Phẫu Thuật Bỏng: Tiếp Cận Và Phương Pháp Điều Trị Từ Trung Quốc (Chinese Burn Surgery)

292
The electrical injury more frequently occurs in the upper
extremities, especially in the wrists, resulting in disability
and abnormity of the hand, when severe injury of the muscle
tendons and nerves occurs. Hence, to restore the function of
the hand, it is very important to preserve the muscle tendons
and nerves. At the beginning of 1964, a young peasant was
hospitalized with a high-voltage electrical injury in both
wrists. There were severe skin fi ssures in the canalis carpalis
and the exposure of the injured muscle tendons and nerves
was confi rmed by electromyography. If the patient had been
treated with the regular procedure at that time, he would defi -
nitely have lost all the function of the hands because of the
exposure of the injured muscle tendons and nerves accompa-
nied by infection and necrosis. ChangZhi De et al. success-
fully repaired the wrists with skin fl aps after early
debridement. There were two tough technical problems with
early skin fl ap repair. First of all, it was diffi cult to ablate all
the necrotic tissue, especially the muscles, because in the
early stages there was no clear ambit between the necrotic
and active tissues. Second, there would be anamorphic
necrosis in paragenetic tissues later on. The key was to com-
pletely ablate the necrotic muscles in case of infection due to
deliquescence of the necrotic tissues under the skin fl ap. The
protection of the skin fl ap would benefi t the recovery of the
injured muscle tendons and nerves. On the fi rst day, the
patient was operated on, the wrists were repaired with skin
fl aps after the necrotic skin, deep fascia, and muscles were
ablated completely using Esmarch’s tourniquet. The hand
function recovered very well, which means that the injured
muscle tendons could be restored.
After the 1970s, new concepts and techniques of plastic
surgery and microsurgery were introduced in the manage-
ment of electrical injury, e.g., axial pattern skin fl ap, muscu-
locutaneous fl ap, fascial cutaneous fl ap, and the free skin
fl ap. From 1978 to 1984, a total of 123 patients with electri-
cal injury underwent early debridement and repair in Ji Shui
Tan Hospital, including injuries of the extremities, head,
face, neck, and torso. The primary healing of the wound
increased to 90 %; the excellent and good recovery rate of
the hand function accounted for 97 %; 85 % of the injured
nerves recovered, and the excellent and good recovery rate of
the major joints was 94 %.
For those patients with injury of the upper extremities,
amputation has to be undertaken when there is severe artery
injury. In 1978, Sun Yonghua and Wang Xuewei et al. coop-
erated with Dr. Wei Jianing, a hand surgeon. They success-
fully saved the severely injured hand by means of radial
artery reconstruction with vascular anastomosis for vein
transplantation. It was the fi rst reported case in the world for
hand-saving after a high-voltage electrical injury via free
blood-vessel graft. For early reconstruction of necrotic cra-
nial bones, there was no method for large areas of necrotic
cranial bones, although a regional fl ap may cover the small
exposed cranial bones. In 1980, Sun Yonghua reported that
the extensive scalp and cranial bones were successfully
reconstructed with transplantation of greater omentum plus
free skin graft. The course of treatment was shortened sig-
nifi cantly and the necrotic cranial bones were saved.
Afterward, Dr Sun reconstructed the defective cranial bones
with allograft of cranial bones covered with skin fl ap directly
or expanded skin fl ap. Shen Zhuyao reconstructed an electri-
cal injury-induced defect of cranial bones with the complex
tissues of the musculus temporalis fascia, cranium perios-
teum, and the outer part of the cranial bones.
For reconstruction after electrical injury, it is important to
ensure vascular anastomosis in the healthy area for a free
skin fl ap and free tissue transplantation; otherwise thrombo-
sis would occur, inducing failure of the skin fl ap. In fact, an
electrical burn induces endangium injury exceeding the
extent of the necrotic tissues. Shen Zhuyao et al. had a good
experience in the judgement of healthy blood vessels and the
site selection for vascular anastomosis based on clinical and
experimental research. The achievement ratio of free skin
fl ap and free tissue transplantation increased dramatically.
The abdominal pedicled skin fl ap used to have the limitation
of the length–breadth ratio of 1:1. Shen Zhuyao et al.
improved the design of the abdominal pedicled skin fl ap,
according to the anatomical characteristics of blood vessel
distribution in the abdomen. The length–breadth ratio of the
fl ap reached 2:1–3:1 without any problems of blood supply
to the fl ap.
12.3.3 Reconstruction of the Deep Wound
with a Proper Skin Flap
Reconstruction of the deep wound with a proper skin fl ap is
the essential measure to protect the injured tissues and to pre-
vent infection. From the 1980s, doctors from all over China,
e.g., Chen Bi, Chen Baojv, Jia Chiyu, Huang Xiaoyuan, Cao
Daxin, Zhu Zhixiang, Xu Mingda, Peng Yizhi, Fu Jinfeng,
Zhao Yaohua, Niu Xihua, Zheng Jiansheng, Wang Shaogen,
Zhu Xiongyi, Xu Huizhen, Liu Dasi, Chen Huade, Zhou
Yiping, Wang Yong, Jiang Ming, Min Dinghong, Li Qingfeng,
Gu Bin et al. successfully reconstructed deep wounds with a
proper skin fl ap, musculocutaneous fl ap, fascial fl ap, pedicled
skin fl ap, and free skin fl ap.
12.3.4 Improvement of Abdominal Pedicled
Skin Flap
The abdominal pedicled skin fl ap is one of the basic mea-
sures for reconstruction of the hands and forearms. A group
of electrical burn patients from 1978 to 1985, hospitalized in
the Burn Department of Beijing Ji Shui Tan Hospital, showed
12 Electrical Burns

293
that 82 % of skin fl aps were abdominal pedicled skin fl aps,
and only 18 % of skin fl aps were carried out with vascular
anastomosis, which means that abdominal pedicled skin
fl aps are still the main type for electrical burn
reconstruction.
12.3.4.1 Axial Pedicled Skin Flap
The ratio of length–breadth in the abdominal pedicled skin
fl ap was traditionally emphasized without paying attention
to the position and direction of the pedicle, which meant a
random pattern skin fl ap. During the past few decades, the
source and distribution of the blood vessels in an abdominal
pedicled skin fl ap have been recognized in detail with the
progress of microsurgery. The position and direction of the
pedicle should be taken into account when designing the
abdominal pedicled skin fl ap. In fact, most abdominal pedi-
cled skin fl aps may be designed as axial pedicled skin fl aps,
in which the named blood vessels are inside the pedicle. In
any case, the pedicle should be as near as the named blood
vessels with a deeper fascia when there are limitations for
axial pedicled skin fl aps. Axial pedicled skin fl aps have the
following advantages:
1. The ratio of length–breadth may increase from 1:1 to
2:1–3:1, even for the island skin fl ap, which is favorable
for wound repair.
2. There will be more blood supply for the skin fl ap and
faster healing of the wound.
3. The far end of the fl ap may be thinner, which is favorable
for the exterior appearance.
4. The pedicle will be freer, which is favorable for the
comfortable position of the patient.
5. The time for cutting the bridge of the pedicled skin may
be shortened.
According to the position and direction of the skin fl aps,
Shen Zhuyao et al. summarized the abdominal pedicled skin
fl aps as eight patterns with 14 positions that could be used
for the repair of electrical burns in the wrists and forearms.
12.3.4.2 Choose Opportunities for Operation
Operative repair is essential for most electrical burns, which
may shorten the course of treatment, improve the appear-
ance, and maintain the function. For operative opportunities,
Chinese surgeons learned from external experience and at
the same time obtained their own experience. Early debride-
ment with wound repair may prevent the injured tissues from
necrosis progrediens and infection with more cosmetic and
functional improvement.
The operation should be carried out as early as possible
provided that the patient’s condition permits. Emergency
operations such as escharotomy, vasotransplantation for the
reconstruction of blood circulation in the extremities, surgery
for open injury in the splanchnocele, visceral hemorrhage or
perforation are lifesaving measures for electrical injury.
Delayed operation on the injured wrists, major joints, or
splanchnocele may result in necrosis progrediens and infec-
tion, or even massive hemorrhage. According to the patient’s
condition and the operative preparation, surgery may be
selected on days 1–7 post-burn. Before operation, the electri-
cal wounds such as cephalic, cervical fascia and extremity
wounds should be protected with silver sulfadiazine (SD-
Ag). Patients who were merely treated with dress- changing or
who were hospitalized latterly were not thought to be suitable
for primary repair because of infection. During the past
20 years, these kinds of delayed electrical wounds were
repaired with soft tissue fl aps that are rich in blood supply,
e.g., axial pedicled skin fl aps, musculocutaneous fl aps, and
epiploon after thorough debridement. These were the basic
measures for late reconstruction of muscle tendons, nerves,
and osteoarticular function. Other options may be complex
tissue fl aps, e.g., skin fl ap plus muscle tendons, musculocuta-
neous fl aps, epiploon plus nerves, and muscle tendons.
12.3.5 Classifi cation of Electrical Injury
in the Wrists
In most electrical injuries in the wrists the more severely
injured areas are in the fl exor aspect of the wrists, in which
there are radial and ulnar arteries passing through, the median
nerve, and the radial nerve and ulnar nerve conducting nerve
signals to the hands. According to the site and extent of the
electrical wound, the degree of injury of the radial and ulnar
arteries, the possibility of hand necrosis, Shen Zhuyao et al.
classifi ed electrical injuries in wrists as patterns I, II, III, and
IV. Pattern I represents an electrical wound merely localized
in the palmar surface of the wrist; pattern II in the palmar and
extensor surface part of the wrist; pattern III in the whole
wrist with blood supply to the hands; and pattern IV in the
whole wrist without blood supply to the hands (Table 12.1 ).
Zhu Zhixiang et al. suggested fourth-degree electrical
wounds be subdivided into index 1–5 so that the operative
protocol could be mapped out accordingly.
12.3.6 Diagnosis and Management of Blood
Vessel Injury
The evidence for diagnosis of blood vessel injury are:
1. Disturbance of the blood circulation of the hand, e.g.,
cyanopathy, hand freeze, delayed response of capillary
angiosclerosis, even with escharotomy. It is important to
know that blood vessel injury cannot be excluded when
there is no disturbance of the blood circulation of the
hand in the early stages.
2. Direct observation of blood vessel injury in electrical
wounds.
12.3 Development of Treatment and Research into Electrical Injury in China

294
3. Detection of the pulse of the radial and ulnar arteries
directly or with Doppler ultrasound diagnosis apparatus.
4. Allen’s test to detect if radial and ulnar arteries are obstructed.
5. Operations research to know if the blood vessels are
injured, e.g., thrombosis, blood vessel necrosis, and blood
stream slowing.
6. Brachial artery arteriography is useful for some patients,
although there are false - positive or -negative results and
acceleration of thrombosis formation in injured blood
vessels. MRI is useful for blood vessel injury.
It is indicated that there will be severe radial and ulnar
artery injury when freeze, cyanopathy, paleness, and adiaem-
orrhysis of the hand appear very soon. In this case, debride-
ment must be performed right away. The radial or ulnar
artery should be reconstructed with vena saphena magna
transplantation when the thrombosed artery is cut off.
Usually, 20 cm or even longer of the vena saphena magna
should be connected to restore the blood stream with proper
protection of skin fl aps. Sometimes, free soft tissue fl aps
with blood vessels may be used to cover the wound. The two
ends of the blood vessel connect with the two sides of ulnar
artery or radial artery via vascular anastomosis, e.g., a free
medial crural skin fl ap containing posterior tibial vein and
artery, or a free epiploon containing gastroepiploic artery.
12.4
Electrical Wound Repair in Different
Sites of the Body
Yonghua Sun and Jianchuan Gao
12.4.1 Electrical Wound Repair in the Head
and Neck
The head is one of the body sites prone to electrical injury
because the head is in the vertex of the body when the electric
wire touches the body directly overhead. Electrical burns in
the head may cause severe injury including extensive necro-
sis in the scalp, skull, and even brain that perplexes surgeons
and could induce a serious result.
12.4.2 Characteristics of Electrical Injury
in the Scalp and Skull
The scalp, with compact conformation and densifi cation,
consists of skin, dense connective tissue, galea aponeurosis,
loose connective tissue, and periosteum. The extremely high
temperature caused by electric current in the scalp results in
necrosis in the whole scalp, including the periosteum,
although the scalp is thick with hair follicles deep in the
corium and has a plentiful blood supply. An electrical burn
seldom induces the whole layer of skull necrosis because
there is cancellous bone between the lamina externa cranii
and the lamina interna cranii. According to the electrically
injured patient’s analysis, the whole layer of skull necrosis
occurred in less than 10 % of electrical burns patients who
had a skull injury, in which parietal bone is mostly involved.
In high-voltage electrical burns, children are more prone
to being injured with extensive scalp necrosis, the whole
layer of skull necrosis, and brain injury because of the thin
scalp and undergrowth of the skull.
12.4.3 Management, Operation, and Outcome
of Necrotic Skull
It is hard to grow granulation tissue in the surface of a
necrotic skull, which means that it would take several months
or years for the necrotic skull wound to heal without surgery.
Previously, extensive holes were drilled in the necrotic skull
and granulation tissue coverage was gradual. It was a long
time with the risk of brain infection, even though this method
Table 12.1 Classifi cation of electrical injury in the wrists
Injured tissues
Classifi cation
I
II
III
IV
Skin
Limited to palmar surface
Palmar and part extensor surface
All
All
Flexor tendons Shallow
+
++
++
++
Deep
−
+
++
++
Nerves
Medial nerve
+, +
++
++
++
Ulnar nerve
−, +
+
++
++
Interosseous tissues
−
+
++
++
Musculus pronator quadratus
−, +, +
++
++
++
Arteries
Radial artery
−, +, +
+, +, ++
++
++
Ulnar artery
−, ±
±, +
++
++
Arteria interossea −
+
++
++
Blood supply to hands
−
+, +
+, ++
++
Improvement with relief incision
Progressive worsening
Hand necrosis
−means no, ±, +, ++ indicate the degree of injury from minor to severe
12 Electrical Burns

