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Radiological and Nuclear
Topic Collection
March 31, 2021

Topic Collection: Radiological and Nuclear

A large-scale radiological release or nuclear detonation incident could result in a significant surge of patients, including those who may not have actually been exposed, but seek medical attention anyway. Power plant incidents, radiation dispersion devices, and improvised nuclear device detonations result in very different injury/exposure patterns and response planning will need to account for each of these. Patients exposed to radiation may simply be “irradiated” (gamma waves pass through them without any direct material on/in the patient) or can be “contaminated” if internal or external radioactive material is present. Both exposures result in dose-dependent damage to body tissues. In most cases of radiation dispersion devices, the risk of injury is very low, but in nuclear device detonations large numbers of patients may have acute radiation illness and require evaluation and treatment. The resources in this Topic Collection include toolkits, reference guides, plan guidance documents, modeling and simulation reports, and manuals that may help first responders and first receivers assess, triage, and treat casualties of radiological and nuclear emergencies. This Topic Collection was updated in July 2018.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category. (Please note: this Topic Collection does not include a comprehensive overview of responder health and safety issues. Please refer to the Responder Safety and Health and Decontamination Topic Collections for related information.)

"Must Reads" were chosen by Subject Matter Experts on the basis of their overall value and the material covered. However, knowledge about Acute Radiation Syndrome (ARS) and patient management has evolved rapidly and prior conclusions about time to onset of vomiting and its correlation with toxicity as well as management of ARS patients may not reflect current practice. Readers are encouraged to use these resources as a starting point and seek specific assessment and treatment recommendations from websites such as the U.S. Department of Health and Human Services Radiation Emergency Medical Management.

Must Reads


American College of Radiology. (2006). Disaster Preparedness for Radiology Professionals.
This primer is geared towards radiologists, radiation oncologists, and medical physicists and summarizes current information on preparing for and responding to a radiation emergency (e.g., handling contaminated patients, assessing dose, and health effects).
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This document provides information that may guide hospital plans for radiological emergencies. It contains a list summarizing "10 basics of response," with individual sections for each of the 10 items.
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Army Center for Health Promotion and Preventive Medicine Aberdeen Proving Ground. (2000). The Medical NBC Battlebook.
This downloadable PDF serves as a quick reference guide for medical personnel in the field. The authors provide information on the following threats: nuclear, radiological hazards, biological, chemical, and lasers/ radiofrequency.
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In this ASPR TRACIE webinar, experts shared tips on assessing, triaging, treating, and following-up with patients affected by radiological and nuclear emergencies. Strategies for handling the initial surge of patients and planning for community reception centers were also discussed.
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This ASPR TRACIE document provides an overview of the potential health and medical response and recovery needs following a radiological or nuclear incident and outlines available resources for planners.
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Berger, M.E., Leonard, R.B., and Ricks, R.C. (2010). Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster. Oak Ridge Institute for Science and Education (ORISE).
This article focuses on the needs of emergency physicians following a radiological or nuclear emergency. Guides for taking a focused history; performing a physical exam and laboratory tests; and managing the initial treatment and disposition of victims of acute radiation syndrome and combined injury are provided.
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Bomanji, J.B., Novruzov, F., and Vinjamuri, S. (2014). Radiation Accidents and Their Management: Emphasis on the Role of Nuclear Medicine Professionals. Nuclear Medicine Communications. 35(10):995-1002.
This article summarizes protocols for decontaminating, assessing, and treating casualties of radiation accidents, and advocates for nuclear medicine specialists to be part of the multidisciplinary care team for these patients. Several relevant tables are also provided in the article.
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Centers for Disease Control and Prevention, Emergency Preparedness and Response. (2015). Radiation Emergencies: Information for Professionals.
This webpage contains links to resources for emergency health professionals and first responders tasked with preparing for and responding to a radiation emergency. Note: many of the resources are included in this Topic Collection; key resources are noted under the Center's listing. in the Agencies and Organizations category.
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Flynn, F. and Goans, R. (2006). Nuclear Terrorism: Triage and Medical Management of Radiation and Combined-Injury Casualties. (Abstract only.) Surgical Clinics of North America. 86:601–636.
The authors discuss triage and medical management of patients with burns, trauma, and/or radiation sickness resulting from a nuclear detonation.
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National Council on Radiation Protection and Measurements. (2008). Management of Persons Accidentally Contaminated with Radionuclides (NCRP Report No. 65). (Abstract only; available for purchase from author site.)
Members of the Council synthesized data and ideas related to accidental contamination into one document that can help medical professionals called upon to manage contaminated patients. The report contains a "quick reference section," and sections on the initial management of the patient, diagnostic methods to measure radioactive contamination, information on therapy procedures and drugs, and other related topics.
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National Security Staff, Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats. (2010). Planning Guidance for Response to a Nuclear Detonation. Second Edition. Homeland Security Council Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats.
This core resource document provides emergency planners (including emergency medical service planners, medical receiver planners, and mass care providers) recommendations specific to nuclear detonation incidents in an urban setting.
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Nuclear Detonation Response Communications Working Group. (2010). Nuclear Detonation Preparedness Communicating in the Immediate Aftermath.
This guidance can help emergency planners and responders at the federal, state, and local levels communicate with the public (including the media) in the immediate aftermath of a nuclear detonation in the U.S.
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NYC Hospital Radiation Response Working Group, NYC Department of Health and Mental Hygiene, Healthcare Emergency Preparedness Program. (2009). NYC Hospital Guidance for Responding to a Contaminating Radiation Incident.
This guidance was prepared to help New York City Hospitals prepare their response to an emergency involving radioactive contamination. The guidance and strategies can be tailored to other city hospitals.
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Oak Ridge Institute for Science and Education. (2015). Radiation Emergency Assistance Center/Training Site.
This webpage links to the Radiation Emergency Assistance Center/Training Site (REAC/TS), which offers several resources to prepare medical professionals to respond to radiological emergencies. There are links to books, live training courses, online trainings, and assessment and treatment guidance documents. REAC/TS staff are available for deployment to provide medical consultation during emergencies, upon request. Note: many REAC/TS resources are included in this Topic Collection; key resources are noted under the Institute’s listing in the Agencies and Organizations category.
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Ross, J., Case, C., Confer, D. et al. (2011). Radiation Injury Treatment Network (RITN): Healthcare Professionals Preparing for a Mass Casualty Radiological or Nuclear Incident. International Journal of Radiation Biology. 87(8): 748–753.
This article discusses the Radiation Injury Treatment Network (RITN), which is a cooperative effort of the National Marrow Donor Program and the American Society for Blood and Marrow Transplantation. RITN works to educate hematologists, oncologists, and stem cell transplant specialists to treat casualties of radiation emergencies with marrow suppression. RITN members are transplant units within hospitals across the nation, and would be available to provide surge capacity either by having patients transferred to one of their sites, or by practitioners providing medical expertise in person or remotely to health care facilities caring for patients with marrow toxic injuries.
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Turai, I., Veress, K., Günalp, B, and Souchkevitch, G. (2004). Medical Response to Radiation Incidents and Radionuclear Threats. British Medical Journal 328(7439):568-72.
The authors provide information on the basic medical management of radiation sickness and radiation injuries, and share information about related training on early recognition of and medical response to radiation accidents and purposeful incidents.
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U.S. Department of Health and Human Services. (2021). Radiation Emergency Medical Management. (Homepage.)
This webpage provides guidance on diagnosis and treatment for healthcare providers. It includes downloadable tools, templates, references, and contact lists. Note: several REMM resources are included in this Topic Collection.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2012). Medical Planning and Response Manual for a Nuclear Detonation Incident: A Practical Response Guide.
This comprehensive document provides emergency planners with information not only on the effects of radiation and how to measure and treat them, but also on how to communicate during a radiological or nuclear emergency. It also describes federal response roles and the distribution of medical countermeasures for acute radiation sickness in an environment of scarce resources.
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U.S. Department of Homeland Security Working Group on Radiological Disperson Device (RDD) Preparedness Medical Preparedness Sub-Group. (2003). Department of Homeland Security Working Group on Radiological Dispersion Device (RDD) Preparedness [Report]: 5/1/03 version.
This report provides information for medical professionals on the immediate management of patients following detonation of an RDD, as well as decontamination, radiological assessment, psychological effects of the event, and how to deal with remains of deceased persons following radiological terrorism. It also provides an extensive discussion of radiological countermeasures.
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Various Authors. (2011). Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
This special issue contains articles highlighting the work of the Nuclear Detonation Scarce Resources Project Working Group. Included are discussions of triage and medical management of casualties resulting from nuclear detonations; social and behavioral response considerations for planners; and guidance to support health care system preparedness to respond to a nuclear detonation.
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Clinical Guidance


