Attack on a Nuclear Power Plant Radiologic Events: Attack on a Nuclear Power Plant

Objectives Recognize the potential consequences of a terrorist attack on a nuclear power plant Describe the different types of radiation particles and waves and their effect on the body

Objectives Differentiate between radiation exposure and contamination Recognize the characteristic signs and symptoms of acute radiation syndrome Learn to perform rapid assessment of nuclear/radiation events in a disaster situation

Objectives Learn specific antidotes and medical interventions for nuclear/radiation terrorism victims Learn specific pre-hospital and hospital management strategies including proper notification of radiation disasters

Case Terrorists attack a nuclear power plant 30 miles outside a major metropolitan area by flying a high jacked jet liner into the plant. The impact results in an explosion and fire. Fire fighters and paramedics are called to the scene.

Case There are multiple casualties and several trauma victims are being transported to your health care facility. The news media is questioning your health team regarding radiation exposure risks

Nuclear Power Plant Disaster: Chernobyl, 1986 This is reactor 4 from Chernobyl, Ukraine. The outside is covered with a concrete sarcophagus to prevent radiation leaks. The inside is pictured following the large graphite meltdown and fire.

Attacks on Reactors Radioisotopes released Large quantities of radioiodines and radiocesiums A large variety of other radioisotopes may be released in smaller quantities

Attacks on Reactors Which way is the wind blowing? The radioactive cloud from the burning reactor will travel according to wind direction. Radioisotopes may also be deposited on soil through gravity or rain Radioiodines which fall on pastures can be incorporated into cows milk

Attacks on Reactors Prevention Individuals in the path of the radioactive cloud need to be evacuated This diagram demonstrates the areas covered by the main body of the radioactive cloud released from Chernobyl, Ukraine on various days after the accident in May 1986. 75,000,000 people were exposed. Since radioiodines incorporate into the thyroid gland, potassium iodide prophylaxis can reduce exposures- This will be discussed later in the presentation.

Electromagnetic Radiation Electromagnetic radiation includes a wide spectrum of radiation energy characterized by frequency and wave length. Ionizing radiation has high frequency and short wave length Ionizing radiation (enough energy to ionize molecules) is characterized by high frequency and short wavelength

Ionizing Radiation Ionizing radiation includes both electromagnetic (X and gamma rays) and particulate radiation

Particles Alpha Beta Neutrons An isotope goes from an unstable state to a more stable state through radioactive decay. In the process it gives off energy in the form of particles and rays

Alpha Particles A helium nucleus Unable to penetrate skin ++ n A helium nucleus Unable to penetrate skin Emitted from radioisotopes such a plutonium, uranium Very destructive once it gets into the body (e.g. inhalation or ingestion) due to its high linear energy transfer Alpha particles consist of 2 protons and 2 neutrons An internal hazard if swallowed

Beta Particles Able to penetrate skin Negatively charged Can produce skin superficial burns Emitted by several radioisotopes (e.g. Cobalt 160) Beta particles are high-energy electrons emitted from a nucleus

Neutron particles Uncharged Able to penetrate deeply Hazard inside nuclear reactors

Penetration Abilities of Different Types of Radiation Alpha Particles Stopped by a sheet of paper Beta Particles Stopped by a layer of clothing or less than an inch of a substance (e.g. plastic) Radiation Source Gamma Rays Stopped by inches to feet of concrete or less than an inch of lead Alpha particles. Alpha particles do not penetrate the dead layer of skin and can be stopped by a thin layer of paper or clothing. If an alpha emitting radioactive material gets inside the body through inhalation, ingestion, or through a wound, the emitted alpha particles can cause ionization that results in damage to tissue. Beta particles. Depending on its energy, beta radiation can travel from inches to many feet in air and is only moderately penetrating in other materials. Some beta radiation can penetrate human skin to the layer where new skin cells are produced. If high enough quantities of beta emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury. Beta emitting contaminants may be harmful if deposited internally. Protective clothing (e.g., universal precautions) typically provides sufficient protection against most external beta radiation. Gamma rays and x-rays (photons). Gamma rays and x-rays are able to travel many feet in air and many inches in human tissue. They readily penetrate most materials. Thick layers of dense materials are needed to shield against gamma radiation. Protective clothing provides little shielding from gamma and x radiation, but will prevent contamination of the skin with the gamma emitting radioactive material. Neutrons. Neutrons also penetrate most materials. They are able to travel many feet in concrete and thousands of feet in air. Thick layers of materials with lots of hydrogen in them (like water or concrete) are needed to shield against neutron radiation. Protective clothing provides no shielding from neutron radiation. Neutrons are not likely to be encountered except in the initial seconds of a nuclear criticality event. Neutrons Stopped by a few feet of concrete

