MINISTRY OF HEALTH OF UKRAINE
Bogomolets National Medical University
«Approved»
at the Methodist Council
of Department of Internal Medicine №3
on 26 August 2021, Protocol №90
Head of the Department
Professor Iaremenko О.B.
Considered and approved by the Cyclic Methodical Commission of
therapeutic disciplines on « » _________________ 2021, Protocol №
METHODICAL RECOMMENDATIONS
for practical lessons for students
Educational
discipline
Training direction
Emergency Medicine
The second (master) level of higher education in the field
of knowledge 22 «Healthcare» Specialty 222 «Medicine»
module Organization of therapeutic care in emergency conditions
Content
№1
Topic of the lesson Radiation damage. The concept of radiation injury, medical
№2
care at the stages of medical evacuation. Acute radiation
sickness. Staged treatment of patients with acute radiation
sickness. Atypical forms of radiation sickness.
Course
6
Reconsidered and reapproved: №____on____________20__
№____on____________20__
№____on____________20__
№____on____________20__
Kyiv, 2021
1. Learning objectives:
To provide an insight about the types of ionizing radiation, units of its
measurement and dosimetry. To acquaint with the main links of biological action
of ionizing radiation and pathogenesis of the main clinical forms of radiation
injuries.
To inform students about clinical manifestations and diagnostic criteria of
various forms of acute radiation sickness. Features of radiation damage in
peacetime.
To acquaint with the classification of the bone marrow form of acute
radiation sickness, as well as the features of the clinical picture in different
periods of the disease.
To learn differential diagnostic criteria for assessing the severity of the
disease. Learn to identify life-threatening conditions in different periods of
illness. Principles of pathogenetic treatment of acute radiation sickness taking
into account the leading manifestations of the disease. The amount of medical
care at the stages of medical evacuation.
To give an idea about clinical manifestations and diagnosis of intestinal,
toxemic, cerebral forms of acute radiation sickness.
To give an idea of the features of radiation damage in peacetime.
To acquaint students with atypical forms of acute radiation sickness.
Clinical picture of acute radiation sickness after external uneven irradiation,
combined radiation injuries, internal irradiation, associated irradiation, neutron
injuries and long-term exposure to small doses. Providing medical care at the
stages of medical evacuation.
2. Competence (forming competence):
● integral:
ability to solve typical and complex specialized tasks and practical
problems in professional activities in the field of health care, or in the learning
process, which involves research and/or innovation and is characterized by the
complexity and uncertainty of conditions and requirements.
● general:
GC1. The capacity for abstract thinking, analysis and synthesis.
GC2. The ability to learn and acquire the latest knowledge.
GC3. Ability to apply knowledge about radiation damage in practical
situations.
GC4. Knowledge and understanding of the subject area and understanding
of professional activity.
GC5. Ability to adapt and act in a new situation.
GC6. Ability to make informed decisions.
GC7. Ability to work in a team.
GC8. The skills of interpersonal interaction.
GC9. Ability to communicate in the state language both orally and in
writing.
GC10. Ability to communicate in a foreign language.
GC11. Skills in the use of information and communication technologies.
GC12. Certainty and persistence on tasks and responsibilities taken.
GC13. The ability to act socially responsibly and consciously.
GC14. The striving to preserve the environment.
GC15. Ability to act on the basis of ethical considerations (motives).
● special (professional, subject):
SC1. Skills of interviewing and clinical examination of a patient with
radiation injuries.
SC2. Ability to determine the required list of laboratory and instrumental
studies and evaluate their results in patients with radiation injuries.
SC3. Ability to establish a preliminary and clinical diagnosis of the
disease.
SC4. Ability to determine the required mode of work and rest in the
treatment of diseases associated with radiation injuries.
SC5. The ability to determine the principles of nutrition in the treatment
of diseases caused by radiation.
SC6. Ability to determine the principles and features of treatment of
diseases caused by radiation.
SC7. The ability to diagnose emergency conditions.
SC8. Ability to determine tactics for providing emergency medical care.
SC9. Skills of emergency medical care.
SC10. Skills of medical manipulations.
SC11. The ability to conduct preventive measures.
SC12. Ability to determine the tactics of management of persons that need
dispensary supervision.
SC13. The ability to conduct medical records.
3. Plan and organizational structure of the lesson.
The name of the
stage
Organizational
measures
Checking
workbooks
Setting learning
goals and motivation
Control of the initial
level of knowledge:
1. Etiology and
pathogenesis
2. Clinical
manifestations
3. Diagnosis
4. Differential
diagnosis
5. Treatment
Stage description
Preparatory stage
Methods of control of theoretical
knowledge:
- individual theoretical survey;
- test control;
- solving typical tasks.
