Radiation Injury and the Surgeon
James A Chambers, MD, MPH, Gary F Purdue, MD, FACS
Surgeons must possess a firm understanding of radiation
injury for a variety of reasons. They are accustomed to
the challenges of operating on patients who have had
adjuvant radiation intervention for neoplasms. Surgeons
have also treated victims of industrial radiation catastro-
phes. From 1944 to 1999, 1,342 persons in the US alone
were involved in a total of 243 radiation accidents, with
30 deaths.1 Of increasing concern, as was iterated in a
recent report from Harvard University,2 the US popu-
lace faces a serious threat of terrorist use of ionizing
radiation, placing a burden on US physicians to be pre-
pared for “the most serious threat to national security.”3
Despite the 1968 Nuclear Proliferation Treaty, the end
of the Cold War, and the diminishing US stockpile,
nuclear weapons have been increasingly sought by na-
tions and rogue organizations worldwide in a search for
prestige and security.
Congressional advisory panels have recently assessed
that “the nation’s health and medical systems . . . are
underprepared to address the full scope of terrorist at-
tacks,” recommending, in part, additional education
and training for medical providers, sentiments echoed
by the AMA and Joint Commission on Accreditation of
Healthcare Organizations.4 Although recent publica-
tions have highlighted important aspects of biologic and
chemical warfare for surgeons, the surgical care of radi-
ation casualties has not been as thoroughly discussed.
ESSENTIAL RADIOBIOLOGY
Refer to Figure 1 and Table 1 for information on radia-
tion types and nomenclature. For perspective, one chest
x-ray yields 0.2 mSv of radiation, or 20 mrem, and the
average American’s annual dose from man-made sources
Competing Interests Declared: None.
This article represents the personal viewpoint of the authors and cannot be
construed as a statement of official US Air Force, Department of Defense, or
the US Government policy.
Received November 10, 2005; Revised September 11, 2006; Accepted Sep-
tember 18, 2006.
From the Department of Surgery, University of Texas Southwestern Medical
Center, Dallas, TX.
Correspondence address: James A Chambers, MD, MPH, Department of
Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines
Blvd, Dallas, TX 75390-9158. email: j.a.chambers@gimail.af.mil
© 2007 by the American College of Surgeons
Published by Elsevier Inc.
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is 0.60 mSv.5,6 The lethal dose of radiation for 50% of
those exposed is 3 to 4.5 Gy (4.5 Sv for radiation with
quality factor of 1) of whole body exposure for a 70-kg
person without advanced medical intervention.5
Although small amounts of background irradiation
can stimulate growth in cultured cells,7 in vivo, excessive
irradiation injures tissue through ionization and free
radical formation, resulting in increased membrane per-
meability and DNA damage. DNA misreads and lethal
chromosomal aberrations lead to somatic or germ cell
mutation or cell death.5,8 Radiation lethality is increased
with concomitant burns or trauma, nutritional deficits,
infection, or coexisting disease. Factors that impact cel-
lular radiation effects include: rate of cell division (rap-
idly dividing cells such as spermatogonal or bone stem
cells are very susceptible), dose, radiation quality (low
versus high linear energy transfer [LET], Table 1), dose
rate, dose fractionation (dividing a dose into multiple
smaller ones), oxygen (oxygen tension ⬎ 40 mmHg ren-
ders tissue two to three times more radiosensitive to low
LET radiation as hypoxic cells), and genetic susceptibil-
ity.7 Refer to Figures 2 and 3 for a summary of radiation
effects on the cell and organism as a whole.
Innate responses to damage include limited lipid per-
oxidation repair through lipid peroxidase and glutathi-
one. An extensive list of medical interventions has been
described with putative variable beneficial effects including
oral vitamin E, vitamin C, vitamin A, selenium,6,9 paren-
teral glutathione, cysteine, and cystamine.7 WR-2721, S-2
ethylphosphorothioic acid,WR-3689, and N-acetylcysteine,6,9
oral curcumin,10 and topical aloe vera.9
TRIAGE AND INITIAL MANAGEMENT
Radiation injury can occur from focused beams or point
sources, criticality events, or explosion of a nuclear de-
vice or “dirty bomb” (conventional bomb designed to
disseminate radiologically contaminated material). Ex-
posure results from vapor or direct skin exposure, inha-
lation, or ingestion of contaminated materials, resulting
in irradiation only, contamination of the patient, or in-
corporated radioactive material after ingestion or inha-
lation. The patient might receive a “whole body dose,”
involving more than one-third of the body and affecting
ISSN 1072-7515/07/$32.00
128 doi:10.1016/j.jamcollsurg.2006.09.014
Vol. 204, No. 1, January 2007 Chambers and Purdue Radiation Injury and the Surgeon 129

Figure 1. Types of ionizing radiation.

