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Title: In-Depth Medical Management for Nuclear/Radiological/Conventional Terrorism Agents


1
In-Depth Medical Management for
Nuclear/Radiological/Conventional Terrorism Agents
  • Editorial Board
  • Fun Fong, MD, FACEP, Senior Medical Officer GA-3
    DMAT, ACEP Section of Disaster Medicine
  • Cham E. Dallas, Ph.D. , Professor Director,
    Interdisciplinary Toxicology Program and Center
    for Leadership in Education and Applied Research
    in Mass Destruction Defense, University of
    Georgia
  • Lorris G. Cockerham, Ph.D., DABFE, Lt. Col. (ret)
    USAF,
  • Former Division Chief, Armed Forces Radiobiology
    Institute

2
Overview
  • Nuclear Scenario Effects
  • Radiation Injury
  • Acute Radiation Syndrome
  • External Contamination
  • Internal Contamination
  • Summary

3
Potential Nuclear/Radiological Hazards in the U.S.
  • Simple Radiological Device
  • Dirty Conventional Bomb (RDD)
  • Improvised Nuclear Device (IND)
  • 1kT backpack bomb
  • Terrorist Nation Ballistic Missle Attack
  • 300 MT Bomb 100 mi over Kansas for EMP

4
Diversion of Nuclear Weapons
  • 50 - 100 1 kT Suitcase Nuclear Weapons
    Unaccounted For

The Threat of Nuclear Diversion. Statement for
the Record by John Deutch, Director of the
Central Intelligence to the Permanent
Subcommittee on Investigations of the Senate
Committee on Government Affairs, 20 Mar 1996.
5
Energy Partition
Standard Fission / Fusion
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
6
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9
Scenario Washington Mall
10
Effective Range For Blast Energy1 kT Weapon
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
11
Effective Range For Blast Energy1 kT Weapon
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
12
Effective Range For Thermal Energy1 kT Weapon
Infrared 700 m 7 cal / cm2 3o Burn 800 m 4 cal
/ cm2 2o Burn 1200 m 2 cal / cm2 1o Burn
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
13
Safe Separation Distances for Eye Injuries1 kT
Weapon
Detonation Altitude - 300 m 5.9 km Flash
Blindness 16.7 km Retinal Burns 46 km Daytime
Visibility 50.8 km Nighttime Flash Blindness
AFRRI, Medical Effects of Nuclear Weapons, Blast
and Thermal Effects Lecture, 1990.
14
Overview Conventional Weapon Terrorism
  • Not a Scenario weapons of choice world-wide
  • Small arms, manufactured ordnance, improvised
  • 5 criminal bombings daily in US
  • gtgt 99 of all terrorist attacks
  • Small Arms high- and low-velocity
  • Ordnance military weapons-grade
  • High-order explosives overpressure blast wave
  • Improvised Explosive Devices (IEDs)
  • Hand-made or extemporized, 75 low-order
    explosives
  • Minimal blast wave, more survivable burns
  • More injuries, fewer fatalities vs. ordnance

15
Overview Conventional Weapon Terrorism
  • Lessons learned from prior wars can not be easily
    applied
  • Terrorist weapons target non-combatant with
    varied demographics
  • Civilians have inconsistent preparation,
    protection, and access to acute- and long-term
    physical care and behavioral support
  • Similarities with radiological weapon injuries
    supports cross-preparedness for both
  • Ordnance over-pressurization injuries will be
    similar to injuries from nuclear devices
  • Both IEDs and nuclear devices can produce
    substantial thermal injuries
  • Dirty grossly contaminated wounds will be the
    rule rather than the exception

16
Take-home Message Local Preparedness for the
Conventional Weapon Threat
  • Avoid Primary Wound Closure
  • Delayed primary closure of contaminated wounds is
    critical for optimal outcome for individual
    victim
  • Establish Regional Systems of Trauma Care
  • Inclusive systems of organized and coordinated
    trauma care from scene to rehabilitation if
    needed.
  • Expedited emergency transfers and referrals
  • Critical for the optimal outcome of the community
  • Right patient to right hospital in right amount
    of time
  • Immediate benefit to the community

17
What is Fallout?
  • A complex mixture of over 200 different isotopes
    of 36 elements
  • 2 oz of fission products formed for each kT of
    yield.
  • Size lt 1 micron to several mm.

