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

 

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

 

 

FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
b. Blood products should be irradiated for nuclear casualties exposed to radiation levels of 300
cGy or greater and requiring transfusions. Blood products provided to radiation casualties should be
irradiated at a dose of 2000 cGy prior to administration to diminish incidence of transfusion-related graft
versus host disease. Irradiated blood products will likely be in short supply and might be nonexistent within
theater medical supply system.
C-12. Patient Warming
Warming techniques for all patients will be accomplished to the maximum extent possible, given the
situation. These techniques include wrapping the patient, utilization of ventilation heater valve, warming
blood/IVs/irrigation fluids through the use of fluid warmers, warming blankets, and controlling environ-
mental temperature as much as possible. All Level 2 and 3 fluid and blood resuscitation requires at least one
blood/fluid warmer per litter/bed in EMT, OR, and ICU.
C-13. Sterilization
The preferred method for instrument reuse is sterilization. However, weight and volume constraints may
prevent resupply of sterilized instrumentation and/or sterilization capability. Therefore, high-level
disinfectants may be used.
C-14. C-Spine Management
The data regarding actual incidence of cervical spine injuries in combat do not warrant the added burden of
cervical collars and spine boards to treat all potential cervical spine injuries. Collars and boards should be
used only in the limited number of patients with very high suspicion of cervical/spine injury.
C-15. Tetanus
Tetanus toxoid usage will be high. By definition, all traumatic wounds will be “dirty” and should require
boosters within 5 years of most recent booster. The current booster schedule is every 10 years. Patients
should receive tetanus toxoid booster at the point where they receive their in-theater surgical care, at Level 3,
or at a point prior to transport out of theater. Tetanus toxoid will not be available at Level 2. It is assumed
anyone deploying will have had at least one tetanus immunization in their lifetime. According to the Center
for Disease Control, there has never been a recorded case of tetanus in a person having received at least one
tetanus during their lifetime. Up to a 72 hour delay between Level 2 and Level 3 should not present a risk of
tetanus to previously immunized individuals.
C-16. Diets
Unless otherwise stated in the briefs:
• ICU patients will be NPO. Special diets will be specified.
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
• ICW patients will advance to regular diet as tolerated.
• MCW patients will advance to regular diet as tolerated.
C-17. Casts and Splints
To reduce weight and volume requirements, all casting/splinting will be done with polymer based casting
and fiberglass tape in preference to plaster cast. No plaster will be available.
C-18. Lab/X-ray/Pharmacy
Diagnosis and treatment is driven by clinical examination with laboratory testing and x-rays being used for
confirmation only when absolutely necessary. Point of care testing, with laboratory service support, is the
optimal choice.
C-19. Oxygen
Oxygen cylinders are hazardous cargo, require a tremendous amount of weight and volume capacity, and
are not readily available for resupply/refill. In the absence of an oxygen generator, oxygen should be used
only if absolutely necessary due to these limiting factors.
C-20. Patient Personal Support Kits
It will be assumed that supplies issued to patients will be transferred with the patient rather than reissuing
supplies such as admission kits, irrigation kits, and so forth. This will markedly reduce the logistical load for
patient support items.
C-21. Water
Water sources will be limited. Conservation of potable water is critical.
C-22. Linen
Linen will not meet the demand in mass casualty (MASCAL) or patient care surges. Timely resupply of
clean linen is unreliable. Disposable linen is the product of choice.
C-23. Refrigeration
There is no refrigeration at any Level 1 facility. Refrigeration exists at some Level 2 and at all Level 3
facilities.
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Section II. TREATMENT BRIEFS
C-24. Treatment Brief No. 1: Radiation Exposure at 0.0–75 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Real or suspected exposure; vital signs (VS): stable; ambulatory patient; alert;
oriented, anxious; 5 percent nausea, mild headache.
Treatment: Reassurance. Routine ground transport 95 percent, RTD 5 percent.
LEVEL 1B
Assumptions: VS: stable. Ambulatory patient; alert; oriented, anxious; 5 percent nausea, mild
headache.
Treatment: Consultation with Combat Stress Control Unit
(CSCU), reassurance, PO pain
medication 10 percent; PO antiemetics 5 percent. RTD 95 percent, routine ground transport 5 percent.
LEVEL 2
Assumptions: VS: stable, ambulatory patient; alert; oriented, anxious; 100 percent nausea, mild
headache; automated differential cell counter available.
Treatment:
25 percent IV fluids laboratory report (LR); rest, 75 percent PO antiemetics and 25
percent IV antiemetics; reassurance/counseling. LAB: 100 percent CBC with differential for lymphocyte
count every 12 hours for two days for prognosis and determination of RTD. LAB: 100 percent draw one
blood specimen per patient for biodosimetry red top tube (clot) (keep refrigerated) for radiation exposure
documentation; 100 percent RTD.
C-25. Treatment Brief No. 2: Radiation Injury at 75–125 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Real exposure; VS: stable; ambulatory patient; alert; oriented, anxious; 5 to 30
percent nausea/vomiting; mild headache; pretreatment with PO antiemetics may block nausea.
Treatment: Reassurance. Routine ground transport 100 percent.
LEVEL 1B
Assumptions: VS: stable to mild tachycardia. Ambulatory patient; alert; oriented, anxious; 5 to 30
percent nausea/vomiting; mild headache.
Treatment: Consultation with CSCU, reassurance; PO pain medication 10 percent; antiemetics 30
percent; further nonmedical radiation exposure must be limited; RTD 50 percent, routine ground transport
50 percent.
LEVEL 2
Assumptions: VS: stable to mild tachycardia. Ambulatory patient; alert; oriented, anxious; nausea/
vomiting 15 to 60 percent; headache; automated differential cell counter available.
Treatment:
60 percent IV fluids LR, rest, 60 percent IV antiemetics; reassurance/counseling.
Consultation with CSCU. LAB: 100 percent draw one blood specimen per patient for biodosimetry (red top
C-8
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
tube [clot] [keep refrigerated]) for radiation exposure documentation; 100 percent CBC with differential for
lymphocyte count every 12 hours for two days for prognosis; 80 percent RTD, routine ground transport 20
percent.
LEVEL 3
Assumptions: VS: stable to mild tachycardia. Ambulatory patient; alert; oriented, anxious; nausea/
vomiting 5 to 10 percent; headache; automated differential cell counter available. Only 10 percent of
casualties reporting to Level 1B will ultimately reach Level 3.
Treatment: EMT: VS; primary assessment, 10 percent IV antiemetics. LAB: 100 percent CBC
with differential one time.
OR: None.
WARDS: ICU: None.
ICW: None.
MCW: VS once daily; supportive care; push PO fluids, advance diet.
LAB: Serial CBC with differential every 12 hours times two days. RTD 100 percent.
C-26. Treatment Brief No. 3: Radiation Injury at 125–300 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Significant exposure; VS: stable to tachycardia; ambulatory patient; alert; oriented,
anxious; 20 to 70 percent nausea/vomiting (n/v); mild headache; 25 to 60 percent mild to moderate fatigability
and weakness; pretreatment with antiemetics decreases vomiting.
Treatment: Reassurance. Routine ground transport 100 percent.
LEVEL 1B
Assumptions: Significant exposure; 5 percent mortality if untreated in 30 days; VS: stable to
tachycardia; ambulatory patient; alert; oriented, anxious; 20 to 70 percent n/v; mild headache; 25 to 60
percent mild to moderate fatigability and weakness; pretreatment with antiemetics decrease vomiting.
Treatment: VS: start IV LR in 20 percent; reassurance, pain medication 10 percent; PO antiemetics
50 percent; further radiation exposure strictly limited to medical diagnostic procedures; routine ground
transport 100 percent.
LEVEL 2
Assumptions: Significant exposure; 5 percent mortality if untreated in 30 days; VS: stable to
tachycardia; ambulatory patient; alert; oriented, anxious; 20 to 70 percent n/v; mild headache; 25 to 60
percent mild to moderate fatigability and weakness; pretreatment with antiemetics decrease vomiting,
automated differential cell counter available.
Treatment: IV fluids 50 percent, rest, 70 percent PO antiemetics, reassurance/counseling. LAB:
CBC with differential for lymphocyte count every 12 hours for prognosis; routine ground transport 100
percent. Since no patients will RTD, biodosimetry will be deferred to Level 3.
LEVEL 3
Assumptions: Significant exposure; 5 percent mortality if untreated; VS: stable to tachycardia;
ambulatory patient; alert; oriented, anxious; 10 to 30 percent n/v; mild headache; 25 to 60 percent mild to
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
moderate fatigability and weakness; pretreatment with PO antiemetics decrease vomiting, automated
differential cell counter available. Confirmation of radiation injury requires two days observation.
Treatment: EMT: VS; primary assessment, PO antiemetics. LAB: 100 percent draw one blood
specimen per patient for biodosimetry red top tube (clot)
(keep refrigerated) for radiation exposure
documentation; 100 percent CBC with differential.
OR: None.
WARDS: ICU: None.
ICW: None.
MCW: 100 percent of patients arriving at Level 3; VS; supportive care;
push PO fluids, diet as tolerated. LAB: serial CBCs with differential every 12 hours. Cytokines (G-CSF
480 mcg subcutaneous daily) in 10 percent of patients; routine air transport 100 percent of patients admitted
to MCW.
C-27. Treatment Brief No. 4: Radiation Injury at 300–530 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Dangerous exposure; VS: stable to tachycardia; ambulatory patient; alert; oriented,
anxious; 50 to 90 percent n/v; 10 percent diarrhea; 60 to 90 percent moderate fatigability and weakness;
pretreatment with antiemetics may decrease vomiting.
Treatment: Reassurance. Routine ground transport 100 percent.
LEVEL 1B
Assumptions: Dangerous exposure; 5 to 50 percent mortality within 30 days if untreated; VS: stable
to tachycardia; ambulatory patient; alert; oriented, anxious; 50 to 90 percent n/v; 60 to 90 percent moderate
fatigability and weakness; pretreatment with antiemetics may decrease vomiting.
Treatment: VS: start IV LR in 80 percent; reassurance; PO antiemetics 90 percent; no further
radiation exposure allowable; routine ground transport 100 percent.
LEVEL 2
Assumptions: Dangerous exposure; 5 to 50 percent mortality within 30 days if untreated; VS: stable
to tachycardia; ambulatory patient; alert; oriented, anxious; 50 to 90 percent n/v; 60 to 90 percent moderate
fatigability and weakness; automated differential cell counter available; pretreatment with antiemetics may
decrease vomiting.
Treatment: Rest; IV fluids LR 100 percent. LAB:
25 percent electrolytes once daily times two
days; 90 percent (45 percent PO and 45 percent injectable) antiemetics; counseling. LAB: CBC with
differential for lymphocyte count every 12 hours for 24 to 36 hours for prognosis. Isolate from communicable
diseases; urgent air transport 20 percent/urgent ground transport 80 percent.
LEVEL 3
Assumptions: Dangerous exposure; 5 to 50 percent mortality if untreated; VS: stable to tachycardia;
ambulatory patient; alert; oriented, anxious; 30 to 60 percent n/v; 60 to 90 percent moderate fatigability
and weakness; pretreatment with antiemetics may decrease vomiting; automated differential cell
counter.
C-10
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Treatment: EMT: VS; primary assessment, 60 percent (30 percent PO and 30 percent injectable)
antiemetics. LAB: 100 percent CBC with differential, 100 percent draw one blood specimen per patient for
biodosimetry red top (clot) (keep refrigerated) for radiation exposure documentation.
