There are no acute, life-threatening complications of a survivable radiation injury that require immediate intervention. Emergency treatment should be supportive and directed toward the prevention of complications.
It will be important to determine, quickly, whether the patients are victims of a radiation exposure or a contamination. Radiation contamination requires that decontamination begin promptly after stabilization. The radiation exposure patient who is not contaminated represents no danger to the hospital staff or other patients. These victims can be managed in the emergency department and require no immediate intervention related to the radiation exposure.
At all times, there must be a proper balance between patient care and the personal safety of rescuers and healthcare workers. Appropriate measures must be taken by both prehospital and hospital personnel to minimize their risk of exposure while managing either life-threatening injuries or the decontamination of the patients they serve. While both prehospital and hospital workers may be at risk, it is the prehospital personnel and other rescuers responding to the site of a radiation accident, who are more often exposed to significant radiation. A threshold of 5000 mrem (5 rem) should be the exposure limit, except to save a life. A once-in-a-lifetime exposure to 100,000 mrem (100 rem) to save a life has been established by the National Council on Radiation Protection as acceptable and will not result in any undue morbidity.
Hospital personnel are at a very low risk of significant radiation exposure when treating victims of a radiation accident. Off-site medical personnel who treated victims of the Three Mile Island and Chernobyl accidents were exposed to radiation doses of <14 mrem. The recent Fukushima Daiichi event resulted in release of large amounts of radioactive iodine and cesium into the environment. A 20-km radius was evacuated for a prolonged period of time and no deaths from acute radiation syndrome were reported. Levels of cesium in adults and children 6 months after the event are much lower than those reported in the Chernobyl accidents. However, the long-term effects of this event are not yet known.14
The history obtained by prehospital personnel is of paramount importance in management decisions regarding radiation victims. For internal exposure, the route of entry, type, and quantity of radioactive material should be determined. If the incident has occurred in an industrial or laboratory setting, initial decontamination procedures may be instituted by on-site personnel according to established protocols before EMS personnel arrive. A quick response in decontamination will limit the exposure to the victim and decrease the amount of further contamination of both the ambulance and the emergency department. For unstable patients, the minimal action performed prior to rapid transport is the removal of contaminated clothing.
After transport of the patient to the hospital, EMS personnel and their vehicles must be inspected for the presence of radioactive contamination before they leave the facility.
Emergency Department Management
Few hospitals will be called on to treat victims of life-threatening radiation accidents. The exceptions are hospitals in close proximity to nuclear power plants or in the event of a nuclear war. It is more likely, however, that hospitals will be called on to attend victims of a minor industrial accident or an accident involving the transportation of radioactive materials. The end result will be a patient with “routine injuries,” whose treatment may be complicated by an inadvertent radiation exposure with or without low-level radioactive contamination.
The Joint Commission requires each emergency department to have a radiation accident plan. In the event of a medically significant radiation accident, a well-prepared and practiced plan will supply emergency care providers with an appropriate knowledge base, management protocols, and additional resources that can be called upon.
A major part of a well-prepared plan facilitates the identification of significant versus perceived radiation danger. The incidence of significant radiation accidents may be rare for some hospitals, but the incidence of perceived radiation accidents may be much greater. A vehicular accident involving a truck or train carrying radioactive material near a school may send dozens (or hundreds) of anxious parents and their children to the emergency department. The staff of a well-prepared emergency department can assess the potential risks and, when appropriate, correct any misconceptions and ease the fears the general public may have.
A lack of experience, an incomplete knowledge base, and a significant degree of fear among healthcare providers often result in the mismanagement of radiation victims. Therefore, it is essential that an emergency department develop protocols for dealing with both the radiation exposure itself and the medical management of these victims. Protocols should be rehearsed and drilled until all staff members who may need to participate are familiar with the process and their anticipated responsibilities.
The final component of an emergency department's resource plan for radiation emergencies is a list of “additional references.” These resources include local, state, regional, and/or national agencies and their 24-hour telephone numbers that can be called for information or assistance. The US Department of Energy is also available to coordinate a federal response and provide assistance through the radiological assistance program (RAP). RAP provides advice and radiological assistance to government agencies and to the private sector for incidents involving radioactive materials that pose a threat to the public health and safety or the environment. RAP can provide field deployable teams of health physics professionals equipped to conduct radiological monitoring and assessment. RAP is managed at eight regional coordinating offices across the country.
Early notification of estimated time of arrival will allow the emergency department to implement its radiation accident plan and to advise EMS personnel on initial prehospital decontamination.
