SUPPLEMENTAL DIGITAL CONTENT 1.doc
TABLE OF CONTENTS
TOPIC
PAGE
ACRONYM LISTING
DEFINITIONS
RADIALOGICAL SCENARIOS
DIAGNOSTIC CRITERIA TABLES
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S5
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S14
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ACRONYM LISTING
AFRRI .................................................................... Armed Forces Radiobiology Research Institute
AFRAT ................................................................................Air Force Radiation Assessment Team
Am................................................................................................................................... Americium
AML.......................................................................................................... Area Medical Laboratory
ANSI .................................................................................... American National Standards Institute
ARS ........................................................................................................ Acute Radiation Syndrome
ASPR................................................................ Assistant Secretary for Preparedness and Response
B ......................................................................................................................................Blast Injury
BARDA............................................ Biomedical Advanced Research and Development Authority
C ........................................................................................................................................Cutaneous
CBRN....................................................................Chemical, Biological, Radiological and Nuclear
CDC ...................................................... United States Centers for Disease Control and Prevention
CDG ...................................................................................................... Clinical Decision Guidance
CHP .......................................................................................................... Certified Health Physicist
Ci ...............................................................................................................................................Curie
CM ......................................................................................................... Consequence Management
CONOPS ....................................................................................................... Concept of Operations
COTS ........................................................................................................ Commercial off-the-shelf
CRN ........................................................................................ Chemical, Radiological and Nuclear
Cs .......................................................................................................................................... Cesium
D........................................................................................................................................... Delayed
DEARE .................................................................... Delayed Effects of Acute Radiation Exposure
DMRTI..................................................................... Defense Medical Readiness Training Institute
DOD ............................................................................................................. Department of Defense
DOE ............................................................................................................... Department of Energy
DSCA ..................................................................................... Defense Support of Civil Authorities
DTRA......................................................................................... Defense Threat Reduction Agency
DU ........................................................................................................................ Depleted Uranium
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E ............................................................................................................................................... Event
E .........................................................................................................................................Expectant
EM............................................................................................................. Emergency Management
EMEDS .......................................................................................... Expeditionary Medical Systems
Eq ..................................................................................................................................... Equivalent
FDA.................................................................................................. Food and Drug Administration
FM ................................................................................................................................ Field Manual
G............................................................................................................................... Gastrointestinal
GI ............................................................................................................................. Gastrointestinal
Gy...................................................................................................................................... Gray Unit
H................................................................................................................................. Hematopoietic
HHS....................................................................................................... Health and Human Services
HIV ............................................................................................... Human Immunodeficiency Virus
HLS .....................................................................................................................Homeland Security
I ........................................................................................................................................ Immediate
IACUC ..................................................................... Institutional Animal Care and Use Committee
IAEA ...................................................................................... International Atomic Energy Agency
IRT ......................................................................................................... Independent Review Team
JCB.............................................................................................................. Joint Capabilities Board
JP .............................................................................................................................Joint Publication
JTF-CS ............................................................................................. Joint Task Force-Civil Support
KI ........................................................................................................................... Potassium Iodide
M .......................................................................................................................................... Minimal
mCi.....................................................................................................................................Millicurie
MCMs ......................................................................................................Medical Countermeasures
METREPOL ....................................Medical Treatment Protocols for Radiation Accident Victims
