WMD test 3

Sources of Radiation

-Medical/research •Diagnostic imaging •X-rays •Radiopharmaceuticals, chemical/drug injected, ingested, or inhaled by a patient •Diagnostic tests •Blood flow, bone structure, heart, lung, kidney, and brain function •Therapeutic treatment •Brachytherapy = Using radioactive sources in close proximity to a tumor to kill cancer cells •Teletherapy = Using intense, focused beams of radiation to treat cancerous tumor growths(theoretically more safe) •Research sources •Pharmaceutical corporations •Academic institutions •Medical institutions •Small research and development companies •Genetic engineering •Forensic analysis Can put a radioactive isotope into a antibody and have the antibody bind to a very specific target. If you can put a antibody with a small radioactive isotope and direct it to the cell. •Industrial •Radioactive material and x-ray generating devices are used in a variety of industrial applications •Check welds and metal for flaws •Check concrete and asphalt compaction •Check soil density and moisture content •Density gauges •Fixed gauges on piping or tanks •Monitor flow in piping or fill level of sealed tanks •Measure thicknesses of material, such as paper or steel •X-ray equipment •Aviation and food processing industries •Irradiators •Calibrate instrumentation •Sterilize blood •Treat food products can "over cook" a sample •Fixed nuclear facilities •Commercial nuclear power plants •104 nuclear power plants in the United States •36 licensed research and test reactors operated by universities and national laboratories •Operate through the fission process and most use fuel made from uranium Nuclear Weapons •Improvised nuclear device (IND) almost impossible, •Crude nuclear device built from components of a stolen weapon or from scratch using nuclear material •Obstacles to nuclear attacks •Limited access to weapon-grade nuclear materials •Building a nuclear weapon is difficult •Crude nuclear weapons are typically very heavy and difficult to transport •Radiological Dispersal Device (RDD) •Intended to disperse radioactive material over a large area for malicious reasons •Not capable of producing a nuclear yield and is not an atomic bomb •Use an explosive device to disperse radioactive material and cause widespread contamination •Uses inexpensive, common items such as pressurized containers, fans, and mechanical devices to spread contamination •Radiological Exposure Device (RED) •Powerful gamma-emitting radioactive source that can be placed in a high-profile location •Used to expose a large number of people or a targeted individual to the intense radioactive source

Acute Radiation Dose

Acute radiation dose may result in a combination of symptoms occurring in stages during a period of hours to weeks after exposure. The picture shows a worker who picked up an industrial radiography source and carried it around in his back pants pocket. Hair Loss The higher the dose of radiation, the faster hair loss occurs. There is a 50% possibility of hair loss at 300,000 mrem. If the radiation dose does not exceed 300,000 mrem, it is possible that hair will grow back after 3 to 6 months. These pictures show victims from the Hiroshima and Nagasaki atomic bombings in World War II. Purpura Purpura is a round, purplish red spot, or bleeding under the skin, and is one of the symptoms of acute radiation sickness. Sore-throat and decay and ulceration of the gums around the teeth (necrotic gingivitis) became present. Radioactive boy scout- David Hahn obsessed with making and learning about radiation, tried to make a homemade breeder nuclear reactor, self sustaining fission . Parents were inattentive and not concerned about any of his experiments Alexander Litvinenko in the intensive care unit of University College London Hospital on November 20, 2006, three days before his death from radiation poisoning.Polonium, it is an alpha emitter, meaning that although it is highly radioactive, it cannot penetrate human skin or a sheet of paper. Polonium-210 emits 5,000 times more alpha particles than radium, and an amount the size of the period at the end of this sentence would contain about 3,400 times the lethal dose. A dose like the one that killed former Russian spy Aleksandr Litvinenko

Nomenclature

Americium Am Cesium Cs Cobalt Co Iodine I Iridium Ir Phosphorous P Plutonium Pu Strontium Sr Technetium Tc Uranium U

Designate the REA radiation emergency area

Area should be identified prior to event Appropriate REA should have the following characteristics: Proper size and layout Exclusive entry Minimal emergency department disruption Let hospital know first and then start trying to get people there •Proper Size and Layout -Should be large enough for one or more patients -REA should be expandable -REA should have the following: •Treatment Area •Ambulatory Decontamination Area •Proper Size and Layout -Features that should be considered when designating the location for the REA include the following: •Water Supply •Drainage •Lighting •Ventilation Public Address Systems Any situation, drainage should be downhill and contained, life saving takes priority over effects but you have to take time afterword to clean up. Have to have supplies and exclusion areas, only people in the exclusion area is emergency personnel and victims •Exclusive Entry -There should be a separate entrance and exit to the REA -Nothing should leave the REA until it has been surveyed and found to be free of contamination -If a contaminated person or object must leave the REA prior to decontamination, the contamination should be contained •Contamination Control -Handling procedures for contaminated patients are similar to strict isolation precautions -Provide prompt care while keeping exposure low and minimizing the spread of contamination -Care providers should dress in protective clothing reference pp 15a slide 9 for supplies for cleanup of patient

history

December 18, 1970, the Baneberry test nevada. Tomsk-7 Reprocessing Complex Seversk, soviet russia April 6, 1993 Three Mile Island Pennsylvania US March 28, 1979 Windscale fire of 10 October 1957 united kingdom Fukushima nuclear disaster Fukushima, Japan March 2011

Acute Exposure and Fatal Cancer

Dose (mrem) Percent 1,000 0.08 5,000 0.4 10,000 0.8 25,000 2.0 50,000 4.0 All this number does is raise our innate cancer rate up by X amount remember chart from EPA All about increasing or decreasing odds, is (normal chance) + (dose/percent x normal chance) Point out that this the chance due to an acute exposure (hours, or few days) to the whole body, and not the accumulated dose over years (chronic dose). This is the risk of a fatal cancer, not the just the risk that the person develops cancer. The 25,000 mrem dose is highlighted because that is the emergency response dose limit for lifesaving actions recommended by the Environmental Protection Agency (EPA). (These dose limits are discussed later in this lesson.) This estimate predicts that a responder who receives the emergency dose limit of 25-rem during a rescue operation, has about a 2% extra chance of dying of cancer. This person may get the cancer and die, for example 30 years from now and maybe not next year.

EPA Guidelines for Emergency Procedures

Dose Limit: Maximum radiation dose that a responder is allowed to receive. Purpose of Dose Limit: Allow responders to perform emergency actions, yet keep risk as low as possible EPA Guidelines for Emergency Procedures Dose limit is the maximum of radiation exposure that a responder is allowed to receive, depending on the circumstances (i.e., average citizen, radiological worker, emergency worker). The purpose of setting dose limits is to allow emergency responders to perform needed emergency actions, yet still keep the risk to the responders as low as possible. Note to instructor: For radiological workers, the Department of Energy (DOE) has established a whole body dose limit for routine exposures of five rem per year (5,000 mrem per year). Dose limit Emergency Activity Performed Condition 5,000 mrem All activities All activities during emergency 10,000 mrem Protecting major property Where lower dose not practicable 25,000 mrem Lifesaving or protection of large populations Where lower dose not practicable More than 25,000 mrem Lifesaving or protection of large populations Only on a volunteer basis to persons fully aware of the risks involved.

Chernobyl Reactor Accident

Explosion and resulting fire sent plume of radioactive fallout over an extensive geographical area •Resulted in the evacuation and resettlement of over 336,000 people •56 direct deaths mostly first responders died

Acute Radiation Effects Dose

Extreme limit for safety limit of 2 mrem Less than 30,000 mrem •No clinical symptoms Between 30,000 and 100,000 mrem •Possible loss of appetite, nausea, and vomiting •Temporary lowering of white cell count Between 100,000 and 250,000 mrem •Nausea, vomiting, diarrhea •No permanent disability Death may occur in some individuals at 120 rem. Between 250,000 and 500,000 mrem •Nausea, vomiting, diarrhea •Lethal Dose 50% in 60 days LD50/60 1,000,000 mrem •Severe nausea, vomiting, diarrhea •Death for almost all people •Lethal Dose 100% LD100 Advanced medical care may raise the LD50/60 level to 800,000 to 900,000 mrem

Response Team Preparation

Inside REA •Team Coordinator •Physician •Triage Officer •Nurse •Technical Recorder •Radiation Safety Officer Survey/Monitor Assistant Outside REA •Administration •Public Information Officer •Security •Engineering •Laboratory Tech •Have supplies available -Regular checks, re-supply Conduct drills regularly

Exposure and Contamination Control

Over(positive) pressure and under(negative) pressure, mainly thermal pulse and blast effects kills most people 10 worst nuclear disasters video Chernobyl releases 100 times more radiation than the ww2 bombs worst disaster in world

Ionizing Radiation 2

Physical change in atoms by making them electrically charged—called ionization

Radiation Burns- Chernobyl

Radiation doses up to 2,000,000 mrem 28 deaths within 4 months, followed by 19 more subsequently As you can see in the photo, the skin exposed to high doses of radiation may turn red and look "puffy." The reddening of the skin will occur quickly for doses more than 600,000 mrem. For lower doses, the reddening (erythema) may take hours or days. The lack of radiation burns immediately after a detonation or release of material does NOT mean the person did not receive a serious dose of radiation and does not mean the person is not contaminated. The photo on the left [removed from this version] shows a case from Russia with erythema caused by an infected tick bite, but the skin reddening looks like the erythema from radiation burns. The photo on the right shows a Soviet soldier involved in the response at the Chernobyl reactor in 1986. The skin on his back shows the red color. This photo was not taken within a few hours of the exposure. You can tell because his hair has already fallen out, and that takes some time.

