Radiation Safety Radiation Poisoning Rick Layman, MS , DABR Instructor Diagnostic Medical Physicist Department of Radiology The Ohio State University Medical Center

Outline Possible Radiation Emergency Scenarios Radiation Safety – Possible scenarios • Medical – Radiation Basics • Terrorist use of nuclear materials – Decontamination procedures • Catastrophic event Medical Aspects of Radiation – Biologic effects – Radiation sickness

1 Medical Radiation Event Medical Radiation Event • 40 year old male underwent a coronary angiography, coronary angioplasty and secondary angiography due to complications, • Radiation Oncology followed by a coronary artery by-pass graft. • All procedures occurred on March 29, 1990 Appearance of skin injury post- procedure: (a) 6-8 wks (b) 16-21 wks (c) 18-21 wks

Shope, T, (a)(b) (c) Radiographics, 1996, 16, 1195-1199, 1996

Medical Radiation Event Terrorist Use of Nuclear

• Acquisition protocols were not set Material properly resulting in excessive exposures • Radiological Dispersal Device • Cedar Sinai (L.A.): 200 patients overexposed during 18 month (i.e. “dirty bomb”) period • Providence St. Joe (L.A.): 34 • Combine radioactive material with patients overexposed during 20 explosive device month period • Glendale Adventist Medical Center • Blast effect plus radioactivity (L.A.): 10 patients overexposed during 10 months After Stroke Scans, Patients Face • 8x national average for exposure Serious Health Risks, The New York Times, August 1, 2010.

2 Terrorist Use of Nuclear Catastrophic Event Material • Goiânia, Brazil • 1985: Private Improvised Nuclear Device or Nuclear Weapon radiotherapy clinic closed • An actual nuclear detonation down • 1987: teletherapy • Allegation that 50 to 100 one kiloton head stolen • Unit dismantled, suitcase nuclear weapons unaccounted Cs-137 source for from former Soviet Union capsule ruptured causing major • Various rogue or terrorist supporting contamination • 50.9 TBq (1375 Ci) states caesium-137 teletherapy Used with permission from Brian Dodd, BD machine left in Consulting, HPS Past President abandoned clinic

Catastrophic Event Goiânia, Brazil Reactor Accidents • 112 000 people monitored • Three Mile Island - 1979 • 249 people contaminated • Chernobyl – 1986 • 49 people 0.1 - 6.2 Gy • Tokaimura, Japan – 1999 (uranium processing • 4 pppeople died facility) 6 y old girl • Fukushima, Japan – 2011 18 y old man War Veterans 22 y old man • Operation UPSHOT-KNOTHOLE 38 y old mother • Exposures ranged from 0.4 – 31 mSv (equivalent to 5 – 390 chest x-rays)

3 Radiological Accident Catastrophic Event Statistics (1944-2000) • Gilan, Iran ~ 400 reported accidents • 1996: Ir-192 source ~ 3000 exposed persons used for industrial > 100 deaths, more than half involving radiograph y f all s out patient s of shielded container In addition, orphan sources can be mixed up with scrap causing • Manual worker picks contamination problems up source and puts it in chest pocket Illicit trafficking involves orphan sources Used with permission from Brian Dodd, BD Consulting, HPS Past President but very few orphan source incidents are due to illicit trafficking events

Gilan, Iran The Basics of Radiation

Ionizing radiation is electromagnetic • Resulting in severe energy or energetic particle emitted from a radiati on b urns t o source. the chest Ionizing radiation is able to strip electrons from atoms causing chemical changes in molecules.

4 Ionizing Radiation Natural Background

Primarily radon and gamma rays • Ionizing radiation is emitted by from the atmosphere • Ground -Radioactive material – 222Rn • Building Materials -Machine generated • Air (x-rays, LINACS) • Food – 238U and 232Th from drinking water • Biological effects from • Universe ionizing radiation are – Gamma rays generated in supernova dependant on the energy and • Elements within our own body type of radiation – 14C Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2, 2006

Electromagnetic Radiation Manmade Sources

Used in medicine, research, and industry • X-ray equipment • Radioactive materials Assumes everyone receives two diagnostic x-ray exams per year

Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2, 2006

5 Key Point: Key Point:

Every individual receives low levels of radiation every day of their life Not all radiation is equal

