Preparing for an Unplanned
Radiation Event
Niel Wald, M.D.
Michael P. Kuniak, D.O.,
M.P.H.
Acknowledgments
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.
Christine Hartmann Siantar, Ph.D.
Deputy Program Leader
Nuclear and Radiological Countermeasures
Monterey Institute of International Studies
Center for Nonproliferation Studies
Resource Links CIF 2004-2005
(http://cif.miis.edu/resource.htm)
Associate Professor UC Davis
OUTLINE
Radiation Terrorism and Response
1. Radiation Basics
2. Radiation Protection Rules
3. Radiation Threats
Nuclear device, “dirty” bomb
Equivalent Experiences: Chernobyl, Goiana
4.
Health Management of Affected Population
What is Radiation?
• For the purpose of this presentation, defined
as energetic emissions from unstable atoms
that can result in ionizing events to target
atoms
• Ionizing radiation is radiation capable of
imparting its energy to the body and causing
chemical changes
• Ionizing radiation is emitted by
– - Radioactive material
– Some devices such as x-ray machines
•
Common Radiation Terms
• Radioisotope - a generic name for a
radioactive element
• Radionuclide - a specific radioisotope
such as Uranium-235
• These terms are often used
interchangeably
Radiation Physics
• Ionizing Radiation
– Radiation with enough energy to cause
ionization of atoms by ejecting electrons
from their atomic orbits
• Types of Radiation
– Electromagnetic (Photons - No Mass)
• X-ray, Gamma
– Particulate
• Alpha (helium nucleus), Beta
(electron), Proton, Neutron
Types of Radiation Emitted from
Radioactive Material
• Particulate
– Charged
• Alpha Radiation
• Beta Radiation
– Uncharged
• Neutron Radiation
• Electromagnetic
• Gamma Radiation
Types of Ionizing 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
Alpha and Beta Radiation
• Alpha
– Typically emitted from a heavy element
– Most have energies between 4-8 MeV
– Particles up to 7.5 MeV stopped by dead skin
layer (only a few microns penetration)
– Can be shielded by paper
– Penetrates a few cm in air
– Does not penetrate the dead layer of skin
• Beta
– Travels about 4 meters in air per MeV
– Penetrates about 0.5 cm in soft tissue per MeV
– Can reach the basal cell layer of skin
Pertinent Alpha Emitters
Neutron Radiation
• Neutral particle emitted from the nucleus
• Can be very penetrating
• Requires special consideration for
shielding
• Can induce radioactivity when absorbed
by stable elements (N, Na, Al, S, Cl, P,
etc.)
Electromagnetic Radiation
• Energy = hf
• Energy expressed typically in KeV or MeV (not
joules)
• Absorption of Electromagnetic Radiation by
matter
– Photoelectric
– Compton Scattering
– Pair production (photon energy must exceed
1.02 MeV)
• Stochastic event
• Low energy photons more readily absorbed
The Electromagnetic Spectrum
Gamma Radiation
• Electromagnetic energy emitted from the
nucleus
• Specific energies can be analyzed to identify
source
• Very penetrating (many meters in air)
• Difficult to shield, often shielded with lead
X-ray Radiation
• Electromagnetic energy emitted from
outside the nucleus
• May be “machine-produced” by bombarding
high energy electrons on a target
• May also be emitted from radioactive
materials
• Similar shielding and penetrating powers as
gamma radiation
Radiation Units
Measure of
Quantity
Unit
Amount of
radioactive
material
Activity
curie (Ci)
Ionization in air
Exposure
roentgen
(R)
Absorbed energy
per mass
Absorbed
Dose
rad
Absorbed dose
Dose
weighted by type
Equivalent
of radiation
For most types of radiation
rem
1 R  1 rad  1 rem
Units of Radioactivity
• Quantity
– 1 Becquerel (Bq) = 1tps
– 1 Curie (Ci) = 3.7 x 1010 tps
• Exposure
– 1 Roentgen (R) = 2.58 x 10-4 C/Kgair
 87.7 ergs/gair
• Exposure to Dose Relationship
– 1 R exposure  95 ergs/g absorption in muscle
Half-Life
• The time required for a radioactive
substance to loose 1/2 of its radioactivity
• Each radionuclide has a unique half-life
• Half-lives range from extremely short
(fraction of a second) to billions of years
Example of the Effect of Half-Life
• Assume an initial amount of 32 uCi of
TC-99m with a half-life (T1/2) of 6 hours