In this ASPR TRACIE webinar, experts shared tips on assessing, triaging, treating, and following-up with patients affected by radiological and nuclear emergencies. Strategies for handling the initial surge of patients and planning for community reception centers were also discussed.
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This ASPR TRACIE document provides an overview of the potential health and medical response and recovery needs following a radiological or nuclear incident and outlines available resources for planners.
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* Berger, M.E., Leonard, R.B., and Ricks, R.C. (2010). Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster. Oak Ridge Institute for Science and Education (ORISE).
This article focuses on the needs of emergency physicians following a radiological or nuclear emergency. Guides for taking a focused history; performing a physical exam and laboratory tests; and managing the initial treatment and disposition of victims of acute radiation syndrome and combined injury are provided.
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Bey, E., Prat, M., Duhamel, P., et al. (2010). Emerging Therapy for Improving Wound Repair of Severe Radiation Burns Using Local Bone Marrow-Derived Stem Cell Administrations. Wound Repair and Regeneration. 18(1):50-8.
This article describes the use of mesenchymal stem cells (MSM) in combination with autograft to treat a severe radiation burn wound in a single patient. The addition of the MSM improved outcomes over traditional surgical techniques used for burn wound repair.
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Bomanji, J.B., Novruzov, F., and Vinjamuri, S. (2014). Radiation Accidents and Their Management: Emphasis on the Role of Nuclear Medicine Professionals. Nuclear Medicine Communications. 35(10):995-1002.
This article summarizes protocols for decontaminating, assessing, and treating casualties of radiation accidents, and advocates for nuclear medicine specialists to be part of the multidisciplinary care team for these patients. Several relevant tables are also provided in the article.
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* Centers for Disease Control and Prevention. (2013). Acute Radiation Syndrome: A Fact Sheet for Clinicians.
This fact sheet provides information on the symptoms and stages of acute radiation syndrome (ARS), as well as patient management for ARS. Information on cutaneous radiation syndrome is also included.
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* Centers for Disease Control and Prevention. (2013). Radiological Terrorism: Tool Kit for Emergency Services Clinicians.
This toolkit contains resources (such as videos and pocket guides) on decontamination, population monitoring, and psychological first aid in radiation emergencies.
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Centers for Disease Control and Prevention. (2017). Determining Deaths from a Radiation Emergency.
This webpage can help medical examiners, coroners (and emergency healthcare providers, planners, and responders) better understand radiation scenarios that may cause death and related illnesses and injuries that may cause death.
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Centers for Disease Control and Prevention. (2018). Information for Clinicians.
This webpage provides links to information on patient management, guidelines and recommendations, training, and the “Radiological Terrorism: Toolkit for Emergency Services Clinicians.”
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Coleman, C.N. and Koerner, J.F. (2016). Biodosimetry: Medicine, Science, and Systems to Support the Medical Decision-Maker Following a Large Scale Nuclear or Radiation Incident. (Abstract only.) Radiation Protection Dosimetry. 172:38-46.
The authors share how biodosimetry assays can help healthcare providers provide medical evaluation and care in a radiological or nuclear incident.
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Coleman, C.N., Knebel, A.R., and Lurie, N. (2011). Preparing and Planning for a Catastrophic Incident of a Nuclear Detonation. Foreword. Disaster Medicine and Public Health Preparedness. 5(S1):S11-S12.
In this foreword to an issue devoted to preparing for a nuclear detonation, the authors provide an overview of the journal articles which highlight collaboration between the federal government, academia, and private sector.
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Coleman, C.N., Sullivan, J.M., Bader, J.L., et al. (2015). Public Health and Medical Preparedness for a Nuclear Detonation: The Nuclear Incident Medical Enterprise. Health Physics. 108:149-160.
The authors summarize Nuclear Incident Medical Enterprise (NIME), the approach developed by the U.S. Department of Health and Human Services by both government and non-government experts. NIME can be used by emergency healthcare planners to support planning for, responding to, and recovering from the effects of a nuclear incident.
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Dainiak, N., Gent, R.N., Carr, Z., et al. (2011). First Global Consensus for Evidence-Based Management of the Hematopoietic Syndrome Resulting from Exposure to Ionizing Radiation. Disaster Medicine and Public Health Preparedness. 5(3):202-12.
A panel convened by the World Health Organization conducted a literature review to develop evidence-based guidelines for the management of hematopoietic syndrome resulting from exposure to ionizing radiation. Although the panel determined the evidence was weak, members strongly recommended granulocyte colony-stimulating factor or granulocyte macrophage colony-stimulating factor. The use of erythropoiesis-stimulating agents or hematopoietic stem cell transplantation was less strongly supported by the evidence.
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Dainiak, N., Gent, R.N., Carr, Z., et al. (2011). Literature Review and Global Consensus on Management of Acute Radiation Syndrome Affecting Nonhematopoietic Organ Systems. Disaster Medicine and Public Health Preparedness. 5(3):183-201.
A panel convened by the World Health Organization conducted a literature review to rank countermeasures for acute radiation sickness (ARS). Data was limited, and based on nonirradiated humans and animal models. The panel applied these findings to a hypothetical scenario involving the hospitalization of 100 to 200 victims. Recommendations include the prophylactic use of a serotonin-receptor antagonist when the suspected exposure is greater than 2 Gy, and topical steroids, antibiotics, and antihistamines for radiation burns, ulcers, or blisters.
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Demidenko, E., Williams, B.B., Swartz, H.M. (2009). Radiation Dose Prediction Using Data on Time to Emesis in the Case of Nuclear Terrorism. Radiation Research. 171(3):310-9.
The authors performed statistical analysis on estimated radiation dose and time to emesis in 108 cases of known radiation exposure over a 55-year period. They conclude that time to emesis is a quick and inexpensive way to estimate radiation dose, but it is imprecise and may lead to false positives. It therefore should be used with other methods to estimate dose received following exposure.
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The authors describe therapeutic principles for the treatment of acute radiation sickness, with a focus on hematopoietic syndrome and cutaneous radiation syndrome.
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Flynn, F. and Goans, R. (2006). Nuclear Terrorism: Triage and Medical Management of Radiation and Combined-Injury Casualties. (Abstract only.) Surgical Clinics of North America. 86:601–636.
The authors discuss triage and medical management of patients with burns, trauma, and/or radiation sickness resulting from a nuclear detonation.
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This discussion paper describes the screening function (Exposure And Symptom Triage – EAST) which will primarily be conducted at Assembly Centers after a nuclear detonation. Geared towards jurisdictional emergency planners and responders as a planning reference, it contains response tools and strategies that will assist them in planning for Assembly Centers and mass screening functions.
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This document can help emergency healthcare providers learn more about medically managing patients who have been internally contaminated through inhalation, ingestion or absorption of radionuclides in a nuclear or radiological emergency. It includes several scenarios and sample data that can be adapted to suit a facility's or jurisdiction's needs.
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* Meit, M., Redlener, I., Briggs, T.W. et al. (2011). Rural and Suburban Population Surge Following Detonation of an Improvised Nuclear Device: A New Model to Estimate Impact. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors describe a “push-pull” model that estimated the evacuation from Manhattan to counties within a 150 mile radius after a nuclear detonation. This model predicted that arriving evacuees could increase the population needing services by between 50 and 150 percent.
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Müller, K., and Meineke, V. (2010). Advances in the Management of Localized Radiation Injuries. (Abstract only.) Health Physics. 98(6):843-50.
This article discusses strategies to treat localized radiation injuries symptomatically, and notes the lack of evidence-based treatment guidelines. The authors advocate for follow-up with patients experiencing radiation injuries, as it could take days to weeks for symptoms to appear and internal damage may accompany skin lesions.
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National Council on Radiation Protection and Measurements. (2008). Management of Persons Accidentally Contaminated with Radionuclides (NCRP Report No. 65). (Abstract only; available for purchase from author site.)
Members of the Council synthesized data and ideas related to accidental contamination into one document that can help medical professionals called upon to manage contaminated patients. The report contains a "quick reference section," and sections on the initial management of the patient, diagnostic methods to measure radioactive contamination, information on therapy procedures and drugs, and other related topics.
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* National Council on Radiation Protection and Measurements. (2008). NCRP Report No. 161, Management of Persons Contaminated With Radionuclides. (Abstract only.)
The information in this report is geared towards medical professionals caring for people exposed to and potentially contaminated in accidental or purposeful releases of large quantities of radionuclides.
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* National Security Staff, Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats. (2010). Planning Guidance for Response to a Nuclear Detonation. Second Edition. Homeland Security Council Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats.
This core resource document provides emergency planners (including emergency medical service planners, medical receiver planners, and mass care providers) recommendations specific to nuclear detonation incidents in an urban setting.
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Oak Ridge Institute for Science and Education. (n.d.). Dose Estimation Resources. (Accessed 4/26/2021.)
The Oak Ridge Institute for Science and Education provides links to several compendia of dose information (e.g., dose estimates for children and pregnant women).
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* Oak Ridge Institute for Science and Education. (n.d.). Procedure Demonstrations for Contaminated Patients. (Accessed 4/26/2021.)
These demonstrations show healthcare providers how to: dress to prevent the spread of radioactive contamination; remove contaminated clothing from a patient; decontaminate a wound; and decontaminate intact skin.
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Oak Ridge Institute for Science and Education. (n.d.). The Medical Aspects of Radiation Incidents. (Accessed 8/21/2017.)
This "pocket guide" (available in PDF and iBook formats) provides the basic information responders need to medically manage victims of radiation incidents.
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Radiation Emergency Assistance Center/Training Site. (2020). Radiation Patient Treatment.
This algorithm can help healthcare providers make quick decisions when treating patients exposed to or contaminated by radiological hazards.
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* Radiation Emergency Medical Management. (2018). Initial On-site Activities.
The resources linked from this webpage can help first responders manage the scene and victims of a radiological incident.
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* Radiation Emergency Medical Management. (2018). Triage Guidelines Including Radiation Triage Guidelines.
This webpage provides links to radiation-related triage tools, guidelines, and algorithms.
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* Radiation Emergency Medical Management. (2019). Prototype/Template for Adult and Pediatric Hospital Orders During a Radiation Incident. U.S. Department of Health and Human Services.
These orders--while meant to serve solely as guidance documents--can be tailored and used by healthcare providers who treat adult and pediatric patients after a radiological incident. Helpful links are included throughout the prototypes.
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Radiation Emergency Medical Management. (2021). Hospital Activities During Radiation Emergencies.
This webpage includes links to resources hospital planners can review to improve preparedness for and response to a radiation incident.
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* Radiation Injury Treatment Network. (2012). Concept of Operations.
This document outlines the anticipated integration of the Radiation Injury Treatment Network (RITN) into the national response to a mass casualty incident resulting in marrow-toxic injuries. It includes graphics and guidelines and principles that will be applied to acute radiation syndrome management scenarios. This short, animated video describes the formation of the RITN and the role member hospitals would play in a radiological disaster: https://www.youtube.com/watch?v=v-qW-z7qXRw.
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Radiation Injury Treatment Network. (2016). Acute Radiation Syndrome Treatment Guidelines.
This PowerPoint presentation highlights treatment guidelines healthcare practitioners can apply in the event of a nuclear detonation. Information includes principles of Acute Radiation Syndrome (ARS) management (and timing and severity of symptoms); altered standards/crisis standards of care; and patient triage and casualty profiles.
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* Radiation Injury Treatment Network. (2017). Prototype for Adult Medical Orders During a Radiation Incident.
Healthcare providers can customize this set of orders—created by REMM and RITN physicians—for adult patients who have been exposed to radiation. It includes links to additional tools throughout that can assist with diagnoses and treatment.
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Ross, J., Case, C., Confer, D. et al. (2011). Radiation Injury Treatment Network (RITN): Healthcare Professionals Preparing for a Mass Casualty Radiological or Nuclear Incident. International Journal of Radiation Biology. 87(8): 748–753.
This article discusses the Radiation Injury Treatment Network (RITN), which is a cooperative effort of the National Marrow Donor Program and the American Society for Blood and Marrow Transplantation. RITN works to educate hematologists, oncologists, and stem cell transplant specialists to treat casualties of radiation emergencies with marrow suppression. RITN members are transplant units within hospitals across the nation, and would be available to provide surge capacity either by having patients transferred to one of their sites, or by practitioners providing medical expertise in person or remotely to health care facilities caring for patients with marrow toxic injuries.
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Ryan, J.L. (2012). Ionizing Radiation: The Good, the Bad, and the Ugly. Journal of Investigative Dermatology. 132(3 Pt 2):985-93.
The author describes the effects of ionizing radiation on the skin, and includes a concise description of how radiation burns manifest, noting how they differ from other burns and why this causes treatment challenges. She concludes after a literature review that there is no “gold standard” for assessing and treating radiation skin injury.
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Singh, V.K., Newman, V.L., Romaine, P.L., et al. (2014). Radiation Countermeasure Agents: An Update (2011-2014). Expert Opinion on Therapeutic Patents. 24(11):1229-55.
This article provides an extensive review of existing radiation countermeasures, as well as those under development and/or being considered for Emergency Use Authorization status by the federal Food and Drug Administration.
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* Turai, I., Veress, K., Günalp, B, and Souchkevitch, G. (2004). Medical Response to Radiation Incidents and Radionuclear Threats. British Medical Journal 328(7439):568-72.
The authors provide information on the basic medical management of radiation sickness and radiation injuries, and share information about related training on early recognition of and medical response to radiation accidents and purposeful incidents.
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* U.S. Department of Health and Human Services. (2011). State and Local Planners Playbook for Medical Response to a Nuclear Detonation.
This playbook provides guidance to state, regional, local, tribal, and territorial sectors; medical professionals; public health planners; and other subject matter experts who are developing plans for a medical response to a nuclear detonation.
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2012). Medical Planning and Response Manual for a Nuclear Detonation Incident: A Practical Response Guide.
This comprehensive document provides emergency planners with information not only on the effects of radiation and how to measure and treat them, but also on how to communicate during a radiological or nuclear emergency. It also describes federal response roles and the distribution of medical countermeasures for acute radiation sickness in an environment of scarce resources.
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This guidance can help preserve responder health and safety in the event of a 10 kiloton improvised nuclear device within the first 72 hours of a detonation.
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* Various Authors. (2011). Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
This special issue contains articles highlighting the work of the Nuclear Detonation Scarce Resources Project Working Group. Included are discussions of triage and medical management of casualties resulting from nuclear detonations; social and behavioral response considerations for planners; and guidance to support health care system preparedness to respond to a nuclear detonation.
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* Veenema, T.G. (2018). Disaster Nursing and Emergency Preparedness: For Chemical, Biological, and Radiological Terrorism and Other Hazards, 4th Edition. (Book available for purchase.) Springer Publishing.
This book provides information to prepare nurses to respond to disasters and public health emergencies. This latest edition includes information on hospital and emergency department preparedness, as well as a digital teacher's guide containing critical thinking questions and exercises.
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Weisdorf, D., Chao, N., Waselenko, J.K., et al. (2006). Acute Radiation Injury: Contingency Planning for Triage, Supportive Care, and Transplantation. Biology of Blood and Marrow Transplantation. 12(6):672-82.
This article focuses on treatment of hematopoietic syndrome as one component of acute radiation sickness. The authors emphasize the value of having transplant physicians, hematologists, and oncologists participate in the development of plans for assessment, triage, treatment, and supportive care due to their respective patient care experience.
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Wolbarst, A.B., Wiley, A.L. Jr., Nemhauser, J.B. et al. (2010). Medical Response to a Major Radiologic Emergency: A Primer for Medical and Public Health Practitioners. Radiology. 254(3):660-77.
This article reviews the types of radiation incidents and the radiation injuries that would be sustained by casualties of a nuclear or radiologic device detonation, or accidental release, such as from a power plant, as well as how to treat them. It also describes the important role physicians who understand the effects of radiation on the human body and how to treat them, will play during a radiological or nuclear emergency.
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Education and Training


