Acute radiation exposure refers to the delivery of high doses of radiation in periods of time on the order of days or less. Acute radiation exposure of human beings can occur through accidents, criminal activity, or acts of war. This report reviews the expected health impacts of exposures to people delivered at high dose rates. Two major variables needed to predict outcomes in people are the amount of radiation dose and its distribution in time, that is, dose rate and fractionation. Health impacts are categorized by time of appearance after irradiation as early and late effects. Early effects are termed deterministic, and their severity is an increasing function of dose and dose rate, with a dose threshold below which symptoms do not appear. Health impacts of relatively uniform irradiation of the whole body include three acute radiation syndromes, namely, the hematopoietic (bone marrow), gastrointestinal (GI), and cerebrovascular (CV) syndromes, with thresholds of about 2, 10, and 50 grays (Gy; 200, 1,000, and 50,000 rads). The dose that is expected to produce 50% mortality from the bone marrow syndrome in a population within 60 days, the LD 50-60 , is over 4 Gy (400 rads) if minimal medical treatment is provided, and over 6 Gy (600 rads) if supportive medical treatment is provided. While the LD 50 values for the GI and CV syndromes are higher, those doses invariably cause bone marrow fatality. Other syndromes that may cause fatality result from non-uniform irradiation. These are the cutaneous syndrome, in which the skin is heavily irradiated by beta irradiation, and the pulmonary syndrome, in which inhalation of beta-emitting or alpha-emitting radioactive material cause damage to the skin or lungs. Other deterministic effects include developmental abnormalities in the embryo, the fetus, or in growing children, such as mental retardation and thyroid disease. Loss of pregnancy, permanent or temporary sterility or impaired fertility, and cataracts (opacification of the crystalline lens of the eye) are also known effects. As doses to skin increase, erythema (skin reddening), desquamation (blistering), ulceration, and necrosis (tissue death) can also occur. Untreated ulceration or necrosis can also lead to death. If people survive the early, deterministic effects, they still bear some risk of late effects such as cancer and leukemia; some non-cancer conditions such as heart disease, stroke, digestive diseases, and respiratory diseases; and heritable ill-health. Cancers and heritable ill-health (formerly called genetic effects) occur in a population with a frequency that is an increasing function of dose, usually without threshold. As an illustration of late effects, in the latest (October 2003) followup of the Japanese nuclear bomb survivors, about 5% of 9,335 solid cancer deaths and 0.8% of 31,881 noncancer deaths in the survivor population are attributable to radiation exposures from the nuclear detonations. Many factors affect the radiosensitivity of people, including dose, dose rate, dose fractionation, the penet...