Medical management of acute radiation syndrome and associated infections in a high-casualty incident

Abstract

A high-casualty incident may result in a significant human toll due to the inability of a community to meet the health care demands of the population. A successful medical response requires health care facilities to not only communicate and integrate medical services, meet surge capacity, protect health care workers and implement triage and treatment protocols, but also to provide the venue for clinical management of acute radiation injuries and their associated infections. Today, clinical management is primarily guided by the recommendations of a Consultancy that were made at the World Health Organization (WHO). This international consensus was reached on evidence-based, clinical management of each of the four sub-syndromes that compose acute radiation syndrome (ARS), including the hematopoietic subsyndrome (HS), gastrointestinal subsyndrome (GIS), neurovascular subsyndrome (NVS) and cutaneous subsyndrome (CS). Major findings in studies meeting inclusion criteria for management strategies for HS were that (i) no randomized controlled studies of medical countermeasures have been (or will likely ever be) performed for ARS cases, (ii) the data for management of HS are restricted by the lack of comparator groups, and (iii) reports of countermeasures for management of injury to non-hematopoietic organs are often incompletely described. Here, (i) recommendations made in Geneva are summarized; (ii) the analysis of countermeasures for HS is updated by review of two additional cases and extended to published reports not meeting inclusion criteria; and (iii) guidelines are provided for management of microbial infections based upon patient risk for prolonged immunosuppression.

Fig. 1.

Cytokine response in individual from Fleurus, Belgium Accident (2006). Shown are total leukocyte counts over time before and after therapy with pegylated granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO) and recombinant human Stem Cell Factor (rh-SCF). Modified from Gourmelon P et al. (European consensus on the medical management of acute radiation syndrome and analysis of the radiation accidents in Belgium and Senegal. Health Phys 2010;98:825–32).

Fig. 2.

Summary of clinical management of infections based on time after exposure. Shown are treatment strategies for three arbitrarily designated periods (‘early’, ‘intermediate’ and ‘late’) following exposure to ionizing radiation.

Fig. 3.

Antibiotics recommended for low-risk patients in the ambulatory (outpatient) and hospitalized (inpatient) settings, based upon Freifield AG et al. (Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2011;52:e56-e93).

Fig. 4.

Antibiotics recommended for high-risk patients, based upon Freifield AG et al. (Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2011;52:e56-e93).

Fig. 5.

Evolution of skin lesion in welder from Yanango, Peru Accident (1999). The individual developed a blister with erythema (Day 2), which evolved into an ulcer of the right thigh, which in turn became infected with an exudative response (Day 27). Purulent necrosis developed (Day 72), requiring surgical management, including amputation of the right lower extremity.