Yttrium, Radioactive

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF TOXICITY
    • 1) Stabilize all patients from their traumatic injuries prior to evaluating them for radiation injuries. Although high intensity external radiation can cause tissue damage (eg, skin burns or marrow depression), it does not make the patient radioactive. However, all staff should be in scrubs covered with a water resistant gown or a Tyvek
  • (R) suit. A cap, mask, and shoe covers should be worn, and 2 pairs of plastic gloves worn with the first pair taped to the gown or suit. Dosimeters should be worn at the collar but under the protective clothing.
    • 2) External decontamination should be performed, which is largely accomplished by removing and bagging the clothing, and washing the skin with warm water and soap. The history obtained at the scene is of great importance. The exact type of exposure (ie, internal versus external and partial versus whole body exposure) should be obtained. The main goals of therapy for acute radiation syndrome are prevention of neutropenia and sepsis. Examine the patient and repeat at 6 hours and 12 hours. Monitor vital signs, including temperature; the sooner the temperature rises, the greater the dose received. Trauma or other urgent medical or surgical situations should be managed prior to treatment for radiation exposure.
    • 3) INGESTION: Patients who ingested any radioactive matter should receive aluminum hydroxide or magnesium carbonate antacids to reduce absorption. Treat patients with persistent nausea and vomiting with granisetron or ondansetron. Early oral feedings are recommended to maintain gut function. All emesis should be collected for the first few days, saving for later analysis. Antidiarrheals may be used to control diarrhea. Internal contamination may require treatment with radiation countermeasure agents such as potassium iodide (radioactive iodine exposure), prussian blue (cesium and thallium exposure), or chelating agents (plutonium, americium, curium exposure). However, these agents do not protect against external radiation absorption and acute radiation syndrome.
    • 4) Colony-stimulating factor treatment should begin within 24 to 72 hours of exposure when granulocyte levels are falling, with daily therapy continued until the absolute neutrophil count increases to more than 1000 cells/mm(3). Patients who develop infection without neutropenia should have antibiotic therapy directed towards the source of infection and the most likely pathogen.
    • 5) LOCALIZED RADIATION INJURY: Localized radiation injury may also occur in conjunction with acute radiation syndrome, usually presenting with delayed erythema and desquamation or blistering 12 to 20 days after exposure. Treatment includes pain management, infection prevention, and vasodilators.
    • 6) PALLIATIVE CARE: Patients who vomited within a few minutes of exposure, with diarrhea developing in less than an hour, fever developing in less than 1 hour, severe headache, a possible history of loss of or altered consciousness, abdominal pain, parotid pain, erythema, and possible hypotension have likely received a lethal dose with poor prognosis. Palliative care should be started immediately, with initial treatment in the ICU if resources allow.
    • 7) Further information is available from the CDC (http://www.bt.cdc.gov/radiation/) and the United States Department of Health and Human Services (http://www.remm.nlm.gov/). Emergency consultation services are also available through the Radiation Emergency Assistance Center/Training Site (REAC/TS) 24 hours a day, 7 days a week at 865-576-1005 (http://orise.orau.gov/reacts/).
  • B) DECONTAMINATION
    • 1) DERMAL: Most decontamination (90%) is accomplished by removal of the outer clothing and shoes. A radiation detector passed over the body (held at a consistent distance from the body) can detect residual contamination. Further decontamination is accomplished by washing with warm soap and water, with gentle brushing while covering open wounds. Reduction of radiation to less than 2 times the background level is the goal of decontamination. Contaminated wounds require further effort. Abrasions are decontaminated with warm water and soap. Lacerations may require excision of contaminated tissue. Punctate lesions may be successfully cleaned using a water pick or oral irrigator. Shrapnel should be removed with forceps.
    • 2) INGESTION: Patients who ingested any radioactive matter should receive aluminum hydroxide or magnesium carbonate antacids to reduce absorption. Gastric lavage may be used if ingestion occurred within 1 to 2 hours, and large ingestions may benefit from cathartics and enemas.
