# Presentation: 601593

## Possible Scenarios

- Nuclear power plant incident
- Hidden source
- “Dirty bomb”
- Improvised nuclear device
- Nuclear weapon

**Notes:**
Unfortunately, terrorism is a very real threat to the U.S. in the 21st Century. 
The use of radioactive materials in a radiological dispersal devise (RDD) or a nuclear weapon by a terrorist is a remote but plausible threat.  The medical consequences depend on the type of device used in a terrorist event. Some possible scenarios are:
 Nuclear power plant incident
 An incident at a nuclear power plant (either accidental or designed) could release radioactive material into the environment. There are well defined emergency plans in place at these sites that are exercised frequently by local authorities including police, fire, and EMT’s. 
 Hidden Source
 A radiation source that is accidentally lost or abandoned; or one that is that is intentionally and secretively placed in areas to expose people is referred to as a silent source. 
 Dirty bomb 
 A dirty bomb is a type of radiological dispersal device.  It is an ordinary explosive device that has radioactive materials inside.  When it goes off, the radioactive material (along with other debris) will scatter and contaminate a small area. 
 Improvised nuclear device/Suitcase nuke
 A small fission bomb is called an improvised nuclear device (IND).  It is compact in size and very dangerous.  It would create a tremendous blast, extreme heat, and a significant dose of radiation to those who were within 2 miles from where it went off. 
 Nuclear Weapon

## Hypothetical Suitcase Bomb

- Chairman Dan Burton Committee – Demonstration of example
-  “suitcase nuke” made from US nuclear shell

**Notes:**
Shown is a hypothetical 1 kiloton IND (suitcase bomb).
October 26, 1999: Rep. Curt Weldon, Chair of the House Subcommittee on Military Research and Development, shows a mockup “suitcase nuke” made from a U.S. nuclear artillery shell as Rep. Dan Burton looks on.

## What is Radiation?

**Radiation is ****energy**** transported in the form of particles or waves.**

**Notes:**
Radiation is energy moving in the form of particles or waves. 

## Penetration Abilities of Different Types of Radiation

**Alpha Particles**
- Stopped by a sheet of paper

**Beta Particles**
- Stopped by a layer of clothing
- or less than an inch of a substance (e.g. plastic)

**Gamma Rays**
- Stopped by inches to feet of concrete
- or less than an inch of lead

**Radiation**
**Source**

**Neutrons**
- Stopped by a few feet of concrete

**Notes:**
Alpha particles. Alpha particles do not penetrate the dead layer of skin and can be stopped by a thin layer of paper or clothing. If an alpha emitting radioactive material gets inside the body through inhalation, ingestion, or through a wound, the emitted alpha particles can cause ionization that results in damage to tissue. 
Beta particles. Depending on its energy, beta radiation can travel from inches to many feet in air and is only moderately penetrating in other materials.  Some beta radiation can penetrate human skin to the layer where new skin cells are produced.  If high enough quantities of beta emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury.  Beta emitting contaminants may be harmful if deposited internally.  Protective clothing (e.g., universal precautions) typically provides sufficient protection against most external beta radiation.
Gamma rays and x-rays (photons).  Gamma rays and x-rays are able to travel many feet in air and many inches in human tissue.  They readily penetrate most materials. Thick layers of dense materials are needed to shield against gamma radiation.  Protective clothing provides little shielding from gamma and x radiation, but will prevent contamination of the skin with the gamma emitting radioactive material. 
Neutrons. Neutrons also penetrate most materials. They are able to travel many feet in concrete and thousands of feet in air. Thick layers of materials with lots of hydrogen in them (like water or concrete) are needed to shield against neutron radiation.  Protective clothing provides no shielding from neutron radiation. Neutrons are not likely to be encountered except in the initial seconds of a nuclear criticality event.

## Detecting Radiation

**Detecting Radiation**

- Beta and Gamma Survey Meter

**Notes:**
One great advantage that hospital personnel have, when it comes to radioactive contamination, is the ease with which radioactive material can be detected. Most radioactive material can be detected easily and in very small quantities with the use of a simple instrument such as a GM survey meter (Geiger counter).

## Radiation vs. Radioactive Material

- Radiation: energy transported in the form of particles or waves (alpha, beta, gamma, neutrons)
- Radioactive Material: material that contains atoms that emit radiation spontaneously

**Notes:**
 Radiation: energy moving in the form of particles or waves
 Radioactive Material: material that contains atoms that are radioactive 
 For example: A cobalt-60 source is radioactive material. The gamma rays being emitted from the source are the radiation.

