Educational discipline “Emergency medicine”

Training manual for English speaking students of 6th course

in 2021/2022 schoolyear

Lesson 2. Radiation damage. Acute radiation sickness.

Staged treatment of patients with acute radiation
sickness. Atypical forms of radiation sickness.

Worked by
assistant of professor Koliadenko D.I.

Kyiv -2021
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 Relevance of the topic
• In terms of local military conflicts and global geopolitical confrontation,
the possibility of nuclear weapon use cannot be ruled out
• 33 countries have more than 440 power units consisting of more than 200
nuclear power plants (NPP)
• Nuclear power units are also used in sea- and spacecraft, in research
institutions, etc.
• Nuclear munitions, nuclear fuel and radioactive waste from the nuclear
industry pose a great danger
• More than 300 radiation accidents with the release of radionuclides into
the environment have been registered in the world
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 Relevance of the topic
• There are currently 4 NPP in Ukraine with 15 nuclear power reactors, 2
research nuclear reactors and more than 8,000 enterprises and organizations
that use radioactive substances in the production, research and medical
practice

Destroyed 4th reactor of Chernobyl NPP

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 Types of ionizing radiation
• Ionizing radiation - any radiation, the interaction of which with the
environment leads to the formation of electric charges of different
signs
• There are the following types of ionizing radiation: α-, β-, photon and
neutron radiation
• All types of radioactive radiation have some common features, and
the main ones are penetrating and ionizing ability
• Ultraviolet radiation and the visible part of the light spectrum do not
belong to ionizing radiation

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 Physical properties of ionizing radiation
Type of Energy, MeV Range in air Range in biological Ionization density
radiation tissue (number of ion pairs per
1 cm path)

Alpha up to 10 up to 10 сm up to 50 mcm 10-50 thousand

Beta up to 3-4 up to 20 m up to 1 сm up to 1 thousand
Gamma up to 2-3 hundreds of dozens of centimeters up to 10
meters

Neutron depending on the hundreds of dozens of centimeters up to several thousand

nature from 0.05 meters (up to 3
to 20 MeV and km)
more

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 Alpha radiation (α-radiation)
• It is a stream of relatively heavy particles (helium nuclei consisting of
two protons and two neutrons) emitted during nuclear
transformations
• The energy of these particles is several megaelectron-volts and is
different for different radionuclides
• Has short path range of particles and weak penetrating power.
Therefore, α-radiation is dangerous only when it enters the body

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 Beta radiation
• It is flux of β-particles (electrons and positrons) that have higher
penetrating power compared to α-radiation
• The range of β-particles in the air can reach several meters, in
biological tissue - a few centimeters
• More dangerous when ingested

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 Gamma radiation (γ-radiation)
• Photon radiation includes X-rays and gamma radiation (γ-radiation)
• The transition of the atomic nucleus from excited state to a lower energy
level (to the normal state) occurs with the release of gamma quanta. Thus, γ-
radiation has an intranuclear origin and is a hard electromagnetic radiation
• γ-rays spread with the speed of light and have high penetrating power. They
can be detained only by a thick lead or concrete slab. The higher the energy
of γ-radiation and, accordingly, the smaller its wavelength, the higher the
penetrating power is
• γ-radiation is a major factor in the damage of the body exposed to radiation
from external sources
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 Neutron radiation
• It is a flux of electrically neutral particles that has extremely high
permeability and ionization density
• Since neutrons are electrically neutral particles, they easily penetrate
atoms and interact with the nucleus. Radioactive isotopes are formed
and the so-called induced radioactivity occurs. Stable nuclei are
converted into radioactive isotopes, emitting β-particles and γ-quanta

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 Units of measurement of ionizing radiation
• Dosimetry is a determination of quantitative and qualitative
characteristics of ionizing radiation
• It is important to take into account not the mass amount of the
radionuclide, but its activity.
• Curie (Сi) is the activity of a radioactive drug in which 3.7 x 1010 decays
occur within 1 sec
• To quantify the effect of ionizing radiation on the object being irradiated,
the concept of "dose" was introduced in dosimetry. There are exposure,
absorbed, equivalent and effective (integrated) radiation doses

