In-Depth Medical Management for

1
In-Depth Medical Management for
Nuclear/Radiological/Conventional Terrorism Agents

• Editorial Board
• Fun Fong, MD, FACEP, Senior Medical Officer GA-3
  DMAT, ACEP Section of Disaster Medicine
• Cham E. Dallas, Ph.D. , Professor Director,
  Interdisciplinary Toxicology Program and Center
  for Leadership in Education and Applied Research
  in Mass Destruction Defense, University of
  Georgia
• Lorris G. Cockerham, Ph.D., DABFE, Lt. Col. (ret)
  USAF,
• Former Division Chief, Armed Forces Radiobiology
  Institute

2
Overview

• Nuclear Scenario Effects
• Radiation Injury
• Acute Radiation Syndrome
• External Contamination
• Internal Contamination
• Summary

3
Potential Nuclear/Radiological Hazards in the U.S.

• Simple Radiological Device
• Dirty Conventional Bomb (RDD)
• Improvised Nuclear Device (IND)
• 1kT backpack bomb
• Terrorist Nation Ballistic Missle Attack
• 300 MT Bomb 100 mi over Kansas for EMP

4
Diversion of Nuclear Weapons

• 50 - 100 1 kT Suitcase Nuclear Weapons
  Unaccounted For

The Threat of Nuclear Diversion. Statement for
the Record by John Deutch, Director of the
Central Intelligence to the Permanent
Subcommittee on Investigations of the Senate
Committee on Government Affairs, 20 Mar 1996.
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Energy Partition
Standard Fission / Fusion
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
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Scenario Washington Mall
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Effective Range For Blast Energy1 kT Weapon
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
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Effective Range For Blast Energy1 kT Weapon
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
12
Effective Range For Thermal Energy1 kT Weapon
Infrared 700 m 7 cal / cm2 3o Burn 800 m 4 cal
/ cm2 2o Burn 1200 m 2 cal / cm2 1o Burn
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
13
Safe Separation Distances for Eye Injuries1 kT
Weapon
Detonation Altitude - 300 m 5.9 km Flash
Blindness 16.7 km Retinal Burns 46 km Daytime
Visibility 50.8 km Nighttime Flash Blindness
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
14
Overview Conventional Weapon Terrorism

• Not a Scenario weapons of choice world-wide
• Small arms, manufactured ordnance, improvised
• 5 criminal bombings daily in US
• gtgt 99 of all terrorist attacks
• Small Arms high- and low-velocity
• Ordnance military weapons-grade
• High-order explosives overpressure blast wave
• Improvised Explosive Devices (IEDs)
• Hand-made or extemporized, 75 low-order
  explosives
• Minimal blast wave, more survivable burns
• More injuries, fewer fatalities vs. ordnance

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Overview Conventional Weapon Terrorism

• Lessons learned from prior wars can not be easily
  applied
• Terrorist weapons target non-combatant with
  varied demographics
• Civilians have inconsistent preparation,
  protection, and access to acute- and long-term
  physical care and behavioral support
• Similarities with radiological weapon injuries
  supports cross-preparedness for both
• Ordnance over-pressurization injuries will be
  similar to injuries from nuclear devices
• Both IEDs and nuclear devices can produce
  substantial thermal injuries
• Dirty grossly contaminated wounds will be the
  rule rather than the exception

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Take-home Message Local Preparedness for the
Conventional Weapon Threat

• Avoid Primary Wound Closure
• Delayed primary closure of contaminated wounds is
  critical for optimal outcome for individual
  victim
• Establish Regional Systems of Trauma Care
• Inclusive systems of organized and coordinated
  trauma care from scene to rehabilitation if
  needed.
• Expedited emergency transfers and referrals
• Critical for the optimal outcome of the community
• Right patient to right hospital in right amount
  of time
• Immediate benefit to the community

17
What is Fallout?

• A complex mixture of over 200 different isotopes
  of 36 elements
• 2 oz of fission products formed for each kT of
  yield.
• Size lt 1 micron to several mm.

18
Early Fallout

• That which reaches the ground during the first 24
  hours after detonation
• Early fallout fraction 50-70 of total
  radioactivity

19
Delayed Fallout

• Arrives after the first day, very fine invisible
  particles which settle in low concentrations over
  a considerable portion of the earths surface
• 40 of total radioactivity

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Bikini Atoll (1 Mar 1954)

• 15 MT Thermonuclear
  Detonation Fallout
• Population Affected
  300 in Public Domain
• Int / Ext Contamination
• Local Radiation Injury
• Mild ARS
• Thyroid Injury

21
Ionizing Radiation
Any Radiation Consisting of Directly or
Indirectly Ionizing Particles or Photons
22
Radiation Exposure Types
23
Acute Radiation Syndrome