EPA Protective Action Guides

Regulations governing radiological emergency planning and preparedness published by FEMA in 1992 gave EPA responsibility for: •Establishing Protective Action Guides (PAGs) •Preparing guidance for implementing the PAGs •The PAGs provide the projected dose to an individual from an unplanned release of radioactive material at which a specific protective action to reduce or avoid that dose is warranted •Projected radiation dose is the dose estimated to be received in a specified time in the absence of protective actions or natural shelter •With the exception of nuclear war, PAGs apply to all radiological incidents, including •Accidents involving a nuclear power plant •Other nuclear facility •Weapons •Transportation •Nuclear-powered satellite •Guidance is aimed at nuclear power facilities

Nuclear Device

The use of a nuclear device by a terrorist would produce devastating effects and would have a tremendous psycho-social impact on the community and the entire country. Fusion: is the combining of atoms Fission: is the splitting of atoms Only element isotopes that are unstable can be split or combined Effects of a Nuclear Detonation •Thermal pulse •Shock wave •Radiation pulse of gamma and neutron radiation •Fires started by the thermal pulse •Contamination from radioactive fallout •Electromagnetic pulse (EMP) knocks out electronics For weapons larger than 10 kilotons (10,000 tons of TNT), there are fewer radiation injuries than the injuries from: •Shock wave •Thermal pulse •Fires started by the thermal pulse

Beta radiation Burns from Contamination

This photo is an example of radiation beta burns injury suffered by a person who had contact with radioactive Cesium without proper gloves. The material on his hands emitted beta and gamma radiation. The radiation beta burns developed hours after the start of the exposure. The skin reddens, and beta burns in the skin appear wet and shiny, but they are not painful. This is a major difference from thermal burns from fire or hot objects. Also notice that the burned areas on the thumbs has turned a bronze color. This is characteristic of beta burns. Radiation burns may not appear immediately, but can occur hours later.

•Acute vs chronic

acute doses -Large radiation dose received in a short period of time -May result in observable health effects •Reduced blood count •Hair loss •Nausea •Fatigue -Low probability of receiving an acute dose while treating radiation accident victims •Chronic Doses -Small radiation dose received over a long period of time -Body more easily repairs damage from chronic doses -Does not result in observable effects

EPA Established Dose LimitsFor Emergency Workers

reference table pp 8 slide 25 Dose Limit (rem) Activity Condition 5 All 10 Protecting valuable property Lower dose not practicable 25 Life saving or protection of large populations Lower dose not practicable >25 Life saving or protection of large populations Only on a voluntary basis to persons fully aware of the risks involved Know table in milli rem Total dose limit , valuable property counts as vital facilities like health and services Voluntary might be based on age and/or chances of having kids Notes on video- giger counters only measure in ionizing radiation. 2 sivers or 200 rem is deadly, trinity bomb glass- trinitite. Airplane has more radiation than other places over 3 micro siverts at highest crusing altitiude. 5 m S at Chernobyl and removed the top soil Fukushima- 5-10 m S an hour Hospital at pripet- fire fighters from Chernobyl were treated and had equipment disposed of, 2000 m S an hour a years worth of background radiation CT scan gives 7000 m S. US radiation workers are limited to 50000mS a year , astronaut 80k, smokers lungs get 160k mS from radium and lead most radiactive place in world

elements

•A chemical element is distinguished by its atomic number - the number of protons in its nucleus •There are 117 elements •92 occur naturally

Chronic Radiation Dose Risks

•A small amount of ionizing radiation received over a long period of time (months, years) • Small increase in cancer risk Airline pilot X-ray machine operator Occupation radiation worker at a nuclear power plant Biological effects from chronic doses of radiation may occur in:Exposed individual Future children of the exposed individual •Somatic health effects (primarily cancer) observed only at doses more than 10,000 mrem •Risk below this dose is speculative

Treatment of ARS

•Acute Radiation Syndrome is usually asymptomatic in the emergency department •If present, symptoms will by nonspecific such as nausea, vomiting, etc. •Initially, there is no specific treatment required for ARS •Extensive treatment becomes necessary as the manifest illness stage is entered Know this, most symptoms look like other diseases or problems and it have to take time to realize what is happening •Serious medical problems have priority over concerns about radiation injury -Conventional injuries that are acute life threats and treatable -ARS is rarely a life threat in the ED - if it is, it's untreatable •The type of treatment will vary according to the radiation dose received. The table below summarizes some acute dose-response effects: Acute Dose Clinical Effects 50 rem Blood count changes 100 rem Vomiting Threshold 150 rem Mortality Threshold 320 - 360 rem LD50/60* (with minimal supportive care) 480 - 540 rem LD50/60 (with supportive medical treatment) 800 rem 100% mortality (with best available treatment)

Acute Radiation Syndrome (ARS)

•Acute illness caused by a large dose of penetrating radiation delivered to most or all of the body in a short period of time, usually within minutes to hours •Also referred to as radiation sickness or radiation toxicity •Atomic bomb survivors and firefighters at the Chernobyl Nuclear Power Plant Accident suffered from ARS Acute- short period of time, quick onset 24-48 hours •Required conditions for ARS: •Radiation dose must be large (greater than 70 rem) 70000 milli rem 30-50 micro rem is background amount for here •Dose is usually external •Radiation must be penetrating, gamma or neutron •Entire body (or significant portion of it) must have received the dose •Dose must have been delivered in a short time •The required conditions for ARS are: -Radiation dose must be large (>0.7 Gray) -Dose is delivered externally (rare for internal exposure to cause ARS) -Radiation must be penetrating (e.g., gamma) -Entire body (or a significant portion of it) must have received the dose -The dose must have been delivered in a short time (usually a matter of minutes) 100 rem per sievert, 1 gray is one sievert

Shipments of Radioactive Material

•Approximately 3 million packages of radioactive materials shipped each year in the United States •Shipped everyday by highway, rail, air, and water •Transportation of radioactive material is strictly regulated •Most regulatory restrictions apply to packaging and methods of shipment used to transport the package reference slide 16 pp10 for percents of transported radioactive materials •During the years 1998-2007: •169,092 hazardous materials incidents •Approximately 17,000 per year •140 incidents involving radioactive material •Approximately 14 per year (.08 %)

Biological Pathways

•Biological pathways that can introduce internal contamination include: •Inhalation- worst of the common exposures •Ingestion •Absorption •Injection

Notification of Radiation Incident

•Call taker should get as much information as possible when informed that potentially contaminated patients are en route: Number of patients Medical status If patients have been surveyed for contamination Radiological status Identity of contaminant, if known Estimated time of arrival Call-back number

Probabilistic Risk, Radiation Carcinogenesis, and Genetic Effects

•Cancer induction well demonstrated above 100 rem •Difficult to demonstrate any carcinogenic risk at doses below 10 rem •Genetic effects have been observed in plant and animal studies, but have never been demonstrated in humans -This includes extended studies of Hiroshima and Nagasaki bomb survivors

Avoiding Spread of Contamination

•Change gloves after handling patients or potentially contaminated equipment •Avoid unnecessary activity in contaminated areas •Avoid rough handling of contaminated clothing to minimize the creation of an airborne hazard •Adhere to the policy of no eating, drinking, smoking, or chewing in contaminated areas •Avoid touching unprotected skin areas while working with contaminated patients

Preparation to Receive Patients

•Contamination control is an important consideration during patient admission to ED •Cover floor between ambulance arrival area and REA •Be aware that plastic coverings can become slippery when wet Floor of patient treatment area should be covered as well •Control Zones -A control zone should be established in the area where patient decontamination will take place -The control zone helps differentiate the controlled (contaminated) area from the noncontrolled (uncontaminated) -Once people or items enter the controlled area, they should not leave without being surveyed for contamination •Steps to Controlling Contamination -Ensure controlled area is large enough to hold patients -Remove/cover non-essential equipment -Cover floor areas -Restrict access to controlled area -Monitor everything leaving controlled area -Use strict isolation procedures -Control waste -Use buffer zone for added contamination control -Control ventilation -Change out supplies as they become contaminated -Use waterproof materials where possible •Decontamination table should be set up inside controlled area for patient decon -Standard treatment table -Burn table •Not all equipment can be decontaminated -Covering material with plastic will help prevent contamination -Porous materials such as straps on hospital carts should be discarded after use

