Acute Radiation Syndrome (A Spectrum of Disease) Doran Christensen, DO Associate Director, REAC/TS.
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Transcript of Acute Radiation Syndrome (A Spectrum of Disease) Doran Christensen, DO Associate Director, REAC/TS.
Acute Radiation Syndrome Acute Radiation Syndrome (A Spectrum of Disease)(A Spectrum of Disease)
Acute Radiation Syndrome Acute Radiation Syndrome (A Spectrum of Disease)(A Spectrum of Disease)
Doran Christensen, DODoran Christensen, DOAssociate Director, REAC/TSAssociate Director, REAC/TS
Acute Radiation Acute Radiation SyndromeSyndromeAcute Radiation Acute Radiation SyndromeSyndrome
Systemic Effects from Acute Radiation Systemic Effects from Acute Radiation ExposureExposure
Multi-Faceted Spectrum of Disease Multi-Faceted Spectrum of Disease
Involvement of One or more Organ SystemsInvolvement of One or more Organ Systems
Systemic Effects from Acute Radiation Systemic Effects from Acute Radiation ExposureExposure
Multi-Faceted Spectrum of Disease Multi-Faceted Spectrum of Disease
Involvement of One or more Organ SystemsInvolvement of One or more Organ Systems
Ionization ProcessIonization ProcessIonization ProcessIonization ProcessDensity of Ionization TrailDensity of Ionization Trail
Chemical BondsChemical BondsDNA DamageDNA DamageSubcellular componentsSubcellular components
Mitotic DelayMitotic DelayRepairRepair
CompleteCompleteIncompleteIncompleteResidual Damage? Measureable?Residual Damage? Measureable?
Density of Ionization TrailDensity of Ionization TrailChemical BondsChemical BondsDNA DamageDNA DamageSubcellular componentsSubcellular components
Mitotic DelayMitotic DelayRepairRepair
CompleteCompleteIncompleteIncompleteResidual Damage? Measureable?Residual Damage? Measureable?
Exposure PrinciplesExposure PrinciplesExposure PrinciplesExposure Principles
Total vs. Partial Body IrradiationTotal vs. Partial Body IrradiationThreshold Effect of DoseThreshold Effect of Dose
ThresholdThresholdDD5050 Dose Dose
Dose RateDose RateDose Protraction or FractionationDose Protraction or Fractionation
Total vs. Partial Body IrradiationTotal vs. Partial Body IrradiationThreshold Effect of DoseThreshold Effect of Dose
ThresholdThresholdDD5050 Dose Dose
Dose RateDose RateDose Protraction or FractionationDose Protraction or Fractionation
Radiation EffectsRadiation EffectsRadiation EffectsRadiation EffectsStochasticStochastic - “All-or-Nothing” Effect - “All-or-Nothing” Effect
Occurrence Probability is Occurrence Probability is Function of DoseFunction of DoseIncreased Risk of Developing CancerIncreased Risk of Developing CancerInheritable MutationsInheritable Mutations
DeterministicDeterministic - - Effect Severity is a Function of Dose Effect Severity is a Function of Dose (Commonly Associated with Threshold)(Commonly Associated with Threshold)Inflammatory ResponseInflammatory ResponseOrgan FailureOrgan FailureFibrosisFibrosis
StochasticStochastic - “All-or-Nothing” Effect - “All-or-Nothing” Effect Occurrence Probability is Occurrence Probability is Function of DoseFunction of DoseIncreased Risk of Developing CancerIncreased Risk of Developing CancerInheritable MutationsInheritable Mutations
DeterministicDeterministic - - Effect Severity is a Function of Dose Effect Severity is a Function of Dose (Commonly Associated with Threshold)(Commonly Associated with Threshold)Inflammatory ResponseInflammatory ResponseOrgan FailureOrgan FailureFibrosisFibrosis
Radiation EffectsRadiation EffectsRadiation EffectsRadiation Effects
0
0.2
0.4
0.6
0.8
1
Effect
Dose
Deterministic
0
0.2
0.4
0.6
0.8
1
Effect
Dose
Stochastic
