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Nuclear Disasters and Children

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Title: Nuclear Disasters and Children


1
Nuclear Disasters and Children
  • Phillip Jacobson, M.D.

2
Possible Situations
  • Dispersing of radioactive substances without
    explosives
  • Dirty Bomb
  • Attack on nuclear reactor (or accident)
  • Detonation of a nuclear weapon
  • Mettler, FA etal. NEJM 20023461554-1561

3
Possible SituationsDispersal of Radioactive
Substances
  • Minimally Radioactive
  • Radiopharmaceutical agents
  • Research isotopes
  • Highly Radioactive
  • Industrial Radiographic Devices
  • Cobalt-60
  • Cesium-137
  • Iridium-192

4
Possible SituationsDirty Bomb
  • The use of conventional explosives to disperse
    radioactive substances. (Radiation Dispersion
    Device or RDD)
  • Health problem would be restricted to a few city
    blocks
  • Purpose would be to cause greater fear and panic

5
Possible SituationsAttack of Nuclear Power Plant
  • A breach in the reactor core would have immediate
    health concerns for people nearby.
  • Large amounts of radioactive iodine would be
    released exposing people at great distances,
    causing long term health effects

6
Possible SituationsDetonation of Nuclear Weapon
  • Destructive effect would be air blast as well as
    thermal radiation
  • Extent of damage depends on size and strength of
    weapon
  • Looking at fireball from several miles can cause
    temporary or permanent blindness

7
History
  • Hiroshima, Nagasaki 1945
  • Marshall Islands 1954
  • Chernobyl 1986
  • Goiania 1987

8
History of Nuclear EventsHiroshima
  • 15 kiloton TNT
  • 66,000 killed
  • 69,000 injured
  • 255,000 exposed
  • Avalon Project, Yale Law School 2002chapter 10

9
History of Nuclear EventsNagasaki
  • 22 kiloton TNT
  • 39,000 killed
  • 195,000 exposed

10
History of Nuclear EventsMarshall Islands
  • Nuclear weapons testing on Bikini Island
  • 32 pediatric patients exposed
  • 4 children developed thyroid cancer
  • 1 child developed leukemia
  • Merke DP, etal In Guzelian PS. Similarities
    and Differences Between Children and Adults
    Implications for Risk Assessment. Washington, DC
    International Life Science Institute
    1992139-149

11
History of Nuclear EventsChernobyl
  • Nuclear power plant meltdown
  • 120 million Ci released
  • 21,000 km2 contaminated in Ukraine, Belarus and
    Russia
  • 17,000,000 exposed to excess radiation
  • 2.5 million children lt 5 y/o age exposed
  • 135,000 people permanently evacuated
  • Likhtarev IA, etal. Health Phys.2002 82290-303

12
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13
History of Nuclear eventsGoiania, Brazil
  • Radioactive Cs (1400 Ci)
  • 250 people exposed
  • 4 people died of acute radiation sickness
  • Thousands of ER visits
  • Collins DL, etal. Behav Med. 1993 18149-157

14
General Principles
  • Ionizing Radiation High frequency energy
    emitted from an unstable atom trying to achieve
    stability.
  • Damages DNA
  • Disrupts chemical bonds
  • Produces free radicals
  • Moulder JE. Radiat Res.2002 158118-124

15
General PrinciplesTypes of Radiation
  • Electromagnetic Energy
  • Gamma Rays
  • Short wavelength, high energy
  • Very penetrating
  • Travels many meters in air
  • Easily penetrates clothes and biological tissue
  • X-rays
  • Longer wavelength than gamma, less energy
  • Very penetrating

16
Types of RadiationParticulate
  • Alpha Particles
  • Composed of 2 neutrons and 2 protons
  • Easily stopped by skin and clothes
  • Only Inhalation or ingestion causes damage
  • Beta Particles (ve electrons)
  • High energy electrons emitted from nucleus
  • Penetrate a few mm into skin.

17
Types of RadiationParticulate
  • Neutrons
  • Highly penetrating
  • 20x more damaging than gamma rays
  • Only emitted during nuclear detonation

18
General Principles
  • Senses cannot detect radiation.
  • Individuals cannot see, hear, smell, taste or
    feel it.
  • Lethal dose of radiation could be delivered
    without realizing it.

