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Slide1 : This presentation, "Emergency Department Management of Radiation Casualties,” was prepared as a public service by the Health Physics Society for hospital staff training. The presentation includes talking points on the Notes pages which can be viewed if you go to the File Menu and "Save As" a PowerPoint file to your computer. The talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points will be presented during the training. The presentation can be edited to fit the needs of the user. The authors request that that appropriate attribution be given for this material and would like to know who is presenting it and to what groups. That information and comments may be sent to Jerrold T. Bushberg, Ph.D., UC Davis Health System, at jtbushberg@ucdavis.edu. Version 2.6


Emergency Department Management of Radiation Casualties : Emergency Department Management of Radiation Casualties CAUTION


Scope of Training : Scope of Training Characteristics of ionizing radiation and radioactive materials Differentiation between radiation exposure and radioactive material contamination Staff radiation protection procedures and practices Facility preparation


Scope of Training (Cont.) : Scope of Training (Cont.) Patient assessment and management of radioactive material contamination and radiation injuries Health effects of acute and chronic radiation exposure Psychosocial considerations Facility recovery Resources


Ionizing Radiation : Ionizing Radiation Ionizing radiation is radiation capable of imparting its energy to the body and causing chemical changes Ionizing radiation is emitted by - Radioactive material Some devices such as x-ray machines


Types of Ionizing Radiation : Types of Ionizing 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


Radiation Units : Measure of Amount of radioactive material Ionization in air Absorbed energy per mass Absorbed dose weighted by type of radiation Radiation Units For most types of radiation 1 R  1 rad  1 rem Quantity Activity Exposure Absorbed Dose Dose Equivalent Unit curie (Ci) roentgen (R) rad rem


Radiation Doses and Dose Limits : Radiation Doses and Dose Limits Flight from Los Angeles to London 5 mrem Annual public dose limit 100 mrem Annual natural background 300 mrem Fetal dose limit 500 mrem Barium enema 870 mrem Annual radiation worker dose limit 5,000 mrem Heart catheterization (skin dose) 26,000 mrem Life saving actions guidance (NCRP-116) 50,000 mrem Mild acute radiation syndrome 200,000 mrem LD50/60 for humans (bone marrow dose) 350,000 mrem Radiation therapy (localized & fractionated) 6,000,000 mrem


Radioactive Material : Radioactive Material Radioactive material consists of atoms with unstable nuclei The atoms spontaneously change (decay) to more stable forms and emit radiation A person who is contaminated has radioactive material on their skin or inside their body (e.g., inhalation, ingestion or wound contamination)


Half-Life (HL) : Half-Life (HL) Physical Half-Life Time (in minutes, hours, days or years) required for the activity of a radioactive material to decrease by one half due to radioactive decay Biological Half-Life Time required for the body to eliminate half of the radioactive material (depends on the chemical form) Effective Half-Life The net effect of the combination of the physical & biological half-lives in removing the radioactive material from the body Half-lives range from fractions of seconds to millions of years 1 HL = 50% 2 HL = 25% 3 HL = 12.5%


Examples of Radioactive Materials : Physical Radionuclide Half-Life Activity Use Cesium-137* 30 yrs 1.5x106 Ci Food Irradiator Cobalt-60 5 yrs 15,000 Ci Cancer Therapy Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon Iridium-192 74 days 100 Ci Industrial Radiography Hydrogen-3 12 yrs 12 Ci Exit Signs Strontium-90 29 yrs 0.1 Ci Eye Therapy Device Iodine-131 8 days 0.015 Ci Nuclear Medicine Therapy Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging Americium-241 432 yrs 0.000005 Ci Smoke Detectors Radon-222 4 days 1 pCi/l Environmental Level * Potential use in radiological dispersion device Examples of Radioactive Materials


Types of Radiation Hazards : Types of Radiation Hazards External Exposure - whole-body or partial-body (no radiation hazard to EMS staff) Contaminated - external radioactive material: on the skin internal radioactive material: inhaled, swallowed, absorbed through skin or wounds External Exposure Internal Contamination External Contamination


