Medical Response to Nuclear and Radiological Terrorism

Satellite Broadcast

10 February 2004

Final Draft

		BARS & TONE
1.		PRE-CON – Graphics/Disclaimers/PHTN open/Show open
2.		SOT:	Dr. Gerberding Roll-in (part of open) Outcue:…” Thank you so much for your time and efforts.”
	3.	Daniels CG:: Kysa Daniels	DANIELS: Hello, I’m KYSA DANIELS. Welcome to “Medical Response to Nuclear and Radiological Terrorism”, coming to you live from the Centers for Disease Control and Prevention in Atlanta, Georgia.
	4.	(BUILD) SS: Program Goals: · Provide information on radiation. SS: · Provide information on the management of radiological injuries. SS: · Provide information on Radiation protection for clinicians.	The goal of this program is to: provide information on radiation, (slight pause) the management of radiological injuries, (slight pause) and radiation protection for clinicians.
	5.	(BUILD) SS: Program Objectives: · Distinguish between radiation exposure and contamination. SS: · Recognize the signs and symptoms of acute radiation syndrome. SS: · Recognize the symptoms of cutaneous radiation syndrome. SS: · Describe how to decontaminate a patient.	Upon successful completion of the program, participants will be able to: · Distinguish between radiation exposure and contamination. · Recognize the signs and symptoms of acute radiation syndrome. · Recognize the symptoms of cutaneous radiation syndrome. · Describe how to decontaminate a patient. (pause)
	6.	SS: Technical Help: (800)728-8232	If you are having technical problems receiving our signal, you can call us here at CDC at 800 – 728 – 8232.
	7.	SS: TTY: (800) 815-8152	The TTY number for this broadcast is: 800-815-8152 (pause)
	8.	SS: Voice: (800) 793-8598	During today’s program, we will have a phone-in question and answer session. For voice calls, the number is 800.793.8598.
	9.	SS: Fax: (800) 553-6323	You can also fax your question or comment to us at 800.553.6323.
	10.	SS : TTY: (800) 815-8152	And finally, our TTY number for questions is: 800.815.8152.
	11.	SS: E Mail: RSB@cdc.gov Indicate: “Medical Response to Nuclear and Radiological Terrorism” in the subject line.	We will answer as many questions as we can on air. If you have any additional questions AFTER the broadcast, you can email them to RSB@cdc.gov. Please indicate “Medical Response to Nuclear and Radiological Terrorism” in the subject line.
12.		SS: CDC Emergency Preparedness and Response-Radiation Emergencies: www.bt.cdc.gov/radiation	You can check for answers to your emailed questions at the CDC Emergency Preparedness and Response-Radiation Emergencies website: w-w-w dot bt dot cdc dot gov forward slash radiation
13.		Daniels SS: CDC/ATSDR Training and Continuing Education: www.phppo.cdc.gov/phtnonline	Continuing education credit will be offered for a variety of professions, based on 1 hour of instruction. A certificate of credit or a certificate of attendance will be awarded to participants who complete the evaluation. That Continuing Education website is w-w-w dot phppo dot cdc dot gov forward slash phtnonline. I will give you more registration information later in the broadcast.
14.		WS Smith CG: James Smith, Ph.D., Assistant Director for Radiation (EHHE)(NCEH) (CDC) Fong CG: Fun Fong, MD, FACEP, Senior Medical Officer, GA-3 DMAT	Joining us today to provide and discuss information on Medical Response to Nuclear and Radiological Terrorism are: Dr. James Smith, Assistant Director for Radiation in the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention. (pause) and Dr. Fun Fong who is an emergency physician in Atlanta and the former Director of Radiation Medicine at the Medical Sciences Division of Oak Ridge Associated Universities. Dr. Fong is author of several textbook chapters on radiation and nuclear accident management and currently serves as the Senior Medical Officer of the Georgia-3 Disaster Medical Team. (pause)
15.		WIDE SHOT	I’d like to welcome you both to today’s broadcast.
16.		2 shot	Dr. Smith could you please give our viewers some possible scenarios for radiological incidents and how these incidents could result in radiation exposure or contamination?