X-Rays and Gamma Rays Gamma and X radiation differ by source: gamma rays comes from the nucleus and X-rays come from the electron orbits Because they don’t have mass or charge, they penetrate very deeply Xrays are similar to gamma but with a longer wavelength A person exposed to X-rays or gamma rays does not become radioactive This black and white photograph shows graphite meltdown that resulted in release of gamma rays.

RADIATION CANNOT BE SEEN, HEARD, TASTED OR SMELLED Detecting Radiation RADIATION CANNOT BE SEEN, HEARD, TASTED OR SMELLED But, it can be easily measured if you have the right equipment SOOO, NO INDICATION OF A LEAK IS NOTED UNTIL SYMPTOMS APPEAR. DAMAGE IS CAUSED BY THE ENERGY FROM RADIOACTIVE MATERIAL. THE LONGER THE EXPOSURE, THE WORSE THE OUTCOME WILL BE.

Beta and Gamma Survey Meter Radiation Detectors Alpha Survey Meter Beta and Gamma Survey Meter There are a variety of survey meters to detect radioactivity. One great advantage that hospital personnel have, when it comes to radioactive contamination, is the ease with which radioactive material can be detected. Most radioactive material can be detected easily and in very small quantities with the use of a simple instrument such as a GM survey meter (Geiger counter).

Radiation Dose Units Unit Value Rad (radiation absorbed dose) 0.01 J/kg Rem (radiation equivalent-man) Bio damage from 0.01 J/kg Gray (Gy) 100 rad Sievert (SV) 100 rem Rad stands for "radiation absorbed dose" and is a measure of energy per gram of body tissue. Rems equal rads multiplied by the relative mutagenic potential of the particular kind of radiation involved.

Contamination Contact with radioactive material (radionuclides) that can be spread to other people / properties Inhaled, ingested, transferred from surface to surface

Exposure vs. Contamination External Exposure: external irradiation of the body with rays or particles  absorbed dose Contamination: radioactive material (radionuclides) on patient (external) or within patient (internal). Radioactive Contamination: radioactive material where it does not belong. It is often attached to dust or dirt. Exposure: irradiation from outside the body External contamination – outside the body (on skin or clothes) can usually be easily washed off Internal contamination – inside the body (taken in through inhalation, ingestion or wounds) usually passes through the body through the normal cleansing mechanisms Contamination can be composed of any radioactive material (perhaps several at once) and the radiation emitted from it can be of any type (usually a combination of alpha, beta or gamma). Contamination can be a solid material, a liquid or a gas. Sometimes it is in the form of dust particles that float through the air and eventually settle to the ground (or some other surface.) For example, patients who have a procedure, such as an x-ray or CT scan, have been exposed to radiation but are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel.

Adapted from CDC Bioterrorism Web site Exposure – a person can be exposed to radiation without actually coming in contact with it. Adapted from CDC Bioterrorism Web site

Radioactive material – can come in any form, including particles similar to dust.

externally contaminated with radionuclides, you can Decontaminate If the patient is externally contaminated with radionuclides, you can Decontaminate Contamination – radioactive material that can be on a patient’s clothing or skin.

Contamination exterior to the body can usually be easily washed off.

If radionuclides have gotten inside the body, consider chelation therapy Internal contamination – radioactive material that has been taken inside the body (often through inhalation).

