RADIATION BASICS FOR CLINICIANS

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RADIATION BASICS FOR CLINICIANS

• SUSAN ECKERT, RN, MSN
• NDMS
• MARCH 20, 2007

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True or False ?

• Exposure to radiation always poses a risk for
  health care workers
• Always decontaminate patients involved in a
  radiation event FIRST, the proceed with medical
  management.
• If a patient contaminated with radiation enters
  the ED, the entire ED must be quarantined.

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Objectives

• Identify two major categories/causes of possible
  exposure/contamination from radiation
• State the three main types of ionizing radiation
• Review units of measurement utilized in measuring
  radiation
• Describe principles in minimizing exposure to
  radiation
• Discuss strategies to prepare the emergency room
  and personnel to receive patients who have been
  contaminated
• State the two primary methods in which a person
  may become contaminated
• Discuss patient management for patients who have
  been internally or externally contaminated

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CBRNE

• Weapon of mass destruction
• Blast
• Radiation
• Terrorists goals
• Psychological damage
• Economic damage

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Causes of Radiation Exposure/Contamination

• Accidents
• - Nuclear reactor
• - Medical radiation therapy
• - Industrial irradiator
• - Lost/stolen medical or industrial radioactive
  sources
• - Transportation

• Terrorist Event
• - Radiological dispersal device (dirty bomb)
• - Attack on or sabotage of a nuclear facility
• - Low yield earth-penetrating nuclear weapons

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Key Concepts

• Radiation-energy released from a source and
  travels through the air or other medium to a
  receiving body.
• May be in the form of electromagnetic waves or
  high speed subatomic particles
• Radiation is present in our environment all
  around us- in the air, soil, and food and water
  we eat and drink
• Radioactive materials can be handled/managed
  safely. Many provide great benefits (medicine,
  scientific research, fuel)
• While ionizing radiation can cause damage to
  cellular DNA, it is a relatively poor carcinogen
  and cells can repair the damage

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Types of Ionizing Radiation
Radiation Source
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
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Radiation Units
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Types of Radiation Hazards

• External Exposure
• Whole-body or partial-body (no radiation hazard
  to EMS staff)
• Contaminated
• External contamination radioactive material on
  the skin
• Internal contamination radioactive material
• - Inhaled
• - Swallowed
• - Absorbed through skin or wounds

Internal Contamination
External Contamination
External Exposure
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Biologic Effects

• Total Dose absorption of radiation energy per
  unit mass of absorber (tissue)
• Dose rate- period of time dose is received (one
  time vs. increments)
• Volume of tissue or anatomical body part
  irradiated
• Type of radiation- penetrating
• Co-existing conditions- trauma, burns
• Pre-existing conditions immunocompromised, age

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

• Annual Limit on Intake
• The amount of radionuclide that, if taken into
  the body, will result in a regulatory limit being
  met
• Internal limit
• 5 rems of a committed dose or 50 rems to an
  individual organ or tissue
• As Low As Reasonably Achievable
• Make reasonable effort to maintain exposure to
  ionizing radiation as far below regulatory limits
  as practical
• External limit
• 100 mR/hno more than 30mR/h from a single source

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Detecting Radiation

• Radiation is colorless, odorless and tasteless
• BUT, unlike chemical and biologic agents, you CAN
  detect it on the scene
• Detection Monitors
• Geiger Counter
• Area monitor

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Patient Management

• Monitor/detectors go off/patients present stating
  they are contaminated with radiation.
• What do you do ?

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First Steps Suspected Radioactive Contamination

• Respond to patient(s) setting off alarm, ask
  Have you had any medical procedures using
  radioactive sources? or Have you been in the
  hospital/clinic having any tests or treatments?
• Confirm presence/amount of radiation with a
  Geiger Counter
• In Field Notify IC
• In Hospital CALL RADIATION SAFETY OFFICER
• Notify nursing supervisor

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YOU CONFIRM THE PATIENT(S) ARE CONTAMINATED

• WHAT NEXT ????

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Treat, Treat, Treat
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Protect yourself !!!

