Medical Management of Radiation Accidents, Second Edition

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In this report, we present the search strategy and results of our review, and a descriptive analysis of the retrieved radiation overexposure accidents. For the purposes of this review, we elected to use the IAEA definition of accident, which is "Any unintended event, including operating errors, equipment failures or other mishaps, the consequences or potential consequences of which are not negligible from the point of view of protection or safety" [ 11 ]. Our study focused on radiation accidents resulting in one or several people overexposed and meeting our inclusion and exclusion criteria.

Reference titles and summaries were screened manually and discarded if not relevant. Selected publications were read in full text for data extraction. Cross-referencing was used to retrieve additional relevant articles. Full reports were read for retrieved cases and extracted if relevant. A case of radiation overexposure was defined as presenting at least one of the following criteria: i unintended global overexposure of 1 Gy or more, ii unintended local skin overexposure of 3 Gy or more, iii unintended local organ overexposure e.

The thresholds used in this review are based on the literature, keeping in mind that these thresholds are not absolute boundaries [ 3 ], [ 4 ], [ 12 — 18 ]. Cases that met none of these criteria were excluded, as were suicide and criminal acts. For cases without occurrence date, we used date of first symptoms as first proxy and date of report as second proxy. Finally, similar cases issued from different reports but with insufficient information to decipher whether they were different or not, were not integrated in the database to prevent duplicates. Two independent researchers screened and reviewed data sources against the inclusion criteria.

For selected reports, full-text documents were evaluated and extracted manually by one reviewer and double-checked by a second reviewer. Any divergence between reviewers regarding selection process was resolved through discussion. For each accident, select information was extracted into a data sheet. Selected data included date and place of occurrence, number of overexposed people and number of people dying from their overexposure, days between exposure and death, type of overexposed people i.

Reported symptoms, course of treatment, and treatment outcomes were also recorded when available. Finally, accidents were categorized by sector of occurrence: "industrial" including industrial irradiator, production, and radiography; "radiation therapy" including teletherapy, brachytherapy, and therapeutic nuclear medicine; "fluoroscopy" used to support diagnostic and interventional radiology; "military" e.

A category "others" included overexposure accidents resulting from scientific experiments and unknown causes. For cases with incomplete information, missing data were reported as unknown in our extraction sheet. Only cases published in peer-reviewed journals or reported by official experts in radiation management e.

Furthermore, all sources selected for data extraction addressed our review question, which was to understand the characteristics of reported radiation overexposure accidents worldwide and their evolution between and Among these, only sources showing evidence of radiation overexposure, as defined in our inclusion criteria, were considered for extraction. Our extraction sheet was used to assess the distribution of reported radiation overexposure accidents along recorded items and over time.

Out of articles and reports identified, met our eligibility criteria and were extracted Fig. Search strategy for retrieving reported radiation overexposure accidents worldwide, — Extracted cases were categorized by sector in which the accident occurred and by type of overexposure Table 1. Over the — period, the number of reported radiation accidents and the number of overexposed people by decade exhibited an overall downward trend Fig. The same trend held for each sector separately, except for accidents reported in radiation therapy and medical fluoroscopy.

The number of reported radiation therapy accidents per decade increased along the three decades, however the number of overexposed people experienced an overall decrease within the same period. Moreover, the number of reported fluoroscopic accidents increased significantly from the decade — to — Then, while reported fluoroscopic accidents decreased during the decade —, the number of overexposed people increased.

Among reported overexposed people, patients represented the largest share Fig. Finally, the types of overexposure in reported accidents also changed Fig.

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However, the share of local organ or local skin overexposures increased over the same period. The number of cases retrieved varied greatly across geographic regions Fig. Furthermore, the distribution of sectors involved was different from one region to another. This review explored a wide array of information sources. This review showed that a limited and decreasing number of worldwide radiation accidents have been reported by decade since and that these accidents can be dramatic, as observed previously [ ].

Furthermore, this review suggested that the characteristics of reported radiation overexposure accidents differ over time and across regions. These new findings are important for future interventions in radiation protection. Our results indicated that the number of reported radiation accidents and overexposed people have decreased over the — period. This likely reflects the impact of continuous efforts in radiation protection.

These standards are used to improve regulation and radiation protection worldwide [ ]. For example, ample documentation including lessons learned from accidents in industrial radiography, guidance on safe work practices and training material, have been developed to promote safety prevention in the industrial sector [ — ]. The downward trend in reported radiation accidents could also reflect a decrease in the reporting level.