Sources of Natural Background Radiation

•Cosmic Radiation Cosmic Radiation comes from the sun and outer space. It consists of positively charged particles, as well as gamma radiation and neutron radiation. At sea level., the average annual cosmic radiation dose is about 26 mrem per year. At higher elevations, the amount of air in the atmosphere above decreases. The air between you and outer space shields you from this radiation. Therefore, the higher in elevation you go, the higher the dose of cosmic radiation you receive. Generally, the exposure increases about one mrem per year for every 100 feet up in altitude a person lives. •Sources in the Earth's Crust Sources of radiation in the earth's crust are referred to as terrestrial radiation. Examples of this are rocks, building materials, and drinking water supplies. Some of the contributors to terrestrial sources are the natural radioactive elements of radium, uranium, and thorium. can also include soil and sand Many areas have elevated levels of terrestrial radiation due to increased concentrations of uranium or thorium in the soil. The total annual dose to the general population from terrestrial radiation is 28 mrem per year •Sources in the Human Body •Food and water in trace amounts •Naturally occurring radioactive materials deposited in our bodies •Combined exposure from internal sources radioactive dose of about 40 mrem per year •Radon •(Gas) formed from the radioactive decay of uranium in the soil •Can collect in basements •Emits alpha radiation •Sources are tobacco products, medical radiations, building materials, domestic water Because alpha radiation cannot penetrate the dead layer of skin on your body, it presents a hazard only if taken into the body (e.g., when inhaled). The average annual dose equivalent from radon gas is approximately 200 mrem per year.

Measuring Radiation Radiation Dose Equivalent

•Customary unit is the "rad" •Can be applied to all types of radiation •Only measures absorbed dose, not the biological damage done from radiation •The same amount of absorbed dose of different kinds of radiation causes different degrees of damage •SI unit is the gray (Gy): 1 Gy = 100 rad•Calculated by multiplying the absorbed dose by the quality factor •The quality factor relates the relative risk from the type of radiation absorbed to that of X or gamma radiation •The "rem" (Roentgen Equivalent Man) is the customary unit of dose equivalence •SI unit, the sievert (Sv): 1 Sv = 100 rem

Local/Partial Body Exposures

•Cutaneous Radiation Injury (CRI) -Injury to the skin from acute exposure to large radiation dose -Can occur without symptoms of ARS •Especially true with beta radiation -Can occur at doses as low as 2 Gray (200 rad) -Can produce itching, tingling, transient erythema, epilation, desquamation, tissue death (necrosis) Dose Effect 3 Sieverts 300,000 mrem Epilation (loss of hair) 6 Sieverts 600,000 mrem Erythemia (redness of skin) 12 Sieverts 1,200,000 mrem Dry desquamation 15 Sieverts 1,500,000 mrem Blistering or wet desquamation 25 Sieverts 2,500,000 mrem Chronic Radionecrosis (long term) •Eyes -Lens is the most sensitive with cataracts possibly developing -Cornea is less sensitive than lens of eye -Doses approaching 50 Gray (5,000,000 mrem) may produce superficial keratitis on the cornea •Lungs -Relatively radioresistant -Doses in the 7-8 Gray (700 to 800 rad) range can produce pneumonitis •Reproductive Organs -Men •Type B spermatogonia are most radiosensitive •Irradiation of as little as 0.15 Gray (15,000 mrem) can cause temporary decrease in sperm count •5 to 6 Gray (500,000 to 600,000 mrem) may cause permanent sterility •Reproductive Organs -Women •Granulosa cells in ovarian follicles are the most radiosensitive •Doses as low as 1.5 Gray (150 rad) may cause delayed temporary sterility •Doses as low as 3.2 Gray (3,200 rad) can cause permanent sterility •The Fetus -Effects on fetus have same characteristics as adults (cell death/damage, alteration in DNA) -During 8 to 25 weeks of gestation, the CNS is highly sensitive to radiation -Fetal doses in excess of 10,000 mrem may cause a decrease in IQ •Cancer induction well demonstrated above 100 rem •Difficult to demonstrate any carcinogenic risk at doses below 10 rem •Genetic effects have been observed in plant and animal studies, but have never been demonstrated in humans -This includes extended studies of Hiroshima and Nagasaki bomb survivors

How Ionizing Radiation Affects the Body

•Damage occurs at the cellular level -Atoms making up the cell are ionized A sufficiently high dose of radiation can: •Damage many cells •Result in noticeable-observable-health effects •Rapidly dividing cells are sensitive to radiation's effects and include: -Blood-forming cells -Cells lining the intestinal tract -Cells in an embryo or fetus •Cells that divide less rapidly or are more specialized are not as easily damaged by ionizing radiation -Nerve cells -Brain cells -Muscle cells Damage on slower dividing cells is really bad because you have had a massive dose of radiation

package markings

•Designed to inform transportation workers and emergency response personnel about the package's radioactive contents •May include: •Proper Shipping Name and UN Identification Number •"Radioactive LSA" or "Radioactive SCO" if applicable •Package type (IP-1, IP-2, IP-3, Type A, or Type B) •Gross weight •"USA" •Orientation arrows •"RQ" if reportable quantity Radioactive pharmaceutical, contained in dry ice, that is radioactive, CO2 can sublimate and doesn't ship easy because hazard to health Radioactive White-I •Applied to packages with very low levels of external radiation •Maximum contact radiation level is 0.5 mrem/hr Know this, for radioactive White 1, measured at box , 0.5 or lower, contents of isotope with activity level Radioactive Yellow-II •Applied to packages with external radiation levels ranging from greater than 0.5 mrem/hr to no more than 50 mrem/hr •Maximum Transport Index is 1 Transportation index is 1 meter away at 1 mili rem per hour, index is X rem per hour on the TI. Cant be more than 1 milli rem Radioactive Yellow-III •Applied to packages with external radiation levels ranging from greater than 50 mrem/hr to a maximum of 200 mrem/hr •Maximum Transport Index is 10 At source 50-200 mrem/hr 10 on the TI Empty •Applied to packages that have been emptied of their contents •May contain some residual radioactive material •Radiation levels outside the package are less than 0.5 mrem/hr Fissile •Applied to packages that contain fissile materials •Appears adjacent to the radioactive material label •Criticality Safety Index can not exceed 50 Weapons grade or power plant that has been used, depleted radioactive materials Placards •Required for: •Packages with Yellow-III label •Exclusive Use LSA/SCO shipments in excepted packages •Highway Route Controlled Quantities of material also can have UN number •Diamond shaped with "Radioactive" in black centered across it with a white background •Upper portion has a black radiation symbol on a yellow background •Approximately 11 X 11 inches •In the bottom corner DOT hazard class number "7" denotes radioactive material •Must be on all four sides of the vehicle •If a tractor is disconnected from the trailer, placards must be on all four sides otherwise the front placard can be on the tractor Highway Route Controlled Quantity (HRCQ) Placard •Looks like the standard placard, except it has a white square background with a black border •Quantity of radioactive material exceeds: •3,000 times the A1 value of the radionuclides (special form) •3,000 times the A2 value of the radionuclides (normal form) •1,000 TBq (27,000 Ci), whichever is least Information Found on Shipping Papers •Identity of each material/radionuclide •Physical and chemical form •"Special form" exclusion •Amount of radioactivity contained in each package •Category of label applied to each package •Assigned transport index for each package •Fissile controls information

Transport Index

•Dimensionless number on package label to designate the degree of control required during transportation •TI = the maximum radiation level in mrem/hr at one meter from an undamaged package •Used to control the total number of packages allowed on a conveyance Don't want to be near curies . Turn back rate is 2 millirems

Inverse Square Law, radiation exposure calculation

•Doubling the distance from a point source of radiation decreases the exposure rate to one-fourth the original exposure rate •Tripling the distance (for example, from two feet to six feet) reduces the exposure to one-ninth of the two-foot exposure rate

Lethal Dose

•Due to biological variability, individuals react differently to radiation exposure •Because of this, we often utilize the dose that is lethal to 50% of the exposed population •LD 50/30 = the dose of radiation expected to cause death (Lethal Dose) within 30 days to 50% of the population exposed without medical treatment •Best estimate for humans is between 300 and 500 rem Know biological variability, people are different sizes, health, age, conditions, environmental exposure in past Know LD 50/30- and kill amount

Type of Radiation

•Each type of radiation transfers energy to a biological system differently •Linear Energy Transfer (LET) measures the energy transferred to material as an ionizing radiation travels through it •Biological effects of high LET radiations are higher than those of low LET radiations with the same energy

