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| '''For patient information click [[Radiation injury (patient information)|here]]''' | | '''For patient information click [[Radiation injury (patient information)|here]]''' |
| {{Infobox_Disease | | | {{Infobox_Disease | |
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| {{Radiation injury}} | | {{Radiation injury}} |
| {{CMG}}; {{AE}} {{CZ}} | | {{CMG}}; {{AE}} {{CZ}}; {{Ochuko}} |
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| ==Table of exposure levels and symptoms== | | ==[[Radiation injury overview|Overview]]== |
| Dose-equivalents are presently stated in [[sievert]]s:
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| ===0.05–0.2 Sv (5–20 REM)=== | | ==[[Radiation injury classification|Classification]]== |
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| No symptoms. Potential for [[cancer]] and mutation of genetic material, according to the Linear no threshold model (LNT model): this is disputed (Note: see [[hormesis]]). A few researchers contend that low dose radiation may be beneficial. [http://www.scienceboard.net/community/perspectives.122.html] [http://hps.org/publicinformation/ate/q299.html] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10453435&query_hl=6&itool=pubmed_docsum] 50 mSv is the yearly federal limit for radiation workers in the United States. In the UK the yearly limit for a classified radiation worker is 20 mSv. In Canada, the single-year maximum is 50 mSv, but the maximum 5-year dose is only 100 mSv. Company limits are usually stricter so as not to violate federal limits. [http://www.nrc.gov/reading-rm/doc-collections/cfr/part020/part020-1201.html]
| | ==[[Radiation injury pathophysiology|Pathophysiology]]== |
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| ===0.2–0.5 Sv (20–50 REM) === | | ==[[Radiation injury causes|Causes]]== |
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| No noticeable symptoms. [[Red blood cell]] count decreases temporarily.
| | ==[[Radiation injury differential diagnosis|Differentiating Radiation Injury from other Diseases]]== |
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| ===0.5–1 Sv (50–100 REM) === | | ==[[Radiation injury risk factors|Risk Factors]]== |
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| Mild radiation sickness with headache and increased risk of infection due to disruption of immunity cells. Temporary male sterility is possible.
| | ==[[Radiation injury screening|Screening]]== |
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| ===1–2 Sv (100–200 REM) === | | ==[[Radiation injury natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ''Light radiation poisoning, 10% fatality after 30 days ([[Lethal dose|LD]] 10/30).'' Typical symptoms include mild to moderate nausea (50% probability at 2 Sv), with occasional [[vomiting]], beginning 3 to 6 hours after irradiation and lasting for up to one day. This is followed by a 10 to 14 day latent phase, after which light symptoms like general illness and [[Fatigue (physical)|fatigue]] appear (50% probability at 2 Sv). The [[immune system]] is depressed, with convalescence extended and increased risk of infection. Temporary male sterility is common. [[Spontaneous abortion]] or [[stillbirth]] will occur in pregnant women.
| | ==[[Radiation injury diagnosis|Diagnosis]]== |
| | [[Radiation injury history and symptoms|History and Symptoms]] | [[Radiation injury physical examination|Physical Examination]] | [[Radiation injury laboratory findings|Laboratory Findings]] | [[Radiation injury MRI|MRI]] | [[Radiation injury other imaging findings|Other Imaging Findings]] | [[Radiation injury other diagnostic studies|Other Diagnostic Studies]] |
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| ===2–3 Sv (200–300 REM) === | | ==Treatment== |
| | [[Radiation injury medical therapy|Medical Therapy]] | [[Radiation injury surgery|Surgery]] | [[Radiation injury primary prevention|Primary Prevention]] | [[Radiation injury cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Radiation injury future or investigational therapies|Future or Investigational Therapies]] |
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| ''Moderate radiation poisoning, 35% fatality after 30 days ([[Lethal dose|LD]] 35/30)''. Nausea is common (100% at 3 Sv), with 50% risk of vomiting at 2.8 Sv. Symptoms onset at 1 to 6 hours after irradiation and last for 1 to 2 days. After that, there is a 7 to 14 day latent phase, after which the following symptoms appear: loss of hair all over the body (50% probability at 3 Sv), fatigue and general illness. There is a massive loss of [[leukocytes]] (white blood cells), greatly increasing the risk of infection. Permanent female sterility is possible. [[Convalescence]] takes one to several months.
| | ==Case Studies== |
| | | [[Radiation injury case study one|Case #1]] |
| ===3–4 Sv (300–400 REM) === | |
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| ''Severe radiation poisoning, 50% fatality after 30 days ([[Lethal dose|LD]] 50/30)''. Other symptoms are similar to the 2–3 Sv dose, with uncontrollable bleeding in the mouth, under the skin and in the kidneys (50% probability at 4 Sv) after the latent phase.
