Sinusitis

Radiation sickness clinic or hospital. Clinic of the development of radiation injuries in humans under various irradiation conditions

Ticket 16.

Acute radiation sickness of mild (I) and moderate (II) severity. Clinic, diagnosis, treatment at the stages of medical evacuation.

Acute radiation sickness develops as a result of the death of dividing cells under the influence of short-term radiation at a dose of more than 1 Gy (100 rad). The development of the disease is possible under conditions of a nuclear power plant accident and after total irradiation of the body for therapeutic purposes. There is a strict dependence of its manifestations on the absorbed dose of ionizing radiation. Radiation energy leads to damage to cellular structures, which causes the development of mainly hematological syndrome.

Clinic for various forms of radiation sickness

In the case of a single irradiation dose of 0.25 Gy, routine clinical examination does not reveal noticeable deviations.

When irradiated at a dose of 0.25-0.75 Gy, mild changes in the blood picture and neurovascular regulation may be noted, occurring in the 5-8th week from the moment of irradiation.

Irradiation at a dose of 1-10 Gy causes typical forms of ARS with a disorder of hematopoiesis leading in its pathogenesis.

Irradiation at a dose of 10-20 Gy leads to the development of the intestinal form with a fatal outcome on the 10-14th day.

When a person is irradiated at a dose of 20-80 Gy, death occurs on the 5-7th day with increasing azotemia (toxemic form).

Direct early damage to the nervous system develops with irradiation at a dose of more than 80 Gy. A fatal outcome in the nervous (acute) form is possible in the very first hours or days after irradiation.

During the bone marrow form there are 4 periods:

I - period of the primary general reaction;

II - period of visible clinical well-being (latent);

III - the period of pronounced clinical manifestations (the height of the disease);

IV - recovery period.

The division of the disease into these periods is relative; it is valid for very uniform exposure.

According to the absorbed doses, acute radiation sickness is usually divided into 4 degrees of severity:

1) light (1-2 Gy);

2) medium (2-4 Gy);

3) severe (4-6 Gy);

4) extremely severe (more than 6 Gy).

The clinical picture of the primary reaction depends on the radiation dose. With a mild degree of the disease, some affected people do not show any signs of a primary reaction at all. But most people experience mild nausea 2-3 hours after irradiation; some may vomit once after 3-5 hours. In the following days, patients feel rapid fatigue during physical activity.

The leading symptom of the primary reaction with moderate severity is vomiting. It occurs 1.5-3 hours after irradiation: the higher the dose and the more irradiated the upper half of the abdomen and chest, the earlier vomiting will occur, and the longer it will last. Along with vomiting, patients note the appearance of general weakness, and at doses of about 4 Gy, moderate redness of the face and slight injection of the sclera are observed. During the day, the symptoms of the primary reaction subside: after 5-6 hours, vomiting stops, weakness gradually disappears. Moderate headache and fatigue persist. Mild facial hyperemia disappears within 2-3 days. A certain place in the characteristics of the primary reaction is occupied by a change in the number of leukocytes in the peripheral blood. In the first hours after irradiation, there is an increase in the number of leukocytes, mainly due to neutrophils. This initial leukocytosis, lasting less than a day, does not show a clear relationship with the dose of exposure, although it may be noted that high leukocytosis is observed more often in more severe cases of damage. The increase in the number of redistributive leukocytes is due to the release of granulocyte reserve from the bone marrow, while the height and duration of leukocytosis do not have a clear dependence on the intensity of irradiation. In this regard, primary leukocytosis is not a reliable indicator of the severity of radiation injury.

The period of external well-being is determined by the dose of radiation exposure and can last from 10-15 days to 4-5 weeks.

In many patients with mild disease severity, at a dose of less than 1.5 Gy, there is no clear clinical picture of the primary reaction, and therefore, in these cases it is difficult to talk about the latent period.

With moderate severity, after the end of the primary reaction, there are insignificant deviations in the well-being of patients: it is difficult for them to do physical labor, it is difficult for them to concentrate for intellectual work, they get tired quickly, although they give the impression of healthy people. Distinct changes are detected in the hematological picture: the number of leukocytes and platelets in the peripheral blood fluctuates. By the 7-9th day, the number of leukocytes decreases to 2000-3000 in 1 μl, then a temporary increase or stabilization of indicators occurs, lasting until 20-32 days, then agranulocytosis occurs, which mainly determines the clinical signs of the height of the disease. The number of platelets and reticulocytes changes similarly.

During the latent period of hematological syndrome, epilation develops, as well as damage to the skin and mucous membranes.

The peak period should be determined primarily by the primary signs of the disease - a decrease in the number of leukocytes and platelets in the peripheral blood. Lymphocytes, due to their very high radiosensitivity, decrease already in the first days after irradiation, but lymphopenia does not noticeably affect the clinical picture of the disease.

With uniform irradiation in medium doses, the period of the height of the disease is characterized exclusively by leuko- and thrombocytopenia and associated complications of an infectious nature, bleeding.