    • 3) EYES: Obtain an x-ray to rule out presence of shrapnel in globe. If corneal contamination is present and globe is intact, carefully irrigate eyes with copious amounts of saline or water. Never irrigate a ruptured globe. To avoid contamination of nasolacrimal duct, direct irrigation stream away from inner canthus and toward outer canthus. Monitor the eyes for conjunctivitis after decontamination. The irrigation fluid should be tested frequently for residual radioactivity. Collect, store, and label irrigation fluid properly for forensic evaluation and proper disposal.
  • C) RADIATION INFORMATION
    • 1) Several historical points should be quickly obtained when whole-body irradiation is a possibility: (
    • 1) location when the potential exposure occurred; (
    • 2) amount of possible shielding, including position inside a building; (
    • 3) amount of time outside away from shielding; and (
    • 4) occurrence of any vomiting or diarrhea. It should be documented whether any decontamination has occurred, and if any loss of consciousness was experienced. If trauma occurred, the mechanism of injury should be determined, and any medication use and allergy history recorded. MEASUREMENT OF RADIATION: In patients who have inhaled, ingested, or absorbed radioactive material through wound, direct measurement of radiation within the patient is a possible to guide therapy. Ingested radioactivity can be measured from collected urine. If inhalation may have occurred, nasal swabs should be taken as soon as possible in order to determine the approximate radiation exposure; combine the 2 measurements and divide by 0.1 to obtain the inhaled amount of radiation. Similar measurements may be taken from contaminated wounds. In all cases, the measurements can be converted into a measure of activity and compared with charts of known annual limits of intake to determine if the amount of radiation internally present is hazardous and requires treatment. Specific medical countermeasures may be employed to treat internal contamination, some of which depend on the specific radionuclide that has been ingested or inhaled.
  • D) AIRWAY MANAGEMENT
    • 1) Administer 100% oxygen as needed for respiratory support. Endotracheal intubation and mechanical ventilation may rarely be required.
  • E) ANTIDOTES
    • 1) DEFEROXAMINE
      • a) USES: Iron, manganese, neptunium, and plutonium.
      • b) DOSES: Not specified by age: 1 g IM or IV (2 ampules) slowly (15 mg/kg/hr); IM is preferred; repeat as indicated as 500 mg IM or IV every 4 hours for 2 doses; then 500 mg IM or IV every 12 hours for 3 days.
    • 2) DIMERCAPROL
      • a) USES: Antimony, arsenic, bismuth, gold, lead, mercury, nickel, polonium-210.
      • b) DOSES: Not specified by age: 300 mg per vial for deep IM use, 2.5 mg/kg (or less) every 4 hours for 2 days, then twice daily for 1 day then once daily for days 5 to 10.
    • 3) EDETATE CALCIUM DISODIUM
      • a) USES: Cadmium, chromium, cobalt, copper, iridium, lead, manganese, mercury, nickel, plutonium, ruthenium, yttrium, zinc, zirconium.
      • b) DOSES: Not specified by age: 1000 mg/m(2)/day added to 500 mL dextrose 5% normal saline over 8 to 12 hours.
    • 4) DTPA, CALCIUM OR ZINC
      • a) USES: Plutonium-239, Americium-241, Curium-244.
      • b) DOSES: ADULTS: 1 g in 5 mL IV push over 3 to 4 minutes or IV infusion over 30 minutes diluted in 250 mL of 5% dextrose in water, Normal Saline (NS), or Ringers Lactate. Nebulized inhalation: 1 g in 1:1 dilution with water or NS. CHILDREN (age under 12 years): 14 mg/kg IV loading dose as soon as possible; MAX: 1 g.
    • 5) PENICILLAMINE
      • a) USES: Antimony, bismuth, copper, gallium, gold, mercury, palladium, polonium.
      • b) DOSES: Not specified by age: 250 mg daily orally between meals and at bedtime; may increase to 4 or 5 g daily in divided doses.