295
was simple. To effect primary healing, the exposed lamina
externa cranii should be covered with a soft tissue fl ap, e.g.,
a skin fl ap, a free musculocutaneous fl ap, an epiploon after
the exposed lamina externa cranii is chiseled into a rugged
face in the early stages of injury or into a cancellous layer of
skull in the late stages of injury. With many years’ follow-up,
we found that the necrotic skull covered with soft tissue fl ap
could be substituted with newly formed bone. Cranioplasty
with xenogenous skull plus skin fl ap or skull substitute plus
skin fl ap has to be performed when there are major skull
defects induced by electrical burns.
12.5
Repair of High-Voltage Electrical
Wound in the Neck
Xiaoyuan Huang and Jianchuan Gao
The neck is one of the most important parts of the body.
High-voltage electrical burns may result in severe injury and
exposure of major blood vessels, nerves, and cervical verte-
bra, which are life-threatening.
12.5.1 Wound Repair
There are several options for wound repair in the neck. Early
debridement and repair of the wound should be taken once
the patient’s vital signs permit. The debrided wound may be
repaired with different soft tissue fl aps accordingly, e.g., a
pedicled skin fl ap, a musculocutaneous fl ap, or a free skin
fl ap with vascular anastomosis. The following pedicled mus-
culocutaneous fl aps are often used for electrical injury in the
neck: the latissimus dorsi myocutaneous fl ap, the trapezius
myocutaneous fl ap, the platysma myocutaneous fl ap, the
pectoralis major myocutaneous fl ap, and a combination of
the latissimus dorsi myocutaneous fl ap and the pectoralis
major myocutaneous fl ap.
12.5.1.1 Latissimus Dorsi Myocutaneous Flap
The latissimus dorsi is a fl at, broad muscle measuring about
20 cm by 40 cm. It extends from the posterior axilla to the
midline of the back and inferiorly to the posterior portion of
the iliac crest. The posterior axillary fold is partially formed
by the anterior edge of the latissimus. The latissimus func-
tions mainly as an adductor and medial rotator of the arm. It
also serves to pull the shoulder inferiorly and posteriorly.
The latissimus dorsi muscle is supplied by two separate
vascular systems. The dominant blood supply arises from the
thoracodorsal artery, which is the terminal branch of the sub-
scapular artery. It also has a secondary blood supply, which
arises from segmental perforating branches off of the inter-
costal and lumbar arteries. These vessels enter the deep sur-
face of the muscle near the posterior midline and are
responsible for perfusion of the inferior and medial latissi-
mus. Because these vessels are disrupted in the process of
harvesting the latissimus, the viability of this portion of the
fl ap can be tenuous.
The posterior axillary fold is identifi ed, and an incision is
marked just posterior to the lateral border of the latissimus
dorsi. Next, the incision is extended posterior–inferiorly, par-
allel to the lateral edge of the muscle, and usually incorporates
the lateral edge of the skin paddle. After the incision is made,
the fl aps are elevated, and the lateral and superior edges of the
latissimus dorsi muscle are identifi ed. The lateral border of the
latissimus is then elevated and retracted posteriorly, thus
exposing the underlying serratus anterior muscle. The space
between the latissimus dorsi and serratus anterior muscles is
enlarged with blunt dissection. The thoracodorsal vessels can
be seen entering the latissimus dorsi about 3 cm medial to the
lateral edge of the muscle. At this level, one or two branches
come from the thoracodorsal to the serratus anterior muscle;
these may be traced proximally to identify the thoracodorsal
artery, and are divided to isolate the latissimus muscle. If used
as a pedicled fl ap, the distal end of the paddle is passed into the
head and neck area through a tunnel created either subcutane-
ously over the pectoralis muscle or through the pectoralis
muscle. The choice is made depending on which route places
the least amount of tension on the pedicle. Removing a portion
of the clavicle to reduce tension may be necessary.
12.5.1.2 Pectoralis Major Myocutaneous Flap
We consider the pectoralis major myocutaneous fl ap a sig-
nifi cant tool for skin fl ap reconstruction in the head and neck
region. The pectoralis major muscle originates from the ster-
num, clavicle, and anterior portions of ribs one through six.
The fi bers course laterally and transversely and converge to
its singular insertion on the humerus. Pectoral nerves depart
the brachial plexus trunks and proceed through the
clavi- pectoral fascia at the level of the mid-clavicle to inner-
vate the pectoralis major muscle.
The fl ap design and the skin island depend on the site, size,
and shape of the defects, but the skin island was usually below
and medial to the nipple at about the level of the sixth rib. The
fl ap elevation normally runs from a distal to a proximal direc-
tion. The perfusion of the sources of the fl ap is the pectoral
branch of the acromiothoracic artery and the lateral thoracic
artery. The pectoral vessels emerge from the clavipectoral
fascia 2–3 cm medial to the coracoid process. During fl ap
elevation the pectoral fascia and the muscle are secured to the
skin to protect the perforator vessels and the muscle is
exposed over the length and the breadth of the pedicle. The
skin and muscle are elevated from the chest wall exposing the
ribs and the intercostal muscles. The fl ap is elevated up as far
as the coracoid process where the pedicle can be narrowed.
As the lateral pectoral vessels become visible they may be left
intact or divided depending on the volume of the fl ap required
and the tension produced if the vessels are left intact.
12.5 Repair of High-Voltage Electrical Wound in the Neck

296
12.5.2 Typical Case
A 20-year-old male patient who was working on the roof of
a house was severely injured by 10,000-V line on the left
side of his neck. He had been suffering from delirium for
about half an hour. The patient was immediately sent to a
local hospital, underwent a tracheotomy and was transferred
to the authors’ hospital. He was in his right senses but rest-
less when he was admitted. The broken proximal end in left
common carotid artery was found in the neck wound but
without bleeding. The left ear was necrotic, while the wound
in his left pre-auricula, left jowl, left neck, and shoulder was
dried eschar. Thirty-eight hours after post-injury, the wound
was debrided with preoperative preparation. Part of the left
clavicle that was necrotic was removed and the left common
carotid artery was explored and found to be thrombosed at
the proximal end. The broken left common carotid artery
was ligated. The left parotid, left mandible, submaxillary
region, muscles in the left-hand side of the neck, the part of
the cucullaris that showed necrosis and charring was
removed. There was a big defect wound with brachial plexus
exposure after debridement that was impossible to recon-
struct with a latissimus dorsi myocutaneous fl ap. The
debrided wound was covered with a pectoralis major myocu-
taneous fl ap plus a latissimus dorsi myocutaneous fl ap. Four
days later, the patient was found that there were mouth secre-
tions and fed milk leaking from the drainage tube under the
fl ap, which meant that a penetrability defect occurred. The
exploratory operation showed a large quantity of necrotic tis-
sue near the genal region and pharyngeal cavity. In order to
drain the mouth secretion effectively, part of the latissimus
dorsi myocutaneous fl ap was lowered below the pharyngeal
cavity. The nutrition had improved 45 days later with nasal
feeding and the fl ap survived. The defective pharyngeal cav-
ity was repaired with part (8 × 8 cm) of the transferred latis-
simus dorsi myocutaneous fl ap (Fig. 12.1 ).
12.5.2.1 Platysma Myocutaneous Flap
The platysma myocutaneous fl ap is a common reconstructive
option for defects in the head and neck region. Its applica-
tions have expanded from the reconstruction of intraoral
defects to include laryngo-pharyngeal, lip, and cheek defects.
The platysma fl ap can be superiorly, posteriorly, or inferiorly
based. The superiorly based fl ap has a robust arterial blood
supply but less effi cient venous drainage, whereas the oppo-
site is the case with the posteriorly based fl ap. The platysma
a
b
c
d
e
Fig. 12.1 ( a ) High-voltage electrical burn, before operation; ( b ) debridement; ( c ) preparation of the pectoralis major myocutaneous fl ap plus latis-
simus dorsi myocutaneous fl ap; ( d , e ) 1.5 years later

12 Electrical Burns

297
is a broad sheet arising from the fascia covering the upper
parts of the pectoralis major and deltoideus; its fi bers cross
the clavicle, and proceed obliquely upward and medially
along the side of the neck. The anterior fi bers interlace,
below and behind the symphysis menti, with the fi bers of the
muscle of the opposite side; the posterior fi bers cross the
mandible, some being inserted into the bone below the
oblique line, others into the skin and subcutaneous tissue of
the lower part of the face and many of these fi bers blend with
the muscles about the angle and lower part of the mouth.
Sometimes fi bers can be traced to the zygomaticus, or to the
margin of the orbicularis oculi. Beneath the platysma, the
external jugular vein descends from the angle of the mandi-
ble to the clavicle (Fig. 12.2 ).
12.5.2.2 Trapizius Myocutaneous Flap
There are large superfi cial muscles at the back of the neck
and the upper part of the thorax or chest. The right and left
trapezius together form a trapezium, an irregular four-sided
fi gure. It originates in the occipital bone at the base of the
skull, the ligaments on either side of the seven cervical
(neck) vertebrae (ligamentum nuchae), and the seventh cer-
vical and all the thoracic vertebrae. It is inserted on the pos-
terior of the clavicle (collarbone) and on the spine of the
scapula ( shoulder blade ). Its chief action is support of the
shoulders and limbs and rotation of the scapula necessary
to raise the arms above shoulder level. The myocutaneous
fl ap of the lower trapezius has proved to be another useful
adjunct in the reconstructive armamentarium of the head
and neck surgeon. The fl ap is based on the descending
branch of the transverse cervical artery and vein. Providing
these structures are protected during neck dissection, this
fl ap may well become the fi rst consideration of fl aps for the
reconstruction of extensive defects of the head and neck.
The fl ap is safe, reliable, and easy to use, with constant vas-
cular anatomy. The donor site functional defi cit is minimal
and the donor site may be closed by direct closure without
a skin graft. Its cutaneous reach and arc of rotation make it
a suitable source of skin and muscle replacement for the
entire neck, face, and occipital region of the scalp and oral
cavity.
12.6
Repair of Major Blood Vessel Injury
in the Extremities
Yonghua Sun and Jianchuan Gao
The extremities are prone to high-voltage electrical burns,
the upper extremities more so than the lower extremities.
The high-voltage electrical burn occurs mostly in an upper
extremity, passes through the body and then comes out from
a lower extremity. The degree of damage in an upper extrem-
ity is more severe than that in a lower extremity, and the
main blood vessel is often damaged. Limb necrosis can be
seen in severe cases. The successful management of injuries
to the great vessels may decrease the amputation rate, and
may be helpful for the recovery of the function of the
extremities.
12.6.1 The Characteristics of Topical Arterial
Injury in High-Voltage Electricity Burns
The vessel walls are often focally injured. Typically, the
most damaged part is the site of the electrical injury in n
upper extremity, and then the fl exor aspect and the wrist, the
lesions gradually becoming smaller or disappearing, until at
the elbow and axil, the lesion emerges again. According to
the fi ndings from 38 cases and partly from pathology results,
a
b
c
Fig. 12.2 ( a ) Design of the platysma myocutaneous fl ap; ( b ) high-voltage electrical burn in the mandible and neck, before operation; ( c ) three
months later