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| ===4–6 Sv (400–600 REM) ===
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| ''Acute radiation poisoning, 60% fatality after 30 days ([[Lethal dose|LD]] 60/30)''. Fatality increases from 60% at 4.5 Sv to 90% at 6 Sv (unless there is intense medical care). Symptoms start half an hour to two hours after irradiation and last for up to 2 days. After that, there is a 7 to 14 day latent phase, after which generally the same symptoms appear as with 3-4 Sv irradiation, with increased intensity. Female sterility is common at this point. Convalescence takes several months to a year. The primary causes of death (in general 2 to 12 weeks after irradiation) are infections and [[internal bleeding]].
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| ===6–10 Sv (600–1,000 REM) ===
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| ''Acute radiation poisoning, near 100% fatality after 14 days ([[Lethal dose|LD]] 100/14).'' Survival depends on intense medical care. [[Bone marrow]] is nearly or completely destroyed, so a [[bone marrow transplant]] is required. Gastric and intestinal tissue are severely damaged. Symptoms start 15 to 30 minutes after irradiation and last for up to 2 days. Subsequently, there is a 5 to 10 day latent phase, after which the person dies of infection or [[internal bleeding]]. Recovery would take several years and probably would never be complete.
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| Devair Alves Ferreira received a dose of approximately 7.0 Sv (700 REM) during the Goiânia accident and survived, partially due to his [[Dose fractionation|fractionated exposure]].
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| ===10–50 Sv (1,000–5,000 REM) ===
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| ''Acute radiation poisoning, 100% fatality after 7 days ([[Lethal dose|LD]] 100/7).'' An exposure this high leads to spontaneous symptoms after 5 to 30 minutes. After powerful fatigue and immediate nausea caused by direct activation of chemical receptors in the brain by the irradiation, there is a period of several days of comparative well-being, called the latent (or "[[walking ghost phase|walking ghost]]") phase. After that, cell death in the gastric and intestinal tissue, causing massive [[diarrhea]], intestinal bleeding and loss of water, leads to water-electrolyte imbalance. Death sets in with [[delirium]] and coma due to breakdown of circulation. Death is currently inevitable; the only treatment that can be offered is pain therapy.
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| [[Louis Slotin]] was exposed to approximately 21 Sv in a critical accident on 21 May 1946, and died nine days later on 30 May. | |
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| At this dose the skin can be damaged. Here is a photo of a man who received a 10 to 20 Gy gamma whole body dose as a result of an industrial accident. He died about 10 days after the photo was taken, about 30 days after the event.
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| ===More than 50 Sv (>5,000 REM) ===
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| A worker receiving 100 Sv (10,000 REM) in an accident at Wood River, Rhode Island, USA on 24 July 1964 survived for 49 hours after exposure, and an operator receiving between 60 and 180 Sv (18,000 REM) to his upper body in an accident at Los Alamos, New Mexico, USA on 30 December 1958 survived for 36 hours; details of this accident can be found on page 16 (page 30 in the PDF version) of Los Alamos' 2000 Review of Criticality Accidents [http://www.csirc.net/docs/reports/la-13638.pdf].
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| ==Acute (short-term) vs chronic (long-term) effects==
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| Radiation sickness is generally associated with acute exposure and has a characteristic set of symptoms that appear in an orderly fashion. The symptoms of radiation sickness become more serious (and the chance of survival decreases) as the dosage of radiation increases. These effects are described as the deterministic effects of radiation. | |
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| Longer term exposure to radiation, at doses less than that which produces serious radiation sickness, can induce [[cancer]] as cell-cycle genes are mutated. If a cancer is radiation-induced, then the disease, the speed at which the condition advances, the [[prognosis]], the degree of pain, and every other feature of the disease are '''not''' functions of the radiation dose to which the sufferer is exposed.
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| Since [[tumor]]s grow by abnormally rapid cell division, the ability of radiation to disturb cell division is also used to treat cancer (see [[radiotherapy]]), and low levels of [[ionizing radiation]] have been claimed to lower one's risk of cancer (see [[hormesis]]).
