Cutaneous Radiation Injuries: REAC/TS Clinical Experience.

The Radiation Emergency Assistance Center/Training Site (REAC/TS) is one of the US Department of Energy (DOE)/National Nuclear Security Administration (NNSA) Nuclear Emergency Response Team (NEST) assets and has been responding to radiological incidents since 1976. REAC/TS is in the Oak Ridge Institute for Science and Education (ORISE). A critical part of the REAC/TS mission is to provide emergency response, advice, and consultation on injuries and illnesses caused from ionizing radiation. Fortunately, radiation injuries are not frequent, but when they occur, they are more likely to be cutaneous radiation injuries (CRI) or internal contamination. In this paper, we will review selected cases from the REAC/TS experience in order to illustrate cutaneous patterns of injury and treatment options.

Effectiveness of FDA-cleared Wound Cleansers for Disinfection of Surgical Surfaces in Resource Limited Environments.

BACKGROUND: Service members experience unique circumstances when providing medical care in austere environments. Some challenges include supply shortages and the need to perform surgery in extreme temperatures. As such, methods for the sanitization of medical tools are sought and efficacy of existing materiel sourced to austere medical facilities should be examined for this purpose. This study tested the efficacy of commercially available, FDA-approved wound cleansers for alternative use as a potential sanitizer of stainless-steel medical devices and instruments found at improvised medical facilities. METHODS: Escherichia coli and Staphylococcus aureus cultures were inoculated onto sterile stainless-steel carriers. After cleanser treatment, samples were held for 2 h, 24 h, or 7 days to represent different turn-around times between uses at ambient (25 °C), cold (-20 °C) and hot (50 °C) temperatures. Additional ex vivo challenges were performed using slurry harvested from porcine cecum. Colony-forming units and log reduction were calculated. Significance was determined using one-way ANOVA and multiple comparisons between treatment groups were calculated using Tukey's multiple comparison test. RESULTS: All wound cleansers demonstrated statistically significant bactericidal activity against lab bacteria and ex vivo cecal slurry. E. coli and S. aureus resulted in approximately a 5-6 log reduction on average, resulting in no growth after treatment for all cleaners at 2 and 24 h. Similarly, 7-day post exposure results in a 6-log reduction after treatment for all groups at 25 °C and -25 °C. While treatment of ex vivo samples did not result in total kill, significant reductions in bacterial load were observed in all groups. CONCLUSIONS: Wound cleansers cleared for use in surgical settings demonstrated antimicrobial effects against bacteria deposited on metal surfaces. These cleansers decreased bacterial viability when challenged against extreme temperatures and few bacteria were harvested from treated surfaces even after 7 days. FDA-approved wound cleaners show promise as a potential sanitizer in resource limited environments.

Cutaneous and local radiation injuries.

The threat of a large-scale radiological or nuclear (R/N) incident looms in the present-day climate, as noted most recently in an editorial in Scientific American (March 2021). These large-scale incidents are infrequent but affect large numbers of people. Smaller-scale R/N incidents occur more often, affecting smaller numbers of people. There is more awareness of acute radiation syndrome (ARS) in the medical community; however, ionising radiation-induced injuries to the skin are much less understood. This article will provide an overview of radiation-induced injuries to the skin, deeper tissues, and organs. The history and nomenclature; types and causes of injuries; pathophysiology; evaluation and diagnosis; current medical management; and current research of the evaluation and management are presented. Cutaneous radiation injuries (CRI) or local radiation injuries (LRI) may lead to cutaneous radiation syndrome, a sub-syndrome of ARS. These injuries may occur from exposure to radioactive particles suspended in the environment (air, soil, water) after a nuclear detonation or an improvised nuclear detonation (IND), a nuclear power plant incident, or an encounter with a radioactive dispersal or exposure device. These incidents may also result in a radiation-combined injury; a chemical, thermal, or traumatic injury, with radiation exposure. Skin injuries from medical diagnostic and therapeutic imaging, medical misadministration of nuclear medicine or radiotherapy, occupational exposures (including research) to radioactive sources are more common but are not the focus of this manuscript. Diagnosis and evaluation of injuries are based on the scenario, clinical picture, and dosimetry, and may be assisted through advanced imaging techniques. Research-based multidisciplinary therapies, both in the laboratory and clinical trial environments, hold promise for future medical management. Great progress is being made in recognising the extent of injuries, understanding their pathophysiology, as well as diagnosis and management; however, research gaps still exist.

An Analysis of the Effectiveness of High-level Disinfection for Surgical Instruments Used by Department of Defense Austere Surgical Teams.