Causes of Radiation Exposure/Contamination : Causes of Radiation Exposure/Contamination Accidents Nuclear reactor Medical radiation therapy Industrial irradiator Lost/stolen medical or industrial radioactive sources Transportation Terrorist Event Radiological dispersal device (dirty bomb) Attack on or sabotage of a nuclear facility Low yield nuclear weapon


Scope of Event : Scope of Event Event Number of Deaths Most Deaths Due to Radiation Accident None/Few Radiation Radioactive Dispersal Device Few/Moderate (Depends on size of explosion & proximity of persons) Blast Trauma Low Yield Nuclear Weapon Large (e.g. tens of thousands in an urban area even from 0.1 kT weapon) Radiation Exposure Blast Trauma Thermal Burns Fallout (Depends on Distance)


Slide15 : Time Minimize time spent near radiation sources Radiation Protection Reducing Radiation Exposure Distance Maintain maximal practical distance from radiation source Shielding Place radioactive sources in a lead container To Limit Caregiver Dose to 5 rem Distance Rate Stay time 1 ft 12.5 R/hr 24 min 2 ft 3.1 R/hr 1.6 hr 5 ft 0.5 R/hr 10 hr 8 ft 0.2 R/hr 25 hr


Slide16 : Key Points Contamination is easy to detect and most of it can be removed It is very unlikely that ED staff will receive large radiation doses from treating contaminated patients Protecting Staff from Contamination Universal precautions Survey hands and clothing with radiation meter Replace gloves or clothing that is contaminated Keep the work area free of contamination


Mass Casualties, Contaminated butUninjured People, and Worried Well : Mass Casualties, Contaminated but Uninjured People, and Worried Well An incident caused by nuclear terrorism may create large numbers of contaminated people who are not injured and worried people who may not be injured or contaminated Measures must be taken to prevent these people from overwhelming the emergency department A triage site should be established outside the ED to intercept such people and divert them to appropriate locations. Triage site should be staffed with medical staff and security personnel Precautions should be taken so that people cannot avoid the triage center and reach the ED


Decontamination Center : Decontamination Center Establish a decontamination center for people who are contaminated, but not significantly injured. Center should provide showers for many people. Replacement clothing must be available. Provisions to transport or shelter people after decontamination may be necessary. Staff decontamination center with medical staff with a radiological background, health physicists or other staff trained in decontamination and use of radiation survey meters, and psychological counselors


Psychological Casualties : Psychological Casualties Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening Mass casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated Establish a center to provide psychological support to such people Set up a center in the hospital to provide psychological support for staff


Facility Preparation : Facility Preparation Activate hospital plan Obtain radiation survey meters Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics) Establish area for decontamination of uninjured persons Establish triage area Plan to control contamination Instruct staff to use universal precautions and double glove Establish multiple receptacles for contaminated waste Protect floor with covering if time allows For transport of contaminated patients into ED, designate separate entrance, designate one side of corridor, or transfer to clean gurney before entering, if time allows


Slide21 : Treatment Area Layout HOT LINE CONTAMINATED AREA BUFFER ZONE CLEAN AREA Clean Gloves, Masks, Gowns, Booties Separate Entrance Trauma Room


Detecting and Measuring Radiation : Detecting and Measuring Radiation Instruments Locate contamination - GM Survey Meter (Geiger counter) Measure exposure rate - Ion Chamber Personal Dosimeters - measure doses to staff Radiation Badge - Film/TLD Self reading dosimeter (analog & digital)


Patient Management - Priorities : Patient Management - Priorities Triage Medical triage is the highest priority Radiation exposure and contamination are secondary considerations Degree of decontamination dictated by number of and capacity to treat other injured patients


Patient Management - Triage : Patient Management - Triage Triage based on: Injuries Signs and symptoms - nausea, vomiting, fatigue, diarrhea History - Where were you when the bomb exploded? Contamination survey


Patient Management - Decontamination : Patient Management - Decontamination Carefully remove and bag patient’s clothing and personal belongings (typically removes 95% of contamination) Survey patient and, if practical, collect samples Handle foreign objects with care until proven non-radioactive with survey meter Decontamination priorities: Decontaminate wounds first, then intact skin Start with highest levels of contamination Change outer gloves frequently to minimize spread of contamination