Transuranic Elements

•Elements with atomic numbers greater than 92 (uranium) •None of the transuranic elements occur naturally on Earth •Generally more hazardous if inhaled or ingested because they are primarily alpha emitters •Plutonium and americium are the most frequently transported

Four Types of Packaging

•Excepted •Industrial •Type A •Type B Type B is most dangerous, life hazardous, Type A example is smoke detector A1 and A2 Values •A1 value = special form •A2 value = normal form table in pp 9 slide 6 Excepted Packaging •Designed to survive normal transportation conditions •Extremely low levels of radioactivity, non lethal levels •Excepted from specific marking, labeling, and shipping paper requirements •Must have the letters "UN" and the appropriate UN identification number Industrial Packaging •Used in shipments of low activity material and contaminated objects, usually radioactive waste •Packages allow no identifiable release of the material during normal transport and handling •Three categories: •IP-1 •IP-2 •IP-3 Type A Packaging Radiopharmaceuticals, radioactive wastes, and sources used in industry •Used in shipments of small quantities of radioactive materials •Cardboard boxes, wooden crates, or drums •Can withstand moderate degrees of heat, cold, reduced air pressure, vibration, impact and water spray Don't warrant placards non lethal levels Type B Packaging •Designed to survive severe accident conditions •May contain life-endangering amounts of radioactive material •Must withstand a series of tests that simulate severe accident conditions •Spent nuclear fuel, high-level radioactive waste, and high concentrations of other radioactive material Must have placards, life endangering amounts You should not expect a release from a Type B Package all openings have been intentional and due to miss identification Fixed Facility Postings •Hospitals, laboratories, industrial sites •Tri-blade symbol •Posted on entry doors, storage vaults, cabinets, or containers

Radiation Exposure

•Exposure means being exposed to ionizing radiation or to radioactive material •Traditional unit is the roentgen •For practical purposes, for gamma radiation: 1 roentgen = 1 rad = 1 rem

Portion of the Body Exposed

•Extremities can withstand a much higher dose of radiation than the "whole body" (head, trunk, arms above the elbow, or legs above the knee) •Whole body exposure = radiation dose delivered to entire body homogeneously •Localized radiation exposure = radiation dose delivered to a portion of the body •Symptoms may not appear for several days Dose in rem Effect Observed 300 Epilation (loss of hair) 600 to 800 Erythemia (redness of skin) from penetrating radiation 1,200 Dry desquamation (shedding of skin) 1,500 Blistering or wet desquamation 2,500 Chronic radionecrosis (long term tissue death)

Biological Variability Factors

•Factors include the exposed person's: •Age •Sex •Health •Rate of metabolism •Size •Weight •Children are very susceptible to radiation damage

Factors that Influence Biological Effects

•Five factors have an impact on the degree of biological effects from radiation exposure: •Total dose- amount total •Dose rate- amount per time •Type of radiation •Biological variability factors •Portion of the body exposed- elbows, knees inward, plus head The greater the dose of radiation, the greater the biological effect Dose in rem Effect Observed 50 Minor blood chemistry changes No outward effect 70 ARS Threshold (Nausea, Chills, Erythema) 100 Vomiting (threshold) 450 LD 50/30 with minimal care 1,000 LD 100/30

Incident Command System (ICS) Functions

•Five functional areas: •Command Staff : Support staff •Operations Section : Hands-on workers •Planning Section : Determines what to do and when •Logistics Section : Provides resources for the incident •Finance/Admin Section : Tracks costs •Team Captain - Interacts with IC, Coordinates team activities and external resources •Communications - Implements communications protocols •Assessment - Directs radiation survey, prevents spread of contamination, establishes radiation hot zones. •Recorder - Documents radiation survey readings, dosimeter readings and communications.

Patient Assessment and Triage

•Follow established local protocols and standards of care in providing patient care -Local protocols, standards of care may need to be amended/modified to reflect care of contaminated patients -Needs to be done by local jurisdiction/hospital medical staff •Patient may have both radiological and non radiological injuries/medical problems •Triage -The process of rapidly sorting and categorizing patients based on the severity of their injuries and the urgency of their need for treatment •An example of a Triage Categorization System: -RED - Emergent -YELLOW - Urgent GREEN - 'Walking Wounded' BLACK - Dead or Mortally Wounded •Nonradiological or conventional injuries, illnesses -Fractures, head injuries, splenic injury, MI, etc. •Radiological -Exposure to radiation, contamination with radioactive materials •Serious non radiological trauma and medical problems have priority over radiological problems Get them stable, then decon and move •Conventional life threats are treatable and failure to treat can cause a death -Pneumothorax, epidural hematoma, etc •Radiation exposure rarely life threat initially -If life threat in E. D., dose massive, universally fatal •Emergent decontamination is rarely indicated •Exception is if level of contamination is high enough to constitute an ongoing hazard to the patient and caregivers, then emergent decon is indicated -This is a rare occurrence!!

London, England - Radiological Homicide—Alexander Litvinenko

•Former KGB agent critic of the Russian government was poisoned with polonium-210 •Poisoning occurred in London •Litvinenko died less than 30 days after falling ill and being hospitalized •UK authorities officially announced that Litvinenko's death was being investigated as a homicide

external decontamination

•Goals of external decontamination -Prevent the spread of contamination -Decrease exposure to radiation by removal of material -Prevent internal contamination and incorporation •Remove clothing Removal of clothing might remove 80-85 percent of contamination •Survey -Put samples in containers and label •Isolate contamination with waterproof barriers •Decontaminate •Remove waterproof barriers •Resurvey •Save everything Priorities of Decontamination •To prevent internalization/incorporation, the portals of entry (wounds, mouth, eyes, nose, and ears) should be decontaminated before intact skin •Areas of highest contamination should be addressed before areas of lower contamination •Wound Decontamination -Consider wounds contaminated until proven otherwise -Save dressings, drainage, debrided tissue for isotopic analysis -A wound with plutonium contamination (or other alpha-emitting material) is difficult to detect •Specialized probes must be used -Following decontamination, all wounds should be covered to prevent cross contamination from other areas •Lacerations -Irrigate with water or saline to remove most of contamination -Hydrogen peroxide or betadine scrubs of wound may be necessary -Jagged edges of wound may be difficult to fully decontaminate -Debridement may be necessary -Expert consultation should be sought prior to debridement •Foreign Bodies -Treat as any suspected foreign body -Save for later analysis -Shrapnel from radiological dispersal device or other radioactive source may be highly radioactive and should be surveyed by trained personnel If treating in the contamination area you can just leave foreign bodies there, if removal cant be done then it can just be done in the hospital •Puncture Wounds -Can often be handled by scrubbing opening and surrounding area -Tourniquet or incision may be used to induce bleeding -Removal of surrounding tissue may be necessary -Expert consultation should be sought before removing tissue—decontaminate but do not mutilate

The Goiania Incident

•Goiania incident is a model for the effectiveness of dirty bombs •Two men stole a teletherapy unit that contained 1400 curies of cesium-137 •Of the 129 victims, five exceeded 300,000 mrem sixteen exceeded 100,000 mrem and twenty-four exceeded 50,000 mrem. •Prussian Blue (Radiogardase®) was administered to forty-six persons Radiation Burns from Gamma and Beta Radiation The victims in these photos handled highly radioactive Cesium powder (Cs-137) that was released from a metal capsule inside of an abandoned cancer treatment machine in Goiania, Brazil in 1987. Some of the victims intentionally rubbed this powder on their bodies because it glowed a "pretty blue" color. After eating food with contaminated hands, the victim on the left showed radiation burns on his tongue and mouth. For most victims of this event, the symptoms did not appear immediately after the contamination. suites protect against contamination not exposure

decontamination of hairy areas

•Hairy Areas -Get a sample of contaminated area or cut a lock of hair. -Shampoo the hair •Prevent contamination of nose, mouth -Cut, do not shave hair if needed •Shaving nicks are portals of entry -Decontaminate intact underlying skin as previously discussed

alpha radiation

•High energy particles that are large, heavy, and only travel a short distance •Lose their energy rapidly •Have a low penetrating ability •Minimal hazard outside the body •Greatest hazard from alpha-emitting material is when it is inhaled or ingested

Incident Command System (ICS) Features

•ICS features include: •Common terminology •Modular organization •Effective span of control •Comprehensive resource management •Incident Action Plans (IAPs) •Integrated communications •Pre-designated facilities how to manage an incident

Exposure Pathways for Emergency Workers

•If releases include radioiodine and radioactive particulates, inhalation may be major concern for potential dose •Direct radiation dose may occur from radioactive materials suspended in a plume = atmospheric pathways •Radioactive materials deposited on surfaces = terrestrial and aquatic pathways

history

•In 1895, X-Rays discovered •Stage set for the use of radiation in medicine, industry, and research •Studies provide a detailed understanding of hazards and benefits of radiation marie curie discovered x rays and eventually with her daughter used x ray tech on battlefield