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Units of measurement of ionizing radiation
• The "dose" of ionizing radiation means the energy transferred by the
radiation to the elementary volume or mass of the irradiated
substance.
• In the international system of units, the unit of kinetic energy is the
joule (J). It also can be measured in ergs or electron volts (eV). 1 еrg =
10-7 J. 1 еV = 1,6∙10-12 еrg = 1,6∙10-19 J
• The form and degree of radiation damage to biological objects
depend on the absorbed radiation energy

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 Absorbed dose
• It is the energy of radiation absorbed per unit mass of the matter
• Gray (Gy) is taken as a unit of this dose in SI, ie when 1 J of energy absorbs 1 kg of
substance; 1 Gy = 1 J/kg
• The extrasystem unit is rad (radiation adsorbed dose) - the energy of any type of
ionizing radiation at 100 erg, absorbed by an irradiated object weighing 1 g (1 rad
= 100 erg/g)
• 1 Gy = 100 rad or 1 rad = 0.01 Gy
• To compare the biological effects of different types of radiation, there is the
concept of relative biological effectiveness (RBЕ).
• RBE of gamma radiation is taken as 1, ie the quality factor or radiation factor of
gamma radiation is equal to 1. The radiation factor of other types of radiation is
given in certain tables (determined experimentally for specific conditions) 12
 Equivalent dose
• It is such an absorbed dose of any radiation in the conditions of long-term
(chronic) irradiation in small doses, which causes the same biological
effect as 1 Gy of the absorbed dose of X-ray or gamma radiation
• It is determined by multiplying the absorbed dose of radiation to the
appropriate type of radiation factor
• The unit of equivalent dose in SI is the sievert (Sv)
• Extrasystem unit of equivalent dose - ber (1 Sv = 100 ber)
• If the whole body is exposed to uniform radiation, the level of damage to
health can be determined on the basis of an equivalent dose

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 Effective (integrated) dose
• Assesses the harm to human health from uneven irradiation of the body
• Helps to determine the overall risk of getting sick or dying from ionizing
radiation, more precisely it is an indicator of the risk of disease or death
from somatic stochastic effects (malignant neoplasms), as well as the risk of
hereditary effects in the first two generations
• When the irradiation of various organs is different (with the incorporation
of a radionuclide, with targeted irradiation of a part of the body), it is
necessary to consider equivalent doses in different irradiated organs
• Integral absorbed dose is the average energy of ionizing radiation absorbed
by a certain tissue mass of the irradiated organ or body part - Gy/kg
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 Biological action of ionizing radiation
• At the time of exposure to ionizing radiation, a person has no sensations
• Instant energy absorption of ionizing radiation by atoms and molecules significantly
exceeds the rate of chemical interaction between them
• The main interaction of radiation with matter is ionization, damage to atoms and
molecules, the appearance of active radicals
• Lack of selective exposure and simultaneous action on various structures of the organism
• Radiobiological paradox - the discrepancy between the extremely small amount of
absorbed energy of ionizing radiation and the most pronounced (up to lethal effect)
reaction of the organism
• Biological effect depends on the density of ionization. Alpha particles and neutrons have
the highest ionization density
• Biological effect is directly proportional to the dose rate
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 The interaction of ionizing radiation with
the biosubstrate
1 phase - energy absorption of ionizing radiation by biosubstrate
2 phase - conversion of ionizing radiation energy into chemical energy with
the formation of ions and active radicals
3 phase - development of radiochemical reactions
There are 2 ways of interaction of ionizing radiation with organic
compounds:
а) direct effect
b) indirect effect mediated by the action of free radicals formed due to
radiolysis of water
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 Bergonie-Tribondeau's law

• Tissue damage by ionizing radiation is directly proportional to mitotic

activity and inversely proportional to the degree of cell differentiation
• Cells are most vulnerable during the generation cycle, especially during
the phase of synthesis and mitosis
• Depending on the nature of chromosome damage, the cell dies during
mitosis (mitotic death), or without entering mitosis (interphase death)
• Primary changes are deficiency of blood cells, intestinal epithelium,
impaired function of the endocrine glands and central nervous system

