MINISTRY OF PUBLIC HEALTH OF THE REPUBLIC OF …
MINISTRY OF PUBLIC HEALTH OF THE REPUBLIC OF KAZAKHSTAN
EDUCATIONAL-METHODICAL SECTION
OF KAZAKH STATE MEDICAL ACADEMY
ON SPECIALITIES OF HIGHER AND POST GRADUATE EDUCATION
KARAGANDA STATE MEDICAL ACADEMY
Taijanova D. J., Toleuova A.S., Kotlyarova O.A.,
Yevseenko L.V.
SPECIAL LECTURES BY MILITARY FIELD THERAPY
Educational manual
Karaganda 2007
UDK 61.355
BBK 58я7
D.J.Taijanova, A.S.Toleuova, O.A.Kotlyarova, L.V.Yevseenko the educational methodical manual “Special lectures by military field therapy". Karaganda, 2007.
Reviewers:
Umbetalina N.S. – d.m.s., professor, the head of department of internal diseases EIF and SPE.
Molotov – Luchanskiy V. B. - c.m.s., assistant professor, the head of department for the
assistant professors’ course of nursing management at KSMA
Baydurin S.A.- d.m.s., professor, the head of department of internal diseases of KazSMA
In this educational methodical manual are presented the contemporary concepts about diseases meeting during War condition, the contemporary diagnostics methods, the criteria of diagnostics, contemporary approaches to the treatments. Educational methodical manual is intended for the foreign students of High Medical School - Institute of Higher Education and interns.
Confirmed and recommended for edition of Academic Council of KSMA
Protocol № _10___ of _26.04.2007
BASIS OF THE ORGANIZATION OF THERAPEUTIC AID IN WORKING ARMY
Definition
Military field therapy – is one of the most important clinical military medicines. Cardinal goals of military field medicine are:
1. Introduction of scientifically based, systematic and perfect methods in the practice of the organizational forms of providence of therapeutic aid to the injured and in patients of other causes in different conditions of military activities of the army.
2. Study of etiology, pathogenesis, clinical signs, earlier diagnosis, prophylaxis, and treatment of the internal diseases, occurred by the action of weapons of mass destruction (atomic, chemical, and bacteriological).
3. Study, prophylaxis, and treatment of the pathological processes occurred in internal organs by the action of fighting traumas (injury, burns, and contusion).
4. Study of the characteristics of the development, clinical progress, and treatment of the diseases in conditions of working army; to this group are also included diseases related with poor professional factors of the armed forces (non favorable conditions of living of the armed forces, and interaction of different forms of toxic substances).
5. Introduction of most effective and available methods of treatment and prophylaxis of diseases in practice in conditions of working army, and the problems of military-medical expertise too.
Military field medicine in conditions of war is the same as in peace conditions, which are as following:
a) knowledge about the development of the diseases and principles of therapeutic aid in all stages of medical evacuations are the same;
b) sequence in the reception of the checking of patients and injured during evacuation;
c) short and correct documentation.
Modern war missions have problems of the following characteristics:
a) To provide qualified therapeutic aid in conditions of war times, in patients undergoing inflammation by use of weapons of mass destruction in different forms of armed forces (armed forces, air forces, submarines, and bran tanks techniques), and also necessary knowledge about climate, hill areas, and possible use of weapons of the enemy. All these factors have a great role in the organization of therapeutic aid in armed forces during war. In all stages of evacuation it is not only necessary to diagnose the disease but also to make the medical-evacuator prognosis, to describe place of effective treatment, and to estimate duration of treatment at that point. Medical work is significantly complicated by the use of weapons of mass destruction by enemies, when there will be admitted mass of inflamed. In this case transporting in short duration is needed, sanitary procedures for the injured, the description of the characteristics of the diseases, the emergency aid, and further evacuations should be done.
It means that doctors working in such conditions should know the clinical signs of the disease, prophylaxis, and treatment in details; he should be tougeed the principles of organization of therapeutic aid in war times. Doctors working in armed forces nowadays should have knowledge on radioactive inflammations and infectious diseases. Most important thing in the case of war conditions is morbidity rate of the armed forces. Different causes of the diseases always act in conditions of battle field. In armed forces it is most common to face different conditions in different wars. All authors who studied the morbidity rate of the passed wars observe the increase of the morbidity rate in war time in comparison with the peace time due to different factors. Past and latest data of the research works show that the number of the patients with diseases caused by disorders of sanitary norms is more than injured.
Study of the past wars show that morbidity rate increases due to infectious diseases in the forms of epidemic, and lethal rate was higher than in injured. Most common diseases in those wars were fever and diarrhea (infections). In the period of passed wars most common were flu, tuberculosis, pneumonia, infectious hepatitis, and other diseases. The cause of the high morbidity rate was the disorder of sanitary norms of the country and armed forces. The study of the rate: World War II in Russia shows such morbidity.
70% of the patients suffered from diseases of internal organs and 30% suffered from nervous, skin, venereal and infectious diseases. In that period most of the diseases characterized for that region disappeared, but other diseases developed with different clinical signs, not characterized for the region.
The rate of rheumatism, bronchial asthma, and croup pneumonia were significantly decreased, but diseases of GIT and hypertension were increased significantly, mostly in young individuals. Diseases of respiratory organs were also increased. Clinical observations showed increased rate of chronic bronchitis in armed forces. Frequent rate of pneumosclerosis was related with bronchitis and pulmonary emphysema. Pneumosclerosis and pulmonary emphysema led into the development of cardiac insufficiency. Frequency of nephritis was also observed. Following characteristics of the pathologies of internal diseases of war times show the appearance of some new and unusual diseases for the region. They are called as diseases of war. These two groups of diseases included: dystrophy, avitaminosis, acutely developed hypertension disease, bronchiolitis and other diseases as Krim’s fever, encephalitis, tularemia, and capillary toxicosis. Experiments of the physicians in period of World War II show that most common diseases of war times were diseases of GIT (non infectious) – 25-30%, on second place were diseases of respiratory organs – 13-20%, and on third place - diseases of CVS, and the diseases of kidneys were on the last place.
In conditions of latest wars, related with the use of weapons of mass destruction, treatment of the patients with diseases of internal organs is one of the important goals of military field medicine. As well as due to disorders of reactivity of organisms under actions of unfavorable conditions. The increased morbidity and a number of patients may not be observed together with the changes of the progress of the diseases. In this case it is to be noted that changed reactivity of the organism may not be only due to intake of medicines, but also due to such pathologies as burns, intoxications, and other diseases related with tissue destructions. In last decade in most of the countries increased rate of allergic reactions (bronchial asthma) was observed. Bronchospasm in chronic bronchitis and pneumonia were observed in more than 61% of patients.
So according to the presence of increased allergic status from one side, and the development of side effects by the use of different antibiotics from other side, especially in patients and injured in the battlefield, whose metabolism is significantly disordered and leads into changed reactivity of the organism. The problem of allergy needs accurate and deep study.
Diagnosis and treatment of the diseases of internal organs in war times is difficult and important task. Diagnosis is mostly based on the data of physical and clinical signs of the patients. Laboratory diagnosis is performed in rare cases.
Structure of the sanitary loss of the therapeutic profile
It is to be noted that some of the characteristics of the sanitary loss of the therapeutic profile in a case of the use of weapons of the mass destruction help in the description of organization of therapeutic aid to inflamed and patients. Principally a new and important fact is that injured need in therapeutic aid are mostly patients with radiation affects, affected from biological weapons, contused and injured and also there may be combined forms of inflammations.
It is most important to note that many groups of injured or inflamed in war times need the emergency therapeutic aid. Research data show that about 30% of patients with acute radiation inflammation need emergency therapeutic aid. More complex is the organization of therapeutic aid in patients affected by biological or chemical weapons. Research data show that more than 60% of the affected will be in need of emergency therapeutic aid. More complicated will be the isolation of groups of different affects, as they represent the danger for other groups.
Organization of therapeutic aid is not only responsible for the emergency aid and treatment, but also their great problem is the prophylaxis, diagnosis, and treatment of the injured, contused and other groups of injured. Nowadays the role of therapeutists is most important due to the use of weapons of mass destruction, leading the increased number of patients with combined pathologies.
Principles of transportation of injured and patients of therapeutic profile
In difference with other past wars the latest wars are characterized by weapons of mass destruction, and transport of the injured and patients is of great importance in the organization of the therapeutic aid.
Transport of the injured and affected patients should be made on the level of battalion and brigade of medical blocks into a medical sanitary battalion and hospitals. Common goal of the battalion is the evacuation and transport of patients with the same group of injury (affect) needing the same therapeutic aids.
Patients and injured who need the therapeutic aid may be divided into 3 groups according to which they are to be transported in medical blocks and hospitals.
The 1st principle is: differentiation of groups of injured and patients needing special procedures and isolation. To these affected by the chemical and biological weapons, ionized radiation, patients with infections, and patients with acute reactive states are included. All these groups of patients are transported to the same post and here their isolation in similar medical blocks or hospitals is organized.
The next principle of transportation: the division of the patients and injured into groups: needing the medical aid at this point and not. These groups include patients with serious injuries and those needing complex manipulations according to the possibilities of the post. This group also included agonized patients needing only in care and to relief their sufferings and patients of life importance and with severe radiations affects, psychoneurotic, somatic disorders and so on.
Medical transportation by principles of need in medical aid in transport-evacuator stages are distributed in 4 groups:
1. needing in emergency aid of life importance;
2. not needing in medical aid at this stage;
3. patients with mild lesions;
4. agonized patients.
According to war conditions and medical possibilities the distinguishing of these group criteria may be significantly changed.
To determine evacuation-transport classification of the patients is necessary. Problems of the evacuation and transport are solved not only at the stage of classification and evacuation but in hospital too: exactly in all divisions of medical blocks. First of all are distinguished temporarily non transportable patients; e.g.: with severe and moderate levels of injury and with toxic edema of lungs; with severe action of microbial toxins and some somatic patients with acute cardiovascular failure. But most of the affected are to be evacuated by sanitary aviation.
Then it is necessary to solve the problem: “who may be and must be evacuated” at first those who have indications for the emergency medical aid. The patients with acute severe injuries should be evacuated with the help of auto transport in laying position. Further evacuation of injured with mild and moderate forms should be proceeded in any possible position. These groups are determined for every medical block for the effective medical aid. It is to be noted that these all points are most important and necessary in the organization of therapeutic aid in armed forces in war times.
Therapeutic aid in case of mass admission of injured
Therapeutic help must be provided on all stages of the medical evacuation, but the volume of aid will be changed according to the concrete war and medical conditions. It is to be noted that only 3 basic characteristics should be applied to provide the therapeutic aid in modern wars.
