Emergency Medicine Book

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Acute Radiation Syndrome

Aka: Acute Radiation Syndrome, Radiation Syndrome, Radiation Poisoning, Radiation Sickness, Radiation Toxicity, Radiation Injury, Ioninzing Radiation Injury, Radiation Sickness Syndrome, Radiation-Induced Disorder
  1. See Also
    1. Radon Gas
    2. Burn Injury
  2. Definitions
    1. Radiation
      1. Energy transmitted from a source through space or objects
    2. Ionizing Radiation
      1. Electromagnetic waves or subatomic particles with energy levels capable of removing electrons from atoms
      2. Examples include higher energy forms of UV light, gamma rays and xrays
      3. Nuclear materials emit ionizing radiation
    3. Non-ionizing Radiation
      1. Lower energy sources that do not cause ionization of atoms (loss of electrons)
      2. Examples include visible light, laser, infrared light, microwaves, radio waves and low level UV light
    4. Acute Radiation Syndrome
      1. Radiation exposure resulting in severe, specific organ injury with risk of death within hours to months
    5. Radiation-Induced Multiorgan Failure
      1. Progressive dysfunction of 2 or more organ systems over time as a result of ionizing radiation exposure
    6. Radiation Combined Injury
      1. Radiation Injury AND blunt Trauma, Penetrating Trauma, Burn Injury, Blast Injury or infection
  3. Pathophysiology
    1. Body tissues with high cell turnover (high mitotic index) are most susceptible to ionizing radiation
      1. Bone Marrow
      2. Gastrointestinal Tract
      3. Skin
    2. Radiation particle type dictates the cell targets and degree of injury
      1. Alpha Particles (e.g. Radon Gas)
        1. Composed of 2 protons and 2 neutrons, with low penetration (blocked by clothing)
        2. Injury is by inhalation with alveolar injury or ingestion with intestinal mucosa injury
        3. Associated with secondary cancer development
      2. Beta Particles (e.g. nuclear power plants, medical nulcear material)
        1. Composed of electrons, with higher penetration than alpha particles
        2. Risk of Skin Injury, ingestion and inhalation
      3. Gamma Rays (e.g. nuclear explosion)
        1. Mass-less rays with high penetration
    3. Radioactive material exposure types
      1. Direct exposure (e.g. nuclear explosion)
      2. Contamination (e.g. ingestion of contaminated food or water)
    4. Radiation exposure levels correlate with effects and mortality
      1. Dose reflects whole body or significant partial body radiation exposure
      2. Dose >1 Gy
        1. Threshold for Acute Radiation Syndrome
      3. Dose >2 to 3 Gy
        1. Hematopoietic Syndrome
      4. Dose 3.5 to 4 Gy
        1. Lethal Dose in 50% of patients within 60 days (LD50/60) without supportive care
        2. With general supportive care LD50/60 increases to 4.5 to 7 Gy
        3. With rapid Intensive Care, reverse isolation, Bone Marrow TransplantLD50/60 increases to 7 to 9 Gy
      5. Dose >5 to 12 Gy
        1. Gastrointestinal Syndrome
      6. Dose >10 to 12 Gy
        1. Uniformly lethal dose
      7. Dose >10 to 20 Gy
        1. Cerebrovascular Syndrome
  4. HIstory
    1. Location of exposure in relation to radiation source
    2. Injuries related to exposure (including burn injuries)
    3. Dose of exposure
      1. High dose rate (high dose over short period) is associated with increased injury
      2. Dose rate decreases by the square of the distance from the source
      3. Shielding reduces exposure
  5. Findings: Acute Radiation Syndrome
    1. Prodromal Phase (0 to 2 days after exposure)
      1. Symptoms reflect severity of exposure
        1. Lower dose exposures (<1 Gy) may be associated with mild or absent symptoms
        2. Significant, potentially lethal exposures (>2 Gy) are associated wih symptoms in the first 2 hours
        3. Highly lethal doses (>10 to 20 Gy) are associated with symptom onset within minutes of exposure
      2. Anorexia
      3. Nausea
      4. Vomiting
      5. Diarrhea
      6. Fever
      7. Tachycardia
      8. Headache
      9. Apathy
    2. Latent Phase (2 to 20 days after exposure)
      1. Symptoms temporarily abate during latent phase
    3. Manifest Illness (21 to 60 days after exposure)
      1. Severe, often life-threatening effects of organ dysfunction
      2. Findings specific to the associated syndrome (see below)
  6. Findings: Associated Syndromes
    1. Cutaneous Syndrome
      1. See Burn Injury
      2. Prodromal findings (within 1-2 days)
        1. Skin erythema and edema
        2. Desquamation (dry or moist)
