1. Emergency Department Management of Radiation Casualties This training program was prepared by the Radiological Emergency Medical Preparedness & Management Subcommittee of the Homeland Security Committee of the Health Physics Society.* Every emergency department should have a medical radiation emergency plan that will allow effective and efficient handling of potentially contaminated radiation accident victims. When such a plan exists and is tested through periodic drills, it minimizes the potential for apprehension and panic should activation of the plan ever be needed. Talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points must be presented during the training. Health Physics Society Version 2.9 Disclaimer: The information contained herein was current as of 9 May 2009 and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. *The Health Physics Society is a nonprofit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the Department of Defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; fax: 703-790-2672; email: HPS@BurkInc.com.
2. Scope of Training The training will include a discussion of the characteristics of ionizing radiation and radioactive materials. The differentiation between radiation exposure and radioactive material contamination is explained. Radiation protection procedures for protecting staff from radioactive contamination are similar to the methods used to protect them from blood-borne pathogens—gloves and face shields. Facility preparation steps will be described.
3. Scope of Training (Cont.) Patient assessment and management of radiation contamination and injuries are addressed. Training should emphasize that resuscitation and stabilization are the most important aspects of treating the radiation accident victim(s). Contamination and possible effects of exposure can be addressed once the patient is stabilized. Emergency room personnel should be aware that individuals who are exposed but not contaminated pose no risk to the ER staff and that normal ER procedures can be used with them. Psychosocial considerations as they relate to patients, staff, and the public will impact emergency departments. The training describes the health effects of acute and chronic radiation exposure. Facility recovery after an incident is described and a list of resources is provided.
4. Ionizing Radiation Alpha particles, beta particles, gamma rays, and x rays are types of ionizing radiation. When they interact with other atoms, they have enough energy to cause ionization of these atoms. Patients with radioactive material on them or inside their bodies are said to be contaminated. Contaminated patients require care in handling to effectively remove and control the contamination. Patients who have only been exposed to the radiation from a radioactive source or a machine, such as an x-ray machine or a linear accelerator, are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel. Radiation safety precautions are not needed for patients who have only been exposed and are not contaminated.
5. Types of Ionizing Radiation Alpha particles. Alpha particles are ejected from (thrown out of) the nuclei of some very heavy radioactive atoms (atomic number &gt; 83). An alpha particle is composed of two neutrons and two protons. Alpha particles do not penetrate the dead layer of skin and can be stopped by a thin layer of paper or clothing. If an alpha-emitting radioactive material gets inside the body through inhalation, ingestion, or a wound, the emitted alpha particles can cause ionization that results in damage to tissue. It is less likely that a patient would be contaminated with an alpha emitter. Beta particles. A beta particle is an electron ejected from the nucleus of a radioactive atom. Depending on its energy, beta radiation can travel from inches to many feet in air and is only moderately penetrating in other materials. Some beta radiation can penetrate human skin to the layer where new skin cells are produced. If high-enough quantities of beta-emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury. Beta emitting-contaminants may be harmful if deposited internally. Protective clothing (e.g., universal precautions) typically provides sufficient protection against most external beta radiation. Gamma rays and x rays (photons). Gamma rays and x rays are able to travel many feet in air and many inches in human tissue. They readily penetrate most materials and are sometimes called “penetrating” radiation. Thick layers of dense materials are needed to shield against gamma radiation. Protective clothing provides little shielding from gamma and x radiation, but will prevent contamination of the skin with the gamma-emitting radioactive material. Gamma and x radiation frequently accompany the emission of beta and alpha radiation.
6. Radiation Units A curie is a very large amount of radioactivity. Contamination of individuals usually involve µCi to mCi quantities. Nuclear medicine patients are injected with µCi to mCi quantities of radioactive material for routine diagnostic exams. The basic unit of radiation dose is the rad. The rad is defined as the deposition of 0.01 joule of energy (a small amount) per kilogram (kg) of tissue. A rad of x rays, a rad of gamma rays, and a rad of beta particles are about equally damaging to tissue. However, a rad of another type of ionizing radiation, such as alpha particles or neutrons, is much more damaging to tissue than a rad of gamma rays. The rem was introduced to take into account this variation in tissue damage. This is important because a person may be exposed to more than one type of radiation. For example, it was found that 100 rad of gamma and beta radiation produced the same effect as 100 rad of x rays. However, only 20 rad of neutrons and 5 rad of alpha particles produced the same effect as 100 rad of x rays. Therefore, neutron and alpha radiations were more potent and required fewer rad to produce the same effect. The number of rem is calculated by multiplying the number of rad by a radiation weighting factor that accounts for the relative amount of biological damage produced by a specific type of radiation. The radiation weighting factor for x rays, gamma rays, and beta particles is 1. Thus, a rad of one of these radiations is equal to one rem. For other types of radiation (that are less likely to be present in accidents), the quality factor may be higher. The International Scientific System (SI) assigns different units to the quantities: 1 R = 2.58 X 10-4 C kg-11 gray (Gy) = 100 rad 1 sievert (Sv) = 100 rem1 becquerel (Bq) = 1 disintegration per second
7. Radiation Doses and Dose Limits Radioactive material has always been a natural part of the earth. It has existed for millions of years in the crust of the earth, in building materials, in the food we eat, in the air we breathe, and in nearly everything that surrounds us. Radiation from these materials, as well as cosmic radiation from the sun and universe, makes up the natural background radiation to which we are constantly exposed. On the average, persons are exposed to about 300 millirem per year from natural sources (NCRP Report No. 101). The guidance from NCRP Report No. 116, Limitation of Exposure to Ionizing Radiation, states that for life-saving or equivalent purposes, workers may approach or exceed 50,000 mrem to a large portion of the body. Emergency exposures are considered once-in-a-lifetime. This is below the threshold for the acute radiation syndrome, discussed later. If an individual is exposed to more than 100 rem at one time, predictable signs and symptoms will develop within a few hours, days, or weeks, depending on the magnitude of the dose. About half of all people exposed to a single dose of 350 rem will die within 60 days (LD50/60) without medical intervention. The large doses used in medicine for radiation therapy, while higher than this dose, are given to only part of the body and are typically given over a period of weeks. Heart catheterization is a skin dose; barium enema is an effective dose. (NRPB Report R-200, 1986) The dose limits are highlighted in orange.
