Nuclear technology and the use of radiation have spread into fields from warfare to healthcare, and from

space exploration to terrestrial transport. With this widespread use comes the possibility of accidents involving radiation, possibly combined with trauma. Natural background radiation is the largest single source of radioactive exposure for most living things on earth. It is made up of cosmic radiation and radiation from naturally occurring radioactivity in the soil. Background radiation is small and mostly unavoidable. Other minor sources of small amounts of radiation abound in everyday life: building materials, televisions, smoke detectors, glaze in ceramics at home, even radon in the air we breathe. Occupational exposure can occur in nuclear power generation, industrial applications, medical and research facilities, and in the disposal of nuclear waste. Radiation injuries, like other trauma, have a scale of severity from minor incidental exposure to large-scale accidents such as Chernobyl and Goiania. The latter are medical, social and ecological disasters, and thankfully are extremely rare. It is much more likely that the medical practitioner will encounter the former, as a result of occupational or accidental public exposure. Radiation injuries are very uncommon, due in part to the fewer nuclear facilities compared to other industries, but also to the strict safeguards imposed by most authorities upon the use, transport and disposal of radioactive material and products, as well as on the use of radiation-producing devices. Key points • Natural background radiation is the largest single source of radioactive exposure for most living things on earth

Basic radiation science Radiation damage is caused by transmission of energy from radiation sources to biological material. These sources may be radioactive materials which emit particles such as alpha and beta particles, and neutrons, or gamma rays (photons), or they may be artificial sources of radiation such as x-ray machines. Radioactive materials may in turn be sealed (where the source is encapsulated) or unsealed (where the source is a potential source of contamination). Radiation can be measured in various ways :

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Exposure, measured in coulomb/kg , refers to the ionisation produced in air by x or gamma rays . Absorbed dose, measured in gray (Gy), refers to the energy absorbed per kilogram by a material such as an organ or tissue. Equivalent dose, measured in sievert (Sv) takes into account the differing effects that each type of radiation has on body tissue. For example, 1 Gy from alpha radiation has twenty times the effect on tissue than that from 1 Gy of gamma or x-radiation.

Effective dose, also measured in Sv, takes into account the differing sensitivity to radiation of various tissues. This allows assessment of severity of injury by converting separate tissue doses into a whole-body

dose, which in turn can be used to estimate the biological relevance of a person’s radiation exposure. The effective dose is derived by adding the product of the equivalent dose and a tissue weighting factor for all exposed organs.

The quantity of a radioactive material (radioisotopes or radionuclides) is called the activity, measured in becquerels (Bq). As the Bq is a very small amount, multiples such as kBq or MBq are common. Each radioisotope has different types and energies of emissions. For photon emitters a quantity sometimes called the dose rate constant, measured in at 1 metre, is used to describe the radiation intensity from a particular radioisotope.

Key points • Radiation damage is caused by transmission of energy from radiation sources to biological material

Types of radiation accidents It is very important to understand the difference between radiation exposure and contamination with radioactive materials. Exposure from sources of x-rays and gamma rays does not itself create a radiation hazard to others. Internal or external contamination, even with low activities of radioisotopes, can create a significant radiation hazard to those treating the patient. In some cases the same radioisotope source can represent very different hazards, depending on whether the source is sealed or unsealed. For example, the amount of radium226 once used in watches constitutes a low level hazard whilst contained, but if incorporated into the body, can be quite toxic. There are four types of radiation accidents :

Whole or partial body irradiation from external sources. Examples of this type of accident are inadvertent exposure from industrial radiography sources, or from picking up a sealed radioactive source and carrying it in a pocket. These patients are not themselves radioactive, but may have received large localised or generalised absorbed doses, which may not have produced any symptoms at the time of presentation. They may be managed in the normal hospital environment quite safely once any sealed source is removed.

Internal contamination only. The patient has ingested, inhaled, or otherwise incorporated an unsealed radioactive material into their body. These accidents may arise from industrial or medical incidents, or even in bizarre cases, attempted suicides. The patient is radioactive, and is a potential source of contamination. If the contamination is totally internal, the patient may be treated in the emergency room, but all body fluids must be assumed to be contaminated until proven otherwise.

