# Presentation: 815447

## MANAGEMENT OF RADIOLOGIC CASUALTIES

- csepp multi-hazard
- medical curriculum

## Nuclear Threat

**Formerly**
- Soviet Union
- Nuclear fallout
**Now**
- NBC threat against civilians
- Accidental exposure of workers and public

**Images:  CIA, FBI**

**Notes:**
     Introduction
     There was a time when many people feared a possible nuclear attack by the Former Soviet Union.  Today a new type of threat confronts  society in which nuclear, biological, or chemical - NBC - weapons are targeted toward civilians by terrorists. In addition there have been a number of incidents involving worker and civilian exposure from medical or industrial accidents or from abandoned sources.
     It is important that first responders - police, fire, emergency medical service (EMS) personnel, physicians, nurses, and disaster planners - understand how radioactive material might be spread in the environment and the consequences of radiation exposure so that they may better respond to and treat victims of events involving a release of radioactive materials.  During such events, rescue should not be attempted until the incident scene is secured, routine monitoring performed, and the responder dressed in appropriate personal protective equipment (PPE).  The nature of the radiation exposure and its medical consequences depends on the type and amount of exposure from:
Radiological-emitting device 
Radiological dispersion device (RDD) or dirty bomb 
Nuclear facility, reactor, fuel storage facility, weapons facility,  reprocessing facility
Improvised Nuclear Device
Nuclear weapon

## Accidental Exposure in Brazil 

- Cesium-137 source found by scavengers in 1987
- Source broken open, contents shared
- 112,800 surveyed for contamination
- 120 externally contaminated only
- 129 internally & externally contaminated
- 20 required hospital treatment
- 14 developed bone marrow depression
- 8 treated with Granulocyte Macrophage Colony-Stimulating Factors (GM-CSF)
- 4 died acute phase, hemorrhage, infection
- 1 died in 1994 from liver failure

**Images:  CIA**

**Notes:**
Two examples can be used to illustrate the problems with unknown exposure, although these were not terrorist events. The first example occurred in September 1987 in the city of Goiania, Brazil where a hospital therapy source was taken from a demolished medical clinic and sold to a junkyard owner. The owner removed the source, 1375 curies of cesium-137, from the source container because of the blue glow it gave off. It was handled and viewed by his family and by a number of other people, believing the material had mystical properties. The incident was not detected for 15 days.  It resulted in 249 people being contaminated, four acute fatalities plus one delayed death, and 112,800 people asking to be monitored. In this case there was both an exposure and a contamination problem, plus logistical problems due to “worried well.”
112,800 	Surveyed for contamination (“worried well”)
       249 	Contaminated
       		120 	Externally contaminated on clothes and shoes
       		129 	Externally and internally contaminated
         20 	Required specific hospital treatment
         14 	Developed bone marrow depression
           8 	Treated with Granulocyte Macrophage Colony-Stimulating Factors 		(GM-CSF)
           4 	Died due to hemorrhage and infection in acute phase
           1 	Died in 1994 from radiation-caused liver failure

## Medical Staff Exposure

**Medical staff received doses: **
-  Maximum 500 millirem (5 millisieverts)
- Natural background radiation dose ~ 200 millirems annually
-  Average 20 millirem (0.2 millisieverts)
- Equivalent to one chest X-ray

**Notes:**
What is interesting is the low exposure received by medical staff. 
Medical staff received doses: 
Maximum:  500 millirem (5 millisieverts); this dose can be taken in the context of the normal natural background radiation exposure - about 200 millirems per year);
Average:  20 millirem (0.2 millisieverts); this dose is roughly equivalent to receiving one full (14 x 17 inch) chest X-ray.
The medical response and clean-up phases took several months to complete.

## Juarez, Mexico Incident

- 400 curies of cobalt-60 in stainless steel therapy device sold for scrap
- Ended up in recycled steel rebar
- Wrong turn into Los Alamos lab
- I0 people significantly exposed
- 1 construction worker died
- bone cancer
- 109 houses demolished in Mexico

**Images:  CIA**

**Notes:**
The second incident occurred in Juarez, Mexico in 1983.  A therapy device containing cobalt-60 was purchased from a medical clinic by a scrap yard.  The stainless steel capsule containing some 6,000 small pin-head-sized cobalt-60 sources was deliberately ruptured, spilling some of the contents into a pickup truck bed. The total activity of the capsule was about 400 Ci. The pellets were scattered throughout the scrap yard, contaminating the scrap metal and eventually ended up in recycled steel. 
In January 1984, a transport truck carrying a load of contaminated steel rebar took a wrong turn into Los Alamos National Laboratory in New Mexico and set off gamma alarms; thus the incident was discovered.  Ten persons received significant exposures, most of whom worked at or visited the scrap yard.  One construction worker exposed to the rebar died from bone cancer.  In Sinola, Mexico, 109 houses contaminated with the rebar were demolished. 

## US Experience 1944-1999

- 243 radiation accidents leading to “serious” classification
- 790 people received significant exposure resulting in 30 fatalities
- Incidents included:
- 137 industrial
- 80 medical
- 11 criticality

**Image:  DOE**

**Notes:**
From 1944 to 1999, 243 radiation accidents have occurred in the United States that meet dose criteria for a ‘serious’ classification. These incidents have resulted in 30 fatalities out of 1342 exposures with 790 people receiving significant exposures.  The last documented serious U.S. radiation exposure, according to Department of Energy literature, was recorded in 1999.  
Documentation related to 228 of these historical incidents indicates that 137 were industrial exposures, 80 occurred in a medical setting, and 11 were criticality accidents; that is, the result of unintended nuclear “chain reactions” resulting in the release of radiation.

## The Basics of Radiation

**Radiation is energy that comes from a source**
**and travels through matter or space**
- Radioactivity is the spontaneous emission of radiation:
- Either directly from unstable atomic nuclei, or
- As a consequence of a nuclear reaction, or
- Machine – produced (X-ray)

**Image:  NOAA**

**Notes:**
Radiation is energy that comes from a source and travels through matter or space. Radioactivity is the property or condition of some elements that results in the spontaneous transformation, or decay, of the nucleus of an unstable atom. As the unstable atom changes to a more stable state, it releases excess energy in the form of radiation.  Substances that undergo this transformation process are called radioisotopes, or more generally, radioactive materials. Once the radioisotopes are processed into a usable form, such as pellets or powders, they are called radioactive sources. 
The risks from radioactive sources vary widely, depending on the radionuclide, the physical and chemical form, and the activity.  Unless breached or leaking, sealed sources present a risk from external radiation exposure only. Breached and leaking sealed sources as well as unsealed radioactive materials can lead to contamination of the environment and the intake of radionuclides into the human body.
Some types of radiation, such as x-rays, gamma rays, and neutrons, are highly penetrating.  That means they can pass through air, clothing, and even the body.  During passage through the body they may deposit energy in a few cells.  The deposited energy may create ions and forms of oxygen that are highly reactive chemically and thus damaging to the cells. Usually the cells can repair the damage, but sometimes - especially during cell division - the repair can be incorrect or faulty. 

## Contamination

- Defined as internal or external deposition of radioactive particles
- Irradiation continues until source removed by washing, flushing or radioactive decay
- Some radiations not harmful unless emitted internally
- Alpha, beta, or gamma irradiation cannot cause objects or people to become radioactive

**Notes:**
There is a common misperception that things exposed to radiation become contaminated or radioactive. This is not true for all radiations other than neutrons. Food is irradiated with photons to preserve it but it does not become radioactive. Irradiation is not the same as becoming radioactive or contaminated.
Contamination occurs when materials containing radioactive particles are deposited on skin, clothing, grass or anyplace where it is not wanted. And radioactive contamination can be spread.  A person contaminated with radioactive materials will be irradiated until the source is removed through washing it off, if external, or by being flushed out of the body in urine or feces if internal. The source will also be removed by radioactive decay.
A high radiation dose from a single exposure (acute) can cause various degrees of radiation sickness or poisoning and even death. Signs and symptoms may not be seen for days or weeks with moderate exposure. Either very low acute exposure or low chronic exposures over long periods of time can cause cancer, premature aging, or genetic effects which are passed on to future generations. 

