1

Medical Response to Nuclear and Radiological

TerrorismStevan Cordas DO MPH

Clinical Associate Professor TCOM/UNTHSC

2

• Consultant Texas Department of Health - WMD Education

• Consultant American Osteopathic Association – Washington Bureau – WMD

• Certified Occupational Medicine (Toxicology)

• Trained in Cleveland Institute of Nuclear Medicine

• Former U.S. Army Medical Corps• Steering Committee - Medical Reserve

Corps (Dallas, Tarrant, Denton and Collins County)

• Author of WMD – AOA DO-online for CME

3

What Is Radiation?

Radiation is energy transported in the form of particles or waves.

4

Exposure Vs. Contamination

Exposure: irradiation of the body absorbed dose (Gray, rad)

Contamination: radioactive material on patient (external)or within patient (internal)

5

6

Penetration Abilities of Different Types of Radiation

Alpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concreteor less than an inch of lead

RadiationSource

NeutronsStopped by a few feet of concreteCDC

7

Measure of

Amount ofradioactive material Ionization in air

Absorbed energy per mass

Absorbed dose weighted by type of radiation

Radiation UnitsQuantity

Activity

Exposure

Absorbed Dose

Dose Equivalent

Unit

curie (Ci)

roentgen (R)

rad

rem

8

A Gray (Gy)

The Gray (Gy) is a unit of absorbed dose and reflects an amount of energy deposited into a mass of tissue (1 Gy = 100 rads). In this lecture, the absorbed dose we are referring to is that dose inside the patient's body (i.e., the dose which is normally measured with personal dosimeters). For most purposes, one rem equal one rad. One mrem is one thousandth of one rem and is a common means of expressing radiation.

9

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 870 mrem

Annual radiation worker dose limit 5,000 mrem

Heart catheterization (skin dose) 45,000 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 mremRadiation therapy (localized & fractionated) 6,000,000 mrem

10

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 their skin or inside their body (e.g., inhalation, ingestion or wound contamination)

11

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-LifeTime required for the body to eliminate half of the radioactive material (depends on the chemical form)

12

Effective Half-life

The net effect of the combination of the physical & 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%

13

Potential Types of Weapons

• Stolen nuclear material from a hospital, industry, university, power plant or disposal facility

• Creation of a “dirty bomb” Generally thought to be the most likely scenario.

• Nuclear detonation from a device.• Nuclear reactor sabotage

14

Hypothetical Suitcase Bomb

Chairman Dan Burton Committee – Demonstration of example “suitcase nuke” made from US nuclear shell

CDC

15

Radionuclide Half-Life Activity Use

Cesium-137 30 yrs 1.5x106 Ci Food Irradiator

Cobalt-60 5 yrs 15,000 Ci Cancer Therapy

Plutonium-239 24,000 yrs 600 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

Examples of Radioactive Materials

16

Examples of Radioactive Materials

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

17

Trinity Site N.M. 5:29 AM July 16th 1945

18

Types of Radiation Hazards• External Exposure - whole-body or partial-

body (no radiation hazard to EMS staff)

• Contaminated - – external radioactive

material: on the skin– internal radioactive

material: inhaled, swallowed, absorbed through skin or wounds

ExternalExposure

InternalContamination

ExternalContamination

19

Scope of Event

Event Number of Deaths Most Deaths Due to

RadiationAccident

None/Few Radiation

RadioactiveDispersalDevice

Few/Moderate(Depends on

size of explosion &proximity of persons)

Blast Trauma

Low YieldNuclear Weapon

Large(e.g. tens of thousands inan urban area even from

0.1 kT weapon) Radiation Exposure

Blast Trauma Thermal Burns

Fallout (Depends on Distance)

20

Map of Our Nuclear Power Plants

21

Facility Preparation• Activate hospital plan

– Obtain radiation survey meters

– Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics)