Panama City, Panama - Radiation Therapy Overexposure Incidents

•In early 2001, incident discovered at cancer treatment facility in Panama City, Panama •Modifications made to computer used to calculate shielding blocks during radiotherapy treatments resulted in overexposures to 28 patients during late 2000 and early 2001 •Overexposures resulted in 17 deaths and 11 injuries

Dose-Effect Relationship

•Indirect Theory -Radiation creates reactive molecules-free radicals, peroxides, etc. -Reactive molecules damage biological molecule •Direct Theory -Radiation damages biological molecule directly

Internal Contamination/Incorporation

•Internal contamination occurs when radioactive contamination gets inside the body -Inhalation, ingestion, absorption, injection •Incorporation refers to the uptake of radioactive materials by body cells, tissues, and organs •Radioactive materials are distributed through the body based upon their chemical properties Internal is worse overall, incorporation is the worst thing •Time is of the essence with internal contamination as incorporation can occur rapidly with some isotopes •Prompt treatment requires a high degree of suspicion based on the history and physical exam, contaminated portals of entry and initial assays of samples obtained treatment is complex also has significant side effects

Contamination Found After Admission

•It is possible that contamination may be discovered after a patient has already been admitted to the hospital. In these cases: -Continue patient care -Secure area (patient and staff) -Don't allow anyone or anything to leave the area until cleared by the radiation safety officer -Establish control lines and prevent spread of contamination -Assess patient's radiological status -Following decontamination, ensure all personnel and equipment are surveyed prior to leaving

Advisory Groups

•National and international experts in biology, medicine, health physics, and other related scientific disciplines •Publish specific recommendations on radiation protection matters •These form the basis for radiation protection standards cant set laws only recommend actions national council on radiation protection and measurements, American national standards institute

nuclitides

•Nuclide •Any species of nucleus •Mass Number (A) •Total number of protons and neutrons in the nucleus •Atomic Number (Z) •Total number of protons in the nucleus Z above A below and X is normal X = Elemental abbreviation Z = Number of protons (atomic number) A = Total number of protons and neutrons (atomic mass number) •Another common means of representing each atom is to list the element and its specific atomic mass number, for example; Plutonium-239, Pu-239, or 239Pu

Exposure Risks

•Numerous studies show that large acute doses (>10,000 millirem) can increase risk of cancer •Epidemiological studies conducted to date show that health risks at doses below 10,000 millirem are either zero or so low that they cannot be measured 2 millirem per hour is the stop line for first responders

beta radiation

•Particles that are smaller, lighter, and travel farther than alpha radiation •Can be shielded by plastic, aluminum, cardboard, or several layers of clothing •Outside the body, only a slight hazard •Exposure to high levels can cause damage to the skin and eyes

neutron radiation

•Particulate radiation ejected from the nucleus of a radioactive atom •Neutrons do not have a charge like alpha and beta particles •Can travel great distances and is highly penetrating like gamma radiation •Best shielded by materials with a high hydrogen content, such as water

Discharging the Patient and Staff

•Patient decontamination is just one step in the decontamination process -Following decon, the patient and staff still needs to exit the REA •Following decon, thoroughly survey patient •Replace gurney sheets •Transfer patient to a clean stretcher with the help of "clean" assistants •Have RSO perform final check of patient and stretcher before removing stretcher from REA •After final approval, wheel patient out of the REA •Alternate lateral transfer to a clean gurney may also be used Trash has to be collected and kept in the contaminated zone, •Carefully remove protective clothing at control line •Protective clothing should be removed in a step-by-step process •Step across control boundary once protective clothing is removed and perform a total-body survey •Take a shower and redress in normal attire

Noble Gases

•Potential hazard in a nuclear power plant accident •Includes helium, neon, argon, krypton, xenon, and radon •Noble radioactive gases may cause beta and gamma exposure to the skin

Primary Assessment

•Primary assessment is the initial, rapid assessment and treatment for life threats—the ABCs •Meet patient at ambulance entrance •Conduct rapid radiological survey for hazardous levels Determine if patient is stable or unstable Airway, breathing, circulation •Unstable Patient -If it is determined that the patient is unstable and requires acute treatment, then he or she should be admitted to the REA and life-threats should be stabilized •Stable patient -Survey for contamination -If contaminated, admit patient to REA •Deliver medical, trauma care -If not contaminated, admit to regular E. D. •Saves space in REA •Reduces risk of patient contamination •Deliver medical, trauma care Assume alpha for detection proposes, have to couple inches away to detect alpha, CDC says ½ inch, takes a few seconds to register on meter, patient is likely not happy, have to be careful to not allow dust to fall on device, if any radiation total decon. Very labor intensive, very hard for controlling patients. ED is emergency department, REA radiation emergency area

Stages of ARS

•Prodrome •Onset -Minutes to 24-48 hours •Symptoms -Nausea, vomiting -Diarrhea -Anorexia -Malaise •Emergency department personnel will usually see the patient during this stage •Latent •Symptoms -Prodrome subside, except for mild fatigue, malaise, fever -Damage done and just becoming clinically apparent •Duration -Hours to three or four weeks •Manifest Illness •Actual biological damage becomes clinically apparent -Hematopoietic- blood -Gastrointestinal -Cardiovascular/Central Nervous System - slow dividers •Specific treatments needed •Recovery or Death •Final Stage -Recovery •Damage heals, illness improves -Death •Direct result of exposure •More commonly complication caused by radiation: infection, bleeding, etc. Radiation warnings are needed to prevent accidental exposure Scrap dealers got radiation canister from an old medical center cesium and spread it around to families and friends, 3000 cubic m of radioactive waste caused sources to be tracked and categorized. Goyanya

Subatomic particles

•Protons •Positive charge •Determine the element's identity •Neutrons •Neutral charge •Determine the nuclear properties •Electrons •Negative charge •Determine the chemical properties

Emergency Response Guidebook (ERG)

•Provides guidelines for responders to use for commonly transported hazardous material, including radioactive material •Lists the four-digit UN ID, package markings and some placards, Proper Shipping Names of hazardous material •Each hazard has a guide and precautions designed to protect responders from harm ERG, Initial White Section •Contains general guidelines for any hazardous material situation •Addresses safety precautions and who to call for assistance •Contains the "table of placards and initial response guides" ERG, Yellow Section •Shows, in numerical order, the four-digit UN ID number assigned to each hazardous material •By looking up the UN ID number, you can find the appropriate guide number and name of the hazardous material ERG, Blue Section •Lists each hazardous material alphabetically by Proper Shipping Name •By looking up the name, you can find the appropriate guide number and UN ID number for that material ERG, Orange Section •Contains the guides for dealing with each hazardous material •Lists the precautions to take for each hazardous material •Identifies potential hazards and emergency actions •Each guide is two pages ERG, Green Section •Contains the table of initial isolation and protective action distances •If an entry is highlighted in the yellow or blue sections, look for the UN ID number and name of the material in the table of initial isolation and protective action distances •"(When spilled in water)" indicates the material is water reactive and is listed at the end of the green section in the table of water-reactive materials which produce toxic gasses

Direct Effect of Ionizing Radiation

•Radiation directly interacts with the atoms of the DNA molecule or other cellular component critical to cell survival •Such interaction may affect the ability of the cell to reproduce and survive •Cell may be destroyed by "direct" interference with its life-sustaining system

Indirect Effect of Ionizing Radiation

•Radiation does not "directly" go after the cell •Causes the formation of free radicals which then affect the cell •Example would be ionization of water molecules in the cell

