Employing High-Fidelity Simulation for the High-Risk, Low-Frequency Diagnosis and Management of Acute Radiation Syndrome (ARS)

Introduction

Acute radiation syndrome (ARS) is a high-risk, low-frequency diagnosis that can be fatal and is difficult to diagnose without an obvious history of ionizing radiation exposure.

Methods

Twenty-two emergency medicine residents and one pharmacy resident participated in an hour-long simulation session. To accommodate all learners, the simulation was conducted eight times over a block of scheduled time (two to four learners/session). Sessions included a prebriefing, pre/post questionnaires, the ARS case, and a debriefing. Learners evaluated and managed a 47-year-old male (manikin) with the hematopoietic and cutaneous subsyndromes of ARS who presented with hand pain/erythema/edema and underlying signs of infection 2 weeks after an unrecognized radiation exposure. Learners had to perform a history and physical, recognize/manage abnormal vitals, order/interpret labs, consult appropriate disciplines, and initiate supportive care.

Results

There was a mean reported increase in ability to recognize signs and symptoms of ARS (p < .001) and appropriately manage a patient with this condition (p = .03) even after controlling for baseline confidence in ability to make and manage uncommon diagnoses, respectively. Learners rated this simulation as a valuable learning experience, effective in teaching them how to diagnose and treat ARS, and one they would recommend to other health care professionals.

Discussion

This simulation aimed to teach the diagnosis and initial management of the hematopoietic and cutaneous subsyndromes of ARS. It should be used to increase awareness of the potential for ionizing radiation exposure under less obvious conditions and raise the index of suspicion for ARS in the undifferentiated patient.

Cutaneous and local radiation injuries

The threat of a large-scale radiological or nuclear (R/N) incident looms in the present-day climate, as noted most recently in an editorial in Scientific American (March 2021). These large-scale incidents are infrequent but affect large numbers of people. Smaller-scale R/N incidents occur more often, affecting smaller numbers of people. There is more awareness of acute radiation syndrome (ARS) in the medical community; however, ionising radiation-induced injuries to the skin are much less understood. This article will provide an overview of radiation-induced injuries to the skin, deeper tissues, and organs. The history and nomenclature; types and causes of injuries; pathophysiology; evaluation and diagnosis; current medical management; and current research of the evaluation and management are presented. Cutaneous radiation injuries (CRI) or local radiation injuries (LRI) may lead to cutaneous radiation syndrome, a sub-syndrome of ARS. These injuries may occur from exposure to radioactive particles suspended in the environment (air, soil, water) after a nuclear detonation or an improvised nuclear detonation (IND), a nuclear power plant incident, or an encounter with a radioactive dispersal or exposure device. These incidents may also result in a radiation-combined injury; a chemical, thermal, or traumatic injury, with radiation exposure. Skin injuries from medical diagnostic and therapeutic imaging, medical misadministration of nuclear medicine or radiotherapy, occupational exposures (including research) to radioactive sources are more common but are not the focus of this manuscript. Diagnosis and evaluation of injuries are based on the scenario, clinical picture, and dosimetry, and may be assisted through advanced imaging techniques. Research-based multidisciplinary therapies, both in the laboratory and clinical trial environments, hold promise for future medical management. Great progress is being made in recognising the extent of injuries, understanding their pathophysiology, as well as diagnosis and management; however, research gaps still exist.

Review of the Terminology Describing Ionizing Radiation-Induced Skin Injury: A Case for Standardization

