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INTRODUCTION — Radiation exposure in children is a rare occurrence. However, the potential for radiation exposure is significant. Since 1944, there have been more than 400 radiation accidents worldwide with 45 incidents occurring between 1961 and 2008. Since 1961, there has been potential radiation exposure of more than 750,000 individuals and at least 106 deaths [1,2] Most of the exposures (88 percent) occurred in the Chernobyl nuclear disaster of 1986, which also resulted in 28 immediate deaths [3]. More than one-half of the accidents (59 percent) meeting criteria for "serious exposure" as defined by the Radiation Emergency Assistance Center and Training Site (REAC/TS) have occurred in the United States [1,4].

Physicians who treat patients who are exposed to radiation must understand the biologic effects of the various types of radiation in order to determine which patients are at risk for radiation injury, to manage patients with radiation exposure, and to minimize the risk of contamination of hospital equipment and personnel.

The management of the various types of radiation injury in children will be reviewed here. An overview of radiation physics, types of radiation exposure, clinical features of radiation injury, and use of radiation therapy in the treatment of childhood cancers are discussed separately.

Treatment of radiation injury in the adult and the emergency care of thermal burns in children and adults are also discussed separately.

TREATMENT PLANNING — Management of radiation exposure, for an individual or a community, requires knowledge of the principles of radiation safety and advance preparation and planning at both the community and healthcare facility level.

Radiation safety — Protection from radiation exposure is accomplished through [5]:

• Minimizing the time of exposure
• Maximizing the distance from the source (if possible)
• Using a shield as appropriate

Maximizing the distance from the exposure source is the most practical and effective method [5]. This is because the radiation dose decreases by the square of the distance from the source (eg, doubling the distance decreases the exposure by a factor of four), a relationship known as the inverse square law. The protective effect of shielding in radiation accidents is limited. This is because radiation accidents usually involve high-energy gamma radiation and the amount of shielding that would be necessary for adequate protection is not practical [5]. Respiratory protection for medical providers with an N-95 mask is recommended.

Communities — As described above, maximizing the distance from the exposure source is the most effective protective strategy. Thus, if at all possible after radiation release from a nuclear diaster, evacuation of the area of exposure should be undertaken [6]. Federal, state, and local agencies will determine whether the need for relocation is temporary or long-term depending upon the persistence of radiation, physical damage to roads and buildings, and other factors affecting population safety [6,7].

Shielding, or sheltering, is a reasonable alternative if evacuation is not possible [6]. A safe place should be sought within the home or other building. The shielding factor (the ratio of the dose of radiation received within a structure to that if the structure were not present) varies depending upon the type of structure, and the location within the structure. As an example, the shielding factor for gamma radiation after a radioactive cloud release in various locations is as follows [7]:

• Wooden frame structure – 0.9
• Home basement – 0.6
• Home basement in a masonry home – 0.4
• Large office or industrial building – 0.2

The need for evacuation or sheltering may arise while children are at school or day care. Families and school or child care facilities should make a plan for reunification in the event that a radiation accident occurs during these times. The duration of sheltering that is necessary depends upon the extent of environmental contamination from the nuclear disaster [6]. Families should follow the instructions provided by the emergency broadcast system.

In addition, in December 2001, the Nuclear Regulatory Commission (NRC) offered to provide two potassium iodide tablets (the mainstay of preventive treatment after known or suspected exposure to radioactive iodine) to every person living within 10 miles of a nuclear power plant [8]. Rapid administration of this drug, in the event of exposure to radioactive iodine, requires that supplies are pre-deployed at homes, schools, and day care centers that are located within the 10-mile radius.

Information on dosage and available preparations (including instructions on how to mix the tablets with food or drink to make them palatable for infants and small children) can be found athttp://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm072254.htm.

Health care facilities — The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) requires every hospital in the United States to have a written plan in place to deal with the victims of a nuclear disaster [9]. To be able to handle such an emergency effectively, major referral hospitals and hospitals that function as the designated receiving center for victims of radiation accidents should rehearse the protocol until it is familiar to all staff members who may need to participate [10]. Rehearsal of and familiarity with the protocols helps to expedite care, to prevent contamination, and to educate medical staff about the biologic risks of radiation and radiation safety. All emergency departments should have ready access to the supplies and equipment necessary in the management of radiation accidents (table 1).