A mild degree at a dose of 1-1.5 Gy is usually not accompanied by agranulocytosis, and therefore there are no infectious complications. The height of the period can only be noted by the decrease in leukocytes to 1500-2000 per 1 μl, which occurs at the beginning or middle of the second month of the disease. Until this period, the abortive rise in the number of leukocytes continues. When the radiation dose approaches 2 Gy, agranulocytosis develops on the 32nd day of the disease, and the clinical picture of the disease corresponds to the average severity of the lesion. The duration of agranulocytosis does not exceed 7-8 days, but it can be very deep (up to 200-500 cells in 1 μl in the complete absence of granulocytes), which causes severe infectious complications. The most common are follicular and lacunar tonsillitis, however, as with any myelotoxic agranulocytosis, the possibility of severe pneumonia, esophagitis, perforated intestinal ulcers, and the development of sepsis cannot be excluded.

If the beginning of the period of the height of the disease should be determined not by external manifestations, but by the fall of leukocytes below critical numbers, then the end of agranulocytosis is sometimes marked not so much by the rise in the number of leukocytes, but by the improvement of the patient’s condition, by the normalization of temperature. Essentially, activation of hematopoiesis occurs earlier, but with a slight increase in granulocytes in the blood, almost all of them are absorbed by the infectious focus.

The picture of the bone marrow during the peak period corresponds to complete aplasia: the trepanate shows the disappearance of foci of hematopoiesis, there are almost no hematopoietic cells. A few days before the cessation of agranulocytosis, before the appearance of granulocytes in the peripheral blood, clear signs of proliferation of hematopoietic cells are already observed in the bone marrow.

When exposed to a dose of more than 3 Gy on the intestinal area, radiation enteritis develops. With irradiation up to 5 Gy, it manifests itself as mild bloating in the 3-4th week after irradiation, non-frequent, pasty stools, and an increase in temperature to febrile levels. The time of appearance of these signs is determined by the dose: the higher it is, the earlier the intestinal syndrome appears. At high doses, severe enteritis develops: diarrhea, flatulence, abdominal pain, bloating, splashing and rumbling, pain in the ileocecal area. Intestinal syndrome may be accompanied by damage to the colon, in particular the rectum, with the appearance of characteristic tenesmus, radiation gastritis, radiation esophagitis. Radiation gastritis and esophagitis develop at the beginning of the second month of the disease, when bone marrow damage is already behind.

Even later, after 3-4 months, radiation hepatitis begins. Its peculiarity is that jaundice occurs without a prodrome, bilirubinemia is low, but the level of transaminases is very high (from 200 to 250 units), and skin itching is pronounced. Over the course of several months, the process goes through many “waves” and gradually subsides. “Waves” consist of increased itching, a slight increase in bilirubin and severe hypertransaminasemia. The prognosis for liver damage appears to be good, although no specific treatment has yet been found (prednisolone clearly worsens the course of radiation hepatitis).

The most radiosensitive skin is the area of the armpits, inguinal folds, elbows, and neck. Radiation dermatitis goes through phases of primary erythema, edema, secondary erythema, development of blisters and ulcers, and epithelization. The prognosis of skin lesions also depends on the damage to the skin vessels of large arterial trunks. Vessels undergo progressive sclerotic changes over many years, and previously healed skin radiation ulcers can cause repeated necrosis over a long period of time. Outside of vascular lesions, secondary erythema ends with pigmentation at the site of the radiation burn, often with thickening of the subcutaneous tissue. In this area, the skin is usually atrophic, vulnerable, and prone to the formation of secondary ulcers. At the sites of the blisters, nodular skin scars form with multiple angioectasia on atrophic skin.

The recovery period begins at the end of the 2-3rd month, when the general condition of the patients gradually improves. But even with the normalization of blood counts and the disappearance of intestinal disorders, severe asthenia remains. Full recovery in patients can take many months and sometimes years. The composition of the blood is normalized in case of mild degree by the end of the second month, in case of moderate degree - by its middle, and in case of severe degree - by the end of the first, beginning of the second month after irradiation. Restoration of the ability to self-care occurs after the elimination of agranulocytosis, oral and intestinal lesions. With a mild degree, patients do not lose the ability to self-care. With moderate severity, when deciding whether to discharge a patient from the hospital, one cannot focus only on the restoration of hematopoiesis. Severe asthenia makes these people unable to work for about six months. Usually, those with a severe degree of illness are discharged from the hospital 4-6 months after the onset of the disease, and sometimes later if the general manifestations of radiation sickness are accompanied by local lesions.

Diagnostics

With a characteristic picture of the primary reaction, knowledge of its temporal characteristics, as well as quantitative and temporal parameters of changes in the levels of lymphocytes, leukocytes, and platelets, the diagnosis of ARS does not present any great difficulties, including the degree of its severity.

