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Acute radiation syndrome - handout


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Summary of preparatory reading for MUHC ED Disaster Preparedness Course for Residents

Summary of preparatory reading for MUHC ED Disaster Preparedness Course for Residents

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  • 1. Adapted from Donnelly et al, Acute Radiation Syndrome: Assessment and Management, Southern Medical Journal, 103:6, June 2010 Acute Radiation Syndrome (ARS) Few clinicians will experience this first hand, therefore theoretical preparation is key to handling patients with radiation exposure should a disaster arise. There are no pathognomonic signs or symptoms so it is difficult to diagnose without an obvious history of exposure. Pathophysiology  More actively replicating cells are most sensitive to radiation.  Tissues affected most: gonads>bone marrow>GI>neuro>connective tissue>muscle>bone 3 classic ARS syndromes There is clinical overlap between the syndromes. Damage to increasingly radio-resistant cells is a marker of higher absorbed dose and clinical severity. Hematopoietic/Bone Marrow syndrome  Occurs with exposure >200 rad  Lymphocytes depleted first, followed by granulocytes and platelets within days  Red cells less sensitive so rapid anemia is unusual (i.e. search for other causes e.g. bleeding)  Death occurs within weeks-months due to infection from impaired immunity or bleeding Gastrointestinal syndrome  Occurs with exposures between 600 – 1000 rad  Abrupt onset within hours of n°/v°, anorexia and crampy abdo pain  Vomiting suppressed >1000 rad  Diarrhea is an ominous sign  Death occurs from overwhelming sepsis, multi-organ failure, bleeding within weeks Neurovascular syndrome  At doses >1000 rad:“fatigue syndrome”: fever, headache, then altered reflexes, dizziness, confusion, disorientation, ataxia, and loss of consciousness with increasing dose  At doses >3500 rad: damaged blood vessels →circulatory collapse, ↑ICP, cerebral vasculitis, meningitis  At doses >5000 rad: death within 48h before other syndromes can manifest Phases All 3 syndromes have 4 phases:  Prodromal phase: n°/v°, fever, headache, parotitis, abdominal cramping, skin erythema, conjunctivitis, and hypotension. Usually <48h duration. More rapid time to onset with higher dose.  Latent phase: hours to weeks of clinical improvement but stems cells are depleted.  Manifest phase: days to months of adverse health effects of each syndrome.  Recovery or death: recovery can take months to years. Patients exposed to very high dose die within days, lower lethal doses cause death within weeks to months. Farooq Khan MDCM PGY3 FRCP-EM McGill University November 14 th 2011
  • 2. Adapted from Donnelly et al, Acute Radiation Syndrome: Assessment and Management, Southern Medical Journal, 103:6, June 2010 Assessment Absolute lymphocyte count  Easy and quick, esp. In mass casualty  CBC q4h for first 8h, then q6h for next 40-48h  Initially low or progressively falling count is highly suggestive of high dose radiation exposure (see nomogram) Time to vomiting Caveats about time to vomiting  Non specific  Suppressed >1000 rad  50% sensitive at 200-300 rad  80-90% sensitive at 500-600 rad Gold standard of dicentric chromosome assay is not offered at most sites and has long turnaround time (weeks) Management Prodromal phase Regardless of triage category:  History and physical examination  Removal of external contamination  Dose estimation  Symptomatic and supportive care (including psychological support of the patient and family)  Replacement of fluids and electrolytes Latent phase Estimate following factors that impact prognosis  Age and underlying health status  Magnitude of absorbed dose  Body volume irradiated  Illness severity  Concomitant infection, physical trauma, or burn/dermal injury Manifest phase  Triage to minimal care, aggressive supportive care, or palliative care depending on prognosis  Transfer of individuals with hematopoietic syndrome to tertiary care centers specializing in the care of pancytopenic patients (incl. ID and Heme for febrile neutropenia)  ANC<0.5×109 leads to higher infection rates  G-CSF (Neupogen) and GM-CSF can stimulating spared or resistant stem cells into repopulating bone marrow. Stem cell transplants can also be done Radiation emergency medicine consultation services provided by the Radiation Emergency Assistance Center/Training Site (REAC/TS) with physicians and health physicists available 24/7 at 865-576-1005. Figure 1 Andrews nomogram Curves 1 to 4 correspond roughly to the following whole-body doses: curve 1: 3.1 Gy (3,100 rad), curve 2: 4.4 Gy (4,400 rad), curve 3: 5.6 Gy (5,600 rad), and curve 4: 7.1 Gy (7,100 rad)