FM 4-02.283 TREATMENT OF NUCLEAR AND RADIOLOGICAL CASUALTIES (December 2001) - page 3

 

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FM 4-02.283 TREATMENT OF NUCLEAR AND RADIOLOGICAL CASUALTIES (December 2001) - page 3

 

 

FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Table 4-3. Clinical Stages of the Cutaneous Radiation Syndrome
STAGE
DEFINITION
SYMPTOMS
OCCURRENCE
DURATION
SYNONYMS
(POSTEXPOSURE TIME)
1
Prodromal
Erythema itch
Minutes to hours
4 to 36 hours
Early erythema
2a
Manifest
Erythema
Days to 2 weeks
2 to 12 weeks
Main erythema
2b
Manifest
Blisters; Dry/moist
Days to 2 weeks
2 to 12 weeks
Main erythema
desquamation
Burn
2c
Manifest
Ulcers
Days to 2 weeks
2 to 12 weeks
Main erythema
3
Subacute
Erythema; Ulceration
6 to 9 weeks
2 to 4 months
Late erythema
4
Chronic Fibrosis
Keratosis; Ulceration
Indefinite to 2 years
Progressive
Telangiectatic
5
Late
Neoplasia; Ulceration
Years to decades
Indefinite
Angiomas
b. Chronic Cutaneous Radiation Syndrome. In the chronic stage of the CRS, three clinical
manifestations dominate the course:
• Radiation keratoses can develop in any exposed area. These lesions must be considered
precancerous and should be monitored thoroughly. Single lesions may be excised.
• Radiation fibrosis is caused by an increase of collagenous tissue from dermal and
subcutaneous fibroblasts and may lead to pseudoatrophy of fatty tissue. Fibrosis may lead to vasculature
occlusion and cause secondary ulceration.
• Telangiectasis are a characteristic sign of the chronic stage of the CRS in humans. Apart
from cosmetic disfiguring, they may cause a permanent itching sensation and a disturbing feeling of warmth.
4-7.
Treatment of the Cutaneous Radiation Syndrome
Standardization of treatment is difficult to achieve due to the rarity of this syndrome. An established
treatment scheme does not exist. Differing procedures in documentation of accidents further reduce the
comparability of therapeutic efforts in differing accident situations. Whatever the circumstance, treatment
must provide symptomatic relief and minimization of additional risk to the patient. Recommended therapies,
dosages, and the therapeutic outcome are summarized in Table 4-4.
a. Experience in the management of the manifest stage of CRS is limited to radiotherapy patients.
In these conditions, an erythematous and erosive condition occasionally occurs, that is often associated with
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a burning itch. Treatment with Loratadine, a non-sedating and mast-cell-stabilizing antihistamine, induced
a marked relief of these symptoms and a shortening of the erythematous phase. Topical steroids generally
have been used with success. Additional treatment modalities that have been reported to be of value in the
manifest stage are cleansing of the oral cavity and administration of pilocarpine for prevention of mucositis.
Heparinization and antibiotic prophylaxis for bacterial and viral infections may be beneficial.
Table 4-4. Symptom-Oriented Therapy for the Cutaneous Radiation Syndrome
SYMPTOM
TREATMENT
APPLICATION
DOSAGE
RESULT
SIDE EFFECTS
Pruritus
Antihistamines
Oral
As appropriate
Relief of itch
Sedation
Erythema
Steroids
Topical
2 X daily
Alleviation
None when used less
than 3 weeks
Blisters
Steroids TCDO
Wet dressing
3 X daily
Alleviation
Dryness
Linoleic acid cream
Topical
1 X daily
Inhibition of
water loss
Keratoses
Tretinoin
Topical
1 X daily
Clearance
Irritation;
Acitretin
Oral
0.1-0.3 mg/kg
moderate
dryness of lips
Inflammation
Mometasone
Topical
3–4 X week
Alleviation
Fibrosis
IFN gamma
Subcutaneous
50 mg 3 X week
Reduction
Fever
PTX and
Oral
400 mg 3 X daily
Reduction
Vitamin E
+ 300 mg 1 X daily
b. Treatment modalities for the chronic stage of the CRS were developed from Chernobyl
sequelae and from therapeutic irradiation patients. Chernobyl patients responded well to a basic therapy
with a linoleic acid ointment that blocked transepidermal water loss. Symptomatic telangiectasias
disappeared after treatment by an Argon laser. Tretinoin cream 0.005 percent applied once daily, led to
clearance of focal and patchy radiation keratoses, however, the cream appeared to cause more irritation
than is common in patients with actinic keratoses. Intermittent anti-inflammatory treatment with topical
nonatrophogenic steroids (Mometasone Buroate) was necessary. In more extensive lesions, oral application
of the retinoid Acitretin (0.1–0.2 mg/kg daily) was used, analogous to the reported treatment of radiation-
induced keratoacanthomas.
c.
Subcutaneous administration of Interferon (IFN) has been beneficial to patients with severe
and extensive radiation fibrosis (IFN gamma, 50 mg subcutaneously three times per week for 18 months).
Using a protocol for scleroderma patients, fibrosis may be reduced almost to the level of uninvolved
contralateral skin. Side effects included low-grade fever to 38.5°C after the first two injections. The
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efficacy of IFN gamma may be explained in part by its antagonistic effect towards the cytokine TGF-beta,
which is of importance for the induction of radiation fibrosis. Another therapeutic option for radiation
fibrosis is the combined administration of PTX (400 mg three times daily) and vitamin E (400 mg once
daily). This regimen, applied for a minimum of 6 months, ameliorated persistent radiation fibrosis that had
been progressive for over 20 years. Topical dressings of TCDO induce considerable granulation and re-
epithelization in erosive skin conditions. Radioprotective properties of TCDO have been reported in
experimental models that also demonstrated regenerative capacities in complicated wounds.
d. Appropriate surgical procedures include excision of ulcers and contractures, wound closure by
split and full thickness skin grafts, and in certain instances, vascularized flaps. Grafts usually heal without
complications, including situations where the surrounding tissue may be affected by late radiation effects.
The surgical experience, derived from patients with skin fibrosis after deeply penetrating radiation therapy,
was that skin grafts do not heal if the surrounding affected tissue is not completely removed.
Section II. INTERNAL CONTAMINATION AND IRRADIATION
4-8.
General
Internal irradiation occurs when unprotected personnel ingest or inhale radioactive contaminants, or have
contaminants become internalized via a traumatic wound. Large intakes of some radioactive contaminants
pose significant health risks. These risks are largely long-term in nature and depend not only on the type and
concentration of the radioactive contaminant absorbed, but also on the health background of the exposed
individual. Potential cancers of the lung, liver, thyroid, stomach, and bone among others are the principal
long-term health concerns (see Chapter 5). Contamination evaluation and therapy must never take
precedence over treatment of conventional acute injuries. However, early recognition of internal
contamination provides the greatest opportunity for removal of the contaminant, thus reducing the potential
for further injury. See National Council on Radiation Protection and Measurements (NCRP) Report No.
65, Management of Persons Accidentally Contaminated With Radionuclides, for further detailed information
on internal irradiation.
4-9.
Internalization of Radioactive Materials
The severity of internal contamination is dependent on the same processes that determine clinical severity
related to exposure to nonradioactive toxins. Severity is dependent on the route of exposure, chemical and
physical form of the nuclide, total intake of the radionuclide(s), and its distribution and metabolism within
the body.
a. Intake. In order of decreasing frequency, contaminants enter the body principally by the
following four routes:
• Inhalation.
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• Ingestion.
• Wound contamination.
• Skin absorption.
(1) Inhalation. Inhalation is the primary intake route for radioactive contamination.
Absorption is dependent on the particle size of the contaminant and on its solubility in the lung. The
contaminant’s particle size determines its deposition within the respiratory tract. For example, particles
smaller than 5 microns will reach the alveolar area. Those smaller than 1 micron will be naturally respired
as the individual breathes out and those between 1 and 5 microns will be deposited in the alveoli. Ninety
percent of the particles greater than 5 microns never reach the alveoli. For those particles deposited in any
area of the respiratory tract, their absorption depends on the chemical solubility of the contaminant. Soluble
particles will be absorbed directly into the circulatory system through either the blood stream or the
lymphatic system and will ultimately be distributed throughout the body. The rate of absorption will probably
be quicker via the alveoli than via the upper respiratory tract due to the enhanced blood supply in the alveolar
beds. Insoluble particles will remain within the respiratory tract. Those insoluble particles within the upper
respiratory tract will be cleared by the mucociliary apparatus but until they are cleared, they will continue to
irradiate the surrounding tissues which can lead to fibrosis and scarring in the respiratory tract. In addition,
most of the secretions from the upper respiratory tract will reach the pharynx and be swallowed and result
in internal exposure through the GI tract (see Table 4-5).
Table 4-5. Clearance Times of Various Branches of the Human Respiratory Tract
for Insoluble Particulates
STRUCTURE
CLEARANCE TIME (HOURS)
CUMULATIVE TIME (HOURS)
Trachea
0.1
0.1
Bronchi
1.0
1.1
Bronchioles
4.0
5.1
Terminal Bronchioles
10.0
15.1
Alveoli
100+ days
100+ days
(2) Ingestion. Radioactive material can enter the GI tract through eating contaminated
foodstuffs, transferring contamination from hands to mouth, or by swallowing contaminated mucous
transported to the pharynx from contamination in the lung. Absorption of the radionuclide through the crypts
of the small intestine is dependent again on the contaminant’s physical and chemical characteristics.
However, most ingested heavy metal radionuclides will pass through the gastrointestinal tract without being
absorbed into the systemic circulation. For example, only 20 percent of radium that is ingested is absorbed,
only 30 percent of strontium that is ingested is absorbed, but 100 percent of tritium, iodine, and cesium that
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are ingested is absorbed. It is the large intestine that receives the greatest radiation exposure due to the
slower transit time for ingested materials. Clearance times of the human GI tract are shown in Table 4-6.
Table 4-6. Clearance Times of the Human Gastrointestinal Tract
ORGAN
MEAN EMPTYING TIME
AVERAGE OCCUPANCY TIME
(HOURS)
(HOURS PER DAY)
Stomach
1
6
Small Intestine
4
14
Upper Large Intestine
13–20
18
Lower Large Intestine
24
22
(3) Wound contamination. Wounds are classified as abrasions, lacerations, or punctures.
