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Hospital Management of Nuclear Casualties

Hospital Management of Nuclear Casualties. Terminal Objective. Recognize the various types of radiological hazards, understand the acute health effects from radiation exposure, hospital procedures for managing exposed and/or contaminated patients, and know how to use radiation protection.

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Hospital Management of Nuclear Casualties

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  1. Hospital Management of Nuclear Casualties

  2. Terminal Objective Recognize the various types of radiological hazards, understand the acute health effects from radiation exposure, hospital procedures for managing exposed and/or contaminated patients, and know how to use radiation protection.

  3. Terrorist Use of Nuclear Material • Terrorist use of nuclear materials • Simple radiological device • Radiological dispersal device • Reactor • Improvised nuclear device • Nuclear weapon

  4. The Basics of Radiation • Ionizing radiation is electromagnetic energy or energetic particle emitted from a source. • Ionizing radiation is able to strip electrons from atoms causing chemical changes in molecules.

  5. The Basics of Radiation Biological Molecular Damage Biological Damage Chemical Damage Free Radicals 10-10 Seconds Cells, tissues, whole animals Hours to years 1. Proteins 2. Membrane 3. DNA Seconds to hours

  6. Ionizing Radiation - Alpha • 2 neutrons and 2 protons • Highly ionizing • Travels several centimeters in air and a few microns in tissue • Component of nuclear fallout • Stopped by a thin paper or clothing • Threat is inhalation or absorption of alpha emitter in wounds

  7. Ionizing Radiation - Beta • High energy “electron” emitted from nucleus • Can have wide range of energies depending upon the particular radionuclide • Moderately penetrating • Up to a few meters in air • Millimeters in tissue • Some protection by PPE

  8. Gamma or X-Ray (Photons) • High energy rays • Very penetrating • Difficult to shield • Can be produced from radioactive decay and a nuclear weapon explosion or reactor accident • PPE will not protect against photon radiation

  9. Ionizing Radiation - Neutrons • Neutral particle emitted from the nucleus • Can be very penetrating • Requires special consideration for shielding

  10. Radiation Detection • Instrumentation • G.M. Survey Meter • Dose Rate Meter - Ionization Chamber • Alpha Meter • Neutron Meter • Personal Dosimeters • Film Badge • Thermoluminescent Dosimeter • Quarts Fiber Dosimeter • Electronic Instantaneous Read Out Dosimeter

  11. Radiation - Units of Measure • rad - basic unit for measuring radiation • rem - quantifies the amount of damage that is suspected from a particular type of radiation dose

  12. Radiation - Units of Measure X-RAY 100 rads = 100 rem BETA 100 rads = 100 rem GAMMA 100 rads = 100 rem NEUTRONS 10 rads x QF10 = 100 rem ALPHA 5 rads x QF20 = 100 rem

  13. Examples of Radioactive Materials SubstanceHalf LifeEmitUse Americium 241 458 years a, g Smoke Detectors Cobalt 60 5.3 years b, g Medical Therapy Plutonium 238 87 years a Thermoelectric Gen. Plutonium 239 24,400 yrs a Reactors and Weapons Radium 226 1,620 yrs a Medical Therapy Uranium (natural) millions yrs a,b, g Reactors and Weapons Iridium 192 74 days b, g Industrial Radiography

  14. Radiation Half-Life • Time required for a radioactive substance to lose half of its radioactivity • Each radionuclide has a unique half-life • Half-lives range from extremely short (fraction of a second) to millions of years Examples: Tc-99m 6.0 hrs I-131 8.05 days Co-60 5.26 yrs Sr-90 28.1 yrs Pu-239 24,400 yrs U-238 4,150,000,000 yrs

  15. Natural Background Radiation Natural background and manmade radiation 360 mrem Diagnostic chest x-ray 10 mrem Flight from LA to Paris 4.8 mrem Barium enema 800 mrem Smoking 1.5 ppd - 1 year dose 16,000 mrem Heart catheterization 45,000 mrem Mild acute radiation sickness 200,000 mrem LD50 for irradiation 450,000 mrem mrem = millirem = 1/1000 of a rem

  16. Radiation Protection Principles • Time • Distance • Shielding • Quantity

  17. Types of Radiation Injury • External irradiation - whole-body or partial-body • Contamination by radioactive materials - external (deposited on the skin) or internal (inhaled, swallowed, absorbed through skin, or introduced through wounds) • Incorporation of radioactive materials - uptake by body cells, tissues, or organs (bone, liver, kidney, etc) • Combined radiation injury - combination of the above complicated by trauma.