## Radiation

- Two categories: ionizing and non-ionizing
- Ionizing - enough energy to remove an electron from an atom, producing charged particles in matter
- Natural ionizing sources: cosmic rays, radon gas, radioactive elements in body
- Human - produced: medical x-rays or therapies and weapons fall-out

**Image:  DOE**

**Notes:**
Radiation is divided into two categories:  ionizing and non-ionizing. Everyone is exposed daily to both types of radiation.
Ionizing radiation has enough energy to remove an electron from an atom, creating an ion. The process results in two charged particles or ions: the molecule with a net positive charge, and the free electron with a negative charge.  
Each ionization event requires approximately 33 electron volts of energy. Compared to other types of radiation that may be absorbed, ionizing radiation deposits a large amount of energy into a small volume. In fact, the 33 electron volts from one ionization event is more than enough energy to disrupt the chemical bond between two carbon atoms. All ionizing radiation is capable, directly or indirectly, of removing electrons from most molecules.
Natural sources of ionizing radiation include cosmic rays from the sun and stars, radon gas from the earth’s crust, rocks, and soil, from radionuclides formed in the “big bang,” and radioisotopes within the body itself.  Sources of human-produced ionizing radiation include medical x-rays or other medical diagnostic or therapeutic procedures, tobacco products, and weapons testing fall-out. 

## Ionizing Radiation 

- Used to produce power, kill cancer cells, manufacture products
- Four main types of ionizing radiation
- alpha particles
- beta particles
- x-rays or gamma rays
- neutrons

**Image:  National Archives**

**Notes:**
Ionizing radiation is the type of radiation that people usually think of as “radiation.” It is taken advantage of to produce electric power, kill cancer cells, and in manufacturing processes.
There are four main types of ionizing radiation:
  • alpha particles
  • beta particles
  • x-rays or gamma rays
  • neutrons

## Ionizing Radiation - Alpha

- Mass of 2 neutrons and 2 protons
- Emitted by some heavy elements; e.g., Ra, U, Pu
- Non-penetrating
- Only travel inch or two in air and 50 microns in soft tissue
- Stopped by paper or clothing
- Alpha particles hazardous if ingested or inhaled or enter wound

**Notes:**
Alpha particles (four units of atomic mass with two units of charge emitted by the nucleus of heavy isotopes, i.e., the helium nucleus) do not penetrate the skin and can be shielded by a thin layer of paper or clothing.  Alpha particles only travel an inch or two in the air. Because the outer layer of skin is dead and several microns thick, the alpha particle is unable to penetrate through the dead layer of skin to reach living cells and thus will not cause skin damage.  If, however, an alpha emitter gets inside the body through inhalation, ingestion, or via a wound, its energy will do damage to nearby tissue.  For this reason, personal protective equipment, particularly a suitable mask, must be worn if indicated to prevent responders from inhaling apha-emitting substances.  Examples of alpha emitters include:
Ra-Radium
U-Uranium
Pu-Plutonium

## Ionizing Radiation - Beta

- Fast - moving electrons ejected from nucleus
- Emitted by many radionuclides
- Moderately penetrating
- Can travel a few yards in air and 1/2 inch in tissue
- Can produce skin injury
- Hazardous if internally deposited
- PPE provides some protection

**Notes:**
Beta particles (high speed electrons - low mass single charge emitted by the nucleus) are slightly more penetrating and can travel a few yards in air. If beta-emitting contaminants are allowed to remain on the skin in sufficient quantities for a period of time, they can cause skin damage.  Beta radiation can penetrate the skin to the ‘germinal layer’ where new skin cells are produced.  PPE provides some protection against beta radiation. 
Beta-emitting radionuclides can cause internal hazards if ingested or inhaled, particularly if long-lived beta emitters are incorporated into tissues such as bone.  PPE may provide some protection against the intake of beta-emitting radionuclides. 

## Ionizing Radiation - Gamma or X-Ray

- Photons: no mass or charge
- Emitted by most radionuclides or machine - produced
- Very penetrating, no fixed range
- Both internal and external hazard
- Dense materials needed for shielding
- PPE does not protect against gamma radiation

**Images:  OSHA, FDA**

**Notes:**
Gamma radiations (photons of no mass or charge emitted by the nucleus) do not have a finite range but rather are attenuated in energy and number as they pass through matter.  They readily penetrate most materials and hence are called “penetrating” radiation.  X-rays are like gamma rays but they arise in the electron shell rather than the nucleus.  They, too, are penetrating radiation, although they are typically of lower energy. 
Radioactive materials that emit gamma radiation represent both an external and internal hazard to humans.  Dense materials like concrete and lead are needed for shielding of gamma and x-rays.  PPE provides little shielding from gamma radiation but will prevent contamination of the skin by gamma-emitting materials.  Gamma radiation frequently accompanies the emission of alpha and beta radiation as the newly-formed nucleus seeks a stable state.

## Ionizing Radiation - Neutrons

- Neutral particle emitted from nucleus
- Emitted by a few radionuclides, produced by machine or nuclear weapon
- Very penetrating
- Requires special shielding for protection
- Can induce radioactivity in matter
- Can cause secondary beta and gamma radiation when interacting with matter

**Notes:**
Neutrons are neutral particles (1 unit of atomic mass) emitted during spontaneous fission of the nucleus. Neurons lose most of their energy through collisions with other atomic nuclei. An analogy that could be used to describe the collisions is that of billiard balls.  When one billiard ball strikes another, energy is transferred from one ball to another.  Under certain circumstances neutrons can be captured by a stable nucleus, making the nucleus radioactive. 
Neutrons are produced during nuclear fission and in some nuclear reactions. Atomic bombs and nuclear reactors produce large numbers of neutrons. Being electrically neutral, neutrons can be very penetrating and their collisions can result in emission of secondary beta and gamma radiations. 

## Non-Ionizing Radiation

- Enough energy to move or vibrate atoms
- Sound waves, radio waves, microwaves
- Visible, ultraviolet and infrared light
- Lasers and heat

**Image:  NASA**

**Notes:**
Radiation that has enough energy to move atoms around or cause molecules to vibrate but not enough energy to remove electrons from the atoms is called non-ionizing radiation. Examples of this kind of radiation include sound waves, visible light, radio waves, and microwaves.
Non-ionizing radiation is described as a series of oscillating electric and magnetic fields traveling at the speed of light. Non-ionizing radiation includes the spectrum of ultraviolet, visible light, infrared, microwave, radio frequency and extremely-low frequency lasers, radio waves, and heat.
Some examples of the uses of non-ionizing radiation are:
•   Microwave radiation for heating food and telecommunications
•   Infrared radiation for keeping food warm
•   Radio waves for broadcasting

## Ionizing and Non-Ionizing Radiation

**High Frequency****                                 **THE ENERGY SPECTRUM**                              ****Low Frequency**

**Cosmic          Gamma           X-Rays         Ultraviolet         Visible Light        Infrared         Microwaves         Radio **

**Images:  NASA**

- IONIZING

**Notes:**
Useful examples of ionizing and non-ionizing radiation in terms of the energy frequency spectrum.  

High frequency→ short wave length
Low frequency→ long wave length

## Radiation Effects

**Chemical **
**Damage**
**Free Radicals**
**10****-10**** Seconds**

**1.  Proteins**
**2.  Membrane**
**3.  DNA**
**Seconds to hours**

**Biological**
**Molecular**
**Damage**

**Cells, tissues,**
**whole persons**
**Hours to years**

**Biological**
**Damage**

**Notes:**
The basic building block of any tissue is the cell, and damage to the cell may change its chemistry or DNA.  The chemical damage is instantaneous, but the clinical expression of this damage can take hours to years to express itself.  At high doses, clinical expression can present within hours and is known as acute radiation syndrome or ARS.  However, at lower doses or even after recovery from ARS, there is the slight probability, although low, of developing a cancer years later.  Cancer risk may persist throughout remaining life.  
Another biological response that may present itself is cataract formation, which requires a prompt dose above 200 rem.  It has been shown that neutrons are more effective than gamma rays in producing this type of injury.
As a result of the atomic bombings in Japan during World War II, some fetuses exposed in utero showed birth defects such as low birth weight or small head circumference with mental retardation.

