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Radiological Terrorism: Medical Response to Mass Casualties Part II. Jeffrey B. Nemhauser, MD Medical Officer Radiation Studies Branch National Center for Environmental Health Centers for Disease Control and Prevention. Triage Key Concepts.

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radiological terrorism medical response to mass casualties part ii

Radiological Terrorism:Medical Response to Mass CasualtiesPart II

Jeffrey B. Nemhauser, MD

Medical Officer

Radiation Studies Branch

National Center for Environmental Health

Centers for Disease Control and Prevention

triage key concepts
TriageKey Concepts
  • Victim categories following radiological/nuclear incident
    • (Possibly) exposed
      • Injured and Uninjured
    • Unexposed
      • Injured and Uninjured
triage key concepts3
TriageKey Concepts
  • Combined Injury
    • Physical, thermal, and/or chemical trauma
    • Radiation exposure in doses sufficient to threaten overall survival / recovery
triage key concepts4
TriageKey Concepts
  • Radiation Exposure (Irradiation)
    • High doses – combined with trauma – can cause serious or life-threatening illness
    • At very high doses, irradiation by itself may cause early, life-threatening adverse health effects
triage key concepts5
TriageKey Concepts
  • Triage during first 24 hours
    • Consider irradiation
    • Treatment decisions based on
      • Adverse Health Effects
        • First 24–48 hours
      • Laboratory Test Results
      • History (medical and exposure)
      • Contamination Assessment
adverse health effects acute radiation syndrome ars
Adverse Health EffectsAcute Radiation Syndrome (ARS)
  • ARS caused by irradiation of whole body or significant portion thereof
  • Adverse health effects
    • Type, severity, and time to onset dependent on radiation dose (i.e., amount of energy deposited in the body)
adverse health effects acute radiation syndrome ars7
Adverse Health EffectsAcute Radiation Syndrome (ARS)
  • Three stages of ARS
    • Prodrome
    • Latent Period
    • Manifest Illness
adverse health effects acute radiation syndrome prodrome
Adverse Health Effects Acute Radiation Syndrome: Prodrome
  • Begins after exposure
  • Lasts 24–48 hours
  • Adverse health effects
    • Nausea/vomiting/diarrhea, fatigue, headache, parotitis, erythema, fever
adverse health effects acute radiation syndrome prodrome9
Adverse Health Effects Acute Radiation Syndrome: Prodrome
  • Prodromal adverse health effects
    • Onset occurs more rapidly with severe ARS than with mild ARS
    • Nausea and vomiting are hallmark
      • Time to emesis may be used as rough estimate of exposure and outcome
adverse health effects acute radiation syndrome prodrome10
Adverse Health Effects Acute Radiation Syndrome: Prodrome
  • Estimation of severity of ARS following a single acute dose exposure
  • Onset of vomiting within 1-2 hours is highly suggestive of a poor prognosis

Source: Berger, et al. [2002]. Hospital Triage in the First 24 Hours After a Nuclear or Radiological

Disaster. REAC/TS Training Site.

adverse health effects acute radiation syndrome prodrome11
Adverse Health Effects Acute Radiation Syndrome: Prodrome

Source: Ann Intern Med [2004] 140(12):1037-1051.

adverse health effects acute radiation syndrome prodrome12
Adverse Health EffectsAcute Radiation Syndrome: Prodrome

Source: Ann Intern Med [2004] 140(12):1037-1051.

laboratory testing acute radiation syndrome prodrome
Laboratory TestingAcute Radiation Syndrome: Prodrome
  • Lymphocytes
    • Highly radiosensitive
    • Progressive decline in absolute lymphocyte counts provides early estimate of injury and outcome
    • Obtain baseline CBC with differential and repeat for 24–48 hrs.

Absolute Lymphocyte Count

Source: Andrews, et al. [1965] Personal Dosimetry for Radiation Accidents. Vienna: International Atomic Energy Agency.

triage combined injury
TriageCombined Injury

*Variability is dependent on the nature and extent of traumatic injury.

Source: Adapted from Ann Intern Med. [2004] 140:1037-1051.

