Regional Response to a Distant Radiation Event (or how I learned to love the bomb) Christy Satterlee, CHTC – Manager, Intake for Related and Unrelated Transplants, Seattle Cancer Care Alliance Tamlyn Thomas, RN – Emergency Management Coordinator University of Washington Medical Center May 9, 2012 Objectives - To review and discuss: • The risk • Radiation Basics • Radiation Biology/Acute Radiation Syndrome • Biodosimetry & Treatment • Radiation Injury Treatment Network • Regional Incident Response • Resources Threat Rankings by the U.S. Government 1) 10-Kiloton Improvised Nuclear Device 2) Aerosol Anthrax (intentional) 3) Pandemic Influenza 4) Plague (intentional) 5) Blister Agent (intentional) 6) Toxic Industrial Chemical release 7) Neurotoxin (intentional) 8) Chlorine Tank Explosion 9) Major Earthquake 10) Major Hurricane 11) Radiological Dispersal Devices 12) Improvised Explosive Devices 13) Food Contamination (intentional) 14) Foreign Animal Disease (Hoof and Mouth Disease, Bovine Encephalopathy) 15) Cyber Attack http://media.washingtonpost.com/wpsrv/nation/nationalsecurity/earlywarning/NationalPlanningScenariosApril2005.pdf 4 Scary government chatter I have to read (not recommended for bedtime reading) The Potential is there. Ne’er do-wells have the motive, means and opportunity: • "Nuclear terrorism is the most serious danger the world is facing." —Mohamed ElBaradei (former director of the IAEA and winner of the 2005 Nobel Peace Prize), February 1, 2009 • With 25 kg (55 pounds) of highly enriched uranium, terrorists could make an improvised nuclear device (IND). • To date, the US has lost 11 nuclear weapons … if you find one, please turn it in to the lost and found. 10 kiloton Improvised Nuclear Device detonation - Scenario planning Limited survival due to: 1) Overpressure (blast) 2) Thermal damage 3) Prompt radiation 0.5 mi 9 miles Fallout over 24 hours 1) > 400 REM exposure 2) 202,000 non-fatal casualties (40,000 hospital beds in US) 3) 180,000 fatalities Interpreted from the U.S. National Planning Scenarios found on www.washingtonpost.com 6 Types of Radiation 7 Radioactive Contamination – radioactive materials on or in a person, animal or object • Contaminated individuals are not themselves radioactive. • Internal contamination requires medical intervention. • 80-90% of external contamination can be removed by stripping clothes off. 8 Acute Radiation Syndrome due to exposure to radiation Weeks After Exposure 0 1 2 3 4 5 6 7 8 0 Prodromal Onset of signs of Approximate Radiation dose (Gy) nausea/vomiting hematopoietic injury time of death 2 Mortality GI 0% symptoms 4 50% 6 100% 100% mortality 8 (may be higher dose with HSCT) 10 CNS injury (100% mortality within days) >100 9 Biodosimetry • Definition – Biodosimetry is the use of biological markers to estimate radiation dose. – Dosing after radiological and nuclear events is complicated by a variety of factors, including shielding (presence of an object between victim and radioactive source). • Standard approaches – Assessing the individual for signs and symptoms of exposure, specifically nausea and vomiting. – Following white blood cell counts over time. – Examining lymphocytes (a type of white blood cell) for chromosome changes. 10 Acute Radiation Sickness: Time to vomiting as a marker of dose Time to Emesis Estimated Dose Degree of ARS <10 minutes >8 Gy Lethal 10-30 minutes 6-8 Gy Very Severe <1 hour 4-6 Gy Severe 1-2 hour 2-4 Gy Moderate >2 hour <2 Gy Mild From: CDC Radiological Terrorism Emergency Management Pocket Guide for Clinicians Pocket Guide: www.bt.cdc.gov/radiation/pocket.asp Medical Care After a Radiological Event Affected population • Treat Symptoms, Burns RITN Treatment Support Supportive care Marrow injury • Medicate to stimulate marrow recovery • Potentially irreversible marrow injury Expedited HLA typing • Salvageable & donor search • Minimal combined injury HSCT • Sustained loss of blood cells Hematopoietic Stem Cell • Available donor Transplant • Acceptable pre-transplant condition 12 Medical timeline for victims Symptom onset, duration and treatment • GI symptoms Nausea/ vomiting – Day 1 Diarrhea – Day 5 to 17 • Loss of blood cell counts – white cells, platelets, red blood cells Onset – Day 1 to 3 HLA typing – Day 6 - 8 Transplant – Day 14 - 21 