Hostname: page-component-cd9895bd7-lnqnp Total loading time: 0 Render date: 2024-12-26T05:29:10.350Z Has data issue: false hasContentIssue false
  • English
  • Français

Proposed “Exposure And Symptom Triage” (EAST) Tool to Assess Radiation Exposure After a Nuclear Detonation

Published online by Cambridge University Press:  31 July 2017

John L. Hick ,
Judith L. Bader ,
C. Norman Coleman ,
Armin J. Ansari ,
Arthur Chang ,
Adela Salame-Alfie ,
Dan Hanfling  and
John F. Koerner
John L. Hick*
Affiliation:
Hennepin County Medical Center and Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota
Judith L. Bader
Affiliation:
REMM (Radiation Emergency Medical Management) website and US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Washington, DC
C. Norman Coleman
Affiliation:
CBRNE Science and Operations, US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Office of Emergency Management, Washington, DC
Armin J. Ansari
Affiliation:
Radiation Studies Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Arthur Chang
Affiliation:
Radiation Studies Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Adela Salame-Alfie
Affiliation:
Radiation Studies Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Dan Hanfling
Affiliation:
Hospital Preparedness Program, US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Office of Emergency Management
John F. Koerner
Affiliation:
CBRNE Science and Operations, US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Office of Emergency Management, Washington, DC
*
Correspondence and reprint requests to John L. Hick, MD, Hennepin County Medical Center, Emergency Medicine, 701 Park Ave. S, Minneapolis, MN 55415 (e-mail: John.hick@hcmed.org).
Get access Rights & Permissions [Opens in a new window]

Abstract

One of the biggest medical challenges after the detonation of a nuclear device will be implementing a strategy to assess the severity of radiation exposure among survivors and to triage them appropriately. Those found to be at significant risk for radiation injury can be prioritized to receive potentially lifesaving myeloid cytokines and to be evacuated to other communities with intact health care infrastructure prior to the onset of severe complications of bone marrow suppression. Currently, the most efficient and accessible triage method is the use of sequential complete blood counts to assess lymphocyte depletion kinetics that correlate with estimated whole-body dose radiation exposure. However, even this simple test will likely not be available initially on the scale required to assess the at-risk population. Additional variables such as geographic location of exposure, sheltering, and signs and symptoms may be useful for initial sorting. An interdisciplinary working group composed of federal, state, and local public health experts proposes an Exposure And Symptom Triage (EAST) tool combining estimates of exposure from maps with clinical assessments and single lymphocyte counts if available. The proposed tool may help sort survivors efficiently at assembly centers near the damage and fallout zones and enable rapid prioritization for appropriate treatment and transport. (Disaster Med Public Health Preparedness. 2018; 12: 386–395)