Currently, a method of chromosomal analysis of peripheral blood lymphocytes stimulated by phytohemagglutinins has been proposed for the diagnosis of radiation injury. Chromosomal analysis detects overexposure long after exposure, but does not provide reliable information on local doses. The preservation in the bone marrow of cells with damaged chromosomes, capable of mitosis under the influence of phytohemagglutinin many years after irradiation of a given area of the bone marrow, significantly refines biological dosimetry in the long term after irradiation. When the irradiation dose of a given area of the bone marrow is more than 5 Gy, the percentage of cells with chromosomal abnormalities almost equal to 100. Determination of higher doses is possible only in a single cell: the higher the dose, the more the cell is saturated with damaged chromosomes.

Treatment

To prevent vomiting, patients are prescribed Cerucal 1 tablet 5 times a day; the drug can be administered intravenously, 2 ml every 2 hours, 4-6 times a day. If the administration of cerucal does not prevent vomiting, injections of droperidol 0.25% - 1.0 ml or haloperidol 0.5-1.0 ml of a 0.5% solution intramuscularly or subcutaneous injection 0.5-1 can be used .0 ml of 0.1% atropine solution.

Classification of pesticides.

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CLINIC OF ACUTE RADIATION DISEASE

Parameter name	Meaning
Article topic:	CLINIC OF ACUTE RADIATION DISEASE
Rubric (thematic category)	Radio

CLASSIFICATION OF ACUTE RADIATION SICKNESS

ACUTE RADIATION SICKNESS

Acute radiation sickness (ARS) is a disease resulting from short-term (from several minutes to 1-3 days) exposure of the entire body or most of it to ionizing radiation (gamma rays, neutrons, X-rays) in a dose exceeding 1 Gy , and characterized by a phased course and polymorphism of clinical manifestations (Table 1). Taking into account the dependence on the dose of external radiation, cerebral, toxemic, gastrointestinal and typical, or bone marrow, forms of acute radiation sickness are distinguished.

The cerebral form of ARS occurs with general irradiation at a dose of more than 80-100 Gy. In this case, direct damage to the central nervous system occurs with profound disruption of its functions. Severe psychomotor agitation, disorientation, and subsequent adynamia, respiratory and circulatory disorders, and convulsions occur. Victims die within the first hours after exposure.

The toxemic form of ARS develops at radiation doses of 50-80 Gy. Due to severe intoxication with tissue metabolic products, those affected also experience severe disturbances in the functional state of the central nervous system. Death occurs within the first 3-8 days after the lesion.

The gastrointestinal form of ARS develops with irradiation at a dose of 10-50 Gy. In victims, severe gastrointestinal disorders predominate - uncontrollable vomiting, diarrhea, tenesmus, paresis of the stomach and intestines. This form of the disease usually ends in death within 5-10 days from the moment of exposure.

The bone marrow (typical) form of ARS occurs at radiation doses of 1-10 Gy and, due to the real prospects for recovery, has the greatest practical importance. The main pathogenetic and clinical changes are pathological changes in the blood system (cytopenia, coagulation disorders), hemorrhagic syndrome, and infectious complications.

Acute radiation exposure in doses less than 1 Gy does not lead to the development of radiation sickness, but manifests itself in the form of a radiation reaction in the 4th – 6th week.

In the pathogenesis of radiation sickness, the following points are important: 1) direct and indirect effects of ionizing radiation on the cells and tissues of the irradiated body with maximum damage to radiosensitive elements (lymphoid, myeloid tissue; germinal, intestinal and integumentary epithelium; secretory cells of the digestive and endocrine glands ); 2) metabolic disorders, formation and circulation in the blood of radiotoxic substances that enhance the biological effect of penetrating radiation; 3) disintegration of the neuroendocrine system, disruption of regulatory influences on internal organs; 4) dysfunction of the vascular system and the development of bleeding; 5) disorders of hematopoiesis and immunogenesis, decreased resistance to injections.

The morphological substrate of acute radiation sickness is: a) dystrophic changes in organs and tissues; b) bone marrow depletion; c) signs of hemorrhagic syndrome; d) infectious complications.

During the clinical course ARS (mainly of the bone marrow form) is distinguished into four periods: the period of the primary reaction, or initial; hidden, or latent; period of height, or pronounced clinical manifestations; recovery period.

Primary reaction period is characterized primarily by neuroregulatory disorders (dyspeptic syndrome), redistribution changes in the composition of the blood (transient neutrophilic leukocytosis), and disorders of the analyzing systems. The direct damaging effect of penetrating radiation on lymphoid tissue and bone marrow reveals itself as lymphopenia, death of young cellular elements, and the presence of chromosomal aberrations in cells of the lymphoid and myeloid type. Typical clinical symptoms of this period based on the severity of ARS are presented in Table 2.

Hidden period characterized by external well-being, subsidence of vasovegetative disorders with a gradual increase in pathological disorders with a gradual increase in pathological changes in the most affected organs (lymphatic system, bone marrow, germinal and intestinal epithelium). The severity of these changes is proportional to the magnitude of the absorbed radiation dose (Table 3).