Treatment area — If possible, contaminated patients should enter the treatment facility through a separate entrance [11]. The entryway should be covered with paper or waterproof sheets that are taped to the ground or floor. If a separate entrance is not available, the contaminated patient can be placed on a clean stretcher outside the emergency department and wrapped in a cloth sheet before transport to the desired area of the hospital [5].

Supplies for radiation decontamination

In addition, the areas traversed by contaminated patients should be taped off and labeled as radioactive. A buffer zone between the contaminated and noncontaminated areas helps to prevent the spread of radioactive material. Designated personnel should remain in this area to transfer material from "clean" to "dirty" by taking uncontaminated material from the clean side and directly handing it to personnel in the contaminated area without individual-to-individual contact. If at all possible, a radiation safety specialist should be on hand to monitor levels of radiation [4,10,12].

The decontamination room should be separate from the rest of the treatment areas of the emergency department. Areas, such as autopsy rooms, casting areas, or isolated areas of the emergency department, can be used [13]. The ventilation system of the decontamination room should be separate from that of the remainder of the hospital. If a separate ventilation system is not in place, the ventilation to the room should be turned off to avoid the spread of radioactive particles. Nonessential equipment should be removed from the room. All handles, switches, and essential equipment should be covered with masking tape, paper tape, or other nonpermeable covering that is sealed with tape.

The decontamination room must be equipped with instruments for monitoring radiation (eg, alpha counters and Geiger-Muller counters). Scrub suits, gowns, gloves, masks, hats, and foot covers should be readily available. After the protective gear is donned by personnel, all openings should be taped closed to create a complete and intact barrier. Plastic bags, waste containers, and lead containers must be available for storage and disposal of contaminated material (table 1). The decontamination process is discussed in detail below.

Real-time dosimeters must be worn by healthcare providers to monitor their total radiation exposure [3,4,10,12-15]. Film badges are not recommended because they do not provide real time measurements. The National Council on Radiation Protection and Measurements recommends a maximum of 100 rem (1 Sv) of exposure for providers in lifesaving emergency situations and 25 rem (0.25 Sv) in less urgent situations [12]. Personnel should be rotated to minimize exposure. Pregnant personnel should be excluded from the treating team.

Once decontamination is complete, all tape and protective coverings should be removed and disposed of in labeled bags, and the area should be rechecked. As they exit the decontamination room, decontamination personnel enter the buffer zone, where they remove their outer protection, turning the garments inside out. They label their dosimeter badges and turn them in to the radiation officer [3,4,10,12,14]. When decontamination is complete, the radiation safety inspector performs a final sweep of the entrance, the transferring area, the buffer zone, and the treatment area to ensure that no excessive radiation remains before the treatment team leaves the contamination area.

GENERAL PRINCIPLES — Once notified of a radiation accident, the receiving facility should try to obtain a detailed account of the accident in order to determine the nature of the exposure [10]:

• What radioactive substances were involved?
• What type of exposure(s) occurred (eg, contamination, incorporation, acute partial body exposure, acute whole body exposure)?
• How many victims were involved?

A radiation safety officer at the receiving facility should be notified and made responsible for monitoring radiation levels, overseeing the storage and disposal of decontaminated materials, and ensuring that contamination is eliminated. A radiology technician with training in dosimetry can serve in this role if the facility does not have a designated radiation safety officer.

The Radiation Emergency Assistance Center and Training Site (REAC/TS) at Oak Ridge, Tennessee is a part of the Department of Energy and provides 24-hour medical consultation and assistance (www.orise.orau.gov/reacts/). The telephone number is 865-576-1005. Consultation with REAC/TS is sometimes necessary before the FDA will release certain medications for management [4]. The treating facility is not required to notify REAC/TS. However, the facility at which the exposure occurred is required to report all incidents of accidental exposure of nuclear compounds to the Department of Energy.

