American Osteopathic College of Occupational and Preventive

American Osteopathic College of Occupational and Preventive Medicine2013 Mid Year Educational Conference, Phoenix, Arizona

February 14-17, 2013

REAC/TS: Local Radiation InjuryCase Reviews

Doran M. Christensen DO

REAC/TS Associate Director/Staff Physician

Radiation Emergency Assistance Center/Training Site (REAC/TS)

Oak Ridge Institute for Science and Education (ORISE)

U.S. Department of Energy (DOE)

24/7 Emergency Phone 865-576-1005

[email protected]

1

Terminal Objective

Review of recent cases to illustratesigns/symptoms, clinical dose

estimation, andevaluation/treatment of local

radiation injury

2

Approximate Surface Dose fromCommon Gamma Emitters

3

rad/min per Ci Sv/min per GBq

137Cs 770 0.21

192Ir 1200 0.32

60Co 3100 0.84

External Dose ThresholdsDeterministic Effects for Skin

4

Dose [rads] Sign Timing

300 Epilation Begins around day 17

600 ErythemaInitial - minutes

thereafter depends upon

dose

1,000–1,500 Dry desquamation2-3 weeks post-

exposure, dependingupon dose

1,500-2,000 Moist desquamation2-3 weeks post-

exposure, depending

upon dose

>2,500-3,000 Ulceration and necrosis > 21 days

Case ReviewSao Paolo, Brazil

21 July 2008REAC/TS Case #2429

5

The Case

6

A teletherapy engineer was changing out a1400 Ci cobalt-60 source for a 6500 Cisource

Using a tool to place the source in theshielded casque, placed his left hand in frontof the shielding on the tool

Had ? seconds of exposure

A-1



The Case

7

Blood count drawn in Brazil - normal

On return to the U.S., dosimeters on wristsdeveloped - 73 rem at wrist

Videotape reenactments led to estimateddose of 600-700 rad to the finger

Clinically, the dose estimate was different

Minor Re-injury - July 2010

8

Pet dog ran out the door brushing leashagainst the original site of injury

Within days, began again with the sameprogression of lesions as occurred in 2008

Same treatment as before plus hyperbaricoxygen therapy (HBOT) - total 80

3 Nov 2010

9

Repair of Linear AcceleratorSeptember 2000

10

Maryland

September 2001

REAC/TS Case #2065

11

Industrial RadiographyEquipment

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Approximate Surface Dose fromCommon Gamma Emitters

13

rad/min per Ci Sv/min per GBq

137Cs 770 0.21

192Ir 1200 0.32

60Co 3100 0.84

Taipei, Taiwan

April 2008

Fluoroscopy for CardiacIntervention

REAC/TS Case #2440

14

Patient D 56YO male

3 PPD smoker X 20Y

Known CAD with 3 MIs previouslywith 1 stent placed

Known DM non-insulin dependent

SCUBA diving in Thailand October2007

15

Patient D

En route back to the US with chestpain

In-flight diversion to Taipei, Taiwan

Had fluoroscopy and stent placementin Taiwan and returns to the US

For unknown reasons, he decides toreturn to Taiwan in April 2008 for“new technique” for stent placement

16

Patient D

In Taiwan:

Stent placed under fluoroscopy fortotal time of 5 hours

Total Dose to back etimated : 40 –50 Gray

17

18

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19

Thermography - Normal Subject

20

21

Patient P

64 year old white female

CC: painful, non-healing wound

SHx: Former secretary in Rad Onc Dept

PMHx: Lupus

Reason for Consult: Patient has exhaustedoptions from 2 major academic medicalcenters without improvement

22

Patient P

HPI

2000-2001:

Bilateral lower extremity weakness withabnormal signal in spinal cord on MRI

10Aug04:

1st angiogram (diagnostic), identified AVfistula off Right L-1 radicular artery

23

Patient P

20Aug04: 2nd angiogram with attemptedembolization; 72.1 min fluoro

25Oct04: 3rd angiogram 46.6 min fluoro

Oct04: laminectomy T12-L2 with resectionL-1 AVM

• Post-op infection / debridement

• Onset of pruritis, “burning” erythema,blisters

24

A-4



Patient P

Oct 04:

PCM rx’d Silvadene, triamcinolone, OTCanti-fungals

July 05:

Saw plastic surgery - had debridement of2 x 1 cm full thickness ulceration and skinnecrosis

Treated with Bactroban, Silvadene

25

Patient PNov 05:

Vascular medicine consult –“maculopapular rash over mid-inferiorlateral right thorax”

Dec 05:

Derm consult – 12 x 9 cm “reticulateerythema on right side w/ central 1.6 cmscabbed area”, with pruritis; given topicalanti-pruritic lotion

26

Patient P

Mar 06:

Rheumatology commented “chronicreddish discoloration of right flank”

Jul 07:

Moved to new area - dermatology didpunch biopsy with diagnosis of “sclerosingdermatitis…findings consistent withmorphea or radiation dermatitis”

27

Patient P

Jul 07: (cont.)

Called REAC/TS – referred to majoracademic center Rad Onc Dept withfollowing treatment recommendations:

• Trental 400mg TID and Vitamin E 2000IU qday

• HBO - was prescribed 30-60 tx at 2ATA for 2hrs

28

Patient PDec 09:

Plastics at new academic med center -described wound as “2cm, superficial andexudative”, and very tender to touch

• Began wet-to-moist dressing changesBID

Jan-Feb 10:

• 3 Gamma Graft™ applied with slightimprovement

29

Patient P

Jul 10: Seen at REAC/TS

Physical exam, skin:

Right hip / flank with 11 x 11 cm area oferythema with a faint outer ring withcentral ring of intense erythema

Central ulceration, 1 x 1 cm with slightserous discharge and pale-yellowcoloration; exquisitely tender to touch;increased heat over central area

30

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Patient P

Skin exam continued:

Midline, vertical thoracolumbar scarringwith retraction, dimpling with proximaltelangiectasias

31

Ultrasound Analysis

32

33

Summary and Questions

Difficult to diagnose

Dose estimation is always imprecise

Management is fraught with issues

Long-term psychological/disability issues

34

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Case Study: 250 kVp X-ray

Injury to the Hand

1. Understand rationale for initial & f/u testing.

2. Understand the importance of a more detailedoccupational history.

3. Understand the acute & chronic health effectsfrom ionizing radiation.

4. Able to develop appropriate RTW instructions.

October 5, 2011 – Initial Presentation

BG a 31 yo wm presented to MVH-ED after an acutex-ray exposure reporting it was localized to the headfor screening laboratories and evaluation.

Initially Reported Exposure 150 rads for 24 seconds

C/O: mild HA, face feels hot

ROS: Negative

PMH: LBP, HA, SOB, Heartburn, Snoring

FMH: None Pertinent

Initial Presentation at MVH-ED (cont.)

SH: 1ppd x 10 yrs., ETOH, Married & SexuallyActive, No Drug Use

SMH: No pertinent surgeries

Current Meds: Nicotine Transdermal Patches21mg/24h

No Reported Allergies

Initial Presentation at MVH-ED (cont.)

Physical Examination: VS: BP: 137/83, P: 86, Resp.: 18, T: 99.2 oF, Ht.: 6’1”,

Wt.: 210 lb., BMI: 27.71 kg/m2, SpO2: 100%

Constitutional: A&O, non-toxic

Skin: Warm & Dry

HEENT: Nl. No evidence of redness or burns

Initial Presentation MVH-ED (cont.)

Physical Examination (cont.) Maxilofacial: No obvious redness or burns

Lymp: No significant adenopathy noted

Neck: Negative

CV: Negative

Lungs/Chest: Negative

Abdominal: Negative

Neurologic: A&Ox3, non-focal

E. Robert Wanat, II, DO, MPH, FAOCOPM

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Initial Presentation MVH-ED (cont.)