OR: None.
WARDS: ICU: None.
ICW: 10 percent of patients arriving at Level 3; VS: qid; supportive care;
100 percent of patients require IV LR fluids (4 liters/day); clear liquids. LAB:
100 percent electrolytes
once daily, serial CBCs with differential every 12 hours daily. Cytokines (G-CSF 480 mcg subcutaneous
daily) in 100 percent of patients; draw blood specimens for HLA typing (three yellow top tubes); reverse
isolation. Patients admitted to ICW priority air transport 100 percent.
MCW: 90 percent of patients arriving at Level 3; VS; supportive care;
push PO fluids, advance diet. LAB: serial CBCs with differential every 12 hours. Cytokines (G-CSF 480
mcg subcutaneous daily) in 100 percent of patients. Reverse isolation. Draw blood specimens for HLA
typing (three yellow top tubes). Patients admitted to MCW—routine air transport 100 percent.
C-28. Treatment Brief No. 5: Radiation Injury at 530–830 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Critical exposure; VS: tachycardia; litter 50 percent, ambulatory 50 percent alert;
oriented, anxious; 80 to 100 percent n/v; 10 percent diarrhea; 90 to 100 percent moderate to extreme
fatigability and weakness; pretreatment with antiemetics is ineffective.
Treatment: Urgent ground transport 100 percent.
LEVEL 1B
Assumptions: Critical exposure; 50 to 95 percent mortality within 30 days if untreated; VS:
tachycardia; litter 50 percent, ambulatory 50 percent alert; oriented, anxious; 80 to 100 percent n/v; 90 to
100 percent moderate to extreme fatigability and weakness; pretreatment with antiemetics is ineffective.
Treatment: VS once, start IV LR in 100 percent; injectable antiemetics
100 percent; pain
medications 10 percent; isolate from communicable diseases; no further radiation exposure allowable;
urgent ground transport 30 percent/urgent air transport 70 percent with overflight to Level 3 if possible.
LEVEL 2
Assumptions: Overflight if possible. Critical exposure; 50 to 95 percent mortality if untreated; VS:
tachycardia; litter 50 percent, ambulatory 50 percent alert; oriented, anxious; 80 to 100 percent n/v; 10
percent diarrhea; 90 to 100 percent moderate to extreme fatigability and weakness; pretreatment with
antiemetics is ineffective.
Treatment: VS; start IV LR in 100 percent; injectable antiemetics 100 percent; reverse isolation; no
further radiation exposure allowable; urgent transport 100 percent to Level 3.
LEVEL 3
Assumptions: Critical exposure; 50 to 95 percent mortality if untreated; VS: tachycardia; litter 50
percent, ambulatory 50 percent; alert; oriented, anxious; 30 to 70 percent n/v; 10 percent diarrhea; 90 to 100
percent moderate to extreme fatigability and weakness; pretreatment with antiemetics is ineffective.
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Automated differential cell counter available. Comment: Air evacuated by day 4, if unable to evacuate by
day four post exposure, antibiotic and antivirals will be needed along with surveillance cultures.
Treatment: EMT: VS once; primary assessment, 70 percent injectable antiemetics, 100 percent
IV LR. LAB: Draw one blood specimen per patient for biodosimetry red top (clot) (keep refrigerated) for
radiation exposure documentation; CBC with differential.
OR: None.
WARDS: ICU: None.
ICW:
100 percent of patients arriving at Level 3. VS: qid; supportive
care; 100 percent of patients require IV fluids (LR, 4 liters/day), NPO 50 percent, clear liquids 50 percent.
LAB: Serial CBCs with differential every 12 hours for the first four days. Cytokines (G-CSF 480 mcg
subcutaneous daily) in 100 percent of patients; 10 percent antidiarrheal medications; reverse isolation.
Draw blood specimens for HLA typing three yellow top tubes. Patients admitted to ICW—Urgent air
transport 100 percent to Level V treatment facility.
MCW: None.
C-29. Treatment Brief No. 6: Radiation Injury at 830–1500 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Critical exposure; VS: tachycardia; litter 100 percent, 90 to 100 percent disoriented,
anxious; immediate onset of 100 percent n/v; diarrhea 10 percent; 100 percent extreme fatigability and
weakness; pretreatment with antiemetics is ineffective.
Treatment: Urgent ground transport 100 percent.
LEVEL 1B
Assumptions: Critical exposure; 100 percent mortality within 15 to 30 days if untreated; VS:
tachycardia, hypotension 25 percent; litter 100 percent, disoriented 90 to 100 percent, anxious; immediate
onset of 100 percent n/v; 10 percent diarrhea; 100 percent extreme fatigability and weakness; pretreatment
with antiemetics is ineffective.
Treatment: VS: once; start IV LR in 100 percent; injectable antiemetics 100 percent; IV/IM
morphine 25 percent; no further radiation exposure allowable; urgent ground transport 100 percent.
LEVEL 2
Assumptions: Critical exposure; 100 percent mortality if untreated; VS: tachycardia, hypotension
25 percent, 50 percent low grade fever; litter 100 percent, disoriented 90 to 100 percent, anxious; 100
percent immediate onset of n/v; 10 percent diarrhea; 100 percent extreme fatigability and weakness;
pretreatment with antiemetics is ineffective. Automated differential cell counter available.
Treatment: VS, start IV LR in 100 percent; injectable antiemetics 100 percent; antidiarrheal
medication 10 percent. LAB: CBC with differential every 12 hours. Comment: Attempt reverse isolation;
no further radiation exposure allowable; urgent ground transport 100 percent to Level 3.
LEVEL 3
Assumptions: Critical exposure; mortality 100 percent if untreated; VS: tachycardia, hypotension
25 percent, low grade fever 50 percent; litter 100 percent, disoriented 40 to 70 percent, anxious; 40 to 70
percent immediate onset of n/v; 10 percent diarrhea; 100 percent extreme fatigability and weakness;
pretreatment with antiemetics is ineffective. Automated differential cell counter available.
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Treatment: EMT: VS once; primary assessment, injectable antiemetics. LAB: Draw one blood
specimen per patient for biodosimetry red top (clot) (keep refrigerated) for radiation exposure documenta-
tion; CBC with differential.
OR: None.
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3; VS, supportive care; 100
percent IV fluids (LR 4 liters/day), NPO 50 percent, clear liquids 50 percent.
LAB:
100 percent serial CBCs with differential every 12 hours daily, electrolytes
q24h. Cytokines (G-CSF 480 mcg subcutaneous daily) in 100 percent of patients; 10 percent antidiarrheal
medications; reverse isolation.
100 percent draw blood specimens for HLA typing three yellow top tubes
acid-citrate dextrose (ACD) (keep refrigerated). Patients admitted to ICW —100 percent urgent air trans-
port to a Level V treatment facility. If unable to evacuate by day four postexposure, blood products (pref-
erably irradiated to 2000 cGy), antibiotics, antivirals, antifungals, and surveillance cultures will be needed.
MCW: None.
C-30. Treatment Brief No. 7: Radiation Injury >1500 cGy Without Other Physical Injury
LEVEL 1A
Assumptions: Lethal exposure; 95 to 100 percent mortality even with treatment; VS; unstable; litter
100 percent, disoriented 75 percent, anxious; 100 percent immediate onset of nausea/vomiting/diarrhea
(n/v/d); 100 percent extreme fatigability and weakness; pretreatment with antiemetics is ineffective.
Treatment: Urgent ground transport 100 percent.
LEVEL 1B
Assumptions: Lethal exposure; 95 to 100 percent mortality even with treatment; VS, unstable; litter
100 percent, disoriented 75 percent, anxious; 100 percent immediate onset of n/v/d; 100 percent extreme
fatigability and weakness; pretreatment with antiemetics is ineffective.
Treatment: VS: once; start IV LR in 25 percent; injectable antiemetics 100 percent; 100 percent IM
morphine 2 to 4 mg q 1 to 4 hours as needed; no further radiation exposure allowable; routine ground
transport 100 percent to Level 2. Comment: Those patients with neurologic signs are expectant.
LEVEL 2
Assumptions: Lethal exposure; 95 to 100 percent mortality even with treatment; VS; unstable; litter
100 percent, disoriented 75 percent, anxious; 100 percent immediate onset of n/v/d; 100 percent extreme
fatigability and weakness; pretreatment with antiemetics is ineffective. Automated differential cell counter.
Expectant patients (with neurologic deficits) 75 percent, nonexpectant 25 percent.
Treatment: For all (100 percent): VS prn; antiemetics IV, IM morphine 2 to 4 mg q 1 to 4 hours as
needed for pain; antidiarrheal medications. Nonexpectant (25 percent): maintain IV LR. LAB: CBC with
differential every 12 hours. Attempt reverse isolation; no further radiation exposure allowable; urgent
ground transport (25 percent). Expectant (75 percent): Routine ground transport 75 percent.
LEVEL 3
Assumptions: Lethal exposure; 95 to 100 percent mortality even with treatment; VS, unstable; litter
100 percent, neurological casualties (75 percent) admitted to MCW for palliative care; 25 percent admitted
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
to ICW (no neurologic signs); 100 percent n/v/d; 100 percent extreme fatigability and weakness. Automated
differential cell counter. Eventual mortality at this level is estimated at 80 percent.
Treatment: EMT: VS: once; maintain IV LR in 25 percent; injectable antiemetics 100 percent;
100 percent IV/IM morphine 2 to 4 mg once if needed. LAB: 100 percent of patients need blood drawn for
biodosimetry (red top clot) (keep refrigerated) for radiation exposure documentation. In those without
neurologic signs (25 percent of patients), CBC with differential and electrolytes; reverse isolation.
OR: None.
WARDS: ICU: None.
ICW: 25 percent of patients arriving at Level 3; VS q4h; supportive care;
100 percent IV fluids (LR 4 liters per day), NPO 100 percent. LAB: 100 percent serial CBCs with
differential every 12 hours daily, 100 percent electrolytes q24h. Cytokines (G-CSF 480 mcg subcutaneous
daily) in 100 percent of patients; 100 percent antidiarrheal medications. Eventual mortality is 80 percent
from this radiation exposure; reverse isolation. Draw blood specimens for HLA typing three yellow top
tubes (ACD) 100 percent (keep refrigerated). Note: If unable to evacuate by day four postexposure, blood
products preferably irradiated to 2000 cGy, antibiotics, antivirals, antifungals, and surveillance cultures will
be needed. Patients admitted to ICW—Urgent air transport 100 percent air evacuate to Level V treatment
facility.
MCW: 75 percent of patients arriving at Level 3; palliative care; 100
percent morphine IV every 1 to 4 hours daily as needed for pain (mortality 100 percent). Patients admitted
to MCW—100 percent mortality.
C-31. Treatment Brief No. 8: Radiation at 0–125 cGy With Nonoperative Trauma (Examples
include concussion, simple lacerations, closed fractures, ligamental injuries, and so forth.)
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 50 percent litter patient (from morphine)/50
percent ambulatory patient (no morphine); VS stable; severe pain in upper extremity; neurovascular status
intact; no significant hemorrhage; moderate deformity of elbow noted; alert; oriented. Radiation effects
include: apprehension and agitation; n/v 5 to 30 percent; mild headache; pretreatment with antiemetics
decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: Sling and swathe extremity; 50 percent patients IM morphine; dress open wounds;
reassurance; 100 percent routine ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 50 percent litter patient/50 percent ambulatory
patient; VS stable; severe pain in upper extremity; neurovascular status intact; no significant hemorrhage;
moderate deformity of elbow noted; alert; oriented. Radiation effects include: apprehension and agitation;
n/v 5 to 30 percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation does not
contribute to mortality at this level.
