Nuclear Disasters and Children

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Nuclear Disasters and Children

• Phillip Jacobson, M.D.

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Possible Situations

• Dispersing of radioactive substances without
  explosives
• Dirty Bomb
• Attack on nuclear reactor (or accident)
• Detonation of a nuclear weapon
• Mettler, FA etal. NEJM 20023461554-1561

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Possible SituationsDispersal of Radioactive
Substances

• Minimally Radioactive
• Radiopharmaceutical agents
• Research isotopes
• Highly Radioactive
• Industrial Radiographic Devices
• Cobalt-60
• Cesium-137
• Iridium-192

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Possible SituationsDirty Bomb

• The use of conventional explosives to disperse
  radioactive substances. (Radiation Dispersion
  Device or RDD)
• Health problem would be restricted to a few city
  blocks
• Purpose would be to cause greater fear and panic

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Possible SituationsAttack of Nuclear Power Plant

• A breach in the reactor core would have immediate
  health concerns for people nearby.
• Large amounts of radioactive iodine would be
  released exposing people at great distances,
  causing long term health effects

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Possible SituationsDetonation of Nuclear Weapon

• Destructive effect would be air blast as well as
  thermal radiation
• Extent of damage depends on size and strength of
  weapon
• Looking at fireball from several miles can cause
  temporary or permanent blindness

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History

• Hiroshima, Nagasaki 1945
• Marshall Islands 1954
• Chernobyl 1986
• Goiania 1987

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History of Nuclear EventsHiroshima

• 15 kiloton TNT
• 66,000 killed
• 69,000 injured
• 255,000 exposed
• Avalon Project, Yale Law School 2002chapter 10

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History of Nuclear EventsNagasaki

• 22 kiloton TNT
• 39,000 killed
• 195,000 exposed

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History of Nuclear EventsMarshall Islands

• Nuclear weapons testing on Bikini Island
• 32 pediatric patients exposed
• 4 children developed thyroid cancer
• 1 child developed leukemia
• Merke DP, etal In Guzelian PS. Similarities
  and Differences Between Children and Adults
  Implications for Risk Assessment. Washington, DC
  International Life Science Institute
  1992139-149

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History of Nuclear EventsChernobyl

• Nuclear power plant meltdown
• 120 million Ci released
• 21,000 km2 contaminated in Ukraine, Belarus and
  Russia
• 17,000,000 exposed to excess radiation
• 2.5 million children lt 5 y/o age exposed
• 135,000 people permanently evacuated
• Likhtarev IA, etal. Health Phys.2002 82290-303

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History of Nuclear eventsGoiania, Brazil

• Radioactive Cs (1400 Ci)
• 250 people exposed
• 4 people died of acute radiation sickness
• Thousands of ER visits
• Collins DL, etal. Behav Med. 1993 18149-157

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General Principles

• Ionizing Radiation High frequency energy
  emitted from an unstable atom trying to achieve
  stability.
• Damages DNA
• Disrupts chemical bonds
• Produces free radicals
• Moulder JE. Radiat Res.2002 158118-124

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General PrinciplesTypes of Radiation

• Electromagnetic Energy
• Gamma Rays
• Short wavelength, high energy
• Very penetrating
• Travels many meters in air
• Easily penetrates clothes and biological tissue
• X-rays
• Longer wavelength than gamma, less energy
• Very penetrating

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Types of RadiationParticulate

• Alpha Particles
• Composed of 2 neutrons and 2 protons
• Easily stopped by skin and clothes
• Only Inhalation or ingestion causes damage
• Beta Particles (ve electrons)
• High energy electrons emitted from nucleus
• Penetrate a few mm into skin.

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Types of RadiationParticulate

• Neutrons
• Highly penetrating
• 20x more damaging than gamma rays
• Only emitted during nuclear detonation

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General Principles

• Senses cannot detect radiation.
• Individuals cannot see, hear, smell, taste or
  feel it.
• Lethal dose of radiation could be delivered
  without realizing it.