– after 1 half-life (6 h):
16 uCi
– after 2 half-lives (12 h):
8 uCi
– after 3 half-lives (18 h):
4 uCi
– after 4 half-lives (24 h):
2 uCi
• After 10 half-lives, less than 1/1000 of the
original activity remains
Selected Radionuclides with Radiations
Radionuclide
Radiation(s)
Half-Life
Eff. Half-Life
Hydrogen-3

12 y
12 d
Cobalt-60

5.26 y
10 d
Strontium-90

28 y
15 y
Iodine-131

8.05 d
8d
Cesium-137

30 y
70 d
Iridium-192

74 d
-
Radium-226

1602 y
44 y
From Mettler, Jr., F.A. and Upton, A.C., Medical Effects of Ionizing Radiation 2 nd edition
Radiation Dose
• Absorbed Dose (D)
• Dose Equivalent (HT)
[ HT = DQ]
1 Gray (Gy) = 1 J/Kg
1 Seivert (Sv) = 1 J/Kg
1 rad = 100 ergs/g
1 rem = 100 ergs/g
100 rad = 1 Gy
100 rem = 1 Sv
Deterministic Acute Effects
Stochastic Late Effects
Note: 1 MeV = 1.6 x 10-13 Joules
Weighting Factors
Organization
NRC
ICRU
NCRP
ICRP
Weighting factor
Q
Q
Q
WR
X &Gamma Rays
1
1
1
1
Beta Rays
1
1
1
1
Thermal Neutrons
2
5
5
Fast Neutrons
10
20
20
Hi Energy Protons
10
1
5
Alpha Particles
20
20
20
25
25
Radiation Doses and Dose Limits
Flight from Los Angeles to London
Annual public dose limit
mrem
Annual natural background
Fetal dose limit
Barium enema
Annual radiation worker dose limit
Heart catheterization (skin dose)
Life saving actions guidance (NCRP-116)
mrem
Mild acute radiation syndrome
LD50/60 for humans (bone marrow dose)
mrem
Radiation therapy (localized & fractionated)
mrem
5 mrem
100
300 mrem
500 mrem
870 mrem
5,000 mrem
45,000 mrem
50,000
200,000 mrem
350,000
6,000,000
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)
Examples of Radioactive Materials
Radionuclide
Physical
Half-Life
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
Radiography
74 days
100 Ci
Industrial
Hydrogen-3
12 yrs
12 Ci
Strontium-90
29 yrs
0.1 Ci
Iodine-131
Therapy
8 days
0.015 Ci
Nuclear Medicine
Technetium-99m
6 hrs
0.025 Ci
Diagnostic Imaging
Americium-241
432 yrs
Radon-222
4 days
Activity
0.000005 Ci
1 pCi/l
Use
Exit Signs
Eye Therapy Device
Smoke Detectors
Environmental Level
Radiation vs. Radioactive Material
• Radioactive Material
– Any substance that
spontaneously gives off
radiation
• Radiation
– The energetic emissions of
radioactive material
– Can be in various
chemical forms
– Can be subatomic particles
(, , n), photons (X-ray, )
or combinations
– If not contained (sealed
source) can lead to
contamination External, Internal or
Both
– Results in ionization of the
absorbing material (if living
tissue  radiation injury)
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)
•
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%
Criticality Incident
Operation Upshot/Knothole, a 1953 test of nuclear artillery projectile
at Nevada Test Site
Nuclear Fission
Fissile Material
• U-235
– Enriched from 0.7% (Natural) to 3%  > 90%
– Used:
• Commercial Reactors
• Research Reactors
• Naval Reactors
• Atomic Bomb
• Pu-239
– Byproduct of U-235 fission
– Used in Breeder Reactor
– Also can be weaponized
Radionuclides of Concern
Causes of Radiation
Exposure/Contamination
• Accidents
– Nuclear reactor
– Medical radiation therapy
– Industrial irradiator
– Lost/stolen medical or industrial radioactive
sources
– Transportation
• Terrorist Event
– Low yield nuclear weapon
– Radiological dispersal device (dirty bomb)
– Attack on or sabotage of a nuclear facility
Size of Event
Event
Radiation
Accident
Radioactive
Dispersal
Device
No. of Deaths
Most Deaths Due to
None/Few
Few/Moderate
Radiation
Blast Trauma
(Depends on
size of explosion &
proximity of persons)
Low Yield
Large
Nuclear Weapon (e.g. tens of thousands in
an urban area even from
0.1 kT weapon)
Blast Trauma
Thermal Burns
Radiation Exposure
Fallout
(Depends on Distance)
Dose Limits - ICRP 60
Application
Occupational
Public
Whole Body
20 mSv/year
Effective dose averaged over
5 years, max: 50 mSv/yr
1 mSv in 1 year
Lens of eye
150 mSv
15 mSv
Skin
500 mSv
50 mSv
Hands & Feet
500 mSv
_
Annual Equiv. Dose:
Emergency Exposure Guidelines - ICRP 60
Dose Limit
(Whole Body)
Activity Performed
Conditions
5 rems
All…..
…….
10 rems
Protecting major property
Where lower dose limit
not practicable.
