Emergency Department: Evaluation and Management of Affected Patients

At a glance

Depending on the location and scale of the detonation, people affected by the incident may arrive immediately (and could include medical facility staff if the detonation occurred nearby) or could arrive hours to days later. In a nuclear detonation, people affected may experience trauma (blast and thermal), Acute Radiation Syndrome (ARS), Cutaneous Radiation Injury (CRI), and external and/or internal contamination with radioactive particles. The types and severity of the above injuries will vary greatly depending upon a person's proximity to the detonation.

A large red-lettered "Emergency" sign on a hospital façade indicating the entrance to an emergency department

Evaluation and management of affected patients

Initial evaluation

Conducting medical care after a nuclear detonation is likely to be challenging because of the large number and severity of injuries, as well as concerned "worried well" individuals. Hospital first receivers should consider implementation of crisis standards of care, including use of mass-casualty triage algorithms, targeted examinations, and resource-appropriate treatment.

Hospital first receivers should use appropriate personal protective equipment to reduce their own exposure to radiation while providing care to affected people:

Traumatic injuries

After initial triage and stabilization, first receivers will need to treat both traumatic injuries resulting from the detonation and radiation-specific illnesses. Blast and burn injuries will need to be addressed first. Patients with significant radiation exposure may experience declines in white blood cell and platelets counts after 48 hours; any surgical operations necessary should be performed within 36-48 hours after radiation exposure.

Radiation injuries

After addressing traumatic injuries, first receivers should evaluate for radiation-specific injuries.

Acute Radiation Syndrome (ARS)

Acute Radiation Syndrome (ARS) is likely to cause significant morbidity and mortality for people exposed to high levels of radiation from a nuclear detonation. ARS can initially present with symptoms of nausea, vomiting, headache and/or diarrhea within hours to days of high ionizing radiation exposure. Patients are at risk for devastating myelosuppression and pancytopenia.

A whole-body dose estimate will be helpful for assessing total radiation exposure, which is predictive of overall prognosis of ARS. Lymphocyte levels at 24 hours after exposure can also help prognosticate. In addition to supportive care, some medical countermeasures, specifically myeloid cytokines, may be helpful in the treatment of some ARS patients.

Cutaneous Radiation Syndrome (CRS) and internal contamination (IC)

Cutaneous Radiation Syndrome (CRS) and internal contamination (IC) may also occur in people exposed to radiation and radioactive contamination from a nuclear detonation.

CRS specifically refers to injury to the dermis and epidermis caused by radiation exposure, particularly from high-energy beta radiation. Cutaneous radiation injuries (CRI) or local radiation injuries (LRI) may lead to development of CRS, which is a sub-syndrome of ARS.

IC occurs when radioactive particles are inhaled, ingested, or enter the body through wounds, and can result in uptake of radionuclides into tissue. Nuclear medicine equipment may be usable to determine the extent of an IC injury, and depending on the specific nuclides involved, medical countermeasures may be available to support expedited removal of the contamination from the body.

Minor injuries

People with no or only minor traumatic injuries (i.e., those who do not need to remain in the hospital for further injury care) and no symptoms of radiation illnesses usually do not need to remain hospitalized solely for radiation exposure. If epidemiological information, specifically their whole-body radiation dose estimate based on their location relative to the detonation and the duration of time spent outside immediately afterward, suggests a significant radiation exposure, collection of an Absolute Lymphocyte Count (ALC) can help prognosticate and determine need for medical countermeasures. If there is no epidemiological evidence to suggest significant exposure, they may be discharged with a plan for follow-up through primary care or a population monitoring site (such as a community reception center (CRC)).

Severe traumatic and/or radiation injuries

People with more severe traumatic and/or radiation injuries may require inpatient management for days to weeks. Collecting laboratory samples may be helpful to guide further management of patients with ARS and IC. The Radiation Injury Treatment Network (RITN) serves as a referral network for people with radiation injuries requiring advanced care. First receivers should consider referring and/or transferring patients to a RITN hospital if needed. Many people will require psychological first aid and mental health follow-up, irrespective of physical injuries.

At-risk populations

Some populations, such as pregnant people, children, elderly, and immune-suppressed individuals, may be at relatively higher risk of radiation injury.

More information on special populations:

Radiation surveys

Patients who do not require an immediate life-saving intervention may undergo a radiation survey to detect contamination with radioactive material if resources permit. Radiation surveys can be performed by trained ED staff or radiation professionals using handheld detectors or portal monitors.

Depending on the number and medical condition of patients and available resources, decontamination procedures may be performed by the patient after instructions from the ED providers.

Potassium iodide

Patients or providers may ask about the need to administer potassium iodide (also known as "KI"), or other medical countermeasures, to patients after a nuclear detonation. Potassium iodide is a treatment specific to internal contamination with radioiodine and is NOT effective against other radionuclides or radiation injury from external exposure. Most patients with radiation exposure from a nuclear detonation will NOT need potassium iodide, as the majority of radiation exposure will be from external sources and not internal contamination with radioactive iodine.

More information about potassium iodide.

Deceased patients

Special care must be taken for handling the remains of internally and externally contaminated deceased patients. Patients who die from their injuries or illness in the ED or the hospital may be externally and or internally contaminated with radioactive material. Proper care may need to be taken when handling decedents after a radiation emergency.

More information:

Disposition from the ED

Inpatient management of ARS

Patients with severe injuries and/or meeting criteria for inpatient admission for ARS (REMM: EAST tool) will need admission. Complete blood counts (CBC) should be followed with focus on lymphocyte count. Pegfilgrastim or other colony stimulating factors (CSFs) should be considered for those whom moderate ARS is predicted. In severe cases, stem cell transplant may be necessary; those patients should be referred to the Radiation Injury Treatment Network (RITN).

Outpatient management of patients at risk for ARS

Patients at risk of ARS based on dose but who are asymptomatic and appear well can be discharged from the hospital. They should be given strict return precautions like those with hematologic cancer patients. They should check their temperatures at home for fevers and return to medical care if they develop initial symptoms of ARS such as nausea, vomiting, headache and/or diarrhea. Outpatient follow-up should consist of blood work with CBC. If there is an abnormality in the cell counts, especially lymphocyte count, pegfilgrastim or other CSFs administration could be considered under supervision of a hematologic specialist.

Outpatient management of patients not at risk for ARS

Patients not at risk for ARS may still have increased risk for developing cancer later in life, depending on the amount of radiation exposure received. Follow-up with a general practitioner may be helpful to determine need for further testing or evaluation.

More information possible health effects.

Additional resources

HHS: Radiation Emergency Medical Management

CDC: Radiation Emergencies

Radiation Injury Treatment Network (RITN)

Oak Ridge Institute for Science and Education: REAC/TS

Disclaimer

The information provided using this website is only intended to be general summary information to the public. It is not intended to take the place of either the written law or regulations.

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Content Source:
National Center for Environmental Health