(3) Patient Management 3: Patient Treatment: (a) Staff must not allow the threat of contamination to impede the delivery of medical assistance. The right thing to do in almost every occasion when an individual who is contaminated and has a life threatening condition is to admit him/her to the Emergency department for immediate care. (b) It is crucial to educate staff on the realities and history of a patient's contamination to provide appropriate patient treatment. Staff who work in an emergency department are exposed to certain risks, including ordinary hospital radiation sources. (c) Initially, hospitals should obtain as much patient and situation history as possible, noting circumstances surrounding the patient and the situation that might indicate exposure. This also includes looking for corroborating evidence. AFRRI has developed a software program in conjunction with Radiation Emergency Assistance Center/Training Site (REAC/TS) that can be effectively used to record information. This software can also be used for dose assessment and treatment management. It can be found at: www.afrri.usuhs.mil/www/outreach/batpage.htm. (d) Emergency department staff can measure complete blood counts (CBCs) with differential initially to serve as a baseline measurement. CBCs taken over the next several days can than be compared to the baseline measurements and used to assess the radiation dose received. These data are of key importance in evaluating patients for acute radiation syndrome. (also see Appendix B) (e) When internal contamination is suspected, body excreta may contain radioactive substances. Collection of urine and feces should be considered on those patients. Also, swabs from body orifices should be taken for survey or analysis for radionuclides. Although state and federal assistance may be made available for receiving and analyzing these samples, hospitals should identify during their emergency planning what agencies or laboratories the samples should go to for analysis. (f) In the first 48 hours, the basic premise is that physicians should conduct standard patient assessment, take care of immediately life-threatening problems, and take care of all other problems that require immediate attention. Emergency department staff should: (f-1) Treat symptoms according to ordinary patient treatment practices and procedures. (f-2) Take care of wounds by irrigating, debriding, and covering to the best extent possible. (f-3) Look for the symptoms of acute radiation syndrome (See Appendix B). Have a trained technician perform a radiation survey if symptoms, patient history, and situation history indicate the possibility of contamination. (g) Suggested supplies and medications to keep on hand and have easily accessible in large quantities include IVs, fluid support, anti-diarrhea, anti-emetic medications, and potassium iodide tablets. (h) Hospitals should consider keeping a supply of potassium iodide to help reduce the risk of thyroid cancer from radioactive iodine exposure. Such exposures may arise from a nuclear power plant incident or in radioactive fallout from a terrorism event involving the detonation of a nuclear device. (i) Hospitals should adhere to FDA recommendations (Guidance: Potassium Iodide as a Thyroid Blocking Agent in Radiation Emergencies, U. S. Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research, December, 2001) for administration of Potassium Iodide, which is summarized in Table 1. (j) Adolescents approaching adult size (> 70 kg) should receive the full adult dose (130 mg). (k) Potassium iodide supplementation is not as effective for those individuals over 40 years of age and therefore it is generally recommended that these individuals only receive supplementation if it is estimated that their exposure is significant enough to potentially destroy the thyroid leading to hypothyroidism (7). FDA guidance on the administration of potassium iodide (KI) based on age, predicted thyroid exposure, pregnancy and lactation status is below. Potassium iodide should be taken immediately though it may still have a significant impact if taken even 3-4 hours after exposure (8). It should be available to those in a radioactive fallout area. The Nuclear Regulatory Commission requires that states with a population within the 10-mile emergency planning zone of commercial nuclear power plants consider including potassium iodide as a protective measure for the general public to supplement sheltering and evacuation in the unlikely event of a severe nuclear power plant accident. (l) Hospital staff should also note that FDA Guidance recommends that persons with known iodine sensitivity should avoid potassium iodide, as should individuals with dermatitis herpetiformis and hypocomplementemic vasculitis, extremely rare conditions associated with an increased risk of iodine hypersensitivity. Individuals with multinodular goiter, Graves' disease, and autoimmune thyroiditis should be treated with caution -- especially if dosing extends beyond a few days. Unless other protective measures are not available, it is not recommended to provide repeat dosing in pregnant females and neonates because of the potential for potassium iodide to suppress thyroid function in the fetus and neonate. (m) Hospital staff should avoid giving the perception to patients and the community that potassium iodide prevents adverse health effects from radiation exposure in general. However, staff should understand that offering potassium iodide may help address some patient psychological concerns