• PPE Universal precautions
• Gown, mask, goggles, hat, shoe covers, gloves.
  Tape gloves over gown
• Obtain a personal dosimeter
• Identify where they are kept in your facility
• Do not eat or drink inside the control zone
• Place OUTSIDE of PPE, clip at waist, neck

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Control Zone Inside

• Control zones create an area to manage/minimize
  contamination. It defines who should be wearing
  PPE/dosimeters and where recovery decon may need
  to occur for the environment
• Create the zone anywhere contaminated patients
  were PLUS 3 feet.
• Use Caution tape and cones
• The rest of the ED can continue if needed

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Control Zones Outside
Guidance for Radiation Accident Management
(Updated 022102) Radiation Emergency Accident
Center/Training site (REAC/TS)
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Patient Treatment External Contamination

• DECONTAMINATION
• Remove all clothing FIRST, cut it off, and roll
  outside in. THIS REMOVES 90 OF THE
  CONTAMINATION!!
• Survey the patient and document contaminated
  areas
• No shower if only local areas

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Treatment continued

• Open wounds first
• Use irrigation sets
• Handle any unknown metal objects with forceps or
  hemostats
• Orifices next
• Skin last Baby wipes, make-up remover pads
• Nasal swabs for samples- needed
• to determine if there has been
• internal contamination
• To determine the effectiveness of decon- resurvey
  the area

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Decontamination Tips

• All contaminated clothes, belongings, etc., stay
  in hot zone and labeled - for ID later and for
  law enforcement if needed
• The contaminated area and equipment (bay,
  stretcher, stethascope) will need to be
  decontaminated after the event
• Specimens should be labeled, placed in a zip lock
  bag and hand carried to the lab. A radioactive
  symbol or code should be placed on the bag.

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Spy Poisoned by Radiation

• Alexander Litvinenko

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Treatment Internal Contamination

• PRIORITY ID THE ISOTOPE/QUANTITY!!
• Nasal swabs
• Wound cultures
• Sputum culture best choice !!!
• Urine/feces analysis
• When all else fails get a good history!!
• Seek guidance IMMEDIATELY on possible
  treatmentsyou have 4-6 hours to initiate
  therapy

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Internal Contamination

• Binding agents Prussian Blue for cesium or
  thallium
• Saturate critical organs Potassium Iodide to
  prevent thyroid cancer
• Displacing agents calcium for radio-stronium
• Chelating agents DPTA for plutonium
• Dilute with fluids water for tritium

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Lets see what you learned !

• A call comes in from EMS stating a bomb
  exploded. Terrorists claim it was a RDD. They
  have 10 patients with a variety of burns on their
  bodies. Do the burns confirm radiation
  contamination?

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• The patients arrive and survey confirms they have
  external contamination, including their arms.
  Many have low blood pressures. Can you start IVs
  for volume resuscitation?

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• One of the patients has shrapnel all though his
  abdomen and is clearly bleeding internally. Can
  he go to the OR ?

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• Another patient has a decreased level of
  consciousness and needs a CT scan. Can she go in
  the scanner ?

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• All patients were stabilizedhow do determine if
  the control zone area can be used again for
  clinical care ?

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Key Points

• Medical stabilization is the highest priority
  treat medically, if indicated, before decon
• Taking off contaminated clothing removes up to
  90 of contamination
• Universal precautions and a dosimeter will
  provide necessary protection.
• The Geiger counter is your friend

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Key points continued

• Early symptoms and their intensity are an
  indication of the severity of the radiation
  injury.
• ID the contaminant as soon as possiblemany
  internal contamination treatments need to be
  initiated within 4-6 hours.
• Use your resources!! Hospital based Radiation
  Safety Office, Radiation Oncology, Nuclear
  Medicine. External REAC/TS, HHS REMM.

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Resources

• Radiation Emergency Assistance Center/ Training
  Site (REAC/TS) - [phone] www.orau.gov/react
  s
• Medical Radiobiology Advisory Team (MRAT) Armed
  Forces Radiobiology Research Institute (AFRRI)
• [phone] www.afrri.usuhs.mil
• Medical Management of Radiological Casualties
  Handbook, 2003 and Terrorism with Ionizing
  Radiation Pocket Guide
• Websites
• www.bt.cdc.gov/radiation - Response to Radiation
  Emergencies by the Center for Disease Control
• www.acr.org - Disaster Preparedness for
  Radiology Professionals by American College of
  Radiology
• www.va.gov/emshg - Medical Treatment of
  Radiological Casualties
• COMING SOON HHS REMM !!!!

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Reference Materials

• Major Radiation Exposure - What to Expect and
  How to Respond, Mettler and Voelz, NEJM, 2002,
  346 1554-61.
• Janes Mass Casualty Handbook Hospital
  Emergency Preparedness and Response
• Radiological Dispersal Device (RDD) Preparedness
• NCRP 65 Management of Persons Accidentally
  Contaminated with Radionuclides. (April, 1980)

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Contact Info

• Susan.E.Eckert_at_medstar.net
• [phone]