Treatment: VS: start IV LR in 50 percent; sling and swathe extremity; IM morphine 50 percent; 30
percent PO antiemetics promethazine; reassurance; 100 percent routine ground transport.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 50 percent litter patients/50 percent ambulatory
patients; VS stable; severe pain in upper extremity; neurovascular status intact in 99 percent; no significant
C-14
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
hemorrhage; moderate deformity of elbow noted. Radiation effects include: apprehension and agitation;
n/v 5 to 30 percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation may
contribute to morbidity at this level.
Treatment: IV/IM morphine; IV fluids LR 80 percent, rest, 30 percent PO antiemetics, reassurance/
counseling. X-ray, neurovascular checks, one percent axillary block and fasciotomy and/or attempted
reduction for compartment syndrome and vascular compromise; splint extremity; sling applied; saline lock.
LAB: CBC with differentials twice daily until transferred; 100 percent routine ground transport.
LEVEL 3
Assumptions: Real or suspected radiation exposure; 50 percent litter patients/50 percent ambulatory
patients; VS stable; x-ray reveals fracture, dislocation of elbow; neurovascular status intact; no other
apparent injuries. Radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild headache;
pretreatment with antiemetics decreases vomiting; radiation may contribute to morbidity at this level.
Treatment: EMT: VS; primary assessment. LAB: 100 percent CBC with differential; draw one
blood specimen per patient for biodosimetry (red top tube [clot] [keep refrigerated]) for radiation exposure
prognosis. Maintain IV; 50 percent IM/IV morphine; orthopedist consult; doppler assessment; x-ray:
elbow, humerus, forearm; compartment pressure assessment 10 percent; orthopedist reduces 90 percent
in EMT and places arm in posterior plaster long arm splint and sling; x-ray: repeat of elbow after
reduction.
OR: 10 percent have open reduction with possible fixation of fracture with plates and
screws/K-wires; further definitive stabilization may be required at higher level; fasciotomy of forearm and
application of long arm splint under axillary block; IV antibiotics; x-ray: elbow; 2 liters RL; OR table
time—180 min. Digital portable radiography in OR.
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3. VS; 100 percent IV LR;
IV antibiotics (10 percent) for operative cases; IV/IM morphine; elevate limb; neuro and circulatory
checks; doppler; dressing changes; CBC with differentials twice daily times four days; reverse isolation.
Priority air transport 100 percent.
MCW: None.
C-32. Treatment Brief No. 9: Radiation at 125–530 cGy With Nonoperative Trauma (Examples
include concussion, simple lacerations, closed fractures, ligamental injuries, and so forth.)
LEVEL 1A
Assumptions: Significant radiation exposure; 75 percent litter patient/25 percent ambulatory patient;
VS stable; severe pain in upper extremity; neurovascular status intact; no significant hemorrhage; moderate
deformity of elbow noted; alert; oriented. Radiation effects include: apprehension and agitation; n/v 50 to 90
percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics decrease
vomiting; radiation does not contribute to mortality at this level.
Treatment: Sling and swathe extremity; 75 percent IM morphine; dress open wounds; reassurance;
100 percent routine ground transport.
LEVEL 1B
Assumptions: Significant radiation exposure; 75 percent litter patient/25 percent ambulatory patient;
VS stable; severe pain in upper extremity; neurovascular status intact; no significant hemorrhage; moderate
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FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
deformity of elbow noted; alert; oriented. Radiation effects include: apprehension and agitation; n/v 50 to 90
percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics decreases
vomiting; radiation does not contribute to mortality at this level.
Treatment: VS: start IV LR in 90 percent; sling and swathe extremity; IM morphine 100 percent;
90 percent PO/IM antiemetics; reassurance; further radiation exposure strictly limited to medical diagnostic
procedures; 100 percent routine transport.
LEVEL 2
Assumptions: Significant and potentially lethal radiation exposure; 75 percent litter patients/25
percent ambulatory patients; VS stable; severe pain in upper extremity; neurovascular status intact in 99
percent; no significant hemorrhage; moderate deformity of elbow noted. Radiation effects include:
apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent;
pretreatment with antiemetics may decrease vomiting; radiation contributes to morbidity at this level.
Automated cell counter available.
Treatment: IV/IM morphine; IV fluids LR 100 percent; rest; 90 percent PO antiemetics, counseling.
X-ray, neurovascular checks, one percent axillary block and fasciotomy and/or attempted reduction for
compartment syndrome and vascular compromise. Splint extremity; sling applied; saline lock. LAB: CBC
with differentials twice daily until transferred; 100 percent routine ground transport.
LEVEL 3
Assumptions: Significant and potentially lethal radiation exposure; 75 percent litter patients/25
percent ambulatory patients; VS stable; x-ray reveals fracture, dislocation of elbow; neurovascular status
intact; no other apparent injuries. Radiation effects include: apprehension and agitation; n/v 50 to 90 per-
cent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics may decrease
vomiting; radiation contributes to morbidity at this level. Radiation will contribute to morbidity at this level
due to immunosuppression.
Treatment: EMT: VS; primary assessment. LAB: CBC with differential, 100 percent draw one
blood specimen per patient for biodosimetry red top tube (clot) (keep refrigerated) for radiation exposure
prognosis; maintain IV; 75 percent IM/IV morphine. Orthopedist consult; doppler assessment; x-ray:
elbow, humerus, forearm; compartment pressure assessment 10 percent; orthopedist reduces 90 percent
in EMT and places arm in posterior plaster long arm splint and sling; x-ray: repeat of elbow after
reduction.
OR: 10 percent have open reduction with possible fixation of fracture with plates and
screws/K-wires; further definitive stabilization may be required at higher level; fasciotomy of forearm and
application of long arm splint under axillary block; IV antibiotics; x-ray: elbow; 2 liters RL. OR table
time—180 minutes. Digital portable radiography in OR.
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3. VS; 100 percent IV LR;
IV antibiotics (10 percent) for operative cases; IV/IM morphine; elevate limb; neuro and circulatory
checks; doppler; dressing changes. Administer cytokines (480 mcg G-CSF) subcutaneous daily in 100
percent; CBC with differentials twice daily. Draw blood specimens for HLA typing (three yellow top tubes
[ACD] [keep refrigerated]). Reverse isolation. Patients admitted to ICW—10 percent early mortality due
to combination of surgery and high dose radiation; 90 percent priority air transport.
MCW: None.
C-16
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-33. Treatment Brief No. 10: Radiation >530 cGy With Nonoperative Trauma (Examples
include concussion, simple lacerations, closed fractures, ligamental injuries, and so forth.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable; severe
pain in upper extremity; neurovascular status intact; no significant hemorrhage; moderate deformity of
elbow noted; alert; oriented. Extreme radiation doses will cause neurological deficits; additional radiation
effects include: apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment
with antiemetics may have no effects; radiation may contribute to morbidity at this level.
Treatment: Dress open wounds; reassurance; sling and swathe extremity; IM morphine; 100
percent priority ground transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable; severe
pain in upper extremity; neurovascular status intact; no significant hemorrhage; moderate deformity of
elbow noted. Extreme radiation doses will cause neurological deficits; additional radiation effects include:
apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics
may have no effects; radiation may contribute to morbidity at this level. Critical radiation injury with
persistent central neurological signs places 10 percent of patients in expectant category at this level.
Treatment: VS; start IV LR in nonexpectant patients (90 percent of patients); sling and swathe
extremity; IM morphine 100 percent; 90 percent PO/IM antiemetics; reassurance. Note: All surgery must
be completed within 36—48 hours; evacuation to a level of care that can provide appropriate wound closure
surgery is essential.
90 percent priority ground transport; 10 percent routine ground transport.
LEVEL 2
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable; severe
pain in upper extremity; neurovascular status intact in 90 percent; no significant hemorrhage; moderate
deformity of elbow noted. Extreme radiation doses will cause neurological deficits; additional radiation
effects include: apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment
with antiemetics may have no effects; radiation may contribute to morbidity at this level. Critical radiation
injury with persistent central neurological signs places 20 percent of patients in expectant category at this
level.
Treatment: VS; Maintain IV LR in nonexpectant patients (80 percent of patients); IV/IM morphine;
x-ray, neurovascular checks, one percent axillary block and fasciotomy and/or attempted reduction for
compartment syndrome and vascular compromise; splint extremity; sling applied; saline lock. LAB: CBC
with differentials twice daily until transferred. Note: All surgery must be completed within 36 to 48 hours;
evacuation to a level of care that can provide appropriate wound closure surgery is essential. Attempt
reverse isolation.
80 percent priority air transport; 20 percent routine air transport.
LEVEL 3
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable; x-ray
reveals fracture, dislocation of elbow; neurovascular status intact in 90 percent of patients arriving at
Level 3; no other apparent injuries. Radiation effects include: apprehension and agitation; n/v 100 percent;
fatigue and weakness 100 percent; pretreatment with antiemetics may have no effects; radiation may
C-17
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
contribute to morbidity at this level. Critical radiation injury with persistent central neurological signs
places 30 percent of patients in expectant category at this level.
Treatment: EMT: VS; primary assessment, maintain IV; 100 percent IM/IV morphine;
orthopedist consult; doppler assessment; x-ray: elbow, humerus, forearm; compartment pressure
assessment 10 percent; orthopedist reduces 90 percent in EMT and places arm in posterior plaster long arm
splint and sling; x-ray: repeat of elbow after reduction. LAB: (for nonexpectant patients—70 percent); CBC
with differential for radiation exposure; 100 percent draw one blood specimen per patient for biodosimetry
(red top [clot] [keep refrigerated]) for prognosis.
OR: 10 percent have open reduction with possible fixation of fracture with plates and
screws/K-wires; further definitive stabilization may be required at higher level; fasciotomy of forearm and
application of long arm splint under axillary block; IV antibiotics; x-ray: elbow; 2 liters RL; OR table
time—180 minutes. Digital portable radiography in OR.
WARDS: ICU: None.
ICW: 70 percent of patients arriving at Level 3; VS; 100 percent IV LR;
IV antibiotics (10 percent) for operative cases; IV/IM morphine; elevate limb; neuro and circulatory
checks; doppler; dressing changes. Administer cytokines (G-CSF 480 mcg subcutaneous daily) in 100
percent; CBC with differentials twice daily. Three yellow top tubes (ACD) for HLA typing, keep
refrigerated. Reverse isolation. Patients admitted to ICW: Mortality 5 percent at this level at 5 to 7 days,
95 percent priority air transport.
MCW: Expectant patients only (30 percent of patients arriving at Level 3);
IV/IM morphine as needed. Patients admitted to MCW: Mortality 100 percent by seven days.
C-34. Treatment Brief No. 11: Radiation at 0–125 cGy With Operative Trauma
LEVEL 1A
Assumptions: Real or suspected radiation exposure; litter patient; alert, cooperative and oriented;
VS: pulse greater than 100, B/P 100/60, no respiratory distress, evidence of closed intra-abdominal
hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decrease vomiting and possibly increase fatigability; radiation
does not contribute to mortality at this level.
Treatment: Start IV 100 percent (LR); reassurance; 100 percent priority ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 5 to 30
percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation does not contribute to
mortality at this level.
