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In-Depth Medical Management for Nuclear/Radiological/Conventional Terrorism Agents

In-Depth Medical Management for Nuclear/Radiological/Conventional Terrorism Agents. Editorial Board Fun Fong, MD, FACEP, Senior Medical Officer GA-3 DMAT, ACEP Section of Disaster Medicine

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In-Depth Medical Management for Nuclear/Radiological/Conventional Terrorism Agents

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

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

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

  4. Diversion of Nuclear Weapons 50 - 100 1 kT Suitcase Nuclear Weapons Unaccounted For The Threat of Nuclear Diversion. Statement for the Record by John Deutch, Director of the Central Intelligence to the Permanent Subcommittee on Investigations of the Senate Committee on Government Affairs, 20 Mar 1996.

  5. Energy Partition Standard Fission / Fusion AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

  6. Scenario: Washington Mall

  7. Effective Range For Blast Energy1 kT Weapon AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

  8. Effective Range For Blast Energy1 kT Weapon AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

  9. Effective Range For Thermal Energy1 kT Weapon Infrared 700 m 7 cal / cm2 3o Burn 800 m 4 cal / cm2 2o Burn 1200 m 2 cal / cm2 1o Burn AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

  10. Safe Separation Distances for Eye Injuries1 kT Weapon Detonation Altitude - 300 m 5.9 km Flash Blindness 16.7 km Retinal Burns 46 km Daytime Visibility 50.8 km Nighttime Flash Blindness AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

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

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

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

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

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

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

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

  18. Alpha Beta Gamma Neutron 1 m Concrete Ionizing Radiation Any Radiation Consisting of Directly or Indirectly Ionizing Particles or Photons

  19. Irradiation External Contamination Internal Contamination * * * * * * * * Radiation Exposure Types

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

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

  22. Gastrointestinal Component(8 - 15 Gy and higher) • Symptoms • Mechanisms • Stem Cell Sterilization - 15 Gy Parameter Brief Protracted Exposure Exposure Threshold 8 18 D50 15 35

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

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

  25. Distribution of Injuries in aNuclear Detonation Single Injuries (30% - 40%) Combined Injuries (65% - 70%) Data from Walker RI, Cerveny TJ Eds., Medical Consequences of Nuclear Warfare, TMM Publications, Falls Church, 1989. p 11.

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

  27. Summary of Deterministic Effects Threshold Exposure (Deterministic Effects) Threshold ED50 Dose Oligospermia (2 Yrs) 0.3 Gy 0.7 Gy Ovulation Suppression (permanent) 0.6 Gy 3.5 Gy Vomiting 0.5 Gy 2 Gy Diarrhea 1 Gy 3 Gy Mortality from Marrow Syndrome (minimal care) 1.5 Gy 3 Gy Mortality from Marrow Syndrome (supportive care) 2.3 Gy 4.5 Gy Thyroiditis 2 Gy 12 Gy Skin - Erythema 3 Gy 6 G Skin - Dry Desquamation 5 - 20 Gy 20 Gy Skin - Wet Desquamation 12 - 20 Gy - Skin - Necrosis 20 - 30 Gy - Mortality from Pulmonary Syndrome Lethality 5 Gy 10 Gy Mortality from Gastrointestinal Injury 8 Gy 15 Gy CNS Incapacitation 6.5 Gy 17 Gy Acute Encephalopathy 5 - 8 Gy - Source: NUREG CR-4214

  28. Hemogram(300 cGy TBI Exposure)

  29. Absolute Lymphocyte Count over 48 hours Confirms Significant Radiation Exposure Andrews Lymphocyte Nomogram From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16

  30. Priorities in Combined-Injury Triage When Radiation Doses are Known Conventional Triage Changes in Expected Triage (No Radiation Exists) Following Radiation Exposure <1.5 1.5 – 4.5 >4.5 [ >3 h 1 – 3 h < 1 h ] Immediate Immediate Immediate Expectant Delayed Delayed Expectant Expectant Minimal Minimal Expectant Expectant Expectant Expectant Expectant Expectant Modified from Medical Consequences of Nuclear Warfare, 1989, p. 39

  31. Surgical Recommendations • Based on Immunocompetence Status • Life-Saving / Major Surgery within 36 - 48 h • Elective Procedures until 45 - 60 days Following Hematopoietic Recovery Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds) Treatment of Radiation Injuries, 1990, Plenum Press, New York, p. 229

  32. REA ( Radiation Emergency Area ) Radiation Checkpoint Hot | Warm | Cold Zones “Hot” Zone “Warm” Zone “Cold” Zone

  33. Incident Site EMS Transport “Hot” Zone CCP (Safe Area) “Warm” Zone Clean Staging Contaminated Staging EMS Transport “Cold” Zone Terrorism Modification of Hot Zone • Larger Secured Hot Zone • Casualty Collection Point in Safe Area • Clean / Contaminated Staging Areas

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

  35. Decontamination Team • Provider (RN / PA / MD) • HP Tech • Decon Assistant (ED Tech) • Circulator • Scribe Nurse • HP Tech #2 Minimal Outside REA

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

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

  38. When Do I Stop? • When No More Comes Off! • Stop Levels: • 1 mR / h beta • 1000 dis / min alpha (air proportional counter w / 60cm2 Window) • If Committed Dose will Not Exceed 15 rem / yr to Skin • Isolate w / Bag & Continue Decon Next Day NCRP #65, p117

  39. Mass Casualty Planning • Relies on Avenues of Self-Decon • More than Finding Shower Facilities Label Clothing Double Bag Clothing Temporary Clothes Towels Return Clothes Bag Male Victims Bag Clothing Shower #1 Shower #2 Bag Clothing Shower #1 Shower #2 Female Victims

  40. 4 Golden Rules of Toxicology (Adapted from Kent Olson, MD FACEP) • Treat the Patient before the Poison • Prevent or Reduce Exposure • Enhance the Elimination of the Agent • Consider Specific Adjuncts and Antidotes

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