However, this explanation is less likely as the decrease is not observed in all sectors. This review suggested that the medical sector accounted for most reported radiation overexposures along — Consistently, most reported cases involved patients and a local skin overexposure component. Unlike other sectors, reported radiation therapy accidents increased along the three last decades, while the number of reported overexposed people tended to decrease. Still, for each decade, radiation therapy accidents represented the highest share of overexposed people.

This upward trend in reported radiation therapy accidents could result from improved reporting or growing use of radiation therapy. The introduction of new technologies e.

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This figure typically varies according to the cause of the accident. While some errors such as errors in treatment site or dose administered, affect a single patient, other errors such as software issue, calibration or treatment programming errors, can affect multiple patients before the issue comes to light. Error reporting systems such as ROSIS allow learning from the past through knowledge of near-misses, incidents or accidents and constitute essential prevention tools [ ]. As the use of radiation therapy is expected to grow even more in the future, it is crucial to ensure high quality assurance standards in order to avoid the multiple possible errors in the course of treatment and thus optimize all benefits of radiation therapy [ — ].

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This review also brings attention to medical fluoroscopy, which ranked second in number of reported accidents for — Corresponding reported radiation accidents increased significantly from the s to the s, and then decreased. This was consistent with the literature [ 17 — 18 ], [ ]. This increase could reflect the expanded use of fluoroscopy since the s. Although fluoroscopy was initially used primarily for diagnostic procedures, it then became widely used during therapeutic interventions e.

Potential serious adverse effects of fluoroscopy, however, were rapidly encountered and acknowledged. In , the FDA issued a warning following the reporting of several injuries resulting from the prolonged use of fluoroscopic procedures [ ], [ ]. Thereafter, the risks of cumulative radiation exposure through fluoroscopy have been documented. Also, important efforts to track and decrease patients' overall exposure to imaging radiation following the ALARA As Low As Reasonably Achievable safety principle were initiated worldwide and some programs have been implemented successfully at the sub-national level [ — ].

Of note, the increase in number of reported overexposed people through fluoroscopy from — to — despite the decrease in reported accidents over the same period, is primarily due to a single accident involving patients. Its cause was an error in resetting a CT scan, which went undetected for 18 months [ ]. This accident also accounted for about two thirds of reported fluoroscopic overexposure cases in North America.

Our exploratory analysis suggests that the causes of reported radiation overexposure accidents differ across regions. One possible explanation relates to variations in radiation equipment and radiation use across countries. The review conducted by UNSCEAR for the period — emphasized that the level of X-ray equipment, radiological examinations, and radiation therapy differ greatly from one country to another and tend to be concentrated in a limited set of countries [ ].

For example, during — three-quarters of all radiation therapy treatments were received in countries, which have at least one physician for every 1, people in the general population. Additionally, differences in reporting by country could also account for the observed differences in causes of overexposure. Thus, these geographic differences should be monitored and accounted for in prevention strategies.

Identifying specific needs and practical challenges in the implementation of the safety standards is cornerstone to adjust prevention efforts adequately and efficiently reduce the incidence of radiation injuries. The reporting of radiation overexposure injuries faces unique challenges even when a well-established regulation and a solid reporting system network are in place. Indeed, the latency period before the appearance of radiation-related adverse effects varies from days to years [ 5 ].

Thus, people can easily go undiagnosed or be misdiagnosed. Furthermore, radiation injuries are uncommon, which can contribute to diagnostic errors [ 17 ], [ ]. Additionally potential lack of knowledge or access to reporting systems and fear of legal liabilities can be other causes of underreporting [ 7 ]. Another major difficulty rises for radiation overexposure accidents resulting from orphan sources or medical fluoroscopy.

In these contexts, the exposed subjects often cannot directly relate their injuries to their radiation exposure as they are not aware that they have been exposed to radiation. Even among medical professionals performing procedures assisted by fluoroscopy, a lack of awareness of risks associated with radiation imaging can still exist [ ], [ ], [ ].

Additionally, patients noticing their skin lesions usually seek advice from a dermatologist, but without necessarily providing information about their history of prior fluoroscopy. They might think this information irrelevant or simply forget it. This makes the diagnostic of radiation injury even more challenging for dermatologists [ 13 ], [ 16 ], [ ], [ ]. Thus, reported radiation accidents are undoubtedly underestimated. This review offers a solid basis of reported radiation overexposure accidents to inform radiation protection planning.