Factors Determining Radiation Exposure Time Distance Shielding Time The longer you are exposed, the greater your exposure Distance The degree of exposure varies with the inverse square of the distance Shielding Reduce your exposure by shielding your body (e.g. lead apron)

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

Acute Radiation Syndrome A Spectrum of Disease

Phases of Acute Radiation Syndrome Prodromal Stage Latent Manifest Illness Recovery Time (days to years) Exposure The four stages of ARS are: Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, and possibly diarrhea (depending on dose) that occur from minutes to days following exposure. After extremely high radiation doses, additional symptoms such as prostration, fever, respiratory difficulties, and increased excitability may develop. The symptoms may last (episodically) for minutes up to several days. Latent stage: In this stage the patient looks and feels generally healthy for a few hours or even up to a few weeks. The latent period shortens as the initial dose increases. Manifest illness stage: In this stage the symptoms depend on the specific syndrome and last from hours up to several months. Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years. www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

Stages of Acute Radiation Syndrome Stage 1: (50-150 rads) No symptoms or minimal viral symptoms for up to 48 hours Spontaneous recovery usually occurs Sterility is a risk

Stages of Acute Radiation Syndrome Stage 2: The Hematopoetic Syndrome (150- 400 rads) Whole body exposure Bone marrow suppression occurs with loss of WBC and platelets Infection and bleeding problems occur LD 50 250-400 rads

Stages of Acute Radiation Syndrome Stage 3: Severe Hematopoetic Syndrome (150-400 rads) Life saving bone marrow transplantation needed Care rationing during MCI will lower LD50

Absolute Lymphocyte Count Measure every 4 - 6 hours initial 48 hours Normal: approx 2500 cells/ml > 1200: probably non-lethal 300 to 1200 cells/ml: significant (hospitalize) < 300 cells/ml: critical

Andrews Curve 1: 1 Gy 2: 4 Gy 3: 6 Gy 4: 7.1 Gy This is the Andrews Curve The Y Axis represents the absolute lymphocyte count The X axis represents the time of exposure in days. The green line represents the radiation exposure measured in Gray units The lower the lymphocyte count (particularly at 48 hours post exposure) and the larger the radiation dose, the greater the lethality of the exposure.

Stages of Acute Radiation Syndrome Stage 4: The Gastrointestinal Syndrome (150-400 rads) GI lining cells die Severe diarrhea and electrolyte losses Life saving fluid and electrolyte replacement May treat with gut sterilization with Neomycin Hematopoetic Syndrome is also present

Stages of Acute Radiation Syndrome Stage 5: The CNS Syndrome (>1500 rads) Confusion, ataxia, and sensory deficits Death within 48 hrs regardless of treatment Early appearance of CNS symptoms is an ominous sign There is no latent phase in stage 5 illness

Pre-Hospital Management Evacuation of persons who are in the path of a radiation cloud is the most effective pre-hospital measure – this action is the responsibility of public health authorities Need effective communication with residents as to steps they can take to reduce exposure Risk communication is important

Patient Management - Priorities Initial triage and decontamination are ideally done outside the hospital (have a plan in place) to avoid contamination of the ED Patients exposed only to external EM radiation (e.g. x-ray or gamma rays) are not radioactive; patients exposed to particulate radiation will be radioactive Standard medical triage is the highest priority Radiation exposure and contamination are secondary considerations

Patient Management - Protocol Based on: Injuries Signs and symptoms Patient history Contamination survey For patients with life-threatening conditions, stabilize and treat physical symptoms according to standard procedures. Unfamiliar embedded objects in patient’s clothing or wounds may be radioactive sources. Handle with long forceps, handle only briefly, and keep distant from staff and patients until proven, with a survey meter, not to be radioactive. If radioactive objects are recovered, they should be placed in a lead container using tongs or forceps. If it is suspected that the patient received a high dose of radiation, take additional blood samples for CBC (complete blood count), with attention to lymphocyte count, as soon as possible and every 2 to 3 hours for the next 24 hours to assess lymphocyte depletion. Also, conduct HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion. Watch for loss of fluids and electrolytes, especially in infants, children and the elderly. Watch for hypotension. The severity and time of onset of nausea, vomiting, diarrhea, fatigue, headache, parotitis, erythema and fever should be noted and treated in routine clinical manner. Patient history will assist in the triage process to predict the potential extent of radiation injury. Obtain as much patient and situation history as possible (Where were you when the bomb exploded?), noticing circumstances surrounding the patient and the situation that might indicate exposure (this also includes looking for corroborating evidence.) After the patient is stabilized, trained staff should survey the patient for radioactive contamination and begin the decontamination process.

