Radiation Injury and Treatment Network by WNFT9h

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									   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

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Types of Radiation




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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.




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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
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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.
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  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.
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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
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     Location of RITN Centers




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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.

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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

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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


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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

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Terrifying actual photo of historic terrorist attempt
to H-bomb a US city.

								
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