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Jerrold T. Bushberg, PhD, UC Davis Health System, at
jtbushberg@ucdavis.edu.
Version 3.0
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Emergency Department Management
of Radiation Casualties
CAUTION
Scope of Training
• Characteristics of ionizing radiation and
radioactive materials
• Differentiation between radiation exposure
and radioactive material contamination
• Staff radiation protection procedures
and practices
• Facility preparation
2
Scope of Training (Cont.)
• Patient assessment and management of
radioactive material contamination and
radiation injuries
• Health effects of acute and chronic radiation
exposure
• Psychosocial considerations
• Facility recovery
• Resources
3
Ionizing Radiation
• 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.
4
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
5
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
weighted by type of
radiation
Dose
Equivalent
rem
For most types of radiation
1 R  1 rad  1 rem
6
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
800 mrem
Annual radiation worker dose limit (U.S.)
5,000 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
7
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 his/her skin or inside his/her body
(e.g., inhalation, ingestion, or wound
contamination).
8
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 and 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%
9
Examples of Radioactive Materials
Radionuclide
Physical
Half-Life
Cesium-137*
30 yrs
1.5 x 106 Ci
Food Irradiator
Cobalt-60*
5 yrs
15,000 Ci
Cancer Therapy
Plutonium-239*
24,000 yrs
300 Ci
Nuclear Weapon
Iridium-192*
74 days
100 Ci
Industrial Radiography
Hydrogen-3
12 yrs
12 Ci
Strontium-90*
29 yrs
0.1 Ci
Iodine-131*
8 days
0.015 Ci
Nuclear Medicine Therapy
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
* Potential use in radiological dispersion device
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Types of Radiation Hazards
Internal
Contamination
• External Exposure Whole-body or partial-body
(no radiation hazard to
EMS staff)
• Contaminated -
External
Contamination
External
Exposure
– External radioactive
material: on the skin or
clothing
– Internal radioactive
material: inhaled,
swallowed, absorbed
through skin or wounds
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Causes of Radiation Exposure/Contamination
• Accidents
– Nuclear reactor
– Medical radiation therapy
– Industrial irradiator
– Lost/stolen medical or industrial radioactive
sources
– Transportation
• Terrorist Incident
– Radiological dispersal device (dirty bomb)
– Attack on or sabotage of a nuclear facility
– Low-yield nuclear weapon
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Scope of Incident
Incident
Number of Deaths
Most Deaths Due to
Radiation
Accident
None/Few
Radiation
Radioactive
Dispersal
Device
Few/Moderate
Blast Trauma
Low-Yield
Nuclear Weapon
(Depends on
size of explosion and
proximity of persons)
Large
(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)
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Radiation Protection
Reducing Radiation Exposure
Time
Minimize time spent near radiation sources.
To Limit Caregiver Dose to 5 rem
Distance
Rate
Stay time
1 ft
12.5 R/hr
24 min
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
Distance
Maintain maximal practical
distance from radiation source.
Shielding
Shield radioactive sources in an
appropriate container.
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Protecting Staff from Contamination
• Follow standard precautions.
• Survey hands and clothing
with radiation meter.
• Replace contaminated gloves or
clothing.
• 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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Mass Casualties, Contaminated but
Uninjured People, and Concerned Citizens
• An incident caused by nuclear terrorism may create large
numbers of contaminated people who are not injured and
concerned 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,
psychological counselors and security personnel.
– Precautions should be taken so
that people cannot avoid the triage
center and reach the ED.
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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.
17
Support for Concerned Citizens & Workers
• Terrorist acts involving toxic agents (especially radiation) are
perceived as very threatening.
• Mass casualty incidents caused by nuclear terrorism will create
large numbers of concerned citizens 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.
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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).
– Establish triage area.
– Establish area for decontamination of uninjured persons.
• Plan to control contamination:
– Instruct staff to use standard precautions.
– 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.
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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
HOT
LINE
Clean
Gloves, Masks,
Gowns, Booties
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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 and digital)
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Patient Management - Priorities
Triage
• Medical triage is the highest priority.
• Radiation exposure and contamination
are secondary considerations.
• Degree of decontamination is 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?
• Contamination survey
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Patient Management - Decontamination
• Carefully remove and bag patient’s clothing and
personal belongings (typically removes 95 percent
of contamination).
• Survey patient and, if practical, collect samples.
• Handle foreign objects with care until proven
nonradioactive with survey meter.
• Decontamination priorities:
– Decontaminate wounds first, then intact skin.
– Start with highest levels of contamination.
• Change gloves frequently to minimize spread of
contamination.
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Patient Management - Decontamination (Cont.)
• Protect noncontaminated 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.
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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 exams . . . residual contamination can
be controlled.
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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. 161, Management of Persons
Contaminated With Radionuclides
Radionuclide
Cesium
Iodine
Radium/Strontium
Americium/
Plutonium/Cobalt/
Iridium
Treatment
Prussian blue
Potassium iodide
Aluminum hydroxide
Ca- and Zn-DTPA
Route
Oral
Oral
Oral
IV infusion,
nebulizer
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Patient Management - Patient Transfer
Transport injured, contaminated
patient into or from the ED:
• Cover clean gurney with two
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) are 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.
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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)
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 > 100 rem
• Prodromal Stage
– Symptoms may include 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.
Time of Onset
• Manifest Illness Stage
– Hematopoietic
– Gastrointestinal
– CNS
Severity of Effect
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Acute Radiation Syndrome (Cont.)