25 rems
Lifesaving or protection of large Where lower dose limit
populations
not practicable
>25 rems
Lifesaving or protection of large Only on a voluntary basis
populations
to personnel fully aware
of the risks involved
Radiography Source
Sealed Source Accident
• 13 Curie Cs-137 Radiography
Source
• Found by a man at an Argentina
construction site
• Carried in front pockets for 18
hours
Accident Dose Calculation
• Cs-137 Gamma Constant = 0.323 R-m2/hr-Ci
•
0.323 R-m2
hr-Ci
x
(18hr)(13Ci)
(0.01m)2
=
755,820 R
Accident Isodose Curves
Basic Radiobiology
• Atom
Molecule
Ionization in Water or Cell Molecules
Chemical Damage
Bond Breakage
DNA
Chromosomal Aberration
Cell Death
Mutation
Radiosensitivity (most to least):
• Lymphocytes
• Endothelial Cells
• Erythroblasts
• Connective Tissue Cells
• Myeloblasts
• Tubular Cells of Kidneys
• Epithelial Cells
• Bone Cells
– Intestinal crypts
• Nerve Cells
– Testis
• Brain Cells
– Ovary
• Muscle Cells
– Skin
– Secretory glands
– Lungs and bile ducts
19-A
Classification of Medical Radiation Problems
• Anxiety
• Acute Radiation Syndrome
• Local Radiation Injury
• External Radionuclide Contamination
• Local Trauma with Radionuclide Contamination
• Internal Radionuclide Contamination
Radiation Injuries
• External exposure to penetrating radiation
– Criticality Incident (,N)
– Sealed Source (,)
– External Contamination (, )
– Beam Generator (,N)
• Internal contamination with radionuclides
– Wound Contamination (, , )
– Injection (, , )
– Inhalation (, , )
– Ingestion (, , )
Late 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%
What are the Risks to Future Children?
Hereditary Effects
• Magnitude of hereditary risk per rem is 10%
that of fatal cancer risk
• Risk to caregivers who would likely receive
low doses is very small - 5 rem increases
the risk of severe hereditary effects by ~
0.02%
• Risk of severe hereditary effects to a patient
population receiving high doses is
estimated as ~ 0.4% per 100 rem
Fetal Irradiation
No significant risk of adverse
developmental effects below 10 rem
Weeks After
Period of
Fertilization
Development
Effects
<2
Pre-implantation
Little chance of
malformation.
• Most probable effect, if any,
is death of embryo.
• Reduced lethal effects.
2-7
Organogenesis • Teratogenic effects.
Fetal
• Growth retardation.
7-40
• Impaired mental ability.
• Growth retardation with
higher doses.
All
• Increased childhood cancer
risk. (~ 0.6% per 10 rem)
Types of Radiation Hazards
Internal
Contamination
• External Exposure whole-body or partialbody (no radiation
hazard to EMS staff)
• Contaminated -
External
Contamination
External
Exposure
– external radioactive
material: on the skin
– internal radioactive
material: inhaled,
swallowed, absorbed
through skin or
wounds
Radioactive Contamination
• Contamination is simply the presence of
radioactive material where it is not wanted
• Persons may be contaminated either
externally, internally or both
• Exposure does not necessarily imply
contamination
In order to limit the amount of radiation you are
exposed to, think about:
SHIELDING, DISTANCE and TIME
Shielding: If you
have a thick shield
between yourself
and the radioactive
materials more of
the radiation will be
absorbed, and you
will be exposed to
less.
Distance: The
farther away from
the blast and the
fallout the lower
your exposure.
Time: Minimizing
time spent exposed
will also reduce
your risk.
ALARA Techniques
• Work quickly and efficiently (TIME)
• Rotate personnel if qualified replacements are available (TIME)
• When not involved in patient care, remain a few feet away from the
patient (DISTANCE)
• Use long-handled forceps to remove contaminated particles,
contaminated dressings, etc. (DISTANCE)
• Remove contaminated materials from the treatment area (DISTANCE
& QUANTITY)
• Put contaminated metal or glass in lead in lead “pigs” obtained from
nuclear medicine department (SHIELDING)
Radiation Protection:
Reducing Radiation Exposure
Time
Minimize time spent near radiation
sources
To Limit Caregiver Dose to 5
rem
Distance
Distance
time
Maintain maximal
practical distance from
radiation source
Rate
Stay
1 ft
min
12.5 R/hr
24
2 ft
3.1 R/hr
1.6 hr
5 ft
0.5 R/hr
10 hr
8 ft
0.2 R/hr
25 hr
Shielding
Place radioactive sources in
a lead container
Risk to Contaminated Patient
• ARS, local radiation injury or contamination (both internal &
external) never demands immediate medical attention.
