Basics of Treatment of Victims of Radiation Terrorism or Accidents
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Transcript of Basics of Treatment of Victims of Radiation Terrorism or Accidents
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Basics of Treatment of Victims of Radiation Terrorism or Accidents
Niel Wald, M.D.Dept. of Environmental and Occupational Health
University of Pittsburgh
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Medical Radiation Problems
External Radiation Source:–Local Radiation Injury –Acute Radiation SyndromeRadionuclide Contamination:–External–Localized in Wound–Internal
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LOCAL RADIATION INJURY: RADIODERMATITIS
Type Manifestation
I Erythema
II Transepidermal Injury
III Dermal Radionecrosis
IV Chronic Radiodermatitis
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Local Injury: Transepidermal (Beta Radiation + Thermal Burns)
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Local Radiation Injury PXD14
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Local Radiation Injury PXD 22
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Local Radiation Injury PXD 90
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Local Radiation Injury Therapy
AMPUTATION STAGESUpper Extremities
5mo
4mo
5mo 6
mo5
mo7mo
7mo
10mo
17mo
12mo
RightLeft
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Arteriole (post-irradiation)
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Local Radiation Injury PXD22
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Local Radiation Injury PXD 29
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Local Radiation Injury PXD 92
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Local Radiation Injury Diagnosis• Inspection: Erythema
• Blood Flow: Thermography; Isotope scanning (201Tl scintigraphy); Skin laser Doppler.
• Tissue Density and Hydration: MRI; CT; 67Ga scintigraphy; 111In-labeled anti-myosin antibody scan.
.
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Useful Steps in Clinical Care of Local Radiation Injury
• History and Physical Examination• Serial Blood Counts• Chromosome Analysis• Re-enactment of Accident• Frequent Color Photographs• Baseline Extremity X-rays• Ophthalmologic Slit Lamp Examination• Sperm Counts• Surgical Consult
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Local Radiation Injury Therapy• Analgesics, Antipruritics• Anti-inflammatories• Antibiotics as needed • Skin Growth Factors• Synthetic Occlusive Dressings• Surgical Intervention:
–Debridement–Excision and Grafting–Amputation
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Diagnostic X-Ray Injury
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Diagnostic X-ray Injury: Repaired
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Acute Radiation Syndromes and Their Management
• Key underlying pathophysiology at the cell and organ level
• Description of syndromes• Diagnostic procedures• Clinical care
589-1
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Acute Radiation Syndromes• Underlying Cellular Radiation Effects
– Mitotic inhibition– Cell killing– Organ malfunction– Vascular reactions
• Clinical Manifestations– Hematological– Gastrointestinal– Neurovascular– Pulmonary
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Three Stage Kinetic Model
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Prodromal Symptoms & SignsNeurogenic Vascular
Anorexia ConjunctivitisNausea Skin ErythemaVomitingDiarrhea FeverWeakness
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Radiation Erythema (PXD 10)
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Radiation Epilation (PXD 23)
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ARS: 45 Days post-Epilation
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ARS: Hematopoietic Form
38-C
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ARS: Hematologic Course
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Hematopoietic Syndrome Systemic Effects
• Immunodysfunction–Increased Infectious
Complications• Hemorrhage
–Anemia• Impaired Wound Healing
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ARS: Gastrointestinal Form
38-D
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Mechanism of GI Syndrome(Gunter-Smith Hypothesis)
627-1
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GI Syndrome Systemic Effects • Malabsorption• Ileus
–Vomiting–Abdominal distention
• Fluid and Electrolyte Shifts–Dehydration–Acute renal failure–Cardiovascular
• GI Bleeding• Sepsis
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ARS: Neurovascular Form
38-E
EXCITATIONPHASE
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Autonomic Nervous System
49-B
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HYPOTHALAMIC SYSTEM
322-1
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Neurovascular Syndrome Systemic Effects
• Vomiting and Diarrhea within Minutes
• Confusion and Disorientation• Severe Hypotension• Hyperpyrexia• Cerebral Edema• Convulsions - Coma• Fatal within 24 to 48 Hours
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ARS- Pulmonary Form (pre-exposure)
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ARS- Pulmonary Form (exudative stage)
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ARS- Pulmonary Form (fibrotic stage)
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Pulmonary Syndrome Systemic Effects • Early Phase
–Dyspnea–Cough–Pulmonary Edema –Acute Respiratory Distress Syndrome
• Late Phase–Interstitial Fibrosis–Interstitial Pneumonitis–Chronic Respiratory Distress Syndrome
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Acute Radiation Syndrome
• Psychological Stress• Infection
– Bacterial, viral, fungal, CMV, herpes• Hemorrhage• Radiation Enterocolitis• Radiation Pneumonitis• Combined Injuries
– Radiation plus trauma, burns, etc.
