Basics of Treatment of Victims of Radiation Terrorism or Accidents Niel Wald, M.D. Dept. of...
-
Upload
jerome-anthony -
Category
Documents
-
view
213 -
download
0
Transcript of Basics of Treatment of Victims of Radiation Terrorism or Accidents Niel Wald, M.D. Dept. of...
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
Radionuclide Contamination:–External–Localized in Wound–Internal
LOCAL RADIATION INJURY: RADIODERMATITIS
Type Manifestation
I Erythema
II Transepidermal Injury
III Dermal Radionecrosis
IV Chronic Radiodermatitis
Local Injury: Transepidermal (Beta Radiation + Thermal Burns)
Local Radiation Injury PXD14
Local Radiation Injury PXD 22
Local Radiation Injury PXD 90
Local Radiation Injury Therapy
AMPUTATION STAGES
Upper Extremities
5mo
4mo
5mo 6
mo
5mo7
mo
7mo
10mo
17mo
12mo
RightLeft
Arteriole (post-irradiation)
Local Radiation Injury PXD22
Local Radiation Injury PXD 29
Local Radiation Injury PXD 92
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.
.
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
Local Radiation Injury Therapy• Analgesics, Antipruritics• Anti-inflammatories• Antibiotics as needed • Skin Growth Factors• Synthetic Occlusive Dressings• Surgical Intervention:
–Debridement–Excision and Grafting–Amputation
Diagnostic X-Ray Injury
Diagnostic X-ray Injury: Repaired
Acute Radiation Syndromes and Their Management
• Key underlying pathophysiology at the
cell and organ level
• Description of syndromes
• Diagnostic procedures
• Clinical care
589-1
Acute Radiation Syndromes• Underlying Cellular Radiation Effects
–Mitotic inhibition–Cell killing–Organ malfunction–Vascular reactions
• Clinical Manifestations–Hematological–Gastrointestinal–Neurovascular–Pulmonary
Three Stage Kinetic Model
Prodromal Symptoms & Signs
Neurogenic VascularAnorexia ConjunctivitisNausea Skin ErythemaVomitingDiarrhea FeverWeakness
Radiation Erythema (PXD 10)
Radiation Epilation (PXD 23)
ARS: 45 Days post-Epilation
ARS: Hematopoietic Form
38-C
ARS: Hematologic Course
Hematopoietic Syndrome Systemic Effects
• Immunodysfunction–Increased Infectious
Complications• Hemorrhage
–Anemia• Impaired Wound Healing
ARS: Gastrointestinal Form
38-D
Mechanism of GI Syndrome(Gunter-Smith Hypothesis)
627-1
GI Syndrome Systemic Effects • Malabsorption• Ileus
–Vomiting–Abdominal distention
• Fluid and Electrolyte Shifts–Dehydration–Acute renal failure–Cardiovascular
• GI Bleeding• Sepsis
ARS: Neurovascular Form
38-E
EXCITATIONPHASE
Autonomic Nervous System
49-B
HYPOTHALAMIC SYSTEM
322-1
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
ARS- Pulmonary Form (pre-exposure)
ARS- Pulmonary Form (exudative stage)
ARS- Pulmonary Form (fibrotic stage)
Pulmonary Syndrome Systemic Effects • Early Phase
–Dyspnea–Cough–Pulmonary Edema –Acute Respiratory Distress Syndrome
• Late Phase–Interstitial Fibrosis–Interstitial Pneumonitis–Chronic Respiratory Distress Syndrome
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
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
General Treatment Plan (cont.)
• Maintain Hydration and Nutrition– Fluids– Electrolytes– Nutrients
• Encourage Cell Renewal– Growth Factors– Stem Cells
• Control Inflammatory Response– Steroids– Vasodilators
Psychological Stress Reducers
• One Responsible Decision-Maker
• Realistic Appraisal of Problem and Clear Communication
• Credible Action Plan and Adequate Resources
• Pre-Emergency Education
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
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
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
Environmental Control in Radiation Pancytopenia
• Air Filtration and Positive Pressure
• Reverse Isolation Procedures
• Dietary Considerations
• Special Precautions for Skin Punctures
• Limitation of Attending Personnel
ARS: Environmental Control
Bedside Debriding of Local Radiation Injury
Preparation For Hematologic Complications In Radiation Pancytopenia
Transfusions: ErythrocytesPlatelets
Growth Factors: GSF, GMCF,IL2, etc.
Stem Cell Transplants: Autografts(Marrow, cord, PB) Isografts
HomograftsXenografts (?)
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
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
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
ARS: Hematologic Response to Stem Cells
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
ARS: Current Treatment Challenge -Pulmonary
679-8
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
ARS: General Therapeutic Approach
• Provide Psychological Support• Use Symptomatic Treatment• Prevent Infection and Hemorrhage • Maintain Hydration and Nutrition• Encourage Cell Renewal• Control Inflammatory Response
ARS: Therapy Summary
583-7
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
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
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
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
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
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
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
Pu-Contaminated Lacerations
Pu-Contaminated Wound Monitoring
Plutonium in Scar Tissue
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
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)
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
Prevention of Health Effects inRadionuclide Contamination Event
• Physical:–Shelter–Evacuation
• Biomedical:–Thyroid Blocking–Personal Decontamination–Control of Intake
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.
• 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.