This presentation, "Emergency Department Management of Radiation Casualties,

1

• This presentation, "Emergency Department
  Management of Radiation Casualties, was prepared
  as a public service by the Health Physics Society
  for hospital staff training.
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  to Jerrold T. Bushberg, PhD, UC Davis Health
  System, at jtbushberg_at_ucdavis.edu.
• Version 3.0

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Emergency Department Management of Radiation
Casualties
CAUTION
3
Scope of Training

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

4
Scope of Training (Cont.)

• Patient assessment and management of radioactive
  material contamination and radiation injuries
• Health effects of acute and chronic radiation
  exposure
• Psychosocial considerations
• Facility recovery
• Resources

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Ionizing Radiation

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

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Types of Ionizing Radiation
Alpha Particles Stopped by a sheet of paper
Radiation Source
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
Measure of Amount of radioactive material
Ionization in air Absorbed energy per
mass Absorbed dose weighted by type of
radiation
Quantity Activity Exposure Absorbed
Dose Dose Equivalent
Unit curie (Ci) roentgen (R) rad rem
For most types of radiation 1 R ? 1 rad ? 1 rem
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Radiation Doses and Dose Limits

• Flight from Los Angeles to London 5
  mrem
• Annual public dose limit
  100 mrem
• Annual natural background 300 mrem
• Fetal dose limit 500 mrem
• Barium enema 800 mrem
• Annual radiation worker dose limit (U.S.) 5,000
  mrem
• Life-saving actions guidance (NCRP-116)
  50,000 mrem
• Mild acute radiation syndrome
  200,000 mrem
• LD50/60 for humans (bone marrow dose)
  350,000 mrem
• Radiation therapy (localized fractionated)
  6,000,000 mrem

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Radioactive Material

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

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Half-Life (HL)

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

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Examples of Radioactive Materials
Physical Radionuclide Half-Life
Activity Use Cesium-137 30
yrs 1.5 x 106 Ci Food
Irradiator Cobalt-60 5 yrs
15,000 Ci Cancer
Therapy Plutonium-239 24,000 yrs 300
Ci Nuclear Weapon Iridium-192
74 days 100 Ci
Industrial Radiography Hydrogen-3
12 yrs 12 Ci Exit
Signs Strontium-90 29 yrs 0.1 Ci Eye Therapy
Device Iodine-131 8 days
0.015 Ci Nuclear Medicine
Therapy Technetium-99m 6 hrs
0.025 Ci Diagnostic
Imaging Americium-241 432 yrs
0.000005 Ci Smoke Detectors Radon-222
4 days 1 pCi/l
Environmental Level Potential use
in radiological dispersion device
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Types of Radiation Hazards
Internal Contamination

• External Exposure -
• Whole-body or partial-body (no radiation
  hazard to EMS staff)
• Contaminated -
• External radioactive material on the skin or
  clothing
• Internal radioactive material inhaled,
  swallowed, absorbed through skin or wounds

External Contamination
External Exposure
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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 Incident
• Radiological dispersal device (dirty bomb)
• Attack on or sabotage of a nuclear facility
• Low-yield nuclear weapon

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Scope of Incident
Incident
Number of Deaths
Most Deaths Due to
Radiation
None/Few
Radiation
Accident
Few/Moderate
Radioactive
Blast Trauma
(Depends on
Dispersal
size of explosion and
Device
proximity of persons)
Blast Trauma
Low-Yield
Large
Thermal Burns
(e.g., tens of thousands in an urban area even
from 0.1 kT weapon)
Nuclear Weapon
Radiation Exposure
Fallout
(Depends on Distance)
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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 Shield radioactive sources in an
appropriate container.
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Protecting Staff from Contamination

• Follow standard precautions.
• Survey hands and clothing with radiation
  meter.
• Replace contaminated gloves or clothing.
• Keep the work area free of contamination.

