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Medical Response to Nuclear and Radiological Events

Cham Dallas, PhD

DirectorCDC Center for Mass Destruction Defense

Overview

• Nuclear scenario effects

• Radiation injury

Acute radiation syndrome

Mass burn casualties

External contamination

Internal contamination

• Pharmaceutical intervention strategies

Question

Which of the following are most likely to occur and result in significant casualties?

A. Nuclear power plant release

B. Improvised nuclear devise

C. Conventional nuclear weapon

D. “Dirty” bomb

Potential Nuclear/Radiological Hazards in the U.S.

• Simple radiological device

• “Dirty” conventional bomb

• Improvised nuclear device (IND)

• 1 kT “suitcase nuke”

• Ballistic missile attack

• 250 kT nuclear weapon: “city killer”

Plutonium

Diversion of Nuclear Weapons

50 –100 1 kT “suitcase” nuclear weapons are 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 March 1996.

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 March 1996.

Standard Fission/FusionStandard Fission/Fusion

AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990..

Fallout 10%

Blast

50%

Thermal

35%

Initial Radiation 5%

Energy Partition

Nuclear Weapon Detonation Results: 1

Nuclear Weapon Detonation Results: 2

Nuclear Weapon Detonation Results: 3

Scenario: Washington Mall

White House

Capitol

Washington Monument

Lincoln Memorial The Mall

Potomac

River

AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

Effective Range for Blast Energy

AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

Effective Range for Thermal Energy 1 kT Weapon

AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

Safe Separation Distances for Eye Injuries 1 kT Weapon

Atlanta SSE Med Wind 250 kT Fatalities

ExpectedProb Population

90% 0.9 455,934

50% 0.5 661,169

10% 0.1 886,681

Fatality Possible (w/meander) Expected

Prob Population90% 0.9 455,934

Probability of Fatality (Default Plot)

Time: 32 days, 0.0 hours

Mean Probability of Fatality

Atlanta 250 kT SSE wind 7 mph

Mortality Probability 3.9m Affected

Red 90%

Lt Brown 80%

Yellow 70%

Green 60%

Pale Blue 50%

Dark Blue 40%

Lt Purple 30%

Dk Purple 20%

Dk Pink 10%

Lt Pink 1%

New York: 250 kT Nuclear Detonation

Seattle Mortality Probability under 350 kT with NNE Wind

What Is Fallout?

• A complex mixture of more than 200 different isotopes of 36 elements

• 2 oz of fission products formed for each kT of yield

• Size <1 micron to several mm

• A complex mixture of more than 200 different isotopes of 36 elements

• 2 oz of fission products formed for each kT of yield

• Size <1 micron to several mm

Question

The risk from delayed fallout that is dispersed long distances (>100 miles) still has a devastating impact on public health.

A. True

B. False

Early Fallout

• That which reaches the ground during the first 24 hours after detonation

• Early fallout fraction 50 –70% of total radioactivity

• Highest degree of fallout risk

• That which reaches the ground during the first 24 hours after detonation

• Early fallout fraction 50 –70% of total radioactivity

• Highest degree of fallout risk

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

• Much lower degree of risk relative to early 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

• Much lower degree of risk relative to early fallout

Bikini Atoll (1 March 1954)

• 15 mT thermonuclear detonation fallout

• Population affected: 300 in public domain

Int/Ext contamination

Local radiation injury

Mild ARS

Thyroid injury

• 15 mT thermonuclear detonation fallout

• Population affected: 300 in public domain

Int/Ext contamination

Local radiation injury

Mild ARS

Thyroid injury

Radioactive Contamination Radiodermatitis

AlphaAlpha

BetaBeta

GammaGamma

1 m concrete

NeutronNeutron

Ionizing Radiation

Radiation that consists of directly or indirectly ionizing particles or photons

Radiation that consists of directly or indirectly ionizing particles or photons

IrradiationIrradiationInternal

ContaminationInternal

ContaminationExternal

ContaminationExternal

Contamination

***

***

*

*

Radiation Exposure Types

Acute Radiation Syndrome

• Systemic effects of radiation Prodromal

Hematologic

Gastronintestinal

Pulmonary

Cutaneous

Neurovascular

• Combined injury

• Systemic effects of radiation Prodromal

Hematologic

Gastronintestinal

Pulmonary

Cutaneous

Neurovascular

• Combined injury

Prodromal Component (0.5–3 Gy and higher)