– Plan for decontamination of uninjured persons

– Establish triage area

22

Develop Radiological Response Team

• Team Coordinator (leader)

• Emergency physician(s)

• Nurse (s)• Triage Officer• Administrator• Radiation Safety

Officer

• Maintenance• Public Information

Officer• Security• Laboratory

Personnel• Technical

Recorder

23

Consult With Radiation Experts

• Radiation Safety Officer

• Health Physicist

• Medical Physicist

• Conference of Radiation Control Program Directors (www.crcpd.org)

CDC

24

Consult With Radiation Experts

• Determining/documenting presence of radioactivity, activity levels, and radiation dose

• Collecting samples to document contamination

• Assisting in decontamination procedures

• Disposing of radioactive waste

25

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 & digital)

26

Biodosimetry Assessment Tool

Armed Forces Radiobiology Research Institute

www.afrri.usuhs.mil/

27

Facility Preparation

• Plan to control contamination

– Instruct staff to use universal precautions and double glove

– Establish multiple receptacles for contaminated waste

– Protect floor with covering if time allows

28

ContaminatedWaste

Waste

Treatment Area Layout

RadiationSurvey

HOTLINE

STEPOFFPAD

CO

NT

AM

INA

TE

D A

RE

AB

UF

FE

R Z

ON

EC

LE

AN

AR

EA

Radiation Survey

& Charting

ED Staff

Clean Gloves, Masks,Gowns, Booties

Separate Entrance

Trauma Room

29

Immediate Medical Management• Triage

– ARS– localized/ cutaneous– combined injury

• Initial stabilization and treatment

• Psychological effects

• Record keeping/ Dose assessment

30

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

Protecting Staff from Contamination

• Universal precautions• Survey hands and clothing

with radiation meter• Replace gloves or clothing that is contaminated• Keep the work area free of

contamination

31

Patient Management - Priorities

Triage• Medical triage is the highest

priority• Radiation exposure and

contamination are secondary considerations

• Degree of decontamination dictated by number of and capacity to treat other injured patients

32

Patient Management - Triage

Triage based on:• Injuries• Signs and symptoms -

nausea, vomiting, fatigue, diarrhea

• History - Where were you when the bomb exploded or incident occurred?

• Contamination survey

33

Psychological Casualties

• Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening

• Mass casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated

34

Psychological Casualties

• Provide psychological support to patients and set up a center in the hospital for staff

• Establish triage (monitoring and counseling) centers to prevent psychological casualties from overwhelming health care facilities– Staff counseling centers with

physicians with a radiological background, health physicists with instrumentation and psychological counselors

35

Patient Management - Decontamination

• Carefully remove and bag patient’s clothing and personal belongings (typically removes 95% of contamination)

• Survey patient and, if practical, collect samples

• Handle foreign objects with care until proven non-radioactive with survey meter

36

Patient Management - Decontamination

• Decontamination priorities: – Decontaminate wounds first, then

intact skin – Start with highest levels of

contamination• Change outer gloves frequently to

minimize spread of contamination

37

38

39

Patient Management - Decontamination (Cont.)

• Protect non-contaminated 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

40

Patient Management - Decontamination (Cont.)

• 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

41

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.

42

Patient Management - Patient Transfer

Transport injured, contaminated patient into or from the ED:

• Clean gurney covered with 2 sheets

• Lift patient onto clean gurney

• Wrap sheets over patient• Roll gurney into ED or out

of treatment room

43

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) 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

44

Data Management

45

Injuries Associated With Radiological Incidents

• Acute Radiation Syndrome (ARS)• Localized radiation injuries/

cutaneous radiation syndrome• Internal or external contamination• Combined radiation injuries with - Trauma - Burns • Fetal effects

CDC

46

• Occurs only in patients who have received very high radiation doses (greater than approximately 100 rem or rads (1 Gy)) 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

Radiation Sickness Acute Radiation Syndrome

47

• Prodromal stage

– 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

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

Time of Onset

Severity of Effect

48

Acute Radiation Syndrome (ARS)

• Radiation must be of penetrating type (X-rays, gamma rays or neutrons)

• Most or all of body must be exposed.• The dose must be from an external

source.• Dose must be delivered in a short

time. Not fractionated.