12.6 Repair of Major Blood Vessel Injury in the Extremities

298
Sun Yonghua et al. in Beijing Ji Shui Tan Hospital divided
blood vessel injuries into fi ve types:
1. Minor injury to the endothelial cells, edema, but the shape
and color of the blood vessels are normal with regular
pulsation.
2. Decohesion and edema in the endothelial layer, partial
loss of elasticity of the endo-elastic layer, slight dilation
of the lumen, occasional micro-thrombosis formation,
variation in the diameter of the blood vessel with cyanosis,
and weak pulsation .
3. Intima damage, smooth muscle degeneration, dilation of
the diameter of the artery with cyanosis and vasodilata-
tion, poor contractile function with thrombosis formation
and lack of a pulse.
4. Necrosis in the whole layer of the artery wall with a serial
port and without a blood stream.
5. Stenosis and stiffening of the artery as steak, loss of con-
tractile function, lumen stenosis when the blood vessel is
cut open.
In order to rescue a wrist with a severe electric burn injury
in the main artery from necrosis, Beijing Ji Shui Tan Hospital
started to design blood reconstruction surgery from 1972,
and succeeded in 1978. Up to 1986, 23 cases had been under-
gone debridement, autossaphenous vein free grafting, and
radial artery or ulnar artery vascular anastomosis for rebuild-
ing the blood stream by means of a pedicled skin fl ap or free
fl ap transplantation to cover the debrided wound. Nineteen
cases were rescued with limb salvage with retention of some
of the functions. The clinical manifestation, management,
and prognosis from four types of electric burns in the upper
extremity are shown in Table 12.2 .
12.6.2 Typical Case
Lee, a male worker, admission number 151623, was injured
by high-voltage electricity (36,000 V) with involvement of all
four extremities. He had been in a coma for about 3 min and
underwent resuscitation on the spot before transferring to
Beijing Ji Shui Tan Hospital. This patient had a vertical extent
electrical burn on his right wrist, with loss of infl ection, and
the skin of his hand had cyanosis, was cold, and had sensory
deprivation. Both his right leg and his two feet had been
burned. Once his wrist had undergone escharotomy reaching
the poneurotic fascia 7.5 h after the accident, the blood circu-
lation in his hand improved. Three hours later, he suffered
cold fi ngers and cyanosis again. These signs were aggravated
gradually. Thus, 12 h after the injury, he underwent wrist
necronectomy. His musculus palmaris longus was burned and
discontinued, the superfi cial layer muscle tendon of the fl exor
aspect was dry and hard. A 10-cm segment of the median
nerve seemed to be tarnishing and a blood vessel embolism
was found in the endoneural membrane. Deep and superfi cial
venter musculi of the fl exor aspect presented sandwich-like
necrosis and had no contractile function. Musculus pronator
quadratus suffered muscular degeneration, was gray and
asystolic. The arteria ulnaris, arteria radialis, and their accom-
panying veins were injured. The veins were congested and
the arteries had 8- and 10-cm thrombosis respectively. To
guarantee the success of vascular anastomosis, necrotic tissue
was removed thoroughly and a deep muscle tendon of the
fl exor aspect was reserved. The blood vessel was cut at over
1 cm from the normal margin as seen by the naked eye, and
the self-saphenous vein was used to carry out arterial anasto-
mosis with the arteria radialis and arteria ulnaris. An abdomi-
nal fl ap was used to cover the debrided wound after a 30-min
observation for the blood stream. The blood stream fl owed
well after surgery. The right hand was saved with satisfactory
hand function recovery. At an 8-year follow-up, he was found
to be able to participate in physical labor.
12.7
The Management of Open
Pneumothorax Caused by
Penetrating Injury of the Chest Wall
Yonghua Sun , Yaohua Zhao , and Xihua Niu
Table 12.2 Classifi cation, management, and prognosis in upper extremity electrical burns
Classifi cation
Management and prognosis
I. Burn necrosis of upper extremity
Amputation at necrosis level
II. Finger and/or palm being injured merely
Debridement with skin graft and skin fl ap in the early stage; debridement with skin graft or
traditional Chinese medicine for decrustation plus skin graft in the late stage, sometimes
with dactylolysis
III. Upper extremity burn with regular blood
stream in the early stage
Debridement with skin graft and skin fl ap transplantation in most patients at an early stage;
debridement with skin graft in a few of the patients at an advanced stage
IV. Wrist-based upper extremity burn with main
artery injury and blood stream disorder
Conservative management (poneurotic fascia open decompression at an early stage with use
of drug such as Maitong, papaverine, etc.)
Amputation in the end in some cases
Surgery (early debridement with rebuilding of the blood circulation of the wrist by means of
a free skin fl ap or abdominal fl ap) to save the injured extremity
12 Electrical Burns

299
12.7.1 Penetrating Injury of the Chest Wall
Accompanied by Open Pneumothorax
In emergency management, the penetration site should be
tamponaded with an aseptic oil bandage or a glove fi lled with
sterilized dressing, and bandaged with pressure bandages.
Closed drainage of the thoracic cavity should be performed.
Debridement, repair of the penetrating wound, e.g., with a
skin fl ap, should be carried out once the systemic condition
has stabilized.
12.7.1.1 Injury of Chest Wall Accompanied by
Organ Injury in the Thoracic Cavity
The traumatic condition is severe when the diameter of the pen-
etrating injury in chest wall exceeds the inner diameter of the
glottis, especially accompanied by lung, pericardium, or dia-
phragm injury in thoracic cavity. It is fatal for a patient without
timely treatment. Some aspects require attention as follows:
1. Pre-hospital care. Close the open wound in the chest wall
in time; prevent the severe consequence of paradoxical
breathing and mediastinal swaying.
2. Systemic treatment. Such patients actively need blood
transfusion, fl uid infusion, and electrolyte disorder cor-
rection. The amount of fl uid infusion is much higher than
that calculated with a routine formula. Once severe hemo-
globinuria or myoglobinuria is detected, alkaline drugs
(5 % sodium bicarbonate) and diuretics should be used as
early as possible to stop hemoglobinuria or myoglobin-
uria quickly in the case of acute renal failure.
3. Measures of infection prevention for extensive electric
burn wounds of the chest wall, especially accompanied
by a penetrating injury in the thoracic cavity, which is
prone to infection. Once a large wound is exposed, there
will be more exudation from the wound and the infection
could be severe and life-threatening. Thus, in addition to
wound covering as early as possible, it is important to use
sensitive systemic antibiotics. Anti-anaerobic drugs, such
as metronidazole, should be added at the same time.
4. Wound repair as soon as possible. This is the key to the
successful management of electrical injuries of the chest
wall. Antishock therapy and making an effort to create
conditions so that the patient can undergo thorough
debridement at an early stage are very important. The
derogative lung tissue and part of the ribs should be
ablated to minimize the thoracic cavity and injured chest
wall. A pectoralis major myocutaneous fl ap, a skin fl ap in
the upper abdomen, or a pedicled latissimus dorsi muscle
musculocutaneous fl ap could be used for wound repair.
The residual wound in the chest wall may be repaired
with a skin graft with the placement of an intrathoracic
drainage tube.
5. The severe, extensive injury in the chest wall that is hard
to reconstruct with use of a skin fl ap should be stuffed in
order to induce residual lung, pericardium, and chest wall
adhesion. And the excision of necrotic tissue should be
strived for, followed by washing and dressing changing
daily to stimulate the growth of granulation tissue. The
wound may be gradually covered with skin graft on gran-
ulation tissue. Free great omentum grafting plus skin
graft could also be used to cover a chest wound.
6. Nutritional support. Patients may develop severe physio-
logical derangement leading to protein disintegration and
consumption increase, synthesis reduction, and glucose
utilization decrease. Nutritional support is also important
to correct the negative nitrogen balance.
12.7.2 Typical Cases
Case 1
A 25-years-old man was hurt by high-voltage electricity of
35 kV on 27 February 1995. After the electric burn, he fell
down from the 1-m site and was in a coma for 5 min. The
patient was sent to a local hospital. His right chest wall had a
perforated burn 6 cm in diameter combined with open pneu-
mothorax. The orifi ce was blocked up with petrolatum gauze
and an antiseptic gauze pad, and an elastic cingulum pecto-
rale wrapped around the chest. Blood transfusion, fl uid
infusion, and antibiotics were used before transfer to Shanghai
Electric Power Hospital on the second day after injury. On
admission, his general condition was not good with paleness,
shortness of breath, RP 34/min, pulse 124/min, total burn area
11 %, and all fourth-degree. The entry point of the electric
current in the right chest wall was a fourth-degree burn and
the exit point was in the left leg. Below the distal two thirds of
his left leg there was dry necrosis. His general condition was
severe. He had paralytic ileus and myoglobinuria. X-rays
showed that the right lung had 90 % compression, and the
mediastinum was pulled to the left. The patient’s condition
improved to some extent after water and electrolyte distur-
bances were corrected, enhancing nutritional support and sys-
temic usage of antibacterial agents (ceftazidime and
metronidazole). He underwent amputation on the distal one
third of the right leg and right chest wall debridement. A
5 × 5 cm burn in the right diaphragmatic dome was found dur-
ing the operation. The whole right lung was covered in a cel-
lulose-like substance. After the cellulose-like substance had
been divested, a burn wound was found in the middle and
inferior lobe of the right lung and the lung could not be
recruited. The pericardium looked edematous and pale too.
Thus, the surgeons made the decision to excise the middle
and inferior lobe of the right lung, the burn tissue in the chest
wall, and the partial diaphragm, and mattress sutures were
administered. Ribs 5, 6, 7, 8, and 9 were partially excised and
modifi ed thoracic surgery was performed. A right pedicled
latissimus dorsi muscle musculocutaneous fl ap was used to
12.7 The Management of Open Pneumothorax Caused by Penetrating Injury of the Chest Wall

300
cover the defective chest wall so as to close the entrance to the
penetrating wound. The remaining wound was covered with a
free skin graft. Drainage tubes were placed at antero-rib2 and
rib9 at the posterior axillary line. General nutritional support
and antibiotics were continued. X-ray 7 days after the opera-
tion showed a large quantity of fl uid in the thoracic cavity and
right upper lung atelectasis. Thus, the second thoracotomy
and debridement were performed 12 days after the fi rst opera-
tion. The necrotic rudimental tissues were removed and
drainage tubes were placed at antero-rib2 and rib9. The upper
drainage tube was used to wash out antibiotics and the lower
one was used as closed drainage of the thoracic cavity. After
6 days, drainage fl uid was basically clear and the lobus supe-
rior pulmonis expanded. Therefore, the drainage tube was
pulled out and changed to a cigarette drain for dressing. The
patient’s condition tended to be stable. Physical training was
reinforced and he was discharged with recovery after
2 months. The right upper lung was found to have good infl a-
tion after 6 months’ follow-up.
Case 2
A 32-year-old male patient received a shock with high- voltage
electricity of 10 kV on 14 March 1972 when he was working
on a high live line. The extent of the third-degree burns was
35 % of the total body surface area. His body, including the
left upper extremity, both lower extremities, from the anterior
axillary line to linea paravertebralis of the left chest wall, from
the humeral callus to the waist, had an enormous wound with
the ribs exposed. He also had severe hemoglobinuria. He was
given antishock and preservation of renal function treatment
when he was admitted to Ji Shui Tan Hospital. The patient suf-
fered from dyspnea, tachycardia, and a high body temperature
of 39.4 °C 2 days after the injury. Parts of the necrotic tissue
on the left side of the chest wall had desquamated; the hole
became darker and larger. He suffered from pneumothorax.
The hole was stuffed with petrolatum gauze (containing 10 %
mafenide). Nine hundred milliliters of gas were drawn out
from the upper chest. Meanwhile, he underwent blood transfu-
sion, fl uid transfusion, and systemic anti-infection medication.
The patient’s condition improved 2 days later. An X-ray indi-
cated that his left lung infl ated very well. Then, the necrotic
tissues were removed gradually, followed by stuffi ng with
10 % mafenide dressing. Although the diameter of the hole
expanded to about 20 cm, the infection was well controlled.
His left lung had adhered to the chest wall and his condition
gradually became stable. This patient underwent amputation
of the middle to inferior parts of both thighs 8 days and 12 days
after the injury respectively. The wound of the chest wall
underwent a free skin graft on the granulation wound (includ-
ing lung tissue) 3 weeks after the injury. He received a free
skin graft fi ve times and his wound was nearly completely
covered after 2 months. The patient was discharged on 26 July
after 3.5 months’ management.
12.8
Management of Abdominal Wall
Electric Burn Accompanied by
Abdominal Cavity Injury
Yonghua Sun and Jianchuan Gao
Organ burns in the abdominal cavity are commonly caused
by direct contact with high-voltage electricity, especially in
pediatric cases. The damaged part is not always the aerial
image of the electric burn in the abdominal wall. This is
probably related to the body posture when injured, gastroin-
testinal tract movement, and the path of the electric current.
According to literature reports, the most common burns are
intestinal and gastric wall burns, which may manifest as a
single or as a multiple injury. Liver, spleen, gallbladder, colic
omentum, bladder and mesenterium burns cases are also
reported. Severe abdominal organ burn is commonly accom-
panied by full-thickness necrosis and perforation in the
abdominal wall, even with a large abdominal wall defect that
needs emergency surgery. Perforated gastrointestinal tract
should be repaired and necrotic intestines may need to be
anastomosed. Intestinal tract stoma at the proximal site may
be performed in multi-intestinal injury. A local gallbladder
wall burn can be closed with a purse inverting suture; gall-
bladder excision may be carried out in severe cases.
Coagulation necrosis on the surface of the liver and spleen
has a tendency toward self-healing and may be awaited with-
out surgery.
Patients with high-voltage electrical burns usually have a
fall history. It should be determined whether the damage to
the abdominal organs has been caused by burn or by trauma.
Burn injury involves coagulation necrosis and peripheral
congestive edema, while wounds caused by trauma are usu-
ally lacerated wounds with tissue or fresh hemorrhage inside
the wound. In some cases, burn and trauma could be found
simultaneously.
Electrical burn of the abdominal wall accompanied by
abdominal organ damage is critical. Anti-infection and
water–electrolyte balance measures should be carried out
when emergency operations for the repair of organs and the
abdominal wall are performed. Intravenous nutrition or
enteral nutrition should be given after surgery. Anemia and
hypoproteinemia should be corrected promptly. Long-term
fever can be seen in some cases of residual infection in the
abdominal cavity, which requires another operation for
drainage.
12.8.1 Typical Case
A 16-year-old male patient received an electrical injury
when he climbed a high-voltage electrical wire pole in the
rain at dawn on 5 July 1967. He fell into a coma immediately
12 Electrical Burns

