Nuclear Attack: What Emergency Physicians Working in the ED Need to Know

nuclear attackEver wonder what would happen if you were working in the emergency department (ED) when a nuclear attack happens? We’ve all had questions on boards or inservice exams about the long-term effect of radiation exposure, but would you know what to ACTUALLY DO if a nuclear attack happened? What do you do in the first few minutes? First few hours? We know that if you are in the immediate bomb vicinity, there is not much you can do. But what if you are 5 miles away? Or 10 miles?

If you look for information regarding nuclear attacks, there are no great summary resources on what to do in the immediate aftermath if you are in the ED. In order to bring this to you in an easily digestible format, we have broken this post up into a few topic areas: This blog post will cover (1) what physically happens in a nuclear attack and (2) what this means in the ED.

1. What happens in a nuclear attack?

Photo credit from

The answer is that it depends on the strength of the bomb (megatons). The bomb that struck Hiroshima was 15 kilotons (kT), and the largest bomb detonated to date was the Tsar Bomba, at 50 megatons (mT) which is equivalent to 3,333 Hiroshima bombs.

There are 2 phases of attack with a nuclear weapon:

Phase 1: Direct effects from the explosion

When a nuclear bomb explodes on the ground, it essentially vaporizes everything within a certain radius, depending on the size of the bomb. These vaporized particles form the characteristic mushroom cloud. If you are at ground zero, there is nothing you can do, and death will be quick. But what if you are not in the direct path but near it? Nuclear bombs can still have adverse effects miles away. To understand these effects, we need to understand what nuclear bombs actually do.

The 5 main initial effects of a nuclear bomb are:

  1. Radiation – Highly penetrating gamma rays are emitted upon explosion. This is referred to as initial nuclear radiation.1 These gamma rays are emitted as a one-time dose that moves through but does not persist in the environment. There is a risk of ongoing radiation exposure, but that is due to the presence of radioactive particles from fallout and not the initial radiation dose. Additionally, infrared radiation can also cause burns as exposed skin absorbs the infrared radiation. This can occur at lower temperatures than would cause clothing to ignite.2
  2. Fire – As the explosion is occurring, the rapid rise in temperature and pressure causes the formation of a massive fireball.1
  3. Shock wave – A pressure wave front forms that moves radially away from the site of explosion causing damage from the “overblast” itself (pressure change) and high winds that can carry projectiles.1,3
  4. Flash blindness – The energy released as light from thermal radiation reaches the eyes of onlookers. The abrupt change in the light intensity can cause temporary or permanent flash blindness.1
  5. Electromagnetic pulse (EMP) – An EMP is a burst of electromagnetic radiation which can shut down a wide variety of electronic devices, including cell phones, computers, and power generators. This can lead to widespread power outages, difficulty communicating, medical equipment malfunction, refrigeration issues, and lack of artificial lighting.4

Phase 2: Fallout

This is a unique complication of a nuclear attack. Fallout occurs when all of the radioactive particles that were vaporized in the initial blast and became airborne coalesce and fall back to the earth, either as dust or in “black rain” precipitation.1 The biggest issue with fallout is that the particles themselves are radioactive and thus are continually emitting radiation. So if you inhale particles or get dust on your clothes and don’t brush it off, you are now carrying radiation-emitting particles with you. Some of this radiation is blocked by skin or clothing, but can cause significant exposure and damage once ingested or inhaled. Additionally, these particles can contain A LOT of radiation. You can receive a lethal dose from a very small amount of fallout.

An additional danger with fallout is that the particles are carried in fast-moving, upper atmospheric winds, which can travel in a completely different direction from winds closer to the ground (the ones we can feel). It thus can be very difficult, especially in the early hours of the attack, to predict where the fallout is going. The resultant effects are:

  1. Highly radioactive, heavier particles can start falling within minutes. This means that you need to seek shelter fast.
  2. Even those fairly far away from the blast need to seek shelter quickly from fallout because particles can be carried significant distances.