In a case of diseases and injuries such medical aid should be provided.
First emergency aid:
- on the battle field (sights of sanitary loss);
- pre-medical aid;
- first medical aid;
- qualified therapeutic aid in hospitals;
- specialized medical aid and treatment in hospitals.
First medical aid to injured and patients is provided on the place of injury by the injured (self aid), also by colleges (inter aid), and by medical staff of the armed forces. This is provided with the help of simple methods: the help in the survival of the patients and the decrease of the risk of the development of complications. In war times individual medicines are used of armed forces and reserves of the medical properties. In war injuries and diseases of therapeutic profile the first aid is provided with the help of medicines paraenterally, artificial respiration, getting off clothes, wearing anti-gas and evacuation to the safe points.
Pre-medical aid to the injured and patients is provided by doctor’s assistant of the battalion.
Doctor’s assistant provide emergency pre-medical aid to injured, inflamed, and patients in state of asphyxia, shock, cramps, in case of disorders of CVS; While the organization of sanitary procedure of the injured dangerous for the surroundings, in infectious diseases; their evacuation from other patients, prophylaxis of injured caused by acute radiation affects. In premedical aid following things are provided: transfusion of antidotes, analgesics, anti-emetics, cardiovascular drugs, and wash of eyes, mouth, and nose. Wash of the stomach in a case of ingestion of toxic substances, inhalation of O2, and artificial respiration.
Regimental medical block is of great importance in the provision of the medical aid of therapeutic characteristics. At this point patients and injured of war get the first therapeutic aid, which is directed to the removal and prophylaxis of life dangerous status, prophylaxis of complications, and evacuation and reference of injured to other places.
Further the doctor of this block distinguishes further grouping of the patients: patients needing in emergency aid, those with mild injuries not needing in emergency aid, and those who are able to continue after medical aid.
The first division is based on emergency and non emergency aid. Emergency aid is needed to the patients with significant disorders of respiration, cardiovascular disorders, patients with shock, toxic edema of lungs, comatose status, cramps, uncontrollable vomiting, significant pain, and in case of other life dangerous situations.
Emergency aid to the first group of patients includes: infusion of antidotes in case of acute intoxications, antitoxic serum in case of bacterial intoxications, non-specific prophylaxis in case of use of bacteriological weapons, removal of foreign bodies from skin, body, eyes, wash of stomach, inhalation of oxygen, artificial respiration, blood reduction 56 injections of cardiovascular drugs (caffeine, cardiamin, camphor, ephidrine), respiratory analeptics (cardiamin, lobelin, sititon), analgesics (promedol, morphine), anti cramps drugs (aminazin, seduxen, magnesium sulfate), ant emetics (atropine, ethaperazine), de-sensibilizing, and other medicines used in case of other life dangerous situations.
Emergency aid to the 2nd group of patients includes: description of symptomatic drugs in the absence of live dangerous situations; anti-toxic treatment, antibiotics, and anti histaminic therapy in case of radio inflammation.
Volume of medical aid, changes according to war conditions and the medical reserve volume.
For accurate provision of medical aid reception and the medical documentation have also a great role. In the primary medical document should be shown diagnosis and performed medical recommendations, also called as primary medical card. In the primary medical card are also shown recommendations for every stage of evacuation, and this card will be with the patients transported to the medical centre, where the patient will be treated according to the pathology.
After the primary medical aid and filling of the primary medical card the injured and patients needing further aid are evacuated to the medical block for the further treatment. Qualified medical help to the injured and patients is provided at the medical block.
Medic-sanitary battalion is the primary block of medical evacuation and here therapeutic aid is provided to the patients and injured by therapeutists. Here the registration of the patients, the first medical aid, division into groups, and if necessary isolation of patients with infectious diseases and disinfection of the wounds is done. Besides the medical block provides temporary hospitalization and treatment of non-transportable patients, treatment of patients with mild injuries and diseases, and patients recovering in duration from to 7-10 days. Hospitalization block is headed by therapeutist, provide therapeutic aid to all un-transportable patients, injured, to patients with surgical manipulations, and also prevent and treat the diseases of internal organs.
Goals of qualified therapeutic aid are: removal of severe and live dangerous complications of war injuries (asphyxia, cramps, collapse, and pulmonary edema), prophylaxis of complications, and formation of favorable conditions for the quick convalescence of the patients and injured.
All manipulations of qualified therapeutic aid are divided into 2 groups:
1. Emergency manipulations in situations of life importance.
2. Manipulations which are delayed.
Emergency manipulations of therapeutic include: the use of antidotes, in acute infections serum infusion, in acute toxicities; the use of specific therapeutic serum (toxicities by bacterial toxins); infusion of cardiovascular drugs; glucocorticoids; blood substitution therapy; and crystalloid solutions in case of cardiac failure; the use of respiratory analeptics, acute artificial respiration in respiratory failure; oxygenation in significant hypoxia; the use of analgesics, desensibilizing drugs, anti emetics, anti cramps drugs in different conditions of emergency statuses; complex therapy in traumatic and burn shocks; therapy of acute renal failure, pulmonary edema; use of tranquilizers and neuroleptics in acute reactive statuses; use of specific drugs in case of injuries of eyes and so on; and use of antibiotics.
To emergency manipulations of therapeutic aid the 2nd group includes: the use of symptomatic medicines, infusion of antibiotics for prophylactic purposes, description of vitamins, physiotherapeutic procedures, and so on.
Specialized medical aid is provided in specialized departments of therapeutic hospitals and in hospitals for the treatment of patients and injured of mild statuses. Specialized medical aid is external form of therapeutic aid provided by general medical specialist with the experience in this field having latest knowledge of diagnosis and treatment. On this stage of management perfect methods of pathogenetic and symptomatic treatment, performed active prophylaxis of possible complications, and wide used physiotherapeutic methods of treatment are used.
Medical documentation
One of the most important things in the evacuation of injured and patients, is the presence of correct and accurate filled primary medical card. This is filled and issued where the first aid is provided to the injured or patient; and with this card the patient is forwarded to the next post of medical aid and evacuation. Second part of the document is then present in accordingly post of medical aid and evacuation. Diagnosis must reflect the characteristics of the disease or injury, clinical progression, level of severity, and the stage of the disease. In primary medical card should also be noted the list of recommended manipulations for the other medical post. Opposite side of the primary medical card is filled on the next post of medical aid and evacuation. Here diagnosis is confirmed, indicated duration and the list of the medical aid manipulations is directed for the next post of medical aid and evacuation. The primary medical card accompanies the patient until the treatment of the disease, and here the card is attached with a case history for the further evaluation of the effect of medical aid and evacuation.
The main document reflecting the dynamics of the progress of disease is a case history of the patient, which is formulated during hospitalization of the patient.
RADIATION EXPOSURE
Harm to people from radiation exposure starts with the damage of cells in the body. The cell damage arises from the damage of constituents of the cell, especially DNA.
Figure 1 shows different types of the damage to DNA produced by the radiation (including ultra violet).
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Figure1. Radiation damage to DNA.
Radiation damage of cells may occur directly from the radiation hit on the critical target or indirectly from free radicals (reactive chemicals) produced by the radiation. Key sources of knowledge of radiation effects are presented in Figure 2 and include knowledge gained from a cell, an animal, and epidemiological studies.
Harm from Small Radiation Doses
Radiation Effects in Somatic and Germ Cells
Most of the cells in the body are somatic cells. Somatic cells are cells other than the germ cells.
Germ cells are involved in reproduction (i.e., producing babies). Skin and lung cells are examples of somatic cells and are not involved in reproduction.
Small radiation doses can affect cells biologically. The effects depend on the type and amount of radiation. These effects include cell killing, altered genes, damaged chromosomes, and cells being temporarily held (arrested) at specific places in the cell cycle called checkpoints.
DNA is checked for damage while cells are arrested at checkpoints, and the damage is most often correctly repaired. However, on rare occasions, the damage is not correctly repaired.
Misrepair (incorrect repair) of DNA damage can lead to unstable DNA in the cell nucleus. Unstable DNA in living cells is called genomic instability.
Cells that survive with genomic instability can, over time, cause big problems for people. Two such problems are cancer in irradiated persons and genetic effects in children of irradiated parents.
Genetic effects arise from genomic instability in germ cells of the irradiated parents.
Cancer arises from genomic instability in somatic cells in the irradiated person.
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Figure 2. Sources of knowledge on radiation effects.
Genetic Effects
Small doses of ionizing radiation can permanently damage DNA in germ cells as previously indicated. One type of permanent damage is gene mutation. A mutation can be transmitted from one generation to another and therefore represents a genetic effect of irradiation.
Two specific germ-cell stages are considered important in evaluating the effects of radiation on the heredity of germ cells:
• the stem-cell spermatogonia in males;
• the oocytes, primarily the immature ones, in females;
• spermatogonia continue to multiply throughout the reproductive life span of an individual. However, oocytes are not replaced during adult life.
The genetic effects that could be caused by radiation are too numerous to be considered here individually. For radiation risk assessment, genetic disorders can be grouped as:
• dominant and X-linked, single-gene disorders;
• chromosome disorders;
• multifactorial disorders.
Harm from Large Radiation Doses
Harm from Short-term Exposure
Large radiation doses can destroy millions or more cells in tissues of the body. Because tissues of the body have important functions, destroying large numbers of cells in tissue can lead to the impairment of organ function, morbidity, and death from organ failure.
Deterministic (nonstochastic) effects of irradiation are those health effects that arise only when large numbers of cells are destroyed by radiation. For such effects, there is a threshold dose below which the health effect does not occur.
For deterministic effects, the severity of the health effect can increase as the radiation dose increases above the threshold.
Deterministic health effects include:
• morbidity;
• lethality;
• associated signs and symptoms or radiation injury.
Deterministic effects usually appear within a few months after brief (short-term) exposure to large radiation doses (e.g., from a nuclear weapon or nuclear accident). The earliest effects seen are associated with what has been called the prodromal phase (acute radiation sickness phase).
The prodromal phase is made up of the symptoms and signs appearing in the first 2 days after brief exposure to radiation. After super-lethal doses of several tens of Gy, all individuals begin to show all symptoms associated with the prodromal phase within about 15 minutes.
Reactions during the prodromal phase are mediated via the autonomic nervous system. They are expressed as gastrointestinal and neuromuscular symptoms.
The gastrointestinal symptoms are:
• appetite loss;
• nausea;
• vomiting;
• diarrhea;
• intestinal cramps;
• salivation;
• dehydration.