External contamination with or without internal contamination. Typical accidents are those arising from transport or handling unsealed radioactive materials. They are a potentially significant source of contamination, and special precautions may be needed to prevent the spread of contamination to the local environment and staff, and to prevent internal contamination of the patient. Patients may need concurrent treatment of injuries, and in most cases, the urgent treatment of injuries should take precedence over decontamination. Use of universal precautions will minimise the risk of contamination in this phase. Once the patient is stabilised, the contamination should be dealt with.

Radioactive sources embedded within the patient. This is an unusual situation, usually arising from explosive accidents, but some patients who are being treated with implanted radioactive material and discharged, could conceivably be an emergency admission due to other causes. The embedded source may be of low activity and hazard, or may be a significant source of radiation.

Many accidents involving the whole body can cause multi-system problems that result in systemic symptoms, where more limited exposure will only manifest as local effects. It is therefore important in radiation injuries to not only assess the patient, but also the incident, and determine the type and dose of radiation. An accident history should be compiled as soon as possible to allow proper assessment of treatment and risks. Key points • • Understand the difference between radiation exposure and contamination with radioactive materials Many accidents involving the whole body can cause multi-system problems that result in systemic symptoms, where more limited exposure will only manifest as local effects

Effects of radiation exposure The injuries that result from radiation exposure depend on several factors, including: • • • • • • dose type of radiation source of radiation body part exposed length and intensity of exposure whether contamination is present

Radiation effects are divided into two categories – stochastic and deterministic: Stochastic effects are those where there is assumed to be a probability of the effect occurring at any dose, with the probability increasing with dose (the linear, no threshold hypothesis). Stochastic effects include carcinogenesis and leukaemogenesis. The period between the radiation exposure and the manifestation of the effect may be many years, more for solid tumours than for leukaemia. The overall population lifetime probability of fatal cancer radiation for low doses at low dose rates is assumed to be 5%/Sv. Deterministic effects are those where there is a threshold dose, below which the effect does not occur. Above the threshold, the severity of the effect increases with dose. Examples are epilation, radiation sickness, erythema, radiation cataract and sterilisation. The thresholds vary markedly. Acute radiation effects are basically a severe form of deterministic effects.

There is a relatively long latent period between the radiation exposure and the clinical manifestation of stochastic effects – up to decades for solid tumours. For deterministic effects, the latent period is however very short – hours to days in many cases. Key points • Radiation effects are divided into two categories – stochastic and deterministic

Acute radiation syndrome (ARS) Acute high level (usually >1Gy) whole body irradiation by penetrating radiation like photons (gamma and x rays) may result in damage to multiple organ systems – a complex clinical entity called acute radiation syndrome. Such radiation exposure can occur in reactor accidents or industrial accidents involving unprotected individuals, or from the use of nuclear weapons. While such exposures are rare, they call for an immediate and careful response. In over 80% of fatal radiation accidents, it is the whole body radiation exposure which has been the cause of death. Organ systems damaged include:


Haematopoietic – Bone marrow suppression occurs resulting in neutropaenia and thrombocytopaenia. An initial reactive rise in neutrophils is followed by a decline that occurs from 1-21 days post-dose. Recovery of cell numbers starts about 30 days after exposure. A brief rise in neutrophils may occur earlier but is not usually sustained. Serial lymphocyte counts can give a prognosis: if the trough count is >109 L-1 then there 1.2 will be a probable benign course. Treatment will be required below this. Troughs <109 L-1 indicate severe illness, and near total lymphopaenia×0.5 in the first 6 hours is usually quickly fatal


Gastrointestinal – The effects are related to the loss of gastrointestinal epithelium. Initial symptoms are nausea, vomiting and diarrhoea. A dose of greater than 12Gy precludes mucosal regeneration. The damage to the mucosa results in decreased gut motility, absorption and secretion. Diarrhoea, malabsorbtive syndromes and GIT infections result. Bloody diarrhoea indicates a very poor prognosis.


Cardiovascular – High dose radiation of about 15 Gy causes tissue oedema and cytokine release which manifests as hypotension, fever and vomiting. Oedema of specific organs has its own consequences, eg., cerebral oedema. Extreme doses of 50 Gy can affect cell membranes directly to cause neurological impairment prior to death.

