Medical response to radiation incidents and radionuclear threats
http://www.100md.com
《英国医生杂志》
1 Department of Protection of the Human Environment, World Health Organization, Geneva 27, CH-1211, Switzerland, 2 Department of Public Health, Semmelweis University, Budapest, Hungary, 3 Department of Nuclear Medicine, Gülhane Medical Academy, Ankara, Turkey, 4 Institute of Pathology and Pathophysiology, Moscow, Russia
Correspondence to: I Turai Turaii@who.int
Events that expose people to radiation are rare, but the threat of radiation injury is increasing. Doctors should know how to recognise and manage suspected exposure or contamination
Introduction
We collected information for this review from our own experience in teaching radiation emergency medicine at national and international training workshops and consulting and treating patients with radiation sickness or radiation injuries, discussions with other experts, reviewing publications of the World Health Organization and International Atomic Energy Agency,8-10 15-17 and from Medline searches using the terms "nuclear terrorism", "radiological terrorism", "radionuclear threat", "radiation accidents", "radiation incidents", "radiation sickness", "radiation injury", "contamination", "medical response", and "medical management".
Summary points
Doctors' unfamiliarity with radiation injuries means they are often misdiagnosed; medical training in this subject needs urgent improvement
Doctors should be aware of the acute and delayed effects of exposure to ionising radiation
Nausea, vomiting, diarrhoea, headache, weakness, and lymphocytopenia may indicate exposure to radiation
The higher the radiation dose to the whole body, the faster and more severe the reduction of blood cell counts
Clinical signs typical for radiation injury of the skin include erythema, depilation, dry and moist desquamation, blistering, ulceration, and necrosis
Doctors need up to date contact information about competent health and radiation protection services
Global statistics and main causes of radiation accidents
As the ionising radiation cannot be detected by human senses, affected people are usually unaware of their exposure. A typical scenario seen repeatedly in recent incidents was people finding shiny metallic objects, actually small radiation sources. The unrecognised sources were often put into pockets, causing severe radiation burns.9 21 Frequently these sources were taken home and the whole family or members of the same residence were exposed. Often the people concerned were collectors of scrap metal or worked as scrap metal dealers.10 12 22
Radiation sickness
Erythema, oedema with pain, blistering, dry and wet desquamation (fig 2), ulceration, necrosis or depilation only in the exposed area of the body. Their time of appearance and severity depend on dose.
Fig 2 Early blister with erythema of large inflammatory halo on rear side of right thigh on day 2, and an extended superficial erosion surrounded by large dusky inflammation on day 9 after 6.5 hour local exposure to iridium-192 source of 0.96 TBq (26 Ci)23
Local skin injuries evolve slowly (usually in weeks to months) and may become painful and difficult to treat with conservative methods. In the absence of history of a skin disease or any other specific information relating its origin to a thermal burn, an insect bite, chemical exposure or allergens, a badly healing dermatological lesion which has been unsuccessfully treated with conservative methods for a substantial period of time (or even with surgery), may be a sign of radiation injury. This should lead a doctor to consider the possibility of a local radiation exposure that could have occurred a few weeks or even months before.
Clinical suspicion
Before offering any care for victims use strict isolation precautions to protect yourself from contamination, dispose of contaminants, and control the spread of radioactivity.15 16 Immediately order complete and differential blood counts to assess severity of exposure. Swab nostrils and oral cavity and wounds to detect any internal contamination. Remove or change the patient's contaminated clothing. Decontaminate the patient with showers and by thoroughly washing open body surfaces. Collect and label urine and faeces of patients who have possible internal radioactive contamination. In case of risk of inhalation of radioactive iodine (after a nuclear incident) urgently seek advice from the health authority or radiation protection authority for use of stable iodine tablets.20
Strategy and safety aspects of the medical response to radiation injuries
Helfand I, Forrow L, Tiwari J. Nuclear terrorism. BMJ 2002;324: 356-9.
Timins JK, Lipoti JA. Radiological terrorism. N J Med 2003;100: 14-21.
Yehezkelli Y, Dushnitsky T, Hourvitz A. Radiation terrorism: the medical challenge. Isr Med Assoc J 2002;4: 530-4.
Kilpatrick JJ. Nuclear attacks. RN. 2002;65: 46-51.
Gonzalez AJ. Securing radioactive sources against terrorism: an international perspective. Health Phys Soc Newsl 2002;30: 3-5.
Mettler FA, Voelz GL. Current concepts: major radiation exposure: what to expect and how to respond. N Engl J Med 2002;346: 1554-61.
Turai I, Veress K, Günalp B, Souchkevitch G. Major radiation exposure. N Engl J Med 2002;347: 946.
Meineke V, van Beuningen D, Sohns T, Fliedner TM. Medical management principles for radiation accidents. Mil Med 2003;168: 219-22.
International Atomic Energy Agency and World Health Organization. Follow-up of delayed health consequences of acute accidental radiation exposure: lessons to be learned from their medical management. Vienna: IAEA, 2002: 129. (IAEA-TecDoc-1300.)