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| ==Patient Management==
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| ===Diagnosis===
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| The signs and symptoms of CRI are as follows:
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| *Intensely painful burn-like skin injuries (including itching, tingling, erythema, or edema) without a history of exposure to heat or caustic chemicals
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| *Note : Erythema will not be seen for hours to days following exposure, and its appearance is cyclic.
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| *Epilation
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| *A tendency to bleed
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| *Possible signs and symptoms of ARS
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| As mentioned previously, local injuries to the skin from acute radiation exposure evolve slowly over time, and symptoms may not manifest for days to weeks after exposure. Consider CRI in the differential diagnosis if the patient presents with a skin lesion without a history of chemical or thermal burn, insect bite, or skin disease or allergy. If the patient gives a history of possible radiation exposure (such as from a radiography source, x-ray device, or accelerator) or a history of finding and handling an unknown metallic object, note the presence of any of the following: erythema, blistering, dry or wet desquamation, epilation, ulceration.
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| Regarding lesions associated with CRI be aware that,
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| *days to weeks may pass before lesions appear;
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| *unless patients are symptomatic, they will not require emergency care; and
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| *lesions can be debilitating and life threatening after several weeks.
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| Medical follow-up is essential, and victims should be cautioned to avoid trauma to the involved areas.
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| ===Initial Treatment===
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| Localized injuries should be treated symptomatically as they occur, and radiation injury experts should be consulted for detailed information. Such information can be obtained from the Radiation Emergency Assistance Center/Training Site (REAC/TS) at www.orau.gov/reacts/ or (865) 576-1005.
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| As with ARS, if the patient also has other trauma, wounds should be closed, burns covered, fractures reduced, surgical stabilization performed, and definitive treatment given within the first 48 hours after injury. After 48 hours, surgical interventions should be delayed until hematopoietic recovery has occurred.
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| A baseline CBC and differential should be taken and repeated in 24 hours. Because cutaneous radiation injury is cyclic, areas of early erythema should be noted and recorded. These areas should also be sketched and photographed, if possible, ensuring that the date and time are recorded. The following should be initiated as indicated:
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| *Supportive care in a clean environment (a burn unit if one is available)
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| *Prevention and treatment of infections
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| *Use of the following:
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| *Medications to reduce inflammation, inhibit protealysis, relieve pain, stimulate regeneration, and improve circulation
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| *Anticoagulant agents for widespread and deep injury
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| *Pain management
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| *Psychological support
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| ===Recommendations for Treatment by Stage===
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| The following recommendations for treatment by stage of the illness were obtained by summarizing recommendations from Ricks et al. (226) and Gusev et al. (231), but they do not represent official recommendations of CDC.
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| *Prodromal Stage —Use antihistamines and topical antipruriginous preparations, which act against itch and also might prevent or attenuate initiation of the cycle that leads to the manifestation stage. Anti-inflammatory medications such as corticosteroids and topical creams, as well as slight sedatives, may prove useful.
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| *Latent Stage —Continue anti-inflammatory medications and sedatives. At midstage, use proteolysis inhibitors, such as Gordox®.
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| *Manifestation Stage —Use repeated swabs, antibiotic prophylaxis, and anti-inflammatory medications, such as Lioxasol®, to reduce bacterial, fungal, and viral infections
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| :* Apply topical ointments containing corticosteroids along with locally acting antibiotics and vitamins.
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| :* Stimulate regeneration of DNA by using Lioxasol® and later, when regeneration has started, biogenic drugs, such as Actovegin® and Solcoseril®.
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| :* Stimulate blood supply in third or fourth week using Pentoxifylline® (contraindicated for patients with atherosclerotic heart disease).
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| :* Puncture blisters if they are sterile, but do not remove them as long as they are intact.
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| :* Stay alert for wound infection. Antibiotic therapy should be considered according to the individual patient's condition.
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| :* Treat pain according to the individual patient's condition. Pain relief is very difficult and is the most demanding part of the therapeutic process.
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| :* Debride areas of necrosis thoroughly but cautiously.
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| ===Treatment of Late Effects===
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| After immediate treatment of radiation injury, an often long and painful process of healing will ensue. The most important concerns are the following:
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| *Pain management
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| *Fibrosis or late ulcers
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| Note : Use of medication to stimulate vascularization, inhibit infection, and reduce fibrosis may be effective. Examples include Pentoxifylline®, vitamin E, and interferon gamma. Otherwise, surgery may be required.
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| *Necrosis
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| *Plastic/reconstructive surgery
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| Note : Surgical treatment is common. It is most effective if performed early in the treatment process. Full-thickness graft and microsurgery techniques usually provide the best results.
