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For centuries, military forces have utilized nonconventional weapons using various chemical and biologic agents. During World War I, powerful chemical weapons were developed that affected hundreds of thousands of soldiers. Nuclear weapons were first created during World War II with devastating results. Today, thousands of these nuclear, biologic, and chemical weapons of mass destruction are stored in facilities throughout the world. An accident at any of these facilities could result in a large number of civilian casualties. In addition, many terrorist organizations are now actively attempting to purchase, steal, or develop such weapons for their use. As with most mass casualty situations, emergency physicians will be at the forefront of patient care. This chapter attempts to provide specific information regarding the management of nuclear, biologic, and chemical weapons injuries.


A terrorist attack utilizing a nuclear weapon would most likely involve the detonation of a nuclear bomb or the detonation of a conventional explosive that also dispersed radioactive material (so-called dirty bomb).

General Considerations

The detonation of a nuclear weapon results in a much larger blast area and much hotter fireball than that produced by conventional explosives. If victims survive the blast trauma and thermal burns, they are at risk for radiation injuries. There are four types of radioactive particles that may cause damage when they interact with body tissue:

  1. Alpha particles are large particles that are stopped by the epidermis and cause no significant external damage. Internal contamination from the inhalation or ingestion of contaminated particles may cause local tissue injury.

  2. Beta particles are small particles that can penetrate the superficial skin and cause mild-burn-type injuries.

  3. Gamma rays are high-energy particles that can enter tissues easily and cause significant damage to multiple body systems.

  4. Neutrons are large particles that are typically produced only during nuclear detonation. Like gamma rays, they cause significant tissue injury.

The effect that radiation will have on the body depends on the type of radiation, the amount of exposure, and the body system involved. Tissues that display higher rates of cellular mitosis, such as the gastrointestinal and hematopoietic systems, are more severely affected. At very high radiation doses, neurovascular effects will also be seen. Radiation injury may cause either abnormal cell function or cell death.

Clinical Findings

A. Symptoms and Signs

The symptoms and signs of radiation exposure occur in three phases: prodromal, latent, and symptomatic.

1. Prodromal phase

Patients will develop nonspecific symptoms of nausea, vomiting, weakness, and fatigue. Symptoms generally last no longer than 24–48 hours. With higher radiation exposures, symptoms will occur earlier and last longer.

2. Latent period

The latent period duration depends on the dose of radiation and the ...

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