18
Early Fallout
  • That which reaches the ground during the first 24
    hours after detonation
  • Early fallout fraction 50-70 of total
    radioactivity

19
Delayed Fallout
  • Arrives after the first day, very fine invisible
    particles which settle in low concentrations over
    a considerable portion of the earths surface
  • 40 of total radioactivity

20
Bikini Atoll (1 Mar 1954)
  • 15 MT Thermonuclear
    Detonation Fallout
  • Population Affected
    300 in Public Domain
  • Int / Ext Contamination
  • Local Radiation Injury
  • Mild ARS
  • Thyroid Injury

21
Ionizing Radiation
Any Radiation Consisting of Directly or
Indirectly Ionizing Particles or Photons
22
Radiation Exposure Types
23
Acute Radiation Syndrome
  • Systemic Effects of Radiation
  • Prodromal
  • Hematologic
  • Gastronintestinal
  • Pulmonary
  • Cutaneous
  • Neurovascular
  • Combined Injury

24
Prodromal Component(0.5 - 3 Gy and higher)
  • Immediate Effect of Cell Membrane Damage
  • Mediated by Inflammatory Elements of Cell
    Destruction
  • Mediated Neurologically by the Parasympathetic
    System

25
Gastrointestinal Component(8 - 15 Gy and higher)
  • Symptoms
  • Mechanisms
  • Stem Cell Sterilization - 15 Gy

Parameter Brief Protracted
Exposure Exposure Threshold 8 18
D50 15 35
26
Respiratory Component(5 - 310 Gy and higher)
  • Sensitive from Highly Vascular Tissue
  • Endothelial Cells
  • Type II Alveolar Cell
  • Effect is dose-rate related
  • Pneumonitis
  • Fibrosis

27
Radiation Skin Injury
  • .75 Gy - Hair Follicles Change
  • 3 Gy - Epilation
  • 6 Gy - Erythema
  • 10 Gy - Dry Desquamation
  • 20 Gy - Wet Desquamation (Transepithelial
    Injury)

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33
Distribution of Injuries in aNuclear Detonation
Single Injuries (30 - 40)
Combined Injuries (65 - 70)
Data from Walker RI, Cerveny TJ Eds., Medical
Consequences of Nuclear Warfare, TMM
Publications, Falls Church, 1989. p 11.
34
Neurovascular Component
  • 1 - 6 Gy - Glial cell damage
  • 10 Gy - Morphologic changes
  • 10 - 20 Gy - Vascular lesions
  • 40 Gy - White matter necrosis
  • 60 Gy - Demyelinization

35
Summary of Deterministic Effects
Threshold Exposure (Deterministic Effects)
Threshold ED50 Dose Oligospermia (2
Yrs) 0.3 Gy 0.7 Gy Ovulation
Suppression (permanent) 0.6 Gy 3.5
Gy Vomiting 0.5 Gy 2
Gy Diarrhea 1 Gy 3 Gy Mortality from
Marrow Syndrome (minimal care) 1.5 Gy 3
Gy Mortality from Marrow Syndrome (supportive
care) 2.3 Gy 4.5 Gy Thyroiditis 2
Gy 12 Gy Skin - Erythema 3 Gy 6
G Skin - Dry Desquamation 5 - 20 Gy 20
Gy Skin - Wet Desquamation 12 - 20 Gy -
Skin - Necrosis 20 - 30 Gy - Mortality
from Pulmonary Syndrome Lethality 5 Gy 10
Gy Mortality from Gastrointestinal Injury 8
Gy 15 Gy CNS Incapacitation 6.5 Gy 17
Gy Acute Encephalopathy 5 - 8 Gy -
Source NUREG CR-4214
36
Hemogram(300 cGy TBI Exposure)
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38
Andrews Lymphocyte Nomogram
  • Absolute Lymphocyte Count over 48 hours
  • Confirms Significant Radiation Exposure