Medical Decision Making:

What would you do?

What The Emergency Department Did:

Called Poison Control

Recommended Blood Work

Ordered:

CBC

Amylase

Other lab recommendations not available

Results: Normal

Medical Decision Making (cont.)

Disposition:

d/c home

Return to ED if further problems

Seen at OM clinic in 1 – 2 days

Do You Agree With ED Decision Making?

HPI on 10/17/11 [12 days post expos.]: Worker x-rays parts for defects

Handed co-worker x-ray cassette & co-worker leftthe x-ray room closing the door, loading the cassette,then activated the x-ray machine while IW wassetting up part to be x-rayed

Est. exposure: 24 seconds @ 140 kV & 10mA

Exposure Badge [issued 10/1/11]: 150 mREM

1st went to company Rad. Safety Officer, then seen atMVH-ED w/in 6 h. of exposure

HPI:

CBC w/ Diff: reported as normal

Hx. not provided to ED

Right Hand was contacting or w/in 12” of x-ray source.Head was also closer than rest of body.

What other history would you like to know?

What Effects Would You Expect? Acute Radiation Syndrome [ARS] Varies with Dose & Area Exposed

Acute effects rarely seen below 100 rems

LD50 ~ 400 rems

5000+ rems: onset of ARS ~ 30 min Uniformly Fatal, usually w/in hours

Chronic Carcinogenic Potential

Genetic Defects

A-8



Physical Examination 10/17/11

12 Days Post-Exposure

VS: BP 112/84 P: 84 R: 12 T: 98.7oF H: 72.5” Wt. 214#

Pad Rt. Thumb: 2 x 2.5 cm area w/ ecchymotic look

Texture: rough and callused feel

Assessment:

3rd degree burn 2o acute radiation exposure

Ecchymosis felt to be due to vascular damage

What would you want to do now?

What would you want to discuss with IW?

When would you see this patient back?

Physical Examination: 10/19/11 [day 14]

Remembered holding line of plumb w/ thumbtouching x-ray tube

c/o altered sensation in Rt. Thumb

Mild – Moderate Constant Tingling & Burning

Appearance:

Ecchymosis

Swelling

Increased pain

Lab: Hgb. mildly elevated @ 17.4 [13.2 – 17.1]



Intrim History: 10/24/11 [day 19]

Employer [Rad Safety Officer consulted w/ Dr. DoranChristensen @ Oak Ridge Institute of Science andEducation [ORISE]

Employer Exposure est.: 200 – 1000 REM

Physical Examination:

Status: worse – more swelling, blistering & thickening ofthe skin

sharp pain if bumped & constant throbbing pain.

Pain varied from mild to severe

Redness, Swelling & Increased Pain

Put on modified work duty

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Intrim History 10/28/11 [23 days]

Dull throbbing pain, itching, sharp with pressure

Minimal severity of pain

Physical Examination

3.5 x 2.25 cm calloused yellow/white appearing skin w/fluid along edges.

Skin erythematous proximal to primary lesion w/erythema extending to dorsal aspect of distal phalanxproximal to nail and ecchymosis proximal aspect of nail

No skin breakdown or desquamation

Hgb 17.3 g/dl [13.2 – 17.1 g/dl] 10/24/11 results

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Medications:

Prednisone 5 mg – 8 day taper

Trental [pentoxifylline] 400mg TID

Betamethasone diproprionate 0.05% Oint.

Vit. E w/ aloe vera lotion

ORISE Initial Findings & Recommendations

Considerable edema in subcutaneous tissue

Erythema is new – increases concern for extension

Discussed need for SQ oxygenation

Course uncertain – very susceptible to trauma

ORISE Recommendations

Allegra 60 mg 1 – 2 x/day

Vit. E 400 IU TID

Naproxen 500 mg BID

Prednisone 10 mg x 10 days

Hyperbaric Oxygen Tx

Follow with monthly CBC w/ diff

Return to ORISE in 1 mo., sooner if worsens

Schedule H’baric Eval & Tx with Dr. Pilati

Monday 10/31/11 @ WPAFB

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History & Systems review 10/31/11

No change in medical history – neg. for DM & CVD

Social Hx: remarkable for 1ppd on Nicoderm patches

ROS: neg. for +/- Wt., GI sx. Other ROS also neg.


