This book contains 38 papers from leading researchers in 18 countries, who participated in the Second Consensus Development Conference on the Treatment of Radiation Injuries organised by the Armed Forces Radiobiology Research Institute and held at Bethesda USA in April 1993. The conference was split into four major subjects that dealt with Sepsis, Aplasia, the Gastrointestinal syndrome and the Cutaneous syndrome. Scientific papers in each area were presented following which committees of experts attempted to reach a consensus on the optimum treatment of each major area, keeping note of the interaction between each syndrome and area. One key message of the conference was the acceptance that radiation burns, particularly beta burns as seen in the casualties at the Chernobyl Nuclear Power Plant accident, is a separate syndrome and that their coexistence with the acute radiation syndrome creates the equivalent of a combined injury. Some preferred treatments for the haematopoietic syndrome would exacerbate the cutaneous syndrome. Sepsis consensus The agreed definition of sepsis is the presence of a documented infection in a patient with clear evidence of a clinically significant deleterious response to that infection. In any patient exposed to significant radiation levels the suppression of bone marrow activity will reduce the resistance to bacterial and viral infections. For febrile neutropenic casualties blood, urine and faecal samples for cultures need to be taken on admission. Patients need to be started on broad spectrum antimicrobials and these should be given until the patient is afebrile. Experience has shown that fungal lung infections can be the cause of late deaths, when all the other radiation effects have been stabilised. Early use of antifungal agents and gamma globulin for viral infections is essential. Aplasia consensus Following a suspected high radiation exposure, initial patient assessment should be based on dosimetric testing (biological, physical), daily full blood counts, viral titres (e.g. CMV, HIV), HLA subtyping for possible bone marrow transplantation (BMT) and the administration of haematopoietic growth factors (Colony Stimulating Factors, such as G or GM-CSF). Particular care is needed if the patient has other injuries, such as pulmonary infections, burns or smoke inhalation. Subsequent supportive therapy might include platelet transfusions particularly if surgery is indicated for other injuries. Other treatments might include the use of thrombopoietic drugs. However, BMTs should only be given if an autologous donor is available. Papers highlight that more research into the interaction between BMT and cytokine therapy is essential. Gastrointestinal consensus The gastrointestinal syndrome shows that the gut is the rate limiting organ for radiation injury. The general view is that vomiting should be controlled by use of effective antiemetics, e.g. ondansetron, as these would reduce mechanical damage of the gut lining, help to retain fluids and because they have a slight constipatory action. The loss of the onset and duration of nausea as a biological indicator of dose was recognised but the therapeutic benefits ethically drive the treatment protocol. Diarrhoea should be treated with fluids and electrolytes and efforts should be made to improve host defences by elemental diets, vitamins and glutamine parenterally or intravenously. Cutaneous consensus The first important decision was that the cutaneous syndrome should be defined in its own right. The consensus treatment for those suspected of having been contaminated with fission products is to remove all clothing as soon as possible, bathe very gently in lukewarm baths, use acetic acid or ion exchangers if surface contamination is thought to be soluble caesium, and only remove contamination mechanically from soles of feet or palms of hands. Later treatments might include use of topical creams, systemic acitretin and gamma interferon. Two key areas raised were the establishment of triage criteria for the cutaneous syndrome and that physical dosimetry is unhelpful in predicting cutaneous damage. The need to develop better biological markers for skin damage is essential. Radiation accidents occur with monotonous frequency worldwide often in areas least able to manage. They invariably occur due to by-passing of safety procedures, such as interlocks. Due to the slow onset of signs and symptoms casualties often present a very significant clinical challenge to medical staff. This book details the consensus on treatment of radiation casualties as seen in 1993 and the Consensus Summary contains a valuable flow diagram to aid those in accident and emergency departments where the specialist triage is needed. The book is very well documented and referenced and forms the best and most concise treatise on the subject that is available worldwide. The editors have done a splendid job in collating the papers delivered at the Conference and in obtaining a consensus from such a large number of experts. This book is an invaluable source of information and should be of assistance to clinicians who have responsibilities for dealing with radiation casualties worldwide.
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John Harrison (1997) studied this question.