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 Pathogenesis of radiation sickness
• There is dependence of damage of this or that system (critical organ) on the
total absorbed dose of irradiation
• For dose range 1-10 Gy critical organ is hematopoietic system
• For dose range 10-20 Gy critical organ is the epithelium of the
gastrointestinal tract. Death occurs within 8-16 days
• Dose range 20-80 Gy leads to significant azotemia and intoxication of the
body with protein breakdown products. Death occurs 4-8 days after
irradiation
• Dose >80 Gy causes direct radiation damage of the central nervous system.
Death occurs within the first three days
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Clinical forms of human radiation damage
• acute radiation sickness (ARS)
• chronic radiation sickness (CRS)
• local radiation damage (LRD)
• associated radiation damage (ARD)
• combined radiation damage (CRD)

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 Clinical classification of radiation injuries
1) Acute radiation reaction is the mildest manifestation of acute radiation
damage that occurs in persons irradiated with a dose of 0.5-1 Gy. At
long and careful supervision the minimum laboratory signs of radiation
damage can be revealed: decrease in number of lymphocytes,
neutrophils and thrombocytes to the lower limit of normal in 6-7
weeks after acute irradiation
2) Acute radiation sickness (ARS) is a separate nosological form that
develops after external, uniform gamma and gamma-neutron
irradiation of the body in a dose exceeding 1 Gy, obtained
simultaneously or over a short period of time (from 3 to 10 days) and is
characterized by certain phases of the course
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 Forms of ARS depending on the radiation
dose
• 1-10 Gy - bone marrow form
• 10-20 Gy - intestinal form
• 20-80 Gy – toxemic
• >80 Gy – cerebral
Forms of ARS with radiation dose >10 Gy are lethal

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Degrees of severity of bone marrow form
ARS
• І – mild – 1-2 Gy
• ІІ – moderate – 2-4 Gy
• ІІІ – severe – 4-6 Gy
• ІV – extremely severe – 6-10 Gy

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 Clinical periods of ARS
1 – initial or period of the general primary reaction to irradiation (GPR)
2 – latent (hidden) or a period of imaginary clinical well-being
3 – the period of pronounced clinical manifestations (manifest illness
period)
4 – period of outcomes (progression, stabilization, early recovery - complete
or partial)
5 – period of long-term effects
• The clearest periodization is typical for moderate and severe bone marrow
form of ARS
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 GPR period of ARS
• Develops after a short time (minutes-hours) after irradiation
• The duration ranges from several hours (mild cases) to 2 or more days (severe
forms of ARS)
• Symptoms:
- dyspeptic - nausea, vomiting (has diagnostic and prognostic value!), diarrhea
- general - fainting, weakness, headache, changes in physical activity, fever
- hematological - lymphocytopenia (relative and absolute), neutrophilic
leukocytosis
- local - changes in the skin, mucous membranes and other tissues in places of
greatest exposure
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   The degree of severity of ARS
Symptoms mild moderate severe extremely severe