• Systemic Effects of Radiation
• Prodromal
• Hematologic
• Gastronintestinal
• Pulmonary
• Cutaneous
• Neurovascular
• Combined Injury

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Prodromal Component(0.5 - 3 Gy and higher)

• Immediate Effect of Cell Membrane Damage
• Mediated by Inflammatory Elements of Cell
  Destruction
• Mediated Neurologically by the Parasympathetic
  System

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Gastrointestinal Component(8 - 15 Gy and higher)

• Symptoms
• Mechanisms
• Stem Cell Sterilization - 15 Gy

Parameter Brief Protracted
Exposure Exposure Threshold 8 18
D50 15 35
26
Respiratory Component(5 - 310 Gy and higher)

• Sensitive from Highly Vascular Tissue
• Endothelial Cells
• Type II Alveolar Cell
• Effect is dose-rate related
• Pneumonitis
• Fibrosis

27
Radiation Skin Injury

• .75 Gy - Hair Follicles Change
• 3 Gy - Epilation
• 6 Gy - Erythema
• 10 Gy - Dry Desquamation
• 20 Gy - Wet Desquamation (Transepithelial
  Injury)

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Distribution of Injuries in aNuclear Detonation
Single Injuries (30 - 40)
Combined Injuries (65 - 70)
Data from Walker RI, Cerveny TJ Eds., Medical
Consequences of Nuclear Warfare, TMM
Publications, Falls Church, 1989. p 11.
34
Neurovascular Component

• 1 - 6 Gy - Glial cell damage
• 10 Gy - Morphologic changes
• 10 - 20 Gy - Vascular lesions
• 40 Gy - White matter necrosis
• 60 Gy - Demyelinization

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Summary of Deterministic Effects
Threshold Exposure (Deterministic Effects)
Threshold ED50 Dose Oligospermia (2
Yrs) 0.3 Gy 0.7 Gy Ovulation
Suppression (permanent) 0.6 Gy 3.5
Gy Vomiting 0.5 Gy 2
Gy Diarrhea 1 Gy 3 Gy Mortality from
Marrow Syndrome (minimal care) 1.5 Gy 3
Gy Mortality from Marrow Syndrome (supportive
care) 2.3 Gy 4.5 Gy Thyroiditis 2
Gy 12 Gy Skin - Erythema 3 Gy 6
G Skin - Dry Desquamation 5 - 20 Gy 20
Gy Skin - Wet Desquamation 12 - 20 Gy -
Skin - Necrosis 20 - 30 Gy - Mortality
from Pulmonary Syndrome Lethality 5 Gy 10
Gy Mortality from Gastrointestinal Injury 8
Gy 15 Gy CNS Incapacitation 6.5 Gy 17
Gy Acute Encephalopathy 5 - 8 Gy -
Source NUREG CR-4214
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Hemogram(300 cGy TBI Exposure)
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Andrews Lymphocyte Nomogram

• Absolute Lymphocyte Count over 48 hours
• Confirms Significant Radiation Exposure

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 3- 16
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Priorities in Combined-Injury Triage When
Radiation Doses are Known
Conventional Triage Changes in Expected
Triage (No Radiation Exists) Following
Radiation Exposure lt1.5 1.5 4.5
gt4.5 gt3 h 1 3 h lt 1 h
Immediate Immediate Immediate Expectant D
elayed Delayed Expectant Expectant Minimal
Minimal Expectant Expectant Expectant Expectan
t Expectant Expectant
Modified from Medical Consequences of Nuclear
Warfare, 1989, p. 39
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Surgical Recommendations

• Based on Immunocompetence Status
• Life-Saving / Major Surgery within 36 - 48 h
• Elective Procedures until 45 - 60 days Following
  Hematopoietic Recovery

Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds)
Treatment of Radiation Injuries, 1990, Plenum
Press, New York, p. 229
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Hot Warm Cold Zones
Hot Zone
Warm Zone
Cold Zone
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Terrorism Modification of Hot Zone

• Larger Secured Hot Zone
• Casualty Collection Point in Safe Area
• Clean / Contaminated Staging Areas

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Decontamination Equipment

• Hospital Surgical Gown (waterproof)
• Cap, Face Shield, Booties (waterproof)
• Double Gloves (inner layer taped)
• Pencil Dosimeters, TLDs, Survey Meters
• Drapes
• Plastic Bags
• Butcher Paper
• Large Garbage Cans
• Radiation Signs and Tape

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Decontamination Team

• Provider (RN / PA / MD)
• HP Tech
• Decon Assistant (ED Tech)
• Circulator
• Scribe Nurse
• HP Tech 2

Minimal
Outside REA
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Decon Agents - 1

• Dry Removal
• Soap / Shampoo
• Household Bleach 110 (Sodium Hypochlorite)
• Waterless Cleansers

47
Decon Agents - 2

• Povidone-Iodine
• Lava Soap
• Cornmeal / Tide 5050
• Vinegar ( 32P ) or Club Soda
• Toothpaste

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When Do I Stop?