When exposed solely to irradiation from γ-rays, x-rays, β-particles, and, frequently, neutrons, patients do not become radioactive. However, the radiation accident plan must assume that there will be external contamination. Figure 142-3 outlines an example of many of the procedures and actions that should be addressed in the radiation accident plan.
Radiation accident plan: recommended emergency department procedures.
Separate contaminated and clean treatment areas must be established. When possible, prepare a separate entrance to the emergency department for radiation victims. The floor of the contaminated treatment area and the ambulance receiving area must be covered with plastic or paper sheets to prevent the spread of contamination. Devices must be immediately available to monitor both the patients and personnel for any evidence of radioactive contamination.
All personnel in the treatment area must wear protective clothing. This includes gowns, caps, masks, shoe covers, double gloves, and personal monitoring devices (film badges). If airborne contaminants are suspected, respirators must be worn. In most cases, decontamination begins during the prehospital stage, significantly reducing the risk of exposure to emergency department staff. Despite this, fear of contamination may persist in poorly educated or ill-prepared hospital personnel.
Separate staff members are assigned to the clean and contaminated treatment areas. Staff assigned to the contaminated areas are provided appropriate personal protective equipment. Medical staff should be designated for triage and initial resuscitation, which must take place before decontamination.
A radiation safety officer should be assigned to monitor the treatment area and everyone within. This officer is given a Geiger–Mueller counter for detecting β- and γ-radiation or a scintillation detector, which offers a higher sensitivity in detecting α-, β-, γ-, and neutron particles. This designated individual oversees the decontamination procedures, the routing of patients, and the movement of hospital personnel. This is important to ensure adequate decontamination and to prevent the unintentional spread of contamination.
Treatment protocols and priorities should be reviewed with assigned staff. Established mechanisms to minimize their exposure, while not compromising patient care, should be reinforced. Ideally, several medical personnel should be assigned to care for each contaminated patient. Individual exposure time can be decreased and a greater distance can be maintained from the patient when the health worker is not involved in direct decontamination or medical management. In cases of a highly radioactive contaminant or foreign body, a lead shield or apron is necessary to protect personnel. However, in most situations, lead aprons are not effective protection against the most common contaminant, the medium-energy γ-ray.
Patients enter the emergency department through a separate entrance where radiation detection equipment is in place. Patients on ambulance stretchers are transferred to clean hospital carts in the ambulance bay.
The ideal decontamination site is an isolated room designed with a closed drainage and ventilation system and fully equipped for a major resuscitation. In many hospitals, the morgue is the only available isolation room meeting these criteria. Alternatively, the route from the ambulance area can be to an outside decontamination area. Resuscitation equipment and other emergency supplies should be relocated to this site when the radiation accident plan is activated.
Management of immediate life-threatening injuries remains the first priority for these patients. Following resuscitation, the radiation victim is carefully evaluated to determine if there is any surface contamination or if there is the possibility of inhaled or ingested radioactive material.
All burns and open wounds must also be evaluated for contamination. They must be irrigated with copious amounts of water and examined for foreign bodies. Highly contaminated foreign bodies, while rare, may represent the greatest single hazard to hospital personnel. These contaminants must be removed from the victim as safely and quickly as possible. Radiation burns may be delayed in their presentation. They are managed in the same way as non–radiation-induced partial- and full-thickness burns. Extensive β-particle burns often result in full-thickness injury and require skin grafting.
Individuals not directly involved in the evaluation or treatment of radiation victims must be kept away from the designated treatment areas. Personnel assigned to either the clean or contaminated treatment areas must remain there. If it becomes necessary to move between the treatment areas, it should be done only after appropriate monitoring for contamination. Once the decontamination process for all victims has been completed, all participating hospital personnel must be reevaluated and decontaminated as needed. Their protective garments must be removed before they leave the treatment area and disposed of properly.
A baseline complete blood count, differential, electrolytes, and urinalysis should be obtained upon presentation. Patients who remain in the hospital should have a repeat CBC with differential drawn every 6 hours for a total of 48 hours and daily electrolytes and urinalysis with microscopy. Patients who exhibit a decrease in absolute lymphocyte count will have to have a type and crossmatch and human leukocyte antigen (HL-A)typing performed in the event that a bone-marrow transplant should become necessary.
