Transcript Slide 1

NMDP Basic
Radiation Training
Presenters name
Date
RITN Overview Presentation
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
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Goals 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
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Section 1:
Radiation Basics
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Types 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
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Sources of Radiation
Exposure in the U.S. Population
• Natural (82%)
– Radon
– Cosmic (outer
space)
– Terrestrial
• Rocks/Soil
– Internal
• Inside
human
body
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Natural 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
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Sources of Radiation
Exposure in the U.S. Population
• Man Made (11%)
- Medical
• X-rays
• CT scans
- Nuclear medicine/
radiation oncology
- Consumer products
- Other
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Atomic Structure (a VERY basic one)
• Protons
– Positive charge
• Neutrons
– No charge
• Electrons
– Negative charge
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Radioactivity and
Ionizing 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
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Three Main Types of
Ionizing Radiation Emitted from
Radioactive Atoms
• Alpha
• Beta
• Gamma
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Ionizing 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)
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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 internallydeposited radioactive material
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Ionizing 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
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Ionizing Radiation
• Alpha and beta radiation: both are
PARTICLES
• Gamma radiation: is a form of
electromagnetic radiation,
transmitting energy in the form of
WAVES
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Electromagnetic Radiation
• Transmitted in the form of waves
• Generally higher in energy
• Originate in the nuclei of atoms
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Radiation 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
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Ionizing Radiation
Gamma rays - deadly
Beta particles
– internally a bit more hazardous
Alpha particles – hazardous internally
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Shielding
• 2-1/2 inches of dense concrete will absorb
approximately 50% of typical gamma rays
• Five inches of water is just as effective
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Exposure vs. Dose
When you are exposed to radiation, your
body absorbs a measurable dose
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Measurement of Radiation Dose
• What needs to be known for medical treatment
• Intensity of exposure
• Time or duration of exposure
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Roentgen
• 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
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Rad (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
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Rem (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
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Exposure Rate
The rate at which an individual is exposed to
radiation
• Expressed in terms of roentgen or
milliroentgen per hour
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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
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Section 2:
Biological Effects
of Radiation
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Biological 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
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Ionizing 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 ionization
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Biologic Effects
• Damage DNA and other structures inside
cells
• Could result in cell death
• Incorrect repair, resulting in mutations that
could cause cancer
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Biological 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
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Biological Factors
• Each person differs in their biological
response to a given dose of radiation
– Age
– Sex
– Diet
– Body temperature
– Overall medical health
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Acute 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
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Acute 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
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Acute 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)
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Four Stages of ARS
• Prodromal phase (within 48 hours)
• Latent Phase (days to weeks)
• Manifest Illness (weeks to months)
• Recovery or Death
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Four 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
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Four 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 Levels
Delayed effects after sublethal dose
(<250 rem*) may be non-specific
 Malaise
 Fever
 Fatigue
 Abdominal pain
 Drowsiness
 Insomnia
 Weight loss
 Restlessness
 Blisters
* For gamma and beta radiation, 1 rem = 1 rad
RITN Overview Presentation
Severity 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 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
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Severity 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 ARS
 Nausea
 Vomiting
 Anorexia
 Reduced number of
platelets
Itching or altered
 Reduced number of white
sensation in the skin
blood cells (lymphocytes,
Swelling and Edema
granulocytes)
Diarrhea
Fatigue
RITN Overview Presentation
Severity of Radiation Injury
Dose Range (Gy)*
Prodrome
Manifest - Illness
Prognosis
(without therapy)
0.5-1.0
Mild
Slight decrease in
Almost certain survival
blood cell counts
1.0-2.0
2.0-3.5
Mild to Moderate
Moderate
Early signs of BM
Highly probable survival
damage
(>90% of victims)
Moderate-severe BM
Probable survival
damage
3.5-5.5
5.5-7.5
7.5-10.0
10.0-20.0
Severe
Severe
Severe
Severe
Severe BM damage;
Death within 3.5-6 weeks
mild GI damage
(50% of victims)
Pancytopenia and
Death probable
moderate GI damage
within 2-3 weeks
Marked GI and BM
Death probable within 1-
damage; hypotension
2.5 weeks
Severe GI damage,
Death certain within 5-12
pneumonitis, altered
days
mental status
20.0-30.0
Abbreviations:
Severe
CV collapse; fever;
Death certain within 2-5
shock
days
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
What is the standard dose of
irradiation used for
total body irradiation (TBI)
in clinical BMT?
RITN Overview Presentation
Severity of Radiation Injury
Dose Range (Gy)
Prodrome
Manifest - Illness
Prognosis
(without therapy)
0.5-1.0
Mild
Slight decrease in
Almost certain survival
blood cell counts
1.0-2.0
2.0-3.5
Mild to Moderate
Moderate
Early signs of BM
Highly probable survival
damage
(>90% of victims)
Moderate-severe BM
Probable survival
damage
3.5-5.5
5.5-7.5
7.5-10.0
10.0-20.0
Severe
Severe
Severe
Severe
12 Gy: TBI dose for clinical BMT
20.0-30.0
Abbreviations:
Severe
Severe BM damage;
Death within 3.5-6 weeks
mild GI damage
(50% of victims)
Pancytopenia and
Death probable
moderate GI damage
within 2-3 weeks
Marked GI and BM
Death probable within 1-
damage; hypotension
2.5 weeks
Severe GI damage,
Death certain within 5-12
pneumonitis, altered
days
mental status
CV collapse; fever;
Death certain within 2-5
shock
days
Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).
Modified from RI Walker and RJ Cerveny,
eds.(reference 21); provided by Dr. J.
Waselenko
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
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Treatments
• 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 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
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Long-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)
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Long-Term Effects
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Section 3:
Exposure versus
Contamination
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Contamination 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 emit
radiation
- Once the contaminated surface is cleaned of the
radioactive material, there is no longer a threat of
radiation
RITN Overview Presentation
Sources of Radioactive Exposure
and Contamination
Direct radiation
Inhalation
Skin contamination
Direct ingestion
Radiation from
contaminated surfaces
Secondary ingestion
(e.g., food, water, milk)
RITN Overview Presentation
Control 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:
Preparedness Planning
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Types 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
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Orphaned Source Case Study
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Dirty 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
Case Study
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Improvised Nuclear Device (IND)
• Estimates based on a 1 kiloton or 10
kiloton IND
• Worst case scenario: Victims will
outnumber BMT community resources
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Improvised Nuclear Device (IND)
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Contingency 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).
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RITN Centers
RITN provides:
– Existing facilities with practicing specialists for intensive
supportive care and treatment
• Infrastructure and process for transplant if needed
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–
–
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 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?
•
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•
•
•
•
•
•
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 USA
UMC
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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 Levels
• The U.S. government is planning to
respond to a 10 kiloton improvised nuclear
device (terrorist nuclear bomb)
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Timelines for Activity Transplants
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RITN 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 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
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Contingency Planning
“By failing to prepare you are
preparing to fail.”
Benjamin Franklin
RITN Overview Presentation
Some Online References
RITN: 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/wpsrv/nation/nationalsecurity/
earlywarning/NationalPlanningScenariosApril2005.pdf
RITN Overview Presentation