• Key Points
• Contamination is easy to detect and most of it
  can be removed.
• It is very unlikely that ED staff will receive
  large radiation doses from treating contaminated
  patients.

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Mass Casualties, Contaminated butUninjured
People, and Concerned Citizens

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

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Decontamination Center

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

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Support for Concerned Citizens Workers

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

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Facility Preparation

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

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Treatment Area Layout
Separate Entrance
CONTAMINATED AREA
Trauma Room
HOT LINE
BUFFER ZONE
Clean Gloves, Masks, Gowns, Booties
CLEAN AREA
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Detecting and Measuring Radiation

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

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Patient Management - Priorities

• Triage
• Medical triage is the highest priority.
• Radiation exposure and contamination
  are secondary considerations.
• Degree of decontamination is dictated by number
  of and capacity to treat other injured patients.

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Patient Management - Triage

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

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Patient Management - Decontamination

• Carefully remove and bag patients clothing and
  personal belongings (typically removes 95 percent
  of contamination).
• Survey patient and, if practical, collect
  samples.
• Handle foreign objects with care until proven
  nonradioactive with survey meter.
• Decontamination priorities
• Decontaminate wounds first, then intact skin.
• Start with highest levels of contamination.
• Change gloves frequently to minimize spread of
  contamination.

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Patient Management - Decontamination (Cont.)

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

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Patient Management - Decontamination (Cont.)

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

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Treatment of Internal Contamination

• Radionuclide-specific
• Most effective when administered early
• May need to act on preliminary information
• NCRP Report No. 161, Management of Persons
  Contaminated With Radionuclides

Radionuclide Treatment Route Cesium Prussian
blue Oral Iodine Potassium iodide Oral Radium/S
trontium Aluminum hydroxide Oral Americium/ Ca-
and Zn-DTPA IV infusion, Plutonium/Cobalt/ nebu
lizer Iridium
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Patient Management - Patient Transfer

• Transport injured, contaminated patient into or
  from the ED
• Cover clean gurney with two sheets.
• Lift patient onto clean gurney.
• Wrap sheets over patient.
• Roll gurney into ED or out of treatment room.

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Facility Recovery

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

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Radiation Sickness Acute Radiation Syndrome

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

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Acute Radiation Syndrome (Cont.)For Doses gt 100
rem

• Prodromal Stage
• Symptoms may include nausea, vomiting, diarrhea,
  and fatigue.
• Higher doses produce more rapid onset and greater
  severity.
• Latent Period (Interval)
• Patient appears to recover.
• Decreases with increasing dose.
• Manifest Illness Stage
• Hematopoietic
• Gastrointestinal
• CNS

Time of Onset
Severity of Effect
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Acute Radiation Syndrome (Cont.)Hematopoietic
Component - latent period from weeks to days

• Dose 100 rem
• 10 percent exhibit nausea and vomiting within 48
  hrs
• mildly depressed blood counts
• Dose 350 rem
• 90 percent exhibit nausea/vomiting within 12
  hrs, 10 percent exhibit diarrhea within 8 hrs
• severe bone marrow depression
• 50 percent mortality without supportive care
• Dose 500 rem
• 50 percent mortality with supportive care
• Dose 1,000 rem
• 90-100 percent mortality despite supportive care

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Acute Radiation Syndrome (Cont.)Gastrointestinal
and CNS Components

• Dose gt 1,000 rem - damage to GI system
• severe nausea, vomiting, and diarrhea (within
  minutes)
• short latent period (days to hours)
• usually fatal in weeks to days
• Dose gt 3,000 rem - damage to CNS
• vomiting, diarrhea, confusion, and severe
  hypotension within minutes
• collapse of cardiovascular system and CNS
• fatal within 24 to 72 hours

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Treatment of Large External Exposures

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

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Localized Radiation Effects - Organ System
Threshold Effects