a considerable portion of the marrow, or might have STABILIZATION, DECONTAMINATION, AND

only sustained damage to a limb or other limited region
(Table 2).
Victims of a nuclear explosion will often have trauma
and burn issues in addition to radiation exposure.11,12 In
both human casualties and rat models, combining radi-
ation injury with burn or mechanical trauma exponen-
tially increases the risk of dying from an otherwise sur-
vivable exposure.12,13 Early closure of open wounds is
necessary to minimize mortality in these patients.12,14
INITIAL ASSESSMENT OF EXPOSURE
A full discussion of decontamination and triage of the
irradiated or contaminated patient are beyond the
scope of this article, and the reader is directed to other
sources, such as NRCP-65.15 Treatment of life-
threatening injuries always takes precedence over de-
contamination and dose-estimation procedures, and
has never resulted in injury to health care workers in
the US.16

Table 1. Radiation Units of Measurement

Measured quantity SI unit Conventional unit Equivalents
Dose: amount of energy absorbed per unit Gray (Gy) Rads (1 Gy ⫽ 100 rads) 1 Gy ⫽ 1 J/kg
mass
Dose equivalent: amount of biologic Sievert (Sv) Rem (1 Sv ⫽ 100 rem) Sv ⫽ Gy ⫻ QF*
damage from a radiation dose (⫽ dose ⫻
“quality factor”*)
Activity – radioactive emission per Becquerel (Bq) ⫽ 1 Curie (Ci) ⫽ 3.7 ⫻ 1010 1 Ci ⫽ 3.7 ⫻ 1010 Bq
unit mass disintegration per second disintegrations/second
For external ␤, ␥, or x-ray exposure, 1 rad ⫽ 1 rem.
*Quality factor (QF) adjusts for the amount of biologic damage caused by a given radiation type: the QF of x-ray, ␥, and ␤ is 1, the QF of ␣ radiation is 20 for
internal exposure, and the QF of neutrons ranges from 3 to 20 depending on the energy. Particulate radiation such as ␣ and neutrons are more densely ionizing
per unit length of tissue exposed than nonparticulate radiation such as x-rays and ␥-rays. The former, more injurious forms of radiation (␣, neutrons, etc) are said
to have a high linear energy transfer (LET), while the x-rays and g-rays are referred to as low LET radiation.

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130 Chambers and Purdue Radiation Injury and the Surgeon J Am Coll Surg

Table 2. Estimation of Whole Body Dose by Prodromal

Abbreviations and Acronyms
Symptoms
Dose (Gy) Onset (h) Duration (h) Latency
ANC ⫽ absolute neutrophil count
ARS ⫽ acute radiation syndrome 0.5–2 Absent to 6 ⬍ 24 Absent to 3 wk
LET ⫽ linear energy transfer 2–3 2–6 12–24 2–3 wk
3–5.5 1–2 24 1.0–2.5
⬎ 5.5 Min to 1 48 2–4 d

Key steps include17: removing the patient from

contamination sources, removing clothes,6,15,18-20 de-
contaminating skin with soap and water, drying with
absorbent material, and evaluating skin and wounds
with radiation probes. Whole body counting is feasi-
ble for ␥, x-rays, or high-energy ␤ particles.21 Nasal
irrigation and unilateral lung lavage can be considered
for inhalation. Gastrointestinal contamination might
require gastric lavage, emetics, activated charcoal,
antacids, or laxatives. Collection of all excreta for assays is
also indicated. Patients with possibly substantial exposure
should have daily complete blood count with differential,
HLA subtyping, and qualititative serologic testing for cy-
tomegalovirus and varicella-zoster virus.22
Surgical debridement can be helpful, with these end
points: ␣ ⬍ 1,000 disintegrations per minute; ␤ ⬍ 1
mR/h (10 uSv/h). Debridement useful for contamina-
tion with ␣-emitters with long half-lives, such as
239
Pu.20 Chelating agents, such as diethylenetriamine
pentaacetate, from the Department of Energy can be
irrigated into wounds or given IV before debridement to
minimize absorption once tissues are disrupted.21 Refer
to Table 3 for information about radionuclides of med-
ical importance.
Exposure can be estimated by clinical symptoms
(type, severity, and time from exposure to onset), and
refined by laboratory analysis (see Tables 2 and 4). It
should be recognized that psychosomatic reactions to
possible radiation exposure manifesting as nausea and
vomiting might be seen in nonirradiated patients, as
evidenced in Goania, Brazil in September 1987.6,23
Radiation does not cause immediate death or imme-
diate burns or wounds. Reenactment of the accident,
frequent color photographs, slit-lamp examination of

Figure 3. Radiation effects on the organism as a whole. CV,

Figure 2. Radiation effects on the cell. LET, linear energy transfer. cardiovascular.