MFM ...................................................................................................... Mass Fatality Management
MORTT........................................................................ Model of Resource and Time-Based Triage
mSv ................................................................................................................................. Millisievert
N................................................................................................................................. Neurovascular
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NATO ....................................................................................... North Atlantic Treaty Organization
NCI............................................................................................................ National Cancer Institute
NCRP ............................................... National Council on Radiation Protection and Measurements
NGDS ..................................................................................... Next Generation Diagnostics System
NIAID ........................................................... National Institute of Allergy and Infectious Diseases
NIH ...................................................................................................... National Institutes of Health
NRC .............................................................................................. Nuclear Regulatory Commission
NRRPT.................................................... National Registry of Radiation Protection Technologists
OCONUS .............................................................................. Outside the Continental United States
Po ....................................................................................................................................... Polonium
R ................................................................................................................................ Radiation Dose
RBCs ....................................................................................................................... Red Blood Cells
RBE .............................................................................................. Relative Biological Effectiveness
RC .......................................................................................................................Response Category
RC1 ...................................................................................................... Response Category 1 – Mild
RC2 .............................................................................................. Response Category 2 – Moderate
RC3 ...................................................................................................Response Category 3 – Severe
RC4 .......................................................................................... Response Category 4 – Very Severe
RDD ..................................................................................................Radiological Dispersal Device
REMM ........................................................................ Radiation Emergency Medical Management
RTD............................................................................................................................Return to Duty
SME ............................................................................................................... Subject Matter Expert
T ................................................................................................................................ Thermal Injury
TBq ............................................................................................................................. Terabecquerel
TRA........................................................................................... Technology Readiness Assessment
TRL ..................................................................................................... Technology Readiness Level
U.S. .............................................................................................................................. United States
USANCA ................... U.S. Army Nuclear and Combating Weapons of Mass Destruction Agency
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DEFINITIONS
CONDUCT INITIAL SCREENING TRIAGE - The purpose of screening triage is simply to
separate personnel with clinically significant exposures that need immediate treatment from
those who do not. Screening triage needs to be rapid, possess a low minimum exposure
detection capability, have a high sensitivity, and be a go/no-go process.
CONDUCT TREATMENT-TRIAGE - The purpose of treatment-triage is to prioritize patient
treatment so that resources (including evacuation assets) can be effectively utilized for
treating personnel who have entered the medical treatment system.
DETERMINE TREATMENT - Treatment is based on: the total injury (radiation and nonradiation) sustained by the patient; the tactical situation; and the availability of resources.
Radiological diagnostics inform treatment decision-making.
GUIDE ONGOING TREATMENT - Radiological diagnostics provide information concerning
treatment effectiveness and the need to alter or cease treatment.
GRAY EQUIVALENT - The sum of all equivalent dose components from neutrons, secondary
gamma rays, weapon gamma rays, and delayed gamma rays.
ROLE 1 MEDICAL TREATMENT – The first medical care military personnel receive is
provided at Role 1 (also referred to as unit-level medical care). It includes immediate
lifesaving measures. Major emphasis is placed on those measures necessary for the patient
to return to duty (RTD) or to stabilize the patient and allow for evacuation to the next role
of care. This role includes treatment provided by combat medics, self-aid and buddy aid,
combat lifesavers, medical personnel (JP 4-02, 26 July 2012, III-1, 2, and 3).
ROLE 2 MEDICAL TREATMENT – Role 2 provides advanced trauma management and
emergency medical treatment including continuation of resuscitation started in Role 1.
Role 2 provides a greater capability to resuscitate trauma patients than is available at Role
1. If necessary, additional emergency measures are instituted, but they do not go beyond
the measures dictated by immediate necessities. Role 2 care has the capability to provide
packed red blood cells (liquid), limited x-ray, laboratory, dental support, combat and
operational stress control, preventive medicine, and Role 2 veterinary medical and
resuscitative surgical support. Role 2 has a limited hold capability (i.e., no bed capacity).
Role 2 aid stations are highly mobile and designed to support land maneuver formations.
(JP 4-02, 26 July 2012, III-1, 2, and 3).
ROLE 3 MEDICAL TREATMENT – In Role 3, the patient is treated in a medical treatment
facility (field hospital) that is staffed and equipped to provide care to all categories of
patients, to include resuscitation, initial wound surgery, and post-operative treatment. This
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role includes provisions for providing care for all categories of patients (JP 4-02, 26 July
2012, III-1, 2, and 3).
ROLE 4 MEDICAL TREATMENT – Role 4 medical care is found in U.S. base hospitals and
robust overseas facilities with the ability to provide advanced definitive care (JP 4-02, 26
July 2012, III-1, 2, and 3).
STOCHASTIC HEALTH EFFECTS – An effect whose probability of occurrence is dose
dependent, but the severity of the effect is independent of dose. A stochastic effect is not
considered to have a threshold dose, i.e. a dose below which the effect does not occur.