INTRODUCTION: The purpose of this investigation was to evaluate the efficacy of currently employed commercial disinfectants in a simulated austere surgical environment similarly faced by ground surgical teams in forward deployed positions. Severe contamination of traumatic combat wounds along with limitations of operations in austere environments may result in available disinfectants providing inadequate surgical instrument decontamination. MATERIALS AND METHODS: The study consisted of nine experimental groups and two control groups evaluating hemostatic forceps found in kits of ground surgical teams. Hemostats were contaminated in a manner replicating the use in austere wartime surgery, cleaned by manual debridement and soaked in a disinfectant. Initially, instruments were debrided in one of three initial liquids (potable water, sterile water, or potable water with Envirocleanse A) and subsequently treated with one of three terminal disinfectants (Cidex OPA, CaviCide, or Neutral Disinfectant Cleaner). Treated hemostats were placed in sterile wire-closure bags for various storage times and tested for viable bacteria measured by colony-forming units. RESULTS: Our findings indicated that mechanical debridement in water, independent of Envirocleanse A, followed by soaking in any of the three terminal disinfectants achieved a marked reduction in recovered bacteria from hemostats regardless of storage length. Of the three disinfectants tested, Cidex OPA appeared to be the most robust in terms of decontamination, followed by CaviCide and Neutral Disinfectant Cleaner. CONCLUSIONS: This study supports the conclusion that all evaluated disinfectants are capable of rapidly producing instruments with minimal bacterial contaminants when standard sterilization is unavailable. Therefore, when lifesaving surgical intervention must be performed in a deployed environment, austere surgical teams can confidently utilize either product with minimal risk of infection. However, of the disinfectants, Cidex OPA appears to be most effective in reducing bacterial contamination for both rapid and slow turnover of instrument usage, and thus, the disinfectants are recommended for application when sterilization is not available.

Unexploded Ordnance Management.

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.

Preliminary Efficacy Testing of the Disinfectant MicrobeCare XLP for Potential Use in Military Operational Environments.

Introduction: A safe, easy-to-use, permanently bonded antiseptic that does not require post-exposure bioload reduction but maintains effectiveness over time would have far-reaching implications across multiple industries. Health care is one such arena, particularly in austere military settings where resources are at a premium. MicrobeCare XLP (MicrobeCare, Buffalo Grove, IL, USA) is a commercially available spray-on agent that is advertised to covalently bond to surfaces and provide a long-lasting antimicrobial coating inhospitable to >99.99% of surface microorganisms. A pilot study was devised to gather baseline data regarding product efficacy and laboratory parameters before consideration of extended investigations and military utilization. The product manufacturer recommends bioload reductions before product application, following product application, and after each pathogenic exposure. To investigate the product's efficacy in circumstances more closely simulating a military operational setting in which post-pathogenic exposure bioload reduction would not be possible, this step was deliberately excluded from the test sequences. Materials and Methods: Using autoclaved surgical forceps, growth of Staphylococcus aureus and Acinetobacter baumannii was evaluated in a controlled manner under multiple conditions. Test variations included duration of submersion in the MicrobeCare XLP solution and air-drying and a second autoclave sterilization. Control and treated forceps were exposed to a bacterial suspension and air-dried before being submerged in sterile saline and vortex mixed. The saline solution was serially diluted and plated on tryptic soy agar (TSA) II plates. Plates were incubated for 24 h and bacterial colony-forming units (CFU)/mL were counted. Results: Statistical significance was defined according to the American Society for Testing and Materials (ASTM) International passing criteria of 3 Log10 or 99.9% reduction of microorganisms. Additionally, p-values were calculated using two-tailed unpaired two-sample t-tests with unequal variance with a threshold of 0.05. In the S. aureus tests, none of the reduction calculations met the ASTM International passing criteria. In addition, the difference between the means of the colony counts in the MicrobeCare XLP-treated forceps and untreated control forceps was not statistically significant (p-value 0.109). Conversely, in the A. baumannii tests, each of the percent reduction calculations met the ASTM International passing criteria; the difference between the means of the colony counts in the treatment and control groups was statistically significant (p-value 0.008). Conclusion: In these independent tests, MicrobeCare XLP effectively prevented growth of A. baumannii but had unpredictable results suppressing S. aureus. These results may relate to inherent properties of the bacteria or autoclave exposure, although the manufacturer asserts that the coating withstands such degradation. Additional testing could be performed using a broader range of microorganisms and exposure to varying conditions including other sterilization methods.