## Exposure vs. Contamination

- Exposure: irradiation of the body  absorbed dose (Gray, rad)
- Contamination: radioactive material on patient (external)or within patient (internal)

**Notes:**
 Exposure: irradiation from outside the body
 Radioactive Contamination: radioactive material where it does not belong. It is often attached to dust or dirt.
 External contamination – outside the body (on skin or clothes)
 can usually be easily washed off
 Internal contamination – inside the body (taken in through inhalation, ingestion or wounds)
 usually passes through the body through the normal cleansing mechanisms
 Contamination can be composed of any radioactive material (perhaps several at once) and the radiation emitted from it can be of any type (usually  a combination of alpha, beta or gamma).
 Contamination can be a solid material, a liquid or a gas. Sometimes it is in the form of dust particles that float through the air and eventually settle to the ground (or some other surface.)
 For example, patients who have a procedure, such as an x-ray or CT scan, have been exposed to radiation but are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel.

## Slide 8

**Notes:**
Exposure – a person can be exposed to radiation without actually coming in contact with it.

## Slide 9

**Notes:**
Radioactive material – can come in any form, including particles similar to dust.

## Slide 10

**Notes:**
Contamination – radioactive material that can be on a patient’s clothing or skin.

## Slide 11

**Notes:**
Contamination exterior to the body can usually be easily washed off.

## Slide 12

**Notes:**
Internal contamination – radioactive material that has been taken inside the body (often through inhalation).

## Consult with Radiation Experts

- Radiation Safety Officer
- Health Physicist
- Medical Physicist
- Conference of Radiation Control Program Directors (www.crcpd.org)

**Notes:**
Consult with radiation experts to plan for a radiation emergency, such as
The Hospital Radiation Safety Officer
Health Physicists
Medical Physicists
And the Conference of Radiation Control Program Directors

## Consult with Radiation Experts 

- Determining/documenting presence of radioactivity, activity levels, and radiation dose
- Collecting samples to document contamination
- Assisting in decontamination procedures
- Disposing of radioactive waste

**Notes:**
Radiation experts will be able to assist hospitals and staff in 
Documenting the presence of radionuclides, activity levels, and accident details
Collecting samples that document contamination
Assist in decontamination procedures
Calculate and document dose calculations
Dispose of radioactive waste

## Injuries Associated with Radiological Incidents 

- Acute Radiation Syndrome (ARS)
- Localized radiation injuries/ cutaneous radiation syndrome
- Internal or external contamination
- Combined radiation injuries with
-    - Trauma
-    - Burns
- Fetal effects

**Notes:**
In this segment we will discuss:
 Acute Radiation Syndrome
Localized radiation injuries/cutaneous radiation syndrome
Internal or external contamination
Combined radiation injuries with
	 - Trauma
	 -  Burns
Fetal effects

## Psychological Casualties

- Terrorist acts perceived as very threatening
- Large numbers of concerned with no apparent injuries
- Mental health professionals should be included
- For more information on radiation exposure and pregnancy
- www.bt.cdc.gov/radiation/prenatalphysician.asp

**Notes:**
Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening.  A mass casualty incident resulting from nuclear terrorism is likely  to generate large numbers of frightened people who may not require decontamination or trauma care.  To reassure these psychological casualties and prevent them from overwhelming healthcare facilities, counseling centers should be established.
 - Include mental health professionals in all stages of the medical response.
 - To counsel pregnant women, use “Prenatal Radiation Exposure: A Fact Sheet for Physicians,” on the CDC website at www.bt.cdc.gov/radiation/prenatalphysician.asp.”

## Radiation Protection for Clinical Staff 

- Fundamental Principles
-     - Time
-     - Distance
-     - Shielding
- Personnel Protective Equipment
- Contamination Control

**Notes:**
In this segment we will discuss:
 Fundamental Principles
 Time 
 Distance
 Shielding
 Personnel Protective Equipment
 And Contamination Control

## Protecting Staff from Contamination

- Use standard precautions (N95 mask if available)
- Survey hands and clothing frequently
- Replace contaminated gloves or clothing
- Keep the work area free of contamination

**Notes:**
 Hospital staff are well versed in protecting themselves and their work areas from microbiological contamination through the use of standard precautions.  The same techniques can be used effectively to protect personnel and the work area from contamination by radioactive materials.
Use standard precautions 
Though standard surgical masks reduce the possibility of blood splashes to the mouth or hand-oral contamination, they do not protect against inhaling all respiratory hazards. Fitted particulate respirators such as N95 or higher will provide a higher level of protection. However, experience suggests that if N95 masks are not available, surgical masks should provide adequate protection.
Survey hands and clothing with radiation meter at frequent intervals
Replace gloves or clothing that is contaminated
Keep the work area free of contamination as much as possible
 Frequent use of the GM survey meter can alert personnel to the need to change their gloves or clothing when they become contaminated or to tell them when contamination is being spread to the work area so that cleanup and extra precautions can be implemented. Such ease of detection and control is not possible with any other type of hazardous material.

