The Burn Center The Burn Center and Radiation and Radiation

IncidentsIncidents

David J. Barillo, MD, FACSDavid J. Barillo, MD, FACS

COL MC USARCOL MC USAR

Commander, FEMA Burn Specialty Team 2Commander, FEMA Burn Specialty Team 2

DisclaimersDisclaimers

I have no financial interests in any of thisI have no financial interests in any of this

Views expressed are my own and do not reflect Views expressed are my own and do not reflect official policy of my various employers, including official policy of my various employers, including FEMA, the Dept of Defense or the US ArmyFEMA, the Dept of Defense or the US Army

Don’t take notes: presentation and references Don’t take notes: presentation and references are onlineare online

at www.burndisaster.comat www.burndisaster.com

OVERVIEWOVERVIEW

Types of radiationTypes of radiation

Units of radiation measurementUnits of radiation measurement

Sources of radiation / radiation patientsSources of radiation / radiation patients

Treatment considerationsTreatment considerations

References References

Alpha particleAlpha particle Rare and emitted by limited number ofRare and emitted by limited number of substances including plutoniumsubstances including plutonium

A large heavy particle carrying significantA large heavy particle carrying significant energy due to massenergy due to mass

Easily blocked: most stopped by paperEasily blocked: most stopped by paper

Not particularly dangerous externallyNot particularly dangerous externally

An internal contamination threatAn internal contamination threat

Needs special instruments to detect:Needs special instruments to detect: not picked up by Geiger Counternot picked up by Geiger Counter

Most substances that emit alpha particles also emit beta and gammaMost substances that emit alpha particles also emit beta and gamma

Beta particleBeta particle High energy electronsHigh energy electrons

Example: tritiumExample: tritium

Blocked by thin lead shieldingBlocked by thin lead shielding

Damage depends on length ofDamage depends on length of exposure and energy of electronsexposure and energy of electrons

Tends to cause burnsTends to cause burns

Beta and Gamma are the clinically relevant exposuresBeta and Gamma are the clinically relevant exposuresARS with cutaneous syndrome from beta and Gamma radiation at Chernobyl (Ricks p 355)

NeutronsNeutrons

Rarest particleRarest particle

Needs specialized instruments to detectNeeds specialized instruments to detect

Not usually found outside of the center of nuclear Not usually found outside of the center of nuclear reactors or the middle of nuclear weapon blastsreactors or the middle of nuclear weapon blasts

Neutron bombardment can make non radioactive Neutron bombardment can make non radioactive substances into radioactive substances (inside substances into radioactive substances (inside of reactors/blasts)of reactors/blasts)

Best shielding is waterBest shielding is water

Gamma RadiationGamma Radiation High-frequency electromagnetic radiation High-frequency electromagnetic radiation

Easily detectedEasily detected

Hard to shield against (thick lead) Hard to shield against (thick lead)

Distance works bestDistance works best

MeasurementMeasurement

Dosimeters Dosimeters

Detection DevicesDetection Devices

Biologic assaysBiologic assays

Rapid estimation by timing of Rapid estimation by timing of symptomssymptoms

Radiation DoseRadiation Dose R: RoentgenR: Roentgen

An early unit for measuring gamma or X-radiation . An early unit for measuring gamma or X-radiation .

The amount of gamma or X radiation needed to ionize The amount of gamma or X radiation needed to ionize air (0.000258 coulomb of energy per kg of air)air (0.000258 coulomb of energy per kg of air)

Doesn’t work well for high energy XR or nuclear Doesn’t work well for high energy XR or nuclear particlesparticles

1 R is roughly = 1 RAD = 1 REM1 R is roughly = 1 RAD = 1 REM

1 R = 0.88 RAD in air1 R = 0.88 RAD in air

Radiation DoseRadiation Dose

RADRAD

Radiation Absorbed DoseRadiation Absorbed Dose

One RAD = 100 ergs deposited in One RAD = 100 ergs deposited in 1 gram of any material (living or 1 gram of any material (living or not)not)