## Examples of Radioactive Materials

_**Radionuclide**_**	****	**_**Half - Life**_**	**_**Emit**_**	**_**Use**_
- Americium-241		432 y			a, g	     	Smoke detectors
- Cobalt-60			5.3 y			b, g	    	Medical therapy
- Californium-252		2.64 y		a, g n	Radiography & medical
- Plutonium-238		87.7 y		a, g 	     	Thermoelectric generation
- Plutonium-239		24,100 y	 	a, g 	     	Reactors & weapons
- Radium-226		1,600 y	 	a, g 	     	Medical therapy
- Uranium (natural)	4 billion y	 	b, g	     	Reactors & weapons
- Iridium-192		73.8 d		b, g	     	Industrial radiography

**Notes:**
Radioactive materials that emit ionizing radiation are used in nuclear medicine, cancer treatment, industrial non-destructive testing, and for research purposes depending on the type of radiation emitted.  A number of radioactive materials, including radioactive waste, are commercially shipped in specialized containers. 
Radioisotopes are chemically identical to their non-radioactive counterparts and hence behave in the body the same manner as their non-radioactive counterparts. For example, radioactive iodine behaves the same as stable iodine and hence is concentrated in the thyroid gland.

## Radiological Quantities - 1

- Activity: the rate of decay of radioactive material expressed as the number of atoms decaying per second.
- Becquerel (Bq): the amount of material that will undergo one decay per second.
- Curie (Ci): the traditional unit of activity based on the activity of 1 g of radium. One curie (Ci) corresponds to 37 billion (3.7x1010) decays per second.

**Notes:**
Activity is defined as the rate of decay of radioactive material expressed as the number of atoms decaying per second.
Becquerel (Bq) is the amount of material that will undergo one decay per second.
Curie (Ci) is the traditional unit of activity based on the activity of 1 g of radium. One curie (Ci) corresponds to 37 billion (3.7x1010) decays per second.

## Radiological Quantities - 2

- Absorbed Dose:  the amount of energy deposited in matter per unit mass. It is expressed in units of joule per kilogram (J/kg) with the special name gray (Gy).
- Equivalent Dose:  the radiation protection quantity that places all radiations on a common scale of damage.  Equivalent dose is the sum of the absorbed dose in tissue (Gy) of each radiation times a radiation weighting factor and given the special name sievert (Sv).  Limited to doses < 0.1 Sv.

**Notes:**
Absorbed Dose is defined as the amount of energy deposited in matter per unit mass. It is expressed in units of joule per kilogram (J/kg) with the special name gray (Gy). 
Equivalent Dose is defined as the radiation protection quantity that places all radiations on a common scale of damage. Equivalent dose is the sum of the absorbed dose in tissue (Gy) of each radiation times a radiation weighting factor and is given the special name sievert (Sv).  It is limited to doses less than 0.1 Sv.

## Radiological Quantities - 3

- Effective Dose: a dosimetric quantity that serves as a measure of the genetic and carcinogenic risk of a radiation exposure. It takes account of the equivalent dose in all the tissues and organs of the body. The effective doses for external and internal irradiation can be summed. This is a useful quantity for low level irradiation (i.e., doses less than 0.1 Sv or 10  rem).

**Notes:**
Effective Dose is defined as a dosimetric quantity that serves as a measure of the genetic and carcinogenic risk of a radiation exposure. It takes account of the equivalent dose in all the tissues and organs of the body. The effective doses for external and internal irradiation can be summed. This is a useful quantity for low level irradiation (i.e., doses less than 0.1 Sv or 10  rem).

## Units of Radiological Quantities

- International System of Units (SI)
- Conventional units are
-   Roentgen (R) for exposure in air
-   Rad for absorbed dose
-   Rem for equivalent dose
-   Microcuries (uCi) or nanocuries
-   Curie for activity

**Notes:**
Most of the time the Board on Radiation Effects Research (BRER) uses the International System of Units (SI) in its reports. However, there are exceptions made in presenting data on radiation exposure, radiation dose, and the activity of radionuclides. Thus, exposure in air may be given in roentgen (R), absorbed dose in rad, equivalent dose in body organs or tissues in rem, and activity of radionuclides in curies (Ci). Decimal submultiples of the units also are used. For example, equivalent dose may be given in mrem; that is, thousandth (10−3) of a rem, and activity may be given in microcuries, or one millionths of a curie (μCi), or in nanocuries; that is, billionths of a curie (nCi).

## RAD and REM 

- Rad - basic physical unit of absorbed dose (energy per mass)
- Rem - unit of dose in radiation protection where the absorbed dose from the various radiations is adjusted for relative potential damage

**Notes:**
The amount of ionizing radiation deposited in tissues or matter is called the absorbed dose. It is usually expressed in the unit of Radiation Absorbed Dose per unit mass, commonly called rad.  The International System of Units for absorbed radiation is the gray (Gy). One gray is equal to 1 joule per kilogram and is equivalent to 100 rad.
The rad is defined as the deposition of 0.01 joule of energy per kilogram (kg) of tissue.  To quantify the amount of damage that is suspected from a radiation exposure, the absorbed dose in rad is converted to equivalent dose in rem, which stands for Roentgen Equivalent Man.  Equivalent dose involves an adjustment to reflect the type of radiation absorbed and the likelihood of damage.  In the case of beta and gamma radiation, the absorbed dose and equivalent dose are numerically equal.  For these radiations 1 rad is equivalent to 1 rem.
For example, an x-ray machine used in a study to compare the biological endpoint of various radiations irradiated a cell culture to an absorbed dose of 100 rad.  It was found that an absorbed dose of 100 rad of gamma and beta radiation produced the same biological effect (damage) as the 100 rad absorbed dose of x-rays.  However, an absorbed dose of only 20 rad of neutrons and 5 rad of alpha produced the same effect as 100 rad of x-ray.  Therefore, it was concluded that neutron and alpha radiations were more potent in causing this endpoint.  The relative biological effectiveness (RBE) of the neutron and alpha radiation relative to x-rays is 5 (100/20) and 20 (100/5), respectively, for this particular endpoint.  In radiation protection, scientific judgment is used to arrive at the weighting factors to be applied to the absorbed doses of the various radiations in deriving the equivalent doses.

## GRAY

- Gray (Gy)- The new international system (SI) unit of radiation dose, expressed as absorbed energy per unit mass of tissue.
- The SI unit "Gray" has replaced the older "rad" designation.
- 1 Gy = 1 Joule/kilogram = 100 rad.
- Gray can be used for any type of radiation (e.g., alpha, beta, neutron, gamma), but it does not describe the biological effects of different radiations.

**Notes:**
As of 2007, most of the scientific literature has replaced Gray or Gy in most of the discussions that formerly used the term “Rad”. It would be important to point this out to the students.

Throughout this module, the attempt has been made to standardize references to absorbed radiation doses using Gy, although there are examples where this was not possible.

## Summary: Radiological Quantities

**Image: SAIC**

| Quantity | Conventional Unit | SI Base Unit | Special Name of SI Unit | Conversion |
| --- | --- | --- | --- | --- |
| Exposure  | Roentgen
( R ) | Coulomb per kilogram
 (C kg-1) |  | 1 R = 2.58 x 1014 C kg-1 |
| Absorbed dose | Radiation absorbed dose (rad) | Joule per kilogram
(J kg-1) | Gray (Gy) | 1 rad = 0.01 Gy |
| Equivalent dose | Radiation equivalent man  (rem) | Joule per kilogram
(J kg-1) | Sievert (Sv) | 1 rem = 0.01 Sv |
| Activity  | Curie
(Ci) | Disintegration per second
(s-1) | Becquerel (Bq) | 1 Ci = 3.7 x 1010 Bq |

**Notes:**
The relationships between the units used and the corresponding SI units and special names are shown in the table.

## Natural Background Radiation

| Sources |  | Dose (mrem) |
| --- | --- | --- |
| Natural Sources |  |  |
|  | Radon | 200 |
|  | Other | 100 |
| Medical |  |  |
|  | Diagnostic x rays |   39 |
|  | Nuclear Medicine |   14 |
| Other |  |    7 |
|  | Total | 360 |

**Notes:**
On average, an individual in the United States receives an annual background (effective) dose of radiation of about 360 mrem (3.6 mSv).  Most of this comes from naturally-occurring radon gas. Radon (Rn222, half-life of 3.8 d) is a member of the chain of radionuclides formed as U-238 (half-life of 4.47 x 109 y) decays to stable lead.  Rn-222 is formed in the decay of Ra-226.  Human-made sources contribute about 60 mrem, for a total of 360 mrem. Scientists cannot detect any harmful effects of these doses.