  18. Radiation Injury - Contamination External Internal

  19. Radiation Injury - Incorporation Thyroid Lung Liver Bone

  20. Radiation - LD50 • We know what radiations are produced • We know how to measure them • But the body senses cannot detect radiation. Therefore, how can we measure the biological damage? • LD50/30 Animals • LD50/60 Man

  21. Examples of LD50 for Given Species SpeciesDose (rads) • Guinea Pigs 250 LD 50/30 • Goat 350 LD 50/30 • Man 250-450 (LD 50/60) • Mouse 570 LD 50/30 • Rat 550-800 LD 50/30 • Frog 700 LD 50/30 • Snail 8,000-20,000 LD 50/30

  22. Severity of Injury The higher the dose, the more severe the early effects and the greater the possibility of delayed effects

  23. Survival Time Survival Time Hematopoietic Gastrointestinal CNS/ CVS 200 Rads 2 Gy 1000 Rads 10 Gy 100,000 Rads 100 Gy

  24. Acute Radiation Syndrome (ARS) • Group of symptoms that develop after total body irradiation (> 100 rads) • May occur from either internal or external radiation • Four important factors are: • High Dose • High Dose Rate • Whole Body Exposure • Penetrating Radiation

  25. ARS - Phases • 1. Prodromal Phase - occurs in the first 48 to 72 fours post-exposure and is characterized by nausea, vomiting, and anorexia. At doses below about 500 rads last 2 to 4 days. • 2. Latent Phase - follows the prodromal phase and lasts for approximately 2 to 2 1/2 weeks. During this time, critical cell populations (leukocytes, platelets) are decreasing as a result of bone marrow insult. The time interval decreases as the dose increases. • 3. Illness Phase - period when overt illness develops • 4. Recovery or Death Phase - may take weeks or months

  26. ARS - Hematopoietic Syndrome 3.0 2.5 Normal Range 2.0 Absolute Lymphocytes (109/L) 1.5 Moderate 1.0 Severe Patient Injury 0.5 Very Severe 0.1 Lethal 0 3 6 17 24 48 hrs

  27. ARS - Blood Count RBC Cell Reduction Neutrophils Lymphocytes Platelets 24-hr 1 week 2 weeks 3 weeks

  28. ARS - Gastrointestinal Syndrome • Radiation > 600 rads • Damages intestinal lining • Nausea and vomiting within the first 2 - 4 hours • May develop diarrhea • Associated with sepsis and opportunistic infections • At 10 days could develop bloody diarrhea resulting in death

  29. ARS - Central Nervous System • Seen with radiation dose > 1,000 rads • Microvascular leaks Õ edema • Elevated intracranial pressure • Death within hours

  30. ARS - Skin Dry Desquamation Moist Desquamation Erythema Necrosis Epilation Response 300 600 1000 >1500 >5000 Dose

  31. ARS & Trauma • Radiation and Trauma = á Mortality • Wound and burn care, surgery, and orthopedic repair should be done in the first 48 hours or delayed for 2 to 3 months Emergency Surgery Hemopoietic Recovery No Surgery Surgery Permitted 24 - 48 Hours After 3 Months 3 Months

  32. Triage • Triage: • Use your own triage method • Ensure ABC’s • Stabilize the patient first and only when this is done does one consider irradiation and contamination.

  33. Classification, Treatment & Disposition • Patients are classified in three categories based on signs and symptoms: • Survival probable < 100 rads • Survival possible 200 - 800 rads • Survival improbable > 800 rads

  34. Evaluation & Treatment - Hospital Care • Activate hospital plan • Establish triage area • Plan to control contamination • Prepare area by cover/marking floor, control ventilation • Prepare staff by issuing protective clothing • Prepare for surveying • Establish area for storage of waste • Plan for decontamination of non-traumatized patients

  35. Hospital Care - Patient Arrival • Carefully remove and bag victim’s clothing and personal belongings • Survey patient and conduct biological sampling • Contaminated patients require decontamination • If patient has a wound, decontaminate it first, then decontaminate skin

  36. Decontamination • Irrigate open wounds and cover with sterile dressing • Soap and water showering (including hair) • Effective for mixed radiation/chemical contamination • Refer for any surgery

  37. Internal Contamination/Incorporation • Various medications can be used to limit uptake or facilitate removal of radioactive material • Numerous medications are approved by the FDA. Certain drugs are investigational and can be used in an emergency (i.e. Radiogardase [Prussian Blue] and DTPA) • NCRP 65

  38. Psychological Casualties • Mass Casualty Incident (MCI) caused by nuclear terrorism will create large numbers of concerned casualties who may not actually be injured or contaminated • Establishing counseling centers will prevent psychological casualties from overwhelming health care facilities

  39. Key Points • Pre-planning to ensure adequate supplies of PPE and survey instruments • Training to ensure competence at all levels • Rescue and treatment protocols vary little for radiation contamination • Donning PPE and decontaminating patients minimizes exposure risk • Early symptoms are an indication of the severity of the radiation dose • Treatment requires a unified effort

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