Published on September 27, 2007
Getting Prepared for a Radiological Terrorist Event: Getting Prepared for a Radiological Terrorist Event David J. Brenner, Ph.D., D.Sc., Center for Radiological Research Columbia University Medical Center firstname.lastname@example.org You can view / download this lecture at www.columbia.edu/~djb3 Goiânia, Brazil, 1987Population 1.3 million: Goiânia, Brazil, 1987 Population 1.3 million Abandoned medical clinic in Goiânia contained 1,400 Curie radioactive cesium sources: Abandoned medical clinic in Goiânia contained 1,400 Curie radioactive cesium sources The radioactive sources were stolen, broken open, and dispersed Goiânia incident: Equivalent to large-sized dirty-bomb scenario in Manhattan: Goiânia incident: Equivalent to large-sized dirty-bomb scenario in Manhattan 130,000 people (10%) came to ER / temporary screening locations 250 (0.2%) were contaminated 20 (0.01%) required treatment Topics that we will cover: Topics that we will cover What is ionizing radiation? How is it harmful? Radiation threat scenarios Appropriate medical responses Psychological aspects Resources Radioactivity: Radioactivity The spontaneous emission of radiations: alpha rays, beta rays, gamma rays from radioactive materials Slide7: Radioactivity: Alpha Rays Slide8: Radioactivity: Beta Rays Slide9: Radioactivity: Gamma Rays The Electromagnetic Spectrum Slide10: Interaction of alpha, beta, gamma rays with matter: Ionization Slide11: Alpha, beta and gamma rays Radiation vs. Radioactive Material: Radiation vs. Radioactive Material Radiation: energy transported in the form of particles or waves (alpha, beta, gamma, neutrons) Radioactive Material: material that contains atoms that emit radiation spontaneously Exposure vs. Contamination: Exposure vs. Contamination External Exposure: irradiation of the body from external source Contamination: radioactive material on patient (external) or within patient (internal) Radiation Dose : Radiation Dose Measured in milliGray (mGy) (1/1000 joule / kg) Equivalent dose is measured in milliSievert (mSv) For our purposes, 1 mGy = 1 mSv Old units are the rad and the rem 10 mGy = 1 rad; 10 mSv = 1 rem Average background radiation dose is 3 mSv / year A mammogram produces about 0.01 mSv. A CT scan produces about 10 mSv. Radioactivity: Radioactivity The activity (strength) of a radioactive source is measured in Curies (Ci) or Becquerels (Bq) 1 Bq = 1 radioactive disintegrations / sec 1 Ci = 37 GBq = 37 thousand million disintegrations / sec The Principal Hazards ofIonizing Radiation: The Principal Hazards of Ionizing Radiation Cancer risks Hereditary risks Effects on the developing embryo/fetus Slide17: Radiation Risks Teratogenic risks Order of magnitude larger than Carcinogenic risks Order of magnitude larger than Hereditary risks The Carcinogenic Effects of Ionizing Radiation: The Carcinogenic Effects of Ionizing Radiation Slide19: Ionizing Radiation and Cancer Most of our information comes from studies of A-bomb survivors Slide20: Lifetime cancer mortality risk as a function of age at exposure Slide21: Individual Susceptibility to Radiation Carcinogenesis There are likely to be subpopulations of individuals who are significantly more sensitive to ionizing radiation than the average: Children ATM heterozygotes (Ataxia Telangiectasia, 1-2% of the population) BRCA1 BRCA2 Radiation-induced hereditary effects: Radiation-induced hereditary effects Radiation does not produce new, unique mutations, but simply increases the incidence of the same mutations that occur spontaneously Teratogenic Risks(i.e., to the embryo/fetus, if relevant): Teratogenic Risks (i.e., to the embryo/fetus, if relevant) Moderate doses of radiation can produce catastrophic effects on the developing embryo and fetus. The principle effects of radiation on the developing embryo and fetus are:: Growth retardation Embryonic, neonatal, or fetal death Congenital malformations and functional impairment, such as mental retardation. The principle effects of radiation on the developing embryo and fetus are: Slide25: Radiation Risks Teratogenic risks order of magnitude larger than Carcinogenic risks order of magnitude larger than Hereditary risks Radiation Threat Scenarios: Radiation Threat