## Additional Annual Radiation Doses

- Lifestyle
- Cigarette smoker 1300 mrem
- Living at higher altitude 100 mrem
- Occupation
- Airline flight crew 1000 mrem
- Nuclear worker 560 mrem
- Medical personnel 70 mrem

**Images: NIH, FAA**

**Notes:**
Some individuals may get higher doses of radiation annually because of their lifestyle, occupation, or where they live. Cigarette smokers, for example, receive annually an additional 1300 mrem. Airline flight crews receive 1000 mrem, nuclear power workers receive 560 mrem, and medical personnel receive 70 mrem annually.  Just living at a higher altitude - as in Denver - increases the annual dose by about 100 mrem due to increased cosmic ray exposure. 

## Terrorist Use of Nuclear Materials

- RED - radiological emission device
- RDD - radiological dispersal device
- IND - improvised nuclear device
- Nuclear weapon
- Sabotage of nuclear facility

**Notes:**
Terrorist Use Of Nuclear Materials
Terrorist use of radioactive materials or a nuclear device constitute plausible threats.  Such an incident could occur through the use of: 
RED - radiological emission device 
RDD - radiological dispersal device
IND - improvised nuclear device 
Nuclear weapon 
Sabotage of nuclear facility

## Radiological Emission Device

- Expose people to radiation without an explosion
- Spread sealed sources contents in environment
- 	Example 1:  Cobalt-60 source placed in a public eating area, exposing individuals to various levels of radiation
- 	Example 2: Introduce cesium-137 powder source into a public water distribution system

**Notes:**
Radiological Emission Device  
This is a device used in the deliberate act of exposing people to radiation without the use of an explosive device.  An example would be the placement of a high-activity radioactive isotope such as cobalt-60 in a public place, exposing numerous individuals to various levels of radiation.  Sealed sources of gamma or neutron radiation could also be used to expose individuals with the level of exposure depending on how close the person was to the source.
A recent example of the actual use of a radiological emission device for malicious purposes occurred in China in September, 2003.  A Chinese nuclear medical expert was convicted of planting radioactive irridium-192 pellets in a colleague’s office ceiling. Soon afterwards the poisoned colleague began complaining of memory loss, fatigue, loss of appetite, headaches, vomiting, and bleeding gums.  Another 74 staff members were found to have similar symptoms.

## Radiological Dispersal Device

- Conventional explosion spreads radioactive materials
- No nuclear reaction
- Atmospheric release
- Contamination of individuals and environment

**SHIELDED CONTAINER**
**RADIOACTIVE                        MATERIAL**
**EXPLOSIVE AGENT**

***CONCEPTUAL DISPERSAL DEVICE***

**Image: SAIC**

**Notes:**
Radiological Dispersal Device
A radiological dispersal device is used to disperse radioactive material in the environment by conventional explosives. It does not cause a nuclear reaction.  Such a device is formed by combining an explosive agent such as TNT or a plastic explosive with radioactive materials that may have been stolen, for example, from a hospital or local industry.  A similar type of event could also occur from a failed nuclear weapon detonation.  In the latter circumstance, only the conventional component of the weapon explodes, rather than a nuclear reaction occurring; the blast causes widespread release of uranium or plutonium.  In either case, the initial explosion may kill or injure those closest to the device/weapon, while the radioactive substances remain to expose and contaminate survivors and emergency responders.
An RDD can take other forms, such as a non-explosive atmospheric release device.  This type of device could spray or otherwise disperse radioactive materials that could then be transported by air currents or spread through ventilation systems. 

## Sabotage of Nuclear Facility

- 1977 - Bomb explodes at US nuclear power plant
- 1979 - Bomb explodes at Spain nuclear power station
- 1982 - 5 rockets fired into nuclear facility in France
- No release of radioactive material from attacks on facilities

**Notes:**
Numerous attempts have been made to sabotage nuclear power facilities throughout the world. These events include bombings, rocket attacks, individual sabotage and ground force assaults. Examples are shown on the slide.
Recent research indicates that it is extremely unlikely that terrorists could successfully cause a major release of radioactive materials from a power plant.  For example, a repeat of the World Trade Center type of airborne attack on a US nuclear power plant would not cause the release of radioactive materials.  Sabotage or a ground assault against the plant poses a more significant likelihood of a radiation release. 

## Nuclear Accidents

**Image: SAIC**

**Three Mile Island nuclear generating station, Middletown, Pennsylvania**

**Notes:**
Nuclear facility sabotage has been attempted on a number of occasions but to date has not resulted in any large release of radioactive materials. There have been reactor accidents at Three-Mile Island in the US, at Chernobyl in the former Soviet Union, and at the Tokaimura nuclear fuel reprocessing plant Japan.  The accident at Chernobyl was caused by the operators bypassing approximately eight safety systems.  The experiment being carried out at the time resulted in melt-down of the core with an extensive fire resulting in widespread contamination of vast areas of land.  This accident caused the death of 28 individuals, mostly firefighters, from acute radiation injury.  A significant increase in highly aggressive thyroid cancers has been seen in children in areas of major Chernobyl fall-out, mainly in Ukraine and Belarus.
No detectable release escaped from the U.S. Three Mile Island plant due to its containment vessel.  In contrast, the Chernobyl-style reactors lack any kind of containment structure, allowing unchecked release of radioactive materials in an accident.

## Improvised Nuclear Device

- Explosive device designed to cause a nuclear event
- May result in partial yield
- Physical and human damage dependent on blast and thermal yield

**Image: SAIC**

**Notes:**
Improvised Nuclear Device  
This is a ‘home-made’ device designed to cause a nuclear detonation.  This type of device, if successfully detonated, would cause widespread damage - possibly on the scale of Hiroshima or Nagasaki - with the release of considerable energy.  Releases include gamma rays, neutrons, and high thermal energy, followed by a blast wave and radioactive fallout.  Construction of such a device to produce a nuclear detonation would be difficult as it is not easy to detonate the weapon correctly. Realistically, at best, a terrorist might be able to achieve a partial yield, producing effects less than those caused by a nuclear weapon.  In some cases, only the conventional high explosives in the improvised nuclear device may detonate, resulting in environmental contamination with plutonium or uranium.  In this event, the improvised nuclear device is effectively a radiological dispersal device.

## A fission or fusion nuclear device
Blast/thermal effects depend on:
 Size of weapon
 Trauma (blast and thermal)
 Height of detonation

- Blast/thermal effects depend on:
-  Size of weapon
-  Trauma (blast and thermal)
-  Height of detonation

**Nuclear Weapon**

**Image: DOE**

**Notes:**
Another concern is of a rogue nation exploding a nuclear weapon through delivery by an intercontinental missile.  If one considers the consequences of a ground-level one-kiloton yield, then the following would occur within one minute around the point of ground zero.
Blast wave damage would reach a distance of approximately 400 yards.
Thermal radiation would reach the same distance as the blast, and ignites fires that spread farther. 
Lethal nuclear radiation (gamma and neutron radiation) would reach approximately half a mile.
The immediate radioactive fallout could produce very high exposure rates, reaching up to half a mile.
In subsequent minutes people within the 20-mile-long fallout plume would be at risk of receiving a lethal dose from the radioactive fall-out.
As the size of the weapon increases, the effects encompass a greater distance.
Individuals close enough to the nuclear explosion will be killed by prompt radiation, by the blast wave or the fires ignited by thermal radiation. Most survivors in the vicinity of the explosion will quickly become symptomatic from the acute radiation exposure; many of them will also suffer from deceleration from blast injuries and from thermal burns. 

## Types of Radiation Injury

- External irradiation - whole-body or partial-body
- Contamination by radioactive materials - external (deposited on the skin) or internal (inhaled, swallowed, absorbed through skin, or introduced through wounds)
- Combined injury:
- Radiation (external and internal)
- Trauma (blast and thermal)

**Notes:**
Regardless of where or how a radiation accident happens, three types of radiation exposure may occur as a result of:  
   •  External irradiation,  whole-body or partial-body 
   •  Contamination with radioactive materials 
   •  Incorporation of radioactive material into the body 
Many may experience a combination of radiation injury and trauma.  These injuries may complicated by pre-existing illness, old age, or the enhanced vulnerability of the very young.
In addition, nuclear devices may cause blast and thermal burn injuries.  The latter may be difficult to differentiate from skin injury due to radiation.  Thermal burns occur shortly after detonation and those due to radiation injury may not appear for several days. 

