Pediatric emergency medicine trisk 498

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 do 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 2 or 3 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