MEDICAL ASPECTS OFMEDICAL ASPECTS OF

RADIOLOGICAL ACCIDENT IN RADIOLOGICAL ACCIDENT IN GILAN, IRANGILAN, IRAN

MEDICAL ASPECTS OFMEDICAL ASPECTS OF

RADIOLOGICAL ACCIDENT IN RADIOLOGICAL ACCIDENT IN GILAN, IRANGILAN, IRAN

Module XIX

Module Medical XIX-(16)

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SummarySummary

Morning of 24 July 1996 a worker (KZ) at Gilan Combined Cycle Fossil Power Plant, while carrying insulation material for lagging pipes, noticed a shiny pencil sized metal object beside of trench

He put it into his loose overall pocket on right side above chest

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Summary-2Summary-2

The metal object - “pigtail” of radiograph with iridium-192 source, led to severe haemopoetic syndrome (bone marrow depression) and unusually extended local radiation injury of chest requiring plastic surgery

Surgery successfully performed a month later in Curie Institute, Paris

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SourceSource

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ESTIMATION OF THE ACTIVITY OF THE 192IR SOURCE

Source: 192Ir (185 GBq, 5 Ci)

Exposure time: 1.5 hours

Estimated whole body

average dose: 2 Gy

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Development of symptoms, Development of symptoms, recognition of accidentrecognition of accident

At 9.30 am, 1.5 hrs after start of exposure, he experienced dizziness, nausea, lethargy and burning feeling in chest

Believing object cause of symptoms, he put it back into trench

13:00, KZ told colleagues about strange shiny object and weak, lethargic feeling

13:30 he was sent for blood sampling

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Investigation of Investigation of accidentaccident

Team of AEOI inspectors investigated accident on site next day

Recommended blood checks for all 600 personnel

All samples normal except for KZ’s

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Course of lymphocytesCourse of lymphocytesEvolution of Lymphocytes

0.00E+00

5.00E+02

1.00E+03

1.50E+03

2.00E+03

2.50E+03

3.00E+03

3.50E+03

4.00E+03

1996-0

7-2

4

1996-0

7-2

6

1996-0

7-2

8

1996-0

7-3

0

1996-0

8-0

1

1996-0

8-0

3

1996-0

8-0

5

1996-0

8-0

7

1996-0

8-0

9

1996-0

8-1

1

1996-0

8-1

3

1996-0

8-1

5

1996-0

8-1

7

1996-0

8-1

9

1996-0

8-2

1

1996-0

8-2

3

1996-0

8-2

5

1996-0

8-2

7

1996-0

8-2

9

1996-0

8-3

1

1996-0

9-0

2

1996-0

9-0

4

No

of

Lym

ph

ocyte

s p

er

mm

3

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Course of leukocytesCourse of leukocytesEvolution of Leucocytes

0

2500

5000

7500

10000

12500

15000

1996-0

7-2

4

1996-0

7-2

5

1996-0

7-2

6

1996-0

7-2

7

1996-0

7-2

8

1996-0

7-2

9

1996-0

7-3

0

1996-0

7-3

1

1996-0

8-0

1

1996-0

8-0

2

1996-0

8-0

3

1996-0

8-0

4

1996-0

8-0

5

1996-0

8-0

6

1996-0

8-0

7

1996-0

8-0

8

1996-0

8-0

9

1996-0

8-1

0

1996-0

8-1

1

1996-0

8-1

2

1996-0

8-1

3

1996-0

8-1

4

1996-0

8-1

5

1996-0

8-1

6

1996-0

8-1

7

1996-0

8-1

8

1996-0

8-1

9

1996-0

8-2

0

1996-0

8-2

1

1996-0

8-2

2

1996-0

8-2

3

1996-0

8-2

4

1996-0

8-2

5

1996-0

8-2

6

1996-0

8-2

7

1996-0

8-2

8

1996-0

8-2

9

1996-0

8-3

0

Nb

Leu

co

cyte

s/m

m3

Hospitalization Teheran (26/07)

Arrival at the Institut Curie, Paris

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Treatment in IranTreatment in Iran

Prophylactic antibiotics Analgesia Topical silver sulphadiazine (on

chest lesion) Platelet transfusion (7 units on Day

20) Cytokine (G-CSF) — Leucomax 400 g

2x/d (subcutaneously)

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Bone marrow Bone marrow samplingsampling

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Transfer to ParisTransfer to Paris

Need for bone marrow transplantation ? Transfer to Radiopathology Unit of the

Institut Curie in Paris on Day 24 (16 Aug96). Findings on examination

Total loss of epidermis on right anterior chest/ upper abdominal wall — 30 x 15 cm — with necrotic epidermis around the edge

Area of moist desquamation on medial side of right antecubital fossa — 6 x 7 cm

 Large hard bulla on palm of left hand — 5 x 5 cm Small area of increased pigmentation and

erythema on anterior middle surface of right thigh — 2 x 2 cm

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Corrected dose estimates, obtained by two methods Days after irradiation

Mean Dose 95% Confid.

interv. (Gy)

Dolphin corrected

dose (Gy)

Estimate of irradiated body

fraction by Dolphin

“Qdr” corrected dose

(Gy)

6 3.3 0.4 4.1 50 % 4.14 27 2.1 0.4 4.6 50 % 3.5 62 1.7 0.5 4.7 50 % 4.7 239 1.45 0.3 2.8 50 % 3.13

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Estimates of dose to KZ based on the frequency of dicentric chromosomes in lymphocytes taken 6 to 562 days after exposure

Day of

sampling Scored

metaphases Dicentrics Centric

rings Excess

acentrics Dicentrics’

Yield Mean Dose 95%

Conf.Int. (Gy) U-test

6 128 80 7 138 0.68 3.3 0.4 3.7 11 138 65 5 94 0.51 2.8 0.4 4,9 27 119 37 0 57 0.31 2.1 0.4 5.7 62 97 21 0 64 0.22 1.7 0.5 10.1 239 288 41 9 46 0.17 1.45 0.3 7.2 562 530 34 4 60 0.07 0.8 0.2 13.6

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Status in June 2001Status in June 2001

Status November 97 (as examined by IAEA medical staff, confirmed June 2001):

1. Chest lesion showed no necrosis but graft was firmly fixed to the chest wall

• Fibrosis leading to some retraction, adversely affecting posture

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Status in June 2001Status in June 2001

2. Elbow lesion completely healed, but

movements restricted in both flexion and

extension - from 45o to 135o

3. Some thickening of left palmar observed,

but with full function and strong grip

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Status in June 2001Status in June 2001

4. Right thigh lesion: hard and fibrotic, but

completely healed and non-painful

5. Complete recovery of all lymphocyte

subpopulations in 18 months

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Lessons – medicalLessons – medical

For non-homogeneous whole body irradiation (as in most accidents), initiate cytokine treatment at earliest opportunity when bone marrow recovery not detected

G-CSF may be drug of choice, but then direct particular attention to monitoring platelet counts

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Lessons - medicalLessons - medical

Use thermography, where available, to assess viability of radiation induced skin injuries for potential spontaneous recovery or suitability for grafting

Where dermal tissues are viable after radiation induced skin injury, and spontaneous re-epithelialisztion is likely to be prolonged, consider early skin grafting to reduce physical and psychological morbidity

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Lessons Lessons - - radiation protectionradiation protection

Teach radiographers safety culture by organizing more training courses for them

Computerize and regularly update records of existing radiation sources, systems, equipment, projects and personnel

Provide psychological support to workers and public affected by any radiological accident