American College of Medical Toxicology. (2021). Chemical & Radiological Agents of Opportunity for Terrorism. (Registration required for download.)
This free, two-day, virtual course provides an overview of the medical and psychological consequences of exposures. The course includes practical information regarding scene safety and provides content in two one-day segments: Radiological Emergency Medical Management and Chemical Agents of Opportunity for Terrorism.
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American College of Radiology. (2006). Disaster Preparedness for Radiology Professionals.
This primer is geared towards radiologists, radiation oncologists, and medical physicists and summarizes current information on preparing for and responding to a radiation emergency (e.g., handling contaminated patients, assessing dose, and health effects).
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American College of Radiology Disaster Preparedness for Radiology Professionals. (2006). Disaster Preparedness for Radiology Professionals.
This educational resource can be used as a quick reference for preparing for a radiation emergency, managing contaminated patients, and assessing radiation exposure health effects. This resource also includes special considerations for pediatric patients exposed to radiation disasters.
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The goal of this hour-long training was to increase the knowledge base among emergency and disaster response personnel, as well as the general public, about the probability, effects, and consequences of radiological disasters and the importance of clear risk communication before, during, and after an incident.
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Blumenthal, D.J., Bader, J.L., Christensen D., et al. (2014). A Sustainable Training Strategy for Improving Health Care Following a Catastrophic Radiological or Nuclear Incident. (Abstract only.) Prehospital and Disaster Medicine. 29(1):80-6.
The authors propose a training strategy that includes all members of the health care delivery team, from first responders to first receivers and hospital support staff, and divides them into four tiers for targeting educational strategies. These strategies are capabilities-driven, and include the addition of radiological and nuclear-focused modules to existing trainings; the incorporation of radiation contamination measures into everyday practice; and providing just-in-time training at the time of an event.
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Centers for Disease Control and Prevention. (2005). Radiological Terrorism: Just in Time Training for Hospital Clinicians.
This 17-minute video provides a quick training for clinicians in radiation principles and procedures and provides demonstrations on their application in different patient care scenarios.
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Centers for Disease Control and Prevention. (2006). Radiological Terrorism: Medical Response to Mass Casualties.
This 2-hour video training uses online lectures and case studies to prepare first receivers to assess, triage, treat, and make disposition decisions for patients following mass casualty radiation incidents.
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Centers for Disease Control and Prevention. (2010). Psychological First Aid in Radiation Disasters.
This web-based course provides health professionals with training on psychological first aid, recognizing the unique psychological effects of radiation and nuclear events.
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* Centers for Disease Control and Prevention. (2011). Communication and Public Information in Radiation Disasters.
This is an hour-long archived webinar on communicating during a radiation disaster. It includes lessons learned from the Fukushima disaster.
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Centers for Disease Control and Prevention. (2014). Radiation Basics Made Simple.
Radiation Basics Made Simple is a training module that introduces participants to the fundamentals of radiation and radioactivity.
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Centers for Disease Control and Prevention. (2015). Medical Countermeasures for Radiation Exposure and Contamination.
Medical Countermeasures for Radiation Exposure and Contamination is a training module that aids in better understanding what medical countermeasures (treatments) are available for radiation exposure and contamination, how they work, and how and when they should be used.
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Centers for Disease Control and Prevention. (2018). Radiation Emergency Training, Education and Tools.
This webpage offers links to educational videos, resource tools, online training modules, and webinars designed to prepare public health and healthcare professionals to respond to radiation emergencies and disasters.
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* Centers for Disease Control and Prevention, Emergency Preparedness and Response. (2015). Virtual Community Reception Center (vCRC).
This web-based training tool teaches emergency healthcare planners how to conduct population monitoring after a mass casualty radiation emergency in community reception centers.
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This document can help emergency healthcare providers learn more about medically managing patients who have been internally contaminated through inhalation, ingestion or absorption of radionuclides in a nuclear or radiological emergency. It includes several scenarios and sample data that can be adapted to suit a facility's or jurisdiction's needs.
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National Security Technologies. (n.d.). Center for Radiological and Nuclear Training at the Nevada National Security Site. (Accessed 7/26/2021.)
This website links to training for radiological and nuclear response (e.g., AWR-140-W and courses on improvised nuclear devices). Both online and in-person courses are available free of charge to qualified individuals.
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* Oak Ridge Institute for Science and Education. (n.d.). Procedure Demonstrations for Contaminated Patients. (Accessed 4/26/2021.)
These demonstrations show healthcare providers how to: dress to prevent the spread of radioactive contamination; remove contaminated clothing from a patient; decontaminate a wound; and decontaminate intact skin.
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Oak Ridge Institute for Science and Education. (n.d.). Understanding Radiation Video Series. (Accessed 8/21/2017.)
These short videos can help health officials and the public better understand radiation and radioactive contamination.
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Oak Ridge Institute for Science and Education (ORISE). (n.d.). Radiation Emergency Assistance Center/Training Site (REAC/TS). (Accessed 7/12/2018.)
This webpage links to the Radiation Emergency Assistance Center/Training Site (REAC/TS), which offers several resources to prepare medical professionals to respond to radiological emergencies. There are links to books, live training courses, online trainings, and assessment and treatment guidance documents. REAC/TS staff are available for deployment to provide medical consultation during emergencies, upon request.
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Radiation Emergency Medical Management. (2018). Radiation Incidents: Multimedia Library.
These illustrations, short videos, and other forms of media can help emergency healthcare preparedness planners how to discover a radiation incident; characterize severity; create a timeline; understand different types of incidents (including nuclear explosions); and communicate with the public in the event of an incident.
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These four videos can help practitioners treat patients in the following categories: Radiation Injury Only; Combined Injury; Minimal Triage; and Initial Triage After a Nuclear Detonation.
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Radiation Injury Treatment Network. (2019). Training Materials.
This web page includes links to RITN training courses for medical and non-medical staff, and include just-in-time training, the RITN YouTube channel, and relevant CDC and FEMA EMI courses.
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* Tennessee Emergency Medical Services for Children. (2012). Responding to Radiation Disasters.
This slide-based web training is part of an online Pediatric Disaster Educational Toolbox. It addresses pediatric-related response issues following radiation disasters.
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Event-Specific Lessons Learned