    • 6) POTASSIUM IODIDE
      • a) USES: radioactive iodine.
      • b) DOSES: ADULTS: 130 mg orally daily for ingestion of radioactive iodine. CHILDREN (age 12 to 18 years, weight greater than 150 pounds): 130 mg orally daily for ingestion of radioactive iodine. CHILDREN (age 12 to 18 years, weight less than 150 pounds): 65 mg orally daily for ingestion of radioactive iodine. CHILDREN (age 3 to 12 years): 65 mg orally daily for ingestion of radioactive iodine. CHILDREN (age 1 month to 3 years): 32.5 mg orally daily for ingestion of radioactive iodine. CHILDREN (birth to 1 month): 16.25 mg orally daily for ingestion of radioactive iodine.
    • 7) PROPYLTHIOURACIL
      • a) USES: Iodine-131.
      • b) DOSES: Not specified by age: 2 tabs (50 mg each) 3 times daily for 8 days.
    • 8) PRUSSIAN BLUE
      • a) USES: Cesium-137, thallium-201, rubidium.
      • b) DOSES: ADULTS: 3 g orally 3 times daily. CHILDREN (age 2 to 12 years): 1 g orally 3 times daily.
    • 9) SUCCIMER
      • a) USES: Arsenic, bismuth, cadmium, cobalt, lead, mercury, polonium.
      • b) DOSES: CHILDREN: initial, 10 mg/kg or 350 mg/m(
    • 2) orally every 8 hours for 5 days. Reduce frequency of administration to 10 mg/kg or 350 mg/m(
    • 2) every 12 hours (two-thirds of initial daily dose) for an additional 2 weeks of therapy (course of therapy: 19 days).
  • F) NAUSEA AND VOMITING
    • 1) Treat patients with persistent nausea and vomiting with granisetron or ondansetron. Early oral feedings are recommended to maintain gut function.
  • G) DIARRHEA
    • 1) Antidiarrheals may be used for the control of diarrhea (eg, loperamide or diphenoxylate/atropine).
  • H) MYELOSUPPRESSION
    • 1) Colony-stimulating factors (FILGRASTIM: ADULTS: 2.5 to 5 mcg/kg once daily subQ. SARGRAMOSTIM: ADULTS: 5 to 10 mcg/kg once daily subQ. PEGFILGRASTIM: ADULTS: 6 mg once subQ) should begin within 24 to 72 hours of exposure when granulocyte levels are falling, with daily therapy continued until the absolute neutrophil count increases to more than 1000 cells/mm(3). Patients who develop infection without neutropenia should have antibiotic therapy directed towards the source of infection and the most likely pathogen. If febrile neutropenia develops, consultation with infectious disease and hematology specialists should be obtained, and guidelines on febrile neutropenia from the Infectious Disease Society of America should be followed for appropriate antibiotic therapy. Patients who received doses of 7 to 10 Gy (700 to 1000 rads) should be considered for bone marrow stem cell transplants. The Radiation Injury Treatment Network was founded to assist in situations in which profound damage to the bone marrow has occurred, and it can be reached at: http://bloodcell.transplant.hrsa.gov/ABOUT/RITN/index.h tml. If transfusion of blood products is required, all products should leukoreduced and irradiated to 25 Gy in order to avoid a transfusion-related graft-vs-host reaction.
  • I) HYPOTENSION
    • 1) Treat hypotension with intravenous fluids; if hypotension persists, administer vasopressors.
  • J) SEIZURES
    • 1) IV benzodiazepines; barbiturates or propofol if seizures recur or persist.
  • K) ENHANCED ELIMINATION PROCEDURE
    • 1) In one in vitro study, charcoal hemoperfusion was NOT effective in decreasing radioactivity in artificial media containing cesium-137.
