Radiation Safety for Family of Patietns Recieving Treatment

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This fact sheet is for clinicians. If you are a patient, we strongly advise that you consult with your doc to interpret the information provided as information technology may apply to you lot. Data on Acute Radiation Syndrome (ARS) for members of the public can be found at http://emergency.cdc.gov/radiation/ars.htm

Acute Radiation Syndrome (ARS) (sometimes known equally radiation toxicity or radiations sickness) is an acute illness caused by irradiation of the entire trunk (or near of the torso) by a high dose of penetrating radiations in a very short menstruum of time (usually a matter of minutes). The major cause of this syndrome is depletion of immature parenchymal stem cells in specific tissues. Examples of people who suffered from ARS are the survivors of the Hiroshima and Nagasaki diminutive bombs, the firefighters that starting time responded after the Chernobyl Nuclear Ability Institute effect in 1986, and some unintentional exposures to sterilization irradiators.

The required conditions for Acute Radiation Syndrome (ARS) are:

• The radiation dose must be large (i.eastward., greater than 0.7 Gray (Gy)^{1, two} or lxx rads).
  • Mild symptoms may be observed with doses as low as 0.iii Gy or 30 rads.
• The dose usually must be external ( i.eastward., the source of radiation is outside of the patient's trunk).
  • Radioactive materials deposited inside the trunk have produced some ARS effects but in extremely rare cases.
• The radiation must be penetrating (i.e., able to reach the internal organs).
  • High energy X-rays, gamma rays, and neutrons are penetrating radiations.
• The unabridged body (or a meaning portion of it) must accept received the dose³.
  • Most radiations injuries are local, frequently involving the easily, and these local injuries seldom cause classical signs of ARS.
• The dose must have been delivered in a short time (ordinarily a affair of minutes).
  • Fractionated doses are frequently used in radiations therapy. These are large full doses delivered in modest daily amounts over a period of fourth dimension. Fractionated doses are less effective at inducing ARS than a unmarried dose of the same magnitude.

The three classic ARS Syndromes are:

• Bone marrow syndrome (sometimes referred to as hematopoietic syndrome) the full syndrome will unremarkably occur with a dose between 0.7 and x Gy (seventy – thousand rads) though mild symptoms may occur every bit depression as 0.3 Gy or 30 rads⁴.
  • The survival rate of patients with this syndrome decreases with increasing dose. The primary cause of death is the devastation of the os marrow, resulting in infection and hemorrhage.
• Gastrointestinal (GI) syndrome: the total syndrome will usually occur with a dose greater than approximately 10 Gy (1000 rads) although some symptoms may occur as depression as half dozen Gy or 600 rads.
  • Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance. Decease usually occurs within 2 weeks.
• Cardiovascular (CV)/ Central Nervous Organisation (CNS) syndrome: the total syndrome will usually occur with a dose greater than approximately fifty Gy (5000 rads) although some symptoms may occur as low as 20 Gy or 2000 rads.
  • Death occurs inside 3 days. Death likely is due to collapse of the circulatory arrangement as well every bit increased force per unit area in the circumscribed cranial vault as the result of increased fluid content acquired by edema, vasculitis, and meningitis.

The four stages of ARS are:

• Prodromal phase (N-V-D stage): The classic symptoms for this stage are nausea, airsickness, as well equally anorexia and possibly diarrhea (depending on dose), which occur from minutes to days following exposure. The symptoms may last (episodically) for minutes upwards to several days.
• Latent stage: In this stage, the patient looks and feels generally healthy for a few hours or even up to a few weeks.
• Manifest disease stage: In this stage the symptoms depend on the specific syndrome (see Table 1) and last from hours up to several months.
• Recovery or death: Most patients who exercise not recover volition die within several months of exposure. The recovery process lasts from several weeks up to ii years.

