RITN Overview Presentation NMDP Basic NMDP Basic Radiation Radiation Training Training Presenters name Date
Apr 01, 2015
RITN Overview Presentation
NMDP Basic NMDP Basic Radiation TrainingRadiation Training
Presenters name
Date
RITN Overview Presentation
Why learn about radiation?Why learn about radiation?
• Many agencies think that there will be a radiological incident in our lifetime– U.S. government– Independent nuclear watch groups
• www.NTI.org (Nuclear Threat Initiative)• http://cns.miis.edu/cns/index.htm (Monterey
Institute for International Studies)
– International Atomic Energy Agency (IAEA)
• Every year hundreds of radiological sources are stolen worldwide
RITN Overview Presentation
Goals of this PresentationGoals of this Presentation• Basics of radiation: sources, types, units of
measurement• Biological and clinical effects of radiation• Symptoms of Acute Radiation Syndrome (ARS)• Exposure and contamination• Protection against radiation exposure: time,
distance, shielding • Preparedness planning and our role with RITN
RITN Overview Presentation
Section 1: Section 1: Radiation BasicsRadiation Basics
RITN Overview Presentation
Types of RadiationTypes of Radiation
• Natural– Many more sources of natural radiation– Insignificant risk associated with typical
exposure
• Man made– Fewer sources of exposure– BUT…potentially deadly if misused– Ionizing radiation is focus of this course
RITN Overview Presentation
Sources of Radiation Sources of Radiation Exposure in the U.S. PopulationExposure in the U.S. Population
• Natural (82%)– Radon – Cosmic (outer
space)– Terrestrial
• Rocks/Soil– Internal
• Inside human body
RITN Overview Presentation
Natural Background RadiationNatural Background Radiation
• Cosmic– Sun (much of this
radiation is shielded by Earth’s atmosphere)
• Terrestrial Sources– Materials in soil– Break down into radon
gas
• Radioactivity in the Body– Very minute quantities
RITN Overview Presentation
Sources of Radiation Sources of Radiation Exposure in the U.S. PopulationExposure in the U.S. Population
• Man Made (11%)
- Medical• X-rays• CT scans
- Nuclear medicine/
radiation oncology
- Consumer products
- Other
RITN Overview Presentation
Atomic Structure (a VERY basic one)Atomic Structure (a VERY basic one)
• Protons– Positive charge
• Neutrons– No charge
• Electrons– Negative charge
RITN Overview Presentation
Radioactivity and Radioactivity and Ionizing RadiationIonizing Radiation
• Radioactivity or radioactive decay:– Emitting excess energy from the nucleus of an
unstable atom– Radioactive decay results in the decrease of
radiation levels over time
• Ionizing radiation: Energy released from unstable (radioactive) atoms
• NOTE: Radioactive Atoms Emit Radiation
RITN Overview Presentation
Three Main Types of Three Main Types of Ionizing Radiation Emitted from Ionizing Radiation Emitted from
Radioactive AtomsRadioactive Atoms
• Alpha
• Beta
• Gamma
RITN Overview Presentation
Ionizing RadiationIonizing Radiation• Alpha Particles
– Heaviest and most highly charged ionizing radiations
– Energy is used up quickly; low penetrating ability
– Cannot travel more than 4 to 7 inches– Stopped by a sheet of paper– Not a serious hazard outside the body– Can be most damaging if inside the body
(e.g., ingestion, inhalation)
RITN Overview Presentation
Ionizing Radiation Ionizing Radiation
• Beta Particles– Smaller and travel much faster than alpha– Physically similar to electrons, but do not orbit
around an atom– Travel faster with less charge than alpha and
penetrate further – Major hazard when emitted by internally-
deposited radioactive material
RITN Overview Presentation
Ionizing RadiationIonizing Radiation
• Gamma Rays– Similar to medical x-rays– Short wavelength and high frequency– Most hazardous from sources outside the
body– Can travel up to a mile in open air– All tissues and organs can be damaged by
sources outside the body
RITN Overview Presentation
Ionizing RadiationIonizing Radiation
• Alpha and beta radiation: both are PARTICLES
• Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVES
RITN Overview Presentation