The main stage
Levels of
assimilation
Questions
Typical tasks
Tests
Written theoretical
tasks
Tables
Figures
Structural and
logical schemes
Audio and video
materials.
Time
45-60
min.
Formation of
practical skills
Formation of
professional skills
1. To provide
curation of patient
2. Make an
examination plan for
the patient.
3. Make a treatment
plan for a patient
with radiation
injuries
Control and
correction of the
level of practical
skills and
professional abilities
Summarizing the
lesson: theoretical,
practical,
organizational
Homework
Method of practical skills
formation:
Practical training
Algorithm for the
formation
of
practical skills.
Method of formation of
professional skills:
training in solving typical and
atypical situational tasks (real
clinical, simulated, textual)
Professional
algorithms for the
formation
of
professional skills;
situational tasks
The final stage
Methods of control of practical
skills:
Individual control of practical
skills and their results
Methods of control of
professional skills: analysis and
evaluation of students' clinical
work results
The results
of
working with a
case history.
100-150
min.
45-60
min.
Atypical situational
tasks.
5-10 min.
Approximate map for
self-dependent work with
literature. Recommended
literature (main, additional)
5 min.
4. The content of the topic
Materials provided by the Department of Military Therapy of the
Ukrainian Military Medical Academy were used in writing this methodical
recommendations.
Currently, in terms of local military conflicts and global geopolitical
confrontation, the possibility of nuclear weapon use cannot be ruled out. It
should also be borne in mind that 33 countries have more than 440 power units
consisting of more than 200 nuclear power plants (NPP). Nuclear power units
are also used on sea- and spacecraft, in research institutions, etc.
In addition, nuclear munitions, nuclear fuel and radioactive waste from
the nuclear industry pose a great danger.
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.
Despite the intensification of NPP safety, it is impossible to completely
eliminate emergencies in the future. To date, more than 300 radiation accidents
with the release of radionuclides into the environment have been registered in
the world.
Fig. 1. Picture of the destroyed 4th reactor of Chernobyl NPP.
Knowledge of the effects of ionizing radiation on the human body is
necessary for doctors. It will help to identify in time persons with probable
radiation damage, to objectify the state of health of victims, to estimate the
diagnostic and prognostic value of various indicators, symptoms and syndromes
in development of pathology, to carry out effective correction and treatment of
physiological and homeostatic disorders.
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.
Ultraviolet radiation and the visible part of the light spectrum do not
belong to ionizing radiation.
Table 1
Physical properties of ionizing radiation
Type of Energy, MeV
Range in
Range
in Ionization
density
radiation
air
biological 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
Gamma
Neutron
up to 3-4
up to 2-3
up to 20 m
hundreds of
meters
depending
on hundreds of
the nature from meters (up
0.05 to 20 MeV to 3 km)
and more
up to 1 сm
dozens
centimeters
dozens
centimeters
up to 1 thousand
of up to 10
of up
to
thousand
several
Alpha radiation (α-radiation) is ionizing radiation, which 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.
This type of radiation has a short path range of particles and is
characterized by weak penetrating power. Therefore, α-radiation is dangerous
only when it enters the body.
Beta radiation is a 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. Like
sources of α-radiation, β-active radionuclides are more dangerous when
ingested.
Photon radiation includes X-rays and gamma radiation (γ-radiation). After
radioactive decay, the atomic nucleus of the final product is often in an excited
state. The transition of the nucleus from this 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.
The neutron flux 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.
Consequently, all types of radioactive radiation have some common
features, and the main ones are penetrating and ionizing ability.
Units of measurement of ionizing radiation
Dosimetry - determination of quantitative and qualitative characteristics
of ionizing radiation. When working with radioactive substances, it is important
to take into account not the mass amount of the radionuclide, but its activity.
Therefore, the amount of radioactive substance is usually measured in units of
activity, ie the number of decays that occur in a given substance per unit time. It
is measured in curie. 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.
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.
Absorbed dose 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 of absorbed
radiation 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). Thus 1 Gy = 100 rad or 1 rad = 0.01 Gy. The power of the absorbed
dose is expressed in Gy/s or rad/s and derivatives mrad/s, mcrad/s, etc.
The ratio between the absorbed radiation dose, expressed in rads and the
exposure dose for air is equal to 1Gy = 0.873 rad.
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).
An equivalent dose 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 - the biological equivalent of
rad - 1 ber (1 Sv = 100 ber).