Keywords

nuclear weaponstriageradiation injuries
Type
Concepts in Disaster Medicine
Information
Disaster Medicine and Public Health Preparedness , Volume 12 , Issue 3 , June 2018 , pp. 386 - 395
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. National Security Staff Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats. Planning Guidance For Response to a Nuclear Detonation. 2nd ed. https://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdf. Published June 2010. Accessed October 24, 2016.Google Scholar
2. Buddemeier, BR, Dillon, MB. Key Response Planning Factors for the Aftermath of Nuclear Terrorism. https://www.remm.nlm.gov/IND_ResponsePlanning_LLNL-TR-410067.pdf. Published August 2009. Accessed February 4, 2017.Google Scholar
3. Buddemeier, BR, Suski, N. Preparing for the Aftermath of Nuclear Detonation: An Analytical Framework for Disaster Management. Nuclear Safety and Security Challenges. https://e-reports-ext.llnl.gov/pdf/785616.pdf. Published November 17, 2014. Accessed February 13, 2017.Google Scholar
4. Buddemeier, BR. Reducing the consequences of nuclear detonation: recent research. The Bridge. 2010 Summer;40(2):28-38. https://www.nae.edu/Publications/Bridge/19804/19920.aspx. Accessed February 13, 2017.Google Scholar
5. DiCarlo, AL, Maher, C, Hick, JL, et al. Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(suppl 1):S32-S44. https://doi.org/10.1001/dmp.2011.17.Google Scholar
6. Knebel, AR, Coleman, CN, Cliffer, KD, et al. Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5(suppl 1):S20-S31. https://doi.org/10.1001/dmp.2011.25.Google Scholar
7. Radiological Dispersion Devices (RDDs). Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/rdd.htm. Accessed February 4, 2017.Google Scholar
8. Miller, CW, Ansari, A, Martin, C, et al. Use of epidemiological data and direct bioassay for prioritization of affected populations in a large-scale radiation emergency. Health Phys. 2011;101(2):209-215. https://doi.org/10.1097/HP.0b013e31821dd9a2.Google Scholar
9. Community Reception Center (CRC) Drill Toolkit. Emergency Preparedness and Response. Centers for Disease Control and Prevention website. https://emergency.cdc.gov/radiation/crc/crctoolkit.asp. Accessed October 24, 2016.Google Scholar
10. Virtual Community Reception Center (vCRC). Emergency Preparedness and Response. Centers for Disease Control and Prevention website. https://emergency.cdc.gov/radiation/crc/vcrc.asp. Accessed June 27, 2017.Google Scholar
11. Brandt, LD, Yoshimura, AS. Analysis of Sheltering and Evacuation Strategies for an Urban Nuclear Detonation Scenario. SANDIA REPORT. SAND2009-3299. http://prod.sandia.gov/techlib/access-control.cgi/2009/093299.pdf. Published May 2009. Accessed October 24, 2016.Google Scholar
12. Hrdina, CM, Coleman, CN, Bogucki, S, et al. The “RTR” medical response system for nuclear and radiological mass-casualty incidents: a functional triage-treatment-transport medical response model. Prehosp Disaster Med. 2009;24(3):167-178. https://doi.org/10.1017/S1049023X00006774.Google Scholar
13. Hick, JL, Weinstock, DM, Coleman, CN, et al. Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011;5(suppl 1):S73-S88. https://doi.org/10.1001/dmp.2011.28.Google Scholar
14. Reeves, G. Overview of use of G-CSF and GM-CSF in the treatment of acute radiation injury. Health Phys. 2014;106(6):699-703. https://doi.org/10.1097/HP.0000000000000090.Google Scholar
15. Singh, VK, Newman, VL, Seed, TM. Colony-stimulating factors for the treatment of the hematopoietic component of the acute radiation syndrome (H-ARS): a review. Cytokine. 2015;71(1):22-37. https://doi.org/10.1016/j.cyto.2014.08.003.Google Scholar
16. Myeloid Cytokines for Acute Myelosuppressive Doses of Radiation (Hematopoietic Subsyndrome of ARS). Radiation Emergency Medical Management. US Dept. of Health and Human Services website. https://www.remm.nlm.gov/cytokines.htm. Accessed February 4, 2017.Google Scholar
17. Dainiak, N, Gent, RN, Carr, Z, et al. First global consensus for evidence-based management of the hematopoietic syndrome resulting from exposure to ionizing radiation. Disaster Med Public Health Prep. 2011;5(3):202-212. https://doi.org/10.1001/dmp.2011.68.Google Scholar
18. Strategic National Stockpile. Office of Public Health Preparedness and Response. Centers for Disease Control and Prevention website. http://www.cdc.gov/phpr/stockpile/stockpile.htm. Accessed October 24, 2016.Google Scholar
19. Strategic National Stockpile. Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/sns.htm. Accessed February 4, 2017.Google Scholar
20. Smith, TJ, Bohlke, K, Lyman, GH, et al. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology Clinical Practice Guideline update. J Clin Oncol. 2015;33(28):3199-3212. https://doi.org/10.1200/JCO.2015.62.3488.Google Scholar
21. Herbst, C, Naumann, F, Kruse, EB, et al. Prophylactic antibiotics or G-CSF for the prevention of infections and improvement of survival in cancer patients undergoing chemotherapy. Cochrane Database Syst Rev. 2009;(1):CD007107.Google Scholar
22. About Lymphocyte Depletion Kinetics. Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/aboutlymphocytedepletion.htm. Accessed October 24, 2016.Google Scholar
23. Goans, RE, Holloway, EC, Berger, ME, et al. Early dose assessment following severe radiation accidents. Health Phys. 1997;72(4):513-518. https://doi.org/10.1097/00004032-199704000-00001.Google Scholar