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| *Psychological effects, such as posttraumatic stress disorder
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| *Possibility of increased risk of skin cancer later in life
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| ==Appendix A: Responses of the Skin to Radiation==
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| *'''Acute epidermal necrosis''' (time of onset: < 10 days postexposure; threshold dose: ~550 Gy or 55,000 rads)— Interphase death of postmitotic keratinocytes in the upper visible layers of the epidermis (may occur with high-dose, low-energy beta irradiation)
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| *'''Acute ulceration''' (time of onset: < 14 days postexposure; threshold dose: ~20 Gy or 2000 rads)—Early loss of the epidermis— and to a varying degree, deeper dermal tissue—that results from the death of fibroblasts and endothelial cells in interphase
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| *'''Dermal atrophy''' (time of onset: > 26 weeks postexposure; threshold dose: ~10 Gy or 1000 rads)— Thinning of the dermal tissues associated with the contraction of the previously irradiated area
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| *'''Dermal necrosis''' (time of onset > 10 weeks postexposure; threshold dose: ~20 Gy or 2000 rads)— Necrosis of the dermal tissues as a consequence of vascular insufficiency
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| *'''Dry desquamation''' (time of onset: 3–6 weeks postexposure; threshold dose: ~8 Gy or 800 rads)— Atypical keratinization of the skin caused by the reduction in the number of clonogenic cells within the basal layer of the epidermis
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| *'''Early transient erythema''' (time of onset: within hours of exposure; threshold dose: ~2 Gray [Gy] or 200 rads)— Inflammation of the skin caused by activation of a proteolytic enzyme that increases the permeability of the capillaries
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| *'''Epilation''' (time of onset: 14–21 days; threshold dose: ~3 Gy or 300 rads)— Hair loss caused by the depletion of matrix cells in the hair follicles
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| *'''Late erythema''' (time of onset: 8–20 weeks postexposure; threshold dose: ~20 Gy or 2000 rads)— Inflammation of the skin caused by injury of blood vessels. Edema and impaired lymphatic clearance precede a measured reduction in blood flow.
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| *'''Invasive fibrosis''' (time of onset: months to years postexposure; threshold dose: ~20 Gy or 2000 rads)— Method of healing associated with acute ulceration, secondary ulceration, and dermal necrosis that leads to scar tissue formation
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| *'''Main erythema''' (time of onset: days to weeks postexposure; threshold dose: ~3 Gy or 300 rads)— Inflammation of the skin caused by hyperaemia of the basal cells and subsequent epidermal hypoplasia (see photos 1 and 2)
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| *'''Moist desquamation''' (time of onset: 4–6 weeks postexposure; threshold dose: ~15 Gy or 1500 rads)— Loss of the epidermis caused by sterilization of a high proportion of clonogenic cells within the basal layer of the epidermis
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| *'''Secondary ulceration''' (time of onset: > 6 weeks postexposure; threshold dose: ~15 Gy or 1500 rads)— Secondary damage to the dermis as a consequence of dehydration and infection when moist desquamation is severe and protracted because of reproductive sterilization of the vast majority of the clonogenic cells in the irradiated area
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| *'''Telangiectasia''' (time of onset: > 52 weeks postexposure; threshold dose for moderate severity at 5 years: ~40 Gy or 4000 rads)— Atypical dilation of the superficial dermal capillaries.
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| ==Appendix B: Images==
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| Figures 1 & 2 . Erythema: These photos display the progression of erythema in a patient involved in an x-ray diffraction accident, 9 days to 96 days postexposure. The day following the exposure (not shown), the patient displayed only mild diffuse swelling and erythema of the fingertips. On day 9, punctuate lesions resembling telangiectasias were noted in the subungal region of the right index finger, and on day 11, blisters began to appear. Desquamation continued for several weeks. The patient developed cellulitis in the right thumb approximately 2 years following exposure. The area of the right fingertip and nail continued to cause the patient great pain when even minor trauma occurred to the fingertip, and he required occasional oral narcotic analgesics to manage this pain. He continued to experience intense pain resulting from minor trauma to the affected areas for as long as 4 years postexposure.