This report details the role of the federal government in helping cities and states clean up after terror attacks using a radiological dispersal device or improvised nuclear device. Recovery activities after the 2006 United Kingdom (UK) polonium incident and the UK Nuclear Recovery Plan Template are also discussed.
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This article presents a snapshot of the recovery process in Japan after the 2011 earthquake. Chapter 3 explains the long-term recovery process from urban planning, community development, and specific population perspectives.
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Becker, S. (2013). The Fukushima Dai-Ichi Accident: Additional Lessons from a Radiological Emergency Assistance Mission. (Abstract only.) Health Physics. 105(5): 455–461.
The author describes response and recovery lessons learned by team members (including an emergency physician, health physicist, and a disaster management specialist) who spent 10 days conducting fieldwork in areas affected by the incident.
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Bromet, E. (2014). Emotional Consequences of Nuclear Power Plant Disasters. Health Physics. 106(2): 206-210.
This article describes the emotional consequences and resilience of two groups of nuclear power plant disaster survivors: mothers of young children and nuclear plant workers. The authors stress the need for considering physical and mental health "in an integrated fashion," the need for more long-term research, and the need for healthcare providers to be able to recognize and manage psychological symptoms.
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* Centers for Disease Control and Prevention. (2011). Communication and Public Information in Radiation Disasters.
This is an hour-long archived webinar on communicating during a radiation disaster. It includes lessons learned from the Fukushima disaster.
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* Coleman, C.N., Blumenthal, D.J., Casto, C.A. et al. (2013). Recovery and Resilience After a Nuclear Power Plant Disaster: A Medical Decision Model for Managing an Effective, Timely, and Balanced Response. (Abstract only.) Disaster Medicine and Public Health Preparedness. 7(2):136-45.
Based on experience from the Fukushima Daiichi nuclear power plant crisis, the authors propose a real-time medical decision-making model to ensure timely, organized, and effective response following a radiological or nuclear disaster. This model is in line with the current National Response Framework, and the authors suggest that it be used to manage "complex, large-scale, and large-consequence incidents."
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Dodgen, D., Norwood, A., Becker, S., et al. (2017). Social, Psychological and Behavioral Responses to a Nuclear Detonation in a US City: Implications for Healthcare Planning and Delivery. Disaster Medicine and Public Health Preparedness. 5(Suppl. 1).
The authors reviewed literature on human responses to radiation incidents and disasters in general, with a focus on behavioral health care provider (BHCP) contributions in the hours and days after a nuclear detonation. They listed the following six broad categories of interventions: promoting appropriate protective actions, discouraging dangerous behaviors, managing patient/survivor flow to facilitate the best use of scarce resources, supporting first responders, assisting with triage, and delivering palliative care when appropriate. The authors also shared recommendations regarding response and recovery phase BHCP interventions.
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Federal Emergency Management Agency. (2012). Millstone Power Station. After-Action Report/Improvement Plan.
This report covers the August 21, 2012 exercise conducted on the plume exposure pathway Emergency Planning Zone (EPZ) around the Millstone Power Station. The purpose of the exercise was to assess the level of state and local preparedness in responding to a radiological emergency. Appendices are included.
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Chapter 5 of this report covers the “Remediation Strategy Implementation,” including hard surface and building decontamination techniques and guidelines, food and agricultural safety, and forest and aquatic area remediation. A chapter on waste management with guidelines on storing contaminated materials follows.
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International Atomic Energy Agency. (2021). Emergency Preparedness and Response.
This webpage provides links to resources on real-world responses to radiological and/or nuclear accidents.
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This report includes follow-up healthcare-specific recommendations for select populations in affected areas and suggestions for future research. Environmental monitoring and remediation suggestions are also provided, followed by recommendations for economic and social policy.
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Lochard, J. and Prêtre, S. (1995). Return to Normality after a Radiological Emergency. Health Physics. 68(1): 21–26.
While dated, the information in this article is focused on helping communities understand how to determine post-incident acceptability (or “return to normal”). The various components covered by the authors include time post-incident, the zoning process (including the negative effects of establishing zones), and the “reference to the norm.”
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Morimura, N., Asari, Y., Yamaguchi, Y., et al. (2013). Emergency/Disaster Medical Support in the Restoration Project for the Fukushima Nuclear Power Plant Accident. Emergency Medical Journal. 30: 997-1002.
The authors describe the medical response to the incident, including patient decontamination. Photos of the decontamination tent and tables illustrating diagnosis and patient outcome are included.
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Elderly residents of care facilities evacuated after a disaster experienced a three-fold increase in mortality compared to baseline mortality in a control group. This potential impact should be considered in evacuation decision-making.
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Siembieda, W. (2012). Multi Location Disaster in Three Countries: Comparing the Recovery Process in Japan, Chile and New Zealand. Focus: Journal of the City and Regional Planning Department. 9(1): 43–50.
The author visited each country and explains similarities and differences in their disaster recovery processes.
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Tanisho, Y., Smith, A., Sodeoka, T., and Murakami, H. (2015). Post-Disaster Mental Health in Japan: Lessons and Challenges. Health and Global Policy Institute.
This report describes lessons learned from the Fukushima nuclear disaster in 2012. It includes recommendations for ensuring that psychosocial and mental health interventions consider the unique circumstances and cultural issues of a given disaster.
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General Guidance


