MEDizzy - A “dirty” bomb is detonated in downtown Boston. The bomb was

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General Considerations in Clinical Medicine 1

A “dirty” bomb is detonated in downtown Boston. The bomb was composed of cesium-137 with trinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power of the blast. The fallout area was about 0.5 mile, with radiation exposure of approximately 1.8 Gy. An estimated 5000 people have been potentially exposed to beta and gamma radiation. Most of these individuals show no sign of any injury, but about 60 people have evidence of thermal injury. What is the most appropriate approach to treating the injured victims?

ExplanationMuch of the initial damage related to a “dirty” bomb is related to the power of the blast rather than the radiation. Following a terrorist attack, it is important to identify all individuals who might have been exposed to radiation. The initial treatment of these individuals should be to stabilize and treat the most severely injured. Those with severe injuries should have contaminated clothing removed prior to transportation to the emergency department, but further care should not be withheld for additional decontamination because the risk of exposure to healthcare workers is low. Individuals with minor injuries who can be safely decontaminated without increasing the risk of medical complications should be transported to a centralized area for decontamination. A further consideration regarding treatment following radiation exposure is the total dose of radiation that an individual was exposed to. At a dose <2 Gy, there are usually no signifcant adverse outcomes and no specific treatment is recommended unless symptoms develop. Many individuals will develop flulike symptoms. However, a complete blood count should be obtained every 6 hours for the first 24 hours because bone marrow suppression can develop with radiation exposure as low as 0.7 Gy. The earliest sign of this is a fall in the lymphocyte count of >50%. Potential treatments of radiation exposure include the use of colony-stimulating factors and supportive transfusions. Stem cell transfusion and bone marrow transplantation can be considered in the case of severe pancytopenia that does not recover. However, this is controversial, given the lack of experience with the procedure for this indication. Following the Chornobyl nuclear reactor accident, none of the bone marrow transplants were successful.