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| [[Image:criphysicianfactsheet_image1.gif|thumb|400px|left|Figure 1. (Photo courtesy of Gusev IA)]]
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| [[Image:criphysicianfactsheet_image2.gif|thumb|400px|left|Figure 2. (Photo courtesy of Gusev IA)]]
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| Figures 3 & 4. Acute ulceration. These photos show acute ulceration in a Peruvian patient who inadvertently placed a 26-Ci (0.962-TBq) irridiun-192 ( 192 Ir) source in his back pocket, 3 days and 10 days postexposure. The source remained in the patient's pocket for approximately 6.5 hours, at which time he complained to his wife about pain in his posterior right thigh. He sought medical advice and was told he probably had been bitten by an insect. In the meantime, his wife sat on the patient's pants (her case appears on the next page) while breastfeeding the couple's 1½-year-old child. The source was recovered several hours later by nuclear regulatory authorities, and the patient was transported to Lima for treatment. This patient exhibited a drastic reduction in lymphocyte count by day 3 postexposure, and a 4-by-4-cm lesion appeared on day 4. Eventually he suffered with a massive ulceration and necrosis of the site with infection, and his right leg was amputated. Grade II and III CRI was also evident on his hands, left leg, and perineum, but he survived and returned to his family.
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| [[Image:criphysicianfactsheet_image3.jpg|thumb|400px|left|Figure 3. 3 days. (Photo courtesy of Ricks RC)]]
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| [[Image:criphysicianfactsheet_image4.jpg|thumb|400px|left|Figure 4. 10 days. (Photo courtesy of Ricks RC)]]
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| [[Image:criphysicianfactsheet_image5.jpg|thumb|400px|left|Figure 5. 26 days postexposure. Moist desquamation. This patient is the wife of the previous case study, 26 days postexposure. She was exposed to the 192 Ir source when she sat on her husband's pants (still containing the source) for approximately 20 minutes after he had changed clothes that evening.(Photo courtesy of Ricks RC)]]
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| [[Image:criphysicianfactsheet_image6.jpg|thumb|400px|left|Figure 6: 2 years postexposure. Necrosis, fibrosis, and telangiectasia. Same patient, 2 years following exposure. (Photo courtesy of Ricks RC) ]]
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| ==Acute Radiation Syndrome: A Fact Sheet for Physicians==
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| Acute Radiation Syndrome (ARS) (sometimes known as radiation toxicity or radiation sickness) is an acute illness caused by irradiation of the entire body (or most of the body) by a high dose of penetrating radiation in a very short period of time (usually a matter of minutes). The major cause of this syndrome is depletion of immature parenchymal stem cells in specific tissues. Examples of people who suffered from ARS are the survivors of the Hiroshima and Nagasaki atomic bombs, the firefighters that first responded after the Chernobyl Nuclear Power Plant event in 1986, and some unintentional exposures to sterilization irradiators.
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| The required conditions for Acute Radiation Syndrome (ARS) are:
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| * The radiation dose must be large (i.e., greater than 0.7 Gray (Gy)1, 2 or 70 rads).
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| :* Mild symptoms may be observed with doses as low as 0.3 Gy or 30 rads.
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| * The dose usually must be external ( i.e., the source of radiation is outside of the patient’s body).
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| :* Radioactive materials deposited inside the body have produced some ARS effects only in extremely rare cases.
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| * The radiation must be penetrating (i.e., able to reach the internal organs).
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| :* High energy X-rays, gamma rays, and neutrons are penetrating radiations.
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| * The entire body (or a significant portion of it) must have received the dose3.
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| :* Most radiation injuries are local, frequently involving the hands, and these local injuries seldom cause classical signs of ARS.
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| * The dose must have been delivered in a short time (usually a matter of minutes).
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| :* Fractionated doses are often used in radiation therapy. These are large total doses delivered in small daily amounts over a period of time. Fractionated doses are less effective at inducing ARS than a single dose of the same magnitude.
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| [[Image:Acute Radiation Syndroms Table 1.jpg|600px|center|Table 1: Acute Radiation Syndromes]]
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| ==The three classic Acute Radiation Syndromes are==
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| * '''Bone marrow syndrome''' (sometimes referred to as hematopoietic syndrome) the full syndrome will usually occur with a dose between 0.7 and 10 Gy (70 – 1000 rads) though mild symptoms may occur as low as 0.3 Gy or 30 rads4.
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| :* The survival rate of patients with this syndrome decreases with increasing dose. The primary cause of death is the destruction of the bone marrow, resulting in infection and hemorrhage.
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| * '''Gastrointestinal (GI) syndrome''': the full syndrome will usually occur with a dose greater than approximately 10 Gy (1000 rads) although some symptoms may occur as low as 6 Gy or 600 rads.
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| :* Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance. Death usually occurs within 2 weeks.
