This standard specifies the diagnostic criteria and treatment principles for acute radiation sickness caused by external exposure. This standard applies to radiation workers who have been exposed to large doses of external radiation after accidental exposure or emergency exposure. Those who have acute radiation sickness caused by exposure in medical exposure or nuclear war can also refer to this standard for diagnosis and treatment. GBZ 104-2002 Diagnostic Standard for Acute Radiation Sickness Caused by External Exposure GBZ104-2002 Standard Download Decompression Password: www.bzxz.net

ICS13.100
National Occupational Health Standard of the People's Republic of China GBZ104-2002
Diagnostic criteria for acute radiation sickness from external exposure Issued on 2002-04-08
Ministry of Health of the People's Republic of China
Implementation on 2002-06-01
Chapters 4 and 5 of this standard are mandatory, and the rest are recommended. GBZ104-2002
This standard is specially formulated in accordance with the Law of the People's Republic of China on the Prevention and Control of Occupational Diseases. In case of any inconsistency between the original standard GB8280-2000 and this standard, this standard shall prevail.
This standard is mainly revised and compiled to meet the needs of the development of nuclear energy and radiation application, and is aimed at the classification, degree diagnosis and treatment of acute radiation sickness caused by external exposure accidents, combined with my country's actual situation, and drawing on relevant domestic and foreign experience. my country has formulated diagnostic criteria and treatment principles for acute radiation sickness caused by external irradiation in 1980, 1987 and 2000. However, since the implementation of the standard in 2000, new progress and new understanding have been made in the diagnosis and treatment of the disease at home and abroad. For example, after active and effective treatment, the bone marrow type below severe may not show the extreme macroscopic clinical manifestations, and new judgment indicators for entering the extreme stage and recovery stage have been proposed. A lot of experience in treatment has been accumulated, such as the application of hematopoietic growth factors. In addition, the diagnostic criteria for intestinal and brain types are separately stipulated. Therefore, it is urgent to revise it to meet the needs of current work.
Appendix A of this standard is a normative appendix.
This standard is proposed and managed by the Ministry of Health of the People's Republic of China. The drafting units of this standard: Affiliated Hospital of the Academy of Military Medical Sciences, Institute of Radiation Protection and Nuclear Safety Medicine of the Chinese Center for Disease Control and Prevention, Institute of Radiation Medicine of the Academy of Military Medical Sciences
The main drafters of this standard: Ye Genyao, Chang Shiqin, Mao Bingzhi, Wang Guilin, Tan Shaozhi, Luo Qingliang. This standard is interpreted by the Ministry of Health of the People's Republic of China. 2
1 Scope
Diagnostic criteria for acute radiation sickness caused by external exposure
This standard specifies the diagnostic criteria and treatment principles for acute radiation sickness caused by external exposure. GBZ104—2002
This standard applies to radiation workers who have received large doses of external radiation after accidental exposure or emergency exposure. Those who suffer from acute radiation sickness after exposure in medical exposure or nuclear war can also refer to this standard for diagnosis and treatment. 2 Normative references
The clauses in the following documents become clauses of this standard through reference in this standard. For any dated referenced document, all subsequent amendments (excluding errata) or revisions are not applicable to this standard. However, parties to an agreement based on this standard are encouraged to study whether to use the latest versions of these documents. For any undated referenced document, the latest version shall apply to this standard. GBZ102 Diagnostic Standards for Combined Radiation Injuries
GBZ103 Diagnostic Standards for Combined Radiation Injuries
GBZ106 Diagnostic Standards for Radiation Skin Diseases 3 Terms and Definitions
The following terms and definitions apply to this standard.
3.1 Acute radiation sickness from external exposure acute radiation sickness from external exposure refers to a systemic disease caused by a human body being exposed to a large dose of external radiation once or several times within a short period of time (several days). According to its clinical characteristics and basic pathological changes, acute radiation sickness caused by external radiation is divided into three types: bone marrow type, intestinal type and brain type. Its course is generally divided into four stages: initial stage, pseudo-healing stage, extreme stage and recovery stage.