## Severity of Radiation Illness

- Dose
- Dose rate
- Radiation type
- Duration of exposure
- Indicators of severity
- Time from exposure to onset of signs and  symptoms
- Severity of symptoms
- Changes in white blood cells after 48 hours

**Notes:**
The severity of radiation illness depends on:
•   The dose
•   The dose rate 
•   The type of radiation
•   Duration of exposure
The effects also depend on whether the person received a whole-body exposure (all organs and tissues receiving a similar dose), or if not, what organs and tissues were exposed.
The best indicators of the severity are:
•   The time from exposure to the appearance of signs and symptoms, especially the onset of vomiting.
•   The severity of signs and symptoms
•   The severity of changes in white blood cell count at 48 hours after  exposure
There is no cure.  Treatment consists of supportive therapy. 

## Radiation Injury - External Photon Irradiation

**Radiation Injury - External Photon Irradiation**

**Source**

**·**

**·**

**·**

**·**

**·**

**Local**

**Partial**
**Body**

**Whole**
**body**

****

****

****

****

**Image: SAIC**

**Notes:**
External irradiation frequently, but not always, results in all organs and tissues of the body being exposed to penetrating radiation from an source external to the body. During exposure this radiation is absorbed by the body.  Partial body exposure occurs if the external source is collimated, as in a medical x-ray examination, or if the body is partially shielded.  Following partial or whole-body external exposure to gamma and x-rays, the individual is not radioactive and can be treated accordingly. 
Partial or whole-body external exposure to neutron radiation will result in the individual becoming radioactive.  Measurements of the induced radioactivity of the body’s sodium and sulfur constituents are often used to estimate the magnitude of the neutron exposure. Patients suspected of any type of radiation exposure should be treated with contact and respiratory precautions by caregivers.

## Radiation Injury - Contamination

**Radiation Injury - Contamination**

**Internal**

**External**

**Images: SAIC**

**Notes:**
The second type of radiation injury involves contamination with radioactive materials.  Contamination means that radioactive materials as liquids or solids are released into the environment and contaminate people externally and/or internally.  The external surface of the body, the skin, can become contaminated and the radioactive materials may get inside the body through the lungs, gastrointestinal tract, or wounds.  Internal contamination results in irradiation of the epithelial lining of the gastrointestinal tract or the airways of the respiratory tract, depending on the route of exposure. Internal contamination with alpha or beta emitters results in alpha- or beta-emitting radionuclides being in close contact with tissues and thus the radiation can cause severe damage over time. 
Contamination results in the victim being radioactive; however, its presence should not preclude the delivery of emergent care.  Health care providers should take contact and respiratory precautions when treating internally- and externally-contaminated patients. 

## Radiation Injury - Incorporation

**Radiation Injury - Incorporation**

**Thyroid**

**Lung**

**Liver**

**Bone**

**Image: NCI, NIH, SAIC**

**Notes:**
The third type of radiation injury that can occur is incorporation of radioactive material.  Incorporation refers to the uptake of radioactive materials by the body with deposition in its tissues and organs such as bone, liver, thyroid, or kidney.  In general, radioactive materials are distributed in the body based upon their chemical and physiological properties.  Incorporation cannot occur unless an intake has occurred.
The effects of external irradiation usually are not evident for days to weeks and while medical treatment for radiological damage is needed, it may not be needed on an emergency basis.  On the other hand, contamination accidents must be considered medical emergencies since they may lead to continued external exposure, further internal contamination, and subsequent incorporation into blood and tissues.  Incorporation can result in protracted irradiation of the body with adverse health effects several years later if the amount of incorporated radioactive material is high.
Hospital emergency department personnel should always use proper priorities in caring for accident victims where potential radiation hazards exist:  treat life-threatening problems or injuries first, limit the radiation dose to both victim and emergency personnel, and control the spread of radioactive contaminants.  Serious injuries always have priority over concerns about radiation, such as radiation monitoring, contamination control, and decontamination. 

## Acute Radiation Syndrome (ARS)

- Group of signs and symptoms that develop after acute total body irradiation (> 50 rads)
- Most probable following exposure to penetrating radiation
- May occur from internal contamination
- Symptoms are predictable depending on the dose
- Severity related to how quickly signs and symptoms develop

**Notes:**
Acute radiation syndrome or ARS is the name given to a group of signs and symptoms that develop after whole body irradiation at doses greater than 50 rad delivered over a short period of time.  The severity of ARS is primarily related to the total dose, dose rate, portion of the body irradiated, type of radiation, age, and health status.
ARS is a relatively acute illness, which follows a roughly predictable course over a period of time ranging from a few hours to several weeks after exposure to ionizing radiation.  The acute radiation syndrome is produced if enough radiation reaches the sensitive tissues.
To these factors, other factors need to be taken into consideration, such as age (young or old), gender, health status, etc.  The source of radiation does not matter if the absorbed dose is high enough.  The same effects will occur for events involving nuclear facility sabotage, a nuclear weapon, industrial sources, or medical therapy sources. 

## ARS Phases

- Prodromal phase
- Occurs in the first 48 - 72 hours post-exposure
- Characterized by nausea, vomiting, and anorexia
- At doses below about 500 rads lasts 2 to 4 days
- Latent period
- Follows prodromal phase
- Lasts for approximately 2 to 2 1/2 weeks
- Critical cell populations (leukocytes, platelets) decrease
- Time interval decreases as the dose increases
- Illness phase
- Period when overt illness develops
- Recovery or death phase
- May take weeks or months

**Notes:**
Signs and Symptoms  
The signs and symptoms that develop in the ARS occur through four distinct phases:
Prodromal phase:  Depending on the total amount of radiation absorbed, patients may experience a variety of signs and symptoms, including loss of appetite, nausea, vomiting, fatigue, and diarrhea.  After high radiation doses, additional symptoms such as prostration, fever, respiratory difficulties, and increased excitability may develop.  This is the stage at which most victims seek medical care
Latent phase: This is the transitional period that may last for up to 3 weeks depending on the radiation dose as many of the initial symptoms are resolved.  This period decreases in duration as the dose increases
Manifest illness phase:  The period of time when overt illness develops, often characterized by infection, bleeding, electrolyte imbalance, diarrhea, changes in mental status, and shock
Recovery or death phase:  This follows the period of overt illness, which may take weeks or months to resolve

## ARS Diagnosis

- People **exposed** to radiation will develop ARS only if all the following are true:
- The radiation dose was high
- The radiation was penetrating (i.e., able to reach internal organs, as with x-rays or gamma rays)
- The person's entire body, or most of it, received the dose
- The radiation was received in a short time, usually within minutes
-                Adapted from _[Acute Radiation Syndrome](http://www.bt.cdc.gov/radiation/ars.asp)_ (HHS/CDC)                http://www.bt.cdc.gov/radiation/ars.asp

**Notes:**

The diagnosis of ARS is based on a history of exposure and clinical findings. 

## ACUTE RADIATION SYNDROME

**Notes:**
The diagnosis of ARS is based on a history of exposure and clinical findings. The above table summarizes a predictable pattern after significant exposure.  

## Acute Radiation Syndrome (ARS)

- ARS-also Known as **Radiation Sickness**
- Clinical severity of the four ARS subsyndromes** **
- will vary with dose and host factors:
- Hematopoietic
- Gastrointestinal
- Neurovascular
- Cutaneous

**Notes:**
There are four sub syndromic type of clinical presentations that may accompany ARS. They are listed above and are further described on slides 46, 47, 48 and 49.

## Survival Time

- 200 Rads
- 2 Gy

- 800 Rads
- 8 Gy

- 10,000 Rads
- 100 Gy

- Hematopoietic
- System

- Gastrointestinal
- System

- CNS

- Survival
- Time

**NO CHANGE IN EXPECTED LIFE**

**Notes:**
The curve of Patt (Domestic Preparedness Defense Against Weapons of Mass Destruction Hospital Provider Course, rev. 7.0,“Management of Nuclear Casualties.” Aberdeen Proving Ground, MD.: U.S. Army Chemical Biological Defense Command, 1998) shows failure of three different organ systems of the body and reduction in the time interval to death.  The graph also shows that in the region of 200 rad, survival is determined by the hematopoietic syndrome while above 10,000 rads the central nervous system (CNS) syndrome limits survival.  At lower doses, death is caused by stopping cell division whereas higher doses produce cell death.