Radiation DoseRadiation Dose

REMREM

Roentgen Equivalent ManRoentgen Equivalent Man

The quantity of any ionizing radiation The quantity of any ionizing radiation which has the same which has the same biological biological effectiveness effectiveness as 1 rad of X-rays as 1 rad of X-rays

1 REM is roughly = 1 RAD = 1 R1 REM is roughly = 1 RAD = 1 R

Radiation DoseRadiation Dose

Gy (Grey)Gy (Grey)

The International System of Units (SI) The International System of Units (SI) measure of radiationmeasure of radiation

1 Gy = 100 Rads1 Gy = 100 Rads

10 milligray (mGy) = 1 Rad= 1 R = 1 REM10 milligray (mGy) = 1 Rad= 1 R = 1 REM

Radiation DoseRadiation Dose

Sv (Sievert)Sv (Sievert) The Si unit of The Si unit of ionizing radiationionizing radiation

Defined as the dose of ionizing radiation that has the Defined as the dose of ionizing radiation that has the same same biological effectivenessbiological effectiveness as 1 Gy of X-rays as 1 Gy of X-rays

1 Sv = 100 REM = roughly 100 RADS, 100 R or 1 Gy1 Sv = 100 REM = roughly 100 RADS, 100 R or 1 Gy

10 millisieverts (mSv) = 1 REM= 1 RAD= 1 R10 millisieverts (mSv) = 1 REM= 1 RAD= 1 R

Sv is now the preferred unit Sv is now the preferred unit

Radiation DoseRadiation Dose

how much is OK?how much is OK?

Public: 0.1 - 0.5 REM/yr (100-500 mREM)Public: 0.1 - 0.5 REM/yr (100-500 mREM)

Occupational: 5 REM/yrOccupational: 5 REM/yr

Emergency lifesaving: 50 -100 REM whole bodyEmergency lifesaving: 50 -100 REM whole body

Emergency nonlifesaving: 25 REMEmergency nonlifesaving: 25 REM

REF: Mettler and National Council on Radiation ProtectionREF: Mettler and National Council on Radiation Protection

Radiation DoseRadiation Dosehow much is bad?how much is bad?

50 -200 R: headache, 5% hospitalization/death50 -200 R: headache, 5% hospitalization/death

200-500 R: N/V, 90% hospitalization200-500 R: N/V, 90% hospitalization 50% death rate 50% death rate

800 R whole body: no long-term survival recorded 800 R whole body: no long-term survival recorded

1000-5000 R: 100% mortality in 30 days1000-5000 R: 100% mortality in 30 days

Radiation SourcesRadiation Sources

NaturalNatural

Man-made (cigarettes, smoke detectors, watch dials)Man-made (cigarettes, smoke detectors, watch dials)

Medical ( both diagnostic and therapeutic)Medical ( both diagnostic and therapeutic)

Industrial, including nuclear powerIndustrial, including nuclear power

Dirty BombsDirty Bombs

Nuclear weaponsNuclear weapons

COMMON

UNCOMMON

Ref: Mettler

CXR: 40 mRADCXR: 40 mRAD

CT: 1000 - 5000 mRADCT: 1000 - 5000 mRADPanorex: 1000mRADPanorex: 1000mRAD

Radiation RegistryRadiation RegistryRadiation Emergency Assistance Radiation Emergency Assistance

/ Training Site, Oak Ridge/ Training Site, Oak Ridge

Whole body dose > 25 REMWhole body dose > 25 REM

Skin dose > 600 REMSkin dose > 600 REM

Absorbed organ dose from external source > 75 Absorbed organ dose from external source > 75 REM REM

Internal contamination => one half permissible Internal contamination => one half permissible body burdenbody burden

Medical misadventures at doses aboveMedical misadventures at doses above

Radiation RegistryRadiation RegistryRadiation Emergency Assistance / Radiation Emergency Assistance /

Training SiteTraining Site Approximately 20 significant events / year (10-15 in Approximately 20 significant events / year (10-15 in

USA)USA)

50-60 assistance calls per year, 2/3 do not involve 50-60 assistance calls per year, 2/3 do not involve significant exposuresignificant exposure

Worldwide 1944-1987: 290 accidents, 136,607 people, Worldwide 1944-1987: 290 accidents, 136,607 people, 24,845 significant exposures, 65 deaths (half from 24,845 significant exposures, 65 deaths (half from Chernobyl).Chernobyl).

