Manual on the Acute Radiation Syndrome –
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Medical Management of Radiation Accidents: Management of the Acute Radiation Syndrome © 2001 The British Institute of Radiology This publication is copyright under the Berne Convention and the Universal Copyright Convention. This publication is posted on this site with the permission of the British Institute of Radiology for personal use only. No part of this publication may be reproduced, or stored on a retrieval system, or transmitted in any form or by any means without the prior permission of the copyright holder. For further information email [email protected] . Radiology Cover 10/10/05 3:38 pm Page 1 BIR MEDICAL MANAGEMENT OF RADIATION ACCIDENTS MEDICAL MANAGEMENT OF Medical RADIATION ACCIDENTS Edited by T M Fliedner, I Friesecke and K Beyrer Management of Radiation Accidents Radiation of Management Edited by T M Fliedner, I Friesecke and K Beyrer Radiation Accident Triage primary* / extended Radiation Accident rral Refe e Triage s a Diagnosis primary* / extended h l p a r c Case history r i e t f + e s Physical examinationR o e D n s Diagnosis + g ocumentation Laboratory a tests a h i + t p D Additiona l d n iagn Management ostic measures c Case history e i t Edited + m s Physical e e xamination o g Organ specific grading D n edical + a e g o by by M Laboratory tests n s a c i a a Grading code + u T M Fliedner M T D h m M Additional diagnostic measures p l Work flow e a RC c n i c i t Organ specific grading t a d u Information flow t e e i o e Referral ? p M Grading co n s de a a , I Friesecke and K Beyrer K and Friesecke I , r Feed back h e p RC h Work flow T c Therapy i t Information flow u Referral ? e p a Feed back r e h Therapy T BIR ACUTE RADIATION SYNDROME MA PublishedBIR by The British InstituteACUTE of RadiologyNUAL RADIATION ON THE SYNDROME MANUAL ON THE Published by The British Institute of Radiology © 2001 The British Institute of Radiology Reprinted 2005, 2007 ISBN 0-905749-46-4 British Library Cataloguing-in Publication Data A Catalogue record for this book is available from the British Library Legal Notice All opinions expressed in this publication are those of the respective authors and not the publisher. The publisher has taken the utmost care to ensure that the information and data contained in this publication are as accurate as possible at the time of going to press. Nevertheless the publisher cannot accept any responsibility for errors, omissions or misrepresentations howsoever caused. All liability for loss, disappointment or damage caused by reliance on the information contained in this publication or the negligence of the publisher is hereby excluded. The British Institute of Radiology The British Institute of Radiology is a registered charity whose aim is to forge links between medicine, science and industry to improve the detection and treatment of disease. It is a multidisciplinary learned society whose activities cover all aspects of the radiological sciences, and whose members consist of radiologists, radiographers, medical physicists, radiotherapists, radiobiologists and industry executives. The BIR publishes two journals: the British Journal of Radiology, a leading peer reviewed journal (12 issues per year) covering all technical and clinical aspects of diagnostic imaging, medical physics, radiotherapy and radiobiology; and Imaging, a review journal (4 issues per year) providing the latest information on the integrated role of imaging modalities in medical diagnosis. Both journals are published in print form and on the Internet (see the BIR website www.bir.org.uk or www.birjournals.org for further information). The BIR organises a full calendar of scientific meetings, many of which are held at the BIR’s headquarters, 36 Portland Place, in London’s West End, and which houses the largest collection of radiological journals and books in the UK, forming the foundation for its Library and Information Service. The BIR is governed by a multidisciplinary Council and has a network of Committees whose role is both to organise the BIR’s scientific meetings and to promote the development of their particular fields. Membership of the BIR is open to all those working in the radiological sciences. Full members receive the British Journal of Radiology and are eligible for discounts on its scientific calendar meetings and its publications. Published by the British Institute of Radiology, 36 Portland Place, London W1B 1AT, UK Typeset by the British Institute of Radiology Printed and bound by Latimer Trend & Company Ltd, Plymouth, UK MEDICAL MANAGEMENT OF RADIATION ACCIDENTS – MANUAL ON THE ACUTE RADIATION SYNDROME – This manual is the result of a Concerted Action called METREPOL (Medical Treatment Protocols for Radiation Accident Victims as a Basis for a Computerised Guidance System), which was supported by the European Commission. EDITORS T M Fliedner I Friesecke K Beyrer Radiation Medicine Research Group and WHO Collaborating Centre for Radiation Accident Management University of Ulm