If there is any evidence of infection, it should be treated in the same way as other infections. Severely neutropenic patients should receive broad-spectrum prophylactic antimicrobial agents. Prophylaxis should include a fluoroquinolone with streptococcal coverage or a fluoroquinolone without streptococcal coverage plus penicillin or amoxicillin, antiviral drugs, and antifungal agents.15
Not all radiation victims will require hospitalization although, in general, exposures >100 rad may warrant inpatient care. If radiation victims exhibit severe vomiting, thrombocytopenia, evidence of CNS symptom or have multiple trauma or severe burns they should be admitted. Reverse isolation measures are used for all documented exposures of 200 to 1000 rem and for those patients with absolute lymphocyte counts <1200/mm3 or 50% of the baseline value. Treatment with colony-stimulating factors should be considered for those at risk for developing neutropenia.11,16 For severely pancytopenic patients, stem cell transplantation is often necessary.17
In addition to the hematopoietic complications (infection and bleeding) that may be seen with whole-body radiation >200 to 600 rad, victims may develop significant fluid and electrolyte complications. Any indicated surgery must be performed without delay to avoid these additional problems.
Transfusion of selected blood products is based on the individual hematologic derangement encountered and should follow the usual guidelines for their use.
External contamination often presents a logistical problem for hospital workers. However, an organized radiation accident plan should facilitate both the logistical and medical management of these patients.18
Victims of radiation exposure who show no signs of injury and are otherwise healthy may be best served at designated decontaminated facilities. In general, hospital resources should be used for radiation victims who also require medical management.
The process of decontamination, or cleaning the patient of particulate radioactive debris, should be initiated as soon as possible following the event. Rescue personnel must wear protective clothing, including rubber gloves, shoe covers, masks, and film badges. This protective clothing does not reduce the exposure to penetrating radiation. Rather, it serves to prevent any radioactive particles from coming in contact with the personnel or their clothing and to facilitate cleanup and disposal.
Initially, any open wounds are covered, and the patient's clothing is removed; all articles are placed in clearly labeled plastic bags. Up to 70% to 90% of external contamination can be eliminated by this action alone. Any open wound is considered contaminated until proven otherwise, and decontamination should precede the irrigation of intact skin surfaces. The skin is then washed with copious amounts of water and soap, with particular attention to skin folds, ears, and fingernails. Decontamination should proceed from areas of highest to lowest radioactivity. The use of damp washcloths with lukewarm water rather than rinsing with running water, may be more practical for some emergency departments. The disposal of contaminated washcloths in plastic bags may be easier than the collection of contaminated wash water. All wastes must be captured in sealed containers labeled “Radioactive Waste.”
Shaving of the patient's hair is to be avoided, along with excessive rubbing of the skin. Both of these maneuvers cause an increased risk of transdermal uptake. Open, uncontaminated wounds are covered with sterile dressings, and contaminated wounds are then cleaned aggressively, similar to other dirty wounds.
Whenever possible, a dosimeter should be used to determine the completeness of the decontamination. The goal is to get the radiation level “as low as reasonably achievable”; this is commonly referred to as the ALARA principle. Metallic fragments and “hot” particles should be localized and removed by mechanical means.19 When dealing with an external contamination, it is important to prevent it from becoming an internal contamination.
Radioactive particles that are ingested or inhaled or that contaminate open wounds can cause significant cellular damage. These particles will continue to irradiate tissues until they are eliminated, neutralized, or blocked, or until they decay naturally. In general, there is a 1- to 2-hour window of time during which absorption of these particles occurs. Therefore, it is crucial that any interventions be performed during this period and as soon as possible.
At times, it may be difficult to determine the presence of an internal contaminant, especially if an external contaminant still clouds the picture. Clues may include the evidence of contamination around the mouth and nose. In addition, special treatment considerations will be determined by the type of radioactive material involved. Therefore, it is extremely important to identify the offending agent as early as possible, so that specific therapies may be started. These therapies include chelation and ion binding.
Diethylenetriaminepentaacetic acid (DTPA) administered as calcium-DTPA (Ca-DTPA) or zinc-DTPA (Zn-DTPA) are injectable chelators used for decorporation of plutonium and other transuranics (e.g., americium and curium) from the body. The United States Food and Drug Administration (FDA) approved both of these agents in 2004 for this indication.20 Ca-DTPA should be given as the first dose as Ca-DTPA is more effective than Zn-DTPA during the first 24 hours after internal contamination. However, after the initial 24 hours, Ca-DTPA has no significant advantage over Zn-DTPA. If ongoing treatment is needed or if treatment is initiated over 24 hours after internal contamination, then Zn-DTPA is preferred as Ca-DTPA causes more loss of essential metals.21
In 2003, the FDA approved the use of Prussian blue (ferric ferrohexacyanate) for the treatment of known or suspected internal contamination with radioactive cesium and thallium. Thallium and cesium undergo enterohepatic circulation. Prussian blue works by trapping thallium and cesium in the gastrointestinal tract, so that they cannot be reabsorbed. Instead they can be passed out of the body in the stool. By enhancing the elimination of these elements from the body, Prussian blue may reduce the risk of death and major illness from internal radioactive cesium or thallium contamination.22 Inquiries for acquisition of any of DTPA agents or Prussian blue can be made to REAC/TS at 865–576–1005.