Medical timeline for victims Symptom onset, duration and treatment Treatment other than transplant: • G-CSF to stimulate bone marrow recovery sooner • Prophylactic antibiotics (minimize risk for infection) • Blood component transfusions as indicated, must be irradiated (ironically) and leukocyte reduced • Pain management • Anti-emetics • IV Hydration / TPN • Psychological support • Precautions for immunosuppressed patients Medical timeline for victims • Victims with delayed loss of cell counts until 10+ days can recovery with support only. Lowest levels average days 20-30. • Those victims with complete loss of cell counts by Day 6 require HSCT (Hematopoietic Stem Cell Transplant) to potentially survive. • Indications for HLA typing / transplant: Total body exposure > 3 grey Rapid decline of platelet levels Neutrophil count < 100 by day 6 Expected to survive other injuries HLA matched donor available Medical timeline for victims Limited resources may require selectivity regarding who can receive G-CSF or a stem cell transplant. Factors may include: • Expert opinion from RITN staff as a group • Presence of other wounds or burns • Other pre-existing or confounding disease states • Consideration by local Clinical Decision Committees / Crisis Standards of Care Committees Management of Urgent Donor Searches Capability to match donors w/recipients is remarkable! NMDP-contracted HLA laboratories: – Currently perform 5-6,000 HLA typings weekly but could be increased to more than 10,000 assuming HLA is prioritized over other work. – Data is transmitted directly from the labs to NMDP via Internet. – Use automated matching of adult donors/CBUs (Cord Blood Units) to potential transplant recipients. 17 Radiation Injury Treatment Network (RITN) • 2003 - established through agreement between the U. S. Navy and the NMDP (National Marrow Donor Program). • 2006 - The Seattle Cancer Care Alliance (SCCA) and 12 other founding institutions met to establish policies and procedures for transplant centers in the instance of a radiation accident or attack. Radiation Injury Treatment Network • Goals: – educate hematologists, oncologists, stem cell transplant practitioners and blood centers about their potential involvement in the response to a radiation event – provide treatment expertise in the aftermath of a radiation event • RITN centers are NOT…. – First responders – Victim triage experts – Decontamination specialists 19 Location of RITN Centers 20 Radiation Injury Treatment Network (RITN) In the aftermath of a radiological event, RITN centers may be asked to: – Accept patient transfers to their institutions. – Coordinate with local blood banks. – Provide treatment expertise to practitioners caring for victims both locally and in other regions. – Assist w/coordination of care to victims as technical experts in local government and healthcare coalition Emergency Operation Centers (EOC’s). – Provide technical expertise to local Crisis Standards of Care Committees. – Provide data on victims treated at their centers. 21 National Response • Assumption is that event is remote, not local. • Notification of partners, RITN, etc. through emergency emails. News of Japan nuclear facility disaster prompted RITN and other emergency services to immediately begin discussion of ramifications. • Takes time to gather victims and transport out of effected area ~ 24-96 hours minimum! • Attempts will be made to decontaminate victims. Theoretically no contaminated victims will be transported. • Limited medical care prior to transportation. • We’ll have a relative luxury of time to prepare. Local Response Receiving victims • Arrival may be delayed by days to weeks. • Reception center at receiving airport. • Very short stay at the airport. • Triage critically ill or injured victims directly to hospitals. • Survey for radioactive contamination. • Decontaminate medically stable victims, if needed. • Transport victims to screening site for further medical assessment. Depending on the volume, this may be an Alternate Care Facility. Management of Victims Stable, uninvolved Managed and monitored by outpatient oncologists, clinics, possibly the ACF. Local EOC’s assist with finding housing and meeting basic needs. Red Cross shelters may be activated. All the other needs of dislocated