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Basics of Treatment of Victims of Radiation Terrorism or Accidents

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

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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
  51. 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
  52. 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
  53. ARS: Hematologic Response to Stem Cells
  54. 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
  55. ARS: Current Treatment Challenge -Pulmonary 679-8
  56. Combined Injury: A-Bomb Patients 402-5
  57. ARS: General Therapeutic Approach Provide Psychological Support Use Symptomatic Treatment Prevent Infection and Hemorrhage Maintain Hydration and Nutrition Encourage Cell Renewal Control Inflammatory Response
  58. ARS: Therapy Summary 583-7
  59. Radiation Accident Management
  60. 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
  61. 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
  62. 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
  63. 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
  64. 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
  65. 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
  66. Pu-Contaminated Lacerations
  67. Pu-Contaminated Wound Monitoring
  68. Plutonium in Scar Tissue
  69. 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
  70. 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)
  71. 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
  72. Prevention of Health Effects inRadionuclide Contamination Event Physical: Shelter Evacuation Biomedical: Thyroid Blocking Personal Decontamination Control of Intake
  73. 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.
  74. 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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