17.		Smith CG: James Smith, Ph.D., Assistant Director for Radiation (EHHE)(NCEH) (CDC) Looking at Kysa Then turns toward camera	Smith: Of course Kysa. It would be my pleasure. Unfortunately, terrorism is a very real threat to the U.S. in the 21st Century. The use of radioactive materials in a radiological dispersal devise (RDD) or a nuclear weapon by a terrorist is a remote but plausible threat. The medical consequences depend on the type of device used in a terrorist event. Some possible scenarios are:
18.		SS: Possible Scenarios: n Nuclear power plant incident n Hidden source n Dirty bomb n Improvised nuclear device n Nuclear Weapon
19.		SS: Hypothetical Suitcase Bomb (BACK TO SMITH?)
20.		SS: What is Radiation? Radiation is energy moving in the form of particles or waves. (BACK TO SMITH?)
21.		SS: Penetration Abilities of Different Types of Radiation
22.		SS: Detecting Radiation (BACK TO SMITH?)
23.		SS: Radiation vs. Radioactive Material n Radiation: energy moving in the form of particles or waves n Radioactive Material: material that contains atoms that are radioactive
24.		SS: Exposure vs. Contamination Exposure: irradiation of absorbed dose (Gray, Rad) Contamination: radioactive material on patient (external) or within patient (internal) (BUILD) (Transparent man) 5 graphics – must be timed to presentation.
25.		SS: Consult with Radiation Experts n Radiation Safety Officer n Health Physicist n Medical Physicist n Conference of Radiation Control Program Directors (www.crcpd.org)
26.		SS: Last Slide (#10) Consult with Radiation Experts n Determining/documenting presence of radioactivity, activity levels, and radiation dose. n Collecting samples to document contamination n Assist in decontamination procedures n Dispose of radioactive waste Smith	Radiation experts will be able to assist hospitals and staff in • Determining/documenting presence of radioactivity, activity levels • Collecting samples that document contamination • Assist in decontamination procedures • Dispose of radioactive waste Dr. Smith should give some "closing" comments related to his previous presentation.
27.		Daniels	DANIELS: Thank you, Dr. Smith, that was very informative.
28.		Fong Looking @ Kysa CG: Fun Fong, MD, FACEP, Senior Medical Officer, GA-3 DMAT	Next, Dr. Fong will be discussing the clinical aspects of radiological incidents.
29.		Fong Still looking @ camera Turns to face camera	Fong: Thank you Kysa. I would like to begin by bringing your attention to this first graphic....
30.		SS: Injuries Associated with Radiological Incidents n Acute Radiation Syndrome (ARS) n Localized radiation injuries/ cutaneous radiation syndrome n Internal or external contamination n Combined radiation injuries with • Trauma • Burns n Fetal effects
31.		SS: Psychological Casualties n Terrorist acts perceived as very threatening n Large numbers of concerned with no apparent injuries n Mental health professionals should be included n More information on radiation exposure and pregnancy: www.bt.cdc.gov/radiation/prenatalphysician.asp
32.		SS: Radiation Protection for Clinical Staff n Fundamental Principles • Time • Distance • Shielding n Personnel Protective Equipment n Contamination Control
33.		SS: Protecting Staff from Contamination n Use standard precautions (N95 mask if available) n Survey hands and clothing frequently n Replace contaminated gloves or clothing n Keep the work area free of contamination
34.		SS: Contamination Control
35.		SS: Pregnant Staff: n NRC limit for pregnant workers is 5 mGy (0.5 rad) n Pregnant staff should be reassigned n CDC prenatal radiation exposure fact sheet: www.bt.cdc.gov/radiation
36.		SS: Dealing With Staff Stress Preplanning Establish information center Train staff on radiation basics Post Event Debrief immediately after event Offer Counseling
37.		SS: 1986 Chernobyl Accident “When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personnel at the site received less than 10 mGy of radiation.”
