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 secondary to infection or hemorrhage and poor healing
*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)
*Characterized by abdominal pain, nausea, vomiting, diarrhea, ileus
*[[Abdominal pain]], [[nausea/vomiting]], [[diarrhea]], [[ileus]]
*Death occurs within weeks secondary to multiorgan failure and sepsis if untreated
*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
**Characterized by ALOC, dizziness, papilledema, ↓ DTRs, ataxia, coma
**[[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 sx
**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 pt survives manifest illness stage, recovery is slow (weeks to years)
*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}}


==Diagnosis==
==Evaluation==
*Clinical diagnosis, based on history and physical
*Clinical diagnosis, based on history and physical
*Absolute lymphocyte count (< 1500) 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>
*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)


==Treatment==
==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:Tox]]
[[Category:Toxicology]]
[[Category:Rads]]
[[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)
  • 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

Cardiovascular (CV)/Central Nervous System (CNS) Syndrome


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

Nausea and vomiting

Critical

Emergent

Nonemergent

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. 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. 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.
  3. 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.
  4. New York State Potassium Iodide (KI) and Radiation Emergencies: Fact Sheet. https://www.health.ny.gov/environmental/radiological/potassium_iodide/fact_sheet.htm.