Law of Bergonié and Tribondeau Law of Bergonié and Tribondeau (1906)(1906)Law of Bergonié and Tribondeau Law of Bergonié and Tribondeau (1906)(1906)
More Differentiated Cells are Less SensitiveMore Differentiated Cells are Less Sensitive
Actively Proliferating Cells are More SensitiveActively Proliferating Cells are More Sensitive
Radiosensitivity is Proportional to Mitotic and Radiosensitivity is Proportional to Mitotic and Developmental Activity DurationDevelopmental Activity Duration
More Differentiated Cells are Less SensitiveMore Differentiated Cells are Less Sensitive
Actively Proliferating Cells are More SensitiveActively Proliferating Cells are More Sensitive
Radiosensitivity is Proportional to Mitotic and Radiosensitivity is Proportional to Mitotic and Developmental Activity DurationDevelopmental Activity Duration
Rapidly Dividing Cells that Are Poorly Differentiated Rapidly Dividing Cells that Are Poorly Differentiated and Have a Long Mitotic Period Are Very Radiosensitiveand Have a Long Mitotic Period Are Very Radiosensitive
Exceptions:Exceptions:Exceptions:Exceptions:
LymphocyteLymphocyte - Most Radiosensitive Cell - Most Radiosensitive CellOocyteOocyte - Non Mitotic Cell - Non Mitotic Cell
LymphocyteLymphocyte - Most Radiosensitive Cell - Most Radiosensitive CellOocyteOocyte - Non Mitotic Cell - Non Mitotic Cell
Radiosensitive CellsRadiosensitive CellsRadiosensitive CellsRadiosensitive Cells
Red MarrowRed MarrowEpithelial Cells of GI System, LungEpithelial Cells of GI System, LungEpithelium of LensEpithelium of LensGerminative Cells of Testis and OvaryGerminative Cells of Testis and OvaryEndothelial Cells of Blood VesselsEndothelial Cells of Blood Vessels
Red MarrowRed MarrowEpithelial Cells of GI System, LungEpithelial Cells of GI System, LungEpithelium of LensEpithelium of LensGerminative Cells of Testis and OvaryGerminative Cells of Testis and OvaryEndothelial Cells of Blood VesselsEndothelial Cells of Blood Vessels
Radiosensitive Cells Radiosensitive Cells (cont’d)(cont’d)Radiosensitive Cells Radiosensitive Cells (cont’d)(cont’d)
Pluripotential Stem CellsPluripotential Stem Cells Rapid Mitotic RateRapid Mitotic Rate Form Intermdiate Precursors and then Form Intermdiate Precursors and then
Mature Elements.Mature Elements. Cells with Large Nuclei Cells with Large Nuclei
Interphase DeathInterphase Death Lymphocyte, Oocyte and Salivary GlandLymphocyte, Oocyte and Salivary Gland
Pluripotential Stem CellsPluripotential Stem Cells Rapid Mitotic RateRapid Mitotic Rate Form Intermdiate Precursors and then Form Intermdiate Precursors and then
Mature Elements.Mature Elements. Cells with Large Nuclei Cells with Large Nuclei
Interphase DeathInterphase Death Lymphocyte, Oocyte and Salivary GlandLymphocyte, Oocyte and Salivary Gland
Effects of Radiation Effects of Radiation ProtractionProtractionEffects of Radiation Effects of Radiation ProtractionProtraction
Prodromal ComponentProdromal Component(Gy)(Gy)
VomitingVomiting Diarrhea DiarrheaBriefBrief ProtractedProtracted BriefBrief ProtractedProtracted
ExposureExposure ExposureExposure ExposureExposure ExposureExposure
DD5050 22 55 33 66
ThresholdThreshold 0.50.5 1.51.5 11 2.52.5NUREG / CR 4214, Part II, p. 21NUREG / CR 4214, Part II, p. 21
GI Cellular HierarchyGI Cellular HierarchyGI Cellular HierarchyGI Cellular Hierarchy
IAEA – UNSCEAR 1988
Skin Cellular HierarchySkin Cellular HierarchySkin Cellular HierarchySkin Cellular Hierarchy
IAEA – UNSCEAR 1988
Phases of Acute Radiation Phases of Acute Radiation Syndrome Syndrome Phases of Acute Radiation Phases of Acute Radiation Syndrome Syndrome
ProdromalStage
ProdromalStage
LatentStage
LatentStage
ManifestIllness
ManifestIllness RecoveryRecovery
Time (60 days)Time (60 days)Time (60 days)Time (60 days)
