Title:
MEDICAL MANAGEMENT OF RADIOLOGICAL CASUALTIES
Version 1.
Prepared by:
Dr. Eduardo D. Herrera Reyes.
Medical Emergency Preparedness Specialist. Incident and Emergency Centre.
Mail : E.D.Herrera-Reyes@iaea.org
T: (+43-1) 2600-21408
Modified by
Dr. Kenzo Fujimoto
E-Mail: kenzo-fujimoto@jcom.home.ne.jp
Dr. Eduardo Herrera Reyes –IEC –IAEA
1|Page
4.1
Introduction
4.2
Basis of medical management on radiation injury
4. 3
Decontamination of skin and hair
4.4
Management for contaminated skin injury
4.5
Management for internally deposited radionuclides
4.6
Diagnosis and medical management of radiation syndromes
4.7
Psychological support
Dr. Eduardo Herrera Reyes –IEC –IAEA
2|Page
MEDICAL MANAGEMENT OF RADIOLOGICAL CASUALTIES
4.1
Introduction
This chapter is not written for medical staff but for the emergency workers to understand and to
relieve anxiety for the medical treatment in case of high exposure or intense contamination.
Therefore, most parts of the content is described briefly.
First priority of handling victims is to stabilize their physical condition even if they are contaminated
or exposed by radiation. Radiation effects are not the matter of first priority except the internal
contamination due to plutonium. Radiation exposed or contaminated persons can be dealt with
radiological problems after the urgent conventional medical treatment. Even the highly exposed
victims have time before manifesting illness due to exposure after prodromal syndrome. During that
time after the exposure which is at least for two days even in case of severe exposure it is necessary
to estimate the exposed dose for the prognosis and future treatment.
4.2
Basis of medical management on radiation injury
For deterministic effects, the radiation symptoms or signs can be modified by some treatments after
irradiation. For stochastic effects on the contrary, there are no treatment to change the occurrence
probability of the effects. Accordingly, deterministic effects needs to be diagnosed or predicted and
treatments to reduce the damages should be considered. For stochastic effects namely cancer,
medical follow-up may detect cancer in early stage and be able to reduce negative impacts of
radiation. Thus, proper follow-up program should be implemented for each victim depending on
dose.
In case of contamination, radiation exposure continues while the radioactive materials exist on the
body surface or in the body. Thus, early decontamination can reduce the radiation dose to the body.
This principle is true both for surface contamination and internal contamination.
4.3
Decontamination of skin and hair
After the medical stabilization of the patient is achieved then the screening is carried out to find the
contamination by radionuclides. If the contamination is found it is better to be removed as soon as
possible and as much as possible. First step for the decontamination is removal of clothes. It stands
to reason that clothing typically covers large part of the body, therefore properly removing the
clothing will likely significantly decrease the amount of radioactive material from the body surface.
Skin contamination is wiped or rinsed with water. Wiping or rinsing can be repeated several times
until the measurement indicates that the procedures would not noticeably decrease the
contamination any more. During these procedures, the operators should exercise caution not to
create a skin scratch nor an abrasion. These skin damages could lead to internal contamination,
which is worse than radioactive materials on the skin. Contaminated hair needs to be wiped or
washed with water. If decontamination of hair with washing is not effective enough, hair cut can be
an option on the condition that the consent of the patient would be obtained. When hair wash is
Dr. Eduardo Herrera Reyes –IEC –IAEA
3|Page
performed, it is important to avoid drainage water to be splashed around the mouth, the nose, or
the eyes.
4.4
Management for contaminated skin injury
Most of radionuclides are not absorbed through a normal skin, with an exception of tritium.
However radionuclides can be absorbed through injured parts, or wounds. Thus, radionuclides in
wounds need to be removed as soon as and as much as possible to reduce internal contamination.
Regular procedure of the wound decontamination is irrigation with normal saline solution or water.
The irrigation can be repeated several times until the measurement results show no significant
decrease anymore. After irrigation, treat the wound like wounds without contamination.
4.5
Management for internally deposited radionuclides
Generic procedure for decorporation of internally deposited radionuclides is shown in the generic
procedures for medical response during a nuclear or radiological emergency in EPR-MEDICAL
[201]. Main aspects of the procedure are shown below.
Identification of radionuclides and rough dose assessment of the internal contamination is desirable
to be obtained before starting treatment for internal contamination. At least one of the following
tests will be conducted for that purpose when there is possibility of internal contamination:



Nose smear test;
Body surface contamination screening, especially wounds screening;
Measurements by a whole body counter.
When the above mentioned tests could not indicate, but internal contamination is still suspected, it
is necessary then to carry out bio-analyses for the identification and quantification of radionuclides
in the body with urine, faeces and blood samples. While, they are a time consuming procedure (24
to 48 h), so that there may be instances when the physician must decide whether or not to begin
treatment exclusively on the basis of presumptive evidences. Some clinical decisions to initiate or
not to, even without the confirmatory tests at hand, are based on the following:



