RITN Radiation Grand Rounds Rev. 2 2008 Delete this slide prior to presenting. Use the speaker notes provided for additional details about each slide, not all slides have notes prepared. Presenters; for questions or comments about this presentation please contact: Cullen Case | [email protected] | 612.884.8402 David Weinstock, M.D. | [email protected] | 617.632.4245
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RITN Radiation Grand Rounds Rev. 2 2008
Delete this slide prior to presenting.
Use the speaker notes provided for additional details about each slide, not all slides have notes prepared.
Presenters; for questions or comments about this presentation please contact:
• In the aftermath of a radiological event, RITN centers may be asked to:– Accept patient transfers to their institutions– Provide treatment expertise to practitioners caring for
victims at other centers– Travel to other centers to provide medical expertise– Provide data on victims treated at their centers
RITN Radiation Grand Rounds Rev. 2 20089
RITN Efforts
• Standard Operating Procedures
• Standardized admission and treatment orders
• Standardized data collection protocol
• Training
• Coordination with international organizations
• Conduct readiness exercises
• Emergency communications equipment
RITN Radiation Grand Rounds Rev. 2 2008
Radiological Event Scenarios
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Radiological Events
Weinstock et al. Blood 2008.
Events Description Anticipated deaths
Radioactive source accident
Loss or theft of a radiological source (e.g. Goiania)
0-100s
Nuclear reactor accident
Release of radioactive gas or material (e.g. Chernobyl)
0-1,000s
Radiological dispersal device
Device or scheme for dispersing radioactive isotope (e.g., dirty bomb or radioactive material in the food supply)
0-100s
Radiological exposure device
(open source)
Radioactive material intended to expose people in the vicinity (e.g. Cesium source on a train)
100s-1,000s
Improvised nuclear device
Incorporates radioactive material intended to produce a low yield nuclear explosion
1,000s-1,000,000s
Military-grade nuclear device
Incorporates radioactive material intended to produce a fusion detonation
0 = Approximate altitude band commercial aircraft use1 = Fat Man 22.5 kilotons (Nagasaki). Little Boy (Hiroshima) was ~10-15 kilotons.2 = Castle Bravo 15 megatons (1st US nuclear bomb test on Bikini Atoll)
RITN Radiation Grand Rounds Rev. 2 2008
Radiation Basics
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Types of Ionizing Radiation
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Radioactive Contamination• Internal contamination requires medical
decorporation• 90% of external contamination can be cleansed by
removing clothing and washing exposed body parts
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Reducing Radiation Exposure
3 steps for protection:
1) Keep your DISTANCE
2) Limit your TIME
exposed
3) SHIELD yourself from
exposure
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Protection from Radiation
Protective Not protective
RITN Radiation Grand Rounds Rev. 2 2008
Acute Radiation Syndrome
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Acute Radiation Syndrome
Weeks After Exposure1 2 3 4 5 6 7 80
0
2
4
6
8
10
0%
50%
100%
Prodromalnausea/vomiting
GIsymptoms
Onset of signs ofhematopoietic injury
Approximatetime of death
100% mortality(may be higher dose with HSCT)
>100CNS injury (100% mortality within days)
Mo
rtal
ity
Rad
iati
on
do
se (
Gy)
RITN Radiation Grand Rounds Rev. 2 200832
Toxicity is Proportional to Dose
• LD50 for humans: LD50 is the level of exposure that is lethal to 50% of people exposed to that dose– 3.5 to 4 Gy
• Without supportive care• However the use of antibiotics and transfusions may
decrease the chance of morbidity
– 4.5 to 7 Gy• With antibiotics, transfusions and other supportive care
– Greater than 10 Gy• With HSCT
• In a radiation incident, shielding will result in heterogenous body dosing
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Acute Radiation Syndrome - Combined Injury
• Most victims with significant injury will have multi-organ dysfunction– Trauma/wounds/burns– Gastrointestinal– Hematologic– Neurologic– Psychiatric
RITN Radiation Grand Rounds Rev. 2 200834
Acute Radiation Syndrome - Neurovascular
Symptoms Degree of severity 1 to 4
Nausea Mild to excruciating
Vomiting 1 per day to >10 times per day
Anorexia Able to drink to requiring parenteral nutrition
Fatigue Normal activity to prevents activity
Headache Minimal to intense
Neurological deficits No deficits to unarousable
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Symptoms Degree of severity 1 to 4Diarrhea - frequency Twice/day >10 times/day
Stool - consistency Bulky to watery
Blood in stools Occult to gross hemorrhage
Abdominal pain/cramps Minimal to excruciating
Nausea Mild to excruciating
Vomiting 1 per day to >10 times per day
Acute Radiation Syndrome - Gastrointestinal
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Acute Radiation Syndrome - CutaneousSymptoms Degree of severity 1 to 4Erythema Minimal to severe
Altered sensation/Itching Pruritis to severe
Edema Asymptomatic to total dysfunction
Blistering Rare to bullae with hemorrhage
Desquamation Absent to confluent
Ulcer/necrosis Epidermal only to muscle/bone
Hair loss Thinning to complete
Onycholysis Absent to complete
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Cutaneous Injuries from Open Sources
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Acute Radiation Syndrome - Hematopoietic
RITN Radiation Grand Rounds Rev. 2 2008
Biodosimetry
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Biodosimetry Tools
• Definition– Biodosimetry is the use of biological markers to estimate
dose– Dosing after radiological and nuclear events is
complicated by a variety of factors, including shielding
• Standard approaches– Lymphocyte Depletion Kinetics– Dicentric Chromosomes in Peripheral Blood
Lymphocytes
• Research approaches– Proteomics– Markers of DNA damage