The differing characteristics of each type of wound affect the absorption and decontamination of radioactive
substances. Abrasions present a large surface area denuded of intact skin that decreases the skin barrier
and increases the potential for absorption. Generally, they are easy to decontaminate due to easily accessible
contaminants. Lacerations also are easy to decontaminate because the contaminated tissue can be excised.
Puncture wounds, however, are difficult to decontaminate because of poor access to the contaminants and
because of difficulty in determining the depth of the wound as well as the depth of contamination. Solubility,
acidity/alkalinity, tissue reactivity, and particle size affect the absorption of a contaminant within a wound.
For example, the more soluble the contaminant, the greater the absorption rate. In addition, comparatively
smaller particles may be phagocytized in the tissues more rapidly and thus internalized more rapidly.
(4) Skin absorption. The skin acts as a physical barrier with the horny epithelial layer acting
as the primary barrier. Percutaneous absorption occurs by passive diffusion, and is not a major concern
except with tritium. Skin that has been mechanically damaged, as from repeated abrasive scrubbing, allows
for greater absorption. Skin that has been exposed to certain chemicals like dimethyl sulfoxide is also more
permeable. Absorption through sweat glands and hair follicles is a minor concern since, overall, they
constitute only a small surface area.
b. Distribution. Once a radionuclide is absorbed, it is distributed throughout the body via the
circulatory and lymphatic systems. The rate of distribution to each organ is relative to the lymphatic or
blood flow through that organ and the metabolic rate of the organ. Deposition is related to the ease of
transport of the radionuclide or its metabolites across cell barriers in a given organ, and the metabolic
processes of the tissue that may involve an affinity for a given radionuclide or nuclide metabolites.
c.
Metabolism and Excretion. After uptake into a particular organ, a radionuclide will be
metabolized according to its chemical properties and will be excreted either in its original state or as a
metabolite. The biologic half-life of a radionuclide, determined by its rate of metabolism and excretion, is
as important as its radiological half-life in determining the significance of the exposure to a specific tissue.
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Most ingested heavy metal nuclides (depending upon the oxide state) will pass through the gastrointestinal
tract unchanged. The primary routes of excretion for absorbed radionuclides are through the urinary tract
via the kidneys, the GI tract via the liver and common bile duct, and the lungs. Minor routes of excretion
include sweat, saliva, milk, and seminal fluid. In general, compounds that are water soluble are excreted
through the urine, while lipid-soluble compounds are excreted via the bile into the intestine.
4-10. Internal Contamination Treatment
a. Immediate Care. As discussed earlier, skin or wound contamination is almost never
immediately life threatening to the patient or to medical personnel. Therefore, attending to conventional
trauma injuries is the first priority. As soon as the patient’s condition permits, steps should be taken to
determine if internal contamination has occurred. Nasal swab samples for radioactivity should be obtained
as early as possible. However, under some situations inhalation exposures may not have an accompanying
positive nasal result. If contamination is present, especially in both nostrils, it is presumptive evidence that
inhalation of a contaminant has occurred. A urine sample and feces sample should also be collected to help
determine whether internal contamination has occurred.7 Advice on collection procedures are discussed in
detail in the NCRP Report No. 65, and may also be provided by a medical military physicist.
b. Treatment Procedures. Treatment of persons with internal contamination focuses on reducing
the radiation dose from absorbed radionuclides and hence the risk of long-term biological effects. Two
general processes are used to achieve this goal: reducing the absorption of radionuclides and their deposition
in target organs and increasing excretion of the radionuclides from the body. A number of procedures are
available for respiratory contamination and GI contamination. As with any medical treatment, the clinician
should consider the risks and benefits to the patient. The benefit of removing the radioactive contaminant
using modalities associated with significant side effects and morbidity must be weighed against the short-
and long-term effects of contamination without treatment. The radioactivity and the toxicity of the
internalized radionuclide must also be considered. Risk estimates include professional judgment combined
with the statistical probability of radiation-induced diseases occurring within a patient’s lifetime. Some of
the immediate simple treatment procedures include: 8
(1) Oral and nasopharyngeal irrigation.
(2) Stomach lavage until stomach washings are relatively free of radioactive material.
(3) Emetics to induce vomiting. Emetics are most effective when taken with 200–300 ml of
water. However, they are contraindicated if the state of consciousness is impaired, such as in the states of
shock or inebriation, or after ingestion of corrosive agents or petroleum hydrocarbons.
(4) Purgatives or laxatives to enhance intestinal motility.
(5) Enemas or colonic irrigations to reduce the time radioactive materials remain in the colon.
7. Ibid.
8. Ibid.
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c.
Therapeutic Agents. The most important considerations in treatment are the selection of the
proper drug for a particular radionuclide, and the timely administration of the drug after the exposure.
Some of the treatment agents which could be used are presented below, with specifics for each agent shown
in a detailed listing in Appendix B, and in NCRP Report No. 65.
(1) Prussian blue. The US Food and Drug Administration has removed earlier restrictions
on the use of Prussian Blue (ferric ferrocyanide) in the US. It has been approved as an investigational new
drug, and the Radiation Emergency Assistance Center/Training Site (REAC/TS) has the license for research
use. Prussian blue is indicated for treatment of cesium, thallium, and rubidium contamination. This
chemical is not absorbed by the GI tract and it works through two modes of action. It decreases the
absorption of many radionuclides into the GI tract, and removes some radionuclides from the capillary bed
surrounding the intestine and prevents their reabsorption. Prussian Blue is most effective when given early
after ingestion and serially thereafter.
(2) Blocking and diluting agents. Blocking and diluting agents work by preventing the uptake
of a radionuclide in a target organ or by overwhelming the organ with stable compounds that reduce the
uptake and incorporation of the radionuclide into that target organ. Potassium iodide is an excellent example
of a blocking agent, and must be given before or within 6 hours of exposure to radioiodine (see Table 4-7).
Table 4-7. Recommended Prophylactic Single Doses of Stable Iodine
AGE GROUP
MASS OF TOTAL
MASS OF KI
MASS OF KIO3
VOLUME OF LUGOLS
IODINE
SOLUTION
Adults/adolescents
100 mg
130 mg
170 mg
0.8 ml
(over 12 yrs)
Children (3–12 yrs)
50 mg
65 mg
85 mg
0.4 ml
Infants (1 mo–3 yrs)
25 mg
32.5
42.5
0.2 ml
Neonates (birth–1 mo)
12.5 mg
16 mg
21 mg
0.1 ml
(3) Mobilizing agents. Mobilizing agents are compounds that increase the excretion of
internal contaminants. Examples of mobilizing agents are the antithyroid medications—(propylthiouracil,
methimazole, and potassium thiocyanate), ammonium chloride, and diuretics.
(4) Chelating agents. Chelators are a specific type of mobilizing agent that enhances the
elimination of metals from the bloodstream before they reach target organs. For example, chelation is
ineffective at removing plutonium already deposited in the bone. Chelators are organic compounds (ligands)
that exchange less firmly bonded ions for metal ions. This stable complex, the chelator and the metal, is then
excreted by the kidney. Chelation therapy has been used for enhanced elimination of lead, mercury,
arsenic, and other heavy metals. In addition, chelation therapy has been used to treat internal radiation
contamination on a limited basis. When used to treat internal radiation contamination, radioactivity levels
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from samples of urine and feces must be followed as well as radioactivity levels based on total body and
chest counts. Continuation of therapy is determined by assessing chelation yield in urine and feces with
remaining body burden. No serious toxicity in humans has been reported when chelators are used in
recommended doses. Examples of chelators include meso-2,3-dimercaptosuccinic acid (DMSA), 2,3-
dimercapto-1-propanesulfonic acid (DMPS), calcium diethylenetriaminepentaacetic acid (CaDTPA), and
DTPA.
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CHAPTER 5
LOW-LEVEL RADIATION
5-1.
Low-Level Radiation Characteristics and Hazards
a. For purposes of this manual, LLR patients are those who have received doses of 75 cGy or
less. Low-level radiation may be present in dispersed radioactive material in solid, liquid, gaseous, or
vapor form, or in the form of discrete point sources. All of the types of radiation described in Chapter 2
(alpha, beta, neutron, and gamma) may be emitted by the material present in LLR sources. Sources of LLR
were discussed in detail in Chapter 1, and are generally radioactive material from nuclear facilities (power
plants), industrial and medical commodities, RDDs, nuclear weapons incidents, and military commodities.
b. The current threat to US Forces involve primarily terrorist actions with improvised nuclear
devices or RDDs, and hazards due to nuclear incidents. In contrast to the risks associated with nonstrategic
or strategic nuclear war, the risk of exposure to low-level radiation is more limited geographically, involves
a limited number of individuals, requires more documentation of exposure history and treatment, and the
immediate health risks to exposed personnel are generally much lower. Except in rare circumstances, the
radiation doses received if these hazards are encountered would likely be well below those that would cause
observable deterministic health effects, with only minor changes in blood CBCs expected at the highest
doses in this range. However, they could be above the US and host nation occupational dose limits that are
applied to civilian workers and military personnel assigned to routine duties involving radiation exposure.
Because of this, doctrine development goes beyond helping military personnel to survive acute radiation
injuries. It now includes medical care and follow-up for delayed health effects from low-level radiation
exposures (primarily the development of radiation induced cancer). This chapter will cover low-level
radiation exposure guidance, delayed/late health effects, prevention, medical care for exposed personnel,
long-term medical follow-up, and documentation of medical records. Further, these medical considerations
will likely be a part of the commander’s operational plan.
Section I. LOW-LEVEL RADIATION EXPOSURE
5-2.
