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	You are here: Home > Prototype for Adult and Pediatric Medical Orders During a Radiation Incident		Help on REMM New Users: Where Do I Start? What's New on REMM? (12/2012) Multimedia Library Tools Download REMM (12/2012) Download Mobile REMM (12/2012) Dictionary Emergency Contacts Dose Estimator for Exposure Scarce Resources Triage Tool Manage ARS Subsyndromes Print Algorithms & Tables Diagnosis & Treatment Patient Management Algorithms Acute Radiation Syndrome (ARS) Hematopoietic Subsyndrome Cutaneous Radiation Syndrome Time/Dose Effects in ARS Time Phases of ARS Isotopes of Interest Countermeasures: Internal Contamination Countermeasures: Exposure Decontamination Procedures Strategic National Stockpile    Population Monitoring and Radionuclide Decorporation Following a Radiological or Nuclear Incident (NCRP Report No. 166, 2011) Nuclear Detonation Scarce Resources Working Group Publications, 3/2011 (HHS/ASPR) Response to a Nuclear Detonation: State and Local Medical Planners Playbook, 3/2011 (HHS/ASPR) Responding to a Radiological or Nuclear Terrorism Incident: A Guide for Decision Makers (NCRP Report No. 165, 2010) Management of Persons Contaminated With Radionuclides: Handbook (NCRP Report No. 161, Vol. I, 2008) Planning Guidance for Response to a Nuclear Detonation, 2nd Ed, 6/2010 (National Security Staff)    AFRRI AHRQ CDC CRCPD DHS DOE EPA FDA HHS HPS IAEA   ICRP NACCHO NARR NCRP NRC OSHA REAC/TS RERF RITN UNSCEAR WHO
	Prototype for Adult and Pediatric Medical Orders During a Radiation Incident View/Print as PDF (PDF - 565 KB) CAUTIONS Authored by REMM and RITN physicians, this set of orders is a prototype only. Orders must be customized for each patient and incident. Specific drugs are suggested for function only. Patients may not need any/every category of drug listed. No HHS, CDC, FDA, or other US government entity endorsement of specific drugs or drug doses is intended or implied by inclusion in this order set. Consult the notes at the end of this document for additional, key information. Internal contamination (decorporation treatments) This Adult and Pediatric Orders Prototype lists only FDA-approved medications as radioisotope countermeasures. Some, but not all of these drugs are currently in the Strategic National Stockpile. Prescribers should consult the FDA drug label for complete prescribing information. Decorporation drugs should be used in children with great caution. The online version of REMM has additional recommendations about additional countermeasure drugs that may be considered. This 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, which discusses this issue. Drug dosages All adult drug doses in this prototype are based on a 70 kg adult with normal renal and hepatic function. Appropriate dose adjustments should be made based on age, weight, drug-drug interactions, nutritional status, renal, and hepatic function. All pediatric drug doses should be prescribed as appropriate for age, weight, and any clinical issues, including allergies. After a mass casualty incident, practitioners may encounter counterfeit drugs. This FDA website will provide information on avoiding and detecting counterfeit drugs and assist with reporting of suspected counterfeit medications. If this order set, Version date 11/19/2012, has been printed for use offline, consult the online version of REMM to see if updates are available. http://www.remm.nlm.gov/adultorderform.htm Table of contents Administrative information Admit to Diagnoses Precautions Urgent consultations Condition Vital signs Allergies Activity Diet Height, weight Age IV fluid management Foley catheter management Monitor I/O Deep vein thrombosis prophylaxis Respiratory therapy Wound care Orthopedic care Admission studies: labs, imaging Standing labs Electrocardiogram Radiation dose assessment Blood bank General medications Radioisotope decorporation or blocking agents Neutropenia therapy and antimicrobials Notes Body chart for recording results of radiation survey top of page 1. Administrative information Name: __________________________________ Unique Identifier: ____________ Address: _________________________________ Phone: _______________ Spoken language: __________ Unaccompanied minor: _________ Next of kin contact information: _________________________________ Special needs: _________________________________________________ top of page 2. Admit to: __ Hospital ward ______________ Area_______________ __ Team: _______________ ICU_______________ __ Physician: _________________ Other _______________ top of page 3. Diagnoses Acute Non-radiation Related Admission Diagnoses: a. ______________________________ b. ______________________________ c. ______________________________ d. ______________________________ e. ______________________________ f. ______________________________ Acute Radiation-related Admission Diagnoses a. Radiation contamination? Yes_____ No_____        See REMM Body Chart (page 18) to record whole body radiation survey. __ External contamination with Isotope (Specify or unknown) ____________ __ Internal contamination with Isotope (Specify or unknown) ____________ __ Contamination suspected, Isotope uncertain b. Radiation Exposure / Acute Radiation Syndrome (ARS)? Yes_____ No_____ Estimated whole body dose from exposure__________(units of gray) See also Item #23 for additional details Other potential complicating factors __ Mass casualty incident __ Other, Specify __________________ Specific populations potentially requiring more customized management? Yes____ No_____ __ Infant (< 1 y) __ Child (1-16 y) __ Age > 65 y __ Pregnant/Possibly pregnant __ Immunosuppressed __ Other, Specify ___________________________________ See REMM page about At-Risk/Special Needs Populations top of page 4. Precautions Infectious __ Contact __ Droplet __ Airborne __ Reverse Isolation/Neutropenic Radiation precautions For persons with known or suspected external or internal contamination. Persons with exposure but NO contamination are NOT radioactive. Patients with exposure only do not need Radiation Precautions. __ Precautions: Single room, gown, mask, cap, boots, and gloves __ Use medical facility procedures for discarding all biological/physical/radioactive waste, including linens/towels/trash/personal protective equipment. __ Contact Radiation Safety Officer for additional instructions. Phone: ______________ Page: ____________ __ Place Radiation Safety Sign on door if patient has internal or external radioactive contamination __ Notify pregnant staff that entry to room is prohibited if patient is/may be contaminated. __ Everyone entering room/area of contaminated patient must wear personal radiation dosimeter assigned by Radiation Safety. __ Use medical facility procedures for disposal of radiation waste, including linens/towels/trash/personal protective equipment. See guidance 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Healthcare Infection Control Practices Advisory Committee (HHS/CDC) Components of a Protective Environment (HHS/CDC) top of page 5. Urgent consultations: specify __ Pediatric Hematology/Oncology __ Adult Hematology / Oncology__ Transfusion Medicine __ Hematopoietic Stem Cell Transplantation __ Radiation Oncology __ Mental Health / Psychiatry __ Endocrinology __ Ophthalmology __ Pain Service __ Dermatology / Plastic Surgery __ Gastroenterology __ Radiation Safety __ Burn Therapy __Other _______________ top of page 6. Condition __ Good __ Fair __ Stable __ Guarded __ Critical top of page 7. Vital Signs __ q 2 hours X 4 __ Ward routine __ q 4 hours X 4 Notify physician for: Temperature ____>38 °C ____ Other: ___________ SBP: _____>180, <100 ____ Other: ___________ DBP: _____ >100, <50 ____ Other: ___________ HR: _____>100, <50 ____ Other: ___________ RR: ______ >30, <8 ____ Other: ___________ O2 saturation: _____<92% ____ Other: ___________ top of page 8. Allergies __ No Known Drug Allergies (NKDA) __ Allergies (drugs, foods) If yes, specify: ________________________________________ top of page 9. Activity __ Bed rest __ Bathroom privileges __ Out of bed every ___ hrs. __ Ambulate as tolerated __ Confine to room top of page 10. Diet __ Regular Diet __ Liquids (full, clear) __ NPO __ Advance as tolerated __ Neutropenic diet __ Special dietary needs/requests: _______________________ top of page 11. Height, weight Height: ____ feet ____ inches or ____ cm Weight: ____ lbs. ____ oz. or ____ Kg Repeat body weight: q ____ hours q ____ days top of page 12. Age Months (if <3 years) _____ Years _____ top of page 13. IV fluid management __ IV Fluids: ______ @ _____ cc/hr, with additive ______ __ IV Fluids: ______ @ _____ cc/hr, with additive ______ top of page 14. __ Foley catheter management (specify) _____________ __ Use radiation precautions for urine and feces for patients with internal radiation contamination. top of page 15. __ Monitor I / O Frequency ____________ __ Use radiation precautions for urine and feces for patients with internal radiation contamination. top of page 16. Deep Venous Thrombosis (DVT) prophylaxis1 __ TED hose to Bilateral Lower-Extremities __ Sequential Compression Devices (SCD) __ Anticoagulation regimen _____________________________________ __ Other Note: 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. top of page 17. Respiratory Therapy __ Use radiation precautions for personnel, equipment, and waste if patient has internal radiation contamination. __ Room air __ Chest tube care (Specify)___________ __ Titrate oxygen supplementation for Oxygen saturation > ____% __ Nebulizer treatment (Specify) ____________________________________ top of page 18. Wound care1 (see also item 25) __ Decontaminate external wounds if there is external contamination. See REMM contaminated wound care recommendations. __ Sterile dressing to wounds daily __ Monitor waste __ Use medical facility procedures for discarding biological/radioactive/physical waste and linens/towels/trash/personal protective equipment. __ Radiation precautions (needed if patient has radiation contamination) __ Silvadene (Silver Sulfadiazine)2 cream topically to burns __ Bacitracin topically to burns __ Other wound management per Burn team/Dermatology/Surgery: Pager ____________ Phone ________________________ top of page 19. Orthopedic care __ Splint/brace/cast __ Other orthopedic management procedure per orthopedics: Pager ___________ Phone ________________________ top of page 20. Admission studies: Labs, Imaging Labs __ CBC w/differential __ Comprehensive Metabolic Panel (CMP) / Chem 14 __ Cardiac enzymes __ PT / PTT __ Urinalysis __ Urine culture __ Blood culture __ Urine HCG __ Serum HCG __ Thyroid Function Tests (Specify) _____________ Serologies: __ Herpes Simplex Virus type 1 (HSV-1) __ Herpes Simplex Virus type 2 (HSV-2) __ Cytomegalovirus (CMV) __ Varicella-zoster virus (VZV) Imaging __ Chest x-ray ______ PA/Lateral _________ Portable __ Other imaging studies    Specify: _________________ top of page 21. Standing labs / studies __ CBC w/diff q ___ hours, x ___ days,   Followed by q ___ until further orders __ Comprehensive Metabolic Panel (CMP) / Chem 14   Followed by q ____ hours, x ____ days   Followed by q ____ until further orders top of page 22. Electrocardiogram __ Electrocardiogram __ STAT Electrocardiogram for chest pain, notify physician top of page 23. Radiation Dose Assessment A. Biodosimetry and Bioassay assays Difference between Biodosimetry and Bioassay Define biodosimetry More about biodosimetry Dicentric chromosome assay B. Biodosimetry assays for radiation exposure See REMM information on Dose Estimator for Exposure: 3 biodosimetry tools Dose Reconstruction Estimated whole body dose from exposure: _____ (Gray) Using which tool(s) ______________________ e.g., vomiting, lymphocyte depletion kinetics, dicentric chromosome assay Note: if different assays give different results METREPOL Scores: Heme___ GI___ Neuro____Cutaneous____ Response Category (RC score) __________ Explain METREPOL Date of exposure: ____________ Time of exposure: ____________ Location of patient at time of exposure:____________ Estimated whole body/partial body dose, specify ________ (dose) Dose unknown: _______ Dicentric Chromosome Assay Instructions: Draw extra green top tube and provide: date ________ time _______ See REMM for location of approved US laboratories that perform this test. Send this tube ON ICE for outside lab study To the attention of: _____________________________________ Name of lab:_____________________________________ Address of lab:____________________________________ C. Radiation bioassay for evaluating/managing internal decontamination Collect ≥ 70 mL Spot urine for ____________(name of radioactive isotope) Directions for sample collection, labeling, packaging and shipping bioassay specimen to CDC bioassay lab. Note: Consult senior radiation event medical managers for name and location of other laboratories that may be available to perform this test in a mass casualty incident. Routine labs generally cannot perform this test. top of page 24. Blood bank __ Type and cross match __ Type and screen For ____ units of packed red blood cells For ____ units of platelets Note: Use only leukoreduced AND irradiated products, if available, unless it is known with certainty that the patient was exposed to alow dose of radiation, e.g. less than 100 cGy. If radiation whole body dose