1990-2002

ISOTOPE R/min

137 Cs 513 192 Ir 813 236 Ra 1310 60 Co 2075

Ref: Mettler

Yanango HydroelectricYanango Hydroelectric Plant, Lima Plant, Lima Peru 1999Peru 1999

Ref: Ricks pp 361

•Industrial radiography 192 Ir source lost and carried home in pants pocket of a welder

•Estimated exposure 1-3 Gy over 6 hr •Nausea and erythema at 6 hrs

•Photo is remaining injury at 2 months

•Transfer to French burn center day 91

•R hip disarticulation, colostomy, •uretheral fistulae, pelvis radionecrosis

Dirty BombDirty Bomb A terrorist or area-denial device involving addition of any radioactive A terrorist or area-denial device involving addition of any radioactive

substance to conventional explosivessubstance to conventional explosives

Most of the damage would be from the conventional explosivesMost of the damage would be from the conventional explosives

Radioactive contamination of the wounds would significantly complicate Radioactive contamination of the wounds would significantly complicate triage, transport and managementtriage, transport and management

Widespread fear and panicWidespread fear and panic

Has never actually been carried out (PBS)Has never actually been carried out (PBS)

British Intelligence thinks that Al Qaeda may have built at least one small British Intelligence thinks that Al Qaeda may have built at least one small device from medical sources. IAEA secured several unguarded medical device from medical sources. IAEA secured several unguarded medical cobalt sources in Afghanistan in 2002 (PBS)cobalt sources in Afghanistan in 2002 (PBS)

• 2000 ft airburst of a 60 kg U235 fission bomb (13 KT)

• Estimated 80,000 immediate fatalities in a total population of 255,000

• Damage or loss of 90 % of buildings

burns were present in: 50% of fatalities 65% of survivors

Nuclear WeaponsHiroshima, Japan August 6, 1945

Ref: textbook of military medicine

Nuclear WeaponsNuclear Weapons

Won’t be seen outside of aWon’t be seen outside of a major war involving big countriesmajor war involving big countries

Won’t ‘go nuclear’ unlessWon’t ‘go nuclear’ unless intentionally detonated in a intentionally detonated in a very specific mannervery specific manner

Estimated 50 incidents of nuclear weapon loss, accident, crash or fire since the 1940’s with ZERO nuclear detonations.

The (conventional) high-explosive component can explode, making large messes

Palomares, Spain, 1966: 650 contaminated acres of soil packaged into 4,810 55 gal drums & shipped thru the PORT OF CHARLESTON, SC for burial at the Savannah River Site, Aiken SC

Ref: Mettler et al 1990

Treatment Treatment Acute vs chronicAcute vs chronic

Whole body vs localWhole body vs local

Exposure vs contamination Exposure vs contamination

Internal vs externalInternal vs external

contaminationcontamination

Isolated radiation vsIsolated radiation vs

radiation plus traumaradiation plus trauma

Outcomes of combined radiation and Outcomes of combined radiation and trauma injury are worse than either trauma injury are worse than either

alonealone

Treatment guidelinesTreatment guidelines

Decontaminate ON-SCENE whenever possibleDecontaminate ON-SCENE whenever possible

Any fixed facility utilizing radioactive substances has Any fixed facility utilizing radioactive substances has both technical expertise and decontamination both technical expertise and decontamination facilities: facilities:

seek out bothseek out both

If you must transport the contaminated, do not use If you must transport the contaminated, do not use rotary wing aircraftrotary wing aircraft