Exposure Guidance
a. In peacetime while not deployed, radiation exposures of service members whose normal
operational duties include, for example, handling of military radioactive commodities, are governed by
Department of Defense Instruction (DODI) 6055.8, Occupational Radiation Protection Program, federal
regulations governing radiation protection, and service specific instructions and regulations. These
limitations are comparable to civilian worker protection regulations that govern radiation protection
“practices.” However, they do not specifically address nonoccupational exposures for military operations,
such as a maneuver unit moving into a radiologically hazardous area. Radiation exposure control measures
in these situations must balance the requirement to adequately protect individual service members with
mission execution. The fundamental radiation protection principle of ALARA (as low as reasonably
achievable) still applies.
b. The occupational annual dose limit is 5 cGy, while 75 cGy is the threshold for the development
of acute health affects that become a concern in nuclear war. The most current exposure guidance between
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these two limits is found in Table 5-1 which is from NATO STANAG 2473, Commanders Guide on Low-
Level Radiation (LLR) Exposure in Military Operations. The exposure guidance applies to missions with
durations ranging from minutes to one year. The risks associated with radiation exposure within this range
of 5 to 75 cGy are confined primarily to the risk of increased incidence of malignant diseases, including solid
tumors and leukemias (see Section II, Delayed/Late Health Effects). Added to this table, are medical notes
for each RES and the stochastic risk of long-term health effects as adapted from AMedP-6(C), NATO
Handbook on Medical Aspects of NBC Operations, Ratification Draft. Military operations may require that
national peacetime regulations governing exposure be exceeded, as when performing humanitarian,
lifesaving, and/or emergency operations. All exposure to radiation must be justified by necessity and
subjected to controls that maintain doses within the concept of ALARA. Refer to STANAG 2473, Annexes
C and D for exposure limits while operating in contaminated areas.
Table 5-1. Low-Level Radiation Guidance for Military Operations
TOTAL CUMULATIVE
RADIATION
RECOMMENDED
STOCHASTIC
MEDICAL
DOSE (SEE
EXPOSURE STATE
ACTIONS
RISK
NOTES
NOTES 1 AND 2)
CATEGORY
0–0.05 cGy
0
–None
Normal Risk: < 0.004%
US baseline 20%
lifetime risk of fatal
cancer.
0.05-0.5 cGy
1A
–Record individual dose readings.
Up to 0.04% increased
None
–Initiate periodic monitoring
risk of lifetime fatal
(including air and water).
cancer.
0.5-5 cGy
1B
–Record individual dose readings.
0.04%–0.4% increased
Reassurance
–Continue monitoring.
risk of lifetime cancer.
–Initiate rad survey.
–Prioritize tasks.
–Establish dose control measures
as part of operations.
5-10 cGy
1C
–Record individual dose readings.
0.4%–0.8% increased
Counsel regarding
–Continue monitoring.
risk of lifetime fatal
increased long-
–Update survey.
cancer.
term risk; no live
–Continue dose control measures.
virus vaccines
–Execute priority tasks only
for 3 months.
(see note 3).
10-25 cGy
1D
–Record individual dose readings.
0.8%–2% increased
Potential for
–Continue monitoring.
risk of lifetime fatal
increased
–Update survey.
cancer.
morbidity of other
–Continue dose control measures.
injuries or
–Execute critical tasks only
incidental disease.
(see note 4).
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Table 5-1. Low-Level Radiation Guidance for Military Operations (Continued)
TOTAL CUMULATIVE
RADIATION
RECOMMENDED
STOCHASTIC
MEDICAL
DOSE (SEE
EXPOSURE STATE
ACTIONS
RISK
NOTES
NOTES 1 AND 2)
CATEGORY
25-75 cGy
1E
–Record individual dose readings.
2%–6% increased
Increased
–Continue monitoring.
risk of lifetime fatal
morbidity of other
–Update survey.
cancer.
injuries or
–Continue dose control measures.
incidental
–Execute critical tasks only
disease.
(see note 4).
NOTES:
1. The use of the measurement multiple of Sv is preferred in all cases However, due to the fact that normally the military has only
the capability to measure cGy, as long as the ability to measure in mSv is not possible, NATO forces will use cGy. For whole
body irradiation, 1 cGy = 1 cSv.
2. All doses should be kept ALARA. This will reduce individual soldier risk as well as retain maximum operational flexibility for
future employment of exposed soldiers.
3. Examples of priority tasks are those missions to avert danger to persons or to prevent damage from spreading.
4. Examples of critical tasks are those missions required to save lives.
Section II. DELAYED/LATE HEALTH EFFECTS
5-3.
General
Delayed health effects may appear months to years after irradiation and include a wide variety of effects
involving almost all tissues or organs. Some of the possible delayed consequences of radiation injury are
carcinogenesis, cataract formation, chronic radiodermatitis, and decreased fertility. However, it should be
emphasized that many victims of exposure to radiation do not manifest late term effects. The Hiroshima,
Nagasaki, and Russian experiences have not shown any genetic effects in humans. At the lower levels of
exposure (background levels to 75 cGy), the risk of effects such as cancer and genetic effects tends to be
stochastic in nature, relating more to a stochastic response in exposed populations than to exposed individuals.
Health risks incurred tend to be long-term in nature, and not immediate, therefore lacking significant
operational impact. These risks may, however, manifest themselves as a significant disease long after the
completion of the military operation.
5-4.
Principles
In relation to associated long-term health risks, several principles need to be reviewed. For purposes of
radiation protection, it is assumed that the risk of stochastic health effects is proportional to the dose
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received. In addition, biological factors relative to the irradiated individual should be considered; for
example, age and sex of the individual, health status, and the individual’s genetic makeup. In addition to the
total dose factor, radiological parameters that factor into long-term health risks include—
• Exposure rate and quality of the radiation.
• Location of the source (external versus internal).
• Nature of exposure (continuous versus fractionated versus protracted; prompt external
exposure versus chronic dosing).
• Time after exposure and requisite repair times and latency times required for pathologies to
manifest.
5-5.
Types of Long-Term Effects
a. Deterministic effects are those that require a certain threshold dose to be exceeded before the
effect is observed, and for which the severity of the effect is proportional to dose. They include both acute
and delayed effects. While individual variations will occur due to individual sensitivity, the severity of the
effect is still directly dose related. Tissue fibrosis, chronic immune system suppression, reproductive tissue
dysfunction, and selected ocular problems are some of the more common and serious symptoms of the late-
arising deterministic pathologies. Formation of ocular cataracts is the most common delayed radiation
injury. Higher doses tend to increase the degree of opacity and shorten the period of latency. Immune
system defects occur at doses of 50 cGy and larger.
b. A stochastic effect is a consequence based on statistical probability. For radiation, tumor
induction is the most important long-term sequelae for a dose of less than 100 cGy. Most of the data utilized
to construct risk estimates are taken from radiation doses greater than 100 cGy, and then extrapolated down
for low-dose probability estimates. There is no substantive epidemiological data that demonstrates stochastic
health effects for whole body doses less than 10 cGy. Subsequently, there is considerable scientific debate
on the actual dose-response relationship for low-level exposures.
5-6.
Embryonic and Fetal Effects
Radiation-induced embryonic/fetal effects have been clearly documented by the increased mental retardation
in Japanese children irradiated in utero as result of the nuclear bomb detonations over Hiroshima and
Nagasaki. The direct military relevance of these fetal effects
(as well as related ones, including
microcephaly, microphthalmia, reduced growth, skeletal defects, neoplasias, and cataracts) is questionable.
Further, the embryonic responses appear to have a broad exposure threshold for induction, with significant
responses being noted only at doses greater than 15 cGy. The current normal incidence rate of occurrence
of congenital abnormalities is 3 to 5 percent of live births. No increase in this rate has ever been observed
among radiation exposed humans.
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5-7.
Reproductive Cell Kinetics and Sterility
a. Despite the high degree of radiosensitivity of some stages of germ cell development, the testes
and ovaries are only transiently affected by single sublethal doses of whole body irradiation and generally go on to
recover normal function. Temporary male sterility due to damage to spermatogonia will occur after 15 cGy of
local or whole body irradiation. As this is a maturation depletion process, the azoospermia will not occur until two
months after irradiation. Protracted radiation exposure will cause a more prolonged episode of azoospermia.
Serum levels of testosterone will be unaffected. Female reproductive tissues appear more resistant.
b. When chromosome aberrations are produced in somatic cells, the injury is restricted to the
specific tissue or cell system. However, when aberrations occur in germ cells, the effects may be reflected
in subsequent generations. Most frequently, the stem cells of the germ cell line do not develop into mature
sperm cells or ova, and no abnormalities are transmitted. If the abnormalities are not severe enough to prevent
fertilization, the developing embryos will not be viable in most instances. Only when the chromosome damage
is very slight and there is no actual loss of genetic material will the offspring be viable and abnormalities be
transferable to succeeding generations. These point mutations become important at low radiation dose levels.
In any population of cells, spontaneous point mutations occur naturally. Radiation increases the rate of these
mutations and thus increases the abnormal genetic content of future cellular generations.
5-8.
Carcinogenesis
Irradiation of almost any part of the body increases the probability of cancer. The type formed depends on
such factors as area irradiated, radiation dose, age, and other demographic factors. Irradiation may either
increase the absolute incidence of cancer or accelerate the time or onset of cancer appearance, or both.
There is a latent period between the exposure and the clinical appearance of the cancer. In the case of the
various radiation-induced cancers seen in man, the latency period may be several years. Latent periods for
induction of skin cancers in man have ranged from 10 to 50 years after therapeutic x-ray exposures, to a
reported 15 years for bone tumors after radium exposure. This latency related to bone tumors is very
dependent upon the dose and type of radiation emitted by the radionuclide.
a. A leukemogenic effect was expected and found among Hiroshima and Nagasaki survivors.
The peak incidence occurred 6 years after exposure and was less marked for chronic granulocytic leukemia
than for acute leukemia. British men receiving radiotherapy for spondylitis showed a dose response
relationship for leukemia, with peak incidence occurring 5 years after the first exposure. Studies have
demonstrated that ionizing radiation can induce more than one kind of leukemia in man, but not chronic
lymphocytic leukemia.
b. It is difficult to address the radiation-induced cancer risk of an individual patient due to the
already high background risk of developing cancer over a lifetime. Current National Academy of Sciences
reports estimate that the lifetime risk of fatal cancer occurrence is increased by 770 cases per 100,000 persons/10
cGy for males and 810 cases per 100,000 persons/10 cGy for females. To illustrate this effect, the US
background lifetime fatal cancer incidence rate is 20,000 cases per 100,000 persons. Therefore, if a mixed
group of 100,000 people receive 10 cGy single dose irradiation, instead of 20,000 cancers, approximately
20,800 fatal cancers would occur. Deciding which 800 of these 20,800 cases were radiation-induced is
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impossible. National cancer incidence rates vary as do the corresponding risk estimates, and account should
be taken of these variables.
c.
