You’ve been tasked with being the local hospital’s disaster response rep. Next week there’s going to be an exercise scenario, specifically a ‘dirty’ bomb attack with subsequent cesium exposure. Specifically, your part in this scenario is recommending which medications, if any, need to be available?

What medication(s), if any, should you be exploring?

SELECT  here for discussion

Prussian Blue capsules (Radiogardase ®). Available from REAC (see below). Pantex (Amarillo, TX) and Houston Medical Center are potential regional suppliers.

Cesium is the primary component of radioactive fallout and radiotherapy devices. Prussian Blue binds cesium and thallium in the GI tract via ion exchange, adsorption, and mechanical trapping to render it insoluble and not available for absorption. It decreases the amount
absorbed and decreases the amount available to enterohepatic recycling.

The adult/adolescent dose of Prussian Blue is 3 grams orally 3 times a day. In patients 2-12 years of age, the dose is one gram orally 3 times a day. A tentative upper therapeutic range is 10 grams per day. High level of internal contamination may require 10-20 grams per day in divided doses (TID). The minimum duration of therapy is 30 days and should be extended based on the level of contamination and judgment of the clinician. When given with food, peristalsis increases and facilitates elimination of the bound radionuclides from the GI tract. With no systemic bioavailability, dose adjustments for hepatic and renal dysfunction or compromise are NOT necessary.

The principle side effects include constipation, blue coloration of body parts and body fluids (esp if capsules are opened), and binding of other electrolytes (sodium, potassium) and some drugs. The manufacturer recommends monitoring serum electrolytes, serum levels of
“critical” drugs (not defined or listed), and give with a high fiber diet or laxative. Constipation increases intestinal transit time and may allow greater systemic absorption of the cesium.

Quick Reference

Iodine    KI (potassium Iodine or SSKI (saturated solution of potassium Iodide) 130mg (tabs) stat, then 130mg po daily for 7 days (if indicated) Blocks thyroid deposition 

Rare Earths

Plutonium

Transplutonics

Yttrium    Zn-DTPA

Ca-DTPA    1 gm Ca-DTPS (Zn-DTPA) in 150-250 ml 5% Dextrose in Water, IV over 60 minutes    Chelation   

Uranium    Bicarbonate    2 amps (NaHCO3 (44.6 mEq/amp, 7.5%) in 1000ml 0.9% NS @ 125ml/hour, OR 2 NaHCO3 tablets (~650mg/tab) every 4 hours until urine pH ~ 8-9    Alkalinization of urine, reduces chance of acute tubular necrosis (ATN)   

Cesium

Rubidium

Thallium 

Prussian Blue [Ferrihexacyano-Ferrate (II)] 1 to 3 grams orally (with 100-200 ml water) TID for Blocks GI absorption from GI tract and prevents recycling   

Some useful numbers/addresses/emails:

MEIR@mx.afrri.usuhs.mil <mailto:MEIR@mx.afrri.usuhs.mil>  or (301) 295-0316 (DSN 295-XXXX)

-    Armed Forces Radiobiology Research Institute
     8901 Wisconsin Avenue, Bethesda, MD, 20889-5603

-    Radiation Emergency Assistance Center/Training (REAC)
     +1-865-576-1005 (Ask for REAC/TS)

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.