You should plan to get to a shelter within 5-30 minutes of the initial blast. The faster, the better. Additionally, as outdoor surfaces may be covered in highly radioactive fallout, once you find shelter you should stay there for at least 24-48 hours (and sometimes longer). It will take some time for the
radioactive decay process to bring radiation levels down into the safe range. The high levels of radiation unfortunately prevent specialized assistance teams from entering the site.

If you would like to see models of how fallout travels, NukeMap allows you to see the effects of various size bombs in various locations. Here is an example of a 150 kT detonation (the largest nuclear warhead rumored to have been tested by North Korea in 2017) in San Francisco. Fallout stretches past Sacramento.

Image created using NukeMap

2. What does this mean in the ED?

If you are in the ED, expect that you will have to manage on your own for at least 48 hours. Even if you are upwind from the fallout (and thus not directly affected), you will not know this fact before you would need to have found shelter to avoid a potentially lethal radiation dose. And, because of downed communications systems due to a possible EMP, you may not be able to determine that information until a response team can physically come and tell you.

So, what do you do if you are in the ED and a nuclear blast occurs nearby? You have to assume that, if you can see/feel the blast, you are in a danger zone and must act appropriately.

Some of your immediate considerations while in the ED should be:

  1. Where is the safest place to go and how many people can we save?
  2. What kind of injuries to expect and how to prepare for them?
  3. How can we decontaminate to keep our shelter radiation-free?
  4. What other logistics need to be considered in an ED response and how to we mitigate damage?

1. Where to go

You want to put as much concrete between you and the outside as possible. Do this immediately, because fallout can start arriving in less than 5 minutes. The safest place to be is an underground space, such as a basement. The next best spaces are the middle floors of multistory building. Both of these areas are the most isolated from the air outside.5,6 If your hospital is a large, mostly concrete building, it is actually one of the safest places to be in the event of a nuclear attack. Try to get to the basement quickly. Because this is a mass casualty situation, triage and concentrate resources on those you have the best chance of saving. Once you are in a shelter or safe place, block any unnecessary vents, gaps under doors or windows, or other openings that could allow contaminated dust in.

Protection from radiation (Image credit 6)

2. What to expect

Initially, you are most likely to be dealing with trauma typical of any blast injury. This includes burns, hollow viscus injury, penetrating injury from shrapnel, falls, and flash blindness. You will also have patients with varying levels of radiation exposure,3,7 but the exposure levels will be difficult to determine in the first few hours.

Although you can roughly predict that patients with early nausea and vomiting may have more lethal levels, it is important that non-lethal doses and alternative etiologies (e.g. psychological distress) may cause vomiting.3,7 Do not use these symptoms solely to triage patients in the first few minutes to hours of a nuclear attack. Implement standard mass casualty triage processes.

3. How to decontaminate

Decontamination should take place outside the space where you are sheltering.8–10 You and all of your patients and staff will have to shelter in place so it is extremely important that you not contaminate your shelter space. Prioritize protection of the health care worker and proper decontamination of the exposed patient.11

Decontamination should occur from head to toe to avoid re-contaminating decontaminated areas. Any run-off water is classified as hazardous waste.11 Dry decontamination (removing and containing clothes) is preferred to wet decontamination (with a shower or fire hose).7 Dry decontamination should be accomplished by carefully removing clothes and gently brushing off any debris, being careful not to inhale any particles. Because self-decontamination can decrease a patient’s contamination by greater ≥90%, have the patient perform the initial decontamination for him/herself.3

4. Other logistics to consider

  1. No electricity: If an EMP disrupts power and electricity, it will be difficult to communicate with the outside world to find out what happened, whether you are in the fallout zone, and how long to stay indoors. Theoretically this could be mitigated by having some communications equipment pre-stored in a Faraday cage, which is a latticed metal box that distributes electromagnetic radiation around the cage, protecting any electronics inside.12
  2. Water potability: Water pipes could be damaged in the blast, so water pressure for sinks and showers may be lost. Additionally this water may have been exposed to fallout and unsafe to use. IV fluids and fluids in sealed containers are safe to use. Use bottled water preferentially for drinking. However, if you run out of safe water, it is better to drink contaminated water and risk health issues in the future than face life-threatening dehydration.

