In-Depth Medical Management for Nuclear

1. In-Depth Medical Management for Nuclear/Radiological/Conventional Terrorism Agents Editorial Board Fun Fong, MD, FACEP, Senior Medical Officer GA-3 DMAT, ACEP Section of Disaster Medicine Cham E. Dallas, Ph.D. , Professor & Director, Interdisciplinary Toxicology Program and Center for Leadership in Education and Applied Research in Mass Destruction Defense, University of Georgia Lorris G. Cockerham, Ph.D., DABFE, Lt. Col. (ret) USAF, Former Division Chief, Armed Forces Radiobiology Institute

2. Overview Nuclear Scenario Effects Radiation Injury Acute Radiation Syndrome External Contamination Internal Contamination Summary

3. Potential Nuclear/Radiological Hazards in the U.S. Simple Radiological Device �Dirty� Conventional Bomb (RDD) Improvised Nuclear Device (IND) 1kT backpack bomb Terrorist Nation Ballistic Missle Attack 300 MT Bomb 100 mi over Kansas for EMP

4. Diversion of Nuclear Weapons 50 - 100 1 kT Suitcase Nuclear Weapons Unaccounted For

5. Energy Partition

9. Scenario: Washington Mall

10. Effective Range For Blast Energy1 kT Weapon

11. Effective Range For Blast Energy1 kT Weapon

12. Effective Range For Thermal Energy1 kT Weapon

13. Safe Separation Distances for Eye Injuries1 kT Weapon

14. Overview Conventional Weapon Terrorism Not a Scenario: weapons of choice world-wide Small arms, manufactured ordnance, & improvised 5 criminal bombings daily in US >> 99% of all terrorist attacks Small Arms � high- and low-velocity Ordnance � military weapons-grade High-order explosives = overpressure blast wave Improvised Explosive Devices (IEDs) Hand-made or extemporized, 75% low-order explosives Minimal blast wave, more survivable burns More injuries, fewer fatalities vs. ordnance

15. Overview Conventional Weapon Terrorism Lessons learned from prior wars can not be easily applied Terrorist weapons target non-combatant with varied demographics Civilians have inconsistent preparation, protection, and access to acute- and long-term physical care and behavioral support Similarities with radiological weapon injuries supports cross-preparedness for both Ordnance over-pressurization injuries will be similar to injuries from nuclear devices Both IEDs and nuclear devices can produce substantial thermal injuries Dirty grossly contaminated wounds will be the rule rather than the exception

16. Take-home Message: Local Preparedness for the Conventional Weapon Threat Avoid Primary Wound Closure Delayed primary closure of contaminated wounds is critical for optimal outcome for individual victim Establish Regional Systems of Trauma Care Inclusive systems of organized and coordinated trauma care from scene to rehabilitation if needed. Expedited emergency transfers and referrals Critical for the optimal outcome of the community Right patient to right hospital in right amount of time Immediate benefit to the community

17. What is Fallout? A complex mixture of over 200 different isotopes of 36 elements 2 oz of fission products formed for each kT of yield. Size < 1 micron to several mm.

18. Early Fallout That which reaches the ground during the first 24 hours after detonation Early fallout fraction 50-70% of total radioactivity

19. Delayed Fallout Arrives after the first day, very fine invisible particles which settle in low concentrations over a considerable portion of the earth�s surface 40% of total radioactivity

20. Bikini Atoll (1 Mar 1954) 15 MT Thermonuclear Detonation Fallout Population Affected: 300 in Public Domain Int / Ext Contamination Local Radiation Injury Mild ARS Thyroid Injury

21. Ionizing Radiation

23. Acute Radiation Syndrome Systemic Effects of Radiation: Prodromal Hematologic Gastronintestinal Pulmonary Cutaneous Neurovascular Combined Injury

24. Prodromal Component(0.5 - 3 Gy and higher) Immediate Effect of Cell Membrane Damage Mediated by Inflammatory Elements of Cell Destruction Mediated Neurologically by the Parasympathetic System

25. Gastrointestinal Component(8 - 15 Gy and higher) Symptoms Mechanisms Stem Cell Sterilization - 15 Gy

26. Respiratory Component(5 - 310 Gy and higher) Sensitive from Highly Vascular Tissue Endothelial Cells Type II Alveolar Cell Effect is dose-rate related Pneumonitis Fibrosis

27. Radiation Skin Injury .75 Gy - Hair Follicles Change 3 Gy - Epilation 6 Gy - Erythema 10 Gy - Dry Desquamation 20 Gy - Wet Desquamation (Transepithelial Injury)