3.2 Bone marrow form of acute radiation sickness, also known as hematopoietic form of acute radiation sickness, is an acute radiation sickness with bone marrow hematopoietic tissue damage as the basic lesion, leukopenia, infection, bleeding as the main clinical manifestations, and a typical staged course. According to the severity of the disease, it is divided into four degrees: mild, moderate, severe and extremely severe. 3.3 Intestinal form of acute radiation sickness is a serious acute radiation sickness with gastrointestinal damage as the basic lesion, frequent vomiting, severe diarrhea and water and electrolyte metabolism disorder as the main clinical manifestations, and a three-stage course of initial, pseudo-healing and extreme stages. 3.4 Cerebral form of acute radiation sickness is a very serious acute radiation sickness with brain tissue damage as the basic lesion, central nervous system symptoms such as impaired consciousness, loss of orientation, ataxia, increased muscle tone, convulsions, and forehead shaking as special clinical manifestations, and a two-stage course of initial and extreme stages. 4 Diagnostic principles
It is necessary to make a correct judgment on whether the exposed individual has suffered radiation damage and the severity of the injury based on the exposure history, on-site personal dose survey and biological dose results (with personal dose files), clinical manifestations and laboratory test findings, and combine with health records for comprehensive analysis. 5 Diagnostic criteria
5.1 The main clinical symptoms, course of disease and laboratory test findings caused by exposure are the main basis for judging the condition. The severity and symptom characteristics are related to the dose size, dose rate, irradiated site and range, and individual conditions. For cases of multiple and/or highly uneven whole-body irradiation, more attention should be paid to certain characteristics of their clinical manifestations. 3
5.2 Diagnostic criteria for acute bone marrow radiation sickness 5.2.1
Uniform or relatively uniform whole-body irradiation of 1 to 10 Gy in multiple or short-term (several days) fractions can be used to make a preliminary graded diagnosis in the early stage. 5.2.2
Initial reaction and lower limit of radiation dose of acute bone marrow radiation sickness GBZ104-2002
1-2 days after radiation, lymph nodes
Extremely severe
Initial manifestations
Fatigue, discomfort, loss of appetite
Dizziness, fatigue, loss of appetite, nausea, vomiting after 1-2 hours, white blood cell count rises briefly and then falls
Multiple vomiting after 1 hour, diarrhea, parotid swelling, and significant decrease in white blood cell count. Multiple vomiting and diarrhea within 1 hour, shock, parotid swelling, and sharp decrease in white blood cell count 1.2wwW.bzxz.Net
1. 0 to 0. 9
0.7 kcal n.6
0.6 + 0. 5
Lymphocytes are coagulated, X 10'/1
Lowest absolute cell count
value (×10°/L)
Symptoms within 15h
Figure 1 Diagnosis of acute radiation sickness in the early stage
Radiation dose
Lower limit (Gy)
Note: According to the absolute value of lymphocytes within 12h or 24-48h after radiation and the most severe symptom experienced by the patient during this period (the lower corner of the solid line inside the right column of the figure), a line is drawn through the central column, and the degree marked in the column is the possible diagnosis of the patient; if the patient is diagnosed 6h after radiation, only the most severe symptom experienced by the patient (the upper edge of the solid line inside the right column of the figure) is drawn to the central column, and the judgment is made according to the degree marked in the column, but the error is greater than that of the judgment 24-48h after radiation. The first lymphocyte examination is best performed before the use of adrenocortical hormones or anti-radiation drugs. 4
GBZ104-2002
5.2.3 In the process of comprehensive examination and close observation of the disease development, a comprehensive analysis can be made with reference to Table 2 to further determine the clinical degree and stage diagnosis.