Hospital Management Security Radiation Safety Officers/dosimeters, GM 24-hour hotline (217) 785-0600 Radiation Duty Officer @ Illinois Department of Nuclear Safety Waste disposal Labeled, plastic bags WHAT SHOULD YOUR HOSPITAL, ASSOCIATE, AND RESOURCE HOSPITALS BE DOING AT THIS TIME?

Management Contaminated patient – immediately isolated until monitored & decontaminated Monitor EMS and ambulance ABC’s Cover all wounds Radiation burns are like sun burns If one only removed and bagged the patient’ s clothing and personal belongings at the scene that would typically remove about 80 to 90% of the contamination and the remaining contamination would usually be on the head, hands and feet. ABC- Airway, Breathing and Circulation All patients wounds may still be contaminated with particulate matter and must be decontaminated.

External Contamination Radioactive material (usually in the form of dust particles) on the body surface and/or clothing Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff External contamination is radioactive material (usually in the form of dust particles) on the outside of a patient’s body, including clothing. Though the radiation dose rate from contamination is usually very low, while it remains on the patient it will continue to irradiate the patient as well as anyone nearby.

Patient Decontamination Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of contamination) Handle foreign objects with care until proven non-radioactive with survey meter Survey patient and collect samples - Survey face, hands and feet - Survey rest of body Carefully remove and bag patient’s clothing and personal belongings (typically removes 80 - 90% of contamination) remove patient’s clothing (should remove 70-90% of contamination) double bag, tie, seal and label (patient name, date, time, etc.) any contaminated material in plastic bags contaminated personal items may be decontaminated (washed) and returned to the patient later Unfamiliar embedded objects in patient’s clothing or wounds may be radioactive sources. Handle with long forceps, handle only briefly, and keep distant from staff and patients until proven, with a survey meter, not to be radioactive. If radioactive objects are recovered, they should be placed in a lead container using tongs or forceps. Survey the patient for contamination scan the face, hands and feet using a standard radiation survey instrument if the results are positive, conduct a thorough survey of the patients entire body the speed of the survey should not exceed 2 inches per second, and the distance between the probe and the patient should be approximately 1 inch record location of contamination and contamination level, along with patient name, date and time of survey

Protecting Staff from Contamination Use standard precautions Survey hands and clothing frequently Replace contaminated gloves or clothing Keep the work area free of contamination Hospital staff are well versed in protecting themselves and their work areas from microbiological contamination through the use of standard precautions. The same techniques can be used effectively to protect personnel and the work area from contamination by radioactive materials. Use standard precautions Though standard surgical masks reduce the possibility of blood splashes to the mouth or hand-oral contamination, they do not protect against inhaling all respiratory hazards. Fitted particulate respirators such as N95 or higher will provide a higher level of protection. However, experience suggests that if N95 masks are not available, surgical masks should provide adequate protection. Survey hands and clothing with radiation meter at frequent intervals Replace gloves or clothing that is contaminated Keep the work area free of contamination as much as possible Frequent use of the GM survey meter can alert personnel to the need to change their gloves or clothing when they become contaminated or to tell them when contamination is being spread to the work area so that cleanup and extra precautions can be implemented. Such ease of detection and control is not possible with any other type of hazardous material.

Examples of Radiation Skin Burns These are victims of the Chernobyl disaster The patient on the right is in reverse isolation because he is immunocompromised

Decontamination of Skin Use multiple gentle efforts Use soap & water Cut hair if necessary (do not shave) Promote sweating Use survey meter Decontaminate patients with several gentle efforts, rather than with a single aggressive effort. Wash contaminated areas with soap and water water is the most important ally in this setting. Contaminated wash water can go down the drain like normal wash water. localized contamination can be wiped off with pre-moistened wipes or washed with soap and water a shower may be best if the patient is ambulatory and the contamination is wide spread take care not to abrade or irritate the skin protect non-contaminated wounds with waterproof dressings survey the patient again to locate contaminated areas and record location of contamination and the contamination level Remove contaminated hair if necessary, using scissors or electric clippers. To avoid cutting the skin and providing an entry for internal contamination, do not shave. Sweating can remove radioactive material from pores. Cover the area with gauze and put a glove or tape plastic over the area to promote sweating.