49

The Three ARS Syndromes

• Hematopoetic – Between 0.7 Gy and 10 Gy– Mortality rate is proportional to dosage.– Death from hemorrhage and infection– Absence of stem cells with leukopenia

and thrombocytopenia. If they survive, anemia later.

50

• Dose ~ 100 rem

– ~10% exhibit nausea and vomiting within 48 hr

– mildly depressed blood counts

• Dose ~ 350 rem

– ~90% exhibit nausea/vomiting within 12 hr, 10% exhibit diarrhea within 8 hr

– severe bone marrow depression

– ~50% mortality without supportive care

Acute Radiation Syndrome (Cont.)Hematopoietic Component - latent period from

weeks to days

51

Acute Radiation Syndrome (Cont.)Hematopoetic Component - Latent

Period From Weeks to Days

• Dose ~ 500 rem

– ~50% mortality with supportive care

• Dose ~ 1000 rem

– 90-100% mortality despite supportive care

52

Andrews LymphocyteNomogram

Andrews LymphocyteNomogram

From From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. Medical Management of Persons Exposed to High Levels of Radiation. In In Personal Personal Dosimetry for Radiation Accidents. Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Vienna, International Atomic Energy Agency, 1965, pp 3- 16

From From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. Medical Management of Persons Exposed to High Levels of Radiation. In In Personal Personal Dosimetry for Radiation Accidents. Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Vienna, International Atomic Energy Agency, 1965, pp 3- 16

Confirms suspected Confirms suspected radiation exposureradiation exposure

Determines significant Determines significant hematological hematological involvementinvolvement

Serial CBCs every 3 - 4 Serial CBCs every 3 - 4 hourshours

Confirms suspected Confirms suspected radiation exposureradiation exposure

Determines significant Determines significant hematological hematological involvementinvolvement

Serial CBCs every 3 - 4 Serial CBCs every 3 - 4 hourshours

53

The Three ARS Syndromes

• Gastrointestinal – – Usually occurs with exposure to 10 and 100 Gy

(1000 to 10,000 rads) – – Nausea, vomiting and diarrhea. – Death within two weeks with complications of

infection (always have the hematopoetic syndrome as well), electrolyte imbalance, dehydration, hemorrhage.

– Survival uncommon.

54

• Dose > 1000 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 > 3,000 rem - damage to CNS– vomiting, diarrhea, confusion, severe

hypotension within minutes– collapse of cardiovascular and CNS– fatal within 24 to 72 hours

Acute Radiation Syndrome (Cont.)

Gastrointestinal and CNS Components

55

The Three ARS Syndromes

• Cardiovascular Syndrome– Usually with extremely high dosage. >

50 Gy or 5000 rads. Some symptoms possible at 20 Gy.

– Cerebral edema, vasculitis, meningitis with convulsions, coma and death

– Cardiovascular collapse– Death in 3 days or less

56

• 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)

Treatment of Large External Exposures

57

Treatment of Large External Exposures

• Treat symptomatically. Prevention and management of infection is the primary objective.

– Hematopoetic growth factors, e.g., GM-CSF, G-CSF (24-48 hr)

– 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)

58

Other Treatment Methods

• Minimize intake.Reduce and/or inhibit absorption.Block uptake.Use isotopic dilution.Promote excretion.Alter chemistry of the substance.Displace isotope from receptors.Chelate.