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Vol. 204, No. 1, January 2007
the eyes, baseline extremity x-rays, radionuclide
blood pool imaging, and bone scans can all be useful
initial measures.
For whole body exposure from penetrating radia-
tion, the most useful laboratory test is the lymphocyte
decrease in the first 48 hours postexposure.21 If lym-
phocytes decrease by 50% and are ⬍ 1,000/mm3
within the first 24 to 48 hours, the patient has likely
received at least a moderate radiation dose.19 An ab-
solute neutrophil count (ANC) at 48 hours of 500 to
1,000 indicates a severe injury, and ⬍ 500 very severe
to lethal injury; continued fall after 48 hours also
portends lethal injury as does a high granulocyte
count that continues to rise after 24 hours.12,24 The
lymphocyte count is less reliable in patients with com-
bined injuries (thermal burns, trauma, and so forth).
Lymphocyte culture is the most sensitive assay for
whole body exposure (detects 1 cGy exposure), but
one must wait 4 to 5 days for results.25 Software exists
to help calculate dosage as well (available at: www.
afrri.usuhs.mil).26
Acute radiation syndrome (ARS) refers to a pattern of
well-defined physiologic derangements occurring after
exposure of most or all of the body to a substantial dose of
penetrating ionizing radiation, and is generally classified (in
increasing severity) as hematologic, gastrointestinal, and
neurovascular syndromes. Of interest to the surgeon, in
Chernobyl, approximately 50% of all patients with ARS
and virtually all with ⬎ 4 Gy whole body exposure also
had considerable skin injury (primarily distal extremities
and face and neck).27 A summary of signs and symptoms
heralding ARS is listed in Table 5.
The hematologic syndrome generally begins after an expo-
sure of 3 or more Gy (the midlethal range for untreated
patients).19 A few hours after exposure, prodromal an-
orexia, nausea, and possibly vomiting for approximately 48
hours appear, followed by a latent period of 1 to 3 weeks.
Infectious complications follow (fever, mucositis, enteritis,
pneumonitis, or septicemia). Hemorrhagic complications
including petechiae, ecchymoses, epistaxis, hematuria, he-
matochezia and melena, hematemesis, or intracranial
bleeding can occur. Patchy or diffuse hair loss can occur in
the third week. Repopulation of the hematopoetic stem
cells occurs around postexposure week 5 (most patients still
alive at 5 to 6 weeks will ultimately survive).18,28
The earliest laboratory finding is lymphopenia, with
absolute lymphocyte counts ⬍ 1,000/mm3 within the
first 48 hours.19 Granulocytes fall after 3 to 4 days before
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Chambers and Purdue Radiation Injury and the Surgeon 131
precipitously dropping to a nadir approximately 30 days
postexposure. The platelet count begins to fall to its
nadir after 7 to 8 days.
Hemorrhagic complications are initially managed
with tissue-typed, irradiated, and leukocyte-depleted
transfusions. Seronegative patients should receive
cytomegalovirus-negative products. Prompt adminis-
tration of cytokines has been useful in radiation acci-
dents in Russia, Brazil, and Mexico.29-31 Granulocyte-
macrophage colony-stimulating factor, granulocyte
colony-stimulating factor, or its pegylated form PEG-
granulocyte colony-stimulating factor should be
started along with prophylactic antibiotics within 24
to 72 hours postradiation if ANC ⬍ 500 or if patients
meet these criteria: healthy with no other injuries and 3
to 10 Gy, or multiply injured or burned with 2 to 6 Gy
exposure.24 Cytokines are continued until ANC ⬎
1,000.31,32 Use of interleukin (IL)-3, and epogen, IL-6,
IL-7, and keratinocyte growth factor are under investi-
gation.6,24 Refer to Table 6 for thresholds for using cyto-
kine therapy in ARS.
Early (first 4 days) transplantation of T-cell–
depleted bone marrow should be considered if a fully
matched sibling donor is available; patient has an ab-
solute lymphocyte count ⬍ 1,000/␮L, radiation dose
is likely to be ⬍ 20 Gy, no other injuries preclude
survival, and irradiation is not ongoing from an inter-
nal source.12,18,27,32-34
Infectious mortality is exponentially increased with
radiation exposure. In mice, sublethal radiation (antici-
pated 100% survival) doses increase mortality from bac-
terial inocula 3- to 10-fold.12 Infectious precautions for
patients with low ANC (ie, granulocytes ⬍ 1,500 or
ANC ⬍ 500) are initially environmental, and include
reverse isolation, sterile and low-microbial food, strict
handwashing and surgical scrubs for staff, topical anti-
microbials, minimal invasive and indwelling devices
(consider use of surgically implanted central venous
catheters), and early oral feedings.35,36
Prophylactic oral antibiotics and surveillance cultures
are initiated once the granulocyte count drops below
1,000/mm3 or ANC ⬍ 100 to 500 cells/mm3.12,19,36
Neutropenic fever is treated with broad spectrum anti-
biotics, antifungals, and immunoglobulins and is con-
tinued until ANC ⬎ 500/␮L.24,35 Antiviral prophylaxis
against cytomegalovirus and herpes simplex virus is
given as appropriate. Although prophylaxis for Pneu-
mocystis carinii might be warranted, trimethoprim-
 132
Table 3. Summary of Radionuclides of Medical Importance
Radionuclide Radiation type Sources Route of exposure Diagnosis Treatment
Americium 242,243Am ␣⬎⬎␥ Plutonium decay, smoke Pulm: 75% absorbed, 10% stay Radiac FIDLER 60 kEv ␥ Ingest/inhale: DTPA or EDTA within
detectors, in lungs 24–48 h exposure. 1 g CaDTPA* in
postdetonation fallout Open wounds: rapid 500 mL D5W (5% dextrose in water)