Electromagnetic RadiationElectromagnetic Radiation
• Transmitted in the form of waves• Generally higher in energy• Originate in the nuclei of atoms
RITN Overview Presentation
Radiation Penetration Into SkinRadiation Penetration Into Skin
• Exposure to alpha & beta from outside body is slight hazard
• Long periods of exposure can cause “heat burns”
• Significant hazard if ingested, inhaled or contaminates a wound
RITN Overview Presentation
Ionizing RadiationIonizing Radiation
Alpha particles – hazardous internally
Beta particles– internally a bit more hazardous
Gamma rays - deadly
RITN Overview Presentation
ShieldingShielding
• 2-1/2 inches of dense concrete will absorb approximately 50% of typical gamma rays
• Five inches of water is just as effective
RITN Overview Presentation
Exposure vs. DoseExposure vs. Dose
When you are exposed to radiation, your body absorbs a measurable dose
RITN Overview Presentation
Measurement of Radiation DoseMeasurement of Radiation Dose
• What needs to be known for medical treatment• Intensity of exposure• Time or duration of exposure
RITN Overview Presentation
RoentgenRoentgen
• The Roentgen is used to express the amount of gamma radiation exposure
• Abbreviated with a capital “R” after the amount of gamma radiation received
• Independent of the time of exposure
RITN Overview Presentation
Rad Rad (radiation absorbed dose)(radiation absorbed dose)
• Relates different types of radiation (alpha, beta, gamma and neutron) to the energy they impart
• Basic unit of absorbed dose of radiation• One roentgen of gamma radiation exposure
results in about one rad of absorbed dose
RITN Overview Presentation
Rem Rem (roentgen equivalent man)(roentgen equivalent man)
• Relates the dose of any radiation to the biological effect of that dose
• For gamma rays and beta particles, 1 rad of exposure results in 1 rem of dose
• For alpha particles, 1 rad of exposure results in ~20 rem of dose
RITN Overview Presentation
Exposure RateExposure Rate
The rate at which an individual is exposed to radiation
• Expressed in terms of roentgen or milliroentgen per hour
RITN Overview Presentation
International System of Units (SI)International System of Units (SI)
• SI uses gray (Gy) instead of rad- 1 Gy = 100 rad
• SI uses sievert (Sv) instead of rem - 1 Sv = 100 rem
• SI units must be used on labels to identify radioactive materials during transport
RITN Overview Presentation
Section 2: Section 2: Biological Effects Biological Effects
of Radiationof Radiation
RITN Overview Presentation
Biological EffectsBiological Effects
• Dependent upon type of exposure
(duration of exposure)
– Acute (limited time of exposure)
– Chronic (extended or repetitive exposure)
• Level of exposure (intensity)
• Certain biological factors
RITN Overview Presentation
Ionizing RadiationIonizing Radiation
• Radiation is a form of energy in motion
• When alpha, beta and gamma radiation
enter the body, some or all of their energy
is lost in collisions with the body’s cells
• Collisions strip away electrons from atoms
in the body
• Removal of electrons is called ionizationionization
RITN Overview Presentation
Biologic EffectsBiologic Effects
• Damage DNA and other structures inside
cells
• Could result in cell death
• Incorrect repair, resulting in mutations that
could cause cancer
RITN Overview Presentation
Biological EffectsBiological Effects
• Acute Exposure
– Significant dose of radiation over a short period of time
– Radiation sickness or death shortly after exposure
– Long-term effects (possibly cancer years later)
• Chronic Exposure
– Small dose of radiation continuously or over many years
– No immediate observable effects
– May result in long-term effects
RITN Overview Presentation
Biological FactorsBiological Factors
• Each person differs in their biological response to a given dose of radiation– Age– Sex– Diet– Body temperature– Overall medical health
RITN Overview Presentation
Acute Radiation SicknessAcute Radiation Sickness
• Occurs when an individual is exposed to a
large amount of radiation in a short period
of time
• Occurs at doses greater than 100 rem