59

• Radionuclide-specific

• Most effective when administered early

• May need to act on preliminary information

• NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides

Treatment of Internal Contamination

Radionuclide Treatment RouteCesium-137 Prussian blue OralIodine-125/131 Potassium iodide OralStrontium-90 Aluminum phosphate OralAmericium-241/ Ca- and Zn-DTPA IV infusion,Plutonium-239/ nebulizerCobalt-60

60

Blocking Radioactive Iodine

• The dominant initial internal contaminant after a reactor accident, nuclear weapons test, or any incident involving fresh fission products is likely to be 131I.

• Block thyroid if radioactive iodine is a factor or if you are unsure. Give potassium Iodide 130 mg immediately to an adult then continue for 7 days.

61

Special Considerations• High radiation dose and trauma interact

synergistically to increase mortality• Close wounds on patients with doses > 100

rem• Wound, burn care and surgery should be

done in the first 48 hours or delayed for 2 to 3 months (> 100 rem)

24 - 48 Hours

~3 Months

EmergencySurgery

Hematopoietic RecoveryNo Surgery

After adequatehematopoietic recovery

SurgeryPermitted

62

Cutaneous Radiation Syndrome

• May occur as part of the ARS

• May occur from beta rays or X-rays without ARS

• May be due to contamination of patients skin or clothing from radioactive particles.

63

Cutaneous Radiation Syndrome

• Inflammation• Erythema usually with itching at first• Dry desquamation, epilation, • Moist desquamation• Ulceration, blisters,• Basal cell layer damaged, sebaceous and

sweat glands destroyed. Hyperpigmentation later

• Delayed onset of about days to weeks.

64

Biological Effects of Ionizing RadiationBiological Effects of Ionizing Radiation

Deterministic effects:Deterministic effects: occur when the dose is above a given threshold

(characteristic for the given effect); severity increases with the dose; many cells must die or have their function altered

examples: erythema, fibrosis, marrow depletion, cataract.examples: erythema, fibrosis, marrow depletion, cataract.

Stochastic (probabilistic):Stochastic (probabilistic): have no known threshold; probability of occurrence increases with dose; may result from alteration in only one or a few

cells examples: carcinogenic - various neoplasms, examples: carcinogenic - various neoplasms, genetic - various hereditary disorders.genetic - various hereditary disorders.

65

Radiation EffectsRadiation Effects

Early(Deterministic only)

LocalRadiation injury ofindividual organs:Functional and/or

morphologicalchanges withinhrs-days-weeks

Acute radiation disease Acute radiation syndrome(LD50/60 ~ 3.5Sv LD ~ 5 Sv)

Late

Deterministic(Above DQ, cummul.) - Rad. Dermatitis- Rad. Cataracta - Teratogenic

(DQ,F~0,1Sv)

(Probability increaseswith dose)- Tumors, leukemia- Genetic effects

StochasticSystemic

66

• Skin - No visible injuries < 100 rem– Main erythema, epilation >500 rem– Moist desquamation >1,800 rem– Ulceration/Necrosis >2,400 rem

• Cataracts– Acute exposure >200 rem– Chronic exposure >600 rem

• Permanent Sterility– Female >250 rem– Male >350 rem

Localized Radiation Effects - Organ System Threshold Effects

67

Time of Onset of Clinical Signs of Skin Time of Onset of Clinical Signs of Skin Injury Depending on the Dose ReceivedInjury Depending on the Dose Received

SymptomsSymptoms Dose range Dose range Time of onset Time of onset

(Gy) (Gy) (day) (day)

Erythema 3-10 14-21 Epilation >3 14-18 Dry desquamation 8-12 25-30 Moist desquamation 15-20 20-28 Blister formation 15-25 15-25 Ulceration >20 14-21 Necrosis >25 >21

Ref.: IAEA-WHO: Diagnosis and Treatment of Radiation Injuries.

IAEA Safety Reports Series, No. 2, Vienna, 1998

68

Longer Term Considerations Following Radiation Injury

• Neutropenia• Pain management

• Necrosis

• Plastic/reconstructive surgery

• Psychological effects (PTSD)

• Counseling

• Dose assessments• Possible increased risk of cancer

Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment: www.orau.gov/reacts/, 865-576-1005.