## Contamination Control

**Contamination Control**

**HOT**
**LINE**

**CONTAMINATED**
** ****AREA**

**BUFFER**
** ****ZONE**

**CLEAN**
** ****AREA**

**Clean **
**Gloves, Masks,**
**Gowns, Booties**

**Separate Entrance**

**Trauma Room**

**Notes:**
To control the spread on contamination, a special treatment area layout should be established. Use of such a layout will allow control of individuals and materials going into the area as well as control and radiation survey of individuals and materials coming out of the area. 
The key to this layout is the buffer zone between the potentially contaminated area and the clean area. This buffer zone should be set up so that persons or things leaving the contaminated area are first monitored for contamination (while still on the step off pad) and contaminated gloves, shoes, clothing, or other materials can be placed in receptacles set aside for them before stepping off the step off pad.
Then staff should survey their entire body with a radiation meter, taking special care of hands, feet and face.
the speed of the survey should not exceed 2 inches per second, and the distance between the probe and the skin should be approximately 1 inch
Contaminated waste water need not be contained if it will unduly complicate the treatment of the patient  or it is otherwise determined to be impractical.  Release of waste water can be justified in almost all situations.

## Pregnant Staff

- NRC limit for pregnant workers is 5 mGy (0.5 rad)
- Pregnant staff should be reassigned
- CDC prenatal radiation exposure fact sheet:

- www.bt.cdc.gov/radiation/prenatalphysician.asp

**Notes:**
 The Nuclear Regulatory Commission (NRC) limits the exposure of pregnant nuclear workers to 5 mGy for the entire pregnancy.
Pregnant staff should be reassigned
Consult the CDC fact sheet on prenatal radiation exposure

## Dealing With Staff Stress

- Preplanning
- Establish information center
- Train staff on radiation basics
- Post Event
- Debrief immediately after event
- Offer Counseling

**Notes:**
Medical staff may also suffer from psychological stress during such an incident.
 the hospital should perform some preplanning, such as establishing an information center for staff to find out the status of their families and to assist staff with dependents (pick up children form school, daycare, eldercare, etc.)
 And training for hospital staff on the basics of radiation and contamination
Following and event: 
The hospital should debrief staff immediately
And offer psychological counseling to staff as needed

## 1986 Chernobyl Accident

- “When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personal at the site received less than 10 mGy of radiation.”
- Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61

**Notes:**
 In April, 1986 the Chernobyl nuclear power plant in the Ukraine had an event that contaminated a broad region and exposed thousands of people. By far, the most highly exposed and contaminated people were the fireman who first responded to the event and attempted to put out the fire. Many of these men suffered from Acute Radiation Syndrome and all were highly contaminated. 
 “When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personal at the site received less than 10 mGy of radiation” (equivalent to one CT pelvic exam).  (Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61)

## Never delay critical care because a patient is contaminated

**Notes:**
 Fortunately, even in the worst case contamination incidents thus far recorded, the dose rate from the patient to the clinical staff was relatively low. 
 That is why in you should never delay critical care because a patient is contaminated.

## Immediate Medical Management

- Triage
- ARS
- localized/ cutaneous
- combined injury
- Initial stabilization and treatment
- Psychological effects
- Record keeping/ Dose assessment

**Notes:**
In this segment we will discuss:
 Triage
 ARS
 localized/ cutaneous
 combined injury
 Initial stabilization and treatment
 Psychological effects
 Record keeping/ Dose assessment

## Patient Management - Priorities

- Standard medical triage is the highest priority
- Radiation exposure and contamination                   are secondary considerations

**Notes:**
Even during a radiological incident, medical triage is the highest priority. 
The symptoms occurring in the first 24 hours after a total or partial body exposure are seldom life-threatening. However, loss of fluids and electrolytes can be problematic in infants, children and the elderly. Also, some lethal exposures have resulted in hypotension.
Resuscitation and stabilization are the primary objectives.  
Radiation exposure and contamination are secondary considerations.