This ASPR TRACIE document provides an overview of the potential health and medical response and recovery needs following a radiological or nuclear incident and outlines available resources for planners.
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This paper, written for and presented at the Vienna Convention of the United Nations, describes the humanitarian crisis that would occur following a nuclear weapon detonation. The author describes sustenance, healthcare, and other needs that need to be addressed in emergency plans.
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Baker, G.H. and Volandt, S. (2018). Cascading Consequences: Electrical Grid Critical Infrastructure Vulnerability. Domestic Preparedness.
This article provides an overview of the national power grid, and related threats (e.g., coordinated physical attacks, cyber-attacks against industrial control systems, electromagnetic pulse denotation, and severe solar storms). The authors examine risks, threats, impacts, current state of preparedness, and conclude with recommendations to enhance critical infrastructure resilience.
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Centers for Disease Control and Prevention. (2015). Radiation and Your Health.
This webpage includes information for individuals on the effects of ionizing and non-iodizing radiation. Separate tabs provide information on “Radiation in Your Life,” “Health Effects of Radiation,” and “Radiation Basics.”
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Based on federal guidance, the authors provide a “framework to ensure that the regulation of exposure to ionizing radiation is carried out in a consistent and adequately protective manner.” The report includes tables of dose coefficients, application considerations, and several appendices.
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This report provides in-depth details, findings, and recommendations from the EMP Commission on intentional and solar superstorm electromagnetic pulse incidents. The Commission highlights challenges and current planning status, and provides overarching recommendations to improve and mitigate against current threats critical infrastructure systems.
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This report reviews the EMP Commission recommendations for HEMP preparedness to ensure critical infrastructure protection. The authors utilized data from Soviet-era nuclear tests to provide recommendations to protect critical infrastructure against threats and vulnerabilities associated with High Altitude Electromagnetic fields.
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Conference attendees from government and nongovernmental organizations, academia, and the private sector discussed the current status of medical and public health preparedness for a nuclear incident, examined how increasing concerns about the use of nuclear warfare could lead to potential changes in these assumptions, and discussed capacity building opportunities and challenges in the current threat environment. Chapter 8 discusses considerations for workforce capacity and willingness to respond.
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Radiation Emergency Medical Management (REMM). (n.d.). Recovery / Resilience after an Incident: Useful Guidance about Recovery and Resilience. (Accessed 6/17/2021.)
This section of this REMM webpage includes links to guidance specific to response to and recovery from incidents.
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* Radiation Injury Treatment Network. (2012). Concept of Operations.
This document outlines the anticipated integration of the Radiation Injury Treatment Network (RITN) into the national response to a mass casualty incident resulting in marrow-toxic injuries. It includes graphics and guidelines and principles that will be applied to acute radiation syndrome management scenarios. This short, animated video describes the formation of the RITN and the role member hospitals would play in a radiological disaster: https://www.youtube.com/watch?v=v-qW-z7qXRw.
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U.S. Department of Energy and The Electric Power Research Institute. (2016). Joint Electromagnetic Pulse Resilience Strategy.
This document presents guidance to support and improve response and recovery efforts after an electromagnetic pulse (EMP) denotation. It provides 5 strategic goals to assist energy sector officials in planning and response to minimize EMP impacts and ultimately enhance resilience.
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U.S. Environmental Protection Agency. (2018). Radiation Protection.
This website provides links to resources that can help protect communities from radiation (e.g., a dose calculator, basic information, protective actions, regulations, and response). A document library and links to related content are also provided.
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Pediatric Considerations


American Academy of Pediatrics, Linet, M.S., Kazzi, Z., Paulson, J.A. (2018). Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies (Technical Report). 142(6).
This Technical Report is the companion document to the “Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies” Policy Statement issued by the American Academy of Pediatrics in 2018. It discusses acute radiation syndrome, acute and long-term psychological effects, cancer risks, and other late tissue reactions after low-to-high levels of radiation exposure, as well as measures to reduce radiation exposure in the immediate aftermath of a radiologic or nuclear disaster.
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Gardner, A.H., Dziuban, E.J., Griese, S., et al. (2018). Medical Countermeasures for Children in Radiation and Nuclear Disasters: Current Capabilities and Key Gaps. (Abstract only.) Disaster Medicine and Public Health Preparedness.
The authors conducted a literature review and gap analysis related to pediatric medical countermeasures. They identified 15 gaps in information needed to support the safe and successful use of MCMs in children during radiation emergencies, and prioritized them based upon the potential to decrease morbidity and mortality, improve clinical management, strengthen caregiver education, and increase the relevant evidence base.
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* Radiation Emergency Medical Management. (2019). Prototype/Template for Adult and Pediatric Hospital Orders During a Radiation Incident. U.S. Department of Health and Human Services.
These orders--while meant to serve solely as guidance documents--can be tailored and used by healthcare providers who treat adult and pediatric patients after a radiological incident. Helpful links are included throughout the prototypes.
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Siegel, D. (2009). Preparation for Terrorist Threats: Radiation Injury. (Abstract only.) Clinical Pediatric Emergency Medicine. 10(3): 136-139.
The author addresses the specific clinical management issues related to the radioactive agents and the special characteristics and needs of child victims of this type of terrorism.
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* Tennessee Emergency Medical Services for Children. (2012). Responding to Radiation Disasters.
This slide-based web training is part of an online Pediatric Disaster Educational Toolbox. It addresses pediatric-related response issues following radiation disasters.
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Yonekura, T., Ueno, S., and Iwanaka, T. (2013). Care of Children in a Natural Disaster: Lessons Learned from the Great East Japan Earthquake and Tsunami. (Abstract only.) Pediatric Surgery International. 29(10): 1047-1051.
The authors incorporate lessons learned from the Fukushima disaster into response recommendations for pediatric surgeons and physicians.
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Plans, Tools, and Templates