There is a concept of effective (integrated) dose to assess the harm to
human health from uneven irradiation of the body. This value 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.
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. However, 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.
The main links of biological action of ionizing radiation and
pathogenesis of the main clinical forms of radiation damage
Ionizing radiation has specific biological action, so it can cause structural
and functional changes in the body. The most important features that determine
its specificity are:
- 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, which leads to
pathological reactions in the body's biosubstrate;
- lack of selective exposure and simultaneous action on various structures
of the organism;
- the presence of a 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;
- different types of ionizing radiation cause the same ionization process in
the irradiated substrate, but their biological effect is different and depends on the
density of ionization. At low densities, rapidly decaying reactions occur, and at
high densities, an autocatalytic reaction occurs that proceeds to self-acceleration
and leads to pronounced biological changes. Alpha particles and neutrons have
the highest ionization density;
- the biological effect is directly proportional to the dose rate.
Biological changes depend not only on the nature of radiation, but also on
the state of the biosubstrate.
The absorbed irradiation energy has a very high efficiency. Thus, the dose
absorbed by the body in 9 Gy has a negligible amount of energy (2–5 x 104
erg/g), which, however, causes profound biological changes that are not
compatible with life. This discrepancy between the absorbed energy and the
degree of radiation damage is associated with the effect of physical and
biological amplification.
The interaction of ionizing radiation with the biosubstrate can be
schematically represented as 3 phases:
- energy absorption of ionizing radiation by biosubstrate;
- conversion of ionizing radiation energy into chemical energy with the
formation of ions and active radicals;
- development of radiochemical reactions.
There are 2 ways of interaction of ionizing radiation with organic
compounds:
а) direct influence;
б) indirect effect mediated by the action of free radicals formed due to
radiolysis of water.
Cells of the same tissue with different state at the time of irradiation and
cells of various tissues respond differently to irradiation. According to
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. Irradiation in this period leads to the
development of local damage to the chromosomal apparatus. Depending on the
nature of chromosome damage, the cell dies during mitosis (mitotic death), or
without entering mitosis (interphase death). Under the influence of ionizing
radiation, not only dividing cells die, but also those that are at dormancy.
Primary changes are deficiency of blood cells, intestinal epithelium, impaired
function of the endocrine glands and central nervous system.
Pathogenesis of radiation sickness
Due to unequal radiation injury of various tissues during external rather
uniform irradiation there is dependence of damage of this or that system (critical
organ) on the total absorbed dose of irradiation. This causes a certain variety of
clinical forms of the disease. Thus, when a person is irradiated at a dose of 1 to
10 Gy, the main pathogenetic factors are hematopoietic disorders, hemorrhagic
syndrome and infectious complications. Hematopoietic organs are critical for
this dose range.
When exposed to radiation doses in the range of 10-20 Gy, along with the
hematopoietic system, the epithelium of the gastrointestinal tract is affected,
which is a critical organ for a given dose of radiation, and postradiation enteritis
determines the development of the entire clinical picture. Death occurs within
8-16 days.
After irradiation at a dose of 20-80 Gy in the pathogenesis of acute
radiation sickness a prominent place is occupied by significant azotemia and
intoxication of the body with protein breakdown products. The affection of the
central nervous system in this case is mainly secondary and is caused by
disorder of cerebrospinal fluid hemodynamics and toxemia. Death occurs 4-8
days after irradiation. Direct radiation damage of the central nervous system is
the leading cause of circulatory and respiratory disorders after irradiation at a
dose more than 80 Gy. Death occurs within the first three days. Moreover, high
doses of radiation also set into action secondary factors of pathogenesis, for
example vascular disorders, especially in the brain. This leads to its massive
oedema, early hemorrhages, severe hypotensive shock.
Neuroendocrine disorders in the initial period of radiation sickness are
leading condition. High reactivity of the nervous system after exposure to
radiation in combination with irritation of afferent receptors, accompanied by
pathological interaceptive impulses involving the endocrine glands and
especially the pituitary-adrenal system, leads to the development of progressive
changes in various organs and tissues. They are accompanied, first of all, by
trophic disorders, disorders of vascular and tissue permeability, changes in the
blood system, metabolic disorders, decreased immune resistance, dystrophic
changes.
An important link in the pathogenesis of radiation damage is the
development of intoxication, which disrupts the function of organs and systems
and leads to the formation of typical syndromes. They are most clearly
manifested in acute radiation sickness of moderate and severe degree:
devastation of hematopoietic organs, hemorrhagic manifestations, radiation
complications, dystrophic changes in organs and tissues, disorders of reparative
processes, mutagenic and genetic manifestations.