Other specific measures include the use of saturation and blocking. A blocking agent reduces radioactive uptake by saturating the tissues with a nonradioactive element. Potassium iodide (KI) is a blocking agent that reduces the uptake of radioactive iodine (131I) by the thyroid gland. The administration of potassium iodide is most effective at blocking the uptake of radioactive iodine when given soon after exposure. One model demonstrates that potassium iodide would yield protective effects as high as 80% if administered 2 hours after exposure in individuals with an iodine-sufficient diets. However, this benefit would be reduced to 40% when potassium iodide was administered 8 hours after exposure.23 An estimated thyroid exposure of 5 rad or more warrants the initiation of this treatment.24 If the diagnosis has not yet been confirmed, there is little harm in administering a first dose of potassium iodine. Indeed, urgent consideration should be given to the administration of this agent to the pediatric population since they are especially vulnerable to radiation-induced thyroid disease.2 The dose of KI is age dependent (Table 142-6).
TABLE 142-6Potassium Iodide Dosing ||Download (.pdf) TABLE 142-6 Potassium Iodide Dosing
Daily Dose (mg)
1 mo–3 y
A comprehensive list of radioactive agents and their respective treatments is beyond the scope of this text. Detailed and current information can be obtained from REAC/TS or through many poison control centers.
Initial stabilization and decontamination of radiation ingestions are the same as those for “routine” ingestions. In addition to supportive care measures, the goal is to prevent absorption and enhance elimination. Gastric decontamination procedures such as gastric emptying methods and activated charcoal are used in the usual manner. All bodily excretions (lavage fluid, emesis, urine, and feces) should be saved and labeled for radioactive evaluation and proper disposal. If ingestion is suspected, urine and feces should continue to be tested for 4 days.
Acute inhalation of radionucleotides is much less common than chronic low-level exposure. An acute inhalation contamination can occur in the event of a radioactive accident in conjunction with a fire or explosion. Radioactive iodine, for example, is highly volatile and likely to be inhaled. Any patient exposed to external contamination that has undergone endotracheal intubation should be treated as internal contamination.25
When an inhalation contamination is suspected, a moistened cotton-tipped applicator can be used to swab the nasal passages and check for radioactivity. Bronchopulmonary lavage is performed for removal of particulate matter. Specific-blocking agents and chelating agents should be administered in this setting.
Wounds that undergo successful decontamination can be surgically closed. Wounds that remain contaminated despite aggressive irrigation are left open for 24 hours. Debridement of these wounds may become necessary for further decontamination. Contaminated surgical instruments must be replaced to prevent further wound contamination.
Amputation of contaminated extremities is rarely indicated. Two situations may warrant this aggressive management. In the first, the amount of persistent contamination is so high that severe radiation-induced necrosis is anticipated. In the second, the degree of traumatic injury is so severe that functional recovery is doubtful.
Aggressive supportive care is the mainstay of treatment for these patients—including fluid resuscitation for severe vomiting and diarrhea, standard trauma and burn care. Prophylactic antimicrobial agents, administration of cytokines, and stem cell transplants are other measures that may help decrease morbidity and mortality. The patient will face the greatest risks and management problems several days to several weeks later, at the onset of the manifest illness stage.
In some cases, nothing will alter the patient's outcome. Victims with a whole-body exposure of >1000 rad will likely die within 2 to 3 weeks.26 For triage purposes, these patients should be classified as expectant or impending. Death ensues from the complications affecting the hematopoietic system as well as the gastrointestinal and central nervous systems. Emergency department management should consist of appropriate sedation, analgesics, and supportive care.
A nuclear explosion presents logistic and patient care issues that may be difficult to manage effectively. To further complicate the situation, routine communications equipment, electronic equipment, and computers may be rendered useless by the electromagnetic pulse generated by the nuclear blast.
Victims of a nuclear explosion will be subject to three types of injury patterns. Mechanical trauma (blunt and penetrating) secondary to the blast effect of the explosion accounts for 50% of the released energy while thermal injury from heat dissipation represents 35% of the energy release. The remaining 15% of the thermonuclear energy release will cause radiation injury, 10% from radioactive fallout, and only 5% as a result of the immediate release of γ-rays and neutrons.