The neuromuscular symptoms are:
• fatigue;
• apathy;
• listlessness;
• sweating;
• fever;
• headache;
• low blood pressure (hypotension), followed by hypotensive shock.
Other deterministic effects of irradiation include: bleeding, infection, hair loss, temporary suppressed sperm counts, and permanently suppressed ovulation. Morbidity can arise from damage to the skin, eye, thyroid, liver, lung, bone marrow, and other sites.
Death can arise from severe damage to key organs (e.g., skin, intestines, bone marrow, lung, and liver).
Radiation-induced deterministic effects can adversely impact the performance of humans (i.e., performance degradation). Members of population exposed to a nuclear weapon could be severely impaired by deterministic effects of brief exposure to neutrons and gamma rays.
The US military uses a computer program called HPAC to evaluate performance degradation based on combinations (complexes) of radiation-induced symptoms and signs over time. The time patterns of the symptom complexes depend on the type of exposure (e.g., brief, chronic, etc.).
Prodromal effects of irradiation can also arise from radiation exposure resulting from a nuclear accident or radiological incident. This happened to Russians involved in the Chernobyl accident that occurred in April 1986.
Three hundred Chernobyl accident victims suspected of suffering from the acute radiation sickness were sent to the specialized treatment center in Moscow and to hospitals in Kiev within the first 3 days following the start of the Chernobyl accident. Over the subsequent days, some 200 additional people were admitted for examinations.
Acute radiation sickness was confirmed in 99 of the 128 people (firemen, Unit 4 reactor operators, turbine-room duty officer, and auxiliary personnel) admitted to the specialized treatment center in Moscow during the first 2 days of the Chernobyl accident and in 6 of the 74 victims hospitalized during the following 3 days.
Harm from Long-term Exposure
Deterministic effects also include radiation effects (other than cancer and genetic effects) that continue to occur after an extended period (e.g., years) of chronic (long-term) exposure. Such chronic exposure can arise from long-lived radionuclides ingested via contaminated food or inhaled via contaminated air.
Russian nuclear workers at the Mayak plutonium production facility in the Chelyabinsk region (near the Urals Mountains) were exposed over years to neutrons plus gamma rays and to alpha radiation plus gamma rays. Various deterministic effects were caused by these radiation exposures. Other effects (e.g., cancer) were also induced.
In addition to cancer, genetic effects (in their children), and prodromal effects, two effects were seen in Mayak workers that were not previously reported in western literature: Pneumosclerosis (severe damage to the lung mainly from inhaled plutonium) is one of the new effects reported in Mayak nuclear workers.
Chronic radiation disease (mainly from exposure over years to gamma rays).
Pneunosclerosis appears to be related to radiation pneumonitis and pulmonary fibrosis in the lung.
Chronic radiation disease (or chronic radiation sickness) was originally reported by the Russian physicians, A. K. Gus'kova and G. D. Baysogolov. They described chronic radiation disease as being characterized by varying degrees of cardiovascular, gastrointestinal, and neural system disorders.
Chronic radiation disease occurred mainly in workers with total gamma-ray doses in excess of 1 Gy.
Both pneumosclerosis and chronic radiation disease can occur years after the start of chronic exposure to radiation.
Radiation poisoning, also called "radiation sickness", is a form of damage to organic tissue due to excessive exposure to ionizing radiation. The term is generally used to refer to acute problems caused by a large dosage of radiation in a short period. Many of the symptoms of radiation poisoning occur as ionizing radiation interferes with the cell division. This interference allows the treatment of cancer cells; such cells are among the fastest-dividing in the body, and will be killed by a radiation dose that adjacent normal cells are likely to survive.
Strictly speaking the correct name for "radiation sickness" is acute radiation syndrome. A chronic radiation syndrome exists but is very uncommon; this has been observed among workers in early radium source production sites and in the early days of the Soviet nuclear program. A short exposure can result in acute radiation syndrome; chronic radiation syndrome requires a prolonged high level of exposure.
The use of radionuclides in the science and industry is strictly regulated in most countries. In the event of an accidental or deliberate release of radioactive material, either evacuation or sheltering in place will be Measuring radiation dosage
The rad is a unit of absorbed radiation dose defined in terms of the energy actually deposited in the tissue. One rad is an absorbed dose of 0.01 joules of energy per kilogram of tissue. The more recent SI unit is the gray, which is defined as 1 joule of deposited energy per kilogram of tissue. Thus one gray is equal to 100 rad.
To accurately assess the risk of radiation, the absorbed dose energy in rad is multiplied by the relative biological effectiveness (RBE) of the radiation to get the biological dose equivalent in rems. Rem stands for "Röntgen equivalent in man." In SI units, the absorbed dose energy in grays is multiplied by the same RBE to get a biological dose equivalent in sieverts (Sv). The sievert is equal to 100 rem.
The RBE is a "quality factor," often denoted by the letter Q, which assesses the damage to tissue caused by a particular type and energy of radiation. For alpha particles Q may be as high as 20, so that one rad of alpha radiation is equivalent to 20 rem. The Q of neutron radiation depends on their energy. However, for beta particles, x-rays, and gamma rays, Q is taken as one, so that the rad and rem are equivalent for those radiation sources, as are the gray and sievert. See the sievert article for a more complete list of Q values.
Acute (short-term) vs chronic (long-term) effects
Radiation sickness is generally associated with acute exposure and has a characteristic set of symptoms that appear in an orderly fashion. The symptoms of radiation sickness become more serious (and the chance of survival decreases) as the dosage of radiation increases. These effects are described as the deterministic effects of radiation.
Longer term exposure to radiation, at doses less than that which produces serious radiation sickness, can induce cancer as cell-cycle genes are mutated. If a cancer is radiation-induced, then the disease, the speed at which the condition advances, the prognosis, the degree of pain and every other feature of the disease is not a function of the radiation dose which the person was exposed to.
Since tumors grow by abnormally rapid cell division, the ability of radiation to disturb cell division is also used to treat cancer (see radiotherapy), and low levels of ionizing radiation have been claimed to lower one's risk of cancer (see hormesis).
Exposure
Nuclear warfare
Types of exposure
Nuclear warfare is made more complex by virtue of the fact that a person can be thus burned at least by three processes. The first (the major cause of burns) is not caused by ionizing radiation.
• Thermal burns from infrared heat radiation.
• Beta burns from shallow ionising radiation.
• Gamma burns from highly penetrating radiation.
In the picture on the right the normal clothing that the woman was wearing would have been unable to attenuate the gamma radiation and it is likely that any such effect was evenly applied to her entire body. Beta burns would be likely all over the body due to contact with fallout, but thermal burns are often on one side of the body as heat radiation does not penetrate through a human body. In addition the pattern on her clothing has been burnt into the skin, this is due to the fact that white fabric reflects more infra-red light than dark fabric. As a result the skin close to dark fabric is burnt more than the skin covered by white clothing.
Radiation caused illness and death after the bombings of Hiroshima and Nagasaki in about 1% of those exposed who survived the initial explosions. The casualty rate due to radiation was higher in Hiroshima, because although Fat Man (the bomb used at Nagasaki) had a higher yield than Little Boy (the bomb used at Hiroshima), Fat Man was a plutonium weapon, which is actually much less radioactive than a uranium weapon of equal yield (except at the moment of critical mass).
Radiation work e.g. industrial radiography
Radiation poisoning can result from accidental exposure to industrial radiation sources. People working with radioactive materials often wear electrometer dosimeters or film "badges" to monitor their total exposure to radiation. These devices are more useful than Geiger counters for determining biological effects, as they measure cumulative exposure over time, and are calibrated to change color or otherwise signal the user before exposure reaches unsafe levels. However, film badge types require the film to be developed, as with photographic film, and are used to measure long-term exposure where brief catastrophic exposures are not expected.
Nuclear reactor accidents
Radiation poisoning was a major concern after the Chernobyl reactor accident. It is important to note that in humans the acute effects were largely confined to the accident site. Of the 100 million curies (4 exabecquerels) of radioactive material, the short lived radioactive isotopes such as 131I Chernobyl released were initially the most dangerous. Due to their short half-lives of 5 and 8 days they have now decayed, leaving the more long-lived 137Cs (with a half-life of 30.07 years) and 90Sr (with a half-life of 28.78 years) as main dangers. Thirty-one people died as an immediate result of the Chernobyl accident.
Ingestion and inhalation
When radioactive compounds enter the human body, the effects are different from those resulting from exposure to an external radiation source. Especially in the case of alpha radiation, which normally does not penetrate the skin, the exposure can be much more damaging after ingestion or inhalation. The radiation exposure is normally expressed as a committed effective dose equivalent (CEDE).
Prevention
The best prevention for radiation sickness is to minimize the dose suffered by the human, or to reduce the dose rate.
Time
The longer that the humans are subjected to radiation the larger the dose will be. The advice in the nuclear war manual entitled "Nuclear war survival skills" published by Cresson Kearny in the USA was that if one needed to leave the shelter then this should be done as rapidly as possible to minimize exposure.
In chapter 12 he states that "Quickly putting or dumping wastes outside is not hazardous once fallout is no longer being deposited. For example, assume the shelter is in an area of heavy fallout and the dose rate outside is 400 R/hr enough to give a potentially fatal dose in about an hour to a person exposed in the open. If a person needs to be exposed for only 10 seconds to dump a bucket, in this 1/360th of an hour he will receive a dose of only about 1 R. Under war conditions, an additional 1-R dose is of little concern."
In peacetime radiation workers are taught to work as quickly as possible when performing a task which exposes them to irradiation. For instance, the recovery of a lost radiography source should be done as quickly as possible.
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Distance
The radiation due to any point source will obey the inverse square law: by doubling the distance the dose rate is quartered. This is why radiation workers are always taught to pick up a gamma source with a pair of tongs rather than their hand.
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Shielding
By placing a layer of a material which will absorb the radiation between the source and the human then the dose and the dose rate can be reduced. For instance in the event of a nuclear war it would be a good idea to shelter within a building with thick stone walls (Fallout shelter). During the height of the cold war, fallout shelters were identified in many urban areas. It is interesting to note that, under some conditions, shielding can increase the dose rate. For instance, if the electrons from a high energy beta source (such as 32P) strike a lead surface then X-ray photons will be generated (radiation produced in this way is known as bremsstrahlung). It is best for this reason to cover any high Z (that is, large numbers of protons (the Z number) in the nucleus) materials (such as lead, tungsten or uranium) with a low Z material such as aluminium, wood, plastic. This effect can be significant if a person wearing lead containing gloves picks up a strong beta source. Also gamma photons can induce the emission of electrons from very dense materials by the photoelectric effect, again by covering the high Z material with a low Z material this potential additional source of exposure to humans can be avoided. Furthermore gamma rays can scatter off a dense object, this enables gamma rays to "go around corners" to a small degree. Hence to obtain a very high protection factor the path in/out of the shielded enclosure should have several 90 degree turns rather than just one.