• Skin - No visible injuries lt 100 rem
• Main erythema, epilation gt600 rem
• Moist desquamation gt1,800 rem
• Ulceration/Necrosis gt2,400 rem
• Cataracts
• Acute exposure 50-200 rem
• Chronic exposure 500 rem
• Permanent Sterility
• Female (acute) gt250 rem
• Male (acute) gt350 rem

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Special Considerations

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

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Chronic Health Effects from Radiation

• Radiation is a weak carcinogen at low doses.
• There are no unique effects (type, latency,
  pathology).
• Natural incidence of cancer is 40 percent
  mortality 25 percent.
• Risk of fatal cancer is estimated as 5 percent
  per 100 rem.
• A dose of 5 rem increases the risk of fatal
  cancer by 0.25 percent.
• A dose of 25 rem increases the risk of fatal
  cancer by 1.25 percent.

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What Are the Risks to Future Children?Hereditary
Effects

• Magnitude of hereditary risk per rem is 10
  percent that of fatal cancer risk.
• Risk to caregivers who would likely receive low
  doses is very small 5 rem increases the risk of
  severe hereditary effects by 0.02 percent.
• Risk of severe hereditary effects to a patient
  population receiving high doses is estimated as
  0.4 percent per 100 rem.

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Fetal IrradiationNo significant risk of adverse
developmental effects below 10 rem
Weeks After Fertilization
Period of Development
Effects
lt2 2-7 7-40 All
Pre-implantation Organogenesis Fetal

• Little chance of malformation
• Most probable effect, if any, is death of embryo
• Reduced lethal effects
• Teratogenic effects
• Growth retardation
• Impaired mental ability
• Growth retardation with higher doses
• Increased childhood cancer risk (0.6
  percent per 10 rem)

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Key Points

• Medical stabilization is the highest priority.
• Train/drill to ensure competence and confidence.
• Preplan to ensure adequate supplies and survey
  instruments are available.
• Standard precautions and decontaminating patients
  minimize exposure and contamination risk.
• Early symptoms and their intensity are an
  indication of the severity of the radiation
  injury.
• The first 24 hours are the worst then you will
  likely have many additional resources.

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Resources

• Radiation Emergency Assistance Center/Training
  Site (REAC/TS), 865-576-1005,
  orise.orau.gov/reacts
• Medical Radiobiology Advisory Team (MRAT) Armed
  Forces Radiobiology Research Institute (AFRRI),
  301-295-0530, afrri.usuhs.mil
• Web sites
• remm.nlm.gov/ - Radiation Event Medical
  Management by Department of Health Human
  Services
• emergency.cdc.gov/radiation/ - Response to
  Radiation Emergencies by the Centers for Disease
  Control and Prevention
• acr.org - Disaster Preparedness for Radiology
  Professionals by the American College of
  Radiology, (search for disaster on website)

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Resources

• Books
• National Council on Radiation Protection and
  Measurements. NCRP Report No. 161, Management of
  Persons Contaminated With Radionuclides, 2009.
• National Council on Radiation Protection and
  Measurements. NCRP Report No. 165, Responding To
  A Radiological of Nuclear Terrorism Incident A
  Guide for Decision Makers, 2010.
• The Medical Basis for Radiation-Accident
  Preparedness REAC/TS Conference, 2002.
• Gusev I, Guskova A, Mettler F, eds. Medical
  management of radiation accidents, 2nd ed. Boca
  Raton, FL CRC Press 2001.
• Mettler F, Upton A. Medical effects of ionizing
  radiation, 3rd ed. Philadelphia Saunders 2008.
• Articles
• Mettler F, Voelz G. Major radiation exposure -
  What to expect and how to respond. New England
  Journal of Medicine 3461554-1561 2002.
• Waselenko J, et.al. Medical management of the
  acute radiation syndrome Recommendations of the
  strategic national stockpile radiation working
  group. Annals of Internal Medicine 1401037-1051
  2004.

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