Radiation Emergencies Charles Stewart MD EMDM Fears n

Radiation Emergencies Charles Stewart MD EMDM

Fears n Media hype 1000’s will die n Cancer n Mutations n n Special interest groups n Terrorists

Real threats Irradiation n Contamination n Incorporation n

Real threats n Is the radiation exposure continuing? n Irradiated patients pose no threat to the EMS system or the provider. n n A patient who has an x-ray or CT does not pose a threat to EMS Continued irradiation is a threat to the provider Gamma emitter or x-ray device n Establish a safe exposure n

Real threats n Is the patient or scene contaminated Contaminated patients can hurt you n Leave the contaminated scene. n n Don’t bring anything with you.

Irradiation n The patient has been subjected to a high flux of gamma rays or neutrons n This patient is not usually radioactive. . . An exception occurs with high neutron flux n Gold and some other materials absorb neutrons and become radioactive n n If irradiation continues, a tolerable dose for medical providers must be ascertained

Exposure. . Irradiation n Dose depends on. . . Duration n Distance n Defenses (shielding) n

Contamination A radioactive material is on the skin, tools, or clothes. n This radioactive substance requires removal or it will continue to damage tissue. n n Decontamination

Incorporation Radioactive material is inhaled, ingested, or contaminates an orifice or open wound. n The radioactive material can cause extensive cellular damage. n n Removal of the material may be an interesting problem. .

A few definitions n Ionizing radiation Electromagnetic radiation that “knocks off” electrons is ionizing n This happens at about 100 electron volts n n Particulate radiation

Ionizing Radiation Any radiation consisting of directly or indirectly ionizing particles or photons. Alpha Beta Gamma Neutron 1 m Concrete 37

α Radiation n Alpha radiation A helium nucleus (2 protons, 2 neutrons) Easily stopped because the mass of the particle is so high

α Radiation n Alpha radiation Alpha particles do not penetrate skin If incorporated, alpha particle emitters will cause significant damage

β Radiation n Beta radiation An electron ejected at high speed The charge and energy of the beta particle depends on the nuclear reaction that occurred.

β Radiation n Beta radiation Beta emitters represent both an internal and external threat to the patient (and to you!)

γ n Radiation Gamma radiation n Exactly like X-rays - from added external energy n Gamma rays - from nuclear decay n n Follows all laws of physics that pertain to light.

Inverse square law n Electromagnetic radiation (EMR) decreases with the square of the distance from the source As distance increases by 2, intensity falls off by 4 • This is why ‘distance’ is part of your protection.

Neutron radiation n Nuclear particles without a charge A product of nuclear fission n Make other materials radioactive by capture of the neutron and subsequent decay of the new isotope n

Protons n Nuclear particles with a positive charge n A product of nuclear fission Van Allen belt n Particle accelerators n n Not a problem for EMS providers

Radiation measurement n “Flux measurement” Measures the flux of the moment n ‘Geiger counter’ (beta and gamma survey) n Scintillation counter (alpha survey) n n Absorbed dose measurement n Dosimeters

Radiation measurement n Dosimeters n Film badge Permanent record n Fog with temperature and humidity n n Ionization meter n n Sensitive to impact Thermoluminescent dosimeter n No permanent record

A few definitions. . n RAD Radiation Absorbed Dose n Deposition of 100 ergs of radiation per gram of tissue. n

A few definitions. . n R Roentgen Deposition of 87 ergs of radiation per gram of air.

A few definitions. . n REM Roentgen Equivalent for Mammals RBE x RAD dose = REM (RBE = Relative Biological Effectiveness).

Maximum exposure permitted n Over age 18 n 5 REM / year for each year over 18 150 REM 1 time exposure in lifetime ever. n 25 REM 1 time exposure in a year. n

Radiation bioeffects History n Perspective n Acute effects n Long term effects n

Acute effects of radiation n Localized n n Skin erythema Whole body Nausea and vomiting n Malaise and fatigue n Fever n Hematologic changes n

Biological effects n Clinical dosimeters n n n Nausea and vomiting Lymphocyte counts Skin erythema

Skin erythema Varies with the type of radiation n Akin to sunburn n Rapid development may indicate a severe exposure n n Not a particularly good dosimeter

Nausea and vomiting n Somewhat dose related Increased dose means quicker onset n Absence of nausea implies minimal exposure n n Severity of symptoms varies immensely n Poor correlation with dose

Nausea and vomiting Nausea alone @ 5 or more hours - mild exposure n Vomiting @ 1 -5 hours - moderate exposure n Vomiting within 1 hour - severe exposure n Vomiting within minutes - probably lethal n

Lymphocyte count Best biological dosimeter n < 500 lymphs/cc @ 48 hours is BAD n > 1200 lymphs/cc @ 48 hours is good. n

Lymphocyte count n Lymphs/cc @ 48 hours 1500 or more - good prognosis n 1000 - 1500 - moderate exposure n 500 - 1000 - severe exposure n 100 - 500 - very severe exposure n less than 100 - uniformly lethal n