Still, it has several limitations. Our literature search only included publications written in English and French languages, which might introduce some publication bias. Hence, our review does not capture cases that are exclusively reported in private databases e. Thus, our review likely underestimates the number of reported radiation accidents. Additionally, when the date of overexposure was not reported cases out of , date of first symptoms was used as first proxy 11 cases and date of report as second proxy cases. This might introduce some bias as symptoms can appear months or years following the overexposure.

Finally, reporting country was also used as a proxy for country of occurrence when not mentioned explicitly cases out of with some localization information. Despite these limitations, this review captured reported radiation accidents in systematic and consistent way, enabling valuable analysis to support future prevention actions. This systematic study updates and broadens the view of reported radiation overexposure accidents. It indicates that reported radiation overexposure accidents are rare and decreased from — to — However, their potential dramatic outcomes stress the importance of radiation protection regulations.

This review suggests the greater share of the medical sector in reported overexposures, for which the use of radiation has become central and is expected to grow even more in the future. Thereby, it confirms the importance of quality assurance programs in radiation therapy and medical fluoroscopy. Finally, this review suggests that the characteristics of reported accidents vary by geography and over time, and are thereby likely to require different interventions. A close reporting and monitoring of radiation overexposure accidents is of great value to inform and prioritize prevention interventions adequately and ultimately reducing further the incidence of these accidents.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. National Center for Biotechnology Information , U. PLoS One. Published online Mar Glassman , 3 Becky Murdock , 3 and Christelle Doucet 4. Erik S.

Carpenter, Academic Editor. Author information Article notes Copyright and License information Disclaimer. No other competing interest was declared by any of the authors. Received Nov 4; Accepted Jan 6. Copyright notice. This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration, which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. This article has been cited by other articles in PMC. S1 Protocol: PDF.

Abstract Background Radiation overexposure accidents are rare but can have severe long-term health consequences. Conclusions This review provides an updated and broader view of reported radiation overexposures. Introduction Radiation overexposure accidents are uncommon, but can have severe long-term health consequences. Inclusion and exclusion criteria A case of radiation overexposure was defined as presenting at least one of the following criteria: i unintended global overexposure of 1 Gy or more, ii unintended local skin overexposure of 3 Gy or more, iii unintended local organ overexposure e.

Selection process Two independent researchers screened and reviewed data sources against the inclusion criteria. Extracted data items For each accident, select information was extracted into a data sheet. Quality of selected articles and reports Only cases published in peer-reviewed journals or reported by official experts in radiation management e. Analysis Our extraction sheet was used to assess the distribution of reported radiation overexposure accidents along recorded items and over time.

Results Study selection process Out of articles and reports identified, met our eligibility criteria and were extracted Fig. Open in a separate window. Fig 1. Table 1 Reported radiation overexposure accidents by sector and type of overexposure worldwide, — Fig 2. Reported radiation overexposure accidents worldwide and sector involved, — Fig 3. Evolution of type of overexposed people and type of injuries in reported radiation accidents worldwide, — Profiles of reported radiation overexposures by region The number of cases retrieved varied greatly across geographic regions Fig.

Fig 4. Distribution of sectors involved in reported overexposed people by region, — Discussion This review explored a wide array of information sources. Overall downward trends Our results indicated that the number of reported radiation accidents and overexposed people have decreased over the — period. Singularity of the medical sector This review suggested that the medical sector accounted for most reported radiation overexposures along — Geographic differences Our exploratory analysis suggests that the causes of reported radiation overexposure accidents differ across regions.

Challenges in reporting radiation injuries The reporting of radiation overexposure injuries faces unique challenges even when a well-established regulation and a solid reporting system network are in place. Limitations This review offers a solid basis of reported radiation overexposure accidents to inform radiation protection planning.

Conclusion This systematic study updates and broadens the view of reported radiation overexposure accidents. Data Availability All relevant data are referenced in Table 1 of the paper. References 1. The importance and unique aspects of radiation protection in medicine. Eur J Radiol. US Nuclear Regulatory Commission. Use of radiation. Accessed Jan Mettler FA.