The Bottom Line

While the effects of a nuclear attack can be terrifying, the emergency physician working in the ED needs to understand the immediate hazards. Early sheltering and rapid triaging are critical time-sensitive priorities. Ultimately early planning and awareness can improve patient outcomes in such disasters.

Additional Reading

Mosher D. If a nuclear bomb explodes nearby, here’s why you should never, ever get in a car. Business Insider. Published May 24, 2017. Accessed May 26, 2018.
Institute of, Altevogt B, Stroud C, Hanson S, Hanfling D, Gostin L. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. January 2009. [PubMed]
Centers for Disease Control and Prevention National Center for Environmental Health Division of Environmental Hazards and Health Effects Radiation Studies Branch . Roundtable on Hospital Communications in a Mass Casualty Radiological Event [Pdf]. Center for Disease Control; 2013:1-23. Roundtable on Hospital Communications in a Mass Casualty Radiological Event. Participants’ Comments, Ideas, and Recommendations: A Summary Report. Accessed May 26, 2018.
Glasstone S, Dolan P. Effects of Nuclear Weapons. U.S. Department of Defense; Department of Energy; 1977:1-634.
B. Mickelson A. Medical Consequences of Radiological and Nuclear Weapons. Department of the Army; 2012.
Federal Emergency Management Agency . Planning Guidance for Response to a Nuclear Detonation [PDF]. Federal Emergency Management Agency; 2010:1-130. Accessed May 26, 2018.
Nuclear Detonation:  Weapons, Improvised Nuclear Devices. Radiation Emergency Medical Management. Published 2018. Accessed May 26, 2018.
Helping Cities Prepare for a Disaster. Lawrence Livermore National Library. Published April 2015. Accessed May 26, 2018.
Buddemeier B, Dillon M. Key Response Planning Factors for the Aftermath of Nuclear Terrorism [Pdf]. National Atmospheric Release Advisor Center; 2009:1-40. Accessed May 26, 2018.
Hick J, Weinstock D, Coleman C, et al. Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011;5 Suppl 1:S73-88. [PubMed]
Waeckerle J. Disaster planning and response. N Engl J Med. 1991;324(12):815-821. [PubMed]
Manthous C, Jackson W. The 9-11 Commission’s invitation to imagine: a pathophysiology-based approach to critical care of nuclear explosion victims. Crit Care Med. 2007;35(3):716-723. [PubMed]
Auf der. The importance of evidence-based disaster planning. Ann Emerg Med. 2006;47(1):34-49. [PubMed]
Holland M, Cawthon D. Personal protective equipment and decontamination of adults and children. Emerg Med Clin North Am. 2015;33(1):51-68. [PubMed]
Hewett DP, Hewitt IJ. Homogenized boundary conditions and resonance effects in Faraday cages. P. 2016;472(2189):20160062. doi:10.1098/rspa.2016.0062

Author information

Andrea G. Tenner, MD

Andrea G. Tenner, MD

Assistant Professor | Global Health Fellowship Director
Co-Director, PAHO/WHO Collaborating Centre for Emergency and Trauma Care
Department of Emergency Medicine
University of California San Francisco

The post Nuclear Attack: What Emergency Physicians Working in the ED Need to Know appeared first on ALiEM.

IDEA Series | Chopped EM: A ‘Palatable’ Way to Teach a Challenging Topic to EM Residents

The Problem

idea series teaching residents quality improvement

Psychiatric and substance use disorder complaints comprise up to 12% of all Emergency Department (ED) visits.1–3 These conditions can present in a multitude of ways, making it essential for emergency physicians (EPs) to be aware of nuanced diagnostic characteristics of psychiatric illnesses in order to provide timely and appropriate care for these patients.