High period begins with a deterioration in health. Appetite disappears, headaches, nausea and vomiting reappear, general weakness, weakness, body temperature rises. Tachycardia, expansion of the borders of the heart, dullness of heart sounds, and hypotension are noted. The ECG shows a decrease in wave voltage, extrasystoles, a decrease in the S-T segment, and distortion of the T wave. Bronchitis and pneumonia, glossitis, ulcerative necrotizing stomatitis, and gastroenterocolitis are often detected. Hemorrhagic diathesis develops. Severe neurological disorders may be detected. Changes in blood and hematopoiesis progress (Table 4). During bacteriological examination, it is possible to inoculate a variety of flora from the blood of patients (Escherichia coli, staphylococcus, Proteus, yeast fungi, etc.) Signs of general intoxication increase.

Recovery period manifested by improved well-being, normalization of body temperature, renewed appetite, disappearance of signs of hemorrhagic diathesis. Restoration of impaired functions and bone marrow hematopoiesis is often delayed for a long time. Asthenia, lability of blood pressure and hematological parameters (short-term leukocytosis, thrombocytosis), some trophic and metabolic disorders remain for a long time.

CLINIC OF ACUTE RADIATION DISEASE - concept and types. Classification and features of the category "CLINIC OF ACUTE RADIATION DISEASE" 2017, 2018.

Acute radiation sickness, caused by an uneven distribution of radiation energy over the surface of the body, i.e., predominant irradiation of individual parts (segments) of the body, can occur in military conditions, since military personnel located in protective structures, trenches, and combat vehicles have various parts of the body may be unequally protected (“shielded”) from the effects of radiation. The symptomatology and course of ARS from sharply uneven (mainly segmental) irradiation have attracted attention in recent years and have been studied to a lesser extent than ARS from general, relatively uniform irradiation.
With uneven irradiation, the general patterns of the course of ARS (cyclicality, hypoplasia of hematopoietic tissue) are less clearly expressed than with generally uniform exposure; Local symptoms associated with damage to predominantly irradiated “critical” organs often come to the fore in the clinical picture of the disease. Obviously, with the same dose load, the clinical picture of ARS in such cases will be determined by the geometry of the irradiation, i.e., the specific distribution of radiation energy throughout the body.
When irradiating predominantly the head (the head part of the body), a pronounced primary reaction is observed: nausea, vomiting, headaches, vasomotor disorders. If the radiation dose exceeds 400-500 r, hyperemia and swelling of the facial skin develops; This is followed by epilation of eyebrows and eyelashes. When examining peripheral blood and sternal puncture, pronounced signs of hematopoietic suppression, as a rule, are not detected.
Irradiation of the thoracic segment of the body occurs with minimal manifestations of the primary reaction; at the same time, in the first two days, unpleasant sensations in the heart area are often observed, up to anginal pain, various disturbances in the rhythm of cardiac activity, and corresponding changes in the electrocardiogram. A study of the sternum punctate reveals inhibition of hematopoiesis, while
peripheral blood shows little or no change. This dissociation in sternal punctate and peripheral blood, characteristic of cases of chest irradiation, is explained by a compensatory increase in hematopoiesis in other (extrasternal) parts of the bone marrow tissue.
Due to the presence of a large reflexogenic zone, irradiation of the abdominal segment of the body is accompanied by a pronounced primary reaction and, often, abdominal pain. The clinical course of the disease is determined mainly by clinical and morphological changes in the abdominal organs, primarily the intestines (segmental radiation colitis, enteritis, etc.), which are characterized by the greatest radiodamage. Changes in the blood system are not pronounced and are transient. In general, it should be noted that in cases of uneven irradiation, in the interests of an objective assessment of the hematopoietic function, it turns out to be necessary to take bone marrow aspirate from different bones (sternum, iliac crest, calcaneus, etc.).
In conclusion, we present an extract from the medical history of patient Ch., who suffered from ARS caused by sharply uneven external gamma irradiation.
Ch., 27 years old, before the disease in question he was a completely healthy, physically strong person. 7/X 1967, grossly violating safety requirements, for 30 minutes. was exposed to gamma rays from the Co60 standard, with an activity of 356 μC. Mostly the left inguinal and iliac region, as well as a significant part of the abdomen, were exposed to irradiation.
Calculations show that the absorbed dose in the center of the radiation lesion at a depth of 1 mm was 4071 rad, at a depth of 5 mm - 1234 rad, 15 mm - 264 rad.
40 minutes after radiation exposure, the victim developed weakness, headache, dizziness, noise in the head and ears, nausea, thirst, dryness and a bitter-salty taste in the mouth. About an hour later, profuse vomiting occurred, which was repeated three more times throughout the day. On the same day, the patient’s appetite disappeared and weakness increased; a shaky, uncertain gait appeared. That night he could not sleep for a long time. In the morning of 8/X I felt exhausted. I was worried about weakness, headache, dizziness, noise in the head, dryness and an unpleasant bitter-salty taste in the mouth, nausea. In the morning I felt a burning pain in the left iliac region (about 10 hours after irradiation). No appetite (I didn’t eat anything all day). When trying to drink a glass of coffee, vomiting occurred. During the day there was a slight nosebleed. In the evening I noticed redness of the skin in the left iliac region (approximately 30 hours after radiation exposure). The next night was also restless: nightmares haunted me, visual hallucinations appeared, often
woke up. On 9/X the vomiting stopped, but the state of health did not noticeably improve. On this day, during a medical examination, facial skin hyperemia was detected. The scleral vessels were injected. The tongue is coated with a brownish coating and is rather dry. Pulse 70 per minute, rhythmic. Blood pressure 90/60 mm Hg. Art. The heart and lungs are unchanged. On palpation, moderate pain in the left iliac region; the liver and spleen were not palpable. Blood test 9/X 1967: Hb 13 gs/o, er. 4,890,000, c. p. 0.81, l. 7800, p. 3%, p. 81%, lymph. 11% (860), mon. 5%, ROE 11 mm/h, platelets 260,000. Urinalysis is normal.
On October 10, 1967 (4th day of illness), a tense bubble about 5 cm in diameter appeared in the center of the erythema. A pain occurred when urinating, which bothered the patient for a week. The urine at this time had a bloody tint. Within a week, the patient's weight decreased by 8 kg.