triage wrap up
  • Acute Radiation Syndrome
    • 3 stages – Prodome is triage key
    • Clinical guides to victim triage
      • Time to prodrome onset (vomiting)
      • Total lymphocyte count
    • Combined injury generally means a worse prognosis
radiological terrorism internal contamination
Radiological Terrorism Internal Contamination
  • Time-dependent phenomenon
  • Related to physical properties of isotope
  • Incorporation can occur rapidly
radiological terrorism internal contamination diagnosis
Radiological Terrorism Internal Contamination: Diagnosis
  • Exposure history
    • Potential for inhalation or ingestion
  • Open wounds containing shrapnel
  • Bioassay
    • Complete Blood Count
    • Urinalysis for radiation
radiological terrorism internal contamination treatment
Radiological Terrorism Internal Contamination: Treatment
  • Treatment most effective when administered early
    • Decision to treat may be based on preliminary data
  • Block or decorporate and treat effects of exposure
radiological terrorism internal contamination treatment19
Radiological Terrorism Internal Contamination: Treatment
  • Anti-emetics as necessary
    • Ondansetron, granisetron, or other serotonin receptor antagonists
  • Anti-diarrheals
    • Loperamide hydrochloride, Lonox (diphenoxylate/atropine)
  • Replace fluids and electrolytes as necessary
pharmacotherapy potassium iodide
PharmacotherapyPotassium Iodide
  • IOSAT™; ThyroSafe™; Thyro-Block™
  • ThyroShield™ solution for children
  • Orally administered radioactive iodine blocking agent
  • Prevents radioactive iodine uptake in thyroid gland by competing for binding sites
pharmacotherapy potassium iodide21
PharmacotherapyPotassium Iodide
  • Radioactive iodine release scenarios
    • Nuclear power plant incident
    • Detonation of improvised nuclear device
    • “Dirty bomb” is unlikely source
pharmacotherapy potassium iodide22
PharmacotherapyPotassium Iodide
  • Blockade of radioactive iodine uptake is time-dependent
    • KI is 80% effective at 2 hours post-exposure; 40% effective at 8 hours

Source: Health Physics [2000]. 78(6):660-7.

pharmacotherapy potassium iodide23
PharmacotherapyPotassium Iodide
  • Thyroid of fetus and young children more sensitive to carcinogenic effects of radioiodine
    • Radioiodine uptake inversely proportional to thyroid size
pharmacotherapy potassium iodide24
PharmacotherapyPotassium Iodide
  • Administration guidance available from US Food and Drug Administration (FDA)
  • Guidance based on prevention of thyroid cancer

Source: Potassium Iodide as a Thyroid Blocking Agent in Radiation

Emergencies [2001].

pharmacotherapy prussian blue
PharmacotherapyPrussian Blue
  • Ferric (III) hexacyanoferrate (II) (Radiogardase®)
  • Orally administered decorporation agent (capsules)
  • Promotes fecal excretion of radioactive cesium and thallium
pharmacotherapy prussian blue26
PharmacotherapyPrussian Blue
  • Binds isotopes in gastrointestinal tract via ion-exchange, adsorption, and mechanical trapping; limits entero-hepatic recirculation
  • Does not treat complications of radiation exposure
    • Need concomitant supportive care
pharmacotherapy prussian blue27
PharmacotherapyPrussian Blue
  • Initiate treatment as soon as possible
  • Treat for minimum of 30 days
    • Duration based on level of contamination
  • Additional guidance
pharmacotherapy dtpa
  • Diethylenetriaminepentaacetate
    • Calcium (Ca) and zinc (Zn) salts
    • Intravenous chelating agents for
      • Plutonium, Americium, Curium
    • DO NOT USE for
      • Uranium, Neptunium
pharmacotherapy dtpa29
  • Ca-DTPA
    • Administration within 6 hours of exposure is most effective
    • Initially 10x more effective than Zn-DTPA
      • 24 hours post-exposure Ca-DTPA and Zn-DTPA have equivalent efficacy
    • Causes depletion of zinc and magnesium
pharmacotherapy dtpa30
  • Ca-DTPA contraindications
    • Minors, pregnant women, serious kidney disease, bone marrow suppression
    • Check renal function prior to each administration
pharmacotherapy dtpa31
  • Additional Guidance
pharmacotherapy filgrastim neupogen
PharmacotherapyFilgrastim (Neupogen®)
  • Colony Stimulating Factors (CSF)
    • Endogenous glycoproteins
    • Induce hematopoietic progenitor cells of bone marrow to proliferate and differentiate into specific mature blood cell types
pharmacotherapy filgrastim neupogen33
PharmacotherapyFilgrastim (Neupogen®)
  • Filgrastim [Granulocyte-CSF (G-CSF)]
    • Genetically engineered protein
    • Daily IV or IM administration
    • Minimal effect on hematopoietic cell types other than neutrophil progenitors
pharmacotherapy filgrastim neupogen34
PharmacotherapyFilgrastim (Neupogen®)
  • FDA-approved for treatment of neutropenia resulting from myelosuppressive cancer therapy
  • Not approved for treatment of ARS
    • Used as investigational drug for persons with unintentional radiological exposures
pharmacotherapy filgrastim neupogen35
PharmacotherapyFilgrastim (Neupogen®)
  • Side effects
    • Allergic reactions (< 1 in 4000 patients)
      • Good response to antihistamines, steroids, bronchodilators and/or epinephrine
      • ~50% have recurrence on re-exposure
    • Fatal and non-fatal splenic rupture
    • Severe sickle cell crises in patients with sickle cell disease
pharmacotherapy filgrastim neupogen36
PharmacotherapyFilgrastim (Neupogen®)
  • Additional Guidance
treatment wrap up
  • Pharmacotherapy must be administered quickly after exposure
  • Match the treatment to the exposure
  • Guidance is available from the FDA and CDC concerning appropriate administration