8. Radioactive Material The difference between radioactive material and radiation should be explained. Radioactivity is a mechanism whereby an unstable nucleus rearranges itself to become more stable. The process often involves the ejection of charged particles from the atomic nuclei. This ejection of particles (beta or alpha) is often accompanied by the emission of gamma rays from the nucleus or x rays from the atom’s electron shells. Beta particles, alpha particles, gamma rays, and x rays are all forms of radiation that can be emitted from radioactive atoms. Radioactive contamination is simply radioactive material (often attached to dust or dirt) that is either on the skin or clothes of the patient or has been taken into the body via inhalation, ingestion, or a wound. Usually most of the external contamination can be removed from the patient by carefully removing the patient’s clothing.
9. Half-Life In any sample of radioactive material, the amount of radioactive material constantly decreases with time because of radioactive decay. The physical half-life is the amount of time required for a given amount of radioactive material to be reduced to half the initial amount by radioactive decay. The biological half-life is the time required for the human body to eliminate half of the radioactive material taken into it. For many radioactive materials, the elimination from the body occurs via urination. However, depending on the chemical composition of the radioactive material, other pathways can also help to eliminate the radioactive material from the body. The effective half-life is a measure of the time it takes for half the radioactive material taken into the body to disappear from the body. Both the physical half-life and the biological half-life contribute to the elimination of the radioactive material from the body. The combination of these two half-lives is called the effective half-life. After one half-life, half of the material remains. After a second half-life, a half of a half (i.e., 25 percent) of the initial amount remains. After 10 half-lives, about 1/1,000 remains. After 20 half-lives, only one millionth of the material remains.
10. Examples of Radioactive Materials Radioactive materials emit ionizing radiation. They are used in medical diagnosis (nuclear medicine), medical therapy (cancer treatment), and industry (food irradiation) and for research. Many radioactive materials, including radioactive waste, are commercially shipped in special containers. A radionuclide is chemically identical to and behaves in the body the same way as the nonradioactive form of the element. For example, radioactive iodine (e.g., I-131) is concentrated in the thyroid in the same way as nonradioactive iodine (i.e., I-127). Quantities of radioactive material (i.e., activity) range from trivial amounts in typical laboratories to much larger quantities, such as in nuclear reactors. Half-lives can range from seconds to millions of years. The nuclides that are in orange are those that are considered to be potential nuclides that could be present in a radiological dispersal device.
11. Types of Radiation Hazards Patients who have only been exposed to the radiation from a radioactive source or a machine, such as an x-ray machine or a linear accelerator, are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel. Radiation safety precautions are not needed for patients who have only been exposed and are not contaminated. Patients with radioactive material on them or inside their bodies are said to be contaminated. Contaminated patients require care in handling to effectively remove and control the contamination. Analogy—You can think of radiation exposure and radioactive material in terms of a trip to the beach. Sand is like radioactivity. The sun is like radiation exposure. Once you go inside, you are not in the sun any longer and there is no more exposure (radiation stops). On the other hand, most of the sand came off when you walked off the beach, however, some sand remains on your skin until you physically remove it (brush or wash it off). The same is true for radioactivity contamination on the skin. A small amount may remain on the skin and need to be washed off.
12. Causes of Radiation Exposure and Contamination Accidents—There are several settings or scenarios in which radiation accidents may occur: nuclear reactor accidents; medical radiation therapy accidents or errors in treatment dose; accidental overexposures from industrial irradiators; lost, stolen, or misused medical or industrial radioactive sources; and accidents during the transportation of radioactive material. Terrorist Use of Nuclear Materials—The use of radioactive materials in an RDD or a nuclear weapon by a terrorist is a remote but plausible threat. The medical consequences depend on the type of device used in a terrorist event. An attack on or sabotage of a nuclear facility, such as an irradiation facility or a nuclear power plant, could result in the release of very large amounts of radioactive material. Radiological Dispersal Device (RDD)—An RDD disperses radioactive material for the purpose of terrorism. An RDD that uses a conventional explosive (e.g., TNT or a plastic explosive) to disperse the radioactive material is called a “dirty bomb.” A dirty bomb is NOT an atomic bomb. The initial explosion may kill or injure those closest to the bomb, while the radioactive material remains to expose and contaminate survivors and emergency responders. Low-Yield Nuclear Weapon—A low-yield nuclear weapon or partial failure of a high-yield weapon could cause a low-yield nuclear detonation. For example, if one considers the consequences of a 0.1 kiloton-yield nuclear detonation (less than 1/100 the size of the weapon used on Hiroshima), then the following would occur within one minute surrounding ground zero. The effects listed below do not take into account that multiple injuries caused by the interaction of the various types of injury will increase the probability of fatality. (NCRP Report No. 138) -The range for 50 percent mortality from trauma from the blast is approximately 150 yards. -The range for 50 percent mortality from thermal burns is approximately 220 yards. -The range for 400 rad from gamma and neutron radiation would be approximately 1/3 mile. -The range for 400 rad in the first hour from radioactive fallout would be almost 2 miles in the downwind direction. -As the size of the weapon increases, the effects encompass a greater distance. This will result in the release of widespread contamination and substantial air blast and heat.
