Management Modifiers for
Treating Radiation Exposure and Contamination

• Burns
• Trauma
• Mass casualty
• Timing of surgery
• Blood products use
• At-Risk / Special Needs populations

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Burns and the Radiation Exposure + Contamination Algorithm

• Both thermal and radiation burns may occur in radiation emergencies.
• Thermal burn injury + radiation exposure = combined injury
  • Prognosis worse than the same burn injury or exposure alone
• Burn injury + contamination
  • Prognosis will depend on the specifics of each case.
  • Burn wounds must be decontaminated before definitive burn care delivered.
• When prioritizing delivery of scarce resources in radiation mass casualty emergencies, it is appropriate to consider prognosis related to
  • Extent of trauma
  • Extent of external whole body radiation exposure and significant exposure from any internal contamination, e.g., Polonium-210
  • Percent body surface area and depth (i.e., degree) of burns
  • Pre-existing medical conditions
• Implementation of "Crisis Standards of Care" may be needed in disaster situations.
  • REMM has extensive information about issues related to issues related to mass casualties that might require modifications of normal standards of care.
• This algorithm and supporting material provide guidelines, not mandates.
• See Burns page for details about thermal burns.
• See Cutaneous Radiation Syndrome page for details.

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Trauma and the Radiation Exposure + Contamination Algorithm

• Trauma + radiation exposure = combined injury
  • Prognosis is worse than the same traumatic injury or exposure alone.
• Trauma + radiation contamination
  • External contamination
    • By itself, will not usually worsen trauma-related prognosis
    • Performing emergency life- and limb-saving tasks/surgery before completing formal external decontamination is appropriate.
    • Removal of contaminated clothing can eliminate about up to 90% of external contamination when there is not time to complete formal decontamination.
    • See Timing of Surgery for details.
  • Internal contamination
    • Some trauma victims may need life- and limb-saving surgery before the level of internal contamination is known.
    • Bioassays to quantify the level of internal contamination are time consuming and may not be widely available at least initially in very large mass casualty incidents.
    • See Radioactive Shrapnel for management guidance
• When prioritizing delivery of scarce resources in radiation mass casualty emergencies, it is appropriate to consider prognosis related to
  • Extent of trauma
  • Extent of external whole body radiation exposure and significant exposure from any internal contamination, e.g., Polonium-210
  • Percent body surface area and depth (i.e., degree) of burns
  • Pre-existing medical conditions
• Implementation of "Crisis Standards of Care" may be needed in disaster situations.
  • REMM has extensive information about issues related to issues related to mass casualties that might require modifications of normal standards of care.
• Suggested treatment sequence for victims of trauma with exposure and contamination
  • Treat life- or limb-threatening injuries first.
  • Consider Timing of Surgery
  • Assess for exposure and the Acute Radiation Syndrome (ARS) and consider early (pre-operative) use of white cell cytokines
  • Perform external decontamination as soon as possible, but do not delay life- or limb-saving emergency surgery.
  • Assess for internal contamination and determine need for treatment.
• This algorithm and supporting material provide guidelines, not mandates.
• See Radiation + Trauma page for details.
• See Mass Casualty page for details.

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Mass Casualty Emergencies and Radiation Exposure + Contamination Algorithm

