COMBINED RADIATION COMBINED RADIATION INJURIESINJURIES

Effects of nuclear weapons and nuclear accident

Chernobyl nuclear reactor accident on 26 April 1986

The detonation of atomic bombs over Hiroshima and Nagasaki

on 6 & 9 August 1945

Combined radiation injuries

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

Classification of combined radiation injures

According to radiation dose combined with other According to radiation dose combined with other factors, combined radiation injures (CRI) can be factors, combined radiation injures (CRI) can be classified as:classified as: thermal CRI:thermal CRI: external/internal irradiation external/internal irradiation

with thermal burnswith thermal burns mechanical CRI:mechanical CRI: external/internal irradiation external/internal irradiation

with wound or fracture, or haemorrhagewith wound or fracture, or haemorrhage thermal-mechanical CRI:thermal-mechanical CRI: external/internal external/internal

irradiation with thermal burns and wound (fracture, irradiation with thermal burns and wound (fracture, haemorrhage)haemorrhage)

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

Predicted Predicted ddistribution ofistribution of iinjuries njuries from from nnuclear uclear eexplosionxplosion

Single Single iinjuries njuries 3030 % to 40% to 40 %%– Ionizing Ionizing rradiationadiation 1515 % to 20% to 20 %%– Burns Burns 1515 % to 20% to 20 %%– Wounds Up to 5Wounds Up to 5 %%

Combined Combined iinjuries: njuries: 6565 % to 70% to 70 %%– Irradiation, burns, wounds Irradiation, burns, wounds 20 20 %%– Irradiation, burns Irradiation, burns 4040 %%– Irradiation, wounds Irradiation, wounds 55 %%– Wounds, burns Wounds, burns 55 %%

Distinctive features of combined radiation injuresPresence at the victim of attributes two or Presence at the victim of attributes two or more pathologiesmore pathologies

Prevalence of one, heavier and expressed Prevalence of one, heavier and expressed during the concrete moment of pathological during the concrete moment of pathological process, so-called “a leading component”process, so-called “a leading component”

Interference (mutual burdening) radiation and Interference (mutual burdening) radiation and non-radiation factors, shown as heavier non-radiation factors, shown as heavier current of pathological process, than it is current of pathological process, than it is peculiar to each componentpeculiar to each component

Phases (periods)of combined radiation injuries

The acute phase or the period of primary The acute phase or the period of primary reactions to radiation reactions to radiation and non-radiation traumasand non-radiation traumas

The period of prevalence of non-radiation The period of prevalence of non-radiation componentscomponents

The period of prevalence of radiation The period of prevalence of radiation componentscomponents

The recovery phase or the period of restorationThe recovery phase or the period of restoration

Burns and Burns and rradiationadiation

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

Radiation and burns

Radiation burns on Japanese atomic bomb victim

Sytemic response to burn injury

Early periodEarly period– sshock with hock with

hypovolemiahypovolemia– gastrointestinalgastrointestinal

ileusileus– ooligligoouriauria

After adequate resuscitation – hyperdynamic stateyperdynamic state::

iincreased ncreased cardiac outputcardiac output ddiuresisiuresis pperipheral eripheral catabolismcatabolism

Causes of burn deaths

• DDirect results of accident irect results of accident 1313 %%• SSepsis epsis 4545 %%• OOrgan rgan //system failure system failure (burn shock, acute renal failure) (burn shock, acute renal failure) 4141 %%• YYatrogenic intervention atrogenic intervention 1 1 %%

Expected mortality from thermal injuries

Burn Burn aarearea,,% of % of bbody ody ssurface urface aarearea

Expected Expected mmortalityortality

> 30> 30 100100 % %

1010 –– 3 300 Survive Survive possible possible with with specific treatmentspecific treatment

<< 1010 Survive even without Survive even without treatmenttreatment

Combined effects of simultaneous whole body irradiation and burns

Principles of burn therapy

Topical antimicrobialsTopical antimicrobials

Early graftingEarly grafting

Stimulation of the bone marrow Stimulation of the bone marrow and and

possibly ofpossibly of skin regeneration skin regeneration with with

cytokinescytokines

Initial surgery

Major skin necrosis on both legs, extending to

subcutaneous tissue

Epifascial excision of

necrotic skin

Complete graft healing after 8 days

Gentle decontamination after stabilization

Passive tetanus immunization even in previously immunized patients

Treatment of contaminated burn injuries

CClassification lassification of of Chernobyl Chernobyl victimsvictims

 

