Be Prepared to Treat Cutaneous Radiation Injuries : U.S. Army dermatologist outlines injuries that could result from terrorist event and how to treat them.

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil