TRIAGE AND MEDICAL MANAGEMENT OF HIGH-VOLUME MASS CASULATIES AFTER A NUCLEAR DETONATION: HIROSHIMA REVISITED

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1 TRIAGE AND MEDICAL MANAGEMENT OF HIGH-VOLUME MASS CASULATIES AFTER A NUCLEAR DETONATION: HIROSHIMA REVISITED Daniel F. Flynn MD, COL US Army (Ret.) dflynn1776@gmail.com Adjunct Faculty, Armed Forces Radiobiology Research Institute (AFRRI) Visiting Faculty, Radiation Emergency Assistance Center Training Site (REAC/TS) ConRad 2017: Nuclear Medical Defense Conference Munich Germany May 8-11,

2 HIROSHOMA INDUSTRIAL PROMOTION HALL ( A -BOMB DOME)

4 U.S. Department of Homeland Security National Planning Scenario 1: 10-kiloton nuclear ground-level detonation in a major urban center

5 Nuclear detonation casualty computer estimates versus weapon yield (No shielding or sheltering) 1 Kiloton 10 Kiloton 100 Kiloton Hotspot (Lawrence Livermore National Laboratory) simulating a surface nuclear weapon burst Ionizing radiation 50% lethality 0.77 km 1.2 km 1.7 km Thermal radiation 50% second degree burns 0.86 km 2.5 km 6.5 km Blast winds 50% lethality 0.43 km 1.0 km 2.1 km

6 BLAST INJURIES THERMAL RADIATION INJURIES 1. Direct- Sudden Impact Overpressure (PSI) Changes 2. Indirect- Blast Shock Front Winds A. Missile Impact on Body B. Displacement of Body 1. Primary- A. Direct Flash (Profile) Burns B. Indirect Flame/Contact Burns 2. Secondary- Fires Inducing Hot Gases NUCLEAR RADIATION INJURIES 1. Prompt Radiation- Immediate 2. Residual Radiation- Delayed Fallout and/or Radioactive Contamination

7 NUCLEAR RADIATION INJURY: ACUTE RADIATION SYNDROME Dose Subsyndromes 0 1 Gy Asymptomatic 1 8 Gy Hematopoietic Syndrome 8 30 Gy Gastrointestinal Syndrome > 30 Gy Neurovascular Syndrome

8 LD 50 (60) : whole-body lethal radiation dose for 50% of exposed group within 60 days [PROVIDED NO COMBINED INJURIES] (trauma or burns) Approximately Gy (untreated) Approximately Gy (treated) REF: NUREG/C-6545, 1997

9 COMBINED EFFECTS OF WHOLE BODY IRRADIATION AND BURN IN VARIOUS ANIMAL MODELS MODEL INJURY LETHALITY % BURN 0 MODEL INJURY LETHALITY 31-35% BURN 50% PIG 400 cgy 20% COMBINED 90% RAT 250 cgy 0 COMBINED 95% 20% BURN 12% 1.5% BURN 9% DOG 100cGy 0 COMBINED 73% GUINEA PIG 250 cgy 11% COMBINED 38% ARMED FORCES RADIOBIOLOGY RESEARCH INSTITUTE (AFRRI)

10 DAMAGE ZONES WITHOUT FALLOUT FOR 10 KT GROUND BURST

11 HIROSHIMA Zonal casualty rate as a function of distance from ground zero Zone Distance From Bomb Isocenter Total Population Killed Injured mile (0-1.0km) miles (1.0km-2.5km) miles (2.5km-5.0km) 31,200 26,700 (86%) 3,000 (10%) 144,800 39,600 (27%) 53,000 (37%) 80,300 1,700 (2%) 20,000 (25%) 256,300 68,000 76,000

HIROSHIMA Approximate casualty rate from day 1 to 4 months post detonation Estimated population at risk 255,000 Uninjured 119,000 Total casualties 136,000 Dead day

12 HIROSHIMA Approximate casualty rate from day 1 to 4 months post detonation Estimated population at risk 255,000 Uninjured 119,000 Total casualties 136,000 Dead day 1 45,000 (70% of total fatalities) Dead day 2 month 4 19,000 16,300 day 2 to day 20 2,700 after 20 days Total dead month 4 64,000 Surviving casualties month 4 72,000

13 Hiroshima: Delayed Radiation Injuries Discovered in Patients Alive 20 days or more after the detonation 1. Alopecia 2. Oropharyngeal lesions (mucositis) 3. Purpura

14 Alopecia

15 Oropharyngeal Lesions: Mucositis

16 Purpura

17 LD = Light Damage or Outer Zone MD = Moderate Damage or Middle Zone NG = No-Go or Severe Damage (SD) or Inner Zone DF = Dangerous Fallout Zone defined by exposure rate of 10 Roentgens/hour DAMAGE ZONES WITH FALLOUT FOR 10 KT GROUND BURST

18 CONVENTIONAL MILITARY MEDICAL TRIAGE FOR MASS CASUALTIES: PHYSICAL TRAUMA AND BURN INJURIES Immediate (I) require immediate treatment to save life, limb or sight (highest triage priority) Delayed (D) require treatment that can be delayed as less urgent than Immediate category Minimal (M) require minor treatment which can be administered as outpatient and returned to duty ( walking wounded ) Expectant (E) require extensive treatment and resources and have poor prognosis even with treatment

19 CONVENTIONAL VERSUS COMBINED-INJURY TRIAGE FROM STRATEGIC NATIONAL STOCKPILE RADIATION WORKING GROUP 2004 Conventional Additional Radiation Injury Injury Triage Gy Gy >4.5-<10 Gy Categories Immediate (I) I I E Delayed (D) D Variable E Minimal (M) M M M Expectant (E) E E E

20 CLINICAL TRIAGE BY ESTIMATED WHOLE BODY RADIATION: TIME TO VOMITING Rapid Radiological Triage: Time to vomiting < 4 hours: Priority treatment Time to vomiting > 4 hours: Observation

21 Radiation Emergency Assistance Center/Training Center (REAC/TS)

22 LABORATORY TRIAGE BY ESTIMATED WHOLE BODY DOSE: LYMPHOCYTE DEPLETION RATE

23 Hematological Response to Whole Body Radiation Dose

24 Figure. Classical Andrews lymphocyte depletion curves Early Lymphocyte Response to Whole Body Radiation Dose Lymphocyte Count WHOLE BODY DOSE: Curve 1: 3.1Gy Curve 2: 4.4Gy Curve 3: 5.6Gy Curve 4: 7.1 GY

25 CLINICAL TRIAGE BY ESTIMATION OF WHOLE BODY RADIATION DOSE: INITIAL BLAST INJURIES OR INITIAL DEGREE OF THERMAL BURNS (NOT DELAYED IONIZING RADIATION BURNS)

26 BLAST INJURIES: 2.3 kilometers from ground zero

27 FIRST DEGREE BURN: 2.5 kilometers from ground zero

28 SECOND DEGREE BURN: 1.9 kilometers from ground zero

29 THIRD DEGREE BURN: within 1 kilometer from ground zero

Radiological Injuries

Radiological Injuries Chapter 28 The reader is strongly advised to supplement material in this chapter with the following two references: 1. Armed Forces Radiobiology Research Institute. Medical Management of Radiological Casualties.