You are here: Home > Prototype for Medical Facility Orders During a Radiation Event View/Print as PDF (PDF - 266 KB) Prototype for Medical Facility Orders During a Radiation Event Orders must be customized for each event and patient! Consider early consultation with: Oncology services: medical, radiation, pediatric, transplant Transfusion medicine Radiation safety Nuclear medicine Mental health Patient Name: ________________________________________________ Patient ID Number: ____________________________________________ Family Contact Information: _____________________________________ 1. Admit to: ___Hospital ward   ______________________________________ ___Team:               ______________________________________ ___Physician:          ______________________________________ ____Area:                ______________________________________ ____ICU:                 ______________________________________ ____Other:              ______________________________________ 2. Diagnosis: event specific and prior Radiation contamination See Body Chart on last page of this document to record results of whole body radiation survey    ___External with isotope:        ______________________________________    ___Internal  with isotope:       ______________________________________    ___Unknown isotope:           Radiation Exposure / Acute Radiation Syndrome (ARS)    ___Estimated whole body/partial body (dose in cGy) _______    ___Dose unknown Other complicating factors    ___Injuries, specify: ____________________________    ___Burns,  specify: ___________________________    ___Specific population: (potentially requiring more customized management)          (See REMM Specific Population Page)       ___Young age                 _____Old age               ______ Pregnant       ___Immunosuppressed      _____Physical accommodation required      ___ Psychiatric issues        _____Language or cultural accommodation required Significant pre-existing medical conditions:       ___________________________       ___________________________       ___________________________       ___________________________       ___________________________ Medications used prior to this event that will be continued:       ___________________________       ___________________________       ___________________________       ___________________________       ___________________________   3. Condition: ___Fair     ___Stable     ___Guarded     ___Critical   4. Vital Signs: ___ Every ___ hours x ______ times, then every ______ hours x ______times ___ Ward routine ___ Other   ______________________________________   Notify physicians for: Adults    Peds    Temperature > 38.5 °C    Systolic BP > 180, < 100    Diastolic BP > 100, < 50    HR >100, < 50    RR >30, < 8    02 sats < 92%    Temperature > 38.5 °C    Systolic BP > ___ , < ___    Diastolic BP > ___, < ___    HR > ___, < ___    RR > ___, < ___    02 sats < 92% 5. Special orders for radiation contamination: ___Radiation precautions Universal precautions with gowns, mask, cap, and gloves Use hospital procedure for discarding biological waste (all body fluids) and physical waste (linens/towels/trash/disposable equipment), which may also be radioactive Page Radiation Safety Office at (xxx) xxx-xxxx for additional instructions Place Radiation Safety sign on door (if patient has internal or external radioactive contamination) Place sign indicating pregnant staff may not enter the room/area Everyone entering room/area must wear personal radiation dosimeter 6. Allergies: ___No known drug allergies ___Yes, allergies.     Specify: _____________________________________________ 7. Activity: ___Bedrest                                ___BRP (bathroom) ___Out of bed every ___ hrs.        ___Ambulate as tolerated 8. Diet: ___NPO                                       ___Advanced as tolerated ___Regular for age                        ___Other, specify: ___________ 9. Height and weight: Height: __ feet __ inches                  Weight: ___ lbs ___ oz            __ cm                                             ___ kg  Measure  Body  weight every ___ hours                                   every ___ days 10. Peripheral IV management: ___IV Fluids____@ _____cc/hr, with additive ______ ___IV Fluids____@ _____cc/hr, with additive ______   11._____ Foley catheter management: Use radiation precautions for all body fluids in patients who may have radiation contamination.   12._____ Monitor I / O   every ___________ Use radiation precautions for all body fluids in patients who may have radiation contamination.   13._____ Deep Venous Thrombosis (DVT) prophylaxis:       ___ Compression garment to Bilateral Lower-Extremities (BLEs)       ___ Sequential Compression Devices (SCD) to BLEs       ___ Anticoagulation regimen:              Specify drug/dose/frequency/delivery route: _________________________________        14. Respiratory  Care: ___Room air ___Oxygen via        Nasal cannula        Other oxygen delivery method, specify: _______________________        Titrate for saturation ≥ ___________% ____Chest tube care,  specify: ________________________ Use radiation precautions for all body fluids in patients who may have radiation contamination. ____Respirator instructions and settings: ____________________ ____Medications for wheezing,  specify: _____________________   15. Wound care: ___Apply sterile dressing to wounds daily. ___Monitor waste: Use radiation precautions for all body fluids in patients who may have radiation contamination. ___ Apply topical medication, specify: _________________________ ___Other management: (pager skin care team xxx-xxxx) ___________________ For skin burns: See REMM burn therapy recommendations Burn topical regimen _____________________________ Replace body fluids ______________________________ Other burn therapy ______________________________ Consult