Radiationinjury

Dose,Gy

Number of hospitalized patients

Total Death Radiation burns

Slight 1 – 2 140 0 0Moderate 2 – 4 55 1 0

Severe 4 – 6 21 7 6

Extremely severe

6 – 10 21 20 20

Chernobyl conclusionsRadiation burns frequentRadiation burns frequentBurns over 50 % of body surface led to death in Burns over 50 % of body surface led to death in 19 out of 28 cases19 out of 28 cases Internal contamination was present in most of Internal contamination was present in most of patients, however, it was significant just in a few patients, however, it was significant just in a few casescasesSepsis uniform cause of deathSepsis uniform cause of deathBone marrow transplantation is very limited Bone marrow transplantation is very limited indicationsindicationsSome radiation burns did not reepithelialize and Some radiation burns did not reepithelialize and required surgeryrequired surgery

Wounds and radiation

Trauma repair

Effects of Effects of ppersistent ersistent ppancytopeniaancytopenia

Decreased oxygenDecreased oxygen capacitycapacityLack of release of new erythrocytes and Lack of release of new erythrocytes and aging of red cell populationaging of red cell population

Decreased clotting abilitDecreased clotting abilityyMegakaryocytes unable to replicateMegakaryocytes unable to replicate,, plateletes consumedplateletes consumed

Altered wound healingAltered wound healingFibroblasts damaged by irradiation do not Fibroblasts damaged by irradiation do not replicate at normal ratereplicate at normal rate

ImmunosuppressionImmunosuppression

Immunosuppressive effect

Bone marrow suppressionBone marrow suppression

Consumption of inflamatory reservesConsumption of inflamatory reserves

Disruption of epidermal barriersDisruption of epidermal barriers

Depression of reticuloendothelial Depression of reticuloendothelial systemsystem

Principles of tPrinciples of treatmentreatment

Control haemorrhageControl haemorrhage Examine and remove alExamine and remove all questionable l questionable tissue and foreign materialtissue and foreign material

Repair vital structuresRepair vital structures

IrrigatIrrigatee

CConsideronsider w wound closureound closure

PProblemsroblems of wound treatment of wound treatment

Wound colonizationWound colonization Wound sepsisWound sepsis Failed delayed primary closureFailed delayed primary closure Delay in healingDelay in healing Occasional amputationOccasional amputation Radioactive nuclidesRadioactive nuclides contaminated contaminated woundwound

Timing of Timing of ssurgical urgical mmanagementanagement

Hiroshima and Nagasaki Hiroshima and Nagasaki conclusions

ComplicationsComplications developed developed 2 to 3 weeks 2 to 3 weeks after exposure characteristic of bone after exposure characteristic of bone marrow depression effectsmarrow depression effects

Open wounds stopped healing, Open wounds stopped healing, haemorrhagedhaemorrhaged

Many patientsMany patients died of sepsis died of sepsis

Medical managementMedical management

TriageTriage Emergency careEmergency care Definitive careDefinitive care

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

Initial triage of combined injury Initial triage of combined injury patients based on conventional injuriespatients based on conventional injuries

Treat associated injuries firstTreat associated injuries first

Emergency procedures

First actions standard emergency First actions standard emergency medical proceduresmedical procedures::– vventilationentilation– circulationcirculation– sstop haemorrhagetop haemorrhage Decontamination after stabilizationDecontamination after stabilization Survivable radiation injury not Survivable radiation injury not acutacuteely life tly life thhreateningreatening

Secondary Secondary aassessment of ssessment of ccombined ombined iinjurynjury

Primary surgical responsibilitiesPrimary surgical responsibilities::– sstabilizetabilize– sset surgical prioritieset surgical priorities– pperform surgeryerform surgery Secondary responsibilitiesSecondary responsibilities::– mmanage post-operative courseanage post-operative course– aassess radiation exposure in post-ssess radiation exposure in post-

operative or post-stabilization periodoperative or post-stabilization period

Prognosis

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

Infections Infections much more difficult to much more difficult to controlcontrol

Burns, wounds and fractures heal Burns, wounds and fractures heal more slowlymore slowly

Summary of lecture• Diagnosis, treatment and prognosis are much more Diagnosis, treatment and prognosis are much more

complex in combined radiation injurescomplex in combined radiation injures• Haematological indices and other laboratory tests Haematological indices and other laboratory tests

can be modified in a way that makes diagnosis of can be modified in a way that makes diagnosis of radiation component difficultradiation component difficult

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

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

Lecture is endedLecture is ended

THANKS FOR ATTENTION

In lecture materials of the International Atomic Energy Agency (IAEA), kindly given by doctor Elena Buglova, were used