(1 Sv), which would be 100 rad (1 Gy) for
gamma rays
RITN Overview Presentation
Acute Radiation SicknessAcute Radiation Sickness• Manifestations
– Changes in blood cells (lymphocytes decrease first)
– Vascular changes– Skin irritation– GI effects (nausea, vomiting,
diarrhea)– Fever– Non specific “flu”-like symptoms– Hair loss
RITN Overview Presentation
Acute Radiation SicknessAcute Radiation Sickness
• Severity and course depends on– How much total dose is received– How much of the body is exposed– Sensitivity of exposed individual to radiation
• May appear shortly after exposure, then disappear for a few days only to reappear in a much more serious form in a week or more (related to amount of exposure)
RITN Overview Presentation
Four Stages of ARSFour Stages of ARS
• Prodromal phase (within 48 hours)
• Latent Phase (days to weeks)
• Manifest Illness (weeks to months)
• Recovery or Death
RITN Overview Presentation
Four Stages of ARSFour Stages of ARS
• Prodromal phase (within 48 hours)– Nausea/vomiting– Headache– Fatigue– Fever, diarrhea– Anorexia– Fluid shifts – Electrolyte imbalance
• Latent Phase (days to weeks)– Temporary improvement
RITN Overview Presentation
Four Stages of ARSFour Stages of ARS
• Manifest Illness (weeks to months)– Intense immunocompromise and symptoms
specific to 4 major organ systems (heme, GI, skin, neurovascular)
• Recovery or Death
Note: After lethal dose, victims may go through these phases in a period of hours resulting in early death
RITN Overview Presentation
Severity LevelsSeverity Levels
Delayed effects after sublethal dose
(<250 rem*) may be non-specific
Malaise
Fatigue
Drowsiness
Weight loss
Fever
Abdominal pain
Insomnia
Restlessness
Blisters
* For gamma and beta radiation, 1 rem = 1 rad
RITN Overview Presentation
Severity LevelsSeverity Levels
Delayed effects after potentially
lethal dose (250 to 650 rem*)
• Significant reduction in production of blood cells• Nausea/vomiting which appears to get better in
3 days• WBC greatly reduced• After two weeks: chills, fatigue, ulceration of the
mouth
* For gamma and beta radiation, 1 rem = 1 rad
RITN Overview Presentation
Severity LevelsSeverity Levels
Delayed effects after
supralethal dose (>650 rem*)
• Damage to the stomach lining and/or intestine– Causing decreased absorption, ulceration and
dehydration
• Seven Days After Exposure– Severe infection, fluid loss, blood loss or collapse of
the circulatory system and may result in death
* For gamma and beta radiation, 1 rem = 1 rad
RITN Overview Presentation
Severity LevelsSeverity Levels
Acute Doses over 1000 rem*
• Irreparable damage to the brain and spinal cord• Symptoms
– Agitation– Lack of coordination– Breathing difficulty– Occasional periods of disorientation– Death occurs within hours to days
* For gamma and beta radiation, 1 rem = 1 rad
RITN Overview Presentation
Key Symptoms of ARSKey Symptoms of ARS
Nausea
Vomiting
Anorexia
Reduced number of white
blood cells (lymphocytes,
granulocytes)
Reduced number of
platelets
Itching or altered
sensation in the skin
Swelling and Edema
Diarrhea
Fatigue
Severity of Radiation Injury
Dose Range (Gy)* Prodrome Manifest - Illness Prognosis
(without therapy)
0.5-1.0 Mild Slight decrease in
blood cell counts
Almost certain survival
1.0-2.0 Mild to Moderate Early signs of BM
damage
Highly probable survival
(>90% of victims)
2.0-3.5 Moderate Moderate-severe BM
damage
Probable survival
3.5-5.5 Severe Severe BM damage;
mild GI damage
Death within 3.5-6 weeks
(50% of victims)
5.5-7.5 Severe Pancytopenia and
moderate GI damage
Death probable
within 2-3 weeks
7.5-10.0 Severe Marked GI and BM
damage; hypotension
Death probable within 1-
2.5 weeks
10.0-20.0 Severe Severe GI damage,
pneumonitis, altered
mental status
Death certain within 5-12
days
20.0-30.0 Severe CV collapse; fever;
shock
Death certain within 2-5
days
Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).
Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko
* 1 Gy = 100 rad
RITN Overview Presentation
What is the standard dose of irradiation used for
total body irradiation (TBI) in clinical BMT?