Clinical Management Problems
648-4
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General Treatment Plan for External Exposure• Provide Psychological Support
– Professional– Family – Clergy
• Use Symptomatic Treatment– Antiemetics– Analgesics
• Prevent Infection and Hemorrhage– Reverse Isolation– Antibiotics– Blood Products
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General Treatment Plan (cont.)
• Maintain Hydration and Nutrition– Fluids– Electrolytes– Nutrients
• Encourage Cell Renewal– Growth Factors– Stem Cells
• Control Inflammatory Response– Steroids– Vasodilators
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Psychological Stress Reducers• One Responsible Decision-Maker
• Realistic Appraisal of Problem and Clear Communication
• Credible Action Plan and Adequate Resources
• Pre-Emergency Education
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Infection Problems Secondary to Radiation Pancytopenia
• Invasion and colonization of rectal or colonic wall by normal flora
• Activation of latent infections• Opportunistic infections
–Gram Negative–Staphylococcus Aureus
56-J
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General Anti-Infection Measures in Radiation Pancytopenia
• Control Bacterial and Fungal Flora of–Naso-Oro-Pharyngeal Tract–Gastrointestinal Tract
• Avoid Disruption of Skin and Mucosa
• Introduce Environmental Control
• Use Optimal Regimen vs. Overt Infection
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Selective Bacterial Decontamination• Some Oral Agents that have been used:
Nasopharyngeal Tract:– B-Lactam Resistant Penicillins p.o. and Bacitracin to nares
Gastrointestinal Tract:– Trimethoprim-Sulfamethoxazole or Polymixin + above, or
Polymixin + Nalidixic Acid and Amphotericin or Nystatin p.o.
– CONSULT INFECTIOUS DISEASE, TRANSPLANT, or HEMATOLOGY/ONCOLOGY SPECIALISTS for BEST CURRENT THERAPY for IMMUNOSUPPRESSED PATIENTS
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Environmental Control in Radiation Pancytopenia
• Air Filtration and Positive Pressure
• Reverse Isolation Procedures
• Dietary Considerations
• Special Precautions for Skin Punctures
• Limitation of Attending Personnel
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ARS: Environmental Control
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Bedside Debriding of Local Radiation Injury
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Preparation For Hematologic Complications In Radiation PancytopeniaTransfusions: Erythrocytes
Platelets
Growth Factors: GSF, GMCF,IL2, etc.
Stem Cell Transplants: Autografts(Marrow, cord, PB) Isografts
HomograftsXenografts (?)
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Infection Therapy in Radiation Pancytopenia
• Aminoglycosides (Gentamicin,etc.)– most effective
• Ureido-Penicillins (Ticarcillin,etc.)– synergistic vs. gram-negative
• Monobactams– effective vs. gram-negative & no renal toxicity
• B-Lactam Resistant Penicillins (Methicillin,etc.)– effective vs. S.aureus
CONSULT INFECTIOUS DISEASE, TRANSPLANT, or HEMATOLOGY/ ONCOLOGY SPECIALISTS for BEST CURRENT THERAPY for IMMUNOSUPPRESSED PATIENTS
Some Systemic Agents that have been used:
434-2
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Uses of Hematopoietic Growth Factors
• Mobilize peripheral-blood progenitor cells• Expand hematopoietic cell population• Speed and enhance hematopoietic recovery• Early hematopoietic recovery will reduce
nonhematological toxicity (infection, mucositis, pneumonia, etc.)
• Augment transplant using smaller number of hematopoietic cells
583-3
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Marrow Transplantation Procedure (after E.D. Thomas and C.D. Buckner)
• Donor: – Compatability matching. – General anesthesia. – 100 sites aspirated in sternum, ant. & post. Iliac crests.
• Marrow:– 4cc aspirates into TC 199 + 5,000 U Connaught preservative-
free heparin.– 9 X 109 marrow cells in 400cc passed through 300u and 200u
S.S. screens.• Recipient:
– Given marrow I.V. rapidly from Fenwall bag.