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RADIOLOGICAL SCENARIO INFORMATION
Scenario 1 – 100kT Detonation in a Rear Area Supporting Combat Operations
Scenario 1 is a 100 kT nuclear air detonation, with 278 meters height of burst that has occurred
over a major U.S. logistics node located in a major Outside the Continental United States
(OCONUS) medium-sized urban port city where U.S. and Coalition Forces are conducting
combat operations.
The incident affects 45,000 Coalition Forces, 33,402 of whom are U.S.
personnel. The host nation may request support, but at this point has not asked for assistance.
Table S1 is a summary of the casualty types resulting from a scenario. The scenario assumes that
one battalion aid station, one area support medical company, and the fleet hospital are
functioning in the aftermath of the detonation. The insult category lists the type of injury where
(T) is thermal injury; (B) is blast injury; and, (R) is radiation dose. The insult category numbers
represent the degree of injury for thermal and blast; and the radiation dose in Gy for radiation. It
should be noted that in combat medical planning, the casualty focus is on "operational
casualties" (e.g. a soldier in the middle of combat whose performance capability drops below
25%) (AMedP 8(A), 2002). The performance degradation caused by burns is due primarily to
pain. While a service member with a serious burn injury will require treatment, they are not
considered an “operational casualty” unless the pain reduces their operational effectiveness
below 25%. The resulting performance algorithm involving burns may lead to the non-intuitive
appearance of non-casualties in Table S1. The table makes it clear that combined injuries
(radiation plus conventional) will represent the majority of the patient population.
Figure S1 shows the results of the NBC CREST modeling for the disposition of casualties over a
48 hour period. The first observation is the importance of Role 1 screening and having the
ability to make accurate RDT decisions. Over half of the soldiers arriving at Role 1 can be RTD
if Role 1 medical personnel have rapid and accurate methods to estimate dose. The RTD
decision is also important at Role 2 as it reduces the patient load and increases the forces that are
able to continue mission requirements. The final observation is that almost all of the patients
that are not RTD at Role 1 eventually will be evacuated to a Role 4 facility.
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Table S1. Summary of Casualties from the NBC CREST Modeling for a 100 kT Air Burst.
Figure S2. Patient flow estimated for Scenario 1 – 100 kT Air Burst Targeting a Rear Area. Figure accounts
for the first two days following the nuclear detonation incident.
The 100 kT air burst in the rear area of an active combat theater provides a plausible worst-case
scenario that was used to identify the types of patients, and a worst-case estimate of numbers of
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patients that each military Role of Care1 would see. The drawback to this scenario is that each
Role of Care will be overwhelmed. If only this maximum scenario were used, the diagnostic
would be required to meet patient loads that no other part of the medical care system can meet.
The second drawback to using the single scenario is the lack of trade-space that could be used to
develop an optimal solution. The third drawback is the relative unimportance of internal
contamination in this scenario. There are no reasonable scenarios where a Role 1 – Role 3
facility would be concerned with the internal contamination from fallout. Scenario 2 was
developed to overcome these shortcomings.
Scenario 2 – Dispersive Radiological Dispersal Device
This scenario depicts a radiological dispersal in the form of radiological isotopes (Cs-137 and
Am-241) mixed into the soda dispenser at the dining facility. The key events and timelines of
this scenario are loosely modeled on the outcomes of the 1987 Cs-137 dispersal that occurred in
Goiânia, Brazil (International Atomic Energy Agency [IAEA], 1988). The Goiânia incident is
important because:
1. It showed that it is possible for a person to survive long enough to disperse a large
quantity of Cs-137. At the time of the incident, there was 50 TBq (1,300 Ci) of
Cs-137 in the capsule that was the source of the event.
2. There was a significant time lapse (approximately 16–19 days) between the event
and the discovery of the event. During this time several people began exhibiting
signs of radiation sickness and were misdiagnosed.
3. The event generated a significant number of personnel who were not exposed but
reported to medical facilities to be screened.
Scenario 2 Sequence of Events
The setting for Scenario 2 is the same as for Scenario 1, the rear area in an established combat
theater. Intelligence indicates that there is a high probability of the enemy use of an RDD. In
response to the threat, a portion of the Air Force Radiation Assessment Team (AFRAT) was
deployed to the theater with the equipment needed to respond to an RDD event. At the time of
the event the AFRAT was operational.