This document provides information that may guide hospital plans for radiological emergencies. It contains a list summarizing "10 basics of response," with individual sections for each of the 10 items.
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Army Center for Health Promotion and Preventive Medicine Aberdeen Proving Ground. (2000). The Medical NBC Battlebook.
This downloadable PDF serves as a quick reference guide for medical personnel in the field. The authors provide information on the following threats: nuclear, radiological hazards, biological, chemical, and lasers/ radiofrequency.
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Becker, S. and Middleton, S. (2008). Improving Hospital Preparedness for Radiological Terrorism: Perspectives From Emergency Department Physicians and Nurses. (Abstract only.) Disaster Medicine and Public Health Preparedness. 2(3):174-184.
This article describes results from a series of focus groups conducted among 77 emergency department physicians and nurses to obtain their concerns and perceptions on radiation emergencies, and their feedback on response guidelines. The findings may assist hospitals with response planning and with identifying staff education and training needs.
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Bell, W.C., and Dallas, C.E. (2007). Vulnerability of Populations and the Urban Health Care Systems to Nuclear Weapon Attack--Examples from Four American Cities. (Abstract and figures only.) International Journal of Health Geographics.  28;6:5.
The authors analyzed the potential effects of 20 kiloton and 550 kiloton nuclear detonations on New York City, Chicago, Washington D.C., and Atlanta, and discuss the relative damage from radiation and blast injuries in each scenario. They conclude that most of the necessary health care resources will be within the blast and/or plume zone, further exacerbating what is expected to be a scarcity of resources following a nuclear weapon detonation.
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* Berger, M.E., Leonard, R.B., and Ricks, R.C. (2010). Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster. Oak Ridge Institute for Science and Education (ORISE).
This article focuses on the needs of emergency physicians following a radiological or nuclear emergency. Guides for taking a focused history; performing a physical exam and laboratory tests; and managing the initial treatment and disposition of victims of acute radiation syndrome and combined injury are provided.
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Bushberg, J.T., Kroger, L.A., Hartman, M.B., et al. (2007). Nuclear/Radiological Terrorism: Emergency Department Management of Radiation Casualties. (Abstract only.) Journal of Emergency Medicine. 32(1):71-85.
The authors discuss the importance of educating emergency department staff on risks from radiation to prepare them to care for casualties of radiological and nuclear emergencies. They also emphasize the need to have plans in place to manage the anticipated large influx of potentially contaminated individuals to the emergency department, regardless of whether or not they are actually injured.
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California Department of Public Health. (2011). California Public Health and Medical Emergency Operations Manual.
Section II of this manual includes function-specific categories (e.g., hazardous materials, nuclear power plant emergencies, and nuclear weapon detonation). For every function, the plan includes an overview, list of response actions, steps for local health departments and other health providers to take, and the role of relevant state agencies.
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This report summarizes recommendations for products and messages made by the roundtable on Hospital Communications in a Mass Casualty Radiological Incident that met in January 2003.
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Centers for Disease Control and Prevention. (2005). Radiological Terrorism: Emergency Management Pocket Guide for Clinicians.
This pocket guide is a supplement to the Centers for Disease Control and Prevention training program "Radiological Terrorism: Just in Time Training for Hospital Clinicians." The guide can help healthcare professionals who provide emergency care in a hospital setting following a radiological terrorism incident.
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* Centers for Disease Control and Prevention. (2013). Acute Radiation Syndrome: A Fact Sheet for Clinicians.
This fact sheet provides information on the symptoms and stages of acute radiation syndrome (ARS), as well as patient management for ARS. Information on cutaneous radiation syndrome is also included.
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* Centers for Disease Control and Prevention. (2013). Radiological Terrorism: Tool Kit for Emergency Services Clinicians.
This toolkit contains resources (such as videos and pocket guides) on decontamination, population monitoring, and psychological first aid in radiation emergencies.
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Centers for Disease Control and Prevention. (2013). Radiological Terrorism: Tool Kit for Public Health Officials.
This toolkit contains resources on decontamination, population monitoring, and psychological first aid in radiation emergencies.
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Centers for Disease Control and Prevention. (2014). Internal Contamination Clinical Reference (ICCR) Application.
The Internal Contamination Clinical Reference is an application (for Android devices, iPads, and iPhones) estimating reference concentrations of radionuclides in urine assuming intakes equal to one Clinical Decision Guide (CDG) for each radionuclide.
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This webpage includes a series of handbooks for portable meters that may be used in the field to detect internal radiation contamination, as well as instructions for using Gamma cameras to assess internal contamination.
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This tool offers summaries, action steps, and checklists for the following ten topics for inclusion in community reception center plans: (1) lead agency and public health role, (2) registry and surveillance, (3) communications, (4) CRC sites, (5) stations, (6) staffing and training, (7) equipment and supplies, (8) demobilization, (9) behavioral health, and (10) access and functional needs. It is intended to be used with jurisdictional point of distribution plans, "Population Monitoring in Radiation Emergencies," and the resources listed with each checklist.
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Centers for Disease Control and Prevention, Emergency Preparedness and Response. (2014). Community Reception Center (CRC) Simulation Tools.
The Centers for Disease Control and Prevention developed two simulation programs (CRC-STEP and RealOpt-CRC) that can help emergency healthcare providers test their Community Reception Center (CRC) models. The programs can help users: analyze CRC throughput; identify bottlenecks; and highlight the need for additional resources.
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Centers for Disease Control and Prevention, Emergency Preparedness and Response. (2014). Radioactive Isotopes.
This webpage hosts links to information by isotope (e.g., cesium, iodine, plutonium). Users can click on the link to learn about each isotope's toxicity.
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* Centers for Disease Control and Prevention, Emergency Preparedness and Response. (2015). Virtual Community Reception Center (vCRC).
This web-based training tool teaches emergency healthcare planners how to conduct population monitoring after a mass casualty radiation emergency in community reception centers.
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Centers for Disease Control and Prevention, National Center for Environmental Health. (2015). A Guide to Operating Public Shelters in a Radiation Emergency.
This document can assist emergency managers with planning and response efforts related to shelter operations in a radiation emergency. The guide includes information on screening for radioactive contamination, decontamination, radiation monitoring, registration, health surveillance, and communications consistent with Centers for Disease Control and Prevention Community Reception Center guidance. Chapter Three of this guidance document shares strategies for screening and decontamination (of people, service animals, pets, possessions, and vehicles) in shelters. Quick guides on decontamination are provided as appendices.
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* Coleman, C.N., Blumenthal, D.J., Casto, C.A. et al. (2013). Recovery and Resilience After a Nuclear Power Plant Disaster: A Medical Decision Model for Managing an Effective, Timely, and Balanced Response. (Abstract only.) Disaster Medicine and Public Health Preparedness. 7(2):136-45.
Based on experience from the Fukushima Daiichi nuclear power plant crisis, the authors propose a real-time medical decision-making model to ensure timely, organized, and effective response following a radiological or nuclear disaster. This model is in line with the current National Response Framework, and the authors suggest that it be used to manage "complex, large-scale, and large-consequence incidents."
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This handbook and pocket card (which may be ordered on-line) provide a training and reference tool for first responders with various degrees of radiological experience to respond to a radiological event.
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Dainiak, N., Carpini, D., Bohan, M., et al. (2006). Development of a Statewide Hospital Plan for Radiologic Emergencies. (Abstract only.) International Journal of Radiation Oncology • Biology • Physics. 65(1):16-24.
The authors describe the development process for and key components of Connecticut's plan for responding to radiologic emergencies.
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Dallas, C.E., and Bell, W.C. (2007). Prediction Modeling to Determine the Adequacy of Medical Response to Urban Nuclear Attack. (Abstract only.) Disaster Medicine and Public Health Preparedness. 1(2):80-9.
The authors modeled the effects of 20- and 550-kiloton nuclear detonations on Los Angeles and Houston, with a focus on thermal effects. They found that the number of burn casualties would number in the tens of thousands, with over 185,000 casualties after a 550-kiloton detonation in Los Angeles. The authors recommend that health care facilities greatly expand the number of personnel involved in burn care, and that regional planning be considered, along with air transport of victims.
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This guidance can be used by community leaders to help plan for, respond to, and recover from RDD and IND incidents. It describes the various phases of an incident; includes a figure that depicts exposure routes, protective measures, and timelines for effects; lists protective actions; and highlights late phase/recovery activities for planning purposes.
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Flood, A.B., Boyle, H.K., Du, G., et al. (2014). Advances in a Framework to Compare Bio-dosimetry Methods for Triage in Large-Scale Radiation Events. Radiation Protection Dosimetry. 159(1-4):77-86.
The authors compared the performance of six bio-dosimetry methods for five different population sizes ranging from 100-1,000,000, at a rate of 15 or 15,000 people per hour with four additional time windows. They conclude that larger population sizes require longer triage times, which decreases the usefulness of time-intensive methods. They discuss the value of using multiple methods to assess casualties.
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Hick, J., Bader, J., Coleman, N., et al. (2017). Proposed “Exposure And Symptom Triage” (EAST) Tool to Assess Radiation Exposure After a Nuclear Detonation. (Abstract only.) Disaster Medicine and Public Health Preparedness, 1-10.
The authors share results from the work of an interdisciplinary working group composed of federal, state, and local public health experts who developed the Exposure And Symptom Triage (EAST) tool. This tool combines estimates of exposure from maps with clinical assessments and single lymphocyte counts (if available) to help emergency healthcare providers triage patients after a nuclear incident.
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International Atomic Energy Agency. (2006). Manual for First Responders to a Radiological Emergency.
This guide provides helpful information for first responders to use within the first few hours of a radiological emergency. Action guides for the incident commander are followed by guides for specific responders (e.g., fire, emergency medical service, law enforcement, forensic evidence collection team, public information officer, hospitals, and emergency operations centers).
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Koerner J.F., Coleman, C.N., Murrain-Hill, P. et al. (2014). The Medical Decision Model and Decision Maker Tools for Management of Radiological and Nuclear Incidents. (Abstract only.) Health Physics. 106(6):645-51.
During or after a radiological or nuclear disaster, onsite subject matter experts may not be immediately available, yet critical decisions for a complex response must be made. The authors describe a model to assist decision makers and describe tools to facilitate timely and effective incident management.
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Lawrence Livermore National Laboratory. (2012). Key Planning Factors for Recovery from a Radiological Terrorism Incident. Federal Emergency Management Agency.
The authors cover seven key planning factors that can help communities prepare for and recover from a radiological incident. Section 4.2 of the guide focuses on public health and medical priorities.
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This "consensus guidance document" can be used by ambulance services owners/operators to prepare for, respond to, and recover from, a radiological incident. It includes sample placards, a list of acronyms and abbreviations, and other resources that can be tailored by others.
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The author synthesized expert opinion on the feasibility of developing self-sustaining volunteer emergency response programs to perform tasks associated with radiation emergencies (e.g., population monitoring) and help in other ways at hospitals, community reception areas, and other areas.
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* Meit, M., Redlener, I., Briggs, T.W. et al. (2011). Rural and Suburban Population Surge Following Detonation of an Improvised Nuclear Device: A New Model to Estimate Impact. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors describe a “push-pull” model that estimated the evacuation from Manhattan to counties within a 150 mile radius after a nuclear detonation. This model predicted that arriving evacuees could increase the population needing services by between 50 and 150 percent.
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* National Council on Radiation Protection and Measurements. (2008). NCRP Report No. 161, Management of Persons Contaminated With Radionuclides. (Abstract only.)
The information in this report is geared towards medical professionals caring for people exposed to and potentially contaminated in accidental or purposeful releases of large quantities of radionuclides.
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* National Security Staff, Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats. (2010). Planning Guidance for Response to a Nuclear Detonation. Second Edition. Homeland Security Council Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats.
This core resource document provides emergency planners (including emergency medical service planners, medical receiver planners, and mass care providers) recommendations specific to nuclear detonation incidents in an urban setting.
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Nuclear Detonation Response Communications Working Group. (2010). Nuclear Detonation Preparedness Communicating in the Immediate Aftermath.
This guidance can help emergency planners and responders at the federal, state, and local levels communicate with the public (including the media) in the immediate aftermath of a nuclear detonation in the U.S.
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NYC Hospital Radiation Response Working Group, NYC Department of Health and Mental Hygiene, Healthcare Emergency Preparedness Program. (2009). NYC Hospital Guidance for Responding to a Contaminating Radiation Incident.
This guidance was prepared to help New York City Hospitals prepare their response to an emergency involving radioactive contamination. The guidance and strategies can be tailored to other city hospitals.
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Office of the Assistant Secretary for Preparedness and Response. (2018). State & Local Planners Playbook for Medical Response to a Nuclear Detonation.
This playbook can help emergency and public health planners and other subject matter experts at all levels prepare their agencies and facilities for a nuclear detonation. Detailed action steps are listed by phase (pre-incident, 0-24 hours post-detonation, 24-96 hours post-detonation, and beyond 96 hours) and links to resources are provided throughout.
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These handbooks cover the radiation incident recovery process for food production, inhabited areas, and drinking water.
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Radiation Emergency Medical Management. (2018). Triage Category and Cytokine (G-CSF) Use after a Nuclear Detonation.
Healthcare providers can use this triage tool in the event of a radiation emergency. While it does not use standard triage categories, providers can classify patients as "Radiation only," "Combined injury (radiation and trauma and/or burn)"; or "Trauma or burn only." Links to the offline tool and triage tool cards are also provided on this page.
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* Radiation Injury Treatment Network. (2017). Prototype for Adult Medical Orders During a Radiation Incident.
Healthcare providers can customize this set of orders—created by REMM and RITN physicians—for adult patients who have been exposed to radiation. It includes links to additional tools throughout that can assist with diagnoses and treatment.
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Radiation Injury Treatment Network. (2019). Radiation Injury Treatment Network: Map and List of Hospitals.
This map and list illustrate the hospitals across the country that participate in the Radiation Injury Treatment Network. The list specifies whether facilities serve adult and/or pediatric patients and if they are trauma centers, burn centers, NDMS hospitals, and/or HPP hospitals. For contact information, copy and paste this link into a new browser: https://ritn.net/workarea/downloadasset.aspx?id=2147484472.
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Radiation Response Volunteer Corps and Population Monitoring. (2016). Radiation Response Volunteer Corps and Population Monitoring.
This website includes a “Templates and Forms” tab that takes the user to a Dropbox page.
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Runge, J. and Buddemeier, B. (2009). Explosions and Radioactive Material: A Primer for Responders. (Abstract only.) Prehospital Emergency Care. 2009;13:407-19.
The authors created a comprehensive, scenario-based primer on planning for and responding to "dirty bombs."
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This checklist provides information to diminish loss of lives following a nuclear detonation. This tool should be used as a preparedness tool and during the planning process.
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Sullivan, J.M., Prasanna, P.G., Grace, M.B., et al. (2013). Assessment of Biodosimetry Methods for a Mass-Casualty Radiological Incident: Medical Response and Management Considerations. Health Physics. 105(6):540-54.
The authors provide an extensive review of biodosimetry methods and their respective utility following a mass casualty radiological incident, taking into account disruptions in infrastructure, limited resources, ease of use, and time to results. They conclude that no single method will be sufficient, and that biodosimetry is one component of what must be a more comprehensive approach to triage and medical management of casualties.
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The Center for HICS Education and Training. (n.d.). Incident Response Guide: Radiation Incident. (Accessed 7/7/2015.)
This document provides a checklist for hospital emergency planners to use to prepare for response to a radiation incident.
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* Turai, I., Veress, K., Günalp, B, and Souchkevitch, G. (2004). Medical Response to Radiation Incidents and Radionuclear Threats. British Medical Journal 328(7439):568-72.
The authors provide information on the basic medical management of radiation sickness and radiation injuries, and share information about related training on early recognition of and medical response to radiation accidents and purposeful incidents.
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2012). Medical Planning and Response Manual for a Nuclear Detonation Incident: A Practical Response Guide.
This comprehensive document provides emergency planners with information not only on the effects of radiation and how to measure and treat them, but also on how to communicate during a radiological or nuclear emergency. It also describes federal response roles and the distribution of medical countermeasures for acute radiation sickness in an environment of scarce resources.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2019). National Health Security Strategy. U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the strategy, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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U.S. Department of Health and Human Services, Radiation and Emergency Medical Management. (2014). Develop a Radiation Response Plan.
This webpage provides links to guidance on developing a community hospital response plan, developing a hospital response team, and general information that should be considered when planning for a nuclear detonation or similar event.
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This planning guide can help agencies improve planning for and protection of responders following a nuclear detonation event. The guide covers topic areas such as incident command, responder safety, decontamination, site control, personal protective equipment, radiation detection and air monitoring equipment, training, communications, and record keeping.
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This planning tool consists of a base document and three corresponding incident-specific planning documents. The base document covers general guidance applicable to all radiological and nuclear incidents, and the other documents provide guidance for suspected or deliberate attacks, inadvertent incidents, and international incidents. This annex can be used by federal, state, local, and voluntary organizations to enhance planning efforts and ensure coordination with federal planning efforts.
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This planning document provides guidance to first responders and local response agencies in understanding the critical missions and tasks that should be undertaken within the first 100 minutes of a radiological dispersal device denotation response. Public messaging, response coordination, personal protective equipment, and equipment resource recommendations are reviewed within the document. The authors also include customizable planning tools and worksheets.
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U.S. Department of Homeland Security Working Group on Radiological Disperson Device (RDD) Preparedness Medical Preparedness Sub-Group. (2003). Department of Homeland Security Working Group on Radiological Dispersion Device (RDD) Preparedness [Report]: 5/1/03 version.
This report provides information for medical professionals on the immediate management of patients following detonation of an RDD, as well as decontamination, radiological assessment, psychological effects of the event, and how to deal with remains of deceased persons following radiological terrorism. It also provides an extensive discussion of radiological countermeasures.
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This manual can help public officials plan for emergency response to radiological incidents. The manual consists of two overarching response areas: protective action guides, and protective actions which are further broken down into early, intermediate, and late phase response actions for radiological incidents. Each phase describes corresponding response actions (e.g., evacuation, sheltering in place, administration of medication, worker protection, and clean up, and disposal of radiological waste).
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* Various Authors. (2011). Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
This special issue contains articles highlighting the work of the Nuclear Detonation Scarce Resources Project Working Group. Included are discussions of triage and medical management of casualties resulting from nuclear detonations; social and behavioral response considerations for planners; and guidance to support health care system preparedness to respond to a nuclear detonation.
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* Veenema, T.G. (2018). Disaster Nursing and Emergency Preparedness: For Chemical, Biological, and Radiological Terrorism and Other Hazards, 4th Edition. (Book available for purchase.) Springer Publishing.
This book provides information to prepare nurses to respond to disasters and public health emergencies. This latest edition includes information on hospital and emergency department preparedness, as well as a digital teacher's guide containing critical thinking questions and exercises.
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Population Monitoring/Community Reception Centers