Turai I, Crick M, Ortiz-Lopez P, Nogueira de Oliveira C, Wrixon AD. Response to radiological accidents: the role of the International Atomic Energy Agency. Radioprot 2001;36: 459-75.
Leikin JB, McFee RB, Walter FG, Edsall K. A primer for nuclear terrorism. Dis Mon 2003;49: 485-516.
Turai I, Veress K. Radiation accidents: occurrence, types, consequences, medical management, and the lessons to be learned. Centr Eur J Occup Envir Med 2001;7: 3-14.
Gower-Thomas K, Lewis MH, Shiralkar S, Snow M, Galland RB, Rennie A. Doctors' knowledge of radiation exposure is deficient. BMJ 2002;324: 919.
Turai I, Veress K. Experience gained in teaching of, and training in radiohygiene. Népegészségügy 1993;74: 203-6. (In Hungarian with English abstract and headings.)
International Atomic Energy Agency and World Health Organization. Diagnosis and treatment of radiation injuries. Vienna: IAEA, 1998: 49. (Safety Reports Series No 2.)
International Atomic Energy Agency. Assessment and treatment of external and internal radionuclide contamination. Vienna: IAEA, 1996: 62. (IAEATecDoc-869.)
International Atomic Energy Agency and World Health Organization. How to recognise and initially respond to an accidental radiation injury . Vienna: IAEA, 2000.
Ricks R. REAC/TS Registry of radiation accidents, 1944-2000. Oak Ridge: REAC/TS, 2001.
Hogan DE, Kellison T. Nuclear terrorism. Am J Med Sci 2002;323: 341-9.
Souchkevitch G, Turai I. Radiation emergency response. Geneva: World Health Organization, 2002: 27. (Internal guidance WHO/PHE/RAD/02.06.)
Cosset JM, Jikia D, Peter RU, Souchkevitch G, Turai I. Health consequences among the Lilo accident victims; medical monitoring in Georgia, France and Germany. Vienna: IAEA, 2002, 49-55. (IAEA TecDoc 1300.)
Turai I, Günalp B, Ergen K. The Istanbul accident: a case report of the mixed (acute and protracted) radiation exposure: main consequences and the medical management. In: Fliedner T, Feinendegen LE, Hopewell JW, eds. Chronic irradiation: tolerance and failure in complex biological systems. Br J Radiol 2002;26(suppl): S80-2.
Zaharia M, Pinillos-Ashton L, Picon C, Heredia A, Berger ME, Goans RE, et al. Medical follow-up of the localized radiation injuries of the victim of the Peruvian radiation accident. Vienna: IAEA, 2002: 57-65. (IAEA TecDoc 1300.)(István Turai, medical off)
Correspondence to: I Turai Turaii@who.int
Events that expose people to radiation are rare, but the threat of radiation injury is increasing. Doctors should know how to recognise and manage suspected exposure or contamination
Introduction
We collected information for this review from our own experience in teaching radiation emergency medicine at national and international training workshops and consulting and treating patients with radiation sickness or radiation injuries, discussions with other experts, reviewing publications of the World Health Organization and International Atomic Energy Agency,8-10 15-17 and from Medline searches using the terms "nuclear terrorism", "radiological terrorism", "radionuclear threat", "radiation accidents", "radiation incidents", "radiation sickness", "radiation injury", "contamination", "medical response", and "medical management".
Summary points
Doctors' unfamiliarity with radiation injuries means they are often misdiagnosed; medical training in this subject needs urgent improvement
Doctors should be aware of the acute and delayed effects of exposure to ionising radiation
Nausea, vomiting, diarrhoea, headache, weakness, and lymphocytopenia may indicate exposure to radiation
The higher the radiation dose to the whole body, the faster and more severe the reduction of blood cell counts
Clinical signs typical for radiation injury of the skin include erythema, depilation, dry and moist desquamation, blistering, ulceration, and necrosis
Doctors need up to date contact information about competent health and radiation protection services
Global statistics and main causes of radiation accidents
As the ionising radiation cannot be detected by human senses, affected people are usually unaware of their exposure. A typical scenario seen repeatedly in recent incidents was people finding shiny metallic objects, actually small radiation sources. The unrecognised sources were often put into pockets, causing severe radiation burns.9 21 Frequently these sources were taken home and the whole family or members of the same residence were exposed. Often the people concerned were collectors of scrap metal or worked as scrap metal dealers.10 12 22
Radiation sickness
Erythema, oedema with pain, blistering, dry and wet desquamation (fig 2), ulceration, necrosis or depilation only in the exposed area of the body. Their time of appearance and severity depend on dose.