## ARS - Hematopoietic System

- Radiation Dose > 50 rem
- Depression of bone marrow function
- Blood profile changes ~ 24 h post exposure
- Lymphocytes rapidly depressed
- Leukocytes & thrombocytes less rapid depression
- Decreased resistance to infection & anemia as early as 10 days, extending to 6-8 weeks

**Notes:**
Radiation Dose > 50 rem
Depression of bone marrow function
Blood profile changes ~ 24 hours post exposure
Lymphocytes rapidly depressed
Leukocytes & thrombocytes less rapid depression
Decreased resistance to infection & anemia as early as 10 days, extending to 6-8 weeks

## ARS - Gastrointestinal System

- Radiation > 600 - 800 rems
- Damages intestinal lining
- Nausea and vomiting within the first 2 to 4 hours
- May develop diarrhea
- Associated with sepsis and opportunistic infections
- At 10 days could develop bloody diarrhea resulting in death

**Notes:**
Signs and Symptoms in this system are regularly seen at acute doses greater than 600 - 800 rem and result from damage to the epithelial cells lining the intestinal tract.  The loss of these cells may result in electrolyte imbalance.  The higher the exposure, the sooner the signs of nausea and vomiting develop, usually within the first 2 - 4 hours.
The presence of these symptoms typically overlaps with the drop in white blood cell count described previously.  As a result, sepsis and opportunistic infections complicate the picture.  Persistent high fever and bloody diarrhea are ominous signs despite adequate fluid and electrolyte replacement. 

## ARS - Central Nervous System

- Seen with radiation dose > 200 Gy range
- Microvascular leaks - edema
- Elevated intracranial pressure
- Death within hours

**Image: NASA**

**Notes:**
Central Nervous System (CNS) signs and symptoms are seen with acute radiation doses in excess of 2,000 rem and are probably due to diffuse microvascular leaks within the brain.  Damage to these blood vessels results in the loss of fluids and electrolytes, edema, increased intracranial pressure, and death.  Symptoms of shock may develop quickly in these patients.  CNS damage is irreversible and the victim rarely lives long enough to demonstrate any hematological or gastrointestinal symptoms.  An associated cardiovascular collapse often occurs in these patients.

## Onset of Clinical Signs of Skin Injury

| Symptom | Dose (rem) | Time (day) |
| --- | --- | --- |
| Erythema | 300 – 1000 | 14 – 21 |
| Epilation | > 300 | 14 -18 |
| Dry desquamation | 800 – 1200 | 25 – 30 |
| Moist desquamation | 1500 – 2000 | 20 – 28 |
| Blister formation | 1500 – 2500 | 15 – 25 |
| Ulceration | > 2000 | 14 – 21 |
| Necrosis  | > 2500 | > 21 |

**Notes:**
Local Injury to Skin    
> 300  rads:  Epilation (hair loss) 17 - 21 days
> 600  rads:  Erythema (redness) which may disappear within a few hours
>1000 rads:  Dry desquamation 2 - 4 weeks
>1500 rads:  Moist desquamation 2 - 8 weeks
>5000 rads:  Necrosis few days to months 
Various skin changes occur, depending on the absorbed dose.  The injuries tend to progress with dose and there appears to be a threshold for these clinical signs.  Early erythema is an important sign to look for.  At doses around 300 rad, erythema will develop within a few hours, but more importantly, it can disappear within a few hours only to reappear at a later time.  Therefore, the patient should be examined on an hourly basis for this sign and ideally photographs should be taken to document this sign.  If local radiation dermatitis develops, the dose is in the region of 1,000 rad.  If blistering occurs then the dose is in the range of 1,500 rad.  Also if necrosis develops, the dose is in the region of > 5,000 rad.  By noting these clinical signs, one is able to establish an approximate dose range that the patient was subjected to and these doses might be confirmed by dosimetry at a later time.
In an accident which took place in Fontana, California, involving a 28 Ci Iridium-192 source, the individual  picked up the source and put it in his back pocket.  This resulted in several blisters within 5 hours.  One large bulla (large blister) formed within 18 hours and within one week, a large necrotic ulcer formed on the right buttock (11 X 7 cm in area and between 2 to 4 cm deep).  The dose at 1 cm depth was calculated to be 52,000 rad.

## ARS & Trauma

- Radiation and Trauma =  Increased Mortality
- Wound and burn care, surgery, and orthopedic repair should be done in the first 48 hours or delayed for 2 to 3 months
- If not within 48 hours then delay surgery for 2 - 3 months

- 24 - 48
- Hours

- 3 Months

**Emergency**
**Surgery**

**Hemopoietic Recovery**
**No Surgery**

- After 3 Months

**Surgery**
**Permitted**

**Notes:**
Patients who have suffered trauma (from an explosive or burn) combined with an acute exposure to penetrating radiation have an increased chance of dying as compared to patients who have suffered from the same dose of radiation without trauma.  All combined injuries are worse than the radiation injury alone.  If a patient receives an acute dose greater than 200 rads, efforts must be made to close any wounds, cover burns, reduce fractures, perform surgical stabilizing, and definitive treatments within the first 48 hours after injury.  After 48 hours, surgical interventions should be delayed for 2 to 3 months.
Compared to thermal or radiation insult alone, a combination of the two increases mortality significantly.  The increase in mortality depends upon the degree of thermal insult and the radiation dose (and dose distribution) received.  Using the LD50 burn model of Alpen, a dose of 100 rad increased the mortality in animals from 50 to 65 percent.  Increasing the dose to 250 rad increased mortality to 90 percent and 100 percent of the animals died when the dose was 500 rad.

## Triage:  Classification, Treatment & Disposition

- Patients are classified in three categories based on signs and symptoms:
- Survival probable      < 100 rads (1 Gy)
- Survival possible    	200 - 800  rads (2-8 Gy)
- Survival improbable   > 800 rads (8 Gy)

**Notes:**
Triage:  Classification, Treatment and Disposition
Once the radiological survey and decontamination procedure is complete, patients may be classified into one of 3 categories, based on their presented signs and symptoms.
Survival Probable Group.  This is a group of patients who present no initial symptoms, or whose symptoms are so minimal, i.e., nausea and vomiting, that they resolve in a few hours.  These individuals have most likely received an absorbed dose less than 100 rad.  The initial CBC and sequential studies will not show a significant decrease in the lymphocyte or granulocyte counts.  These patients can be safely sent home and instructed to return if symptoms redevelop.
Survival Possible Group.  These patients present with nausea and vomiting, which typically lasts 24 to 48 hours followed by an asymptomatic period.  During the latent phase, laboratory evaluations will show a drop in various white blood cell counts (that is, lymphocytopenia, leukocytopenia, and thrombocytopenia).  If vomiting is severe, the patients should be admitted for fluid and electrolyte therapy and treated with antiemetics.

## Radiation Protection Guidelines

**Radiation Protection Guidelines**

- Time
- Distance
- Shielding

**Images:  DOE, NASA, SAIC**

**Notes:**
Radiation protection guidelines  
First responders should keep firmly in mind the best method to protect oneself is through time, distance and shielding. 
Time: The shorter the time in a radiation field, the less the radiation exposure.  Work quickly and efficiently.  A rotating team approach can be used to keep individual radiation exposures to a minimum.
Distance: The farther a person is from a source of radiation, the lower the radiation dose.  Do not touch radioactive materials.  Use shovels, brooms, etc., to move materials to avoid physical contact.
Shielding: Although not always practical in emergency situations, shielding offered by barriers such as concrete walls or even cars can reduce radiation exposure.

## Rescue - General Principles

- Locate operation base 150 ft. upwind (2,000 ft. or greater in nuclear explosion)
- Assume environment and occupants are contaminated
- Don PPE before rescue
- Radiological survey should be performed
- Responding personnel should have dosimeters

**Notes:**
General Principles for First Responders
Prior to initiating plans for rescue, the following should be considered when responding to any incident potentially involving radioactive materials.
If a radioactive material is known or suspected to have been released, assume that the environs and its occupants have been exposed and are contaminated. EMS personnel should not enter the area without personal protection, including a respirator or high-efficiency particulate air (HEPA) filter mask, eye protection, and gloves. Approach to the site should be made with caution, surveying for evidence of hazardous materials.  The deployment of EMS personnel depends on the nature and magnitude of the event. Position the personnel and vehicles at a distance of 150 feet upwind from the site (2,000 feet or more in the case of a nuclear explosion). 
The identification of the radioactive material and the extent of both the exposure and contamination will require specialized detection devices and outside assistance such as Hazardous Material Response Teams (HMRTs), state radiological health officials, Radiological Safety Officers (RSOs), and Radiological Assistance Program (RAP) personnel.  This should not be considered a primary responsibility of EMS personnel.  However, it is desirable that all EMS personnel be equipped with personal dosimeters that measure their level of exposure.  The extent of their exposure can be determined at a later date.    