The more important radiobiological conditions that factor into cancer induction (or for that
matter any of the somatic effects) include those parameters previously mentioned, namely dose, dose-rate,
and radiation quality. Cancer is not a single disease, but a complex of diseases comprised of both cancers of
the blood (leukemias), and cancers of solid tissues of both epithelial and mesothelial origins. The radiogenic
nature of these specific cancers differs substantially. Bone tumors
(osteosarcomas) serve as a good
example, as they are prominent late arising pathologies associated with internally deposited, bone-seeking
radionuclides such as Strontium-90. However, bone tumors are rarely associated with the cancers that stem
from exposure to external radiation sources such as Cobalt-60.
d. Cancer types that are unequivocally inducible by ionizing radiation are the lymphohematopoietic
cancers, cancers of the lung, mammary tissues, liver, thyroid, colon, stomach, pancreas, salivary glands,
and kidneys. Cancers with either a low incidence or a low probability of induction include cancers of the
larynx, nasal sinuses, parathyroid, nervous tissue, and connective tissue. Cancers that are probably not
inducible include the chronic lymphocyte leukemias and cancers of the uterus, cervix, prostate, testis,
mesentery, and mesothelium. The nominal risks for radiation induced cancers and fatal cancers for the
general population are given in Table 5-2. The information presented is an International Council on Radiation
Protection (ICRP) summary of risks as presented in the reference manual for the Oak Ridge Institute for
Science and Education course on Medical Planning and Care in Radiation Accidents. Note that these values
should not be used to interpret individual risks, which are dependent on numerous factors such as age, sex,
heredity and environment.
Table 5-2. International Council on Radiation Protection Summary of Risks per Milligray
EFFECT
RISK PER MILLIGRAY
Hereditary
10 x 10-6 (all generations)
Cancer
Fatal Probability
Leukemia (active marrow)
5 x 10-6
Skin
0.2 x 10-6
Breast (females only)
4 x 10-6
Stomach
11 x 10-6
Sum of fatal cancer risk for whole
50 x 10-6 (1 in 20,000)
body irradiation (males and females)
Baseline cancer mortality
0.15 (1 in 6.7) to 0.25 (1 in 4)
5-9.
Cataract Formation
A late effect of eye irradiation is cataract formation. It may begin anywhere from 6 months to several years
after exposure. While all types of ionizing radiation may induce cataract formation, neutron irradiation is
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especially effective in its formation, even at relatively low doses. Cataract formation begins at the posterior
pole of the lens and continues until the entire lens has been affected. Growth of the opacity may stop at any
point. The rate of growth and the degree of opacity are dependent upon the dose as well as the type of
radiation. According to BEIR V, Health Effects of Exposure to Low Levels of Ionizing Radiation, cataract
formation has been observed in atomic bomb survivors from exposures estimated at 60 to 150 cGy.
However, the threshold in persons treated with x-rays to the eye range from about 200 cGy for a single
exposure to more than 500 cGy for multiple exposures over a period of weeks. A 50 percent cataract risk
has been estimated at acute doses of approximately 300 cGy. This estimate assumes a low LET exposure,
and it has been recently suggested that with high LET particle irradiation, the initiating cataractogenic dose
might be considerably lower, well within 70 cGy.
Section III. PREVENTION, INITIAL ACTIONS
AND MEDICAL CARE AND FOLLOW-UP
5-10. Prevention
Military operations may require that regulations governing occupational exposure be exceeded. However,
all exposure to radiation must be justified by necessity and subjected to controls that maintain doses
ALARA. There are several measures commanders and units can take to prevent or reduce radiation
exposure. For example, the commander may establish individual protective clothing measures, such as
specifying mission-oriented protective posture (MOPP) levels. For a detailed discussion of protective
measures, see FM 3-4, NBC Protection, which is under revision as a multiservice manual. Medical
personnel contribute to the prevention effort by providing input into the following staff actions:
• A risk assessment that includes analysis of intelligence information on the area of operations.
This analysis should provide information on civil nuclear facilities, industrial radioactive sources, and
medical radioactive sources present in the area of operations.
• Development of contingency plans that deal with the most likely risks. These plans should
identify the potential risks, possible incident scenarios, and medical response actions. The plan should also
specify dose limits and identify RADIAC equipment available.
• When the possibility of exposure exists, equip deploying forces with dosimeters and other
radiation detection devices. Within equipment constraints, equip as many individuals as possible. Priority
will go to units which have the greatest risk of exposure. Ensure that medical facilities conduct radiation
detection as part of initial patient medical survey/entry procedures.
• Establishment of hazard avoidance measures including control and restriction of entry into
nuclear installations and radioactive areas, ensuring personnel do not tamper with radiological containers,
and clearance of suspected radioactive waste dumps.
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5-11. Initial Actions
If personnel encounter a radiological hazard, initial actions may include evacuation from the area, calling in
the proper NBC reports, informing the local civil authorities, and requesting specialized monitoring and
survey teams. At this time, medical personnel will provide input into staff estimates and plans that will
establish control measures to contain the LLR hazard. This would include advice on modifying the
commander’s OEG and adherence to established guidance. The medical staff must also advise the
commander on the monitoring and dose recording of those individuals, who for operational reasons, must
remain within the hazard area.
5-12. Medical Care
Medical care following exposure to low-level radiation involves the diagnosis and management of both the
early and delayed deterministic events from doses above threshold levels (bone marrow depression, skin
injuries), and the management of stochastic effects, primarily nonspecific tumors and leukemia that may
become clinically evident years after exposure to radiation. Within the low-level dose range (5 to 75 cGy),
the greatest risk is the appearance of stochastic effects, that is, the appearance of benign and malignant
tumors and leukemia years after the event. However, because of the uncertainty of the dose that may be
received during certain situations, deterministic effects may appear within months of certain types of acute
exposures.
a. Early and Delayed Deterministic Effects. It is unlikely that symptoms of deterministic effects
will appear due to acute whole or partial body radiation doses of less than 100 cGy. Early evidence of acute
radiation-induced cellular injury, for example, structural changes in the chromosomes of some circulating
lymphocytes, and falls in the absolute lymphocyte and sperm counts, is, however, clinically detectable in
asymptomatic individuals who have received lower doses.9
b. Stochastic Effects. The primary stochastic late effect of exposure to radiation is the
development of radiation-induced tumors and leukemia (see paragraph 5-8). Radiation-induced or radiogenic
tumors are histologically and clinically indistinguishable from spontaneously occurring tumors. Their
diagnosis, treatment, and management are the same as those for spontaneously occurring cancers of the
same type.10
5-13. Medical Follow-Up
The low-level dose range (5 to 75 cGy) is unlikely to cause delayed acute or chronic deterministic effects.
Therefore, this paragraph will address medical follow-up actions involved with the main long-term effect of
radiation exposure—malignant disease.11
9. Potential Radiation Exposure in Military Operations, Protecting the Soldier Before, During, and After
(National Academy of Sciences, 1999).
10. Ibid.
11. Ibid.
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a. Medical Assessment. Medical assessment is the evaluation of the basic parameters of general
and radiological health status after a known or suspected exposure to radiation or radioactive contamination.
Such an evaluation may be prompted by the development of nonspecific symptoms, trauma, or an observed
degradation of individual performance during or after a military operation conducted in an area of known or
suspected radiation or radioactive contaminants. Personnel are not likely to develop symptoms of acute
radiation exposure at the low-level dose range; however, medical assessment is recommended after
personnel exit radiologically hazardous areas. The purpose of the assessment of asymptomatic individuals
in these situations is to—
• Rule out that personnel were exposed to higher than expected doses.
• Obtain baseline clinical data to assist in estimating the individual’s radiation dose.
• Establish a basis for recommendations regarding the individual’s need for medical care,
periodic monitoring, or specific testing.
b. Medical Monitoring.
(1) Medical monitoring is a systematic screening of a population of asymptomatic individuals
for preclinical disease with the purpose of preventing or delaying the development and progression of
chronic disease in those individuals. However, medical monitoring after radiation exposure is not routinely
suggested or practiced for individuals with known or suspected exposures to radiation. An exposure or a
presumed exposure to radiation is not, by itself, sufficient to justify a medical monitoring program. The
decision about whether a medical monitoring program is appropriate and necessary in a given situation
should be based on the consideration of a number of factors including a rigorous cost-benefit analysis. This
analysis should take into account the following considerations:
• The certainty, type, intensity, and duration of the dose concerned.
• The history and population prevalence of the disease concerned.
• The effectiveness, sensitivity, specificity, and potential hazardous side effects of
available screening tests.
• If test results are positive, the availability, benefits, and risks of treatment protocols.
(2) The latent period between radiation exposure and the development of a clinically detectable
tumor or leukemia may have an effect on the design of a screening program. For the US Armed Forces,
personnel are usually between 20 and 40 years of age when they are exposed, and most radiation-induced
tumors would be expected to become clinically evident when they are older than 40, and in most cases, older
than 50. Since most cancers occur spontaneously at older ages (older than 50 years) without exposure to
radiation, few tests have shown to be of benefit in terms of improving either survivability or quality of life.
Tests that have been recommended include the pap smear, prostate-specific antigen tests, and
mammography. Since the risk of cancer in nonexposed populations is high over a normal lifetime, the risk
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of radiation-induced tumors due to exposure to low-level radiation would always be far less than the risk of
normal spontaneous incidence.
(3) The Institute of Medicine in their committee report: Potential Radiation Exposure in
Military Operations (1999), recommends the establishment of registries for tracking individuals who have
received cumulative effective doses in excess of 5 cGy. This action may be helpful in addressing follow-on
health related issues. The committee also recommends that annually, and upon demobilization or discharge,
potentially exposed military personnel should be given a written record of their radiation exposure with
estimated doses (annual and cumulative), even if the doses are zero.
