1. DPT 7.0 Do not print this slide. Chart only used for Note page. Domestic Preparedness Hospital Provider Course

2. DPT 7.0 Hospital Management of Nuclear Casualties

3. DPT 7.0 Terminal Objective Recognize the various types of radiological hazards, understand the acute health effects from radiation exposure, hospital procedures for managing exposed and/or contaminated patients, and know how to use radiation protection.

4. DPT 7.0 Terrorist Use of Nuclear Material Terrorist use of nuclear materials –Simple radiological device –Radiological dispersal device –Reactor –Improvised nuclear device –Nuclear weapon

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6. DPT 7.0 Do not print this slide. Chart only used for Note page.

7. DPT 7.0 The Basics of Radiation Ionizing radiation is electromagnetic energy or energetic particle emitted from a source. Ionizing radiation is able to strip electrons from atoms causing chemical changes in molecules.

8. DPT 7.0 Do not print this slide. Chart only used for Note page.

9. DPT 7.0 The Basics of Radiation Chemical Damage Free Radicals 10 -10 Seconds 1. Proteins 2. Membrane 3. DNA Biological Molecular Damage Cells, tissues, whole animals Hours to years Biological Damage Seconds to hours

10. DPT 7.0 Ionizing Radiation - Alpha 2 neutrons and 2 protons Highly ionizing Travels several centimeters in air and a few microns in tissue Component of nuclear fallout Stopped by a thin paper or clothing Threat is inhalation or absorption of alpha emitter in wounds

11. DPT 7.0 Ionizing Radiation - Beta High energy “electron” emitted from nucleus Can have wide range of energies depending upon the particular radionuclide Moderately penetrating –Up to a few meters in air –Millimeters in tissue Some protection by PPE

12. DPT 7.0 Gamma or X-Ray (Photons) High energy rays Very penetrating Difficult to shield Can be produced from radioactive decay and a nuclear weapon explosion or reactor accident PPE will not protect against photon radiation

13. DPT 7.0 Ionizing Radiation - Neutrons Neutral particle emitted from the nucleus Can be very penetrating Requires special consideration for shielding

14. DPT 7.0 Radiation Detection Instrumentation –G.M. Survey Meter –Dose Rate Meter - Ionization Chamber –Alpha Meter –Neutron Meter Personal Dosimeters –Film Badge –Thermoluminescent Dosimeter –Quarts Fiber Dosimeter –Electronic Instantaneous Read Out Dosimeter

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16. DPT 7.0 Radiation - Units of Measure rad - basic unit for measuring radiation rem - quantifies the amount of damage that is suspected from a particular type of radiation dose

17. DPT 7.0 X-RAY100 rads=100 rem BETA100 rads=100 rem GAMMA100 rads=100 rem NEUTRONS10 rads x QF10=100 rem ALPHA5 rads x QF20=100 rem Radiation - Units of Measure

18. DPT 7.0 Substance Half Life Emit Use Americium 241 458 years ,  Smoke Detectors Cobalt 60 5.3 years ,  Medical Therapy Plutonium 238 87 years  Thermoelectric Gen. Plutonium 239 24,400 yrs  Reactors and Weapons Radium 226 1,620 yrs  Medical Therapy Uranium (natural) millions yrs  ,  Reactors and Weapons Iridium 192 74 days ,  Industrial Radiography Examples of Radioactive Materials

19. DPT 7.0 Radiation Half-Life Time required for a radioactive substance to lose half of its radioactivity Each radionuclide has a unique half-life Half-lives range from extremely short (fraction of a second) to millions of years Examples: Tc-99m6.0 hrs I-1318.05 days Co-605.26 yrs Sr-9028.1 yrs Pu-23924,400 yrs U-2384,150,000,000 yrs

20. DPT 7.0 Natural Background Radiation Natural background and manmade radiation 360 mrem Diagnostic chest x-ray 10 mrem Flight from LA to Paris 4.8 mrem Barium enema 800 mrem Smoking 1.5 ppd - 1 year dose 16,000 mrem Heart catheterization 45,000 mrem Mild acute radiation sickness 200,000 mrem LD 50 for irradiation 450,000 mrem mrem = millirem = 1/1000 of a rem

21. DPT 7.0 Radiation Protection Principles Time Distance Shielding Quantity

22. DPT 7.0 Types of Radiation Injury External irradiation - whole-body or partial-body Contamination by radioactive materials - external (deposited on the skin) or internal (inhaled, swallowed, absorbed through skin, or introduced through wounds) Incorporation of radioactive materials - uptake by body cells, tissues, or organs (bone, liver, kidney, etc) Combined radiation injury - combination of the above complicated by trauma.