ExposureExposureExposureExposure
Acute Radiation Acute Radiation SyndromeSyndromeAcute Radiation Acute Radiation SyndromeSyndrome
Components of Radiation Effects:Components of Radiation Effects:Prodromal Prodromal (0.5 - 3 Gy) (0.5 - 3 Gy) Hematological Hematological (1.5 - 6 Gy)(1.5 - 6 Gy)Respiratory Respiratory (5 - 310 Gy)(5 - 310 Gy)CutaneousCutaneous (5 - 10 Gy)(5 - 10 Gy)Gastrointestinal Gastrointestinal (8 - 15 Gy)(8 - 15 Gy)Neurovascular Neurovascular (6 - 50 Gy)(6 - 50 Gy)
Combined InjuryCombined Injury
Components of Radiation Effects:Components of Radiation Effects:Prodromal Prodromal (0.5 - 3 Gy) (0.5 - 3 Gy) Hematological Hematological (1.5 - 6 Gy)(1.5 - 6 Gy)Respiratory Respiratory (5 - 310 Gy)(5 - 310 Gy)CutaneousCutaneous (5 - 10 Gy)(5 - 10 Gy)Gastrointestinal Gastrointestinal (8 - 15 Gy)(8 - 15 Gy)Neurovascular Neurovascular (6 - 50 Gy)(6 - 50 Gy)
Combined InjuryCombined Injury
Prodromal ComponentProdromal Component(0.5 - 3 Gy and higher)(0.5 - 3 Gy and higher)Prodromal ComponentProdromal Component(0.5 - 3 Gy and higher)(0.5 - 3 Gy and higher)
Immediate Effect of Cell Membrane DamageImmediate Effect of Cell Membrane DamageMediated by Inflammatory Elements of Cell Mediated by Inflammatory Elements of Cell
DestructionDestructionMediated Neurologically by Mediated Neurologically by
Parasympathetic SystemParasympathetic System
Immediate Effect of Cell Membrane DamageImmediate Effect of Cell Membrane DamageMediated by Inflammatory Elements of Cell Mediated by Inflammatory Elements of Cell
DestructionDestructionMediated Neurologically by Mediated Neurologically by
Parasympathetic SystemParasympathetic System
Prodromal ComponentProdromal Component(Gy)(Gy)
VomitingVomiting Diarrhea DiarrheaBriefBrief ProtractedProtracted BriefBrief ProtractedProtracted
ExposureExposure ExposureExposure ExposureExposure ExposureExposure
DD5050 22 55 33 66
ThresholdThreshold 0.50.5 1.51.5 11 2.52.5NUREG / CR 4214, Part II, p. 21NUREG / CR 4214, Part II, p. 21
TBI Dose Estimates TBI Dose Estimates for Prodromal Symptomsfor Prodromal Symptoms
Hematopoietic Hematopoietic ComponentComponent(1.5 - 6 Gy and higher)(1.5 - 6 Gy and higher)
Hematopoietic Hematopoietic ComponentComponent(1.5 - 6 Gy and higher)(1.5 - 6 Gy and higher)
LymphocytesLymphocytesNeutrophilsNeutrophilsThrombocytesThrombocytesErythrocytesErythrocytes
LymphocytesLymphocytesNeutrophilsNeutrophilsThrombocytesThrombocytesErythrocytesErythrocytes
HemogramHemogram3 Gy (300 Rad) TBI Exposure 3 Gy (300 Rad) TBI Exposure HemogramHemogram3 Gy (300 Rad) TBI Exposure 3 Gy (300 Rad) TBI Exposure
Source – REAC / TS Diagram – Human Irradiation 3 Gy (300 Rads)
Gastrointestinal Gastrointestinal ComponentComponent(8 - 15 Gy and higher)(8 - 15 Gy and higher)
Gastrointestinal Gastrointestinal ComponentComponent(8 - 15 Gy and higher)(8 - 15 Gy and higher)
SymptomsSymptomsMechanismsMechanismsGI Epithelial Sterilization - 15 GyGI Epithelial Sterilization - 15 GyVeno-Occlusive Disease of LiverVeno-Occlusive Disease of Liver
SymptomsSymptomsMechanismsMechanismsGI Epithelial Sterilization - 15 GyGI Epithelial Sterilization - 15 GyVeno-Occlusive Disease of LiverVeno-Occlusive Disease of Liver
Respiratory ComponentRespiratory Component(5 - 310 Gy and higher)(5 - 310 Gy and higher)Respiratory ComponentRespiratory Component(5 - 310 Gy and higher)(5 - 310 Gy and higher)
Sensitive from Highly Vascular TissueSensitive from Highly Vascular TissueEndothelial CellsEndothelial CellsType II Alveolar CellType II Alveolar Cell
Effect is Dose-Rate RelatedEffect is Dose-Rate RelatedPneumonitisPneumonitisFibrosisFibrosis