• When No More Comes Off!
• Stop Levels
• 1 mR / h beta
• 1000 dis / min alpha (air proportional counter w
  / 60cm2 Window)
• If Committed Dose will Not Exceed 15 rem / yr to
  Skin
• Isolate w / Bag Continue Decon Next Day

NCRP 65, p117
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Mass Casualty Planning

• Relies on Avenues of Self-Decon
• More than Finding Shower Facilities

Label Clothing
Double Bag Clothing
Temporary Clothes
Towels
Return Clothes Bag
Male Victims
Bag Clothing
Shower 1
Shower 2
Shower 2
Shower 1
Bag Clothing
Female Victims
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4 Golden Rules of Toxicology
(Adapted from Kent Olson, MD FACEP)

• Treat the Patient before the Poison
• Prevent or Reduce Exposure
• Enhance the Elimination of the Agent
• Consider Specific Adjuncts and Antidotes

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Radiation Accidents can Pose Toxicology Problems

• The Dose makes the Poison
• Acute (Threshold Effects)
• Long-Term Toxicity
• ALI / MPBB
• lt 1 ALI - No Treatment Necessary
• 1 - 10 ALI - Consider Short-Term Tx
• gt 10 ALI - Treatment

1
1Radiation Protection Dosimetry, Vol 41, No 1,
1992, p. 25
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Internal Contamination Involves 4 Stages

• Deposition Along Route of Entry
• Translocation
• Deposition in Target Organ
• Clearance

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Schematic Model of Radionuclide Uptake(After
Voelz)
Inhalation
Surface
Intake
Ingestion
Lung Clearance
Lung
Skin 1. Intact 2. Wounds
GI Tract
Lymph Nodes
Uptake
Blood
(Recycle)
Kidney
Deposition Sites
1. Whole Body 2. Bone 3. Liver 4. Thyroid
Excretion
Feces
Urine
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RN Therapeutic Interventions

• Plutonium / Transuranics - DTPA
• Cesium - Insoluble Prussian Blue
• Uranium - Alkalinization of Urine
• Radioiodine - Radiostable Iodine
• Tritium - Radiostable Water
• Fission Products (Fallout) - Combination

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DTPA Administered for Soluble 239Pu Within One
Hour

• Retention
• Organ Control DTPA Treated
• Liver 14 0.47
• Skeleton 57.0 5.9

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Insoluble Prussian Blue Effective for Cs-137

• Binds Ions in the Gut
• Biological Half-Life Reduced to 1/3
• Not Systemically Absorbed
• Side Effects - Constipation, GI
  Upset at Higher Doses (20 g / day)

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Uranium - Alkalinize Urine

• 235U - 186 keV Gamma
• Eff Half Time Depends on Solubility
• At Normal Enrichment Levels, Primary Renal
  Toxicity
• Maintain Urine pH 7.5 to 8
• Use Bicarbonate tablets
  (Do not use Alka Seltzer from old texts!)
• Use Supplimental KCl tablets to maintain alkaline
  diuresis

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Iodine / Technetium - Block

• 131I - Eff Half Life 7.6 days
• 99mTc - Eff Half Life 1 day
• Treat within 4 Hours
  ( Best 1 Hour Before Exposure! )
• KI or NaI 300 mg tablet
• SSKI (1 g / ml) - 5 - 6 drops in water
• Povidone Iodine Theoretically Useful

NCRP Report No 65, p 83-86, 104
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Tritium - Dilute

• Beta Emitter - 5.7 keV (18 keV Max)
• 2 Binds to Cellular Components
• Essentially Occupies TBW Space
• Force Fluids 3 - 4 L / day
• Reduces Half-Time by 1/3 - 1/2

NCRP Report No 65, p 105-106
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Radiostrontium Contamination Therapy

• Al Phosphate (100 ml) Reduces Absorption as much
  as 85
• Ba Sulfate
• Na Alginate Inhibits Uptake by Factor 8 - 10
• 10 g po
• Ca Competes with Sr given po / IV
• Ammonium Chloride po provides Synergy for max
  effect

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Fission Products (Fallout)from Safety Series 47

• Wounds Apply potassium rhodizonate (1 g)
• Inhalation / Ingestion - Calcium Alginate (10 g)
• Potassium Iodide (130 mg)
• Prussian Blue (1 g)
• DTPA (1 g)

