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	Radiation + Trauma (Combined Injury) General Information Expected Changes in Triage Categories After Whole-body Irradiation References 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 Ensure the safety of the responders Evaluate and treat patients with life-threatening injuries 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 top of page Expected Changes in Triage Categories After Whole-body Irradiation D 1. Based on dose of radiation (in units of gray) (What is gray (Gy)?) 2. Priorities in triage of patients with and without combined injury 3. Definition of triage categories: minimal, delayed, immediate, expectant Source: Planning Guidance for Response to a Nuclear Detonation, First edition, page 74, 1/16/2009 (PDF - 1.69 MB), (Homeland Security Council Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats) top of page References Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster (PDF - 503 KB) (REAC/TS) Ledney GD, Elliott TB. Combined injury: factors with potential to impact radiation dose assessments. Health Phys. 2010 Feb;98(2):145-52. [PubMed Citation] Pellmar TC, Ledney GD. Combined Injury: Radiation in Combination with Trauma, Infectious Disease, or Chemical Exposures (PDF - 222 KB) (NATO RTG-099, 2005) 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] Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation] Combined Injury Modeling: Radiation and Burn Workshop Report (PDF - 335 KB) (Defense Threat Reduction Agency, 2010)

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