By the evening of October 13th (7th day of illness), the patient’s state of health noticeably improved. I have an appetite. The dryness and bitter-salty taste in the mouth disappeared. Headache, dizziness, nausea began to bother me much less. Thus, we can assume that the period of the primary reaction lasted for 6 days in the patient.
Despite the clear improvement in health, the patient continued to complain of weakness and headaches. During this period, he experienced increased vasomotor reactions, hyperhidrosis of the palms, armpits, face, and head.
On the 20th day of illness, the exfoliated epidermis was removed from the main lesion. A smooth, eroded surface was exposed, without purulent discharge. In the center of the erosion is a grayish-brown, oval-shaped area of necrosis with smooth borders. The erosion surface was painful, the necrosis zone was painless. In other areas of the lesion, the formation of small bubbles, about 1-2 mm in diameter, began. Blood test 18/X: Hb 13.2 g%gt; er. 4 300 LLC, c. p. 0.92, l. 4600 S. 1% (50), p. 4% (185), p. 54% (2480), e. 12% (550), b. 1% (45), lymph. 17% (780), m. 11% (510), ROE 5 mm per hour, tr. 120,000. Urine and stool tests are unchanged. The sternum punctate (17th day of illness) contained 18,500 myelokaryocytes per 1 mm3. Cellular composition without significant qualitative changes; There was only an increase in the content of eosinophils (6%). The punctate from the right iliac crest contained 10,000 myelokaryocytes per 1 mm3 and a decrease in the content of young forms of both white (2%) and red (4.8%) sprouts was observed.
On 27/X (21st day of illness), fine, not very loud, rales began to be heard along the lower edge of both lungs. Body temperature increased to 37.0° Blood test: Hb 14 g%, er. 4,530,000, l. 5500. p. 13% (700),
With. 53% (2900), e. 2% (100), lymph. 23% (1300), m. 9% (500), ROE -30 mm per hour. The patient's condition began to noticeably deteriorate (the beginning of the peak period). From 30/X fever appeared, weakness and sweating increased, appetite and juice worsened. The itching in the erythema area became stronger. Body temperature in the morning is 37.5°, in the evening -37.7°. Pulse - 78 per minute, blood pressure 115/80 mm Hg. Art. A gentle systolic murmur began to be heard at the apex of the heart. Breathing - 22 per 1 min. On the left, in the lower-lateral sections of the lungs, against the background of hard breathing, sonorous fine-bubble rales were heard. The next day, the same wheezing appeared on the right side along the axillary lines below the 6th rib. Blood test 31/X: Hb 14.2 g%. er. 4,060,000, l. 8600, p. 10% (860), p. 66% (5700), e. 3% (260), lymph. 12% (1020), m. 9% (760). ROE - 29 mm per hour.
Although the peak period was not clearly expressed and was not clearly demarcated from the period of imaginary well-being (we attribute the latter to days 7-12) and the period of resolution, it can be considered with a certain convention as the beginning of the 21-24th day of illness and the end of the 45th day. Day 47 Throughout this so-called peak period, the patient’s well-being and condition were not significantly impaired. He complained only of weakness, sweating, loss of appetite, and sleep disturbances. What bothered him most was the itching and pain in the area of the radiation injury, which usually occurred in the evening and at night, which is why he sometimes had to resort to injections of promedol. I was also constantly bothered by moderate aching pain in the area of the left ilium and the upper third of the left thigh.
On November 19 (43rd day), cramping pain appeared in the upper half and middle of the abdomen, its bloating, as well as intestinal rumbling, accompanied by an imperative urge to go down and copious discharge of gases. These pains often appeared in the evening and at night and were usually relieved with antispasmodic drugs, but sometimes it was necessary to resort to an injection of promedol. Outside of attacks of pain, the patient's condition was satisfactory. The stool was formed all the time, but not regular. From the 25th to the 38th day of illness, streaks of blood appeared on the surface of the stool.
Vii ^"and x-ray examination on November 11, 1967 in the area of VI, VII and 41 segments of the lower lobe of the right lung, peribronchial infiltration of pulmonary tissue of a pneumonic nature was determined.
During sigmoidoscopy on 31/X (25th day of illness), 2 erosions of about 2 mm in diameter were found on the surface of the mucosa at a depth of 16 cm, without perifocal