## Patient Management - Protocol

- Based on:
- Injuries
- Signs and symptoms
- Patient history
- Contamination survey

**Notes:**
For patients with life-threatening conditions, stabilize and treat physical symptoms according to standard procedures. 
Unfamiliar embedded objects in patient’s clothing or wounds may be radioactive sources.  Handle with long forceps, handle only briefly, and keep distant from staff and patients until proven, with a survey meter, not to be radioactive.  If radioactive objects are recovered, they should be placed in a lead container using tongs or forceps.
If it is suspected that the patient received a high dose of radiation, take additional blood samples for CBC (complete blood count), with attention to lymphocyte count, as soon as possible and every 2 to 3 hours for the next 24 hours to assess lymphocyte depletion.
Also, conduct HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion.
Watch for loss of fluids and electrolytes, especially in infants, children and the elderly.
Watch for hypotension.
The severity and time of onset of nausea, vomiting, diarrhea, fatigue, headache, parotitis, erythema and fever should be noted and treated in routine clinical manner.
Patient history will assist in the triage process to predict the potential extent of radiation injury.
Obtain as much patient and situation history as possible (Where were you when the bomb exploded?), noticing circumstances surrounding the patient and the situation that might indicate exposure (this also includes looking for corroborating evidence.) 
After the patient is stabilized, trained staff should survey the patient for radioactive contamination and begin the decontamination process.

## Prenatal Radiation Exposure

- Human embryo and fetus highly sensitive to ionizing radiation
- At higher doses, effects depend on dose and stage of gestation
- Pregnant patients should receive special dose assessments and counseling
- Information on prenatal radiation exposure
- www.bt.cdc.gov/radiation/prenatalphysician.asp

**Notes:**
The human embryo and fetus are particularly sensitive to ionizing radiation, and the health consequences of exposure can be severe, even at radiation doses too low to immediately affect the mother. Such consequences can include growth retardation, malformations, impaired brain function, and cancer. 
At higher doses, the health effects depend on dose and stage of gestation
Pregnant patients should receive special dose assessments and counseling

For more information on prenatal radiation exposure, please visit the CDC web site listed here.

## Required Conditions forAcute Radiation Syndrome

- Large dose
- Penetrating
- Most of body exposed
- Acute

**Notes:**
The required conditions for Acute Radiation Syndrome (ARS) are: 
 The radiation dose must be large  (i.e., greater than the equivalent of ~ 75 CT pelvic exams.) 
 Mild symptoms may be observed as low as the equivalent of 35 CT pelvic exams. 
 The radiation must be penetrating (i.e., able to reach the internal organs). 
 High energy X-rays, gamma rays, and neutrons are penetrating radiations. 
 The entire body (or a significant portion of it) must have received the dose. 
 Most radiation injuries are local, frequently involving the hands, and these local injuries seldom cause classical signs of ARS. 
 The dose must have been delivered in a short time (usually a matter of minutes). 
 Fractionated doses are often used in radiation therapy. These are large total doses delivered in small daily amounts over a period of time. Fractionated doses are less effective at inducing ARS than a single dose of the same magnitude. 

## Acute Radiation Syndrome (A Spectrum of Disease)

- Acute Radiation Syndrome (A Spectrum of Disease)

**Notes:**
 In many radiological terrorism events the vast majority of people involved will be exposed to very low doses of radiation, if they are exposed at all. In these cases there will be no immediate effects, with the potential for delayed effects increasing with increasing dose.
 Some people may be exposed to doses large enough to cause immediate effects. The severity of the immediate effects will also depend on the size of the radiation dose.
 Acute Radiation Syndrome (ARS) (sometimes known as radiation toxicity or radiation sickness) is an acute illness caused by irradiation of the entire body (or most of the body) by a high dose of penetrating radiation in a very short period of time (usually a matter of minutes). 
 Acute Radiation Syndrome is actually a combination of syndromes, effecting different systems, depending on the severity of the dose.

The three classic ARS Syndromes are:
 Bone marrow syndrome (sometimes referred to as hematopoietic syndrome) 
 The survival rate of patients with this syndrome decreases with increasing dose. The primary cause of death is the destruction of the bone marrow, resulting in infection and hemorrhage. 
 Gastrointestinal (GI) syndrome
 Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance. Death usually occurs within 2 weeks. 
 Cardiovascular (CV)/ Central Nervous System (CNS) syndrome
 Death occurs within 3 days. Death is likely due to collapse of the circulatory system as well as increased pressure in the confining cranial vault as the result of increased fluid content caused by edema, vasculitis, and meningitis. 