The scenario is initiated when a local national working in a dining facility was recruited to spike
one of eight bags of soda with a mixture of 10 Ci of Cs-137 and 10 mCi of Am-241. The spiked
soda was delivered to an active dining facility and placed into service. Approximately 68 hours
after placing the contaminated bag into service, the local national was told to report to the
1
Refer to the supporting information for definitions of military roles of care adapted from JP 4-02, 26 July 2012,
III-1, 2, and 3.
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medical facility when he became ill and began vomiting. Facility management feared food
poisoning and wanted a medical determination to allow appropriate actions to be taken. As a
precaution, the dining facility was closed and patrons were re-routed to another facility.
Event (E)+68 hrs. Medical personnel became suspicious when they noticed what appeared to be
second degree burns on the hands of the local national. Fearing radiation exposure, medical
personnel requested the assistance of the AFRAT. The AFRAT personnel rapidly determined
the patient was contaminated with Cs-137 and an as-of-yet unidentified alpha emitter.
E+78 hrs. The AFRAT re-deployed to the dining facility and found significant contamination in
the dining area. A survey of the area led the team to the empty soda bag. Very high levels of
contamination were found on the bag. The AFRAT took a sample of the remaining liquid for
isotopic identification and initiated actions to identify personnel who used the facility and
initiated procedures to survey facility patrons.
Medical personnel began screening patients in the hospital and found five patients with very high
radiation readings. The patients were admitted with flu-like symptoms.
E+ 90 hrs. Multiple screening stations were established and priority was given to personnel who
frequented the dining facility.
Scenario 2 Dose Modeling
The personnel exposure used in the modeling effort is shown in Figure S3. The figure shows the
total number of people that drank soda from the eight bags purchased from the local national. A
total of 192 persons drank soda from the contaminated bag and a total of 1,344 persons drank
from the seven remaining uncontaminated bags.
The NBC CREST scenario assumes the Cs-137 was in a soluble form and was distributed
uniformly in the soda. The Am-241 was assumed to be in a relatively insoluble form and would
tend to settle with time. Soda from this style of bag is dispensed from the bottom of the bag
which means the intake of Am-241 would be non-uniform. As shown in Figure 4, the settling of
Am-241 resulted in a non-uniform distribution of Am-241 in which only the first 17 cups of soda
contained Am-241.
The intakes and the estimated doses from Cs-137 are shown in Table S2. The first variable
considered is the amount of ice in the cup. The second was the number of cups consumed. The
table provides two doses; the first is the RBE-weighted dose to the bone marrow for a 30-day
period after the intake of Cs-137. NCRP 161, 2011, uses the 30-day dose to provide an estimate
of the deterministic effects. The second dose (gray-equivalent dose with the hematopoietic
syndrome as the endpoint) gray-equivalent was estimated by DTRA, and takes into account the
impact of dose rate on the total dose needed to cause a health endpoint. The same dose delivered
at a lower dose rate will have less of an impact.
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The intakes of Am-241 and the resulting gastrointestinal (GI) doses, as a function of cups
dispensed, are shown in Figure 5. The Am-241 was assumed to decrease as an exponential
function of cups taken. The GI doses were estimated by DTRA and are in units of Gy-Eq for GI
syndrome.
The combined GI dose from the Cs-137 and the Am-241 is shown in Table S3. The Am-241
dose is the dose resulting from the ingestion of each cup dispensed. The maximum and
minimum possible Cs-137 doses are provided to yield a maximum and a minimum GI dose for
each of the Am-241 intakes listed in the table. The model indicated 13 fatalities and 124
symptomatic patients are likely in the RDD event along with 1399 individuals with negligible
effects.
Two conclusions can be drawn from the preceding analysis:
1. The potential is high that a few of the 192 personnel ingesting the mixture will
have sufficient bone marrow damage and GI damage to have both hematopoietic
and GI syndromes.
2. All of the 192 will need to be tested to determine the levels of Cs-137 and Am241 that are in each person, so that effective prioritized treatment can be initiated.