5-14. Documentation of Radiation Exposure Records
a. The OEG concept requires that all units maintain radiation exposure records. Currently, US
Army records are based on platoon-level data received daily, or after a mission in a radiological contaminated
area. The unit dose is an average of the doses to individuals in the unit who have dosimeters, usually two per
squad in the US Army. Therefore, the US Army assumes that each soldier receives an individual dose equal
to that of the average for the platoon. The records are usually kept by the unit chemical officer at battalion
level. When a soldier transfers out of an exposed unit, the RES for that platoon is noted in the soldier’s
personnel file. When possible, soldiers are reassigned to platoons with the same RES category. Although
this might create personnel strength management problems, it is intended to prevent personnel from
incapacitation due to overexposure to radiation in future operations. The other services have service
specific requirements to maintain radiation dose records. Individual dosimetry should be requested if the
situation warrants, since individual dosimetry can greatly assist with patient assessment and management.
b. In an LLR environment, STANAG 2473, Commanders Guide on Low Level Radiation (LLR)
Exposure in Military Operations, not only reinforces the requirement to maintain dose records, it also
stipulates that
“commanders will need to be aware of individual dose histories when planning future
operations at risk of LLR exposure.” Clearly, the intent is to equip all service members in the unit with
appropriate dosimeters if the unit anticipates conducting operations in a radiologically hazardous area. The
NATO NBC Medical Working Group is currently developing STANAG 2474, Low-Level Radiation Dose
Recording in order to clarify record-keeping requirements.
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CHAPTER 6
PSYCHOLOGICAL EFFECTS AND TREATMENT
OF PSYCHOLOGICAL CASUALTIES
6-1.
General
In a nuclear war scenario, psychological casualties would seem to be insignificant compared to the casualties
from physical trauma, but they can dramatically alter the outcome of a battle. The neuropsychiatric
casualties of World War II were the largest single cause of lost military strength in that war. The Arab-
Israeli Yom Kippur War of 1973 lasted only 3 weeks, but psychiatric casualties were 23 percent of all
nonfatal casualties. Complicating matters further, psychological stress can mimic the early symptoms and
signs of acute radiation injury. Gastrointestinal symptoms (nausea, vomiting and diarrhea), fatigue, and
headaches were frequently seen symptoms during episodes of battle fatigue in World War II. In RDD or
nuclear incident scenarios, psychological stress is also a factor. Even if neuropsychiatric trauma does not
produce a casualty, it can degrade the performance of normal duties. Slightly altered reaction times,
attention, or motivation have important consequences across the entire spectrum of military operations.
Regardless of the situation, it must be emphasized that the most extreme psychological damage occurs when
physiological symptoms from an unknown toxic exposure become manifest. Significant degradation in
performance may occur as military personnel become concerned about the material they were exposed to,
the dose, and the long-term effects of that exposure.
6-2.
Radiation Dispersal Devices and Nuclear Incidents
Although RDDs and nuclear incidents lack the destructive power of a nuclear detonation, the psychological
impact of these events might impede military operations by denying key terrain or installations and by
degrading unit morale and cohesiveness. If an incident occurs in a civilian setting, psychological stress is
expected to increase. Material in this paragraph is an estimate of the problems likely to be encountered,
since an RDD has not yet been employed against US forces or civilians, and approximately 35 years have
passed since US forces have dealt with a major nuclear incident (Palomares, Spain).
a. Psychological Effects of RDDs and Nuclear Incidents. The use of an RDD or a nuclear
incident would be expected to produce acute anxiety effects, including psychosomatic effects such as nausea
and vomiting. Symptoms of acute radiation sickness in just a few personnel might trigger an outbreak of
similar symptoms in the unit and/or in the civilian populace. Emergency personnel responding to the
incident may have a false perception of the threat that has little connection to the actual physical hazard
present. Experience from industrial accidents shows that both real and imagined illnesses may be attributed
to radiation exposure. The severity of the psychological effects of an RDD or a nuclear incident will depend
on the nature of, and the extent of the physical effects. Malicious use of a sealed source of radioactivity left
in an area of personnel traffic would pose only an external radiation hazard, which depending on the dose
received, may lead to acute radiological injury. Similarly, an RDD that distributes radioactive material
using passive means would likely generate a contamination hazard with little, if any acute physical injury.
However, blast injuries, in addition to radiation effects, may be caused by an RDD that uses a conventional
explosion, or if the high explosive component of a nuclear weapon detonates. The greater the number of
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casualties from the blast and a generally more chaotic situation will intensify the level of stress on military
personnel and likely produce more psychological casualties.
b. Incidence. Exposure, or perceived exposure to radiation can be expected to increase the
number of psychological stress casualties. The number of casualties will also depend on the level of
leadership, cohesiveness, and morale in the unit. Long-term chronic psychological stress patterns could be
expected to arise from the uncertainty about the effects of exposure to radiation. Some of the potential
effects include phobias, depression, and post traumatic stress disorder. An RDD or a nuclear incident
within a civilian population center may produce more detrimental psychological effects to military personnel
than if it occurred in a strictly military operations area. Recently, the military has seen increased stability
and support operations, where closer relationships may exist between civilians and military personnel.
Requests for treatment of civilian casualties, especially women and children, after an incident might
markedly increase the psychological impact on military personnel. A civilian mass casualty situation could
severely overload emergency medical operations and increase distress in military personnel. Behaviors
such as altruism, heroism, and loyalty to comrades typically seen in units with exceptional esprit de corps,
may alleviate some of the psychological stress.
6-3.
Nuclear Detonation
Personnel witnessing a nuclear detonation are likely to suffer sensory overload as well as the fear of injury
or death. Depending upon the yield of the weapon and the distance, the service member may see a brilliant
flash that temporarily blinds him, hear a deafening explosion at incredible decibels, suffer thermal injury,
feel the shock of blast winds, and then experience the ground quaking beneath his feet. At night, flash
blindness could affect personnel miles beyond the range of any other acute effects. Some personnel may
have immediate adverse psychological reactions, even in the absence of actual physical injury.
a. Contrary to media portrayals of disasters, mass panic is rare in disaster situations. It seems to
occur primarily in situations where there are limited avenues of escape and possible entrapment, such as
mine fires or mine collapses, sinking ships, or fires in crowded areas where exit routes are limited. The
most frequent psychological effect after disasters is a temporary emotional disruption where people are
stunned or dazed. This transient response may last minutes to days. Typically, such individuals will be able
to respond to strong leadership and direction. Another psychological response is to become more efficient in
the face of danger; this is more likely in well-trained units with high morale. A third type of response would
be that of a psychological casualty, where the transient emotional disruption is continued and more severe.
Reactions include stunned, mute behavior, tearful helplessness, apathy, inappropriate activity, and
preoccupation with somatic symptoms (often of emotional origin).
b. Somatic effects such as nausea, vomiting, diarrhea, and a feeling of weakness or fatigue would
be likely to occur. These individuals may exhibit helpless, aimless, or disorganized behaviors. In the
aftermath of the Hiroshima and Nagasaki bombings, some people were stunned into meaningless, repetitive
behaviors with no obvious goal orientation or survival value. Some wandered uselessly in the debris, with no
conscious effort to either escape or aid others. Many withdrew into an apathy approaching catatonia,
apparently shutting themselves off from the outside world.
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6-4.
Fallout Field
The most stressful effects of a fallout field or contaminated area are likely to be the uncertainties of the
levels of radiation present, lack of defined boundaries of the area, and the perceived acute and chronic
effects of radiation. A chronic level of high stress will also exist when monitoring an area for radiation
hazards. Stress in this situation resembles that of troops clearing an area of mines or patrolling a booby-
trapped area. Military personnel may not know their individual exposure since only unit dosimetry may be
available. They may fear that they are getting a much larger dose than deemed wise, especially if there is
a lack of trust in the leadership. Stress levels can be decreased with positive identification that defines the
contamination field and with proper training of military personnel as to the actual hazards and their effects.
6-5.
Psychosocial Sequelae of Radiation Exposure
a. Psychosocial Sequelae. Even in the absence of actual exposure, fear that one has been exposed
to radiation may cause psychosocial sequelae. Since fear and anxiety are stressors, the person may
experience psychosomatic symptoms, some of which may mimic early ARS symptoms. For example, in
the accident at Three Mile Island in 1979, surveys of the surrounding population found an increase in such
psychosomatic symptoms as nausea, anorexia, and skin rashes, even though there was no detectable
radiation exposure in most of these areas. At Goiânia, Brazil, after scavengers opened a medical
radiotherapy device containing radiocesium, approximately 5,000 of the first 60,000 persons (8 percent) to
be screened for radioactive contamination showed symptoms of acute stress or allergies such as a rash
around the neck and upper body, vomiting, and diarrhea. However, none of these individuals were
contaminated. Thus, the perceptions and preconceptions about radiation may be just as important as the
radiation itself in terms of subsequent pathology.
b. Psychological Factors at Chernobyl.
(1) Many of the recovery team members, liquidators, called in to help with the cleanup of the
reactor at Chernobyl were military personnel. A study of Estonian liquidators found no increases in cancer,
leukemia, or overall mortality, but they did find an increase in suicide. A study of Latvian liquidators found
that almost half had psychosomatic disorders. The fear of radiation in the liquidators was probably enhanced
by their lack of knowledge, the misinformation published in the media, and a distrust of the Red Army’s
record of the radiation doses. An epidemic of vegetative dystonia occurred in liquidators and people from
the contaminated areas. The symptoms of vegetative dystonia resemble the medically unexplained physical
symptoms (MUPS) seen in Agent Orange Syndrome and Gulf War Illness, as well as neurocirculatory
asthenia or effort syndrome that was prevalent during and after both World Wars. The vegetative dystonia
was more prevalent in liquidators who suffered acute radiation sickness, but was also seen in others who
suffered no acute effects.
(2) Many people living upwind of Chernobyl and hundreds of miles away received detectable
doses of radiation equivalent to, or less than a doubling of the normal background radiation level. Some
people became so afraid of the fallout that their whole lives began to revolve around avoidance. Whenever
possible, they refused to go outside or eat locally grown produce. Some sank into deep despair and
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committed suicide rather than risk what they believed would be the inevitable and horrible effects of
radiation. Such severe reactions were referred to as radiophobia by the media. However, those with social
support were better able to handle the increased psychological stress.
6-6.
Treatment
a. The treatment of psychological stress resulting from actual or perceived exposure to radiation
is the same as that for battle fatigue. The principles of proximity, immediacy, expectancy, simplicity
(PIES) are the cornerstones of treatment—
• Proximity means to treat the psychological casualty as close as possible to the unit and the
area from which he came, so as to prevent evacuating a casualty to a distant medical facility.
• Immediacy refers to initiating treatment as soon as possible to prevent the strengthening
of maladaptive habits and the self-perception of illness or disability.
• Expectancy means that medical personnel should convey the positive expectation that the
casualty will fully recover and be able to return to duty after a short break from the operation.