38.		SS: Never delay critical care because a patient is contaminated (BACK TO FONG?)
39.		SS: Immediate Medical Management n Triage • ARS • localized/ cutaneous • combined injury n Initial stabilization and treatment n Psychological effects n Record keeping/ Dose assessment
40.		SS: Patient Management - Priorities n Standard medical triage is the highest priority n Radiation exposure and contamination are secondary considerations
41.		SS: Patient Management - Protocol Based on: n Injuries n Signs and symptoms n Patient History n Contamination survey
42.		Fong Demonstration: Geiger meter/Earthenware	Determining the amount of contamination can be tricky…..then the counts will be fewer.
43.		SS: Prenatal Radiation Exposure n Human embryo and fetus highly sensitive to ionizing radiation n At higher doses, effects depend on dose and stage of gestation n Pregnant patients should receive special dose assessments and counseling n Information on prenatal radiation exposure www.bt.cdc.gov/radiation/prenatalphysician.asp
44.		SS: Required Conditions for Acute Radiation Syndrome n Large dose n Penetrating n Most of body exposed n Acute
45.		SS: Acute Radiation Syndrome (A Spectrum of Disease) (BACK TO FONG?)
46.		SS: Biodosimetry Assessment Tool (BACK TO FONG?)
47.		GRAPHIC: Andrews Lymphocyte Nomogram Confirms suspected radiation exposure Determines significant hematological involvement Serial CBCs every 3 - 4 hours
48.		CAM: Fong
49.		SS: Phases of Acute Radiation Syndrome
50.		SS: Special Considerations n High radiation dose and trauma interact synergistically to increase mortality n Close wounds on patients with doses > 1 Gy (100 rad) Perform wound/burn care and surgery in first 48 hours or delayed for 2 to 3 months when dose is > 1 Gy (100 rad)
51.		SS: Skin Effects (Photo) Photo and bullets	• Localized radiation injury can occur when a person receives a very high radiation dose to only a portion of their body. Depending on the dose, the location on the body, and the fraction of the body that is exposed, extreme damage may occur, with or without symptoms of acute radiation syndrome. Skin damage is the most typical effect. • The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome resulting from acute radiation exposure to the skin. ARS will usually be accompanied by some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or x-rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes.
52.		Fong	• When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged causing epilation. Within a few hours after irradiation a transient and inconsistent erythema (associated with itching) can occur. Then, there may be a latent phase that lasts from a few days up to several weeks, when intense reddening, blistering and ulceration of the irradiated site is visible. • The cycle of healing, and then a return of symptoms may recur several times, with symptoms often worsening each time. • In most cases healing occurs by regenerative means; however, very large skin doses can cause permanent hair loss, damaged sebaceous and sweat glands, atrophy, fibrosis, decreased or increased skin pigmentation, and ulceration or necrosis of the exposed tissue. This photo is from a patient who had 3 angioplasty procedures under fluoroscopic guidance. It shows deep necrosis of the skin 22 months after an exposure of ~2000 rad.
53.		SS: Treatment of Large Exposures n Treat patients symptomatically n Prevent and manage infections • Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hr) (Neupogen®) • Irradiated blood products • Antibiotics/reverse isolation • Electrolytes SS: (ADDED) n More information on ARS: www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp
54.		SS: Treatment of Cutaneous Radiation Syndrome n Lesions do not appear for days to weeks n Perform surgical treatments within 48 hrs n Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment, 865-576-1005 or www.orau.gov/reacts/
55.		SS: Decontamination of Patients n External • Skin • Wound n Internal • Decorporation agents
56.		SS: Patient Decontamination n Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of contamination) n Handle foreign objects with care until proven non-radioactive with survey meter n Survey patient and collect samples • Survey face, hands and feet • Survey rest of body
57.		SS: External Contamination n External contamination: radioactive material (usually in the form of dust particles) on the body surface and/or clothing n Radiation dose rate from contamination is usually low, but while it remains on the patient it will continue to expose the patient and staff
58.		SS: Decontamination Priorities n Wounds n Intact skin (areas of highest contamination first) Change outer gloves frequently to minimize spread of contamination
59.		SS: Decontamination of Wounds n Contaminated wounds: • Irrigate and gently scrub with surgical sponge • Debride surgically only as needed n Contaminated thermal burns: • Gently rinse. • Changing dressings will remove additional contamination Avoid overly aggressive decontamination Change dressings frequently
60.		SS: Decontamination of Skin n Use multiple gentle efforts n Use soap & water n Cut hair if necessary (do not shave) n Promote sweating n Use survey meter
61.		SS: Cease Patient Decontamination n When decontamination efforts produce no significant reduction in contamination n When the level of radiation of the contaminated area is less than twice background n Before intact skin becomes abraded Consider internal contamination.
62.		SS: Internal Contamination n Radioactive material may enter the body through • Inhalation • Ingestion • Wounds n Internal contamination generally does not cause early signs or symptoms n Internal contamination will continue to irradiate the patient
63.		SS: Treatment of Internal Contamination (BACK TO FONG?)
64.		SS: Potassium Iodide (KI) n Only helpful in special cases n KI saturates the thyroid gland with stable iodine n KI must used prior to or within hours of exposure to radioactive iodine n See the FDA web site: www.fda.gov/cder/drugprepare
65.		SS: Longer Term Considerations Following Radiation Injury n Neutropenia n Pain management n Necrosis n Plastic/reconstructive surgery n Psychological effects (PTSD) n Counseling n Dose assessments SS: (ADDED) Consult Radiation Emergency Assistance Center/ Training Site (REAC/TS) for advice for further treatment: www.orau.gov/reacts/, 865-576-1005.
66.		SS: Key Points n Stabilization is the highest priority n Radiation experts should be consulted n Training and drills should be offered n Adequate supplies and survey instruments should be stocked SS: (ADDED) Key Points n Standard precautions (N95 mask if available) reduce contamination n Early symptoms and their intensity indicate the severity of the radiation injury n First 24 hours are the most critical
67.		SS: More Incident Assistance n The Radiation Emergency Assistance Center/ Training Site (REAC/TS) • www.orau.gov/reacts • (Phone: (865) 576-1005) SS: (ADDED) More Incident Assistance n The Armed Forces Radiobiology Research Institute, Medical Radiobiology Advisory Team (MRAT) • www.afrri.usuhs.mil • (Phone: (301) 295-0530) SS: (ADDED) More Incident Assistance n The American Association of Poison Control Centers • http://www.aapcc.org • 1-800-222-1222	Dr. Fong should give some "closing" comments related to his previous presentation.
68.		WS	DANIELS: Thank you, Dr. Fong. I'm sure our viewers learned quite a bit from your presentation.
69.		Daniels	Daniels: And now we'd like both Dr. Smith & Dr. Fong to answer a few questions that we have received from you, our viewers.
70.		Cam: Daniels	Our first question is for….
71.		SS: E-Mail radiation related questions to RSB@cdc.gov Indicate: “Medical Response to Nuclear and Radiological Terrorism” in the subject line.	Unfortunately that’s all the time we have for answering your questions. If you have any radiation related questions after this broadcast you can email them to RSB@cdc.gov. Please indicate “Medical Response to Nuclear and Radiological Terrorism” in the subject line.
72.		SS: CDC Emergency Preparedness and Response-Radiation Emergencies website: www.bt.cdc.gov/radiation/	And don’t forget, you can check for answers to your emailed questions and find additional information at the CDC’s Emergency Preparedness and Response-Radiation Emergencies website: W-W-W dot bt dot cdc dot gov forward slash radiation.