The Innovation

We sought to create a fun and interactive activity to review common presentations and management decisions of psychiatric and substance use disorders in the ED. We transformed the Food Network cooking show Chopped into a clinical vignette competition. Residents were given a basket with mystery psychiatric “ingredients” needed to create a narrative around a fictional patient. As in the show, residents could add additional “ingredients” from their knowledge of psychiatric and substance use disorders, but all of the basket’s signs and symptoms had to be used to construct the vignette. The narrative “dish” was then served to a panel of faculty physician judges for detailed evaluation.

Target Learners

Residents of all post-graduate levels (i.e., PGY 1-3) from the EM residency at Thomas Jefferson University Hospital participated in this educational activity during weekly scheduled conference time.

Group Size

This activity was performed with 6 groups of 5-6 residents per group.

Description of the Innovation

  • We modified the structure of the Food Network cooking show Chopped into our weekly emergency medicine (EM) conference during the psychiatry block of the curriculum.
  • Residents were divided into six teams composed of 5-6 residents each.
  • Each group received the same basket of “ingredients” (Figure 1) which contained pre-selected mystery items to form the clinical vignette “dish.” Residency leadership was responsible for making these selections.
  • Common signs and symptoms of psychiatric and substance use disorders encountered in the ED were appropriately identified and suggested as potential ingredients. Ingredients could include history of present illness (HPI) elements, physical examination (PE) elements, and diagnostic elements.

Figure 1. Residents were provided with a “basket” of “ingredients” from which to construct a narrative.

  • Six basket ingredients were selected for this iteration of Chopped EM: altered mental status (HPI), history of ingestion (HPI), psychomotor agitation (PE), diaphoresis (PE), elevated creatinine (diagnostic data), and prolonged QT interval on electrocardiogram (diagnostic data).
  • The teams were given 20 minutes to use these “ingredients” to formulate a logical patient narrative using every single of the items provided in the basket. Residents were free to integrate additional components to create a robust vignette.
  • A representative from each small group presented their respective narrative to the large group, including a panel of attending physician judges. Faculty judges included educational leadership from the department. Judges were asked to evaluate and score the presented vignette through the use of a pre-developed scoring rubric (Figure 2).

Figure 2. The scoring rubric included 3 categories: creativity, diagnostic accuracy, and argument for best diagnosis.

  • The highest combined score determined the Chopped EM
  • The goal of the session was to promote collaborative and active learning during a 1-hour time frame of EM conference.

Lessons Learned

  • Overall, the activity was well received. A post-session survey showed that 77% of residents would like to see this activity incorporated into future resident educational events.
  • Multiple learners pointed out that the activity would be improved upon by having multiple “baskets” with varying ingredients, instead of all teams using the identical set of ingredients to construct their narratives.
  • The residents described being the most engaged while interacting in small groups and constructing their narratives.
  • Creativity and broad differential diagnoses were encouraged through the use of ambiguous “ingredients.”
  • The session proved to be a fun and interactive way to discuss a challenging topic by promoting active learning and collaboration.

Theory Behind the Innovation

  • Constructivism4,5Learners had to construct knowledge as they used the data provided to them in the basket while applying prior knowledge. While each of them engaged in this activity, residents came together as a group to interact, make meaning of information, and experiment to build a logical and coherent narrative.
  • Social Constructivism4,5Each individual resident had the opportunity to internalize the experience and build knowledge and skills while interacting with the signs and symptoms provided, as well as with one another. They also learned from one another, scaffolding each other’s learning process.

Read more about the IDEA Series.

Larkin G, Claassen C, Emond J, Pelletier A, Camargo C. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677. [PubMed]
Weiss AJ, Barrett ML, Heslin KC, Stocks C. Trends in Emergency Department Visits Involving Mental and Substance Use Disorders, 2006–2013. AHRQ; 2016:1-13.
Olshaker J, Browne B, Jerrard D, Prendergast H, Stair T. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128. [PubMed]
Taylor D, Hamdy H. Adult learning theories: implications for learning and teaching in medical education: AMEE Guide No. 83. Med Teach. 2013;35(11):e1561-72. [PubMed]
Kay D, Kibble J. Learning theories 101: application to everyday teaching and scholarship. Adv Physiol Educ. 2016;40(1):17-25. [PubMed]

Author information

Carlos Rodriguez, MD

Carlos Rodriguez, MD

Medical Education Fellow
Clinical Instructor
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA

The post IDEA Series | Chopped EM: A ‘Palatable’ Way to Teach a Challenging Topic to EM Residents appeared first on ALiEM.