VS – normal

Wound right thumb w/ intact blister

Care

Start HBOT 90 minutes O2 x 20 tx.

Took down blister & start Silvadene cream


Occasional Minimal pain, dull & throbbing worse ifbumps thumb

Dr. Pilati debrided area and hyperbaric tx. started

Dr. Pilati Rx’ed Silvadine cream


4 x 3 cm calloused area underlying tissue appeared pinkand healthy

CBC w/ differential – normal [10/28/11 results

Treatment

Cleansed and did further debridement

Continued current medications


Reports doing better, occasional minimal sharp –dull pain

Completed 13 of 20 approved hyperbaric tx.

Physical Examination Erythema, ecchymosis and swelling have improved

Hgb, Hct & Absolute Neutrophils elevated from11/7/11 visit (17.5 [13.2 – 17.1 g/dl] 50.7 [38.5 –50.0%] 7939 [1500 – 7800 cells/uL])

Treatment

Cont. Naproxen, Trental, Vit. E and Silvadine

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Minimal pain if bumps or overuse

Completed initial Hyperbaric tx. & Prednisone

Cont. Naproxen, betamethasone, Trental, silvadine,Vit. E

REACTS update 11/30/11

Doing Well

Verified ↓ capillary refill & temp. [2½o C diff.]

Inflammation of IP joint, improved temp in thenar

Est. Exposure: 2500 Gy. (Rad) based on nail clippings

Reconstruction Est. 1400 – 3000 Gy. (Rad)

What were REACTS medical carerecommendations?

What were REACTS Return to Work [RTW]recommendations?

REACTS Recommendations:

20 – 40 more Hyperbaric treatments

Cont. anti-inflammatories, anti-oxidants & Trental

RTW: No forceful gripping or friction, Avoid temp.extremes, Bulky dressing


Central area of burn has re-epithealialized but stillwhite in appearance

Dusky purple under nail

12/1/11 CBC w/ differential - normal

Care provided:

Refilled: naproxen, Trental, betamethasone oint. &

Continue Vit. E 400 IU TID & lotion locally

Stop Silvadine

Re-check in 2 weeks

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Minimal/no pain unless bumped

Re-started Hyperbaric Oxygen tx.


Ecchymosis under nail

Erythema volar aspect of distal phalanyx

Indurated @ tip of distal phalanyx

Care

d/c’ed naproxen 2o GI c/o, trial Volterin XR, cont.betamethasone oint., Vit. E oral & topical


Sore with pinch grip

Saw Dr. Christensen @ REACTS 2/15/12

↓ micro-circulation based on thermography

Not @ MMI for up to 2 years

No additional benefit from more Hyperbaric tx.


Erythema volar aspect distal phalanyx

Mild atrophy [4 mm smaller]

Care:

d/c Volterin XR 2o to dyspnea

Cont. Trental 400 mg TID and Vit. E

A-14




No pain or significant changes

Cont. to use Trental, Vit E. 400 IU TID & lotion

Notes decreased dryness

Reports good capillary refill esp. w/ hot shower


Atrophy and ridge on nail growing out

Care

Cont. oral & topical meds

Cont. work restrictions/precautions


Moderate sharp pain if bumped

Discoloration @ tip

Sensitive to temperature and friction

Avoids twisting [e.g. bottle tops]


Hypopigmented & indurated area @ lateral aspect tip ofdistal phalanx just under nail edge

Slight atrophy

Care

Refill Trental 400 mg TID x 3 months

Follow-up in 3 months – transferred care to UWV

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