13. Scope of Event 428 major radiation accidents have been reported worldwide in the years 1944 to 2002. These accidents caused 126 deaths due to radiation. Their effects were dependent on exposure, contamination, and the number of people involved. There were an additional eight nonradiation deaths that would likely have resulted in eventual death due to the radiation. (REAC/TS Registry, 2002) There have been no uses of radioactive dispersal devices. The outcome of such an event would depend on the size of the explosion, the radioactive material involved, the activity (amount) of the radioactive material, the number of people in the vicinity, and the effectiveness of the emergency response. There have been no low-yield nuclear weapon detonations by terrorists. The outcome from such an event would depend on the yield, the location of the detonation, and the number of people in the vicinity.
14. Reducing Radiation Exposure There are three methods for reducing radiation exposure: time, distance, and shielding. All three of these methods can be used to keep radiation exposure to a minimum. The longer a person is exposed to a radiation source, the higher will be the dose received. To minimize the dose, reduce the time of exposure to the radiation. For example, ED nurses who do not have to stand beside a contaminated patient can minimize exposure by stepping close to the patient only when assistance is needed and stepping away as soon as they are done. In addition to minimizing the exposure time, the nurse can further reduce exposure by taking advantage of distance. Radiation dose rate falls off very quickly as the distance between the radiation source and the individual is increased. Time and distance are effective methods of minimizing dose. Another method of minimizing dose is through the use of shielding. Radiology personnel use leaded aprons to shield themselves from the x rays that are scattered from the patient undergoing an x-ray procedure. Leaded aprons are not recommended and usually provide little shielding protection from the types of radiation expected from contaminated patients. An effective way to use shielding is to place radioactive materials removed from patients into lead containers called “pigs.” The thick lead walls of these containers absorb the radiation from the radioactive material.
15. Protecting Staff from Contamination Hospital staff are well versed in protecting themselves and their work areas from microbiological contamination through the use of “Universal Precautions.” The same techniques can be used effectively to protect personnel and the work area from contamination by radioactive materials. One great advantage that hospital personnel have, when it comes to radioactive contamination, is the ease with which radioactive material can be detected. Most radioactive material can be detected easily and in very small quantities with the use of a simple instrument such as a GM survey meter (Geiger counter). Frequent use of the GM survey meter can alert personnel to the need to change their gloves or clothing when they become contaminated or to tell them when contamination is being spread to the work area so that cleanup and extra precautions can be implemented. Such ease of detection and control is not possible with any other type of hazardous material. Medical personnel working on the Chernobyl site after the accident received less than 1,000 mrem. (Mettler and Voelz, New England Journal of Medicine, 2002; 346:1554-1561) Emphasize the Key Points that most contamination is easy to detect and remove, and it is very unlikely that ED staff will receive large radiation doses from treating contaminated patients.
16. Mass Casualties, Contaminated but Uninjured People, and Worried Well A mass-casualty incident resulting from nuclear terrorism is likely to generate large numbers of frightened people who may not require decontamination or trauma care. It may also generate people who are contaminated, but not injured or whose injuries do not require care in the emergency department. It is important to take measures to prevent these people from overwhelming the emergency department. A triage site should be established outside the ED. Security personnel will be needed to directed people to the triage site and prevent them avoiding the triage site and reached the emergency department.
17. Decontamination Center A decontamination center should be established to monitor people who may be contaminated and to provide facilities for decontamination. Ideally, it should provide showers. In a crisis, hoses could be used. A decontamination center should be staffed by physicians with a radiological background, health physicists or other staff familiar with decontamination procedures and the use of radiation survey meters, and psychological counselors. Towels and replacement clothing should be available. Provisions, especially in inclement weather, may be needed to shelter people or to transport them elsewhere after decontamination.
18. Psychological Casualties The hospital should plan to provide psychological support to patients and set up a center in the hospital for counseling the staff. These should be staffed by physicians with a radiological background and by psychological counselors.
19. Facility Preparation The hospital should activate its radiological emergency medical response plan. A triage area should be identified for accepting patients and the worried well. The plan should address contamination control for staff and facilities. There should be a call-out list to obtain additional staff and equipment. Staff protects themselves from contamination by using universal precautions and double gloving. Staff should know where to obtain radiation survey meters and personnel to operate them. Environmental Services should establish multiple receptacles for contaminated waste. Call for additional support from hospital staff: Nuclear Medicine, Radiation Oncology, Radiation Safety/Health Physics. Plan for the decontamination of uninjured persons away from the ED. Protect the floor with covering if time allows.
20. Treatment Area Layout The layout for the handling of a contaminated radiation accident victim should be established to control the spread of contamination by using universal precautions. Control of individuals and materials going into the area. Control and survey of materials and personnel coming out of the area. Use appropriate steps to prevent the spread of contamination (e.g., monitor gloves and change as necessary, monitor shoes when leaving, etc.). Monitoring of the patient and the trauma room to detect, control, and remove contamination. Contaminated waste water need not be contained if it will unduly complicate the treatment of the patient or it is otherwise determined to be impractical. Release of wastewater can be justified in almost all situations.