## Biodosimetry Assessment Tool 

- Armed Forces Radiobiology Research Institute
- www.afrri.usuhs.mil/

## Andrews LymphocyteNomogram

- Andrews LymphocyteNomogram

***From *****Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry  to the Medical Management of Persons Exposed to High Levels of Radiation.  *****In *****Personal Dosimetry for Radiation Accidents. **
** ****Vienna,  International Atomic Energy Agency, 1965, pp 3- 16**

- Confirms suspected radiation exposure
- Determines significant hematological involvement
- Serial CBCs every 3 - 4 hours

**Notes:**
 Note that all of the signs and symptoms of acute radiation exposure can be caused by stress or other illnesses. 
 Chromosomal analysis of lymphocytes is the best determinant of radiation dose. However, this requires special analysis and usually takes 3 to 4 days. In the mean time the dose can be estimated by observing the onset of signs and symptoms and observation of the rate of lymphocyte depletion. 
 The Andrews Lymphocyte Nomogram can be used to both confirm suspected radiation exposure as well as predict the extent of the injury.
 Note: The concentration of lymphocytes in circulation can be altered by trauma and can complicate the use of this as an indicator for radiation exposure.

## Phases of Acute Radiation Syndrome 

- Phases of Acute Radiation Syndrome

- www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

**Notes:**
The four stages of ARS are:
 Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, and possibly diarrhea (depending on dose) that occur from minutes to days following exposure. After extremely high radiation doses, additional symptoms such as prostration, fever, respiratory difficulties, and increased excitability may develop.  
The symptoms may last (episodically) for minutes up to several days. 
 Latent stage: In this stage the patient looks and feels generally healthy for a few hours or even up to a few weeks. The latent period shortens as the initial dose increases.
 Manifest illness stage: In this stage the symptoms depend on the specific syndrome and last from hours up to several months. 
 Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years. 

## Special Considerations

- High radiation dose and trauma interact synergistically to increase mortality
- Close wounds on patients with doses > 1 Gy (100 rad)
- Perform wound/burn care and surgery in first 48 hours or delayed for 2 to 3 months when dose is > 1 Gy (100 rad)

**Notes:**
Combined injury is present when trauma, thermal or chemical injury occurs along with radiation exposure sufficient to cause immunosuppression, delayed healing, pancytopenia and other problems.
Patients who have combined injury will have increased morbidity as compared to patients who have received the same dose of radiation without trauma. Patients with serious trauma, thermal, or chemical injury therefore require prompt assessment, stabilization and subsequent treatment.
Likewise, pre-existing conditions that result in immunosuppression, blood loss, and danger of infectious complications will result in increased morbidity and mortality.
If a patient has received an acute dose greater than 1 Gy (100 rad), efforts must be made to close wounds, cover burns, reduce fractures, and perform surgical stabilizing and definitive treatments within the first 48 hours after injury. 
After 48 hours, surgical interventions should be delayed until hematopoietic recovery has occurred.

## Skin Effects

**NUREG / CR-4214, p II-68**

- Epilation
- Erythema
- Pigmentation
- Dry desquamation
- Moist desquamation that heals

**Notes:**
 Localized radiation injury can occur when a person receives a very high radiation dose to only a portion of their body. Depending on the dose, the location on the body, and the fraction of the body that is exposed, extreme damage may occur, with or without symptoms of acute radiation syndrome. Skin damage is the most typical effect.
 The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome resulting from acute radiation exposure to the skin. 
 ARS will usually be accompanied by some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or x-rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes. 
 When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged causing epilation. Within a few hours after irradiation a transient and inconsistent erythema (associated with itching) can occur. Then, there may be a latent phase that lasts from a few days up to several weeks, when intense reddening, blistering and ulceration of the irradiated site is visible. 
 The cycle of healing, and then a return of symptoms may recur several times, with symptoms often worsening each time.
 In most cases healing occurs by regenerative means; however, very large skin doses can cause permanent hair loss, damaged sebaceous and sweat glands, atrophy, fibrosis, decreased or increased skin pigmentation, and ulceration or necrosis of the exposed tissue. 
 This photo is from a patient who had 3 angioplasty procedures under fluoroscopic guidance.  It shows deep necrosis of the skin 22 months after an exposure of ~2000 rad. 

## Treat patients symptomatically

Prevent and manage infections
Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®)
Irradiated blood products
Antibiotics/reverse isolation
Electrolytes

More information on ARS:
www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

- Treatment of Large External Exposures

- Treat patients symptomatically
- Prevent and manage infections
- Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®)
- Irradiated blood products
- Antibiotics/reverse isolation
- Electrolytes
- More information on ARS:
- www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp

**Notes:**
Patients with higher exposures will require hospitalization. Consider the use of a burn unit.
Treat patients symptomatically as they occur for nausea, vomiting, diarrhea, fatigue, electrolyte imbalance, and pancytopenia.  Treatment should focus on prevention of infection.  Antibiotics should be given to sterilize the gut and treat opportunistic infections.
Hematopoietic growth factors should be given within the first 24-48 hours and then daily.
Neupogen (filgrastim) is a human granulocyte colony stimulating factor (G-CSF) that causes the body to produce more white blood cells.
It has been used successfully for cancer patients and should provide similar benefits for persons who have been exposed to accidental high doses of radiation.
For more information on acute radiation syndrome, go to the CDC web site.