Scenarios Nuclear device Damage to nuclear power plant Dirty bombs Nuclear Device: Nuclear Device Risk Exposure to rays and neutrons Fallout of fission products (including short-lived iodine isotopes) Outcome Large number of acute deaths Long-term carcinogenesis Likelihood Remote Attack on a nuclear power plant: Attack on a nuclear power plant Risk Attack on the reactor itself: Attack on stored used fuel elements Release of fission products: I-131, Cs-137, etc Outcome Unlikely to involve acute deaths Long-term carcinogenesis Likelihood Extremely unlikely Dirty Bombs (Radioactive dispersal devices, RDD): Dirty Bombs (Radioactive dispersal devices, RDD) Risk Release of radioactive cesium, cobalt or americium Small number of contaminated people Large number of very slightly contaminated people Psychological chaos (many frightened people) Outcome Unlikely to result in acute deaths Risk of long-term carcinogenesis Likelihood Likely Slide30: Radioactive Dispersal Device (RDD) Dirty Bombs: Dirty Bombs How available are the radioactive materials? August 1994: August 1994 Three people arrested at Munich airport having flown on a Lufthansa flight from Moscow carrying 363 grams of plutonium November 1995: November 1995 Moscow, Russia -- A group of Chechen rebels contacts a Russian TV station to claim that they have buried a cache of radiological materials in Moscow's Ismailovsky Park. There, the authorities find a partially buried container of radioactive cesium. December 1998: December 1998 Argun, Chechnya – A container filled with radioactive materials found attached to an explosive mine hidden near a railway line. It is safely defused. The location is Argun, near the Chechen capital of Grozny, where a Chechen group, led by Shamil Basayev, operated an explosives workshop. June 2002: June 2002 Chicago, Illinois -- Jose Padilla, a US citizen with links to Al Qaeda, is arrested in Chicago airport on suspicion of planning to build and detonate a dirty bomb. F.B.I agents suspect Padilla had recently undergone training in Pakistan, where he allegedly studied the mechanics of dirty-bomb construction, including how to wire explosive devices and how to optimize bombs for radiological dispersion. January 2003: January 2003 A collage of dirty bomb plans journalists recently discovered in Afghanistan Herat, Afghanistan -- Based on evidence uncovered in Herat, including detailed diagrams and computer files, British intelligence agents conclude that Al Qaeda has succeeded in constructing a small dirty bomb, though the device has not been found. March 1998: March 1998 Cesium tubes similar to the ones missing from Greensboro Greensboro, North Carolina -- Nineteen small tubes of cesium are taken from a locked safe in Moses Cone Hospital. The total activity was 22 Gbq (0.6 Ci). Each tube was three-quarters of an inch long by one-eighth of an inch wide and were used in the treatment of cervical cancer. The cesium is never recovered. March 2002Nucor Steel Mill, Hertford, NC: March 2002 Nucor Steel Mill, Hertford, NC 2 Ci cesium industrial gauge found on scrap metal conveyer belt Traced back to a batch of four belonging to a bankrupt Baltimore chemical company. Three have been located.... Moisture Density Gauges, contain small quantities of americium-241 and cesium-237About 22,000 in use in the US. About 50 per year reported as missing: Moisture Density Gauges, contain small quantities of americium-241 and cesium-237 About 22,000 in use in the US. About 50 per year reported as missing August 2004: August 2004 London: Islamic terrorist cell, led by Dhiren Barot, raided. Large cache of household smoke detectors found, each containing small quantities of americium-241 Small and large dirty bombs (RDD: Radioactive dispersal device): Small and large dirty bombs (RDD: Radioactive dispersal device) Small RDD: High explosives dispersing 0.1 to 10 Curies Intermediate RDD High explosives dispersing 10 to 1,000 Ci Large RDD: High explosive dispersing 1,000 to 10,000 Ci Small Dirty Bomb (RDD): 2 Ci cesium source + 10 lb TNT: Small Dirty Bomb (RDD): 2 Ci cesium source + 10 lb TNT Inner Ring: One cancer death per 100 people due to remaining radiation (typical dose 25 cGy) Middle Ring: One cancer death per 1,000 people due to remaining