Severity of Radiation Injury
Dose Range (Gy) Prodrome Manifest - Illness Prognosis
(without therapy)
0.5-1.0 Mild Slight decrease in
blood cell counts
Almost certain survival
1.0-2.0 Mild to Moderate Early signs of BM
damage
Highly probable survival
(>90% of victims)
2.0-3.5 Moderate Moderate-severe BM
damage
Probable survival
3.5-5.5 Severe Severe BM damage;
mild GI damage
Death within 3.5-6 weeks
(50% of victims)
5.5-7.5 Severe Pancytopenia and
moderate GI damage
Death probable
within 2-3 weeks
7.5-10.0 Severe Marked GI and BM
damage; hypotension
Death probable within 1-
2.5 weeks
10.0-20.0 Severe Severe GI damage,
pneumonitis, altered
mental status
Death certain within 5-12
days
20.0-30.0 Severe CV collapse; fever;
shock
Death certain within 2-5
days
Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).
Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko
12 Gy: TBI dose for clinical BMT
RITN Overview Presentation
The standard dose of irradiation used for total body irradiation (TBI) in clinical BMT is 12 Gy (1200 rad), but….
- this total dose is administered in multiple fractions over several days to allow repair of normal cells and tissues
- the lungs are usually given a lower total exposure (e.g., 9 Gy) to reduce risks of pulmonary toxicity
RITN Overview Presentation
TreatmentsTreatments
• Exposure results in a full range of injuries,
from changes in the blood cells to skin
burns to serious radiation sickness
• Analysis of peripheral blood may diagnose
exposure before other effects appear
• Treatment depends upon the nature and
severity of the injury
RITN Overview Presentation
Long-Term EffectsLong-Term Effects
• Probability increases as level of exposure increases
• Three most notable effects– Cancer– Cataracts
• Acute exposure of 200 rads (2 Gy)• Chronic exposure (months) of 1,000 rads (10 Gy)
– Shortening of lifespan
RITN Overview Presentation
Long-Term EffectsLong-Term Effects
• Animal experiments
– Same disease, earlier age
• Data from populations of Hiroshima and
Nagasaki
– Very slight risk (i.e., <1 years per 100 R)
RITN Overview Presentation
Long-Term EffectsLong-Term Effects
RITN Overview Presentation
Section 3: Section 3: Exposure versus Exposure versus ContaminationContamination
RITN Overview Presentation
Contamination versus RadiationContamination versus Radiation
Contamination: the deposition of radioactive material in undesired locations
NOTE: one can be exposed to radiation without becoming contaminated (e.g., radiation therapy treatments)
Radioactive contamination on a surface does not make the surface itself radioactive
- Remember that radioactive materials emitradiation- Once the contaminated surface is cleaned of theradioactive material, there is no longer a threat ofradiation
RITN Overview Presentation
Sources of Radioactive ExposureSources of Radioactive Exposureand Contaminationand Contamination
Direct radiation
Inhalation
Skin contamination
Direct ingestion
Radiation fromcontaminated surfaces
Secondary ingestion(e.g., food, water, milk)
RITN Overview Presentation
Control of Radiation ExposureControl of Radiation Exposure
• Protective Measures– Time
• Less time = less exposure
– Distance• Further away = less exposure
– Shielding• Intensity is reduced by
absorption and scattering by the material between you and the source
RITN Overview Presentation
Section 4: Section 4: Preparedness PlanningPreparedness Planning
RITN Overview Presentation
Types of Radiological IncidentsTypes of Radiological Incidents
• Orphaned source– Lost/stolen radiation source that exposes people– Can be purposely placed to injure
• Radiological Dispersal Device– a.k.a. “dirty bomb”
• Improvised Nuclear Device (IND)– a.k.a. “terrorist nuke”– could fit into a suitcase
RITN Overview Presentation
Orphaned Source Case StudyOrphaned Source Case Study
RITN Overview Presentation
Dirty BombsDirty Bombs
• Conventional bomb attached to a source of radioactivity (e.g., Cobalt-60)
• Explosion spreads radioactivity resulting in widespread contamination
• Result in few casualties
• Public panic is greatest danger
• Economic impact is far reaching when compared to INDs or military weapons
RITN Overview Presentation
Radiological Dispersal Device Radiological Dispersal Device Case StudyCase Study
RITN Overview Presentation
Improvised Nuclear Device (IND)Improvised Nuclear Device (IND)
• Estimates based on a 1 kiloton or 10
kiloton IND
• Worst case scenario: Victims will
outnumber BMT community resources
RITN Overview Presentation
Improvised Nuclear Device (IND)Improvised Nuclear Device (IND)
RITN Overview Presentation
Contingency PlanningContingency Planning
The Radiation Injury Treatment NetworkSM (RITN) provides comprehensive evaluation and treatment for victims of radiation exposure or other marrow toxic injuries. RITN develops treatment guidelines, educates health care professionals, works to expand the network, and coordinates situation response. RITN is a cooperative effort of the National Marrow Donor Program® (NMDP) and The American Society for Blood and Marrow Transplantation (ASBMT).
