30.1

Radiological Injuries

Chapter 30

Radiological Injuries

The reader is strongly advised to supplement material

in this chapter with the following two references:

1. Medical Management of Radiological Casualties

Handbook, 2003, Armed Forces Radiobiology Research

Institute, Bethesda, MD.

2. Medical Management of the Acute Radiation Syndrome:

Recommendations of the Strategic National Stockpile.

Radiation Working Group, Strategic National

Stockpile (Annals of Internal Medicine, 15 June 2004).

Introduction

Radiological casualties on the battlefield may occur with

improvised or conventional nuclear devices or radiological

dispersal devices (“dirty bombs”) (Table 30-1).

 Conventional nuclear weapons.

ο The relative casualty-causing potential depends primarily

on four factors:

♦ Yield of the weapon.

♦ Height of burst.

♦ Environmental conditions in which the detonation

occurs.

♦ Distribution and shielding of troops in the target area.

ο A nuclear detonation generally causes injuries with the

following distribution:

♦ Blast injury: 50%.

♦ Thermal injury: 35%.

♦ Ionizing radiation injury.

◊ Initial: 5%.

◊ Residual: 10%.
30.2

Emergency War Surgery

 A radiological dispersal device (RDD) is any device, including

any weapon or equipment, other than a nuclear explosive

device, specifically designed to spread radiation.

ο RDDs contaminate conventional casualties with radionuclides, complicating medical evacuation.

ο RDDs are ideal weapons for terrorism and are used to

intimidate and deny access to an area by spreading

radioactive material.

Table 30-1. Radiological casualties.

Weapon Effect Weapon Yield (Kiloton)/Distance (Meters)

1 kt 10 kt 100 kt 1,000 kt

Blast (50% casualties) 140 m 360 m 860 m 3,100 m

Thermal radiation 370 m 1,100 m 3,190 m 8,020 m

(50% deep burns)

Ionizing radiation 600 m 950 m 1,400 m 2,900 m

(50% immediate transient

ineffectiveness)

Ionizing radiation 800 m 1,100 m 1,600 m 3,200 m

(50% lethality)

Triage

 Different from conventionally injured patients, because

survivable radiation injury is not manifested until days to

weeks after exposure.

ο Based primarily on conventional injuries, then modified

by radiation injury level.

ο Make a preliminary diagnosis of radiation injury only for

those with exposure symptoms, such as nausea, vomiting,

diarrhea, fever, ataxia, seizures, prostration, hypotension.

ο Radiation patient triage classifications.

♦ Delayed: casualties with only radiation injury, without

gross neurological symptoms (ataxia, seizures, impaired

cognition). For trauma combined with radiation injury,

all surgical procedures must be completed within 36–

48 hours of radiation exposure, or delayed until at least

2 months after the injury.
30.3

Radiological Injuries

♦ Immediate: those requiring immediate lifesaving

intervention. Pure radiation injury is not acutely lifethreatening unless the irradiation is massive. If a

massive dose has been received, the patient is classified

as Expectant.

♦ Minimal: buddy care is particularly useful here.

Casualties with radiological injury should have all

wounds and lacerations meticulously cleaned and then

closed.

♦ Expectant: receive appropriate supportive treatment

compatible with resources; large doses of analgesics as

needed.

 Table 30-2 provides medical aspects of radiation injuries.

Table 30-2. Medical aspects of radiation injuries.

Signs and Symptoms

Unlikely – –– ––– –

Probable ++ + +/– +/– – – –

Severe +++ +++ +/+++ +/+++ –/++ +/++ –/++

The lethal dose of radiation, which will kill 50% of a population

within 60 days of exposure, is called LD50/60. The LD50/60 is

approximately 3–4 Gray (Gy) for a population with radiation

injury alone and with no significant medical care. The LD50/60

for a population with radiation injury alone and the best

available medical care (including antiemetics, antivirals,

antibiotics, hematopoietic cytokines, and transfusion) may be 6

Gy or more. Combined injuries with radiation and trauma and/

or burns will markedly lower the LD50. Probability/degree of exposure Nausea

Vomiting

Diarrhea

Hyperthermia

Erythema

Hypotension

CNS

dysfunction
30.4

Emergency War Surgery

Significant medical care may be required at 3–5 weeks for 10%–

50% of personnel. Anticipated problems should include

infection, bleeding, fever, vomiting, and diarrhea. Wounding

or burns will markedly increase morbidity and mortality.

 Treatment.

ο Fluid and electrolytes for GI losses.

ο Cytokines for immunocompromised patients (follow

granulocyte counts).

ο Restricted duty. No further radiation exposure, elective

surgery, or wounding. May require delayed evacuation

from theater during nuclear war IAW command guidance.