Treatment guidelinesTreatment guidelines

Someone Someone exposedexposed to radiation is not to radiation is not radioactive. In virtually NO case does a nuclear radioactive. In virtually NO case does a nuclear weapon casualty become radioactive weapon casualty become radioactive

Someone Someone contaminatedcontaminated with fallout or other with fallout or other radioactive material is not radioactive, but the radioactive material is not radioactive, but the stuff on the casualty IS radioactive and needs to stuff on the casualty IS radioactive and needs to be removed (think of it as radioactive dirt). be removed (think of it as radioactive dirt).

Remove the clothing, wash or shower the Remove the clothing, wash or shower the patient, and then treat like anyone elsepatient, and then treat like anyone else

Bloodborne PPE, disposable itemsBloodborne PPE, disposable items

Treatment guidelinesTreatment guidelines

Internal contamination may result from inhalation or Internal contamination may result from inhalation or ingestion of a radioactive substance, or passage of ingestion of a radioactive substance, or passage of radioactive materials thru open woundsradioactive materials thru open wounds

Internally contaminated victims with intact skin pose Internally contaminated victims with intact skin pose little hazard, but isolate any body fluids or wastelittle hazard, but isolate any body fluids or waste

Internal contamination resulting from explosions with Internal contamination resulting from explosions with remaining radioactive substances embedded in open remaining radioactive substances embedded in open woundswounds CAN CAN pose a risk to rescuers or medical pose a risk to rescuers or medical teams teams

Personal ProtectionPersonal Protection

TimeTime DistanceDistance ShieldingShielding

Absorbed dose varies as the inverse square

of the distance between source and patient

double distance = ¼ of the radiation

triple distance = 1/9th of the radiation

Ref: Mettler

Seek AdviceSeek Advice

Radiology, Nuclear Medicine and Health Radiology, Nuclear Medicine and Health PhysicsPhysics

Fire Department/Hazmat TeamFire Department/Hazmat Team

REAC/TS (REAC/TS (www.orau.gov/reacts/www.orau.gov/reacts/))

Dept of Energy Oak Ridge Op Center 1 865 Dept of Energy Oak Ridge Op Center 1 865 576 1005576 1005

(ask for REAC/TS)(ask for REAC/TS)

TriageTriage

Most immediate or early deaths from Most immediate or early deaths from radiation incidents are due to radiation incidents are due to concurrent trauma and not to radiationconcurrent trauma and not to radiation

Basic guide: deal with the life-Basic guide: deal with the life-threatening injuries first, worry about threatening injuries first, worry about the radiation injury laterthe radiation injury later

Exposure estimation based on symptomsExposure estimation based on symptoms

Early severe CNS failure and convulsions: 5000 Rad (50 Gy)Early severe CNS failure and convulsions: 5000 Rad (50 Gy) -all will die in 2 days-all will die in 2 days

Cardiovascular instability or collapse: similar. Hypotension in a Cardiovascular instability or collapse: similar. Hypotension in a radiation MASCAL setting is expectantradiation MASCAL setting is expectant

Vomiting within 4 hours: 300 Rad (3 Gy)Vomiting within 4 hours: 300 Rad (3 Gy) Without medical care, 50% will die within 2 monthsWithout medical care, 50% will die within 2 months

Vomiting in 50% of victims within 6 hours: 100-200 Rad (1-2 Gy) Vomiting in 50% of victims within 6 hours: 100-200 Rad (1-2 Gy)

No noticeable effects: under 100 Rad (1 Gy)No noticeable effects: under 100 Rad (1 Gy)

Dose estimation based on Dose estimation based on lymphocyte countlymphocyte count

nuclear war triagenuclear war triage

First triage and treat conventional injuries First triage and treat conventional injuries