Reduction of incorporation into the human body
Potassium iodide (KI), administered orally immediately after exposure, may be used to protect the thyroid from ingested radioactive iodine in the event of an accident or terrorist attack at a nuclear power plant, or the detonation of a nuclear explosive. KI would not be effective against a dirty bomb unless the bomb happened to contain radioactive iodine, and even then it would only help to prevent thyroid cancer.
Fractionation of dose
While Devair Alves Ferreira got a large dose during the Goiânia accident of 7.0 Gy, he lived while his wife got a dose of 5.7 Gy and died. The most likely explanation is that his dose was fractionated into many smaller doses which were absorbed over a length of time, while his wife stayed in the house more and was subjected to continuous irradiation without a break, giving her body less time to repair some of the damage done by the radiation. In the same way, some of the people who worked in the basement of the wrecked Chernobyl plant received doses of 10 Gy, but in small fractions, so the acute effects were avoided.
It has been found in radiation biology experiments that if a group of cells are irradiated, then as the dose increases, the number of cells which survive decreases. It has also been found that if a population of cells is given a dose before being set aside (without being irradiated) for a length of time before being irradiated again, then the radiation causes less cell death. The human body contains many types of cells and the human can be killed by the loss of a single type of cells in a vital organ. For many short term radiation deaths (3 days to 30 days), the loss of cells forming blood cells (bone marrow) and the cells in the digestive system (microvilli which form part of the wall of the intestines are constantly being regenerated in a healthy human) cause death.
In the graph below, dose/survival curves for a hypothetical group of cells have been drawn, with and without a rest time for the cells to recover. Other than the recovery time partway through the irradiation, the cells would have been treated identically.
Treatment
Whole body vs. part of body exposure
In the case of a person who has had only part of their body irradiated then the treatment is easier, as the human body can tolerate very large exposures to the non-vital parts such as hands and feet, without having a global effect on the entire body. In short if the hands get a 100 Sv dose which results in the body receiving a dose (averaged over your entire body of 5 Sv) then the hands may be lost but Radiation poisoning would not occur. The resulting injury would be described as localised radiation burn.
Experimental treatments designed to mitigate the effect on bone marrow
Neumune, an androstenediol, was introduced as a radiation countermeasure by the US Armed Forces Radiobiology Research Institute, and is currently under joint development with Hollis-Eden Pharmaceuticals. Neumune is in Investigational New Drug (IND) status and Phase I trials are being completed.
The exposure levels and symptoms
Dose-equivalents are presently stated in sieverts:
0.05–0.2 Sv (5–20 REM)
No symptoms. Potential for cancer and mutation of genetic material, according to the LNT model: this is disputed (Note: see hormesis). A few researchers contend that low dose radiation may be beneficial. 50 mSv is the yearly federal limit for radiation workers in the United States. In the UK the yearly limit for a classified radiation worker is 20 mSv. In Canada, the single-year maximum is 50 mSv, but the maximum 5-year dose is only 100 mSv. Company limits are usually stricter so as not to violate federal limits.
0.2–0.5 Sv (20–50 REM)
No noticeable symptoms. Red blood cell count decreases temporarily.
0.5–1 Sv (50–100 REM)
Mild radiation sickness with headache and increased risk of infection due to disruption of immunity cells. Temporary male sterility is possible.
1–2 Sv (100–200 REM)
Light radiation poisoning, 10% fatality after 30 days (LD 10/30). Typical symptoms include mild to moderate nausea (50% probability at 2 Sv), with occasional vomiting, beginning 3 to 6 hours after irradiation and lasting for up to one day. This is followed by a 10 to 14 day latent phase, after which light symptoms like general illness and fatigue appear (50% probability at 2 Sv). The immune system is depressed, with convalescence extended and increased risk of infection. Temporary male sterility is common. Spontaneous abortion or stillbirth will occur in pregnant women.
2–3 Sv (200–300 REM)
Severe radiation poisoning, 35% fatality after 30 days (LD 35/30). Nausea is common (100% at 3 Sv), with 50% risk of vomiting at 2.8 Sv. Symptoms onset at 1 to 6 hours after irradiation and last for 1 to 2 days. After that, there is a 7 to 14 day latent phase, after which the following symptoms appear: loss of hair all over the body (50% probability at 3 Sv), fatigue and general illness. There is a massive loss of leukocytes (white blood cells), greatly increasing the risk of infection. Permanent female sterility is possible. Convalescence takes one to several months.
3–4 Sv (300–400 REM)
Severe radiation poisoning, 50% fatality after 30 days (LD 50/30). Other symptoms are similar to the 2–3 Sv dose, with uncontrollable bleeding in the mouth, under the skin and in the kidneys (50% probability at 4 Sv) after the latent phase.
4–6 Sv (400–600 REM)
Acute radiation poisoning, 60% fatality after 30 days (LD 60/30). Fatality increases from 60% at 4.5 Sv to 90% at 6 Sv (unless there is intense medical care). Symptoms start half an hour to two hours after irradiation and last for up to 2 days. After that, there is a 7 to 14 day latent phase, after which generally the same symptoms appear as with 3-4 Sv irradiation, with increased intensity. Female sterility is common at this point. Convalescence takes several months to a year. The primary causes of death (in general 2 to 12 weeks after irradiation) are infections and internal bleeding.
6–10 Sv (600–1,000 REM)
Acute radiation poisoning, near 100% fatality after 14 days (LD 100/14). Survival depends on intense medical care. Bone marrow is nearly or completely destroyed, so a bone marrow transplant is required. Gastric and intestinal tissues are severely damaged. Symptoms start 15 to 30 minutes after irradiation and last for up to 2 days. Subsequently, there is a 5 to 10 day latent phase, after which the person dies of infection or internal bleeding. Recovery would take several years and probably would never be complete.
Devair Alves Ferreira received a dose of approximately 7.0 Sv (700 REM) during the Goiânia accident and survived, partially due to his fractionated exposure.
10–50 Sv (1,000–5,000 REM)
Acute radiation poisoning, 100% fatality after 7 days (LD 100/7). An exposure this high leads to spontaneous symptoms after 5 to 30 minutes. After powerful fatigue and immediate nausea caused by direct activation of chemical receptors in the brain by the irradiation, there is a period of several days of comparative well-being, called the latent (or "walking ghost") phase. After that, cell death in the gastric and intestinal tissue, causing massive diarrhea, intestinal bleeding and loss of water, leads to water-electrolyte imbalance. Death sets in with delirium and coma due to breakdown of circulation. Death is currently inevitable; the only treatment that can be offered is pain therapy.
50–80 Sv (5,000–8,000 REM)
Immediate disorientation and coma in seconds or minutes. Death occurs after a few hours by total collapse of nervous system.
More than 80 Sv (>8,000 REM)
U.S. military forces expect immediate death. A worker receiving 100 Sv (10,000 REM) in an accident at Wood River, Rhode Island, USA on 24 July 1964 survived for 49 hours after exposure, and an operator receiving 120 Sv (12,000 REM) to his upper body in an accident at Los Alamos, New Mexico, USA on 30 December 1958 survived for 36 hours; details of this accident can be found on page 16 (page 30 in the PDF version) of Los Alamos' 2000 Review of Criticality Accidents.
Internal organs diseases at the injured and contused patients
A brief background of ballistics: In the 19th century rifle bullets were of low power and would often lodge in the victim but the quality of military surgery was so poor that unless the bullet was easily found it was safer to leave it in situ than to operate. The Lee and Enfield 303 was the standard infantry rifle of both world wars and the ammunition for Vickers machine guns and Bren guns (a light machine gun so named as it was invented in Brno in Czechoslovakia and Enfield in England) was similar. It has much more penetrating power and would usually pass right through the victim. On entry the bullet would start to tumble and the somersault action would do more damage than a straight path and the exit wound was typically rather larger than the entry. Full exploration of the wound is essential.
One of the early innovations of rifles, when they superseded muskets, was a series of spiral grooves in the barrel, called rifling, to make the bullet twist in the air, improving range and accuracy. This is also standard for hand guns except dualling pistols where inherent inaccuracy is desirable to reduce the risk of fatality. The definition of a shotgun is that it does not have rifling. A shotgun can fire a single missile called a slug but usually it fires many small pellets. The pellets spread out and this makes it much easier to hit a flying bird or running small animal and limits the damage that may make meat inedible. Shotgun pellets would be unlikely to do much harm to a human above 30 metres range unless they caused penetrating injury to the eye and they have been used with bird shot for riot control. A pump action shotgun is used for this whilst sporting guns are double barreled, allowing just 2 rounds before re-loading. A shotgun fired at a person at short range would penetrate the body with many pellets spreading out. At close range a shotgun produces a great deal of damage and probably no exit wound. The close range wound would be a large hole surrounded by many tiny ones.
The caliber of a bullet is its diameter. This is usually measured in inches or millimetres. The decimal point with inches is usually ignored so that it is called a 38 Smith and Wesson or a Colt 45. 0.38 inches is 9mm. Most manufacturers now use metric measurements so that the Lee and Enfield 303 was replaced by the 7.62mm SLR (self loading rifle). In addition to caliber, length is required to give an idea of the size of the bullet. Shotguns are graded according to the number of cartridges that weigh 1lb. Thus for a 12 bore gun 12 cartridges weigh 1lb, 20 for a 20 bore and 8 for an 8 bore.
In 1947 Sergeant Anton Kalashnikov, of the Soviet army, developed an assault rifle that was named the AK-47 after his initials and the year of development.8 It is still used by many armies around the world as well as numerous militias and terrorists. The British infantry weapon is the SA 80 that uses 5.62mm ammunition.9 The standard L85 individual weapon has an effective range of 400m but the L86 light support weapon is identical but slightly longer with an effective range of 1000m. The accuracy of these weapons was such an improvement that the army had to redesign its firing range tests. The American M16 uses the same caliber so that ammunition is interchangeable amongst NATO forces. Even handguns are much more powerful than they were giving much higher muzzle velocities with very much greater destructive power. Magnum is a term that means that extra explosive is used in the cartridge and the Smith and Wesson 38 magnum is the most powerful handgun in the world. The Browning 9mm has developed considerably since its invention in 1920 and its first production in 1935 and is now far more powerful.