Ionizing radiation causes injury to the skin that produces a complex clinical presentation that is managed by various paradigms without clear standards. The situation is further complicated by the fact that clinicians and researchers often use different terms and billing codes to describe the spectrum of cutaneous injury. There is, however, general agreement between the two most commonly-used diagnostic scales, the Radiation Therapy Oncology Group and the Common Terminology Criteria for Adverse Events, and in their use to describe skin injury following radiation therapy. These scales are typically used by radiation oncologists to quantify radiation dermatitis, a component of the radiation-related disorders of the skin and subcutaneous tissue family of diagnoses. In rare cases, patients with severe injury may require treatment by wound care or burn specialists, in which case the disease is described as a “radiation burn” and coded as a burn or corrosion. Further compounding the issue, most US government agencies use the term Cutaneous Radiation Injury to indicate skin damage resulting from large, whole-body exposures. In contrast, the US Food and Drug Administration approves products for radiation dermatitis or “burns caused by radiation oncology procedures.” A review of the literature and comparison of clinical presentations shows that each of these terms represents a similar injury, and can be used interchangeably. Herein we provide a comparative review of the commonly used terminology for radiation-induced skin injury. Further, we recommend standardization across clinicians, providers, and researchers involved in the diagnosis, care, and investigation of radiation-induced skin injury. This will facilitate collaboration and broader inclusion criteria for grant-research and clinical trials and will assist in assessing therapeutic options particularly relevant to patient skin pigmentation response differences.

Label-free SERS diagnostics of radiation-induced injury via detecting the biomarker Raman signal in the serum and urine bio-samples based on Au-NPs array substrates

A sensitive approach based on surface enhanced Raman spectroscopy (SERS) has been developed to evaluate the radiation caused biological injury. To achieve the effective SERS substrate, canonical anodic aluminum oxide (AAO) templates with regular array of nanotips were fabricated, and by plasma sputtering the gold nanoparticles (Au-NPs) were distributed on the nanotips to form the Au-NPs array with plenty of hotspots. The SERS substrates were utilized to examine the serum samples taken from the mice with the treatment of total body irradiation (TBI) of X-ray. The impact of TBI on the mice was analyzed and it was found that the SERS peak intensity at 532 cm^-1 increased as a function of duration or dose of TBI. We confirmed that this Raman signature belongs to the myoglobin as a biomarker for the muscle damage due to the radiation caused injury. Furthermore, we also tested several blood and urine specimen of cancer patients who received radiotherapy. The results showed that our approach to some extent could distinguish the bio-samples from normal, X-ray treated and untreated individuals. Therefore, the proposed methodology may have the potential for prompt prognosis of radiation injury at early stage.

Successful Rescue of the Victim Exposed to a Super High Dose of Iridium-192 during the Nanjing Radiological Accident in 2014

Here we report on the interventions taken to treat a patient exposed to high-dose radiation and provide a protocol for treating such patients in the future. The patient, Mr. Wang, was a 58-year-old male janitor who was accidentally exposed to a ¹⁹²Ir source with an activity of 966.4 GBq or 26.1 Ci. The dose estimated to the lower right limb was 4,100 Gy, whereas the whole-body effective dose was 1.51 Gy. The diagnosis was made according to the results of the patient dose estimation and clinical manifestations. Systemic treatment included stimulating bone marrow hematopoietic cells, enhancing immunity, anti-infection and vitamin supplements. The treatment of radiation-induced skin lesions consisted of several debridements, two skin-flap transplantations and application of mesenchymal stem cells (MSCs). Skin-flap transplantations and MSCs play important roles in the recovery of skin wound. A combination of antibiotics and antimycotic was useful in reducing inflammation. The application of vacuum sealing drainage was effective in removing necrotic tissue and bacteria, ameliorating ischemia and hypoxia of wound tissue, providing a fresh wound bed for wound healing and improving skin or flap graft survival rates. The victim survived the accident without amputation, and function of his highly exposed right leg was partially recovered. These results demonstrate the importance of collaboration among members of a multidisciplinary team in the treatment of this patient.

Focal cutaneous squamous cell carcinoma following radium-223 extravasation

Long-term sequelae due to extravasation of intravenous radioisotopes resulting in radiation injuries are rarely reported. As the use of radioactive isotopes for the treatment of osteoblastic metastases increases, information regarding the prevention, treatment, and long-term monitoring of suspected extravasation injury will become increasingly important. We present a patient with no previous history of skin cancer who developed an aggressive cutaneous squamous cell carcinoma at the site of prior radium-223 extravasation. We recommend that patients who experience extravasation of therapeutic radioisotopes be monitored by dermatologists for long-term sequelae. Cutaneous squamous cell carcinoma should be recognized as a rare but potential adverse event following cutaneous extravasation of radium-223 and is likely a side effect that is severely underreported.