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COMBINED RADIATION INJURIES. Module X IV. Introduction - effects of nuclear bomb and nuclear accident. The detonation of atomic bombs over Hiroshima and Nagasaki on 6 & 9 August 1945. Chernobyl nucl e ar reactor accident on 26 April 1986. Classification.

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COMBINED RADIATION INJURIES

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Combined radiation injuries l.jpg

COMBINED RADIATION INJURIES

Module XIV


Introduction effects of nuclear bomb and nuclear accident l.jpg

Introduction-effects of nuclear bomb and nuclear accident

The detonation of atomic bombs over Hiroshima and Nagasaki on 6 & 9August 1945

Chernobyl nuclear reactor accident on 26 April 1986

Module Medical XIV.


Classification l.jpg

Classification

According to radiation dose combined with other factors, CRI can be classified as:

  • thermal CRI: external/internal irradiation with thermal burns

  • mechanical CRI: external/internal irradiation with wound or fracture, or haemorrhage

  • chemical CRI: external/internal irradiation with chemical burns or chemical intoxication

Module Medical XIV.


Predicted d istribution of i njuries from n uclear e xplosion l.jpg

Predicted distribution ofinjuries from nuclear explosion

  • Single injuries 30% to 40%

    • Ionizing radiation

      (including fallout) 15% to 20%

    • Burns 15% to 20%

    • Wounds Up to 5%

Module Medical XIV.


Predicted d istribution of i njuries from n uclear e xplosion5 l.jpg

Predicted distribution of injuries from nuclear explosion

  • Combined injuries: 65% to 70%

    • Irradiation, burns, wounds 20%

    • Irradiation, burns 40%

    • Irradiation, wounds 5%

    • Wounds, burns 5%

Module Medical XIV.


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Medical Management

  • Triage

  • Emergency care

  • Definitive care

Module Medical XIV.


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Triage

  • In radiation accident or nuclear detonation, many patients can suffer from burns and traumatic injuries in addition to radiation

  • Initial triage of combined injury patients based on conventional injuries

  • Treat associated injuriesfirst

Module Medical XIV.


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Emergency procedures

  • First actions standard emergency medical procedures

    • Ventilation

    • Circulation

    • Stop haemorrhage

  • Decontamination after stabilization

  • Survivable radiation injury not acutely life threatening

Module Medical XIV.


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Secondary assessment of combined injury

  • Primary surgical responsibilities

    • Stabilize

    • Set surgical priorities

    • Perform surgery

  • Secondary responsibilities

    • Manage post-operative course

    • Assess radiation exposure in post-operative or post-stabilization period

Module Medical XIV.


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Prognosis

  • Prognosis for all combined injuries worse than for radiation injury alone

  • Infections much more difficult to control; wounds and fractures heal more slowly

Module Medical XIV.


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Burns and radiation

Boy was 1.5 miles from the detonation of the Nagasaki atomic bomb

Module Medical XIV.


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Radiation and burns

Radiation burns on Japanese atomic bomb victim

Module Medical XIV.


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Early period

Shock with hypovolemia

Gastrointestinal ileus

Oligouria

After adequate resuscitation

Hyperdynamic state

Increased cardiac output

Diuresis

Peripheral catabolism

Sytemic response to major burn injury

Module Medical XIV.


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Causes of burn deaths

  • Direct results of accident 13%

  • Sepsis 45%

  • Organ /system failure

    (burn shock, acute renal failure) 41%

  • Iatrogenic intervention 1%

Module Medical XIV.


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Expected mortality from thermal injuries

Module Medical XIV.


Combined e ffects of s imultaneous w hole b ody i rradiation and b urns o n r ats l.jpg

Combined effects of simultaneous whole body irradiation and burns on rats

Module Medical XIV.


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Burn therapy

  • Topical antimicrobials

  • Early grafting

  • Stimulation of the bone marrow and possibly of skin regeneration with cytokines

Module Medical XIV.


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Principles of controlling infection in burn care

  • Use antimicrobials

  • Support immune mechanisms

  • Eliminate infection reservoirs

  • Suppress infection transfer

Module Medical XIV.


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Suggestions

  • Full thickness burns ideal bacterial culture media - excise and graft

  • Make no change in indications for escharotomy

  • Partial thickness burnscould be treated with aggressive topical therapy; avoid nosocomial sepsis

Module Medical XIV.


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Initial surgery

Major skin necrosis on both legs, extending to t subcutaneous tissue

Complete graft healing after 8 days

Epifascial excision of necrotic skin

Module Medical XIV.


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Treatment of Contaminated Burn Injuries

  • Gentle decontamination after stabilization

  • Passive tetanus immunization even in previously immunized patients

Module Medical XIV.


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Radiation

injury

Dose

(Gy)

Number of hospitalized patients

Total

Deaths

(from rad.)

Radiationburns

Slight

1-2

140

0

0

Moderate

2-4

55

1

0

Severe

4-6

21

7

6

Extremely severe

6-10

21

20

20

Chernobyl victims -classification

Module Medical XIV.


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Chernobyl conclusions

  • Radiation burns frequent

  • Burns over 50% of body surface led to death in 19 out of 28 cases

  • Internal contamination was present in most of patients, however, it was significant just in a few cases.

  • Sepsis uniform cause of death

  • BMT – very limited indications

  • Some radiation burns did not re-epithelialize and required surgery

Module Medical XIV.


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Wounds and radiation

Module Medical XIV.


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Trauma repair

Module Medical XIV.


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Effects of persistent pancytopenia

  • Decreased oxygencapacity

    Lack of release of new erythrocytes and aging of red cell population

  • Decreased clotting ability

    Megakaryocytes unable to replicate, plateletes consumed

  • Altered wound healing

    Fibroblasts damaged by irradiation do not replicate at normal rate

  • Immunosuppression

Module Medical XIV.


Combined i njury i mmunological e ffects l.jpg

Combined injury immunological effects

  • Bone marrow suppression

  • Consumption of inflamatory reserves

  • Disruption of epidermal barriers

  • Depression of reticuloendothelial system

Module Medical XIV.


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Experience from Hiroshima and Nagasaki patients

  • Complications developed 2 to 3 weeks after exposure characteristic of bone marrow depression effects

  • Open wounds stopped healing, haemorrhaged

  • Many patients died of sepsis

Module Medical XIV.


Wound p roblems l.jpg

Wound problems

  • Wound colonization

  • Failed delayed primary closure

  • Wound sepsis

  • Delay in healing

  • Occasional amputation

  • Radiologically contaminated wound

Module Medical XIV.


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Treatment

  • Control haemorrhage

  • Debride extensively

  • Repair vital structures

  • Irrigate

  • Consider wound closure

Module Medical XIV.


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Timing of surgical management

Module Medical XIV.


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Combined radiation injuryReview-I

  • Diagnosis, treatment and prognosis are much more complex in CRI

  • Haematological indices and other laboratory tests can be modified in a way that makes diagnosis of radiation component difficult

Module Medical XIV.


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Combined radiation injuryReview-II

  • Because radiation injury is not immediately life threatening, initial care should address emergency medical procedures for ventilation, perfusion and treatment of haemorrhage

Module Medical XIV.


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Combined radiation injuryReview-III

  • Patients with multiple injuries complicated by radiation injury require more aggressive treatment than non-irradiated patients

  • Combined injury requires all urgent surgery to be completed within 48 hours of irradiation

Module Medical XIV.


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