Centers for Disease Control and Prevention. (n.d.). Community Reception Center Flow Diagram. (Accessed 2/3/2020.)
This is a set of floorplans for various stages of Community Reception Centers, including intake, emergency medical care or transfer, and discharge.
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This guide provides information for state and local planners to develop post radiological emergency response plans. This guide describes processes for managing the radiation monitoring required to evaluate exposure in the affected population, including the use of community reception centers.
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Centers for Disease Control and Prevention. (2015). Community Reception Center (CRC) Drill Toolkit.
The CRC Drill toolkit provides guidance and templates that any jurisdiction can adapt to exercise the full range of CRC operations. The drill was developed to be compatible with the U.S. Department of Homeland Security’s Homeland Security Exercise and Evaluation Program (HSEEP). It also incorporates insights, issues, and lessons learned from real-world events.
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Conference of Radiation Control Program Directors, Inc. (n.d.). Radiation Response Volunteer Corps Development ToolKit. (Accessed 4/26/2021.)
This website includes a “Templates and Forms” tab. Helpful templates include; Kansas Community Center Flow Diagram; Kansas Radiation Incident Community Reception Center Standard Operating Guidelines; Kansas Department of Health and Environment CRC Template; and Union County (OH) Example CRC Supply and Equipment List.
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Florida Department of Health. (n.d.). Community Reception Center (CRC) Form. (Accessed 7/12/2018.)
First responders can use this intake form as a model when creating their own CRC forms. It includes incident-specific questions and two pages of instructions.
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Florida Department of Health. (2011). After-Action Report and Improvement Plan Matrix.
This report covers the July 12, 2011, Community Reception Center (CRC) Drill conducted at Cypress Creek High School in Orlando, Florida. The Improvement Plan highlights recommendations and adjudications to the state CRC plan. Appendices are included.
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This discussion paper describes the screening function (Exposure And Symptom Triage – EAST) which will primarily be conducted at Assembly Centers after a nuclear detonation. Geared towards jurisdictional emergency planners and responders as a planning reference, it contains response tools and strategies that will assist them in planning for Assembly Centers and mass screening functions.
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This document provides steps for responders to take upon receipt of residents at Community Reception Centers. It includes forms for responders and handouts for visitors.
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This master’s thesis includes a detailed literature review of published and gray literature on the effectiveness of community reception centers for managing population evaluation.
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Resources for Emergency Responders