Table 2 Clinical diagnosis basis of acute radiation sickness of bone marrow Stage and degree
After irradiation, days
Oropharyngitis
Highest body temperature, ℃
Tarnished stool
Lowest white blood cell value (×10°/L)
Lower limit of radiation dose, Gy
Not obvious at the extreme stage
Note: +, ++, +++, respectively represent mild, moderate and severe. Moderate
Extremely severe
++~+++
5.2.4 After effective and active treatment, bone marrow acute radiation sickness below severe may not show macroscopic clinical manifestations of the extreme stage, such as bleeding, infection (including fever, pharyngitis, diarrhea, anorexia, tarry stools, etc.), making the symptoms of the extreme stage less obvious. At this time, the white blood cell count can be continuously lower than 1×10°/L, or the neutrophil count can be lower than 0.5×10°/L, platelet count less than 10×10°/L, and hair loss are used as indicators for the judgment of the extreme stage (severe). Conversely, the transition from the extreme stage to the recovery stage can also be judged comprehensively from the improvement of bone marrow hematopoietic function, such as the transition from hypoplasia to active proliferation, the appearance of immature cells, monocytes, etc., as well as the recovery of peripheral blood such as reticulocytes, neutrophils, and platelets, and the appearance of mononuclear cells in groups or batches, so-called "shower phenomenon". 5.3 Diagnostic criteria for intestinal acute radiation sickness
5.3.1 Uniform or relatively uniform whole-body irradiation greater than 10Gy once or in a short period of time (several days). 5.3.2 Mild intestinal acute radiation sickness: the exposure dose is 1020Gy. In addition to severe nausea and vomiting within 1 hour after exposure, diarrhea with loose stools, bloody stools, and parotid swelling and pain may occur within 1 to 3 days. After a 3-6 day false recovery period, the above symptoms worsen to the beginning of the extreme stage, which may be accompanied by watery stools or bloody stools and fever.
5.3.3 Severe intestinal acute radiation sickness: exposure dose 20-50Gy. Frequent vomiting, unbearable abdominal pain, severe watery stools, hemoconcentration, dehydration, systemic failure, and hypothermia occur within 1 day after exposure. This is followed by severe vomiting of bile or coffee-like substances. In severe cases, bloody stools or stools mixed with detached intestinal mucosal tissue, fecal incontinence, and high fever occur in the second week. 5.3.4 Severe vomiting and diarrhea after exposure, such as hemoglobin rising to more than 110% within 2-5 days after injury. Attention should be paid to the occurrence of intestinal acute radiation sickness.
5.4 Diagnostic criteria for acute cerebral radiation sickness
Uniform or relatively uniform whole-body irradiation greater than 50G at one time or within a short period of time (several days). Occasionally seen in extremely large nuclear accidents and personnel who are exposed to extremely large doses of radiation in an instant under conditions of nuclear war5.4.1
. 5.4.2 The irradiation dose is 50-100Gy, and the course of the disease is about 2 days. After exposure, there will be signs such as unsteady standing, gait mites, ataxia, disorientation and judgment disorders, limb or eye nystagmus, tonic convulsions, opisthotonos, etc. If the irradiation dose is >100Gy, there will be loss of consciousness, dilated pupils, incontinence, decreased blood pressure, shock, coma, and the patient will die quickly. The course of the disease is only a few hours. 5.5 Differential diagnosis of acute radiation sickness of bone marrow, intestinal and brain types The key point of the diagnosis of acute radiation sickness is the differentiation of intestinal type from extremely severe bone marrow type and brain type radiation sickness. According to the clinical manifestations, radiation dose and course of the patient after exposure, the three types of radiation sickness can be distinguished, see Table 3. 5
Ataxia
Increased muscle tone
Limb tremor
Nystagmus
Vomiting bile
Watery stool
Bloody stool
Tarnished stool
Increased hemoglobin
Maximum body temperature, ℃
Radiation dose, Gy
Disease course, days
6 Treatment principles
3 Key points for clinical differential diagnosis of three types of acute radiation sickness Table 3
Extremely severe bone marrow type
Note: +++ indicates severe, ++ indicates moderate, + indicates mild, and - indicates no occurrence.
According to the severity of the disease and the different characteristics of each stage, take comprehensive treatment measures of Chinese and Western medicine as soon as possible. 6.1 Treatment principles for acute bone marrow radiation sickness GBZ104-2002
6.1.1 Mild: Generally no special treatment is required. Symptomatic treatment can be adopted, nutrition can be strengthened, and attention can be paid to rest. For patients with severe symptoms or low lymphocyte count in the early stage, hospitalization for close observation and proper treatment is required. 6.1.2 Moderate and severe: Different protective isolation measures are taken according to the condition, and corresponding treatment plans are formulated according to the different clinical manifestations in each stage.