This means that when a bullet strikes a person it does far more damage. Rapid evacuation from the battlefield with urgent resuscitation and surgery saved the lives of many American soldiers in the Vietnam War. The role of the anesthetist cannot be overstated. The tissue damage from high powered bullets is such that the wound must be thoroughly explored and all non-viable tissue removed to prevent gas gangrene. If this cannot be done with currently available resources the wound must be left open for secondary closure when this can be done. This basic doctrine was not recognized by Argentinean doctors in the Falklands War.
Soft nose bullets were developed in Dum-dum in India for elephant hunting but also put to military use. The soft nose spreads out on impact, increasing the damage. They were outlawed by the Hague Treaty in 1899, well before the Geneva Convention, but it applies only in war between co-signatories. Soft nose bullets are being used more often in counter-terrorism operations where the ability to stop an adversary is crucial but there is concern about hitting someone behind the target or ricochet. If firearms are to be used in aeroplanes such bullets would be essential. They are also liked by snipers. If you do not find an exit wound think of soft nose bullets and think of more, not less tissue damage. These bullets may seem to explode on impact but are not true exploding bullets as banned under the St Petersberg Declaration of 1868. True exploding bullets are difficult to buy but can be manufactured by adapting others. They are more popular with fiction writers than in real life and they are not armour piercing. A home adapted exploding bullet was used in an attempt to assassinate President Ronald Reagan in 1981.
Bullet proof jackets have considerable limitations. The protection offered is graded I to IV. By and large I and II will protect against hand guns but assault rifles and other high power weapons require ceramic tiles to give grade III or IV. Like mediaeval armour they are rather heavy and cumbersome and the Americans call them full metal jacket.
Gunshot injuries
Most GPs will never have to deal with firearms injuries in their entire professional lives but for anyone who does it is important to have a logical and systematic approach.
Mechanism of injury
It is necessary to understand something about ballistics to comprehend the nature of gunshot wounds. A bullet wound is not like a knife wound. When a projectile strikes it dissipates energy. The energy of a body is e = mv² where e is energy, m is mass and v is velocity. Thus energy is proportional to mass. Caliber will give an indication of size but remember the length of the bullet too. Hence the bullet from a Colt 45 revolver has about 1.5 times the diameter of a Lee and Enfield 303 rifle, but it is a shorter and lighter projectile. Most modern guns give high velocity, especially assault rifles and even a 9mm Browning pistol of modern design is a formidable weapon. Twice the velocity gives four times the energy. It is the transmission of this energy that causes tissue damage.
When a low velocity round strikes it starts to tumble or somersault. This is why the exit wound can be much bigger than the entrance with considerable damage done on the way. A high velocity bullet imparts substantial energy and can make a big hole and cause a great deal of damage.
When soft tipped bullets, originally called Dum-dums, strike they spread out and cause disproportionate damage.
Assessment: When faced with gunshot wounds there are certain questions the doctor must ask. The first question the victim or witnesses may answer. The other two he must ask of himself.
• What type of weapon was used? This does not have to be make and model but a generic classification like a small handgun, a shotgun or if it was a sniper from afar it was probably a high powered rifle.
• Where is the entry wound and where is the exit wound? It is very easy to be so concerned with the entry wound that the exit wound is ignored yet it might be a much bigger hole.
• What structures may have been damaged between the two? Lungs, major vessels, vascular organs like liver and kidneys or bones may be involved. If the trajectory was at an unusual angle there may be an unusual combination.
Circulation: Make an assessment of the general state of the patient. Considerable bleeding may be internal and hence occult. The cardiovascular system of a young person adapts well to blood loss and even tachycardia may be a fairly late feature whilst hypotension suggests very marked blood loss. If the equipment is available, get intravenous access as soon as possible. If it is possible to secure bleeding vessels then do so. In a hospital environment, get blood grouped and cross matched fast. 6 units is not an unreasonable request. Rapid haemorrhage may necessitate operation before adequate resuscitation but anaesthesia may induce collapse of a compromised circulation and an experienced anaesthetist is essential.
Compression is permissible to stem bleeding but a tourniquet is not. It enhances ischaemic damage distal to itself.
Do not attempt primary closure of a wound before full exploration and debridement. Low velocity bullets cause significant tissue damage and high velocity bullets cause considerable tissue damage. Closure of a wound with non-viable tissue inside may result in gas gangrene. Tetanus prophylaxis, possibly with antibiotics should be considered.
Chest injuries: Penetration of the chest may damage pleura, lung, great vessels, heart, mediastinum, diaphragm and abdominal contents. The commonest injury is a haemopneumothorax from damage to lung and chest wall. This requires a large (adult: 32G) chest drain. Any deterioration or cardiac arrest demands prompt thoracotomy. Wounds of the intercostal vessels or heart can cause massive haemorrhage. If drainage is initially >1500ml, or >300ml/h, thoracotomy is needed.
Sucking chest wounds must be closed immediately. Vaseline® gauze pads sealed on only 3 sides can act as a flutter valve. The seal is completed when the chest drain inserted. Relieve any tension pneumothorax by needling the chest on the side of the suspected lesion before inserting a 32G chest drain or doing X-rays. Delay may be fatal. A tension pneumothorax gives hyper-resonance on that side and the trachea is deviated away from it.
Respiratory embarrassment due to pain, flail chest, or diaphragmatic injury requires intubation and ventilation. Insert a chest drain if there is any chance of a tear to lung, bronchus, or chest wall.
Infection of chest wounds in a theatre of war is a major problem. Risk is reduced by early drainage of haemothorax, wide debridement of damaged tissue, delayed closure of wounds and prolonged antibiotics.
Cardiac tamponade: 15% of deep chest injuries involve the heart.
Diagnosis: Beck's triad is rising venous pressure, falling systemic pressure and a small, quiet heart but often these are not observed. Pulsus paradoxus may be noted as with constrictive pericarditis. The JVP may not be visible if there is hypovolaemia. Pericardial aspiration is a useful diagnostic tool and may be a life-saving treatment. It also buys time before definitive anterolateral thoracotomy.
Procedure: Insert an 18G needle to the left of the xiphoid. Aim at the left shoulder, but with the needle angled downwards at 45° to the horizontal.
All these patients need:
• cross matching of 6 units of blood;
• at least one and preferrably two large-bore IV cannula are required for vigorous fluid replacement. However avoid hypertension which may exacerbate blood loss - aim for a systolic BP of 100-110mmHg;
• monitoring: vital signs; blood gases; CXR; ECG monitoring;
• ITU care with a chest drains immediately to hand and facilities for immediate thoracotomy if there is any deterioration or a cardiac arrest.
Abdominal injuries: All but the most superficial penetrating wound of the abdomen require full exploratory laparotomy. This applies as much to knife as to bullet wounds. Observation is inadequate as there may be occult bleeding or perforation of bowel.
Pathophysiology: Physiologic evaluation of the patient with penetrating abdominal trauma concentrates on two major findings: peritonitis and hemodynamic instability.
Peritoneal signs develop when the peritoneal envelope and the posterior aspect of the anterior abdominal wall are both inflamed. The peritoneal or retroperitoneal blood and organ contents inflame deeper nerve endings (visceral afferent pain fibers) and result in poorly defined pain. Irritation of the parietal peritoneum leads to somatic pain, which tends to be more localized; however, the diffuse nature of intra-abdominal spillage often leads to diffuse findings. The back or shoulder distribution of pain may provide a clue to the damaged organ (ie, shoulder pain from a damaged spleen with subphrenic blood).
Hemodynamically stable patients with penetrating abdominal trauma and peritonitis can be assumed to have a hollow visceral perforation and may have significant intra-abdominal hemorrhage. Thus, peritonitis on physical examination is a trigger for emergent intervention regardless of vital signs.
Hypotension, narrow pulse pressure, and tachycardia or signs of inadequate end organ perfusion in the setting of penetrating abdominal trauma provide evidence of significant intra-abdominal injury, especially vascular trauma, and warrant immediate surgical exploration. Confounding injuries or medical problems, such as tension pneumothorax or acute myocardial infarction, need be excluded.
Wounds located on the anterior abdomen can be explored locally to determine whether they penetrate the peritoneum. On the flank area and back area, exploration is more difficult and less reliable. Therefore, flank and back wounds are not explored and are considered penetrating unless obviously superficial.
Gunshot wounds, considered high-velocity projectiles, are the most common cause (64%) of penetrating abdominal trauma, followed by stab wounds (31%) and shotgun wounds (5%). Injury patterns differ depending on the weapon. Low-velocity stab wounds are generally less destructive and have a lower degree of morbidity and mortality than gunshot wounds and shotgun blasts. Gunshot wounds and other projectiles have a higher degree of energy and produce fragmentation and cavitation, resulting in greater morbidity.
The severity of shotgun wounds depends on the distance of the victim from the weapon. The mass of a bullet is minimal, and, thus, their velocity decreases rapidly when the bullet leaves the barrel of the gun. When the distance is less than 3 yd, the injury is considered high velocity, and if the distance exceeds 7 yd, most of the buckshot penetrates only the subcutaneous tissue.
In penetrating abdominal trauma due to stab wounds, the most commonly injured organs are the liver (40%), small bowel (30%), diaphragm (20%), and colon (15%). Intra-abdominal injuries from a gunshot wound are to the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25%).
The death rate from penetrating abdominal trauma spans the entire spectrum (0-100%), depending on the extent of injury. Patients with violation of anterior abdominal wall fascia without peritoneal injury have a 0% mortality rate and minimal morbidity rate, while those with multiorgan injury complexes presenting with hypotension, base deficit less than -15 mEq/L HCO3, lactate level more than 20 mmol/L, and near exsanguination have an almost 100% mortality rate.
An average mortality rate for all patients with penetrating abdominal trauma is approximately 5% in most level 1 trauma centers, but this population is necessarily biased given the higher acuity seen at such centers, thus skewing the data.
The most common morbidities following penetrating abdominal trauma are wound infection (2-8%) and intra-abdominal abscess with or without sepsis (10-80%, depending on presence or absence of bowel injury in combination with major vascular injury).
Clinical
History: The history provides clues to the most likely injury patterns and potential management priorities. Emergency medical services (EMS) personnel are often essential in providing a history, especially in a critically ill patient or someone with altered mental status.
A common acronym is the AMPLE history:
• allergies;
• medications;
• prior illnesses and operations;
• last meal;
• events and environment surrounding injury.
Further historical factors include the following:
Anatomic location of injury and type of weapon (ie, gun, knife), which directs the diagnostic process; the number of gunshots heard, times stabbed, and position of the patient at the time of injury help describe the trajectory and path of the injuring object.
Close-range injuries transfer more kinetic energy than those sustained at a distance, although range is often difficult to ascertain when assessing gunshot wounds.