This treatment will be based upon the uptake of Am-241 and Cs-137.
The 100 kT scenario highlighted the importance of the return to joint service duty decisions at
each of the roles of care but especially at Roles 1 and 2. Well over half of the casualties (17,593
out of 27,344) were returned to duty at Roles 1 and 2. This is significant because the dose
thresholds for return to duty are low (75 cGy and 125 cGy) for exposure only and very low for
personnel with injuries. Personnel with injuries and any radiation exposure are evacuated out of
theater.
A dispersive RDD overcomes the shortcomings of the 100 kT air burst. An explosive RDD is
routinely used for homeland security planning purposes. Use of the explosive RDD will
significantly reduce the number of patients seen at each of the Roles of care; however, the level
of internal contamination is relatively unimportant for an explosive RDD. Primary medical
concerns—especially at Role 3—are injuries and external exposure. The use of a dispersive
RDD, where radioactive material is purposefully introduced into food or water, heightens the
importance of internal contamination to the point where it is the primary concern while
maintaining the importance of diagnostics for acute radiation injury if a high-energy gamma
emitter such as Cs-137 is the source.
The RDD scenario used showed that, unlike explosive RDDs, dispersive RDD scenarios can
result in sufficient internalization to generate ARS. The primary unknown at this point is
whether the Am-241 intake would result in GI syndrome. The modeling used by DTRA resulted
in GI tract doses sufficient to cause GI syndrome. The IAEA assumes the RBE for alpha
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emitters in the GI tract is “0” because it is unlikely that the alpha particles emitted by the Am241 in the lumen of the GI tract primary will irradiate the sensitive portions of the GI tract.
The purpose of developing CONOPS for the radiological diagnostics is to ultimately establish
operational scope, context, and conditions for the candidate technologies and explore “if and
how” the candidate diagnostic tools can be integrated into the current DOD radiological medical
CONOPS in support of military operations.
Table S2. Estimated range of bone marrow doses – 30d and Gray-Equivalent
#Cups
Ice
Intake (mCi)
Bone Marrow Dose From Cs-137
30d Dose
(Gy)
1
1/2 Ice
26
2.86
Gray
Equivalent
(Gy-Eq)
1.7
2
1/2 Ice
52
5.72
3.3
1
Very Little Ice
52
5.72
3.3
2
Very Little Ice
104
11.4
6.6
Figure S3 Distribution of radioactive material in the soda bags
1 bag contaminated
with Cs-137 and Am-241
192 people injest
radioactive soda
8 soda bags purchased
7 bags unaffected
1,344 people think they
could have ingested
radioactive soda
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1,536 people present to
medical treatment
facility
Table S3. Estimated GI Dose from Am-241 and Cs-137 Based on NBC CREST Scenario 2 Model
Am-241
Cs-137
Total GI Dose
Intake (mCi)
GI Dose
(Gy-Eq)
Min Dose to
a Person
Max Dose to
a Person
Max GI Dose
(Gy-Eq)
6.6
Min GI
Dose
(Gy-Eq)
30
5
28
1.7
2.5
14
1.7
6.6
16
21
1.25
0.63
7
1.7
6.6
8.7
14
3.5
1.7
6.6
5.2
10
0.31
1.7
1.7
6.6
3.4
8.3
0.16
0.9
1.7
6.6
2.6
7.5
0.078
0.43
1.7
6.6
2.1
7.0
0.039
0.22
1.7
6.6
1.9
6.8
0.020
0.11
1.7
6.6
1.8
6.7
0.010
0.06
1.7
6.6
1.8
6.7
0.005
0.03
1.7
6.6
1.7
6.6
0.002
0.01
1.7
6.6
1.7
6.6
0.001
<0.01
1.7
6.6
1.7
6.6
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The two scenarios were used to estimate the throughput requirements for the radiation injury
treatment diagnostic and the diagnostic to determine treatment to reduce the level of an
internalized radionuclide. Estimated throughput requirements for radiation injury diagnostics
were determined using both Scenario 1 and Scenario 2, as shown in Table S4. Scenario 1
provided the high-volume throughput and Scenario 2 will provideprovided an estimate of the
threshold throughput requirements. Scenario 2 was also used to estimate the throughput
requirements for diagnostics that will determine the amount of a radionuclide in a patient.
