david weinstock, md dana-farber/harvard cancer center radiation injury treatment network
DESCRIPTION
Radiation Injury Treatment Network: Leveraging existing expertise to provide radiation casualty management. David Weinstock, MD Dana-Farber/Harvard Cancer Center Radiation Injury Treatment Network [email protected]. Radiation Injury Treatment Network (RITN): Definition. - PowerPoint PPT PresentationTRANSCRIPT
Radiation Injury Treatment Network: Leveraging existing expertise to provide
radiation casualty management
David Weinstock, MDDana-Farber/Harvard Cancer CenterRadiation Injury Treatment Network
Radiation Injury Treatment Network (RITN): Definition
• Voluntary network of 47 academic medical centers, 7 blood donor centers and 7 umbilical cord blood banks
• Organized by National Marrow Donor Program and American Society of Blood and Marrow Transplantation
• Supported by the US Navy• Coordinated with the Office of the ASPR, DHHS
• Education and training:– REAC/TS mini-course – Grand rounds and online presentations (<2300 trained)– REMM (www.remm.nlm.gov) treatment algorithms
• Annual tabletop exercises• International consensus guidelines• National planning
– Scarce Resources project– National Planning Guidance– State and Local Planners Playbook for Medical Response to a
Nuclear Detonation
Radiation Injury Treatment Network (RITN): Pre-event
• 0-76, Be aware of the Radiation Injury Treatment Network (RITN)• I-19, HHS activation of National Disaster Medical System (NDMS) and other HHS
assets (DMATs and burn teams). HHS to activate AABB TF for blood supports through Assistant Secretary for Health (ASH) activate RITN
• II-6, Prepare for air-based transfer of victims to other jurisdictions, NDMS hospitals, RITN and Veterans Administration hospitals.
• II-36, Support transfer and tracking of victims and potential victims of acute radiation syndrome to regional, NDMS, and RITN centers
• II-42, Work with hospitals to identify patients for transfer to regional facilities, NDMS, RITN centers or burn facilities.
• III-6, Continue transfer of victims who may need delayed medical care to National Disaster Medical System (NDMS), RITN and other jurisdictions.
State and Local Planners Playbook for Medical Response to a Nuclear Detonation
• Surge capacity• National guidance – online, teleconsult• Coordination of stem cell transplantation:
– Donor searches (>10,000 per week)– Product harvesting and transport– Treatment guidelines
Radiation Injury Treatment Network (RITN):Response
Ground Zero
Evacuation
Victim collection points
Decon
Deco
n
Triage
Trauma centers
Triage
Trauma centers
Specialty care & treatment centers
Specialty care & treatment centers
Potential for life-threateningexposure during clean-up
Radiation events
MC
MC
MC
ACAC
MC
Evacuationcenters
RTR3 (collection)
AC
RTR1 (collection)
AC
Referral centerModified from Weinstock et al. Blood 2008
RTR1 (blast)
RTR2 (plume)
MC
RTR2 (plume)
Ambulatory
Critical
DHHS evacuation strategy – 2 types of radiation injury
Hiroshima after the bombHiroshima before the bomb
New York City 2011Hiroshima before the bomb
Estimated number of irradiated victims
Waselenko et al. Annals Int Med 2004
300,000
600,000
Resource demand and availability after a nuclear detonation in Washington DC
Symptomatic injured persons or incident demandmin - med - max
Single hospital
City Nation
Persons injured (next column) or population of designated area (city, nation)
930,000 – 990,000 – 1,600,000
N/A 592,000 300 million
Hospital beds (unoccupied) 70,000 –180,000 – 300,000
165 (40) 3,670 (920)
947,000 (295,000)
ICU beds (unoccupied) 24,000 – 61,000 – 110,000
20.5 (1.6) N/A 118,000 (9,400)
Operating rooms N/A 6 N/A 30,000
Burn beds (unoccupied) 0 – 0 – 1,100 N/A 32 (5) 1,760 (580)
Ambulances N/A N/A 38 48,400
Modeling Division of BARDAPublic Health Emergency Medical Countermeasures Enterprise (PHEMCE) Blood and Tissue Requirements Working GroupGryphon Scientific
Surge capacity based on tabletop exercises
R. Cassagrande, Gryphon Scientific
Combined injury worsens outcome in humans
Hick JL, Weinstock DM et al. Disaster Med Health Prep 2011
Alert and Notification
Prepare to receive Patients
Earliest patients arrive at distant RITN centers
Initiate G-CSF
Day: 0 3 10 21 35 60+
Prodromal symptoms
Preparation for HSCTManifest
illness
Recovery
• ~40 radiological accident victims have been reported– More are known to have undergone HSCT after Chernobyl but details
are limited– Treated with a variety of approaches and HSC products– Many had multiorgan dysfunction
• 4 survived more than one year– All 4 reconstituted autologous hematopoiesis– Unclear how many others would have – Almost none received growth factors prior to HSCT
• 25% died of transplant-related mortality
HSCT for radiological injury: the experience
• Highly heterogeneous exposure
• High dose rate - 22 second exposure at sterilization facility (15 Gy/min)
• Responded to cytokines - Cytokine treatment only
Gourmelon et al. Health Physics 2010
Lessons learned from industrial accidents
22
Ongoing Initiatives• Strengthen relationships with:
• State/local/territorial public health
• NDMS
• Pediatric treatment guidelines
• Support planning of outpatient and inpatient capabilities at non-RITN centers
• Educate non-physician hospital staff