The first priority in the management of children who are exposed to radiation is stabilization of life- and limb-threatening conditions.

Immediate therapy for radiation effects is rarely necessary except in individuals who received extremely high (and probably lethal) doses of radiation [16]. The effects of radiation exposure that require treatment usually manifest after a latency period of days to weeks. After medical stabilization, decontamination is initiated to minimize continued irradiation in individuals who have been contaminated.

Triage — Emergency departments that are eligible to receive victims of radiation accidents must be prepared to manage large numbers of victims. In mass casualty situations, the receiving hospital must triage patients according to its capabilities, with priority given to those who are likely to survive [16,17]. If resources are limited, it may be necessary to provide palliative care only (eg, pain control, antiemetics, antiepileptics) to victims who are known to have received a lethal dose of gamma radiation.

Appropriate triage of victims requires accurate estimation of the received dose of radiation. Initial estimates of radiation dose are based upon the timing, severity, and duration of symptoms; these estimates are revised based upon laboratory studies that are performed as soon as is practical (see below).

As a general rule, patients who demonstrate symptoms within two hours of exposure should be assumed to have received a high and possibly lethal dose of radiation. However, it is important to remember that some symptoms, such as nausea, vomiting, and diarrhea, may be caused by stress rather than the acute radiation syndrome [16]. The response to antiemetics can be helpful in distinguishing the origin of nausea and vomiting. Antiemetics are usually ineffective in patients who received lethal doses of radiation, whereas they may be helpful in patients who received lower doses. In addition, prodromal nausea and vomiting in patients who are likely to recover may last up to 48 hours (but usually not longer) [16].

Laboratory evaluation — The laboratory evaluation of patients exposed to radiation is performed to evaluate the biologic effects of radiation and to prepare for therapies that may be necessary (eg, blood transfusion, bone marrow transplantation, fluid and electrolyte therapy). Assay of the biologic effects of radiation helps to refine the clinical estimates of initial dose of radiation received and better prepare for potential sequelae and complications.

• CBC with differential – A complete blood count with differential should be obtained in all patients with suspected radiation injury at the time of presentation and every six hours for 48 hours [4]. The absolute lymphocyte count can be used to estimate the initial radiation dose and the severity of injury [4]. The venipuncture should be performed at a noncontaminated site (if possible); the puncture site should be covered after the procedure.
• Cytogenetic studies – The observed levels of dicentrics (chromosomes with two centromeres) after arrest in first metaphase also can be related to dose via an established dose-response calibration curve [18,19]. As soon as practical after the irradiation event, 10 to 15 mL of peripheral blood should be collected in a heparinized blood collection tube and immediately transported (under refrigeration) to the cytogenetic laboratory for processing.
• Electrolytes – Blood chemistries should also obtained [10,20]. Hyponatremia, hypernatremia, hypokalemia, and acidosis may be caused by massive loss of fluid and electrolytes through the gastrointestinal tract. Chemistries should be monitored daily unless the patient's clinical condition requires more frequent monitoring.
• Blood and human leukocytes antigen typing – Because blood transfusions and, possibly, hematopoietic stem cell transplantation may be required to treat the effects of radiation on the bone marrow, type and crossmatch and blood for human leukocyte antigen (HLA) typing should be obtained; the sample for HLA typing should be obtained before the lymphocyte count falls.
• Urinalysis – Patients with suspected radiation injury also should have a baseline urinalysis at the time of presentation, daily urinalysis with microscopy, and strict monitoring of urine output to evaluate radiation-induced changes in kidney function. If renal impairment develops, consultation with a nephrologist should be arranged; rare patients may require long-term dialysis or renal transplantation.

All samples should be placed in separate containers that are labeled with the patient's name, date, and details of the sample (eg, time, site). Appropriate advice (eg, legal, radiation safety) regarding the storage and disposition requirements of collected samples should be obtained and followed [4].