33. Distribution of Injuries in aNuclear Detonation

34. Neurovascular Component 1 - 6 Gy - Glial cell damage 10 Gy - Morphologic changes 10 - 20 Gy - Vascular lesions 40 Gy - White matter necrosis 60 Gy - Demyelinization

35. Summary of Deterministic Effects

36. Hemogram(300 cGy TBI Exposure)

38. Andrews Lymphocyte Nomogram Absolute Lymphocyte Count over 48 hours Confirms Significant Radiation Exposure

40. Priorities in Combined-Injury Triage When Radiation Doses are Known

41. Surgical Recommendations Based on Immunocompetence Status Life-Saving / Major Surgery within 36 - 48 h Elective Procedures until 45 - 60 days Following Hematopoietic Recovery

42. Hot | Warm | Cold Zones

43. Terrorism Modification of Hot Zone Larger Secured Hot Zone Casualty Collection Point in Safe Area Clean / Contaminated Staging Areas

44. Decontamination Equipment Hospital Surgical Gown (waterproof) Cap, Face Shield, Booties (waterproof) Double Gloves (inner layer taped) Pencil Dosimeters, TLDs, Survey Meters Drapes Plastic Bags Butcher Paper Large Garbage Cans Radiation Signs and Tape

45. Decontamination Team Provider (RN / PA / MD) HP Tech Decon Assistant (ED Tech) Circulator Scribe Nurse HP Tech #2

46. Decon Agents - 1 Dry Removal Soap / Shampoo Household Bleach 1:10 (Sodium Hypochlorite) Waterless Cleansers

47. Decon Agents - 2 Povidone-Iodine Lava Soap Cornmeal / Tide 50:50 Vinegar ( 32P ) or Club Soda Toothpaste

48. When Do I Stop? When No More Comes Off! Stop Levels: 1 mR / h beta 1000 dis / min alpha (air proportional counter w / 60cm2 Window) If Committed Dose will Not Exceed 15 rem / yr to Skin Isolate w / Bag & Continue Decon Next Day

49. Mass Casualty Planning Relies on Avenues of Self-Decon More than Finding Shower Facilities

50. Treat the Patient before the Poison Prevent or Reduce Exposure Enhance the Elimination of the Agent Consider Specific Adjuncts and Antidotes 4 Golden Rules of Toxicology

51. The Dose makes the Poison Acute (Threshold Effects) Long-Term Toxicity ALI / MPBB < 1 ALI - No Treatment Necessary 1 - 10 ALI - Consider Short-Term Tx > 10 ALI - Treatment Radiation Accidents can Pose Toxicology Problems

52. Internal Contamination Involves 4 Stages Deposition Along Route of Entry Translocation Deposition in Target Organ Clearance

53. Schematic Model of Radionuclide Uptake(After Voelz)

54. RN Therapeutic Interventions Plutonium / Transuranics - DTPA Cesium - Insoluble Prussian Blue Uranium - Alkalinization of Urine Radioiodine - Radiostable Iodine Tritium - Radiostable Water Fission Products (Fallout) - Combination

55. Retention Organ Control DTPA Treated Liver 14% 0.47% Skeleton 57.0% 5.9% DTPA Administered for Soluble 239Pu Within One Hour

56. Insoluble Prussian Blue Effective for Cs-137 Binds Ions in the Gut Biological Half-Life Reduced to 1/3 Not Systemically Absorbed Side Effects - Constipation, GI Upset at Higher Doses (20 g / day)

57. Uranium - Alkalinize Urine 235U - 186 keV Gamma Eff Half Time Depends on Solubility At Normal Enrichment Levels, Primary Renal Toxicity Maintain Urine pH 7.5 to 8 Use Bicarbonate tablets (Do not use Alka Seltzer from old texts!) Use Supplimental KCl tablets to maintain alkaline diuresis

58. Iodine / Technetium - Block 131I - Eff Half Life = 7.6 days 99mTc - Eff Half Life = 1 day* Treat within 4 Hours ( Best 1 Hour Before Exposure! ) KI or NaI 300 mg tablet SSKI (1 g / ml) - 5 - 6 drops in water Povidone Iodine Theoretically Useful

59. Tritium - Dilute Beta Emitter - 5.7 keV (18 keV Max) 2% Binds to Cellular Components Essentially Occupies TBW Space Force Fluids 3 - 4 L / day Reduces Half-Time by 1/3 - 1/2