• Simplicity refers to the use of simple, brief, and straightforward methods to restore
physical well being and self-confidence.
b. Generally, treatment modalities consist of the following—
(1) Reassurance and suggestion that the situation will improve. Psychological casualties are
suggestible early in their disruptive phase and simple reassurance using a positive, direct approach is usually
successful. The individual should be made to feel that he or she has an excellent chance of recovery, which
is true in most cases.
(2) Rest with removal from immediate danger. A short period of rest in a safe area is of
great benefit.
(3) Elimination of negative emotions by expression of those emotions (catharsis). Retention
of fear and anxiety by the more severely incapacitated frequently blocks effective communication. When
the patient expresses his or her feelings, this tends to remove the block. This communication is essential
before the individual can recover enough to rejoin the activities of his or her group or unit.
c.
Sedatives or tranquilizers should be avoided unless they are essential to manage sleep or
agitated behavior. Stress casualties should only be evacuated to the next higher echelon if their symptoms
make them too disruptive to manage at a given echelon. Similarly, hospitalization should be avoided unless
absolutely necessary, and those requiring hospitalization should be transferred to a non-hospital treatment
setting as soon as their condition permits.
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6-7.
Prevention and Risk Communication
a. Prevention. Prevention, when possible, is always preferred to treatment. Prior to deployment
to an area where nuclear and radiological hazards are present, medical personnel can implement programs
on behalf of the line commanders that instruct their units about radiation and its effects. In general, troops
who are psychologically prepared for specific stresses are better able to endure them and will suffer fewer
and less severe adverse reactions. This same principle is widely used in preparing troops to cope with
MOPP gear, chemical agent exposure, and other adverse environments. Postexposure training will be
much less effective. Lack of information about the physical hazards of radiation increases the incidence of
fear and anxiety in troops regardless of the actual physical hazard. Units should have operational RADIAC
equipment and dosimeters. Normally, only unit dosimetry readings are possible. Dosimeters should be
issued to each individual in accordance with the commander’s priorities and equipment availability
constraints. Individual dose information can therefore be provided to alleviate fears of receiving large
doses. In fallout fields, combat stress is reduced by positively identifying and assessing the radiation field,
its boundaries, the exposure levels and the risks associated with continued exposure. Primary and backup
personnel should be fully trained in proper equipment operation and in proper NBC reporting procedures
and formats.
b. Risk Communication.
(1) To effectively communicate risks, the training should be tailored in layman’s terms, it
should be realistic and accurate, and it should highlight practical (not theoretical) measures on self-protection.
Specific training in radiation effects, radiation protection, radiation risk communication and psychological
casualty prevention should be given. The principles of minimizing time, increasing distance, and increasing
shielding from a radiation source should be introduced as ways of decreasing radiation exposure. Service
members should gain an understanding that exposure to natural sources of radiation is continuous throughout
life. Normal background radiation levels, medical exposures, and exposures from expected missions should
all be put in context with one another. Questions about increased cancer risks from potential mission
exposures should be answered with relation to normal cancer incidence rates. For fallout fields, troops
should understand that decontamination is the simple act of dusting oneself off (or changing clothes) and
washing exposed skin areas with soap and water. In addition to training military units, radiation training
must also be provided to deploying mental health personnel.
(2) The credibility of leaders, and the trust on which that credibility is based, must be
maintained. Leaders must keep troops informed on possible mission exposures, realistic risk estimates, unit
dose information from RADIAC equipment, and other information that removes ambiguities and
uncertainties in any given situation. Leaders must address, and not dismiss, real concerns. Leaders should
know the OEG for their mission, the radiation exposure state (RES) of their unit, and the risks associated
with their mission. They should have an understanding of acute radiation exposure hazards in comparison
with the immediate dangers of conventional combat. They should also understand the potential for long-term
health risks when troops receive radiation exposures. Leaders should also be knowledgeable on how to
request assistance in interpreting risks associated with radiation exposures or with readings from RADIAC
equipment.
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APPENDIX A
DEPLETED URANIUM
A-1. General
Depleted uranium is neither a weapon of mass destruction nor a chemical or radiological hazard. It is also
not a nuclear or a radiological weapon. The hazards associated with DU are comparable to other munitions.
Depleted uranium is included in this manual for the convenient access of information by military medical
personnel. Depleted uranium munitions and armor plating proved their effectiveness during Operation
Desert Storm (ODS). In fact, DU armor and munitions were so successful that other nations are now using,
or developing DU munitions and armor plating. Therefore, in any future conflict involving antiarmor
weapons systems using kinetic energy (KE) ammunition, it is likely that the enemy will use DU munitions
against US ground forces. This appendix will discuss the characteristics of DU, toxicity and health risks,
and clinical treatment of personnel wounded by DU munitions.
A-2. Depleted Uranium Characteristics and Uses
Depleted uranium is a heavy, silvery-white metal when freshly machined. It is a little softer than steel,
ductile and slightly paramagnetic. In air, DU becomes coated with a layer of oxide that gives it a dull black
or yellow color. Chemically and toxicologically, DU has the same characteristics as natural uranium.
Natural uranium is predominantly Uranium-238 (U-238) by weight, but also contains isotopes U-234 and
U-235. As part of the nuclear fuel cycle, natural uranium is processed in enrichment facilities to obtain
uranium with a higher U-235 content; this is called enriched uranium. The enriched uranium is then used in
nuclear reactors and nuclear weapons. The waste product of the enrichment process is uranium that has a
lower content of U-235 and is known as DU because it is depleted of the high activity radioactive isotope.
Therefore, it is less radioactive than natural or enriched uranium. Table A-1 shows an isotope comparison
between DU and natural uranium. Alpha, beta, and gamma radiation are emitted from DU, but because of
the long half-life of U-238, the specific activity is relatively low. For example, to obtain one curie of
radioactivity from DU would require a single piece weighing 6,615 pounds. DU also contains trace amounts
of transuranics: Plutonium-238, 239/240, Neptunium-237, Americium-241. It also contains trace amounts
of Uranium-236 and Technetium-99. These amounts are so low that they do not increase the toxicological
risk, and increase the radiation dose by much less than one percent.
Table A-1. Comparison Between Depleted Uranium and Natural Uranium
URANIUM ISOTOPE
NATURAL URANIUM
DEPLETED URANIUM
U-234
0.0057%
0.0005%
U-235
0.7204%
0.2500%
U-238
99.2739%
99.7495%
TOTAL
100%
100%
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a. Because of its high density and structural properties, DU is useful for conventional munitions
and as part of US tank armor. Depleted uranium armor is the most effective armor for protection against all
types of munitions, including KE munitions made out of tungsten carbide and DU. The Abrams tank family
(M1, IPM1, M1A1, and M1A2) has an improved hull armor envelope that does not contain DU. However,
M1A1 heavy armor (HA) and M1A2s have armor modules on the existing left and right frontal turret
armor. The DU in these modules is completely encapsulated in steel. The front slope of the turrets of these
tanks has a radioactive signature; a little less than 0.005 mSv/hour.
b. Depleted uranium is also used offensively in antiarmor ammunition. The combination of high
hardness, strength, and density makes DU alloys well suited for KE ammunition. Another useful property
of DU is that as it moves through the armor it maintains the sharpness of the penetrator, further enhancing
its penetrating power.
(The fact that tungsten carbide and other types of tungsten penetrators do not sharpen
on impact—but in fact mushroom to a certain extent—is one reason they are less effective for overcoming
armor plating.) Current US weapons systems and their associated DU munitions are shown in Table A-2.
In general, DU ammunition may only be fired during combat and, similar to other types of service
ammunition, is not fired in peacetime training. DU is fired on ranges for testing and quality assurance
purposes on ranges which have been approved and licensed by the Nuclear Regulatory Commission (NRC).
Table A-2. List of Depleted Uranium Munitions by Weapons System
TANK AMMUNITION
TANK AMMUNITION
BRADLEY FIGHTING
A-10
HARRIER
PHALANX
105 mm
120 mm
25 mm
30 mm
25 mm
20 mm
M774
M827
M1919
PGU-14/B
PGU-20
MK-149
M833
M829
PGU-14A/B
M900
M829A1
PGU-14B/B
M829A2
PGU-14A/A
A-3. Depleted Uranium Toxicity
Although DU is not a chemical or radiological hazard, it can present a chemical toxicity hazard and perhaps
a long-term radiological health risk under some conditions when it is introduced internally to the body. Some
risks associated with DU munitions have been evaluated experimentally, some risks are still under study,
and some risks were identified from practical experience during ODS. Depleted uranium internalization via
inhalation is the primary concern.
a. When a kinetic energy penetrator strikes armor plating, a pyrophoric effect occurs. That is, a
very fast moving, dense heavy metal penetrator striking steel armor will produce a white-hot ignition (flash)
at the point of penetration. This pyrophoric effect occurs with either a conventional tungsten carbide
penetrator (although to a lesser extent) or a DU penetrator. With a DU round, the penetration process
generates high concentrations of airborne, breathable, DU oxides and high velocity shards of metal that can
cause serious wounds. Data gathered from tests and friendly fire incidents show that only personnel in, on,
or near (within 50 meters) the target vehicle at the time the vehicle was struck by a DU penetrator may
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internalize DU in excess of safety standards. This internalization takes place through inhalation, ingestion,
wound contamination, and embedded DU fragments. Almost as soon as the round hits and the dust has
settled, the levels of airborne DU on the outside of the vehicle will rapidly fall to levels that are much lower
than the safety standards prescribed by Occupational Safety and Health Act (OSHA) and the NRC. It is
important to place the possible hazards due to DU penetration into perspective. When a DU penetrator
strikes a vehicle, the effects include a spray of molten metal, shards of both penetrator and vehicle armor,
and secondary explosions in stored ammunition. The interior of the struck vehicle will be contaminated with
both DU dust and fragments, and with other materials generated from burning interior components.
Therefore, medical personnel need to focus on managing the more immediate severe conventional injuries
such as blast and ballistic wounds, burns, and inhalation injuries derived from the initial penetration as well
as from secondary fires or explosions.
b. Inhaled uranium compounds may be metabolized, and result in urinary excretion of these
compounds. Absorption will be determined by the solubility of the uranium. While soluble salts such as
chlorides are readily absorbed, DU metal is not. Consequently, shortening gastrointestinal transit time will
diminish adsorption.