The integral effect of the biological action of ionizing radiation on the
body is realized by the development of radiation sickness (acute or chronic) with
its polysyndromic manifestations (after uniform irradiation) or local lesions
(after local irradiation).
Clinical classification of radiation injuries
Depending on the dose acute radiation exposure may cause acute radiation
reaction or acute radiation sickness.
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.
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 Gray (Gy), obtained simultaneously or over a short
period of time (from 3 to 10 days) and is characterized by certain phases of the
course.
Exposure to ionizing radiation causes ionization and excitation of
molecules and atoms, and thus the formation of aggressive substances and
radicals that cause damage to cells and tissues. At the same time there is a
saturation of an organism with toxic products of protein disintegration,
hemolysins, histamine-like substances which altogether suppress hematopoiesis
in a bone marrow.
There are 4 forms of ARS depending on the radiation dose: from 1 to 10
Gy - bone marrow form; from 10 to 20 Gy - intestinal form; 20-80 Gy - toxemic;
more than 80 Gy - cerebral. The higher the absorbed dose, the more difficult the
course of ARS will be. Forms of ARS with radiation dose >10 Gy are lethal.
Bone marrow form of ARS develops at radiation doses from 1 Gy to 10
Gy and has 4 degrees of severity:
І – mild – 1-2 Gy;
ІІ – moderate – 2-4 Gy;
ІІІ – severe – 4-6 Gy;
ІV – extremely severe – 6-10 Gy.
According to the conditions of irradiation, there are following main
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).
These clinical forms of radiation damage have certain features of the
course depending on the type, duration of exposure and location of the source of
ionizing radiation.
Clinical picture of acute radiation sickness (ARS).
A characteristic feature of the course of ARS is stages of its development.
This division is not always clear and does not reflect real changes in the body. In
typical cases of the disease caused by the general rather uniform irradiation,
there are 5 phases (periods):
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 of the disease
(manifest illness period);
4 – period of outcomes (progression, stabilization, early recovery complete or partial);
5 – period of long-term effects.
Significance of these periods varies at different forms and degrees of
severity of radiation sickness. The clearest periodization of the course is typical
for moderate and severe bone marrow form of ARS.
In mild and extremely severe bone marrow form of ARS the separate
periods are expressed not clearly enough. The course of intestinal, toxemic and
cerebral forms of radiation damage is characterized by the same features. Thus,
mild degree of ARS is with weakly expressed clinical manifestations of the
disease, and in intestinal, toxemic and cerebral forms there is almost no latent
period and significant GPR are overlapped with symptoms of manifest illness
period.
Period of the general primary reaction to irradiation (GPR)
After a short time (minutes-hours) after irradiation, the body develops
primary radiochemical transformations reflected in certain clinical
manifestations. Symptoms of GPR can be divided into four groups:
- dyspeptic - nausea, vomiting, diarrhea;
- general clinical - 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.
The intensity and duration of manifestations of GPR depend on the total
absorbed radiation dose (minimum - 1-2 Gy), its distribution in the organs and
tissues (predominant irradiation of a body segment), the general condition of the
patient at the time of irradiation, sex, age.
The most characteristic manifestations of GPR are the symptoms of acute
functional disorders of the CNS, digestive, cardiovascular, respiratory system,
and thermoregulation.
The most demonstrative symptom of GPR in ARS is vomiting (it is
important to determine the time of onset, frequency and duration). This
symptom has important diagnostic and prognostic value.
Epigastric pain and sudden vomiting that appear 2 hours after exposure
suggest mild damage, while exhausting uncontrollable vomiting that occurs
early (in 5-20 minutes) - the extremely severe degree ARS. Well-being may
remain satisfactory in period between vomiting acts. Vomiting is often preceded
by nausea that has no prognostic value. Diarrhea, paresis of the stomach or
intestines are characteristic of extremely severe damage.
General condition, consciousness and body temperature should be
particularly noted among the general clinical symptoms. Thirst, dry mouth,
lethargy, drowsiness, depression, subfebrile temperature are characteristic for the
second and third degree of severity of ARS, while dizziness, higher temperature
(38-39˚C) indicate the development of severe and extremely severe damage.
Palpitations, cardialgia, arthralgia are an indicator of extremely severe damage.
An indirect sign, which also has diagnostic value, is general muscle weakness from mild at doses of 1-2 Gy, to significant (decrease in physical activity) at
doses over 4 Gy. Hypo- and adynamia is caused by dysfunction of the central
nervous system and a neuromuscular tonus.