Blood loss at the scene should be quantified as accurately as possible from EMS personnel. However, previous research has shown that this assessment is very difficult and rarely reliable. The character of the bleeding (eg, arterial pumping, venous flow) may assist in determining whether major vascular injury has occurred.
The initial level of consciousness or, for moribund patients, the presence of any signs of life at the scene (ie, pupillary response, respiratory efforts, heart rate or tones) is vital to determine the prognosis and to guide resuscitative efforts. Evidence of hypotension in the field should raise suspicion for intra-abdominal injury.
Physical: The initial physical examination begins with visual assessment of the patient with particular focus on the ABCs. Rapid determinations regarding respiratory effort, perfusion, external hemorrhage, and consciousness level are usually easily made.
Initial vital signs assist in determining injury severity and need for operative intervention. Tachycardia, high or low respiratory rate, and hypotension are indicators for need for greater resource availability.
Primary survey
The primary survey is defined by the mnemonic ABCDE: Airway, Breathing, Circulation, Disability, and Exposure/Environment. Although described sequentially, much of this evaluation may be performed simultaneously and problems identified are managed immediately.
Airway - The airway always is assessed immediately for patency, protective reflexes, foreign body, secretions, and injury.
Breathing - Breathing is assessed by determining the patient's respiratory rate and by subjectively quantifying the depth and effort of inspiration.
Circulation: The circulation assessment begins with an evaluation of the patient's mental status, skin color, and skin temperature. Patients in significant hemorrhagic shock will progress from anxiety to agitation and finally coma if their blood loss continues unabated. The traditional vital signs of heart rate, blood pressure, and respiratory rate are not sensitive or specific for hemorrhagic shock.
Disability: This is assessed early to document neurologic deficits before giving sedation or paralytics. The Glasgow Coma Score and the gross motor and sensory status of all 4 extremities should be determined and recorded. The physician also should recognize the need for cerebro-protection measures in cases of brain injury.
Exposure/environment: Exposure is particularly important in the patient with a traumatic mechanism of injury where failure to identify a second or third injury may result in major morbidity due to failure to diagnose a life-threatening injury. Complete exposure and head-to-toe visualization of the patient is mandatory in a patient with penetrating abdominal trauma. This includes buttocks, posterior part of the legs, scalp, posterior part of the neck, and perineum. There is little to be gained by practicing spinal immobilization unless spinal injury is obvious.
Once the primary survey is complete, a complete head-to-toe physical examination is performed as an integral part of the secondary survey, including digital rectal and genital examinations. This detailed examination may need to be delayed until after operative therapy has corrected obvious life-threatening injury.
Secondary survey and injury assessment
External inspection for injuries with respect to anatomic landmarks aids identification of possible intracavitary injury. In evaluating patients with penetrating abdominal trauma, the abdomen is classically divided as follows:
Anterior abdomen - Anterior costal margins to inguinal creases, between the anterior axillary lines
Intrathoracic abdomen or thoracoabdominal area - Fourth intercostal space anteriorly (nipple) and seventh intercostal space posteriorly (scapular tip) to inferior costal margins
Flank - Scapular tip to iliac crest, between anterior and posterior axillary lines
Back - Scapular tip to iliac crest, between posterior and axillary lines
The physical examination is a more reliable indicator for surgical intervention with penetrating abdominal trauma than with blunt trauma. At many trauma centers, repeated abdominal examinations are the preferred approach for managing hemodynamically stable patients with penetrating abdominal stab wounds. Development of peritonitis or hemodynamic instability is an indication for operative intervention. While selective nonoperative management of penetrating abdominal trauma is practiced at most trauma centers in this country, hemodynamic instability and diffuse abdominal tenderness indicating peritonitis are surgical indications.
Common physical examination recommendations include evaluation for tympany (a bell-like or percussive note upon gently tapping on the abdomen), dullness to percussion, and bowel sounds. Abdominal distention, not clearly due to "bagging" or swallowed air, may be an indicator of an intra-abdominal catastrophe. A vascular injury is often found in combination with hollow or solid viscus penetration or devitalization.
Evisceration has historically been a clear indication for operative management. However, some centers replace eviscerated omentum and serially observe or image these patients.
Impaling objects may tamponade otherwise uncontrolled hemorrhage if the object resides within or crosses a major vessel or solid organ such as the portal vein or liver. Therefore, penetrative objects should not be removed except where definitive treatment can be provided.
Increasing pain, peritoneal findings (eg, point tenderness, involuntary guarding, rebound tenderness), or diffuse and poorly localized pain that fails to resolve also indicates that surgical exploration should be undertaken.
Limb injuries: Nerves, tendons and vessels are endangered, so examine the limb in a good light. Test for pulses but their presence does not exclude arterial injury. Note sensation and sweating. Any damage identified will need formal surgical repair. Direct pressure will staunch bleeding but avoid a tourniquet.
First medical aid in life emergency states
First aid
|Introduction to Stage | |
|On the scene of an accident, you must be able to recognize the difference between fainting and unconsciousness, since one is more serious than | |
|the other when performing first aid. | |
|The level of consciousness can be assessed by the person’s ability to open his eyes, to speak, to move his hands and to respond to pain. The | |
|level of consciousness may vary depending on how serious the person’s injury or illness is. | |
|Before going further, I am going to show you the recovery position, which you must understand if you are to render the first aid. | |
|Presentation/Development of TP | |
|Recovery position | |
|An unconscious, breathing person should be placed in the recovery position if his injuries allow this. If the person is on his back, his tongue| |
|may fall to the back of the throat and obstruct the airway, and at may stop breathing. | |
|* Demonstrate as follows : | |
|kneel on the casualty's side and flex the knee on the casualty's far leg; | |
|place the casualty's far arm across his chest; | |
|extend the near arm of the casualty fully above his head so that it should be in line with his body; | |
|position yourself on the waist of the casualty. Hold the head with one hand, and the flexed knee with the other: while supporting the | |
|casualty's head, roll him smoothly towards you. Allow the bent knee to come to rest on the ground so that the casualty will be braced and | |
|cannot roll forward; | |
|take the hand that was across the chest and place it onto his opposite shoulder and lower the head to the outstretched arm. Ensure that the | |
|casualty's airway is open and that his head is positioned to permit drainage from his mouth. | |
| | |
|Fainting | |
|Definition | |
|Fainting is a loss of consciousness that lasts a very short time – no more than a few minutes. It is caused by a temporary shortage of oxygen | |
|to the brain. The person will lose consciousness, even if only for a few moments. | |
|Most common causes: | |
|fatigue; | |
|hunger; | |
|lack of fresh air; | |
|long periods of standing or sitting in one position; | |
|fear, anxiety or the sight of blood; | |
|illness; | |
|injury (severe pain); | |
|underlying medical problem. | |
|Signs and symptoms: | |
|There may be some warning of an impending faint. The person may : | |
|become pale; | |
|start to perspire; | |
|feel dizzy. | |
|Prevention (If the person feels dizzy): | |
|seat the person with his head lowered, or lay him on his back and raise his feet about 30 cm(12in); | |
|ensure a supply of fresh air; | |
|loosen tight clothing at the neck and waist. | |
|First aid (If the person has fainted): | |
|start ESM – do a scene survey; have a bystander call for the medical aid as soon as unresponsiveness is recognized. | |
|check the ABC’s making sure the casualty’s airway is clear, he/she is breathing, has a pulse, check for shock; | |
|do a secondary survey if needed the first aid; | |
|place him in the recovery position; | |
|ensure that his airway is open; |
|loosen tight clothing; |
|ensure a supply of fresh air; |
|make the person comfortable as soon as consciousness returns, and recommend to remain lying down for 10 to 15 minutes; |
|recovery from a faint should be quick and complete. If this is not the case, stay with the casualty until medical aid is taking over or consult a |
|doctor if the condition persists. |
|Unconsciousness |
|Definition |
| Unconsciousness is any change in the level of consciousness, other than for normal sleep. |
| Thus, the unconscious person will not be able to open his eyes, to speak or to grasp the First Aider’s hand, and will show no response to |
|pain. |
|Some examples of injury’s and illnesses that can cause changes are: |
|a breathing emergency; |
|a heart attack; |
|a head injury; |
|shock; |
|a medical condition (epilepsy, diabetes, etc.); |
|poisoning; |
|alcohol or drug abuse. |
|Assessing the LOC (level of consciousness) |
|Consciousness means how a person is aware of her/himself and her/his surroundings. There is a full range of levels of consciousness form completely |
|conscious to completely unconscious. Many injuries and illnesses can cause changes in a casualty’s level of consciousness. A first aider uses the |
|modified Glasgow Coma Scale to assess and describe levels of consciousness. |
|The scale is based on the casualty’s ability: |
|to open the eyes – this is the eye opening response; |
|to speak – this is the verbal response; |
|to move muscles – this is the motor response; |
| |
|First aid. |
| |
|Unconsciousness is a breathing emergency |
| |
|If the unconscious casualty is lying on his back, the airway may become blocked by the tongue falling to the back of the throat, or by fluids |
|draining into the airway. Maintaining effective breathing is the first priority: |
|ensure proper breathing – Look , listen and feel (if necessary, open the airway and give artificial respiration) recheck breathing frequently; |
|perform a secondary examination (assess vital signs, examine from head to foot, and check for Medic-Alert devices); |
|treat for any conditions or injuries; |
|loosen any tight clothing; |
|place the person in the recovery position if his injuries permit; |
|keep the person warm; |
|give nothing by mouth; |
|seek medical aid. |
|Notes: |
| |
|do not try to resuscitate the person; |
|give nothing to drink; |
|never leave the person unattended. |
| |
|Introduction to Stage |
| We often hear about a shock without knowing what it is. It is important to be able to recognise shock, since it is a serious condition |
|that can lead to death if it is not promptly treated. Any injury or illness can be accompanied by shock. |
|Presentation/Development of TP | |
|Shock | |
|Definition | |
