COMBINED INJURY

Nuclear weapons and RDD detonations can result in radiation exposure, external and internal contamination, and concomitant trauma. Combined injuries have a synergistic effect leading to a poorer prognosis.24,25

Patients with hematopoietic subsyndrome of ARS will have an increased risk of infection and hemorrhage. Myeloid cytokine therapy and romiplostim should be initiated as soon as possible.24,26,27 Surgical procedures should be completed as soon as possible before lymphopenia and thrombocytopenia occurs. Use of cytokines may prolong the surgical window prior to cell line depletion. Transfusions should be accomplished with irradiated blood products, when possible.

Table 10. Combined Effects of Whole-Body Irradiation and Burns in Various Animal Models

INITIAL MEDICAL CARE

- Standard life saving interventions for combined injuries.
- XABCs (Exsanguination risks, Airway, Breathing, Circulation).
- Assess risks for Acute Radiation Syndrome AFTER lifesaving treatment.
- Vomiting <4 hours → Presume patient WILL be
- Begin serial Complete Blood Counts every 6-8 hours to assess for hematopoietic subsyndrome on all patients at risk.
- Lymphocyte kinetics: 50% drop in lymphocytes at 48 hours correlates with 3-4 GRAY dose.
- Consider advanced biodosimetry techniques like Dicentric Chromosome Assays (DCA).

PREGNANCY

- Fetus is very sensitive to radiation.
- Dose to fetus is usually less than mother, except when:
  - Internal contamination is present - bladder proximity to uterus
  - With radioiodine exposure - the fetal thyroid is very iodine avid after 12 weeks
- Requires patient specific dose estimate.
- Category C drugs (adverse effect in animals but not studied in humans)
- All colony stimulating factors
- Most antimicrobials
- Many antiemetics
- Water is a great way to shield from radiation.

EARLY SURGICAL INTERVENTION

- Refers to procedures that are not lifesaving (which should be done immediately), but procedures that should be done within 1-2 weeks for a normal non-irradiated patient (e.g. facial bone fractures)
- Surgery should be done before Neutrophils and Platelets begin dropping
- Within the first 36 – 48 hours
- Use of G-CSF cytokines might be able to extend this window

Figure 6. Surgical timing within 36-48 hours