• Immediate effect of cell membrane damage

• Onset of nausea, vomiting, diarrhea

• Mediated neurologically by the parasympathetic system

• Immediate effect of cell membrane damage

• Onset of nausea, vomiting, diarrhea

• Mediated neurologically by the parasympathetic system

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

• Sensitive from highly vascular tissue

Endothelial cells

Type II alveolar cell

• Effect is dose-rate related

• Pneumonitis

• Fibrosis

Healthy lung

Pneumonitis

Radiation Skin Injury

• 0.75 Gy Hair follicles change

• 3 Gy Epilation

• 6 Gy Erythema

• 10 Gy Dry desquamation

• 20 Gy Wet desquamation (transepithelial injury)

• 0.75 Gy Hair follicles change

• 3 Gy Epilation

• 6 Gy Erythema

• 10 Gy Dry desquamation

• 20 Gy Wet desquamation (transepithelial injury)

Erythema

Radiation Burns

Direct result of accident 13%

Infection 45%

Organ system failure 41%

Iatrogenic intervention 1%

Causes of Burn Deaths

Burns + Irradiation 40% Wounds < 5%

Burns + Wounds + Irradiation

20%

Irradiation 15–20%

Burns 15–20%

Wounds + Irradiation 5%

Wounds + Burns

5%

Distribution of Injuries in aNuclear Detonation

Single injuries(30%–40%)

Combined injuries

(65%–70%)

Combined injuries

(65%–70%)

Data from Walker RI, Cerveny TJ Eds., Medical Consequences of Nuclear Warfare, TMM Publications, Falls Church, 1989. p 11.

Andrews Lymphocyte Nomogram

• Absolute lymphocyte count over 48 hours

• Confirms significant radiation exposure

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

Priorities in Combined-Injury Triage- Radiation Doses

Conventional Triage Changes in Expected Triage(No Radiation Exists) Following Radiation Exposure

<1.5Gy 1.5–4.5Gy >4.5Gy >3 hr 1–3 hr <1 hr

onset onset onset

Immediate Immediate Immediate Expectant

Delayed Delayed Expectant Expectant

Minimal Minimal Expectant Expectant

Expectant Expectant Expectant Expectant

Conventional Triage Changes in Expected Triage(No Radiation Exists) Following Radiation Exposure

<1.5Gy 1.5–4.5Gy >4.5Gy >3 hr 1–3 hr <1 hr

onset onset onset

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. 39Modified from Medical Consequences of Nuclear Warfare, 1989, p. 39

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

• 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

Question

Which of the following is the best decontamination agent?

A. Dry removal

B. Bleach

C. Soap & water

D. Waterless cleanser

Decon Agents: 1

• Dry removal

• Soap/shampoo

• Household bleach 1:10 (sodium hypochlorite)

• Waterless cleansers

• Povidone-iodine

• Lava soap

• Cornmeal/Tide 50:50

• Vinegar (32P) or club soda

• Toothpaste

• Dry removal

• Soap/shampoo

• Household bleach 1:10 (sodium hypochlorite)

• Waterless cleansers

• Povidone-iodine

• Lava soap

• Cornmeal/Tide 50:50

• Vinegar (32P) or club soda

• Toothpaste

Internal Contamination Involves 4 Stages

• Deposition along route of entry

• Translocation

• Deposition in target organ

• Clearance

• Deposition along route of entry

• Translocation

• Deposition in target organ

• Clearance

Therapeutic Interventions

• Plutonium/transuranics: DTPA

• Cesium: insoluble Prussian Blue

• Uranium: alkalinization of urine

• Radioiodine: radiostable iodine

• Tritium: radiostable water

…is for good men and women to do nothing.

…is for good men and women to do nothing.

All that is necessary for the triumph of evil…