Medical effects and risks of exposure to ionising radiation. Journal of radiological protection. J Radiol Prot. Ann ICRP. Diagnosis and treatment of radiation injuries. Safety Reports Series No. Vienna: IAEA; Radioprotection un awareness in cardiologists, and how to improve it. Int J Cardiovasc Imaging.

Volume II. Annex C: Radiation exposures in accidents. Report to the General Assembly; Oak ridge institute for science and education. Radiation Accident Registries. Radiother Oncol. Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases. J Eur Acad Dermatol Venereol. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Chronic radiodermatitis following percutaneous transluminal coronary angioplasty. J Dtsch Dermatol Ges.

Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. Am J Roentgenol. Otterburn D, Losken A. Iatrogenic fluoroscopy injury to the skin.

IN ADDITION TO READING ONLINE, THIS TITLE IS AVAILABLE IN THESE FORMATS:

Ann Plast Surg. Rehani MM, Srimahachota S. Skin injuries in interventional procedures. Radiat Prot Dosimetry. Lost and found dangers. Orphan radiation sources raise global concerns. IAEA bulletin. Sources and effects of ionizing radiation. Annex D: Occupational radiation exposures. Volume I. Annex E: Occupational radiation exposures. Consequences of radiation accidents. Accidental radiation injury to the hand: A case report. Eur J Plast Surg. Becker J, Rosen T. Acute radiodermatitis from occupational exposure to iridium Yet there are few if any comprehensive publications on the medical management of radiation accidents.

Medical Management of Radiation Accidents provides a complete reference for those concerned with radiation accidents nationally as well as abroad. Substantially different from the first edition, which dealt predominantly with radiation accident experiences in the United States, this updated and revised Second Edition represents an international cooperative effort that reflects current international approaches and experiences related to the medical management of radiation accidents.

It is organized into areas that include: the fundamental aspects, medical characteristics, and classification of radiation accidents aspects of radiation on the entire body and specific tissues the history of accidents throughout the world a general overview of certain types of accidents with specific examples a follow-up of persons accidentally exposed to radiation with considerations related to epidemiological studies and a few selected examples radiation protection and dosimetry issues, psychological considerations, and accidental exposure of pregnant females.

Chapter 3 Radiation Sickness Classification. Underlying Principles and Assessment. Chapter 5 Treatment of Acute Radiation Sickness. Chapter 8 Review of Chinese Nuclear Accidents. Chapter 30 Hospital Preparation for Radiation Accidents. Radiation exposure may be internal or external, and can be acquired through various exposure pathways. Internal exposure to ionizing radiation occurs when a radionuclide is inhaled, ingested or otherwise enters into the bloodstream for example, by injection or through wounds. Internal exposure stops when the radionuclide is eliminated from the body, either spontaneously such as through excreta or as a result of a treatment.

External exposure may occur when airborne radioactive material such as dust, liquid, or aerosols is deposited on skin or clothes. This type of radioactive material can often be removed from the body by simply washing. Exposure to ionizing radiation can also result from irradiation from an external source, such as medical radiation exposure from X-rays.

External irradiation stops when the radiation source is shielded or when the person moves outside the radiation field. People can be exposed to ionizing radiation under different circumstances, at home or in public places public exposures , at their workplaces occupational exposures , or in a medical setting as are patients, caregivers, and volunteers.

Exposure to ionizing radiation can be classified into 3 exposure situations. The first, planned exposure situations, result from the deliberate introduction and operation of radiation sources with specific purposes, as is the case with the medical use of radiation for diagnosis or treatment of patients, or the use of radiation in industry or research. The second type of situation, existing exposures, is where exposure to radiation already exists, and a decision on control must be taken — for example, exposure to radon in homes or workplaces or exposure to natural background radiation from the environment.

The last type, emergency exposure situations, result from unexpected events requiring prompt response such as nuclear accidents or malicious acts. Annually worldwide, more than million diagnostic radiology examinations are performed, 37 million nuclear medicine procedures are carried out, and 7. The potential damage from an absorbed dose depends on the type of radiation and the sensitivity of different tissues and organs. The effective dose is used to measure ionizing radiation in terms of the potential for causing harm. The sievert Sv is the unit of effective dose that takes into account the type of radiation and sensitivity of tissues and organs.

It is a way to measure ionizing radiation in terms of the potential for causing harm. The Sv takes into account the type of radiation and sensitivity of tissues and organs.

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