CONTAMINATION — External contamination occurs when material that contains radioactive atoms is deposited on skin, clothing, or other surfaces. Because persons contaminated with radioactive materials are exposed to radiation until the source of radiation is removed, decontamination should occur as soon as possible after life- and limb-threatening conditions are addressed [11,21]. Medical staff who care for contaminated patients, particularly at the accident site, must take precautions to avoid irradiating themselves [22].

External — A child who is externally contaminated with radioactive particles should have all clothing removed, preferably at the scene of the accident. This procedure will usually remove most of the radioactive particles [10]. Clothing should be placed in labeled plastic bags. Equipment that was used to transport the patient, and any ambulance equipment that may have had contact with the patient, should remain separate from the receiving hospital equipment until the transport equipment can be surveyed for radiation and decontaminated if necessary. At the receiving hospital, the contaminated patient should be treated in an area that is separate from the rest of the treatment center, or in an area that is clearly marked as contaminated if such an area is available.

Radiation survey — Once he or she is medically stabilized, the patient should be surveyed with alpha and Geiger counters to evaluate for radioactivity, which if present should be documented on an anatomic chart (figure 1A-B). This information is then used to determine the sequence of decontamination of intact skin. To assess the possibility of internal contamination, separate saline- or water-moistened swabs should be used to wipe the skin, nares, ears, mouth, and wounds [21]. These swabs should be placed in bags, labeled with the anatomic collection site, and assessed for radioactivity with a Geiger counter or alpha-radiation detection device [10].

Decontamination — Decontamination should begin with debridement of open wounds to remove as much debris as possible. Metallic fragments can be highly radioactive and should be removed with tongs or forceps (to increase the distance to the exposure source) rather than the fingers [22]. The debris should be stored in lead containers and surveyed for radioactivity. Wounds should then be copiously irrigated with normal saline until they are free of radioactivity, and then covered with a waterproof dressing. Contaminated burns should be treated as any other thermal or chemical burn [11]; contaminants may slough off with the burn eschar, leading to contamination of dressings and bed linens, which should be handled accordingly [21].

The mouth, nose, eyes, and ears require special attention in decontamination because of the potential for more rapid absorption of radioactive material [21].

• Frequent mouth rinsing and tooth brushing with toothpaste are encouraged if radioactive material has entered the oral cavity; gargling with a 3 percent hydrogen peroxide solution also may be helpful. Gastric lavage may be indicated if radioactive materials were swallowed.
• If the eyes have been contaminated, they should be rinsed by directing a stream of water from the inner canthus to the outer canthus. Care should be taken to avoid contamination of the nasolacrimal duct.
• If the auditory canals have been contaminated and the tympanic membrane is intact, an ear syringe can be used to rinse the auditory canal.

Decontamination should then proceed from areas with highest to lowest radioactivity. Decontamination should be performed with sponging of lukewarm water and a mild soap. Cold water should be avoided because it closes the pores and can trap radioactive materials; hot water should be avoided because it opens the pores and causes vasodilation, increasing the risk of absorption [21]. Care should be taken to avoid further abrasion or erythema of the skin, which also may increase absorption [10,14,20]. Areas that are sponged should be resurveyed every three to five minutes until the counts are consistent with background levels. To obtain accurate results, contaminated drapes and dressings should be removed before each episode of monitoring [21].

"Hot" particles are microscopic particles that can be highly radioactive and difficult to detect and/or dislodge [22]. Such particles can sometimes be localized by placing a thick piece of lead between the suspected site and the radiation detector; if the particle is properly localized, the radiation count should decrease. Localized particles can usually be removed by mechanical means, although sometimes punch biopsy of the skin is necessary [22]. Hair may need to be clipped if washing is insufficient for decontamination; it should not be shaved, since shaving may increase absorption. The liquids and materials used for decontamination should be stored in marked containers for disposal.

After decontamination, the patient should be dried and placed on a clean stretcher or in a wheelchair that is pushed by an individual who was not involved in the decontamination. The patient can then be evaluated by emergency department personnel for further care [10].

All equipment used in decontamination should be surveyed before leaving the decontamination area. Individuals who leave the decontamination area should follow a clearly marked path in order to minimize cross-contamination. Personnel leaving the decontamination area should deposit all gloves, masks, hats, scrub suits, and shoe covers into marked, designated receptacles before leaving. The radiation safety specialist should collect dosimeters after they have been labeled with appropriate identifying information [10,14,20,21].