Table S4. Patient throughput requirements for Scenario 1 and Scenario 2
Role
Scenario 1: 100 kT Detonation
Intake
(# of Patients)
Patients/h
Role 1
27344
Role 2
Role 3
2
2
Scenario 2: Dispersive RDD
Intake
(# of Patients)
Patients/h
570
1536
32
10577
220
192
4
9745
203
192
4
Based on 48 hour timeframe.
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DIAGNOSTIC CRITERIA TABLES
Table S5. Screening triage parameters for external exposure
Parameter
Value
Rationale
Dose
0.5 Gy; 0.75 Gy, 1.5 Gy, 2
Gy, and ~10 Gy Uninjured
Dose
~1 Gy - Combined Injury
(Swartz et al., 2010)
The first dose (0.5 Gy) is used as the demarcation
between exposed and unexposed personnel. 3
The second (0.75 Gy) is used for an RTD
decision at Role 1. The next two doses (1.5 Gy, 2
Gy) are used by the DOD and BARDA
respectively, to determine those requiring
treatment based on radiation exposure only. The
last dose (10 Gy) is for triage into the expectant
category.
This is the dose quoted by Swartz et al., 2010 as
the dose that will change outcomes for some
combined injuries.
Results Obtained
Seconds to minutes per
patient
Results need to be obtained onsite under austere
environmental conditions without need to go to a
laboratory or conduct long analysis
False Positive
Moderate Degree (Swartz et
al., 2010)
The second screening will be able to find the false
positives.
False Negatives
Avoid (Swartz et al., 2010)
A false negative results in a patient who needs
treatment not being reevaluated.
Accuracy and
Precision
From ±0.25 Gy to ±0.5 Gy
This is based on the dose interval between key
screening-triage doses.
Throughput
Screening Triage
Optimal: 500 patients/h
Threshold: 30 patients/h
Time period signal is
present
Signal is present and usable
for at least 12–24 hours after
the exposure
Time before signal is
present
Immediately to minutes after
exposure
Training
Required Supplies
3
Minimal
The Role 1 values are used for the optimal value.
A technology that is adequate for screening at
Role 1 will be adequate for the remaining roles.
Role 1 is a rapid screening phase where RTD
decisions are made quickly.
Some patients will be rapidly transported to Role
1 facilities and will need to be rapidly screened.
Training at Role 1 is basic life-saving.
None to very limited
These doses were selected based on deterministic effects being the end-points of interest.
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Table S6. Screening-Triage parameters for internal exposure
Parameter
Value
Rationale
Dose
1 CDG
Dose
1/5th CDG
This is the value used for pregnant women and children weighing
less than 70 pounds.
Results Obtained
Within 1 hour per
patient
Needs to be done onsite without the need to go to a laboratory or
conduct long analysis.
False Positive
Moderate Degree
The second screening will be able to find the false positives –
sensitivity >90%.
Avoid
A false negative results in a patient who needs treatment not
being reevaluated.
False Negatives
Throughput
Time period signal
is present
Time before signal
is present
Training
Required Supplies
This is the value currently being used by the NCRP for adults.
Currently, the DOD does not have a value specified in doctrine.
Threshold – 4 samples
per hour
Optimal 32 samples
per hour
Signal is present and
usable for at-least 1224 hours after the
exposure
These values are taken from the results of Scenario 2.
Immediately to
minutes after exposure
Role 1 is a rapid screening phase where RTD decisions are made
quickly.
Minimal
None to very limited
Role 1 is a rapid screening phase where RTD decisions are made
quickly.
Training at Role 1 is basic life-saving.
Minimize support burden
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Table S7. Summary of technical criteria for dose-based radiological diagnostics used for treatment-triage and
treatment medical decisions
Parameter
Dose Range
Dose Accuracy
Value
Rationale
0.5 Gy to 10 Gy
Exposures less than 0.5 Gy require no immediate medical
treatment. Doses in excess of 10 Gy are considered
expectant (FM 4-02.283, 2001; AFRRI, 2010; Coleman et
al., 2011)
If the device is less accurate than the threshold, it will not
be useful for estimating lowest doses in the dose range.