301
and was sent to hospital 4.5 h later. On admission, he had
regained consciousness, with blood pressure 120/90 mmHg
and heart rate 100 beats/min. Deep electrical wounds were
found in the head, chest, abdomen, both upper extremities,
and the right thigh with about 15 % of total body surface area
affected. The right forearm and the right hand had dry necro-
sis. There was an irregular abdominal wall defect 3 cm in
diameter in deviation to the left of the navel. Intestinal con-
tents overfl owed, the exposed intestine looked dark red, with
no peristalsis, and with arteria mesenterica pulsation. A rup-
ture with a 0.4-cm cleft in the exposed intestine was found at
the top-left of the abdominal wall defect. The skin around the
defective abdominal wall was burnt, with excoriation and a
gray wound. Hemoglobinuria could be seen in urine drained
from the urethral catheter.
The patient underwent an emergency operation immedi-
ately after admission. He was amputated at the middle third
of the right upper arm under ether anesthesia via intubation.
The incision was made at the right border of the injury in the
abdominal wall, near the navel so as to thoroughly expose
the abdominal cavity. The jejunum cleft could be seen at the
site from the ligament of Treitz and measured 20 cm. The
intestine exposed from the abdominal cavity measured about
40 cm. The exposed intestine was totally excised, followed
by end-to-end double anastomosis. The distal end of the
ileum had two clefts with the mucosa turned over, and the
distance between the two clefts was about 10 cm. End-to-end
double anastomosis was performed after intestine between
the two clefts had been excised. Exploration of the rest of the
intestine and organs found no abnormalities. The burnt skin
of the abdominal wall, subcutaneous tissue, and partial mus-
culus rectus abdominis were cut. The abdominal cavity was
washed thoroughly. The abdominal wall defect after debride-
ment was 12 cm long and 10 cm wide. In the skin on two
sides of the wound in the abdominal muscle underwent sub-
cutaneous dissociation, and in the peritoneum and full-thick-
ness abdominal wall interrupted sutures were used. The
sutured skin had tension slightly. The operation lasted 3.5 h,
400 ml of blood was transfused, and the blood pressure and
pulse were stable.
Fasting, gastrointestinal decompression, and transfusion
were performed after the operation, with IM new benzyl
penicillin-I, 4 g per day. He was permitted to drink water on
the second day after the operation. Bowel sound was present.
The gastric tube was withdrawn on the third day after opera-
tion and he was able to eat a liquid diet. He produced stools
once. He could eat semiliquid without dregs on the fi fth day.
New benzyl penicillin I was stopped on the sixth day and
changed to an oral antibiotic. Only an area of about
10 × 2.5 cm of the abdominal wound had a nonhealing infec-
tion 1 week after operation. Disjunction dermal sutures with-
drawal was undertaken. He suffered from a slight fever on
the ninth day after operation, which was probably related to
the burn wound decrustation and necrotic tissue on the right
upper arm stump. He was given erythromycin, 1.2 g per day.
Right upper arm reamputation under general anesthesia was
performed at 27 days after injury. Auto-skin was used to
cover the wound on the chest, abdomen, and left hand. The
dermatoplasty was successful and the abdominal wound
continued to heal. The patient’s general condition recovered
well, abdomen symptoms no longer appeared, and stomach
and intestinal function were normal. He left hospital
4 months after injury and had artifi cial limbs fi xed. At fol-
low- up after 6 years, his everyday life and physical labor
were good.
12.9
Repair of High-Voltage Electrical
Burns in the Penis
Xiaoyuan Huang
High-voltage electrical burns to the penis are not common,
accounting for only about 3.9 % of high-voltage electrical
burns. Most penis burns may be accompanied by one lateral
inguinal fold burn. In severe cases, the penis, scrotum, and
testicles may have necrosis, which gives rise to tremendous
pain. It is important to reconstruct the physiological function
and provide support for the mental trauma. The anatomical
features of the penis and scrotum are as follows:
1. The penis is one of the most important organs for a man.
It consists of two cavernous bodies of the penis and one
cavernous body of the urethra. Each cavernous body is
covered in tunica albuginea corporis spongiosi and the
three cavernous bodies are all covered by the deep fascia
of the penis and the fascia penis superfi cialis. Fascia penis
superfi cialis sticks the skin tightly. The penile blood sup-
ply is extremely plentiful and comes mainly from the
arteria penis, a branch of the arteria pudenda interna. The
arteria penis divides into the arteria dorsalis penis and the
arteriae profunda penis. The arteria dorsalis penis passes
between the deep fascia of the penis and fascia penis
superfi cialis until the balanus. The arteriae profunda penis
passes the foot of the cavernous body foot continuing into
the cavernous body of the penis. Penile veins divide into
the deep and superfi cial sets. The superfi cial set (superfi -
cial veins of the penis) is located between the deep fascia
of the penis and fascia penis superfi cialis. A deep set
(deep veins of the penis) is located in the dorsi groove of
the deep fascia of the penis and the fascia penis
superfi cialis. Innervation mainly comes from the second
and fourth sacral nerves. The penis is dominated by the
dorsal nerve of the penis except for the root of penis. The
root of the penis is dominated by the inguinal fold nerve.
2. The scrotum can be divided into the left and right scro-
tum. Each scrotum has a testicle, epididymis, and
12.9 Repair of High-Voltage Electrical Burns in the Penis

302
spermatic bag. Subcutaneously, the fascia superfi cialis
has generous smooth muscle fi ber and is short of fat. It
combines skin tightly, and is called the dartos, which has
the characteristics of expansion on heating and contrac-
tion on cooling. The arteriae scrotales anteriores (coming
from the superfi cial external pudendal artery) supply
blood to the anterolateral skin of the dartos. The lateral
artery of the scrotum (coming from the cutaneous branch
of the anterior arteria obturatoria) supplies blood to the
lateral one third of the dartos. The lateral branch of the
posterior arteriae scrotales supplies blood to the postero-
lateral scrotum. The scrotal septum artery supplies blood
to the scrotal septum and the surrounding skin. These
arterial branches coincide with one another, forming a
fairly rich vascular network. Veins accompany the arter-
ies fl owing into the great saphenous vein and the internal
pudendal vein.
12.9.1 Repair Strategy
Debridement should be carried out fi rst, the parabiotic tis-
sues should then be reserved to the limit and the penis length
retained as far as possible. Direct suture, skin graft or scrotal
skin fl ap transfer may be performed according to condition
of the wound. Reconstruction of the penis should be carried
out if there is gangrene of the penis. Preputium penis is the
relatively loosening of the penis; thus, a small amount of
necrosis in the skin may be directly excised and sutured.
Split-thickness skin graft should be administered if direct
suturing cannot be performed. If the area of the skin defect is
comparatively large, especially accompanied by injury in the
cavernous body of the penis or gangrene, the patient should
undergo skin fl ap repair for reconstruction.
According to the swelling situation after electrical injury
to the scrotum, the position and area of the electrical wound,
a single pedicled skin fl ap, a double pedicled skin fl ap or
penis embolia can be used in the scrotal skin fl ap transfer
procedure. The separation level is under the dartos. Thorough
separation should be ensured in case the suture tension is so
great as to cause skin fl ap necrosis or wound dehiscence.
Estrin treatment is needed to prevent penile erection and the
dressing should be used to keep the scrotum in position to
lessen the swelling. If the penis is set into a scrotal fl ap, the
pedicle of skin fl ap should be cut off 1–2 months after the
operation. The penis should be turned out at the same time.
Typical Case 1
A 22-year-old patient was burned by 10,000 V of electricity
in his right hand, the right inguinal fold and the penis. He
was admitted to the author’s hospital 3 days later. Five days
later, excision of the eschar in the inguinal fold and the penis
was undertaken, followed by an inguinal fold large free skin
graft. Necrosis in part of the cavernous body of the penis was
found during surgery and the deep veins of the penis were
exposed but basically normal. The wound of the penis was
ring-shaped with normal glans penis. A bilateral scrotal skin
fl ap was transferred to repair the penis. The scrotal skin
a
b
c
d
e
f
Fig. 12.3 ( a , b ) High-voltage electrical burn in the right inguinal fold and penis before surgery; ( c , d ) reconstruction with bilateral pedicled scrotal
skin fl ap, 6 months later; ( e ) division of pedicled scrotal skin fl ap; ( f ) 2 months after division of pedicled skin fl ap

12 Electrical Burns

303
fl ap’s pedicle was cut off 6 months later with penis turned
out. Penile function recovered satisfactorily (Fig. 12.3 ).
Gangrene of penis and reconstruction of penis : A free
skin fl ap with vascular anastomosis or pedicled abdominal
fl ap may be used for penis reconstruction. The latter is rather
simple. The pedicled abdominal skin fl ap containing the
superfi cial epigastric artery and the superfi cial iliac circum-
fl ex artery may be designed to reconstruct penis. The pedicle
may contain merely a small piece of skin (about 3 cm) with
a skin fl ap at the distal end of about 14 × 14 cm. The whole
skin fl ap looks like a ping-pong racket. The skin fl ap may be
transferred through an incised way. Broad skin epidermis in
the center measuring 0.6 cm was removed. The lateral skin
fl ap (3 cm in width) encircled the urinary canal with a piece
of iliac bone to form the penis.
Typical Case 2
The right hand, chest and abdomen, right inguinal fold,
penis, and scrotum of a 20-year-old man were burned by
high-voltage electricity. He underwent cystostomy in the
local hospital and transferred to our hospital on the second
day of injury. Excision of the eschar in the inguinal fold and
large free skin graft transplantation were carried out on the
third day after admission. After free skin grafting success on
the 12th day post-operation, he underwent penis and scrotum
eschar excision and debridement. During the operation, we
found that about 1 cm of cavernous body on the root of the
penis was basically normal. One third of the skin of the scro-
tum was necrotic, and partial tissue of the dartos fascia of the
scrotum was parabiotic. Thus, the parabiotic tissue was
reserved. The residual scrotal skin fl ap was used to repair the
stump of the penis wound. An incisal “+”opening was made
on the skin of the scrotum for an apical stitch with the uri-
nary canal. The urethral orifi ce debouched on the skin of the
scrotum. The urethral catheter was reserved. After wound
healing, the urethral catheter was removed and the patient
was able to undertake voluntary micturition. His wound
healing was fairly good. A left abdominal fl ap with a piece of
iliac bone was transplanted to reconstruct the penis. A hole
was drilled at one end of the piece of iliac bone, and it was
inserted between the cavernous body of the penis and suture
to fi x. The shape and function of penis were satisfactory after
the operation (Fig. 12.4 ).
12.9.2 Experience and Understanding
Most high-voltage electrical burns in the penis are exit
wounds caused by the perineal region making contact with
an object. High-voltage electrical burn to the penis often
results in partial or complete absence of the penis body
(including the cavernous body and anterior urethra). The
perineal region and inguinal fold are often burnt too. The
injury is extensive and the available skin fl ap and its blood
vessels may possibly be destroyed. This is one of the tough-
est problems in clinical treatment.
The wound of a high-voltage electrical burn undergoes
complicated changes such as necrobiosis. Early excision of
eschar with skin fl ap coverage is practical in most cases.
Both remodeling of the external genitalia and restoring sat-
isfactory function are important post-penis injury. For
example, free skin grafting may lack elasticity, patients
may have tightness when experiencing erection, while a
satisfactory effect can be obtained by using a scrotal skin
fl ap to repair a penile electrical burn. The scrotal skin fl ap
has abundant blood supply, it is easy to obtain materials,
and it is easy to operate safely. The skin of the scrotum is
fi lmy with no subcutaneous fat; its texture is soft and it con-
tains sensory nerves. Thus, it fi ts the requirement for physi-
ological function. The skin of the scrotum has a high degree
of fl exibility, which enables the donor site to be sewn up
directly without infl uencing the shape and function. The
disadvantage is that the skin color of the scrotum looks
deep and has crinis pubis. We consider that when using a
scrotal skin fl ap to repair a penile electrical burn, do not
excessively pursue a single pedicle or a bridging double
pedicled skin fl ap. Although the skin of the scrotum has an
abundant blood supply and many axle-like blood vessels,
the scrotum may obviously swell post-electrical burn.
Blood vessels could be destroyed. We prefer to use the
penis embolia scrotal skin fl ap, waiting to cut off the pedi-
cle and uncover the penis during the second operation.
When carrying out debridement of a penile electrical burn,
as much of the parabiotic tissue should be preserved as pos-
sible, especially the tissues that can affect penis length,
such as the cavernous body of the penis. In some cases,
even a little of the residual cavernous body at the root may
be useful for later reconstruction and restoration of erectile
effectiveness.
Penis reconstruction after penile defect caused by an elec-
trical burn is not very common in case reports. Sometimes
the range of injury is extensive, the perineal and inguinal
regions have scar contracture and severe deformation. Meatal
stenosis can be seen in some cases. When designing the skin
fl ap to reconstruct the penis, the blood supply to the skin fl ap
and the size and shape of the wound after scar healing should
all be considered. Using an abdominal fl ap and a free piece
of iliac bone to transplant and complete the reconstruction of
the penis in one operation can achieve a satisfactory result.
Authors consider that using the abdominal wall to recon-
struct the penis, a good blood supply can be obtained and
there is no need for the blood vessels to coincide. The proce-
dure is relatively simple and safe. The donor site is concealed
and patients are willing to accept it. However, the shortcom-
ing is that the penis may look rather fat and clumsy and pro-
vide less sensation in overweight patients.
12.9 Repair of High-Voltage Electrical Burns in the Penis