| Shock is a circulation problem where the body’s tissues don’t get enough blood. It results when the brain and other vital organs are | |
|deprived of oxygen. The development of shock can be gradual or rapid. Medical shock is life threatening because the brain and other organs cannot | |
|function properly. If shock gets bad enough, it leads to unconsciousness or to death. Because there is often shock in an emergency situation, and | |
|because it can progress very quickly, always check for shock and asses whether it is getting bad enough to be a medical emergency by itself. Like | |
|safety, shock is one of those things you always have to be thinking about. | |
|Shock is caused by: | |
|severe bleeding, external or internal, including major fractures (heavy loss of blood); | |
|loss of blood plasma (e.g.: burns); | |
|spinal cord injuries; | |
|cardiac emergencies (heart attacks); | |
|Medical emergencies (eg. Diabetes, allergies, poisoning). | |
|IT IS MPORTANT TO KNOW: Some degree of shock accompanies every injury or illness. | |
|Severe shock can also result from medical emergencies such as diabetes, epilepsy, infection, poisoning or a drug overdose. Pain, anxiety and fear | |
|don’t cause shock, but they can help make it worse, or make it progress faster. That is why reassuring a casualty and making it as comfortable is so| |
|important. | |
|Signs and symptoms (may appear gradually): | |
|restlessness and anxiety (first signs); | |
|pale or blue-grey colour of the skin (ears, lips, nostrils and fingernails = cyanosis); | |
|cold, clammy skin; | |
|profuse sweating; | |
|shallow and irregular breathing; could be rapid and gasping for air; | |
|weak and rapid pulse; (in later stages the radial pulse may be absent; | |
|gradual loss of consciousness. | |
|The casualty may tell you of: | |
|feelings of anxiety and doom; | |
|being confused and dizzy; | |
|extreme thirst; | |
|nausea; | |
|faintness; | |
|pain. | |
| c. First Aid | |
| Shock must be prevented from progressing, by providing the first aid appropriate to the cause of shock, as quickly as possible: | |
|reassure the casualty; | |
|handle the casualty gently; | |
|loosen tight clothing; | |
|keep the casualty warm, without making him too hot; | |
|give nothing by mouth in cases of severe shock; | |
|moisten the lips only if the casualty complains of thirst; | |
|a conscious casualty should be made to lie down, with the feet and legs raised 30 cm (recommended position of shock), if injuries permit; | |
|place an unconscious casualty in the recovery position, if injuries permit; | |
|obtain medical aid as soon as possible. | |
| | |
|First medical aid | |
| | |
|Bleeding | |
|Control of bleeding is one of the few actions by which you can critically influence on the outcome. Control external bleeding by applying pressure over the| |
|bleeding area until bleeding stops or EMS rescuers arrive. The important factors in successful control of bleeding are to apply pressure firmly and for a | |
|long time. Methods of applying pressure include: | |
|manual pressure on gauze or other cloth placed over the bleeding source; if bleeding continues do not remove the gauze; add more gauze on top and apply | |
|more pressure; | |
|an elastic bandage firmly wrapped over gauze to hold it in place with pressure. | |
|The effectiveness, feasibility, and safety of tourniquets to control bleeding by first aid providers are unknown, but the use of tourniquets is potentially| |
|dangerous. Tourniquets are routinely used in the operating room under controlled conditions and have been effective in controlling bleeding from an | |
|extremity, but potential undesired effects include temporary or permanent injury to the underlying nerves and muscles, as well as systemic | |
|complications resulting from limb ischemia, including acidemia, hyperkalemia, arrhythmias, shock, limb loss, and death. Complications are related to | |
|tourniquet pressure and occlusion time. Pressure has been found to be superior to tourniquets in controlling bleeding, although tourniquets may be useful | |
|under some unique conditions (eg, the battlefield, when rapid evacuation is required and ischemic time is carefully monitored). The method of application | |
|and the best design of tourniquets are under investigation. | |
|There is insufficient evidence to recommend for or against the first aid use of pressure points or extremity elevation to control hemorrhage. The efficacy,| |
|feasibility, and safety of pressure points to control bleeding have never been subjected to study, and there have been no published studies to determine if| |
|the elevation of the bleeding extremity helps in bleeding control or causes harm. Using these unproven procedures has the potential to compromise the | |
|proven intervention of direct pressure. | |
|Wounds and Abrasions | |
|Irrigate wounds and abrasions with clean running tap water for [pic]5 minutes or until there appears to be no foreign matter in the wound. If running | |
|water is unavailable, use any source of clean water. Wounds heal better and with less infection if an antibiotic ointment or cream is used; triple | |
|antibiotic ointment appears to be superior to single antibiotic ointment or cream. Apply antibiotic ointment or cream only if the victim’s wound is an | |
|abrasion or is superficial. | |
|Burns | |
|Thermal Burns | |
|Cool thermal burns with cold water as soon as possible and continue at least until pain is relieved. Cooling reduces the injury and relieves pain. There | |
|is some evidence that brief cooling of small burns with ice water may be effective but direct application of ice to a burn may produce tissue ischemia, and| |
|prolonged cold exposure even of small burns can lead to further injury. Avoid cooling of burns with ice or ice water for longer than 10 minutes, | |
|especially if the burn is large (>20% of body surface area). | |
|Burn Blisters | |
|Loosely cover burn blisters with a sterile dressing but leave them intact. | |
|Electrocution and Electrical Burns | |
|The severity of electrical injuries can vary widely, from an unpleasant tingling sensation caused by low-intensity current to thermal burns, | |
|cardiopulmonary arrest, and death. Thermal burns may result from burning clothing that is in contact with the skin or from electric current traversing a | |
|portion of the body. When current transverses the body, thermal burns may be present at the points where the current entered and exited the body and | |
|internally along its pathway. Cardiopulmonary arrest is the primary cause of immediate death from electrocution. Cardiac arrhythmias, including | |
|ventricular fibrillation, ventricular asystole, and ventricular tachycardia that progresses to ventricular fibrillation, may result from exposure to low- | |
|or high-voltage current. Respiratory arrest may result from electrical injury to the respiratory center in the brain or from tetanic contractions or | |
|paralysis of respiratory muscles. | |
|Do not place yourself in danger by touching an electrocuted victim while the power is on. Turn off the power at its source; at home the switch is usually | |
|near the fuse box. In case of high-voltage electrocution, such as that caused by fallen power lines, immediately notifies the appropriate authorities (ie, | |
|911, fire department, etc). All materials will conduct electricity if the voltage is high enough, so do not enter the area around the victim or try to | |
|remove wires or other materials with any object, including wooden ones, until the power has been turned off by knowledgeable personnel. | |
|Once the power is off, assess the victim, who may need CPR, defibrillation, and treatment for shock and thermal burns. All victims of electric shock | |
|require medical assessment because the extent of injury may not be apparent. | |
|Spine Stabilization | |
|There is an approximately 2% risk of injury to the cervical spine after blunt trauma that is serious enough to require spinal imaging in an emergency | |
|department, and this risk is tripled in patients with craniofacial injury or a Glasgow Coma Scale score of 65 years of age; | |
|has a head or neck injury. | |
|In these situations or any situation in which you suspect a possible spinal injury, manually stabilize the head so that the head, neck, and spine do not | |
|move and are kept in line. Do not use any immobilization devices because their benefit in the first aid has not been proven and may be harmful. | |
|Immobilization devices may be needed in special circumstances when immediate extrication (ie, rescue of drowning victim) is required. First aid providers | |
|should be trained in the proper use of these devices before using them. | |
|Musculoskeletal Trauma: Sprains, Strains, Contusions, and Fractures | |
|Soft-tissue injuries include joint sprains and muscle contusions. Apply cold to soft-tissue injuries. Cold application decreases hemorrhage, edema, pain, | |
|and disability. Cooling is best accomplished with a plastic bag or damp cloth filled with a cooling modality that undergoes a phase change (eg, ice). | |
|Refreezable gel packs are not as good as ice. To prevent cold injury, limit each application of cold to periods [pic]20 minutes and place a barrier, such | |
|as a thin towel, between the cold container and the skin. | |
|There is insufficient evidence to recommend for or against the use of a compression bandage to reduce edema following a closed soft-tissue injury such as a| |
|joint sprain. | |
|Assume that any injury to an extremity includes a bone fracture. Cover open wounds with a dressing if one is available. Do not move or straighten an | |
|injured extremity. If you are far from definitive health care, you may stabilize the extremity in the position found. If an injured extremity is blue or | |
|extremely pale, activate EMS immediately because this could be a medical emergency. | |
|A victim with an injured lower extremity should not bear weight until advised by definitive health care. | |
|Dental Injuries | |
|Traumatic dental injuries are common. The first aid for dental injuries: | |
|handle the tooth by the crown, not the root (do not handle the part that was embedded in the gum); | |
|clean bleeding wounds with saline solution or tap water; | |
|stop bleeding by applying pressure with a piece of cotton for 5 minutes; | |
|if there is an avulsed tooth, rinse it in water (do not scrub it), place it in milk, and bring it with you and consult a dentist as quickly as possible; | |
|if there are other dental injuries, consult a dentist. | |
|Environmental Emergencies | |
|Cold Emergencies | |
|Hypothermia | |
|Hypothermia is caused by exposure to cold. The urgency of treatment depends on the length of exposure and the victim’s body temperature. Immediately begin | |
|rewarming a victim of hypothermia. Move the victim to a warm environment, remove wet clothing, and wrap all exposed body surfaces with anything at hand, | |
|including blankets, clothing, newspapers, etc. If you are far from definitive health care, you may begin active rewarming for a victim of hypothermia. For| |
|example, active rewarming may be achieved by placing the victim near a heat source and placing containers of warm, but not hot, water in contact with the | |
|skin. Active rewarming should not delay definitive care. | |
|Frostbite | |
|Frostbite usually affects an exposed extremity. In case of frostbite, remove wet clothing and make sure if the victim does not develop hypothermia. Get the| |
|victim to a medical facility as rapidly as possible. Do not try to rewarm the frostbite if there is any chance that it might refreeze or if you are close | |
|to a medical facility. If you are in a remote area far from a medical facility, you may slowly rewarm the frostbite using warm water (100°F to 105°F) | |
|(Class Indeterminate). | |