radiation (typical dose 2 cGy) Outer Ring: One cancer death per 10,000 people due to remaining radiation (typical dose 0.2 cGy) EPA suggests decontamination Slide43: Intermediate RDD: 2,000 Ci of cesium chloride, from a seed irradiator, and 10 lb of Semtex Slide44: Inner Ring: One cancer death per 100 people due to residual contamination (typical dose 25 cGy) Middle Ring: One cancer death per 1,000 people due to residual contamination (typical dose 2 cGy) Outer Ring: One cancer death per 10,000 people due to residual contamination (typical dose 0.2 cGy) Large RDD: 10,000 Ci cobalt source (food irradiator rod) Slide45: Inner Ring: Same radiation level as permanently closed zone around Chernobyl Middle Ring: Same radiation level as permanently controlled zone around Chernobyl Outer Ring: Same radiation level as periodically controlled zone around Chernobyl Large RDD: 10,000 Ci cobalt source (food irradiator rod) You need to be part of a radiation casualty : You need to be part of a radiation casualty Health providers Physicists Social workers / administrators team Immediate Medical Management Issues Immediate Medical Management Issues: Immediate Medical Management Issues Triage Decontamination Initial stabilization and treatment of life-threatening injury Health care provider health and safety Surge capacity: availability of staff (quantity and specialists), supplies, space Almost all the individual presenting at ER / clinic will not have a measurable radiation exposure: Almost all the individual presenting at ER / clinic will not have a measurable radiation exposure Goiânia 99.8% of individuals at ER/clinic not contaminated 8% had “psychosomatic reactions which mimicked radiation exposure” Israel, attacked by Scud missiles during 1991 Gulf war 51% of individuals at ER were “stress casualties” The job of the radiation physicists : The job of the radiation physicists Determining / documenting radioactivity levels, and radiation dose levels Collecting samples to document contamination Assisting in decontamination procedures Disposing of radioactive waste Staff radiation protection : Staff radiation protection Fundamental Principles - Time - Distance - Shielding Personnel Protective Equipment Contamination Control Slide51: Contamination Control HOT LINE CONTAMINATED AREA BUFFER ZONE CLEAN AREA Clean Gloves, Masks, Gowns, Booties Separate Entrance Trauma Room Slide52: Protecting Staff from Contamination Use standard precautions (N95 mask if available) Survey hands and clothing frequently Replace contaminated gloves or clothing Keep the work area free of contamination Pregnant Staff: Pregnant Staff Pregnant staff should be reassigned We need to be prepared for a radiological incident: We need to be prepared for a radiological incident Facilities should plan in advance and include procedures in their Disaster Plan Everyone needs training! If there is a plan in place and staff are well trained, radiation exposure to staff should be very low: If there is a plan in place and staff are well trained, radiation exposure to staff should be very low “When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personal at the site received less than 10 mGy of radiation.” Mettler & Voelz, New England Journal of Medicine, 346: 1554 (2002) Patient Management - Priorities: Patient Management - Priorities Standard medical triage is the highest priority – don’t delay giving critical care because a patient is contaminated Radiation exposure and contamination are secondary considerations External Contamination : External Contamination Radioactive material (usually in the form of dust particles) on the body surface and / or clothing Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff Patient Decontamination: Patient Decontamination Remove and bag patient’s clothing and personal belongings (typically removes 80 - 90% of contamination) Handle foreign objects with care until proven non-radioactive with survey meter Survey patient and collect samples Decontamination Priorities: Decontamination Priorities Wounds Intact skin Change outer gloves frequently to minimize spread of contamination Decontamination of Wounds: Decontamination of Wounds Contaminated wounds: Irrigate, gently scrub with surgical sponge Debride