## Treatment of Cutaneous Radiation Syndrome

- Lesions do not appear for days to weeks
- Perform surgical treatments within 48 hrs
- Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment, 865-576-1005 or www.orau.gov/reacts/

**Notes:**
 Lesions do not appear for days to weeks. Unless symptomatic, emergency care is not needed urgently.
The signs and symptoms of localized radiation injury are:
 Burn-like skin injuries without a history of heat exposure. The signs and symptoms are itching, tingling,  erythema or edema.
 Epilation
 A tendency to bleed
 Possible signs and symptoms of ARS
 Treat localized injuries symptomatically as they occur, with consultation from radiation injury experts
 As with other kinds of trauma, if the patient is also suffering from ARS, efforts must be made to close wounds, cover burns, reduce fractures, and perform surgical stabilizing and definitive treatments within the first 48 hours after injury. 
 After 48 hours, surgical interventions should be delayed until hematopoietic recovery has occurred.
A baseline CBC and differential should be taken and repeated in 24 hours.
 Later, these lesions may be debilitating and life threatening. Medical follow-up is essential and victims should be cautioned to avoid trauma to the involved areas.
 Because cutaneous radiation syndrome is cyclic, it is important to note and record areas of early erythema. Sketch these places and photograph (if possible). Be sure to record and date the time.
 Turn to Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment: www.orau.gov/reacts/, 865-576-1005.

## Decontamination of Patients 

- External
- Skin
- Wound
- Internal
- Decorporation agents

**Notes:**
In this segment we will discuss treatment for:
 External Contamination
 Of Skin
 Of Wounds
 Internal Contamination
 and the use of decorporation agents.

## Patient Decontamination

- Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of contamination)
- Handle foreign objects with care until proven non-radioactive with survey meter
- Survey patient and collect samples
- - Survey face, hands and feet
- - Survey rest of body

**Notes:**
Carefully remove and bag patient’s clothing and personal belongings (typically removes 80 - 90% of contamination)
remove patient’s clothing (should remove 70-90% of contamination)
double bag, tie, seal and label (patient name, date, time, etc.) any contaminated material in plastic bags
contaminated personal items may be decontaminated (washed) and returned to the patient later
Unfamiliar embedded objects in patient’s clothing or wounds may be radioactive sources.  Handle with long forceps, handle only briefly, and keep distant from staff and patients until proven, with a survey meter, not to be radioactive.  If radioactive objects are recovered, they should be placed in a lead container using tongs or forceps.
Survey the patient for contamination
scan the face, hands and feet using a standard radiation survey instrument
if the results are positive, conduct a thorough survey of the patients entire body
the speed of the survey should not exceed 2 inches per second, and the distance between the probe and the patient should be approximately 1 inch
record location of contamination and contamination level, along with patient name, date and time of survey

## External Contamination 

- Radioactive material (usually in the form of dust particles) on the body surface and/or clothing
- Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff

**Notes:**
 External contamination is radioactive material (usually in the form of dust particles) on the outside of a patient’s body, including clothing.
 Though the radiation dose rate from contamination is usually very low, while it remains on the patient it will continue to irradiate the patient as well as anyone nearby.

## Decontamination Priorities

- Wounds
- Intact skin (areas of highest contamination first)
- Change outer gloves frequently to minimize spread of contamination

**Notes:**
 Decontaminate wounds first, then intact skin 
 Start with highest levels of contamination
 Change outer gloves frequently to minimize spread of contamination

## Decontamination of Wounds

- Contaminated wounds:
- Irrigate and gently scrub with surgical sponge
- Debride surgically only as needed
- Contaminated thermal burns:
- Gently rinse
- Changing dressings will remove additional contamination
- Avoid overly aggressive decontamination
- Change dressings frequently

**Notes:**
 Protection of non-contaminated wounds with waterproof dressings will minimize the potential for uptake of radioactive material.
 To decontaminate wounds, irrigate and gently scrub with a surgical sponge.  Normal wound debridement should be performed.  Excision around wounds solely to remove contamination should only be performed in extreme cases and upon the advice of  radiological emergency medical experts. 
 irrigate and gently scrub with a surgical sponge
 debride wound only as needed, being sure not to overdo it.
 in extreme cases, with advice from radiological emergency medical experts, excise around the wound to remove contamination
 cover the wound with waterproof dressing
 frequent dressing changes can also aid wound decontamination
 note that with thermal burns, washing may increase the severity of the wound, so just gently rinse. 
 Many times, radioactive material will exude from wounds into gauze dressings so frequent changing of dressings may aid wound decontamination.  The dressing also serves to keep the contamination in place.

