INITIAL MEDICAL AND SURGICAL MANAGEMENT

Surgery — Surgical intervention, when required, should be carried out within 36 hours, and not later than 48
hours after exposure [20]. Additional surgery, if required, should not be performed until at least six weeks
post-exposure, in order to assure recovery from the period of cytopenia and immunosuppression, which
would otherwise seriously add to the risk of developing surgical complications (i.e., infection, poor wound
healing). Precautions for removal of radioactive fragments are described above (see 'Removal of radioactive
fragments' above).

Nausea and vomiting — Given the importance of the time elapsed between radiation exposure and the
onset of vomiting in determining individual radiation dose, prophylaxis against vomiting is not initially desired,
and may also be impractical given the short time to onset of vomiting with clinically significant exposures
(table 3) [21]. In addition, at low exposure doses, vomiting usually abates after 48 to 72 hours; therefore,
prolonged antiemetic therapy is not usually warranted.

If treatment is required, the use of serotonin receptor antagonists is preferred [22]. Neuroleptic antiemetics
may also be employed. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in
adults" and "Radiotherapy-induced nausea and vomiting: Prophylaxis and treatment".)

General supportive measures — Issues requiring active or preventative treatment include any or all of the
following:

●Maintaining normal vital signs and assuring an open airway. These are especially important in those
sustaining additional injuries (e.g., blast damage, burns, and trauma)
●Rapid replacement of fluid, electrolyte, and blood losses, especially in those presenting with shock,
hypotension, significant burns, hypovolemia, and/or multiorgan failure shortly after exposure
●Seizure control, if present
●Control of nausea, vomiting, and/or diarrhea
●Judicious use of analgesics, anxiolytics, sedatives

Hematologic support (e.g., transfusion of blood components, use of cytokines, hematopoietic cell
transplantation) may be appropriate in those having estimated exposures in the range of 2 to 10 Gy, as
outlined below. (See 'Management of the hematopoietic radiation injury syndrome' below.)

Antibiotics — in non-neutropenic patients, use of antibiotics should be reserved for obvious foci of infection
secondary to extensive burns, penetrating wounds, and/or abdominal/visceral trauma. Since altering the
anaerobic gut flora has worsened outcomes in irradiated animals, antibacterial gut prophylaxis should only
be administered in patients with an abdominal wound or C. difficile enterocolitis [23] or in patients with critical
illness in the intensive care unit [24].

Thyroid protection — In the case of significant exposure to radioactive isotopes of iodine (eg, nuclear
reactor incident, atomic blast), prevention of significant uptake of radioactive isotopes of Iodine, especially
Iodine-131, by the thyroid is imperative. This is especially important in the exposed fetus after the 12th week
of gestation, as well as in the child or adolescent, all of whom are most prone to the development of
radiation-induced thyroid carcinoma. This form of the thyroid cancer also appears to be biologically more
aggressive than de novo forms. (See "Radiation-induced thyroid cancer", section on 'Potassium iodide for
thyroid protection in a nuclear accident'.)

Potassium iodide (KI) is available in 130 mg tablets. A one-time oral dose of 130 mg is recommended for
pregnant or lactating women and adults >18 years of age (table 10) [25]. Oral KI should be administered as
soon as possible, preferably less than 6 hours after the exposure [26]. However, if it anticipated that a
person will be exposed to radioactive iodine for more than 24 hours, additional doses should be taken every
24 hours. Guidance and KI recommendations will be provided by emergency management officials after an
incident. Information on the use of potassium iodide as a thyroid blocking agent in radiation emergencies
can be found on the FDA website at:
<www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm080542.pdf>
[27].