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General Principles

• Radiation hazard is related to
• Strength of source of radioactivity
• Total radioactivity absorbed per volume of tissue
• Exposure and Absorption depends on
• Time
• Dose
• Distance
• Shielding

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General PrinciplesMeasurements

• Rad (Radiation absorbed dose) 0.01 J/Kg
• Rem (Radiation equivalent man) Biological damage
  from 0.01 J/kg of x-rays
• Gray (Gy) 1 J/kg 100 rad
• Sievert (Sv) 100 rem

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General PrinciplesTypes of Injury

• Exposure to external radiation
• Contamination with radioactive material
• Incorporation of radioactive material into body
  tissues
• Trauma

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General PrinciplesTypes of Injury

• Contamination, 2 types
• External radioactive materials (solids,
  liquids, gas) released in atmosphere and
  precipitating down. Exposed surfaces of body
  become contaminated.
• Internal Inhalation, ingestion, exposed wounds

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General PrinciplesTypes of Injury

• Incorporation Uptake of radioactive materials
  by organs, tissue and cells. Distribution
  depends on physical and chemical forms and
  solubility and cell type

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General Principles Vulnerabilities of Children

• Higher Minute Ventilation
• Closer to ground
• Thinner, more delicate skin
• Proportionately greater body S.A.
• Lower intravascular volume

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General Principle Vulnerabilities of Children,
Short Term

• Contaminated breast milk
• Contaminated cows milk
• Transplacental transmission of radionuclides1
• Thyroid glands concentrate more iodine2
• 1. Merke DP in Similarities and difference
  between Children and Adults Implications for
  Risk Assessment. Washington, DC International
  Life Sciences Institute 1992139-149
• 2.Young RW. Pharmacol Ther. 19983927-32

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General Principles Vulnerabilities of Children,
Long Term

• Longer Life ( time for radiation effects)
• thyroid cancer1
• leukemia1
• breast cancer2
• severity and longevity of psych and behavior
  problems3
• 1. Yu, CE Pediatr. Ann 200332169-176
• 2. AAP Pediatrics 1998101717-719
• 3. Pynoos RS Child Adolesc Clin North Am.
  19987195-210

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Biological EffectsMechanism of Radiation Damage

• Direct 20
• Chromosomal breaks occur directly from radiation
  energy
• Indirect 80
• Body water ionized with H and OH- which cause
  DNA damage
• Biological expression at the cellular level can
  take seconds to hours

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Clinical Effects

• Trauma
• Air Blast
• Flying or falling debris
• Burns
• Thermal Radiation
• Acute Radiation Syndrome
• National Council on Radiation Protection and
  Measurements. Management of Terrorist Events
  Involving Radiactive Material 2001

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Acute Radiation Syndrome

• Factors for time of onset and degree of severity
• Dose
• Dose rate
• Penetrating radiation
• body exposure

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Acute Radiation Syndrome (ARS)Definition

• The acute radiation syndrome is a broad term
  used to describe a range of signs and symptoms
  that reflect severe damage to specific organ
  systems and that can lead to death within hours
  or up to several months after exposure.
• National Council on Radiation Protection and
  Measurements. Management of Terrorist Events
  Involving Radioactive Material 2001

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Acute Radiation SyndromeGeneral Considerations

• Cell death can occur by impairment of cell
  division (without killing the cell outright)
• Organ systems with most rapidly dividing cell
  lines and least differentiated are most
  vulnerable (GI and Hematopoietic)
• The higher the radiation dose, the more rapid
  onset of symptoms

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Acute Radiation SyndromeGeneral Principles

• LD50/60 is about 2.5 to 4.5 Gy
• lt 0.7 Gy unlikely to cause ARS
• 4 phases of ARS
• 1. Prodrome
• 2. Latency
• 3. Illness
• 4. Recovery or Death

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Acute Radiation Syndrome

• Prodrome
• Occurs minutes to hours after exposure
• NV, anorexia
• Can last for 2 to 4 days
• Onset within 2 hrs is bad prognostic sign