## Scene Assessment

- Don PPE before entering area
- Assume environment and occupants are  contaminated
- Responding personnel should have dosimeters
- Identify all hazards (physical, chemical, fire, etc.)
- Radiological survey should be performed

**Image: SAIC**

**Notes:**
Scene Assessment
A scene evaluation (hazard analysis) should be performed immediately by the first responding personnel in PPE with the resulting information provided to the incident commander.  Identify all hazards including fire, explosion, toxic fumes, electrical, structural collapse or their potential.  Use radiation survey instruments if available. If at all possible, all responding personnel should wear personal dosimeters.

## Check for Presence of  Radiological Contamination

- Instruments needed in:
- Reception area
- Emergency treatment area
- Roving (as needed - patients, personnel, waste)
- Different instruments respond differently
- Instruments respond to gamma and beta
- Few instruments respond to alpha emissions
- Know what you are trying to measure

**Image: DOE**

**Notes:**
Checking for radiological contamination should be done prior to any rescue and decontamination efforts.  Identification of local resources prior to the event will enable proper resource utilization at the time of the release.  Many hospitals will have a RSO who can assist in determining the scene or site contamination.  State and county emergency management officials may assist in the identification of local experts.  These experts should be identified in the planning process.  Regardless of who is tasked with surveying for radioactive contamination, it must be remembered that different measuring devices respond to different types of radiation.  Most available survey meters can measure beta and gamma radiation; some have a shield which can screen out beta and measure gamma only.  Alpha meters are used to detect alpha emitters.
Several detection devices might be needed to protect against inadvertent spread of contamination after a nuclear terrorism incident.  Emergency treatment areas, triage or reception areas, and decontamination dirty dump areas can be monitored to help assess the level of hazard and efficacy of decontamination.  Monitoring will not be limited to patients; emergency responders will also require screening if they have worked in a potentially contaminated area or handled patients or equipment from one.

## Radiation Detection Instruments

- Instruments
- G.M. Survey Meter
- Ionization Chamber
- Scintillation Detector
- Alpha Meter

**Image: SAIC**

**Notes:**
Radiation Detection
Unfortunately our body senses cannot detect radiation, but we have good instruments to detect it.  The presence of radiation is usually detected by collecting charged particles or ions liberated by the radiation within the instrument’s detector volume.  The radiation measured is usually expressed as exposure per unit time, using various units of measure, including the curie (Ci), the becquerel (Bq), and counts per minute (CPM).  The most commonly used instruments to detect the presence of radiation include:
The Geiger Mueller meter or Geiger counter can detect low levels of gamma and most beta radiation.  The instrument typically has a window that can block beta radiation, thus providing the means to distinguish between gamma and beta radiation.  This instrument can be used to measure ambient radiation levels and to quickly evaluate potentially contaminated victims.  If a high level of radiation is anticipated, a higher range instrument (such as an ionization chamber) should be used.  At high radiation levels, the GM meter may saturate and thus incorrectly indicate a lower level or it may go off-scale and provide no reading.
The ionization chamber measures gamma ray dose/rate when high-level radiation hazards are suspected.  It is not sensitive enough to indicate low-level gamma contamination. Dose rate meters measure the dose rate (mrad/hour or rad/hour).  To find the dose that an individual is receiving, the dose rate is multiplied by the exposure time.

## PRINT PAGE.DO NOT PROJECT SLIDE.

**Notes:**
Radiation Detection (cont’d)
Scintillation detectors. Handheld scintillation detectors generally use a sodium iodide (NaI) crystal to detect gamma and x-rays.  These are rather highly sensitive meters that might be used in surveys following decontamination and in efforts to control the spread of contamination.
Alpha meters are designed to detect the presence of alpha particles.  These instruments are rather fragile as they have very thin windows to enable the alpha particles to enter into the sensitive volume of the detector.  Because of the short range of the alpha, alpha-emitters are difficult to detect in wounds and in this case the x-ray emission following alpha decay is generally detected.

## Personal Radiation Dosimeters

- Personal Dosimeters
- Film Badge
- Thermoluminescent Dosimeter
- Pocket Ion Chamber
- Electronic Dosimeter

**Images: SAIC**

**Notes:**
Personal dosimeters are used to detect radiation dose on individuals.
Radiation Film Badge:  Some badges contain film within in a plastic badge with areas of the film covered by material of varying thickness..  The readings from these areas can be used to estimate the energy of the radiation field. Today generally the badge will contain a thermoluminescent material; e.g., lithium fluoride (TLD) rather than film.  These devices normally are not read in the field 
Pocket Ion Chamber:  This device is a direct-reading ionization chamber.  It is  used to measure the accumulated radiation dose from gamma and x-rays.  These devices can easily be read in the field
Electronic Dosimeter: This device is an electronic version of the pocket ion chamber.  The gas-filled ionization chamber is replaced with a small semiconductor detector.  Unlike the ion chamber, these devices are battery-powered and can provide dose rate information

## Establishing a Hot Line and Decontamination Area

- Hot line separates clean and contaminated areas
- Defined by radiological survey
- Decontamination and treatment areas upwind of release

**Image: SAIC**

**Notes:**
It is critical to establish a hot line and decontamination area immediately.  A hot line is established to separate the clean and contaminated sides of the release area for all responding personnel.  If the identity of the radioactive source or the extent of the release is unknown, the limits of the contamination must be found using survey meters so that a hot line and clean area can be established.  A decontamination area should be set up, upwind and upgrade (uphill) from the release area near the treatment stations.  While the hotline is being established attention to accident victims should begin.

## Triage Considerations

** **Classify on basis of survival probability*
- Maximize existing resources
- Principles the same regardless of contamination
- Degree of irradiation injury may not be apparent initially
- Lethal dose indicated by early onset of confusion, delirium, vomiting, or diarrhea

**Notes:**
Medical sorting, or triage, is the key to effectively managing large numbers of sick and wounded victims.  Successful triage is built on sorting victims in an orderly, timely, and efficient manner that maximizes existing resources.  It includes the immediate classification of patients according to type, seriousness of the injury, and the likelihood of survival.  Triage also includes the establishment of priorities for treatment and evacuation to ensure that the medical resources available benefit the largest number of people. 
The principles of triage in a radiological event are similar to a hazardous materials incident or accident scene.  Victims are classified with regard to the need for treatment based on probability of survival, and are categorized as requiring minimal treatment, immediate care, delayed care, or as expectant (fatality).  Since the degree of radiation injury may not be initially apparent, triage criteria will need to be based on conventional injuries and complaints.  The triage method used will vary according to local jurisdictions and their standard operating procedures (SOPs).
Victims who have received very high doses of radiation from a gamma or neutron source may exhibit signs and symptoms that would indicate their level of exposure.  In the absence of other injury, neurological signs such as confusion or delirium may indicate a lethal dosage of radiation.  Other signs of lethal radiation injury include high fever, profuse vomiting, and bloody diarrhea within 2 hours of exposure (nearly 100 percent mortality).

## Limit Further Radiation Exposure

- Remove the victim from the contaminated area
- Perform rapid immobilization if possible
- Enter high radiation area only for life-saving rescues
- Limit time spent in hazardous environment
- Rotating rescue teams
- Quick ingress and egress

**Image: SAIC**

**Notes:**
The most important part of victim rescue is removing them from the radioactive source.  Survival depends not only on the dose received, but also how long the individual is exposed to the source.  During rescue efforts, a significant way to reduce the responders’ level of radiation exposure is to limit the amount of time spent in the hazardous environment.  Therefore, there may be times when you must move a patient quickly before a complete assessment can be accomplished.  This may be especially true in a terrorist event when the scene is hazardous.  Other considerations include repositioning of the victim to gain access to other injured individuals.  Quickly assessing and removing the victim from the area may be the only safe approach.  In this case, use rapid immobilization and techniques such as cradle carry, shoulder drag, foot drag, blanket drag, one-rescuer assist, etc.  Only life-saving rescue actions should be undertaken in a high radiation area, as determined by radiological experts.