6.1.2.1 Initial stage: sedation, desensitization and antiemetic, regulation of nerve function, improvement of microcirculation disorders, and use of anti-radiation drugs as soon as possible. 6.1.2.2 Pseudo-healing period: Prophylactic use of antibacterial drugs is indicated (total white blood cell count is less than 3.0×10%L, skin and mucous membrane bleeding), mainly targeting Gram-positive bacteria, to prevent bleeding and protect hematopoietic function. When the total white blood cell count is less than 2.0×10°/L and the platelet count is less than 50×10°/L, hematopoietic growth factors (rhG-CSF/rhGM-CSF) should be used as soon as possible. Fresh whole blood or platelet suspension irradiated with 15-25Gy can also be transfused. 6.1.2.3 Extreme stage: According to bacteriological examination or estimation of the source of infection, take effective anti-infection measures (especially against Gram-negative bacteria). Disinfection and isolation measures should be strict, and laminar flow clean rooms should be used as needed and possible. Control bleeding, reduce hematopoietic damage, and transfuse fresh whole blood or platelet suspension irradiated with 15-25Gy of Y line. Correct water and electrolyte disorders. Pay attention to prevent pulmonary edema. 6.1.2.4 Recovery stage: Strengthening treatment to promote recovery. 6.1.3 Extremely severe: Refer to the treatment principles of severe cases. However, special attention should be paid to taking anti-infection and anti-bleeding measures as soon as possible. Use hematopoietic growth factors as soon as possible. Pay attention to correcting water and electrolyte disorders, retain Hickman catheter intubation, continue infusion, actively relieve gastrointestinal and nervous system symptoms, and pay attention to the prevention and treatment of intussusception. While using large doses of antibacterial drugs, pay attention to the prevention and treatment of fungal and viral infections. Generally, for patients with radiation of more than 9Gy, allogeneic bone marrow transplantation can be considered when there is a suitable donor with human leukocyte antigen (HLA) matching, and pay attention to the prevention and treatment of host-versus-host disease. 6.2 Principles of treatment of intestinal acute radiation sickness
According to the severity of the disease, take active comprehensive symptomatic supportive treatment, and pay special attention to proper early treatment. 6.2.1 Aseptically isolate patients with mild intestinal radiation sickness as soon as possible, correct water, electrolyte, and acid imbalances, improve microcirculation disorders, regulate autonomic nervous system functions, actively fight infection and bleeding, and perform bone marrow transplantation in a timely manner when conditions permit. 6
6.2.2 For patients with severe intestinal radiation sickness, symptomatic treatment measures should be applied to relieve the patient's pain and prolong life. 6.3 Treatment principles for acute cerebral radiation sickness
GBZ104-2002
Relieve the patient's pain and prolong the patient's survival time. Actively use sedatives to stop convulsions, quickly give dehydrating agents to protect the brain, resist shock, use adrenal cortex hormones and other comprehensive symptomatic treatments. 7
Treatment principles after clinical recovery of acute radiation sickness Long-term separation from radiation work, strict medical follow-up observation and regular health assessment after the condition stabilizes, pay attention to possible long-term effects, and give corresponding treatment, and recuperate, rest or arrange appropriate work according to the recovery situation. GBZ104-2002
Appendix A
(Normative Appendix)
Instructions for the correct use of this standard
A1 Acute radiation sickness is a deterministic effect of ionizing radiation, and has a dose threshold. The severity of acute radiation sickness after reaching a certain dose is related to the size of the exposure dose. As reported in domestic and foreign literature, a single whole-body irradiation of more than IGy can often cause acute radiation sickness, but due to different individual radiation sensitivities, the exposure dose is only 0.6-0.8Gy, and there are also a few people who suffer from mild acute radiation sickness. Therefore, those who have an exposure dose of less than 1Gy and more than 0.5Gy should still be closely observed and should not be taken lightly to avoid missed diagnosis and missed treatment opportunities. According to the experience of the Chernobyl nuclear accident in the former Soviet Union, 237 people were initially diagnosed with acute radiation sickness, of which the radiation dose range for mild acute radiation sickness was 0.8-2.1Gy. After follow-up, 134 people were diagnosed with acute radiation sickness, and the other 103 were not diagnosed. Therefore, for those who were initially diagnosed with mild acute radiation sickness, it is best to observe for about three months. Regarding the classification of acute radiation sickness, some scholars at home and abroad have proposed in recent years that there may be a special type between intestinal and cerebral acute radiation sickness, namely