• Priority 1: True medical emergencies
– ABC’s
– Bleeding assessment
– Trauma assessment
– Wound assessment
• Remove contaminated clothing as soon as reasonably
possible (removes  80% of external contamination)
• Proceed with decontamination procedures after patient
stabilized
Risk to Healthcare Provider
• Minimal if using proper precautions
• Remember ALARA techniques
• Worst case - 15 mSv/hr close to contaminated wound
• At 1 foot ( 30 cm) - 0.02 mSv/hr
• NCRP public monthly equivalent dose to embryo/fetus:
0.5 mSv
Healthcare Provider - Controlling the
Spread of Contamination
• Goal: Minimize and control contamination
• Use proper protective clothing
• Do not eat drink or smoke in contamination areas
• Check yourself for contamination prior to leaving a
potentially contaminated area
• Limit access to treatment area to necessary
personnel only
Putting It All Together
OUTLINE
Radiation Terrorism and Response
1. Radiation Basics
2. Radiation Protection Rules
3. Radiation Threats
Nuclear device, “dirty” bomb
Equivalent Experiences: Chernobyl, Goiana
4.
Health Management of Affected Population
Mass Exposure Events
• Criticality Events
– Improvised Nuclear Device (IND)
– Reactor Release
• Nuclide Contamination
– Radiological Dispersal Device (RDD) aka: Dirty Bomb
– Intentional Contamination of Resources
• External Radiation Source
-- Industrial or Medical Source
Injury Sources From
Nuclear Device Detonation
Terrorist Event
Low yield nuclear weapon
• Energy Distribution
– 50% Blast
– 35% Thermal Radiation
– 15% Ionizing Radiation
• Health Consequences
– Injury
– Burns
– Penetrating Ionizing Radiation
• Prompt (1/3)
• Delayed (2/3)
– Fallout
• Contamination
• Penetrating Ionizing Radiation
A nuclear weapon is expected to
cause many deaths and injuries:
radiation is not the primary hazard
• Blast and thermal
effect comprise of
the majority of
effects/casualties
• Radiation lethality
out-distances
thermal and blast
damage only in low
yield weapons (≤ 1
kiloton)
Thermal: 35% of the energy
1st “flash” Pulse
2nd pulse (99% of the energy)
The pattern is from the dark
colored areas on her kimono
Long distance visual effects
Retinal burn: visual capacity is permanently lost in the burned
area. Retinal burns can be produced at great distances from the
nuclear detonation because the probability of occurrence does not
follow the inverse square law as is true of many other types of
nuclear radiation.
Flash Blindness, also referred to as "dazzle," is a
temporary impairment of vision. Victim does not have to
be looking directly at the source for this to occur.
Nighttime greatly increases distance of effect
Fallout: important for surface bursts
• A nuclear detonation
results in a fireball with a
temperature estimated to
be several tens of
millions of degrees.
• The radioactive particles
resulting from nuclear
fission and activation of
surrounding materials
are carried up by the
fireball and then drift
downwind to later settle
on the ground.
Real-World Example Similar to Russian
Suitcase Nukes
Same type of nuclear
warhead was used in
a small artillery
round, called Davy
Crockett.
Davy Crockett Fallout – NYC
FOR TRAINING PURPOSES
ONLY
•
Results from Davy Crockett overlaid on
New York City map
•
Building that houses detonation device
is destroyed
•
Adjoining buildings damaged
•
People within 1200 feet receive lethal
dose of radiation (650,000 mrem or
higher) from blast (not fallout)
•
1~50,000 fatalities in estimation
•
1~200,000 casualties
10,000
mrem/hr
1,000
mrem/hr
10,000 mrem/hr
Lethal Dose
Area
Point of
Detonation
Atomic Weapon NuclideYields
Approximate Yields of the Principal
Nuclides per Megaton of Fission
Nuclide
Half-life
MCi
89Sr
90Sr
95Zr
103Ru
106Ru
131I
137Cs
131Ce
144Ce
bFrom
Klement (1965)
cFrom Knapp (1963)
53 d
28 y
65 d
40 d
1y
8d
30 y
1y
33 d
20.0b
0.1b
25.0b
18.5b
0.29b
125.0c
0.16b
39.0b
3.7b
Environmental Radioactivity 4th Ed., Eisenbud M (1997)
The Chernobyl Accident
Chernobyl:
Healthcare Resources Used
• Local medical facilities
• 400 special medical brigades
– M.D., H.P., etc.
• 15,000 health workers
– 2,000 M.D.’s, 4,000 nurses, med
students, etc
• 213 mobile laboratories
• Special hospitals (Kiev, Moscow)
Chernobyl:
Healthcare Procedures
Medical
Examinations
1,000,000 persons
Dosimetric & lab 700,000
tests
(216,000 children)
Inpatient care
32,000 persons
(12,000 children)
Iodine
prophylaxis
5,400,000 persons
(1,700,000 children)
Chernobyl:
Aftermath
• 31 deaths
– 1 from roof collapse
– 1 severe burns
– 21 of 22 with ARS and skin burns (400-1600 r)
– 7 of 23 (200-400 r)
• Estimate additional 300 cases of thyroid cancer in
exposed children and 100 cases in exposed adults.
