Hospital Management of
Nuclear Casualties
DPT 7.0
Terminal Objective
Recognize the various types of radiological hazards,
understand the acute health effects from radiation
exposure, hospital procedures for managing
exposed and/or contaminated patients, and know
how to use radiation protection.
DPT 7.0
Terrorist Use of Nuclear Material
• Terrorist use of nuclear
materials
– Simple radiological
device
– Radiological dispersal
device
– Reactor
– Improvised nuclear
device
– Nuclear weapon
DPT 7.0
The Basics of Radiation
Ionizing radiation is
electromagnetic energy
or energetic particle
emitted from a source.
Ionizing radiation is able
to strip electrons from
atoms causing chemical
changes in molecules.
DPT 7.0
The Basics of Radiation
Chemical
Damage
Free Radicals
10-10 Seconds
Biological
Molecular
Damage
Biological
Damage
Cells, tissues,
whole animals
1. Proteins
2. Membrane
3. DNA
Hours to years
Seconds
to hours
DPT 7.0
Ionizing Radiation - Alpha
• 2 neutrons and 2 protons
• Highly ionizing
• Travels several centimeters in air and a few
microns in tissue
• Component of nuclear fallout
• Stopped by a thin paper or clothing
• Threat is inhalation or absorption of alpha
emitter in wounds
DPT 7.0
Ionizing Radiation - Beta
• High energy “electron” emitted from nucleus
• Can have wide range of energies depending
upon the particular radionuclide
• Moderately penetrating
– Up to a few meters in air
– Millimeters in tissue
• Some protection by PPE
DPT 7.0
Gamma or X-Ray (Photons)
• High energy rays
• Very penetrating
• Difficult to shield
• Can be produced from radioactive decay and a
nuclear weapon explosion or reactor accident
• PPE will not protect against photon radiation
DPT 7.0
Ionizing Radiation - Neutrons
• Neutral particle emitted from the nucleus
• Can be very penetrating
• Requires special consideration for shielding
DPT 7.0
Radiation Detection
• Instrumentation
–
–
–
–
G.M. Survey Meter
Dose Rate Meter - Ionization Chamber
Alpha Meter
Neutron Meter
• Personal Dosimeters
–
–
–
–
Film Badge
Thermoluminescent Dosimeter
Quarts Fiber Dosimeter
Electronic Instantaneous Read Out Dosimeter
DPT 7.0
Radiation - Units of Measure
• rad - basic unit for measuring radiation
• rem - quantifies the amount of
damage that is suspected from a
particular type of radiation dose
DPT 7.0
Radiation - Units of Measure
X-RAY
100 rads
=
100 rem
BETA
100 rads
=
100 rem
GAMMA
100 rads
=
100 rem
NEUTRONS
10 rads x QF10
=
100 rem
ALPHA
5 rads x QF20
=
100 rem
DPT 7.0
Examples of Radioactive Materials
Substance
Half Life
Emit
Use
Americium 241
458 years
a, g
Smoke Detectors
Cobalt 60
5.3 years
b, g
Medical Therapy
Plutonium 238
87 years
a
Thermoelectric Gen.
Plutonium 239
24,400 yrs
a
Reactors and Weapons
Radium 226
1,620 yrs
a
Medical Therapy
Uranium (natural)
millions yrs
a, b, g
Reactors and Weapons
Iridium 192
74 days
b, g
Industrial Radiography
DPT 7.0
Radiation Half-Life
• Time required for a radioactive substance to lose half of its
radioactivity
• Each radionuclide has a unique half-life
• Half-lives range from extremely short (fraction of a second)
to millions of years
Examples:
Tc-99m
I-131
Co-60
Sr-90
Pu-239
U-238
6.0 hrs
8.05 days
5.26 yrs
28.1 yrs
24,400 yrs
4,150,000,000 yrs
DPT 7.0
Natural Background Radiation
Natural background and manmade radiation
360 mrem
Diagnostic chest x-ray
10 mrem
Flight from LA to Paris
4.8 mrem
Barium enema
800 mrem
Smoking 1.5 ppd - 1 year dose
16,000 mrem
Heart catheterization
45,000 mrem
Mild acute radiation sickness
200,000 mrem
LD50 for irradiation
450,000 mrem
mrem = millirem = 1/1000 of a rem
DPT 7.0
Radiation Protection Principles
• Time
• Distance
• Shielding
• Quantity
DPT 7.0
Types of Radiation Injury
• External irradiation - whole-body or partial-body
• Contamination by radioactive materials - external
(deposited on the skin) or internal (inhaled, swallowed,
absorbed through skin, or introduced through wounds)
• Incorporation of radioactive materials - uptake by body
cells, tissues, or organs (bone, liver, kidney, etc)
• Combined radiation injury - combination of the above
complicated by trauma.
DPT 7.0
Radiation Injury - Contamination
External
Internal
DPT 7.0
Radiation Injury - Incorporation
Thyroid
Lung
Liver
Bone
DPT 7.0
Radiation - LD50
• We know what radiations are produced
• We know how to measure them
• But the body senses cannot detect radiation.
Therefore, how can we measure the biological
damage?
