Basics of Treatment of Victims of Radiation Terrorism or Accidents - PowerPoint PPT Presentation

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Basics of Treatment of Victims of Radiation Terrorism or Accidents

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  1. Basics of Treatment of Victims of Radiation Terrorism or Accidents Niel Wald, M.D. Dept. of Environmental and Occupational Health University of Pittsburgh

  2. MedicalRadiation Problems External Radiation Source: • Local Radiation Injury • Acute Radiation Syndrome Radionuclide Contamination: • External • Localized in Wound • Internal

  3. LOCAL RADIATION INJURY: RADIODERMATITIS TypeManifestation I Erythema II Transepidermal Injury III Dermal Radionecrosis IV Chronic Radiodermatitis

  4. Local Injury: Transepidermal (Beta Radiation + Thermal Burns)

  5. Local Radiation Injury PXD14

  6. Local Radiation Injury PXD 22

  7. Local Radiation Injury PXD 90

  8. 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

  9. Arteriole (post-irradiation)

  10. Local Radiation Injury PXD22

  11. Local Radiation Injury PXD 29

  12. Local Radiation Injury PXD 92

  13. 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. .

  14. 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

  15. Local Radiation Injury Therapy • Analgesics, Antipruritics • Anti-inflammatories • Antibiotics as needed • Skin Growth Factors • Synthetic Occlusive Dressings • Surgical Intervention: • Debridement • Excision and Grafting • Amputation

  16. Diagnostic X-Ray Injury

  17. Diagnostic X-ray Injury: Repaired

  18. Acute Radiation Syndromes and Their Management • Key underlying pathophysiology at the cell and organ level • Description of syndromes • Diagnostic procedures • Clinical care 589-1

  19. Acute Radiation Syndromes • Underlying Cellular Radiation Effects • Mitotic inhibition • Cell killing • Organ malfunction • Vascular reactions • Clinical Manifestations • Hematological • Gastrointestinal • Neurovascular • Pulmonary

  20. Three Stage Kinetic Model

  21. ProdromalSymptoms & Signs NeurogenicVascular Anorexia Conjunctivitis Nausea Skin Erythema Vomiting Diarrhea Fever Weakness

  22. Radiation Erythema (PXD 10)

  23. Radiation Epilation (PXD 23)

  24. ARS: 45 Days post-Epilation

  25. ARS: Hematopoietic Form 38-C

  26. ARS: Hematologic Course

  27. Hematopoietic Syndrome Systemic Effects • Immunodysfunction • Increased Infectious Complications • Hemorrhage • Anemia • Impaired Wound Healing

  28. ARS: Gastrointestinal Form 38-D

  29. Mechanism of GI Syndrome(Gunter-Smith Hypothesis) 627-1

  30. GI Syndrome Systemic Effects • Malabsorption • Ileus • Vomiting • Abdominal distention • Fluid and Electrolyte Shifts • Dehydration • Acute renal failure • Cardiovascular • GI Bleeding • Sepsis

  31. ARS: Neurovascular Form EXCITATION PHASE 38-E

  32. Autonomic Nervous System 49-B

  33. HYPOTHALAMIC SYSTEM 322-1

  34. 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

  35. ARS- Pulmonary Form (pre-exposure)

  36. ARS- Pulmonary Form (exudative stage)

  37. ARS- Pulmonary Form (fibrotic stage)

  38. Pulmonary Syndrome Systemic Effects • Early Phase • Dyspnea • Cough • Pulmonary Edema • Acute Respiratory Distress Syndrome • Late Phase • Interstitial Fibrosis • Interstitial Pneumonitis • Chronic Respiratory Distress Syndrome

  39. 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

  40. 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

  41. General Treatment Plan (cont.) • Maintain Hydration and Nutrition • Fluids • Electrolytes • Nutrients • Encourage Cell Renewal • Growth Factors • Stem Cells • Control Inflammatory Response • Steroids • Vasodilators

  42. Psychological Stress Reducers • One Responsible Decision-Maker • Realistic Appraisal of Problem and Clear Communication • Credible Action Plan and Adequate Resources • Pre-Emergency Education

  43. 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

  44. 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

  45. 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

  46. Environmental Control in Radiation Pancytopenia • Air Filtration and Positive Pressure • Reverse Isolation Procedures • Dietary Considerations • Special Precautions for Skin Punctures • Limitation of Attending Personnel

  47. ARS: Environmental Control

  48. Bedside Debriding of Local Radiation Injury

  49. 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 (?)

  50. 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