60. Radiostrontium Contamination Therapy Al Phosphate (100 ml) Reduces Absorption as much as 85% Ba Sulfate Na Alginate Inhibits Uptake by Factor 8 - 10 10 g po Ca Competes with Sr given po / IV Ammonium Chloride po provides Synergy for max effect

61. Fission Products (Fallout)from Safety Series 47 Wounds � Apply potassium rhodizonate (1 g) Inhalation / Ingestion - Calcium Alginate (10 g) Potassium Iodide (130 mg) Prussian Blue (1 g) DTPA (1 g)

62. Radiation Accident Medical Response - Individual Data-Gathering Resource Management Contamination Control Medical Care ( Compromised? ) Radiation Toxicity Issues Contamination Issues Systemic Issues Toxicological Issues Disposition Issues

63. Radiation Accident Medical Response - Large Scale Establish Credibility of Incident Health Physics Support for Dose Estimates Contamination Precautions Assess Patients for Systemic Effects Determine Need for Decorporation Therapy Record Patient Data for Follow-up

64. Lessons Learned

65. All that is Necessary for the Triumph of Evil

66. References - 1 Walker RI, Cerveny TJ Eds., Medical Consequences of Nuclear Warfare, TMM Publications, Falls Church, 1989. Brill AB Ed: Low Dose Radiation Effects: A Fact Book, New York, Society of Nuclear Medicine 1982; p1-5. Kathren RL Ed: Principles and Application of Collective Dose in Radiation Protection, NCRP Report 121. Bethesda MD, National Council on Radiation Protection and Measurements, 1995; p65. "Nonstochastic Effects of Ionizing Radiation," Annals of the ICRP , ICRP Publication 41. New York, Pergamon Press, 1984;p.2. After REAC/TS Videotape - Hospital Management of Radiation Accidents, Oak Ridge, TN, Oak Ridge Associated Universities, 1980. Wheater RH Ed: A Guide to the Hospital Management of Injuries Arising from Exposure to or Involving Ionizing Radiation. Chicago, American Medical Association, 1984; pp.4-5.

67. References - 2 Mettler FA, Ricks RC Medical Management of Radiation Accidents. Contemp Diag Radiol 1982,5:8;p1. Agency for Toxic Substances Disease Registry (ATSDR). Managing Hazardous Materials Incidents, Vol. I-III. US Dept. Of Health and Human Services, 1992. Mettler FA, Kelsey, Ricks RC Eds: Medical Management of Radiation Accidents. Boca Raton, FL, CRC Press, 1990. The Radiological Accident in Goi�nia, Vienna, IAEA, 1988; p.2. Saenger, E.L., Andrews, G.A., Linnemann, R.E., Wald, N., Radiation Accident Preparedness, Medical and Managerial Aspects, Science-Thru-Media, Inc., New York, NY, 1981. Nishiyama H, Lukes SJ, Saenger EL: Low-Level Internal Radionuclide Contamination: Use of Gamma Camera for Detection. Radiol 1984 150:1, pp 235-40.

68. References - 3 Nishiyama H, Saenger EL, Grossman LW, Lukes SJ. Accidental Cs-137 Contamination. Radiol 1985 154:2, pp 513-7. Voelz G Ed: Management of Persons Accidentally Contaminated with Radionuclides, NCRP Report 65. Bethesda MD, National Council on Radiation Protection and Measurements, 1980. Gerber GB, Thomas RG Eds:"Guidebook for the Treatment of Accidental Inernal Radionuclide Contamination of Workers" Radiation Protection Dosimetry (1992) 41:1. Barabanova A. REAC/TS Newsletter. Winter 1992, Oak Ridge, TN, p 1-2. Andrews GA, Auxier JA, Lushbaugh CC, "The Importance of Dosimetry to the Medical Managment of Persons Accidentally Exposed to High Levels of Radiation," in Personnel Dosimetry for Radiation Accidents, International Atomic Energy Agency (IAEA), Vienna, pp 3-16, 1965.

69. References - 4 Roberts GB, Col - �Nuclear Weapons-Grade Fissile Materials - The Most Serious Threat to US National Security Today?� Airpower Journal, Special Edition 96 Academy of Health Sciences, US Army �Medical Aspects of Nuclear Weapons and Their Effects on Medical Operations� subcourse MED447, Jun 1990 Aldridge JP �The Role of Health Physicists in Contemporary Radiological Emergency Response� Master�s Thesis, Georgia Tech, Mar 1998 The Threat of Nuclear Diversion. Statement for the Record by John Deutch, Director of the Central Intelligence to the Permanent Subcommittee on Investigations of the Senate Committee on Government Affairs, 20 Mar 1996.