Treatment: VS: Maintain IV LR in 100 percent; stabilization and IM morphine; reassurance; 30
percent treatment with antiemetics; 10 percent cervical spine stabilized; 100 percent urgent air transport.
Note: All surgery must be completed within 36 to 48 hours; evacuation to a level of care that can provide
appropriate urgent surgery.
C-18
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 5 to 30
percent; mild headache; pretreatment with antiemetics decrease vomiting and possibly increase fatigability;
radiation may contribute to morbidity at this level.
Treatment:
25 percent exploratory laparoscopy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter. Remaining 75 percent: IV fluids LR 100 percent; rest; 30 percent IV/IM antiemetics;
reassurance/counseling. Note: All surgery must be completed within 36 to 48 hours; evacuation to a level of
care that can provide appropriate urgent surgery. If appropriate surgery has been provided at this level, then
routine evacuation (25 percent) to Level 3; otherwise urgent air transport (75 percent).
LEVEL 3
Assumptions: Real or suspected radiation exposure; litter patient; Class III hemorrhage; VS:
pulse 120, B/P 100/70, respirations normal; alert; oriented. Radiation effects include: apprehension
and agitation; n/v 5 to 30 percent; mild headache; pretreatment with antiemetics decreases vomiting; 25
percent will receive appropriate wound closure surgery at Level 2; radiation may contribute to morbidity at
this level.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube; LAB: 100 percent CBC with
differential, UA, TC for 4 units; x-rays: chest, 50 percent pelvis films. LAB: 100 percent draw one blood
specimen per patient for biodosimetry red top tube (clot) (keep refrigerated), for radiation exposure
prognosis.
OR:
75 percent of patients arriving at Level 3. Laparotomy and drainage of liver
injury under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters RL; 2 units blood;
arterial line 10 percent. Lab: CBC, blood gases; OR table time—120 minutes. Note: All surgery must be
completed within 36 to 48 hours of radiation exposure.
WARDS: 25 percent of patients arriving at Level 3—direct admit from Level 2.
ICU: 100 percent of patients arriving at Level 3. VS; maintain IV fluids; IV
antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent maintain
ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain central
line and monitoring and arterial line; cardiac monitor and pulse oximeter; dressing reinforcement; dc
central/arterial line before leaving ICU. LAB: CBC with differential twice daily, electrolytes, clotting
studies, Amylase, LFTs on admission; x-ray: chest, 10 percent c-spine. Consider cytokines (G-CSF 480
mcg subcutaneous daily).
ICW:
100 percent of patients arriving at Level 3 will be transferred
from ICU by day 2. VS; IVs with IV antibiotics; parenteral pain medications; 25 percent on O2 by mask;
Foley catheter care; maintain NG tube; NPO; dressing reinforcement; drain care. Consider cytokines
(G-CSF 480 mcg subcutaneous daily); CBC with differentials three times daily. Routine air transport 100
percent.
MCW: None.
C-19
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-35. Treatment Brief No. 12: Radiation at 125–530 cGy With Operative Trauma
LEVEL 1A
Assumptions: Significant radiation exposure; 100 percent litter patient; alert, cooperative and
oriented; VS pulse greater than 100, B/P 100/60, no respiratory distress, evidence of closed intra-abdominal
hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild
headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics decrease vomiting; radiation
does not contribute to mortality at this level.
Treatment: Start IV 100 percent (LR); reassurance; 100 percent priority ground transport.
LEVEL 1B
Assumptions: Significant radiation exposure; 100 percent litter patients; alert, cooperative and
oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-abdominal
hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild
headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics decrease vomiting; radiation
contributes to morbidity at this level.
Treatment: VS; maintain IV LR in 100 percent; stabilization and IM morphine; reassurance; 90
percent Kytril IV; 10 percent cervical spine stabilized; 100 percent urgent air transport. Note: All surgery
must be completed within 36 to 48 hours; evacuation to a level of care that can provide appropriate urgent
surgery.
LEVEL 2
Assumptions: Significant and potentially lethal radiation exposure; 100 percent litter patients; alert,
cooperative and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of
closed intra-abdominal hemorrhage and injury. Radiation effects include apprehension and agitation; n/v 50
to 90 percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with antiemetics may
decrease vomiting; radiation contributes to morbidity at this level. Automated cell counter available.
Treatment:
25 percent exploratory laparotomy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter. Remaining 75 percent:
90 percent IV antiemetics (Kytril), counseling. LAB: CBC with
differentials twice daily until transferred. Note: All surgery must be completed within 36 to 48 hours;
evacuation to a level of care that can provide appropriate urgent surgery. If appropriate surgery has been
provided at this level, then routine evacuation (25 percent) to Level 3; otherwise urgent air transport (75
percent).
LEVEL 3
Assumptions: Significant and potentially lethal radiation exposure; litter patient; Class III
hemorrhage; VS: pulse 120, B/P 100/70, respirations normal; alert; oriented. Radiation effects include
apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent;
pretreatment with antiemetics may decrease vomiting; radiation contributes to morbidity at this level.
25
percent will receive appropriate surgery at Level 2; radiation will contribute to mortality and morbidity at
this level. Radiation at this level combined with trauma multiplies mortality rates over baseline values.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube; lab: CBC with differential, UA, TC
C-20
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
for 4 units; x-rays: chest, 50 percent pelvis films, 90 percent IV antiemetic (Kytril); 100 percent draw one
blood specimen per patient for biodosimetry red top tube (clot).
OR:
75 percent of patients arriving at Level 3. Laparotomy and drainage of liver
injury under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters LR; 2 units blood;
arterial line 10 percent. LAB: CBC, blood gases; OR table time—120 minutes. Note: All surgery must be
completed within 36—48 hours of radiation exposure.
WARDS: ICU: 100 percent of patients arriving at Level 3. VS; maintain IV fluids;
IV antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent
maintain ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain
central line and monitoring and arterial line; cardiac monitor and pulse oximeter; dressing reinforcement;
dc central/arterial line before leaving ICU. LAB: CBC with differential twice daily, electrolytes, clotting
studies, Amylase, LFTs on admission; x-ray: chest, 10 percent c-spine. Administer cytokines (G-CSF 480
mcg subcutaneous daily) in 100 percent.
100 percent draw blood specimens for HLA typing (three yellow
top tubes [ACD] [keep refrigerated]). Reverse isolation.
ICW: 100 percent of patients arriving at Level 3 will be transferred from
ICU by day 2. VS; IVs with IV antibiotics; parenteral pain medications; 25 percent on O2 by mask; Foley
catheter care; maintain NG tube; NPO; dressing reinforcement; drain care. Administer cytokines (G-CSF
480 mcg subcutaneous daily) in 100 percent. LAB: CBC with differentials twice daily. 100 percent draw
blood specimens for HLA typing (three yellow top tubes [ACD]; keep refrigerated). Reverse isolation. 100
percent urgent air transport.
MCW: None.
C-36. Treatment Brief No. 13: Radiation >530 cGy With Operative Trauma
LEVEL 1A
Assumptions: Critical to lethal radiation exposure; 100 percent litter patient; VS: pulse greater than
100, B/P 100/60, no respiratory distress, evidence of closed intra-abdominal hemorrhage and injury.
Extreme radiation doses will cause neurological deficits; additional radiation effects include: apprehension
and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics may have
no effects; radiation may contribute to morbidity at this level. Critical radiation injury with major trunk and/
or head trauma places patient in expectant category.
Treatment: Start IV 100 percent (LR) reassurance. Patients with major trauma and high dose
radiation have the lowest transport priority; 95 percent expectant patients routine ground transport; 5 percent
nonexpectant patients urgent ground transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS: pulse greater
than 100, B/P 100/60, no respiratory distress; evidence of closed intra-abdominal hemorrhage and injury.
Extreme radiation doses will cause neurological deficits; additional radiation effects include: apprehension
and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics may have
no effects; radiation contributes to morbidity at this level. Critical radiation injury with major trunk and/or
head trauma places patient in expectant category.
Treatment: VS: Maintain IV LR in 5 percent (nonexpectant); stabilization and IM morphine;
reassurance; 90 percent Kytril IV; 10 percent cervical spine stabilized; 5 percent Overfly—urgent air
C-21
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
transport, 95 percent routine ground transport. Note: All surgery must be completed within 36 to 48 hours;
evacuation to a level of care that can provide appropriate urgent surgery.
LEVEL 2
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS: pulse greater
than 100, B/P 100/60, no respiratory distress; evidence of closed intra-abdominal hemorrhage and injury.
Extreme radiation doses will cause neurological deficits; additional radiation effects include: apprehension
and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics may have
no effects; radiation contributes to morbidity at this level. Critical radiation injury with major trunk and/or
head trauma places the patient in expectant category. Radiation at this level combined with trauma
multiplies mortality rates over baseline values.
Treatment: Parenteral pain medications (morphine); 100 percent routine ground transport.
LEVEL 3
Assumptions: Critical to lethal radiation exposure; litter patient; Class III hemorrhage; VS: pulse
120, B/P 100/70, respirations normal. Extreme radiation doses will cause neurological deficits; additional
radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent;
pretreatment with antiemetics may have no effects; radiation contributes to morbidity and mortality at this
level. Critical radiation injury with major trunk and/or head trauma places patient in expectant category.
Radiation at this level combined with trauma multiplies mortality rates over baseline values.
Treatment: EMT: VS; primary assessment, 3 percent of patients arriving at Level
3 are
nonexpectant requiring surgery. IV restarted, give 2 liters LR; 2d IV started; IV antibiotics; parenteral
morphine; Foley catheter; NG tube; LAB: CBC with differential, UA, TC for 4 units; x-rays: chest, 50
percent pelvis films, 90 percent IV antiemetic (Kytril); 97 percent of patients arriving at Level 3 are
expectant and transferred to MCW. One hundred percent of patients arriving at Level 3 draw one blood
specimen per patient for biodosimetry red top tube (clot).
OR: 3 percent of patients arriving at Level 3. Laparotomy and drainage of liver injury
under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters RL; 4 units blood;
arterial line 10 percent. LAB: CBC, blood gases; OR table time—120 minutes. Note: All surgery must be
completed within 36 to 48 hours of radiation exposure.
WARDS: ICU: 3 percent of patients arriving at Level 3. VS; maintain IV fluids; IV
antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent maintain
ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain central
line and monitoring and arterial line; cardiac monitor and pulse oximeter; dressing reinforcement; dc
central/arterial line before leaving ICU. LAB: CBC with differential twice daily, electrolytes, clotting
studies, Amylase, LFTs on admission. Administer cytokines (480 mcg G-CSF) subcutaneous daily in 100
percent. Draw blood specimens for HLA typing (three yellow top tubes ACD; [keep refrigerated]).
Reverse isolation. Patients admitted to ICU—100 percent of patients to ICW after two days.
ICW:
3 percent of patients arriving at Level 3 will be transferred from
ICU by day 2. VS; IVs with IV antibiotics; parenteral pain medications; 25 percent on O2 by mask; Foley
catheter care; maintain NG tube; NPO; dressing reinforcement; drain care. Administer cytokines (G-CSF
480 mcg subcutaneous daily) in 100 percent. LAB: CBC with differentials twice daily; 100 percent draw
blood specimens for HLA typing (three yellow top tubes [ACD] [keep refrigerated]). Reverse isolation.
MCW: Expectant patients only (97 percent of patients arriving at Level 3);
IM pain medications as needed. Patients admitted to MCW—mortality 90 percent by seven days.