Fig 2 Early blister with erythema of large inflammatory halo on rear side of right thigh on day 2, and an extended superficial erosion surrounded by large dusky inflammation on day 9 after 6.5 hour local exposure to iridium-192 source of 0.96 TBq (26 Ci)23
Local skin injuries evolve slowly (usually in weeks to months) and may become painful and difficult to treat with conservative methods. In the absence of history of a skin disease or any other specific information relating its origin to a thermal burn, an insect bite, chemical exposure or allergens, a badly healing dermatological lesion which has been unsuccessfully treated with conservative methods for a substantial period of time (or even with surgery), may be a sign of radiation injury. This should lead a doctor to consider the possibility of a local radiation exposure that could have occurred a few weeks or even months before.
Clinical suspicion
Before offering any care for victims use strict isolation precautions to protect yourself from contamination, dispose of contaminants, and control the spread of radioactivity.15 16 Immediately order complete and differential blood counts to assess severity of exposure. Swab nostrils and oral cavity and wounds to detect any internal contamination. Remove or change the patient's contaminated clothing. Decontaminate the patient with showers and by thoroughly washing open body surfaces. Collect and label urine and faeces of patients who have possible internal radioactive contamination. In case of risk of inhalation of radioactive iodine (after a nuclear incident) urgently seek advice from the health authority or radiation protection authority for use of stable iodine tablets.20
Strategy and safety aspects of the medical response to radiation injuries
Helfand I, Forrow L, Tiwari J. Nuclear terrorism. BMJ 2002;324: 356-9.
Timins JK, Lipoti JA. Radiological terrorism. N J Med 2003;100: 14-21.
Yehezkelli Y, Dushnitsky T, Hourvitz A. Radiation terrorism: the medical challenge. Isr Med Assoc J 2002;4: 530-4.
Kilpatrick JJ. Nuclear attacks. RN. 2002;65: 46-51.
Gonzalez AJ. Securing radioactive sources against terrorism: an international perspective. Health Phys Soc Newsl 2002;30: 3-5.
Mettler FA, Voelz GL. Current concepts: major radiation exposure: what to expect and how to respond. N Engl J Med 2002;346: 1554-61.
Turai I, Veress K, Günalp B, Souchkevitch G. Major radiation exposure. N Engl J Med 2002;347: 946.
Meineke V, van Beuningen D, Sohns T, Fliedner TM. Medical management principles for radiation accidents. Mil Med 2003;168: 219-22.
International Atomic Energy Agency and World Health Organization. Follow-up of delayed health consequences of acute accidental radiation exposure: lessons to be learned from their medical management. Vienna: IAEA, 2002: 129. (IAEA-TecDoc-1300.)
Turai I, Crick M, Ortiz-Lopez P, Nogueira de Oliveira C, Wrixon AD. Response to radiological accidents: the role of the International Atomic Energy Agency. Radioprot 2001;36: 459-75.
Leikin JB, McFee RB, Walter FG, Edsall K. A primer for nuclear terrorism. Dis Mon 2003;49: 485-516.
Turai I, Veress K. Radiation accidents: occurrence, types, consequences, medical management, and the lessons to be learned. Centr Eur J Occup Envir Med 2001;7: 3-14.
Gower-Thomas K, Lewis MH, Shiralkar S, Snow M, Galland RB, Rennie A. Doctors' knowledge of radiation exposure is deficient. BMJ 2002;324: 919.
Turai I, Veress K. Experience gained in teaching of, and training in radiohygiene. Népegészségügy 1993;74: 203-6. (In Hungarian with English abstract and headings.)
International Atomic Energy Agency and World Health Organization. Diagnosis and treatment of radiation injuries. Vienna: IAEA, 1998: 49. (Safety Reports Series No 2.)
International Atomic Energy Agency. Assessment and treatment of external and internal radionuclide contamination. Vienna: IAEA, 1996: 62. (IAEATecDoc-869.)
International Atomic Energy Agency and World Health Organization. How to recognise and initially respond to an accidental radiation injury . Vienna: IAEA, 2000.
Ricks R. REAC/TS Registry of radiation accidents, 1944-2000. Oak Ridge: REAC/TS, 2001.
Hogan DE, Kellison T. Nuclear terrorism. Am J Med Sci 2002;323: 341-9.
Souchkevitch G, Turai I. Radiation emergency response. Geneva: World Health Organization, 2002: 27. (Internal guidance WHO/PHE/RAD/02.06.)
Cosset JM, Jikia D, Peter RU, Souchkevitch G, Turai I. Health consequences among the Lilo accident victims; medical monitoring in Georgia, France and Germany. Vienna: IAEA, 2002, 49-55. (IAEA TecDoc 1300.)
Turai I, Günalp B, Ergen K. The Istanbul accident: a case report of the mixed (acute and protracted) radiation exposure: main consequences and the medical management. In: Fliedner T, Feinendegen LE, Hopewell JW, eds. Chronic irradiation: tolerance and failure in complex biological systems. Br J Radiol 2002;26(suppl): S80-2.
Zaharia M, Pinillos-Ashton L, Picon C, Heredia A, Berger ME, Goans RE, et al. Medical follow-up of the localized radiation injuries of the victim of the Peruvian radiation accident. Vienna: IAEA, 2002: 57-65. (IAEA TecDoc 1300.)(István Turai, medical off)