For convenience, the temporal sequence of events following exposure is somewhat arbitrarily divided into : (1) prodromal period, (2) latent period, (3) period of illness, and (4) period of recovery or death (Table. 23.1) The prodromal period occurs in the few hours after exposure, and is when transitory symptoms are apparent, the type, timing and severity of which depend on dose. The latent period is the time before the development of the symptoms of bone marrow, gastrointestinal or neurovascular abnormalities. A period of manifest illness then occurs which consists of the organ system damage effects described above. The course of illness is completed by recovery over months or death if the organ damage was too high. Death can occur at any stage. The approximate timing of some of the symptoms of ARS is shown in Table 23.2 Key points

Acute high level (usually >1Gy) whole body irradiation by penetrating radiation like photons (gamma and x rays) may result in damage to multiple organ systems – a complex clinical entity called acute radiation syndrome

Local injury effects In any radiation exposure accident there is usually a variation in absorbed dose along the exposed region of the body. If the trunk dose is not high enough to cause ARS, but there has been a high dose to a limited area, it is usually referred to as local radiation injury. Such exposure can occur when body parts or skin are exposed to small radioactive sources outside their normal containment, or when exposed to direct x ray beams in industrial or medical settings. High dose radiotherapy can have the same effects. The local effects depend on the tissue affected and the depth of penetration of the radiation. The type of radiation is therefore important, given that photons (gamma and x rays) penetrate much further than beta particles, which give a high dose to superficial tissue. It is important to realise that, even if the exposure was very localised, ARS may still co-exist with local effects. Skin reactions are the main effect of local exposure since skin (most often the hand) generally receives the highest dose in these cases. The effects may be erythema with or without oedema, loss of hair, flaking of skin, blisters, and dry or moist desquamation with subsequent tissue necrosis. Time frames and duration vary as shown in Fig. 23.1. When radiation damages cutaneous and subcutaneous tissue, subsequent disease may be related to the loss of sweat glands, nerve tissue, hair follicles, and blood vessels, with some damage occurring similar to burns. Radiation damage may persist long after the corresponding physical trauma and become manifest years later as necrosis or tissue breakdown. Key points • Skin reactions are the main effect of local exposure

Long term effects Local long term effects from radiation include fibrosis, tissue atrophy, necrosis, and chronic skin conditions. Both skin and underlying tissue, such as lung, gut or muscle can be affected, long after the other injuries from exposure have resolved. For example, lung fibrosis can follow years after chest exposure to high energy photons during breast radiotherapy. Specific disorders include joint stiffening and decreased range of movement due to tendon and synovial thickening or breakdown, changes to sensation of exposed skin, and the development of cataracts in the eyes. The sequelae of whole body exposure depend on the complications from the acute radiation syndrome. Infection, damage to haematopoietic and other systems will dictate the course of illness and recovery. Exposure of the whole body will produce similar late effects to exposed areas as from local exposure if the skin dose was sufficiently high.

Radiation has the potential to transform genetic material. Radiation exposure to the foetus can result in mental retardation of the infant, an increased risk of the future development of leukaemia and other childhood cancers years after the exposure, as well as organ maldevelopment. Although the doses needed to cause some of these effects are relatively high, foetal exposure may at times be a cause for concern. Analysis of data after the atomic bombing of Hiroshima and Nagasaki, and later of major radiation accidents such as the reactor disaster at Chernobyl, has demonstrated increases in the incidence of cancer, supported by studies of people exposed to low dose radiation by their occupation or environment. Cancers particularly associated with radiation are:

Skin cancers – these result from larger doses, usually associated with radiodermatitis. The skin is more resistant to carcinogenesis by radiation than internal organs, but non-melanoma skin cancers can and do occur at higher doses.

Lung cancer – can be induced by inhalation of radioactive particles or gases (such as radon) or by exposure to external sources. Evidence of increased lung cancer has been found for both atomic bomb survivors and to early radiotherapy patients treated with high dose x-rays to the chest.

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Bone cancers – eg., osteosarcomas, have been induced especially by internalised sources such as radium, absorbed by the body by ingestion or contamination. Other radionuclides can have similar effects. Thyroid cancer – there is a confirmed link between thyroid cancer incidence and radiation exposure. This exposure includes direct exposure to external x-rays (eg., medical equipment), ingestion of food products from a contaminated source, or from a radioiodine contaminated environment. The foetus is particularly at risk.

Leukaemias – even relatively small doses of radiation have been found to be associated with a rise in leukaemia incidence. Breast cancer – modern mammographic techniques and equipment however deliver very small doses to the breast.