Background Radiation Around the World Particulate Ionizing Radiation

• Alpha particles: two protons and two neutrons • Beta particles: release gamma • Neutrons: causes other substances to become radioactive

6 Gamma or X-Ray Radiosensitivity Physical Factors (Photons) • Linear Energy Transfer (LET) • High energy rays – Measure of the rate at which energy is transferred from ionizing radiation to soft tissue. • Very penetrating • Relative Biologic Effect (RBE) • Difficult to shield – Ability to produce biologic damage • Can be produced from • Fractionation radioactive decay and a nuclear Biologic Factors weapon explosion or reactor • Oxygen Effect accident – Tissue is more sensitive in the presence of oxygen • PPE will not protect against • Recovery photon radiation • Age

Radiation Sensitivity and Age

7 Law of Bergonie and Radiation Doses and Dose Limits Tribondeau • Stem cells are radiosensitive. The more Flight from Los Angeles to London 5 mrem mature a cell, the more resistant to Annual public dose limit 100 mrem radiation it is. • The younger the tissue and organs, the Annual natural background 300 mrem more radiosensitive they are. Fetal dose limit 500 mrem • When the level or metabolic activity is Barium enema 870 mrem high, radiosensitivity is also high. • As the proliferation rate for cells and the Annual radiation worker dose limit 5,000 mrem growth rate for tissue increase, the radiosensitivity also increases.

Measures of Radiation Radiation Doses and Dose Limits

Exposure Heart catheterization 45,000 mrem • Rad = Radiation Absorbed Dose: measures amount of energy actually absorbed by a Life saving actions guidance 50,000 mrem material (i.e. tissue) (NCRP-116) • Rem = Roentggqen Equivalent Man: measures biologic damage of radiation; takes into Mild acute ra diat ion syn drome 100,000 mrem account dose and type of radiation involved • In most situations, 1 Rem = 1 Rad LD50/60 for humans 350,000 mrem (bone marrow dose) • 1 Gray (Gy) = 100 Rads • 1 cGy = 1 Rad Radiation therapy 6,000,000 mrem (localized & fractionated) • 1 Sievert = 100 Rems • 1 millisievert = 0.1 Rem

8 Radioactive Material Radiation Exposure Types • Radioactive material consists of atoms External Internal with unstable nuclei Irradiation Contamination Contamination • The atoms spontaneously change (decay) to more stable forms and emit radiation ** ‘‘ • A person who is contaminated has * ‘ ‘ radioactive material on their skin or * ‘‘‘ inside their body (e.g., inhalation, ingestion, shrapnel, or wound * contamination) *** • A person exposed to radiation may, or may not, be contaminated. • Not all radioactive materials are equal

Types of Radiation Hazards Examples of Radioactive Materials • External Exposure - Physical Internal Radionuclide Half-Life Activity Use whole-body or partial-body Contamination (no radiation hazard to ED Cesium-137 30 yrs 1.5x106 Ci Industrial radiography External staff) Contamination Cobalt-60 5 yrs 15,000 Ci Cancer Therapy • Contaminated - Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon External Iridium-192 74 days 100 Ci Industrial Radiography – external radioactive Exposure material: on the skin Hydrogen-3 12 yrs 12 Ci Exit Signs Strontium-90 29 yrs 0.1 Ci Eye Therapy Device – internal radioactive material: inhaled, Iodine-131 8 days 0.015 Ci Nuclear Medicine swallowed, absorbed Therapy through skin or wounds Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging Americium-241 432 yrs 0.000005 Ci Industrial radiography Radon-222 4 days 1 pCi/l Environmental Level

9 ARS - Phases 1. Prodromal Phase - occurs in the first 48 to Medical Aspects of Radiation 72 fours post-exposure and is characterized by nausea, vomiting, malaise and anorexia. At doses below about 500 rads last 2 to 4 days. The earlier the symptoms, the worse the exposure Richard Nelson, MD Vice Chair 2. Latent Phase - follows the prodromal phase Department of Emergency Medicine and lasts for approximately 2 to 2 1/2 weeks. During this time, critical cell populations The Ohio State University (leukocytes, platelets) are decreasing as a result of bone marrow insult. The time interval decreases as the dose increases.