23. DPT 7.0 Radiation Injury - External Irradiation s     Local Partial Body Whole Body 

24. DPT 7.0 Radiation Injury - Contamination InternalExternal

25. DPT 7.0 Radiation Injury - Incorporation Thyroid Lung Liver Bone

26. DPT 7.0 Radiation - LD 50 We know what radiations are produced We know how to measure them But the body senses cannot detect radiation. Therefore, how can we measure the biological damage? –LD 50/30 Animals –LD 50/60 Man

27. DPT 7.0 Examples of LD 50 for Given Species Species Dose (rads) Guinea Pigs250 LD 50/30 Goat350 LD 50/30 Man250-450 (LD 50/60) Mouse570 LD 50/30 Rat550-800 LD 50/30 Frog700 LD 50/30 Snail8,000-20,000 LD 50/30

28. DPT 7.0 Severity of Injury The higher the dose, the more severe the early effects and the greater the possibility of delayed effects

29. DPT 7.0 Survival Time 200 Rads 2 Gy 1000 Rads 10 Gy 100,000 Rads 100 Gy Hematopoietic Gastrointestinal CNS/ CVS Survival Time

30. DPT 7.0 Acute Radiation Syndrome (ARS) Group of symptoms that develop after total body irradiation (> 100 rads) May occur from either internal or external radiation Four important factors are: –High Dose –High Dose Rate –Whole Body Exposure –Penetrating Radiation

31. DPT 7.0 ARS - Phases 1.Prodromal Phase - occurs in the first 48 to 72 fours post- exposure and is characterized by nausea, vomiting, and anorexia. At doses below about 500 rads last 2 to 4 days. 2.Latent Phase - follows the prodromal phase and lasts for approximately 2 to 2 1/2 weeks. During this time, critical cell populations (leukocytes, platelets) are decreasing as a result of bone marrow insult. The time interval decreases as the dose increases. 3.Illness Phase - period when overt illness develops 4.Recovery or Death Phase - may take weeks or months

32. DPT 7.0 ARS - Hematopoietic Syndrome 3.0 2.5 2.0 1.5 1.0 0.5 0.1 036172448 hrs Normal Range Moderate Severe Very Severe Lethal Injury Absolute Lymphocytes (10 9 /L) Patient

33. DPT 7.0 ARS - Blood Count 24-hr1 week2 weeks3 weeks Lymphocytes Neutrophils Platelets RBC Cell Reduction

34. DPT 7.0 ARS - Gastrointestinal Syndrome Radiation > 600 rads Damages intestinal lining Nausea and vomiting within the first 2 - 4 hours May develop diarrhea Associated with sepsis and opportunistic infections At 10 days could develop bloody diarrhea resulting in death

35. DPT 7.0 ARS - Central Nervous System Seen with radiation dose > 1,000 rads Microvascular leaks Õ edema Elevated intracranial pressure Death within hours

36. DPT 7.0 ARS - Skin Response Epilation Erythema Dry Desquamation Moist Desquamation Necrosis 300600 1000 >1500 >5000 Dose

37. DPT 7.0 ARS & Trauma Radiation and Trauma =  Mortality Wound and burn care, surgery, and orthopedic repair should be done in the first 48 hours or delayed for 2 to 3 months 24 - 48 Hours 3 Months Emergency Surgery Hemopoietic Recovery No Surgery After 3 Months Surgery Permitted

38. DPT 7.0 Triage Triage: –Use your own triage method –Ensure ABC’s –Stabilize the patient first and only when this is done does one consider irradiation and contamination.

39. DPT 7.0 Classification, Treatment & Disposition Patients are classified in three categories based on signs and symptoms: –Survival probable < 100 rads –Survival possible 200 - 800 rads –Survival improbable > 800 rads

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41. DPT 7.0 Evaluation & Treatment - Hospital Care Activate hospital plan Establish triage area Plan to control contamination –Prepare area by cover/marking floor, control ventilation –Prepare staff by issuing protective clothing –Prepare for surveying –Establish area for storage of waste –Plan for decontamination of non-traumatized patients

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43. DPT 7.0 Hospital Care - Patient Arrival Carefully remove and bag victim’s clothing and personal belongings Survey patient and conduct biological sampling Contaminated patients require decontamination If patient has a wound, decontaminate it first, then decontaminate skin

44. DPT 7.0 Decontamination Irrigate open wounds and cover with sterile dressing Soap and water showering (including hair) Effective for mixed radiation/chemical contamination Refer for any surgery

45. DPT 7.0 Internal Contamination/Incorporation Various medications can be used to limit uptake or facilitate removal of radioactive material Numerous medications are approved by the FDA. Certain drugs are investigational and can be used in an emergency (i.e. Radiogardase [Prussian Blue] and DTPA) NCRP 65

46. DPT 7.0 Psychological Casualties Mass Casualty Incident (MCI) caused by nuclear terrorism will create large numbers of concerned casualties who may not actually be injured or contaminated Establishing counseling centers will prevent psychological casualties from overwhelming health care facilities

47. DPT 7.0 Key Points Pre-planning to ensure adequate supplies of PPE and survey instruments Training to ensure competence at all levels Rescue and treatment protocols vary little for radiation contamination Donning PPE and decontaminating patients minimizes exposure risk Early symptoms are an indication of the severity of the radiation dose Treatment requires a unified effort

48. DPT 7.0 Do not print this slide. Chart only used for Note page.