Jamie K. Waselenko, MD; Thomas J. MacVittie, PhD; William F. Blakely, PhD; Nicki Pesik, MD; Albert L. Wiley, MD, PhD; William E. Dickerson, MD; Horace Tsu, MD; Dennis L. Confer, MD; C. Norman Coleman, MD; Thomas Seed, PhD; Patrick Lowry, MD; James O. Armitage, MD; Nicholas Dainiak, MD
Physicians, hospitals, and other health care facilities will assume the responsibility for aiding individuals injured by a terrorist act involving radioactive material. Scenarios have been developed for such acts that include a range of exposures resulting in few to many casualties. This consensus document was developed by the Strategic National Stockpile Radiation Working Group to provide a framework for physicians in internal medicine and the medical subspecialties to evaluate and manage large-scale radiation injuries.
Individual radiation dose is assessed by determining the time to onset and severity of nausea and vomiting, decline in absolute lymphocyte count over several hours or days after exposure, and appearance of chromosome aberrations (including dicentrics and ring forms) in peripheral blood lymphocytes. Documentation of clinical signs and symptoms (affecting the hematopoietic, gastrointestinal, cerebrovascular, and cutaneous systems) over time is essential for triage of victims, selection of therapy, and assignment of prognosis.
Recommendations based on radiation dose and physiologic response are made for treatment of the hematopoietic syndrome. Therapy includes treatment with hematopoietic cytokines; blood transfusion; and, in selected cases, stem-cell transplantation. Additional medical management based on the evolution of clinical signs and symptoms includes the use of antimicrobial agents (quinolones, antiviral therapy, and antifungal agents), antiemetic agents, and analgesic agents. Because of the strong psychological impact of a possible radiation exposure, psychosocial support will be required for those exposed, regardless of the dose, as well as for family and friends. Treatment of pregnant women must account for risk to the fetus. For terrorist or accidental events involving exposure to radioiodines, prophylaxis against malignant disease of the thyroid is also recommended, particularly for children and adolescents.
Shown are approximate times for hematopoietic, gastrointestinal (GI), and central nervous system (CNS) symptoms at different ranges of dose of whole-body radiation for exposed, living persons. Hematopoietic changes include development of lymphopenia, granulocytopenia, or thrombocytopenia. Gastrointestinal symptoms include headache, nausea, vomiting, or diarrhea. Cerebrovascular signs and symptoms include headache, impaired cognition, disorientation, ataxia, seizures, prostration, and hypotension. Note that the signs and symptoms of different organ systems significantly overlap at each radiation dose and that cerebrovascular symptoms do not appear until exposure to a high whole-body dose. The relative severity of signs and symptoms is measured on an arbitrary scale. Prepared from data in reference 16.
A numeric degree of severity is assigned for the cutaneous, gastrointestinal (GI), neurovascular, and hematopoietic systems, as defined in Tables 2 and 3. The highest degree of toxicity to an organ system indicates the physiologic “response category” (that is, 1, 2, 3, or 4). Modified with permission from reference .
Shown are the absolute leukocyte count (top left panel), estimated organ dose (top right panel), areas of skin injury (middle panels), injury to oral cavity and gastrointestinal system (bottom lefe panel), and body position relative to the radioactive source (bottom right panel) as a function of time after the exposure. To convert cells/mm to ×10 cells/L, multiply by 0.001. Redrawn with permission from reference 29.
Note the abortive rise (transient increase before the fall) in counts of leukocytes, which are primarily composed of granulocytes, in doses less than 5 Gy. Neutropenia may not occur for weeks, especially with lower exposures, and its duration may be prolonged. To convert cells/mm to ×10 cells/L, multiply by 0.001. Redrawn with permission from reference 36.
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Martin T Donohoe
Old Town Clinic and Portland State University
July 3, 2004
Prevention of acute radiation emergencies
Waselenko et al.'s otherwise comprehensive review (1) neglects to mention how changes in United States government policies could decrease the risk of nuclear accidents and terrorism and the role of physicians in preventing major radiation events.
The US possesses the world's largest stockpile of nuclear weapons, enough to destroy civilization many times over. We have spent little to upgrade and protect our aged, accident-prone nuclear power plants, and have failed to develop an environmentally-sustainable, fiscally- responsible energy policy. We plan to bury 100,000 tons of high-level nuclear waste on Native American land at Yucca Mountain, near an earthquake fault and major aquifer. Much of the transported waste will travel through major population centers, risking an accident or terrorist attack.
Current administration policies which increase risk of an acute radiation event include: Nuclear Posture Review (consideration of first strike nuclear weapons use), Anti-Ballistic Missile Treaty withdrawal, and boycotting the Comprehensive Nuclear Test Ban Treaty conference, risking another nuclear arms race and sending a message to foreign governments that they too can develop and produce nuclear weapons; funding development of "mini-nukes"; spending billions of dollars to support research and development of a so-called "Missile Defense Shield," despite opposition from most reputable scientists and spectacular failures in highly structured tests; and allocating inadequate sums for disposal and safe- keeping of nuclear weapons in former Soviet block countries and for halting nuclear materials trafficking.