burn team: (pager xxx-xxxx) _________________   16. Orthopedic care: ___Splint/brace/cast, specify: ______________________ ___Other ortho management procedure per orthopedics (Ortho pager xxx-xxxx)       Specify: ____________________________________   17. Admission studies: ___CBC w/differential ___Metabolic panel or equivalent, specify: _____________________ ___Cardiac enzymes ___PT/PTT ___Urinanalysis/Urine culture and sensitivity ___Urine HCG ___Serum HCG ___Thyroid Function Tests: specify as appropriate ___Serologies:        _____Herpes Simplex Virus type 1 (HSV-1)        _____Herpes Simplex Virus type 2 (HSV-2)        _____Cytomegalovirus (CMV)        _____Varicella-zoster virus (VZV) ___EKG (baseline study, specify any additional details _______________ ___CXR (specify where, when, request details) _____________________ ___Other imaging studies, specify: _______________________________   18. Standing laboratory studies: ___CBC w/diff:      Every ____ hours, x ____ days, then      Every ____ hours until further orders ___Metabolic panel or equivalent, specify: _________________________      Every ____ hours, x ____ days      Every ____ days ___Other, specify: ________________________________________   19. EKG (subsequent) ___STAT EKG for chest pain, notify physician   20. Biodosimetry tests: Dicentric chromosome count: to evaluate radiation exposure dose ___Draw extra green top tube on (specify when) and send to lab on ice Where to send dicentric chromosome specimen assays? Armed Forces Radiobiology Research Institute http://www.afrri.usuhs.mil/ 8901 Wisconsin Avenue Bethesda, MD 20889-5603 Contact Security in Emergencies: 1-301-295-0530 Medical Radiology Advisory Team: 1-301-295-0316 or Oak Ridge Institute for Science and Education, Radiation Emergency Assistance Center/Training Site (REAC/TS) Cytogenetic Biodosimetry Laboratory http://orise.orau.gov/reacts/cytogenetics-lab.htm Attn: Dr. Doran Christensen P.O. Box 117, MS 39 Oak Ridge, TN 37831-0117 Emergency: DOE/ORO: 1-865-576-1005 (ask for REAC/TS), this is also the after hours number At other times: 1-865-576-3131 (between 8:30-4:30 CST) Evaluate for internal decontamination ___Spot urine for _______ radioactive isotope ___24-hour urine for _______ radioactive isotope ___Spot fecal specimen for _______ radioactive isotope ___24-hour fecal specimen for _______ radioactive isotope Send specimens for evaluation of radioactive isotope to outside lab:      Name of Lab:           _____________________________________      Address of Lab:       ______________________________________      To the Attention of: ______________________________________   21. For isotope decorporation: Caution See details on REMM Countermeasures Table: Many of the listed countermeasures have an unfavorable risk-to-benefit ratio when used to treat persons having low levels of internal contamination. Most authorities do not recommend treatment of internal contamination when the body burden is less than one annual limit of intake (ALI). Treatment is strongly recommended when the body burden exceeds 10 ALI.  For internal contamination levels greater than 1 ALI and less than 10 ALI, clinical judgment dictates treatment of internal contamination. Special caution should be used when these countermeasures are used in children.   22. Type and screen Use leukoreduced AND irradiated products only for patients with significant radiation exposure. See REMM blood recommendations       For ______ units ______ packed red blood cells       For ______ units ______ platelets   23. General Medications: Use as appropriate for each patient.   For stomach (ulcer) prophylaxis:     ___ Specify medication of choice ___________________   For nausea & vomiting:    ___ Specify medication of choice ___________________   For anxiety/insomnia/breakthrough nausea:    ___ Specify medication of choice ___________________   For fever:        ___ Specify medication of choice ___________________       For diarrhea:    ___ Specify medication of choice ___________________         For constipation:    ___ Specify medication of choice ___________________   For rash/itching:     ___ Specify medication of choice ___________________   For pain:     ___ Specify medication of choice ___________________         24. Neutropenia therapy, if indicated: Consider whether treatment is prophylactic or therapeutic, i.e., after organism is identified. Evaluate febrile neutropenia:    ___Blood cultures x 2 sets                                         ___UA w/culture    ___Sputum culture + sensitivity                                  ___CXR    ___Other culture + sensitivity, specify: _________________   Antimicrobial therapy: if indicated       Anti-bacterial  ___________________________________            Anti-viral _______________________________________             Anti-fungal ______________________________________       Other Supportive Care _____________________________           Body Chart for Recording Results of Radiation Survey		Population Monitoring in Radiation Emergencies: A Guide for State and Local Public Health Planners, 8/2007 (HHS/CDC) HHS Public Health Emergency Medical Countermeasures Plan for Chemical, Biological, Radiological and Nuclear (CBRN) Threats, 4/2007 (HHS) Medical Countermeasures Against Radiological and Nuclear Threats (NIH/NIAID)    New Users: Where Do I Start? Use REMM: Earn CME Patient Management Algorithms Print Algorithms & Tables Isotopes of Interest Countermeasures Decontamination Procedures Dose Estimator for Exposure Manage ARS Subsyndromes Hematopoietic Subsyndrome Time/Dose Effects in ARS Strategic National Stockpile Animations, Illustrations, Photos Dictionary Emergency Contacts Download This Site (10/2007)    AFRRI AHRQ CDC CRCPD DHS DOE EPA FDA   HHS IAEA ICRP NCRP NRC OSHA REAC/TS WHO

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