Internal — Emergency department personnel must intervene quickly to prevent radioactive elements from being incorporated into the body, a process that can occur within minutes. If the radiation accident involved an explosion or fire, inhalation (and incorporation) of radioactive material should be assumed, and the patient treated accordingly. Patients with external contamination who have undergone endotracheal intubation also are considered to have internal contamination and should be managed similarly [23]. Decontamination of the mouth, eyes, and ears is discussed above. Once external decontamination is complete, patients with internal contamination usually pose no hazard to caregivers or to the medical facility, although their fecal and urinary excretion products should be measured for radioactivity and disposed of in marked, sealed containers [9].

Radiation survey — Radioassay and whole body counting can assist in determining the magnitude of contamination and response to therapy. To assess the possibility of internal contamination, separate saline- or water-moistened cotton-tipped applicators should be used to swab the skin, nares, ears, mouth, and wounds before and after decontamination [21]. These swabs should be placed in bags, labeled with the anatomic collection site, and assessed for radioactivity with a Geiger counter or alpha-radiation detection device [10]. If these samples have radioactivity in excess of background, incorporation of radioactive material through ingestion, inhalation, or absorption is possible.

If internal contamination has occurred or is suspected, samples of feces, urine, wound secretions, or emesis should be obtained as soon as possible upon arrival to the treating facility. Urine and feces should continue to be tested for four days [21]. If internal contamination has occurred, urine and feces may contain radioactive material, creating a potential contamination hazard, and appropriate precautions must be taken [9].

Management — The goals of management are to limit exposure and reduce further damage to the child's rapidly proliferating cellular systems [14]. Absorption can be prevented by several methods [12,21,24]:

• Forming a complex with the substance
• Binding the substance in a resin
• Reducing absorption from the bowel
• Facilitating elimination by decreasing bowel transit time or forcing diuresis

Isotope identification is necessary before directed treatment. Isotope identifiers are available from state radiation departments, National Guard Civil Support Teams, and some HazMat units.

Hospitals that are designated as the receiving centers for radiation accidents at facilities that handle nuclear materials (eg, laboratories, industry) should have rapid access to chelating agents, some of which are available only by FDA protocol. Information regarding these agents, as well as expert guidance about the management of internal contamination, is available at www.orise.orau.gov/reacts/,the National Council on Radiation Protection [25], poison control centers, or by calling REAC/TS at its 24-hour emergency number (865-576-1005).

Specific management of internal contamination depends upon the radioactive element involved and its chemical form. The following information is also summarized in a table that is available at http://orise.orau.gov/files/reacts/medical-aspects-of-radiation-incidents.pdf.

• All patients who were potentially exposed to radioactive iodine should be treated with supersaturated potassium to block thyroid deposition [12,21,24]. When administered immediately before, and two, eight, and 24 hours after exposure, potassium iodide prevents 100, 80, 40, and 7 percent, respectively, of the radioiodine deposition [26]. Because potassium iodide works best when administered near the time of exposure, it should be available in homes, schools, and day care settings, particularly those that are located near nuclear power plants (within a 10-mile radius) [6,11,27]. Information on dosage and available preparations for children can be found at http://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm072254.htm.
• Patients with potential incorporation of the transuranics (eg, plutonium-239 or yttrium-90) can receive calcium or zinc diethylene triamine penta-acetate (DTPA) for chelation [21].
• Sodium bicarbonate can be helpful in alkalinizing the urine of patients contaminated with uranium to reduce the risk of acute tubular necrosis [12,21].
• Prussian blue (ferrihexacyano-ferrate II) should be administered to patients contaminated with substances, such as cesium-137, rubidium-82, or thallium-201, to prevent recycling of the radioactive substance [21].
• Oral calcium or aluminum phosphate solutions can block the absorption of strontium through competitive inhibition [12,21,24].