RITN Overview Presentation
RITN CentersRITN Centers
RITN provides:– Existing facilities with practicing specialists for intensive
supportive care and treatment• Infrastructure and process for transplant if needed
– Training of physicians and other health care workers– Assistance during an emergency– Donor search support– IRB - approved data collection plan– Increases transplant community awareness about
potential need of their services in time of crisis– Involves transplant community in emergency
preparedness
RITN Overview Presentation
Available through RITN WebsiteAvailable through RITN Website
www.nmdp.org/ritn
• RITN Acute Radiation Syndrome treatment guidelines
• RITN center standard operating procedure templates
• Donor selection criteria• NMDP data collection protocol• Training resources• Pertinent publications
RITN Overview Presentation
What is RITN Doing to Prepare?What is RITN Doing to Prepare?
• Standard Operating Procedures• Basic radiation training completed by staff• Grand rounds presentation in development• Additional training resources provided on RITN
Web site• Conduct an annual tabletop exercise• Emergency communications tests• GETS cards and satellite telephones• Coordinating with government (DHHS-ASPR)
RITN Overview Presentation
RITN Distribution Across USARITN Distribution Across USA
UMC
RITN Overview Presentation
What if there is a disaster?What if there is a disaster?
If an improvised nuclear device (terrorist nuclear
bomb) is detonated, what will happen?
• The federal government will:– Setup outside the hazard area
– Receive, decontaminate and triage victims
– Forward them on for appropriate care
• Any victim with trauma or burns would be treated for that
before being evaluated for treatment due to marrow
toxicity
• This leaves a smaller subset for marrow reconstitution
RITN Overview Presentation
Possible Casualty LevelsPossible Casualty Levels
• The U.S. government is planning to respond to a 10 kiloton improvised nuclear device (terrorist nuclear bomb)
RITN Overview Presentation
Timelines for Activity - Timelines for Activity - TransplantsTransplants
RITN Overview Presentation
RITN CentersRITN Centers
• Admission to RITN several days after event (unless hospital is in the vicinity of the event)– Initial triage and decontamination is
completed by first responders– Identifying a destination for each victim
• Health & Human Services working with RITN
– Initial treatment and diagnosis• Conducted by RITN, NCI and NDMS centers
RITN Overview Presentation
Urgent BMTUrgent BMT
• Small subset of patients will require transplantation
• Expediting the evaluation of donor(s) is key
• Housing needs for donors and patients
• Expect that altered standards of care will be implemented by the Dept. of Health and Human Services during this time to facilitate treatment
RITN Overview Presentation
Contingency PlanningContingency Planning
“By failing to prepare you are preparing to fail.”
Benjamin Franklin
RITN Overview Presentation
Some Online ReferencesSome Online ReferencesRITN: www.nmdp.org/RITN
HHS Radiation Event Medical Management (REMM): http://www.remm.nlm.gov
CDC: – Radiological Terrorism: Medical Response to Mass Casualties:
http://www.bt.cdc.gov/radiation/masscasualties/training.asp – Radiological Terrorism: Just in Time Training for Hospital
Clinicians: http://www.bt.cdc.gov/radiation/justintime.asp – Medical Response to Nuclear and Radiological Terrorism:
http://www2.cdc.gov/phtn/webcast/radiation-04/default.asp – The Role of Public Health in a Nuclear or Radiological Terrorist
Incident: http://www2.cdc.gov/phtn/nuclear05/default.asp
National Planning Scenarios:http://media.washingtonpost.com/wp-srv/nation/nationalsecurity/earlywarning/NationalPlanningScenariosApril2005.pdf