| | |
|Drowning | |
|Drowning is a major cause of unintentional death. It can be prevented with isolation fencing around swimming pools (gates should be self-closing and | |
|self-latching), wearing personal flotation devices (life jackets) while in, around, or on water, and never swimming alone. | |
|Outcome following drowning depends on the duration of the submersion, the water temperature, and how promptly CPR is started. Case reports have documented | |
|intact neurological survival in small children following prolonged submersion in icy waters. Remove the victim rapidly and safely from the water, but do | |
|not place yourself in danger. If you have special training, you can start rescue breathing while the victim is still in the water if it does not delay | |
|removing the victim from the water. There is no evidence that water acts as an obstructive foreign body, so don’t waste time trying to remove it. Start CPR| |
|with 2 effective ventilations and continue with 5 cycles (about 2 minutes) of chest compressions and ventilations before activating EMS. If 2 rescuers are | |
|present, send the second rescuer to activate EMS immediately. | |
|Poison Emergencies | |
|Poison Control Centers | |
|There are a large number of poisonous substances at home and at the worksite. It is important to understand the toxic nature of the chemical substances in | |
|your environment and the proper protective equipment and emergency procedures in case of toxic exposure. The Poison Control Center (800-222-1222) is an | |
|excellent resource for treating ingestion of, or exposure to, a potential poison. Inform the Poison Control Center of the nature about the exposure, the | |
|time of exposure, and the name of the product or toxic substance. | |
|Chemical Burns | |
| | |
|Brush powdered chemicals off the skin with a gloved hand or piece of cloth. Remove all contaminated clothing and make sure not to contaminate yourself in | |
|the process. In case of an acid or alkali exposure to the skin or eye, immediately irrigate the affected area with copious amounts of water. | |
|Ingested Poisons | |
|Milk or Water | |
|Do not administer anything by mouth unless advised to do so by a poison control center. Animal studies suggest that dilution or neutralization of a caustic| |
|agent by water or milk reduces tissue injury, but no human studies have shown a clinical benefit, and the possibility of emesis with aspiration must be | |
|considered. | |
|Activated Charcoal | |
|There is insufficient evidence to recommend for or against the use of activated charcoal as the first aid for ingestions. Until more definitive evidence | |
|becomes available, do not administer activated charcoal unless you have been advised to do so by a poison control center. Activated charcoal is effective | |
|for adsorbing toxins, but there is no evidence that charcoal administered by a first aid provider improves outcome. Many children will not take the | |
|recommended dose and there are reports of harm. | |
|Ipecac | |
|Do not administer syrup of ipecac for ingestions. There are several problems with ipecac. These include questions about the amount of poison removed, | |
|longer lengths of stay in the emergency department, and lack of evidence that it improves outcome. Side effects include lethargy and the potential hazard | |
|of aspiration during emesis. Syrup of ipecac is contraindicated in hydrocarbon or corrosive substance ingestion. | |
| | |
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| | |
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|Test control | |
| | |
|1. During the typical form of acute radiation sickness all periods distinguish, except for: | |
|Initial (primary reaction) | |
|Latent (imaginary well-being) | |
|The height of the disease | |
|Subacute | |
|Restoration | |
|2. In initial stage of ARS (acute radiation sickness) all symptoms are typical, except for: | |
|Nausea, vomiting | |
|Headache | |
|Excitation or oppression | |
|Tachycardia | |
|Increase of muscular tonus | |
|3. In an initial stage of acute radiation sickness all changes in blood are typical, except for: | |
|Leucocytosis | |
|Shift to the left | |
|Reticulocytosis | |
|Limphopenia | |
|Erithrocytosis | |
|4. For the latent period of acute radiation sickness everything is typical, except for: | |
|Mobilization of protective forces of an organism | |
|Improvement of state of health | |
|Moderate astenization | |
|Tachycardia | |
|Accrues leucocytosis | |
|5. For the period of a height of acute radiation sickness all syndromes are typical, except for: | |
|Hematological | |
|Intestinal | |
|Hypercoagulation | |
|Intoxication | |
|Infectious complications | |
|6. For hematologic syndrome during the height of acute radiation sickness everything is typical, except for: | |
|Leucopenia | |
|Erythrocytosis, lymphocytosis | |
|Thrombocytopenia | |
|Agranulocytosis | |
|Lymphocytosis | |
|7. Immunological protection of an organism during the height of acute radiation sickness promote oppression | |
|Agranulocytosis, lymphocytosis | |
|Anemia | |
|Leucocytosis | |
|Lymphocytosis | |
|Erythrocytosis | |
|8. During the height of acute radiation sickness all infectious complications can join, except for: | |
|Pneumonia | |
|Sepsis | |
|Ulceronecrotic quinsy | |
|Acute hepatitis | |
|Enteritis | |
|9. During of height of acute radiation sickness all displays of hemoragic syndrome are typical, except for: | |
|Dermal hemorrhages | |
|Nasal, gingival bleedings | |
|Thromboemboly of pulmonary artery, ischemic insult | |
|Uterine bleedings | |
|Gastroenteric bleedings | |
|10. In development of hemoragic syndrome at acute radiation sickness all factors are typical, except for: | |
|Anemia | |
|Increase of permeability of vascular wall | |
|The syndrome of disseminated intravascular coagulation, a thrombocytopenia | |
|Deficiency of factors of coagulation of blood | |
|Thrombocytosis | |
| | |
| | |
|11. The remote consequences of acute radiation sickness are all complications, except for: | |
|Cataract | |
|Leucosis | |
|Tumours | |
|Genetic infringements | |
|Epilepsy | |
|12. In a irregular irradiation for current of acute radiation sickness all is typical, except for | |
|Cyclicity is less expressed | |
|Expressed hematological syndrome | |
|The basic semiology is connected with the defeat of irradiated organs | |
|Less expressed hypoplasia of hemopoietic tissue | |
|Moderately expressed, simptomology of acute radiation sickness | |
|13. For the clinic of acute radiation sickness in incorporal infection everything is typical, except for: | |
|Shotening of latent period | |
|The early beginning of the period of a height | |
|Frequently hemoragic syndrome is absent | |
|Great edema is developed | |
|Unexpressed hair epilation | |
|14. For clinic of acute radiation sickness in incorporal infection everything is typical, except for: | |
|Damage of a thyroid gland | |
|Dehydratation of the organism | |
|Hair epilation | |
|Chronic radiation sickness is often developed | |
|Further tumor development | |
|15. Features of clinic of the combined radiating defeats include everything, except for: | |
|The trauma changes the course of radiation sickness | |
|The prognosis is becoming worse | |
|Complications are often developed | |
|Slow wounds healing | |
|The clinical course of acute radiation sickness | |
|is more easy | |
|16. To arrest the primary reaction on radiation all measures are necessary, except for: | |
|Aeron | |
|Atropine | |
|Sedative preparations | |
|Anticoagulants | |
|Desintoxication therapy | |
|17. To treat cardiovascular insufficiency in primary reaction on irradiation everything is used, except for: | |
|Cordiamin | |
|Mesaton | |
|Noradrenalin | |
|Glycosides | |
|Clonidine | |
|18. Therapy of the latent period of acute radiation sickness includes everything, except for: | |
|A sparing regime | |
|Dietetic therapy | |
|Polyvitamins | |
|Prevention of infections | |
|Anticoagulants | |
|19. Treat infectious complications during the height of acute radiation sickness it is possible to apply all antibiotics, except for: | |
|Semisintetic penicillins | |
|Sulfanilamids | |
|Aminoglicosids | |
|Cephalosporin | |
|Macrolids | |
|20. To treat of infectious complications during the height of acute radiation sickness everything is used, except for: | |
|Antibiotics of wide spectrum | |
|Leucoconcetrates | |
|Stimulators of immunity (levomisol) | |
|Sterilization of intestines (canamicin,polymicsin) | |
|Sulphanilamids | |
|21. At wounds all changes of intimate-vascular system are frequently observed, except for | |
|A. A tachycardia | |
|B. A pain in the field of heart | |
|C. A hypotonia | |
|D. Warm hypostases | |
|E. A short wind, weakness | |
| | |
|22. Functional infringements of cardiovascular system are observed at wound of all bodies, except for | |
|A. A cranium | |
|B. A backbone | |
|C. A thorax | |
|D. A blunt injury of a thorax | |
|E. Food | |
| | |
|23. At wounds in a cranium and vertebral column all vasomotor phenomena are characteristic, except for | |
|A. Paleness, or hyperemia of face | |
|B. Extremity coldness | |
|C. Acrocyanosis | |
|D. Hyperhidrosis | |
|E. Warm edema | |
| | |
|24. At wounds in the thorax all changes of cardiovascular system are observed, except for | |
|A. Dyspnae, palpitation | |
|B. Chest pain, dysrrhythmia | |
|C. Anuria | |
|D. Weakness, dyspnea | |
|E. Swelling cervical veins | |
| | |
|25. At wounds in a thorax in late terms all phenomena can be kept, except for | |
|A. Cardiomegaly | |
|B. Tachycardia | |
|C. Diminished of the first sound | |
|D. Moderate changes on ECG | |
|E. Hemopericarditis | |
| | |
|26. Overcooling can arise at all factors, except for | |
|A. Humidity | |
|B. Wind | |
|C. Dry weather | |
|D. Wet clothes | |
|E. Low temperature of air | |
| | |
|27. At penetrating wounds all pathologies can develop all, except for | |
|A. Haemorrhages in the lung | |
|B. Hydrothorax | |
|C. Acute bronchitis | |
|D. Hemopneumothorax | |
|E. Hemopericarditis | |
| | |
|28. Factors of defeat of a blast wave is all, except for | |
|A. Ionizing radiation | |
|B. Raised atmospheric pressure | |
|C. Impact by the compressed air | |
|D. Negative pressure in flat zone | |
|E. Pressure difference | |
| | |
|29. Early pneumonias develop at all wounds, except for | |
|A. Legs | |
|B. Crania | |
|C. Face | |
|D. Abdomen | |
|E. Thorax | |
| | |
|30. The sharpest changes at defeat by a blast wave are marked from: | |
|A. Cardiovascular system | |
|B. Bodies of breath | |
|C. Bodies of digestion | |
|D. Bodies of urination | |
|E. Nervous system | |
|Answers | |
|1-d,2-e,3-e,4-e,5-c,6-b,7-a,8-d,9-c,10-c;11-e,12-b,13-d,14-c,15-e,16-d,17-e,18-e,19-b,20-e,21-d,22-e,23-e,24-c,25-e,26-c,27-c,28-a,29-a,30-a | |
| | |
|Contents | |
|I. Basis of the organization of therapeutic aid in working army | |
|1. Definition | |
|2. Structure of the sanitary loss of the therapeutic profile | |
|3. Principles of transportation of injured and patients of therapeutic profile | |
|4. Therapeutic aid in case of mass admission of injured | |
|5. Medical documentation | |
|II. Radiation exposure | |
|1. Harm from Small Radiation Doses | |
|2. Genetic Effects | |
|3. Harm from Large Radiation Doses | |
|4. Harm from Long-term Exposure | |
|5. Exposure | |
|6. Prevention | |
|7. Treatment | |
|III. Internal organs diseases at the injured and contused patients | |
|Gunshot injuries | |
|Clinical | |
|IV. First medical aid in life emergency states | |
|First aid | |
|First medical aid | |
|Environmental Emergencies | |
|Poison Emergencies | |
|5. Chemical Burns | |
|6. Ingested Poisons | |
|V. References | |
|VI. Test control | |
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Отпечатано в типографии КГМА
г. Караганда, ул. Гоголя, 40
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