Next determine exposureNext determine exposure

lymphocytes > 1500: no rx necessarylymphocytes > 1500: no rx necessary

lymphocytes 500-1000:severe radiation lymphocytes 500-1000:severe radiation injuryinjury

lymphocytes < 500: may prove fatallymphocytes < 500: may prove fatal

not detectable: survival very unlikelynot detectable: survival very unlikely

Finally treat according to exposure or resourcesFinally treat according to exposure or resources

Acute Radiation Acute Radiation SyndromeSyndrome

ARS HematopoieticARS Hematopoietic

Seen with exposure of 70 R or Seen with exposure of 70 R or higherhigher

30 R may cause mild symptoms30 R may cause mild symptoms Drop in lymphocyte countsDrop in lymphocyte counts Get q6h CBC first day, then dailyGet q6h CBC first day, then daily HLA typingHLA typing

ARS GastrointestinalARS Gastrointestinal

Seen with exposure of 600- 1000 R or higherSeen with exposure of 600- 1000 R or higher

Depopulation of epithelial liningDepopulation of epithelial lining

In sublethal doses, presents as GI distress in 2 daysIn sublethal doses, presents as GI distress in 2 days

Death in 3-10 days without massive supportDeath in 3-10 days without massive support

Treat dehydration, nausea, vomiting, diarrhea Treat dehydration, nausea, vomiting, diarrhea symptomaticallysymptomatically

ARS Central Nervous ARS Central Nervous SystemSystem

Seen with total body exposure of 5000RSeen with total body exposure of 5000R

Death in hoursDeath in hours

Other syndromes don’t have time to Other syndromes don’t have time to developdevelop

ARS CardiovascularARS Cardiovascular

Seen with total body exposure of 2000- 5000RSeen with total body exposure of 2000- 5000R

Within minutes: skin burning sensation, Within minutes: skin burning sensation, confusion, nausea, oliting, diarrhea, LOCconfusion, nausea, oliting, diarrhea, LOC

Death usually in minutes to hoursDeath usually in minutes to hours

Other syndromes don’t have time to developOther syndromes don’t have time to develop

ARS SkinARS Skin(skin doses, not whole body (skin doses, not whole body

doses)doses)

Seen with exposure to high doses of beta radiationSeen with exposure to high doses of beta radiation

Washing off contaminants can prevent skin damageWashing off contaminants can prevent skin damage

Acute: 600 - 2000 R causes erythemaAcute: 600 - 2000 R causes erythema

Acute: 2000-4000R causes skin breakdown in 2 weeksAcute: 2000-4000R causes skin breakdown in 2 weeks

Acute: > 30,000 R immediate skin blisteringAcute: > 30,000 R immediate skin blistering

Chronic: > 2000 R causes delayed and irreversible structuralChronic: > 2000 R causes delayed and irreversible structural changes, dermatitis with increased cancer riskchanges, dermatitis with increased cancer risk

????

www.burndisaster.comwww.burndisaster.comwww.bst2.orgwww.bst2.org

dave@bst2.orgdave@bst2.org

ReferencesReferences Zajtchuk, R, ed: Textbook of military medicine part 1: military Zajtchuk, R, ed: Textbook of military medicine part 1: military

consequences of nuclear warfare. TMM Publications, 1989consequences of nuclear warfare. TMM Publications, 1989

Medical management of radiation casualties, Second Edition Medical management of radiation casualties, Second Edition 2003 2003 www.afrri.usuhs.milwww.afrri.usuhs.mil

Mettler, FA, Kelsey, CA & Ricks, RC: Medical managementMettler, FA, Kelsey, CA & Ricks, RC: Medical management of radiation accidents Boca Raton: CRC Press 1990of radiation accidents Boca Raton: CRC Press 1990

Ricks, RC, Berger, ME and O’Hara, FM: The medical basis for Ricks, RC, Berger, ME and O’Hara, FM: The medical basis for radiation accident preparedness. New York: Parthenon radiation accident preparedness. New York: Parthenon Publishing 2002Publishing 2002