## Illness and Injury Treatment

- Treat according to BTLS and ATLS guidelines
- Treatment should not be delayed for decontamination
- Treatment may be delayed to ensure safety of personnel
- Expose wounds, flush, and cover with sterile dressing

**Image: SAIC**

**Notes:**
Illness and Injury Treatment
Other associated illnesses and injuries should be treated according to Basic Trauma Life Support (BTLS) and Advanced Trauma Life Support (ATLS) guidelines. Lifesaving procedures should not be delayed for decontamination, although treatment might be delayed to ensure the safety of the first responders.  Expose wounds, flush with water, and then cover them with a sterile dressing

## Decontamination

- Personnel should don PPE
- Remove and bag victim’s clothing
- Shower with soap and water
- Effective for mixed radiation and chemical contamination

**Image: SAIC**

**Notes:**
If contamination is detected or suspected and the patient’s condition permits, the patient can be decontaminated at the scene.  Pre-hospital personnel should be dressed in appropriate PPE as dictated by the incident commander or radiation safety officer (RSO) before decontaminating the patient.  The  patient’s clothing and personal items should be removed and placed in a labeled plastic bag.  Ideally, a soap and water shower should be provided, washing from head to toe, and all of the runoff gathered into a collection pool or container.  Cotton-tip swabs can be used to remove contamination from nostrils and external ear canals; however, this should not be done in the field in most cases because careful taking of nasal swabs and their measurement by a trained RSO or health physicist can be used to determine how much contamination the patient may have inhaled.  After showering, the patient should be re-surveyed and checked for the continued presence of radiation contamination.  If present, the decontamination procedure should be repeated.  This decontamination procedure is also appropriate for those patients who may be contaminated with both radioactive substances and other hazardous material including chemical agents.
If the patient is unstable, removing his/her clothing will remove much of the contamination, depending on how much clothing covers the patient’s body.  After removing the clothing, wrap the patient in a clean sheet to help contain any remaining contamination.  This simple procedure will allow safe and expeditious transport to an emergency department for further assessment, stabilization, and definitive decontamination.

## Patient Transport

- EMS personnel should don PPE
- “Package” patient prior to transport
- Prepare “clean” ambulance
- Must be cleared before returning to service

**Notes:**
Patient Transport  
Ideally, a “clean” ambulance that has not been in the contamination area should transport the patient. The patient should be “packaged” for transport by wrapping with a blanket or sheet to minimize secondary exposure and contamination of EMS personnel. EMS personnel caring for the patient should follow routine universal precautions.  Hospitals should be notified of the patient transport.  The EMS vehicle and crew should not return to regular service until the ambulance, personnel, and equipment have undergone monitoring and necessary decontamination by the responsible Radiation Safety Officer. 

## Patient Assessment

- Assign patients a tracking number
- Record:
- Type and route of exposure
- Medical status of patients
- ID of radioactive material, if available
- Patient survey and decontamination status
- Signs and symptoms
- ETA to definitive care
- Enter data into patient tracking database

**Notes:**
Patient Assessment
At the scene patients should be surveyed and symptoms recorded. The general procedure is as follows.
 Assign patients a tracking number
 Record:
  Type and route of exposure
  Medical status of patients
  ID of radioactive material, if available
  Patient survey and decontamination status
  Signs and symptoms 
  ETA to definitive care
 Enter data into patient tracking database

## Internal Contamination/Incorporation

- Various medications and treatments can be used to limit uptake or facilitate removal of radioactive material
- Numerous medications are approved by the FDA.  Certain drugs are investigational and can be used in an emergency (i.e. Radiogardase [Prussian Blue] and DTPA)
- See NCRP 65 (currently under revision) for further advice

**Notes:**
Once radioactive materials cross cell membranes, they are said to be incorporated.  Incorporation is a time-dependent, physiological phenomenon related to both the physical and chemical natures of the contaminant.  The rate of incorporation can be quite rapid, occurring in minutes, or it can take days to months.  Thus, time can be critical and treatment (via decorporation agent) urgent.  Several methods of preventing incorporation (e.g., catharsis, gastric and respiratory lavage) might be applicable and can be prescribed by a physician.  Some medications or preparations used in decorporation might not be available locally and should be stocked when a decontamination station is being planned and equipped.
If internal contamination is suspected or has occurred, the physician or RSO should request samples of urine, feces, vomitus, wound secretions, etc.  Whole-body counting and bioassay also can help evaluate the magnitude of the problem and the effect of any treatment.  The contaminated patient admitted with an airway device or endotracheal tube must be considered to be internally contaminated.
NCRP 65- National Council on Radiation Protection and Measurements, Report 65 (currently being updated).

## Psychological Effects

- Mass Casualty Incident (MCI) caused by nuclear terrorism may create large numbers of concerned individuals who may not actually be injured or contaminated - often called the “worried well”
- As noted in 1989 Brazil incident
- Establishing counseling centers will help prevent psychological casualties from overwhelming health care facilities

**Notes:**
A mass casualty incident resulting from nuclear terrorism may generate large numbers of frightened individuals, the so-called worried well, who may not actually require any decontamination or medical care.  The 1989 Brazil incident generated tens of thousands of such persons.  To reassure these psychological casualties and prevent them from overwhelming health care facilities, separate counseling centers should be established.  The number of centers will depend on the population affected and on the magnitude of the incident.  These centers should each be staffed by a physician with radiological background, a psychiatrist, a health physicist, a RSO with instrumentation, a psychological counselor, and social workers.  A center should also be set up in the hospital for staff treating victims.  The staff and location should be identified in advance during the planning stage.

## Persistent Psychological Effects of Radiation Exposure

- Increase in anxiety, depression, and impairment of daily routine
- Highlighted concern about harm and illness
- Obsessive thoughts
- Distrust and alienation from others
- Persist over time (1 1/2 - 5 years)
- Considered a subtype of Post Traumatic Stress Disorder (PTSD)

**Notes:**
These findings are based on longitudinal studies at Three Mile Island in Pennsylvania, the Fernald uranium processing plant in Ohio, and in Scandinavia following the Chernobyl nuclear power plant accident. The psychological effects of radiation exposure were found to be similar to an exposure from a toxic chemical release. 
Following these radiological events, people experienced an increase in anxiety and depression.  They also tended to have heightened concern over possible harmful effects from potential radiation exposure and often obsessed about this concern and on other matters.  Researchers also found an increase in distrust, particularly of parties affiliated with the accident. It has also been observed that people become alienated, particularly from authorities. These effects were found to persist over time.  At Three Mile Island, impacts grew over time and were still in effect five years after the accident.
These effects have been labeled the “toxic contamination stress” (TCS) syndrome. The syndrome is considered a subset of the Post Traumatic Stress Disorder (PTSD) but differs somewhat from events that are characterized by massive destruction and fatalities.  The psychological impacts of TCS are driven by lack of information, uncertainty, stigma, and the inability to take action to cope with the situation.

## Key Points

- Spend as little time as possible in any radiation exposure environment
- Donning PPE and decontaminating patients minimizes exposure risk to victim and medical personnel alike
- Maintain maximum possible distance from radiation source
- Limit time spent in contaminated area
- Early symptoms are an indication of the severity of the radiation dose

**Notes:**
No danger will occur to responding and treating personnel if proper PPE is utilized, time in a radiation environment is minimized, the victims’ clothing is removed, and the patients are properly decontaminated.  Carefully evaluating the type, severity, and time course of early presenting signs and symptoms, such as nausea, vomiting, and lowered white cell counts, can provide a general indicator of the radiation dose and the patient’s ultimate prognosis.  Since no antidote exists for radiation exposure, treatment is primarily supportive with more specialized care directed towards patients requiring immediate surgical intervention, and whole-body decontamination (decorporation) for those with internal contamination.

## Questions

- ?

**Notes:**
Questions regarding radiological exposure?

## SUGGESTED READINGS

**Second Edition, MEDICAL MANAGEMENT OF RADIOLOGICAL CASUALTIES HANDBOOK. Military Medical Operations Armed Forces Radiobiology Research Institute, Bethesda, Maryland 20889–5603**** ****April 2003.  Website also has information on Prussian Blue administration. Available online at: **_[http://](http://www.afrri.ushs.mil/)__[www.afrri.ushs.mil](http://www.afrri.ushs.mil/)_
**CASUALY MANAGEMENT AFTER DETONATION OF A NUCLEAR WEAPON IN AN URBAN ENVIRONMENT. May 20, 2005. DHHS. CDC Guidance. Available online at: **_[http://www.remm.nlm.gov/](http://www.remm.nlm.gov/)_** ****(website updated July, 2007)**