73.		SS: SS: (ADDED) SS: (ADDED) · Oak Ridge Associated Universities: www.orau.gov/reacts SS: (ADDED) · Armed Forces Radiobiology Research Institute: www.afrri.usuhs.mil	You may also want to visit these web sites for information. · the Oak Ridge Associated Universities · Armed Forces Radiobiology Research Institute
74.		SS: CDC/ATSDR Training and Continuing Education www.phppo.cdc.gov/phtnonline	Participants of this broadcast are encouraged but not required to register and evaluate the program on the CDC Training and Continuing Education Online System. That address is: w-w-w dot phppo dot cdc dot gov forward slash phtnonline
75.		SS: COURSE NUMBERS: Satellite – SB0150 Webcast – WC0050 Web-on-demand – WD0037	Participant registration and evaluation will begin today, February 10th, and end on March 12, 2004. Here are the course numbers you will need. The number for the satellite broadcast is SB 0-1-5-0. The webcast number is WC 0-0-5-0. Web-on-Demand W-D-0-0-3-7 begins March 15, 2004 and ends February 10, 2007. Please take a moment now, to write down these important numbers. (PAUSE)
76.		SS: Registration Questions: (800)41-TRAIN (800) 418-7246 SS : E Mail: ce@cdc.gov.	Questions about registration should be directed to 800-41-TRAIN, T-R-A-I-N, or email at: ce@cdc.gov. When emailing a request, please indicate “Medical Response to Nuclear and Radiological Terrorism” in the subject line.
77.		SS: CDC Clinician Registry for Terrorism and Emergency Response v Alerts clinicians to changes or additions to the CDC websites v Informs clinicians of new training opportunities at CDC SS: To Register: www.bt.cdc.gov/clinreg	I want to make sure clinicians who watch our program are aware of the clinicians’ registry. Clinicians that register at this site will receive: Alerts and updates on public health threats and Information on CDC sponsored training. To join this registry visit: w-w-w dot bt dot cdc dot gov forward slash clinreg.
78.		SS: Videotape Information: RSB@cdc.gov	Information about ordering videotapes can be obtained by sending an email to RSB@cdc.gov (Pause)
79.		WS	DANIELS: It has been my pleasure being your moderator for this broadcast. My thanks to our panelists Dr. James Smith and Dr. Fun Fong for joining us today. And thank YOU, our viewers, for participating in this very informative program on Medical Response to Nuclear and Radiological Terrorism. On behalf of everyone at CDC and The Public Health Training Network, I'm Kysa Daniels wishing you a GOOD DAY from Atlanta.
80.		SS: Other Resources n Books • Medical Management of Radiological Casualties Handbook 2nd ed. AFRRI; 2003. • Medical Management of Radiation Accidents. Gusev, Guskova, Mettler; 2001. • Disaster Medicine 1st ed. Hogan, Burnstein; 2002. SS: (ADDED) Other Resources n Books • The Medical Basis for Radiation-Accident Preparedness. REAC/TS. Berger, O’Hara, Ricks, and Ricks; 2002. • NCRP Report No. 65: Management of Persons Accidentally Contaminated With Radionuclides. NCRP; 1980. • NCRP Report No. 138: Management of Terrorist Events Involving Radioactive Material. NCRP; 2001. SS: (ADDED) Other Resources n Books n AFRRI Publications: Medical Management of Radiological Casualties Handbook; Jarrett, 2003, and Terrorism with Ionizing Radiation Pocket Guide
81.		Fong: SS: Article: “Major Radiation Exposure - What to Expect and How to Respond,” Mettler and Voelz, New England Journal of Medicine, 2002; 346: 1554-61. SS: (ADDED) n Web Sites: • www.va.gov/emshg/ - Department of Homeland Security Working Group on Radiological Dispersal Device Preparedness, Medical Treatment of Radiological Casualties • www.crcpd.org – Conference of Radiation Control Program Directors SS: (ADDED) • www.bt.cdc.gov/radiation/index.asp - Centers for Disease Control and Prevention Radiation Emergencies Page • www.acr.org/flash.html - Disaster Preparedness for Radiology Professionals • www.hps.org/ - The Health Physics Society • www.fda.gov/ - The Food and Drug Administration Fong	Fong: I would like to close by showing some other resources that you can use to prepare for a radiological incident.
82.		SS: Produced by: The Public Health Training Network Division of Professional Development and Evaluation Public Health Practice Program Office Centers for Disease Control and Prevention SS: Produced for: National Center for Environmental Health Centers for Disease Control and Prevention SS: A Special Thanks To: Armed Forces Radiology Research Institute (AFRRI) Health Physics Society Radiation Emergency Assistance Center/Training Site (REAC/TS) SS: Medical Response to Nuclear and Radiological Terrorism Good Day From Atlanta