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	Manage Subsyndromes of Acute Radiation Syndrome Instructions: Evaluate as many of the 4 Acute Radiation Syndrome (ARS) subsyndromes as you have information for, by degree of severity:         In each row, click the box reflecting your patient's clinical status or laboratory value View suggested treatments Based on items checked, Wizard auto-calculates Response Category 1 (RC): H C G N = RC (Read-only fields) RC is assigned to patient based on highest degree of severity in any subsyndrome RC suggests how to triage patient to appropriate facility See also: Time/dose effects in Acute Radiation Syndrome See also: Time phases of ARS See also: Cutaneous radiation syndrome HEMATOPOIETIC SUBSYNDROME    H C G N = RC   Sign/Symptom/Test Degree 1 Degree 2 Degree 3 Degree 4 Suggested Treatment 24 - 48 hours  Serial CBCs recommended to improve estimation of severity. (Lymphocyte kinetics and dose)   (Frequency of CBCs) Lymphocyte count (109 cells/L) ≥ 1.5 1.5 - 1 1 - 0.5 < 0.5 Granulocyte count (109 cells/L) > 2 4 - 6, mild granulocytosis 6 - 10, moderate granulocytosis > 10, marked granulocytosis Platelet count (109 cells/L) ≥ 100 100 - 50 100 - 50 100 - 50 3 - 7 days    Serial CBCs recommended to improve estimation of severity. (Lymphocyte kinetics and dose)   (Frequency of CBCs) Lymphocyte count (109 cells/L) ≥ 1 1 - 0.5 0.5 - 0.1 < 0.1 Granulocyte count (109 cells/L) > 2 > 2 > 5 (note: high granulocyte count with low platelets is poor prognostic sign) > 5 (note: high granulocyte count with low platelets is poor prognostic sign) Platelet count (109 cells/L) ≥ 100 100 - 50 50 - 20 < 20 Other Signs Blood Loss petechiae; easy bruising; normal Hb mild blood loss with ≤ 10% decrease in Hb gross blood loss with 10-20% decrease in Hb Spontaneous bleeding or blood loss with > 20% decrease in Hb Checkboxes below are read-only Reassurance Seek more info; serial CBCs/platelets; systemic evaluation If blood product support: irradiated & leuko-reduced Cytokines/growth factors HLA type recipient Consider PICC line Search for donors Reverse isolation Start fluconazole when neutropenic Consider acyclovir if HSV+ Consider fluoroquinolone Consider coverage for skin flora if burns present Consider early stem cell transplantation by 2 weeks or sooner if donor is available Time surgery appropriately Special Note: Consider reports by Fliedner et. al. 1 2 3 4 suggesting that tracking granulocyte, lymphocyte, platelet counts for days to weeks after exposure reveals distinct patterns that reliably predict patients who have reversible hematologic injury (H3) and are likely to recover with appropriate supportive care vs. those who have irreversible hematologic injury (H4) and may need hematopoietic stem cell transplant. See also: Illustration of H1, H2, H3, and H4 See also: Hematopoietic Subsyndrome Treatment Top of Page Top of Hematopoietic Subsyndrome Section CUTANEOUS SUBSYNDROME    H C G N = RC                 Sign/Symptom/Test Degree 1 Degree 2 Degree 3 Degree 4 Suggested Treatment Erythema (hours - 30 days - 10 weeks) Minimal and transient Moderate; < 10% BSA Marked; 10-40% of BSA Severe; > 40% BSA Sensation/Itching (hours - 30 days) Pruritus Slight & intermittent pain Moderate & persistent pain Severe & persistent pain Swelling/Edema (5 days - 8 weeks) Present; asymptomatic; Symptomatic; tension Secondary dysfunction Total dysfunction Blistering (5 days - 3 weeks) Rare, sterile fluid Rare, hemorrhagic Bullae, sterile fluid Bullae, hemorrhagic Desquamation (5 days - 8 weeks) Absent Patchy dry Patchy moist Confluent moist Ulcer/necrosis (5 days - > 12 weeks) Epidermal only Dermal Subcutaneous Muscle/bone involvement Hair loss (2 - 8 weeks) Thinning, not striking Patchy, visible Complete and reversible Complete and irreversible Onycholysis (2 - 8 weeks) Absent Partial Partial Complete Checkboxes below are read-only Topical, mild soothing agents: aqueous lotion/powder/soap Topical anti-inflammatory glucocorticoids (water-based preparations) Topical/systemic anti-histamine Drying agents for opened blisters Topical antibiotics for documented infection Seek more detailed history & additional lab data Minimize chances of skin trauma/remove constricting objects Consider pain management Aspiration of fluids from infected or weight-bearing blisters Debridement as appropriate Non-adherent dressing Consider skin grafting Surgical consultation Systemic antibiotics for documented infection See also: Cutaneous radiation syndrome Top of Page Top of Cutaneous Subsyndrome Section GASTROINTESTINAL SUBSYNDROME    H C G N = RC   Sign/Symptom/Test Degree 1 Degree 2 Degree 3 Degree 4 Suggested Treatment Diarrhea - frequency 2-3 stools/d 4-6 stools/d 7-9 stools/d ≥ 10 stools/d Diarrhea - consistency Bulky Loose Loose Watery Diarrhea - bleeding Occult Intermittent Persistent Persistent with large amount Abdominal cramps / pain Minimal Moderate Intense Excruciating Vomiting See Neurovascular System Nausea See Neurovascular System Checkboxes below are read-only Anti-diarrheal meds, e.g. Loperamide, appropriate to severity Measure intake/output, sequential body weights IV fluid and electrolyte replacement as needed Antibacterial agents for culture positive Antifungal agents for culture positive Antiviral agents for culture positive Seek etiology, ± consider surgical consultation Universal precautions, if needed Top of Page Top of Gastrointestinal Subsyndrome Section NEUROVASCULAR SUBSYNDROME    H C G N = RC   Sign/Symptom/Test Degree 1 Degree 2 Degree 3 Degree 4 Suggested Treatment Nausea (immediate - hours) Mild Moderate Intense Excruciating Vomiting (immediate - hours) Occasional, 1/day Intermittent, 2-5/day Persistent, 6-10/day Refactory, > 10/day Anorexia (immediate - hours) Able to eat Intake decreased Minimal intake Parenteral nutrition Fatigue syndrome (immediate - hours) Able to work Impaired work Needs assistance for activities of daily living No activities of daily living Headache (hours - days) Minimal Moderate Intense Excruciating Fever (hours - days) < 38 degree C 38-40 degree C > 40 degree C, < 24 h > 40 degree C, > 24 h Hypotension (hours - days) HR > 100 / BP > 100/70 BP < 100/70 BP < 90/60; transient BP < 80/?; persistent Neurological deficits (hours - weeks) Barely detectable Easily detectable Prominent Life threatening, loss of consciousness Cognitive deficits (hours - weeks) Minor loss Moderate loss Major impairment Complete impairment Checkboxes below are read-only Anti-emetics: 5-HT3 receptor antagonists Fluid management - May require fluid restriction; Balance with GI issues Consider glucocorticoids if shock or increased intracranial pressure Consider mannitol if increased intracranial pressure Monitor/control body temperature and blood pressure for fever and hypotension Monitor neurologic status regularly Consider CNS imaging for neurological deficits Seek more detailed history & additional lab data Consider biodosimetry Monitor intake/output, sequential body weights Consider pain management, as appropriate Top of Page Top of Neurovascular Subsyndrome Section Modified from Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. Oxford: British Institute of Radiology; 2001. Adapted from Dainiak N, Waselenko JK, Armitage JO, MacVittie TJ, Farese AM. The hematologist and radiation casualties. Hematology Am Soc Hematol Educ Program. 2003;473-96. [PubMed Citation] top of page References Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. Oxford: British Institute of Radiology; 2001. Gorin NC, Fliedner TM, Gourmelon P, Ganser A, Meineke V, Sirohi B, Powles R, Apperley J. Consensus conference on European preparedness for haematological and other medical management of mass radiation accidents. Ann Hematol. 2006 Oct;85(10):671-9. [PubMed Citation] Fliedner TM, Dorr HD, Meineke V. Multi-organ involvement as a pathogenetic principle of the radiation syndromes: a study involving 110 case histories document in SEARCH and classified as the bases of haematopoietic indicators of effect. BJR Suppl. 2005;27:1-8. [PubMed Citation] Fliedner TM. Nuclear terrorism: the role of hematology in coping with its health consequences. Curr Opin Hematol. 2006 Nov;13(6):436-44. [PubMed Citation] Fliedner TM, Graessle D, Meineke V, Dorr H. Pathophysiological principles underlying the blood cell concentration responses used to assess the severity of effect after accidental whole-body radiation exposure: an essential basis for an evidence-based clinical triage. Exp Hematol. 2007 Apr;35(4 Suppl 1):8-16. [PubMed Citation] Dainiak N, Waselenko JK, Armitage JO, MacVittie TJ, Farese AM. The hematologist and radiation casualties. Hematology Am Soc Hematol Educ Program. 2003;473-96. [PubMed Citation] Anno GH, Baum SJ, Withers HR, Young RW. Symptomatology of acute radiation effects in humans after exposure to doses of 0.5-30 Gy. Health Phys. 1989 Jun;56(6):821-38. [PubMed Citation]

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