These stages are described in farther particular in Tabular array 1

Table ane: Acute Radiation Syndromes

Syndrome	Dose*	Prodromal Stage	Latent Stage	Manifest Illness Stage	Recovery
Hematopoietic (Bone Marrow)	> 0.7 Gy (> 70 rads) (balmy symptoms may occur as low as 0.3 Gy or 30 rads)	• Symptoms are anorexia, nausea and vomiting. • Onset occurs 1 hour to 2 days after exposure. • Stage lasts for minutes to days.	• Stalk cells in os marrow are dying, although patient may appear and feel well. • Stage lasts i to 6 weeks.	• Symptoms are anorexia, fever, and angst. • Driblet in all blood cell counts occurs for several weeks. • Main crusade of death is infection and hemorrhage. • Survival decreases with increasing dose. • Nearly deaths occur inside a few months afterwards exposure.	• in most cases, bone marrow cells will begin to repopulate the marrow. • There should be full recovery for a large per centum of individuals from a few weeks up to two years after exposure. • death may occur in some individuals at 1.ii Gy (120 rads). • the LD50/60† is well-nigh 2.5 to 5 Gy (250 to 500 rads)
Gastrointestinal (GI)	> ten Gy (> 1000 rads) (some symptoms may occur as depression every bit 6 Gy or 600 rads)	• Symptoms are anorexia, astringent nausea, vomiting, cramps, and diarrhea. • Onset occurs within a few hours afterwards exposure. • Stage lasts about 2 days.	• Stem cells in bone marrow and cells lining GI tract are dying, although patient may appear and feel well. • Stage lasts less than 1 week.	• Symptoms are angst, anorexia, severe diarrhea, fever, dehydration, and electrolyte imbalance. • Expiry is due to infection, dehydration, and electrolyte imbalance. • Death occurs within ii weeks of exposure.	• the LD100‡ is almost x Gy (1000 rads)
Cardiovascular (CV)/ Central Nervous System (CNS)	> 50 Gy (5000 rads) (some symptoms may occur as depression equally twenty Gy or 2000 rads)	• Symptoms are extreme nervousness and confusion; severe nausea, airsickness, and watery diarrhea; loss of consciousness; and burning sensations of the pare. • Onset occurs within minutes of exposure. • Stage lasts for minutes to hours.	• Patient may return to partial functionality. • Stage may last for hours just often is less.	• Symptoms are render of watery diarrhea, convulsions, and coma. • Onset occurs v to half-dozen hours after exposure. • Decease occurs inside 3 days of exposure.	• No recovery is expected.

* The absorbed doses quoted here are "gamma equivalent" values. Neutrons or protons generally produce the aforementioned furnishings every bit gamma, beta, or X-rays merely at lower doses. If the patient has been exposed to neutrons or protons, consult radiations experts on how to interpret the dose.

† The LD50/threescore is the dose necessary to kill 50% of the exposed population in 60 days.

‡ The LD100 is the dose necessary to kill 100% of the exposed population

Cutaneous Radiations Syndrome (CRS)

The concept of cutaneous radiations syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome that results from astute radiation exposure to the skin.

ARS usually will exist accompanied past some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or 10-rays. Sometimes this occurs when radioactive materials contaminate a patient'due south skin or clothes.

When the basal cell layer of the skin is damaged past radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged, causing epilation. Within a few hours subsequently irradiation, a transient and inconsistent erythema (associated with itching) tin can occur. Then, a latent phase may occur and last from a few days up to several weeks, when intense reddening, blistering, and ulceration of the irradiated site are visible.

In most cases, healing occurs by regenerative means; nevertheless, very large skin doses can crusade permanent hair loss, damaged sebaceous and sweat glands, atrophy, fibrosis, decreased or increased skin pigmentation, and ulceration or necrosis of the exposed tissue.

Patient Management

Triage: If radiation exposure is suspected:

• Secure ABCs (airway, breathing, apportionment) and physiologic monitoring (claret pressure level, blood gases, electrolyte and urine output) equally appropriate.
• Treat major trauma, burns and respiratory injury if evident.
• In addition to the blood samples required to address the trauma, obtain blood samples for CBC (complete blood count), with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to whatsoever initial transfusion and at periodic intervals following transfusion.
• Care for contamination as needed.
• If exposure occurred within 8 to 12 hours, repeat CBC, with attending to lymphocyte count, 2 or iii more times (approximately every 2 to iii hours) to appraise lymphocyte depletion.

Diagnosis
The diagnosis of ARS tin be difficult to make because ARS causes no unique disease. Also, depending on the dose, the prodromal stage may not occur for hours or days after exposure, or the patient may already be in the latent phase by the time they receive handling, in which instance the patient may appear and feel well when first assessed.

If a patient received more than 0.05 Gy (v rads) and three or four CBCs are taken inside 8 to 12 hours of the exposure, a quick estimate of the dose can be made (see Ricks, et. al. for details). If these initial blood counts are not taken, the dose can nevertheless be estimated by using CBC results over the first few days. It would be best to have radiation dosimetrists conduct the dose assessment, if possible.

If a patient is known to have been or suspected of having been exposed to a large radiation dose, describe claret for CBC analysis with special attention to the lymphocyte count, every 2 to 3 hours during the offset 8 hours subsequently exposure (and every 4 to 6 hours for the side by side two days). Observe the patient during this fourth dimension for symptoms and consult with radiation experts before ruling out ARS.