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| * '''Cardiovascular (CV)/ Central Nervous System (CNS) syndrome''': the full syndrome will usually occur with a dose greater than approximately 50 Gy (5000 rads) although some symptoms may occur as low as 20 Gy or 2000 rads.
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| :* Death occurs within 3 days. Death likely is due to collapse of the circulatory system as well as increased pressure in the confining cranial vault as the result of increased fluid content caused by edema, vasculitis, and meningitis.
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| ==The four stages of ARS are==
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| * Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, as well as anorexia and possibly diarrhea (depending on dose), which occur from minutes to days following exposure. The symptoms may last (episodically) for minutes up to several days.
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| * Latent stage: In this stage, the patient looks and feels generally healthy for a few hours or even up to a few weeks.
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| * Manifest illness stage: In this stage the symptoms depend on the specific syndrome (see Table 1) and last from hours up to several months.
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| * Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years.
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| ==Cutaneous Radiation Syndrome (CRS)==
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| The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome that results from acute radiation exposure to the skin.
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| ARS usually will be accompanied by some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or X-rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes.
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| When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged, causing epilation. Within a few hours after irradiation, a transient and inconsistent erythema (associated with itching) can occur. Then, a latent phase may occur and last from a few days up to several weeks, when intense reddening, blistering, and ulceration of the irradiated site are visible.
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| In most cases, healing occurs by regenerative means; however, very large skin doses can cause permanent hair loss, damaged sebaceous and sweat glands, atrophy, fibrosis, decreased or increased skin pigmentation, and ulceration or necrosis of the exposed tissue.
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| Patient Management
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| Triage: If radiation exposure is suspected:
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| * Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood gases, electrolyte and urine output) as appropriate.
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| * Treat major trauma, burns and respiratory injury if evident.
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| * In addition to the blood samples required to address the trauma, obtain blood samples for CBC (complete blood count), with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion.
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| * Treat contamination as needed.
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| * If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or 3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion.
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| ===Diagnosis===
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| The diagnosis of ARS can be difficult to make because ARS causes no unique disease. Also, depending on the dose, the prodromal stage may not occur for hours or days after exposure, or the patient may already be in the latent stage by the time they receive treatment, in which case the patient may appear and feel well when first assessed.
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| If a patient received more than 0.05 Gy (5 rads) and three or four CBCs are taken within 8 to 12 hours of the exposure, a quick estimate of the dose can be made (see Ricks, et. al. for details). If these initial blood counts are not taken, the dose can still be estimated by using CBC results over the first few days. It would be best to have radiation dosimetrists conduct the dose assessment, if possible.
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| If a patient is known to have been or suspected of having been exposed to a large radiation dose, draw blood for CBC analysis with special attention to the lymphocyte count, every 2 to 3 hours during the first 8 hours after exposure (and every 4 to 6 hours for the next 2 days). Observe the patient during this time for symptoms and consult with radiation experts before ruling out ARS.
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| If no radiation exposure is initially suspected, you may consider ARS in the differential diagnosis if a history exists of nausea and vomiting that is unexplained by other causes. Other indications are bleeding, epilation, or white blood count (WBC) and platelet counts abnormally low a few days or weeks after unexplained nausea and vomiting. Again, consider CBC and chromosome analysis and consultation with radiation experts to confirm diagnosis.
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| ===Initial Treatment and Diagnostic Evaluation===
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| Treat vomiting, and repeat CBC analysis, with special attention to the lymphocyte count, every 2 to 3 hours for the first 8 to 12 hours following exposure (and every 4 to 6 hours for the following 2 or 3 days). Sequential changes in absolute lymphocyte counts over time are demonstrated below in the Andrews Lymphocyte Nomogram (see Figure 1). Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening or blistering of the skin. Be sure to include time of onset.
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| [[Image:radiation_graph.gif|left|thumb|300px|Figure 1. Andrews Lymphocyte Nomogram (From Andrews GA, Auxier JA, Lushbaugh CC. The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In Personal Dosimetry for Radiation Accidents. Vienna : International Atomic Energy Agency; 1965)]]
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| Note and record areas of erythema. If possible, take color photographs of suspected radiation skin damage. Consider tissue, blood typing, and initiating viral prophylaxis. Promptly consult with radiation, hematology, and radiotherapy experts about dosimetry, prognosis, and treatment options. Call the Radiation Emergency Assistance Center/Training Site (REAC/TS) at (865) 576-3131 (M-F, 8 am to 4:30 am EST) or (865) 576-1005 (after hours) to record the incident in the Radiation Accident Registry System.