Sensitive from Highly Vascular TissueSensitive from Highly Vascular TissueEndothelial CellsEndothelial CellsType II Alveolar CellType II Alveolar Cell
Effect is Dose-Rate RelatedEffect is Dose-Rate RelatedPneumonitisPneumonitisFibrosisFibrosis
Pulmonary Lethality Pulmonary Lethality SyndromeSyndromePulmonary Lethality Pulmonary Lethality SyndromeSyndrome
Dose Rate (Gy/hr)Dose Rate (Gy/hr) Threshold Threshold (Gy)(Gy)
Dose Rate (Gy/hr)Dose Rate (Gy/hr) Threshold Threshold (Gy)(Gy)0.05 310
0.1 160
0.5 40
1 20
10 7
100 5
0.05 310
0.1 160
0.5 40
1 20
10 7
100 5NUREG / CR-4214, Part II, p. 55
Neurovascular Neurovascular ComponentComponent(8 - 50 Gy and higher)(8 - 50 Gy and higher)
Neurovascular Neurovascular ComponentComponent(8 - 50 Gy and higher)(8 - 50 Gy and higher)
Brain Cells are Fixed, Post-Mitotic CellsBrain Cells are Fixed, Post-Mitotic Cells
Weak Link -- Stromal CellsWeak Link -- Stromal Cells
Endothelial Cells Turnover Endothelial Cells Turnover 2 Months to 3 Years (3 Days)2 Months to 3 Years (3 Days)
EEG Changes Doses as Low as 1 GyEEG Changes Doses as Low as 1 Gy
Brain Cells are Fixed, Post-Mitotic CellsBrain Cells are Fixed, Post-Mitotic Cells
Weak Link -- Stromal CellsWeak Link -- Stromal Cells
Endothelial Cells Turnover Endothelial Cells Turnover 2 Months to 3 Years (3 Days)2 Months to 3 Years (3 Days)
EEG Changes Doses as Low as 1 GyEEG Changes Doses as Low as 1 Gy
Neurovascular Neurovascular Component Component (continued)(continued)
Neurovascular Neurovascular Component Component (continued)(continued)
1 - 6 Gy 1 - 6 Gy - Glial Cell Damage- Glial Cell Damage 10 Gy 10 Gy - Morphologic Changes- Morphologic Changes 10 - 20 Gy10 - 20 Gy - Vascular Lesions - Vascular Lesions 40 Gy 40 Gy - White Matter Necrosis- White Matter Necrosis 60 Gy 60 Gy - Demyelinization- Demyelinization
1 - 6 Gy 1 - 6 Gy - Glial Cell Damage- Glial Cell Damage 10 Gy 10 Gy - Morphologic Changes- Morphologic Changes 10 - 20 Gy10 - 20 Gy - Vascular Lesions - Vascular Lesions 40 Gy 40 Gy - White Matter Necrosis- White Matter Necrosis 60 Gy 60 Gy - Demyelinization- Demyelinization
Ovarian FunctionOvarian FunctionOvarian FunctionOvarian Function Ovarian Dose (Gy) Results
0.6 - No Deleterious Effect
1.5 - Some Risk for Ovulatory Suppression in Women over 40
2.5 - 5.0 - 60% Women Aged 15-40 Have Permanent SuppressionRemainder have Temporary Amennorrhea 100% Women Over 40 have Permanent Suppression
5.0 - 8.0 - 60-70% Women Aged 15-40 Have Permanent SuppressionRemainder have Temporary Amennorrhea
>8.0 - 100% Permanent Ovulatory Suppression
Ovarian Dose (Gy) Results
0.6 - No Deleterious Effect
1.5 - Some Risk for Ovulatory Suppression in Women over 40
2.5 - 5.0 - 60% Women Aged 15-40 Have Permanent SuppressionRemainder have Temporary Amennorrhea 100% Women Over 40 have Permanent Suppression
5.0 - 8.0 - 60-70% Women Aged 15-40 Have Permanent SuppressionRemainder have Temporary Amennorrhea
>8.0 - 100% Permanent Ovulatory Suppression
NUREG / CR-4214, p II-70NUREG / CR-4214, p II-70NUREG / CR-4214, p II-70NUREG / CR-4214, p II-70
Sperm ProductionSperm ProductionSperm ProductionSperm Production Testicular Dose (Gy) Results
0.1 - 0.3 - Temporary Oligospermia
0.3 - 0.5 - 100% Temporary Aspermia from 4 - 12 mo Post-IrradiationFull Recovery by 48 mo
0.5 - 1.0 - 100% Temporary Aspermia from 3 - 17 moFull Recovery Beginning at 8 - 38 mo
1 - 2 - 100% Temporary Aspermia from 2 - 15 moRecovery Beginning at 11 - 20 mo
2 - 3 - 100% Aspermia Beginning at 1 - 2 moNo Recovery Observed after 40 mo
Testicular Dose (Gy) Results
0.1 - 0.3 - Temporary Oligospermia
0.3 - 0.5 - 100% Temporary Aspermia from 4 - 12 mo Post-IrradiationFull Recovery by 48 mo
0.5 - 1.0 - 100% Temporary Aspermia from 3 - 17 moFull Recovery Beginning at 8 - 38 mo