individuals (think Katrina) – family reunification, social work, psychosocial support Management of Victims Stable victims w/inpatient medical needs. • Care for at Alternate Care Facility (ACF) if hospital surge capacity is maxed out. • Provide ongoing monitoring of biodosimetry markers. • Care of associated injuries like small burns, minor injuries as well as side effects. • Activation of ACF requires staff contributions from hospitals and clinics. Management of Victims Unstable victims w/complex inpatient medical needs. • Placed in hospitals. Likely distributed among all hospitals in region. • Medical needs may be pre-existing or event related. • Provide ongoing monitoring of biodosimetry markers. • Assess for further intervention and qualification for medical therapies. Management of Urgent Donor Searches • NMDP-computer systems: – Facilitate contact, communication and coordination with the adult donors/CBU banks – Are available 24x7 to meet the demands of the increased search load • HapLogic uses advanced logic to predict high-resolution matches – Easier identification of donors and/or CBUs most likely to match patients – Reduction in the number of donors called for testing that would be unlikely to match the patient – Faster matches for some patients, which may mean getting to transplant sooner resulting in improved survival 28 Seattle Cancer Care Alliance RITN activation response plan • Activate their Emergency Operations Center and implement Emergency Operations Plan. • Notification and Communication with: Department of Health – state and local Health and Medical Area Command Disaster Medical Control Center (DMCC) NMDP and RITN • Identification of potential logistical problems, including current pharmaceutical stock, patient care supplies as well as laboratory, blood bank, and Intensive Care Unit capabilities. Seattle Cancer Care Alliance RITN activation response plan Assemble and assign additional medical teams to: • Triaging existing transplant patients. • Provide 24/7 expert consultation to medical providers caring for disaster victims. • Establish timelines for HLA typing. • Staff the SCCA clinic 24/7 to assist with evaluation and referral of deteriorating victims. • Assists with staffing the ACF along with other hospitals and clinics. Seattle Cancer Care Alliance RITN activation response plan • Provide screening and monitoring parameters and tools to the medical community. • Provide information to the Joint Information Centers (JICs) for media distribution. • Assists with distribution of the victims. • Conduct Urgent Donor searches through the NMDP. • Coordinates and shares information with other RITN members. • Collaborates with the Puget Sound Blood Center and Harborview Blood Transfusion Program for necessary blood products. Bottom line, you might have an opportunity do more than just text money to a relief organization…. • Working with the RITN folks - our clinics, hospitals, public health departments and all the jurisdictional EOC’s will be critical partners saving lives that may have otherwise been lost. • We hope not, but someday we may be called upon to help victims – unlike other major disasters this century, you will be able to directly make a difference. Resources for further investigation • Incidents: – IAEA nuclear events list: http://www-news.iaea.org/news/ – www.johnstonsarchive.net/nuclear/radevents/index.html • Treatment: – Radiation Injury Treatment Network (RITN): www.RITN.net – Radiation Event Medical Management (REMM): www.remm.nlm.gov – Radiation Emergency Assistance Center/Training Site (REAC/TS): www.orau.gov/reacts – Radiation Countermeasures Center of Research Excellence (RadCCORE): www.radccore.org • Bio-dosimetry & Treatment: – Armed Forces Radiobiology Research Institute (AFRRI): www.afrri.usuhs.mil • Other: – IAEA Library: http://www.iaea.org/DataCenter/Library/catresources.html 33 Biodosimetry Tools • AFRRI Biodosimetry Assessment Tool (BAT) – Downloadable software • Radiation Event Medical Management (REMM) www.remm.nlm.gov – Web-based software – Provides suggested treatments based on estimated dose – Standardized admission and treatment order templates 34 Terrifying actual photo of historic terrorist attempt to H-bomb a US city.
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