Acute radiation syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Also called radiation poisoning, radiation toxicity, or radiation sickness. | *Also called radiation poisoning, radiation toxicity, or radiation sickness. | ||
*Acute illness caused by exposure to high doses (at least 1 Gy)<ref name="SNSRWG">Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004 Jun 15;140(12):1037-51.</ref> of ionizing radiation over a short period of time. | *Acute illness caused by [[radiation exposure (disaster)|exposure]] to high doses (at least 1 Gy)<ref name="SNSRWG">Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004 Jun 15;140(12):1037-51.</ref> of ionizing radiation over a short period of time. | ||
**1 Gray (Gy) = 100 rads | **1 Gray (Gy) = 100 rads | ||
*Generally requires exposure of whole body (or most of the body) | *Generally requires exposure of whole body (or most of the body) | ||
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====Bone Marrow Syndrome==== | ====Bone Marrow Syndrome==== | ||
*Clinical syndrome seen at doses >100-200 rad (1-2 Gy) | *Clinical syndrome seen at doses >100-200 rad (1-2 Gy) | ||
**Smaller doses cause clinically insignificant pancytopenia | **Smaller doses cause clinically insignificant [[pancytopenia]] | ||
*Lymphocytes depleted first, then granulocytes, platelets, and RBCs | *[[leukopenia|Lymphocytes depleted]] first, then granulocytes, [[thrombocytopenia|platelets]], and [[anemia|RBCs]] | ||
**Lymphocyte depletion is predictable based on dose | **Lymphocyte depletion is predictable based on dose | ||
*Death usually | *Death usually secondary to [[infection]] or [[hemorrhage]] and poor healing | ||
**Doses >350 rad fatal within several months if untreated | **Doses >350 rad fatal within several months if untreated | ||
====Gastrointestinal (GI) Syndrome==== | ====Gastrointestinal (GI) Syndrome==== | ||
*Syndrome occurs at 600-1000 rad (6-10 Gy) | *Syndrome occurs at 600-1000 rad (6-10 Gy) | ||
* | *[[Abdominal pain]], [[nausea/vomiting]], [[diarrhea]], [[ileus]] | ||
*Death occurs within weeks | *Death occurs within weeks secondary to multiorgan failure and [[sepsis]] if untreated | ||
====Cardiovascular (CV)/Central Nervous System (CNS) Syndrome==== | ====Cardiovascular (CV)/Central Nervous System (CNS) Syndrome==== | ||
*Syndrome occurs at >1000-2000 rad (10-20 Gy) | *Syndrome occurs at >1000-2000 rad (10-20 Gy) | ||
**At this dose, vomiting is suppressed | **At this dose, vomiting is suppressed | ||
** | **[[Dizziness]], [[syncope|LOC]], [[papilledema]], ↓ DTRs, [[ataxia]], [[coma]] | ||
*Doses >3500 rad (35 Gy) damage large blood vessels → cardiovascular failure, cerebral edema | *Doses >3500 rad (35 Gy) damage large blood vessels → [[sock|cardiovascular failure]], [[elevated ICP|cerebral edema]] | ||
*Doses >5000 rad (50 Gy) cause death within 48 hours | *Doses >5000 rad (50 Gy) cause death within 48 hours | ||
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====Prodromal Stage==== | ====Prodromal Stage==== | ||
*Characterized by nausea and vomiting | *Characterized by [[nausea and vomiting]] | ||
**Other symptoms include: malaise, fever, conjunctivitis | **Other symptoms include: malaise, [[fever]], [[conjunctivitis]] | ||
**Doses over 1000 rad (10 Gy), vomiting is not seen in early | **Doses over 1000 rad (10 Gy), vomiting is not seen in early symptoms | ||
*Occurs within 48h-6d of exposure (at higher doses, can begin within minutes) | *Occurs within 48h-6d of exposure (at higher doses, can begin within minutes) | ||
*Lasts up to 2 days | *Lasts up to 2 days | ||
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====Recovery or Death==== | ====Recovery or Death==== | ||
*If | *If patient survives manifest illness stage, recovery is slow (weeks to years) | ||
*If lethal dose received, death can occur within days (very high, rapid doses) or may be delayed up to several months | *If lethal dose received, death can occur within days (very high, rapid doses) or may be delayed up to several months | ||
*Doses over 1000 rad (10 Gy) are uniformly fatal | *Doses over 1000 rad (10 Gy) are uniformly fatal | ||
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{{Nausea and vomiting DDX}} | {{Nausea and vomiting DDX}} | ||
== | ==Evaluation== | ||
*Clinical diagnosis, based on history and physical. | *Clinical diagnosis, based on history and physical | ||
*Absolute lymphocyte count is the best prognosticator at 48hrs post-exposure<ref>Colwell CB: Radiation injuries, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 146: pp 1945-1951.</ref> (<1500 is abnormal and indicates a significant exposure) | |||
== | ==Management== | ||
*Aggressive supportive care is hallmark of ED management | *Aggressive supportive care is hallmark of ED management | ||
*[[Potassium iodide]] as thyroid protectant, at 130mg QD for adults, until radiation exposure ceases<ref>New York State Potassium Iodide (KI) and Radiation Emergencies: Fact Sheet. https://www.health.ny.gov/environmental/radiological/potassium_iodide/fact_sheet.htm.</ref> | |||
==Disposition== | ==Disposition== | ||
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*[[Radiation exposure (disaster)]] | *[[Radiation exposure (disaster)]] | ||
*[[Disaster medicine]] | *[[Disaster medicine]] | ||
==External Links== | |||
*https://emergency.cdc.gov/radiation/arsphysicianfactsheet.asp | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Toxicology]] | ||
[[Category: | [[Category:Radiology]] | ||
[[Category:EMS]] | [[Category:EMS]] |
Revision as of 20:10, 1 October 2019
Background
- Also called radiation poisoning, radiation toxicity, or radiation sickness.