Prevention should include efforts to reverse these policies, as well as enhanced medical education regarding: 1) The political, cultural, economic and religious contributors to environmental destruction, war, and human suffering (2, 3), factors which lead to disenfranchisement, discontent, desperation, and the kind of hopelessness which impels terrorists to consider the use of radiation weapons, such as dirty bombs; 2) The horrifying short- and long-term health consequences of nuclear explosions and accidents (South Pacific weapons testing, Hiroshima, Nagasaki and Chernobyl) (4); 3) The shameful involvement of physicians in the development, dissemination, and use of weapons of mass destruction (e.g., Nazi and Japanese scientists who conducted biological weapons "experiments" in World War II) and human rights abuses (e.g., Serbia's Radovan Karadzic and Al Qaeda's Ayman Al-Zawahri); 4) How medical students and physicians can create peace and justice in the world; and 5) Medical organizations working for peace and justice (e.g., Physicians for Social Responsibility and Physicians for Human Rights). Regrettably, these subjects are almost entirely absent from medical school and residency curricula. (5)
References: 1) Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: Recommendations of the strategic national stockpile radiation working group. Ann Int Med 2004;140:1037-1051. 2) Donohoe MT. Causes and health consequences of environmental degradation and social injustice. Soc Sci and Med 2003;56(3):573-587. 3) Donohoe MT. Individual and societal forms of violence against women in the United States and the developing world: an overview. Curr Women's Hlth Reports 2002;2(5):313-319. 4) Donohoe MT. Remember Hiroshima and Nagasaki: the legacy of nuclear weapons. The Oregonian 2001 (August 6), editorial - web publication: www.oregonlive.com/opinion. 5) Donohoe MT. Bioterrorism curricula too limited. Acad Med 2004 (Apr 14). Available at http://www.academicmedicine.org/cgi/eletters/79/4/366
May 11, 2011
Overuse of Potassium Iodide Against Lack of Evidence During Nuclear Accidents
TO THE EDITOR: The nuclear accident at the Fukushima power station in Japan, which reminded us of the nightmare of Hiroshima and Nagasaki, has internationally raised serious concerns about radiation exposure. Although stable iodine, e.g., potassium iodide (KI) is indicated only as a thyroid- blocking agent to prevent the uptake of radioactive iodine, people living 1000 miles from Fukushima frantically tried to obtain KI (1), because they believed that it was a general radioprotective agent and a magic bullet in the event of a nuclear accident.
The current recommendations in the guidelines (2, 3) for KI therapy derive almost exclusively from the observational studies on the incidence of thyroid cancer in children following the accident at Chernobyl. As of May 12, 2011, 8 weeks after the tsunami hit the Fukushima nuclear station, no more major nuclear accident, from which any new evidence can be obtained, should be expected at Fukushima. Although the data collected from the Chernobyl accident are less convincing than those from clinical trials, they are the best evidence currently available, since clinical trials for exposure to radioactive iodine are unethical and unfeasible. The recommendations have practically specified that the risk of thyroid cancer in adults exposed to radioactive iodine is minimal, which seems appropriate, considering that many hyperthyroid patients have been exposed to radioactive iodine for the purpose of treatment. Regarding exposure to radioactive iodine, people above 20 years of age are at little risk for thyroid cancer, and those above 40 years of age are at virtually no risk (4). Therefore, the use of KI for prophylaxis of thyroid cancer is a concern in children and pregnant and lactating women. Seven million adults in Poland took KI against the recommendations after the Chernobyl disaster (5). Since there is a limited time window for the prophylactic administration of KI, prompt availability should be ensured for those who most benefit from KI during nuclear accidents, and its overuse should be avoided.
1. Rockoff JD. Potassium Iodide Runs Low as Americans Seek It Out. The Wall Street Journal. 2011 March 15.
2. Waselenko JK, MacVittie TJ, Blakely WF et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004;140:1037-51.
3. WHO. Guidelines for Iodine Prophylaxis following Nuclear Accidents. Geneva. WHO/SDE/PHE/99.6. Accessed at http://www.who.int/ionizing_radiation/pub_meet/Iodine_Prophylaxis_guide.pdf on 11 May 2011.
4. Thompson DE, Mabuchi K, Ron E et al. Cancer incidence in atomic bomb survivors. Part II: Solid tumors, 1958-1987. Radiat Res. 1994;137:S17 -S67.
5. Nauman J, Wolff J. Iodide prophylaxis in Poland after the Chernobyl reactor accident: benefits and risks. Am J Med. 1993;94:524-32.
Waselenko JK, MacVittie TJ, Blakely WF, Pesik N, Wiley AL, Dickerson WE, et al. Medical Management of the Acute Radiation Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004;140:1037-1051. doi: 10.7326/0003-4819-140-12-200406150-00015
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Published: Ann Intern Med. 2004;140(12):1037-1051.
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