21. Detecting and Measuring Radiation You cannot see, smell, taste, feel, or hear radiation, but we have very sensitive instrumentation to detect it at very low levels. Radiation monitoring instruments detect the presence of radiation. The radiation measured is usually expressed as exposure per unit time, using various units of measure, milliroentgen per hour (mR/hr) and counts per minute (CPM). Anything with “milli” in front of it is SMALL! The most commonly used instruments to detect the presence of radiation include: Geiger-Mueller Survey Meter. The Geiger-Mueller (GM) survey meter (also known as a Geiger counter) will detect low levels of gamma and most beta radiation. The instrument typically has the capability to distinguish between gamma and most beta radiation. This instrument is used to quickly determine if a person is contaminated. GM survey meters are very sensitive and other instruments may be needed to measure higher levels. Ionization Chamber Survey Meter. This device can accurately measure radiation exposure. These meters measure from low levels (mR/hr) to higher levels (many R/hr). To find the dose an individual is receiving, multiply the dose rate by the time the person is exposed. Personal Dosimeters. These devices measure the cumulative dose of radiation received by persons wearing them. Film and TLD badges must be analyzed by the company that supplies them, so the dose received is not typically known for several days. However, self-reading dosimeters allow the wearers to immediately see the total dose they have received.
22. Patient Management – Priorities Medical stabilization takes priority over decontamination.
23. Patient Management – Triage Resuscitation and stabilization are the primary objectives. Decontamination efforts should be secondary to patient stabilization. Severity and time of onset of nausea, vomiting, diarrhea, and fatigue are noted and treated in routine clinical manner. Patient history will assist in the triage process to predict the potential extent of radiation injury. Contamination surveys are secondary to patient stabilization.
24. Patient Management – Decontamination Patient decontamination should be performed after stabilization of the patient. Removal of clothing usually occurs in the field, prior to transport to the hospital. The approach to decontamination as described in the slide will minimize contamination of and exposure to attending personnel. If internal contamination is suspected, take nasal swipes and 24-hour urine and fecal collections. Unfamiliar embedded objects in patient’s clothing or wounds may be radioactive sources. Handle with long forceps, handle only briefly, and keep distant from staff and patients until proven, with a survey meter, not to be radioactive. If radioactive objects are recovered, they should be placed in a lead container using tongs or forceps and then placed at a distance from staff and patients.
25. Patient Management – Decontamination (Cont.) Protection of noncontaminated wounds with waterproof dressings will minimize the potential for uptake of radioactive material. To decontaminate wounds, irrigate and gently scrub with a surgical sponge. Normal wound debridement should be performed. Excision around wounds solely to remove contamination should only be performed in extreme cases and upon the advice of radiological emergency medical experts. Many times, radioactive material will exude from wounds into gauze dressings, so frequent changing of dressings may aid wound decontamination. The dressing also serves to keep the contamination in place. Remove contaminated hair if necessary, using scissors or electric clippers. To avoid cutting the skin and providing an entry for internal contamination, do not shave. Usual washing methods are effective for removal of radioactive material. Overly aggressive decontamination may abrade the skin, which would increase absorption of radioactive material, and should be avoided. Sweating can remove radioactive material from pores. Cover the area with gauze and put a glove or tape plastic over the area to promote sweating. Use a GM survey meter to monitor the effectiveness of the cleaning method.
26. Patient Management – Decontamination (Cont.) Cease decontamination of the skin and wounds when the area is less than twice the background reading on the survey meter or there is no significant reduction between washings. Under no circumstances should decontamination cause the skin to become abraded. Contaminated thermal burns can be gently rinsed while ensuring that there will be no further damage to the skin. Additional contamination will be removed with the exudate as dressings are changed. Do not delay surgery or other necessary medical procedures because of contaminated skin or wounds. Staff will be protected from becoming contaminated by using universal precautions. Sheets and dressings will keep contamination in place.
27. Treatment of Internal Contamination Deposition of radioactive materials in the body (i.e., internal contamination) is a time-dependent, physiological phenomenon related to both the physical and chemical natures of the contaminant. The rate of radionuclide incorporation into organs can be quite rapid. Thus, time can be critical and treatment (decorporation) urgent. Several methods of preventing incorporation (e.g., catharsis, gastric lavage) might be applicable and can be prescribed by a physician. Some of the medications or preparations used in decorporation might not be available locally and should be stocked. NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides, addresses the strategies to limit the exposure from internal contamination by radioactive materials. Radiation Protection Dosimetry published the Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers (1992), which provides additional information on patient management. In January 2003, the Food and Drug Administration (FDA) determined that Prussian blue had been shown to be safe and effective in treating people exposed to radioactive elements such as Cesium-137. In August 2004, the FDA determined that two drugs, pentetate calcium trisodium injection (Ca-DTPA) and pentetate zinc trisodium injection (Zn-DTPA), are safe and effective for treating internal contamination with plutonium, americium, or curium. The drugs increase the rate of elimination of these radioactive materials from the body.
28. Patient Management Emergency personnel at the scene will probably remove patient’s clothing, which will remove a significant amount of radioactive contamination. Contamination may persist when the patient arrives at the ED. The method shown on the slide can be used to transfer a contaminated patient into the ED without spreading contamination. The patient is transferred onto the clean gurney outside the ED, the sheets are wrapped over the patient, and the gurney is rolled into the ED and to the treatment room. When the patient is ready to be moved from the ED to other areas of the hospital, the patient can be transferred to a clean gurney. The gurney can be rolled into the potentially contaminated treatment room on a clean sheet or plastic. After the patient is transferred onto the gurney he/she can be transported through the hospital without concern for the spread of radioactive contamination.