        3. Bullae
        4. Skin Ulceration (may affect deep tissue down to Muscle or bone)
        5. Onycholysis
      3. Manifest Illness
        1. May be delayed years
    2. Hematopoietic Syndrome (Dose >2 to 3 Gy)
      1. Prodromal Findings
        1. Lymphopenia (see labs above)
        2. Neutropenia and Thrombocytopenia nadir at 2 to 4 weeks, but may persist months
        3. Anemia (also compounded by gastrointestinal Hemorrhage)
      2. Manifest Findings (over weeks to months)
        1. Bone Marrow aplasia or hypoplasia
        2. Pancytopenia
        3. Immunocompromised
        4. Poor Wound Healing
        5. Increased bleeding risk
    3. Gastrointestinal Syndrome (Dose >5 to 12 Gy)
      1. Onset within 5 days of exposure
      2. Mild GI symptoms (Nausea, Vomiting) are seen at low dose exposures (<1.5 Gy) in prodromal phase
      3. High dose exposures (>5 Gy) are associated with loss of intestinal crypt cells and mucosal barrier
      4. Prodromal Findings
        1. Crampy Abdominal Pain
        2. Diarrhea
        3. Nausea and Vomiting
        4. Gastrointestinal Bleeding
      5. Manifest Findings (typically after day 7)
        1. Vomiting
        2. Severe Diarrhea
        3. Malnutrition
        4. High fever
        5. Sepsis
        6. Bowel wall necrosis, perforation, ileus
    4. Cerebrovascular Syndrome (Dose >10 to 20 Gy)
      1. Associated with capillary injury at blood brain barrier, Cerebral edema and Meningitis
      2. Findings
        1. Severe Nausea and Vomiting
        2. Headache
        3. Altered Mental Status
        4. Seizures
        5. Ataxia
        6. Decreased Deep Tendon Reflexes
  7. Labs
    1. See Unknown Ingestion
    2. ABO Type and Screen
    3. Serum Electrolytes
    4. Mouth and nasal swabs for radiation testing
    5. Complete Blood Count (CBC) with differential
      1. Repeat CBC every 6 to 12 hours
      2. Observe for decreased White Blood Cells (esp. Absolute Lymphocyte Count)
        1. Absolute Lymphocyte Count depletion course best predicts exposure and prognosis
        2. Lymphocyte Count >1000 is associated with a better prognosis
          1. Lymphocyte Count maintained at 50% of normal in first week suggests <1 Gy exposure
        3. Lymphocyte Count <500 is associated with very poor prognosis (highly lethal if <100)
          1. High dose exposure (>5 Gy): 50% Lymphocyte drop in 24 hours, and more severe drop in 48 hours
  8. Management
    1. Staff should use appropriate Personal Protective Equipment (PPE)
    2. Consult nuclear exposure experts
    3. Decontamination
      1. Remove all clothing (removes 70-90% of contaminants)
      2. Wash skin
        1. See Skin Decontamination
      3. Consider chelating agents (e.g. DTPA, Prusssian Blue, Calcium Phosphate, aluminum phosphate)
    4. Thyroid Cancer Risk
      1. Risk of Radioactive Iodine uptake in children and pregnant women
      2. Give prophylactic Potassium iodide to patients at risk
        1. Adult: 130 mg orally daily
        2. Child (over age 3 years old): 65 mg orally daily
        3. Infant (one month to age 3 years): 32 mg
    5. Infection Risk
      1. Perform any urgent or emergent surgery in first 24 to 36 hours
      2. Treat infections early
      3. Consider prophylactic antibiotics in Neutropenia
      4. Evaluate for CMV risk
      5. Evaluate for Pneumocystitis carinii risk (CD4 <200/ul)
    6. Treat specific injuries
      1. See Burn Management
    7. Basic Supportive Care
      1. Intravenous Fluids
      2. Anti-emetics (e.g. Ondansetron)
      3. Analgesics
      4. Maintain gastric acidity (avoid Proton Pump Inhibitors and H2 Blockers)
        1. May use sucralfate for Stress Ulcer prevention
      5. Platelet Transfusion indications
        1. Platelet Count <20,000 (or <75,000 if perioperative)
    8. Intensive Care
      1. Acute Radiation Syndrome scoring systems are used to guide interventions
      2. Reverse Isolation (>2 to 3 Gy exposure)
      3. Cytokines
      4. Hematopoietic Stem Cell Transplant
    9. Patient Triage to three categories
      1. Recovery is expected with minimal supportive care (<1 Gy exposure)
        1. Employ basic measures as above
      2. Survival is possible with aggressive supportive care
        1. Triage to Intensive Care
      3. Expected to succumb (>10 Gy exposure, concurrent injuries or inadequate resources)
        1. Triage to Palliative Care
  9. References
    1. Acosta and Warrington (2022) Radiation Syndrome, Stat Pearls, Treasure Island, accessed 5/11/2022
    2. López (2011) Rep Pract Oncol Radiother 16(4):138-46 +PMID: 24376971 [PubMed]