304
12.9.3 Typical Cases of Refractory High-
Voltage Burns
Case 1
Jinfeng Fu, Ming Liang, Dinan Wei, Bin Chen
Multi-position burns of the head, trunk, and both lower
extremities caused by high-voltage electricity
Cai Lixin, male, 34 years old. He was admitted for
burns to the head, trunk, and both lower extremities – 48 %
third- degree and 38 % fourth-degree burns – on 15 June
2001. He suffered acute renal failure 2 days later. On the
19 June, the patient underwent excision of eschar and
debridement of both lower extremities protected by hemo-
dialysis. The middle and inferior segments of his left leg
were completely necrotic, the tibia/fi bula was revealed, the
anterior tibial artery and veins were embolic, but the pos-
terior tibial artery and veins were fi ne, and the footplate
and part of the skin of the dorsum of the foot were
undamaged.
The crux of the case was that the skin of both lower
extremities was completely lost and a large amount of bone
was revealed; thus, neighboring tissue could not be used for
repair. A free skin fl ap from any other position would give
the patient a new injury.
The solution of this case was to use rudimentary skin soft
tissue after amputation to perform free grafting. The wound
was covered with the left amputed footplate fl ap (Fig. 12.5 ).
Case 2
Yonghua Sun, Shuhuan Wang, Daxin Cao
Colic omentum free grafting to repair extensive electrical
burn of the cranial bone.
High-voltage electrical burns to the parietal region often
damage the cranial bone. Sometimes the injury can even
involve full-thickness bones of the skull, and meningeal and
brain tissue. Skin grafting after debridement at an early stage
or regional local fl ap grafting can be used to treat local elec-
trical burns of the skull. It is diffi cult to treat an extensive
a
b
c
d
Fig. 12.4 ( a ) High-voltage electrical burn affecting the inguinal groove, penis, and scrotum, preoperatively; ( b ) reconstruction of the penis, design
of the abdominal fl ap; ( c ) reconstruction of penis; ( d ) 6 months after reconstruction

12 Electrical Burns

305
a
b
c
d
e
f
Fig. 12.5 ( a ) Electrical injury wound of both lower extremities (preop-
eratively); ( b ) post-epluchage of both legs; ( c ) total necrosis of soft tis-
sue on the right leg; ( d ) left tibia revealed; ( e ) complex tissue fl ap of the
foot without bone reserved from amputation below the right knee; ( f )
complex tissue fl ap of the foot without bone free grafting to the left
lower extremity to cover neck exposure; ( g ) footplate fl ap alive 1 year
later; ( h ) stair activity 1 year later

12.9 Repair of High-Voltage Electrical Burns in the Penis

306
scalp defect and a large area of osteonecrosis of the skull in
the early stages. Traditional methods include debridement,
skull perforation or free skin grafting after removal of all the
necrosis and use of a skin tube (skin fl ap), or implantation of
a bone graft or bone substitute. The patient needs many oper-
ations and a long course of treatment. We have used colic
omentum for free grafting for the past few years in one case
with success, now reported as the following.
Male patient, 28 years old. He was burned by high- voltage
electricity of 6,000 V in the head, face, neck, and left hand.
The total area of burns was 9 % and the area of fi rst- to third-
degree burns was 3 %. The large part of the corona capitis
was burned with extensive necrosis. Parts of eschar were
desquamated after using external adhesive plaster for pro-
moting tissue regeneration. A large area of necrotic skull was
revealed and granulation tissue was growing around it. Colic
omentum free grafting was performed under general anes-
thesia on 22 January 1979. The operation was divided among
three groups: the fi rst group carried out head debridement,
discussed the normal skin near the edge of the wound mea-
suring 0.5 cm, which was cut to reach the aponeurosis of the
occipitofrontalis muscle and the necrotic tissue of the wound
was excised at the same time. Two places with necrotic cra-
nial bone were exposed; the areas measured 14 × 6 cm and
24 × 24 cm respectively. The surface layer of the necrotic
lamina externa cranii was chiseled and the inferior part was
preserved. After debridement, the wound measured
24 × 24 cm. The second group took colic omentum, preserv-
ing the right gastroepiploic artery and vein (diameter 1.5 mm
and 1.7 mm respectively) to use as the pedicle of the blood
vessel so that they could coincide. The third group exposed
the superfi cial temporal artery and vein on the tempori dex-
tro (diameter 1.5 mm and 1.8 mm respectively), coinciding
with right gastroepiploic artery and vein, and then sewed up
in a fi gure of “8” shape of sutures, rebuilding the blood sup-
ply of the colic omentum, and the head wound was well cov-
ered by the colic omentum. The periphery was sewn up to fi x
in position. Two medium-thickness fault-free skin grafts
were cut from the left thigh, with the areas of 10 × 25 cm and
10 × 20 cm respectively; the thickness measured about
0.4 mm. The skin fl ap was used to cover the transplanted
colic omentum, the peripheral edges were sewn up, to fi x the
fl ap slightly. The dressing was uncovered 11 days after the
operation, and the whole skin fl ap was alive. The patient was
discharged 1 month after the operation with his new hair-
piece. The appearance was good at the 8-month follow-up
and X-ray showed neoplastic bone formation of cranial
bones (Fig. 12.6 ).
Case 3
Lee, male, worker, admission number 151623, was injured
by high-voltage electricity (36,000 V) with involvement of
four extremities. He went into a coma at about 3 min and
resuscitation was performed on the spot before transferring
to Beijing Ji Shui Tan Hospital. This patient had a vertical
extent electrical burn on his right wrist with loss of infl ection
and the skin of his hand was cyanotic, cold, and had sensory
deprivation. His right leg and both feet had been burned. His
wrist underwent escharotomy reaching the poneurotic fascia
7.5 h after the accident and the blood circulation to the hand
was improved at once. However, 3 h later, he suffered cold
fi ngers and cyanosis again. These signs were gradually
g
h
Fig. 12.5 (continued)
12 Electrical Burns

307
aggravated. Thus, 12 h after injury, he underwent wrist
necronectomy. His musculus palmaris longus was burnt and
discontinued, and the superfi cial layer of muscle tendon of
the fl exor aspect was dry and hard. A 10-cm segment of the
medial nerve seemed to be tarnishing and a blood vessel
embolism was found in the endoneural membrane. Deep and
superfi cial venter musculi of the fl exor aspect presented
sandwich-like necrosis and had no contractile function. The
musculus pronator quadratus suffered muscular degenera-
tion, and was grey and asystolic. The arteria ulnaris, arteria
radialis, and their accompanying veins were injured. The
veins were congested, and the arteries had 8- and 10-cm
areas of thrombogenesis respectively. To guarantee the suc-
cess of vascular anastomosis, necrotic tissue was removed
thoroughly and deep muscle tendon of the fl exor aspect was
preserved. The blood vessel was cut at over 1 cm from the
normal margin seen by the naked eye and the self-saphenous
vein was used for arterial anastomosis with the arteria radia-
lis and arteria ulnaris. An abdominal fl ap was used to cover
the wound after 30-min blood transport observation. The
blood transport was good after the surgery and the stem was
cut off 3 weeks later. The patient’s right hand was preserved
and recovered satisfactory function. At the 8-year follow-up,
he was already able to participate in physical labor (Fig. 12.7 ).
Case 4
Bi Chen
Burn Center, Xi Jing Hospital, Fourth Military Medical
University, Xi’an, 710032, People’s Republic of China
The management of ulnar artery and radial artery throm-
bosis, with blood transport discontinuation caused by upper
extremity high-voltage electrical burn.
Management of severe high-voltage electrical burns of
the abdomen.
Liang, male, 28 years old, an electrician was urgently
charged with a high-voltage electrical burn that caused full-
thickness left abdominal wall defect and the intestines were
revealed on 27 May 1987 at Xi Jing Hospital. On admission,
a
b
c
d
Fig. 12.6 ( a ) Two months post-injury; ( b ) free grafting of colic omentum; ( c ) tenacious pachydermia on colic omentum graft; ( d ) the patient
wears a hairpiece at the 1-year follow-up

12.9 Repair of High-Voltage Electrical Burns in the Penis

308
his general condition was poor, RP 30/min, HR 140 beats/min,
BP 90/70 mmHg. After resuscitation therapy, he underwent
exploratory laparotomy. Seven places in the jejunum, four
places in the ileum, most of the fl exura lienalis coli and colon
descendens had necrosis. Large parts of left peritoneum were
pale and necrotic. One meter of intestine was cut including
12.5 cm of the jejunum, 45 cm of the ileum, and 38 cm of the
colon. The jejunum and ileum underwent end-to- end anasto-
mosis. The colon transversum underwent colostomy. Necrotic
and defective areas of the peritoneum were blocked up with
colic omentum. The patient made progress without any com-
plications. A musculus tensor fasciae latae–musculus sartorius
skin fl ap was used to cover the incomplete abdominal wall. He
is currently able to carry out general work (Fig. 12.8 ).
Case 5
Mingda Xu, Dahai Hu
Department of Burns and Cutaneous Surgery, Burn Center
of PLA, Xijing Hospital, the Fourth Military Medical
University, No. 127 Changle west Road, Xi’an, 710032,
People’s Republic of China
Burns of the perineum, buttocks, and lower limbs caused
by high-voltage electricity.
Dong, male, 20 years old, was burned by 10,000 volts
high- voltage electricity. His perineum, buttocks, and both
lower extremities were severely damaged. He had already
undergone penis, scrotum, and bilateral testicle excision. His
necrotic coccygeal bone, bilateral gluteus, and parts of both
thighs had been cut too. The posterior wall of the rectum was
revealed and he underwent wound skin grafting. Physical
examination on admission revealed penis, scrotum and bilat-
eral testicles defects, full-thickness necrosis of the pubic
symphysis, pubis, huckle bone, the greater and lesser tro-
chanter of the femur were revealed, most of them were
necrotic. The stump of the urethral orifi ce was at the mem-
branous urethra, vesical rupture at articulation of the pubis,
and leakage of urine was found. Parts of both gluteus and
thigh muscles were absent. The left sciatic nerve was dam-
aged. Movement and feeling below the articularis genu were
deprived. The left foot had dropped. He underwent cystos-
tomy and colostomy on his abdomen (Fig. 12.9a, b ). His
designed back skin fl ap measured 42 × 44 cm (Fig. 12.9c ).
a
b
c
Fig. 12.7 Management of ulnar artery and radial artery thrombosis, blood transport discontinuation caused by upper extremity high-voltage
electrical burn

12 Electrical Burns

309
After being delayed fi ve times with fl ow-through fl ap, the
skin fl ap was transferred to the buttocks and the posterior
part of the thigh to cover the buttocks. Scarring, the wound of
the left ischial tuberosity, the left greater and lesser trochanter
of the femur, and the posterior wall of the rectum were cut
(Fig. 12.9d–f ). An iliolumbar skin fl ap was used to cover the
inferior abdomen and mons veneris scar (Fig. 12.9g ). A left
iliolumbar skin fl ap and anterolateral femoral overlength fl ap
were used to cover the pubic symphysis wound after
perineum tissue and dead bone were removed, and the blad-
der was repaired (Fig. 12.9h, i ,). The overlength skin fl ap all
survived (Fig. 12.9j ). Thus, this created the conditions for
later closing up of colo-vesical fi stulas, reconstruction of the
penis, and repair of the sciatic nerve (Fig. 12.9 ).
Fig. 12.8 Management of a severe high-voltage electrical burn of the abdomen
a
b
c
d
e

12.9 Repair of High-Voltage Electrical Burns in the Penis

310
f
g
h
Fig. 12.8 (continued)
12 Electrical Burns

311
Fig. 12.9 ( a ) Electrical burn of the perineum and the fronts of both
thighs; ( b ) electrical burn of the buttocks and the back of thighs; ( c )
design of the back skin fl ap; ( d ) using pieces of 3 l plastic bags to pad
when the skin fl ap is delayed; ( e ) using rubber tubing under local anes-
thesia when the skin fl ap is delayed; ( f ) tightening the skin fl ap “bridge”
after back skin fl ap transfer to the buttocks to block up blood transport;
( g ) using an iliolumbar skin fl ap to repair the inferior abdomen and
mons veneris scar; ( h ) design of the anterolateral femoral overlength
fl ap after perineum tissue, dead bone removed and bladder repair ( 1 )
lateral view, ( 2 ). anterior view. ( i ) Anterolateral femoral overlength fl ap
transfer to cover the perineal wound. ( j ) Overlength skin fl ap survival
18 days after operation (using skin fl ap assisting equipment for 1 week)
a
b
c
d
e
f

