ritn overview presentation nmdp basic radiation training presenters name date

RITN Overview Presentation

NMDP Basic NMDP Basic Radiation TrainingRadiation Training

Presenters name

Date


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

http://www.nti.org/

http://cns.miis.edu/cns/index.htm


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


Section 1: Section 1: Radiation BasicsRadiation Basics


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


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


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


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


Atomic Structure (a VERY basic one)Atomic Structure (a VERY basic one)

• Protons– Positive charge

• Neutrons– No charge

• Electrons– Negative charge


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


Three Main Types of Three Main Types of Ionizing Radiation Emitted from Ionizing Radiation Emitted from

Radioactive AtomsRadioactive Atoms

• Alpha

• Beta

• Gamma


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)


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


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



• Alpha and beta radiation: both are PARTICLES

• Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVES


Electromagnetic RadiationElectromagnetic Radiation

• Transmitted in the form of waves• Generally higher in energy• Originate in the nuclei of atoms


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



Alpha particles – hazardous internally

Beta particles– internally a bit more hazardous

Gamma rays - deadly


ShieldingShielding

• 2-1/2 inches of dense concrete will absorb approximately 50% of typical gamma rays

• Five inches of water is just as effective


Exposure vs. DoseExposure vs. Dose

When you are exposed to radiation, your body absorbs a measurable dose


Measurement of Radiation DoseMeasurement of Radiation Dose

• What needs to be known for medical treatment• Intensity of exposure• Time or duration of exposure


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


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


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


Exposure RateExposure Rate

The rate at which an individual is exposed to radiation

• Expressed in terms of roentgen or milliroentgen per hour


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


Section 2: Section 2: Biological Effects Biological Effects

of Radiationof Radiation


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



• 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


Biologic EffectsBiologic Effects

• Damage DNA and other structures inside

cells

• Could result in cell death

• Incorrect repair, resulting in mutations that

could cause cancer


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


Biological FactorsBiological Factors

• Each person differs in their biological response to a given dose of radiation– Age– Sex– Diet– Body temperature– Overall medical health


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


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


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)


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



• Prodromal phase (within 48 hours)– Nausea/vomiting– Headache– Fatigue– Fever, diarrhea– Anorexia– Fluid shifts – Electrolyte imbalance

• Latent Phase (days to weeks)– Temporary improvement



• 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


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



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




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




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



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


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


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


days

20.0-30.0 Severe CV collapse; fever;

shock


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


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


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


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



• Animal experiments

– Same disease, earlier age

• Data from populations of Hiroshima and

Nagasaki

– Very slight risk (i.e., <1 years per 100 R)


Section 3: Section 3: Exposure versus Exposure versus ContaminationContamination


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


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)


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


Section 4: Section 4: Preparedness PlanningPreparedness Planning


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


Orphaned Source Case StudyOrphaned Source Case Study


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


Radiological Dispersal Device Radiological Dispersal Device Case StudyCase Study


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


Improvised Nuclear Device (IND)Improvised Nuclear Device (IND)


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 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


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


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 Distribution Across USARITN Distribution Across USA

UMC


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


Possible Casualty LevelsPossible Casualty Levels

• The U.S. government is planning to respond to a 10 kiloton improvised nuclear device (terrorist nuclear bomb)


Timelines for Activity - Timelines for Activity - TransplantsTransplants


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


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


Contingency PlanningContingency Planning

“By failing to prepare you are preparing to fail.”

Benjamin Franklin


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

ritn overview presentation nmdp basic radiation training presenters name date

Documents

radiation slide

ritn slide

beta radiation

radiation basics

time ionizing radiation

particles gamma radiation

misused ionizing radiation

time of exposure slide