Moskowitz, S. (n.d.). Disaster Mental Health: Assisting People Exposed to Radiation. (Accessed 6/17/2021.)
This presentation describes the prominent psychosocial issues related to radiological exposure, examines the evidence-based psychosocial interventions, including effective risk communication practices, and identifies key elements of self-care for first responders and public health professionals.
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* Radiation Emergency Medical Management. (2018). Initial On-site Activities.
The resources linked from this webpage can help first responders manage the scene and victims of a radiological incident.
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Radiation Emergency Medical Management. (2018). Planners: Preparedness and Response.
This webpage includes links to resources that can help emergency planners establish procedures for before, during, and after a radiological or nuclear event.
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Radiation Emergency Medical Management. (2018). Transport Victims of Radiation Emergencies.
This webpage contains links to resources geared towards teaching responders how to transport victims contaminated in a radiological incident.
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* Radiation Emergency Medical Management. (2018). Triage Guidelines Including Radiation Triage Guidelines.
This webpage provides links to radiation-related triage tools, guidelines, and algorithms.
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Radiation Emergency Medical Management. (2019). First Responders in the Field.
This webpage includes links to helpful resources for responders on radiation-specific personal protective equipment, incident response (including casualty management and triage), and online training courses.
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* U.S. Department of Health and Human Services. (2011). State and Local Planners Playbook for Medical Response to a Nuclear Detonation.
This playbook provides guidance to state, regional, local, tribal, and territorial sectors; medical professionals; public health planners; and other subject matter experts who are developing plans for a medical response to a nuclear detonation.
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This planning document provides guidance to first responders and local response agencies in understanding the critical missions and tasks that should be undertaken within the first 100 minutes of a radiological dispersal device denotation response. Public messaging, response coordination, personal protective equipment, and equipment resource recommendations are reviewed within the document. The authors also include customizable planning tools and worksheets.
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Scarce Resources


Caro, J.J., DeRenzo, E.G., Coleman, C.N. et al. (2011). Resource Allocation After a Nuclear Detonation Incident: Unaltered Standards of Ethical Decision Making. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors provide practical ethical guidance for healthcare providers faced with making decisions after a nuclear detonation, prior to the establishment of a coordinated response.
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Casagrande, R., Wills, N., Kramer, E., et al. (2011). Using the Model of Resource and Time-Based Triage (MORTT) to Guide Scarce Resource Allocation in the Aftermath of a Nuclear Detonation. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors used the model of resource- and time-based triage (MORTT) and found that in settings where resources were scarce, prioritizing victims with moderate life-threatening injuries over victims with severe life-threatening injuries saves more lives and reduces demand for intensive care.
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Coleman, C.N., Knebel, A. R., Hick, J.L. et al. (2011). Scarce Resources for Nuclear Detonation: Project Overview and Challenges. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
This article summarizes the medical challenges associated with scarce resources and nuclear detonations, and serves as an introduction to the rest of the articles in this issue.
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Coleman, C.N., Weinstock, D.M., Casagrande, R. et al. (2011). Triage and Treatment Tools for Use in a Scarce Resources-Crisis Standards of Care Setting After a Nuclear Detonation. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
Based on the information shared in other articles in this issue, the authors discuss possible triage options during the first four days after an event.
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DiCarlo, A.L., Maher, C., Hick, J.L. et al. (2011). Radiation Injury After a Nuclear Detonation: Medical Consequences and the Need for Scarce Resources Allocation. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
This literature review focuses on radiation injuries from human exposures and animal models and is accompanied by various triage and management approaches (covered in the rest of this special issue).
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Hick, J.L., Weinstock, D.M., Coleman, C.N. et al. (2011). Health Care System Planning for and Response to a Nuclear Detonation. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors use vignettes to describe how a nuclear the incident may unfold for the various components of the health and medical systems. They also emphasize the need for first responders to protect themselves physically and psychologically.
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Knebel, A.R., Coleman, C.N., Cliffer, K.D. et al. (2011). Allocation of Scarce Resources After a Nuclear Detonation: Setting the Context. Disaster Medicine and Public Health Preparedness. Volume 5. Supplement 1.
The authors emphasize the need for all involved sectors to plan and practice for the allocation of scarce resources in a nuclear incident.
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U.S. Department of Health and Human Services, Radiation Emergency Medical Management. (2016). Nuclear Detonation Scarce Resources Project Working Group Publications.
This link takes users to the full triage module on REMM. This provides users access to an online flowchart/decision tree for complex triage decisions and links to various resources which provide the background information on triaging and medically managing patients in the early days following a radiological event. The online Triage tool allows for data entry and customization of decision-making.
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Agencies and Organizations


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Centers for Disease Control and Prevention. Radiation Emergencies.
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Oak Ridge Institute for Science and Education. Radiation Emergency Assistance Center/Training Site.
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U.S. Department of Health and Human Services. Radiation Emergency Medical Management.
Resources are placed into the following sections:
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. ASPR CBRNE Science.
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