ECMO for ARDS: Key Pearls for Emergency Physicians from the EOLIA Trial

The role of extracorporeal membrane oxygenation (ECMO) in the management of acute respiratory distress syndrome (ARDS) has been a source of debate within the critical care community.1 The use of ECMO has steadily increased over the past decade;2 however, evidence to support the widespread adoption of this expensive and invasive technology is limited. As advances in ECMO technology have rapidly outpaced evidence, clinicians have been left to speculate as to ECMO’s true value. Is ECMO a promising tool to advance the care of patients with respiratory failure3 or an expensive distraction that has inappropriately supplanted evidence-based strategies?4

All who care for patients with ARDS have been eagerly awaiting the results of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial which were recently published in May 2018’s New England Journal of Medicine.5

Clinical Question

Does the early use of ECMO improve mortality in adult patients with severe ARDS?


The EOLIA trial was an international randomized controlled trial conducted primarily in France. The trial enrolled adults with early severe ARDS. To be eligible, patients had to meet at least 1 of the following criteria within 7 days of the initiation of mechanical ventilation:

  1. PaO2/FiO2 < 50 mmHg for > 3 hours
  2. PaO2/FiO2 < 80 mmHg for > 6 hours
  3. pH < 7.25 + PaCO2 ≥ 60 mmHg for > 6 hours

Patients were randomized to ECMO or a control arm, which followed evidence-based practices for ARDS including all of the following:

  1. Lung-protective ventilation (e.g., low tidal volumes and low plateau pressures)
  2. Neuromuscular blockade
  3. Prone positioning

Crossover from the control arm to the ECMO arm was allowed for 6 hours of refractory hypoxemia. The trial was designed to detect a 20% mortality reduction in patients randomized to ECMO.


1,015 patients were screened and 249 underwent randomization. Pneumonia was the most common etiology of ARDS (64%). The median time from intubation to randomization in both groups was 34 hours. Overall, patients were quite ill with the mean PaO2/FiO2 being roughly 70 mmHg (“severe ARDS” is defined as PaO2/FiO2 < 100 mmHg) and 70% were on vasopressors. All but 3 patients in the ECMO arm were placed on ECMO.

Patients in both groups were receiving evidence-based ARDS management at the time of randomization:

  1. The mean tidal volume in both arms was 6 mL/kg of predicted body weight (PBW).
  2. The mean plateau pressure was < 30 cmH2O.
  3. Over 90% of patients were on neuromuscular blockade.
  4. Over 50% received prone positioning.

The trial was stopped for futility after the 4th planned interim analysis by an independent data safety monitoring board according to pre-specified criteria. In an intention-to-treat analysis, 60-day mortality was 35% in the ECMO group vs 46% in the control arm (relative risk 0.76; 95% CI, 0.55-1.04, p=0.09). Because there was an an extremely low probability of finding a benefit to ECMO at subsequent analyses, the trial was stopped.

Of note, 28% of patients in the control arm received rescue ECMO for refractory hypoxemia. These patients had a 60-day mortality of 57%.


In patients with severe ARDS, the early use of ECMO did not significantly improve 60-day mortality compared to standard care.

Take-Home Points for Emergency Physicians

Does this end the debate about ECMO in ARDS?

