It has been concluded that the management of radiation accidents is a very challenging process and that nuclear medicine physicians have to be well organized in.

1. Emergency Department Management
of Radiation Casualties
CAUTION

2. 1
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
training.
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
jtbushberg@ucdavis.edu.
Version 2.9

3. 2
Scope of Training
• Characteristics of ionizing radiation and
radioactive materials
• Differentiation between radiation exposure
and radioactive material contamination
• Staff radiation protection procedures
and practices
• Facility preparation

4. 3
Scope of Training (Cont.)
• Patient assessment and management of
radioactive material contamination and
radiation injuries
• Health effects of acute and chronic radiation
exposure
• Psychosocial considerations
• Facility recovery
• Resources

5. 4
Ionizing Radiation
• Ionizing radiation is radiation capable of
imparting its energy to the body and causing
chemical changes.
• Ionizing radiation is emitted by:
- Radioactive material.
- Some devices such as x-ray machines.

6. 5
Types of Ionizing Radiation
Alpha Particles
Stopped by a sheet of paper
Beta Particles
Stopped by a layer of clothing
or less than an inch of a substance
(e.g. plastic)
Gamma Rays
Stopped by inches to feet of concrete
or less than an inch of lead
Radiation
Source

7. 6
Measure of
Amount of
radioactive material
Ionization in air
Absorbed energy
per mass
Absorbed dose
weighted by type of
radiation
Radiation Units
For most types of radiation 1 R  1 rad  1 rem
Quantity
Activity
Exposure
Absorbed
Dose
Dose
Equivalent
Unit
curie (Ci)
roentgen (R)
rad
rem

8. 7
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

9. 8
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 his/her skin or inside his/her body
(e.g., inhalation, ingestion, or wound
contamination).

10. 9
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-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%

11. 10
Physical
Radionuclide Half-Life Activity Use
Cesium-137* 30 yrs 1.5 x 106 Ci Blood 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

12. 11
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
External
Exposure
Internal
Contamination
External
Contamination

13. 12
Causes of Radiation Exposure/Contamination
• Accidents
– Nuclear reactor
– Medical radiation therapy
– Industrial irradiator
– Lost/stolen medical or industrial radioactive
sources
– Transportation
• Terrorist Event
– Radiological dispersal device (dirty bomb)
– Attack on or sabotage of a nuclear facility
– Low-yield nuclear weapon

14. 13
Scope of Event
Event Number of Deaths Most Deaths Due to
Radiation
Accident
None/Few Radiation
Radioactive
Dispersal
Device
Few/Moderate
(Depends on
size of explosion and
proximity of persons)
Blast Trauma
Low-Yield
Nuclear Weapon
Large
(e.g., tens of thousands in
an urban area even from
0.1 kT weapon)
Radiation Exposure
Blast Trauma
Thermal Burns
Fallout
(Depends on Distance)

15. 14
Time
Minimize time spent near radiation sources.
Radiation Protection
Reducing Radiation Exposure
Distance
Maintain maximal practical
distance from radiation source.
Shielding
Place radioactive sources in a
lead container.
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

16. 15
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
• Follow universal precautions.
• Survey hands and clothing
with radiation meter.
• Replace contaminated gloves or
clothing.
• Keep the work area free of
contamination.

17. 16
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
personnel.
– Precautions should be taken so
that people cannot avoid the triage
center and reach the ED.

18. 17
Decontamination Center
• 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.

19. 18
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.
• Establish a center to provide psychological support to such
people.
• Set up a center in the hospital to provide psychological support
for staff.

20. 19
Facility Preparation
• 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.

21. 20
Contaminated
Waste
Waste
Treatment Area Layout
Radiation
Survey
HOT
LINE
STEP
OFF
PAD
CONTAMINATED
AREA
BUFFER
ZONE
CLEAN
AREA
Radiation
Survey
& Charting
ED
Staff
Clean
Gloves, Masks,
Gowns, Booties
Separate
Entrance
Trauma Room

22. 21
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 and digital)

23. 22
Patient Management - Priorities
Triage
• Medical triage is the highest priority.
• Radiation exposure and contamination
are secondary considerations.
• Degree of decontamination is dictated
by number of and capacity to treat
other injured patients.

24. 23
Patient Management - Triage
Triage based on:
• Injuries
• Signs and symptoms - nausea,
vomiting, fatigue, diarrhea
• History - Where were you when
the bomb exploded?
• Contamination survey

25. 24
Patient Management - Decontamination
• Carefully remove and bag patient’s clothing and
personal belongings (typically removes 95 percent
of contamination).
• 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
of contamination.

26. 25
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
decontamination.

27. 26
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.

28. 27
• 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 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,
Plutonium-239/ nebulizer
Cobalt-60

29. 28
Patient Management - Patient Transfer
Transport injured, contaminated
patient into or from the ED:
• Cover clean gurney with two
sheets.
• Lift patient onto clean gurney.
• Wrap sheets over patient.
• Roll gurney into ED or out of
treatment room.

30. 29
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.

31. 30
• 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
Radiation Sickness
Acute Radiation Syndrome

32. 31
• 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
– Hematopoietic
– Gastrointestinal
– CNS
Acute Radiation Syndrome (Cont.)
For Doses > 100 rem
Time of Onset
Severity of Effect

33. 32
• 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 hrs
– 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

34. 33
• 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
within minutes
– collapse of cardiovascular system and CNS
– fatal within 24 to 72 hours
Acute Radiation Syndrome (Cont.)
Gastrointestinal and CNS Components

35. 34
• 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
– Electrolytes
• Seek the guidance of experts.
– Radiation Emergency Assistance Center/Training Site (REAC/TS)
– Medical Radiobiology Advisory Team (MRAT)
Treatment of Large External Exposures

36. 35
• 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

37. 36
Special Considerations
• 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
Emergency
Surgery
Hematopoietic Recovery
No Surgery
After adequate
hematopoietic recovery
Surgery
Permitted

38. 37
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
rem.
• 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.

39. 38
What Are the Risks to Future Children?
Hereditary Effects
• 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
100 rem.

40. 39
Fetal Irradiation
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
• Teratogenic effects
• Growth retardation
• Impaired mental ability
• Growth retardation with higher
doses
• Increased childhood cancer
risk (~0.6 percent per 10 rem)
<2
2-7
7-40
All
Pre-implantation
Organogenesis
Fetal
Weeks After
Fertilization
Period of
Development Effects

41. 40
Key Points
• 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.

42. 41
Resources
• Radiation Emergency Assistance Center/Training Site (REAC/TS),
865-576-1005, www.orise.orau.gov/reacts
• 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

43. 42
Resources
• Books:
– 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 ed. Philadelphia:
Saunders; 1995.
– The Medical Basis for Radiation-Accident Preparedness; REAC/TS Conference,
2002.
– 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
No. 138.
• Articles:
– 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.

44. 43
Acknowledgments
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
Consultants
Fred A. Mettler, Jr., MD
Niel Wald, MD
William E. Dickerson, MD
Appreciation to Linda Kroger, MS, who assisted in this effort.

45. 44
 Health Physics Society* Version 2.9
Disclaimer: The information contained herein was current as of May 9, 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 non profit scientific professional organization whose
mission is to promote the practice of radiation safety. Since its formation in 1956, the
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