If no radiations exposure is initially suspected, you lot may consider ARS in the differential diagnosis if a history exists of nausea and vomiting that is unexplained by other causes. Other indications are bleeding, epilation, or white claret count (WBC) and platelet counts abnormally depression a few days or weeks after unexplained nausea and airsickness. Again, consider CBC and chromosome analysis and consultation with radiation experts to confirm diagnosis.

Initial Treatment and Diagnostic Evaluation
Care for airsickness^v, and repeat CBC assay, with special attention to the lymphocyte count, every 2 to 3 hours for the starting time viii to 12 hours following exposure (and every 4 to 6 hours for the following two or 3 days). Sequential changes in absolute lymphocyte counts over fourth dimension are demonstrated below in the Andrews Lymphocyte Nomogram (see Figure 1). Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening or blistering of the pare. Be sure to include fourth dimension of onset.

Figure 1: Andrews Lymphocyte Nomogram

From Andrews GA, Auxier JA, Lushbaugh CC. The Importance of Dosimetry to the Medical Management of Persons Exposed to Loftier Levels of Radiation. In Personal Dosimetry for Radiations Accidents. Vienna : International Atomic Energy Agency; 1965.

Note and record areas of erythema. If possible, take color photographs of suspected radiation pare harm. Consider tissue, claret typing, and initiating viral prophylaxis. Promptly consult with radiation, hematology, and radiotherapy experts about dosimetry, prognosis, and treatment options. Call the Radiation Emergency Assistance Center/Training Site (REAC/TS) at (865) 576-3131 (M-F, eight am to 4:30 am EST) or (865) 576-1005 (afterwards hours) to record the incident in the Radiation Accident Registry System.

After consultation, brainstorm the post-obit (every bit indicated):

• supportive care in a clean surround (if available, the use of a burn unit may be quite effective)
• prevention and treatment of infections
• stimulation of hematopoiesis past use of growth factors
• stalk cell transfusions or platelet transfusions (if platelet count is too low)
• psychological support
• conscientious ascertainment for erythema (certificate locations), pilus loss, skin injury, mucositis, parotitis, weight loss, or fever
• confirmation of initial dose approximate using chromosome abnormality cytogenetic bioassay when possible. Although resource intensive, this is the best method of dose assessment post-obit acute exposures.
• consultation with experts in radiations accident management

For More Help

Technical assistance tin can be obtained from the Radiation Emergency Assistance Heart/Training Site (REAC/TS) at (865) 576-3131 (M-F, eight am to 4:xxx pm EST) or (865) 576-1005 (after hours), or on their spider web site at http://www.orau.gov/reacts/external icon, and the Medical Radiobiology Informational Team (MRAT) at (301) 295-0316.

Also, more data can exist obtained from the CDC Health Alert Network at emergency.cdc.gov or by calling (800) 311-3435.

References

Berger ME, O'Hare FM Jr, Ricks RC, editors. The Medical Footing for Radiation Accident Preparedness: The Clinical Care of Victims. REAC/TS Conference on the Medical Ground for Radiations Accident Preparedness. New York : Parthenon Publishing; 2002.

Gusev IA , Guskova AK , Mettler FA Jr, editors. Medical Management of Radiation Accidents, 2 nd ed., New York : CRC Press, Inc.; 2001.

Jarrett DG. Medical Direction of Radiological Casualties Handbook, 1 st ed. Bethesda , Maryland : Armed services Radiobiology Research Found (AFRRI); 1999.

LaTorre TE. Primer of Medical Radiobiology, 2 nd ed. Chicago : Year Book Medical Publishers, Inc.; 1989.

National Council on Radiations Protection and Measurements (NCRP). Direction of Terrorist Events Involving Radioactive Material, NCRP Report No. 138. Bethesda , Maryland : NCRP; 2001.

Prasad KN. Handbook of Radiobiology, 2 nd ed. New York : CRC Press, Inc.; 1995.

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1. The Grey (Gy) is a unit of measurement of absorbed dose and reflects an amount of free energy deposited into a mass of tissue (one Gy = 100 rads). In this document, the referenced absorbed dose is that dose inside the patient'southward torso (i.east., the dose that is normally measured with personal dosimeters).
2. The referenced absorbed dose levels in this document are assumed to be from beta, gamma, or 10 radiation. Neutron or proton radiation produces many of the wellness effects described herein at lower captivated dose levels.
3. The dose may not exist compatible, merely a large portion of the body must accept received more than 0.7 Gy (70 rads).
4. Note: although the dose ranges provided in this document apply to most healthy adult members of the public, a corking deal of variability of radiosensitivity amongst individuals exists, depending upon the historic period and condition of health of the individual at the time of exposure. Children and infants are especially sensitive.
5. Collect vomitus in the outset few days for later analysis.

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Source: https://www.cdc.gov/nceh/radiation/emergencies/arsphysicianfactsheet.htm