# Presentation: 346626

## Radiological Terrorism:Medical Response to Mass CasualtiesPart I

**James M. Smith, PhD**
**Associate Director for Radiation**
**Division of Environmental Hazards and Health Effects**
**Centers for Disease Control and Prevention**
** **

## Radiation Events and Mass Casualties : A Unique Challenge

**Medical response infrastructure untested for major radiological event in the U.S.**
**Clinician inexperience with radiation injuries**** **
**Fear of radiation exposure expressed by public and caregivers**** **
**Could be an exceptionally large number of casualties **** **

## Potential Terrorist Scenarios

**Targeted attack on a nuclear installation****	**
**Radiological **_**Exposure**_** Device (RED), e.g, hidden      ****  radioactive source**
**Radiological **_**Dispersal**_** Device (RDD), e.g., “Dirty bomb” **
**Detonation of an**
**  ****Improvised Nuclear Device (IND)**

## Radiological Exposure DeviceCase Study: Goiânia, Brazil, 1987

**Radioactive source stolen **
**Contamination spread throughout community**
**54 hospitalized, 8 with radiation sickness; 4 died**
**112,000 people monitored (>10% of total population)**

**Source:  International Atomic Energy Agency (IAEA)**

**Notes:**
As a result of this accidental radiological dispersal event, 249 people were exposed to radiation or contaminated with Cs-137. Fifty-four people were hospitalized, 8 with radiation sickness, 4 of whom died. However, the important public health message to remember from this incident is that, although only 249 people in the city of Goiania were affected by this incident, 112,000 people demanded to be monitored for contamination and screened for exposure. That is 10% of the total population of Goiania. 

Furthermore, it is interesting to note, that this event was first identified approximately 10 days after the powder was first released from the unit. And the person who made the discovery was a physician working in a public health clinic when a patient with radiation sickness came to him seeking treatment.

## Can Terrorists Obtain Radioactive Sources?

**157,000 licensed users in U.S.**** **
**2,000,000 devices containing radioactive sources**** **
**About 400 sources lost or stolen in U.S. every year**

## Radiological Dispersal Device (RDD): The “dirty bomb” 

**Usually detonation of conventional explosive laced with radioactive material (e.g. Co-60)**
**Significant radiation exposures not likely unless victim  near explosion**** **
**Tens to hundreds could present with conventional traumatic injury, external contamination and potential internal contamination**** **
**Hundreds to thousands could present for radiological screening, counseling on health effects, or psychosocial trauma  **

## Worst Case: Improvised Nuclear Device (IND)

**Immediate national emergency would be declared with military disaster assistance**
**Could potentially kill/injure tens of thousands in a metropolitan area**
**Thousands could present with combined blast, burn and radiation  injury**
**Hundreds of thousands could be****displaced and require exposure and****medical monitoring, decontamination,****counseling**
**Major hospitals could****be destroyed or rendered inoperable**

**Notes:**
Could potentially kill/injure tens of thousands (dependingon urban proximity)Thousands could present with combined injury (conventional trauma such as blast/penetrating injuries and/or burns combined with ARSImmediate national emergencywould be declared with militarydisaster assistance Hundreds of thousands could bedisplaced and require exposure andmedical monitoring, decontamination,counselingMajor metropolitan hospital(s) couldbe destroyed or rendered inoperable

Examples of Immediate Effects of a One Kiloton Improvised Nuclear Device:
Blast 
Deaths to 200 yds
Lung damage, ruptured eardrums to 1/3 mile
Thermal 
3rd degree burns to 1⁄2 mile
1st degree burns to 2 miles
Blindness to 2.5 miles or more 
Retinal burns as far as the burst can be seen directly
Radiation 
50% deaths to 1⁄2 mile
Acute radiation sickness to 3⁄4 mile
No immediate health effects > 1 mile

## National Response Plan

**Describes how federal government will coordinate operations**
**Outlines procedures, roles and responsibilities for specific contingencies**
**Defines resources/groups most likely needed during an incident**
**Remember: “All emergencies are local.” **
**Federal/State resources will require many hours to days before arriving**

## Community Emergency Planning

**Community Emergency Planning**

**Hospital**

**Nursing Homes, Assisted Living Facilities**

**Churches, Social Welfare Organizations**

**Utilities, Communication Providers**

**Ports/Airports**

**Other Area Hospitals/Clinics**

**Urgent Care Centers, Dialysis Centers**

**Pharmacies**

**Fire, Police, EMS**

**Public Works, Highways**

**Local Community Organizations**

**Medical/Nursing Associations**

**Public Officials/Civic Leaders**

**Local Businesses**

**Weather Services**

**Health Departments**

**News Media**

**Red Cross**

## The Secondary Assessment Center

**Establish *****secondary assessment center (s) in advance****** ***
**Useful for pre-clinical screening, assessing exposure and contamination, conducting triage & decon, reuniting families**
**Separate from hospital**
**Basic step in protecting hospital**

**Notes:**
First responders should perform as much decontamination away from hospital as practical

Establishment of secondary assessment centers
Basic step in protecting hospital

Useful for pre-clinical screening, assessing exposure and contamination, conducting triage & decon, reuniting families
Establish by working with communities and local/state agencies in advance

Consider nontraditional sites and personnel 
Community facilities (schools, churches)
Allied health professionals, retired health care workers, community nurses

## Secondary Assessment Center  (continued)

**Establish by working with communities and local/state agencies in advance**
**Consider nontraditional sites and personnel **
**Community facilities (schools, churches)**
**Allied health professionals, retired health care workers, community nurses**

## Decontamination

## DecontaminationKey Principles

**Contamination is easy to detect and most of it can be removed**
**It is highly unlikely that radiological contamination poses a significant risk to care providers**
***Therefore:***** provision of **_**life-saving treatment**_** should take priority over radiological decontamination **
**Patients **_**without**_** life-threatening injury should be decontaminated prior to treatment**

## Protecting Staff from Contamination

**Standard precautions PPE (with N-95 if available)**
**Change outer gloves frequently**
**Personal dosimeters**** recommended**
**Full body survey **
**when exiting warm**
**zone**

**Notes:**
Cap, face shield, booties (waterproof)
Double gloves (inner layer taped)
Surgical mask is adequate
N-95 recommended, if available
Surgical gown (waterproof)
Tyvek type suits may be more practical for external decontamination

## Embedded Radioactive  Fragments

**Although unlikely, metallic shrapnel from a highly radioactive source may become embedded in wounds**
**A radiation survey identifies a high radiation field**
**Remove radioactive fragments with forceps; seal in lead container (work with radiation protection specialsit)**
**Use additional staff protection measures **
**Time (decrease time spent near radioactive source)**
**Distance (increase distance between you and source)**
**Shielding (increase physical shielding between you and source)**

## Summary of Part I

**A variety of scenarios exist for radiological and nuclear terrorism**
**These scenarios are possible, and radioactive sources are plentiful**
**Radiation exposures vary widely with different scenarios**
**“****All emergencies are local”**
**Federal/State resources will require many hours to days before arriving**

## Summary of Part I (cont.)

**Contamination is easy to detect and most of it can be removed**
**Provision of life-saving treatment should take priority over radiological decontamination**

## References for Part I www.bt.cdc.gov/radiation 

**Radiological Terrorism: Just in Time Training for Hospital Clinicians**
**Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident**
**Dirty Bombs**
**Nuclear Blast**