Environmental Pathways of Radionuclide Transport

•Radiation exposure can include multiple environmental pathways •Exposure may be relatively simple •Exposure may be a complex, multi-step process •Atmospheric Pathway •Radioactive materials are released into the atmosphere •Potential hazards depend on: •Total amount of radioactivity released •How the material is diluted and transported by the atmosphere •How the contaminants deposit on surfaces •Swirling winds diffuse the material as the plume is transported •Combined influences of diffusion and transport = Dispersion •Gaseous and particulate radioactive materials may be removed within the plume •Precipitation •Removal process = Rainout •Gaseous and particulate radioactive materials may be removed below the plume •Falling precipitation = Washout •Material may be removed through gravitational settling or adhering to the ground, vegetation, or other ground cover •Dry Deposition •Terrestrial Pathway •Once deposited on the ground, radionuclides can affect people in several ways: •Children may ingest contaminated soil •Vegetation can become contaminated as material is deposited onto leafy vegetables, which are then eaten by people or animals •Radionuclides can be re-suspended in the air some terrestrial paths apply to chemical and biological contaminations •Once deposited on the ground, radionuclides can affect people in several ways: •Radionuclides can be taken up by root system of vegetation or crops •Rain can transport radionuclides from the ground surface to aquifer wells or surface streams •Groundshine Direct radiation (gamma rays) emanating from the soil contaminated by gamma-emitting radionuclides •Milk and meat contamination •Dairy cows who graze on contaminated pasture grass will concentrate certain radionuclides into milk production •Radionuclides can also concentrate in the meat of grazing animals •Protection of the air-pasture-cow-milk pathway •Control systems used by nuclear power plants •Crop contamination •Two primary pathways lead to contamination of plants: •Dry deposition on crops and vegetation caused by plume depletion of contaminated air ·Radionuclide uptake in plants due to irrigation from contaminated surface streams or groundwater wells •Aquatic Pathway •Direct discharge of radioactive material into a body of water •Consumption of fish, seafood, and water from surface water sources (lakes and streams) are the main pathways for exposure •Direct exposure from swimming or contact with sediments deposited on shoreline •Aquifer wells may become contaminated •Computer modeling used in the nuclear industry, mining of uranium, and at radioactive waste disposal sites

Radiation Versus Contamination

•Radiation is a type of energy; contamination is material in an unwanted location •Exposure to radiation will not contaminate you •Radioactive contamination emits radiation •A contaminated patient could expose you to both radiation and contamination •Contamination is a more serious concern -Proper use of PPE will protect you from contamination •Likelihood of patient presenting a radiation hazard to caregivers is extremely rare •Time, Distance, Shielding external contamination- external is something on you is contaminating you internal contamination- something has entered your body and Internal incorporation is most hard to remove and worst case scenario, internal can be flushed out or removed in some cases Use PPE when treating potentially contaminated patients Do not: Eat Drink Smoke Chew

Ionizing Radiation

•Radiation that comes from atoms •Has enough energy to remove electrons from other atoms •Process of removing electrons from atoms is called ionization Unstable atoms trying to become stable, know definitions 4 Types of Ionizing Radiation All radiation forms from some type of radioactive decay Alpha- range 2 in, cant penetrate skin or paper, dangerous if ingested. Beta- range up to 30 ft , can penetrate paper and 2 layers of skin but can be blocked by dense tissue. Can penetrate soft tissue, ingestion hazard Gamma- range 300ft , goes through concrete, fully penetrate dense tissue and works like an x ray exposed film looks black, non exposed film looks white. Whole body hazard, photon Neutron- dangerous, go 300 ft, highly penetrate need 3 ft concrete or fair amount of metal, whole body hazard, child between alpha and gamma,

Radioactive Material and Radioactivity

•Radioactive material is any material that spontaneously emits ionizing radiation •Process of an unstable atom emitting radiation is called radioactivity •When a radioactive atom goes through the process of radioactivity, also called radioactive decay, it will change to another type of atom. •Radioactive decay is measured in half-lives •Half-life is the time it takes for ½ of the radioactive atoms present to decay to another form •Half-life is unique to each radioactive isotope and can vary greatly •Radioactive pharmaceutical products (called radiopharmaceuticals) typically have half-lives of a few hours or days Radioactive pharmaceuticals are dyes that have short term half lives •Regardless of the half-life, the radioactivity level of any given amount of radioactive material is constantly decreasing half-life references pp2 slide 13

Radiological/Nuclear Terrorism Threat

•Radiological/nuclear -Nuclear weapons are the most devastating of the CBRNEs because of the massive destruction and death they can cause. -There are three mechanisms by which terrorists can carry out a radiological attack: •Detonation of a nuclear bomb •Dispersal of radiological material Attack on a nuclear power plant or research laboratory dispersal device is in particular "easy" to make It takes explosives and radiological materials, radioactive materials are just in for the ride, the explosives just disperse it. Can have significant effects. Weapon of mass disruption not destruction Can have long term health and economic effects on an area, could find radioactive material in smoke detectors(amorisium) , and other industrial materials, lantern materials(thorium), clock(radium) , is very hard to construct and get, can also get it from some stores and online, buying the radioactive material is very hard and dispersing it is very hard, Fiesta ceramic plates have some uranium, can use an identifinder to identify the radiation, total cost in US is 1 billion

ALARA

•Rule for radiation protection, keep exposure As Low As Reasonably Achievable •Based on the assumption that any exposure in any amount presents some risk •The concept applies in all cases •Radiation workers •General public Emergency workers Regulatory groups include US nuclear regulatory commission, US Environmental protection agency, US department of transportation use time distance and shielding, radiation control Time •Some incidents will require lifesaving or other time-consuming first aid •Priority is given to lifesaving care first, then, exposure control of the patient •In rare cases exposure rates could be quite high and responders may have to perform prolonged operations •Shortening time spent in the area is important in preventing overexposure •Time in the high-radiation area can be minimized by alternating personnel Distance •The farther from the source, the better •Moving injured patients from the radiation area will reduce their exposure •Lifesaving first aid should be performed wherever the patient is located Shielding •Anything between you and the source will help reduce your exposure Hot Zone •Control line is usually set at 1-2 mR/hr •The hot line or checkpoint should be placed upwind of the radiation source •Post requirements for entering the area •Set up step-off pad and waste container •No individual, materials, or equipment should be allowed into the clean, non-contaminated area until monitored Warm Zone •Area around the Hot Zone to allow for monitoring and implementation of decontamination measures •Anticipate the spread of contamination and adjust accordingly •Outer boundary should be at, or near, background levels to allow for monitoring personnel for contamination when exiting Cold Zone •Area around the Warm Zone •Contains command post and other support functions necessary to control the incident •Also called the clean or support zone

Isotopes

•Same number of protons; different number of neutrons •Same chemical properties •Different nuclear properties Protium, deuterium, tritium,

Goiania, Brazil - Abandoned Teletherapy Source

•Scavengers found and dismantled an abandoned radioactive teletherapy unit •Victims suffered from open sores, hair loss, burns, and severe depletion of white blood cells •43 were hospitalized •4 deaths from exposure

Biological Effects

•Scientists began to collect and analyze information about the biological effects of ionizing radiation shortly after its discovery •100 years of study focusing on 4 groups: -Early radiation workers -Survivors of Hiroshima and Nagasaki -People involved in radiation accidents at nuclear facilities -Cancer patients chemo is pharmaceutical, radiation treatment is just that

Mechanism of Injury

•Sites of radiation damage include but are not limited to: -Cellular membranes -Cytoplasm -Nucleus -DNA •Cellular membrane -Lipid peroxidation -Increases apoptosis •Cytoplasm -Proteins destroyed -Multiple copies exist -Can be replaced if DNA intact -Damage less critical than DNA Extremely high doses directly kill cell •Nucleus -100 times more sensitive than rest of cell •DNA -Carries genetic code •Codes for all proteins -Mechanisms for repair of damage exists •Base deletion, damage -Single-repair possible -Double-impossible •Single strand break -Repair possible •Double strand break -Repair difficult •Repair not perfect, errors occur •Can be saturated

Sample Collection

•Substances that would normally be discarded should be saved •Clinical and lab tests are used to assess the biological effects of radiation exposure •Isotope identification is very important when determining a course of treatment •Any samples taken should be placed in a sealed container and properly labeled

Fate of Irradiated Cells

•Survives and functions normally •Survives, but functional impairment -Nature of impairment depends on site of the damage •Neoplastic transformation •Cell dies •Not all cell types equally sensitive to radiation •Cells more sensitive to radiation include: -Immature, rapidly reproducing cells -Cells which are dividing at time of exposure •Highly sensitive -Lymphocytes •5 rem may kill -Spermatogonia -Bone marrow stem, immature cells -Small intestine epithelium crypt •Less sensitive -Colon, stomach -Mature blood cells (except lymphocytes) -CNS -Muscle Bone

Regulatory Guides

•The CFR does not always provide the methodology for carrying out the requirements of the regulations •As a result, a CFR sometimes references regulatory guides •Referenced regulatory guides carry the force of the law •Otherwise, regulatory guides are not the law

Code of Federal Regulations (CFR)

•The Code of Federal Regulations (CFR) is the codification of rules published in the Federal Register by the executive departments and agencies of the Federal Government •Regulations have the effect of law •Legal basis for administering any program •Sets permissible exposure limits for occupationally exposed radiation workers •Defines criteria for licensees of radioactive material •Defines for nuclear reactor utilities their responsibilities relating to public welfare •Divided into 50 Titles •Each Title is divided into Chapters Each Chapter is divided into Parts found in ch 8 pp