19
General Principles
  • Radiation hazard is related to
  • Strength of source of radioactivity
  • Total radioactivity absorbed per volume of tissue
  • Exposure and Absorption depends on
  • Time
  • Dose
  • Distance
  • Shielding

20
General PrinciplesMeasurements
  • Rad (Radiation absorbed dose) 0.01 J/Kg
  • Rem (Radiation equivalent man) Biological damage
    from 0.01 J/kg of x-rays
  • Gray (Gy) 1 J/kg 100 rad
  • Sievert (Sv) 100 rem

21
General PrinciplesTypes of Injury
  • Exposure to external radiation
  • Contamination with radioactive material
  • Incorporation of radioactive material into body
    tissues
  • Trauma

22
General PrinciplesTypes of Injury
  • Contamination, 2 types
  • External radioactive materials (solids,
    liquids, gas) released in atmosphere and
    precipitating down. Exposed surfaces of body
    become contaminated.
  • Internal Inhalation, ingestion, exposed wounds

23
General PrinciplesTypes of Injury
  • Incorporation Uptake of radioactive materials
    by organs, tissue and cells. Distribution
    depends on physical and chemical forms and
    solubility and cell type

24
General Principles Vulnerabilities of Children
  • Higher Minute Ventilation
  • Closer to ground
  • Thinner, more delicate skin
  • Proportionately greater body S.A.
  • Lower intravascular volume

25
General Principle Vulnerabilities of Children,
Short Term
  • Contaminated breast milk
  • Contaminated cows milk
  • Transplacental transmission of radionuclides1
  • Thyroid glands concentrate more iodine2
  • 1. Merke DP in Similarities and difference
    between Children and Adults Implications for
    Risk Assessment. Washington, DC International
    Life Sciences Institute 1992139-149
  • 2.Young RW. Pharmacol Ther. 19983927-32

26
General Principles Vulnerabilities of Children,
Long Term
  • Longer Life ( time for radiation effects)
  • thyroid cancer1
  • leukemia1
  • breast cancer2
  • severity and longevity of psych and behavior
    problems3
  • 1. Yu, CE Pediatr. Ann 200332169-176
  • 2. AAP Pediatrics 1998101717-719
  • 3. Pynoos RS Child Adolesc Clin North Am.
    19987195-210

27
Biological EffectsMechanism of Radiation Damage
  • Direct 20
  • Chromosomal breaks occur directly from radiation
    energy
  • Indirect 80
  • Body water ionized with H and OH- which cause
    DNA damage
  • Biological expression at the cellular level can
    take seconds to hours

28
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29
Clinical Effects
  • Trauma
  • Air Blast
  • Flying or falling debris
  • Burns
  • Thermal Radiation
  • Acute Radiation Syndrome
  • National Council on Radiation Protection and
    Measurements. Management of Terrorist Events
    Involving Radiactive Material 2001

30
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31
Acute Radiation Syndrome
  • Factors for time of onset and degree of severity
  • Dose
  • Dose rate
  • Penetrating radiation
  • body exposure

32
Acute Radiation Syndrome (ARS)Definition
  • The acute radiation syndrome is a broad term
    used to describe a range of signs and symptoms
    that reflect severe damage to specific organ
    systems and that can lead to death within hours
    or up to several months after exposure.
  • National Council on Radiation Protection and
    Measurements. Management of Terrorist Events
    Involving Radioactive Material 2001

33
Acute Radiation SyndromeGeneral Considerations
  • Cell death can occur by impairment of cell
    division (without killing the cell outright)
  • Organ systems with most rapidly dividing cell
    lines and least differentiated are most
    vulnerable (GI and Hematopoietic)
  • The higher the radiation dose, the more rapid
    onset of symptoms

34
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35
Acute Radiation SyndromeGeneral Principles
  • LD50/60 is about 2.5 to 4.5 Gy
  • lt 0.7 Gy unlikely to cause ARS
  • 4 phases of ARS
  • 1. Prodrome
  • 2. Latency
  • 3. Illness
  • 4. Recovery or Death

36
Acute Radiation Syndrome
  • Prodrome
  • Occurs minutes to hours after exposure
  • NV, anorexia
  • Can last for 2 to 4 days
  • Onset within 2 hrs is bad prognostic sign