Blood parameters are quite important in assessing the severity of radiation
damage in the GPR. Within a few hours after irradiation there is a neutrophilic
leukocytosis with left shift, relative and absolute lymphocytopenia, a tendency
to reticulocytosis. The severity and consistency of relative (from 1 to 20%) and
absolute (0.1-1 x 109/l) lymphocytopenia in the first 2-3 days clearly indicate the
severity of ARS. At moderate and severe degrees of ARS there is leukocytosis
more than 12 x 109/l with a predominance of neutrophils (segmental and band
forms) and a left shift. In the bone marrow there is a reduced number of
myelokaryocytes, erythroblasts, a decrease in the number of mitoses and mitotic
index, the disappearance of young cell forms, increased cytolysis.
The skin condition in victims during GPR is a reliable objective
diagnostic indicator of radiation exposure. The presence and severity of primary
erythema ("radiation tanning") of the skin and visible mucous membranes,
hyperhydrosis largely depend on the dose of local irradiation. In extremely
severe cases, scleral icterus also appears.
The duration of GPR ranges from several hours (mild cases) to 2 or more
days (severe forms of ARS).
Table 2
Characteristics of clinical manifestations of the general primary
reaction in the bone marrow form of ARS of different severity
The degree of severity of ARS
Symptoms
mild
moderate
severe
extremely
severe
Vomiting (time of After 2-3 hours, After
1-2 After 30-40 After 5-20 min,
onset, severity) once
hours,
min, multiple unrestrained
repeated
Muscle weakness Insignificant,
Moderate
Significant
Severe
short-term
(adynamia)
Headache
Absent or mild
Moderate,
long-term
Significant,
recurrent
Body temperature Normal
Subfebrile
Subfebrile
(37,1-37,5˚С) (37,6-38˚С)
Severe,
expressed
постійний
Sometimes
confusion
Febrile
(>38°С)
Сonsciousness
Clear
Clear
Clear
Skin hypaeremia Mild
Distinct
Significant
GPR duration
1 day
Expressed,
stable
2 days
110-100
100-80
More than 2
days
Often collapse
100-120
130-150
>150
Several hours
Hypotension
Absent
(systolic
BP,
mmHg)
HR, beats/min
80-100
The measures of emergency first aid include the following:
Immediate evacuation of the victim from the area of radioactive
contamination, referral of the victim to a specialized medical institution.
Use of individual and collective means of protection (respirators, gas
masks, etc);
After exposure of skin and uniforms to nuclear explosion products, partial
sanitation is carried out after leaving the area of radioactive contamination, as
well as the 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 if radioactive substances entered the respiratory
tract.
Measures are aimed at reducing dyspeptic disorders, toxemia, shock
conditions and maintaining the function of vital organs and systems, prevention
of severe cardiovascular and neurological disorders. Prevention and termination
of GPR helps to maintain the combat capability of personnel and facilitates
medical and evacuation measures. 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 .
Victims who enter the stage of medical care are sorted by principle:
1) the need for special sanitation;
2) necessity and priority of providing medical health care.
In case of skin and uniform exposure to radioactive substances (above
acceptable levels) sanitary treatment at the site of decontamination can be
carried out in the form of cleansing of exposed parts of the body, mouth and
pharynx wash, eye irrigation (partial personal cleansing), or wash with shower
soap, change of linen and uniform (full personal cleansing) before first aid.
According to the principle of need for medical care there are:
- persons in need of first aid;
- persons to whom first aid can be postponed and provided in the
subsequent stages of medical evacuation;
- lightly injured, wounded and sick, who can be returned to their units;
- agonizing, wounded and sick who need only care.
Medical tactics in the period of primary reaction:
1. Hospitalization in the nearest hematology department.
2. Bed regime.
3. Antiemetics (dimetcarb, cerucal, etaperazine, atropine).
4. Detoxification measures such as correcting fluid and electrolyte balance
(rheosorbilact, reopolyglukin, isotonic sodium chloride solution, glucose
solution 5%, saline solutions like Ringer-Locke’s). An effective method of
detoxification therapy is hemosorbtion.
5. Diuretics (such as 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.
The latent period of ARS is characterized by a relatively satisfactory
state of the irradiated person.
In the latent period, despite the improvement of patients' well-being, a
special examination reveals signs of progressive disorders of the functional state
of the nervous and endocrine systems, changes in the blood, dystonic and
metabolic disorders. At the same time, general weakness, decreased exercise
tolerance, sweating, intermittent headache, mood instability, sleep disorders, loss
of appetite, dyspeptic disorders may persist.