IRRADIATION — Patients who were exposed only to gamma radiation pose no risk of contamination to medical personnel [10]. They should be treated as all other trauma victims: life-threatening injuries should be stabilized before radiation exposure is addressed [28].

Partial-body exposure — In acute partial-body exposure, one part of the body receives the majority of exposure. This type of injury comprises the majority of gamma radiation exposure incidents, usually from industrial accidents in which radioactive sources were handled inappropriately. Decontamination should be performed as needed (ie, if the patient was also exposed to alpha or beta particles).

The skin is the area the most commonly involved. Patients who received partial-body doses less than 500 rad (5 Gy) usually have damage limited to erythema, severe xerosis, vesiculation, and loss of hair with eczematous changes that may be permanent. Healing is delayed and may take one to two months. These injuries may need to be treated at a center that specializes in burns.

In patients who received partial-body doses greater than 500 rad (5 Gy), wet gangrene and ulceration may develop caused by damage to the underlying vasculature and connective tissue [28]. Management of these types of injuries requires consultation and close coordination between burn specialists, plastic surgeons, orthopedists, occupational and physical therapists, orthotists, and psychologists.

Acute radiation syndrome — The treatment for patients who have been exposed to large doses (>200 rad [2 Gy]) of whole-body radiation is based upon the symptoms, which usually begin between 21 and 60 days after exposure [22]. Consultation with experts in radiation accident management is encouraged and is available through REAC/TS (www.orise.orau.gov/reacts/; telephone: 865-576-1005 or 865-576-3131) [21].

Hematopoietic syndrome — To monitor the hematopoietic effects of radiation exposure, a complete blood count with differential should be obtained at the time of presentation and repeated every six hours for 24 to 48 hours to monitor the trend. The lymphocyte count at 48 hours can be used to estimate the initial exposure dose and prognosis. If the dose of radiation exceeded 500 rad (5 Gy) or the 48-hour lymphocyte count drops below 500, the exposed patient should be transferred to a tertiary care facility with capabilities for bone marrow transplant, since survival without such a procedure is unlikely [29].

Symptoms requiring treatment (eg, bleeding, anemia) may not develop until 21 to 30 days after exposure [22]. The management is centered on the control of bleeding and anemia; blood products should be transfused as necessary. Hematology consultation should be obtained to assist with life-threatening neutropenia. The use of granulocyte-colony stimulating factor may help speed recovery [14,20]. The administration of broad-spectrum antibiotics is necessary to prevent death from an overwhelming infection in patients who develop fever. Prophylaxis against viral infections may be considered [21].

GI syndrome — The gastrointestinal manifestations of radiation exposure depend upon the absorbed dose. At low doses (150 rad [1.5 Gy]), only the prodromal phase of nausea, vomiting, and gastric suppression are observed [30]. At doses greater than 200 rad (2 Gy), the gastrointestinal syndrome typically manifests within five days of initial exposure (following the prodromal phase and a short latent phase) [17,18]. More severe symptoms of gastrointestinal tract damage develop at doses greater than 600 to 800 rad (6 to 8 Gy), and doses greater than 1000 to 1200 rad (10 to 20 Gy) may cause death [31].

Explosive vomiting and bloody diarrhea occur as the gastrointestinal epithelium is shed, the intestinal crypts and mucosal barrier are destroyed, and intestinal motility is disrupted [30]. Severe electrolyte imbalance and hypovolemic shock may result. In addition, the disruption of the mucosal barrier permits bacteria to enter the systemic circulation, which, when combined with the depleted immune system, markedly increases the risk of death from sepsis.

Aggressive fluid resuscitation with continual monitoring of serum chemistries and fluid balance is crucial for patients with the gastrointestinal syndrome, since life-threatening electrolyte disturbances will occur. Antiemetic and antidiarrheal agents should be used liberally [20]. Consultation with gastroenterologists should be obtained, and parenteral nutrition should be initiated to promote tissue anabolism. Antibiotics are necessary for treatment if bacteremia develops. Despite these measures, the onset of fever usually precedes irreversible septic shock that unfortunately remains the overwhelming cause of death [20,28].