significant inflammatory changes and with stale hemorrhages in their bottom; the same erosions were found at a depth of 18 and 20 cm. The mucosa of the anterior transitional fold is pale in color with a pronounced vascular pattern. With secondary sigmoidoscopy 16/XI, the mucous membrane is pale pink. At a depth of 13 cm, a submucosal hemorrhage of about 1.5 cm in diameter was detected.
On the ECG, recorded multiple times, moderately pronounced muscle changes were observed, BCG had I-II degree of changes according to Brown.
Blood test 10/XI (35th day of illness): Hb 14.2 g%, er. 4,520,000, c. p. 0.94, l. 4000, p. 1.5% (50), p. 64.5% (2590), e. 6.5% (260), lymph. 15.5% (620), m. 12% (480), ROE - 37 mm per hour, platelets 210,000, reticulocytes 1.4%.
However, the healing of local radiation damage was extremely sluggish. Over two weeks (from the 47th to the 59th day), the erosion surface almost did not decrease in size. The area of central necrosis became dry, almost black, and small cracks appeared on its surface. Touching the erosive surface was painful. At the sites of small lesions, depigmented spots with a narrow rim of hyperpigmentation along the edges formed.
From the 60th day, periodic cramping pains in the abdomen began to bother me, which more often occurred for no apparent reason, and sometimes in connection with the act of defecation. The appearance of pain was accompanied by increased intestinal motility, flatulence, and the urge to go down; after the gas passed, the pain went away or weakened. At the height of the pain, vomiting of food mixed with bile sometimes occurred. The stool was once a day, mushy, without mucus or blood. Due to the pain, which occurred more often at night, I had trouble sleeping. Body temperature remained normal. On palpation of the abdomen, moderate pain was noted in the center and in the area of the burn. There were no symptoms of peritoneal irritation. Laboratory examination parameters were, as a rule, within normal limits.
1/1 1968 (86th day of illness) abdominal pain appeared under the burn surface, worsening with deep breathing. They were especially strong when trying to induce a bowel movement that had not been done for 4 days. The patient became lethargic, apathetic, and haggard. Appetite gone. The abdomen was somewhat swollen and was difficult to breathe. The anterior abdominal wall is moderately tense. On palpation, pain was detected in the left half of the abdomen and especially in the area of the radiation burn, where a painful infiltrate of about 10 cm in diameter was palpated. There were no peritoneal symptoms. During a digital examination of the rectum, the lumen was empty and no pathological formations were found. Blood test 6/1 1968: l. 10 250, S. 0.5% (50), p. 4.5% (450), p. 75% (7700), e. 2% (200), lymph. 11.5% (1200), m. 6.5% (650), ROE - 35 mm per hour.
On January 7, 1968 (93rd day of illness), the patient’s condition noticeably worsened. The clinical picture indicated developing partial intestinal obstruction due to compression of the sigmoid colon by the infiltrate formed under the radiation burn, and possibly due to perisigmoiditis. The patient was transferred to the military field surgery clinic of the academy. On the second day - 9/1 i968 (95th day of illness) - due to the pronounced clinical and radiological picture of intestinal obstruction and the failure of the conservative measures taken, he was operated on (surgeon - B.V. Serikov). During the operation, it was discovered that the sigmoid colon in the projection of the radiation injury was soldered to the abdominal wall by a dense inflammatory-scar infiltrate. The mesentery of the small intestine and the area of the omentum were pulled up and soldered to the infiltrate. The lumen of the sigmoid colon is almost completely closed. Small intestinal contents and gases were removed through the enterostomy, which was then closed. The transverse colon was pulled to the left hypochondrium and an unnatural anus (colostomy) was placed. After the operation, the patient's condition gradually improved. Healing of postoperative wounds occurred by primary intention. The colostomy functioned normally. The patient's appetite and sleep were restored. His condition became quite satisfactory.
The patient received antibiotics (penicillin, streptomycin, erythromycin, oletetrin, chloramphenicol with nystatin, spofadazine, diphenhydramine, pipolfen, large doses of vitamins). On the 62nd and 66th days of illness, two transfusions were performed
blood by direct method, 200 and 300 ml. To relieve pain in the burn area and in the abdomen, intravenous administration of a 4% solution of novocaine, 100 ml, by drop method was successfully carried out. During pain in the burn area, analgin was also prescribed, both orally and intramuscularly. For spastic pain in the abdomen, the patient took papaverine , no-shpu, halidor, belladonna extract. However, these drugs were not always effective. They tried to use drugs as rarely as possible and only in cases where other means failed to relieve pain.
The food was high in calories, with sufficient protein content. The patient additionally received liver, lactic acid products, and fresh fruits. Particular attention was paid to the toilet of the skin and oral cavity.
For local treatment of radiation burns, lotions with furatsilin and rivanol were first used. Later - oxycort, locacorten. If there was candida on the surface of the burn, nystatin ointment was used.
Thus, the postoperative period proceeded without significant complications. However, despite the fairly vigorous restorative treatment, including repeated blood transfusions and infusions of protein hydrolysates, the patient persistently and for a long time had symptoms of general endogenous dystrophy. Also noteworthy was the extremely slow development of reparative processes in the area of local radiation injury (epithelialization in the burn area was limited only to its peripheral parts, etc.).
A neurological examination (A.G. Panov, D.A. Ulitovsky) revealed symptoms of multiple nerve lesions in the left ilio-inguinal region.

