Chapter 143

• Ionizing radiation is named for its ability to interact with matter, converting atoms to ions as a result of their gain or loss of electrons. Ionizing radiation is more dangerous than nonionizing radiation because such reactions lead to breaks in both DNA and RNA, damaging important biologic functions at the cellular metabolic level.
• The clinical effects of radiation exposure are related to the type of radiation involved, the amount of radiation and the nature of the exposure (continuous or intermittent). In addition, the harmful effects of ionizing radiation may be affected by the total time of the exposure, the distance from the radiation source, and the presence of any shielding (amount and type).
• There are two categories of radiation injuries with which the emergency physician should be familiar:
• Exposure injury, which generally represents no threat to emergency care providers.
• Contamination, which may represent a risk to emergency personnel.
• Radiation injury should be considered in the differential diagnosis for any patient who presents with a painless “burn,” but who does not remember a thermal or chemical insult.
• Acute radiation syndrome may develop following a whole-body exposure of 100 rad or more that occurs over a relatively short period of time. Organ systems with rapidly dividing cells (bone marrow and gastrointestinal tract) are the most vulnerable to radiation injury.
• Although the effect of radiation on the hematopoietic system is characterized by pancytopenia, the absolute lymphocyte count represents the best way to estimate exposure hematologically. Leukocyte counts may be elevated initially because of demargination, but the lymphocyte portion of the differential will quickly start to decrease.
• Total-body irradiation with >1000 rad results in a neurovascular syndrome since, at such high radiation levels, even cells that are relatively resistant to injury are damaged. Ataxia and confusion quickly develop and there is direct vascular damage, with resultant circulatory collapse. The patient usually expires within hours.
• In the presence of contamination, if the patient's condition permits, decontamination should begin in the prehospital setting, which will reduce the potential spread of radioactive material and decrease the potential contamination of hospital workers or other rescuers. Fortunately, if appropriate management steps are taken, the radiation-contaminated patient should present little danger to hospital staff, even if decontamination was incomplete prior to arrival at the hospital.
• While both prehospital and hospital workers may be at risk, it is the prehospital personnel and other rescuers, who respond to the site of a radiation accident, who are more often exposed to significant radiation. A threshold of 5000 mrem (5 rem) should be the exposure limit, except to save a life. A once-in-a-lifetime exposure to 100 000 mrem (100 rem) to save a life has been established by the National Council on Radiation Protection as acceptable and will not result in any undue morbidity.
• The Joint Commission requires each emergency department to have a radiation accident plan. In the event of a medically significant radiation accident, a well-prepared and practiced plan will supply emergency care providers with an appropriate knowledge base, ...

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