What is the management for cesium (Cs) exposure?

Management of Cesium Exposure

The management of cesium exposure requires immediate decontamination followed by specific treatment with Prussian blue to enhance elimination, along with supportive care for radiation sickness if radioactive cesium is involved. 1, 2

Initial Management and Decontamination

• Remove contaminated clothing and shoes immediately, which can accomplish 70-95% of decontamination 1
• For external contamination, irrigate exposed skin with copious amounts of running water for at least 15 minutes 3, 1
• Brush off any dry chemical before irrigation with water 3
• Remove contaminated jewelry and other personal items 1
• Decontamination should ideally be completed in the field or outside the medical center to prevent facility contamination 1
• Healthcare staff must wear appropriate personal protective equipment during decontamination 1

Specific Treatment for Internal Contamination

• Administer Prussian blue (ferric hexacyanoferrate) as the primary treatment for internal cesium contamination, which enhances fecal excretion of cesium via ion exchange 4, 2
• Prussian blue binds to cesium in the intestines, preventing its reabsorption and facilitating elimination from the body 4, 5
• Continue Prussian blue treatment until whole blood cesium levels decrease significantly 5

Management of Radiation Sickness (for Radioactive Cesium Exposure)

• Assess severity of acute radiation syndrome based on:

  • Time to onset of vomiting
  • Lymphocyte depletion kinetics
  • Presence of chromosome dicentrics 3

• For significant neutropenia (absolute neutrophil count < 0.500 × 10^9 cells/L):

  • Administer broad-spectrum prophylactic antimicrobial agents including fluoroquinolones with streptococcal coverage 3
  • Add antiviral drugs (acyclovir or congeners) and antifungal agents (fluconazole) 3
  • Continue antimicrobial prophylaxis until neutrophil recovery 3

• For patients with whole-body or significant partial-body radiation exposure >3 Gy:

  • Initiate colony-stimulating factors (CSFs) as soon as possible 3
  • Continue CSF treatment until the absolute neutrophil count reaches >1.0 × 10^9 cells/L 3
  • Consider epoetin or darbepoetin for anemia 3

• For severe bone marrow damage:

  • Provide transfusion of leukoreduced and irradiated blood products 3
  • Consider stem-cell transplantation for exposures of 7-10 Gy in patients without significant burns or other major organ toxicity 3

Supportive Care

• Provide fluid resuscitation for patients with significant burns, hypovolemia, or hypotension 3
• Administer antiemetic agents for nausea and vomiting, which are common with radiation exposure 3
• Provide antidiarrheal agents for gastrointestinal symptoms 3
• Manage pain with appropriate analgesic agents 3
• Apply topical treatments for burns 3
• For cardiac complications (particularly with non-radioactive cesium chloride exposure):
  • Monitor for QT prolongation and ventricular arrhythmias 5
  • Provide appropriate cardiac support and antiarrhythmic medications as needed 5, 3

Special Considerations

• For pregnant women, assess risk to the fetus 3
• For children and elderly (>60 years), consider a lower threshold (2 Gy) for initiating CSF therapy 3
• Provide psychological support for patients and families, as radiation exposure often causes significant anxiety 3
• Contact regional poison centers (1-800-222-1222) for additional guidance on management 3

Monitoring and Follow-up

• Perform regular complete blood counts with differential to monitor bone marrow function 3
• Monitor whole blood cesium levels to guide duration of Prussian blue therapy 5
• Provide long-term follow-up for patients with significant exposure due to potential late effects 2, 6

Pitfalls to Avoid

• Do not delay decontamination while waiting for specialized equipment 1
• Avoid using alcohol-based products on damaged skin 1
• Do not allow contaminated individuals to enter clean areas of healthcare facilities 1
• Do not forget to protect healthcare workers with appropriate personal protective equipment 1
• Avoid experimental treatments with unproven efficacy, such as high-dose oral cesium chloride, which has been associated with serious toxicity including death 5, 7