C-22
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-37. Treatment Brief No. 14: Radiation at 0–125 cGy With Mild Burn
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; VS stable,
alert and oriented; additional radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decrease vomiting; radiation does not contribute to mortality at this
level.
Treatment: Clean and dress burns; pain medication; reassurance; 100 percent routine ground
transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; VS stable,
alert and oriented; additional radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decrease vomiting; radiation does not contribute to mortality at this
level.
Treatment: VS; stabilization, IV LR; pain medication; reassurance; 100 percent routine ground
transport.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; VS stable,
alert and oriented. Additional radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decreases vomiting; radiation does not contribute to mortality at
this level.
Treatment: IV fluids LR (1 Liter); pain medication; moist cool compress/bulky dressing, one
percent of patients receive O2 (carbon monoxide poison), rest, reassurance/counseling. LAB: CBC with
differentials twice daily until transferred; routine ground/air transport 100 percent.
LEVEL 3
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; VS stable,
alert and oriented; additional radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decrease vomiting; radiation does not contribute to mortality at this
level.
Treatment: EMT: VS; primary assessment. LAB: 100 percent draw one blood specimen per
patient for biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure
prognosis; tetanus toxoid; topical antibiotics.
OR: 1 percent of patients arriving at Level 3; 1 percent escharotomy, under MAC
anesthesia, maintain IVs; topical burn agents; wound dressing; OR table time 60 minutes.
WARDS: ICU: None.
ICW: 30 percent of patients arriving at Level 3. CBC with differentials
twice daily. Patients admitted to ICW—routine air transport 100 percent.
MCW: 70 percent of patients arriving at Level 3, VS; supportive care;
push PO fluids, advance diet. LAB: 100 percent CBC with differentials twice daily; topical burn agents;
wound dressing. Patients admitted to MCW—RTD 10 percent; routine air transport 90 percent.
C-23
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-38. Treatment Brief No. 15: Radiation at 125–530 cGy With Mild Burn (Without treatment
90 percent mortality.)
LEVEL 1A
Assumptions: Significant radiation exposure; 75 percent ambulatory patients; VS stable, alert and
oriented; additional radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild headache;
mild fatigability and weakness 25—60 percent; pretreatment with antiemetics decrease vomiting; radiation
does not contribute to mortality at this level.
Treatment: Clean and dress burns; reassurance; 25 percent IM morphine; 75 percent oral pain
medications; 100 percent priority ground transport.
LEVEL 1B
Assumptions: Significant radiation exposure; 80 percent ambulatory patients; 20 percent litter
patients; VS stable, alert and oriented; additional radiation effects include: apprehension and agitation; n/v
50 to 90 percent; mild headache; mild fatigability and weakness 25 to 60 percent; pretreatment with
antiemetics decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: VS: Stabilization, IV LR, and 25 percent IM morphine; reassurance; 90 percent IV
antiemetics, 100 percent priority ground transport.
LEVEL 2
Assumptions: Significant radiation exposure; 75 percent ambulatory patients; 25 percent litter
patients; VS stable, alert and oriented; additional radiation effects include: apprehension and agitation; n/v
50 to 90 percent; mild headache; mild fatigability and weakness 25 to 60 percent; pretreatment with
antiemetics decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: IV fluids LR (1 Liter) and IV/IM morphine; moist cool compress/bulky dressing,
1 percent of patients receive O2 (carbon monoxide poison), rest, reassurance; counseling. LAB: CBC
with differential twice daily until transferred; attempt reverse isolation;
100 percent priority ground
transport.
LEVEL 3
Assumptions: Significant radiation exposure; no respiratory injuries; 75 percent ambulatory patients;
25 percent litter patients; VS stable, alert and oriented; additional radiation effects include: apprehension
and agitation; n/v 30 to 60 percent; mild headache; mild fatigability and weakness 25 to 60 percent;
pretreatment with antiemetics decrease vomiting.
Treatment: EMT: VS; primary assessment. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]) CBC with differential for radiation exposure prognosis,
parenteral/oral morphine; tetanus toxoid; topical antibiotics.
OR:
1 percent escharotomy, under MAC anesthesia, maintain IVs; topical burn
agents; wound dressing; OR table time 60 minutes.
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3. CBC with differentials
twice daily. Draw blood specimens for HLA typing (three yellow top tubes [ACD] [keep refrigerated]).
Cytokines (G-CSF 480 mcg subcutaneous daily). Sixty percent IV antiemetics. Reverse isolation. Patients
admitted to ICW—100 percent priority air transport.
MCW: None.
C-24
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-39. Treatment Brief No. 16: Radiation >530 cGy With Mild Burn (Without treatment
100 percent mortality.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable, alert and
oriented. Central neurological deficits will be indicative of extreme radiation doses. Additional radiation
effects include: apprehension and agitation; n/v 90 to 100 percent; fatigue and weakness 90 to 100 percent;
pretreatment with antiemetics may have no effects; radiation may contribute to morbidity at this level.
Treatment: Clean and dress burns; IM morphine; reassurance; 100 percent priority ground
transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure; 100 percent litter patient; VS alert and oriented;
central neurological deficits will be indicative of extreme radiation doses. Additional radiation effects
include: apprehension and agitation; n/v 90 to 100 percent; fatigue and weakness 90 to 100 percent;
pretreatment with antiemetics may have no effects; radiation will contribute to morbidity at this level.
Critical radiation injury with persistent central neurological signs places patient in expectant category (10
percent of patients at this level).
Treatment: VS: start IV LR in nonexpectant patients (90 percent of patients); stabilization and IM
morphine/IV antiemetics; reassurance; 90 percent priority ground transport; 10 percent routine ground
transport.
LEVEL 2
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable, alert and
oriented. Central neurological deficits will be indicative of extreme radiation doses; additional radiation
effects include: apprehension and agitation; n/v 90 to 100 percent; fatigue and weakness 90 to 100 percent;
pretreatment with antiemetics may have no effect; radiation will contribute to morbidity at this level.
Critical radiation injury with persistent central neurological signs places patient in expectant category (10
percent of patients at this level). Automated differential cell counter available.
Treatment: Maintain IV fluids LR and IV/IM morphine; 100 percent injectable antiemetics; moist
cool compress/bulky dressing, 1 percent of patients receive O2 (carbon monoxide poison), rest, reassurance/
counseling. LAB: CBC with differentials twice daily until transferred; attempt reverse isolation; 10
percent routine ground/air transport, 90 percent priority air transport.
LEVEL 3
Assumptions: Critical to lethal radiation exposure; 100 percent litter patient; no respiratory injuries.
VS stable; central neurological deficits will be indicative of extreme radiation doses; additional radiation
effects include: apprehension and agitation; n/v 90 to 100 percent; fatigue and weakness 90 to 100 percent;
pretreatment with antiemetics may have no effects; radiation will contribute to morbidity and mortality at
this level. Critical radiation injury with persistent central neurological signs places patient in expectant
category.
Treatment: EMT: VS; primary assessment. LAB:
100 percent draw one blood specimen per
patient for biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure
prognosis; parenteral/oral morphine; tetanus toxoid; topical antibiotics.
C-25
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
OR: 1 percent escharotomy, under MAC anesthesia, maintain IVs; topical burn
agents; wound dressing; OR table time 60 minutes. Third degree burn excision skin grafts must be in place
by 48 hours.
WARDS: ICU: None.
ICW: 80 percent of patients arriving at Level 3. CBC with differentials
twice daily times four days. Administer cytokines (480 mcg G-CSF) subcutaneous daily in 100 percent;
CBC with differentials twice daily times four days. Draw blood specimens for HLA typing (three yellow top
tubes [ACD] [keep refrigerated]); reverse isolation. Patients admitted to ICW— mortality 12 percent at this
level at 5 to 7 days; 60 percent priority air transport; 38 percent routine air transport.
MCW: 20 percent of patients arriving at Level 3; expectant patients only;
IM morphine as needed. Patients admitted to MCW—mortality 100 percent by seven days.
C-40. Treatment Brief No. 17: Radiation at 0–125 cGy With Moderate Burn
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; both upper
extremities involved in burn; alert; oriented; VS: stable; no other apparent injuries. Radiation effects
include: apprehension and agitation; n/v 5 to 30 percent; mild headache; pretreatment with antiemetics
decrease vomiting; radiation does not contribute to mortality at this level.
Treatment: Clean and dress burns; 80 percent IM morphine; reassurance; 100 percent priority
ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 20 percent ambulatory patients; 80 percent
litter patients; VS stable, alert and oriented. Radiation effects include: apprehension and agitation; n/v
5 to 30 percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation does not
contribute to mortality at this level.
Treatment: VS: Stabilization, 100 percent IV LR; reassurance; 80 percent IM morphine/antiemetics;
100 percent priority ground transport.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent ambulatory patients; VS stable,
alert and oriented. Radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild headache;
pretreatment with antiemetics decrease vomiting; radiation does not contribute to mortality at this level.
Automated differential cell counter available.
Treatment: VS: Stabilization; 100 percent IV LR and 80 percent IV/IM morphine; IV antiemetic;
rest, reassurance, counseling. LAB: CBC with differentials twice daily until transferred; 100 percent
priority ground/air transport.
LEVEL 3
Assumptions: Real or suspected radiation exposure; 20 percent ambulatory patients; 80 percent
litter patients; VS stable, alert and oriented. Radiation effects include: apprehension and agitation; n/v
5 to 30 percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation does not
contribute to morbidity and mortality at this level.
C-26
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Treatment: EMT: VS; primary assessment. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]); CBC with differential for radiation exposure prognosis.
Start IV in unburned area on 20 percent, give 3 liters LR; tetanus toxoid; topical antibiotics; debridement in
EMT.
OR:
10 percent escharotomy, under MAC anesthesia, maintain IV’s; topical burn
agents; wound dressing; OR table time 60 minutes. Comment: For 3d degree burn excision skin grafts must
be in place by 48 hours (those with 6 to 10 percent 3d degree burns).
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3; CBC with differentials
twice daily. IV/IM morphine; (topical antibiotic); IV LR 6 liters per day; general surgeon consult; PT
consult; CBC with differentials twice daily times four days. Reverse isolation; culture surveillance beginning
day 3. Patients admitted to ICW—mortality 5 percent estimated at this level at 5 to 7 days; 95 percent
priority transport.
MCW: None.
C-41. Treatment Brief No. 18: Radiation at 125–530 cGy With Moderate Burn (Without treatment
100 percent mortality.)
LEVEL 1A
Assumptions: Significant radiation exposure; 100 percent litter patients; both upper extremities
involved in burn; alert; oriented; VS: stable; no other apparent injuries. Radiation effects include:
apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent;
pretreatment with antiemetics decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: Clean and dress burns; 100 percent IV LR; pain medication prn, IM morphine;
reassurance; 100 percent priority ground transport.
LEVEL 1B
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert and
oriented. Radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue
and weakness 25 to 60 percent; pretreatment with antiemetics decreases vomiting; radiation does not
contribute to mortality at this level.
Treatment: VS; stabilization, maintain IV LR; reassurance; injectable pain medication
(IM
morphine) antiemetic medication; 100 percent priority ground transport.
LEVEL 2
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert and
oriented. Radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue
and weakness 25 to 60 percent; pretreatment with antiemetics decrease vomiting; radiation does not
contribute to mortality at this level. Automated differential cell counter available.
Treatment: VS: Stabilization, 100 percent IV LR, 90 percent IV antiemetics and pain medication
(IV/IM morphine); reassurance; attempt reverse isolation as operational constraints and logistics allow;
100 percent priority ground/air transport.