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| ===After consultation, begin the following (as indicated):===
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| * supportive care in a clean environment (if available, the use of a burn unit may be quite effective)
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| * prevention and treatment of infections
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| * stimulation of hematopoiesis by use of growth factors
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| * stem cell transfusions or platelet transfusions (if platelet count is too low)
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| * psychological support
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| * careful observation for erythema (document locations), hair loss, skin injury, mucositis, parotitis, weight loss, or fever
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| * confirmation of initial dose estimate using chromosome aberration cytogenetic bioassay when possible. Although resource intensive, this is the best method of dose assessment following acute exposures.
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| * consultation with experts in radiation accident management.
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| ==Diagnostic Findings==
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| ===Plain X-ray===
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| ([http://www.radswiki.net Image courtesy of RadsWiki])
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| <gallery>
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| Image:Radiation-necrosis-001.jpg|Pelvic radiograph demonstrates radiation osteonecrosis
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| </gallery>
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| ===MRI===
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| ([http://www.radswiki.net Images courtesy of RadsWiki])
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| <gallery>
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| Image:Radiation_necrosis_MRI_001.jpg|Radiation necrosis
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| Image:Radiation_necrosis_MRI_002.jpg|Radiation necrosis
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| Image:Radiation_necrosis_MRI_003.jpg|Radiation necrosis
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| </gallery>
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| <gallery>
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| Image:Radiation_necrosis_MRI_004.jpg|Radiation necrosis
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| Image:Radiation_necrosis_MRI_005.jpg|Radiation necrosis
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| </gallery>
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| ==Case Examples==
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| ===Case #1===
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| ====Clinical Summary====
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| This 60-year-old white female had developed retraction of her left nipple six years earlier, at which time breast carcinoma was found. A radical mastectomy was performed. Examination of the surgical specimens showed metastases in regional lymph nodes and local irradiation was thus administered.
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| Two years later, carcinoma of the right breast was found. Following a modified mastectomy, more irradiation was given. A year later the patient developed recurrences for which chemotherapy (cytoxan and adriamycin) was given. After a two year period without problems, the patient developed decreased exercise tolerance, dyspnea on exertion, shortness of breath, paroxysmal nocturnal dyspnea, and orthopnea increasing in severity over 10 days. Chest examination revealed decreased breath sounds with dullness over the left base. Chest x-ray showed a globose cardiac silhouette and left pleural effusion.
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| A pericardiectomy was done because of suspected cardiac tamponade; however, the patient died soon after the operation.
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| ====Autopsy Findings====
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| There was metastatic carcinoma in the pericardium, chest wall, diaphragm, both lungs, and mediastinal lymph nodes. Severe nonobstructive cardiomyopathy, probably secondary to adriamycin, was found. Areas of pleural thickening with adhesions and interstitial fibrosis were found involving the anterior aspect of both lungs.
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| ====Histopathological Findings====
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| [[Image:Lung fibrosis case 001.jpg|left|thumb|400px|This is a gross photograph of lung demonstrating areas of fibrosis on the pleural surface (arrow). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 002.jpg|left|thumb|400px|This is a gross photograph of cut sections of lung. There are several areas of fibrosis (arrows) within the lung parenchyma. ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 003.jpg|left|thumb|400px|This is a gross photograph showing a closer view of a cut section of lung. An area of fibrosis (arrow) is evident in this photograph. ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 004.jpg|left|thumb|400px|This is a low-power photomicrograph of lung section. Note the thickening of the alveolar septa (arrows). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 005.jpg|left|thumb|400px|This is a higher-power photomicrograph of lung section. Note the thickening of the alveolar septa (1) and accumulations of anthracotic pigment (2). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 006.jpg|left|thumb|400px|This is another high-power photomicrograph of lung section showing the thickening of the alveolar septa (arrows) and accumulations of black anthracotic pigment.]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 007.jpg|left|thumb|400px|This high-power photomicrograph of lung section shows the thickening of the alveolar septum (arrows) by fibrous connective tissue.]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 008.jpg|left|thumb|400px|This is a photomicrograph of a trichrome-stained section of lung demonstrating the extensive fibrosis throughout this section (green-blue stained material is fibrous connective tissue). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 009.jpg|left|thumb|400px|This is a photomicrograph of an area of tissue exhibiting diffuse fibrosis and thickening of the alveolar septa.]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 0010.jpg|left|thumb|400px|This is another high-power photomicrograph of an area of tissue with diffuse fibrosis and thickening of the alveolar septa. There are also accumulations of anthracotic pigment in this area (arrows). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 0011.jpg|left|thumb|400px|This medium-power photomicrograph shows fibrosis and severe intimal changes in blood vessels (arrows). ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 0012.jpg|left|thumb|400px|This high-power photomicrograph shows intimal changes (arrows) in this blood vessel in the lung. ]]
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| <br clear="left"/>
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| [[Image:Lung fibrosis case 0013.jpg|left|thumb|400px|This is a high-power photomicrograph of a recanalized blood vessel in the lung. Notice the anthracotic pigment adjacent to the vessel (arrows). ]]
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| <br clear="left"/>
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| ==Source==
| |
|
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|
| | ==External Links== |
| *[http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp#table1 Centers for Disease Control and Prevention] | | *[http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp#table1 Centers for Disease Control and Prevention] |
|
| |
| ==References==
| |
|
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| * Berger ME, O’Hare FM Jr, Ricks RC, editors. The Medical Basis for Radiation Accident Preparedness: The Clinical Care of Victims. REAC/TS Conference on the Medical Basis for Radiation Accident Preparedness. New York : Parthenon Publishing; 2002.
