Module Seven Radiation Emergencies - ACMT€¦ · TICs & TIMs Module Seven – Radiation...

Chemical Agents of Opportunity for Terrorism: TICs & TIMs!

Training Support Package 1

Module Seven Radiation Emergencies

Chemical Agents of Opportunity for Terrorism: TICs & TIMs

2 Module Seven – Radiation Emergencies

Learning Objectives

•  Review key concepts: radiation types and exposure/dose

•  Identify where radiation is found •  Describe five potential major terrorist scenarios

involving radiation •  Describe clinical response strategies



Where are Nuclear Materials Found

•  Irradiation facilities •  Nuclear reactors •  Materials testing •  X-ray devices •  Isotope production facilities •  Radionuclides used in

medicine/research •  ???????



Devices Containing Radioactive Source Materials

•  Estimated 2 million devices in the USA contain licensed radioactive sources, but there is no comprehensive national inventory.

•  Companies have reported losing track of almost 1700 sources since 1998. More than half have yet to be found.

[Nuclear Threat Initiative, Monterrey Institute of International. Studies. 2003]



Five major terrorist scenarios

1.  Surreptitious placement of a radiation source 2.  Stealth dispersal of radioactive material 3.  Explosive radiation dispersal (“dirty bomb”) 4.  Attack on a nuclear power plant 5.  Detonation of a nuclear weapon



Surreptitious Placement of Radiological Source



Malevolent Use of Radiation Guangdong Province, China 2002 •  A nuclear medicine expert who managed

a laser medical center got into a dispute with his partner.

•  He used forged papers to purchase an industrial device containing iridium-192, and placed the source in the ceiling of his partner's office.

•  The partner became ill within days, experiencing low white blood count, bleeding gums, fatigue, dizziness, nausea.

•  74 members of the hospital staff were also sickened before an inspection identified the source.

[www.cnn.com/2003/world/asiapcf/east/10/02/china.radiation]



(Stealth) Dispersal of Radioactive Material: Cesium-137 Radiation Accident

Goiania, Brazil (1987) •  On 9/13/87, two scavengers found abandoned

teletherapy device in abandoned medical clinic building. Device contained 1,375 Ci of Cesium-137.

•  Unit partially dismantled, then sold a few days later to a junkyard, where dealer used power tools to gain access to luminescent powder. Powder was distributed among relatives and neighbors.

•  11 heavily exposed people admitted to hospital over next 2 weeks, suffering from nausea, vomiting, diarrhea, dizziness, and skin lesions. On 9/28/87, the illnesses were recognized as acute radiation syndrome and a major public health response was initiated.



Goiania Radiation Accident •  Widespread population monitoring due to concern over water

contamination from junkyard run-off. •  112,000 surveyed for contamination •  249 contaminated

–  120 externally contaminated clothing –  129 externally and internally contaminated

•  46 received chelation with Prussian Blue •  20 required specific hospital treatment •  14 developed bone marrow depression •  8 treated with GM-CSF •  4 died due to hemorrhage and infection. •  Exposure was 4-6 Gy



Radiological Dispersal Devices: “Dirty Bombs”

•  A relatively small conventional explosive may be able to disperse radiation from even a small source over many city blocks

•  However, if radiation is detected promptly, few individuals are likely to absorb a lethal dose before they can evacuate the area

•  In terms of human casualties, unlikely to be a “weapon of mass destruction.”

•  Radiation sickness will be limited to individuals who have ingested, inhaled, or otherwise internalized substantial amounts of the source



Attack on a Nuclear Power Plant



Chernobyl (April, 1986) The world’s largest example of a

“smoking disperser of radioactive material?”

•  134 Acute Radiation Syndrome victims, 48 with burns

•  28 Acute radiation injury deaths, plus 19 late deaths

•  Up to 4000 excess cancer deaths estimated among 600,000 heaviest exposed (liquidators, evacuees, nearby residents)

•  Source: WHO Chernobyl Forum 2006



What is Radiation?

•  Radiation is Energy •  This energy can be in the form of:

–  electromagnetic waves, or –  subatomic particles



What is Ionizing Radiation? •  Ionizing radiation has enough

energy to strip electrons off atom-all nuclear radiation is ionizing

•  Ionizing or “nuclear” radiation has the clear potential to “terrify” the public as it is associated with the destructive force of nuclear weapons

•  Invisible •  Undetectable to the senses



What is Non-ionizing Radiation •  Many other forms of

radiation are non-ionizing •  Examples:

–  UV –  Radio waves –  Microwaves –  Light



Types of Ionizing Radiation •  Alpha

–  High energy “helium nucleus” •  Beta

–  High energy “electron” •  Gamma

–  Electromagnetic energy from within a nucleus

•  X-ray –  Electromagnetic energy from

outside a nucleus •  Neutron

–  Neutral particle emitted from the nucleus



Different Types of Radiation



Radiation vs Radioactive Material

•  Radiation –  Energy transported in the form of waves or particles (i.e

alpha, beta, gamma, or x-rays) •  Radioactive material

–  Materials that emit ionizing radiation



Exposure



Contamination (Internal or External)



