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 :

• 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 Gy.hr-1.MBq-1 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:

1. 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

2. 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.

3. 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.

• 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.

• 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.

• 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

Conclusion
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.