Patient Management - Decontamination (Cont.) : Patient Management - Decontamination (Cont.) Protect non-contaminated wounds with waterproof dressings Contaminated wounds: Irrigate and gently scrub with surgical sponge Extend wound debridement for removal of contamination only in extreme cases and upon expert advice Avoid overly aggressive decontamination Change dressings frequently Decontaminate intact skin and hair by washing with soap & water Remove stubborn contamination on hair by cutting with scissors or electric clippers Promote sweating Use survey meter to monitor progress of decontamination


Patient Management - Decontamination (Cont.) : Patient Management - Decontamination (Cont.) Cease decontamination of skin and wounds When the area is less than twice background, or When there is no significant reduction between decon efforts, and Before intact skin becomes abraded. Contaminated thermal burns Gently rinse. Washing may increase severity of injury. Additional contamination will be removed when dressings are changed. Do not delay surgery or other necessary medical procedures or exams…residual contamination can be controlled.


Slide28 : Radionuclide-specific Most effective when administered early May need to act on preliminary information NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides Treatment of Internal Contamination Radionuclide Treatment Route Cesium-137 Prussian blue Oral Iodine-125/131 Potassium iodide Oral Strontium-90 Aluminum phosphate Oral Americium-241/ Ca- and Zn-DTPA IV infusion, Plutonium-239/ nebulizer Cobalt-60


Patient Management - Patient Transfer : Patient Management - Patient Transfer Transport injured, contaminated patient into or from the ED: Clean gurney covered with 2 sheets Lift patient onto clean gurney Wrap sheets over patient Roll gurney into ED or out of treatment room


Facility Recovery : Facility Recovery Remove waste from the Emergency Department and triage area Survey facility for contamination Decontaminate as necessary Normal cleaning routines (mop, strip waxed floors) typically very effective Periodically reassess contamination levels Replace furniture, floor tiles, etc. that cannot be adequately decontaminated Decontamination Goal: Less than twice normal background…higher levels may be acceptable


Slide31 : Occurs only in patients who have received very high radiation doses (greater than approximately 100 rem) to most of the body Dose ~ 15 rem no symptoms, possible chromosomal aberrations Dose ~ 50 rem no symptoms, minor decreases in white cells and platelets Radiation Sickness Acute Radiation Syndrome


Slide32 : Prodromal stage nausea, vomiting, diarrhea and fatigue higher doses produce more rapid onset and greater severity Latent period (Interval) patient appears to recover decreases with increasing dose Manifest Illness Stage Hematopoietic Gastrointestinal CNS Acute Radiation Syndrome (Cont.) For Doses > 100 rem Time of Onset Severity of Effect


Slide33 : Dose ~ 100 rem ~10% exhibit nausea and vomiting within 48 hr mildly depressed blood counts Dose ~ 350 rem ~90% exhibit nausea/vomiting within 12 hr, 10% exhibit diarrhea within 8 hr severe bone marrow depression ~50% mortality without supportive care Dose ~ 500 rem ~50% mortality with supportive care Dose ~ 1000 rem 90-100% mortality despite supportive care Acute Radiation Syndrome (Cont.) Hematopoietic Component - latent period from weeks to days


Slide34 : Dose > 1000 rem - damage to GI system severe nausea, vomiting and diarrhea (within minutes) short latent period (days to hours) usually fatal in weeks to days Dose > 3,000 rem - damage to CNS vomiting, diarrhea, confusion, severe hypotension within minutes collapse of cardiovascular and CNS fatal within 24 to 72 hours Acute Radiation Syndrome (Cont.) Gastrointestinal and CNS Components


Slide35 : Estimating the severity of radiation injury is difficult. Signs and symptoms (N,V,D,F): Rapid onset and greater severity indicate higher doses. Can be psychosomatic. CBC with absolute lymphocyte count Chromosomal analysis of lymphocytes (requires special lab) Treat symptomatically. Prevention and management of infection is the primary objective. Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) Irradiated blood products Antibiotics/reverse isolation Electrolytes Seek the guidance of experts. Radiation Emergency Assistance Center/ Training Site (REAC/TS) Medical Radiobiology Advisory Team (MRAT) Treatment of Large External Exposures


