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FIGURE 90.14 Treatment of radiation injuries NCRP, National Council on Radiation Protection and Measurements External Contamination External contamination is treated in the same way as contamination by other hazardous chemical or biologic agents Personnel should wear gloves, a gown, shoe covers, and a mask, which keeps them clean and makes cleanup easier The garments not decrease the exposure to penetrating radiation If available, film badges or other devices to measure radiation exposure should be worn by hospital staff in close contact with the patient If external contamination is widespread, it may be helpful to cover the floor If only a small area of contamination is present, spread can be prevented by simply wrapping the contaminated area until it can be cleaned Because it is much easier to detect radioactive contamination than chemical or biologic hazards, cleanup following a radiation accident will be much more effective External contamination is rarely a significant medical problem, but decontamination requires preplanning Externally contaminated patients should be admitted through a separate entrance of the ED If this is not possible, then patients should be placed on a clean stretcher outside the ED and wrapped in a cloth (not plastic) sheet and then transported to the desired area of the hospital Access to the treatment area should be controlled TABLE 90.17 DECONTAMINATION Remove clothes Wash with a damp cloth Pay special attention to skin folds and fingernails Cover clean wounds to prevent contamination Prevent external and tepid water contamination from becoming internal Do not abrade the skin Removal of the patient’s clothing will eliminate up to 90% of the external contamination ( Table 90.17 ) Contaminated articles should be placed in labeled plastic bags Residual contamination is likely to be on the hands, face, hair, and wounds These should be washed with lukewarm water and soap Cleaning the skin with damp washcloths is better than cleaning with running water The radioactive dirt on the damp washcloth can be contained by placing the cloth in a plastic bag Radioactive dirt in wash water is much more difficult to control Shaving should not be performed because this may make small cuts and increase absorption through the skin Excessive rubbing of the skin may also increase transdermal uptake Open uncontaminated wounds should be covered to prevent them from becoming contaminated Contaminated wounds should be cleaned like any other dirty wound All samples from the patient should be saved and labeled if there is any question about the identity of the radionuclides A Geiger counter should be used to monitor and document the progress of the decontamination efforts If contamination persists, the source may be fixed to the skin or may be internal Radiation experts should be consulted before performing more aggressive decontamination Some residual contamination may be acceptable Exposure Other than symptomatic measures, there is no immediate treatment to reverse whole-body or local radiation exposure Medically significant whole-body radiation exposure is unlikely if the patient does not present with nausea and vomiting Serial CBCs (with special attention to the lymphocyte count) every several hours are also helpful in excluding the diagnosis of a recent large wholebody exposure to radiation ( Table 90.18 ) In the absence of other major trauma, the absolute lymphocyte count will rapidly fall in patients who have been exposed to a large radiation dose If a patient has been exposed to a large acute dose of radiation, there is little in the way of specific medical treatment in the ED The threat to the patient’s life will occur within days to weeks after the exposure and medical management includes prevention and treatment of infections, stimulation of hematopoiesis with the use of growth factors, stem cell transfusions, or platelet transfusions with severe thrombocytopenia For any accident involving radioactive materials, reports should be made to the appropriate state and federal agencies The diagnosis of a local radiation injury requires vigilance The physician should consider the possibility of a local radiation injury whenever there is an unexplained painless “burn” blister, ulceration, or necrosis of the skin A CBC to exclude an accompanying whole-body exposure and consultation with a radiation expert is indicated The prognosis of a local radiation injury depends on the dose The dose may be estimated by having a qualified physicist reconstruct the accident that led to the exposure TABLE 90.18 APPROPRIATE LABORATORY TESTS FOR PATIENTS INVOLVED IN A SIGNIFICANT RADIATION ACCIDENT In the emergency department Complete blood cell count with special attention to the lymphocyte count, repeat every 2–3 hours for the first 8–12 hours following exposure and then every 4–6 hours for the following or days Nasal swabs Collect all excreta Later Cytogenetics Sperm count Eye examination (baseline for cataracts) Human leukocyte antigen typing BITES AND STINGS Goals of Treatment General care should include relief of pain and itching, tetanus prophylaxis, antibiotics if needed, and emotional support Animals must be identified as venomous or not, and appropriate methods to inactivate the venom should be instituted, or if available specific antivenom should be administered Additional clinical observation may be required to determine the extent of injury CLINICAL PEARLS AND PITFALLS Knowledge of common animals in your location of practice is essential in identification and/or treatment of potential victims Shock can occur even with seemingly minor local injury because of the systemic effects of toxins Consider tetanus prophylaxis in all victims of bites or stings Wound closure may be delayed when there is a high risk of infection MARINE INVERTEBRATES ... 90.18 APPROPRIATE LABORATORY TESTS FOR PATIENTS INVOLVED IN A SIGNIFICANT RADIATION ACCIDENT In the emergency department Complete blood cell count with special attention to the lymphocyte count, repeat