Germany Published by The British Institute of Radiology 2001 i NOTICE Every effort has been made by the authors of this manual to ensure that recommendations are in agreement with the standards of practice at the time of publication. However, owing to progress in clinical experience and continuing laboratory studies these recommendations may need to be changed with time. Therefore, we urge that the reader check especially the diagnostic and therapeutic recommendations against the latest developments in clinical (radiation) medicine. In addition, there may be special cases that are beyond the scope of this manual and therefore require individual care and external expert advice. THE EDITORS ii The participants of the METREPOL team jointly prepared this manual. Apart from providing overall input each member particularly contributed as follows: Gourmelon P Neurovascular system France Lebaron-Jacobs L Neurovascular system France Fliedner T M Haematopoietic system Germany Wagemaker G Haematopoietic system The Netherlands Gottlöber P Cutaneous system Germany Hopewell J W Cutaneous system United Kingdom Peter R U Cutaneous system Germany Rezvani M Cutaneous system United Kingdom Griffiths N M Gastrointestinal system France Beyrer K General concepts Germany Friesecke I General concepts Germany Special thanks are due to the following for their support and scientific advice in the development of this manual: Calrençon D France Cosset J M France Dainiak N USA Dubois A USA Ganser A Germany Keyeux A J Belgium Körbling M USA Lefaix J-L France Neta R USA Panizzon R G Switzerland Schaefer U W Germany Sharp C United Kingdom Teunen D Belgium Trott K-R United Kingdom iii FOREWORD In the Nuclear Fission Safety Program (DG XII Science) of the European Atomic Energy Community, the Commission of the European Communities accepted and supported a Concerted Action called “Medical Treatment Protocols for Radiation Accident Victims as a Basis for a Computerised Guidance System”, in short METREPOL (Contract number FI4PCT970067). The work of the Concerted Action started in December 1997. One of the main purposes of this interdisciplinary project was to develop a new approach in the medical management of radiation accidents with respect to diagnostic procedures and therapeutic options based on the recognition and evaluation of health impairments after acute radiation exposure. The work of the group is pre- sented in the form of this manual on the acute radiation syndrome. The acute radiation syndrome (ARS) is very complex, because the interactions and combined effects of dam- age to different organ systems after radiation exposure are diverse and not yet fully understood. Furthermore, the clinical management of patients suffering from an ARS requires immediate and specialised care. In cases of accidental exposure to ionising radiation, guidance for appropriate diagnostic and therapeutic procedures is therefore required. This manual is compiled to help assess in the shortest time possible the state and possible outcome of radiation accident victims. It specifies what has to be examined and what should be documented, and it provides a scientific basis for deciding the most appropriate therapeutic interventions. It is hoped that the wide distribution and broad acceptance of this manual on the acute radiation syndrome will make a useful contribution to the management, harmonisation and standardisation of diagnosis and therapy of future radiation accident victims. It is also hoped that an international standard for the scientific evaluation of health impairments of radiation accident victims is promoted, no matter in which country or region a radiation accident occurs and what level of health care is available. The Co-ordinator is grateful to the participants of this Concerted Action. The development of this manual was possible only with their continuous commitment and input based on special scientific/medical experience. Furthermore, on behalf of the METREPOL team, the Co-ordinator would like to thank the external experts for reviewing this manual and giving their advice and support. THE EDITORS v EXECUTIVE SUMMARY The medical management of radiation accident victims, in terms of diagnosis and treatment, is classically centred on the assessment and reconstruction of the radiation dose. In the past, this has been the key information for medical decision-making and patient prognosis. The argument for adopting such an approach is the strong relationship between the radiopathological manifestations and the energy deposited. However, the physical parameter “dose” is not sufficient to predict the clinical evolution of damage in an individual patient. It is not a reliable prognostic indicator in the development of the acute radiation syndrome (ARS). In operational situations, dose assessment and reconstruction is a lengthy process involving considerable uncertainties. This becomes particularly apparent at low doses owing to the heterogeneity of the exposure and the radiation quality, both of which affect the pathophysiological processes in man.