Radiation injury (C0034530)

Definition (MSH) Harmful effects of non-experimental exposure to ionizing or non-ionizing radiation in VERTEBRATES.
Concepts Injury or Poisoning (T037)
MSH D011832
SnomedCT 24803000, 81018009
English Injuries, Radiation, Injury, Radiation, Radiation Injuries, Radiation Injury, Radiation injuries, INJ RAD, RAD INJ, Injury due to exposure to ionizing radiation, Radiation injury, Injury radiation, Radiation injury NOS, Radiation Injuries [Disease/Finding], effects radiation tissue, radiation injury, radiation injuries, radiation injury (diagnosis), Injury due to exposure to ionizing radiation (disorder), Radiation injury (morphologic abnormality), injury; radiation, radiation; injury, Radiation injury, NOS
Spanish lesión traumática por exposición a una fuente de radiación ionizante, Herida por radiación, Lesión por radiación NEOM, lesión traumática por radiación, Lesiones por Radiación, injuria por radiación, lesión traumática por exposición a una fuente de radiación ionizante (trastorno), Lesiones por radiación, Lesión por radiación, lesión traumática por radiación (anomalía morfológica), lesión por radiación (anomalía morfológica), lesión por radiación, Traumatismos por Radiación
Italian Lesione da radiazioni, Lesione da radiazioni NAS, Lesioni da radiazioni
Dutch bestralingsletsel NAO, letsel bestraling, letsel; straling, straling; letsel, bestralingsletsels, bestralingsletsel, Bestralingstrauma, Bestralingstraumata, Trauma, bestralings-, Traumata, bestralings-
French Lésion postradique, Lésions radiques SAI, Lésion par irradiation, Lésions dues aux radiations, Lésions radio-induites, Atteintes radiques, Lésions post-radiques, Lésions postradiques, Lésions radiques
German Verletzung durch Bestrahlung NNB, Strahlenverletzungen, Verletzung durch Bestrahlung, Strahlenschäden
Portuguese Lesão por radiações, Lesão por radiações NE, Traumatismos por Radiação, Lesão por radiação, Lesões por radiações, Lesões por Radiação
Japanese 放射線損傷NOS, 放射線損傷, ホウシャセンソンショウNOS, ホウシャセンソンショウ, 放射線傷害, 放射線宿酔, 放射線症候群, 放射能症, 電離放射線障害, 放射線障害
Swedish Strålningsskador
Finnish Säteilyvauriot
Russian LUCHEVYE POVREZHDENIIA, LUCHEVAIA BOLEZN', LUCHEVOI SINDROM, POVREZHDENIIA OT IONIZIRUIUSHCHIKH I NEIONIZIRUIUSHCHIKH IZLUCHENII, ЛУЧЕВАЯ БОЛЕЗНЬ, ЛУЧЕВОЙ СИНДРОМ, ЛУЧЕВЫЕ ПОВРЕЖДЕНИЯ, ПОВРЕЖДЕНИЯ ОТ ИОНИЗИРУЮЩИХ И НЕИОНИЗИРУЮЩИХ ИЗЛУЧЕНИЙ
Czech Radiační poranění, Poškození radiací, Poškození zářením NOS, Radiační poškození, radiační poškození, záření - poranění, radiační poranění
Croatian RADIJACIJSKA OŠTEĆENJA
Polish Urazy popromienne, Choroba popromienna, Uszkodzenie popromienne
Hungarian Irradiatiós sérülés, Sugárzás okozta sérülés, Irradiatiós sérülés k.m.n., Sugárzás sérülések
Norwegian Strålingsskader, Stråleskader
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Acute Radiation Syndrome (C0520799)