1 - 2 - 100% Temporary Aspermia from 2 - 15 moRecovery Beginning at 11 - 20 mo
2 - 3 - 100% Aspermia Beginning at 1 - 2 moNo Recovery Observed after 40 mo
NUREG / CR-4214, p II-73NUREG / CR-4214, p II-73NUREG / CR-4214, p II-73NUREG / CR-4214, p II-73
Radiation Skin InjuryRadiation Skin InjuryRadiation Skin InjuryRadiation Skin Injury
EffectsEffects
Time FrameTime Frame
Injury CourseInjury Course
EffectsEffects
Time FrameTime Frame
Injury CourseInjury Course
Radiation Skin InjuryRadiation Skin InjuryRadiation Skin InjuryRadiation Skin Injury
.75 Gy.75 Gy - Hair Follicles Change- Hair Follicles Change
3 Gy 3 Gy - Epilation- Epilation
6 Gy 6 Gy - Erythema- Erythema
10 Gy 10 Gy - Dry Desquamation- Dry Desquamation
20 Gy 20 Gy - Wet Desquamation - Wet Desquamation (Transepithelial Injury)(Transepithelial Injury)
.75 Gy.75 Gy - Hair Follicles Change- Hair Follicles Change
3 Gy 3 Gy - Epilation- Epilation
6 Gy 6 Gy - Erythema- Erythema
10 Gy 10 Gy - Dry Desquamation- Dry Desquamation
20 Gy 20 Gy - Wet Desquamation - Wet Desquamation (Transepithelial Injury)(Transepithelial Injury)
Skin EffectsSkin EffectsSkin EffectsSkin Effects
EffectEffect ParameterParameter Brief Brief Protracted Protracted ExposureExposure Exposure Exposure
ErythemaErythema ThresholdThreshold 33 66DD5050 66 2020
TransepithelialTransepithelial ThresholdThreshold 1010 4040InjuryInjury DD5050 2020 8080
EffectEffect ParameterParameter Brief Brief Protracted Protracted ExposureExposure Exposure Exposure
ErythemaErythema ThresholdThreshold 33 66DD5050 66 2020
TransepithelialTransepithelial ThresholdThreshold 1010 4040InjuryInjury DD5050 2020 8080
NUREG / CR-4214, p II-68NUREG / CR-4214, p II-68
Skin EffectsSkin EffectsSkin EffectsSkin Effects
EffectEffect Single Single Onset Onset Dose (Gy)Dose (Gy) Time Time
EpilationEpilation 3 - 73 - 7 ~18 days~18 days
ErythemaErythema 10 - 2010 - 20 12 - 17 days12 - 17 days
PigmentationPigmentation 10 - 2010 - 20
Dry DesquamationDry Desquamation 10 - 2010 - 20 30 - 70 days30 - 70 days
Moist DesquamationMoist Desquamation 20 - 2420 - 24 30 - 50 days30 - 50 days That HealsThat Heals
TelangiectasiaTelangiectasia 17 - 2417 - 24 6 mo - years6 mo - years
Nonhealing NecrosisNonhealing Necrosis > 60 > 60 months, years months, years
EffectEffect Single Single Onset Onset
Dose (Gy)Dose (Gy) Time Time
EpilationEpilation 3 - 73 - 7 ~18 days~18 days
ErythemaErythema 10 - 2010 - 20 12 - 17 days12 - 17 days
PigmentationPigmentation 10 - 2010 - 20
Dry DesquamationDry Desquamation 10 - 2010 - 20 30 - 70 days30 - 70 days
Moist DesquamationMoist Desquamation 20 - 2420 - 24 30 - 50 days30 - 50 days That HealsThat Heals
TelangiectasiaTelangiectasia 17 - 2417 - 24 6 mo - years6 mo - years
Nonhealing NecrosisNonhealing Necrosis > 60 > 60 months, years months, years NUREG / CR-4214, p II-68NUREG / CR-4214, p II-68
El Salvador Patient + 32 El Salvador Patient + 32 DaysDaysEl Salvador Patient + 32 El Salvador Patient + 32 DaysDays
Hyperpigmentation ( Bronzing )
El Salvador Patient + 32 El Salvador Patient + 32 DaysDaysEl Salvador Patient + 32 El Salvador Patient + 32 DaysDays
Dry Desquamation
El Salvador Patient + 32 El Salvador Patient + 32 DaysDaysEl Salvador Patient + 32 El Salvador Patient + 32 DaysDays
Transition to Wet Desquamation
El Salvador Patient + 32 El Salvador Patient + 32 DaysDaysEl Salvador Patient + 32 El Salvador Patient + 32 DaysDays
Wet Desquamation
TriageTriageTriageTriage
By Conventional InjuriesBy Conventional InjuriesTraumaTraumaBurnsBurns
By Radiation InjuryBy Radiation InjuryProdromal SymptomsProdromal SymptomsHematologic PictureHematologic Picture
By Conventional InjuriesBy Conventional InjuriesTraumaTraumaBurnsBurns
