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This brief paper provides a summary of key issues facing local, state, and national responders in preparing for and counteracting acts of nuclear or radiological terrorism, including medical management and follow-up care for victims. We also provide a brief look at important issues that remain to be addressed., Published in The Bridge, p50-57, Summer 2010.

This handbook addresses medical management of casualties in the first 72 hours of a radiation event. The most important consideration in the medical evaluation of a radiation event is the relative magnitude of the situation and the resources needed to address the emergency. In many cases, order of magnitude estimates of the scale of the event will be sufficient for emergency response. ? Small-scale events are those occurring in laboratories, hospitals, nuclear power plants, etc., involving small amounts of radionuclides with the potential exposure and/or contamination of one or a few individuals. ? Large-scale events are those involving relatively large quantities of radionuclides and the potential exposure or contamination of large numbers of people, e.g., terrorist attacks with radiological weapons, nuclear weapons detonation, and large-scale nuclear power plant disasters. High-level external ionizing radiation poses the greatest danger to living organisms. Low levels of internal or external contamination generally pose very low risk. A site known to be radiologically contaminated should be surveyed before entering and responders should be advised to limit their time in high dose-rate areas. There is generally no hazard associated with handling a radiologically contaminated casualty. See the topic Decontamination Techniques. U.S. military planning. The U.S. military has established a system for mission-specific risk-based dose limits that includes life-saving activities. In current doctrine, U.S. military personnel become restricted from engaging in operational radiological/nuclear missions once they have exceeded a 125-cGy dose accumulation. Military commanders set their Operational Exposure Guidance (OEG; i.e., dose limits to U.S. troops) in nuclear war. For operations other than war, military commanders generally limit OEG levels to 75-cGy. For guidance see JP 3-11, Operations in Chemical, Biological, Radiological, and Nuclear (CBRN) Environments, 26 August 200

Radiation exposures from accidents, nuclear detonations or terrorist incidents are unlikely to be homogeneous; however, current biodosimetric approaches are developed and validated primarily in whole-body irradiation models. A workshop was held at the Armed Forces Radiobiology Research Institute in May 2008 to draw attention to the need for partial-body biodosimetry, to discuss current knowledge, and to identify the gaps to be filled. A panel of international experts and the workshop attendees discussed the requirements and concepts for a path forward. This report addresses eight key areas identified by the Workshop Program Committee for future focus: (1) improved cytogenetics, (2) clinical signs and symptoms, (3) cutaneous bioindicators, (4) organ-specific biomarkers, (5) biophysical markers of dose, (6) integrated diagnostic approaches, (7) confounding factors, and (8) requirements for post-event medical follow-up. For each area, the status, advantages and limitations of existing approaches and suggestions for new directions are presented.

In the aftermath of a radiological terrorism incident or mass-casualty radiation accident, first responders and receivers require prior guidance and pre-positioned resources for assessment, triage and medical management of affected individuals [NCRP, 2005. Key elements of preparing emergency responders for nuclear and radiological terrorism. NCRP Commentary No. 19, Bethesda, Maryland, USA]. Several recent articles [Dainiak, N., Waselenko, J.K., Armitage, J.O., MacVittie, T.J., Farese, A.M., 2003. The hematologist and radiation casualties. Hematology (Am. Soc. Hematol. Educ. Program) 473-496; Waselenko, J.K., MacVittie, T.J., Blakely, W.F., Pesik, N., Wiley, A.L., Dickerson, W.E., Tsu, H., Confer, D.L., Coleman, C.N., Seed, T., Lowry, P., Armitage, J.O., Dainiak, N., Strategic National Stockpile Radiation Working Group, 2004. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann. Intern. Med. 140(12), 1037-1051; Blakely, W.F., Salter, C.A., Prasanna, P.G., 2005. Early-response biological dosimetry-recommended countermeasure enhancements for mass-casualty radiological incidents and terrorism. Health Phys. 89(5), 494-504; Goans, R.E., Waselenko, J.K., 2005. Medical management of radiation casualties. Health Phys. 89(5), 505-512; Swartz, H.M., Iwasaki, A., Walczak, T., Demidenko, E., Salikhov, I., Lesniewski, P., Starewicz, P., Schauer, D., Romanyukha, A., 2005. Measurements of clinically significant doses of ionizing radiation using non-invasive in vivo EPR spectroscopy of teeth in situ. Appl. Radiat. Isot. 62, 293-299; Weisdorf, D., Chao, N., Waselenko, J.K., Dainiak, N., Armitage, J.O., McNiece, I., Confer, D., 2006. Acute radiation injury: contingency planning for triage, supportive care, and transplantation. Biol. Blood Marrow Transplant. 12(6), 672-682], national [National Council of Radiation Protection and Measurements (NCRP), 1994. Management of persons accidentally contaminated with