surgically only as needed Contaminated thermal burns: Gently rinse Change dressings to remove additional contamination Avoid overly aggressive decontamination Change dressings frequently Decontamination of Skin: Decontamination of Skin Use multiple gentle efforts Use soap & water Cut hair if necessary (do not shave) Use survey meter Cease Patient Decontamination: Cease Patient Decontamination When decontamination efforts produce no significant reduction in contamination When the level of radiation of the contaminated area is less than about twice background Slide63: Removing internal contamination is more problematic Internal contamination countermeasures?: Internal contamination countermeasures? Potassium iodide blocks radioactive iodine from being absorbed in the thyroid. Very limited utility Internal contamination countermeasures?: Internal contamination countermeasures? Potassium iodide blocks radioactive iodine from being absorbed in the thyroid. Totally useless Internal contamination countermeasures?: Internal contamination countermeasures? Traps cesium in the intestine, so that it can be passed out of the body in the stool rather than be re-absorbed Recently approved by FDA Only useful if the radioactive material is cesium High-dose radiation syndromes: High-dose radiation syndromes Self Renewing Tissuese.g. lining of the G.I. tract: Self Renewing Tissues e.g. lining of the G.I. tract Stem-cell compartment Differentiating compartment Mature functioning cells Prodromal Effects: Prodromal Effects Symptoms to be expected at about 50% lethal dose: Neuromuscular – Easy fatigability Gastrointestinal – Anorexia, vomiting Additional symptoms to be expected after a supra-lethal dose: Neuromuscular – Fever & hypotension Gastrointestinal – Immediate diarrhea Slide70: Gastrointestinal Syndrome Results from whole-body exposure to >8 Gy. Due to crypt cell depletion and sloughing off of intestinal villi Symptoms include nausea, vomiting, prolonged diarrhea, loss of appetite, lethargy, dehydration, emaciation, exhaustion Symptoms start a few hours after exposure but, depending upon the dose, there is often a latent period around day 2-6, at which time severe symptoms return Death occurs in around 5-15 days. Slide71: Hematopoietic Syndrome Results from whole-body exposure to 3 - 8 Gy. Due to depletion of blood stem cells Symptoms include all of GI syndrome: nausea, vomiting, diarrhea, with similar latent period ~ 3 weeks after exposure, chills, fatigue, skin hemorrhages, mouth ulceration, anemia, epilation Death within ~60 days due to infections and fever (lymphocyte and granulocyte depression), or hemorrhage (platelet depletion) Some individuals may be saved by antibiotics, platelet infusions, bone marrow transplants, or growth factors. Slide72: Treatment of Large Radiation Exposures Treat patients symptomatically Prevent and manage infections Reverse isolation Assess for infection and thrombocytopenia Antibiotics Electrolytes Hematopoietic growth factors, e.g., GM-CSF, G-CSF (Neupogen) Continued assessment and supportive care Bottom Line: Bottom Line Medical centers in major cities need to be able to quickly assemble a competent team to cope with a radiation incident: Physicists Emergency room specialists Radiation oncologist / radiologist Psychologists Selected Further Information: Selected Further Information CDC and OSHA have good starting websites: www.bt.cdc.gov/radiation/index.asp www.osha.gov/SLTC/emergencypreparedness/rdd_tech.html Documents American College of Radiology: “Disaster Preparedness for Radiology Professionals” Download at www.acr.org/departments/educ/disaster_prep/dp_primer.html National Council on Radiation Protection and Measurement Report No. 138, 2001 “Management of Terrorist Events Involving Radioactive Material” The real bottom line: The real bottom line The threat of radiological terror is real Most scenarios will present primarily organizational challenges The real bottom line: The real bottom line The threat of radiological terror is real Most scenarios will present primarily organizational challenges The answer:
Radiation Awareness Training Radiation Awareness Training Craig Woodworth Radiation Safety Officer Room 147 Science Center Clarkson University Tel. 315-268 ...