Author:  Nathaniel Sundquist, DO, Emergency Medicine Resident, PGY I
Faculty:  Alexis Cates, DO, Medical Toxicology/Emergency Medicine Attending

The Case.

A 16-year-old female presented to the emergency department in Brazil with multiple generalized complaints including abdominal pain associated with nausea and vomiting, progressively worsening fatigue and gradually worsening swelling in the upper body, headache and hair loss. She states that she initially had nausea and vomiting which intermittently improved, but then acutely worsened upon presentation.

The patient denies any suspicious food sources or any new known exposures.  She does report that her father is the owner of a junkyard and brought home a blue glowing substance which she has been playing with and showing off to her friends.

The patient’s labs are notable for pancytopenia, acute kidney injury and hepatic injury.  Given these findings and in conjunction with her history, hospital staff were concerned for a potential radiation exposure or bio-terrorism agent and admitted the patient with airborne and contact isolation precautions.

You are part of a team of elite toxicologists who have been sent to the hospital to evaluate the patient. You know now that on the patient’s chest x-ray there appears to be evidence of lung damage with fibrosis.  Other advanced imaging revealed evidence of internal bleeding and developed a disseminated macular purpuric rash.  During her course in the hospital, the patient became septic from an unknown source and, despite aggressive interventions, succumbed to her illness.

There are similar reports of illness within the patient’s family contacts and in the nearby community. Hospital staff wonder if they could have done anything differently and what they can learn from this to help the surrounding community.

Learning Point 1: What is radiation and what is acute radiation syndrome?

Radioactive material is any material containing unstable atoms that emit ionizing radiation as it decays.

Radioactive decay occurs when an unstable atomic nucleus loses energy by emitting energy in the form of emitted particles or electromagnetic waves, called radiation. 

Alpha particle- A particle consisting of two protons and two neutrons bound together, identical to a helium nucleus.

Beta particle- A high energy electron released during beta decay.

Gamma decay- Some decay reactions release energy in the form of electromagnetic waves called gamma rays. Gamma radiation (γ) is part of the electromagnetic spectrum, just like visible light. The only substances that can absorb this radiation are thick lead and concrete.

• Acute Radiation Syndrome (ARS):  acute illness caused by irradiation of a large portion of the body by a high dose of penetrating radiation in a very short period of time
  • Caused by depletion of immature parenchymal stem cells in specific tissues
  • Radiation dose must be large (i.e., greater than 0.7 Gray (Gy)1, 2 or 70 rads) and must be within a short period of time (1 hour to 2 days)
• Bone marrow syndrome: also known as hematopoietic syndrome  
  • Dose between 0.7 and 10 Gy (70 – 1000 rads)
  • Primary cause of death is the destruction of the bone marrow, resulting in pancytopenia and ultimately infection and hemorrhage
• Gastrointestinal (GI) syndrome: destruction of the GI tract from radiation 
  • Dose greater than approximately 10 Gy (1000 rads) 
  • Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance
  • Death usually occurs within 2 weeks
• Cardiovascular (CV)/ Central Nervous System (CNS) syndrome: involves both cardiovascular and central nervous systems
  • Dose greater than approximately 50 Gy (5000 rads) 
  • Death likely is due to collapse of the circulatory system as well as increased pressure in the cranial vault.
  • There is increased fluid content caused by edema, vasculitis, and meningitis

This case is based on a real-life incident which occurred in the Goiânia accident in 1987.  A forgotten radiotherapy source which contained cesium-137 was stolen from an abandoned hospital site in the city.  It was subsequently handled by multiple people which resulted in exposure to 212,000 people, who were examined for radioactive contamination.  There were 4 fatalities including the individuals who stole the radioactive source and some other family members and also 249 people were found to have been contaminated.

Learning Point 2: Decontamination and management

If radiation exposure is suspected, external decontamination should be completed.