PAG phases

•The PAG manual divides the emergency response effort into three major phases: •Early, or emergency phase •Intermediate phase •Begins after the source and releases have been brought under control •Late or recovery phase •Begins when actions are intended to reduce radiation levels in the environment to acceptable levels for unrestricted use PAG Early Phase •For response during the early phase of a nuclear incident •PAG for evacuation or sheltering is 1-5 rem •This means that evacuation of the public will usually be justified when the projected dose to an individual is 1 rem •For administration of potassium iodine (KI) the PAG is 25 rem •Requires approval of state health officials PAG Intermediate Phase •For exposure to deposited radioactivity •Greater than or equal to 2 rem for relocation of the general population •Less than 2 rem for application of simple dose reduction techniques PAG Late Phase •Involves protection from inhalation of re-suspended radioactivity •PAGs for the late phase have not yet been finalized by EPA •The protective actions will involve: •Relocation •Decontamination of land and property

Clinical Manifestations of ARS

•The clinical manifestations of ARS fall into one or more of the following syndromes -Hematopoietic •Results from exposures of greater than 1-2 Sievert (>100 rem) •Clinical picture attributed to damage to bone marrow Pancytopenia -Depletion of all blood cell lines -Leukopenia - decreased WBC •Lymphocyte - radiosensitive, falls early •Granulocte, monocyte lines •Impaired immunity, healing •Serious, difficult to treat infections -Opportunistic infections •Clinical Effects -Prodrome may take several hours to develop and last for a few days •Gastrointestinal symptoms (nausea, vomiting, anorexia, weakness, fatigue) -Latent (3-4 weeks) •Mild fatigue •Clinical Effects -Manifest Illness Stage •White blood cells decrease - leukopenia -Severe infections -Opportunistic infections -Difficult to treat •Red blood cells decrease -Anemia -Impaired oxygen transport •Platelets decrease - thrombocytopenia -Severe bleeding, blood won't clot Anemia - decreased RBC Impaired oxygen transport, tissue ischemia Thrombocytopenia - decreased platelet count Impaired clotting, increased bleeding •Treatment -Transfusion of red blood cells and platelets •Leukoreduced, irradiated (25 Gray) blood should be used •Decreases graft vs. host reactions -Gastrointestinal •Results from exposures of greater than about 7 Gray (700 rad) •Occurs along with severe hematopoietic syndrome (if patient survives) •Clinical picture attributed to destruction of the intestinal epithelium •Clinical Effects -Prodrome (usually within an hour or less) •Anorexia, nausea, vomiting, possibly diarrhea -Latent (1-4 days) •Weakness, fatigue -Manifest Illness Stage •Abdominal pain, nausea, vomiting, diarrhea •Dehydration, electrolyte derangements, malabsorption •Emesis and diarrhea often bloody •Sepsis from enteric organisms •Mouth, esophagus, stomach, and colon also affected •Extensive and intensive -Replacement of fluid and electrolyte losses -Antibiotics for infection -Also treatment for the hematopoietic syndrome •Mortality rate will be high - despite treatment -Death usually in less than 2 weeks -Central Nervous System/Cardiovascular •Results from exposures above 30 Gray (3,000 rad) •Clinical picture attributed to damage to the blood vessels supplying blood to the nervous system and to the heart •Clinical Effects -Prodrome (onset within first hour) •Severe nausea and vomiting •Confusion, ataxia, prostration -Latent Period •Short latent period lasting, at most, a few hours •Clinical Effects -Manifest Illness •Severe nausea, vomiting, and watery diarrhea •Confusion, combativeness, seizures, loss of consciousness, respiratory distress, hypotension •Death -Universally fatal within a few hours to days despite treatment •Comfort measures -IV fluids -Analgesics -Antiemetics Seizure control

radioactivity

•The natural process by which some atoms spontaneously disintegrate •Particles and energy are emitted as the atoms transform into more stable atoms •Also called radioactive decay •Measured in terms of disintegrations, or decays, per unit time (eg., counts per second or counts per minute)

Dose Rate

•The rate at which a person receives a radiation dose has an impact on the degree of biological damage •Two categories of radiation doses: •Acute radiation doses •Large dose of radiation received in a short period of time •Body can't repair or replace cells fast enough after a large acute dose, so physical effects may be seen •Possible health effects may take days to manifest and include: •Reduced blood count-illness •Hair loss •Nausea and vomiting •Diarrhea Fatigue cellular functions can repair DNA •Chronic radiation doses •Small dose of radiation received over a long period of time •Body can repair the damage from chronic doses because fewer cells need repair at any given time •Chronic doses do not result in observable health effects of acute doses •Natural background radiation and doses received by workers in nuclear and medical facilities

Treatment of ARS continued

•The table below summarizes some general effects of local irradiation: Clinical Effect Threshold Onset Early transient erythema 200 rad hours Main erythema 600 rad ~ 10 d Temporary epilation 300 rad ~ 3 wk Permanent epilation 700 rad ~ 3 wk Dry desquamation 1,400 rad ~ 4 wk Moist desquamation 1,800 rad ~ 4 wk Secondary ulceration 2,400 rad > 6wk Late erythema 1,500 rad ~ 8-10 wk Ischemic dermal necrosis 1,800 rad > 10 wk •Local irradiation of the following produces varying effects: -Skin -Eyes -Lungs -Reproductive organs

Types of Radiation Injury

•There are three types of radiation injury that may be seen in the ED: •External Irradiation -Occurs when all or part of the body is exposed to penetrating radiation (gamma/X-ray) from an external source -Exposure alone does not make patient radioactive -Irradiated patients present no radiological danger to care givers -Exposure can be to the whole body or localized •Contamination -Occurs when the radioactive material is deposited on, or ingested by, the patient -A patient can be contaminated externally, internally, or both -Inhalation, ingestion, absorption, and injection are methods by which radioactive material can enter the body -Contaminated patients can present a radiological contamination hazard to care givers -Wear appropriate PPE •Incorporation -Refers to the uptake of radioactive material into body cells, tissues, bones, and target organs such as the liver, thyroid, or kidney -Material distributed throughout the body based on its chemical properties -Can occur rapidly and is most difficult to remove

Effects of Nuclear Detonation

•Thermal (flash) injuries from thermal pulse •Shock wave injuries, collapsed buildings •Radiation burns and sickness •Injuries from fires •External/internal contamination •Long-term effects Beta Burns from Radioactive Fallout Eye Injury from Nuclear Blast be flash blindness, a temporary condition in which the visual pigment of the retina is bleached by the intense light. Vision is completely recovered as the pigment regenerates, a process that takes several seconds to 10 to 15 minutes. Radiation cataract causes partial opacity (cloudiness) in the crystalline lens. Symptoms may persist for months or even two to three years on the average following radiation exposure. Retinal injury is the most far-reaching injury effect of nuclear explosions and can occur at any distance from which the fireball is visible, but is relatively rare since the eye must be looking directly at the detonation. The risk of injury is greater at night since the pupil is dilated and admits more light. Thermal Pulse Injury from Nuclear Blast High temperatures can cause dramatic changes to the material and tissues.Loose, light-colored clothing significantly reduces the effects of flash burns.Firestorms and fires will create flame burns.The temperature in the air will be extremely hot, and this condition creates many casualties, with inhalation and steam burns from exposure to hot gases. called flash burns

Decontamination Procedures: Thermal and Chemical Burns, mouth, nose,eyes, intact skin

•Thermal and Chemical Burns -Large areas of damaged skin may provide pathway for absorption of radionuclides -Normal "burn care" in the ED will remove most of the radioactive material -Dressings should always be contained, labeled, and saved for analysis •Orifices - Mouth -Sample with swabs •Under tongue, between gums and lips -Remove foreign bodies -Brush teeth, gargle, rinse mouth, spit •Avoid swallowing •Orifices - Nose -Sample each nostril with moist swabs then label and save -Remove foreign bodies -Blow nose gently -Saline lavage •Head forward, keep saline out of mouth, pharynx - High likelihood of swallowing -Clip hairs carefully as not to damage mucosa •Eyes -Give first consideration to location and removal of foreign bodies -Second consideration to chemical contaminants which can cause immediate damage to eyes -Sample eyes with moist swabs for analysis -Irrigate with saline •Irrigate eyes medial to lateral to avoid contamination of lacrimal duct and nose -Protect skin and ears from contamination •Intact Skin -Decontamination of intact skin is a relatively simple procedure -Complete decontamination is not always possible as some contamination may remain "fixed" on the skin surface Decontamination should only be as thorough as is practical Procedures to Decontaminate Intact Skin 1.Removing clothing will remove majority of contamination 2.Sample contaminated areas with moistened gauze or swabs 3.Isolate contaminated area with waterproof drapes Have to be careful with removing clothing otherwise contamination might occur 4. Use least aggressive method for decontamination so as not to abrade the skin a.Use 4x4 for small areas b.Irrigate with lukewarm water c.Gently scrub skin with soap and warm water d.Use bleach diluted 10:1 on intact skin e.Use cornmeal/detergent mix on calloused areas 5. Decon is a repetitive process

