Medical Response to Nuclear and Radiological Terrorism

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Medical Response to Nuclear and Radiological
Terrorism

• Stevan Cordas DO MPH
• Clinical Associate Professor TCOM/UNTHSC

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• 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

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What Is Radiation?
Radiation is energy transported in the form of
particles or waves.
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Exposure Vs. Contamination

• Exposure irradiation of the body ? absorbed dose
  (Gray, rad)
• Contamination radioactive material on patient
  (external)or within patient (internal)

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Penetration Abilities of Different Types of
Radiation
Alpha Particles Stopped by a sheet of paper
Radiation Source
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
Neutrons Stopped by a few feet of concrete
CDC
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Radiation Units
Measure of Amount of radioactive material
Ionization in air Absorbed energy per
mass Absorbed dose weighted by type of
radiation
Unit curie (Ci) roentgen (R) rad rem
Quantity Activity Exposure Absorbed
Dose Dose Equivalent
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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.

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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 limit 5,000 mrem
• Heart catheterization (skin dose) 45,000
  mrem
• Life saving actions guidance (NCRP-116)
  50,000 mrem
• Mild acute radiation syndrome
  200,000 mrem
• LD50/60 for humans (bone marrow dose)
  350,000 mrem
• Radiation therapy (localized fractionated)
  6,000,000 mrem

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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)

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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)

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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

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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

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Hypothetical Suitcase Bomb
CDC
Chairman Dan Burton Committee Demonstration of
example suitcase nuke made from US nuclear
shell
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Examples of Radioactive Materials
Radionuclide Half-Life
Activity Use Cesium-137 30 yrs
1.5x106 Ci Food
Irradiator Cobalt-60 5 yrs
15,000 Ci Cancer
Therapy Plutonium-239 24,000 yrs 600 Ci Nuclear
Weapon Iridium-192 74 days
100 Ci Industrial
Radiography Hydrogen-3 12 yrs
12 Ci Exit
Signs Strontium-90 29 yrs 0.1 Ci Eye Therapy
Device
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Examples of Radioactive Materials

• Iodine-131 8 days
  0.015 Ci Nuclear Medicine
  Therapy
• Technetium-99m 6 hrs
  0.025 Ci Diagnostic Imaging
• Americium-241 432 yrs 0.000005
  Ci Smoke Detectors
• Radon-222 4 days
  1 pCi/l Environmental Level

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Trinity Site N.M. 529 AM July 16th 1945
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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

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

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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

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Consult With Radiation Experts

• Radiation Safety Officer
• Health Physicist
• Medical Physicist
• Conference of Radiation Control Program Directors
  (www.crcpd.org)

CDC
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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

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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)

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Biodosimetry Assessment Tool

• Armed Forces Radiobiology Research Institute
• www.afrri.usuhs.mil/

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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

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Treatment Area Layout
Separate Entrance
CONTAMINATED AREA
Trauma Room
HOT LINE
BUFFER ZONE
Clean Gloves, Masks, Gowns, Booties
CLEAN AREA
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Immediate Medical Management

• Triage
• ARS
• localized/ cutaneous
• combined injury
• Initial stabilization and treatment
• Psychological effects
• Record keeping/ Dose assessment

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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

• 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

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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

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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

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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

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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

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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

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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

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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

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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

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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 examsresidual contamination can be
  controlled.

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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

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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
  backgroundhigher levels may be acceptable

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Data Management
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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
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Radiation Sickness Acute Radiation Syndrome

• 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

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Acute Radiation Syndrome (Cont.)For Doses gt 100
rem

• 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

Time of Onset
Severity of Effect
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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.

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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.

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Acute Radiation Syndrome (Cont.)Hematopoietic
Component - latent period from weeks to days

• 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

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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

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Andrews LymphocyteNomogram

• Confirms suspected radiation exposure
• Determines significant hematological involvement
• Serial CBCs every 3 - 4 hours

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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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.

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Acute Radiation Syndrome (Cont.)Gastrointestinal
and CNS Components

• Dose gt 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 gt 3,000 rem - damage to CNS
• vomiting, diarrhea, confusion, severe hypotension
  within minutes
• collapse of cardiovascular and CNS
• fatal within 24 to 72 hours

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The Three ARS Syndromes

• Cardiovascular Syndrome
• Usually with extremely high dosage. gt 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

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Treatment of Large External Exposures

• 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)

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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)

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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.

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Treatment of Internal Contamination

• 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

Radionuclide Treatment Route Cesium-137 Prussia
n blue Oral Iodine-125/131 Potassium
iodide Oral Strontium-90 Aluminum
phosphate Oral Americium-241/ Ca- and Zn-DTPA IV
infusion, Plutonium-239/ nebulizer Cobalt-60
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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.