• 135,000 persons from 176 communities evacuated
out to 30 km from plant
• Dose to public (3-15 km zone): estimate 43 rem (50
year commited dose)
Lessons Learned
• In the USSR highly organized Civil Defense,
Health system, Military and other government
resources were quickly mobilized.
• In the US less centralized resources might
currently have more difficulties, although the
maturation of the Homeland Security Agency
should facilitate such a response.
OUTLINE
Radiation Terrorism and Response
1. Radiation Basics
2. Radiation Protection Rules
3. Radiation Threats
Nuclear device, “dirty” bomb
Equivalent Experiences: Chernobyl, Goiana
4.
Health Management of Affected Population
What Is a Radiation Threat?
A radiation threat or
"Dirty Bomb" is the
use of common
explosives to
spread radioactive
materials.
It is not a nuclear blast.
The force of the explosion
and radioactive
contamination will be
more localized. In order to
limit the amount of
radiation you are exposed
to, think about shielding,
distance and time.
Local authorities may
not be able to
immediately provide
information on what is
happening and what
you should do.
However, you should
watch TV, listen to the
radio, or check the
Internet often for
official news and
information as it
becomes available.
Russian Nuclear SuitcaseDevices
• 84 of 132 devices are missing
“We do not know what the status of
the other devices is, we just could not
locate them…”
Russian General Lebed, 1998
• “No direct evidence that any have
been stolen.”
US Assistant Sec of Defense of Nuclear
Chemical Biological Programs, January 2003
Black Market Smuggling
Total Number of Material
Seizures
(April 2001)
•
•
•
217 low-grade nuclear
material
14 weapons usable
material
299 Radioactive
Sources
Sophisticated RDD
May not be
recognized
before it is
exploded
Probability of RDD
Terrorist Event Radiological dispersal
device (dirty bomb)
Health Consequences:
Injury
Burns
Single Nuclide Contamination(?)
Much higher probability than the use of a nuclear
weapon:
•
Simple to build
•
Widely available materials
•
Ease of building simple explosives
•
More than 200 naturally-occurring and man-made
radionuclides can be potentially used for RDD
Background
• After the 1991 Gulf War Iraqis disclosed they had
worked on an RDD made of iron bombs packed
with zirconium oxide irradiated in a research
reactor. (USAF SAB, 1998 and IAEA
documentation)
• ~ 200 of the 2 million regulated radioactive
sources and devices are lost, stolen, or
abandoned each year in the USA.
• Cesium-137, the most commonly lost radiation
source has a 33 year half-life emits Beta (0.510,
1.17 MeV), and Gamma (~0.662 KeV) and
substitutes for Potassium in the body.
Radiation exposure from most RDDs in
urban areas would expose many, kill few
• The principal type of dirty bomb, or Radiological Dispersal Device (RDD),
combines a conventional explosive, such as dynamite, with radioactive
material. In most instances, the conventional explosive itself would have
more immediate lethality than the radioactive material. At the levels
created by most probable sources, not enough radiation would be present
in a dirty bomb to kill people or cause severe illness. However, certain
other radioactive materials, dispersed in the air, could contaminate up to
several city blocks, creating fear and possibly panic and requiring
potentially costly cleanup. Prompt, accurate, non-emotional public
information might prevent the panic sought by terrorists.
• A second type of RDD might involve a powerful radioactive source hidden
in a public place, such as a trash receptacle in a busy train or subway
station, where people passing close to the source might get a significant
dose of radiation.
• A dirty bomb is in no way similar to a nuclear weapon. The presumed
purpose of its use would be therefore not as a Weapon of Mass
Destruction but rather as a Weapon of Mass Disruption.
Good reference:
http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/dirty-bombs.html
Concerns
• Immediate radiation injury—very few
• Cancer—small (if any) increase on overall
25% probability of dying from cancer
 Exceptions:
iodine and children’s thyroid
cancer
• Birth defects—only a concern for a few (if
any), has been dramatically overestimated
in the past
Goiania Contamination Accident
454-2
Location of Goiania, Brazil
451-1
Goiania Accident Source
137Cs
teletherapy source capsule:
Physical form: CsCl hygroscopic
powder with blue fluorescence as it
absorbed moisture.