29. Facility Recovery If you have in-house radiation safety staff, they will supervise decontamination efforts. Environmental Services staff should remove waste from the emergency department and triage area and take it to a holding place until it can be surveyed for radioactive material before disposal. A radiation survey of the facility will identify any areas that need decontamination. Normal cleaning routines are typically very effective. If there is residual contamination after normal cleaning, items such as furniture and floor tiles can be replaced. The decontamination goal is for the equipment and floors to be less than twice the normal background reading. Higher levels of fixed contamination should not deter the use of emergency facilities during periods of critical need.
30. Radiation Sickness – Acute Radiation Syndrome Radiation sickness (acute radiation syndrome [ARS]) is an acute illness following exposure to a very large dose of ionizing radiation. It is produced if a large dose of radiation reaches enough sensitive tissue within the body. The acute radiation syndrome follows a roughly predictable course over a period of time ranging from a few hours to several weeks. For doses of approximately 15 rem, the patient should be asymptomatic, but an increased number of chromosomal aberrations may be detectable in circulating lymphocytes. For doses of approximately 50 rem, the patient should be asymptomatic, but show minor decreases in white cells and platelets.
31. Acute Radiation Syndrome (Cont.) The signs and symptoms that develop in the ARS occur in four distinct phases: prodromal (initial), latent period, manifest illness stage, and recovery or death. Prodromal phase. Depending on the dose of radiation, patients may experience a variety of symptoms including loss of appetite, nausea, vomiting, fatigue, and diarrhea. After extremely high radiation doses, additional symptoms such as prostration, fever, respiratory difficulties, and increased excitability may develop. Latent period. This is a transitional period in which many of the initial symptoms partially or completely resolve. It may last for a few hours or up to a few weeks depending on the radiation dose. The latent period shortens as the initial dose increases. Manifest Illness Stage. These three phases occur with increasing radiation exposure and are described on the following slides. The severity of the symptoms increases with dose, amount of the body exposed (whole body vs. partial body exposure), and the penetrating ability of the radiation. The severity is also affected by factors such as age, gender, genetics, medical conditions, etc.
32. Acute Radiation Syndrome (Cont.) Radiation in very large whole-body doses can cause death of the individual exposed. The clinical progression of the symptoms is dose dependent, as is the body system that exhibits the most profound effects. For very high whole-body doses, the duration of time from exposure to onset of symptoms is shortened and the effects exhibited are dose dependent.
33. Acute Radiation Syndrome (Cont.) Doses greater than 1,000 rem will progress on a medically unalterable course.
34. Treatment of Large External Exposures The faster the onset of signs and symptoms and the greater the severity of the drop in the lymphocytes and other blood elements will indicate higher radiation doses. N, V, D, F refers to nausea, vomiting, diarrhea, and fatigue. Time to EmesisUpper Bound Dose Estimate (Gy) &gt; 2 h&lt; 9 &gt; 4 h&lt; 4 &gt; 10 h&lt; 2 These upper bound dose estimates are adapted from Figure 1, Parker and Parker, Estimating Radiation Dose from Time to Emesis and Lymphocyte Depletion, Health Physics, 2007. The actual dose to any person in the specified category of time to emesis is likely to be much less than the upper bound dose in this table. A recommendation is: Triage patients with time-to-emesis less than 4 hours to professional medical care and delay medical attention for patients with time-to-emesis greater than 4 hours, if resources are scarce. (Parker and Parker, 2007; Goans and Waselenko, Health Physics, 2005). The complete blood cell with absolute lymphocyte count should be taken initially and about every six hours thereafter (purple top tube containing EDTA). The concentration of lymphocytes in circulation can be altered by trauma and can complicate the use of this as an indicator for radiation exposure. For chromosomal analysis of lymphocytes, use a blood collection tube with lithium heparin anticoagulant. Sodium heparin anticoagulant is also acceptable if a tube with lithium heparin is not available. (IAEA Technical Report Series No. 405, 2001) Chromosomal analysis of lymphocytes requires about four days, one day to ship the blood sample to the analysis laboratory and three days to perform the test. Treat patients symptomatically as they occur for nausea, vomiting, diarrhea, fatigue, electrolyte imbalance, and pancytopenia. Treatment should focus on prevention of infection. Antibiotics should be given to sterilize the gut and treat opportunistic infections. Hematopoietic growth factors should be given within the first 24 to 48 hours and then daily. Patients with higher exposures will require hospitalization. The telephone numbers for REAC/TS and MRAT are given in a subsequent slide.
35. Localized Radiation Effects – Organ System Threshold Effects Partial-body radiation can cause localized effects if the dose is sufficiently high. Radiation doses to the skin can cause reddening of the skin, blistering, and ulceration. Higher doses are required for blistering and ulceration than for skin reddening. This photo is from a patient who had three angioplasty procedures under fluoroscopic guidance. It shows deep necrosis of the skin 22 months after an exposure of ~2,000 rem. Effect on Skin Threshold dose (Gy)Time of Onset Early transient erythema22 to 24 hours Main erythema6~1.5 weeks Temporary epilation3~3 weeks Permanent epilation7~3 weeks Dry desquamation14~4 weeks Moist desquamation18~4 weeks Secondary ulceraction 24&gt; 6 weeks (due to microvasular occlusion) Late erythema158 – 10 weeks Ischemic dermal necrosis18&gt; 10 weeks Late dermal necrosis12&gt; 1 year Reference: Koenig, Wolff, Mettler, Wagner. Skin Injuries from Fluoroscopically Guided Procedures: Part 1, AJR, 2001. A patient may present with injuries from exposure to a lost or stolen high-activity commercial radiation source. The patient may not be aware that he or she was exposed. Such a patient may have localized burn-like skin injuries without a history of heat exposure. Epilation, a tendency to bleed, nausea and vomiting, and/or other symptoms of the acute radiation syndrome may be present. Cataracts have developed in some early radiation workers who received high doses to the lens of their eyes. Loss of fertility has occurred in both males and females whose gonads were exposed to very high doses of radiation.