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Key points Local long term effects from radiation include fibrosis, tissue atrophy, necrosis, and chronic skin conditions

Management of radiation accident victims Immediate management Radiation accidents can involve trauma of more conventional nature. Burns, physical trauma, chemical effects, or inhalational injuries can be part of the accident and more acutely life threatening. Adequate resuscitation must take priority.

Particular care must be taken to ensure the safety of medical, paramedical and emergency services staff attending an incident having a possible radiation component. Hospitals near a nuclear site with potential for radiation accidents will normally have a disaster plan that incorporates procedures for dealing with accident victims. In addition to resuscitation and treatment of acute conditions, the initial (hospital) management of the radiation accident victim should include: • • • • Monitoring and decontamination – as above, with priority to remove any internal radioactive contamination Serial blood & urine samples – to assess ingested radionuclide uptake and retention Serial blood counts – for lymphocyte counts to help prognosis Full history of any existing conditions or illnesses, especially incompletely treated infections or unhealed wounds. These may have an altered course as a result of the exposure.

Key points • • Adequate resuscitation must take priority Local radiation regulatory authorities must be informed, and radiation professionals such as medical physicists must be included into the treatment team at the earliest possible stage

In addition, the local radiation regulatory authorities must be informed, and radiation professionals such as medical physicists must be included into the treatment team at the earliest possible stage. This ensures appropriate procedures and equipment, such as the correct detectors for the particular radiation involved. Information gathering about the event is vital. Much of the relevant history will be about the type of radiation, the period of exposure and the exposed body parts. The patient is unlikely to have this information, and it will have to be sought from the victim’s employer for example (see Table 23.3).

Decontamination After identification of a radiation accident involving contamination, strict controls must be instituted to prevent further contamination outside those already affected. These include: • Protective clothing and equipment for all rescue and treating staff Establishment of a restricted and isolated zone incorporating the area of increased radioactivity . All personnel must be checked in and out and all equipment and contaminated clothing removed at the exit. • Removal of patient’s contaminated clothing – as soon as practicable given resuscitation needs and other injuries. Outer clothing should be cut off the patient. Outer surfaces should be folded inwards to prevent spread. Personal items can be kept safely but also in a controlled area until decontaminated.

Monitoring – use of detection devices to monitor what items are contaminated. Monitoring of all patients is required to separate those contaminated. Regular monitoring of staff is required to ensure their safety.

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Prevention of contamination or equipment – place plastic sheets under equipment and casualties. If contamination could be spread to other areas of the hospital, for example with unstable patients, barriers and controlled areas should be set up within the hospital. There should be covered floors in the treatment area, and a covered route to and from the receiving area.

There must be a system of collection and disposal of waste in labelled double bags to an appropriate facility. After clean up, monitoring of the area is necessary to assess any persistent radiation.

Small numbers of contaminated particles on the skin can be removed at the scene. More extensive decontamination may need to take place at the hospital or disaster centre. Decontamination involves washing of skin multiple times with soap/detergent and monitoring between washes. Damage to skin should be avoided. Covering of clean parts of the body while washing will reduce spread of contaminants. Wounds should be cleaned in the usual manner, but irrigated several times afterwards. Do not forget eyes, ears, mouth and nose as possible areas of contamination. However, complete decontamination can rarely be achieved. Inhaled, ingested or absorbed contamination needs a more complex treatment depending on the type of substance and route of contamination. Gastrointestinal clearance can be achieved by increasing transit speed, gastric lavage and aspiration via nasogastric tube, and by manipulating the gut environment to reduce absorbtion of radioactive material. In the case of absorbed radioactive iodine, the administration of stable iodine can saturate the thyroid gland to minimise further uptake of the radioisotope. Other substances can be diluted by administration of large amounts of non-radioactive isotopes to displace or increase excretion of the radioactive isotope. Chelating agents can also be use to bind radioisotopes. Examples are EDTA for transuranic elements, DTPA for transuranics and some rare earths, and desferoxamine for plutonium. More radical approaches for clearance of lungs such as pulmonary lavage are possible, but have significant associated morbidity. In all cases, the effect of decontamination is assessed by monitoring the patient and the patient’s urine and faeces to monitor absorption and clearance. Key points • • Strict controls must be instituted to prevent further contamination Small numbers of contaminated particles on the skin can be removed at the scene. More extensive decontamination may need to take place at the hospital or disaster centre.

