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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. Medical Radiation Problems. External Radiation Source: Local Radiation Injury Acute Radiation Syndrome

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Basics of treatment of victims of radiation terrorism or accidents l.jpg

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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MedicalRadiation Problems

External Radiation Source:

  • Local Radiation Injury

  • Acute Radiation Syndrome

    Radionuclide Contamination:

  • External

  • Localized in Wound

  • Internal


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LOCAL RADIATION INJURY: RADIODERMATITIS

TypeManifestation

IErythema

IITransepidermal Injury

IIIDermal Radionecrosis

IVChronic 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 STAGES

Upper Extremities

Left

Right

4

mo

5

mo

5

mo

5

mo

6

mo

7

mo

7

mo

10

mo

12

mo

17

mo


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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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ProdromalSymptoms & Signs

NeurogenicVascular

Anorexia Conjunctivitis

Nausea Skin Erythema

Vomiting

Diarrhea

Fever

Weakness


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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

EXCITATION

PHASE

38-E


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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

Clinical Management Problems

  • Psychological Stress

  • Infection

    • Bacterial, viral, fungal, CMV, herpes

  • Hemorrhage

  • Radiation Enterocolitis

  • Radiation Pneumonitis

  • Combined Injuries

    • Radiation plus trauma, burns, etc.

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 Pancytopenia

Transfusions:Erythrocytes

Platelets

Growth Factors:GSF, GMCF,

IL2, etc.

Stem Cell Transplants:Autografts

(Marrow, cord, PB)Isografts

Homografts

Xenografts (?)


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Infection Therapy in Radiation Pancytopenia

Some Systemic Agents that have been used:

  • 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

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 - GastrointestinalSyndrome 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


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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


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Internal Exposure Variables

Routes of Entry:

  • Inhalation, Ingestion, Injection and Absorption

    Decay Rates and energies

    Chemical 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 Decontamination

Removal 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

  • The Medical Basis for Radiation-Accident Preparedness: The Clinical Care of Victims. Ricks, R.C., Berger, M.E. and O’Hara, Jr., F.M.,Editors. Parthenon Publishing Group, New York, 2002.

  • Medical Management of Radiation Accidents. Gusev, I.A., Guskova, A.K. and Mettler Jr., F.A., Editors, CRC Press, Boca Raton, FL, 2001.

  • 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.

Medical Effects of Ionizing Radiation. 2nd Edition. Mettler, F.A.Jr, and Upton, A.C., W.B. Saunders, Philadelphia, PA, 1995.

NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides. National Council on Radiation Protection and Measurements Committee, George L. Voelz, Chairman; NCRP, Washington, DC, 1980.


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