Nuclear Radiation

The greatest likelihood of dealing with patients who are exposed to ionizing radiation would come from a nuclear power plant or reactor accident, and in decreasing order of likelihood, from a terrorist action and last from a detonation of a nuclear bomb.
The experience from Chernobyl should indicate the kind of injuries and results that anesthesiologists can anticipate from nuclear accidents, including radiation burns, bone marrow suppression, destruction of the lining of the GI tract, GI bleeding with translocation of bacteria, infection, sepsis, septic shock, and death.
Potential Sources of Ionizing Radiation Exposure
1. We are exposed to radiation on an annual basis from cosmic radiation, radon, and medical devices and in multiple stores and factories. (Half of our exposure comes from natural sources with most of the remaining exposure originating from medical imaging and devices.)
2. The greatest concern is the exposure to ionizing radiation that is unintentional as occurred at the Chernobyl nuclear power plants.
3. Individuals should be familiar with types of ionizing radiation (including alpha particles, beta particles, gamma rays, x-rays, and neutrons) and understand how radiation is measured.
  1. Human tissue will block alpha particles (but if inhaled, alpha particles can penetrate up to 50 µm into the pulmonary epithelium material, leading to the development of lung cancer) but will not stop beta particles or gamma rays.
  2. Beta particles are stopped by aluminum shields, but gamma rays can penetrate even concrete walls, and lead is required to shield for both gamma and x-rays.
4. The most likely injury from ionizing radiation is to tissues that have the greatest turnover rate (sensitivity of tissues to radiation from greatest to least is for lymphoid, GI, reproductive, dermal, bone marrow, and nervous system tissue).
  1. In reality, the response of lymphoid and bone marrow to ionizing radiation causes the greatest problems.
  2. Thrombocytopenia, granulocytopenia, and GI injury lead to bleeding and bacterial translocation across the GI epithelium, leading to sepsis and bleeding, the hallmarks of acute radiation syndrome, which lead to death.
5. Because ionizing radiation is invisible, individuals may appear normal. Patients who present with nausea, vomiting, diarrhea, and fever are likely to have severe acute radiation syndrome. Hypotension, erythema, and central nervous system dysfunction manifest later.
Management
1. If a radiation disaster occurs, it would be followed by a huge coordinated local, state, and federal response.
2. Of most importance, depending on the type of catastrophe, would be the immediate evacuation of the area.
3. The principle of disaster management always involves containment (avoid bringing patients with material emitting ionizing radiation to the hospital).
  1. Removal of clothing is critically important followed by washing the skin with warm, soapy water.
  2. Potassium iodide can attenuate most of the radiation-induced thyroid effects, but it must be given as quickly as possible because after 24 hours, there is little protective effect.
  3. The initial response should be as per the advanced trauma life support guidelines.
Explosives
1. Patients have burns, fractures, lacerations, multiple shrapnel injuries, soft tissue trauma, and traumatic amputations.
2. Patients with any evidence of burns to the face or airway require appropriate airway management (intubated awake if possible because a significant number of these patients will have mild to moderate glottic edema at the time of intubation).
3. Surgery is performed as soon as possible to stop the bleeding, thereby decreasing the need for blood products and the chances of developing a dilutional coagulopathy.
4. In patients with crush injuries and markedly elevated creatine phosphokinase levels, alkalinization of the urine may attenuate renal failure from myoglobinuria.

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