##  Decontamination of Skin

- Use multiple gentle efforts
- Use soap & water
- Cut hair if necessary (do not shave)
- Promote sweating
- Use survey meter

**Notes:**
Decontaminate patients with several gentle efforts, rather than with a single aggressive effort.
Wash contaminated areas with soap and water
 water is the most important ally in this setting. Contaminated wash water can go down the drain like normal wash water.
 localized contamination can be wiped off with pre-moistened wipes or washed with soap and water
 a shower may be best if the patient is ambulatory and the contamination is wide spread
 take care not to abrade or irritate the skin
protect non-contaminated wounds with waterproof dressings
survey the patient again to locate contaminated areas and record location of contamination and the contamination level
Remove contaminated hair if necessary, using scissors or electric clippers.  To avoid cutting the skin and providing an entry for internal contamination, do not shave.
Sweating can remove radioactive material from pores.  Cover the area with gauze and put a glove or tape plastic over the area to promote sweating.

##  Cease Patient Decontamination

- When decontamination efforts produce no significant reduction in contamination
- When the level of radiation of the contaminated area is less than twice background
- Before intact skin becomes abraded
- Consider internal contamination

**Notes:**
Cease decontamination of the skin and wounds when the area is less than twice the background reading on the survey meter or there is no significant reduction between washings.  Under no circumstances should decontamination cause the skin to become abraded. 
Do not delay surgery or other necessary medical procedures because of contaminated skin or wounds.  Staff will be protected from becoming contaminated by using universal precautions.  Sheets and dressings will keep contamination in place.
The degree of decontamination for each patient should be dictated by the number of, and capacity to treat, other injured patients.
If the patient is still shows a positive reading for contamination on the torso, but no there is no reduction between decontamination efforts, consider the possibility of internal contamination. 

## Internal Contamination

- Radioactive material may enter the body through
- - Inhalation
- - Ingestion
- - Wounds
- Internal contamination generally does not cause early signs or symptoms
- Internal contamination will continue to irradiate the patient

## Treatment of Internal Contamination

- * Treatment for these involves investigational
- new drugs available from REAC/TS

- Rare earths *
-    - Plutonium
-    - Transplutonics
-    - Yttrium
- Uranium
- Cesium, rubidium, thallium *
- Tritium

**Notes:**
  The less time that radioactive materials are inside a patient’s body, the less radiation exposure they will receive to their internal organs. Therefore, treatment of internal contamination focus’ on the decorporation of these materials.
 Treatment is radionuclide-specific (see the table) and because the rate of radioactive incorporation is often quite rapid, treatment is most effective when administered early.
 You may need to act on preliminary information
 Several methods of preventing incorporation (e.g., catharsis, gastric lavage) might be applicable and can be prescribed by a physician.  
 Some of the medications or preparations used in decorporation might not be available locally and should be stocked.
 NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides addresses the strategies to limit the exposure from internal contamination by radioactive materials.  Radiation Protection Dosimetry published a Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers (1992) that provides additional information on patient management.
 Consult with your local poison control center.
 Consult with the Radiation Emergency Assistance Center/ Training Site (REAC/TS) about use of these substances at their web site or by phone 865-576-1005

## Potassium Iodide (KI)

- Only helpful in special cases
- KI saturates the thyroid gland with stable iodine
- KI must used prior to or within hours of exposure to radioactive iodine
- See the FDA web site:

**www.fda.gov/cder/drugprepare/KI_Q&A.htm**

## Longer Term Considerations Following Radiation Injury

- Neutropenia
- Pain management
- Necrosis
- Plastic/reconstructive surgery
- Psychological effects (PTSD)
- Counseling
- Dose assessments
- Possible increased risk of cancer
- Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment: www.orau.gov/reacts/, 865-576-1005.