C-27
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
LEVEL 3
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert and
oriented. Radiation effects include: apprehension and agitation; n/v 50 to 90 percent; mild headache; fatigue
and weakness 25 to 60 percent; pretreatment with antiemetics decrease vomiting; radiation does contribute
to morbidity and mortality at this level.
Treatment: EMT: VS; primary assessment. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]); CBC with differential every 6 hours for radiation exposure
prognosis, electrolytes every 12 hours. Start IV in unburned area on 20 percent, give 3 liters LR; tetanus
toxoid; topical antibiotics; debridement in EMT.
OR:
10 percent escharotomy, under MAC anesthesia, maintain IVs; topical burn
agents; wound dressing; OR table time 60 minutes. Comment: For 3d degree burn excision skin grafts must
be in place by 48 hours (those with 6 to 10 percent 3d degree burns and < 300 cGy).
WARDS: ICU: None.
ICW: 100 percent of patients arriving at Level 3; CBC with differentials
twice daily. IV/IM morphine; (topical antibiotic); IV LR 6 liters per day; general surgeon consult; PT
consult; administer cytokines (480 mcg G-CSF) subcutaneous daily in 100 percent; CBC with differentials
twice daily draw blood specimens for HLA typing (three yellow top tubes [ACD] [keep refrigerated]).
Reverse isolation. Culture surveillance beginning day 3. Patients admitted to ICW—mortality 40 percent
estimated at this level at 5 to 7 days, 30 percent to (MCW—Expectant), 60 percent priority air transport.
MCW: 30 percent of patients arriving at Level 3 (transferred from ICW);
100 percent IV/IM morphine for pain control.
C-42. Treatment Brief No. 19: Radiation >530 cGy With Moderate Burn (With or without treat-
ment 100 percent mortality.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; both upper extremities
involved in burn; alert; oriented; VS: stable; no other apparent injuries. Central neurological deficits will be
indicative of extreme radiation doses; additional radiation effects include: apprehension and agitation; n/v
100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics may have no effects;
radiation may contribute to morbidity at this level.
Treatment: Clean and dress burns; IM morphine; reassurance; 100 percent priority ground
transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure; 100 percent litter patient; VS stable, alert and
oriented. Central neurological deficits will be indicative of extreme radiation doses; additional radiation
effects include: apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment
with antiemetics may have no effects; radiation will contribute to morbidity at this level. Critical radiation
injury with persistent central neurological signs places the patient in expectant category (10 percent of
patients at this level).
Treatment: VS: IV LR in nonexpectant patients (70 percent of patients at this point); stabilization
and injectable morphine/antiemetic medication; reassurance;
70 percent priority ground transport;
30
percent routine ground transport.
C-28
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
LEVEL 2
Assumptions: Critical to lethal radiation exposure; 100 percent litter patients; VS stable. Central
neurological deficits will be indicative of extreme radiation doses; additional radiation effects include:
apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics
may have no effects; radiation will contribute to morbidity at this level. Critical radiation injury with
persistent central neurological signs places patient in expectant category (10 percent of patients at this level).
Automated differential cell counter available.
Treatment: 100 percent IV fluids LR and IV/IM morphine; 100 percent injectable antiemetics; rest,
reassurance/counseling. LAB: CBC with differentials twice daily until transferred; attempt reverse
isolation; 70 percent priority air transport; 30 percent routine ground transport.
LEVEL 3
Assumptions: Critical to lethal radiation exposure; 100 percent litter patient; VS stable. Central
neurological deficits will be indicative of extreme radiation doses; additional radiation effects include:
apprehension and agitation; n/v 100 percent; fatigue and weakness 100 percent; pretreatment with antiemetics
may have no effects; radiation will contribute to mortality and morbidity at this level. Critical radiation
injury with persistent central neurological signs places the patient in expectant category (10 percent of
patients at this level).
Treatment: EMT: VS; primary assessment, 100 percent IV antiemetics. LAB: Draw one blood
specimen per patient for biodosimetry (red top [clot] [keep refrigerated]); CBC with differential every 6
hours for radiation exposure prognosis, electrolytes every 12 hours. Start IV in unburned area on 20
percent, give 3 liters LR; tetanus toxoid; topical antibiotics; debridement in EMT.
OR:
10 percent escharotomy, under MAC anesthesia, maintain IV’s; topical burn
agents; wound dressing; OR table time 60 minutes. Comment: For 3d degree burn excision skin grafts must
be in place by 48 hours.
WARDS: ICU: 20 percent of patients arriving at Level 3; maintain IVs; topical burn
agents; wound dressing; administer cytokines (480 mcg G-CSF) subcutaneous daily in 100 percent; LAB:
CBC with differentials twice daily. Draw blood for HLA typing (three yellow top tubes [ACD] [keep
refrigerated]). Reverse isolation. Patients admitted to ICU—100 percent to ICW after two days.
ICW:
50 percent of patients arriving at Level 3; CBC with differentials
twice daily. IV/IM morphine; (topical antibiotic); IV LR 6 liters per day; general surgeon consult; PT
consult. Administer cytokines (480 mcg G-CSF) subcutaneous daily in 100 percent; CBC with differentials
twice daily. Draw blood specimens for HLA typing (three yellow top tubes [ACD]; keep refrigerated).
Reverse isolation. Patients admitted to ICW at 5 to 7 days; 75 percent estimated mortality at this level; 30
percent priority air transport.
MCW: 30 percent of patients arriving at Level 3, expectant patients; IM/
IV morphine as needed. Patients admitted to MCW—mortality 100 percent by seven days.
C-43. Treatment Brief No. 20: Radiation at 0–125 cGy With Severe Burn (Without treatment
20 percent mortality.)
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; VS stable, alert,
oriented, both extremities injured; no other traumatic injuries. Radiation effects include: apprehension and
C-29
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
agitation; n/v 5 to 30 percent; pretreatment with antiemetics decreases vomiting; radiation does not contribute
to mortality at this level. Deaths and expectant designation in accordance with burn protocols.
Treatment: Clean and dress burns; 100 percent IV LR; IM morphine; reassurance; 100 percent
priority ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; VS stable, alert,
oriented, both extremities injured; no other traumatic injuries. Radiation effects include: apprehension and
agitation; n/v 5 to 30 percent; pretreatment with antiemetics decreases vomiting; radiation does not contribute
to mortality at this level.
Treatment: VS: Stabilization, IV LR (1 Liter); reassurance; injectable morphine/antiemetic
(Promethazine) medication; 100 percent priority ground transport.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; VS stable, alert,
oriented, both extremities injured; no other traumatic injuries. Radiation effects include: apprehension and
agitation; n/v 5 to 30 percent; pretreatment with antiemetics decreases vomiting; radiation does not contribute
to mortality at this level. Automated differential cell counter available.
Treatment: VS: Stabilization; IV fluids LR and IV/IM morphine; rest, reassurance/counseling. 90
percent IV antiemetics. Moist cool compress/bulky dressing, 10 percent of patients O2, splint. LAB: CBC
with differentials twice daily until transferred; 100 percent priority air transport.
LEVEL 3
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; VS stable, alert,
oriented, both extremities injured; no other traumatic injuries. Radiation effects include: apprehension
and agitation; n/v 5 to 30 percent; pretreatment with antiemetics decreases vomiting; radiation does not
contribute to morbidity and mortality at this level. Deaths and expectant designation in accordance with burn
protocols.
Treatment: EMT: VS; primary assessment. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure prognosis.
Maintain LR IVs; topical antibiotics; IM/IV morphine; forced fluids; dressing changes.
OR:
50 percent of patients arriving at Level 3 undergo debridement of the hands;
MAC anesthesia; 2 liters LR; OR table time 60 minutes.
WARDS: ICU:
50 percent of patients arriving at Level
3. LAB: CBC with
differentials twice daily. Maintain LR IVs; topical antibiotics; IM/IV morphine; forced fluids; dressing
changes. Reverse isolation. Patients admitted to ICU—100 percent transferred out of ICU after two days
(50 percent AIREVAC; 45 percent of patients to ICW; 5 percent to MCW).
ICW: 70 percent of patients arriving at Level 3; VS; maintain IVs; physical
therapy consult; topical antibiotics; IM/IV morphine; forced fluids; dressing changes. LAB: CBC with
differentials twice daily. Reverse isolation; culture surveillance beginning day 3; patients admitted to
ICW—100 percent priority air transport.
MCW: 10 percent of patients arriving at Level 3. Mortality 100 percent by
day 7.
C-30
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-44. Treatment Brief No. 21: Radiation at 125–530 cGy With Severe Burn (Without treatment
100 percent mortality.)
LEVEL 1A
Assumptions: Significant radiation exposure; 100 percent litter patients; VS: stable, alert, oriented,
both extremities injured; no other traumatic injuries. Additional radiation effects include: apprehension and
agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with
antiemetics decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: Clean and dress burns; 100 percent IV LR; IM morphine; reassurance; 100 percent
priority ground transport.
LEVEL 1B
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert, oriented,
both extremities injured; no other traumatic injuries. Additional radiation effects include: apprehension and
agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with
antiemetics decreases vomiting; radiation does not contribute to mortality at this level.
Treatment: VS: Stabilization, IV LR (1 Liter), and IM morphine; reassurance; 100 percent priority
ground transport.
LEVEL 2
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert, oriented,
both extremities injured; no other traumatic injuries. Additional radiation effects include: apprehension and
agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with
antiemetics decrease vomiting; radiation will not contribute to mortality at this level. Third degree burn
patients are expectant. Automated differential cell counter available.
Treatment: Third degree burn patients (50 percent of patients arriving at Level 2); 100 percent IV/
IM morphine as needed for pain; 100 percent injectable antiemetic medication; reassurance; routine ground
transport. Second degree burn patients (50 percent of patients arriving at Level 2): VS: Stabilization, 100
percent IV LR (2 liters), and IV/IM morphine; moist cool compress/bulky dressing, 10 percent of patients
O2, splint, CBC with differential. Reassurance; 100 percent priority air transport.
LEVEL 3
Assumptions: Significant radiation exposure; 100 percent litter patients; VS stable, alert, oriented,
both extremities injured; no other traumatic injuries. Additional radiation effects include: apprehension and
agitation; n/v 50 to 90 percent; mild headache; fatigue and weakness 25 to 60 percent; pretreatment with
antiemetics decreases vomiting; radiation will significantly contribute to mortality at this level. Third
degree burn patients are expectant.
Treatment: EMT: VS; primary assessment. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure prognosis.
Maintain LR IVs; topical antibiotics; IM/IV morphine; forced fluids; dressing changes.
OR:
50 percent of patients arriving at Level 3 undergo debridement of the hands;
MAC anesthesia; 2 liters LR; OR table time—60 minutes.
WARDS: ICU: None.
ICW: 50 percent of patients arriving at Level 3; VS; maintain IVs; physical
therapy consult; topical antibiotics; IM/IV morphine; forced fluids; dressing changes; CBC with differentials
C-31
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
twice daily. Reverse isolation. Draw blood specimens for HLA typing (three yellow top tubes [CD] [keep
refrigerated]). Cytokines (G-CSF 480 mcg subcutaneous daily). Patients admitted to ICW—100 percent
priority air transport.
MCW: 50 percent of patients arriving at Level 3 are expectant; IM/IV
morphine for pain as needed. Patients admitted to MCW—mortality 100 percent by 15 days. Comment:
Approximately 67 percent of expectant patients will have a prolonged dying process of greater than one
week. Routine air transport when and if available.