CNS syndrome — Patients exposed to doses of radiation that are high enough to cause the CNS syndrome have an extremely poor prognosis. In mass casualty situations, the treatment of these victims is dependent upon the availability of resources and potential for survival [17].

FOLLOW-UP — Victims of radiation accidents experience a great deal of psychologic stress related to perceived radiation injury and concern about future cancer risk [11,22,32]. All victims, regardless of the degree of exposure, should have follow-up arranged with providers who can address these concerns (eg, environmental health or radiation specialists, psychologists, primary care physicians).

Children who received radiation exposure to the thyroid gland should have their thyroid glands checked regularly. The frequency and method of follow-up of irradiated patients depends upon their estimated risk and the clinical findings at the initial evaluation.

Patients with ocular exposure, particularly to neutron radiation, should undergo regular examination for cataract development [18].

ADDITIONAL RESOURCES — Further guidance on the management of radiation exposure in children is available as follows:

• Oak Ridge Institute for Science and Education (ORISE) – Hospital triage and medical aspects of radiation incidents, including detailed procedure demonstrations for decontamination are available athttp://www.orise.orau.gov/reacts/resources/default.aspx.
• Food and drug administration – Information on dosage and available preparations (including instructions on how to mix the tablets with food or drink to make them palatable for infants and small children) can be found at http://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm072254.htm.
• Regional poison control centers – In the United States, regional poison control centers are available to provide radiation exposure information and resources (eg, access to local radiation safety officers). To obtain emergency consultation, call 1-800-222-1222. The World Health Organization maintains a list of international poison centers at www.who.int/ipcs/poisons/centre/directory/en. 

SUMMARY AND RECOMMENDATIONS

Radiation safety

• Protection from radiation exposure is accomplished through:

• Minimizing the time of exposure
• Maximizing the distance from the radiation source (if possible)
• Using a shield as appropriate (eg, sheltering in place in the basement of a home or other building)

• Evacuation of an exposed region is the most effective means of reducing radiation exposure in a community. Sheltering in place is the main alternative if timely evacuation is not possible.
• All health care facilities should have a written radiation disaster plan that is known and rehearsed by hospital staff and maintain ready access to the supplies and equipment necessary in the management of radiation accidents (table 1).

Management: irradiation with contamination

• The treatment of life- and limb-threatening conditions while minimizing radiation exposure to health care workers and contamination of the health care facility is the first priority in the management of children who are exposed to radiation.
• A radiation safety officer at the receiving facility should be notified and made responsible for monitoring radiation levels, overseeing the storage and disposal of decontaminated materials (eg, irrigation solutions, contaminated bedding and clothing, exposed patients’ urine and feces), and ensuring that contamination is eliminated.
• After initial stabilization, decontamination begins by having externally contaminated patients remove all clothing followed by a radiation survey using alpha and Geiger counters to identify and document areas of heaviest contamination (figure 1A-B).
• Decontamination should begin with debridement of open wounds to remove as much debris as possible. Metallic fragments can be highly radioactive and should be removed with tongs or forceps (to increase the distance between the exposure source and the health care provider’s fingers) rather than the fingers. Wounds should then be copiously irrigated with warmed, normal saline until they are free of radioactivity, and then covered with a waterproof dressing.
• To assess the possibility of internal contamination, separate saline- or water-moistened cotton-tipped applicators should be used to swab the skin, nares, ears, mouth, and wounds before and after decontamination.
• Specific management of internal contamination depends upon the radioactive element involved and its chemical form. Information regarding these agents, as well as expert guidance about the management of internal contamination, is available at www.orise.orau.gov/reacts/, the National Council on Radiation Protection, poison control centers, or by calling REAC/TS at its 24-hour emergency number (865-576-1005).

Managment: irradiation without contamination

• Patients who were exposed only to gamma radiation pose no risk of contamination to medical personnel. They should be treated as all other trauma victims: life-threatening injuries should be stabilized before radiation exposure is addressed.
• In acute partial-body exposure, one part of the body receives the majority of exposure. Cutaneous findings are typical and the degree of changes depends on the dose of radiation received. Specialized wound care (eg, burn center) is warranted.
• The treatment for patients who have been exposed to large doses (>200 rad [2 Gy]) of whole-body radiation is based upon the symptoms, which usually begin between 21 and 60 days after exposure. Consultation with experts in radiation accident management is encouraged and is available through REAC/TS (www.orise.orau.gov/reacts/; telephone: 865-576-1005 or 865-576-3131).