36. Special Considerations Patients who have suffered trauma (from an explosive or burn) combined with an acute high-level exposure to penetrating radiation will have increased morbidity as compared to patients who have received the same dose of radiation without trauma. If a patient has received an acute dose greater than 100 rad, efforts must be made to close wounds, cover burns, reduce fractures, and perform surgical stabilizing and definitive treatments within the first 48 hours after injury. After 48 hours, surgical interventions should be delayed until hematopoietic recovery has occurred.
37. Chronic Health Effects from Radiation High radiation doses have been linked to a modest increase in the incidence of cancer in exposed populations, such as the atomic bomb survivors. At low doses, below about 20 rem, the potential for cancer causation is uncertain and generally believed to be quite small. The natural incidence of cancer in the population of the United States, over a lifetime, is estimated to be approximately 40 percent and the risk of mortality is approximately 25 percent. (Reference – SEER [Surveillance, Epidemiology and End Results] Program of the National Cancer Institute) Risk of fatal cancer from ICRP Publication 60, pg. 177, 1991; 5 percent per 100 rem. There are several sets of recommendations for acceptable doses to emergency workers performing life-saving actions. While these doses are 5 to 10 times higher than annual occupational dose limits, it represents a modest increase in cancer risk during life-saving measures. EPA/NRC 25 rem NCRP/ICRP Approach or exceed 50 rem (EPA, Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, 1992) (NCRP Report 116, Limitation on Exposure to Ionizing Radiation, 1993) (IRCP Report 60, 1990 Recommendations of the International Commission on Radiological Protection, 1991)
38. What Are the Risks to Future Children? Hereditary Effects Concern over radiation-induced hereditary (genetic) effects is quite common due to a century of misrepresentation, by the media and the entertainment industry, of radiation’s ability to produce hereditary effects. The natural incidence of malformations and genetic disease at 1-2 years of age is 6-10 percent. (Mossman KL, Hill LT: Radiation Risks in Pregnancy , Obsts Gynecol 60:237-242, 1982) No direct evidence of hereditary effects exceeding normal incidence have been observed in any of the studies of humans exposed to radiation, even with high doses. Risk of severe hereditary effects from UNSCEAR Hereditary Effects of Radiation, pg. 2, 2001; 0.3-0.47 percent per gray.
39. Fetal Irradiation Termination of pregnancy is NOT justified based upon radiation risks for fetal doses less than 10 rem. Excess childhood cancer risk is ~0.06 percent per rem. Normal childhood cancer incidence is 0.075 percent. Fetal doses greater than 50 rem can cause significant fetal damage, the magnitude and type of which is a function of dose and stage of pregnancy. For fetal doses between 10 and 50 rem, decisions regarding termination of pregnancy should be made based upon individual circumstances.
40. Key Points Emphasize that medical stabilization of the patients is the highest priority. Patients will not succumb immediately from radiation injury. Radiation exposure and contamination are not immediately life threatening nor are contamination levels or exposure levels of significant hazard to personnel. Training and drills are the best preparation to ensure competence and confidence by the the ED and other staff identified in the Emergency Plan. Preplan to ensure that adequate supplies and survey instruments are available. Identify non-ED staff who can assist. Staff from Nuclear Medicine, Radiation Oncology, and Radiation Safety have expertise in radiation protection practices and the use of survey meters. The staff can protect themselves from radioactive contamination by using universal precautions while treating these patients. Treating these patients is not an immediate hazard to ED staff health and the long-term risks from the radiation exposure are small. Early symptoms and their intensity in patients 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 from state and federal agencies.
41. Resources This is a list of resources both for developing a plan for handling radiation casualties and for use in responding to an actual event. REAC/TS and MRAT can be contacted for advice during the management of a specific event. The phone numbers listed are answered 24/7. Medical Treatment of Radiological Casualties was prepared by the Department of Homeland Security Working Group on Radiological Dispersal Device Preparedness. Medical Management of Radiological Casualties Handbook is available at http://www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf
42. Resources This is a list of resources both for developing a plan for handling radiation casualties and for use in responding to an actual event. It is advised that some documents be procured in advance for reference during an event. For example, NCRP Report No. 65 is an excellent resource for treatment of patients who have inhaled, ingested, or absorbed radioactive material. Radiation Protection Dosimetry published the Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers (1992), which provides additional information on the treatment of such patients.
43. Acknowledgments Comments may be sent to Jerrold T. Bushberg, PhD. at email@example.com.
Emergency Department Management of Radiation Casualties
Emergency Department Management
of Radiation Casualties
This presentation, "Emergency Department Management of
Radiation Casualties,” was prepared as a public service by the
Health Physics Society for hospital staff training.
The presentation includes talking points on the Notes pages,
which can be viewed if you go to the File Menu and "Save As"
a PowerPoint file to your computer.
The talking points are provided with each slide to assist the
presenter in answering questions. It is not expected that all the
information in the talking points will be presented during the
The presentation can be edited to fit the needs of the user. The
authors request that that appropriate attribution be given for
this material and would like to know who is presenting it and to
what groups. That information and comments may be sent to
Jerrold T. Bushberg, PhD, UC Davis Health System, at
Scope of Training
• Characteristics of ionizing radiation and
• Differentiation between radiation exposure
and radioactive material contamination
• Staff radiation protection procedures
• Facility preparation
Scope of Training (Cont.)