The leukocytosis observed in the first period is replaced by leukopenia,
the number of reticulocytes and thrombocytes decreases. There are qualitative
changes in blood cells: hypersegmentation of neutrophils, nuclear polymorphism
of lymphocytes, cytoplasmic and nuclear vacuolization, chromatin lysis, toxic
granulation of neutrophils. Typical changes in peripheral blood and bone
marrow within 1-1.5 weeks after irradiation predict the severity of ARS with a
sufficient degree of probability.
The duration of the latent period is 3-4 weeks after mild irradiation, and it
may be absent after extremely severe irradiation.
Medical tactics in the latent period:
1. Sanitation of all foci of chronic infection.
2. Nutritional therapy.
3. Symptomatic therapy: multivitamins, adaptogens, sedatives,
antihistamines.
4. Desintoxication therapy (rheosorbilact, haemodesis, isotonic sodium
chloride solution, 5% glucose solution).
The diet should exclude coarse food.
Patients with mild disease can receive outpatient treatment or day patient
facility. They are prescribed a sparing regimen and medical nutrition. The food
should be mechanically and chemically gentle.
Patients with severe radiation sickness are hospitalized with strict aseptic
and antiseptic regulations. They receive desintoxication therapy, hidden foci of
infection are detected and sanitized. Increased fluid intake, antihistamine drugs,
forced diuresis are prescribed.
The manifest period of ARS begins with the deterioration of the general
condition of patients, as well as signs of 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.
For the manifest illness period such syndromes are characteristic:
•
hematological (results from bone marrow aplasia) - there is severe
leukopenia (the term agranulocytosis is used if the number of white blood cells
is below 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.
Patients have sleep and appetite disturbances, significant general
weakness, adynamia, headache, dizziness, palpitations, cardialgia. Body
temperature is usually rised in the form of constant or hectic fever with chills
and profuse sweating. The heart rate increases, the heart becomes enlarged, its
sounds become muffled, and a systolic murmur is heard above the apex.
Bronchitis and focal pneumonia often occur. In severe cases, in addition to
dyspeptic disorders and loss of appetite there are ulcerative or
ulcerative-necrotic stomatitis, glossitis, tonsillitis and enterocolitis. Due to the
severe tenderness of gum mucous membrane and painful swallowing, the patient
can not eat. Severe sweating, high fever, diarrhea lead to dehydration and
disbalance of electrolyte homeostasis.
Bleeding firstly occurs on the mucous membrane of oral cavity, later
hemorrhages appear on the skin of the axillary areas, on the inner surfaces of the
thighs, legs, forearms, in the lower triangle of the abdomen; often nasal and
intestinal bleeding, hematuria may be seen. Hair begins to fall out on the head,
pubis, then on the chin, armpits and torso.
Neurological examination reveals severe lethargy of patients, asthenia,
sometimes symptoms of meningeal irritation, anisoreflexia, decreased tendon
and periosteal reflexes, hypotonia. Congestion with small hemorrhages may be
seen at the fundus of the eye.
On the electrocardiogram signs of deterioration of a functional condition
of a myocardium are registered: decreased voltage, expansion of a ventricular
complex, increased stroke volume index, decreased amplitude of T and P waves,
changes in ST segment.
Table 3
Changes in hematological parameters in the bone marrow form of
ARS of different severity
Indicator
The severity of ARS
9
Lymphocyte count, х10 /l
(on the 3rd day)
Leukocyte count, х109/l (on
7–9th day)
Platelet count, х109/l (on
20th day)
The onset of
agranulocytosis (leukocyte
count < 1x109/l)
I
1–0,6
II
0,6–0,3
III
0,3–0,1
IV
<0,1
>3
3–2
1,9–0,5
<0,5
>80
79–50
50–20
<20
Absent or Since
in 30 days 20-30th
day
Since 8–20th In first 7
day
days
Reduction of proliferating
erythroblasts on 4th day
Mitotic index of the bone
marrow, % (on 3–4th day)
Absent
5,4–4,8
On
25–30%
1,8–0,9
On 50–60%
0,8–0,2
On
100%
0,1–0
In the manifest period of ARS treatment of infectious-inflammatory and
hemorrhagic complications, intestinal and oropharyngeal syndromes,
elimination of general intoxication are performed.
Medical tactics in the manifest illness period.