is not known with certainty, leukoreduced AND irradiated products are preferred, if available. See REMM blood use page for additional information. top of page 25. General Medications1: Suggested dose ranges for pediatric patients (PEDS) are included for some but not all drugs. Drug names are generally listed as follows Generic (Brand) names Some drugs with bold blue font have DailyMed hyperlinks with additional information. For gastric acid suppression: __ Lansoprazole (Prevacid)2 15-30 mg PO daily PEDS: 1 mg/kg, max 30 mg/dose. Dose: ______ For radiation-induced nausea & vomiting: __ Ondansetron (Zofran)2 4 mg IV q 8h PRN nausea/emesis PEDS: 0.15 mg/kg, max 8 mg, IV/PO Q 8hrs PRN. Dose: _____ __ Lorazepam (Ativan)2 0.5 mg - 1 mg PO q 6-8h PRN    anxiety/insomnia/breakthrough nausea PEDS: 0.03 mg/kg IV/PO q 6 hrs PRN. Dose: ______ __ Prochlorperazine2 10 mg PO/IM/IV q 6-8h PRN    anxiety/insomnia/breakthrough nausea See ASCO antiemetic guidelines for adults3: Basch E, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guidelines Update, J Clin Oncol 2011;29:4189-4198 [PubMed Citation] Kris MG, Kesketh PJ, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006, J Clin Oncol 2006 Jun 20;24(18):2932-47 [PubMed Citation] See New England Journal of Medicine June 5, 2008 article: Chemotherapy induced nausea and vomiting3 See National Comprehensive Cancer Network (NCCN) Antiemetic Guideline for Adults: NCCN Guideline Version 1.20123 For fever: __ Acetaminophen (Tylenol)2 650 mg PO q 6 - 8h PRN temperature> 38 °C PEDS: 15 mg/kg, max 650 mg PO Q 6 hrs PRN. Dose: _______ 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 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 PEDS: 1 mg/kg, max 50 mg IV/PO Q 6 hrs PRN. Dose _______ For pain: ___ Morphine sulphate2 ____ mg ____ route ____ frequency PEDS: 0.05-0.1 mg/kg IV Q 2 hrs PRN; 0.2-0.5 mg/kg PO Q 4 hrs PRN. Dose _____ For skin burns: (see also item 18: wound care) Burn topical regimen __________________________________________ Replace body fluid ___________________________________________ Other burn therapy __________________________________________ For oral mucositis: Mouth care regimen __________________________________________ top of page 26. Radioisotope decorporation or blocking agents: Note: Only FDA approved radiation countermeasures are listed in table below. See REMM Radiation Countermeasures for Treatment of Internal Contamination table for longer list of countermeasures which have been recommended by some experts but are not FDA approved as radiation countermeasures. Medical Countermeasure Administered for Route of Administration Dosage Duration Ca-DTPA2,4 Zn-DTPA2,4 See REMM's DTPA information. See FDA's Zn-DTPA drug label. See FDA's Ca-DTPA drug label. Americium (Am-241)2 Californium (Cf-252)3 Cobalt (Co-60)3 Curium (Cm-244)2 Plutonium (Pu-238 and Pu-239)2 Yttrium (Y-90)3 IV2: Give once daily as a bolus or as a single infusion, i.e., do not fractionate the dose. DTPA is FDA-approved for intravenous Rx of known or suspected internal contamination with Am, Cm, and Pu only. Nebulized inhalation2: DTPA is FDA-approved for nebulized inhalation in adults only, and if the route of contamination is through inhalation. IV: 1 g in 5 cc 5% dextrose in water (D5W) or 0.9% sodium chloride (normal saline, NS) slow IV push over 3-4 minutes OR 1 g in 100-250 cc D5W or NS as an infusion over 30 minutes PEDS: <12 years old: 14mg/kg IV qd, no more than 1g/day Nebulized inhalation: 1 g in 1:1 dilution with sterile water or NS over 15-20 min PEDS: nebulized dosing same as adults Ca-DTPA for the first dose Give Zn-DTPA for any follow-up doses (i.e., maintenance as indicated) Duration of therapy depends on total body burden and response to treatment Potassium iodide2 See REMM's KI summary information. See FDA's KI information. Iodine (I-131) PO Adults >40 years: 130 mg/day (for projected thyroid dose ≥500 cGy) Adults 18-40 years: 130 mg/day (for projected thyroid dose ≥ 10 cGy) Pregnant or lactating women of any age: 130 mg/day (for projected thyroid dose ≥ 5 cGy) PEDS: 3-18 yrs: 65 mg/d 1 month - 3 yrs: 32.5 mg/d Birth-1 month: 16 mg/d Some incident will require only a single dose of KI. Incident managers may recommend additional doses if ongoing radioactive iodine ingestion or inhalation represents a continuing threat. See also: Potassium Iodide (KI): Duration of Therapy. Prussian blue, insoluble2 See REMM's Prussian Blue summary information. See FDA's Prussian