C-45. Treatment Brief No. 22: Radiation >530 cGy with Severe Burn (With or without treatment
100 percent mortality.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; pretreatment with antiemetics may have no effects.
Treatment: Clean and dress burns; IM morphine; reassurance; 100 percent routine ground transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; mortality 10 percent at this level.
Treatment: Comfort measures only; 100 percent morphine IV/IM as needed for pain, 100 percent
injectable antiemetic medication; reassurance; 90 percent routine ground transport.
LEVEL 2
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; mortality 50 percent within 24 hours.
Treatment: Comfort measures only; 100 percent morphine IV/IM as needed for pain, 100 percent
injectable antiemetic medication; reassurance; 100 percent routine ground/air transport.
LEVEL 3
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent.
Treatment: EMT: Patients are all expectant. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure.
OR: None.
WARDS: ICU: None.
ICW: None.
C-32
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
MCW: 100 percent of patients arriving at Level 3 are expectant. IM pain
medications (morphine) as needed. Patients admitted to MCW—mortality 100 percent by five days.
C-46. Treatment Brief No. 23: Radiation at 0–125 cGy with Operative Trauma and Mild Burn
LEVEL 1A
Assumptions: Real or suspected radiation exposure; litter patient; alert, cooperative and oriented;
VS pulse greater than 100, B/P 100/60, no respiratory distress, evidence of closed intra-abdominal
hemorrhage and injury. Radiation effects include: apprehension and agitation, n/v 5 to 30 percent; mild
headache; pretreatment with antiemetics decrease vomiting and possibly increase fatigability; radiation
does not contribute to mortality at this echelon.
Treatment: Dress open wounds; start IV 100 percent (LR); IM morphine; reassurance; 100 percent
priority ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent litter patients, alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 5 to 30
percent; mild headache; pretreatment with antiemetics decrease vomiting and possibly increase fatigability;
radiation does not contribute to mortality at this level.
Treatment: VS: Maintain IV LR in 100 percent; stabilization and IM morphine; reassurance;
30 percent IV/IM antiemetics (Kytril); 10 percent cervical spine stabilized; 100 percent urgent air transport.
Note: All surgery must be completed within 36 to 48 hours; evacuation to a level of care that can provide
appropriate urgent surgery.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury; thermal burns to extremities. Radiation effects include: apprehension
and agitation; n/v 5 to 30 percent; mild headache; mild fatigability and weakness 25 to 60 percent;
pretreatment with antiemetics decrease vomiting and possibly increase fatigability; radiation may contribute
to morbidity at this level due to immunosuppression.
Treatment:
25 percent exploratory laparotomy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter, moist cool compress/bulky dressing, 1 percent O2 (carbon monoxide poison). Remaining 75
percent: 30 percent IV/IM antiemetics (Kytril), topical antibiotic, counseling. LAB: CBC with differentials
twice daily until transferred. Note: All surgery must be completed within 36 to 48 hours; evacuation to a
level of care that can provide appropriate urgent surgery. If appropriate surgery has been provided at this
level, then routine evacuation (25 percent) to Level 3; otherwise urgent air transport (75 percent).
LEVEL 3
Assumptions: Real or suspected radiation exposure; litter patient; Class III hemorrhage; VS: pulse
120, B/P 100/70, respirations normal; alert; oriented. 25 percent will receive appropriate surgery at Level 2.
C-33
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
Radiation effects include: apprehension and agitation; n/v 5 to 30 percent; mild headache; pretreatment with
antiemetics decreases vomiting; radiation will contribute to morbidity at this level due to immuno-
suppression.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube. LAB: CBC with differential, UA,
TC for 4 units; x-rays: chest, 50 percent pelvis films, start IV in unburned area on 20 percent, give 3 liters
LR; tetanus toxoid; topical antibiotics (sulfamylon); 10 percent debridement; 30 percent IV/IM antiemetics;
100 percent draw one blood specimen per patient for biodosimetry (red top tube [clot] [keep refrigerated])
for radiation exposure prognosis.
OR:
75 percent of patients arriving at Level 3. Laparotomy and drainage of liver
injury and debridement under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters
RL; 2 units blood; arterial line 10 percent. LAB: CBC, blood gases; OR table time—150 minutes. Note:
All surgery must be completed within 36 to 48 hours of radiation exposure.
WARDS: ICU:
100 percent of patients arriving at Level 3; moist cool compress/
bulky dressing, 1 percent O2 (carbon monoxide poison). LAB: CBC with differential twice daily for
radiation exposure prognosis. Consider cytokines (G-CSF 480 mcg subcutaneous daily); maintain IV fluids;
IV antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent
maintain ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain
central line and monitoring and arterial line; cardiac monitor and pulse oximeter; CBC with differentials
twice daily. IV/IM morphine; topical antibiotic sulfamylon); IV LR 6 liters per day; dressing reinforcement;
dc central/arterial line before leaving ICU; 90 percent to ICW by day 2; 10 percent transferred to MCW.
Percentages based on patients admitted to ICU.
ICW: 90 percent of patients arriving at Level 3 will be transferred from
ICU by day 2. VS; IVs with IV antibiotics; 25 percent on O2 by mask; Foley catheter care; maintain NG
tube; NPO; CBC with differentials twice daily. IV/IM morphine; topical antibiotic (sulfamylon); IV LR 6
liters per day; dressing reinforcement; drain care, moist cool compress/bulky dressing, 1 percent O2
(carbon monoxide poison). LAB: CBC with differential twice daily for radiation exposure prognosis.
Consider cytokines (G-CSF 480 mcg subcutaneous daily); routine air transport 40 percent, priority air
transport 60 percent. Percentages based on patients admitted to ICW.
MCW: 10 percent of patients arriving at Level 3. VS; supportive care;
IV/IM morphine. LAB: CBC with differential twice daily; 100 percent mortality. Percentages based on
patients admitted to MCW.
C-47. Treatment Brief No. 24: Radiation at 125–530 cGy With Operative Trauma and Mild Burn
(Without treatment 100 percent mortality.)
LEVEL 1A
Assumptions: Significant and potentially lethal radiation exposure; 100 percent litter patients; alert,
cooperative and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress, evidence of
closed intra-abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v
50 to 90 percent; significant fatigability and weakness 25 to 60 percent; pretreatment with antiemetics
decrease vomiting; radiation does not contribute to mortality at this level.
Treatment: Dress open wounds; reassurance; start IV 100 percent (LR); IM morphine; 100 percent
priority ground transport.
C-34
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
LEVEL 1B
Assumptions: Significant and potentially lethal radiation exposure; 100 percent litter patients; alert,
cooperative and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of
closed intra-abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v
50 to 90 percent; headache; significant fatigability and weakness 25 to 60 percent; pretreatment with
antiemetics decrease vomiting; radiation does not contribute to mortality at this level.
Treatment: VS: Maintain IV LR in 100 percent; stabilization and IV morphine; reassurance; IV
antiemetics (Kytril); 10 percent cervical spine stabilized; 100 percent urgent air transport. Note: All
surgery must be completed within 36 to 48 hours; evacuation to a level of care that can provide appropriate
urgent surgery.
LEVEL 2
Assumptions: Significant and potentially lethal radiation exposure. 100 percent litter patients; alert,
cooperative and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of
closed intra-abdominal hemorrhage and injury; thermal burns to extremities. Radiation effects include:
apprehension and agitation; n/v 50 to 90 percent; headache; significant fatigability and weakness 25 to 60
percent; pretreatment with antiemetics decrease vomiting; radiation will contribute to morbidity at this level
due to immunosuppression.
Treatment:
25 percent exploratory laparotomy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter, moist cool compress/bulky dressing, 1 percent O2 (carbon monoxide poison). Remaining 75
percent:
90 percent IV/IM antiemetics (Kytril), topical antibiotic (sulfamylon), counseling. LAB: CBC
with differentials twice daily until transferred. If appropriate surgery has been provided at this level, then
routine evacuation (25 percent) to Level 3; otherwise urgent air transport (75 percent). Note: All surgery
must be completed within 36 to 48 hours; evacuation to a level of care that can provide appropriate urgent
surgery.
LEVEL 3
Assumptions: Significant and potentially lethal radiation exposure; 100 percent litter patients; Class
III hemorrhage; VS: pulse 120, B/P 100/70, respirations normal; alert; oriented. Radiation effects include:
apprehension and agitation; n/v 50 to 90 percent; headache; fatigability and weakness 25 to 60 percent;
pretreatment with antiemetics decreases vomiting; 25 percent will receive appropriate surgery at Level 2;
radiation will contribute to morbidity at this level due to immunosuppression.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube. LAB: CBC with differential, UA,
TC for 4 units; x-rays: chest, 50 percent pelvis films, start IV in unburned area on 20 percent, give 3 liters
LR; tetanus toxoid; topical antibiotics (sulfamylon); 10 percent debridement; 30 percent IV/IM antiemetics;
100 percent draw one blood specimen per patient for biodosimetry (red top tube [clot] [keep refrigerated])
for radiation exposure prognosis.
OR: 75 percent of patients arriving at Level 3, laparotomy and drainage of liver injury
and debridement under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters RL; 2
units blood; arterial line 10 percent. LAB: CBC, blood gases; OR table time—150 minutes. Note: All
surgery must be completed within 36 to 48 hours of radiation exposure.
C-35
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
WARDS: ICU:
100 percent of patients arriving at Level 3; moist cool compress/
bulky dressing, 1 percent O2 (carbon monoxide poison). LAB: CBC with differential twice daily for
radiation exposure prognosis; 100 percent cytokines (G-CSF 480 mcg subcutaneous daily); maintain IV
fluids; IV antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10
percent maintain ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask;
maintain central line and monitoring and arterial line; cardiac monitor and pulse oximeter; CBC with
differentials twice daily. IV/IM morphine; topical antibiotic (sulfamylon); IV LR 6 liters per day; dressing
reinforcement; dc central/arterial line before leaving ICU; 20 percent to MCW, 50 percent priority air
transport, and 30 percent to ICW by day 3. Percentages based on patients admitted to ICU.
ICW: 30 percent of patients arriving at Level 3, VS; IVs with IV antibiotics;
25 percent on O2 by mask; Foley catheter care; maintain NG tube; NPO; CBC with differentials twice
daily. IV/IM morphine; topical antibiotic (sulfamylon); IV LR 6 liters per day; dressing reinforcement;
drain care, moist cool compress/bulky dressing, 1 percent O2 (carbon monoxide poison). LAB: CBC with
differential twice daily; 100 percent cytokines (G-CSF 480 mcg subcutaneous daily); 70 percent mortality;
30 percent priority air transport. Percentages based on patients admitted to ICW.
MCW: 20 percent of patients arriving at Level 3, VS; supportive care; IV/
IM morphine. LAB: CBC with differential twice daily 100 percent mortality. Percentages based on
patients admitted to MCW.
C-48. Treatment Brief No. 25: Radiation >530 cGy With Operative Trauma and Mild Burn (With
or without treatment 100 percent mortality.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; pretreatment with antiemetics may have no effects.
Treatment: Clean and dress burns; IM morphine; reassurance; 100 percent routine ground transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; mortality 10 percent at this level.
Treatment: Comfort measures only; 100 percent morphine IV/IM as needed for pain, 100 percent
injectable antiemetic medication; reassurance; 90 percent routine ground transport.