– LD50/30 Animals
– LD50/60 Man
DPT 7.0
Examples of LD50 for Given Species
Species
Dose (rads)
• Guinea Pigs
250
LD 50/30
• Goat
350
LD 50/30
• Man
250-450
(LD 50/60)
• Mouse
570
LD 50/30
• Rat
550-800
LD 50/30
• Frog
700
LD 50/30
• Snail
8,000-20,000 LD 50/30
DPT 7.0
Severity of Injury
The higher the dose, the more
severe the early effects and the
greater the possibility of
delayed effects
DPT 7.0
Survival Time
Survival
Time
Hematopoietic
Gastrointestinal
CNS/
CVS
200 Rads
2 Gy
1000 Rads
10 Gy
100,000 Rads
100 Gy
DPT 7.0
Acute Radiation Syndrome (ARS)
• Group of symptoms that develop after total body
irradiation (> 100 rads)
• May occur from either internal or external radiation
• Four important factors are:
– High Dose
– High Dose Rate
– Whole Body Exposure
– Penetrating Radiation
DPT 7.0
ARS - Phases
1. Prodromal Phase - occurs in the first 48 to 72 fours postexposure and is characterized by nausea, vomiting, and
anorexia. At doses below about 500 rads last 2 to 4 days.
2. Latent Phase - follows the prodromal phase and lasts for
approximately 2 to 2 1/2 weeks. During this time, critical cell
populations (leukocytes, platelets) are decreasing as a result
of bone marrow insult. The time interval decreases as the
dose increases.
3. Illness Phase - period when overt illness develops
4. Recovery or Death Phase - may take weeks or
months
DPT 7.0
Absolute Lymphocytes (109/L)
ARS - Hematopoietic Syndrome
3.0
2.5
Normal Range
2.0
1.5
Moderate
1.0
Severe
Patient
0.5
0.1
0 3 6 17 24
48 hrs
Very Severe
Lethal
DPT 7.0
Injury
ARS - Blood Count
RBC
Cell
Reduction
Neutrophils
Lymphocytes
Platelets
24-hr
1 week
2 weeks
3 weeks
DPT 7.0
ARS - Gastrointestinal Syndrome
• Radiation > 600 rads
• Damages intestinal lining
• Nausea and vomiting within the
first 2 - 4 hours
• May develop diarrhea
• Associated with sepsis and
opportunistic infections
• At 10 days could develop bloody
diarrhea resulting in death
DPT 7.0
ARS - Central Nervous System
• Seen with radiation dose >
1,000 rads
• Microvascular leaks 
edema
• Elevated intracranial
pressure
• Death within hours
DPT 7.0
Response
300
600
Necrosis
Moist
Desquamation
ARS - Skin
1000 >1500 >5000
Dose
DPT 7.0
ARS & Trauma
• Radiation and Trauma =  Mortality
• Wound and burn care, surgery, and orthopedic
repair should be done in the first 48 hours or
delayed for 2 to 3 months
Emergency
Surgery
Hemopoietic Recovery
No Surgery
Surgery
Permitted
24 - 48 Hours
3 Months
After 3 Months
DPT 7.0
Triage
• Triage:
– Use your own triage method
– Ensure ABC’s
– Stabilize the patient first and only when this is
done does one consider irradiation and
contamination.
DPT 7.0
Classification, Treatment & Disposition
• Patients are classified in three categories based on
signs and symptoms:
– Survival probable < 100 rads
– Survival possible 200 - 800 rads
– Survival improbable > 800 rads
DPT 7.0
Evaluation & Treatment - Hospital Care
• Activate hospital plan
• Establish triage area
• Plan to control contamination
– Prepare area by cover/marking floor, control ventilation
– Prepare staff by issuing protective clothing
– Prepare for surveying
– Establish area for storage of waste
– Plan for decontamination of non-traumatized patients
DPT 7.0
Hospital Care - Patient Arrival
• Carefully remove and bag victim’s clothing and
personal belongings
• Survey patient and conduct biological sampling
• Contaminated patients require decontamination
• If patient has a wound, decontaminate it first, then
decontaminate skin
DPT 7.0
Decontamination
• Irrigate open wounds and cover with sterile
dressing
• Soap and water showering (including hair)
• Effective for mixed radiation/chemical
contamination
• Refer for any surgery
DPT 7.0
Internal Contamination/Incorporation
• Various medications can be used to limit uptake or
facilitate removal of radioactive material
• Numerous medications are approved by the FDA.
Certain drugs are investigational and can be used
in an emergency (i.e. Radiogardase [Prussian
Blue] and DTPA)
• NCRP 65
DPT 7.0
Psychological Casualties
• Mass Casualty Incident (MCI) caused by nuclear
terrorism will create large numbers of concerned
casualties who may not actually be injured or
contaminated
• Establishing counseling centers will prevent
psychological casualties from overwhelming
health care facilities
DPT 7.0
Key Points
• Pre-planning to ensure adequate supplies of PPE
and survey instruments
• Training to ensure competence at all levels
• Rescue and treatment protocols vary little for
radiation contamination
• Donning PPE and decontaminating patients
minimizes exposure risk
• Early symptoms are an indication of the severity
of the radiation dose
• Treatment requires a unified effort
DPT 7.0