Radiation + Trauma (Combined Injury)

• General Information
• Expected Changes in Triage Categories After Whole-body Irradiation
• References

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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
  • Special procedures are needed for external decontamination in the presence of open wounds
  • Careful removal of radioactive shrapnel is required
• 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
    • Use of white cell growth factors (cytokines) may alter this time window
    • Close hematologic monitoring is required before and after surgery
    • Leuko-reduced, irradiated blood is required to treat blood loss for any patient with dose from exposure > 2 Gy

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Expected Changes in Triage Categories After Whole-body Irradiation

Scarce Resources Triage Tool:

• Proposes a method of changing triage assignments during austere conditions after an IND detonation
• The tool is based on a group of 10 publications from many experts.

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References

1. Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster (PDF - 503 KB) (RITN)
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)