Safety Series 47, Manual on Early Medical
Treatment of Possible Radiation Injury 1978, p.
131
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Radiation Accident Medical Response - Individual

• Data-Gathering
• Resource Management
• Contamination Control
• Medical Care ( Compromised? )
• Radiation Toxicity Issues
• Contamination Issues
• Systemic Issues
• Toxicological Issues
• Disposition Issues

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Radiation Accident Medical Response - Large Scale

• Establish Credibility of Incident
• Health Physics Support for Dose Estimates
• Contamination Precautions
• Assess Patients for Systemic Effects
• Determine Need for Decorporation Therapy
• Record Patient Data for Follow-up

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Lessons Learned
Dont fight the Americans without nuclear
weapons
Indian Chief of Staff - in reponse to a question
about the lesson of the Persian Gulf War
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All that is Necessary for the Triumph of Evil
Is for Good Men to Do Nothing
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References - 1

• Walker RI, Cerveny TJ Eds., Medical Consequences
  of Nuclear Warfare, TMM Publications, Falls
  Church, 1989.
• Brill AB Ed Low Dose Radiation Effects A Fact
  Book, New York, Society of Nuclear Medicine 1982
  p1-5.
• Kathren RL Ed Principles and Application of
  Collective Dose in Radiation Protection, NCRP
  Report 121. Bethesda MD, National Council on
  Radiation Protection and Measurements, 1995 p65.
• "Nonstochastic Effects of Ionizing Radiation,"
  Annals of the ICRP , ICRP Publication 41. New
  York, Pergamon Press, 1984p.2.
• After REAC/TS Videotape - Hospital Management of
  Radiation Accidents, Oak Ridge, TN, Oak Ridge
  Associated Universities, 1980.
• Wheater RH Ed A Guide to the Hospital Management
  of Injuries Arising from Exposure to or Involving
  Ionizing Radiation. Chicago, American Medical
  Association, 1984 pp.4-5.

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References - 2

• Mettler FA, Ricks RC Medical Management of
  Radiation Accidents. Contemp Diag Radiol
  1982,58p1.
• Agency for Toxic Substances Disease Registry
  (ATSDR). Managing Hazardous Materials Incidents,
  Vol. I-III. US Dept. Of Health and Human
  Services, 1992.
• Mettler FA, Kelsey, Ricks RC Eds Medical
  Management of Radiation Accidents. Boca Raton,
  FL, CRC Press, 1990.
• The Radiological Accident in Goiânia, Vienna,
  IAEA, 1988 p.2.
• Saenger, E.L., Andrews, G.A., Linnemann, R.E.,
  Wald, N., Radiation Accident Preparedness,
  Medical and Managerial Aspects,
  Science-Thru-Media, Inc., New York, NY, 1981.
• Nishiyama H, Lukes SJ, Saenger EL Low-Level
  Internal Radionuclide Contamination Use of Gamma
  Camera for Detection. Radiol 1984 1501, pp
  235-40.

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References - 3

• Nishiyama H, Saenger EL, Grossman LW, Lukes SJ.
  Accidental Cs-137 Contamination. Radiol 1985
  1542, pp 513-7.
• Voelz G Ed Management of Persons Accidentally
  Contaminated with Radionuclides, NCRP Report 65.
  Bethesda MD, National Council on Radiation
  Protection and Measurements, 1980.
• Gerber GB, Thomas RG Eds"Guidebook for the
  Treatment of Accidental Inernal Radionuclide
  Contamination of Workers" Radiation Protection
  Dosimetry (1992) 411.
• Barabanova A. REAC/TS Newsletter. Winter 1992,
  Oak Ridge, TN, p 1-2.
• Andrews GA, Auxier JA, Lushbaugh CC, "The
  Importance of Dosimetry to the Medical Managment
  of Persons Accidentally Exposed to High Levels of
  Radiation," in Personnel Dosimetry for Radiation
  Accidents, International Atomic Energy Agency
  (IAEA), Vienna, pp 3-16, 1965.

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References - 4

• Roberts GB, Col - Nuclear Weapons-Grade Fissile
  Materials - The Most Serious Threat to US
  National Security Today? Airpower Journal,
  Special Edition 96
• Academy of Health Sciences, US Army Medical
  Aspects of Nuclear Weapons and Their Effects on
  Medical Operations subcourse MED447, Jun 1990
• Aldridge JP The Role of Health Physicists in
  Contemporary Radiological Emergency Response
  Masters Thesis, Georgia Tech, Mar 1998
• The Threat of Nuclear Diversion. Statement for
  the Record by John Deutch, Director of the
  Central Intelligence to the Permanent
  Subcommittee on Investigations of the Senate
  Committee on Government Affairs, 20 Mar 1996.

Version 1.0 - 18 Nov 1998