Definition (MSH) A condition caused by a brief whole body exposure to more than one sievert dose equivalent of radiation. Acute radiation syndrome is initially characterized by ANOREXIA; NAUSEA; VOMITING; but can progress to hematological, gastrointestinal, neurological, pulmonary, and other major organ dysfunction.
Concepts Injury or Poisoning (T037)
MSH D054508
SnomedCT 360002
English Acute Radiation Syndrome, Acute Radiation Syndromes, Radiation Syndrome, Acute, Radiation Syndromes, Acute, Acute radiation syndrome, Acute Radiation Syndrome [Disease/Finding], Acute radiation disease, Acute radiation disease (disorder)
Portuguese Síndrome Aguda da Radiação, Síndrome aguda por radiações, Síndrome da Radiação Aguda
Spanish Síndrome de Radiación Aguda, Síndrome de radiación aguda, enfermedad aguda por radiación (trastorno), enfermedad aguda por radiación
Finnish Äkillinen säteilysairaus
French Syndrome d'irradiation aigüe, Syndrome d'irradiation aiguë, Syndrome de radio-exposition aiguë, Syndrome de radio-exposition aigüe, Syndrome radique aigu, SIA (Syndrome d'Irradiation Aiguë), SIA (Syndrome d'Irradiation Aigüe)
German Akute Strahlenkrankheit, Akutes Strahlensyndrom, akutes Strahlensyndrom
Italian Sindrome acuta da radiazioni
Russian РАДИАЦИОННЫЙ СИНДРОМ ОСТРЫЙ, RADIATSIONNYI SINDROM OSTRYI
Dutch acuut bestralingssyndroom
Japanese 急性放射線症候群, キュウセイホウシャセンショウコウグン
Swedish Akut strålningssyndrom
Czech Akutní syndrom z ozáření, akutní radiační syndrom
Polish Zespół popromienny ostry, Ostry zespół popromienny
Hungarian Acut irradiatiós szindróma
Norwegian Akutt strålesyndrom
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Radiation Sickness (C1510432)

Concepts Injury or Poisoning (T037)
MSH D011832
SnomedCT 157715000, 370402009, 20558004, 85983004
English Radiation Sicknesses, Sickness, Radiation, Sicknesses, Radiation, Radiotherapy induced vomiting, RAD SICKNESS, radiation toxicity (diagnosis), radiation sickness (diagnosis), radiation sickness, radiation toxicity, toxicity radiation, Radiation sickness, Radiation sickness (disorder), Radiation-induced vomiting, toxicity, radiation, Radiation sickness, NOS, Radiation Toxicity, Radiation Sickness
Czech nemoc z ozáření
Portuguese Doença por Radiação
Spanish Enfermedad por Radiación, malestar inducido por radiación (trastorno), malestar inducido por radiación
French Mal des rayons, Maladie des rayons
German Strahlenkrankheit
Norwegian Strålesyke
Italian Malattie da radiazioni
Dutch Bestralingsziekte
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Radiation-induced disorder (C1527225)

Definition (NCI) A non-neoplastic or neoplastic disorder which results from exposure to radiation. Examples of non-neoplastic disorders include dermatitis, enteritis, stomatitis, pneumonitis, and cerebritis. Examples of neoplastic disorders include myelodysplastic syndromes, leukemias, and sarcomas.
Concepts Injury or Poisoning (T037)
SnomedCT 362974007, 85983004
Spanish trastorno por exposición a una fuente de radiación ionizante, enfermedad por radiación, trastorno por exposición a una fuente de radiación ionizante (trastorno)
English radiation exposure disorder, Radiation-induced disorder, Radiation-induced disorder (disorder), Radiation-Induced Disorder, Radiation disease, Disorder due to exposure to ionising radiation, Disorder due to exposure to ionizing radiation (disorder), Disorder due to exposure to ionizing radiation, Disorder due to exposure to radiation, disease (or disorder); radiation, Radiation disease, NOS, Radiation-Induced Abnormalities, Radiation-Induced Abnormality
Dutch aandoening; straling
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Radiation sickness syndrome (C1709833)

Definition (NCI) The complex of symptoms characterizing the disease known as radiation injury, resulting from excessive exposure (greater than 200 rads or 2 gray) of the whole body (or large part) to ionizing radiation. The earliest of these symptoms are nausea, fatigue, vomiting, and diarrhea, which may be followed by epilation, hemorrhage, inflammation of the mouth and throat, and general loss of energy. In severe cases, where the radiation exposure has been approximately 1000 Rad (10 gray) or more, death may occur within two to four weeks. Those who survive six weeks after the receipt of a single large dose of radiation to the whole body may generally be expected to recover. (U.S. Nuclear Regulatory Commission).
Definition (NCI_FDA) Radiation induced skin desquamation
Concepts Disease or Syndrome (T047)
English Radiation Sickness Syndrome, Radiation sickness syndrome, SICKNESS SYNDROME, RADIATION, SYNDROME, RADIATION SICKNESS, RADIATION SICKNESS SYNDROME
Dutch bestralingsziekte syndroom
German Strahlensyndrom
Japanese 放射線宿酔症候群, ホウシャセンシュクスイショウコウグン
Czech Syndrom nemoci z ozáření
Spanish Síndrome por radiación
Portuguese Síndrome de doença por radiação
Italian Sindrome da radiazioni
French Syndrome de maladie radique
Hungarian Sugárzás betegség syndroma
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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