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	Management Modifiers for Exposure Algorithm Burns Trauma Mass casualty Timing of surgery Blood products use Specific populations Burns and the Radiation Exposure Algorithm Both thermal and radiation burns may occur in radiation emergencies. Thermal burn + radiation exposure = combined injury Prognosis is worse than the same burn injury or exposure alone. 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 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. The Institute of Medicine has provided extensive guidance. Resource limitations may be severe initially, but will improve over time. This algorithm and supporting material provide guidelines, not mandates. See Burns page for details about thermal burns. See Cutaneous Radiation Syndrome page for details about radiation burns. top of page Trauma and the Radiation Exposure Algorithm Trauma + radiation exposure = combined injury Prognosis is worse than the same traumatic injury or exposure alone. 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. The Institute of Medicine has provided extensive guidance. Resource limitations may be severe initially, but will improve over time. Suggested treatment sequence for victims of trauma with exposure Treat life- or limb-threatening injuries first. Assess for exposure and the Acute Radiation Syndrome (ARS) and consider early (pre-operative) use of white cell cytokines Consider Timing of Surgery This algorithm and supporting material provide guidelines, not mandates. See Radioactive Shrapnel for guidance on management. See Radiation + Trauma page for details. See Mass Casualty page for details. top of page Mass Casualty Emergencies and Radiation Exposure Algorithm The REMM Exposure Algorithm Is appropriate for events small enough to permit individualized victim evaluation and treatment Algorithm modifications may be needed for radiation mass casualty emergencies because of Limited numbers of medical staff, hospital personnel Shortages of equipment and resources Physical damage to healthcare facilities including medical laboratories Overwhelming numbers of victims presenting for care, some acutely ill Exposure algorithm modifications during radiation mass casualty emergencies 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 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, based on clinical estimates of dose and ARS severity. FDA Emergency Use Authorization may be needed to access medical countermeasures from the Strategic National Stockpile. 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. The Institute of Medicine has provided extensive guidance. Resource limitations may be severe initially, but will improve over time. This algorithm and supporting material provide guidelines, not mandates. See Mass Casualty page for details. See Radiation + Trauma for details. top of page Timing of Surgery and the Radiation Exposure 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. This algorithm and supporting material provide guidelines, not mandates. See Radiation Effects on Blood Counts page for details. top of page Blood Products Use and the Radiation Exposure Algorithm Patients with significant whole body radiation exposure (Acute Radiation Syndrome) 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. This algorithm and supporting material provide guidelines, not mandates. See Blood Products page for details top of page Specific Populations and the Radiation Exposure Algorithm See the Specific Populations page Describes groups especially vulnerable to the effects of radiation These populations may require Modification of treatment protocols for radiation exposure (Acute Radiation Syndrome) 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. top of page

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