Vomiting (time of After 2-3 hours, once After 1-2 hours, After 30-40 min, After 5-20 min,
onset, severity) repeated multiple unrestrained
Muscle weakness Insignificant, short- Moderate Significant Severe (adynamia)
term
Headache Absent or mild Moderate, Significant, Severe, expressed
  long-term recurrent постійний
Сonsciousness Clear Clear Clear Sometimes
confusion
Body temperature Normal Subfebrile Subfebrile Febrile
(37,1-37,5˚С) (37,6-38˚С) (>38°С)
Skin hypaeremia Mild Distinct Expressed, stable Significant
GPR duration Several hours 1 day 2 days More than 2 days
Hypotension (systolic Absent 110-100 100-80 Often collapse
BP, mmHg)
HR, beats/min 80-100 100-120 130-150 >150
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 Measures of emergency first aid
• Immediate evacuation of the victim from the area of radioactive contamination, referral to a
specialized medical institution
• Use of individual and collective means of protection (respirators, gas masks, etc)
• Partial sanitation of skin and uniform
• Removal of radioactive substances from the human body by gastric lavage with warm water,
use of laxatives and diuretics, washing of oral cavity and eyes, expectorant drugs
• Reducing dyspeptic disorders, toxemia, shock conditions and maintaining the function of vital
organs and systems
• Radioprotective agents may be used, for example cystamine - 6 tablets once and 1 tablet of
potassium iodide, if necessary their administration is repeated
• For the prevention of the primary reaction and treatment of dyspepsia it is necessary to use
an antiemetic - etaperazine (one tablet). If vomiting has already developed, injectable forms
of antiemetics are used
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 Medical tactics in the GPR period
1. Hospitalization in the nearest hematology department
2. Bed regime
3. Antiemetics (dimetcarb, cerucal, etaperazine, atropine)
4. Detoxification: correcting fluid and electrolyte balance (rheosorbilact, reopolyglukin, isotonic sodium
chloride solution, glucose solution 5%, saline solutions like Ringer-Locke’s), hemosorbtion
5. Diuretics (furosemide) may be used when not contraindicated due to dehydration caused by vomiting
5. Treatment of acute vascular insufficiency (caffeine benzoate, cordiamine, mesaton, norepinephrine,
hydrocortisone)
6. Sedatives and neuroanaleptics (seduxen, phenobarbital, aminazine) for treatment of psychomotor
agitation and anxiety
General recommendations to the population: to come to special shelters, to take shelter in basements,
to seal living quarters, to use individual respiratory protection equipment (gas mask, respirator, gauze
and cotton dressing), to take radioprotectors from an individual first-aid kit. Eat uncontaminated food
and drinking water. 27
 The latent period of ARS
• The duration is 3-4 weeks after mild irradiation, and it may be absent
after extremely severe irradiation
• Improvement of patients' well-being
• Signs of progressive disorders of the functional state of the nervous
and endocrine systems, changes in the blood, metabolic disorders
• Leukopenia, the number of reticulocytes and thrombocytes
decreases, hypersegmentation of neutrophils, nuclear polymorphism
of lymphocytes, cytoplasmic and nuclear vacuolization, chromatin
lysis, toxic granulation of neutrophils

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 Medical tactics in the latent period
1. Sanitation of all foci of chronic infection
2. The food should be mechanically and chemically gentle. Increased
fluid intake
3. Symptomatic therapy: multivitamins, adaptogens, sedatives,
antihistamines
4. Desintoxication therapy (rheosorbilact, haemodesis, isotonic sodium
chloride solution, 5% glucose solution), forced diuresis

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 The manifest period of ARS
• Deterioration of the general condition of patients and progressive
disorders of hematopoiesis and metabolism, infectious complications, in
severe cases sepsis and bleeding develop
• Onset of manifest illness period and its duration depend on the severity
of ARS:
I - occurs on the 30th day, lasts up to 10 days
ІІ - on 20th, lasts up to 15 days
ІІІ - on 10th, lasts up to 30 days
ІV - on 4-8th, at 3-6th week death usually occurs
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 Clinical syndromes in the manifest period of
ARS
• hematological (results from bone marrow aplasia) - severe leukopenia (the term
agranulocytosis is used if the number of white blood cells is <1 x 109/L), anemia,
thrombocytopenia. Leukopenia leads to the development of severe infectious and
toxic complications. Thrombocytopenia leads to the development of hemorrhagic
syndrome (bleeding)
• general intoxication - hectic temperature, asthenia, collaptoid state
• intestinal - vomiting, diarrhea, anorexia
• oral-pharyngeal - ulcerative-necrotic lesions on the mucous membranes of the mouth
and tonsils, accompanied by severe pain and such patients mostly need tube feeding
• alopecia - hair loss
• astheno-neurotic syndrome, sleep and appetite disturbances
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 Changes in hematological parameters in
the bone marrow form ARS of different
Indicator
severityThe severity of ARS
 
I II III IV
Lymphocyte count, х109/l 1–0,6 0,6–0,3 0,3–0,1 <0,1
(on the 3rd day)