1. Patients need isolation with strict adherence to aseptic and antiseptic
regulations (isolation ward, non-contact care). Particular attention is paid to
avoidance of exogenous infection. Skin and hair should be prepared daily with
solutions of antiseptics, sterile water.
2. Antibiotic therapy is used with the simultaneous use of several
antibiotics in the maximum possible dosage. The choice of antibacterial agents
should be made by determining the sensitivity of the microflora to them. At the
same time antifungal drugs are prescribed. Antibiotic therapy is continued until
resolution of agranulocytosis. Preference is given to parenteral administration.
For persistent urinary tract infection nitrofuran drugs are indicated. Of
particular importance in the prevention of infectious complications are measures
aimed at sterilization of the intestine. For this purpose, orally administered
antibiotics that are poorly absorbed in the gastrointestinal tract are used.
3. Correction of immune disorders, including leukopoiesis stimulants and
the use of immunoglobulins.
4. Desintoxication therapy (rheosorbilact, isotonic sodium chloride
solution, 5% glucose solution).
5. Antihemorrhagic and antianemic drugs (ambene, aminocaproic acid,
dicynone, hematopoietic stimulants, as well as substitution therapy - erythrocyte
and thrombocyte concentrate). Bone marrow transplantation is an effective
treatment for severe ARS.
6. Treatment of oral-pharyngeal and intestinal syndromes:
•
tube nutrition;
•
rinsing the oral cavity with a solution of furagin (1: 13000),
decamethoxine, miramistin and other antiseptics, followed by application to the
mucous membranes of cotton swabs soaked in solutions of anesthetics (5%
solution of novocaine, anesthesin emulsion).
•
lubrication of the oral cavity with eucalyptus and sea buckthorn oil;
•
parenteral nutrition (intravenous polyamine or amekin; lipofundin or
lipomaise and other fat emulsions).
Due to the suppression of enzyme production in the small intestine, it is
necessary to provide substitution drugs (pancreatin, etc.), which at the received
doses of radiation from 3 to 6 Gy 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, for example: 2 ml 2% of a solution of drotaverine SQ or IM; 2 ml - 2% solution of papaverine SQ
or IV; 1 ml - 0.1% solution of atropine sulfate SQ, pirenzepine (gastrotypin,
gastrozepin) IV, IM 10-15 mg 2 times a day.
Prebiotics are indicated (lactulose 10–15 ml x 3 times a day or hylak forte
30–40 drops 3 times a day, or bionorm 2-3 tablets 2-3 times a day) in
combination with probiotics (linex, bifiform, yogurt, laktovit forte, lacidophilin,
etc.) 1-2 doses 3 times a day.
7. Treatment of cardiovascular failure and other related disorders.
Favorable outcome of the disease is characterized by a recovery period
lasting 6-12 months. Sometimes it is delayed for many years with residual or
long-term somatic and genetic effects. Long-term effects include
asthenovegetative syndrome, reduction of life expectancy, cataract development,
decreased fertility, predisposition to leukemia and tumors.
Patients continue to receive clinical nutrition and are gradually transferred
to the general motor mode under daily medical supervision. The main attention
is paid to the normalization of the function of nervous system, hematopoietic
organs. Vitamin B12, folic acid, sodium nucleic acid, iron preparations are
prescribed from the moment of initial restoration of hematopoiesis. Anabolic
hormones (methandrostenolone, nandrolone), drugs that correct dysmetabolic
disorders, stimulate erythro- and thrombocytopoiesis, improve tissue
regeneration processes and increase appetite are used to accelerate the
normalization of metabolic processes. With the progression of anemia,
erythrocyte concentrate or fresh blood is transfused. Adaptogens (ginseng,
eleutherococcus, vitamin complex) improve the functional state of the nervous
system. Exercise therapy is recommended.
In the period of long-term effects different combinations of drugs with
radioprotective,
antioxidant,
adaptogenic,
membrane-protective,
hemostimulating, immunomodulatory, vasoactive, nootropic and sedative action
are used at the hospital stage, depending on the state of health, specific diseases.
Great importance is also attached to the methods of physical and mental
rehabilitation, the use of physiotherapy procedures and methods of alternative
medicine. Symptomatic therapy is widely used in all periods of the disease.
Table 4
Classification of ARS according to the possibility of patient's survival
ARS,
Dose,
Possibility of survival
severity
Gy
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
>10
Survival is unlikely, but modern treatment can lead to the
survival of some patients
Survival is impossible
The diagnosis of ARS is based on the history (contact of the patient with
ionizing radiation), dosimetry data and/or clinical manifestations of the disease.