69

Chronic Health Effects From Radiation

• Radiation is a weak carcinogen at low doses• No unique effects (type, latency, pathology)• Natural incidence of cancer ~ 40%;

mortality ~ 25%• Risk of fatal cancer is estimated as ~ 4%

per 100 rem • A dose of 5 rem increases the risk of fatal

cancer by ~ 0.2%• A dose of 25 rem increases the risk of fatal

cancer by ~ 1%

70

Stochastic Effects of Radiation Exposure

Frequency is proportional to doseFrequency is proportional to dose

No threshold doseNo threshold dose

No method for identification of the No method for identification of the appearance of this effect of ionizing appearance of this effect of ionizing radiation in individualsradiation in individuals

Increase in occurrence of stochastic effect Increase in occurrence of stochastic effect can be proved with epidemiological method can be proved with epidemiological method onlyonly

71

Human Data on Radiation CancerogenesisHuman Data on Radiation Cancerogenesis

Type or localization of cancer

Populationgroups

Leukemia Thyroidgland

Lung Breast Bone Skin

A-bombsurvivors + + + +Ra-dial painters +Earlyradiologists +U-miners +

Exposed in anuclearaccident

+

72

Cancer Deaths Attributable to A-bombs

In 86,572 survivors of Hiroshima and Nagasaki A-bombing 7,827 persons died of cancer in 1950-90:

Observed Expected Excess (%)All tumors 7578 7244 334 (4.4)Leukaemia 249 162 87 (35.0)All cancers 7827 7406 421 (5.4)

Ref: Pierce et al, Rad.Res. 146: 1-27, 1996

73

Cancer mortality of nuclear industry workersCancer mortality of nuclear industry workers

Observed/Expected deaths Total Trend

Dose ranges, mSv number test

<10 10- 20- 50- 100- 200- 400- of deaths (p-value)

O/E number of deaths from cancers other than leukemia

2234/

2228.3

462/

465.4

445/

479.6

276/

254.3

196/

190.5

161/

147.6

56/

67.3

3830 -0.28

(0.609)

O/E number of deaths from leukemia other than CLL (chronic lymphocytic leukemia)

60/

62.0

19/

17.2

14/

17.2

8/

9.0

8/

6.4

4/

4.7

6/

2.3

119 1.85

(0.046)

The ERR (excess relative risk) per Sv among the 95,673 nuclear industry workers of Canada,UK and USA (having a mean cumulative dose of 36.6 mSv in the combined cohort for thetotal period of observation, ie. 34 yrs in the USA and UK, and 29 years in Canada ) is

–0.07 for all cancers excluding leukemia, and 2.18 for leukemia excluding CLL.

Ref.: Cardis, E. et al: Combined Analyses of Cancer Mortality Among Nuclear IndustryWorkers in Canada, the UK and the USA. IARC Technical Report No.25, Lyon, 1995

74

Latency Periods for Radiation-induced CancerLatency Periods for Radiation-induced Cancer

75

Teratogenic Effects of RadiationTeratogenic Effects of Radiation Mental retardationMental retardation

Highest risk during major neuronal migration, on 8-15 weeks. Incidence increases with dose. At 1 Gy fetal dose 75% experience severe retardation

At 16-25 weeks, fetus shows no increase in mental retardation at doses < 0.5 Gy

IQ - Risk factor associated with diminution of IQ is 21-33 points at 1 Gy to fetus on 8-15 weeks.

