Pediatric emergency medicine trisk 497

radioactive materials is accomplished by treating the patient in a single location,
controlling access to that location, and by using standard contact precautions.
Internal contamination. Internal contamination can be a serious problem
because it is difficult to eliminate some long-lived radioactive materials from
within the body. Death due to radiation from internal contamination is rare. A few
deaths have been caused by medical misadministrations. A familiar example of
intentional, nonlethal internal contamination is the bone scan performed in a
nuclear medicine department. Treatment of hyperthyroidism with 131I
(radioactive iodine) also is, in a sense, planned internal contamination.
Metal fragment. Another source of possible contamination is the radioactive
metallic fragment, which can be intensely radioactive. These could, in principle,
be found if a “dirty bomb” was constructed with a radioactive metal source such
as 192Ir (radioactive iridium). Radioactive metal fragments can be embedded in
the patient’s skin and should never be touched with the examiner’s fingers. Tongs
or forceps will increase the distance between the radioactive metal fragment and
the fingers, and thus greatly reduce any radiation dose to the healthcare worker.
Hot particles. “Hot” particles are microscopic particles that can be highly
radioactive. Typically, they contain 60Co (radioactive cobalt) or other fission
products and might be found on a nuclear reactor worker after a reactor accident.
These particles can be difficult to localize and remove and may give a large
radiation dose to a small volume of tissues. If the particle is trapped under a nail
or is in the fold of the skin, routine washings may not dislodge it. The particle can
sometimes be localized by using a thick piece of lead. If the lead is placed
between the particle and the radiation detector, the exposure rate should decrease
substantially. Once the particle is localized, it can usually be removed by using
simple mechanical means. Rarely, a punch biopsy of the skin may be necessary.
Terrorist events. Nuclear materials may be used intentionally in a terrorist
event. An intact sealed source could be placed in a populated area, generating
whole-body exposures but no contamination. A conventional explosive combined
with radioactive materials, the so-called “dirty bomb,” could be employed to
disseminate radioactive materials over an area. Victims of such an attack would

likely have radiation exposure as well as injuries from the explosion itself. An
attack on a research or commercial power reactor could produce a large-scale
dispersion of nuclear material; victims could be exposed to whole-body and
localized radiation, as well as internal and external contamination. Transported
nuclear materials such as radiopharmaceuticals or radioactive waste could be the
subject of a terrorist attack. The effects would vary depending on whether the
containers were breached—intact containers would produce only potential


exposures, whereas destruction of the containers and dispersal of their contents
could also lead to contamination. A “dud” nuclear weapon that does not undergo
a nuclear fission reaction would still disperse radioactive materials by the
associated conventional explosion, leading to contamination in addition to effects
from the conventional explosion itself. A nuclear weapon effectively detonated
by a terrorist group might be relatively small scale but still capable of widespread
damage, including thermal and blast effects from the denotation along with
contamination and exposure of affected persons.

Triage Considerations
Triage and management should focus on securing ABCs (airway, breathing,
circulation) and monitoring vital signs. Major trauma, burns, and respiratory
injury should be treated first. No survivable radiation injury requires direct
immediate lifesaving treatment; hence, medical staff should focus their attention
on the treatment of non–radiation-related, life-threatening conditions. Once
stabilized, the radiation-related injuries can be addressed. In addition to routine
trauma labs, it is recommended that a CBC be obtained to assess lymphocyte
count.
Because there is no immediate treatment of radiation exposure, the problem of
radioactive contamination should be addressed first. In most circumstances, a
Geiger counter can be used to determine the presence of contamination. The

probability of contamination can be assessed by obtaining an accurate description
of the accident and the likely radiation source. If the patient is a radiation worker,
finding his or her radiation badge and performing a “reenactment” of the accident
may be critical for dose estimation.

Management and Diagnostic Studies
Internal Contamination
Treatment of internal contamination is most effective if initiated promptly. The
requirement for prompt treatment is a dilemma for the physician as it is difficult
to determine if internal contamination is present until the external contamination
has been removed. Moistened cotton Q-tips can be used to perform nasal swabs.
If these show radioactivity, inhalation of radioactive materials is possible. The
nature of the accident may provide clues to the possibility of internal
contamination (e.g., a fire with smoke leading to the inhalation of radioactive
particles). The most effective treatment requires knowledge of the radionuclide
involved and its chemical form. This information is usually not immediately
available. Fortunately, there are simple general treatment measures that can be


effectively instituted before the magnitude of the internal contamination is fully
known.
TABLE 90.16
DOSE OF STABLE IODINE (SSKI a ) BY AGE
Age

Dose (po) (mg)

<1 mo

16

1 mo–3 yrs
3–18 yrs

32
65

>18 yrs

130

a SSKI

(saturated solution of potassium iodide).

If given soon after exposure, stable iodine (saturated solution of potassium
iodide [SSKI]) is effective for preventing the uptake of radioactive iodine by the
thyroid gland. Prompt administration of stable iodine should be considered if
there is a possibility of external contamination, or ingestion or inhalation of
radioactive iodine ( Table 90.16 ). Because radioactive iodine is volatile, it is
likely to be inhaled. If a contaminated child were brought to the ED after an
accident with a radiopharmaceutical truck carrying radioactive iodine,
administration of stable iodine would be appropriate. Of note, for a given internal
contamination level, the radiation dose to the thyroid for infants is eight or nine
times as large as that for adults. If further investigation revealed no radioactive
iodine, little harm would have been done by having administered the stable
iodine. A single dose of oral iodine is highly unlikely to cause any adverse
reactions, even in persons who have serious reactions to iodinated contrast agents
or seafood.
After a nuclear reactor accident that results in the release of a large amount of

radioactive iodine, three steps can be taken to minimize the adverse effects on the
public. First, the public should be sheltered or evacuated to prevent further
exposure via fallout or gaseous materials. Second, potassium iodide (KI) may be
administered if available. However, it is important to note that many of the
nuclear reactors in the United States do not house radioactive iodine, making KI a
non-useful treatment option. Third, the food supply should be monitored carefully
to prevent further ingestion of radioactive iodine or other radionuclides. If a
reactor accident occurs that involves contamination of the public, understandable
concern by members of the public will ensue. If this happens, emergency medical


facilities should try to preserve their valuable resources for patients who need
lifesaving medical treatment. Plans may need to be made to refer uninjured
persons and persons with minor injuries to other facilities. It may be prudent to
prevent hospitals from becoming decontamination centers.
Several simple steps can be taken to treat internal contamination
nonspecifically. The goals of treatment are to prevent the absorption of the
radionuclide and to enhance its excretion. Safe techniques that can prevent the
absorption of radionuclides include the administration of activated charcoal and
alginate-containing antacids. Enhanced excretion can be achieved by hydration
and administration of a purgative. Specific treatment of internal contamination
depends on the radionuclide, its chemical and physical forms, and the route of
internal contamination. Recommendations for many specific treatments can be
found in the NCRP Report 161, titled Management of Persons Contaminated with
Radionuclides. This report should be available in every hospital ED and can be
downloaded for free from the NCRP website ( ) ( Fig.
90.14 ). Initiation of treatments that entail some risk to the patient (e.g.,
pulmonary lavage, intravenous chelating agents) should be undertaken only after
consultation with experts. The benefits of the treatment should be significantly
greater than the risks.