Tareg Bey, MD, FAAEM, FACMT, DEAA

Professor of Emergency Medicine

Department of Emergency Medicine
University of California Irvine
Orange, CA

Nuclear and Radiological Emergencies

Tareg Bey, MD, FAAEM, FACMT,DEAA
Professor of Emergency Medicine
Department of Emergency Medicine
University of California Irvine
Orange, CA

Goals and Objectives

Emphasize the need for more education of health care
providers, rescue and public safety personnel for
radionuclear
Review the different radionuclides and their sources
which could serve for radioactive contamination,
incorporation and radiological terrorism.
Discuss the need for reviewing the stockpile situation
for radionuclear decorporation antidotes.
Review briefly two examples for incorporation of a
radionuclide. One for which decorporation is effective
and one for which it is not.

About Radiation

Sources of Radionuclides

Hospital, Medicine
Industry
Private
Aerospace
Household
Research
Energy

Terrorists Scenario Choice

1. Nuclear Device
Detonation
2. Meltdown of Nuclear
Reactor
3. Dirty Bomb
4. Placement of
Radioactive Materials
in Public Places
http://japanifik.files.wordpress.com/2007/08/nagasaki-bomb-fat-man.jpg

Nuclear Weapon:
20 kT Ground Burst
180 ft (60 m) radius crater
Within 0.5 miles (800 m), 50 % fatalities from
debris impact
Within 1.8 miles (2.9 km), 50 % fatalities from
thermal burns
Within 1 mile (1.6 km) radius, 50 % fatalities
from immediate radiation exposure
Within 7.7 miles (12.4 km) 50 % fatalities from
radiation exposure within one hour.

Question:
What Are We Preparing For ?

http://www.atomicarchive.com/Hi
story/coldwar/p19_image.shtml

http://www.atomicarchive.com/Pho
tos/Nagasaki/images/NG30.jpg

International Nuclear Event Scale

(INES by the IAEA)
Scale 0 7
0: No Safety Significance
7: Major Accident
4-7: Upper level
1-3: lower level
Matrix; industrial accident
Radioactivity release- public
interest
http://www.iaea.org/Publications/Factsheets/English/ines.pdf

Examples of Rated Events

1986 Chernobyl/Soviet Union: widespread
effect INES Level 7
Tokaimura/Japan: Nuclear fuel processing
facility. 2 workers dead, 40 contaminated,
INES level 4
Mihama/Japan nuclear power plant. 5
people die, 7 injured with hot steam.
Officially no release of radioactivity. INES
level 1.

Accidents in Nuclear Power Plants

http://news.bbc.co.uk/1/hi/sci/tech/5165736.stm
http://www.iaea.org/Publications/Factsheets/English/ines.pdf

http://news.bbc.co.uk/nolpda/ukfs_news/hi/newsid_3547000
/3547828.stm

http://www.fema.gov/hazard/nuclear/index.shtm
http://www.rps.psu.edu/probing/nuclearpower.html
http://sciencelinks.jp/j-east/article/200523/000020052305A0920525.php

Radiological Terrorism Scenarios

Nuclear Device Detonation

Meltdown of Nuclear Reactor
Dirty Bomb
Placement of Radioactive Materials
in Public Places

Radioactive Isotopes Suitable for

Nuclear Terrorism
Cobalt- 60 (Medicine, glass industry )
Cesium-137 (Medicine)
Iridium-192
___________________________
Strontium-90 (Medicine, remote weather stations, TV
screens..)

Radium-226 (brachytherapy, medicine)

Plutonium-238 (heat source, energy in aerospace
industry)

Protection Against Radiation and

Radioactivity
Alpha particles: Sheet of paper
Beta particles: 3 mm aluminum
Gamma: Lead and distance
Chemical protective suits do not offer a barrier to
gamma radiation.
A radiation safety officer or health physicist
should assist with preparedness planning.
In doubt evacuate and help trauma victims.

Radiation Accidents:
Categories of Injuries

Trauma
Burns, wounds
Irradiation
Internal Contamination
External Contamination
Wound contamination

Radioactive Isotopes Suitable for

Nuclear Terrorism
Cobalt- 60 (Medicine, glass industry )
Cesium-137 (Medicine)
Iridium-192
___________________________
Strontium-90 (Medicine, remote weather stations, TV
screens..)

Radium-226 (brachytherapy, medicine)

Plutonium-238 (heat source, energy in aerospace
industry)

Exposure versus Contamination

Contamination:
Radioactive material
is on the patient (and
clothes) or has been
incorporated.
Example: Radioactive
dust in hair or
Ingestion of Polonium
210 and distribution
within the body.

