Post on 18-Dec-2015
transcript
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 According to radiation dose combined with other factors, combined radiation injures (CRI) other factors, combined radiation injures (CRI) can be classified as:can be classified as: thermal CRI:thermal CRI: external/internal irradiation external/internal irradiation
with thermal burnswith thermal burns mechanical CRI:mechanical CRI: external/internal external/internal
irradiation with wound or fracture, or haemorrhageirradiation with 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 injures
Presence 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
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
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 0
Moderate 2 – 4 55 1 0
Severe 4 – 6 21 7 6
Extremely severe
6 – 10 21 20 20
Chernobyl conclusions
Radiation 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 indicationsindications
Some radiation burns did not reepithelialize and Some radiation burns did not reepithelialize and required surgeryrequired surgery
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
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
TriageTriage
In 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