LEVEL 2
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; mortality 50 percent within 24 hours.
Treatment: Comfort measures only; 100 percent morphine IV/IM as needed for pain, 100 percent
injectable antiemetic medication; reassurance; 100 percent routine ground/air transport.
C-36
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
LEVEL 3
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent.
Treatment: EMT: Patients are all expectant. LAB: Draw one blood specimen per patient for
biodosimetry (red top [clot] [keep refrigerated]), CBC with differential for radiation exposure.
OR: None.
WARDS: ICU: None.
ICW: None.
MCW: 100 percent of patients arriving at Level 3; expectant patients only;
IM pain medications (morphine) as needed. Patients admitted to MCW—mortality 100 percent by five days.
C-49. Treatment Brief No. 26: Radiation at 0–125 cGy With Operative Trauma and Moderate Burn
(Without treatment 100 percent mortality.)
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS pulse greater than 100, B/P 100/60, no respiratory distress, evidence of closed intra-
abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 50 to 90
percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation does not contribute to
mortality at this level.
Treatment: Dress open wounds; start IV 100 percent (LR); IM morphine; reassurance; 100 percent
priority ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 50 to 90
percent; mild headache; pretreatment with antiemetics decrease vomiting; radiation contributes to morbidity
at this level.
Treatment: VS: Maintain IV LR in 100 percent; stabilization and IM morphine; reassurance; 90
percent Kytril IV; 10 percent cervical spine stabilized; 100 percent urgent air transport. Note: All surgery
must be completed within 36 to 48 hours; evacuation to a level of care that can provide appropriate urgent
surgery.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury; thermal burns to extremities. Radiation effects include: apprehension
and agitation; n/v 50 to 90 percent; mild headache; pretreatment with antiemetics may decrease vomiting;
radiation contributes to morbidity at this level. Automated cell counter available.
Treatment:
25 percent exploratory laparotomy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
C-37
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter. Remaining 75 percent:
90 percent IV antiemetics (Kytril), topical antibiotic (sulfamylon),
counseling. LAB: CBC with differentials twice daily until transferred. Note: All surgery must be
completed within 36 to 48 hours; evacuation to a level of care that can provide appropriate urgent surgery. If
appropriate surgery has been provided at this level, then routine evacuation (25 percent) to Level 3;
otherwise urgent air transport (75 percent).
LEVEL 3
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; Class III hemorrhage;
VS: pulse 120, B/P 100/70, respirations normal; alert; oriented. Radiation effects include: apprehension
and agitation; n/v 50 to 90 percent; mild headache; pretreatment with antiemetics may decrease vomiting;
radiation contributes to morbidity at this level; 25 percent will receive appropriate surgery at Level 2;
radiation will contribute to mortality and morbidity at this level. Radiation at this level combined with
trauma multiplies mortality rates over baseline values.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube. LAB: CBC with differential, UA,
TC for 4 units; x-rays: chest, 50 percent pelvis films. Start IV in unburned area on 20 percent, give 3 liters
LR; tetanus toxoid; topical antibiotics (sulfamylon); 10 percent debridement; 90 percent IV antiemetic
(Kytril); 100 percent draw one blood specimen per patient for biodosimetry red top tube (clot) for radiation
exposure prognosis.
OR:
75 percent of patients arriving at Level 3. Laparotomy and drainage of liver
injury and debridement under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters
RL; 2 units blood; arterial line 10 percent. LAB: CBC, blood gases; OR table time—150 minutes. Note:
All surgery must be completed within 36 to 48 hours of radiation exposure.
WARDS: ICU:
100 percent of patients arriving at Level 3. VS; IV antibiotics;
parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent maintain ET tube and
ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain central line and
monitoring and arterial line; cardiac monitor and pulse oximeter. IV/IM morphine; topical antibiotic
(sulfamylon); IV LR 6 liters per day; dressing reinforcement; dc central/arterial line before leaving ICU.
LAB: CBC with differential twice daily, electrolytes, clotting studies, Amylase, LFTs on admission; x-ray:
chest, 10 percent c-spine. Administer cytokines (G-CSF 480 mcg subcutaneous daily) in 100 percent.
100
percent draw blood specimens for HLA typing (three yellow top tubes [ACD] [keep refrigerated]). Reverse
isolation.
ICW: 90 percent of patients arriving at Level 3 will be transferred from
ICU by day 2. VS; IV antibiotics; 25 percent on O2 by mask; Foley catheter care; maintain NG tube; NPO;
CBC with differentials twice daily. IV/IM morphine; topical antibiotic (sulfamylon); IV LR 6 liters per day;
dressing reinforcement; drain care. Administer cytokines (G-CSF 480 mcg subcutaneous daily) in 100
percent. LAB: CBC with differentials twice daily; 100 percent draw blood specimens for HLA typing (three
yellow top tubes [ACD] [keep refrigerated]). Reverse isolation. Ten percent mortality; 90 percent priority
air evacuation.
MCW: 10 percent of patients arriving at Level 3 will become expectant
and transferred from ICU by day 2. Mortality 100 percent.
C-38
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
C-50. Treatment Brief No. 27: Radiation at 0–125 cGy With Operative Trauma and Severe Burn
(Without treatment 100 percent mortality.)
LEVEL 1A
Assumptions: Real or suspected radiation exposure; 100 percent litter patients; VS: pulse greater
than 100, B/P 100/60, no respiratory distress; alert, oriented, both extremities burned, evidence of closed
intra-abdominal hemorrhage and injury. Radiation effects include: apprehension and agitation; n/v 5 to 30
percent; mild headache; pretreatment with antiemetics decrease vomiting and possibly increase fatigability;
radiation does not contribute to mortality at this level.
Treatment: Dress open wounds and burns; reassurance; start IV LR 100 percent, IM morphine; 100
percent urgent ground transport.
LEVEL 1B
Assumptions: Real or suspected radiation exposure; 100 percent litter patients, alert, cooperative
and oriented; VS: pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury, both extremities burned. Additional radiation effects include:
apprehension and agitation; n/v 5 to 30 percent; mild headache; pretreatment with antiemetics decrease
vomiting and possibly increase fatigability; radiation does not contribute to mortality at this level.
Treatment: VS: Maintain IV LR in 100 percent; stabilization and IM morphine; 100 percent IV
antiemetics (promethazine); reassurance; reevaluate dressing; 10 percent cervical spine stabilized; 100
percent urgent air transport.
LEVEL 2
Assumptions: Real or suspected radiation exposure; 100 percent litter patients, alert, cooperative
and oriented; VS: Pulse greater than 100, B/P 100/60, no respiratory distress; evidence of closed intra-
abdominal hemorrhage and injury. Additional radiation effects include: apprehension and agitation; n/v
5 to 30 percent; mild headache; pretreatment with antiemetics decrease vomiting and possibly increase
fatigability; radiation will contribute to morbidity at this level due to immunosuppression.
Treatment:
25 percent exploratory laparotomy at this level; general anesthesia; 2d IV; NG tube,
parenteral pain medications
(morphine), HCT, type and cross, blood, irrigation and debridement,
hemorrhage control, hemostatic agents, IV antibiotics, dressing, cardiac monitor, pulse oximeter, ventilator,
Foley catheter, moist cool compress/bulky dressing, 10 percent escharotomy, 10 percent 02, splint.
Remaining 75 percent: IV fluids LR 100 percent; rest; 30 percent IV/IM antiemetics. LAB: CBC with
differential; reassurance/counseling. Note: All surgery must be completed within 36 to 48 hours; evacuation
to a level of care that can provide appropriate urgent surgery. If appropriate surgery has been provided at
this level, then routine evacuation (25 percent) to Level 3; otherwise urgent air transport (75 percent).
LEVEL 3
Assumptions: Real or suspected radiation exposure; 100 percent litter patients, Class III hemorrhage,
alert; oriented; VS pulse 120, B/P 100/70, respirations normal. Radiation effects include: apprehension and
agitation; n/v 5 to 30 percent; mild headache; pretreatment with antiemetics decreases vomiting; 25 percent
will receive appropriate wound closure surgery at Level 2; radiation will contribute to morbidity at this level
due to immunosuppression.
Treatment: EMT: VS; primary assessment, IV restarted in 20 percent, give 2 liters LR; 2d IV
started; IV antibiotics; parenteral morphine; Foley catheter; NG tube. LAB:
100 percent CBC with
C-39
FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B
differential, UA, TC for 4 units; x-rays: chest, 50 percent pelvis films; doppler assessment, tetanus toxoid,
topical antibiotics (sulfamylon); LAB: 100 percent draw one blood specimen per patient for biodosimetry
(red top tube [clot] [keep refrigerated]), for radiation exposure prognosis.
OR:
75 percent of patients arriving at Level 3. Laparotomy and drainage of liver
injury under general anesthesia; 50 percent large bore central line; IV antibiotics; 8 liters LR; 2 units blood;
arterial line 10 percent. LAB: CBC, blood gases; 50 percent escharotomy for burn; MAC anesthesia; 2
liters LR; OR table time—120 minutes. Note: All surgery must be completed within 36 to 48 hours of
radiation exposure.
WARDS:
25 percent of patients arriving at Level 3—direct admit from Level 2.
ICU: 100 percent of patients arriving at Level 3. VS; maintain IV fluids;
IV antibiotics; parenteral morphine; Foley catheter care; drain care; NG tube care, NPO; 10 percent
maintain ET tube and ventilator with O2, extubate before leaving ICU; 90 percent on O2 by mask; maintain
central line and monitoring and arterial line; cardiac monitor and pulse oximeter; dressing reinforcement;
dc central/arterial line before leaving ICU; topical antibiotics; 20 percent cytokines (G-CSF 480 mcg
subcutaneous daily). LAB: CBC with differential twice daily, electrolytes, clotting studies, Amylase, LFTs
on admission; x-ray: chest, 10 percent c-spine. Twenty-percent to ICW by day 3; 60 percent priority
transport; 20 percent to MCW. Percentages based on patients admitted to ICU.
ICW: 20 percent of patients arriving at Level 3; LAB: CBC with differential
twice daily times four days for radiation exposure prognosis. VS; IVs with IV antibiotics; parenteral
morphine; topical antibiotics (sulfamylon), 25 percent on O2 by mask; Foley catheter care; maintain NG
tube; NPO; dressing reinforcement; drain care, doppler. Twenty-percent cytokines (G-CSF 480 mcg
subcutaneous daily). Mortality 50 percent, priority air transport 50 percent. Percentages based on patients
admitted to ICW.
MCW: 20 percent of patients arriving at Level 3; VS; supportive care.
LAB: CBC with differential twice daily for radiation exposure prognosis. 100 percent mortality.
Percentages based on patients admitted to MCW.
C-51. Treatment Brief No. 28: Radiation >125 cGy With Operative Trauma and Moderate or
Severe Burn (With or without treatment 100 percent mortality.)
LEVEL 1A
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; pretreatment with antiemetics may have no effects.
Treatment: Clean and dress burns; IM morphine; reassurance; 100 percent routine ground transport.
LEVEL 1B
Assumptions: Critical to lethal radiation exposure, but 100 percent mortality when combined with
this severity of burn injury; litter patient; central neurological deficits will be indicative of extreme radiation
doses. Additional radiation effects include: apprehension and agitation; n/v 100 percent; fatigue and
weakness 100 percent; mortality 10 percent at this level.
Treatment: Comfort measures only; 100 percent morphine IV/IM as needed for pain, 100 percent
injectable antiemetic medication; reassurance; 90 percent routine ground transport.
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