• The REMM Exposure + Contamination Algorithm
  • Is appropriate for events small enough to permit individualized victim evaluation and treatment
• Algorithm modifications may be needed for large radiation mass casualty emergencies because of
  • Limited numbers of medical staff, hospital personnel
  • Shortage of equipment and resources
  • Physical damage to healthcare facilities including medical laboratories
  • Overwhelming numbers of victims presenting for care, external decontamination, treatment of internal contamination, reassurance
  • See REMM page about Population monitoring for contamination due to fallout, after a nuclear detonation
• Limited resources (people, training, procedures and equipment) in the emergency phase of a large radiological or nuclear emergency may also require changes in the normal routines used to monitor, assign, document, and control dose among responders, ancillary workers and the general public.
  • In depth recommendations have has been provided by this document: Guidance for Emergency Response Dosimetry, (NCRP Report 179), Bethesda, MD, 2017, including the following:
    • “With minimal dosimetry resources, how to responders make decisions to control the total dose and associated risk?
    • How are doses assigned to responders when not every responder is issued a dosimeter before exposure occurs?
    • What is the regulatory framework for responders who are not trained as radiation workers?”
• Exposure + contamination algorithm modifications during large radiation mass casualty emergencies
  • Exposure
    • Diagnosing exposure and the Acute Radiation Syndrome (ARS) usually requires clinical laboratory support.
      • See Dose Estimator for Exposure
    • Without sufficient lab capacity, clinicians may need to estimate dose and ARS severity, initiate triage, and begin treatment by
      • Matching the reported location of a victim to estimated radiation levels in the environment at that location (physical dosimetry)
      • Using clinical signs and symptoms to diagnose ARS
        • Time to onset of nausea/vomiting after radiation exposure
        • Signs and symptoms of ARS
    • Empiric use of white cell cytokines may be advised for some victims if supplies are available.
      • These recommendations would be based on clinical estimates of dose and ARS severity even if laboratory confirmation of dose estimate is not available.
  • External contamination
    • Limiting/altering radiation surveys
      • Conducting one-time screenings of head, neck, hands, and forearms
      • Avoiding multiple whole body screenings and re-evaluations during initial triage
    • Altering targets for decontamination
      • Accepting target decontamination levels in excess of 2 times background
    • Directing ambulatory victims away from medical facilities to community reception centers and
    • Providing instructions for self-decontamination at home
  • Internal contamination
    • Bioassays to quantify the level of internal contamination are time consuming and may not be widely available at least initially in very large mass casualty incidents.
      • Collection of certain biological specimens (e.g. radioisotope bioassays, nasal swabs) may need to be delayed or omitted.
      • Initial simple screening of large numbers of bioassay specimens may be needed to identify those with the highest levels of internal contamination.
      • Follow-up evaluation will be recommended first for those whose initial results suggest the highest level of contamination.
    • Empiric treatment of internal contamination may be advisable in highly selected, life-threatening circumstances, even in the absence of definitive diagnostic test results.
      • For large mass casualty events, countermeasures from the Strategic National Stockpile may be needed.
• When prioritizing delivery of scarce resources in radiation mass casualty emergencies, it is appropriate to consider prognosis related to
  • Extent of trauma
  • Extent of external whole body radiation exposure and significant exposure from any internal contamination, e.g., Polonium-210
  • Percent body surface area and depth (i.e., degree) of burns
  • Pre-existing medical conditions
• Implementation of "Crisis Standards of Care" may be needed in disaster situations.
  • REMM has extensive information about issues related to issues related to mass casualties that might require modifications of normal standards of care.
• Suggested treatment sequence for victims of exposure and contamination
  • Treat life- or limb-threatening injuries first.
  • Perform external decontamination as soon as possible, but do not delay life- or limb-saving emergency surgery
  • Consider Timing of Surgery .
  • Assess for exposure and ARS and consider early use of white cell cytokines
  • Assess for internal contamination and determine need for treatment
• Significant changes to standard triage and medical care of patients may be needed after detonation of an IND: see publications and tools
• See Mass Casualty page for details.
• See Radiation + Trauma page for details.

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Timing of Surgery and the Radiation Exposure + Contamination Algorithm

• Radiation exposure + trauma requiring emergency surgery
  • Attempt to take surgical emergencies to the operating room
    • Within 36-48 hours after high-dose radiation exposure
    • Before decline of white blood cell and platelet counts
  • Pre-operative administration of white cell cytokines may extend the time window for surgery.
• External contamination + trauma requiring emergency surgery
  • Formal external decontamination is appropriate.
  • When clinical urgency does not permit formal decontamination
    • Removal of contaminated clothing can eliminate about up to 90% of external contamination.
    • Traditional surgical skin prep will also help eliminate skin contamination.
    • Avoid pre-op shaving, if possible, to help maintain an intact skin barrier against radioactive materials.
• Activate hospital emergency radiation response plans
  • If contaminated patients are admitted to the hospital
  • To ensure the health and safety of hospital staff and healthcare team
  • To manage/minimize potential contamination of hospital spaces, including operating and radiology suites
• This algorithm and supporting material provide guidelines, not mandates.
• See Radiation Effects on Blood Counts for details.

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Blood Products Use and the Radiation Exposure + Contamination Algorithm

• Patients with significant whole body radiation exposure (Acute Radiation Syndrome [ARS]) will be immunosuppressed.
  • They are at risk for post-transfusion graft versus host disease (GVHD).
• Guidelines suggest that these patients should received blood products that have been both
  • Irradiated and
  • Leuko-reduced
• If irradiated, leuko-reduced blood is unavailable,
  • Emergency transfusions may still be considered.
  • Attention should be paid to possible post-transfusion GVHD.
• Patients with certain kinds of internal contamination (e.g., Polonium-210)
  • Can also be at risk for ARS
  • Should be evaluated for ARS before receiving blood products
• Most patients with external contamination but no known radiation exposure
  • Are unlikely to develop ARS
  • Should be evaluated for ARS before receiving blood products
• This algorithm and supporting material provide guidelines, not mandates.
• See Blood Products page for details

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At-Risk / Special Needs Populations and the Radiation Exposure + Contamination Algorithm

• See the At-Risk / Special Needs Populations page
  • Describes groups especially vulnerable to the effects of radiation
• These populations may require
  • Modifications of radiation exposure (Acute Radiation Syndrome) treatment protocols
  • Modification of decontamination procedures
  • Modification of internal contamination treatment protocols
  • Additional accommodations for their special needs
• Effective and ethical allocation of medical resources is crucial for all populations.
• This algorithm and supporting material provide guidelines, not mandates.

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