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COMBINED RADIATION INJURIES

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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  1. COMBINED RADIATION INJURIES Module XIV

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. Medical Management • Triage • Emergency care • Definitive care Module Medical XIV.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. Burns and radiation Boy was 1.5 miles from the detonation of the Nagasaki atomic bomb Module Medical XIV.

  12. Radiation and burns Radiation burns on Japanese atomic bomb victim Module Medical XIV.

  13. 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.

  14. 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.

  15. Expected mortality from thermal injuries Module Medical XIV.

  16. Combined effects of simultaneous whole body irradiation and burns on rats Module Medical XIV.

  17. Burn therapy • Topical antimicrobials • Early grafting • Stimulation of the bone marrow and possibly of skin regeneration with cytokines Module Medical XIV.

  18. Principles of controlling infection in burn care • Use antimicrobials • Support immune mechanisms • Eliminate infection reservoirs • Suppress infection transfer Module Medical XIV.

  19. 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.

  20. 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.

  21. Treatment of Contaminated Burn Injuries • Gentle decontamination after stabilization • Passive tetanus immunization even in previously immunized patients Module Medical XIV.

  22. 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.

  23. 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.

  24. Wounds and radiation Module Medical XIV.

  25. Trauma repair Module Medical XIV.

  26. 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.

  27. Combined injury immunological effects • Bone marrow suppression • Consumption of inflamatory reserves • Disruption of epidermal barriers • Depression of reticuloendothelial system Module Medical XIV.

  28. 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.

  29. Wound problems • Wound colonization • Failed delayed primary closure • Wound sepsis • Delay in healing • Occasional amputation • Radiologically contaminated wound Module Medical XIV.

  30. Treatment • Control haemorrhage • Debride extensively • Repair vital structures • Irrigate • Consider wound closure Module Medical XIV.

  31. Timing of surgical management Module Medical XIV.

  32. 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.

  33. 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.

  34. 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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