Radioactivity: 50.9 TBq (1375Ci)
Dose rate @1 m: 4.56 Gy/hr (456
rad/hr)
Goiania Event Sequence
451-3
Goiania Medical Disposition
580-9
Goiania Casualty Burial
Goiania Local Injury
454-5
Goiania Contaminated Areas
451-2
Goiania Population Screening
55-3
Goiania Accident Magnitude
People monitored:
Chromosome analyses:
Roads monitored:
Remediation workers:
Above DL:
10 mSv CDE)
112,000
110
2,000 Km
755
38 (Highest:
Homes contaminated:
Demolished:
85
7
Vehicles contaminated:
50
Radwaste created:
3,800 - 200L drums
Lessons Learned
Lack of awareness of the detrimental health
effects of radiation exposure can impede its
recognition on the part of patients and medical
practitioners until much damage is done.
The alert M.D. who faces an unusual public
health problem must find a collaborating H.P.
to evaluate its possible radiogenic origin and if
confirmed, to help deal with it.
Shelter if you can’t
evacuate
• Use the Shelter to
Shield and Distance
yourself from the fallout
contamination.
Particle Filtering Factors
• Filtration Efficiencies
– Man’s cotton handkerchief, 16 thick.
94%
– Man’s cotton handkerchief, 8 thick.
88%
– Toilet paper, 3 thick.
91%
– Bath towel, 2 thick.
– Cotton Shirt, 2 thick.
• Turn off ventilation
85%
65%
Recommended Accumulated Dose Levels at which to
Consider Evacuation and/or Relocation
Fallout: The 7-10 Rule of Thumb
Time (hours)
Relative Fallout
Dose Rates
H + 1*
100%
H + 7 (1•7)
10 %
H+49 (7•7)
1%
H+343 (7•7•7)
~14 Days
0.1%
H+2401 (74)
~100 Days
0.01%
• Shelter as long as
possible before
evacuating across
fallout contamination.
Waiting 2 days will
reduce exposure by a
factor of 100!
Decontamination: important for nuclear weapons and
radiation dispersal devices
Evacuate the Fallout Path
• Although
dose rates
are highest
within the
first few
hours, this
only
represents a
relatively
small area
• Evacuating
the fallout
area before
fallout arrival
will save the
most lives
If there is a radiation or a
“dirty bomb” threat
1. If you are outside and there is an explosion or
authorities warn of a radiation release nearby,
cover your nose and mouth and quickly go inside a
building that has not been damaged. If you are
already inside check to see if your building has
been damaged. If your building is stable, stay
where you are. Close windows and doors; turn off
air conditioners, heaters or other ventilation
systems.
If there is a radiation or a
“dirty bomb” threat
1.
If you are inside and there is an explosion near where you are
or you are warned of a radiation release inside, cover nose
and mouth and go outside immediately. Look for a building or
other shelter that has not been damaged and quickly get
inside.
2.
Once you are inside, close windows and doors; turn off air
conditioners, heaters or other ventilation systems.
3.
If you think you have been exposed to radiation, take off your
clothes and wash as soon as possible.
4.
Stay where you are, watch TV, listen to the radio, or check the
Internet for official news as it becomes available.
If there is a nuclear blast
If there is advance warning:
Take cover immediately, as far below ground as possible, though any
shield or shelter will help protect you from the immediate effects of the
blast and the pressure wave.
If there is no warning:
1.
Quickly assess the situation.
2.
Consider if you can get out of the area or if it would be better to go inside
a building to limit the amount of radioactive material you are exposed to.
3.
If you take shelter go as far below ground as possible, close windows and
doors, turn off air conditioners, heaters or other ventilation systems. Stay
where you are, watch TV, listen to the radio, or check the Internet for
official news as it becomes available.
To limit the amount of radiation you are exposed to, think about shielding,
distance and time.
Use available information to assess the situation. If there is a significant
radioactive contamination threat, health care authorities may advise you
to take potassium iodide. It may protect your thyroid gland, which is
particularly vulnerable, from radioactive iodine exposure. Plan to speak
with your health care provider in advance about what makes sense for
your family.
Conclusions
• Radiation dispersal devices could cause significant
contamination with low levels of radiation, but would result
in few if any radiation casualties.
 Much of the radiation dispersal device’s impact will
depend on how much we over-react to the dangers of
radiation.
• A nuclear weapon would result in substantial casualties
and confusion from many effects, with radiation injury
being the dominant one in the fallout region.
 In a fallout scenario, wise actions on
sheltering/evacuation will save thousands of lives.
• You can prepare by knowing (and teaching) the facts about
radiation, and having a plan about what to do in a radiation
emergency—a good place to start is www.ready.gov.
OUTLINE
Radiation Terrorism and Response
1. Radiation Basics
2. Radiation Protection Rules
3. Radiation Threats
Nuclear device, “dirty” bomb
Equivalent Experiences: Chernobyl, Goiana
4.