Unfortunately, no. ECMO skeptics will see EOLIA as further evidence that routine ECMO use should be abandoned; proponents will point to the 11% difference in 60-day mortality between the 2 arms at the time the trial was stopped and the signal of benefit in a secondary composite end point as evidence that ECMO does indeed have a role in the management of severe ARDS. Our ability to now manage select patients on ECMO without mechanical ventilation (so that a patient with ARDS can now be extubated, awake, eating, and working with physical therapy while on ECMO) ensures this will be an area of controversy and innovation for the foreseeable future.6

How is this relevant for the Emergency Department?

ARDS is not exclusively an Intensive Care Unit (ICU) diagnosis; EM providers care for patients with ARDS7,8 and should be familiar with evidence-based management strategies. The publication of EOLIA provides a timely opportunity to review some key aspects of ARDS management for EM providers:

  • The delivery of cutting-edge ARDS care depends on prompt recognition. Emergency physicians should know the Berlin Definition of ARDS9 and review the diagnosis criteria for every patient intubated for hypoxemic respiratory failure. If your patient has a PaO2/FiO2 ≤ 300 mmHg and bilateral opacities on imaging that you don’t think is primarily due to heart failure or volume overload, think ARDS.
  • Sepsis and pneumonia are the most common risk factors for ARDS.10
  • The cornerstone of ARDS management remains mechanical ventilation with low tidal volumes (a goal of 6 mL/kg PBW) and low plateau pressures (< 30 cmH2O). Despite widespread consensus that this strategy saves lives, it is implemented with distressingly low frequency in both the Emergency Department7 and the ICU.10
  • The control arm of EOLIA provides a nice snapshot of high-level ARDS care. Almost all patients received mechanical ventilation with low tidal volumes and low plateau pressures in addition to early neuromuscular blockade and prone positioning. A conservative fluid management strategy would be the other important evidence-based component of early ARDS care11 that is not explicitly mentioned in the trial. The adoption of prone positioning has been one of the biggest advances in the care of ARDS patients since the publication of a landmark trial in 2013.12
  • The availability of advanced therapies for ARDS including ECMO and prone positioning varies highly by center. EM providers should know what options are available at their institution and be familiar with any institutional protocols to guide their use. As an example, at my institution there is a multidisciplinary ECMO team that can be rapidly mobilized to discuss management options for patients in the Emergency Department with refractory hypoxemia.
Fan E, Pham T. Extracorporeal membrane oxygenation for severe acute respiratory failure: yes we can! (But should we?). Am J Respir Crit Care Med. 2014;189(11):1293-1295. [PubMed]
Karagiannidis C, Brodie D, Strassmann S, et al. Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med. 2016;42(5):889-896. [PubMed]
Abrams D, Brodie D. Emerging indications for extracorporeal membrane oxygenation in adults with respiratory failure. Ann Am Thorac Soc. 2013;10(4):371-377. [PubMed]
Li X, Scales D, Kavanagh B. Unproven and Expensive before Proven and Cheap: Extracorporeal Membrane Oxygenation versus Prone Position in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2018;197(8):991-993. [PubMed]
Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965-1975. [PubMed]
Hoeper M, Wiesner O, Hadem J, et al. Extracorporeal membrane oxygenation instead of invasive mechanical ventilation in patients with acute respiratory distress syndrome. Intensive Care Med. 2013;39(11):2056-2057. [PubMed]
Fuller B, Mohr N, Miller C, et al. Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study. Chest. 2015;148(2):365-374. [PubMed]
Mikkelsen M, Shah C, Meyer N, et al. The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsis. Shock. 2013;40(5):375-381. [PubMed]
ARDS D, Ranieri V, Rubenfeld G, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533. [PubMed]
Bellani G, Laffey J, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA. 2016;315(8):788-800. [PubMed]
National H, Wiedemann H, Wheeler A, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-2575. [PubMed]
Guérin C, Reignier J, Richard J, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168. [PubMed]

Author information

Mac Walter, MD

Mac Walter, MD

Assistant Professor
Department of Medicine
Division of Pulmonary and Critical Care Medicine
Northwestern University Feinberg School of Medicine

The post ECMO for ARDS: Key Pearls for Emergency Physicians from the EOLIA Trial appeared first on ALiEM.