataract. Stochastic (probabilistic): n have no known threshold; n probability of occurrence increases with dose; n may result from alteration in only one or a few cells examples: carcinogenic - various neoplasms, examples: carcinogenic - various neoplasms, genetic - various hereditary disorders. genetic - various hereditary disorders.

65 65 Radiation Effects Radiation Effects Early (Deterministic only) Local Radiation injury of individual organs: Functional and/or morphological changes within hrs-days-weeks Acute radiation disease Acute radiation syndrome (LD 50/60 ~ 3.5Sv LD ~ 5 Sv) Late Deterministic (Above D Q, cummul. ) - Rad. Dermatitis - Rad. Cataracta - Teratogenic (D Q,F ~0,1Sv) ( Probability increases with dose) - Tumors, leukemia - Genetic effects Stochastic Systemic

66 66 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 Localized Radiation Effects - Organ System Threshold Effects

67 67 Time of Onset of Clinical Signs of Skin Injury Depending on the Dose Received Symptoms Dose range Time of onset (Gy) (day) (Gy) (day) l Erythema l Epilation > l Dry desquamation l Moist desquamation l Blister formation l Ulceration > l Necrosis >25 >21 Ref.: IAEA-WHO: Diagnosis and Treatment of Radiation Injuries. IAEA Safety Reports Series, No. 2, Vienna, 1998

68 68 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:

69 69 Chronic 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%

70 70 Stochastic Effects of Radiation Exposure l Frequency is proportional to dose l No threshold dose l No method for identification of the appearance of this effect of ionizing radiation in individuals l Increase in occurrence of stochastic effect can be proved with epidemiological method only

71 71 Human Data on Radiation Cancerogenesis

72 72 Cancer Deaths Attributable to A-bombs In 86,572 survivors of Hiroshima and Nagasaki A- bombing 7,827 persons died of cancer in : Observed ExpectedExcess (%) All tumors (4.4) Leukaemia (35.0) All cancers (5.4) Ref: Pierce et al, Rad.Res. 146: 1-27, 1996

73 73 Cancer mortality of nuclear industry workers

74 74 Latency Periods for Radiation-induced Cancer

75 75 Teratogenic Effects of Radiation l Mental retardation n Highest risk during major neuronal migration, on weeks. Incidence increases with dose. At 1 Gy fetal dose 75% experience severe retardation n At weeks, fetus shows no increase in mental retardation at doses < 0.5 Gy n IQ - Risk factor associated with diminution of IQ is points at 1 Gy to fetus on 8-15 weeks. l Microcephaly n Observed in 30 children of ~1000 exposed in Hiroshima and Nagasaki pregnant women n The effect <0.3 Gy is not significantly different of control

76 76 Fetal Irradiation No 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) < All Pre-implantation Organogenesis Fetal Weeks After Fertilization Period of Development Effects

77 77 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

78 78

79 79 The Three Basic Ways to Reduce Radiation Exposure TIME Decrease the amount of time you spend near the source of radiation. DISTANCE Increase your distance from a radiation source. SHIELDING Increase the shielding between you and the radiation source. Shielding is anything that creates a barrier between people and the radiation source. Depending on the type of radiation, the shielding can range from something as thin as a plate of window glass or as thick as several feet of concrete. Being inside a building or a vehicle can provide shielding from some kinds of radiation.

80 80 Personally, What You Should Do! Radiological Attack Avoid inhaling dust as it could be radioactive. If an explosion occurs outdoors and you are informed that radiation is involved, if you are outdoors, cover nose and mouth and seek indoor shelter as soon as possible. If you inside an undamaged building, stay there. Close windows and doors and shut down ventilation system. Exit when told that it is safe after testing.

81 81 Personally, What You Should Do! Radiological Attack If an explosion occurs inside your building, cover nose and mouth and evacuate as soon as possible. Decontaminate by removing clothing and showering. Relocate outside the contaminate zone. Obey public officials. This is the scenario of a dirty bomb.

82 82 Personally, What You Should Do! Actual Nuclear Attack Move out of the path of a nuclear fallout cloud as quickly as possible (10 minutes or less) if you are in the blast zone and can do so. Find medical help ASAP.

83 83 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. Reproduced with permission

84 84 Other Resources Additional slides by permission Istvan Turai MD PhD, International Atomic Energy Commission CDC Video Medical Response to Nuclear and Radiological Terrorism REACT/ REAC/TS (Oak Ridge Radiation Emergency Assistance Center/Training Site) DOE/OROC (865)

85 85 Always Contact Local Public Health Department Tarrant County Public Health 1101 S. Main Street Fort Worth, Texas Dallas County Department of Health & Human Services 2377 N. Stemmons Freeway Dallas, Texas

86 86 We will Always Remember

87 87 Thank You for Coming Stevan Cordas DO MPH

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