• Patient assessment and management of
radioactive material contamination and
• Health effects of acute and chronic radiation
• Psychosocial considerations
• Facility recovery
• Ionizing radiation is radiation capable of
imparting its energy to the body and causing
• Ionizing radiation is emitted by:
- Radioactive material.
- Some devices such as x-ray machines.
Types of Ionizing Radiation
Stopped by a sheet of paper
Stopped by a layer of clothing
or less than an inch of a substance
Stopped by inches to feet of concrete
or less than an inch of lead
Ionization in air
weighted by type of
For most types of radiation 1 R ≈ 1 rad ≈ 1 rem
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) 26,000 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 mrem
Radiation therapy (localized & fractionated) 6,000,000 mrem
• Radioactive material consists of atoms with
• The atoms spontaneously change (decay) to
more stable forms and emit radiation.
• A person who is contaminated has radioactive
material on his/her skin or inside his/her body
(e.g., inhalation, ingestion, or wound
• 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-Life
Time required for the body to eliminate half of the radioactive
material (depends on the chemical form)
• Effective Half-Life
The net effect of the combination of the physical and 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%
Radionuclide Half-Life Activity Use
Cesium-137* 30 yrs 1.5 x 106
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
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
* Potential use in radiological dispersion device
Examples of Radioactive Materials
Types of Radiation Hazards
• External Exposure -
Whole-body or partial-body
(no radiation hazard to EMS
• Contaminated -
– External radioactive
material: on the skin
– Internal radioactive
through skin or wounds
Causes of Radiation Exposure/Contamination
– Nuclear reactor
– Medical radiation therapy
– Industrial irradiator
– Lost/stolen medical or industrial radioactive
• Terrorist Event
– Radiological dispersal device (dirty bomb)
– Attack on or sabotage of a nuclear facility
– Low-yield nuclear weapon
Scope of Event
Event Number of Deaths Most Deaths Due to
size of explosion and
proximity of persons)
(e.g., tens of thousands in
an urban area even from
0.1 kT weapon)
(Depends on Distance)
Minimize time spent near radiation sources.
Reducing Radiation Exposure
Maintain maximal practical
distance from radiation source.
Place radioactive sources in a
To Limit Caregiver Dose to 5 rem
Distance Rate Stay time
1 ft 12.5 R/hr 24 min
2 ft 3.1 R/hr 1.6 hr
5 ft 0.5 R/hr 10 hr
8 ft 0.2 R/hr 25 hr
• Contamination is easy to detect and most of it can be
• It is very unlikely that ED staff will receive large
radiation doses from treating contaminated patients.
Protecting Staff from Contamination
• Follow universal precautions.
• Survey hands and clothing
with radiation meter.
• Replace contaminated gloves or
• Keep the work area free of
Mass Casualties, Contaminated but
Uninjured People, and Worried Well
• An incident caused by nuclear terrorism may create large
numbers of contaminated people who are not injured and
worried people who may not be injured or contaminated.
• Measures must be taken to prevent these people from
overwhelming the emergency department.
• A triage site should be established outside the ED to intercept
such people and divert them to appropriate locations.
– Triage site should be staffed with medical staff and security
– Precautions should be taken so
that people cannot avoid the triage
center and reach the ED.
• Establish a decontamination center for people who
are contaminated, but not significantly injured.
– Center should provide showers for many people.
– Replacement clothing must be available.
– Provisions to transport or shelter people after
decontamination may be necessary.
– Staff decontamination center with medical staff with a
radiological background, health physicists or other staff
trained in decontamination and use of radiation survey
meters, and psychological counselors.
• 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
• Establish a center to provide psychological support to such
• Set up a center in the hospital to provide psychological support
• Activate hospital plan:
– Obtain radiation survey meters.
– Call for additional support: Staff from Nuclear Medicine, Radiation
Oncology, Radiation Safety (Health Physics).
– Establish area for decontamination of uninjured persons.
– Establish triage area.
• 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.
– For transport of contaminated patients into ED, designate separate
entrance, designate one side of corridor, or transfer to clean gurney
before entering, if time allows.
Treatment Area Layout
Detecting and Measuring Radiation
– 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 and digital)
Patient Management - Priorities
• Medical triage is the highest priority.
• Radiation exposure and contamination
• Degree of decontamination is dictated
by number of and capacity to treat
other injured patients.
Patient Management - Triage
Triage based on:
• Signs and symptoms - nausea,
vomiting, fatigue, diarrhea
• History - Where were you when
the bomb exploded?
• Contamination survey
Patient Management - Decontamination
• Carefully remove and bag patient’s clothing and
personal belongings (typically removes 95 percent
• Survey patient and, if practical, collect samples.
• Handle foreign objects with care until proven
nonradioactive with survey meter.
• Decontamination priorities:
– Decontaminate wounds first, then intact skin.
– Start with highest levels of contamination.
• Change outer gloves frequently to minimize spread
Patient Management - Decontamination (Cont.)
• Protect noncontaminated 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.
• 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
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
– Before intact skin becomes abraded.
• Contaminated thermal burns
– Gently rinse. Washing may increase severity of injury.
– Additional contamination will be removed when dressings
• Do not delay surgery or other necessary medical
procedures or exams . . . residual contamination can
• 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 Route
Cesium-137 Prussian blue Oral
Iodine-125/131 Potassium iodide Oral
Strontium-90 Aluminum phosphate Oral
Americium-241/ Ca- and Zn-DTPA IV infusion,
Patient Management - Patient Transfer
Transport injured, contaminated
patient into or from the ED:
• Cover clean gurney with two
• Lift patient onto clean gurney.
• Wrap sheets over patient.