The optimal dose accuracy is based on the analysis in
Swartz et al., 2010.
The 24 hour mark is key for cytokine treatment and
determining when surgery should be performed (AFRRI,
2010; Coleman et al., 2011)
Once the correct treatment category is assigned and the
initial treatment (treatment required in 24–48 hrs) is
completed, the time constraints are days to weeks.
Doses or follow-on diagnostics obtained during treatment
will be able to find the false positives.
Threshold: ±0.25 Gy
Optimal: ±0.05 Gy
Results Obtained
Treatment-Triage
1 to <24h
Results Obtained
Treatment
Hours to Days
False
positive/negative
treatment-triage
False
Positive/Negative
Treatment
Minimum
Detection Dose
Moderate degree
Throughput
Treatment-Triage,
Treatment
Time Period Signal
is Present
Treatment-Triage
Threshold – 4
patients/hour
Optimal 200
Patients/hour
Signal is present and
usable within hours and
persists for days
Time Period Signal
is Present
Treatment
Signal is present and
usable within hours and
persists for weeks
Training
Treatment-Triage
and Treatment
Required Supplies
Advanced training is
possible
Avoid
This should not be an issue at this point in the process
because of the data accumulated to date.
0.5 Gy
Treatment-triage detection thresholds need to be able to
distinguish non-exposed from those exposed to at least 0.5
Gy.
The threshold value was based on Roles 2 and 3 for
Scenario 2. The optimal value was based on Roles 2 and 3
for Scenario 1.
Similar to current
hospitals
Initial treatment needs to occur within 24 hours, surgery
needs to be performed within 24–48 hours after the
exposures.
Treatment is a long-term process that will continue for
weeks to months depending on the dose.
Treatment-triage and treatment will take place at hospitals
and experts can be used for the analysis.
Ideally, the diagnostic will use equipment and reagents
that are already in use in most hospitals.
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Table S8. Summary of Technical Criteria for Organ-Injury-Based Diagnostics Used for Treatment-Triage
and Treatment Medical Decisions
Parameter
ARS RC, degree
ARS RC accuracy
treatment triage and
treatment
Value
Rationale
1 – 4 RC
Technology must be able to place the patient in all four of the
RCs for the targeted organ system. These values inform the need
for immediate and delayed treatment.
±1/3rd RC degree
ARS RC degree range was selected using the rationale that the
variation in response to the same dose would render more precise
estimates clinically irrelevant.
Results obtained
treatment triage
<1 to <24 h
Results obtained
treatment
Hours to days
False
positive/negative
treatment-triage
Moderate degree
The 24 hour mark is important for cytokine treatment and
determining when surgery should be performed.
Once the correct treatment category is assigned and the initial
treatment (treatment required within 24–48 hrs) is completed, the
time constraints are days to weeks.
ARS risk diagnostics obtained during treatment will be able to
find the false positives.
False
positive/negative
treatment
Minimum detection
level
Avoid
This should not be an issue at this point in the process because of
the data accumulated to date.
RC 0
The system must be able to identify personnel who do not need
any form of medical attention and can be returned to duty.
Throughput
treatment-triage
and treatment
Time period signal
is present
treatment-triage
Threshold – 4
patients/h
Optimal 200 Patients/h
Signal is present and
usable within hours
and persists for days
The threshold value was based on Roles 2 and 3 for Scenario 2.
The optimal value was based on Roles 2 and 3 for Scenario 1.
Time period signal
is present treatment
Signal is present and
usable within hours
and persists for weeks
Treatment is a long-term process that will continue for weeks to
months depending on the ARS risk.
Training treatmenttriage and treatment
Required Supplies
Advanced training is
possible
Similar to current
hospitals
Treatment-triage and treatment will take place at hospitals and
experts can be used for the analysis.
Ideally, the diagnostic will use equipment and reagents that are
already in use in most hospitals, many of which contribute to the
assessment of radiation exposure.
Initial treatment-triage needs to occur within 24 to 48 hours after
the exposure.
S17