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Acute Radiation Syndrome

• Latent Phase
• Only occurs with low doses (2 3) Gy
• Onset is 2 4 days
• Lasts 2 4 weeks
• in lymphocytes, leukocytes and platelets

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Acute Radiation Syndrome

• Illness Phase Signs and Symptoms
• N V, Diarrhea
• Fatigue
• Infection
• Shock

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Acute Radiation SyndromeHematopoietic Syndrome

• in lymphocyte line, granulocytes, platelets,
  reticulocytes
• Anemia
• Hemorrhage
• Infection
• Impaired wound healing
• Lymphocyte count at 48 hrs. correlates well with
  dose received

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Acute Radiation syndromeGI Syndrome

• Damage to epithelial lining of intestine
• N V, diarrhea
• Hypovolemia, electrolyte imbalance
• Translocation of Bacteria
• Opportunistic infection
• Occurs at doses of gt 800 rad

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Acute Radiation SyndromeCerebrovascular Syndrome

• Capillary leaks in vessels of brain
• Cerebral edema
• Confusion, disorientation, convulsions, coma,
  hyperthermia.
• No recovery. Certain death within days
• Only occurs at doses of gt 30 Gy

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Acute Radiation SyndromeSkin Involvement

• Can arise from local contamination
• Type of skin lesion is a good indicator of dose
• Epilation lt erythema lt dry desquamation lt wet
  desquamation lt necrosis

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ManagementOrganizational

• Integrated fed, state, local PH response
• e.g. Emergency broadcasting, evacuation,
  sheltering, antidote therapy
• Disaster command teams for each hospital
• e.g. Supplies, staffing, safety of health care
  workers, communication

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ManagementMedical

• ABC
• Trauma and burns are emergencies that must be
  dealt with first
• Radiation exposure is not an immediately life
  threatening emergency
• Decontamination

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ManagementDecontamination

• ER divided into clean and dirty area
• Remove clothing (if not already done)
• Shower thoroughly (soap and water)
• Universal precautions of health care workers
  (hcw)
• HCW should wear dosimeters.
• HCW should be rotated frequently to avoid toxic
  exposure

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ManagementLab Tests

• Nasal and throat swabs, urinary, fecal, skin and
  wound samples to identify internal contamination
  of radioactive materials
• CBC Q4-6 (watch lymphocyte and neutrophil counts
  carefully)
• Cytogenetic analysis of lymphocytes
• Na24 identification
• Managing Radiation Emergencies
  www.orau.gov/reacts/medical.htm

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ManagementOngoing

• Administer antidote
• Support fluid and electrolytes
• Rigorous infection control and treatment
• Transfusions, hematopoietic growth factors
• Continued support of trauma and burns

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ManagementAntidotes

• Potassium Iodide (KI) for Thyroid Protection
• 131I is a common byproduct of nuclear disasters
• 131I cause thyroid cancer
• KI prevents thyroid uptake of 131I
• KI blocks 90 of 131I uptake when given within 1
  hr of exposure
• Linneman RE. JAMA 1987258637-643

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ManagementAntidotes, KI
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Antidotes
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Long Term Effects
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Psychological Effects

• Developmental Regression
• Chronic fear and anxiety
• Nightmares, sleep problems
• Altered play, social withdrawal
• Direct correlation with parents response
• Warwick MC. Mo Med. 20029915-16
• AAP Work Group on Disasters. Psychosocial Issues
  for Children and Families in Disasters. US Dept
  of HHS 1995
• Sugar M. Child Psychiatr Hum Dev. 198919163-179

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SummaryNuclear Disasters

• Radiation energy is particulate and
  electromagnetic
• We have increased risk of nuclear terrorism
• Children are more vulnerable
• ABCs trauma and burns first priorities
• Exposure depends on time, dose, distance and
  shielding
• Decontamination

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Summary Nuclear Disasters

• Acute Radiation Syndrome
• Hematopoietic and GI most prominent
• Antidotes (e.g. KI)
• Long Term Effects (leukemia, cancer)
• Psychological Effects (most prevalent problem)
• Many would die. Many could be saved
• Were not adequately prepared.