Chambers and Purdue

GI: minimally absorbed IV over 60 min; alternate 1 g in 6 mL
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5% D5W slow IV infusion.

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Wound: irrigate with 1 g CaDTPA in

250 mL D5W (5% dextrose in water)
Cesium 134,135Cs ␤, ␥ Medical radiotherapy Pulm: completely absorbed Radiac ␥ Ingest/inhale: Prussian blue† (ferric
instruments Open wounds: completely ferrocyanide) as 1 g in 100–200 mL
absorbed water po tid for several days; lavage/
GI: completely absorbed purge if early. K supplements can also
inhibit uptake.
Follows K and is excreted in urine.

Radiation Injury and the Surgeon

Wound: same.
Cobalt 60Co ␤,␥ Medical radiotherapy Pulm: rapidly absorbed Gastric lavage, purgatives
instruments, commercial GI: ⬍ 5% absorption Penicillamine chelation for severe
food irradiators Open wounds: ? cases
Toxicity primarily from WBI/
ARS–␥ is high energy and ␤ is
0.31 MeV
Iodine 129,131I ␤⬎␥ Reactor accidents/ Detected in urine If anticipate exposure, 130 mg NaI or
destruction/fission immediately after KI po qd prevent uptake
exposure Postexposure 300 mg NaI/KI po qd ⫻
1–2 w. K perchlorate can be used as
alternate. 90% effective if given within
1 h, and should be administered
within 12 h. Alternate:
PTU 100 mg po q8h ⫻ 8 d or
methimazole 10 mg po q8h ⫻ 2 d
then 5 mg po q8h ⫻ 6 d
Phosphorus 32P ␤ Research laboratories, Pulm: completely absorbed Lavage, Al(OH)3, oral phosphates.
tracer in medical GI: completely absorbed Stable phosphorus (1 g)
facilities Open wounds: completely
absorbed
Plutonium 236,238,239Pu ␣ ⬎⬎⬎ ␥ Uranium reactors, Pulm: primary means of Thin-walled ␥ probe 1 g CaDTPA within 24 h of exposure,
240,242,244
Pu (Curium (241Pu ⫽ ␤) nuclear weapons absorption, ⬍ 5 ␮ remain in Feces (⫹) after 24 h IV or nebs. Then 1 g ZnDTPA qd
and californium would lung, leading to local damage 24 h urine (⫹) after 2 wk while monitoring urine levels of Pu.
be managed similarly) GI: depends on chemical state; Overall, dose DTPA as for americium
metal not absorbed
Open wounds: variable, can be

J Am Coll Surg
washed from intact skin. Not
an external hazard as trace ␥ is
from Am contamination
(table continued)
 Vol. 204, No. 1, January 2007
Table 3. (continued)
Radionuclide Radiation type Sources Route of exposure Diagnosis Treatment
Radium 223,224,226Ra ␣ ⬎⬎ ␤, ␥ Certain industrial and dated Pulm: ? Lavage with 10% MgSO4, (epsom
(225,228Ra medical equipment GI: 30% absorbed (primary salts) followed by saline/mg
predom. ␤)
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route) purgatives. NH4Cl can increase

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Open wound: ? fecal elimination. Consider

barium sulfate (200–300 g)
Alternately, 20% calcium
gluconate 10 mL IV qd/bid
Follows Ca in bone deposition
Chronic exposure associated with
leukemia, aplastic anemia,
sarcoma
Strontium 89,90Sr ␤, ␥ Daughter of uranium fission Pulm: readily absorbed Aluminum OH or Al PO4 gel po
GI: readily absorbed (100 mL). BaS04 (200–300 g) or
Open wound: ? sodium alginate (10 g)
Gavison useful Stable Sr can
inhibit metabolism and enhance
excretion. Calcium and urine
acidification increase excretion
AlCl3 3 g po tid also useful.
⬃50% goes to bone
Thallium 201Tl ␥, x-ray Rat poisoning GI: readily absorbed Prussian blue 3.5 g qid