Biological effects n Whole body exposure n n Mild exposure Hematopoietic syndrome GI syndrome Neurovascular syndrome

Mild exposure Less than 200 rads n Symptoms n Nausea and vomiting n Possible hair loss n n Prognosis - excellent n Use contraception for 6 months

Hematopoietic syndrome 200 - 1000 rads n Symptoms n Nausea and vomiting n Diarrhea n Pancytopenia n Bone marrow suppression n n Prognosis - good to poor

Gastrointestinal syndrome 1000 to 5000 rads n Symptoms n Intractable nausea and vomiting n Bowel necrosis n Bone marrow suppression n n Prognosis - poor

Neurovascular syndrome 5000+ rads n Symptoms n n Prodromal nausea and vomiting n Rapid onset Listlessness n Tremors and ataxia n Convulsions n n Prognosis - hopeless

Where can we intervene. . n n Intermediate exposure High level exposure

Radiation exposure treatment n No acute therapy n n Some pre-exposure treatment available Radiation injury team concept Protection from infection n Control of bleeding n Supportive therapy n

Intermediate Exposure 100 - 400 rads n 5 -50% death (untreated) n Bone marrow suppression n Nausea, vomiting and diarrhea n n Treatment helpful

High level exposure 400 - 1000 rads n Combination of GI and hematologic syndromes n Maximum lifesaving effort required n About 1 week to arrange the consults n Laminar airflow “clean” rooms n Marrow transplant n

Long term effects Cataracts n Shortened life span n Genetic effects n Cancers n Leukemia n Bone cancer (incorporation) n Lung cancer (incorporation) n

Long term effects n Dose related The minimum dose has not been established n Lower incidence of disease ? ? n Lowered resistance to infection n

Exposure. . Measure the type and amount of the radioactive source. n If the source cannot be shielded or removed, then the allowable radiation exposure times must be calculated. n

Decontamination Starts at the scene n Treat patient first n Medical therapy n Remove contamination n Wash patient n

Decontamination n Contamination can be reduced remarkably by simply removing the clothing

Decontamination preparation n Disposable equipment Makeshift ambulances n Litters and gurneys n n Nondisposable equipment Cover all equipment with plastic n Remove everything you can n Don’t use expensive vehicles n

Decontamination preparation n Establish a secured area Controlled access n ? Cover with plastic sheeting n Showers with a holding tank n No “dirt” to leave the area n

Decontamination agents Soap and water n Phosphate detergents n n Tide EDTA or DPTA n Potassium permanganate and sodium bisulfate n

Establish protocols n n n Train

Treat the patient first Keep in mind that the patient is not radioactive. . . n You have to protect yourself from contamination not from the patient. n

PROTECT yourself n Wear a dosimeter Dosimeters are not protective! n They just tell you how much you got. n

Distance *Increasing distance will decrease the dose by a factor calculated by the inverse square law

Decontamination n Estimates The amount remaining n The amount removed n n Save all fluids/stools/tissues n If the patient excretes it, uses it, or loses it. . . save it.

Decontamination n Flush. . . don’t scrub n Scrubbing damages the skin May use soap or decontamination solutions n Decontaminate highest radiation areas first. . if possible n

Decontamination n May be augmented by. . . Prevention of uptake n Enhancement of excretion n n Check with your friendly radiation biophysicist for further details! Chelation n Blocking n Isotope dilution n

Decontamination n Hair Shower n Cut n Do not shave n

Decontamination n After decontamination. . Bag it. Patient clothing n Dressing materials n Metal items n Tools n n Label: Radioactive / do not discard

Decontamination n Staff Shower n Fresh clothing n Monitor for contamination n

Special problems Wounds n Inhalation n Ingestion / splash n

Wounds n Cover with a self-adhesive surgical drape n Prevents recurrent contamination Then decontaminate / irrigate n Surgical debridement n

Inhalation n Half will be returned to pharynx n Do not swallow Save sputum n ? ? lung lavage n

Ingestion / splash n Irrigate Mouth n Eyes n Ears n ? Genitalia n n Save the irrigation for analysis

Prophylaxis Evacuation from area n Agents to decrease uptake n Iodine n Fluids n ? ? depends on contaminants n

Prophylaxis For radioactive iodine contamination a stable isotope of iodine is administered. . . SSKI n For radioactive tritium, a stable isotope of hydrogen is used. . . water n

Prophylaxis n Chelating agents may be used if the patient has internal contamination with any of the transuranic elements n Plutonium, uranium, neptunium, americium. . ect.

Exposure protective zones

Electromagnetic Pulse Seen with nuclear weapons Effects ALL unshielded electronics May render computers unusable Auto ignition CT Monitoring devices Phones, radios and other communications 74

Electromagnetic Pulse Operation ‘Starfish Prime’ 1962 Killed power in Hawaii 800 miles away Worst with airburst > 30, 000 feet Still bad with ground burst Needs to be studied. Faraday cage may be sufficient 75