CLASSIFICATION OF ACUTE RADIATION SICKNESS

ACUTE RADIATION SICKNESS

Acute radiation sickness (ARS) is a disease resulting from short-term (from several minutes to 1-3 days) exposure of the entire body or most of it to ionizing radiation (gamma rays, neutrons, X-rays) in a dose exceeding 1 Gy , and characterized by a phased course and polymorphism of clinical manifestations (Table 1). Depending on the dose of external radiation, cerebral, toxemic, gastrointestinal and typical, or bone marrow, forms of acute radiation sickness are distinguished.

Acute radiation exposure in doses less than 1 Gy does not lead to the development of radiation sickness, but manifests itself in the form of a radiation reaction in the 4th – 6th week.

In the pathogenesis of radiation sickness, the following points are important: 1) direct and indirect effects of ionizing radiation on the cells and tissues of the irradiated body with maximum damage to radiosensitive elements (lymphoid, myeloid tissue; germinal, intestinal and integumentary epithelium; secretory cells of the digestive and endocrine glands); 2) metabolic disorders, formation and circulation in the blood of radiotoxic substances that enhance the biological effect of penetrating radiation; 3) disintegration of the neuroendocrine system, disruption of regulatory influences on internal organs; 4) dysfunction of the vascular system and the development of bleeding; 5) disorders of hematopoiesis and immunogenesis, decreased resistance to injections.

The morphological substrate of acute radiation sickness is: a) dystrophic changes in organs and tissues; b) bone marrow depletion; c) signs of hemorrhagic syndrome; d) infectious complications.

Primary reaction period is characterized primarily by neuroregulatory disorders (dyspeptic syndrome), redistribution changes in the composition of the blood (transient neutrophilic leukocytosis), and disorders of the analyzing systems. The direct damaging effect of penetrating radiation on lymphoid tissue and bone marrow reveals itself as lymphopenia, death of young cellular elements, and the presence of chromosomal aberrations in cells of the lymphoid and myeloid type. Typical clinical symptoms of this period, depending on the severity of ARS, are presented in Table 2.

High period begins with a deterioration in health. Appetite disappears, headaches, nausea and vomiting, general weakness, adynamia reappear, and body temperature rises. Tachycardia, expansion of the borders of the heart, dullness of heart sounds, and hypotension are noted. The ECG shows a decrease in wave voltage, extrasystoles, a decrease in the S-T segment, and distortion of the T wave. Bronchitis and pneumonia, glossitis, ulcerative necrotizing stomatitis, and gastroenterocolitis are often detected. Hemorrhagic diathesis develops. Severe neurological disorders may be detected. Changes in blood and hematopoiesis progress (Table 4). During bacteriological examination, it is possible to inoculate a variety of flora from the blood of patients (Escherichia coli, staphylococcus, Proteus, yeast fungi, etc.) Signs of general intoxication increase.

Recovery period manifested by improved well-being, normalization of body temperature, renewed appetite, and disappearance of signs of hemorrhagic diathesis. Restoration of impaired functions and bone marrow hematopoiesis is often delayed for a long time. Asthenia, lability of blood pressure and hematological parameters (short-term leukocytosis, thrombocytosis), some trophic and metabolic disorders remain for a long time.

In the case of a single irradiation dose of 0.25 Gy, routine clinical examination does not reveal noticeable deviations.

When irradiated at a dose of 0.25-0.75 Gy, mild changes in the blood picture and neurovascular regulation may be noted, occurring in the 5-8th week from the moment of irradiation.

Irradiation at a dose of 1-10 Gy causes typical forms of ARS with a disorder of hematopoiesis leading in its pathogenesis.

Irradiation at a dose of 10-20 Gy leads to the development of the intestinal form with a fatal outcome on the 10-14th day.

When a person is irradiated at a dose of 20-80 Gy, death occurs on the 5-7th day with increasing azotemia (toxemic form).