Chambers and Purdue

Tritium 3H ␤ Nuclear weapons, some Rapidly absorbed through intact Single urine within Biologic half-life (10–12 h)
Western luminescent gun skin (unique). Otherwise, not a 12 h Decreased with oral hydration
sights substantial external hazard if (6–12 L/d)
does not contact skin
Uranium 235,238U ␣ ⬎ ␤, ␥ (␥ Fuel rods, weapons-grade Pulm: absorbed Urine (24 h) and Inhaled/ingested: NaHCO3 ⫾
most substantial) materials GI: depends on chemical state feces (⫹) after 24 h tubular diuretics can help avoid
Natural uranium not serious (soluble salts, but not metal, nephrotoxicity
threat absorbed) Wound: same as above, plus wash
wound with bicarbonate

Radiation Injury and the Surgeon

Uranium, Depleted ␣,␤⬎␥ Armor-piercing Not generally considered a End-window NaHCO3 ⫾ tubular diuretics to
ammunition; armor serious radiation threat. G-M counter decrease nephrotoxicity
Removal of fragments not Labs as above
recommended unless ⬎ 1 cm or
intraarticular/intrathecal
Table modified from Medical Management of Radiological Casualties Handbook. 1st ed. Bethesda, MD: Military Operations Office, Armed Forces Radiobiology Research Institute; 1999 and International
Atomic Energy Agency, Vienna, 1974, Technical Reports Series No. 152, Evaluation of Radiation Emergencies and Accidents: Selected Criteria and Data.
*Ca-DTPA chelates plutonium, americium, curium, californium. Side effects include nausea, vomiting, fever, cramps, and pruritis. Contraindicated in pregnancy and minors and in patients with severe
renal dysfunction, thrombocytopenia, or leukopenia. Ca-DTPA more effective than Zn-DTPA, and is preferred for first 24 to 48 h. Zn-DTPA less toxic, recommended for prolonged treatment and for
pregnant patients. Ca-EDTA chelates lead, plutonium, and americium. Side effects include gastrointestinal upset, pain at injection site, bone marrow depression, and nephrotoxicity.
†
Prussian blue is in investigational new drug status with Radiation Emergency Assistance Center/Training Site; call for guidance. Use for cesium, thallium, rubidium. Negligible side effects.
ARS, acute radiation syndrome; DTPA, diethylenetriamine pentaacetate; EDTA, ethylenediamine tetraacetic acid; FIDLER, Field Instrument for the Detection of Low Energy Radiation, used to detect
low energy gamma; GI, gastrointestinal; G-M counter, Geiger-Müller counter; Pulm, pulmonary; sx, symptoms; WBI, whole body irradiation.