12.9 Repair of High-Voltage Electrical Burns in the Penis

312
g
h1
h2
i
j
Fig. 12.9 (continued)
12 Electrical Burns

313
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_13,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
13.1
Introduction
13.1.1 Concept and Research Survey
on Combined Radiation–Burn Injury
A combined injury is defi ned as an injury that is induced
concurrently or in succession in an organism by two or more
harmful factors with different characteristics. This means
that they may bring about a kind of independent, specifi c
injury, such as radiation injury caused by radioactive rays, a
burn induced by high temperature, etc. The same harmful
factor affecting different parts of the organism may induce
many injuries called multiple injuries, which are different
from combined injuries.
Radiation combined injury indicates that the organism
is injured by radiation combined with other damage (such
as burn, blast injury, and injury caused by a firearm); the
combined radiation–burn injury is a radiation injury com-
plicated by a burn. The radiation–burn injury is usually
characterized by a high incidence of early shock, early
and severe infection, obvious disorder of gastro-intestinal
function, evident hematopoietic dysfunction, serious loss
of water and electrolytes, and delayed wound healing.
The whole condition of the injury is severe, expands
quickly and is difficult to diagnose and treat. Therefore,
we have to increase the research into this topic, and con-
tinuously improve the theoretical knowledge and the
level of treatment and cure for combined radiation–burn
injury.
Scientists at home and abroad have paid a great deal of
attention to research into combined injury. Some of the larger
foreign countries, such as Russia, USA, Germany, France,
India, the former Yugoslavia, and Japan were studying com-
bined radiation–burn injury, in which the Russian scientists
researched the topic more than the others. In China, research
into combined injury was mainly centralized at the Research
Institute of Combined Injury, the Third Military Medical
University.
13.1.2 Conditions for Inducing Combined
Radiation–Burn Injury
During the wartime and in peacetime, there are many oppor-
tunities to induce combined radiation–burn injuries. The
main conditions are described below.
13.1.2.1 Explosion of Nuclear Weapons
There are four killing factors occurring from the explosion of
nuclear weapons. These factors act on an individual under
different conditions with different strengths and in different
ways, causing many kinds of combined injuries. The com-
bined injuries that occur are closely related to the equivalent
weight of the nuclear weapons, the means of explosion, and
the distance from the explosive center, the environment in
which it is located, and whether there are protective devices.
Some data showed that radiation combined injury occurred
mainly below 100,000 metric tonnes, and the injured radius
of the area was within 400,000 m. When the equivalent
weight of the nuclear weapon was less than 10,000 ton and
the radius less than 1,200 m, the combined radiation–burn
blast injuries increased signifi cantly, and most individuals
without a protective device and within 300 m were killed on
the spot. The combined radiation–burn injury was mainly
found at nuclear explosive sites of low altitude. In the fi eld of
medicine for protecting from atomic bombs, the combined
radiation–burn injury was the main type of combined injury.
When the nuclear weapon exploded, the burn wound con-
tamination with radionuclides (including radioactive fl oating
dust) may have occurred. The radionuclides not only con-
taminated the body surface and the burn wound, but also
entered the body through the wound surface and in other
ways, causing radiation injury from internal exposure. It is a
specifi c kind of combined injury.
In the statistical data from the explosion of nuclear weap-
ons in Hiroshima and Nagasaki, Japan showed that the total
incidence of combined injury accounted for 60–85 % of the
total wounded personnel if including subjects who died early
Combined Radiation–Burn Injury
Tianmin Cheng
13

314
on. The incidence of combined injury in Hiroshima and
Nagasaki accounted for 40 and 42 % of the total wounded
respectively if subjects who survived 20 days were included,
in which the incidence of combined radiation–burn injury
was much higher than that of the nonradiation combined
injury. The sum of the incidence of the three combined inju-
ries—the radiation–burn blast, radiation–burn, and the radia-
tion blast—in Hiroshima and Nagasaki accounted for 85 and
90.5 % of the total combined injuries respectively. Out of the
radiation combined injuries, the incidence of the radiation
blast combined injury was the highest, followed by the inci-
dence of combined radiation–burn injury, while the inci-
dence of the radiation–burn blast was lower.
13.1.2.2 Accidents in Nuclear Power Stations
In using nuclear energy, the nuclear reactor is the most impor-
tant nuclear installation. It is a device that can control and
make the chain reaction of nuclear fi ssion work continuously,
releasing energy that is carried out by heat-carrying agents
(such as water, metallic sodium, etc.) taking the form of heat
through certain channels for utilizing the energy. The nuclear
reactor is also the core device of the nuclear power station.
Once a disastrous accident had happened, the chain reaction
would lose control; thus, a large quantity of products from
nuclear fi ssion would spill over, and then produce a large
amount of gas, such as carbon monoxide, hydrogen, and
methane, to explode, graphite to burn, and the channels would
exploded and break up except for a large quantity of radioac-
tive substance discharged and a vast amount of radioactive
rays given off, which would caused subjects to incur radiation
injuries. What is more, a great deal of heat energy and the
secondary confl agration would bring about thermal burn, or
even cause a combined radiation–burn injury. For example,
on 26 April 1986, the No.4 Generating Unit of Chernobyl
Nuclear Power Plant in the former Soviet Union (now in
Ukraine) exploded, giving off more than 8 tons of highly
radioactive substances. After the accident, most of the sub-
jects wounded with acute radiation injury, particularly the
severe cases, were complicated by a large surface burn, while
the subjects with extremely severe radiation injury were com-
plicated by burns of the body surface accounting for 40–90 %.
13.1.2.3 Injuries Caused by a Depleted
Uranium Bomb
Depleted uranium is a by-product produced by extracting the
U 235 from uranium. From the beginning of the Gulf War in 1991
to the Confl ict in Kosovo in 1999 and the Iraqi War in 2003, the
depleted uranium weapons were used in numbers that gave rise
to casualties and environmental pollution. There were four kill-
ing factors involved in depleted uranium weapons:
1. The shell fragments, which caused splinter injury, namely
after the depleted uranium bomb had been shot out of the
tank, forming many small bomb splinters or shrapnel
(pieces of uranium and steel), and the injured suffered
many wounds caused by the splinters;
2. When injured by the depleted uranium bomb with sponta-
neous combustion, high temperatures would be produced,
causing the individuals in the tank and nearby to be
burned. If burning in the tank with limited space, apart
from the burns on the body surface, burns of the respira-
tory tract and inhalation injury from the poisonous gas
would occur.
3. The aerosol of depleted uranium would enter the body
through inspiration, eating, and the wound surface, caus-
ing injury of α-ray internal exposure.
4. Toxic injury would be caused by the chemical toxins of
the heavy-metal uranium. Since the physical half-life
period of depleted uranium is long, it exists in the atmo-
sphere for a long time; thus, it may pass through the pol-
luted soil, underground water, animals and plants, and
fi nally enter the human body through the food chain.
Therefore, the injuries caused by the depleted uranium
weapons are the most combined of injuries. If the organism
suffers not only internal exposure injury but also burns due to
the spontaneous combustion of uranium, a combined radia-
tion–burn injury are the result.
13.1.2.4 Accidents from Clinical Radiotherapy
If a subject were irradiated with an overdose of γ-ray or X-ray
in the clinic, except for radiation injury occurring on the whole
body (radiation sickness), he would usually suffer radiation
injury of the local skin because of receiving a large dose of
irradiation (or called radiation burn of the skin). This type of
injury may occur in the malpractice of radiotherapy. In acci-
dents involving contact with radionuclide (including medical
nuclide), if the skin was seriously contaminated by the nuclide
without it being removed in time, skin injury caused by β-rays
(β-burn of skin) may occur. If the radionuclides entered into
the body, the radiation injury of internal exposure would
simultaneously occur. In addition, sometimes not only had the
person been irradiated with γ-rays externally but he had also
suffered internal and external injuries with the β-rays of radio-
nuclides (including skin injury by β-rays). Under such circum-
stances there would be radiation injury of the skin together
with the radiation sickness of the whole body. Thus, we have
to treat the skin wounds and carry out general anti-radiation
treatment as well, which must be paid more attention.
13.1.2.5 Secondary Injuries and Terrorist Injuries
Nuclear installations and nuclear power stations, etc., are
often the key targets for attack. If they were directly attacked
by some precise weapons and broken down, the leakage of
nuclear raw material, fi re and explosion would occur, which
would cause combined radiation–burn injuries. Terrorists
may obtain nuclear materials to make rough nuclear rough
weapons, known as “dirty bombs”, adding explosive mate-
13 Combined Radiation–Burn Injury

315
rial, which may cause radiation combined injury, including
radiation–burn injury.
13.2
Protection of Heart Function
and Anti-shock in Combined
Radiation–Burn Injury
In the course of the combined radiation–burn injury (called
“radiation–burn” for short below), there are several key links
that merit our attention: they are stress, shock, infection,
hematopoietic dysfunction, and wound healing delay.
Among them, shock is often the fi rst vital problem encoun-
tered. In single radiation injury (called “single radiation” for
short below), shock at an early stage is rare, while in com-
bined radiation–burn, shock occurs early on, its incidence
increases, and its degree becomes more severe. Serious
shock is usually the major cause of early death in
radiation–burn.
The symptoms of shock in radiation–burn are on the
whole the same as those in a single injury; however, the for-
mer is more serious than the shock with the same amount of
hemorrhage without being complicated by radiation injury.
Although single infusion may improve the symptoms, it can-
not cure the injury completely. Therefore, we have to con-
sider other factors. First of all, we should think of the problem
of myocardial function in radiation–burn.
13.2.1 Dysfunction of Myocardium
in the Shock Stage of Radiation–Burn
13.2.1.1 Dynamic Change in Blood Flow
After Radiation–Burn
After the rat was injured by single irradiation with 6 Gy by
60 Co γ-rays, its blood pressure, hematocrit, heart rate, cardiac
output, the work of each heart beat, and the general periph-
eral resistance of blood vessels were not obviously changed,
except that the amount of blood fl ow in the coronary arteries
(the rate of myocardium taking Rb) clearly increased after
the injury. After a single third-degree burn of 30 %, the arte-
rial pressure may drop, the hematocrit increased, the heart
rate progressively decreased, the cardiac output decreased,
the cardiac output of each beat progressively reduced, and
the resistance of blood vessels and the amount of coronary
blood fl ow increased. After radiation–burn, the extent of the
blood pressure decrease was obviously serious compared
with the single burn group; the hematocrit also increased
much more than that of the single burn group; the changing
tendency of heart rate was the same as that of the single burn
group but its degree was more severe; the cardiac output was
more severely reduced than that of the single burn group; the
work of each heart beat decreased after being injured, and
the resistance of blood vessels increased. From among these
changes, shock occurred in both the burn group and the radi-
ation–burn group, and the changing regularity of every
dynamic target of blood fl ow in the combined injury group
was similar to that in the burn group; however, the former
was more serious, while there was no distinct change in the
single radiation injury group.
13.2.1.2 The Mechanical Changes
of Myocardium After
Radiation–Burn Injury
Changes in Myocardial Function In Vivo
After Radiation–Burn Injury
After injury by single 6 Gy irradiation, the maximum left
ventricular systolic pressure (LVSP), the maximum chang-
ing speed of intraventricular pressure (+d p /d t max ), the
changing speed of intraventricular pressure of 1 kp isovolu-
metric systolic pressure (d p /d t -TP1), the changing speed of
intraventricular pressure of 5 kp isovolumetric systolic
pressure (d p /d t -TP5), and the maximum systolic time (t-d p /
d t max) were all unchanged. After a single 30 % third-degree
burn, LVSP would drop for 1 h after the burn, the change in
+d p /d t max would fall progressively; after being injured both
d p /d t -TP1 and d p /d t -TP5 would fall, and t-d p /d t max pro-
longed. After radiation–burn, LVSP fell for 1 h after injury,
while it changed more severely than that in the burn group;
+d p /d t max fell progressively, d p /d t -TP1 fell, while d p /d t -
TP5 fell more remarkably than the corresponding any time
phase point in the single burn group; t-d p /d t max was pro-
longed, while it changed more obviously than that in single
burn group.
Changes of Myocardial Function
In Vitro 6 h After Injury
After single radiation injury, all targets of systolic function
in vitro did not change, while LVSP, left ventricular end-
diastolic pressure (LVEDP), +d p /d t max , and aortic pressure
(AP) all fell noticeably after burn or radiation–burn. The
changes in diastolic function in vitro in each group were as
follows: LVSP, LVEDP, and AP were unchanged, −d p /d t max
in irradiation group was unchanged, while that in both the
burn group and the radiation–burn fell.
The Regularity of Myocardial Mechanical
Changes In Vitro After Injury
After the radiation–burn of the whole body with 30 % third-
degree burns, LVSP, +d p /d t max, −d p /d t max , cardiac output
(CO), and AP, etc.—all targets of cardiac function fell, and
these fi gures reach the lowest points 8 h after injury, until the
24th hour after injury, when these fi gures were gradually
restored to the level of the control groups. All the targets in
the single radiation injury group did not visibly change.
13.2 Protection of Heart Function and Anti-shock in Combined Radiation–Burn Injury