By Radiation InjuryBy Radiation InjuryProdromal SymptomsProdromal SymptomsHematologic PictureHematologic Picture
Modified USSR Classification Modified USSR Classification (1986)(1986)Modified USSR Classification Modified USSR Classification (1986)(1986)
Class 1 Class 1 Class Class 22
ProdromeProdrome >3 hrs>3 hrs** 1 - 3 hrs*1 - 3 hrs*Lymphs (3-6 days)Lymphs (3-6 days) 600 - 1000600 - 1000 300 - 500300 - 500TBI DoseTBI Dose 1 - 2 Gy1 - 2 Gy 2 - 4 Gy2 - 4 GySurvival EstimateSurvival Estimate Probable w / o txProbable w / o tx Possible w / o txPossible w / o tx
Class 3 Class 3 Class Class 44
ProdromeProdrome .5 - 1 hr .5 - 1 hr < .5 hr< .5 hrLymphs (3-6 days)Lymphs (3-6 days) 100 - 200 100 - 200 <100<100TBI DoseTBI Dose 4.2 - 6.3 Gy4.2 - 6.3 Gy 6 - 12, 16 Gy6 - 12, 16 GySurvival EstimateSurvival Estimate Probable w / txProbable w / tx Not LikelyNot Likely
Class 1 Class 1 Class Class 22
ProdromeProdrome >3 hrs>3 hrs** 1 - 3 hrs*1 - 3 hrs*Lymphs (3-6 days)Lymphs (3-6 days) 600 - 1000600 - 1000 300 - 500300 - 500TBI DoseTBI Dose 1 - 2 Gy1 - 2 Gy 2 - 4 Gy2 - 4 GySurvival EstimateSurvival Estimate Probable w / o txProbable w / o tx Possible w / o txPossible w / o tx
Class 3 Class 3 Class Class 44
ProdromeProdrome .5 - 1 hr .5 - 1 hr < .5 hr< .5 hrLymphs (3-6 days)Lymphs (3-6 days) 100 - 200 100 - 200 <100<100TBI DoseTBI Dose 4.2 - 6.3 Gy4.2 - 6.3 Gy 6 - 12, 16 Gy6 - 12, 16 GySurvival EstimateSurvival Estimate Probable w / txProbable w / tx Not LikelyNot Likely
Mettler FA, Kelsey CA, Ricks RC Eds. Mettler FA, Kelsey CA, Ricks RC Eds. Medical Management of Radiation Accidents.Medical Management of Radiation Accidents. Boca Raton: CRC Press, 1990, p. 72. Boca Raton: CRC Press, 1990, p. 72.*Barabanova A. *Barabanova A. REAC/TS Newsletter.REAC/TS Newsletter. Winter 1992, Oak Ridge, TN, p 1-2. Winter 1992, Oak Ridge, TN, p 1-2.
Mettler FA, Kelsey CA, Ricks RC Eds. Mettler FA, Kelsey CA, Ricks RC Eds. Medical Management of Radiation Accidents.Medical Management of Radiation Accidents. Boca Raton: CRC Press, 1990, p. 72. Boca Raton: CRC Press, 1990, p. 72.*Barabanova A. *Barabanova A. REAC/TS Newsletter.REAC/TS Newsletter. Winter 1992, Oak Ridge, TN, p 1-2. Winter 1992, Oak Ridge, TN, p 1-2.
Andrews LymphocyteAndrews LymphocyteNomogramNomogramAndrews LymphocyteAndrews LymphocyteNomogramNomogram
From From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. Persons Exposed to High Levels of Radiation. In In Personal Dosimetry for Radiation Accidents. Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Vienna, International Atomic Energy Agency, 1965, pp 3- 16
From From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. Persons Exposed to High Levels of Radiation. In In Personal Dosimetry for Radiation Accidents. Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Vienna, International Atomic Energy Agency, 1965, pp 3- 16
Confirms suspected Confirms suspected radiation exposureradiation exposure
Determines significant Determines significant hematological hematological involvementinvolvement
Serial CBCs every 6 hSerial CBCs every 6 h
Confirms suspected Confirms suspected radiation exposureradiation exposure
Determines significant Determines significant hematological hematological involvementinvolvement
Serial CBCs every 6 hSerial CBCs every 6 h
Goans Nomogram – The Next Goans Nomogram – The Next AdvanceAdvanceGoans Nomogram – The Next Goans Nomogram – The Next AdvanceAdvance
Goans, RE, “Clinical Care of the Radiation-Accident Patient: Patient Presentation, Assessment, and Initial Diagnosis” in Ricks RC, Berger ME, O’Hara FM, The Medical Basis for Radiation Accident Preparedness – The Clinical Care of Victims, p18.