37
Acute Radiation Syndrome
  • Latent Phase
  • Only occurs with low doses (2 3) Gy
  • Onset is 2 4 days
  • Lasts 2 4 weeks
  • in lymphocytes, leukocytes and platelets

38
Acute Radiation Syndrome
  • Illness Phase Signs and Symptoms
  • N V, Diarrhea
  • Fatigue
  • Infection
  • Shock

39
Acute Radiation SyndromeHematopoietic Syndrome
  • in lymphocyte line, granulocytes, platelets,
    reticulocytes
  • Anemia
  • Hemorrhage
  • Infection
  • Impaired wound healing
  • Lymphocyte count at 48 hrs. correlates well with
    dose received

40
Acute Radiation syndromeGI Syndrome
  • Damage to epithelial lining of intestine
  • N V, diarrhea
  • Hypovolemia, electrolyte imbalance
  • Translocation of Bacteria
  • Opportunistic infection
  • Occurs at doses of gt 800 rad

41
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42
Acute Radiation SyndromeCerebrovascular Syndrome
  • Capillary leaks in vessels of brain
  • Cerebral edema
  • Confusion, disorientation, convulsions, coma,
    hyperthermia.
  • No recovery. Certain death within days
  • Only occurs at doses of gt 30 Gy

43
Acute Radiation SyndromeSkin Involvement
  • Can arise from local contamination
  • Type of skin lesion is a good indicator of dose
  • Epilation lt erythema lt dry desquamation lt wet
    desquamation lt necrosis

44
ManagementOrganizational
  • Integrated fed, state, local PH response
  • e.g. Emergency broadcasting, evacuation,
    sheltering, antidote therapy
  • Disaster command teams for each hospital
  • e.g. Supplies, staffing, safety of health care
    workers, communication

45
ManagementMedical
  • ABC
  • Trauma and burns are emergencies that must be
    dealt with first
  • Radiation exposure is not an immediately life
    threatening emergency
  • Decontamination

46
ManagementDecontamination
  • ER divided into clean and dirty area
  • Remove clothing (if not already done)
  • Shower thoroughly (soap and water)
  • Universal precautions of health care workers
    (hcw)
  • HCW should wear dosimeters.
  • HCW should be rotated frequently to avoid toxic
    exposure

47
ManagementLab Tests
  • Nasal and throat swabs, urinary, fecal, skin and
    wound samples to identify internal contamination
    of radioactive materials
  • CBC Q4-6 (watch lymphocyte and neutrophil counts
    carefully)
  • Cytogenetic analysis of lymphocytes
  • Na24 identification
  • Managing Radiation Emergencies
    www.orau.gov/reacts/medical.htm

48
ManagementOngoing
  • Administer antidote
  • Support fluid and electrolytes
  • Rigorous infection control and treatment
  • Transfusions, hematopoietic growth factors
  • Continued support of trauma and burns

49
ManagementAntidotes
  • Potassium Iodide (KI) for Thyroid Protection
  • 131I is a common byproduct of nuclear disasters
  • 131I cause thyroid cancer
  • KI prevents thyroid uptake of 131I
  • KI blocks 90 of 131I uptake when given within 1
    hr of exposure
  • Linneman RE. JAMA 1987258637-643

50
ManagementAntidotes, KI
51
Antidotes
52
Long Term Effects
53
Psychological Effects
  • Developmental Regression
  • Chronic fear and anxiety
  • Nightmares, sleep problems
  • Altered play, social withdrawal
  • Direct correlation with parents response
  • Warwick MC. Mo Med. 20029915-16
  • AAP Work Group on Disasters. Psychosocial Issues
    for Children and Families in Disasters. US Dept
    of HHS 1995
  • Sugar M. Child Psychiatr Hum Dev. 198919163-179

54
SummaryNuclear Disasters
  • Radiation energy is particulate and
    electromagnetic
  • We have increased risk of nuclear terrorism
  • Children are more vulnerable
  • ABCs trauma and burns first priorities
  • Exposure depends on time, dose, distance and
    shielding
  • Decontamination

55
Summary Nuclear Disasters
  • Acute Radiation Syndrome
  • Hematopoietic and GI most prominent
  • Antidotes (e.g. KI)
  • Long Term Effects (leukemia, cancer)
  • Psychological Effects (most prevalent problem)
  • Many would die. Many could be saved
  • Were not adequately prepared.
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