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
39
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40
Priorities in Combined-Injury Triage When
Radiation Doses are Known
Conventional Triage Changes in Expected
Triage (No Radiation Exists) Following
Radiation Exposure lt1.5 1.5 4.5
gt4.5 gt3 h 1 3 h lt 1 h
Immediate Immediate Immediate Expectant D
elayed Delayed Expectant Expectant Minimal
Minimal Expectant Expectant Expectant Expectan
t Expectant Expectant
Modified from Medical Consequences of Nuclear
Warfare, 1989, p. 39
41
Surgical Recommendations
  • Based on Immunocompetence Status
  • Life-Saving / Major Surgery within 36 - 48 h
  • Elective Procedures until 45 - 60 days Following
    Hematopoietic Recovery

Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds)
Treatment of Radiation Injuries, 1990, Plenum
Press, New York, p. 229
42
Hot Warm Cold Zones
Hot Zone
Warm Zone
Cold Zone
43
Terrorism Modification of Hot Zone
  • Larger Secured Hot Zone
  • Casualty Collection Point in Safe Area
  • Clean / Contaminated Staging Areas

44
Decontamination Equipment
  • Hospital Surgical Gown (waterproof)
  • Cap, Face Shield, Booties (waterproof)
  • Double Gloves (inner layer taped)
  • Pencil Dosimeters, TLDs, Survey Meters
  • Drapes
  • Plastic Bags
  • Butcher Paper
  • Large Garbage Cans
  • Radiation Signs and Tape

45
Decontamination Team
  • Provider (RN / PA / MD)
  • HP Tech
  • Decon Assistant (ED Tech)
  • Circulator
  • Scribe Nurse
  • HP Tech 2

Minimal
Outside REA
46
Decon Agents - 1
  • Dry Removal
  • Soap / Shampoo
  • Household Bleach 110 (Sodium Hypochlorite)
  • Waterless Cleansers

47
Decon Agents - 2
  • Povidone-Iodine
  • Lava Soap
  • Cornmeal / Tide 5050
  • Vinegar ( 32P ) or Club Soda
  • Toothpaste

48
When Do I Stop?
  • When No More Comes Off!
  • Stop Levels
  • 1 mR / h beta
  • 1000 dis / min alpha (air proportional counter w
    / 60cm2 Window)
  • If Committed Dose will Not Exceed 15 rem / yr to
    Skin
  • Isolate w / Bag Continue Decon Next Day

NCRP 65, p117
49
Mass Casualty Planning
  • Relies on Avenues of Self-Decon
  • More than Finding Shower Facilities

Label Clothing
Double Bag Clothing
Temporary Clothes
Towels
Return Clothes Bag
Male Victims
Bag Clothing
Shower 1
Shower 2
Shower 2
Shower 1
Bag Clothing
Female Victims
50
4 Golden Rules of Toxicology
(Adapted from Kent Olson, MD FACEP)
  • Treat the Patient before the Poison
  • Prevent or Reduce Exposure
  • Enhance the Elimination of the Agent
  • Consider Specific Adjuncts and Antidotes

51
Radiation Accidents can Pose Toxicology Problems
  • The Dose makes the Poison
  • Acute (Threshold Effects)
  • Long-Term Toxicity
  • ALI / MPBB
  • lt 1 ALI - No Treatment Necessary
  • 1 - 10 ALI - Consider Short-Term Tx
  • gt 10 ALI - Treatment

1
1Radiation Protection Dosimetry, Vol 41, No 1,
1992, p. 25
52
Internal Contamination Involves 4 Stages
  • Deposition Along Route of Entry
  • Translocation
  • Deposition in Target Organ
  • Clearance