## Key Points

- Stabilization is the highest priority
- Radiation experts should be consulted
- Training and drills should be offered
- Adequate supplies and survey instruments should be stocked
- Standard precautions (N95 mask if available) reduce contamination
- Early symptoms and their intensity indicate the severity of the radiation injury
- First 24 hours are the most critical

**Notes:**
Medical stabilization of the patients is the highest priority.  Patients will not succumb immediately from radiation injury.  Radiation exposure and contamination are not immediately life threatening nor are contamination levels or exposure levels of significant hazard to personnel.
Consult with radiation experts in all stages of the medical response.
Training and drills are the best preparation to ensure competence and confidence by the the ED and other staff identified in the Emergency Plan.
Pre-plan to ensure that adequate supplies and survey instruments are available.  Identify non-ED staff that can assist.  Staff from Nuclear Medicine, Radiation Oncology and Radiation Safety have expertise in radiation protection practices and the use of survey meters.
The staff can protect themselves from radioactive contamination by using standard precautions while treating these patients.  Treating these patients is not an immediate hazard to ED staff health and the long term risks from the radiation exposure are small. N95 masks are preferable, but if not available, standard surgical masks will provide adequate protection.
Early symptoms and their intensity in patients are an indication of the severity of the radiation injury.
The first 24 hours are the most critical.  Then you will likely have many additional resources from state and federal agencies.

## More Incident Assistance

- The Radiation Emergency Assistance Center/ Training Site (REAC/TS)
- - _[www.orau.gov](http://www.orau.gov/reacts/)__[/reacts/](http://www.orau.gov/reacts/)_
- - Phone: (865) 576-1005
- The Armed Forces Radiobiology Research Institute, Medical Radiobiology Advisory Team (MRAT)
- - _[www.afrri.usuhs.mil](http://www.afrri.usuhs.mil/)__[/](http://www.afrri.usuhs.mil/)_
- - Phone: (301) 295-0530
- The American Association of Poison Control Centers
- - _[www.aapcc.org](http://www.aapcc.org/)__[/](http://www.aapcc.org/)_
- - Phone: (800) 222-1222

## Other Resources

- Books:
*- Disaster Medicine*; Hogan and Burnstein, 2002.
*- Medical Management of Radiation Accidents*; Gusev, Guskova, Mettler, 2001.
*- The Medical Basis for Radiation-Accident Preparedness*; REAC/TS Conference, 2002.
*- National Council on Radiation Protection and Measurement Report No. 65: Management of Persons Accidentally Contaminated With Radionuclides*, 1980.
*- National Council on Radiation Protection and Measurement Report No. 138: Management of Terrorist Events Involving Radioactive Material*, 2001.
- AFRRI Publications: *Medical Management of Radiological Casualties Handbook*; Jarrett, 2003, and Terrorism with Ionizing Radiation Pocket Guide

**Notes:**
This is a list of resources both for developing a plan for handling radiation casualties and for use in responding to an actual event. 
 Books: 
 Medical Management of Radiation Accidents; Gusev, Guskova, Mettler, 2001.
 The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference, 2002. 
 National Council on Radiation Protection and Measurement Report No. 65: Management of Persons Accidentally Contaminated With Radionuclides, 1980.
 National Council on Radiation Protection and Measurement Report No. 138: Management of Terrorist Events Involving Radioactive Material, 2001.
 AFRRI Publications: Medical Management of Radiological Casualties Handbook; Jarrett, 2003, and Terrorism with Ionizing Radiation Pocket Guide

## Other Resources

- Article: “Major Radiation Exposure - What to Expect and How to Respond,” Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61.
- Web Sites:
- - _[www.va.gov/emshg](http://www.va.gov/emshg/)__[/](http://www.va.gov/emshg/)_ - Department of Homeland Security Working Group on Radiological Dispersal Device Preparedness, Medical Treatment of Radiological Casualties
- - _[www.crcpd.org](http://www.crcpd.org/)_ – Conference of Radiation Control Program Directors
- - _[www.bt.cdc.gov/radiation/index.asp](http://www.bt.cdc.gov/radiation/index.asp)_ - Centers for Disease Control and Prevention Radiation Emergencies Page
- - _[www.acr.org/flash.html](http://www.acr.org/flash.html)_ - Disaster Preparedness for Radiology Professionals
- - _[www.hps.org](http://www.hps.org/)__[/](http://www.hps.org/)_ - The Health Physics Society
- - _[www.fda.gov](http://www.fda.gov/)__[/](http://www.fda.gov/)_ - The Food and Drug Administration

**Notes:**
The following internet sites are very helpful:
 Article: “Major Radiation Exposure - What to Expect and How to Respond,” Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61. 
www.va.gov/emshg/ - Department of Homeland Security Working Group on Radiological Dispersal Device Preparedness, Medical Treatment of Radiological Casualties
 www.bt.cdc.gov/radiation/index.asp - Centers for Disease Control and Prevention Radiation Emergencies Page
 www.acr.org/flash.html - Disaster Preparedness for Radiology Professionals
 www.hps.org/ - The Health Physics Society
 www.fda.gov/ - The Food and Drug Administration