Character of the accident;
Radioactive concentration in the air where the workers was present;
Toxicity of the drug to be used for decorporation.
Decorporation of internal contamination is not an easy task. It is better to decide based on
estimated dose if possible, efficiency of decorporation and adverse effect of each treatment. And
there are only limited decorporation agents which could apply to certain radionuclides.
4.6
Diagnosis and medical management of radiation syndromes
Dr. Eduardo Herrera Reyes –IEC –IAEA
4|Page
Cutaneous radiation syndrome (CRS)
Especially for non-uniform irradiation, skin injury becomes main concern in some cases. Table A
indicates dose and time to cause some skin symptoms.
Table A
Stage/symptoms
Dose range (Gy)
Time of onset (d)
Erythema
3–10
14–21
Epilation
>3
14–18
Dry desquamation
8–12
25–30
Moist desquamation
15–20
20–28
Blister formation
15–25
15–25
Ulceration (within skin)
>20
14–21
Necrosis
(deeper penetration)
>25
>21
[201, 202]
Local radiation injury results in skin lesions quite similar to thermal burns. However, thermal burns
are different from “radiation burns” in the following aspects:




Radiological burns are dynamic; their temporal and spatial evolution is unpredictable and
even relatively independent of the initial clinical evolution;
Patients do not present initial shock;
Pain is not immediate in local radiation injury, but when it later appears it is very severe and
resistant to drugs;
It is a prognostic symptom which indicates a new wave of clinical recurrence;
Acute Radiation Syndrome
A combination of clinical signs and symptoms are occurring phased over a period of hours to weeks
due to a significant partial-body or whole body exposure of > 1 Gy, as injury to various tissues and
organs.
ARS has 4 phases: (1) prodromal phase, (2) latent phase, (3) manifest illness, (4) death or recovery.
As a part of diagnosis, exposed dose should be identified. Exposed dose can be assessed by
biological methods or physical methods. Some typical methods for external exposure are listed in
Table B. As one of biological methods, clinical symptoms are very useful for dose estimation
although it is applicable only for high dose. Prodromal symptoms, such as nausea, vomiting, or
diarrhea have threshold. Latency periods and degree of symptoms are depending on dose, so the
existence and degree of symptoms are useful information. Lymphocyte count is also a useful tool for
dose estimation, because lymphocyte count starts to decrease quite rapidly just after a few hours.
Dr. Eduardo Herrera Reyes –IEC –IAEA
5|Page
Chromosome analysis is another special method for dose evaluation. However, this method requires
at lease two days to obtain the estimates.
Table B. Dose assessment method for external exposure
Category
Typical methods
Biological methods
 Clinical symptoms
 Lymphocyte count
 Chromosome analysis
Physical methods
 Reconstruction
 Work environment
assessment
 Personal dosimeter
Treatments of prodromal syndrome are all symptomatic treatments. In manifest illness period, the
treatments are oriented for each organ system, for example, isolation, prophylactic antibiotics,
cytokines, blood transfusion, or bone marrow transplantation that can be considered for a bone
marrow injury.
4.7
Psychological support
When carrying on medical treatment of exposed or contaminated victims medical staff as well as
some relevant persons who come to contact with the patients should always consider psychological
aspects of the patients as well as their family members. Most of the cases psychological aspects are
more important than the actual exposure or contamination. The medical status and plan for
diagnosis and treatment should be explained to the patients as well as to the family. It is necessary
to involve the patient in decisions about care. A communication to the family should be allowed as
much as possible. And psychiatrist or psychologist should be involved in addition to medical
treatment.
Radiation symptoms in just a few people can produce devastating psychological effects on an entire
community or group of responders as well. The acute anxiety has the potential to become the
significant source of emotional stress.
It is clearly recognized that knowledge of radiation and its effects can reduce stress. While the
‘stressor’ or the causative agent cannot be removed, effort is needed to change the way in which it
is perceived. Psychological reactions to radiation could be prevented, decreased or relaxed using
different methods applied before, during or after the emergency or malicious act. In general, a
malicious act involving radioactive material will generate more psychological distress than other
types of radiation emergency. Appropriate officials at the national and local levels need to perform
the actions needed to arrange psychological support. These actions are to be planned at the stage of
preparedness.
References
[201] INTERNATIONAL ATOMIC ENERGY AGENCY, Generic procedures for medical response
during a nuclear or radiological emergency, EPR-MEDICAL, IAEA, Vienna (2005).
Dr. Eduardo Herrera Reyes –IEC –IAEA
6|Page
[202] INTERNATIONAL ATOMIC ENERGY AGENCY, IAEA Safety Reports Series No.2: Diagnosis and
Treatment of Radiation Injuries, IAEA, Vienna (1998).
Dr. Eduardo Herrera Reyes –IEC –IAEA
7|Page