316
13.2.1.3 The Effects of Radiation–Burn
on the Intracellular K + Ion
Concentration in Ventricular
Myocardium
Within 24 h after injury the intracellular [K + ] of myocardium
in the single radiation group did not change remarkably;
while [K + ] in the single burn group and the radiation–burn
group was clearly reduced, especially severely in the single
burn group, [K + ] reaching the lowest point 8 h after injury,
and was 65.9 ± 1.0 % of the normal control group and
85.7 ± 1.7 % of the control group in the radiation–burn group;
24 h after injury, [K + ] in the single burn group was restored
to 73.7 ± 1.1 % of the normal value and 93.9 ± 1.6 % in the
radiation–burn group. The changes in [K + ] concentration in
the ventricular myocardial cells in the three injured groups
showed that the effect on the intracellular [K + ] of myocar-
dium in single radiation group was the slightest, the burn
group the most serious, yet that in the combined radiation–
burn group was close to the normal level. The static potential
of the myocardial cells caused by the three injured groups
fell, the static potential in the combined injury was also
clearly reduced. The action potentials of the ventricular
myocardial cells in the three injured groups were all changed:
the depolarization speed in O stage slowed down, the ampli-
tude dropped (mainly from reduction of the static potential).
However, the effects on the repolarization in the three injury
groups were different: in both the single radiation group and
radiation–burn groups, it was prolonged, while it was shorter
in the single burn group, which showed that the effect mech-
anism of ionic fl ow in the course of repolarization was differ-
ent in the three injured groups.
13.2.1.4 The Effects of Radiation–Burn
on the Action Potential of Ventricular
Myocardial Cells In Vivo
After a single 6 Gy radiation injury, a single 15 % three-
degree burn injury and radiation–burn, the action potential of
the ventricular myocardial cells in vivo showed that the three
injured groups were affected remarkably by the courses of
depolarization and repolarization of the ventricular myocar-
dial cells, with the following characteristics: compared with
the control groups, after the 24 h radiation–burn, the ampli-
tude of the action potential fell by 13.6 %, the maximum
depolarization rate was reduced by 41.2 %. The heart rates in
these groups were different: in the burn group they increased
by 9.8 %, in the radiation group they were reduced by 17.4 %,
in the combined injury group 24 h after injury it still
approached the normal level, while 3 days after combined
injury, the heart rate was reduced by 12 %, and after 5 days
it was just restored a little. The average repolarization rate in
combined injury was reduced (by −13.2 to −26.3 %), and the
action potential duration (APD) was prolonged, especially
obviously in APD 50 and APD 90 (by +22.9 to +33.7 % and
+6.9 to 18 % respectively). It showed that the effect of the
action potential of the ventricular myocardium in radiation–
burn was not singly adding to the effects in the two single
injuries together. In some respects (such as the maximum
depolarization rate), both had synergistic effects; in the other
respects (such as the heart rate), both were counteractive
toward each other. Experiments showed that the wound
effect of the combined injury was reversed; namely, if the
parameter of the injured reaction appeared early, the wound
healed quickly, and if it appeared late, it healed slowly.
13.2.1.5 The Effect of Serum in Radiation–Burn
on the Ionic Channel Activities
of Ventricular Myocardial Cells
The Effect of Serum and Its Components
on the L-type Ca 2+ Channel Activities
of Cultured Myocardial Cells
After the serum (fi nal concentration was 20 μl serum/ml
immersed solution) acted on the different groups, the chan-
nel activity of normal serum was without remarkable effect,
and all of the L-type calcium channel opening activities were
strengthened by the serum of the three injured groups (R1,
B1, and RB1 stand for the serum action of the radiation,
burn, and combined injuries respectively). Among them, the
effect of high molecular components in serum after injury on
the L-type Ca 2+ channel activity was not distinct, and the
channel activities showed no remarkable changes, while the
effect of low molecular components and lipid components in
serum on the L-type Ca 2+ channel activity was obvious: add-
ing low molecular components of the serum in different
groups respectively into 1 ml of immersed solution (N3, R3,
B3, and C3 stand for the effects of low molecular compo-
nents of serum in the normal, radiation, burn, and combined
injury groups respectively; equivalent to 20 μl of the amount
of corresponding low molecular components in serum),
among them N3 had no distinct effect, while R3, B3, and C3
increased the channel opening activities. The effect of lipid
components in the serum of different groups (N4, R4, B4,
and C4 stand for the effects of lipid components in serum in
normal, radiation, burn, and combined injuries respectively)
in 0.1 mg/ml infusion were as follows: the effect of N4 on
the channel activity was not obvious, while the effects of R4,
B4, and C4 showed no difference from that of the low mol-
ecules in serum after injury. Among these effects, the effect
of serum components in the combined injury group was the
most intensive, the effect of serum components in the burn
group was second, while that of the serum components in the
radiation injury group was the weakest. Meanwhile, the
effect of lipid components in serum activating the L-type
Ca 2+ channel after injury was depressed by superoxide dis-
mutase (SOD): based on the effects of R4, B4, and C4 in
0.1 mg/ml, then adding 1,000 μl/ml of SOD may remarkably
reduce the increasing extent of the opening channels. Also,
13 Combined Radiation–Burn Injury

317
continuously adding SOD to 3,000 μl/ml of solution would
restore the channel activity to normal levels.
The Effect of the Serum Components After Injury
on the Activity of Inward Rectifi er Potassium
Channel of Cultured Myocardial Cells
A. The effect of serum low molecular components after injury
on the activity of the potassium channel was as follows.
Adding serum low molecular components (N3, R3, B3,
and C3; equivalent to 20 μl of the amount of correspond-
ing low molecular components in serum) of different
groups in 1 ml of immersed solution, among them, the
effect of N3 on the channel activity was not obvious, while
R3, B3, and C3 all strengthened the channel opening:
1. The gradient electric conductances in the range of
−70 to −30 mV increased from the 25 pS of the nor-
mal control to 30 pS, 37.5 pS and 40 pS respectively.
2. The channel average electric current during −70 mV
increased from 1.665 pA of the normal control to
2.205 pA, 2.628 pA, and 2.814 pA respectively.
3. The time constants of channel opening during
−70 mV, R3, and B3 increased from the 0.047 ms of
the control group to 0.096 and 0.083 ms respectively;
the difference between the two time constants was not
obvious, while C3 allowed the fi tting pattern of open-
ing time distribution from the primary exponential fi t-
ting to turn into the secondary exponential fi tting, the
two opening time constants were 0.053 and 0.284 ms
respectively.
4. When the time constant of channel closing was at the
condition of −70 ms clamping potential, the effect of
R3 was not obvious, the effects of B3 and C3 on the
time constant ( τ 1) of short closing were not remark-
able, while they caused the time constant ( τ 2) of long
closing to be clearly shortened.
5. The probability of opening (Po) increased, that of R3,
B3, and C3 increased from the 0.003 of the normal
control to 0.007, 0.009, and 0.009 respectively.
6. In general, the effect of the combined radiation–burn
group was the strongest, that of the single burn group
was second strongest, and that of the single radiation
group was the weakest.
B. The effect of lipid components in serum on the activity of
the potassium channel after injury was as follows. In the
immersed solution of having formed a cell-attached
membrane, adding lipid components in serum (N4, R4,
B4, C4) 0.1 mg/ml to each group respectively, under the
condition of −70 mV clamping level.
1. The main form of channel opening changed from the
cluster opening into the form of rectangular opening.
2. Probabilities of channel opening (Po) were increased,
R4, B4, and C4 from 0.003 of N4 increased to 0.022,
0.050, and 0.061 respectively.
3. The amplitudes of channel average current were
increased with the opening of several levels, R4, B4,
and C4 made the average currents from 1.665 pA
increase to 2.610 pA, 3.577 pA, 3.593 pA
respectively.
4. The average times of channel opening were pro-
longed, R4, B4, and C4 made the opening time con-
stant from a 0.047 ms increase to 0.398, 0.455 and
0.562 ms respectively; N2 (the effect of high mole-
cules in normal serum) also increased it to 0.183 ms,
while compared with R4, B4 and C4, it still shortened
markedly. They all had no effect on the fi tting pattern
of opening time distribution.
5. The closing time constants were shortened, among
them, R4 and B4 had no distinct effect on the short
closing constant ( τ 1), while C4 shortened the constant
remarkably; as for the long closing time constants
( τ 2), the effects of R4, B4, and C4 were remarkably
shortened, i.e., from 9.618 ms shortening to 2.754 ms,
1.530 ms, and 1.459 ms respectively. The effect of the
lipid component of serum in the combined injury
group was the strongest, the burn group the second,
the radiation injury group had the weakest effect,
although the lipid component in normal serum also
prolonged the opening time, and taking the rectangu-
lar opening as the main form, compared with the radi-
ation, burn, and combined groups there were still
remarkable differences among them.
C. The effect of serum components on the K + channel activ-
ity in smooth muscle of coronary arteries after injury is
detailed below.
1. The effect of low molecular components in serum on
the channel activity after injury was as follows. In the
effects of low molecular components in serum of nor-
mal, radiation, burn, and combined groups (N3, R3,
B3, C3; equivalent to 20 μl of corresponding low
molecular components in serum), the effect of N3 on
the K + channel activity of coronary smooth muscle
was not remarkable, while the low molecular compo-
nents in serum after injury could all strengthen the
activity of channel opening, under the condition of
−70 mV:
(a) R3, B3, and C3 made the strength of channel
activity increase from 2.510 to 3.025 pA,
4.050 pA, and 5.000 pA respectively.
(b) The opening time constants increased from 0.060
to 0.193 ms, 0.269 ms and 0.280 ms respectively.
(c) The closing time constants shortened, among
them the effect on the short closing time constant
( τ 1) was not obvious, while the effect on the long
closing time constant ( τ 2) was markedly short-
ened, they changed from 10.985 ms shortening to
8.979 ms, 5.433 ms and 5.002 ms respectively.
13.2 Protection of Heart Function and Anti-shock in Combined Radiation–Burn Injury

318
(d) The probabilities of channel opening (Po) were
raised from 0.003 to 0.009, 0.022, and 0.023.
Among them the effect of C3 was the strongest,
B3 the second strongest, and R3 the weakest, but
the fi tting patterns of the opening and closing
time distributions were all unchanged. The effects
of low molecular components in different concen-
trations after injury on the average current ampli-
tudes of the channel were inconsistent, among
which the effect of R3 has an increasing trend
with the increase in the amount of activity, while
the changing trend of the effects of B3 and C3
with the amount of activity was not obvious.
2. The effect of serum lipid on the channel activity after
injury and the intensity of the effect were as follows.
In the action of lipid components (N4, R4, B4, C4) in
serum with 0.1 mg/ml concentration, the effect of N4
on the channel activity was unremarkable, while in
the serum after injury all components strengthened the
channel activity, among them the effect of C4 was
the strongest, B4 the second strongest, and R4 was the
weakest. R4, B4, and C4 increased the average cur-
rent of channel (I) from 2.510 to 3.054 pA, 3.836 pA,
and 4.620 pA respectively. Their effects on the aver-
age opening time constants ( τ ) increased from 0.060
to 0.182 ms, 0.324 ms, and 0.370 ms respectively. The
effects on the average closing time constants of τ 1
were not obvious, while those of τ 2 were shortened
from 10.985 to 3.572 ms, 2.375 ms, and 2.364 ms. As
for the probabilities of channel opening (Po), they
increased from 0.003 to 0.011, 0.025, and 0.029.
The mechanism of effect : the effect of serum lipid after
injury being added into infusion with the cell-attached mem-
brane did not show immediately and clearly, only after a short
incubation period. If adding the serum lipid after injury into
the infusion with the inside-out membrane, the activating
action of the channel showed rapidly, and made the incuba-
tion period even shorter. If adding the serum lipid after injury
into infusion with the cell-attached membrane, after having
recorded the activating action on the channel, then changing
to the inside–out membrane, the action was not markedly
reduced, and it showed a trend toward strengthening.
The forms of action : although the serum lipid after injury
prolonged the opening time of the channel and shortened the
closing time, the fi tting form of its time distribution did not
change. After changing the infusion to remove the effect of
the serum lipid after injury on the membrane, the opening
activity of the channel was remarkably reduced. If the infu-
sion were repeatedly changed and rinsed, then the opening
activity of the membrane would be restored to the level
before the serum lipid was added.
All the three of the injuries would lead to reduced activ-
ity of the Na + - K + -ATPase and in the single burn and radiation–burn
groups 8 h after injury, the inhibitive effect on the enzymes
was the most severe. Fructose 1-6 diphosphate and Na
2-ATP may obviously improve the cardiac function in the
single radiation and single burn groups, but they poorly
improved the cardiac function in the radiation–burn group.
Protopanaxadiol saponin may evidently improve the cardiac
function 8 h after the burn.
13.2.2 Study of the Mechanism of Myocardial
Dysfunction at the Shock Stage
in Radiation–Burn from Some
Intervening Measures
13.2.2.1 The Effect of Early Fluid Infusion
on the Dynamics of Blood Flow
and Myocardial Function
in Radiation–Burn
The Protective Effect of Early Fluid Infusion
on the Dynamics of Blood Flow
According to the formula of burn fl uid infusion, the amount
of fl uid infusion for 24 h =1.5(ml) × burn surface (%) × body
weight (kg), we can calculate the total amount of fl uid infu-
sion for 24 h, and let the subject immediately be injected
with sterile normal saline (half of the total amount of fl uid
infusion) intraperitoneally after the burn or combined injury.
After infusion it showed that the arterial pressure of the infu-
sion group, compared with the corresponding injured group,
was increased remarkably, but still lower than the control
group. The hematocrit of the burn group after infusion
returned to the normal level, and that of the combined injury
group after infusion was lower, but still higher than that of
the control group. The heart output in the burn group and
combined injury group after infusion was still lower than
that of the normal subject. The effect in the combined injury
group after infusion on the heart output was worse than that
in burn infusion group corresponding to the same time phase.
The work of each heart beat in the single burn group after
infusion was raised more clearly than that in the group with-
out infusion, while that of the combined injury group after
infusion was still lower than the normal group. The total
peripheral vascular resistance in the burn group and com-
bined injury group after infusion was lower than that of the
subjects without infusion, but was still higher than that of the
control group. After infusion, the blood fl ow of the myocar-
dium in both groups was increased compared with that
before infusion.
The Protective Effect of Early Fluid Infusion
on the Myocardial Mechanics
The systolic changes of the myocardium in vivo: after having
infused for 1–2 h, the maximum LVSP in both the burn group
and the combined injury group increased rapidly to a normal
13 Combined Radiation–Burn Injury