During the bone marrow form there are 4 periods:

I—period of the primary general reaction;

II - period of visible clinical well-being (latent);

III - period of pronounced clinical manifestations (the height of the disease);

IV - recovery period.

The division of the disease into these periods is relative; it is valid for very uniform exposure.

According to the absorbed doses, acute radiation sickness is usually divided into 4 degrees of severity:

1) light (1-2 Gy);

2) medium (2-4 Gy);

3) severe (4-6 Gy);

4) extremely severe (more than 6 Gy).

The given doses are average.

With a severe degree of damage, the primary reaction is characterized by a greater severity of these symptoms and an earlier date of their onset; vomiting occurs 0.5-1.5 hours after irradiation. The primary reaction in severe patients ends within 1-2 days; vomiting stops after 6-12 hours, the headache subsides, and weakness gradually decreases. Facial hyperemia disappears by 4-5 days, and scleral hyperemia disappears earlier. In patients with severe lesions, up to the development of agranulocytosis and associated infectious complications, severe asthenia remains.

In extremely severe cases, the primary reaction begins early. Vomiting appears within 30 minutes from the moment of irradiation. It is painful and has an indomitable character. Sometimes patients develop a short-term loss of consciousness 10-15 minutes after irradiation. When the abdominal area is irradiated at doses exceeding 30 Gy, profuse diarrhea may appear within the first hours. All these phenomena are usually accompanied by collapse.

A certain place in the characteristics of the primary reaction is occupied by a change in the number of leukocytes in the peripheral blood. In the first hours after irradiation, there is an increase in the number of leukocytes, mainly due to neutrophils. This initial leukocytosis, lasting less than a day, does not show a clear relationship with the dose of exposure, although it may be noted that high leukocytosis is observed more often in more severe cases of damage. The increase in the number of redistributive leukocytes is due to the release of granulocyte reserve from the bone marrow, while the height and duration of leukocytosis do not have a clear dependence on the intensity of irradiation. In this regard, primary leukocytosis is not a reliable indicator of the severity of radiation injury.

The period of external well-being is determined by the dose of radiation exposure and can last from 10-15 days to 4-5 weeks.

In severe cases of the disease, after the end of the primary reaction, the patients’ well-being also improves, but general asthenia is more pronounced, and sometimes low-grade fever is noted. The dynamics of changes in peripheral blood are characterized by an initial decrease in the number of leukocytes to 1000-2000 per 1 μl, reaching its greatest severity at 2-3 weeks after irradiation. At a dose of more than 6 Gy, agranulocytosis develops starting from the 7-8th day. During the period of agranulocytosis, the level of platelets also drops below critical numbers, reaching several thousand in 1 μl.

In extremely severe cases, patients’ well-being may improve for several days - the temperature drops to low-grade levels, headaches decrease, and sleep improves. The level of leukocytes decreases by 6-8 days to 1000 per 1 µl and below (at doses of several tens of Gy, the number of leukocytes can drop to 1000 per 1 µl on the 5th day after irradiation). At the same time, there is a sharp drop in the number of platelets.

During the latent period of hematological syndrome, epilation develops, as well as damage to the skin and mucous membranes.

In severe cases, in the interval from 7 to 20 days, the number of leukocytes drops below 1000 in 1 μl. At a dose close to 6 Gy, agranulocytosis begins on the 7-8th day, and at a dose close to 4 Gy - on the 18-20th day. The severity of infectious complications at these doses may be more pronounced, since along with damage to the bone marrow there is serious damage to the epithelium of the mucous membranes - the oral cavity, intestines. Patients develop necrotic tonsillitis, stomatitis, and various septic complications are possible. The duration of agranulocytosis is no more than 1.5-2 weeks, although if the dose exceeds 6 Gy, it may be prolonged. Recovery from agranulocytosis is characterized by a more or less rapid rise in leukocytes in the blood. The increase in the platelet count may be 1-2 days ahead of the increase in the number of leukocytes.

In humans, acute radiation sickness is characterized by a serious hemorrhagic syndrome (if deep thrombocytopenia lasts no more than 2-3 weeks). However, since the number of platelets in the peripheral blood is reduced, bruising at the injection sites and short-term bleeding from the mucous membranes are possible. Severe anemic syndrome is also rare, which is associated with the high radioresistance of erythrocytes and their long life in the blood. Moderate anemia (2.5-3 * 1012/l erythrocytes) is observed, as a rule, after recovery from agranulocytosis, on days 30-35. This is followed by an increase in the number of reticulocytes, correlating with the radiation dose, and normalization of the number of red blood cells and hemoglobin.

When irradiated at doses above 5 Gy, the so-called oral syndrome develops on the oral mucosa, swelling of the oral mucosa in the first hours after irradiation, a short period of weakening of the edema and its intensification from the 3-4th day, dry mouth, impaired salivation, the appearance of viscous , causing vomiting of saliva and the development of ulcers on the mucous membrane. All these changes, as well as ulcerative stomatitis, are caused by local radiation damage, they are primary and usually precede agranulocytosis, which can aggravate the infection of oral lesions.