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

2. Radiological Events 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

3. Radiological Events 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. Radiological Events 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 Objectives

5. Radiological Events 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. Radiological Events 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. Radiological Events Nuclear Power Plant Disaster: Chernobyl, 1986

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

9. Radiological Events Attacks on Reactors Which way is the wind blowing? –The radioactive cloud from the burning reactor will travel according to wind direction.

10. Radiological Events Attacks on Reactors Prevention –Individuals in the path of the radioactive cloud need to be evacuated

11. Radiological Events 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

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

13. Radiological Events Alpha Neutrons Beta Particles

14. Radiological Events A helium nucleus Unable to penetrate skin Emitted from radioisotopes such a plutonium, uranium ++ n n Alpha Particles

15. Radiological Events Able to penetrate skin Negatively charged Can produce skin superficial burns Emitted by several radioisotopes (e.g. Cobalt 160) Beta Particles

16. Radiological Events 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) Gamma Rays Stopped by inches to feet of concrete or less than an inch of lead Radiation Source Neutrons Stopped by a few feet of concrete

18. Radiological Events 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 X-Rays and Gamma Rays

19. Radiological Events RADIATION CANNOT BE SEEN, HEARD, TASTED OR SMELLED But, it can be easily measured if you have the right equipment Detecting Radiation

20. Radiological Events Alpha Survey Meter Radiation Detectors Beta and Gamma Survey Meter

21. Radiological Events Radiation Dose Units UnitValue 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

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

23. Radiological Events 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).

24. Adapted from CDC Bioterrorism Web site

26. If the patient is externally contaminated with radionuclides, you can Decontaminate

28. If radionuclides have gotten inside the body, consider chelation therapy

29. Radiological Events Factors Determining Radiation Exposure Time Distance Shielding

30. Radiological Events 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. Radiological Events Acute Radiation Syndrome A Spectrum of Disease

32. Radiological Events Phases of Acute Radiation Syndrome Prodromal Stage Latent Stage Manifest Illness Recovery Time (days to years) Exposure www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

33. Radiological Events 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

34. Radiological Events 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

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

36. Radiological Events 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

37. Radiological Events Andrews Curve 1: 1 Gy 2: 4 Gy 3: 6 Gy 4: 7.1 Gy

38. Radiological Events Stage 4: The Gastrointestinal Syndrome (150-400 rads) GI lining cells die Severe diarrhea and electrolyte losses Life saving fluid and electrolyte replacement Stages of Acute Radiation Syndrome

39. Radiological Events 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 Stages of Acute Radiation Syndrome

40. Radiological Events 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

41. Radiological Events 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. Radiological Events Patient Management - Protocol Based on: Injuries Signs and symptoms Patient history Contamination survey

43. Radiological Events 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 Hospital Management

44. Radiological Events Contaminated patient – immediately isolated until monitored & decontaminated Monitor EMS and ambulance ABC’s Cover all wounds Radiation burns are like sun burns Management

45. Radiological Events 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

46. Radiological Events 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

47. Radiological Events Protecting Staff from Contamination Use standard precautions Survey hands and clothing frequently Replace contaminated gloves or clothing Keep the work area free of contamination

48. Radiological Events Examples of Radiation Skin Burns

49. Radiological Events Decontamination of Skin Use multiple gentle efforts Use soap & water Cut hair if necessary (do not shave) Promote sweating Use survey meter

50. Radiological Events 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

51. Radiological Events 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

52. Radiological Events Specific Therapy RadionuclideTherapeutic Approach TritiumDilution (force fluids) Iodine-125 or I-131KI, or SSKI Cesium-134 or cesium- 137Prussian blue Strontium-89, or 90Decrease abs (antacids), blockage (strontium lactate), displacement (oral phosphate), mobilization (ammonium chloride) PlutoniumZinc or calcium (DTPA)

53. Radiological Events Radioiodines and Thyroid Cancer Radioiodines concentrate In the thyroid gland and can increase the risk of thyroid cancer

54. Radiological Events 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

55. Radiological Events Dosage (KI) Age GroupDosage Infants < 1 month16 mg Children 1 month – 3 yrs32 mg Children 3–18 yrs65 mg Adults130 mg

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

57. Radiological Events Patient can be: –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

58. Radiological Events 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

59. Radiological Events Acute Radiation Syndrome: –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

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

61. Radiological Events Questions?

62. Radiological Events Question #1 Which of the following are deep penetrating ionizing radiation particles? a.Alpha b.Beta c.Gamma d.Neutron e.Sigma

63. Radiological Events If a nuclear event caused a gamma ray whole body exposure of 400 RADs to a victim, what is the probable clinical result? a.Bone marrow depression b.Acute encephalopathy c.Radiation pneumonitis d.Thyroid cancer e.Death within minutes to hours Question #2

64. Radiological Events Which laboratory data are critical in assessing acute radiation sickness? a. Absolute lymphocyte count b. Hemoglobin/Hematocrit c. Serum Potassium d. Oxygen saturation e. Platelet count Question #3

65. Radiological Events Three firefighters present to the emergency department after battling a fire that resulted from an explosion of the core of a nuclear reactor. All are covered in soot. What is the best thing to do with their contaminated clothing? a.Remove clothing and send to radiology to be X- rayed b.Put clothing in a plastic bag and label as a radiation hazard c.Decontaminate clothing and return them to the family d.Clothing should be burned at the scene Question #4

66. Radiological Events Following the Chernobyl, Ukraine nuclear disaster, what has been the most common adverse outcome? a.Sudden cardiopulmonary arrest b.Leukemia c.Thyroid cancer d.Radiation pneumonitis e.Chronic paralysis Question #5

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

68. Radiological Events This completes the current presentation.