Combined-Injury Triage whenCombined-Injury Triage whenRadiation Doses are Known*Radiation Doses are Known*Combined-Injury Triage whenCombined-Injury Triage whenRadiation Doses are Known*Radiation Doses are Known*
Conventional Triage Changes in Expected Triage CategoryCategories if Injuries are followingOnly Trauma Whole-Body Radiation Dose (Gy)
No Radiation Exists < 1.5 (150 rad) 1.5-4.5 (150-450 rad) > 4.5 (450 rad)Prodrome Onset < 3 h 1 – 3 h < 1 h
Immediate Immediate Immediate ExpectantDelayed Delayed Expectant ExpectantMinimal Minimal Expectant ExpectantExpectant Expectant Expectant Expectant
*Decision based on whole-body radiation dose, assuming all casualties are wearing personal dosimetersSource: Medical Consequences of Nuclear Warfare, 1989, p. 39
Combined InjuryCombined InjuryCombined InjuryCombined Injury
Combined Injury -Combined Injury -Total Body Irradiation + Total Body Irradiation + BurnsBurns
Combined Injury -Combined Injury -Total Body Irradiation + Total Body Irradiation + BurnsBurns
100 R 250 R 500 R
50
0
70
50
0
95
50
20
100
0
10
20
30
40
50
60
70
80
90
100
Percent Lethality
100 R 250 R 500 R
Burns
Radiation
Combined
100 R 250 R 500 R
50
0
70
50
0
95
50
20
100
0
10
20
30
40
50
60
70
80
90
100
Percent Lethality
100 R 250 R 500 R
Burns
Radiation
Combined
Rat ModelRat Model
AFRRI AFRRI Medical Effects of Nuclear Weapons Medical Effects of Nuclear Weapons Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35AFRRI AFRRI Medical Effects of Nuclear Weapons Medical Effects of Nuclear Weapons Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35
Treatment OverviewTreatment OverviewTreatment OverviewTreatment OverviewSupportive CareSupportive CareSurgical RecommendationsSurgical RecommendationsSelective Gut DecontaminationSelective Gut DecontaminationBone Marrow Transplants (not as successful)Bone Marrow Transplants (not as successful)Biological Response ModifiersBiological Response ModifiersCytokines (more successful)Cytokines (more successful)Complications of Acute Radiation SyndromeComplications of Acute Radiation Syndrome
Supportive CareSupportive CareSurgical RecommendationsSurgical RecommendationsSelective Gut DecontaminationSelective Gut DecontaminationBone Marrow Transplants (not as successful)Bone Marrow Transplants (not as successful)Biological Response ModifiersBiological Response ModifiersCytokines (more successful)Cytokines (more successful)Complications of Acute Radiation SyndromeComplications of Acute Radiation Syndrome
Supportive CareSupportive CareSupportive CareSupportive Care
Fluid and Electrolyte ReplacementFluid and Electrolyte ReplacementReverse IsolationReverse IsolationTotal Parenteral NutritionTotal Parenteral NutritionEmpiric Antibiotics for Documented InfectionEmpiric Antibiotics for Documented Infection
Fluid and Electrolyte ReplacementFluid and Electrolyte ReplacementReverse IsolationReverse IsolationTotal Parenteral NutritionTotal Parenteral NutritionEmpiric Antibiotics for Documented InfectionEmpiric Antibiotics for Documented Infection
Supportive Care Supportive Care (cont’d)(cont’d)Supportive Care Supportive Care (cont’d)(cont’d)
Irradiated Blood ProductsIrradiated Blood ProductsEnteral FeedingsEnteral Feedings Intravenous GlutamineIntravenous GlutamineSucralfateSucralfate
Irradiated Blood ProductsIrradiated Blood ProductsEnteral FeedingsEnteral Feedings Intravenous GlutamineIntravenous GlutamineSucralfateSucralfate
Surgical RecommendationsSurgical RecommendationsSurgical RecommendationsSurgical RecommendationsBased on Immunocompetence Status Based on Immunocompetence Status
(neutropenia immunocompetence)(neutropenia immunocompetence)Life-Saving / Major Surgery within 36 - 48 hLife-Saving / Major Surgery within 36 - 48 hElective Procedures until 45 - 60 days Elective Procedures until 45 - 60 days
Following Hematopoietic RecoveryFollowing Hematopoietic Recovery