• Examples of supplies: disposable waterproof paper for covering the floor, tape to secure the covers, emergency medical equipment, patient sheets and gowns, table with a drainage system to collect contaminated washings, large buckets for collection of waste water, plastic bags for disposal of swabs, clothing and trash, lead containers for possible radioactive foreign bodies, solutions for decontamination (saline, water, soap, hydrogen peroxide) and soft brushes.
• Recommendation: 
  • Carefully remove all contaminated clothing, working from head to toe and rolling it outward away from the patient’s skin, trapping the contaminant material inside. If necessary, clothing should be cut off, not tearing, to prevent spread of radioactive materials through contact or airborne transmission. 
  • Start from the periphery (hair first) of the contaminated area and move towards the center. Repeat until radioactivity less than two times acceptable background activity.

Management in the ED may vary based on resources.  In general, these steps can be considered:

1. Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood gases, electrolyte and urine output) as appropriate.

2. Treat major trauma, burns, and respiratory injury if evident.

3. In addition to the blood samples required to address the trauma, obtain blood samples for CBC (complete blood count), with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion.

4. Treat contamination as needed.

5. If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or 3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion.

Learning Point 3: Internal Decontamination for Inhaled or Ingested Particles

For alpha and beta particle radiation, it may be necessary to treat with internal decontamination to reduce absorption and promote excretion before radioisotopes become incorporated into tissue. 

Prussian blue has been used as an ion exchanger to trap substances such as Cesium 137. 

• Traps radioactive cesium 
• Prevents absorption in the intestinal tract, limits the amount of time the body is exposed to radiation
• Reduces the biological half-life of cesium from about 110 days to about 30 days
• Dosing:
  • Available in 500 mg capsules
  • 3 grams (6 capsules) orally 3 times per day for total daily dose 9 grams
  • Treatment may be 30 days or longer
• Indications/Duration:
  • Cesium or thallium exposure most beneficial 
  • Initiate as soon as contamination suspected 
  • Attempt to obtain quantitative baseline levels of cesium or thallium when possible
  • Monitor levels in urine/feces when possible to calculate elimination rate 

In any case of such exposure, it is always recommended to contact your local poison control center, toxicology service or Radiation Emergency Assistance Center/Training Site at 865-576-1005.

Conclusion.

During the real life incident in Goiana, 112,000 people were examined for radioactive contamination; 249 were found to have significant levels of radioactive material in or on their body and of this group 129 had evidence of internal contamination with only very limited radiation exposure. Only 28 were found to have evidence of radiation sickness which required hospitalization. Prussian blue was used extensively for those exposed. Unfortunately, utility may have been limited as by the time it was initiated the Cesium is likely to have been absorbed into tissues from the bloodstream.  This highlights how crucial it is to quickly and promptly identify those who have been exposed to radioactive sources, even before they start to exhibit symptoms to prevent acute radiation sickness and to attempt source control before further spread of radioactive damage. In all cases, the emergency physician should notify their local poison control center and the Radiation Emergency Assistance Center to mobilize the needed resources for such incidents to appropriately decontaminate, isolate, and consider prophylactic treatment and other interventions in exposed individuals. 

References

Centers for Disease Control and Prevention. (2018, April 4). CDC radiation emergencies. Centers for Disease Control and Prevention. Retrieved November 22, 2021, from https://www.cdc.gov/nceh/radiation/emergencies/arsphysicianfactsheet.htm. 

Centers for Disease Control and Prevention. (2021, April 2). Facts about Prussian blue. Centers for Disease Control and Prevention. Retrieved November 22, 2021, from https://www.cdc.gov/nceh/radiation/emergencies/prussianblue.htm. 

Domínguez-Gadea, L., & Cerezo, L. (2011, July 7). Decontamination of radioisotopes. Reports of practical oncology and radiotherapy : Journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology. Retrieved November 22, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863184/. 

International Atomic Energy Agency. 1988. ISBN 92-0-129088-8. Archived (PDF) from the original on March 12, 2016. Retrieved November 22, 2021.

 Jang, S. C., Kim, J. Y., Huh, Y. S., & Roh, C. H. (1970, January 1). Adsorption mechanism of radioactive cesium by Prussian Blue. Journal of Radiation Industry. Retrieved November 22, 2021, from https://inis.iaea.org/search/search.aspx?orig_q=RN%3A47084819. 

What effect does radiation have on the body? (n.d.). Retrieved November 22, 2021, from https://www.instadose.com/blog/what-effect-does-radiation-have-on-the-body.