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	Management Modifiers for Exposure + Contamination Algorithm Burns Trauma Mass casualty Timing of surgery Blood products use At-Risk / Special Needs populations 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. 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. top of page 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 75-90% 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 internal contamination are time consuming and not widely available. 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. 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 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. top of page 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 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 not widely available, particularly in radiation mass casualty events. 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. 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 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. top of page 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 75-90% 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. top of page 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 top of page 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. top of page

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