Leukocyte count, х109/l >3 3–2 1,9–0,5 <0,5

(on 7–9th day)
Platelet count, х109/l (on 20th day) >80 79–50 50–20 <20

The onset of agranulocytosis Absent or in 30 Since 20-30th Since 8–20th day In first
(leukocyte count <1x109/l) days day 7 days

Reduction of proliferating Absent On 25–30% On 50–60% On 100%

erythroblasts on 4th day
Mitotic index of the bone marrow, 5,4–4,8 1,8–0,9 0,8–0,2 0,1–0
% (on 3–4th day)
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 Medical tactics in the manifest illness
period
1. Isolation with strict adherence to aseptic and antiseptic regulations (isolation
ward, non-contact care, daily preparation of skin and hair with solutions of
antiseptics, sterile water.
2. Antibiotic therapy (several parenteral antibiotics in the maximum possible
dosage) until resolution of agranulocytosis. Antifungal drugs are also used.
3. Leukopoiesis stimulants and the use of immunoglobulins.
4. Desintoxication (rheosorbilact, isotonic sodium chloride solution, 5% glucose
solution).
5. Antihemorrhagic and antianemic drugs (aminocaproic acid, dicynone,
hematopoietic stimulants, substitution therapy - erythrocyte and thrombocyte
concentrate). Bone marrow transplantation for severe ARS.
6. Treatment of cardiovascular failure and other related disorders. 33
 Medical tactics in the manifest illness
period
7. Treatment of oral-pharyngeal and intestinal syndromes:
• tube nutrition
• rinsing the oral cavity with antiseptic solution (furagin 1: 13000, decamethoxine, miramistin),
followed by application of cotton swabs with anesthetic solutions (5% solution of novocaine)
• lubrication of the oral cavity with eucalyptus and sea buckthorn oil
• parenteral nutrition (intravenous polyamine or amekin, fat emulsions)
• substitution enzyme drugs (pancreatin, etc.) are prescribed since 15-20th days after exposure
to 3-6 Gy of radiation and since the first days after irradiation in higher doses
• drugs with gastrocytoprotective action are used for protection of intestinal mucous
membrane
• antispasmodics are used for spastic abdominal pain: 2 ml 2% solution of drotaverine SQ, IM; 2
ml 2% solution of papaverine SQ or IV; 1 ml 0.1% solution of atropine sulfate SQ, pirenzepine
IV, IM
• prebiotics (lactulose 10-15 ml t.i.d.) in combination with probiotics (linex) 1-2 doses t.i.d. 34
 Recovery period
• Lasts 6-12 months
• Long-term effects include asthenovegetative syndrome, reduction of life expectancy,
cataract development, decreased fertility, predisposition to leukemia and tumors
• Treatment:
- clinical nutrition
- vitamin B12, folic acid, sodium nucleic acid, iron preparations are prescribed from
the moment of initial restoration of hematopoiesis
- anabolic hormones (methandrostenolone, nandrolone), stimulators of erythro- and
thrombocytopoiesis are used to accelerate the normalization of metabolic processes
- physical and mental rehabilitation
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 Classification of ARS according to the
possibility of patient's survival
ARS, Dose, Gy Possibility of survival
severity

I 1-2 Survival is guaranteed

II 2-4 Modern treatment should ensure the survival of all patients

III 4-6 Modern treatment should ensure the survival of most patients

IV 6-10 Survival is unlikely, but modern treatment can lead to the

survival of some patients

>10 Survival is impossible

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Life-threatening for the victim during the
GPR are:
• early development of symptoms of GPR
• early onset of bloody diarrhea
• early onset of vomiting with blood
• radiation tan on the face
• loss of consciousness during irradiation
• early adynamia

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Life-threatening for the victim during the
manifest illness period are:
• early onset of manifest illness period
• severe infectious complications
• severe general intoxication
• severe hemorrhagic and anemic syndromes
• significant gastrointestinal syndrome
• disorders of the cardiovascular and respiratory functions
• occurrence of oliguria, anuria
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Life-threatening for the victim during the
period of outcomes are:
• deterioration of hematopoietic parameters
• deterioration of the clinical course of ARS
• lack of positive dynamics in hematopoietic indicators

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Thank you! Good luck!

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