Blue drug label. Cesium (Cs-137) Thallium (Tl-201) PO Adults: 3 g PO tid (see FDA package insert) OR 1 - 3 g PO tid with 100-200 mL water, up to 10-12 g/day (based on Goiânia accident data) PEDS: >12 yrs: 1 - 3 g po TID; 2-12 yrs: 1 gm TID Minimum 30 days course per FDA Obtain bioassay and whole body counting to assess treatment of efficacy Duration of therapy depends on total body burden and response to treatment   top of page 27. Neutropenia therapy, if indicated1, 5: Neutropenia definition: a total count of neutrophils + bands in the peripheral blood <1,000 /µL    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. See additional REMM information on white cell growth factors/cytokines. In a mass casualty radiation event, use of these drugs would be off-label or require a formal Emergency Use Authorization. Myeloid cytokines Cytokine3 Adult dose Pregnant Women6 G-CSF or filgrastim3 (Neupogen) Subcutaneous administration 5 μg/kg/day via single daily injection Continue until absolute neutrophil count > 1.0 x 109 cells/L PEDS: 5 μg/kg/day via single daily injection3 Class C6 (Same as adults) Pegylated G-CSF or pegfilgrastim3 (Neulasta) 1 subcutaneous dose, 6 mg Consider second 6 mg dose 7 or more days after initial dose, if significant neutropenia persists Class C6 (Same as adults) GM-CSF or sargramostim3(Leukine) Subcutaneous administration 250 μg/m2/day Continue until absolute neutrophil count > 1.0 x 109 cells/L Class C6 (Same as adults) See Practice Guidelines for myeloid growth factors National Comprehensive Cancer Network American Society of Clinical Oncology For Antimicrobial prophylaxis with neutropenia1: For patients with neutropenia who have NOT HAD NEUTROPENIC FEVER. Use as appropriate for each patient. Drugs listed are examples only. Anti-bacterial prophylaxis: __ Levofloxacin (Levaquin)2 500 mg PO/IV daily PEDS: 16 mg/kg/day divided q12H NOT TO EXCEED ADULT DOSE Dose: __________ Anti-viral prophylaxis (neutropenia without fever) __ Acyclovir (Zovirax)2 400 mg PO q12h, or __ Acyclovir (Zovirax)2 250 mg/m2 IV q12h PEDS: 250 mg/m2 IV bid or 10 mg/kg IV bid Dose: _________ Anti-fungal prophylaxis (neutropenia without fever) __ Fluconazole (Diflucan)2 400 mg PO/IV daily - beginning when absolute neutrophil Count (ANC) becomes < 1000 PEDS: 5 mg/kg PO/IV daily, max 400 mg daily Dose: _________ or __ Posaconazole (Noxafil)2 200 mg PO tid with food - beginning when absolute Neutrophil Count (ANC) becomes < 1000 For treatment of neutropenia AND fever (defined as T>38 °C while neutropenic)1 Anti-microbial work-up and therapy __ Blood cultures __ Urinalysis w/culture __ Sputum culture + sensitivity __ Chest x-ray __ Cefepime (Maxipime)2 2gm IV q 8h PEDS: 50 mg/kg, max 2000 mg IV Q8h Dose: ________ __ Vancomycin (Vancocin)3 1gm IV q 12h – Consider if: suspected catheter-related infection, skin or soft tissue infection, pneumonia or hemodynamic instability. Consider trough level before 4th dose PEDS: 15 mg/kg IV Q8h Dose: _____ Antifungal therapy Consider one of the following1 if: fever >72 hours on antibacterial therapy, evidence of fungal infection or hemodynamic instability. __ Voriconazole (Vfend)3 6mg/kg IV q12h for two doses, then 4 mg/kg IV q12h PEDS: 15 mg/kg IV Q8h Dose: ______ __ Caspofungin (Cancidas)2 70 mg IV once then 50 mg IV daily PEDS: 70 mg/m2 IV once, then 50 mg/m2 IV daily (max dose 70 mg once then 50 mg daily) Dose: ___ __ Liposomal amphotericin B (Ambisome)2 3 mg/kg/day IV over 1-4h PEDS: same dose Dose: ___ __ Amphotericin B lipid complex (Abelcet)2 3 mg/kg/day IV over 1-4h PEDS: same dose Dose: ___ See Fever and Neutropenia Guidelines with cancer: Freifeld AG, Bow EJ, Sepkowitz KA, et al: Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 52(4):e56-e93, 2011. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology: Prevention and Treatment of Cancer-Related Infections. Version 2.2011. New ASCO guidelines expected in 2012   top of page NOTES 1. 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. 2. FDA approved for this indication 3. This drug is not approved by the FDA for this indication. If used, this would be an “off label useâ€�, and physician discretion is strongly advised. 4. 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. 5. 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. 6. 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. Body Chart for Recording Results of Radiation Survey   top of page

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