A New Paradigm and Protocol for Use A New Paradigm and Protocol for Use of the CDG to Enable Local Health of the CDG to Enable Local Health Care Professionals to Participate in Care Professionals to Participate in the Medical Management of the the Medical Management of the Stochastic Risks Associated with Stochastic Risks Associated with Internal Contamination ,Following Internal Contamination ,Following Radiological Mass Casualty Scenarios Radiological Mass Casualty Scenarios Albert L. Wiley, BNE, MD, PhD, FACR REAC/TS and WHO Collaborating Ctr. At Oak Ridge Emeritus Professor, Human Oncology, Univ. of Wisc.-Madison [email protected]U.S. Department of Energy (DOE)
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A New Paradigm and Protocol for A New Paradigm and Protocol for Use of the CDG to Enable Local Use of the CDG to Enable Local
Health Care Professionals to Health Care Professionals to Participate in the Medical Participate in the Medical
Management of the Stochastic Management of the Stochastic Risks Associated with Internal Risks Associated with Internal
Contamination ,Following Contamination ,Following Radiological Mass Casualty Radiological Mass Casualty
ScenariosScenariosAlbert L. Wiley, BNE, MD, PhD, FACR
REAC/TS and WHO Collaborating Ctr. At Oak RidgeEmeritus Professor, Human Oncology, Univ. of Wisc.-
Example: Inhalation of Cs-Example: Inhalation of Cs-137(There are worried populations, 137(There are worried populations,
“in” and “out” of the plume !) “in” and “out” of the plume !)
Collect Samples from:Collect Samples from:
Nose Mouth Wounds Also: Baseline
urine, then 24-hour samples of urine and feces
Medical Countermeasures Medical Countermeasures Are Generally Element SpecificAre Generally Element Specific
Nuclide Medication Comments
Am-241 Ca and Zn DTPA by IV, aerosol,?IM
Clelation,Works on liver even after long deposition
Cf-252 Ca and Zn DTPA
Cs-137 Prussian Blue Binds Cs,hepato-enteric cycle
Co-60 penicillamine Gastric lavage,?DTPA
Fission Products Depends on mixture Spectroscopic identificationnuclides isotope,specific RX
H-3 Forced H2O Isotopic dilution
I-131 KI or SSKI Give in first 1-6 hours
P-32 Phosphates Isotopic dilution
Pu-239 Ca and Zn DTPA EDTA less effective
Sr-89/90 Sr,Ca gluconate,iv Consider alginates
The goal is to reduce the stochastic and the deterministic risks by
averting ,as much as possible, the committed radiation dose(CED) from internalized radionuclides by use of
medical countermeasures. Generally, reduction of the stochastic risk is the
primary and possibly only risk of concern. But ,in some scenarios, such as the Goiania and London
Po210 incidents, death can rarely occur from internal contamination.
The Goiania and Po-210 Incidents The Goiania and Po-210 Incidents ( where many thousands of people ( where many thousands of people
insisted on being monitored promptly insisted on being monitored promptly for internal contamination) for internal contamination)
demonstrate the need for the CDG in demonstrate the need for the CDG in altering/supplementing our current US altering/supplementing our current US medical emergency response plans to medical emergency response plans to
with a new paradign ,because with a new paradign ,because
-current US mass casualty medical -current US mass casualty medical emergency response plans direct emergency response plans direct
people to reception centers ; but, past people to reception centers ; but, past experience from such incidents experience from such incidents
confirms that probably most people confirms that probably most people will instead seek their medical will instead seek their medical
management from their personal, local management from their personal, local providers (most of whom have No providers (most of whom have No
Knowledge of radiological issues, and Knowledge of radiological issues, and there will be no time to train them !) there will be no time to train them !)