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|
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| * Gusev IA , Guskova AK , Mettler FA Jr, editors. Medical Management of Radiation Accidents, 2 nd ed., New York : CRC Press, Inc.; 2001.
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|
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| * Jarrett DG. Medical Management of Radiological Casualties Handbook, 1 st ed. Bethesda , Maryland : Armed Forces Radiobiology Research Institute (AFRRI); 1999.
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|
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| * LaTorre TE. Primer of Medical Radiobiology, 2 nd ed. Chicago : Year Book Medical Publishers, Inc.; 1989.
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|
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| * National Council on Radiation Protection and Measurements (NCRP). Management of Terrorist Events Involving Radioactive Material, NCRP Report No. 138. Bethesda , Maryland : NCRP; 2001.
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|
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| * Prasad KN. Handbook of Radiobiology, 2 nd ed. New York : CRC Press, Inc.; 1995.
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|
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| ==Additional Resources==
| |
|
| |
| *Michihiko Hachiya, ''Hiroshima Diary'' (Chapel Hill: University of North Carolina, 1955), ISBN 0-8078-4547-7.
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| *John Hersey, ''Hiroshima'' (New York: Vintage, 1946, 1985 new chapter), ISBN 0-679-72103-7.
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| *Ibuse Masuji, ''Black Rain'' (1969) ISBN 0-87011-364-X
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| *Ernest J. Sternglass, ''Secret Fallout: low-level radiation from Hiroshima to Three-Mile Island'' (1981) ISBN 0-07-061242-0 ([http://www.ratical.org/radiation/SecretFallout/ online])
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| *Norman Solomon, Harvey Wasserman ''Killing Our Own: The Disaster of America's Experience with Atomic Radiation, 1945-1982'', New York: Dell, 1982. ISBN 0-385-28537-X, ISBN 0-385-28536-1, ISBN 0-440-04567-3 ([http://www.ratical.org/radiation/KillingOurOwn/ online])
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| *George N. Hamawy, ''A Brief Introduction to Radiation Safety'' (Tucson, Arizona: Wheatmark, 2007), [http://amzn.to/ftiS7P ISBN 1587368935]
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|
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| ==External links==
| |
| * [http://bjr.birjournals.org/cgi/reprint/Supplement_27/1/41.pdf Radiation accidents with multi-organ failure in the United States] | | * [http://bjr.birjournals.org/cgi/reprint/Supplement_27/1/41.pdf Radiation accidents with multi-organ failure in the United States] |
| * [http://www.johnstonsarchive.net/nuclear/radevents/radaccidents.html List of radiation accidents and other events causing radiation casualties] | | * [http://www.johnstonsarchive.net/nuclear/radevents/radaccidents.html List of radiation accidents and other events causing radiation casualties] |
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| * [http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp The Center for Disease Control's fact sheet on Acute Radiation Syndrome] | | * [http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp The Center for Disease Control's fact sheet on Acute Radiation Syndrome] |
| * [http://courses.cs.vt.edu/~cs3604/lib/Therac_25/Therac_1.html Therac-25 computerized radiation therapy machine accidents] | | * [http://courses.cs.vt.edu/~cs3604/lib/Therac_25/Therac_1.html Therac-25 computerized radiation therapy machine accidents] |
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| {{Consequences of external causes}} | | {{Consequences of external causes}} |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