Slide36 : Skin - No visible injuries < 100 rem Main erythema, epilation >500 rem Moist desquamation >1,800 rem Ulceration/Necrosis >2,400 rem Cataracts Acute exposure >200 rem Chronic exposure >600 rem Permanent Sterility Female >250 rem Male >350 rem Localized Radiation Effects - Organ System Threshold Effects


Special Considerations : Special Considerations High radiation dose and trauma interact synergistically to increase mortality Close wounds on patients with doses > 100 rem Wound, burn care and surgery should be done in the first 48 hours or delayed for 2 to 3 months (> 100 rem)


Chronic Health Effects from Radiation : Chronic Health Effects from Radiation Radiation is a weak carcinogen at low doses No unique effects (type, latency, pathology) Natural incidence of cancer ~ 40%; mortality ~ 25% Risk of fatal cancer is estimated as ~ 5% per 100 rem A dose of 5 rem increases the risk of fatal cancer by ~ 0.25% A dose of 25 rem increases the risk of fatal cancer by ~ 1.25%


What are the Risks to Future Children?Hereditary Effects : What are the Risks to Future Children? Hereditary Effects Magnitude of hereditary risk per rem is ~10% that of fatal cancer risk Risk to caregivers who would likely receive low doses is very small - 5 rem increases the risk of severe hereditary effects by ~ 0.02% Risk of severe hereditary effects to a patient population receiving high doses is estimated as ~ 0.4% per 100 rem


Fetal IrradiationNo significant risk of adverse developmental effects below 10 rem : Fetal Irradiation No significant risk of adverse developmental effects below 10 rem Little chance of malformation Most probable effect, if any, is death of embryo Reduced lethal effects Teratogenic effects Growth retardation Impaired mental ability Growth retardation with higher doses Increased childhood cancer risk (~ 0.6% per 10 rem) <2 2-7 7-40 All Pre-implantation Organogenesis Fetal Weeks After Fertilization Period of Development Effects


Key Points : Key Points Medical stabilization is the highest priority Train/drill to ensure competence and confidence Pre-plan to ensure adequate supplies and survey instruments are available Universal precautions and decontaminating patients minimizes exposure and contamination risk Early symptoms and their intensity are an indication of the severity of the radiation injury The first 24 hours are the worst; then you will likely have many additional resources


Resources : Resources Radiation Emergency Assistance Center/ Training Site (REAC/TS) (865) 576-1005 www.orise.orau.gov/reacts Medical Radiobiology Advisory Team (MRAT) Armed Forces Radiobiology Research Institute (AFRRI) (301) 295-0530 www.afrri.usuhs.mil Medical Management of Radiological Casualties Handbook, 2003; and Terrorism with Ionizing Radiation Pocket Guide Websites: www.bt.cdc.gov/radiation - Response to Radiation Emergencies by the Center for Disease Control www.acr.org - “Disaster Preparedness for Radiology Professionals” by American College of Radiology www.va.gov/emshg - “Medical Treatment of Radiological Casualties”


Resources : Resources Books: Medical Management of Radiation Accidents; Gusev, Guskova, Mettler, 2001. Medical Effects of Ionizing Radiation; Mettler and Upton, 1995. The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference, 2002. National Council on Radiation Protection Reports Nos. 65 and 138 Articles: “Major Radiation Exposure - What to Expect and How to Respond,” Mettler and Voelz, New England Journal of Medicine, 2002, 346: 1554-61. “Medical Management of the Acute Radiation Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group,” Waselenko, et.al., Annals of Internal Medicine, 2004, 140: 1037-1051. Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers; Gerber, Thomas RG (eds), Radiation Protection Dosimetry, 1992.


Acknowledgments : Acknowledgments Prepared by the Medical Response Subcommittee of the National Health Physics Society Homeland Security Committee. Jerrold T. Bushberg, PhD, Chair Kenneth L. Miller, MS Marcia Hartman, MS Robert Derlet, MD Victoria Ritter, RN, MBA Edwin M. Leidholdt, Jr., PhD Consultants Fred A. Mettler, Jr., MD Niel Wald, MD William E. Dickerson, MD Appreciation to Linda Kroger, MS who assisted in this effort.