133
134 Chambers and Purdue Radiation Injury and the Surgeon
Table 4. Estimation of Whole Body Dose by Clinical and Laboratory Examination 20,26
Modality Finding
Physical examination Erythema
Physical examination Epilation
Laboratory Lymphocytes ⬍ 1,000/mm3
Laboratory Chromosome rings, and/or fragments
sulfamethoxazole should be avoided because of possi-
ble additional marrow suppression. Selective gut
decontamination does not decrease mortality.4,36
Emesis is best treated with 5-HT inhibitors, and di-
arrhea can be effectively managed with loperamide. Self-
limited parotiditis can occur with high doses of radia-
tion, but requires no specific therapy.27
The gastrointestinal syndrome typically follows dos-
ages of 6 to 10 Gy and is almost uniformly fatal.6 Pro-
dromal signs and symptoms present early (within hours)
and include diarrhea and severe nausea and vomiting.
The latent period is days to a week. Gastrointestinal
bleeding, fever and other signs of infection, ileus and
emesis with malnutrition, hemorrhagic shock, and
electrolyte imbalances from bloody diarrhea can oc-
cur, in addition to complications associated with the
hematologic syndrome. Patients usually die with a
fulminating enterocolitis before epilation and other
slower-developing sequelae. Laboratory findings are
similar to those in the hematologic syndrome, albeit
more substantial and sooner; hemoconcentration from
fluid loss can also occur.21 Therapy with IL-11, IL-15,
keratinocyte growth factor, and intestinal trefoil factor
are being studied.30
After exposures of 15 to 30 Gy, the neurovascular
syndrome results. Prodromal symptoms are immediate
(minutes) and severe, with generalized burning sensa-
tion, nausea, projectile vomiting, and explosive diarrhea.
Apparent improvement ensues for several hours, fol-
lowed by development of watery diarrhea, respiratory
distress, CNS dysfunction (ranging from somnolence to
convulsions), fever, edema, and hemodynamic instabil-
ity. Lymphopenia and a granulocyte level up to 40,000
Table 5. Signs and Symptoms of Acute Radiation Syndrome20
Signs/symptoms
Nausea, vomiting, or both, and some blood count derangement within 2 d
Marked leukocyte and lymphocyte count derangement within 3 d
Diarrhea within 4 d and marked platelet derangement within 6 to 9 d
Nausea, vomiting, diarrhea within minutes or ataxia, disorientation, shock or coma within
minutes to hours
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J Am Coll Surg
Time of onset Minimum exposure (Gy)
Hours to days 3
2–3 wk 3
Within 48 h 1
Within hours 0.1
can be present within hours. Coma and death occur
within hours to 2 days.20,21
TISSUE-SPECIFIC EFFECTS
Substantial injury from a small point source generally
requires proximity of 1 to 3 cm to the patient from
␥-emitters, such as radioactive iridium and cobalt. Sur-
face dose varies considerably among radionuclides (ie,
60
Co ⬎ 226Ra ⬎ 192Ir ⬎ 137Cs).22 ␣-Radiation does not
create problems for keratinized skin, although beta radi-
ation can induce superficial burns. The chronology of
evolving symptoms listed below has been well-
documented from ␥-irradiation accidents in El Salvador
and Pittsburgh.6,8,37,38
Ionizing radiation compromises nutrient and oxygen
supply to tissues by causing edema and an inflammatory
arteriolar vasoconstrictive response. After initial endo-
thelial edema, increased permeability, and possible
thrombosis, obliterative arteritis, and endophlebitis oc-
curs, most pronounced in smaller vessels.25,35,38-42 The
end result is progressive ischemia, fibrosis, and necrosis
of extremities.25 Excruciating chronic pain frequently
occurs after severe exposures, resulting in part from
mummified eschar compressing nerve bundles.43
Pharmacologic interventions have not been shown to
alter longterm outcomes.25 Thoracodorsal sympa-
thectomy has been reported to temporarily decrease
ischemic pain and discoloration of extremities in
upper extremity exposure, but not prevent distal
amputation.25,44
Initial treatment of skin lesions is conservative.6 Ex-
amples from notable world incidents include Chernobyl
(1986) and Goiania, Brazil (1987), in which topical an-
Implication
Minor hematologic syndrome
Major hematologic syndrome
Gastrointestinal syndrome
Neurovascular syndrome
Vol. 204, No. 1, January 2007
Table 6. Thresholds for Adjunctive Treatment of Substantial Whole Body Irradiation27
Range (Gy) for
Population cytokines
Healthy, no other injuries 3–10
Multiple injuries, burns 2–6*
*2-Gy threshold only recommended for elderly or preadolescent children. NA, not applicable.
tiinflammatory and antimicrobial agents along with sys-
temic antiplatelet medications were given.6,27 Limited
debridement, use of biologic dressings, physical therapy,
and wound irrigation have been shown to be useful
adjuncts.6,27
Hyperbaric oxygen therapy has been advocated for
chronic lesions to increase the oxygen gradient in tissues,
although counterproductive hyperbaric oxygen-induced
vasoconstriction has been reported.25,30,45 After 10 days
of hyperbaric oxygen therapy (⬃20 to 24 treatments of
2.4 ATM), sufficient neovascularization and oxygen ten-
sion to support a skin graft can be achieved. If no im-
provement is noted after this time, a pedicled or free flap
will likely be necessary.46,47
With ⬍ 20 Gy of local exposure, limb salvage has
been reported. But because of the numerous factors af-
fecting radiation dose (source, distance, length of expo-
sure, compounded with uncertainty of witness memory)
it can be exceedingly difficult to determine total ex-