- Acute illness caused by exposure to high doses (at least 1 Gy)[1] of ionizing radiation over a short period of time.
- 1 Gray (Gy) = 100 rads
- Generally requires exposure of whole body (or most of the body)
- Fast-replicating cell lines most affected - GI, lymphohematopoietic, spermatocytes
- Healthcare providers should use isolation precautions and decontamination procedures
- Geiger counters may be useful in identifying contamination
Clinical Features
Clinical Syndromes[1][2]
Bone Marrow Syndrome
- Clinical syndrome seen at doses >100-200 rad (1-2 Gy)
- Smaller doses cause clinically insignificant pancytopenia
- Lymphocytes depleted first, then granulocytes, platelets, and RBCs
- Lymphocyte depletion is predictable based on dose
- Death usually secondary to infection or hemorrhage and poor healing
- Doses >350 rad fatal within several months if untreated
Gastrointestinal (GI) Syndrome
- Syndrome occurs at 600-1000 rad (6-10 Gy)
- Abdominal pain, nausea/vomiting, diarrhea, ileus
- Death occurs within weeks secondary to multiorgan failure and sepsis if untreated
Cardiovascular (CV)/Central Nervous System (CNS) Syndrome
- Syndrome occurs at >1000-2000 rad (10-20 Gy)
- At this dose, vomiting is suppressed
- Dizziness, LOC, papilledema, ↓ DTRs, ataxia, coma
- Doses >3500 rad (35 Gy) damage large blood vessels → cardiovascular failure, cerebral edema
- Doses >5000 rad (50 Gy) cause death within 48 hours
Clinical Course[1][2]
- Each ARS syndrome typically progresses through 4 stages of disease
Prodromal Stage
- Characterized by nausea and vomiting
- Other symptoms include: malaise, fever, conjunctivitis
- Doses over 1000 rad (10 Gy), vomiting is not seen in early symptoms
- Occurs within 48h-6d of exposure (at higher doses, can begin within minutes)
- Lasts up to 2 days
Latent Stage
- Short period of symptom improvement
- Lasts several days to 1 month
Manifest Illness Stage
- Manifestation of symptoms of clinical syndromes
- Severity based on, among other things:
- Overall dose
- Irradiated body volume
- Comorbidities and overall health status
- Age
- Characterized by significant immunosuppression
- Lasts for days to months
Recovery or Death
- If patient survives manifest illness stage, recovery is slow (weeks to years)
- If lethal dose received, death can occur within days (very high, rapid doses) or may be delayed up to several months
- Doses over 1000 rad (10 Gy) are uniformly fatal
Differential Diagnosis
Mass casualty incident
- Radiation exposure (disaster)
- Dirty bomb
- Bioterrorism
- Chemical weapons
- Mass shooting
- Natural Disaster (e.g. Hurricane, Earthquake, Tornado, Tsunami, etc)
- Unintentional large-scale incident (e.g. building collapse, train derailment, etc)
- Major pandemic
- Explosions
Nausea and vomiting
Critical
Emergent
- Acute radiation syndrome
- Acute gastric dilation
- Adrenal insufficiency
- Appendicitis
- Bowel obstruction/ileus
- Carbon monoxide poisoning
- Cholecystitis
- CNS tumor
- Electrolyte abnormalities
- Elevated ICP
- Gastric outlet obstruction, gastric volvulus
- Hyperemesis gravidarum
- Medication related
- Pancreatitis
- Peritonitis
- Ruptured viscus
- Testicular torsion/ovarian torsion
Nonemergent
- Acute gastroenteritis
- Biliary colic
- Cannabinoid hyperemesis syndrome
- Chemotherapy
- Cyclic vomiting syndrome
- ETOH
- Gastritis
- Gastroenteritis
- Gastroparesis
- Hepatitis
- Labyrinthitis
- Migraine
- Medication related
- Motion sickness
- Narcotic withdrawal
- Thyroid
- Pregnancy
- Peptic ulcer disease
- Renal colic
- UTI
Evaluation
- Clinical diagnosis, based on history and physical
- Absolute lymphocyte count is the best prognosticator at 48hrs post-exposure[3] (<1500 is abnormal and indicates a significant exposure)
Management
- Aggressive supportive care is hallmark of ED management
- Potassium iodide as thyroid protectant, at 130mg QD for adults, until radiation exposure ceases[4]
Disposition
- Admit
See Also
External Links
References
- ↑ 1.0 1.1 1.2 Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004 Jun 15;140(12):1037-51.
- ↑ 2.0 2.1 Donnelly EH1, Nemhauser JB, Smith JM, et al. Acute radiation syndrome: assessment and management. South Med J. 2010 Jun;103(6):541-6.
- ↑ Colwell CB: Radiation injuries, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 146: pp 1945-1951.
- ↑ New York State Potassium Iodide (KI) and Radiation Emergencies: Fact Sheet. https://www.health.ny.gov/environmental/radiological/potassium_iodide/fact_sheet.htm.