Radiation + Trauma (Combined Injury)

General Information

  • Combined injury is physical, thermal, and/or chemical trauma combined with radiation exposure at a dose sufficient to diminish the likelihood of overall survival or functional recovery.
  • Combined injury will be common in a radiation mass casualty event
    • Combined injury patients have a worse overall prognosis than do patients with trauma alone or radiation exposure alone
  • Treatment priorities in order are
    1. Ensure the safety of the responders
    2. Evaluate and treat patients with life-threatening injuries
    3. Manage radiation issues, including internal and external contamination and exposure
  • Personal Protective Equipment (PPE) must be worn by first responders in the field and
    • Wearing appropriate PPE diminishes risk to responders, especially if patients have external contamination
    • Medical personnel wearing appropriate PPE generally receive minimal radiation exposure from patients who have only radiation contamination, with the exception of patients who have radioactive shrapnel
    • The radiation safety team should limit duty time of responders/receivers in an environment of high contamination and/or continuing exposure. (See Response Worker Exposure Guidelines)
  • Trauma treatment resources available to victims will be determined by
    • Status and capacity of response infrastructure
    • Number of victims
  • Mass casualty triage algorithms improve efficiency and outcome; examples include
    • START Triage Algorithm (Adult)
    • JumpSTART Triage Algorithm (Children)
  • Triage tags, especially designed for radiation incidents, are helpful in a mass casualty event
    • Radiation triage tags record radiation dose, type of exposure, distribution of contamination, decontamination procedures performed, and results of decontamination in addition to the standard emergency parameters
    • Some tags can also record chemical and biological exposures and treatments
  • Burn triage issues must also be considered
  • Combined injury management and the Acute Radiation Syndrome
    • Dose guidelines for initiating growth factor therapy may be lower in patients with combined injury
    • Decisions concerning use of growth factors depend on
      • Size of the radiation mass casualty incident
      • Total number of victims
      • Nature of their injuries
      • Availability of resources
  • Managing contaminated open wounds
  • Surgery and the Acute Radiation Syndrome
    • There may be a 24- to 36-hour window when surgery can be performed prior to the onset of cytopenias in the Acute Radiation Syndrome

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Expected Changes in Triage Categories After Whole-body Irradiation

Scarce Resources Triage Tool:

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  1. Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster (PDF - 503 KB) (REAC/TS)
  2. Ledney GD, Elliott TB. Combined injury: factors with potential to impact radiation dose assessments. Health Phys. 2010 Feb;98(2):145-52. [PubMed Citation]
  3. Pellmar TC, Ledney GD. Combined Injury: Radiation in Combination with Trauma, Infectious Disease, or Chemical Exposures (PDF - 222 KB) (NATO RTG-099, 2005)
  4. Dicarlo AL, Hatchett RJ, Kaminski JM, Ledney GD, Pellmar TC, Okunieff P, Ramakrishnan N. Medical Countermeasures for Radiation Combined Injury: Radiation with Burn, Blast, Trauma and/or Sepsis. Report of an NIAID Workshop, March 26-27, 2007. Radiat Res. 2008 Jun;169(6):712-21. [PubMed Citation]
  5. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation]
  6. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury (The National Academy Press, 2016)
  7. Combined Injury Modeling: Radiation and Burn Workshop Report (PDF - 335 KB) (Defense Threat Reduction Agency, 2010)