Combined radiation injuries
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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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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.


Triage l.jpg
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.


Secondary a ssessment of c ombined i njury l.jpg
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.


Burns and r adiation l.jpg
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.


Sytemic r esponse to m ajor b urn i njury l.jpg

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.


Causes of b urn d eaths l.jpg
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.


Expected m ortality from t hermal i njuries l.jpg
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.


Principles of c ontrolling i nfection in b urn c are l.jpg
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.


Chernobyl victims c lassification l.jpg

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.


Chernobyl conclusions l.jpg
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.


Wounds and r adiation l.jpg
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.


Experience from hiroshima and nagasaki p atients l.jpg
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.


Treatment l.jpg
Treatment

  • Control haemorrhage

  • Debride extensively

  • Repair vital structures

  • Irrigate

  • Consider wound closure

Module Medical XIV.


Timing of s urgical m anagement l.jpg
Timing of surgical management

Module Medical XIV.


Combined radiation injury review i l.jpg
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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