Management of Radiation Accident victim

Physician and Hospital Responses to Radiological Incidents
By: Robert E Henkin, MD, FACNP, FACR
Professor of Radiology
Director, Nuclear Medicine

Robert H. Wagner, MD, MSMIS
Associate Professor of Radiology
Section on Nuclear Medicine/Department of Radiology
Loyola University
Maywood, IL

Experience of Authors

* Dr Wagner trained at Loyola and the DOE in Oak Ridge - Radiation Emergency Assistance Center/Training Site (REAC/TS)
* Drs Wagner and Henkin co-wrote the original manual for hospital management that was used by the State of Illinois
* Dr Wagner is has been consultant for Radiation Management Consultants since 1990 and trains and drills approximately 5 hospitals/year until 1998. Developed the plan for radiation accidents at Loyola

* Dr Henkin is a member of the Radiation Information Network of the American College of Nuclear Physicians
* Drs Wagner and Henkin are Board Certified by ABNM

Radiation and Terrorism
* Public perceptions of radiation
* The good news and the bad news
* Terrorism scenarios
* Types of radiation injuries
* Hospital response to radiation incidents

The Public Perceptions
The Bad News
* Almost nothing creates more terror than radiation
o It’s invisible to touch, taste, and smell
o Most people have unrealistic ideas about radiation
o Most physicians don’t even understand it
* The objective of the terrorist is as much or more panic than it is physical harm

The Good News

* Nuclear Medicine and Radiation Therapy professionals are well trained in the fundamentals of radiation
* Respect radiation, but do not fear it
* Understand what radiation can and cannot do
* There have been industrial radiation accidents that we have learned much from
* It is easily detected in contrast to biological and chemical agents

What Can We Expect?
* Radiological/Nuclear Terrorism
o A true nuclear detonation
o A failed nuclear detonation
o Radiation dispersal device
* Power Plant attacks

A Nuclear Detonation
* Least likely scenario (fortunately)
* Most likely from a stolen nuclear weapon
* Results would be devastating, both psychologically and in terms of damage

The Unthinkable
* Effects of a 1 megaton detonation in Chicago
o 30% of all hospitals destroyed in 50 mile radius
o Transportation and infrastructure compromised
o Emergency vehicles and professionals unable to respond
o Walking wounded with burns may have been fatally irradiated – unknown effects for days to weeks

Radiological Devices
* Not a “nuclear explosion”
* Consists of a bomb designed to disperse radioactive materials in air and water
o Designed to create panic
o Difficult to clean up, material spreads
o Biological effects may take years to appear
* “A Dirty War” HBO/BBC Films 2005

Failed Nuclear Detonation
* Most likely from an improvised nuclear device (IND)
* Beyond the scope of an individual terrorist – would need 10-15 people
* Greatest barrier is availability of weapons grade material
* Would create a critical mass or explosion, but not the same degree as a true nuclear detonation.
* Nuclear material needs to stay in contact for a longer period of time to allow flux to form

Radiological Dispersal Device
* The most likely scenario
* Simply a bomb loaded with radioactive materials
* Uses stolen hospital or industrial materials
* Acute effects are limited to psychological and traumatic injury
* Long term effects would be on contamination of large areas
* Huge expense for cleanup

Chernobyl Comparison
Co-60 food irradiation pencil in a RDD
Radiation Levels
* Inner ring – same as permanently closed around Chernobyl
* Middle ring – same as permanently controlled area around Chernobyl
* Outer ring – same as periodically controlled zone around Chernobyl

Cancer Deaths
Co-60 food irradiation pencil in a RDD

Increase risk of cancer
* Inner ring – 1 per 100 people
* Middle ring – 1 per 1,000 people
* Outer ring – 1 per 10,000 people

What do I Need to Know?
* Fundamental Radiobiology
o Radiation effects are delayed
o Burns if you see them are chemical or thermal in origin.
o Dose limits
* Key personnel
* Contamination control
* Focus on the medical problems

1. Radiation - Fundamentals
* Types of Radiation
* All radiation is part of the electromagnetic spectrum
* This spectrum ranges from infrared through radio/TV transmission and beyond
* Ranges of common exposures

Radiation - Definition
* Energy that is transferred through space
* Examples
o Microwaves
o Radio waves
o Visible Light
o Nuclear radiation (Alpha, Beta, Gamma)
o X-Radiation

Effectiveness of a Lead Apron
Isotope
Percent Stopped
Don’t wear one during an accident!
Measurement Units
* Roentgen – radiation dose measured in air
* Radiation Absorbed Dose (RAD) – a pseudo biologic unit
* Gray – 100 RADS
* Radiation Effective Dose Man (REM) – a biologically corrected dose
* Millrem - .001 REM

We Live in Radioactive World
* Naturally occurring radioactive elements abound
* Cosmic radiation
* Man-made radiation accounts for less than 1% of total radiation
* Average human dose 150 to 170 mR/year
* Dose varies by geographic location

Low Level Radiation 500 - 5,000 mR
High Level Radiation 5- 50 R
Decrease In Sperm Count (transient)
High Level Radiation 500- 5,000 R
LD 50/60 (Estimated With Intensive Support - Possible BMT)
Neurological syndromes
Typical Therapy for Cancer (Divided Doses)
Contamination In Perspective

Radiation Injuries
* Dependent on dose
o Non-Stochastic effects (Dose related)
+ Decrease in sperm count – 15 R
+ Hematological effects – 150 R
+ Gastrointestinal effects, epilation – 300 R
+ CNS effects – 1000 R
o Stochastic Effects (Non-dose related)
+ Increase in cancer risk
+ Genetic abnormalities
Burns From Radiation
* Generally do not appear immediately
* Healing is extremely poor
* Not likely to be seen in the acute setting

2. Introduction to Radiobiology
* Mechanism of Cellular Injury
* Comparison of Tissue Sensitivities
* Dose Effect Relationships
* Genetic Effects
* Carcinogenic Effects
* Embryonic and Fetal Effects
* How to Limit Exposure
Mechanism of Cellular Injury
DNA STRAND
Biological Effects of Radiation Depend on:
* Total Dose Received
* Rate of Exposure
* Total or Partial Body
Radiation In Perspective
Genetic Effects
Radiation In Perspective
Carcinogenic Effects
Embryonic and Fetal Effects
Methods of Decreasing Exposure to Staff

* Time – linear relationship
* Distance – geometric relationship
* Shielding – half value layers.....

What’s My Role?

* Learn the institutional protocols
* Do not wait for the disaster to train
* Know who and where your resources are
* Do not contribute to panic with uninformed statements
* Refer questions to the scene commanders

Management of Radiation Accident victim