Cease Patient Decontamination When decontamination efforts produce no significant reduction in contamination When the level of radiation of the contaminated area is less than twice background Before intact skin becomes abraded Consider internal contamination Cease decontamination of the skin and wounds when the area is less than twice the background reading on the survey meter or there is no significant reduction between washings. Under no circumstances should decontamination cause the skin to become abraded. Do not delay surgery or other necessary medical procedures because of contaminated skin or wounds. Staff will be protected from becoming contaminated by using universal precautions. Sheets and dressings will keep contamination in place. The degree of decontamination for each patient should be dictated by the number of, and capacity to treat, other injured patients. If the patient is still shows a positive reading for contamination on the torso, but no there is no reduction between decontamination efforts, consider the possibility of internal contamination.

Decontamination of Wounds Contaminated wounds: Irrigate and gently scrub with surgical sponge Debride surgically only as needed Contaminated thermal burns: Gently rinse Changing dressings will remove additional contamination Change dressings frequently Avoid overly aggressive decontamination Protection of non-contaminated wounds with waterproof dressings will minimize the potential for uptake of radioactive material. To decontaminate wounds, irrigate and gently scrub with a surgical sponge. Normal wound debridement should be performed. Excision around wounds solely to remove contamination should only be performed in extreme cases and upon the advice of radiological emergency medical experts. irrigate and gently scrub with a surgical sponge debride wound only as needed, being sure not to overdo it. in extreme cases, with advice from radiological emergency medical experts, excise around the wound to remove contamination cover the wound with waterproof dressing frequent dressing changes can also aid wound decontamination note that with thermal burns, washing may increase the severity of the wound, so just gently rinse. Many times, radioactive material will exude from wounds into gauze dressings so frequent changing of dressings may aid wound decontamination. The dressing also serves to keep the contamination in place.

Specific Therapy Radionuclide Therapeutic Approach Tritium Dilution (force fluids) Iodine-125 or I-131 KI, or SSKI Cesium-134 or cesium- 137 Prussian blue Strontium-89, or 90 Decrease abs (antacids), blockage (strontium lactate), displacement (oral phosphate), mobilization (ammonium chloride) Plutonium Zinc or calcium (DTPA) Diethylenetriamine pentaacetic acid (DTPA) These are chelation agents or antidotes for specific radionuclide exposures. These antidotes are generally difficult to obtain and each hospsital should develop a plan of mobilizing specific antidotes if needed emergently

Radioiodines and Thyroid Cancer The most common cancer noted among Chernobyl survivors was thyroid cancer. Radioiodines concentrate In the thyroid gland and can increase the risk of thyroid cancer

You can reduce the radioiodine thyroid dose by giving potassium iodide Potassium Iodide (KI) considerations Who should get KI? Useful at the beginning of an exposure Only protects against thyroid cancer Gives false sense of security This is controversial in the management of radioiodine exposures

Dosage (KI) Age Group Dosage Infants < 1 month 16 mg Children 1 month – 3 yrs 32 mg Children 3–18 yrs 65 mg Adults 130 mg The dose of KI should be properly adjusted for pediatric victims since they are greatest risk for thyroid cancer.

Key Points Ionizing radiation includes: Electromagnetic radiation: X and gamma Particulate radiation: alpha, beta, neutrons

Key Points Patient can be: Which patients are radioactive? Irradiated externally Contaminated with radionuclides Which patients are radioactive? Those contaminated with radionuclides These patients need to be decontaminated Some internally deposited radionuclides can be removed with chelation therapy

Key Points Protect yourself from radiation: Reduce the time of exposure Increase the distance from the radiation source Apply shielding between yourself and the radiation source

Key Points Acute Radiation Syndrome: Long-term consequences Stages progress from hematopoetic to gastrointestinal to central nervous system with increasing dose The absolute lymphocyte count is the best predictor of dose Long-term consequences Increase in cancer, especially thyroid cancer With radioiodine exposure, thyroid dose can be reduced by using KI

Key Points Have a radiation disaster management plan in place for your hospital Be prepared for psychological consequences

Resources CDC Bioterrorism – www.bt.cdc.gov Radiation Emergency Assistance Center & Training Site (REAC/TS) - http://www.orau.gov/reacts/default.htm Medical management of radiological casualties handbook - www.afrri.usuhs.mil

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