Closing out the REA

•To close out the REA, everything must be surveyed to ensure it is not contaminated and then decontaminated if needed •Decontamination of equipment can be very technical and a licensed contractor should be consulted •Consult with law enforcement before initiating cleanup actions if incident was the result of a terrorist or criminal act—evidence preservation •Who is responsible for cleanup costs? Cleanup contractor does the rest

Detecting Internal Contamination/Incorporation

•To rapidly detect internal contamination and/or incorporation, check for one or more of the following: -History of splash/spray, etc. with radioactive material -Contamination in or near portals of entry—mouth, nose, wounds, etc. -Contamination found in emesis, sputum, urine, feces, saliva etc •Not finding contamination in initial sputum, urine, etc. does not rule out the presence of internal contamination •Prevent internalization of material •The method of treatment depends in part on the isotope and its chemical nature •Treatment may need to be instituted based on suspicion of internal contamination •Risk/benefit ratio must be weighed, and treatment started only if the possible benefits outweigh the potential risks involved strontium and iodine have longer half lifes •Four basic strategies for the removal of internally contaminating radioisotopes include: -Decrease absorption from gut -Dilute isotope -Block incorporation -Administer mobilizing agents •Decrease absorption from the gut -Gastric lavage - timing, forcing through pylorus -Barium sulfate - radium and strontium -Al and Mg salts - decreases absorption of radium and strontium -Prussian blue - cesium, thallium •Included in the Strategic National Stockpile -PH adjustment - changes solubility of some compounds •Isotopic dilution -Administering large amounts of the stable isotope of the same element to increase excretion of radioisotope -Works well for tritium -Water, IV fluids, other oral fluids -Maintain copious urine output •Block incorporation -Saturate the target tissue/organ with the stable isotope to reduce uptake of the radioisotope -Radioiodine is the prototype for use Stable Iodine in the thyroid blocks radioactive iodine. Can take in lots of calcium to prevent strontium •Mobilizing agents -Chemicals that enhance elimination of the radioisotope from the body -Chelation (EDTA, DTPA, etc.) for heavy metals/transuranics -Diuretics used to increase excretion of electrolytes Rapid elimination, chelation binds to multiple areas of metal ions or regular ions

Man-Made Sources of Radiation

•Tobacco products 1,300 mrem per/yr •Medical radiation approx 54 mrem/yr •Building materials approx 7 mrem/yr •Domestic water supply approx 5mrem/yr Total of natural background and man-made sources for the average American - 360 mrem per year (about 1 mrem per day) Average due to smoking cigarettes (1 pack a day) - 1300 mrem per year (about 3 mrem per pack) Tobacco contains small amounts of radioactive polonium and radioactive lead that result from radioactive radon that seeps up out of the ground. Airline flights give you a small radiation dose because there is less atmosphere above the plane to shield the passengers from cosmic radiation. The higher you fly, the more cosmic radiation you receive. NATURAL BACKGROUND mrem/year Cosmic Radiation 26 Terrestrial (Earth's crust) 28 Internal Sources (body) 40 Radon 200 MAN-MADE SOURCES mrem/year Smoking (Tobacco Products) 1300 Medical X-rays 40 Medical Diagnosis and Therapy 14 Building Materials 7 Domestic Water Supply5 other minor contributors •Atmospheric testing of nuclear weapons •Consumer products •Industrial causes

Factors Affecting Sensitivity to Ionizing Radiation

•Total dose •Dose rate •Portion of body exposed •Uniformity of exposure •Biological variability ••Genetic predisposition •Availability of treatment •Type and energy of radiation •Location and type of emitter

Factors Affecting Cell Damage

•Total dose •Dose rate •Type of radiation •Area of the body •Cell sensitivity •Individual sensitivity •General state of health

Radiological Units

•Traditional units of measure and International System of Units (SI) are used in measuring radiation and radioactivity •For radiation measurement: Exposure Absorbed Dose Dose Equivalent Common Units roentgen (R) rad rem SI Units coulomb/kilogram (C/kg) gray (Gy) sievert (Sv) Know this , US uses common units radiation equivalent measure SI is everyone else. 1 sievert = 100 rem also in glossary/appendix 1ms is 100 mrem. Mili is 1 thousandth •Radioactivity is measured in the number of nuclear decays or disintegrations that occur during a specific time •Radioactivity or the strength of a radioactive source is measured in: • -Traditional units of curies (Ci) •1 Ci = that quantity of radioactive material in which 37 billion atoms disintegrate per second • -SI units of becquerel (Bq) •1 Bq = that quantity of radioactive material in which 1 atom disintegrates per second Know units and scientific notation micro is 10^-6, Milli is 10^-3, centi is 10^-2

Scenarios Resulting in Contaminated Patients

•Transportation accidents (highway, rail, ship, etc.) •Nuclear power plant accident •Accident at facility that handles radioactive material, such as fuel processing plant, laboratory, medical facility, sterilization plant that uses radioactive sources, etc. •Industrial radiography accident Non-Accidental Events •Radiological Dispersion Device (RDD) •Radioactive source planting •Nuclear detonation

Measuring Radiation the Roentgen

•Unit used to measure radiation exposure •A measure of the ability of photons to produce ionizations in air •1 roentgen = 2.58 E-4 coulombs/kg of air •The SI unit for exposure is the C/kg

Conversion Steps

•Using Appendix F, page F-1, Abbreviations and Conversions for Radiation Units •Step 1: On the left side, find the unit you want to convert from •Step 2: Find the factor in that line for the unit you want to convert to •Step 3: Multiply the original value by the factor and the result will be the measure in the desired units scientific notation •Since very small and very large numbers are used in quantifying radioactive materials, use numerical abbreviations to write values in a practical way •Refer to the Numerical Prefixes found in Appendix F, page F-2 Milli m 10-3 Micro μ 10-6 Nano n 10-9 Pico p 10-12

gamma radiation

•Waves of energy that have no mass and no electrical charge •Commonly referred to as photons •Can travel a great distance •Poses a hazard to the entire body •Dense materials such as lead, steel, and concrete used to shield gamma radiation

Radiation: Dose and Dose Rate

•We live with radiation everyday •Radiation exposure comes from a variety of natural and manmade sources •Radiation Dose: -The amount of radiation energy deposited in the body -Often measured in millirem •Dose Rate: -The rate at which radiation energy is deposited in the body -Often measured in millirem per hour Most radiation events are chronic exceptions for acute are like bombs, or disaster Know dose rate and radiation dose biological effects Cellular level effects mostly, actively dividing cells are more affected by radiation like blood or skin cells, acute dose is a large amount of radiation given at a single time and damages mainly include rapidly dividing cells like blood cell depletion and hair cell depletion intestine, reproductive cells, can be used by cancer treatment, chronic dose is radiation received over time, body can handle chronic cell lose much more easily and outward effects are very manageable, 10 rems are easily mitigated

dress of personel

•Wearing PPE reduces your chance of getting contaminated •Use waterproof PPE wherever possible and tape pants and sleeve cuffs •PPE provides protection against contamination but not penetrating radiation

Radioactive Contamination

•When radioactive material is where it is not wanted (e.g., on the ground, in water, or on you), we refer to it as "contamination" •Radioactive material in a place where it is not wanted •Material may be in solid, liquid, or gas form •Contaminated patient presents little or no hazard of ionizing radiation to personnel Most first responders think solid not liquid or gas, because they have only trained with solids •External -Easiest to remove and least harmful -80% of contaminant removed with clothing removal •Internal -Radioactive material ingested, inhaled, injected (impaled), or absorbed into body •Incorporation -Radioactive material taken into the cells, tissues, and organs

Initial Monitoring

•Where contamination is readily detectable, other factors must be considered before protective actions are recommended: •Whether contamination is airborne or contained •Extent of the contamination •Type and level of contamination •Location of the contamination problem •Contamination can become airborne if radioactive materials are involved in a fire •Responders may not be able to perform air monitoring in the midst of lifesaving, fire-fighting, or other response operations •Until this airborne hazard is ruled out, protective actions should be taken •Surface contamination may also be encountered, including: •People, clothing, and equipment •Monitoring instruments •Vehicles •Rescue tools •Walls •Ceilings •The floor or ground •Monitoring instruments will not distinguish between fixed and removable contamination •A direct survey must be combined with a smear survey to determine if the surface contamination is removable, fixed, or a combination of the two •The smear (or wipe/swipe test) is the universal method of assessing removable contamination •A representative area of the surface should be wiped in a sweeping "S" shape, covering about 100 square centimeters of surface area •Items used to reduce the spread of contamination: •Disposable gloves •Trash bags and ties •Full-sized sheets •Blankets •Rope and barrier tape