53
Schematic Model of Radionuclide Uptake(After
Voelz)
Inhalation
Surface
Intake
Ingestion
Lung Clearance
Lung
Skin 1. Intact 2. Wounds
GI Tract
Lymph Nodes
Uptake
Blood
(Recycle)
Kidney
Deposition Sites
1. Whole Body 2. Bone 3. Liver 4. Thyroid
Excretion
Feces
Urine
54
RN Therapeutic Interventions
  • Plutonium / Transuranics - DTPA
  • Cesium - Insoluble Prussian Blue
  • Uranium - Alkalinization of Urine
  • Radioiodine - Radiostable Iodine
  • Tritium - Radiostable Water
  • Fission Products (Fallout) - Combination

55
DTPA Administered for Soluble 239Pu Within One
Hour
  • Retention
  • Organ Control DTPA Treated
  • Liver 14 0.47
  • Skeleton 57.0 5.9

56
Insoluble Prussian Blue Effective for Cs-137
  • Binds Ions in the Gut
  • Biological Half-Life Reduced to 1/3
  • Not Systemically Absorbed
  • Side Effects - Constipation, GI
    Upset at Higher Doses (20 g / day)

57
Uranium - Alkalinize Urine
  • 235U - 186 keV Gamma
  • Eff Half Time Depends on Solubility
  • At Normal Enrichment Levels, Primary Renal
    Toxicity
  • Maintain Urine pH 7.5 to 8
  • Use Bicarbonate tablets
    (Do not use Alka Seltzer from old texts!)
  • Use Supplimental KCl tablets to maintain alkaline
    diuresis

58
Iodine / Technetium - Block
  • 131I - Eff Half Life 7.6 days
  • 99mTc - Eff Half Life 1 day
  • Treat within 4 Hours
    ( Best 1 Hour Before Exposure! )
  • KI or NaI 300 mg tablet
  • SSKI (1 g / ml) - 5 - 6 drops in water
  • Povidone Iodine Theoretically Useful

NCRP Report No 65, p 83-86, 104
59
Tritium - Dilute
  • Beta Emitter - 5.7 keV (18 keV Max)
  • 2 Binds to Cellular Components
  • Essentially Occupies TBW Space
  • Force Fluids 3 - 4 L / day
  • Reduces Half-Time by 1/3 - 1/2

NCRP Report No 65, p 105-106
60
Radiostrontium Contamination Therapy
  • Al Phosphate (100 ml) Reduces Absorption as much
    as 85
  • Ba Sulfate
  • Na Alginate Inhibits Uptake by Factor 8 - 10
  • 10 g po
  • Ca Competes with Sr given po / IV
  • Ammonium Chloride po provides Synergy for max
    effect

61
Fission Products (Fallout)from Safety Series 47
  • Wounds Apply potassium rhodizonate (1 g)
  • Inhalation / Ingestion - Calcium Alginate (10 g)
  • Potassium Iodide (130 mg)
  • Prussian Blue (1 g)
  • DTPA (1 g)

Safety Series 47, Manual on Early Medical
Treatment of Possible Radiation Injury 1978, p.
131
62
Radiation Accident Medical Response - Individual
  • Data-Gathering
  • Resource Management
  • Contamination Control
  • Medical Care ( Compromised? )
  • Radiation Toxicity Issues
  • Contamination Issues
  • Systemic Issues
  • Toxicological Issues
  • Disposition Issues

63
Radiation Accident Medical Response - Large Scale
  • Establish Credibility of Incident
  • Health Physics Support for Dose Estimates
  • Contamination Precautions
  • Assess Patients for Systemic Effects
  • Determine Need for Decorporation Therapy
  • Record Patient Data for Follow-up

