Disaster Medicine and Public Health Preparedness

Review Article

Literature Review and Global Consensus on Management of Acute Radiation Syndrome Affecting Nonhematopoietic Organ Systems

Nicholas Dainiak, Robert Nicolas Gent, Zhanat Carr, Rita Schneider, Judith Bader, Elena Buglova, Nelson Chao, C. Norman Coleman, Arnold Ganser, Claude Gorin, Martin Hauer-Jensen, L. Andrew Huff, Patricia Lillis-Hearne, Kazuhiko Maekawa, Jeffrey Nemhauser, Ray Powles, Holger Schünemann, Alla Shapiro, Leif Stenke, Nelson Valverde, David Weinstock, Douglas White, Joseph Albanese and Viktor Meineke c1

ABSTRACT

Objectives: The World Health Organization convened a panel of experts to rank the evidence for medical countermeasures for management of acute radiation syndrome (ARS) in a hypothetical scenario involving the hospitalization of 100 to 200 victims. The goal of this panel was to achieve consensus on optimal management of ARS affecting nonhematopoietic organ systems based upon evidence in the published literature.

Methods: English-language articles were identified in MEDLINE and PubMed. Reference lists of retrieved articles were distributed to conferees in advance of and updated during the meeting. Published case series and case reports of ARS, publications of randomized controlled trials of relevant interventions used to treat nonirradiated individuals, reports of studies in irradiated animals, and prior recommendations of subject matter experts were selected. Studies were extracted using the Grading of Recommendations Assessment Development and Evaluation system. In cases in which data were limited or incomplete, a narrative review of the observations was made.

Results: No randomized controlled trials of medical countermeasures have been completed for individuals with ARS. Reports of countermeasures were often incompletely described, making it necessary to rely on data generated in nonirradiated humans and in experimental animals. A strong recommendation is made for the administration of a serotonin-receptor antagonist prophylactically when the suspected exposure is >2 Gy and topical steroids, antibiotics, and antihistamines for radiation burns, ulcers, or blisters; excision and grafting of radiation ulcers or necrosis with intractable pain; provision of supportive care to individuals with neurovascular syndrome; and administration of electrolyte replacement therapy and sedatives to individuals with significant burns, hypovolemia, and/or shock. A strong recommendation is made against the use of systemic steroids in the absence of a specific indication. A weak recommendation is made for the use of fluoroquinolones, bowel decontamination, loperamide, and enteral nutrition, and for selective oropharyngeal/digestive decontamination, blood glucose maintenance, and stress ulcer prophylaxis in critically ill patients.

Conclusions: High-quality studies of therapeutic interventions in humans exposed to nontherapeutic radiation are not available, and because of ethical concerns regarding the conduct of controlled studies in humans, such studies are unlikely to emerge in the near future.

(Disaster Med Public Health Preparedness. 2011;5:183–201)

(Received June 28 2011)

(Accepted August 16 2011)

Key Words:

  • countermeasures for ARS;
  • treatment of ARS;
  • narrative review of countermeasures for ARS;
  • acute radiation syndrome;
  • reviews;
  • radiation effects;
  • gastrointestinal diseases;
  • skin diseases;
  • burns;
  • neurologic manifestations;
  • ethics, medical;
  • palliative care;
  • diabetes mellitus;
  • infection control;
  • critical care

Correspondence

c1 Correspondence: Address correspondence and reprint requests to Dr Viktor Meineke, Bundeswehr Institute of Radiobiology, Neuherbergstrasse 11, D-80937, Munich, Germany (e-mail: ViktorMeineke@bundeswehr.org).

Author Affiliations: Dr Dainiak is with the Yale University School of Medicine and Yale-New Haven Health-Bridgeport Hospital; Dr Gent is with the Health Protection Agency (Porton Down); Dr Carr is with the World Health Organization; Dr Schneider is with the Department of Nuclear Medicine, University of Würzburg; Drs Bader and Coleman are with the National Cancer Institute; Dr Buglova is with the International Atomic Energy Agency; Dr Chao is with Duke University; Dr Gansler is with the Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School; Dr Gorin is with Hospital Saint-Antoine; Dr Hauer-Jensen is with the University of Arkansas for Medical Science; Drs Huff and Lillis-Hearne are with the Armed Forces Radiobiology Research Institute; Dr Maekawa is with the Kanto Central Hospital; Dr Nemhauser is with the Centers for Disease Control and Prevention; Dr Powles is with the Parkside Oncology Clinic; Dr Schünemann is with McMaster University; Dr Shapiro is with the US Food and Drug Administration; Dr Stenke is with the Karolinska Institute; Dr Valverde is with the JLVF Consultants for Hospital & Health Management; Dr Weinstock is with the Dana-Farber Cancer Institute; Dr White is with the University of Pittsburgh Program on Ethics and Critical Care Medicine; Dr Albanese is with the Yale-New Haven Health Center for Emergency Preparedness and Disaster Response; and Dr Meineke is with the Bundeswehr Institute of Radiobiology.