posure and predict outcomes. Progressive necrosis has
been reported beyond clinical estimates up to 15
months postexposure.45 Psychologically, it is exceed-
ingly difficult for patients to deal with amputation of
an extremity that can initially not appear irrevocably
damaged.48 Early amputation is not recommended.
Instead, alternative ways to close wounds, such as
biologic dressings and skin grafts, should be pursued
along with splinting in and physical therapy to avoid
contractures.46,48,49
Flaps are generally required for areas that will re-
quire additional reconstructive operations (tendons,
nerves), in severely scarred areas that would likely fail
to support a skin graft, to cover exposed bone, carti-
lage, tendon, nerve or vessels, or to augment regional
blood flow. Free tissue transfer is particularly appeal-
ing as unaffected tissue beds can be brought to the
area of injury, to support healing, and decrease fibro-
sis in surrounding tissues.40,47,48,50 In many instances
early definitive excision of soft tissue with distant flap
and microanastamoses outside the radiation zone is
ideal.51,52
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Chambers and Purdue Radiation Injury and the Surgeon 135
Range (Gy) for antibiotics, Range (Gy) for possible stem
other supportive care cell transplantation
2–10 7–10; 4–10 if previous autograft stored or
syngeneic donor available
2–6* NA
Objections to strictly following a conservative course
have been raised. Physicians involved in a Salvadoran37
accident concluded that earlier amputation of the af-
fected extremities could have avoided observed systemic
complications, such as infection, inflammation, and se-
vere pain (with concomitant side effects of analgesics).
Others with similar experience have added that reha-
bilitation could have been accelerated if amputation
had been performed earlier (within 2 to 3 months of
exposure) at a definitive level instead of performing
11 operations over a 2-year period.6,32,40 Involved sur-
geons remarked that distribution of early erythema
and particularly bleb formation corresponded with
ultimate levels of necrotic demarcation, but epilation
was more generalized and not a useful guide.34 Clinical
estimation of wound depth can be refined with MRI,
technetium angioscintillography, thermography, or
ultrasonography.6
The timing of surgical intervention after whole body
irradiation is dictated by fibroblast damage, bleeding
diathesis, and infectious risks. One should strongly
avoid operating 3 to 60 days postexposure, or when
wound is hyperemic.14,40,51 In rabbit and mice IP surgery
models, mortality associated with perioperative radia-
tion exposure did not substantially increase if the oper-
ation was performed immediately after irradiation or
during the latent period, but substantially increased if
performed during manifest illness.28 Rat models with
open skin wounds and whole body irradiation likewise
demonstrate improved survival if wounds are closed be-
fore the fourth postirradiation day.53 Not surprisingly,
wounds in animals after whole body irradiation demon-
strate increase of wound size, and a lag in wound con-
tracture rate, with a higher incidence of wound compli-
cations including hemorrhage.9,53,54
Burn and reconstructive surgeons are not the only
specialists who must deal with radiation exposure. Tran-
sient corneal sensitivity is seen with exposures ⬎ 2 Gy,
followed several weeks later by superficial keratitis,
which is largely self-limited.27 With exposures ⬎ 2 to 6
Gy, posterior cataracts are likely to develop.19,37 Deter-
136 Chambers and Purdue Radiation Injury and the Surgeon
ministic effects resulting in arteriosclerosis occur along a
sigmoid dose response curve, as with ophthalmologic
processes.6 Hypothyroidism and, to a lesser degree, para-
thyroid dysfunction, has been noted in persons years
after exposure to whole body exposure of several hun-
dred rads.19,37 Pulmonary fibrosis can develop after as
little as 10 cGy isolated to chest, seen after the 1999
Japanese Tokai-Mura accident. Longterm T-cell and hu-
moral immune system suppression has also been noted
in survivors of atomic bomb explosions, but excess in-
fectious morbidity and mortality has not been consis-
tently described.37
Symptomatic gastrointestinal damage occurs in 50%
of persons at the following thresholds: esophagus, 75
Gy; stomach, 50 Gy; small bowel and colon, 65 Gy;
rectum, 80 Gy.55 Acute disease stems from loss of prolif-
erative cells in the mucosa. Leukocytic infiltrate follows,
with crypt abscess formation in 2 to 4 weeks. Initial
symptoms are diarrhea, nausea and vomiting, abdomi-
nal pain, and can take several weeks to resolve. After 6 to
24 months, the gut becomes thickened and ulcerated
with a progressive injury caused in part by an obliterative
vasculitis.56 Complications include malabsorption, per-
foration, and stricture. Proctocolitis is most commonly
described in literature, and can resolve spontaneously,57
despite the general rule that radiation enteritis is a pro-
gressive disease.58 Radiation-induced adenocarcinoma
of the colon has been demonstrated in rats. Enterocolitis
can be ameliorated with prostaglandin-inhibitors such
as aspirin, in addition to standard symptomatic treat-
ment. Total parenteral nutrition can also be of benefit.
Proctitis can be managed with sucralfate enemas, endo-
scopic argon plasma coagulation, or application of 4%
formalin. Intestinal anastamoses after resection should
be guided by two principles to minimize leakage. First, if