MicrocephalyMicrocephaly Observed in 30 children of ~1000 exposed in

Hiroshima and Nagasaki pregnant women The effect <0.3 Gy is not significantly different of

control

76

Fetal IrradiationNo Significant Risk of Adverse

Developmental Effects Below 10 Rem

•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 withhigher doses.•Increased childhood cancer risk. (~ 0.6% per 10

rem)

<2

2-7

7-40

All

Pre-implantation

Organogenesis

Fetal

Weeks After Fertilization

Period ofDevelopment

Effects

77

Key Points• Medical stabilization is the highest priority• Train/drill to ensure competence and

confidence • Pre-plan to ensure adequate supplies and

survey instruments are available • Universal precautions and decontaminating

patients minimizes 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

78

DISTRIBUTION OF 237 CHERNOBYL PATIENTS TREATEDFOR ACUTE RADIATION SYNDROME BY THE SEVERITYOF SICKNESS AND RANGE OF WHOLE BODY EXPOSURE

Degreeof ARS

Numberof patients

Deaths in3 months

Whole bodydose, Gy

IV 21 20 6-16

III 22 7 4-6

II 50 1 2-4

I 41 0 1-2

I-IV 134 28 1-16Not confirmed 103 0 <2

Ref.: Ilyin L.A.: Chernobyl - Myth and reality, Megapolis, Moscow, 1995 Wagemaker G. et al., IAEA/WHO/CEC Chernobyl Conf. Vienna, 1996

79

The Three Basic Ways to Reduce Radiation ExposureTIMEDecrease the amount of time you spend near the source of radiation.DISTANCEIncrease your distance from a radiation source.SHIELDINGIncrease the shielding between you and the radiation source. Shielding is anything that creates a barrier between people and the radiation source. Depending on the type of radiation, the shielding can range from something as thin as a plate of window glass or as thick as several feet of concrete. Being inside a building or a vehicle can provide shielding from some kinds of radiation.

80

Personally, What You Should Do!

Radiological Attack Avoid inhaling dust as it could be radioactive.

• If an explosion occurs outdoors and you are informed that radiation is involved, if you are outdoors, cover nose and mouth and seek indoor shelter as soon as possible.

• If you inside an undamaged building, stay there. Close windows and doors and shut down ventilation system. Exit when told that it is safe after testing.

81

Personally, What You Should Do! Radiological Attack

• If an explosion occurs inside your building, cover nose and mouth and evacuate as soon as possible.

• Decontaminate by removing clothing and showering.

• Relocate outside the contaminate zone.• Obey public officials.• This is the scenario of a dirty bomb.

82

Personally, What You Should Do! Actual Nuclear Attack

• Move out of the path of a nuclear fallout cloud as quickly as possible (10 minutes or less) if you are in the blast zone and can do so. Find medical help ASAP.

83

Prepared by the Radiological Emergency Medical Preparedness & Management Subcommittee of the National Health Physics Society Ad Hoc Committee on Homeland Security.

Jerrold T. Bushberg, PhD, ChairKenneth L. Miller, MSMarcia Hartman, MS

Robert Derlet, MDVictoria Ritter, RN, MBA

Edwin M. Leidholdt, Jr., PhD

ConsultantsFred A. Mettler, Jr., MD

Niel Wald, MDWilliam E. Dickerson, MD

Appreciation to Linda Kroger, MS who assisted in this effort.

Reproduced with permission

84

Other Resources• Additional slides by permission

Istvan Turai MD PhD, International Atomic Energy Commission

• CDC Video “Medical Response to Nuclear and Radiological Terrorism”

• REACT/• REAC/TS (Oak Ridge Radiation

Emergency Assistance Center/Training Site) DOE/OROC (865) 576-1005 http://www.orau.gov/orise.htm

85

Always Contact Local Public Health Department

• Tarrant County Public Health 1101 S. Main Street Fort Worth, Texas 76104 817-321-4700

• Dallas County Department of Health & Human Services2377 N. Stemmons Freeway Dallas, Texas 75207-2710 214-819-2004.

86

We will Always Remember

87

Thank You for Coming

Stevan Cordas DO MPH

www.drcordas.com