Health Management of Affected Population
The Real Medical Radiation Problems
• Fear
• Communication Failure
• Uncertainty
• Inaction
• Chaos
Key Points for Emergency Responders
• Responders
– Lifesaving first aid is the First Priority
– Familiarize yourself with work area
• Survey instrumentation, protective clothing, respiratory
protection suitable to accident conditions
– Evacuate personnel to safe areas
– Assessment of radiological hazard
• Public
– Prevention is key as therapeutic measures are limited
– Shelter vs Evacuation
– Contamination
• Rule of thumb: 80 - 90% contamination removed with
clothing
• Showering will remove an additional 7%
Facility Preparation
• Activate hospital plan
– Obtain radiation survey meters
– Call for additional support: Staff from Nuclear Medicine,
Radiation Oncology, Radiation Safety (Health Physics)
– Establish area for decontamination of uninjured persons
– Establish triage area
• 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
– For transport of contaminated patients into ED, designate
separate entrance, designate one side of corridor, or transfer
to clean gurney before entering, if time allows
Decontamination Center
• Establish a decontamination center for people
who are contaminated, but not significantly
injured.
– Center should provide showers for many people.
– Replacement clothing must be available.
– Provisions to transport or shelter people after
decontamination may be necessary.
– Staff decontamination center with medical staff with
a radiological background, health physicists or other
staff trained in decontamination and use of radiation
survey meters, and psychological counselors
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
CLEAN
AREA
BUFFER
ZONE
CONTAMINATED
AREA
Treatment Area Layout
Separate
Entrance
ED
Staff
Radiation
Survey
&
Charting
Contaminated
Waste
Waste
Trauma Room
STEP
OFF
PAD
Radiation
Survey
Clean
Gloves,
Masks,
Gowns,
Booties
HOT
LINE
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)
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
Patient Management - Triage
Triage based on:
• Injuries
• Signs and symptoms nausea, vomiting, fatigue,
diarrhea
• History - Where were you
when
the bomb
exploded?
• Contamination survey
Classification of Medical Radiation
Problems
• Anxiety
• Acute Radiation Syndrome
• Local Radiation Injury
• External Radionuclide Contamination
• Local Trauma with Radionuclide
Contamination
• Internal Radionuclide Contamination
82-A
Mass Casualties, Contaminated but
Uninjured People, and Worried Well
• An incident caused by nuclear terrorism may create
large numbers of contaminated people who are not
injured and worried people who may not be injured or
contaminated
• Measures must be taken to prevent these people from
overwhelming the emergency department
• A triage site should be established outside the ED to
intercept such people and divert them to appropriate
locations.
– Triage site should be staffed with medical staff and
security personnel
– Precautions should be taken so
that people cannot avoid the triage
center and reach the ED
Radiation Anxiety
• In the event of a nuclear or
radiological weapon detonation,
thousands of victims will be
concerned about their possible
exposure to ionizing radiation.
• Accurate knowledge of radiation
dose can dramatically affect the
assignment of triage category,
BUT
• accepted methods for accurate
post-exposure dosimetry take
days to measure.
• Thus, clinical signs, symptoms
and blood counts are best early
indicators of radiation injury.
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
• Establish a center to provide psychological support to
such people
• Set up a center in the hospital to provide psychological
support for staff
Acute Radiation Syndrome
• Depending on the magnitude of the
exposure, the hematopoietic system, the
gastrointestinal tract, the cardiovascular and
central nervous systems may be involved in
damage. There are three major forms (in
order of severity):
– Hematological form
– Gastrointestinal form
– Neurovascular form
Thoma/Wald
Prognostic Categories
•Group 1: 0.5 to 1.5 Gy; mostly asymptomatic with
occasional minimal prodromal symptoms
•Group 2: 1.5 to 4 Gy; clinically manifested by
transient N/V and mild hemotopoietic changes
•Group 3: 4 to 6 Gy; clinically manifested by severe
hematopoietic changes with some GI symptoms
•Group 4: 6 to 14 Gy; clinically manifested by severe
hematopoietic complications dominated by GI
complications
•Group 5: >50Gy; manifested by marked early neurovascular changes
Acute Radiation Syndrome (Cont.)
For Doses > 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
Time of Onset
– decreases with increasing dose
• Manifest Illness Stage
– Hematopoietic
– Gastrointestinal
– CNS
Severity of Effect
Prodromal Appearance Time
39-J
Clinical Effects of ARS
Acute Local Radiation Injury
Effect
Erythema
Time of Appearance
(days)
Threshold Dose
(cGy)
minutes to weeks (dose
dependant)
600
at threshold 8-17
Epilation
Dry desquamation
Moist
desquamation
 17-21
300
 21
1000-1500
14-21
1800-3000
Localized Radiation Effects - Organ
System Threshold Effects
• 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
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)
Emergency Hematologic Recovery
Surgery
No Surgery
24 - 48
Hours
~3 Months
Surgery
Permitted
After adequate
hematopoietic recovery
OUTLINE
Radiation Terrorism and Response
1. Radiation Basics
2. Radiation Protection Rules
3. Radiation Threats
Nuclear device, “dirty” bomb
Equivalent Experiences: Chernobyl, Goiana
4.