  • L) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Any patient who is asymptomatic, totally decontaminated as indicated by survey, and has a normal CBC and platelet count may be safely discharged. Follow-up instructions should include a repeat CBC in 48 hours and reevaluation following the onset of any gastrointestinal symptoms (eg, nausea, vomiting, and diarrhea).
    • 2) ADMISSION CRITERIA: Admission is required for fluid and electrolyte therapy if severe vomiting and diarrhea are present. Patients manifesting thrombocytopenia, granulocytopenia, and/or lymphopenia require hospital admission. Hospital admission is also necessary for standard indications for multiple trauma or burns associated with radiation exposure.
    • 3) CONSULT CRITERIA: For patients with localized injury, referral may be required for plastic surgery, grafting, or amputation.
    • 4) PATIENT-TRANSFER CRITERIA: Initially, patients should be field-triaged to a facility designated for handling radioactively-contaminated patients. Other conditions (eg, multiple trauma) may necessitate transporting patients to a trauma center. After stabilization, decontamination, and initial evaluation, patients with the hematopoietic syndrome should be transferred to a facility with expertise in the treatment of pancytopenia. If transfer is indicated, it should be undertaken on the first day or as soon as possible.
  • M) PITFALL
    • 1) Early symptoms of radiation exposure may be delayed or not evident (eg, myelosuppression). Appropriate therapy may be delayed due to failure to contact a radiation specialist. Beware of secondary exposures that may come from rescuers who were also exposed. History of radiation exposure may be difficult to obtain in some settings.
  • N) KINETICS
    • 1) Systemic contamination will occur following ingestion, inhalation, skin absorption, or wound contamination of radioactive material. Following absorption, a radionuclide crosses capillary membranes through passive and active diffusion mechanisms and then is distributed throughout the body. Rate of distribution to each organ is dependent on organ metabolism, ease of chemical transport, and the affinity of the radionuclide for chemicals within the organ. The organs with the highest capacities for binding radionuclides are the liver, kidney, adipose tissue, and bone due to their high protein and lipid makeup. Each radionuclide has a unique half-life, with half-lives ranging from extremely short (fraction of a second) to millions of years. Samples of some radionuclides and their half-lives are: Tc-99m: 6 hours; I-131: 8.05 days; Co-60: 5.26 years; Sr-90: 28.1 years; Pu-239: 24,400 years; U-238: 4,150,000,000 years.
  • O) DIFFERENTIAL DIAGNOSIS
    • 1) Local injuries such as chemical or thermal burn, insect bite, skin disease or allergy, trauma; food poisoning, gastroenteritis; chemotherapeutic agents, or myelosuppression agents.
0.4.3 INHALATION EXPOSURE
  • A) In patients who have inhaled radioactive material, direct measurement of radiation within the patient is possible to guide therapy. Nasal swabs should be taken as soon as possible in order to determine the approximate radiation exposure; combine the 2 measurements and divide by 0.1 to obtain the inhaled amount of radiation. In all cases, the measurements can be converted into a measure of activity and compared with charts of known annual limits of intake to determine if the amount of radiation internally present is hazardous and requires treatment. Specific medical countermeasures may be employed to treat internal contamination, some of which depend on the specific radionuclide that has been inhaled.
  • B) Refer to ORAL OVERVIEW AND MAIN SECTIONS for specific treatment information.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) Most decontamination (90%) is accomplished by removal of the outer clothing and shoes. A radiation detector passed over the body (held at a consistent distance from the body) can detect residual contamination. Further decontamination is accomplished by washing with warm soap and water, with gentle brushing while covering open wounds. Reduction of radiation to less than 2 times the background level is the goal of decontamination. Contaminated wounds require further effort. Abrasions are decontaminated with warm water and soap. Lacerations may require excision of contaminated tissue. Punctate lesions may be successfully cleaned using a water pick or oral irrigator. Shrapnel should be removed with forceps.
    • 2) Refer to ORAL OVERVIEW AND MAIN SECTIONS for specific treatment information.
Find more information on this substance at: Hazardous Substances Data Bank , TOXNET , PubMed