possible, ensure at least one of the ends was not in the
radiation field; second, wrap the anastomosis in healthy
omentum.55,59
Impaired male fertility occurs with as little as 0.35 Gy
of local exposure or 1.2 Gy whole body irradiation, with
permanent sterility developing after gonadal doses of 6
Gy.37 In nongravid females, fractionated doses of 1.5 Gy
have no effect on fertility; 3.5-Gy fractionated doses will
result in 60% sterility and temporary amenorrhea. Per-
manent sterility results from a single 6-Gy dose or a
fractionated dose of 15 Gy over 10 days. A threshold
dose of 0.5 Gy is required for most substantial adverse
fetal effects.37,60 Risk of major malformations is the pri-
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19, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
J Am Coll Surg
mary concern during gestational days 18 to 40. Specific
windows for fetal radiation harm in survivors are (in
gestational days) well defined: 0 to 6 days, cataracts; 0 to
37 days, exencephaly; 4 to 11 days, embryonic death; 8
to 15 weeks and beyond, microcephaly, mental retarda-
tion, growth and developmental delay; 9 to 90 days,
anencephaly or microcephaly; 16 to 32 days, anooph-
thalmia; 20 to 37 days, cleft palate; 25 to 85 days, skel-
etal dyscrasias; 50⫹ days, growth retardation (3 to 20
weeks).37
Interestingly, studies of Hiroshima and Nagasaki
survivors give no indication of excess stillbirth or ma-
jor congenital defects in humans.61-64 Specifically, co-
hort studies in over 31,000 children born to survivors
in Nagasaki and Hiroshima matched to those with no
substantial radiation exposure, demonstrated no dif-
ference in rates of stillbirth, major congenital defects,
death among children, cancer up to 20 years of age, or
nonlethal chromosomal anomalies.63 Although not
necessarily clinically apparent, the sum of regressions
of the various indicators involved suggests a genetic
doubling dose (double rate of spontaneous muta-
tions) for fetal exposure to be approximately 2 Sv.61,62
The United Nations has reported a 1.19% per Gy risk
of “hereditary harm” of low-LET radiation.65
About neoplasms, in adult survivors of Hiroshima
and Nagasaki, the earliest and most consistent neo-
plasms were acute leukemias and chronic granulocytic
leukemia, usually diagnosed at least 2 to 5 years after
exposure. Likewise, in industrial workers exposed to
low-level ␥-radiation, an excess relative risk for neo-
plasm development is found only for leukemia, at a rate
of 2.2 per Sv.37,66 Thyroid, breast, colon, stomach, ovar-
ian, and lung neoplasms were also noted in excess in
post-WWII Japan, and International Committee on Ra-
diation Protection estimates a 5% per Gy whole body
irradiation excess risk of fatal cancer over a lifetime,
based in part on the Japanese experience.8,37 But short-
ening of life expectancy from cancer was not demon-
strated in that same Japanese population, partly because
solid tumor excess commonly occurs at ages comparable
with when they naturally occur.37,66 In children and ad-
olescents of Belarus and Ukraine, after the Chernobyl
disaster, the incidence of papillary thyroid cancer rose
dramatically, although definitive evidence of association
of radiation from that incident with leukemia or solid
organ tumors has been not conclusively demonstrated;
lag time to tumor development and difficulty in ascer-
Vol. 204, No. 1, January 2007
taining dose exposure have limited studies of Chernobyl
sequelae so far.67-70 Associations have also been found
among the following: CNS neoplasms in children and
cranial irradiation,71 lung cancer and radon and plu-
tonium exposure,67,72 osteosarcoma and laboratory
animal exposure to transuranic radionuclides, ra-
dium, strontium, and thorium. Chronic radioderma-
titis can be considered a premalignant condition, and
excision with autograft has been described to avoid
malignant transformation.39
“A new problem has been posed to the surgeon by
the potential threat of atomic warfare,” was printed
over 50 years ago,73 a concern increased in importance
with the relatively recent specter of radiologic terror-
ism through nuclear weapons or “dirty bombs.” Al-
though medical and industrial radiologic accidents
continue to sporadically call on the surgeon for expert
management, we must diligently be prepared for
rapid and effective response to intentional disasters.
Knowledge of the surgeon’s role and responsibilities
in the team of responders to such an event in both the
acute and elective setting, both as primary caregiver
and consultant, is necessary to best prioritize issues
and determine the timing and appropriateness of sur-
gical interventions in conjunction with adjuvant
therapies.
For 24-hour assistance with radiologic casualties, call:
DTRA-AFRRI MRATREF: (301) 295-3909/0316
or 1-800-SKY-PAGE, #8010-338
DOE-Oak Ridge, REAC/TS, Ph (615) 481-1000,
beeper #241, web: www.orau.gov/reacts.
Direct support from these organizations can be pro-
vided, or through Department of Energy regional Ra-
diologic Assistance Program team deployments. Such
teams provide expert personnel in health physics, public
information, and so forth, and bring a basic set of radi-
ation monitors (for ␣, ␤, ␥, and neutron emission), and
other technical equipment.
For additional information or training contact:
REAC/TS, PO Box 117, Oak Ridge, TN 37831-
0117, Ph (865) 576-3131
National Radiobiology Center, Bethesda, MD,
MEIR Course Director, Ph (301) 295-0505
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