64
Lessons Learned
Dont fight the Americans without nuclear
weapons
Indian Chief of Staff - in reponse to a question
about the lesson of the Persian Gulf War
65
All that is Necessary for the Triumph of Evil
Is for Good Men to Do Nothing
66
References - 1
  • Walker RI, Cerveny TJ Eds., Medical Consequences
    of Nuclear Warfare, TMM Publications, Falls
    Church, 1989.
  • Brill AB Ed Low Dose Radiation Effects A Fact
    Book, New York, Society of Nuclear Medicine 1982
    p1-5.
  • Kathren RL Ed Principles and Application of
    Collective Dose in Radiation Protection, NCRP
    Report 121. Bethesda MD, National Council on
    Radiation Protection and Measurements, 1995 p65.
  • "Nonstochastic Effects of Ionizing Radiation,"
    Annals of the ICRP , ICRP Publication 41. New
    York, Pergamon Press, 1984p.2.
  • After REAC/TS Videotape - Hospital Management of
    Radiation Accidents, Oak Ridge, TN, Oak Ridge
    Associated Universities, 1980.
  • Wheater RH Ed A Guide to the Hospital Management
    of Injuries Arising from Exposure to or Involving
    Ionizing Radiation. Chicago, American Medical
    Association, 1984 pp.4-5.

67
References - 2
  • Mettler FA, Ricks RC Medical Management of
    Radiation Accidents. Contemp Diag Radiol
    1982,58p1.
  • Agency for Toxic Substances Disease Registry
    (ATSDR). Managing Hazardous Materials Incidents,
    Vol. I-III. US Dept. Of Health and Human
    Services, 1992.
  • Mettler FA, Kelsey, Ricks RC Eds Medical
    Management of Radiation Accidents. Boca Raton,
    FL, CRC Press, 1990.
  • The Radiological Accident in Goiânia, Vienna,
    IAEA, 1988 p.2.
  • Saenger, E.L., Andrews, G.A., Linnemann, R.E.,
    Wald, N., Radiation Accident Preparedness,
    Medical and Managerial Aspects,
    Science-Thru-Media, Inc., New York, NY, 1981.
  • Nishiyama H, Lukes SJ, Saenger EL Low-Level
    Internal Radionuclide Contamination Use of Gamma
    Camera for Detection. Radiol 1984 1501, pp
    235-40.

68
References - 3
  • Nishiyama H, Saenger EL, Grossman LW, Lukes SJ.
    Accidental Cs-137 Contamination. Radiol 1985
    1542, pp 513-7.
  • Voelz G Ed Management of Persons Accidentally
    Contaminated with Radionuclides, NCRP Report 65.
    Bethesda MD, National Council on Radiation
    Protection and Measurements, 1980.
  • Gerber GB, Thomas RG Eds"Guidebook for the
    Treatment of Accidental Inernal Radionuclide
    Contamination of Workers" Radiation Protection
    Dosimetry (1992) 411.
  • Barabanova A. REAC/TS Newsletter. Winter 1992,
    Oak Ridge, TN, p 1-2.
  • Andrews GA, Auxier JA, Lushbaugh CC, "The
    Importance of Dosimetry to the Medical Managment
    of Persons Accidentally Exposed to High Levels of
    Radiation," in Personnel Dosimetry for Radiation
    Accidents, International Atomic Energy Agency
    (IAEA), Vienna, pp 3-16, 1965.

69
References - 4
  • Roberts GB, Col - Nuclear Weapons-Grade Fissile
    Materials - The Most Serious Threat to US
    National Security Today? Airpower Journal,
    Special Edition 96
  • Academy of Health Sciences, US Army Medical
    Aspects of Nuclear Weapons and Their Effects on
    Medical Operations subcourse MED447, Jun 1990
  • Aldridge JP The Role of Health Physicists in
    Contemporary Radiological Emergency Response
    Masters Thesis, Georgia Tech, Mar 1998
  • The Threat of Nuclear Diversion. Statement for
    the Record by John Deutch, Director of the
    Central Intelligence to the Permanent
    Subcommittee on Investigations of the Senate
    Committee on Government Affairs, 20 Mar 1996.

Version 1.0 - 18 Nov 1998
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