REFERENCES

10. Leonard RB, Ricks RC. Emergency department radiation accident protocol. Ann Emerg Med 1980; 9:462.

11. Mettler FA Jr, Voelz GL. Major radiation exposure--what to expect and how to respond. N Engl J Med 2002; 346:1554.

12. Shannon BE, Jenkins JL, Braen GR. Radiation Injury. In: Manual of Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2000. p.435.

13. Linnemann RE. Medical experience and preparedness for handling radiation injuries. J Med Assoc Ga 1989; 78:95.

14. Rutherford, MW, Seward, JP. Radiation injuries and illnesses in pediatric emergency medicine. Clin Pediatr Emerg Med 2001; 2:141.

15. Sholtis J. Ionizing radiation and their interactions with matter. In: Military Radiobiology, Conklin JJ, Walker RI (Eds), Academic Press, Orlando 1987. p.57.

16. Darte JM, Little WM. Management of the acute radiation syndrome. Can Med Assoc J 1967; 96:196.

17. Jones F. Neuropsychiatric casualties of nuclear, biological, and chemical warfare. In: Textbook of Military Medicine, Zajtchuk R (Ed), Office of the Surgeon General, Washington DC 1995. p.98.

18. Jarrett, DG. Medical management of radiological casualities. Military Medical Operations Office. Armed Forces Radiobiology Research Institute. Bethesda, MD 1999. www.afrri.usuhs.mil.

19. Littlefield LG, Joiner EE, DuFrain RJ, et al. Cytogenetic dose estimates from in vivo samples from persons involved in real or suspected radiation exposures. In: The Medical Basis of Radiation Accident Preparedness, Hubner KF, Fry SA (Eds), Elsevier, North Holland 1980. p.375.

20. Reeves GI. Radiation injuries. Crit Care Clin 1999; 15:457.

21. Guidance for Radiation Accident Management. www.orau.gov/reacts/guidance.htm (Accessed on December 07, 2005).

22. Mettler FA, Royal HD, Drum DE. Radiation accidents. In: Textbook of Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1033.

23. Fong F, Schrader DC. Radiation disasters and emergency department preparedness. Emerg Med Clin North Am 1996; 14:349.

24. Asch SM. Radiation exposure. In: Pediatric Emergency Medicine: Concepts and Clinical Practice, Barkin RM, Caputo GL, Jaffe DM, et al (Eds), Mosby, St. Louis 1997. p.522.

25. Management of Persons Contaminated with Radionuclides: Handbook. NRCP report no. 161, National Council on Radiation Protection and Measurement; Bethesda, MD, 2009.

26. Zanzonico PB, Becker DV. Effects of time of administration and dietary iodine levels on potassium iodide (KI) blockade of thyroid irradiation by 131I from radioactive fallout. Health Phys 2000; 78:660.

27. U.S. Food and Drug Administration, Home preparation procedure for emergency administration of potassium iodide tablets to infants and children using 130 milligram (mg) tablets. www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm072254.htm (Accessed on June 09, 2009).

28. Conklin JJ, Walker RI, Hirsch EF. Current concepts in the management of radiation injuries and associated trauma. Surg Gynecol Obstet 1983; 156:809.

29. Saenger EL. Radiation accidents. Ann Emerg Med 1986; 15:1061.

30. Dubois A, Walker RI. Prospects for management of gastrointestinal injury associated with the acute radiation syndrome. Gastroenterology 1988; 95:500.

31. Gale RP. Medical response to radiation and nuclear accidents: lessons for the future. J Natl Cancer Inst 1988; 80:995.

32. Becker SM. Psychosocial assistance after environmental accidents: a policy perspective. Environ Health Perspect 1997; 105 Suppl 6:1557.