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
Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not necessarily those of the U.S. Army, the Department of Defense, or the Centers for Disease Control and Prevention. Mention of specific commercial equipment or therapeutic agents does not constitute endorsement by the U.S. Department of Defense or the Centers for Disease Control and Prevention; trade names are used only for the purpose of clarification.
Acknowledgments: The authors thank R.C. Ricks, PhD, for allowing access to the database maintained at the Radiation Emergency Assistance Center/Training Site; J. Osmolik for outstanding secretarial support; W.E. Jackson for assistance in preparation of the biodosimetry tables; and D.G. Jarrett, MD, R. Goans, MD, PhD, and R.C. Myhand, MD, for review of the manuscript.
Potential Financial Conflicts of Interest:Honoraria: T.J. MacVittie (Amgen), J.O. Armitage (Amgen); Stock ownership or options (other than mutual funds): P.C. Lowry (Amgen); Grants received: T.J. MacVittie (Amgen); Patents received: W.F. Blakely.
Requests for Single Reprints: Nicholas Dainiak, MD, Department of Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Waselenko: Walter Reed Army Medical Center, 6900 Georgia Avenue, WD78, Washington, DC 20307.
Dr. MacVittie: Greenebaum Cancer Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201.
Dr. Blakely: Armed Forces Radiobiology Research Institute, 8901 Wisconsin Avenue, Bethesda, MD 20889-5603.
Dr. Pesik: Strategic National Stockpile Program, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333.
Drs. Wiley and Lowry: Radiation Emergency Assistance Center/Training Site, Oak Ridge Associated Universities, 150 Vance Road, Oak Ridge, TN 37830.
Drs. Dickerson and Tsu: Armed Forces Radiobiology Research Institute, 8901 Wisconsin Avenue, Bethesda, MD 20889-5603.
Dr. Confer: National Marrow Donor Program, 3001 Broadway Street, NE 500, Minneapolis, MN 55413.
Dr. Coleman: National Cancer Institute, National Institutes of Health, Building 10, B3869, Bethesda, MD 20892-1002.
Dr. Seed: Catholic University of America, 620 Michigan Avenue NE, Washington, DC 20064.
Dr. Armitage: University of Nebraska, 987680 Nebraska Medical Center, Omaha, NE 68198.
Dr. Dainiak: Department of Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610.
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.
Approximate time course of clinical manifestations.GICNS
Table 1. Phases of Radiation Injury
Table 2. Grading System for Response of Neurovascular, Gastrointestinal, and Cutaneous Systems
Table 3. Levels of Hematopoietic Toxicity
Table 4. Mass Casualty Scenario for a Nuclear Detonation
Table 5. Biodosimetry Based on Acute Photon-Equivalent Exposures
Table 6. Priorities in Triage of Patients with and without Combined Injury, Based on Dose of Radiation
Approach to triage and therapy for persons exposed to radiation in a limited-casualty scenario.GI
Table 7. Guidelines for Treatment of Radiologic Victims
Table 8. Recommended Doses of Cytokines
Table 9. Sources for Additional Information on Assessment, Triage, and Clinical Management of Radiologic Victims
Summary of a medical record of a patient injured in a radiation accident.top left paneltop right panelmiddle panelsbottom left panelbottom right panel
Leukocyte count based on exposure dose in patients exposed to radiation in Chernobyl.
Appendix Table. Threshold Dose and Recommended Doses of Potassium Iodide for Different Risk Groups
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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. ;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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