58-D
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ARS: Hematologic Response to Stem Cells
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ARS: Current Treatment Challenges - Gastrointestinal Syndrome Therapy
• 5HT3 (5-hydroxytriptamine) receptor antagonist• Radioprotectants (WR-2721)• Cytokines (IL-1, G-CSF)• Prostaglandin antagonists• Sucralfate• Gut microbial and fungal suppression• Vasopressin• Elemental Diet (amino acids, sucrose, limited fat) • Glutamine
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ARS: Current Treatment Challenge -Pulmonary
679-8
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Combined Injury: A-Bomb Patients
402-5
Type of Injury % Died Before 20 px-days
% Alive at 20 or more px-days
Radiation 95.1 81.2
Severe Rad Sx 58.5 75.2
Thermal burns 57.2 25.1
Mechanical Trauma
57.2 61.8
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ARS: General Therapeutic Approach
• Provide Psychological Support• Use Symptomatic Treatment• Prevent Infection and Hemorrhage • Maintain Hydration and Nutrition• Encourage Cell Renewal• Control Inflammatory Response
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ARS: Therapy Summary
583-7
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Radiation Accident Management
Type of Accident
Worst Consequence
Preparation _ Time___
External Exposure
Death in 0-6 Weeks
1-2 Weeks After Accident
Internal Contamination
Cancer in 5-25 Years
Months-Years before Accident
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Internal Exposure Variables Routes of Entry:– Inhalation, Ingestion, Injection and AbsorptionDecay Rates and energiesChemical Compounds, Solubility, Particle Size, etc.Time and Duration
Radionuclides and Forms Metabolic Behavior– Deposition, Retention, Elimination and Critical Organs
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Initial Management of the Externally Contaminated Patient
FIRST AID prn. for SHOCK, BLEEDING and ACUTE RESPIRATORY DISTRESS
Gross DecontaminationRemoval of Contaminated Clothing
– Washing and removal of Contaminated Hair– Removal of Gross Wound Contamination
Intermediate Stage (at clean location,if necessary)– Removal of Contaminated Clothing– Further Local Decontamination, Swabs of Body Orifices
Final Stage– Patient Discharged with Fresh Clothing– More Definitive Decontamination (surgical) and Other Therapy
at Dispensary or Hospital
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Decontaminating Agents• Soap and Water• Abrasive Soap and Water• Detergents
– (10%) Dreft, Tide; Phisohex, Hemosol• Oxidizers
– Chlorox (20%), KMnO4• Complexers
– Citric Acid (1%)• Chelators
– Versene (1%) EDTA, DTPA
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Early Treatment For Radionuclide Inhalation
• Irrigate Nose, Mouth and Pharynx
• No Effective Medical Means to enhance lung clearance
• Consider Bronchopulmonary Lavage for Major Long-Lived High-Hazard Lung Contamination
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Early Treatment For Radionuclide Ingestion
• Irrigate Nose, Mouth and Pharynx• Remove Gastric Contents• Give Purgative (10gm MgSO4 in 100 ml
water)• Give Chemical Antidote for Blocking,
Diluting or Chelating
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Early Treatment For Contaminated Wounds
• Irrigate Wound – Saline– Water
• Decontaminate Skin (But Do Not Injure)– Detergent
• Continue Wound Irrigation Until Radiation Level Is Zero or Constant
• Treat Wound as Usual– Consider Excision of Embedded Long-
Lived High-Hazard Contaminants
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Pu-Contaminated Lacerations
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Pu-Contaminated Wound Monitoring
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Plutonium in Scar Tissue
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Treatment of Internal Contamination
• Reduce G.I. Absorption• Hasten Excretion• Use Blocking or Diluting Agents When
Appropriate• Use Mobilizing Agents• Use Chelating Agents If Available
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Therapy For Isotope Decorporation• Dilution
– 3H: Water– 32P: Phosphorus (Neutraphos)
• Blocking– 137Cs: Prussian Blue– 131I, 99Tc: KI (Lugol’s)– 90Sr, 85Sr: Na-Alginate (Gaviscon),
Al-Phosphate or Hydroxide Gel (Phosphajel or Amphojel)
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Therapy For Isotope Decorporation (cont.)
Mobilization– 86Rb: Chlorthalidone (Hygroton)Chelation– 252Cf, 242Cm, 241Am, 239Pu, 144Ce, Rare Earths, 143Pm, 140La, 90Y,
65Zn, 46Sc: DTPA – 210Pb: EDTA, Penicillamine – 210Po: Dimercaprol (BAL) – 203Hg, 60Co: Penicillamine
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Prevention of Health Effects inRadionuclide Contamination Event
• Physical:–Shelter–Evacuation
• Biomedical:–Thyroid Blocking–Personal Decontamination–Control of Intake
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Bibliography
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• NCRP Report No. 138. Management of Terrorist Events Involving Radioactivity. National Council on Radiation Protection and Measurements Committee 46-14, John W. Poston, Sr. Chairman; NCRP, Washington, DC, 2001.
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• Advances in the Biosciences: Advances in the Treatment of Radiation Injuries. MacVittie, T.J., Weiss, J.F., and Browne, D., Pergamon Press, New York, 1996.
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