cardiovascular or septicemia acute radiation sickness. The dose range for causing this type of acute radiation sickness is 20-50Gy, but the relevant issues need further research and discussion. In addition to the determination and estimation based on physical methods (including simulation tests when necessary), the determination of A2 exposure dose should also refer to the results of biological methods. Among them, in addition to the initial symptoms and peripheral blood count (total white blood cell count and absolute lymphocyte count), the analysis of lymphocyte chromosome aberration rate is currently a commonly used reliable indicator, and its effective dose range is 0.25 to 5.0Gy. In addition, the exposure dose can also be estimated by referring to the examination results of lymphocyte micronucleus rate (cytoplasmic division arrest method, CB method). A3 Figure 1 (early diagnosis diagram of acute radiation sickness) is drawn based on the actual data analysis of 231 over-dose exposed personnel in my country, 8 cases of acute radiation sickness of different degrees and 44 cases of nuclear accident exposure abroad. Practice has proved that the diagnosis accuracy of this diagram is high and the method is simple, so this diagram can be used in practice. In use, attention should be paid to the effect of adrenal cortex hormone drugs on lymphocytes. A4 The lower limit of the exposure dose in Tables 1 and 2 refers to a relatively uniform external irradiation of the whole body with X-rays and Y-rays. When estimating and judging the disease with reference to physical dose, if the whole body is uneven and/or fractionated irradiation, the influencing factors such as different irradiated parts, ranges, unevenness, fractionated irradiation and number of times should be taken into account, and the equivalent dose calculated by the average dose of red bone marrow or the weighted survival of red bone marrow hematopoietic stem cells and the equivalent dose of "one" irradiation corrected by the time factor shall prevail. A5 Compared with a single whole-body uniform irradiation of the same dose, the damage caused by multiple highly non-uniform whole-body irradiations has the following main characteristics: the initial reaction is generally more severe and lasts longer; it is often accompanied by obvious local damage, and the degree of decrease in the number of neutrophils and platelets is less than that of the total number of white blood cells; the cumulative dose required to cause the same degree of radiation effect is high. In order to estimate the degree of damage, it is often necessary to convert multiple cumulative doses into an equivalent dose equivalent to a single whole-body uniform irradiation. It is recommended that before there is a better conversion formula, you can refer to formulas (A1) and (A2) for conversion: Whole-body irradiation mainly to the head and neck: 1gY=1.9060-0.5911lgX Whole-body irradiation mainly to the abdomen: 1gY=1.9811-0.44091gX Where: Y-the ratio of the effective dose to the cumulative dose (expressed as a percentage); X-the number of irradiation days.
This formula is based on the relationship between the actual biological effects (clinical and blood picture changes) and the cumulative dose of 16 tumor patients who were exposed to uneven accidental irradiation mainly in the head, neck or abdomen during 60Co radiotherapy. Although it has its specific conditions and limitations, it is based on human materials after all, so it can be used as an auxiliary means to estimate the effective dose under similar irradiation conditions. Its applicable conditions are: the average whole-body dose of each irradiation of Y-ray external irradiation is 0.6-2.6Gy: the interval is 24h; the unevenness is 25-100 times. A6 Early use of anti-radiation drugs in acute radiation sickness can reduce radiation damage, simplify comprehensive treatment measures, and improve treatment effects. Therefore, in moderate or above acute radiation sickness, it should be used as soon as possible without losing the opportunity. A7 In the process of comprehensive treatment, diagnosis and treatment can be carried out according to the clinical characteristics of acute radiation sickness, treatment principles and the specific conditions of the patient. For those with acute radiation skin damage, refer to GB8282 for treatment. For patients with burns or shock injuries, GBZ102 or GBZ103 can be used for treatment.
GBZ104-2002
Clinical practice shows that the current treatment principles and measures can cure most or all of the acute radiation sickness in the near term. However, regular follow-up observation is still necessary, especially for acute radiation sickness above moderate or extremely uneven irradiation, local damage effects should be paid attention to, so as to detect possible long-term harmful effects as early as possible, and to make a clear diagnosis and proper treatment in a timely manner. For mild cases or cases that have been clinically confirmed to be cured after several years of observation, they should no longer be treated or handled as acute radiation sickness. 9
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