Radiation Terms •  Activity

–  Amount of disintegrations/sec –  Units: Curie or Becquerel

•  Absorbed dose –  Amount of energy deposited –  Units: rad or Gray

•  Dose equivalent –  Amount of biological damage/risk –  Units: rem or Sievert

Marie Curie



Radiation Exposures •  Natural background radiation (annual average):

360 mrem •  Air travel round trip (London-New York):

4 mrem •  Chest X-ray:

10 mrem •  Smoking 1.5 packs/day x1 yr:

16,000 mrem •  Mild acute radiation sickness:

200,000 mrem •  LD50 for irradiation (w/i 60 days w/o treatment):

450,000 mrem



Injuries Associated with Radiological Incidents

•  Acute Radiation Syndrome •  Localized radiation injuries •  Fetal effects •  Contamination •  Trauma



What Radiation Does Not Do

•  Immediate death •  Immediate burns/wounds •  Irradiation alone is not a medical emergency or

threat to medical providers •  Treat the patient first!



Acute Radiation Syndrome (ARS)

•  A group of signs and symptoms that develop after total body irradiation.

•  Generally requires high dose whole body exposure, at a high dose rate, to penetrating (e.g. gamma) radiation

•  More severe exposures lead to more rapid onset of symptoms and severity of illness



Phases of Acute Radiation Syndrome



Acute Radiation Syndrome

•  Subclinical •  Hematopoietic •  Cutaneous •  Gastrointestinal •  CNS

<100 rads >100 rads >300 rads >600 rads >3000 rads

Current nomenclature: 1 Grey (Gy) = 100 rads



Hematopoietic Syndrome (1-5 Gy)

•  Manifests as fall in lymphocyte count •  Lymphocyte nadir typically 8-30 days post exposure •  Higher doses → earlier nadir •  Stem cells die, platelets are consumed •  Pancytopenia → death from sepsis, hemorrhage



Prognosis

•  Prognosis poor above 6 Gy, and improbable > 8 Gy •  Gastrointestinal syndrome

–  Nausea, vomiting, diarrhea within 2 to 4 hours, lasting 2 days, followed by short latent phase (0 to 7 days). Then return of severe N, V, diarrhea, + fever, electrolyte imbalance, marrow suppression.

–  Death occurs within 1 to 2 weeks. •  Central Nervous System Syndrome

–  Onset within minutes to an hour of violent N, V, D, followed by confusion, fever, hypotension, convulsions, coma, and death within 48 hours.



Diagnosis of ARS

•  History of possible exposure •  Note signs/symptoms & time to onset •  CBC w/ diff and follow every 4-6 hrs



Diagnosis of ARS Various algorithms relate symptoms (vomiting) and lymphocyte

depletion kinetics (next slide) to management (e.g.) •  Time to vomiting not completely reliable at moderate doses

–  30% of patients exposed to 2 Gy vomit within 5 hours => admit to general hospital

–  90% of patients exposed to 6 Gy vomit within 1 hour => require urgent specialized care http://www.remm.nlm.gov/onsetvomiting.htm



(1) 300 rads (2) 440 rads (3) 560 rads (4) 710 rads

Patterns of Early Lymphocyte Response in Relation to Dose



Localized Radiation Injury

•  One part of the body receives higher dose than rest of the body

•  Diagnosis is difficult •  ARS may or may not be present



Localized Radiation Injury

300 rads

600 rads

1000 rads

2000 rads

>5000 rads

•  Epilation starting on day 17

•  Erythema starting mins to weeks

•  Dry desquamation

•  Moist desquamation in 2-3 weeks

•  Necrosis and deep ulceration



Local Radiation Diagnosis

•  History •  Amount of tissue injury = retrospective dosimeter •  Accident mock-up = prospective dosimeter



Treatment for Local Injury •  Pain control •  Avoid nicotine •  Prevent/treat infections •  Surgical treatment for necrosis •  Hyperbaric oxygen therapy may

have a role in improving healing •  Problems

–  Wounds evolve slowly –  Healing is extremely prolonged



Fetal Radiation Exposure

•  Human embryo and fetus highly sensitive to ionizing radiation

•  Effects depend on dose and stage of gestation •  Uterine absorption 0.2 – 0.5 Sv: •  1st week post-conception risks lethality •  2-7 wks risks congenital abnormality •  8-15 weeks risks mental retardation



Contamination •  Standard medical triage

(ABC’s) is the highest priority

•  Radiation exposure and contamination are secondary considerations



Contamination

“When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personnel at the site received less than 1 rad of radiation.”

Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61



Protecting Staff from Contamination

•  Use standard precautions •  Survey hands and clothing frequently •  Replace contaminated gloves or clothing •  Keep the work area free of contamination



Contamination Control

Hot Zone!

Warm Zone!

Cold Zone!



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



Decontamination of Skin •  Use multiple gentle efforts •  Use soap & water •  Cut hair if necessary (do not

shave) •  Promote sweating •  Use survey meter



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 –  Avoid overly aggressive decontamination

–  Change dressings frequently



Internal Contamination

•  Radioactive material may enter the body through –  Inhalation –  Ingestion –  Wounds

•  Internal contamination generally does not cause early signs or symptoms

•  Internal contamination will continue to irradiate the patient



Specific Therapy for Internal Contamination

Radionucleotide Therapy

Tritium Dilutional Iodine-125, 131 Potassium Iodide Strontium-89 Aluminum Phosphate

Cesium-137, Thallium Prussian Blue Plutonium, Americium, Curium DTPA

Unknown Charcoal / Lavage



Prussian Blue - Radiogardase® (ferric hexacyanoferrate)

•  Pharmaceutical chelator that forms high affinity, nonabsorbable complexes with cesium and thallium

•  After oral administration, diminishes intestinal Cs absorption, or interrupts enterohepatic or enteroenteric circulation, accelerating elimination in the feces

•  Approved by FDA in 2003 for treatment of contamination with radioactive cesium (137Cs)



Ca-DTPA Trisodium Calcium (diethylenetriaminepentaacetate)

•  Approved as an I.V. chelating agent for individuals with internal contamination with plutonium, americium, and curium. Aerosol administration also possible

•  Can bind to radioactive atoms and accelerate their elimination in the urine

•  Treatment is most effective if begun promptly, I.e. within hours of first exposure. If treatment is begun after 24 hours, Zn-DTPA should be used if available.



Immediate Medical Management

•  Triage –  ARS –  localized/ cutaneous –  combined injury

•  Initial stabilization and treatment

•  Psychological effects •  Record keeping/ Dose

assessment



Consult with Radiation Experts

•  Consult with Radiation Safety Officer or Health Physicist: –  Determining/documenting presence of radioactivity,

activity levels, and radiation dose –  Collecting samples to document contamination –  Assisting in decontamination procedures –  Disposing of radioactive waste

•  REAC/TS phone number 865-576-1005



Radioactive Isotopes as Delayed-Onset Toxins

The saga of Alexander Litvinenko



Background on Polonium-210

Alpha-emitters characteristics •  High-energy and severely damage genetic material

–  Po-210 especially high-energy, gives off 5,000 times more alpha particles than does the same amount of radium

•  Penetrate short distances – only harmful to humans through inhalation, ingestion, or contact with open wounds



Litvinenko Case Timeline Nov. 1st, 2006

–  Meets with two Russian men at a restaurant, one an Italian security expert –  Litvinenko hospitalized that very same day –  British toxicologist suggests thallium poisoning

•  Italian Senator Paolo Guzzanti, former head of a parliamentary commission examining past cases of KGB infiltration, said that Litvinenko was considered a traitor by enemies in the Kremlin and a helper of traitors, i.e. the Chechens.

•  On his deathbed, the patient blamed Russian President Vladimir Putin for the poisoning, a charge Putin strongly denied. He died 11/23, just over 3 weeks post-exposure.



Radiation Exposure: History Clues

•  Finding an unknown metallic object. •  Working with fluorescence spectroscopy, industrial

radiography, etc. •  Family history of several family members or close

friends with skin lesions and a history of nausea, vomiting and fatigue.



Radiation Exposure: Exam Clues •  Skin ulceration, skin peeling (desquamation), skin redness

(erythema), loss of hair or abnormal sweating of an area of skin

•  Unexplained infections or bleeding, particularly in the gums or gastrointestinal tract.

•  Weight loss, diarrhea, fluid or electrolyte imbalance, kidney failure.

•  Shock •  Confusion, disorientation, brain edema, loss of coordination

(ataxia), seizures, or coma (1-2 days after severe exposure).



Audience Response

When caring for patients exposed to high levels of radiation, it is important to understand that:

1.  They are radioactive and pose a significant risk to providers 2.  Seriously injured patients must first be decontaminated. 3.  Providers must be decontaminated before emergency care is given 4.  They are not necessarily radioactive and pose little health risk to

others



Key Points

•  Stabilization is the highest priority •  Radiation experts should be consulted •  Training and drills should be offered •  Adequate supplies and survey instruments should

be stocked •  Standard precautions reduce contamination •  Early symptoms and their intensity indicate the

severity of the radiation injury

Chemical Agents of Opportunity for Terrorism: TICs & TIMs!

Training Support Package 59

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