Based on Immunocompetence Status Based on Immunocompetence Status (neutropenia immunocompetence)(neutropenia immunocompetence)
Life-Saving / Major Surgery within 36 - 48 hLife-Saving / Major Surgery within 36 - 48 hElective Procedures until 45 - 60 days Elective Procedures until 45 - 60 days
Following Hematopoietic RecoveryFollowing Hematopoietic Recovery
Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds) Treatment of Radiation Injuries, 1990, Plenum Press, New York, p. 229Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds) Treatment of Radiation Injuries, 1990, Plenum Press, New York, p. 229
Selective Gut DecontaminationSelective Gut DecontaminationSelective Gut DecontaminationSelective Gut Decontamination
Historical BackgroundHistorical BackgroundNon-Systemic Abx vs. Systemic AbxNon-Systemic Abx vs. Systemic AbxFluoroquinolones Fluoroquinolones
Ciprofloxacin, OfloxacinCiprofloxacin, OfloxacinNorfloxacin Norfloxacin
Historical BackgroundHistorical BackgroundNon-Systemic Abx vs. Systemic AbxNon-Systemic Abx vs. Systemic AbxFluoroquinolones Fluoroquinolones
Ciprofloxacin, OfloxacinCiprofloxacin, OfloxacinNorfloxacin Norfloxacin
Cytokine CombinationsCytokine CombinationsCytokine CombinationsCytokine Combinations
IL-3/G-CSFIL-3/G-CSF IL-3/GM-CSFIL-3/GM-CSF
IL-3/G-CSFIL-3/G-CSF IL-3/GM-CSFIL-3/GM-CSF
Acute Radiation Syndrome Acute Radiation Syndrome ComplicationsComplicationsAcute Radiation Syndrome Acute Radiation Syndrome ComplicationsComplications
Hematologic/GastrointestinalHematologic/Gastrointestinal Interstitial Pulmonary FibrosisInterstitial Pulmonary FibrosisVeno-occlusive Disease of the LiverVeno-occlusive Disease of the LiverHerpes Simplex (HSV) ReactivationHerpes Simplex (HSV) ReactivationCytomegalovirus (CMV) ReactivationCytomegalovirus (CMV) ReactivationCombined InjuriesCombined Injuries
Hematologic/GastrointestinalHematologic/Gastrointestinal Interstitial Pulmonary FibrosisInterstitial Pulmonary FibrosisVeno-occlusive Disease of the LiverVeno-occlusive Disease of the LiverHerpes Simplex (HSV) ReactivationHerpes Simplex (HSV) ReactivationCytomegalovirus (CMV) ReactivationCytomegalovirus (CMV) ReactivationCombined InjuriesCombined Injuries
Any Questions?Any Questions?Any Questions?Any Questions?
ReferencesReferencesReferencesReferencesNUREG / CR-4214, Health Effects Models for Nuclear Power PlantAccident Consequence Analysis: Low LET Radiation, Part II: Scientific Bases for Health Effects Models, US Nuclear Regulatory Commission, 1989.
Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds)Treatment of Radiation Injuries, 1990, Plenum Press, New York, p. 229
AFRRI Medical Effects of Nuclear Weapons Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35
IAEA, The Radiological Accident in San Salvador, 1989
Ricks RC, Berger ME, O’Hara FM, The Medical Basis for Radiation-AccidentPreparedness – The Clinical Care of Victims, Parthenon Publishing Group, Inc:New York:2002.
Saenger EL, Andrews GA, Linnemann RE, Wald N: Radiation Accident Preparedness-Medical and Managerial Aspects. Science-Thru-Media: New York 1981, p 15.
NUREG / CR-4214, Health Effects Models for Nuclear Power PlantAccident Consequence Analysis: Low LET Radiation, Part II: Scientific Bases for Health Effects Models, US Nuclear Regulatory Commission, 1989.
Browne D, Weiss JF, MacVittie TJ, Pillai MV (eds)Treatment of Radiation Injuries, 1990, Plenum Press, New York, p. 229
AFRRI Medical Effects of Nuclear Weapons Course “Triage and Treatnent of Radiation Casualties” Lecture, slide 35
IAEA, The Radiological Accident in San Salvador, 1989
Ricks RC, Berger ME, O’Hara FM, The Medical Basis for Radiation-AccidentPreparedness – The Clinical Care of Victims, Parthenon Publishing Group, Inc:New York:2002.
Saenger EL, Andrews GA, Linnemann RE, Wald N: Radiation Accident Preparedness-Medical and Managerial Aspects. Science-Thru-Media: New York 1981, p 15.
Revision 6.1 – 17 Apr 2004