COMBINED RADIATION INJURIES

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COMBINED RADIATION INJURIES
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Effects of nuclear weapons and nuclear accident
The detonation of atomic bombs over Hiroshima and
Nagasaki on 6 9 August 1945
Chernobyl nuclear reactor accident on 26 April
1986
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Combined radiation injuries

• Combined radiation injuries is the kind of
  defeats arising at simultaneous or consecutive
  influence on an organism of ionizing radiation
  and non-radiation factors

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Classification of combined radiation injures

• According to radiation dose combined with other
  factors, combined radiation injures (CRI) can be
  classified as
• thermal CRI external/internal irradiation with
  thermal burns
• mechanical CRI external/internal irradiation
  with wound or fracture, or haemorrhage
• thermal-mechanical CRI external/internal
  irradiation with thermal burns and wound
  (fracture, haemorrhage)
• chemical CRI external/internal irradiation with
  chemical burns or chemical intoxication

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Predicted distribution of injuries from nuclear
explosion

• Single injuries 30 to 40
• Ionizing radiation 15 to 20
• Burns 15 to 20
• Wounds Up to 5

• Combined injuries 65 to 70
• Irradiation, burns, wounds 20
• Irradiation, burns 40
• Irradiation, wounds 5
• Wounds, burns 5

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Distinctive features of combined radiation
injures

• Presence at the victim of attributes two or more
  pathologies
• Prevalence of one, heavier and expressed during
  the concrete moment of pathological process,
  so-called a leading component
• Interference (mutual burdening) radiation and
  non-radiation factors, shown as heavier current
  of pathological process, than it is peculiar to
  each component

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Phases (periods)of combined radiation injuries

• The acute phase or the period of primary
  reactions to radiation
• and non-radiation traumas
• The period of prevalence of non-radiation
  components
• The period of prevalence of radiation components
• The recovery phase or the period of restoration

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Burns and radiation
Boy was 1.5 km from the detonation of the
Nagasaki atomic bomb
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Radiation and burns
Radiation burns on Japanese atomic bomb victim
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Sytemic response to burn injury

• After adequate resuscitation hyperdynamic
  state
• increased cardiac output
• diuresis
• peripheral catabolism

• Early period
• shock with hypovolemia
• gastrointestinal ileus
• oligouria

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Causes of burn deaths

• Direct results of accident 13
• Sepsis
  45
• Organ /system failure
• (burn shock, acute renal failure) 41
• Yatrogenic intervention 1

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Expected mortality from thermal injuries
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Combined effects of simultaneous whole body
irradiation and burns
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Principles of burn therapy

• Topical antimicrobials
• Early grafting
• Stimulation of the bone marrow and possibly of
  skin regeneration with cytokines

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Initial surgery
Complete graft healing after 8 days
Major skin necrosis on both legs, extending to
subcutaneous tissue
Epifascial excision of necrotic skin
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Treatment of contaminated burn injuries

• Gentle decontamination after stabilization
• Passive tetanus immunization even in previously
  immunized patients

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Classification of Chernobyl victims
 
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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
• Bone marrow transplantation is very limited
  indications
• Some radiation burns did not reepithelialize and
  required surgery

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Wounds and radiation
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Trauma repair
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Effects of persistent pancytopenia

• Decreased oxygen capacity
• 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

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Immunosuppressive effect

• Bone marrow suppression
• Consumption of inflamatory reserves
• Disruption of epidermal barriers
• Depression of reticuloendothelial system

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Principles of treatment

• Control haemorrhage
• Examine and remove all questionable tissue and
  foreign material
• Repair vital structures
• Irrigate
• Consider wound closure

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Problems of wound treatment

• Wound colonization
• Wound sepsis
• Failed delayed primary closure
• Delay in healing
• Occasional amputation
• Radioactive nuclides contaminated wound

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Timing of surgical management
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Hiroshima and Nagasaki conclusions

• Complications developed 2 to 3 weeks after
  exposure characteristic of bone marrow depression
  effects
• Open wounds stopped healing, haemorrhaged
• Many patients died of sepsis

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Medical management

• Triage
• Emergency care
• Definitive care

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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 injuries first

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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

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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

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Prognosis

• Prognosis for all combined injuries worse than
  for radiation injury alone
• Infections much more difficult to control
• Burns, wounds and fractures heal more slowly

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Summary of lecture

• Diagnosis, treatment and prognosis are much more
  complex in combined radiation injures
• Haematological indices and other laboratory tests
  can be modified in a way that makes diagnosis of
  radiation component difficult
• Because radiation injury is not immediately life
  threatening, initial care should address
  emergency medical procedures for ventilation,
  perfusion and treatment of haemorrhage
• Combined injury requires all urgent surgery to be
  completed within 48 hours of irradiation

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Lecture is ended
THANKS FOR ATTENTION
In lecture materials of the International Atomic
Energy Agency (IAEA), kindly given by doctor
Elena Buglova, were used