A-4. Health Effects of Exposure to Depleted Uranium
a. General. The Gulf War was the first time there was widespread use of DU, so there is
relatively little experience in dealing with the health effects of this material. However, since 1993, the
Department of Veterans Affairs (VA) has been conducting a follow-up of 33 Gulf War veterans who were
seriously injured in friendly fire incidents involving DU. Many of these veterans continue to have medical
problems relating to the physical injuries they received during these incidents. About half of this group still
have DU metal fragments in their bodies. This follow-up effort and other related studies indicate that the
major health concerns about internalized DU relate to its chemical toxicity as a heavy metal rather than to its
radioactivity, which is very low. In fact, DU is classified in the lowest hazard class of all radioactive
materials.
(See the Rand Report, A Review of the Scientific Literature as it Pertains to Gulf War Illness,
Volume 7, Depleted Uranium, for a detailed discussion of the health effects of DU.)
b. External Exposure. Depleted uranium emits alpha, beta, and weak gamma radiation. Due to
the metal’s high density, much of the radiation never reaches the surface of the metal. It is thus “self-
shielding”. Also, intact DU rounds and armor are packaged to provide sufficient shielding to stop the beta
and alpha radiations. Gamma radiation exposure is minimal. After several months of continuous operations
in an armored vehicle completely loaded with DU munitions, crew exposures might exceed peacetime
general population exposure limits but would not exceed peacetime occupational exposure limits. Hence,
DU is not a serious irradiation threat.
c.
Internal Exposure. In a ground combat environment, routes of internal exposure are generally
inhalation, ingestion, wound contamination and embedded fragments. For example, the pyrophoric effect
produces uranium dusts or aerosol particles, which can be inhaled resulting in uranium entering the blood
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from the lungs.12 Also, some inhaled uranium and some of the uranium originally in the lungs ends up in
the GI tract as a result of mucociliary clearance from the respiratory tract and subsequent swallowing. In
the case of embedded fragments, uranium is introduced to the body as the fragments slowly dissolve.
Uranium accumulates to some degree in all organs, however, the kidney is considered to be the target organ
for uranium chemical toxicity.13 Gulf War veterans with embedded DU fragments have shown higher than
normal levels of uranium in their urine since monitoring began in 1993. The key to the health effect is the
amount internalized. Studies have shown that safety standards for internalized uranium may be exceeded
only for personnel who were in, on, or near (less than 50 meters) an armored vehicle at the time the vehicle
was struck by DU.
d. Chemical Toxicity. In 1997, 29 of the original 33 Gulf War veterans were reevaluated. Of
those evaluated, about half were identified as having retained DU fragments. The majority of these
individuals had elevated 24-hour urinary uranium levels. This suggests that DU was being dissolved in body
fluids; thus, these metal fragments are not entirely inert. Although these individuals have an array of health
problems, many of which are related to their combat injuries, to date all tests for kidney function have been
normal. Laboratory tests also found DU in semen in samples from some, but not all, veterans exposed
to DU. To date, all babies fathered by these veterans between 1991 and 1997 have had no birth defects.
Wounds that contain DU may develop cystic lesions that alter and allow the absorption of the uranium metal.
This has been demonstrated in two veterans of the Persian Gulf War who were wounded by DU frag-
ments that were subsequently removed. Of the known casualties wounded by DU munitions, all have
elevated urinary concentrations of uranium. Studies in scientific models have demonstrated that uranium
will slowly be distributed systemically with primary deposition in the bone and kidneys from these wounds.
Scientific data now demonstrate skeletal and renal deposition of uranium secondary to implanted DU
fragments. There is uncertainty over the toxic level for long-term chronic exposure to internal uranium
metal, but no renal or skeletal damage has been documented to date in Gulf War veterans with embedded
DU fragments.
e.
Radiological Toxicity. The biological properties of uranium in the body and its absorption from
the GI and respiratory tracts are reasonably well known from occupational exposures (for example,
uranium miners), studies of normal environmental intake, and animal studies. There is no evidence of
cancer or any other negative health effect related to the radiation received from exposure to natural
uranium, whether inhaled or ingested, even at very high doses. There is evidence of lung cancer in uranium
miners from previous epidemiological studies, but this is related to exposure to a combination of airborne
short-lived decay products of radon and other air toxicants, such as silica dust, diesel fumes, and cigarette
smoke. Based on the distribution in the body and the known body organ content, no health effects from
radiation would be expected even for high occupational exposures. This results mainly because of the low
radioactivity of natural uranium and the inability to get enough into the body to deliver a radiation dose that
could be significant in causing cancer. The same would be true for DU. Studies have not shown a
link between the inhalation or ingestion of either natural uranium or depleted uranium and any form of
cancer.
12. Harley, Naomi H., et al., A Review of the Scientific Literature as it Pertains to Gulf War Illnesses, Vol. 7, Depleted Uranium (The
Rand Corporation, 1999).
13. Ibid.
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A-5. Patient Management of Personnel Wounded by Depleted Uranium Munitions
a. Determining the Presence of Depleted Uranium.
(1) There are several situational indicators pointing to the presence of DU that may have
been observed by the patient or other members of the unit:
• Patient’s vehicle was struck by a KE penetrator.
• Patient’s vehicle was struck by friendly fire from US tanks or aircraft. This alone
does not confirm DU was used since US weapons systems fire a variety of antiarmor munitions.
• An observer reports that he saw a white hot flash and sparkler-like burning
fragments when the vehicle was struck (pyrophoric effect). Again, this alone does not necessarily confirm
a DU munition, since all KE penetrators present a white hot flash to a certain extent.
• Patient’s medical card stated suspected wounding with DU munitions or inhalation
of DU particles.
(2) Because of DU’s high density, fragments are readily visible on a radiograph and will
appear similar to steel or lead fragments in the body. However, radiography alone is not sufficient to
determine the presence of DU, since there will be some soldiers in vehicles struck by DU munitions that will
have embedded metallic fragments from the vehicle’s armor and other components. Also, shards from
tungsten carbide penetrators will cause similar wounds and will appear radiographically the same.
(3) If readily available, Radiac Meter AN/VDR-2 with the beta shield open may be used to
monitor wounds, burns, or suspected sites with embedded fragments. This will confirm DU wound
contamination, and will provide confirmation of wound decontamination. UNDER NO CIRCUMSTANCES
SHOULD TREATMENT BE DELAYED IN ORDER TO OBTAIN AN AN/VDR-2.
(4) Operation Desert Storm experience showed that the most sensitive indicator that DU has
been internalized is a uranium urine bioassay. In general, embedded DU fragments will slowly dissolve and
be transported in the blood. Eventually, the patients will excrete uranium in the urine. The level of uranium
in the urine will remain constant for long periods of time. Results of the medical monitoring of patients from
ODS showed that the highest uranium urine levels were on the order of 30 to 40 micrograms of total uranium
per gram of creatinine. The monitoring was initiated in 1993, and the levels have remained generally
constant. In all likelihood, the levels were higher at the time the soldiers were wounded. How much higher
is not known. See Memorandum For The Commander, USA AMEDD Center and School, dated 9 April
1999, Subject: Policy for the Treatment of Personnel Wounded by Depleted Uranium Munitions for detailed
procedures on conducting DU urine bioassays.
b. Clinical Treatment of Personnel Wounded By DU Munitions.
(1) Casualties may have DU contamination on their clothing and skin. UNDER NO
CIRCUMSTANCES SHOULD CASUALTY EXTRACTION, TREATMENT, OR EVACUATION BE
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DELAYED DUE TO THE PRESENCE OF DU. Standard aidman procedures for treating combat wounds
should be followed.
(2) Wounds and burns should be cleaned and debrided using standard surgical procedures.
Normal “universal precautions” (surgical gloves, surgical mask, and throwaway surgical gowns) are more
than adequate to protect medical personnel from accidental contamination with DU. Items contaminated
with DU should be disposed of using standard universal precaution procedures. The use of a sensitive
radiation meter may assist in wound debridement and cleaning. The AN/VDR-2 RADIAC Meter with the
beta window open may assist in locating DU contamination in the wound or burn. UNDER NO
CIRCUMSTANCES SHOULD REQUIRED TREATMENT BE DELAYED TO PERFORM THIS
MONITORING.
(3) Embedded DU fragments in wounds should be removed using standard surgical criteria
(see Emergency War Surgery NATO Handbook, 1988), except that large fragments (greater than 1 cm in
diameter) should be more aggressively removed unless the medical risk to the patient is too
great.
(4) Monitoring of kidney function is recommended for those patients who have contaminated
wounds or embedded DU fragments. The monitoring should follow the current protocol in use by the
Baltimore VA Depleted Uranium Program.
(a) As with all heavy metals, the kidney is one of the organs most sensitive to uranium
toxicity. Recommended tests include urinalysis, 24-hour uranium urine bioassay, serum blood urea nitrogen
(BUN), creatinine, beta-2-microglobulin, and creatinine clearance.
(b) Chelation therapy is not recommended based upon current estimates of DU
exposure.
(5) Once the patient is in recovery, he should be informed of the risks associated with
internalized DU. The key point is that the presence of any DU fragments in the service member’s body
presents no risks to family members. As with other heavy metals retained in the body, the DU in all bodily
fluids (urine, feces, sweat, saliva, and semen) present absolutely no hazard to the soldier or the people he
has contact with. Also, no special precautions are required by anyone having contact with the patient.
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APPENDIX B
MEDICATIONS
Table B-1 is a listing of medications available for use when treating nuclear and radiological casualties.
Stockage levels of specific medications will be as authorized by unit assemblages and standard operating
procedures (SOP). The medications are grouped according to general category (for example, “antidiarrheal
agents”), and information is given on trade name, generic name, class, and so forth.
Table B-1. Medications
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APPENDIX C
TREATMENT BRIEFS
C-1. Scope of Treatment Briefs
In this appendix, 28 patient categories involving a range of radiation doses are briefly described. Several
patient categories involve radiation alone, and others describe patients receiving radiation in combination
with trauma and/or burns. These descriptions are termed Treatment Briefs (TBs) and are derived from the
work of the 1999—2000 Nuclear Warfare Casualty Panel of the Joint Readiness Clinical Advisory Board
(JRCAB). The primary purpose of the Treatment Briefs is to help the JRCAB develop medical planning
tools and resource estimates. The TBs are not designed or intended as medical protocols. However,
physicians and other medical staff may find much of the information helpful as quick reference material for
treatment of radiation casualties. Table C-1 below lists the 28 Treatment Briefs in accordance with dose
range and combined injury, if applicable. In addition to the assumptions specifically provided in each
Treatment Brief, the
assumptions and background information that are in Section I are applied to
all
Treatment Briefs.