How Does Dispersed Radioactive Material

Become Dangerous to Humans ?
Exposure:
Contamination (alpha and beta radiation)
External contamination (radioactive dust)
Internal contamination (ingestion, inhalation,
wound contaminationblast injuries)
Internal contamination can be extremely
dangerous

Exposure to ionizing radiation (gamma

radiation)

Contamination with
Radioactive Material
External contamination: Removing outer
clothes may get rid of 90 % of all
radioactive dust. Follow by external
decontamination. Thorough washing with
special attention to hair.
Internal contamination with incorporation
of radioactive material poses a great
hazard because of continuous irradiation

Decontamination of Radionuclides
Decontamination of external radiological
contamination is a key measure to
decrease morbidity and mortality from
radioactive material.
External decontamination will also help to
prevent further internal contamination
(inhalation, food or wounds)

Radiation Protection
of Personnel
Time, distance, shielding; 3 principles.
Distance is the best protection.
Protective masks and personal protective
equipment (PPE) to avoid INHALATION
and SKIN CONTACT.
No eating, drinking or smoking at the
rescue site. Danger of radioactive
incorporation.
Evacuation and decontamination

Decontamination Equipment

Detection and Protection

Detectors
Geiger counter (beta and gamma)
Alpha meter
Dosimeter (gamma in rads/hour)

Personal Protective Equipment

Water resistant gowns, caps, masks, shoe
covers, eye protection, double glove

Background
Current U.S. stockpiling
strategies focus on
medical countermeasures
Biological
Chemical incidents

The Centers for Disease

Controls Strategic National
Stockpile initially for
biological incidents,
forward CHEMPACK
(chemical incidents) added
later

Stockpiling for
radiation
emergencies
is needed
Focus now by
the World
Health
Organization

Terrorists Scenario Choice

1. Nuclear Device
Detonation
2. Meltdown of Nuclear
Reactor
3. Dirty Bomb
4. Placement of
Radioactive Materials
in Public Places

Scenario Modeling and

Hazard Vulnerability
Number of potentially exposed patients
Types of radionuclides
System for rapid identification of
involved radionuclides
Treatment regimens
Consider availability within minutes to
hours

Scenario Modeling and

Hazard Vulnerability
Determine placement of
countermeasure stockpiles
Supply limitations (Prussian blue/single
German manufacturer)
An activation, distribution, and local
incident management system must all
be in place and exercised

Radiation Accidents:
Categories of Injuries

Trauma
Burns, wounds
Irradiation
Internal Contamination
External Contamination
Wound contamination

Example:
Nuclear Power Plant Accident
Industrial accident
Multiple types of injuries have been
described including trauma
Possible exposure to radiation and
contamination will complicate medical
management

Recommended Antidotes
Radionuclide Approach
Titrium
Iodine-125 or 131

Dilution (force fluids)

Blockage (potassium iodide)
Mobilization (antithyroid
drugs)

Cesium-134 or
cesium-137

Reduction of GI absorption
(Prussian Blue)

Plutonium or other Chelation with zinc or

transuranic elements calcium diethylenetriamine
pentaacetic acid (DPTA)

Diethylenetriamene pentaacetate
(DTPA)
Ca-DTPA and Zn-DTPA
Within first 24 hrs Ca-DTPA is 10 times
more effective than Zn-DPTA. Then
equally effective
Indications (FDA): Americium, plutonium,
Curium (Ca, Bk)
Intravenous form (also aerosol Zn-DTPA)

DTPA
Source:

http://orise.orau.gov/images/reacts/dtpa-sm.jpg

Diethylenetriamene pentaacetate
(DTPA)
The first 24 hours are important for
effective treatment
Decorporation treatment is time-sensitive
Greatest effect within 1 hour
1 g , daily , for five days
Bioassay

Recommended Antidotes
Radionuclide Approach
Strontium-89 or
strontium-90

Reduction of absorption:
aluminum phosphate gel antacids
Blockage: strontium lactate
Displacement: Oral phosphate
Mobilization: ammonium chloride
or parathyroid extract

Unknown

Reduction of absorption (emetics,

lavage, charcoal or laxatives)

Pharmacokinetics
Absorption

Prevent further absorption

Decontamination, reduction
of absorption

Distribution

Reduce uptake in a specific

organ. Thyroid gland -

Biotransformation

--- ---

Elimination
Increase elimination via
kidney and gut

Radioisotops and Pharmacology

An Isotope is one of two or more atoms
with the same atomic number but with
different numbers of neutrons.
A radioisotope is an unstable element that
releases radiation as it breaks down.
Radioisotopes can be used in imaging
tests or as a treatment for cancer. A stable
isotope is a chemical isotope that is not
radioactive.

Radioisotops
Example: Iodine with an Atomic Number
or 53. Number of electrons: 53
Stable Iodine: Atoms 53. Neutrons: 74
53 (A) +74 (N) = 127

Radioisotopes and Pharmacology

Stable isotopes of the same element the
same chemical characteristics and
therefore behave chemically and
physiologically almost identically.
The mass differences are due to a
difference in the number of neutrons

Example: I-131
I-131 is radioactive, has an 8 day half-life,
and emits beta and gamma radiation. Both
iodine-129 and iodine-131 are produced
by the fission of uranium atoms during
operation of nuclear reactors and by
plutonium (or uranium) in the detonation of
nuclear weapons.

RADPACK Considerations
Blast injuries
Thermal injuries
Radiation injuries

Treat the patient before

the poison
Prevent or reduce
exposure
Enhance the
elimination of the agent
Consider specific
adjuncts

Summary
Additional education for health care providers,
rescue and public safety personnel is important
Different radionuclides and their sources can
cause radioactive contamination, incorporation
and be used for radiological terrorism.
Decontamination of radionuclides is a key
measure but it should not health care personnel
to address major life-threatening trauma first.
Multiple hospitals across the US have started to
stockpile radionuclear decorporation antidotes.