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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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.

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

9. 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

10. 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 ,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.

11. 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

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

13. 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

14. 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

15. 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

16. Neutron particles Uncharged Able to penetrate deeply
Hazard inside nuclear reactors

17. 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

18. 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.

19. 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.

20. 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).

21. 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.

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

23. 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.

24. 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

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

26. 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.

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

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

29. 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)

30. 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

31. Acute Radiation Syndrome A Spectrum of Disease

32. 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.

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

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

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

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

37. 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.

38. Stages of Acute Radiation Syndrome
Stage 4: The Gastrointestinal Syndrome
( 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

39. 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

40. 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

41. 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

42. 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.

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

44. 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.

45. 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.

46. Patient Decontamination
Remove and bag the patient’s clothing and personal belongings (this typically removes % 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 % 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

47. 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.

48. 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

49. 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.

50. 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.

51. 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.

52. 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

53. 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

54. 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

55. 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.

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

57. 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

58. 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

59. 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

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

61. Resources CDC Bioterrorism – www.bt.cdc.gov
Radiation Emergency Assistance Center & Training Site (REAC/TS) -
Medical management of radiological casualties handbook -

62. This completes the current presentation.
End presentation and distribute activity survey.