Table C-1. List of Treatment Briefs
TREATMENT BRIEF
DOSE RANGE (cGy)
COMBINED INJURY
1
75
None
2
75–125
None
3
125–300
None
4
300–530
None
5
530–830
None
6
830–1500
None
7
>1500
None
8
0–125
Nonoperative trauma
9
125–530
Nonoperative trauma
10
>530
Nonoperative trauma
11
0–125
Operative trauma
12
125–530
Operative trauma
13
>530
Operative trauma
14
0–125
Mild burn
15
125–530
Mild burn
16
>530
Mild burn
17
0–125
Moderate burn
18
125–530
Moderate burn
19
>530
Moderate burn
20
0–125
Severe burn
21
125–530
Severe burn
22
>530
Severe burn
23
0–125
Operative trauma and mild burn
24
125–530
Operative trauma and mild burn
25
>530
Operative trauma and mild burn
26
0–125
Operative trauma and moderate burn
27
0–125
Operative trauma and severe burn
28
>125
Operative trauma and moderate or severe burn
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Section I. GLOBAL ASSUMPTIONS
C-2. Level of Care
Levels of Care are defined by capability rather than on unit size and geographical locations on the battlefield.
The levels of care are:
a. Level 1A. Self-care/Buddy care/Combat Medic/Corpsman.
b. Level 1B. Combat Medic/Corpsman/Battalion Aid Station/Surface Combatant Ships/Am-
phibious Casualty Receiving Treatment Ship/Wing Support Squadron Aid Station.
c.
Level 2. Level 2 may include Forward Surgical Resuscitation, defined as surgery that focuses
on specific lifesaving practices. These practices include management of severe bleeding, airway
compromise, life threatening chest injuries, and preparation of casualties for evacuation. Based on the
concept of the “Golden Hour” of trauma treatment, Level 2 would receive some, but not all, of the patients
that are acutely injured in combat requiring expeditious surgery to save life or limb. Level 2 will usually
provide resuscitative level care and surgical interventions to improve patient chances for transport to
Level 3. However, if it is possible to provide Level 3 care at the Level 2 facilities without jeopardizing the
mission, then Level 3 care may be done on a case-by-case basis. This may include holding patients up to 72
hours. Note that an Army FST will only hold patients for recovery, then move them to the supported
medical company for evacuation.
d. Level 3. Level 3 is the first level at which patients are admitted into a hospital for medical
treatment within the theater of operations. Patients that cannot receive definitive care and RTD within the
time allocated by the theater medical evacuation policy are stabilized and evacuated out of the theater.
Typical Level 3 facilities are combat support hospitals and USAF air transportable general hospitals.
e.
Level 4. Level 4 is the highest level of care provided in theater. Patients that cannot receive
definitive care and RTD within the theater evacuation policy are further stabilized and evacuated out of the
theater. Typical Level 4 facilities are field hospitals or general hospitals.
C-3. Combined Injury
Combined injuries include thermal burn/blast trauma/radiation injuries and are discussed in Treatment
Briefs 14—28. These briefs are based on thermal injury being the dominant determinant of morbidity and
mortality. Human data sets regarding treatment of radiation combined injuries are scarce. General
descriptions of trauma and burns assumed in the combined injury Treatment Briefs are provided below.
a. Nonoperative Blast Trauma. Examples include concussion (without intracranial hemorrhage),
simple lacerations, closed fractures, ligamental injuries, simple pneumothorax, and so forth.
b. Operative Blast Trauma. Examples include open fractures, major lacerations, hemo-
pneumothorax, and so forth.
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c.
Burns. All burns (including White Phosphorous) will be treated with moist dressings and/or
absorbent gel-type dressing materiel and antibacterial agents. This is due to the removal of cupric sulfate
from the world market. Percentages of body surface area (BSA) are approximations:
• Mild Burns:
1st degree—1 to 100 percent BSA; 2d degree—1 to 15 percent BSA; 3d
degree—1 to 5 percent BSA.
• Moderate Burns:
2d degree—16 to 30 percent BSA; 3d degree—6 to 15 percent BSA.
• Severe Burns:
2d degree—>30 percent BSA; 3d degree—20 percent BSA.
C-4. Wound Closure
a. All Level 2 operative procedures for trauma will be left open (irrigated, debrided, packed, and
dressed only). An exception includes patients exposed to radiation with operative trauma. Wounds that are
left open and allowed to heal by secondary intention will serve as a potentially fatal nidus of infection in the
radiologically injured patient. Wound healing is markedly compromised within hours of radiation injury. If
at all possible, wounds should be closed primarily as soon as possible. Extensive debridement of wounds
may be necessary in order to allow this closure.
b. Traditionally, combat wounds are not closed primarily due to the high level of contamination,
devitalized tissue, and the subsequent morbidity and mortality of the closed-space contamination. In the case
of the radiation/combined injury patient, aggressive therapy will be required to allow survival. The decision
to amputate an extremity that in ordinary circumstances would be salvageable will rest with the surgeon in
the first two days following the combined injury. No studies are available regarding the use of aggressive
marrow resuscitation as described for the physically wounded patient.
c.
All surgical procedures must be accomplished within 36 to 48 hours of radiation injury. If
surgery cannot be completed at far-forward locations, patients with moderate injury will need early
evacuation to a level where surgical facilities are immediately available.
C-5. Return to Surgery
If not evacuated within 72 hours, there will be a percentage of patients that will require a return to surgery.
If there is radiation exposure, the return to surgery must be anticipated within 36 to 48 hours post-
irradiation.
C-6. Psychological Casualties
The Treatment Briefs do not address psychological and related combat stress casualties associated with
nuclear warfare (see Chapter 6).
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C-7. Decontamination
Decontamination is not included in the Treatment Briefs. Not all casualties exposed to radiation will be
contaminated. A quick survey of casualties with a RADIAC meter can determine if contamination is
present. Decontamination is highly desirable prior to treatment of all casualties contaminated with
radioactivity. This should consist of destruction of uniforms/clothes, washing the casualty with soap and
water, and washing personal items (glasses, etc.) with soap and water. See Chapter 4 of this manual and
FM 8-10-7 for more information on patient decontamination.
C-8. Incidence Rates
The Treatment Briefs assume that 100 percent of the force exposed to radiation will eventually enter the
medical system. Therefore, the statistics in the Treatment Briefs for the incidence of symptoms, for
example, nausea and vomiting, is based on doctrine that considers the total population exposed. The
percentages for providing treatment, determining evacuation, and RTD are planning estimates. The
mortality rates used for patient conditions are sequential and represent estimates of “middle of the road”
patient expectations. Thus, 50 percent mortality at Level 1, with 50 percent mortality at Level 2, and 50
percent mortality at Level 3, will result in 88 percent mortality and 12 percent salvage rate for in-theater
care.
C-9. Evacuation
The assumed evacuation policy is that evacuation from the theater for nonreturn to duty personnel is 7 to 15
days from time of injury. Note that the Theater Commander sets the actual evacuation policy. Expected
evacuation times are as follows:
• MEDEVAC Transport Categories (Level to Level of Care):
2 Hours = Urgent; 4 hours =
Priority; 6 hours = Routine
• AIREVAC Transport (Out of theater): 6 Hours = Urgent; 24 Hours = Priority; 72 Hours =
Routine
C-10. Patient Holding Capabilities
Level 1 has no holding capability. Those Level 2 facilities with holding capability may RTD or will have
materials to provide nursing care up to 72 hours if unable to evacuate, except as otherwise noted. The
holding capability at Level 2 is highly varied between the Services as shown below:
Air Force MFST—None
Air Force MASF—2 hours
Air Force EMEDS Basic—24 hours
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Air Force EMEDS + 10 AFTH—7 days (evacuate when stable)
Air Force EMEDS + 25 AFTH—7 days (evacuate when stable)
Air Force EMEDS ATH—30 days
Marine Surgical Company—72 hours
Army Forward Support Medical Company with FST attached—40 cots and 8 ICU/Recovery beds —
30 surgical procedures over 72 hours (10 per 24 hours) and holds 1 to 6 hours for postoperative recovery. If
evacuation assets are not available, patients would be transferred to the patient holding section of the FSMC
for up to 72 hours.
Army FST—8 ICU/Recovery beds holding for 1 to 6 hours. Doctrinally always collocated with
FSMC and dependent for power, lab, x-ray, and so forth.
Navy Primary Casualty Receiving & Treatment Ships—72 Hours.
C-11. Blood Products
a. Current doctrine states that group O blood—packed cells (85 percent Rh Positive and 15
percent Rh Negative (for Rh Negative females) will be available at Level 2. Albumin (100 ml 25 percent
can) is also available as a volume expander. Fresh frozen plasma (FFP), type-specific blood and platelet
concentrate would not generally be available. Irradiated blood products (2000 cGy) will generally not be
available at Level 2 and 3. Limited storage capacity of 50 units per field medical refrigerator exists at Level
2, and maximums are usually set at this level on the amount of blood to be transfused to any specific patient.
The Armed Services Blood Program Office’s planning factor of 4 units per wounded in action/nonbattle
injury casualty is intended for the entire continuum of care and not identified on level of care. Table C-2
shows supply planning factors for Level 2 and 3 matrices for blood products and crystalloid fluid. All Class
IV hemorrhage patients will require large bore vascular access.
Table C-2. Level 2 and 3 Blood Product Matrices
LEVEL 2 BLOOD USE ASSOCIATED WITH HEMORRHAGE CLASSIFICATION
Hemorrhage Classification
Blood
Albumin
Class II
0
0
Class III
0.5 Units
2 (200 ml)
Class IV
2 Units
4 (400 ml)
LEVEL 3 BLOOD USE ASSOCIATED WITH HEMORRHAGE CLASSIFICATION
Hemorrhage Classification
Blood
Crystalloid
Albumin
Class II
0
4 Liters
0
Class III
2 Units
8 Liters
2 (200 ml)
Class IV
2 Units plus 4 Units FFP
12 Liters
4 (400 ml)
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