Orders must be customized for each event and patient!
Specific drugs are suggested for function only, and patients may not need any/every category of drug listed. Consult the notes at the end of this document.
This Adult Orders Prototype lists only FDA-approved medications as radioisotope countermeasures for internal contamination. These drugs are currently in the Strategic National Stockpile. Prescribers should consult the FDA drug label for complete information.
All dosages in this prototype are based on a 70 kg adult with normal renal and hepatic function. Appropriate dosage adjustments should be made based on age, weight, drug-drug interactions, nutritional status, renal and hepatic function. Pediatric doses are not referenced, except for Potassium Iodide.
This Adult Orders Prototype does not address threshold levels of internal contamination that would trigger initiation, continuation, or discontinuation of decorporation treatment. See REMM Countermeasures Caution and Comment information that discusses this issue.
After a mass casualty event, practitioners may encounter counterfeit drugs.
This FDA website will provide information on avoiding and detecting counterfeit drugs and assist reporting of suspected counterfeit medications.
See "Notes" at end of order list for additional information.
History of prior significant chronic disease(s) or conditions
Specify each, including meds or special needs required for each:
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TED hose to Bilateral Lower-Extremities
Sequential Compression Devices (SCD)
Anticoagulation regimen _____________________________________
Other
The potential benefit of anticoagulation (e.g. heparin1,2) should be balanced against the risk of excessive bleeding in patients with severe thrombocytopenia or significant gastrointestinal toxicity.
Respiratory Therapy: (Radiation precautions needed if patient is contaminated.)
Room air Chest tube care (Specify) ____________
Titrate oxygen supplementation for Oxygen saturation > ____________%
Nebulizer treatment (Specify) ____________________________________
For Bioassay: tests evaluating/managing internal decontamination:
Spot urine for ________ name of radioactive isotope
24-hour urine for ________ name of radioactive isotope
Spot fecal specimen for ________ name of radioactive isotope
24-hour fecal specimen for ________ name of radioactive isotope
Send specimen to: _______________________________
Special requirements for containment, labeling, and shipping of specimen: ______________________________
Note: Consult senior radiation event medical managers for name and location of specialized laboratories if your facility cannot perform these assays.
For ________ units of packed red blood cells
For ________ units of platelets
Use only leukoreduced AND irradiated products, if available, unless it is known with certainty that the patient was exposed to a low dose of radiation, e.g. less than 100 Gy.
If dose is not known with certainty, leukoreduced AND irradiated blood is preferred, if available.
For fever: Acetaminophen (Tylenol)2 650 mg PO q 6 - 8h PRN temperature > 38 °C
For diarrhea:
Loperamide hydrochloride (Imodium)2:
Recommended initial dose is 4 mg (2 capsules) followed by 2 mg (1 capsule) after each unformed stool.
Daily dose should not exceed 16 mg (8 capsules)
For constipation:
Senna (Senokot)2 2 tabs PO BID, hold for loose stools
Docusate (Colace)2 100 mg PO BID, hold for loose stools FDA monograph: 50 to 360 mg QD or divided BID for adults
For rash:
Topical sterile dressing
Diphenhydramine hydrochloride (Benadryl)2 25-50 mg PO q 4-6 hours for pruritis, not to exceed 300 mg/24 hours
For pain:
Morphine sulphate2 ____ mg ____ route ____ frequency
For skin burns: (see also item 15: wound care)
Burn topical regimen __________________________________________
Replace body fluid ___________________________________________
Other burn therapy __________________________________________
For oral mucositis:
Mouth care regimen __________________________________________
Note: Only FDA approved radiation countermeasures are listed in table below.
See REMM Countermeasures Table for longer list of countermeasures which have been recommended by some experts but are not FDA approved as radiation countermeasures.
Although the 3 drugs listed below are FDA-approved for the treatment of chemotherapy induced neutropenia, none is approved either for radiation induced neutropenia or as prophylactic treatment prior to the onset of neutropenia.
Consider using one of the following1:
Liposomal amphotericin B (Ambisome)2 3 mg/kg/day IV over 1-4h
Amphotericin B lipid complex (Abelcet)2 3 mg/kg/day IV over 1-4h
Voriconazole (Vfend)2 6 mg/kg IV q 12h for two doses, then 4 mg/kg IV q 12h
Caspofungin (Cancidas)2 70 mg IV once then 50 mg IV q 24h
Suggested drugs are listed as representatives of a functional class, and no specific medication endorsement is implied. Dosages are based on a 70 kg adult with normal baseline renal and hepatic function. Appropriate dosage adjustments should be made based on age, weight, drug-drug interactions, nutritional status, renal and hepatic function, and any other patient-specific characteristics that may apply.
FDA approved for this indication
This drug is not approved by the FDA for this indication. If used, this would be an "off label use", and physician discretion is strongly advised.
Ca-DTPA and Zn-DTPA have not been approved by FDA for treating internal contamination with californium, thorium, and yttrium. For initial treatment, Ca-DTPA is recommended, if available, within the first 24 hours after internal contamination. Zn-DTPA is preferred for maintenance after the first 24 hours, if available, due to safety concerns associated with prolonged use of Ca-DTPA.
When to initiate treatment with cytokines
Initiation of treatment should be strongly considered for victims who develop an absolute neutrophil count of < 0.500 x 109 cells/L and are not already receiving colony-stimulating factor.
Evidence from animal studies indicates that outcomes may be improved if colony stimulating factors are administered as soon as possible after radiation exposure, and prior to the onset of neutropenia.
Although most therapy for ARS is directed at actual clinical signs and symptoms, some clinical effects of ARS can be anticipated and potentially mitigated, as with the use of prophylactic white cell cytokines. This prophylactic use is also off label.
Emergency Use Authorization will be required for use of cytokines for radiation induced neutropenia in a mass casualty setting.
See published guidelines links in section 24.
For pregnant women:
Experts in biodosimetry must be consulted.
Any pregnant patient with exposure to radiation should be evaluated by a health physicist and maternal-fetal specialist for an assessment of risk to the fetus.
Class C refers to U.S. Food and Drug Administration Pregnancy Category C, which indicates that studies have shown animal, teratogenic, or embryocidal effects, but there are no adequate controlled studies in women; or no studies are available in animals or pregnant women.