ο If there are more than 1.7 • 109 lymphocytes per liter, 48

hours after exposure, it is unlikely that an individual has

received a fatal dose.

Patients with low (300–500) or decreasing lymphocyte counts,

or low granulocyte counts, should be considered for cytokine

therapy and biological dosimetry using metaphase analysis

where available.

 Asymptomatic patients with lethal radiation dose may

perform usual duties until symptomatic.

Potential Injuries

 Thermal/flash burns or thermal pulse burns are caused

directly by infrared radiation. Close to the fireball, the thermal

output is often so great that everything is incinerated, and

even at great distances, thermal/flash burns will occur (see

Chapter 28, Burns, for management).

ο Burn mortality rates associated with radiation exposure

are significantly higher due to bone marrow suppression

and infection (a 50% TBSA burn associated with radiation

exposure has a mortality of 90%).

 Blast injuries associated with a nuclear detonation include:

ο Direct blast wave overpressure forces measured in terms

of atmosphere overpressure.

ο Indirect blast wind drag forces, measured in terms of wind

velocity, which may displace large objects such as vehicles

or cause the collapse of buildings.
30.5

Radiological Injuries

 Radiation injuries are due to ionizing radiation released both

at the time of the nuclear detonation and for a considerable

time afterward. The two types of radiation released are

electromagnetic (gamma) radiation and particulate (alpha,

beta, and neutron) radiation.

ο Alpha particles can be shielded against by clothing.

ο Beta particles shielding requires solid materials, like a wall.

ο Gamma and neutron radiation are the most biologically

active, and require lead equivalent shielding for protection.

ο Fission products are the major radiation hazard in fallout,

because a large number emit penetrating gamma radiation.

This can result in injuries, even at great distances.

ο Fallout causes whole body irradiation from gammaemitting isotopes, because they do not actually have to be

on a person’s skin to cause damage.

 Flash blindness may occur as the result of a sudden

peripheral visual observation of a brilliant flash of intense

light energy. Retinal burns may also occur and result in

scarring and permanent altered visual acuity.

Treatment of Combined Injuries

 Following the detonation of a nuclear device, the majority of

resulting casualties will have sustained a combination of blast,

thermal, and radiological injuries.

 The usual methods of treatment for blast injuries must be

modified in those casualties simultaneously exposed to

ionizing radiation.

Traditionally, combat wounds are left open. However, wounds

left open to heal by secondary intention in the irradiated

patient will serve as a nidus of infection. Wounds exposed to

ionizing radiation should be debrided and closed at a secondlook operation within 36–48 hours.

 Hypotension should always be assumed to be hypovolemia

and not due to radiologic injury.

 Hyperthermia is common.

 Radiological injuries increase the morbidity and mortality of

injuries due to compromise of the normal hematopoietic and
30.6

Emergency War Surgery

immune responses to injury. Surgical procedures may need

to be delayed during bone marrow suppression if at all

possible.

 Potassium iodide may be used for prevention of thyroid

uptake of radioisotopes after nuclear reactor accidents.

 Chelating agents may be used to eliminate metals from the

bloodstream before they reach target organs.

 Mobilizing agents are used to increase the excretion of internal

contaminants.

 Prussian blue is used to remove radionuclides from the

capillary bed surrounding the intestine and prevents their

reabsorption. Delay until patient is stable. Treat ABCs first.

Decontamination

 No healthcare provider has ever been injured with radiation

while performing ABCs on a radiation victim.

 Removal of the casualty’s clothing can remove as much as

90% of the radiological contamination.

 The first priority of surface decontamination should be to

open wounds, then other areas.

ο To prevent rapid incorporation of radioactive particles,

wounds should be copiously irrigated with normal saline

for several minutes.

ο The eyes, ears, nose, mouth, areas adjacent to uncontaminated wounds, hair, and remaining skin surface should

be decontaminated with soap and water.

ο Personnel providing decontamination must protect

themselves from ionizing radiation exposure with:

♦ Protective outer clothing.

♦ Aprons, gloves, and masks.

 Amputation should be seriously considered when the

contamination burden is great and severe radionecrosis is likely.

Logistics of Casualty Management

 If nuclear weapons are employed within the theater, the

entire medical evacuation and treatment system will be

severely overburdened and some system of classification and

sorting of casualties must be added to the normal procedures

of evacuation and hospitalization.
30.7

Radiological Injuries

 Patients entering a medical treatment facility should be

routinely decontaminated if monitoring for radiation is not

available.

 These two requirements, the sorting of casualties and the

holding of the excess numbers, must be planned for and

drilled as part of the normal organization and operation of

the health service support system in a theater of operations

where radiation exposure potential is high.
30.8

Emergency War Surgery