Acute Radiation Syndrome ARS - Phases (ARS) • Group of symptoms that develop after 3. Illness Phase - period when overt illness develops total body irradiation ( > 100 rads) • May occur from either internal or 4. Recovery or Death Phase - may take external radiation weeks or months • Four important factors are: – High Dose – High Dose Rate – Whole Body Exposure – Penetrating Radiation

10 Prodromal Phase and Prognosis ARS - Skin • If time to emesis is <4 hours: exposure at least 3.5 Gy sis amation oist o u

• If time to emesis is < 1 hour: exposure M at least 6.5 Gy Response Desq Necr 300 600 1000 >1500 >5000 Dose

Acute Radiation Sickness • Skin/hair • Gastrointestinal tract • Hematopoietic system • Central nervous system

11 12 ARS - Hematopoietic Syndrome /L) 9 3.0 2.5 Normal Range

ytes (10 2.0 c 1.5 Moderate 1.0 Patient Severe Injury 0.5 Very Severe 0.1 Lethal 0361724 48 hrs Absolute Lympho

ARS - Gastrointestinal ARS Blood Counts Syndrome • 48 hour absolute lymphocyte count > • Radiation > 600 rads 1200: good prognosis; 300 - 1200: • Damages intestinal lining significant radiation exposure; <300: • Nausea and vomiting within probably lethal the first 2 - 4 hours • Absolute granulocyte counts: should be • May develop diarrhea followed with higher-level exposures; • Associated with sepsis and nadir occurs at 8 to 30 days post-exposure opportunistic infections • Other parameters: platelet counts, • At 10 days could develop reticulocyte counts, numbers of dicentric bloody diarrhea resulting in chromosomes in blood and bone marrow death

13 ARS - Central Nervous Evaluation & Treatment - System Hospital Care • Seen with radiation • Activate hospital plan • Establish triage area (separate entrance) dose > 1,000 rads • Plan to control contamination (don’t count on • Microvascular ppyg)atients already being decontaminated) – Prepare area by cover/marking floor, leaks Õ edema control ventilation • Elevated – Prepare staff by issuing protective clothing – Prepare for surveying; call radiation safety intracranial officer pressure – Establish area for storage of waste – Plan for decontamination of non- • Death within hours traumatized patients

Prehospital Care Patient Management: Triage Triage based on: • Information is critical: type of exposure, • Injuries internal vs. external vs. whole vs. partial • Signs and symptoms body, radioactive materials involved - nausea, vomiting, • Decontamination if time permits fatigue, diarrhea – remove and bag clothing • History - Where were – soap and water cleansing of exposed you when the skin bomb exploded/ how close? – retain wash water • Contamination • Emphasis on treating life-threatening survey with G-M injuries meter

14 Patient Management: Priorities Staff Protection Levels of PPE Triage • Level A – IDLH • Medical treatment is the environments, fully highest priority encapsulated, requires • Radiation exposure and SCBA contamination are • Level B – Chemicals or secondary substances with considerations inhalation hazard, • Degree of decontamination requires SCBA or SAR dictated by number of, • Level C – Known and capacity to treat, contaminants, requires other injured patients air-purifying respirator

Protecting Staff from Contamination Decon Agents - 1 • Use universal precautions • Survey hands and clothing with radiation meter • Dry Removal • Replace gloves or clothing • Soap / Shampoo that is contaminated • Keep the work area free of • Household Bleach 1:10 contamination Key Points (Sodium Hypochlorite) • Most contamination is easy to detect and • Waterless Cleansers most of it can be removed • It is very unlikely that ED staff will receive large radiation doses from treating contaminated patients

15 Decon Agents - 2 Patient Management: Decontamination • Carefully remove and bag • Povidone-Iodine patient’s clothing and personal • Lava Soap belongings (typically removes 75-95% of contamination). This • Cornmeal / Tide 50:50 may have been done at the scene. • Vinegar ( 32P ) or Club • Survey patient and, if practical, Soda collect samples (skin/wound • Toothpaste swabs)

Decontamination Patient Management: Decontamination • Handle foreign objects with care until determined non-radioactive • Irrigate open wounds and cover with survey meter with sterile dressing • Decontamination priorities: • Soap and water showering – Decontaminate wounds first, (including hair) then intact skin • Effective for mixed – Start with highest levels of radiation/chemical contamination contamination • Refer for any surgery • Change outer gloves frequently to minimize spread of contamination