• Roll gurney into ED or out of
• Remove waste from the emergency department and
• Survey facility for contamination.
• Decontaminate as necessary:
– Normal cleaning routines (mop, strip waxed floors) typically
– 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.
• Occurs only in patients who have received very high
radiation doses (greater than approximately 100 rem)
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
Acute Radiation Syndrome
• Prodromal Stage
– Symptoms may include 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
Acute Radiation Syndrome (Cont.)
For Doses > 100 rem
Time of Onset
Severity of Effect
• Dose ~100 rem
– ~10 percent exhibit nausea and vomiting within 48 hrs
– mildly depressed blood counts
• Dose ~350 rem
– ~90 percent exhibit nausea/vomiting within 12 hrs, 10 percent exhibit diarrhea within 8
– severe bone marrow depression
– ~50 percent mortality without supportive care
• Dose ~500 rem
– ~50 percent mortality with supportive care
• Dose ~1,000 rem
– 90-100 percent mortality despite supportive care
Acute Radiation Syndrome (Cont.)
Hematopoietic Component - latent period from weeks to days
• Dose > 1,000 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, and severe hypotension
– collapse of cardiovascular system and CNS
– fatal within 24 to 72 hours
Acute Radiation Syndrome (Cont.)
Gastrointestinal and CNS Components
• 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)
• Treat symptomatically. Prevention and management
of infection is the primary objective.
– Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hours)
– Irradiated blood products
– Antibiotics/reverse isolation
• Seek the guidance of experts.
– Radiation Emergency Assistance Center/Training Site (REAC/TS)
– Medical Radiobiology Advisory Team (MRAT)
Treatment of Large External Exposures
• Skin - No visible injuries < 100 rem
– Main erythema, epilation >500 rem
– Moist desquamation >1,800 rem
– Ulceration/Necrosis >2,400 rem
– Acute exposure >200 rem
– Chronic exposure >600 rem
• Permanent Sterility
– Female >250 rem
– Male >350 rem
Localized Radiation Effects - Organ System
• High radiation dose and trauma interact
synergistically to increase mortality.
• Close wounds on patients with doses > 100 rem.
• Wound care, 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
Chronic Health Effects from Radiation
• Radiation is a weak carcinogen at low doses.
• There are no unique effects (type, latency, pathology).
• Natural incidence of cancer is ~40 percent;
mortality ~25 percent.
• Risk of fatal cancer is estimated as ~5 percent per 100
• A dose of 5 rem increases the risk of fatal cancer
by ~0.25 percent.
• A dose of 25 rem increases the risk of fatal cancer
by ~1.25 percent.
What Are the Risks to Future Children?
• Magnitude of hereditary risk per rem is ~10 percent that
of fatal cancer risk.
• Risk to caregivers who would likely receive low doses is
very small; 5 rem increases the risk of severe hereditary
effects by ~0.02 percent.
• Risk of severe hereditary effects to a patient population
receiving high doses is estimated as ~0.4 percent per
No 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
•Impaired mental ability
•Growth retardation with higher
•Increased childhood cancer
risk (~0.6 percent per 10 rem)
• Medical stabilization is the highest priority.
• Train/drill to ensure competence and confidence.
• Preplan to ensure adequate supplies and survey
instruments are available.
• Universal precautions and decontaminating patients
minimize 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.
• Radiation Emergency Assistance Center/Training Site (REAC/TS),
• Medical Radiobiology Advisory Team (MRAT) Armed Forces Radiobiology
Research Institute (AFRRI), 301-295-0530, www.afrri.usuhs.mil
– Medical Management of Radiological Casualties Handbook, 2003; and
Terrorism with Ionizing Radiation Pocket Guide
• Web sites:
– http://remm.nlm.gov/ - Radiation Event Medical Management by Department
of Health & Human Services
– http://emergency.cdc.gov/radiation/ - Response to Radiation Emergencies by
the Centers for Disease Control and Prevention
– www.acr.org - “Disaster Preparedness for Radiology Professionals” by the
American College of Radiology, (search for “disaster” on website)
– www1.va.gov/emshg - Medical Treatment of Radiological Casualties
– Gusev I, Guskova A, Mettler F, eds. Medical management of radiation accidents, 2nd
ed. Boca Raton, FL: CRC Press; 2001.
– Mettler F, Upton A. Medical effects of ionizing radiation, 2nd
– The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference,
– National Council on Radiation Protection and Measurements. Management of
persons accidentally contaminated with radionuclides. Bethesda, MD: NCRP; NCRP
Report No. 65.
– National Council on Radiation Protection and Measurements. Management of
terrorist events involving radioactive material. Bethesda, MD: NCRP; NCRP Report
– Mettler F, Voelz G. Major radiation exposure - What to expect and how to respond.
New England Journal of Medicine 346:1554-1561; 2002.
– Waselenko J, et.al. Medical management of the acute radiation syndrome:
Recommendations of the strategic national stockpile radiation working group. Annals
of Internal Medicine 140:1037-1051; 2004.
– Gerber GB, Thomas RG, eds. Guidebook for the treatment of accidental internal
radionuclide contamination of workers. Radiation Protection Dosimetry. 41:1; 1992.
Prepared by the Medical Response Subcommittee of the National
Health Physics Society Homeland Security Committee.
Jerrold T. Bushberg, PhD, Chair
Kenneth L. Miller, MS
Marcia Hartman, MS
Robert Derlet, MD
Victoria Ritter, RN, MBA
Edwin M. Leidholdt, Jr., PhD
Fred A. Mettler, Jr., MD
Niel Wald, MD
William E. Dickerson, MD
Appreciation to Linda Kroger, MS, who assisted in this effort.