Non-radiation trauma In a disaster situation, it is likely that those affected will have physical and/or chemical trauma as well as the radiation effects. The treatment of these injuries may not be significantly affected by radiation exposure. There are some important factors to take into account: • Radiation exposure can reduce healing. Radiation injury and other injuries will combine to give a longer recovery period and greater morbidity and mortality. • Any surgical procedures necessary are best done in the first 48 hours before any fall in blood cell numbers occurs. Other surgery is best delayed by up to months to enable recovery from radiation syndromes. • Infection control is of paramount importance. Haematology advice should be sought regarding transfusions, and platelet replacement before surgical procedures in the pancytopenic patient. • The symptoms and signs of radiation illness are altered in the presence of other trauma – the patient may be assessed as having a higher dose of radiation due to thermal burns or gastrointestinal bleeding from physical trauma.

Key points • • • Those affected will have physical and/or chemical trauma as well as the radiation effects Infection control is of paramount importance The symptoms and signs of radiation illness are altered in the presence of other trauma

Treatment of specific conditions Acute radiation syndrome This syndrome is treated according to the dose received and severity of symptoms, and is aimed at supporting the patient, treating the haematopoietic damage and controlling opportunistic infection. Supportive treatment aims to alleviate symptoms. Control of nausea is achieved using centrally and peripherally acting medications. H3 receptor antagonists can be more effective in the control of radiation induced emesis. Support in the form of fluids and adequate feeding is necessary to restore losses from diarrhoea and reduced absorption in the gastrointestinal system. The high turnover of cells also increases the body’s requirements. A high energy diet should be formulated that includes essential amino acids, vitamins A and E and selenium. Specialist dietetic advice should be sought. Damage to the gastrointestinal system may require the use of antibiotic cover and parenteral feeds. The treatment of the haematopoietic damage is aimed at supporting the patient while the system recovers. If the exposure leaves sufficient stem cells viable (about 10%), the patient will in time be able to regenerate the losses. Haematology review and supervision should be requested as the regime will be similar to that for

haematology/oncology patients with neutro-, lympho- or throbocytopaenia. This may include colony stimulating factors, or even stem cell transplant if the patient has received a very high dose. Complications at this stage are bleeding and infection. Control of infection starts when the patient is first assessed. All practical effort should be made to exclude or treat infection while the patient still has sufficient immune resources. If in hospital, isolation such as that for neutropaenic oncology patients should be observed. Broad spectrum antibiotic cover may be necessary for febrile patients, depending on specialist advice. Key points • Support the patient Treat haematopoietic damage Control opportunistic infection

Local radiation effects Care of superficial skin damage may be supportive, by keeping clean and excluding infection while the skin heals. Irritating methods and substances such as brushes and soaps should be avoided. Protection from sun exposure is required. For comfort, non-steroid creams can be applied. More extensive skin damage involving deeper layers, pain, breaks in the skin or tissue necrosis requires more active treatment. High doses of radiation result in skin that cannot be saved. Necrosis and ulceration occur and are treated on a symptomatic basis with adequate analgesia and prevention of infection. As in other extensive skin trauma, skin grafting may be required, particularly in larger areas of dead skin, radiodermatitis, or to improve function or appearance. In radiation trauma, there may be significant damage to underlying vascular tissue which may not be macroscopically apparent, and this can compromise graft survival. Late tissue necrosis may occur up to years after the dose, as well as skin cancers, tendon and joint degeneration. Follow up Given the public sensitivity to radiation matters, and the potential for serious long term effects, follow up of radiation trauma patients is essential. As in other trauma, counselling is effective, but explanation of risks to expectant mothers, possible genetic risks, and the potential for future effects including cancer should all be addressed. For low dose exposure, most patients will not require long term follow up. For more severe exposure, the patient should be made aware of the need to seek advice even at times far removed from the event Key points • Follow up of radiation trauma patients is essential


Although it is unlikely that hospitals will ever have to deal with radiation injury, it is important that plans are developed to seek the relevant advice should such an incident occur. Radiation safety officers and/or medical physicists are employed in many institutions using radiation equipment or radioactive materials, including hospitals. From accidental minor exposure in the workplace to large disasters, an awareness of the basic issues in radiation injury management will enable the trauma worker to identify when specialist help needs to be sought. With radiation a new technology increasingly in our lives, it behoves us to be ready to manage its potential dangers.

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