Objective: Hematopoietic syndrome (HS) is a clinical diagnosis assigned to people who present with ≥1 new-onset cytopenias in the setting of acute radiation exposure. The World Health Organization convened a panel of experts to evaluate the evidence and develop recommendations for medical countermeasures for the management of HS in a hypothetical scenario involving the hospitalization of 100 to 200 individuals exposed to radiation. The objective of this consultancy was to develop recommendations for treatment of the HS based upon the quality of evidence.

Methods: English-language articles were identified in MEDLINE and PubMed. Reference lists of retrieved articles were distributed to panel members before the meeting and updated during the meeting. Published case series and case reports of individuals with HS, published 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 (GRADE) system. In cases in which data were limited or incomplete, a narrative review of the observations was made. No randomized controlled trials of medical countermeasures have been completed for individuals with radiation-associated HS. The use of GRADE analysis of countermeasures for injury to hematopoietic tissue was restricted by the lack of comparator groups in humans. Reliance on data generated in nonirradiated humans and experimental animals was necessary.

Results: Based upon GRADE analysis and narrative review, a strong recommendation was made for the administration of granulocyte colony-stimulating factor or granulocyte macrophage colony-stimulating factor and a weak recommendation was made for the use of erythropoiesis-stimulating agents or hematopoietic stem cell transplantation.

Conclusions: Assessment of therapeutic interventions for HS in humans exposed to nontherapeutic radiation is difficult because of the limits of the evidence.

(Disaster Med Public Health Preparedness. 2011;5:202-212)

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)

The Hospital Emergency Incident Command System (Hospital Emergency Incident Command System), nowin its third edition, has emerged asa popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the Hospital Emergency Incident Command System in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (Severe Acute Respiratory Syndrome) outbreaks in eastern Asia and Toronto, Canada.

Several modifications of the Hospital Emergency Incident Command System are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the Hospital Emergency Incident Command System to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in chemical, biological, radiological, nuclear emergencies; (3) new unit leaders in theOperations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, anddependents in terrorismrelated emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types ofpatients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems.

New uses of the Hospital Emergency Incident Command System in hospital emergency management also are recommended, including: (1) the adoption of the Hospital Emergency Incident Command System as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the Hospital Emergency Incident Command System not only to healthcare facilities, but also to healthcare systems.

Finally, three levels of healthcare worker competencies in the Hospital Emergency Incident Command Systemare suggested: (1) basic understanding of the Hospital Emergency Incident Command System for all hospital healthcare workers; (2) advanced understanding and proficiency in the Hospital Emergency Incident Command Systemfor hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the Hospital Emergency Incident Command System ad hoc from existing healthcare workers in resource-deficient settings. The Hospital Emergency Incident Command System should be viewed asa work in progress that will mature as additional challenges arise and ashospitals gain further experience with its use.

This article considers the critical roles of risk and risk assessment in the management of health emergencies and disasters. The Task Force on Quality Control of Disaster Management (TFQCDM) has defined risk as the “objective (mathematical) or subjective (inductive) probability that something negative will occur (happen)”. Risks with the greatest relevance to health emergency management include: (1) the probability that a health hazard exists or will occur; (2) the probability that the hazard will become an event; (3) the probability that the event will lead to health damage; and (4) the probability that the health damage will lead to a health disaster. The overall risk of a health disaster is the product of these four probabilities.

Risk assessments are the tools that help systems at risk—healthcare organizations, communities, regions, states, and countries—transform their visceral reactions to threats into rational strategies for risk reduction. Type I errors in risk assessment occur when situations are predicted that do not occur (risk is overestimated). Type II errors in risk assessment occur when situations are not predicted that do occur (risk is underestimated). Both types of error may have serious, even lethal, consequences.

Errors in risk assessment may be reduced through strategies that optimize risk assessment, including the:(1) adoption of the TFQCDM definition of risk and other terms; (2) specification of the system at risk and situations of interest (hazard, event, damage, and health disaster); (3) adoption of a best practice approach to risk assessment methodology; (4) assembly of the requisite range of expert participants and information; (5) adoption of an evidence-based approach to using information; (6) exclusion of biased, irrelevant, and obsolete information; and (7) complete characterizations of any underlying fault and event trees.

Numerous examples exist of the benefits of the timely access to information in emergencies and disasters. Information technology (IT) is playing an increasingly important role in information-sharing during emergencies and disasters.

The effective use of IT in out-of-hospital (OOH) disaster response is accompanied by numerous challenges at the human, applications, communication, and security levels.Most reports of IT applications to emergencies or disasters to date, concern applications that are hospital-based or occur during non-response phases of events (i.e., mitigation, planning and preparedness, or recovery phases). Few reports address the application of IT to OOH disaster response.

Wireless peer networks that involve ad hoc wireless routing networks and peer-to-peer application architectures offer a promising solution to the many challenges of information-sharing in OOH disaster response. These networks offer several services that are likely to improve information-sharing in OOH emergency response, including needs and capacity assessment databases, victim tracking, event logging, information retrieval, and overall incident management system support.

This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.