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Special Considerations

• High radiation dose and trauma interact
  synergistically to increase mortality
• Close wounds on patients with doses gt 100 rem
• Wound, burn care and surgery should be done in
  the first 48 hours or delayed for 2 to 3 months
  (gt 100 rem)

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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.

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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.

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Biological Effects of Ionizing Radiation

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

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Radiation Effects
Early (Deterministic only)
Late
Local Radiation injury of individual
organs Functional and/or morphological changes
within hrs-days-weeks
Systemic
Deterministic (Above DQ, cummul.) - Rad.
Dermatitis - Rad. Cataracta - Teratogenic
(DQ,F0,1Sv)
Stochastic
Acute radiation disease Acute radiation
syndrome (LD50/60 3.5Sv LD 5 Sv)
(Probability increases with dose) - Tumors,
leukemia - Genetic effects
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Localized Radiation Effects - Organ System
Threshold Effects

• Skin - No visible injuries lt 100 rem
• Main erythema, epilation gt500 rem
• Moist desquamation gt1,800 rem
• Ulceration/Necrosis gt2,400 rem
• Cataracts
• Acute exposure gt200 rem
• Chronic exposure gt600 rem
• Permanent Sterility
• Female gt250 rem
• Male gt350 rem

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Time of Onset of Clinical Signs of Skin Injury
Depending on the Dose Received

• Symptoms Dose range Time of onset
• (Gy) (day)
• Erythema 3-10 14-21
• Epilation gt3 14-18
• Dry desquamation 8-12 25-30
• Moist desquamation 15-20 20-28
• Blister formation 15-25
  15-25
• Ulceration gt20 14-21
• Necrosis gt25 gt21
• Ref. IAEA-WHO Diagnosis and Treatment of
  Radiation Injuries.
• IAEA Safety Reports Series, No. 2, Vienna, 1998

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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 www.orau.gov/reacts/, 865-576-1005.

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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

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Stochastic Effects of Radiation Exposure

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

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Human Data on Radiation Cancerogenesis
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Cancer Deaths Attributable to A-bombs

• In 86,572 survivors of Hiroshima and Nagasaki
  A-bombing 7,827 persons died of cancer in
  1950-90
• Observed Expected Excess ()
• All tumors 7578 7244 334 (4.4)
• Leukaemia 249 162
  87 (35.0)
• All cancers 7827 7406
  421 (5.4)
• Ref Pierce et al, Rad.Res. 146 1-27, 1996

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Cancer mortality of nuclear industry workers
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Latency Periods for Radiation-induced Cancer
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Teratogenic Effects of Radiation

• Mental retardation
• Highest risk during major neuronal migration, on
  8-15 weeks. Incidence increases with dose. At 1
  Gy fetal dose 75 experience severe retardation
• At 16-25 weeks, fetus shows no increase in mental
  retardation at doses lt 0.5 Gy
• IQ - Risk factor associated with diminution of IQ
  is 21-33 points at 1 Gy to fetus on 8-15 weeks.
• Microcephaly
• Observed in 30 children of 1000 exposed in
  Hiroshima and Nagasaki pregnant women
• The effect lt0.3 Gy is not significantly
  different of control

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Fetal IrradiationNo Significant Risk of Adverse
Developmental Effects Below 10 Rem
Period of Development
Weeks After Fertilization
Effects

• 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)

lt2 2-7 7-40 All
Pre-implantation Organogenesis Fetal
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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

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The Three Basic Ways to Reduce Radiation Exposure

• TIMEDecrease the amount of time you spend near
  the source of radiation.DISTANCEIncrease your
  distance from a radiation source.SHIELDINGIncrea
  se 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.

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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.

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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.

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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.

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Reproduced with permission
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,
ChairKenneth L. Miller, MS Marcia Hartman, MS
Robert Derlet, MDVictoria Ritter, RN, MBA
Edwin M. Leidholdt, Jr., PhD ConsultantsFred
A. Mettler, Jr., MD Niel Wald, MD William E.
Dickerson, MD Appreciation to Linda Kroger, MS
who assisted in this effort.
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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 [phone]
  http//www.orau.gov/orise.htm

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Always Contact Local Public Health Department

• Tarrant County Public Health 1101 S. Main Street
  Fort Worth, Texas 76104
• 817-321-4700
• Dallas County Department of Health Human
  Services2377 N. Stemmons Freeway Dallas, Texas
  75207-2710
• 214-819-2004.

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We will Always Remember
87
Thank You for Coming Stevan Cordas DO
MPH www.drcordas.com