Health Management of Affected Population
Emergency Department
Management
of Radiation Casualties
CAUTION
Patient Management - Decontamination
• Carefully remove and bag patient’s 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
• Decontamination priorities:
– Decontaminate wounds first, then intact skin
– Start with highest levels of contamination
• Change outer gloves frequently to minimize
spread of contamination
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
• 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
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.
Initial Management of Externally Contaminated Patient
• Gross Decontamination
– Removal of Contaminated Clothing
– Washing and removal of Contaminated Hair
– Removal of Gross Wound Contamination
• Intermediate Stage (at clean location,if necessary)
– Removal of Contaminated Clothing
– Further Local Decontamination, Swabs of Body Orifices
– Supportive Measures, First Aid
• Final Stage
– Patient Discharged with Fresh Clothing
– More Definitive Decontamination (surgical) and Other
Therapy at Dispensary or Hospital
Handling contaminated patients
Patient decontamination
• Monitor to determine if
decontamination is needed
• Remove outer clothing
• Wash exposed skin surfaces
• Flush wounds with water
• Do not scrub or abrade skin! Low
levels of contamination are not a
health hazard and can be left in
place if not easily removed
(they will decay quickly).
Early Treatment For Radionuclide Contaminated
Wounds
• Irrigate Wound
– Saline
– Water
• Decontaminate Skin (But Do Not Injure)
– Detergent
• Continue Wound Irrigation Until Radiation Level Is
Zero or Constant
• Treat Wound as Usual
– Consider Excision of Embedded Long-Lived High- Hazard
Contaminants
Therapy For Isotope Decorporation
• Dilution
– 3H: Water
–
32P:
Phosphorus (Neutraphos)
• Blocking
–
137Cs:
–
131I, 99Tc:
–
90Sr, 85Sr:
Prussian Blue
KI (Lugol’s)
Na-Alginate (Gaviscon), AlPhosphate or Hydroxide Gel (Phosphajel or
Amphojel)
Therapy For Isotope Decorporation
(cont.)
• Mobilization
–
86Rb:
Chlorthalidone (Hygroton)
• Chelation
–
252Cf, 242Cm, 241Am, 239Pu, 144Ce,
–
210Pb:
EDTA, Penicilamine
–
210Po:
Dimercaprol (BAL)
–
203Hg, 60Co:
Rare Earths,
143Pm, 140La, 90Y, 65Zn, 46Sc: DTPA
Penicilamine
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
Cesium-137
Iodine-125/131
Strontium-90
Treatment
Route
Prussian blue
Oral
Potassium iodide
Oral
Aluminum phosphate Oral
Americium-241/
Plutonium-239/
Cobalt-60
Ca- and Zn-DTPA
IV /or
nebulizer
Treatment of Internal Contamination:
Treatment Options
• Reduce G.I. Absorption
• Hasten Excretion
• Use Blocking and Diluting Agents When
Appropriate
• Use Mobilizing Agents
• Use Chelating Agents If Available
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
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
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
Resources
• Radiation Emergency Assistance Center/ Training Site
(REAC/TS)
(865) 576-1005www.orau.gov/reacts
• Medical Radiobiology Advisory Team (MRAT) Armed
Forces Radiobiology Research Institute (AFRRI) (301)
295-0530 www.afrri.usuhs.mil
– Medical Management of Radiological Casualties Handbook, 2003;
and Terrorism with Ionizing Radiation Pocket Guide
• Websites:
– www.bt.cdc.gov/radiation - Response to Radiation
Emergencies by the Center for Disease Control
– www.acr.org - “Disaster Preparedness for Radiology
Professionals” by American College of Radiology
– www.va.gov/emshg - “Medical Treatment of Radiological
Casualties”
• Books:
Resources
– Medical Management of Radiation Accidents; Gusev, Guskova,
Mettler, 2001.
– Medical Effects of Ionizing Radiation; Mettler and Upton, 1995.
– The Medical Basis for Radiation-Accident Preparedness; REAC/TS
Conference, 2002.
– National Council on Radiation Protection Reports No. 65
(Contaminated Patient Care) and No. 138 (Radiation Injury Care).
• Articles:
– “Major Radiation Exposure - What to Expect and How to Respond,”
Mettler and Voelz, New England Journal of Medicine, 2002, 346: 155461.
– “Medical Management of the Acute Radiation Syndrome:
Recommendations of the Strategic National Stockpile Radiation
Working Group,” Waselenko, et.al., Annals of Internal Medicine, 2004,
140: 1037-1051.
– Guidebook for the Treatment of Accidental Internal Radionuclide
Contamination of Workers; Gerber, Thomas RG (eds), Radiation
Protection Dosimetry, 1992.