16 Patient Management: Decontamination (cont.) Special Considerations • High radiation dose and trauma interact • Cease decontamination of skin synergistically to increase mortality and wounds • Close wounds on patients with doses > 100 rem – When the area is less than twice • Wound, burn care and surgery should be background, or done in the first 48 hours, or delayed for – When there is no significant 2 to 3 months (> 100 rem) reduction between decon efforts, Hematopoietic and Emergency Surgery Surgery Recovery Permitted – Before intact skin becomes abraded. No Surgery

24 - 48 Hours ~3 Months After adequate hematopoietic recovery

Patient Management: Decontamination Patient Management: (cont.) Psychological Casualties • Contaminated thermal burns • Terrorist acts involving toxic agents – Gently rinse. Washing may (especially radiation) are perceived as increase severity of injury. very threatening – Additional contamination will be • Mass casualty incidents caused by removed when dressings are nucliillllear terrorism will create large changed. numbers of worried people who may not be injured or contaminated • Provide psychological support to • Do not delay surgery or other patients and set up a center in the necessary medical procedures or hospital for staff exams…residual contamination can be controlled

17 Patient Management: Potassium Iodide Psychological Casualties • Blocks thyroid uptake of Iodine-131 (a • Establish triage (monitoring and beta emitter) counseling) centers to prevent psychological casualties from • Treat within 4 Hours (no utility >12 hours) overwhelming health care facilities • Has no protective effect on anything else • Staff counseling centers with physicians with a radiological background, health • Soviets administered KI 72 hours after physicists with instrumentation and Chernobyl, and had thousands of cancers psychological counselors • KI or NaI, 300 mg tablet • SSKI (1 g / ml), 5 - 6 drops in water

NCRP Report No 65, p 83-86, 104

Patient Management : Treatment of Radiostrontium Internal Contamination Contamination Therapy • Radionuclide-specific, and time sensitive • Most effective when administered early • May need to act on preliminary information • Al Phosphate (100 ml) reduces • NCRP Repp,gort No. 65, Management of Persons absorption as much as 85% Accidentally Contaminated with Radionuclides • Ba Sulfate is also effective Radionuclide Treatment Route Cesium-137 Prussian blue Oral • Na Alginate inhibits uptake by Iodine-125/131 Potassium iodide Oral Strontium-90 Aluminum phosphate Oral 80–90% (10g po) Americium-241/ Ca- and Zn-DTPA IV infusion Plutonium-239/ Cobalt-60

18 Prussion Blue DPTA chelation

• Blocks intestinal absorption • Plutonium ooCsf Cs-137 • Americium • curium

Penicillamine Other adjuncts

• Radioactive heavy metal • Filgrastim and sargramostim poisoning (lead) to treat neutropenia

19 Localized Radiation Effects – Organ Fetal Irradiation System Threshold Effects No significant risk of adverse health effects below 10 rem

• Skin - No visible injuries < 100 rem Weeks After Period of Effects – Prompt - erythema, epilation >500 rem Fertilization Development – Moist desquamation >1,800 rem <2 Pre-implantation • Little chance of malformation – Ulceration/Necrosis >2,400 rem • Most probable effect, if any, is dthfdeath of emb ryo • Cataracts – Acute exposure >200 rem 2-7 Organogenesis • Reduced lethal effects – Chronic exposure >600 rem • Teratogenic effects • Growth retardation • Permanent Sterility • Impaired mental ability 7-40 Fetal – Female >250 rem • Growth retardation with higher doses – Male >350 rem • Increased risk of childhood All cancer

Chronic Health Effects Key Points From Radiation • Early symptoms are an indication of the severity of the radiation dose • At low doses, radiation is a weak carcinogen • Pre-planning to ensure adequate supplies of PPE and survey instruments • Risk of fatal cancer due to radiation exposure is estimated as • Rescue and treatment protocols vary little ~ 4% per 100 rem for radiation contamination • Treatment of medical/surgical • A dose of 5 rem increases the risk emergencies takes priority of fatal cancer by ~ 0.2% • Donning PPE and decontaminating • A dose of 25 rem increases the risk patients minimizes exposure risk of fatal cancer by ~ 1% • Treatment requires a unified effort

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