Accordingly ,in order to deal with this Accordingly ,in order to deal with this situation, a new paradigm is now situation, a new paradigm is now
proposed. Specifically , emergency proposed. Specifically , emergency planners should understand that there planners should understand that there is neither the time nor the logistics in is neither the time nor the logistics in
the US to deliver sufficient the US to deliver sufficient radiological training to the many radiological training to the many
hundreds of local providers who will hundreds of local providers who will surely be called upon by their patients surely be called upon by their patients to manage the possibility of their IC.to manage the possibility of their IC.
Purpose of CDG(NCRP 161) The Clinical Decision Guide(CDG) may
be used to simplify for general health care professionals the emergency triage and the medical management of inhalation or ingestion of intakes of specific radionuclides ( i.e., to expedite the decision on whether decorporation drug therapy is needed or not ,and to monitor the response to such therapy).
CDG = the maximum, once-in-a-lifetime intake of a CDG = the maximum, once-in-a-lifetime intake of a radionuclide that represents:radionuclide that represents:
““Stochastic risk, as judged by the calculated Stochastic risk, as judged by the calculated ED over 50Y for intake by adults and to age ED over 50Y for intake by adults and to age 70Y for intake by children, that is in the range 70Y for intake by children, that is in the range of risks associated with guidance on dose of risks associated with guidance on dose limits for emergency situations (DOE, 2008a; limits for emergency situations (DOE, 2008a; FEMA, 2008; ICRP, 1991a; NCRP, 1993; FEMA, 2008; ICRP, 1991a; NCRP, 1993; 2005a)”2005a)”
Clinical Decision Guidelines (CDG)Clinical Decision Guidelines (CDG)CDG = the maximum, once-in-a-lifetime intake of a CDG = the maximum, once-in-a-lifetime intake of a
radionuclide that represents:radionuclide that represents:
““Avoidance of deterministic effects as judged Avoidance of deterministic effects as judged by the calculated 30d RBE-weighted absorbed by the calculated 30d RBE-weighted absorbed doses to red marrow and lungs, with doses to red marrow and lungs, with allowance for the significant uncertainties allowance for the significant uncertainties often involved in an initial evaluation of the often involved in an initial evaluation of the chemical and physical form of a radionuclide chemical and physical form of a radionuclide and the level of activity taken into the body and the level of activity taken into the body during an incident.”during an incident.”
This table can easily be simplified by asking those laboratories which are providing the 24 hr. urine analysis results to report to the health care provider who ordered the test results in intake units of CDG(rather than dpm/24 hr collection). Therefore ,any CDG value by definition above “1” CDG will prompt and facilitate the clinician in making triage and treatment decisions .
In the US one can expect that there will In the US one can expect that there will be many thousands of worried people be many thousands of worried people
in the region of any radiological in the region of any radiological dispersal incident ;and , (as local dispersal incident ;and , (as local
physicians ,and we at REAC/TS often physicians ,and we at REAC/TS often heard during the Po-210 , the heard during the Po-210 , the
Fukushima and other incidents) they Fukushima and other incidents) they will say : “Prove to me that I am not will say : “Prove to me that I am not
contaminated –and ,if I am contaminated –and ,if I am contaminated , I want treatment now !)contaminated , I want treatment now !)
In lieu of trying to provide emergency In lieu of trying to provide emergency training of hundreds of providers on training of hundreds of providers on radiological training in the area of a radiological training in the area of a radiological dispersal incident ,it is radiological dispersal incident ,it is proposed that the necessity for the proposed that the necessity for the training of and understanding of training of and understanding of
radiological issues and terminology radiological issues and terminology can be eliminated by use of the CDG.can be eliminated by use of the CDG.
Specifically, clinicians generally Specifically, clinicians generally manage medical, conditions in their manage medical, conditions in their
patients by the use of laboratory tests patients by the use of laboratory tests which involve changes in simple which involve changes in simple
numbers –i.e., as with the PSA test , an numbers –i.e., as with the PSA test , an increase from “4” to “10” prompts a increase from “4” to “10” prompts a
medical treatment decision . medical treatment decision . Use of the CDG is similar. It simplifies Use of the CDG is similar. It simplifies medical management by use of simple, medical management by use of simple,
