Combined Injury Syndrome - Reflections about surgical management

Combined injury syndrome (CIS) is defined as mechanical and/or thermal trau ma associated with radiation injury. Each of these injuries is characterize d by several systemic reactions,influencing especially the immune system an d fluid balance. Experiences gained during World War II, the clinical obser vations after radiation accidents and experimental studies demonstrate that CIS can be considered as an own entity of disease characterized by increas ed mortality due to additive effects of the combined injuries. Up to now, our knowledge concerning the pathomechanisms of combined injurie s is not sufficient. Nevertheless, there is a growing body of evidence that two basically different effects compromise organ function: (i) resembling or identical reactions of each trauma type simply added up to an increased systemic damage and (ii) posttraumatic alterations, where the effect of one kind of tra uma synergistically increases the totally different effect of the other. Due to the associated acute radiation syndrome and the special p athophysiology of CIS, surgical treatment has to be considerably different from that of conventional multiple injured patients. Initial surgical procedures must be completed during the short time period of 48-72 h before onset of radiation-induced neutropenia and thrombocytopen ia. This includes primary wound closure, management of all the abdominal, t horacical and vascular injuries as well as definite osteosynthesis. Later, all invasive procedures must be avoided due to the high risk of opportunist ic infections and possible massive hemorrhage. When hematopoietic recovery begins, subsequent steps of surgical treatment can be taken into considerat ion. However, it is important, that as in conventional trauma, resuscitatio n and emergency care have priority and should be performed independent of t he degree of radiation injury.