24. Goans, RE, Holloway, EC, Berger, ME, Ricks, RC. Early dose assessment in criticality accidents. Health Phys. 2001;81(4):446-449. https://doi.org/10.1097/00004032-200110000-00009.Google Scholar
25. Andrews, GA, Auxier, JA, Lushbaugh, CC. The importance of dosimetry to the medical management of persons exposed to high levels of radiation. In: Personal Dosimetry for Radiation Accidents. Vienna: International Atomic Energy Agency; 1965. https://doi.org/10.2172/4606717.Google Scholar
26. Wilkins, RC, Romm, H, Kao, TC, et al. Interlaboratory comparison of the dicentric chromosome assay for radiation biodosimetry in mass casualty events. Radiat Res. 2008;169(5):551-560. https://doi.org/10.1667/RR1272.1.Google Scholar
27. Prasanna, PG, Moroni, M, Pellmar, TC. Triage dose assessment for partial-body exposure: dicentric analysis. Health Phys. 2010;98(2):244-251. https://doi.org/10.1097/01.HP.0000348020.14969.4.Google Scholar
28. Exposure: Diagnose and Manage Acute Radiation Syndrome (including integrated calculators). Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/exposureonly.htm. Accessed February 4, 2017.Google Scholar
29. Coleman, CN, Weinstock, DM, Casagrande, R, et al. Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(suppl 1):S111-S121. https://doi.org/10.1001/dmp.2011.22.Google Scholar
30. Lethality as a Function of Dose and LD 50/60 - Illustration. Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/LD50-60.htm. Accessed February 4, 2017.Google Scholar
31. Waselenko, JK, MacVittie, TJ, Blakely, WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 2004;140(12):1037-1051. https://doi.org/10.7326/0003-4819-140-12-200406150-00015.Google Scholar
32. Casagrande, R, Wills, N, Kramer, E, et al. Using the model of resource and time-based triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011;5(S1):S98-S110. https://doi.org/10.1001/dmp.2011.16.Google Scholar
33. Chilcott, RP, Amlot, R, eds. Decontamination Guidance for Chemical Incidents. Primary Response Incident Scene Management (PRISM). Biomedical Advanced Research and Development Authority (BARDA). US Department of Health and Human Services website. https://www.medicalcountermeasures.gov/barda/cbrn/decontamination-guidance-for-chemical-incidents/. Accessed February 4, 2017.Google Scholar
34. Sandgren, DJ, Salter, CA, Levine, IH, et al. Biodosimetry Assessment Tool (BAT) software-dose prediction algorithms. Health Phys. 2010;99(suppl 5):S171-S183. https://doi.org/10.1097/HP.0b013e3181f0fe6c.Google Scholar
35. Interagency Modeling and Atmospheric Assessment Center (IMAAC). US Department of Homeland Security website. https://www.dhs.gov/imaac. Accessed February 4, 2017.Google Scholar
36. Adalja, AA, Watson, M, Wollner, S, Toner, E. A possible approach to large-scale laboratory testing for acute radiation sickness after a nuclear detonation. Biosecur Bioterror. 2011;9(4):345-350. https://doi.org/10.1089/bsp.2011.0042.Google Scholar
37. Mettler, FA Jr, Voelz, GL. Major radiation exposure—what to expect and how to respond. N Engl J Med. 2002;346(20):1554-1561. https://doi.org/10.1056/NEJMra000365.Google Scholar
38. Mettler, FA Jr, Upton, AC. Medical Effects of Ionizing Radiation. 3rd ed. Philadelphia: Saunders Elsevier; 2008:353-359.Google Scholar
39. Fliedner, TM, Friesecke, I, Beyrer, K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. Oxford, United Kingdom: British Institute of Radiology; 2001.Google Scholar
40. Gorin, NC, Fliedner, TM, Gourmelon, P, et al. Consensus conference on European preparedness for haematological and other medical management of mass radiation accidents. Ann Hematol. 2006;85(10):671-679. https://doi.org/10.1007/s00277-006-0153-x.Google Scholar
41. Lerner, EB, McKee, CH, Cady, CE, et al. A consensus-based gold standard for the evaluation of mass casualty triage systems. Prehosp Emerg Care. 2015;19(2):267-271. https://doi.org/10.3109/10903127.2014.959222.Google Scholar
42. Demidenko, E, Williams, BB, Swartz, HM. Radiation dose prediction using data on time to emesis in the case of nuclear terrorism. Radiat Res. 2009;171(3):310-319. https://doi.org/10.1667/RR1552.1.Google Scholar
43. Parker, DD, Parker, JC. Estimating radiation dose from time to emesis and lymphocyte depletion. Health Phys. 2007;93(6):701-704. https://doi.org/10.1097/01.HP.0000275289.45882.29.Google Scholar
44. Camarata, AS, Switchenko, JM, Demidenko, E, Flood, AB, Swartz, HM, Ali, AN. Emesis as a screening diagnostic for low dose rate (LDR) total body radiation exposure. Health Phys. 2016;110(4):391-394. https://doi.org/10.1097/HP.0000000000000476.Google Scholar
45. About Time to Onset of Vomiting. Radiation Emergency Medical Management. US Department of Health and Human Services website. https://www.remm.nlm.gov/aboutvomiting.htm#references. Accessed February 4, 2017.Google Scholar
46. Farese, AM, Brown, CR, Smith, CP, et al. The ability of filgrastim to mitigate mortality following LD50/60 total-body irradiation is administration time-dependent. Health Phys. 2014;106(1):39-47. https://doi.org/10.1097/HP.0b013e3182a4dd2c.Google Scholar
47. Radiation Injury Treatment Network. National Marrow Donor Program. http://www.ritn.net/. Accessed October 24, 2016.Google Scholar