Hematopoietic Component - latent period from weeks to days
• Dose ~100 rem
– ~10 percent exhibit nausea and vomiting within 48 hrs
– mildly depressed blood counts
• Dose ~350 rem
– ~90 percent exhibit nausea/vomiting within 12 hrs, 10 percent exhibit diarrhea
within 8 hrs
– severe bone marrow depression
– ~50 percent mortality without supportive care
• Dose ~500 rem
– ~50 percent mortality with supportive care
• Dose ~1,000 rem
– 90-100 percent mortality despite supportive care
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Acute Radiation Syndrome (Cont.)
Gastrointestinal and CNS Components
• Dose > 1,000 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 > 3,000 rem - damage to CNS
– vomiting, diarrhea, confusion, and severe hypotension
within minutes
– collapse of cardiovascular system and CNS
– fatal within 24 to 72 hours
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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)
• Treat symptomatically. Prevention and management
of infection is the primary objective.
– Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hours)
– 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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Localized Radiation Effects - Organ System
Threshold Effects
• Skin - No visible injuries < 100 rem
– Main erythema, epilation
>600 rem
– Moist desquamation
>1,800 rem
– Ulceration/Necrosis
>2,400 rem
• Cataracts
– Acute exposure
50-200 rem
– Chronic exposure
500 rem
• Permanent Sterility
– Female (acute)
>250 rem
– Male (acute)
>350 rem
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Special Considerations
• High radiation dose and trauma interact
synergistically to increase mortality.
• Close wounds on patients with doses > 100 rem.
• Wound care, burn care, and surgery should be
done in the first 48 hours or delayed for 2 to 3
months (> 100 rem).
Emergency
Surgery
Hematopoietic Recovery
24-48 Hours
~3 Months
No Surgery
Surgery
Permitted
After adequate
hematopoietic recovery
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Chronic Health Effects from Radiation
• Radiation is a weak carcinogen at low doses.
• There are no unique effects (type, latency, pathology).
• Natural incidence of cancer is ~40 percent;
mortality ~25 percent.
• Risk of fatal cancer is estimated as ~5 percent per 100
rem.
• A dose of 5 rem increases the risk of fatal cancer
by ~0.25 percent.
• A dose of 25 rem increases the risk of fatal cancer
by ~1.25 percent.
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What Are the Risks to Future Children?
Hereditary Effects
• Magnitude of hereditary risk per rem is ~10 percent 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 percent.
• Risk of severe hereditary effects to a patient population
receiving high doses is estimated as ~0.4 percent per
100 rem.
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Fetal Irradiation
No significant risk of adverse
developmental effects below 10 rem
Weeks After
Fertilization
<2
Period of
Development
Pre-implantation
2-7
Organogenesis
7-40
Fetal
All
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 percent per 10 rem)
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Key Points
• Medical stabilization is the highest priority.
• Train/drill to ensure competence and confidence.
• Preplan to ensure adequate supplies and survey
instruments are available.
• Standard precautions and decontaminating patients
minimize 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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Resources
• Radiation Emergency Assistance Center/Training Site (REAC/TS),
865-576-1005, orise.orau.gov/reacts
• Medical Radiobiology Advisory Team (MRAT) Armed Forces
Radiobiology Research Institute (AFRRI), 301-295-0530,
afrri.usuhs.mil
• Web sites:
– remm.nlm.gov/ - Radiation Event Medical Management by
Department of Health & Human Services
– emergency.cdc.gov/radiation/ - Response to Radiation
Emergencies by the Centers for Disease Control and Prevention
– acr.org - “Disaster Preparedness for Radiology Professionals” by
the American College of Radiology, (search for “disaster” on
website)
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Resources
•
Books:
– National Council on Radiation Protection and Measurements. NCRP Report No. 161,
Management of Persons Contaminated With Radionuclides, 2009.
– National Council on Radiation Protection and Measurements. NCRP Report No. 165,
Responding To A Radiological of Nuclear Terrorism Incident: A Guide for Decision
Makers, 2010.
– The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference,
2002.
– Gusev I, Guskova A, Mettler F, eds. Medical management of radiation accidents, 2nd
ed. Boca Raton, FL: CRC Press; 2001.
– Mettler F, Upton A. Medical effects of ionizing radiation, 3rd ed. Philadelphia:
Saunders; 2008.
•
Articles:
– Mettler F, Voelz G. Major radiation exposure - What to expect and how to respond.
New England Journal of Medicine 346:1554-1561; 2002.
– Waselenko J, et.al. Medical management of the acute radiation syndrome:
Recommendations of the strategic national stockpile radiation working group. Annals
of Internal Medicine 140:1037-1051; 2004.
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Acknowledgments
Prepared by the Medical Response Subcommittee of the National
Health Physics Society Homeland Security Committee.
Subcommittee members when issued:
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.
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 Health Physics Society*
Version 3.0
Disclaimer: The information contained herein was current as of 10 June 2011, and is
intended for educational purposes only. The authors and the Health Physics Society
(HPS) do not assume any responsibility for the accuracy of the information presented
herein. The authors and the HPS are not liable for any legal claims or damages that
arise from acts or omissions that occur based on its use.
*The Health Physics Society is a non profit scientific professional organization whose
mission is to promote the practice of radiation safety. Since its formation in 1956, the
Society has grown to nearly 5,000 scientists, physicians, engineers, lawyers, and other
professionals representing academia, industry, government, national laboratories, the
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research in radiation science, developing standards, and disseminating radiation safety
information. Society members are involved in understanding, evaluating, and controlling
the potential risks from radiation relative to the benefits. Official position statements are
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