Hematological parameters are of great importance. In differential
diagnosis particular attention should be paid to leukopenia, the rate of its
development and time of onset. There should not be significant difficulties in the
differential diagnosis. Anamnestic data (stay of the victim in the zone of nuclear
catastrophe), manifestations of the general primary reaction (time of
development and duration), appearance of the victim (sluggish, adynamic,
hyperemia of open skin areas, icteric sclera, state of consciousness), objective
clinical data (BP, HR, RR), laboratory data (primary leukocytosis, absence of
young forms of neutrophils in the blood, suppression of leukopoiesis and
lymphocytopenia) is sufficient to establish a preliminary diagnosis and
determine the severity of the disease.
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.
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.
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.
5. Questions for self-preparation of the student for practical lesson:
1.
The concept of radiation situation.
2.
Types of ionizing radiation, units of measurement and dosimetry.
3.
Methods for assessing the radiation situation.
4.
Methods of dosimetric control.
5.
The main links of the biological action of ionizing radiation and the
pathogenesis of the main clinical forms of radiation damage.
6.
Acute radiation sickness and its severity. Periods of radiation
sickness.
7.
Principles of radiation exposure limit.
8.
Principles of protection of the population in the center of radiation
pollution.
9.
Principles of pathogenetic treatment of acute radiation sickness,
taking into account the leading manifestations of the disease.
10. Features of radiation damage in peacetime.
11. Atypical forms of ARS.
12. Features and content of medical care at the stages of medical
evacuation.
6. Recommended literature
Main:
1.
Військова токсикологія, радіологія, медичний захист :
підручник / за ред. О. Є. Левченко. – К. : СПД Чалчинська Н. В., 2017. –
788 с.
2.
Воєнно-польова терапія: підручник [за ред. Г.В. Осьодло, А.В.
Верби]. – К. СПД Чалчинська Н.В., 2017. – 620 с.
3.
Екстрена медична допомога військовослужбовця на до
госпітальному етапі в умовах збройних конфліктів :навч. посіб. / М. І.
Бадюк [та ін.]. – К. : СПД Чалчинська Н. В., 2018. – 204 с.
4.
Михайлюк, В. О. Цивільна безпека : навч. посіб. для студентів
ВНЗ / В. О. Михайлюк, Б. Д. Халмурадов. – К. : Центр учб. л-ри, 2017. –
158 с.
5.
Перша медична (екстрена) допомога з елементами тактичної
медицини на до госпітальному етапі в умовах надзвичайних ситуацій :
навч. посіб. / В. С. Тарасюк [та ін.]. – 2 вид., випр. – К. : ВСВ «Медицина»,
2017. – 368 с.
Additional:
1.
Бебешко В. Г., Прістер Б. С., Омельянець М. І. Радіо-біофізичні
та медикобіохімічні наслідки Чорнобильської катастрофи: шляхи пізнання
та подолання: практичний посібник [для сімейного лікаря]. – Ужгород:
ТДВ «Патент», 2017. – 504 с.
2.
Гребенюк А. Н., Легеза В. И. Перспективы использования
радиопротекторов
для
повышения эффективности медицинской
противорадиационной защиты Вооруженных сил // ВМЖ. - 2013. - Т. 334,
№ 7. - С. 46-50.
3.
Керівництво з медичного забезпечення Збройних Сил України :
введено в дію наказом ГШ ЗСУ від 26.12.2013 року № 317 / М. І. Бадюк [та
ін.]. – К., 2016. – 512 с.
4.
Медицина катастроф. Військова медицина : рек. анотований
бібліогр. покажч. / уклад.: Н. Б. Гавриш, В. В. Хівренко, І. М. Лазоренко, Л.
М. Драган. – Х., 2018. – 36 с.
5.
Практикум з дисципліни «Організація медичного забезпечення
військ» (практикум до самостійної роботи студентів вищих медичних
навчальних закладів України ІІІ–ІV рівні акредитації) / під ред. проф. М. І.
Бадюка. – К., 2017. – 86 с.
6.
Тимчасова Настанова з медичної евакуації поранених і хворих
у Збройних Силах України на особливий період/ за редакцією Верби А.В.,
Хорошуна Е.М./К.: НДІ ПВМ УВМА, 2016. – 60 с.
7.
Allied joint doctrine for medical support / NATO standard AJP-4.10
// With UK National elements. – 2020. – Edition B, Version 1
https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/922182/doctrine_nato
_med_spt_ajp_4_10.pdf
Methodical recommendation was composed by associate professor
Dobrianskyi D.V.
(position, full name of the teacher)