319
level; at the other time phase points they were all lower than
in the control group. In the burn group after fl uid infusion for
6 h, the maximum changing rate of LVSP (+d p /d t max ) was
slightly increased, there were no changes at the other time
phase points, and that in the combined injury group after
infusion for 1, 4, 6 and 8 h was markedly increased, while
still lower than the burn group at the same time phase points.
In the burn group after infusion for 1 or 2 h, the changing rate
of LVSP (d p /d t -TP1) increased to 100 and 91 % of the con-
trol group; in the combined injury group after infusion for 1
and 8 h, there were remarkable changes, while at the other
time phase points there were no changes. In the burn group
after infusion for 2 h, the changing rate of LVSP (d p /d t -TP5)
was clearly increased, while at the other time phase points
there were no changes. d p /d t -TP5 in the combined injury
group after infusion for 1, 2, and 4 h was increased, and that
at the other time phase points was lower than in the single
burn group. The maximum contractive times of LSVP (t-d p /
d t max ) in the burn group after infusion for 4 h and in the com-
bined injury group after infusion for 6 and 8 h, were mark-
edly shorter than those in the uninfused groups, but they
were still higher than those of the control group. Vce max fl uid
infusion could restore the subjects with burn after 1 and 2 h
and those with combined injury after 1, 2 and 8 h. In the
other groups they were lower than in the control group except
for the burn group injured for 1 h.
The diastolic changes in the myocardium in vivo: in the
burn group after infusion for 4 and 8 h and in the combined
injury group after infusion for 1, 4, and 8 h, the d p /d t max
would be somewhat restored, but still lower than the control
value. After infusion in the burn group for 2, 4, 6, and 8 h,
and in the combined injury group for 6 and 8 h, the LVEDP
would be restored to some extent, while in the combined
injury group it was still lower than the value in the burn
group.
Changes in myocardial systolic function 6 h after injury
in vitro: the effects of fl uid infusion on the LVSP, LVEDP,
t-d p /d t max , and AP, were markedly increased, but they were
still lower than in the control group. In the combined injury
group after infusion, the LVEDP was clearly increased.
The changes in myocardial diastolic function after being
injured for 6 h in vitro: there was no effect in the burn group
after infusion on the diastolic function, but it may cause the
−d p /d t max in the combined injury group to increase from 60
to 80 %.
13.2.2.2 The Effect of the Calcium Antagonist
Verapamil on the Cardiac Function
Changes in Cardiac Function After Using Verapamil
After using verapamil in the normal control group and the
radiation injury group, the maximum LVSP basically did not
change, that in the burn group was also not markedly
increased, but in the radiation–burn group 6 and 8 h after
injury, it clearly increased. The effect was the same as in the
corresponding infusion group, the other time phases were
lower than in the infusion groups. During fl uid infusion, con-
currently adding verapamil in the burn group after 2, 4, and
6 h and in the combined injury group after 2, 4, 6, and 8 h,
the LVSP would be markedly increased; compared with the
single infusion group, the LVSP in the burn group after 1 and
6 h and in the combined injury group after 6 and 8 h were
also markedly increased; compared with the group using
verapamil only, the LVSP in the burn group after 2, 4, and
6 h, and in the combined injury group after 2, 4, 6, and 8 h,
were clearly increased; among them, in the burn group after
1, 2, and 4 h and in the combined injury group after 1 or 2 h
the LVSP reached a normal level.
With regard to +d p /d t max , the effects of using verapamil
only and that of using fl uid infusion in the burn group showed
no difference. When using fl uid infusion and concurrently
adding verapamil 6 and 8 h after the burn, it increased sig-
nifi cantly; as for the time phase points in the combined injury
group, it also clearly increased, close to the level under the
same condition in the burn group. Compared with using fl uid
infusion only, it markedly increased 8 h after the burn, and
combined injury 2 and 8 h after the burn.
Regarding d p /d t -TP1, by using verapamil only, it was
somewhat increased 8 h after the burn; in the other time
phases, it was not markedly changed. In the combined injury
group the effect was identical to that using fl uid infusion.
When using fl uid infusion and simultaneously adding vera-
pamil, d p /d t -TP1 increased 1 h and 8 h after the burn; after
1 h it reached the normal level. At all of the time phase points
d p /d t -TP1 was raised in the combined injury group; after 1
and 2 h it reached the normal level. Compared with the use
of fl uid infusion only, at each time phase point 1 and 8 h after
the burn and in the combined injury group it was markedly
increased. Compared with using verapamil only, 1 h after the
burn, and in combined injury in each time phase it was
clearly increased.
With regard to d p /d t -TP5, in the verapamil burn and com-
bined injury groups after 8 h, it was increased; all were
higher than that in the fl uid infusion group. By adding the
verapamil to the group with combined injury after 8 h it was
lower than that of the burn group under the same condition,
while after 1, 2, and 4 h it was lower than that of the subjects
with fl uid infusion only. When using fl uid infusion concur-
rently with verapamil in the burn group after 2 and 8 h and in
the combined injury group after 1, 2, 4, 6, and 8 h, it was
increase. Among them, they reached the normal level in the
burn group after 1, 2, and 4 h and in the combined injury
group after 1 h; compared with using fl uid infusion only, it
was markedly increased in the burn group after 8 h and com-
bined injury after 6 and 8 h; compared with the use of vera-
pamil only, it was also increased in the burn group after 2 h
and in the combined injury group after 1, 2, 4, 6, and 8 h, but
13.2 Protection of Heart Function and Anti-shock in Combined Radiation–Burn Injury

320
after 2, 4, 6, and 8 h it was still lower than that in the normal
control group.
With regard to t-d p /d t max , the changes in the burn group
and the combined injury group showed no difference between
the groups with the use of verapamil alone and with the use
of fl uid infusion alone. The t-d p /d t max was obviously short-
ened in the burn group after 4 h and in the combined injury
group after 2, 6, and 8 h by using fl uid infusion with the
simultaneous addition of verapamil; in the combined injury
group after 2 h it reached the normal level, while in the burn
group there was no difference between the groups with the
use of fl uid infusion only and use of verapamil only. In the
combined injury group after 2 and 8 h, the fl uid infusion only
for 1 and 2 h was markedly shorter than the group using vera-
pamil alone, but after 4 and 6 h, it was more prolonged than
that in the burn group under the same conditions.
Regarding Vce max , verapamil would raise the Vce max to
some extent in the burn group after 1, 2, and 8 h; the effect
caused by verapamil in the burn group after 1 and 2 h was
less than that in group using fl uid infusion only. As for the
combined injury group after 8 h, it increased and reached the
level in the fl uid infusion group. When using fl uid infusion
with the simultaneous addition of verapamil, Vce max would
be somewhat restored in the burn group after 1 and 8 h;
among them, in the burn group after 1 h, it reached normal
levels, while in the burn group after 8 h, it was higher than in
the subjects undergoing fl uid infusion only, and there was no
difference from the verapamil only group. All the time phase
points in the combined injury group were clearly increased;
it was also higher than that in fl uid infusion only and vera-
pamil only groups, but after 4, 6, and 8 h, it was still lower
than that in the normal control group.
With regard to −d p /d t max , verapamil would raise it to some
extent in the burn group after 2, 6, and 8 h and in the com-
bined injury group after 2, 4, 6, and 8 h, but all of them were
still lower than in the normal control group, of which that in
the combined injury group after 1 and 2 h was less than that
in the corresponding burn groups. When using fl uid infusion
with simultaneous addition of verapamil, it was increased in
the burn group after 4, 6, 8 h. Among them, it was higher
than that in fl uid infusion only group, and in the burn group
after 4 h. It was even higher than that in the subjects using
verapamil only; it was clearly increased at all time phase
points after combined injury; among them, it was higher than
that in the subjects 2, 4, 6, and 8 h after injury using fl uid
infusion only, while in the combined injury group after 1 and
2 h, it was higher than that in subjects using verapamil only.
Regarding the LVEDP , it would be clearly increased in the
combined injury group after 6 h with use of verapamil only.
The other time phases were not affected; among them, it was
clearly more reduced in the burn group after 2, 6, and 8 h and
in the combined injury group after 8 h than in the correspond-
ing fl uid infusion only group. When treated by fl uid infusion
and concurrently adding verapamil for 8 h, they would obvi-
ously be increased in the burn group after 1, 2, 4, 6, and 8 h
and in the combined injury group after 4, 6, 8 h after treat-
ment started; among them, they were remarkably higher in
the burn group after 1, 6, and 8 h and combined injury after 4,
6, and 8 h than that in the corresponding fl uid infusion only
group. As for the burn group after 1, 2, 6, and 8 h and the
combined injury group after 4, 6, and 8 h, it was markedly
higher than in the group treated by use of verapamil only.
With regard to the systolic function of the myocardium
in vitro for 6 h , verapamil had no effect on any of the targets
of myocardial systolic function in vitro in the normal group
or in the radiation injury group; after the burn the LVEDP,
+d p /d t max , and AP were all clearly increased; there was no
marked effect on the combined injury group.
Regarding the diastolic function of the myocardium
in vitro for 6 h , there were no distinct changes in LVDP,
LVEDP, and APD in every group. As for −d p /d t max , there was
also no obvious change in the radiation injury group, while it
was reduced in the burn and combined injury groups, and
that in the burn group was more severe than that in the com-
bined injury group. When treated by fl uid infusion with the
addition of verapamil there was no distinct effect in the burn
group, but fl uid infusion may cause −d p /d t max to markedly
increase in the combined injury group; also, it was higher
than that of the subjects treated by verapamil only.
Changes in the Energy Metabolism
of the Myocardium in the Early Stages
of Radiation–Burn
The control rate of respiration during the fi rst 8 h was
unchanged after the whole body was irradiated with 6 Gy; it
would be reduced 12, 24, and 48 h after injury, by 67.6, 67.6,
and 52.2 % of the control group value respectively. The con-
trol rates of respiration in the myocardial mitochondria in the
burn group were markedly reduced after injury for 1, 3, 8, 12,
24, and 48 h; they were 79.1, 75.7, 72.2, 72.2, 77.9, and 74.0 %
of the control group before injury respectively. The control
rate of respiration in the radiation–burn group was reduced
more severely than that in the single burn group; the values
were 62.7, 70.5, 66.2, 61.8, 55.3, and 61.8 % respectively.
The Degrees of Activity of ATP-ase in Myocardial
Myosin Indicate the Extent of Energy Utilization
There was no change in the irradiated group 1 and 3 h after
injury, but after 8, 12, 24, and 48 h they were 75.8, 70.4,
70.4, and 68.3 % of the control group values respectively. It
was evident that either synthesis of energy or utilization of
energy after injury was inhibited. Radiation injury, burn and
radiation–burn may induce the lipid of over-oxidized mito-
chondrial membrane, which would reduce the activity of
SOD and glutathione peroxidase, thus affecting the function
of the mitochondria and of the myocardial systole.
13 Combined Radiation–Burn Injury

321
The Effect of Verapamil on the Ca 2+ (Calcium Ion)
Transportation Function Within the Myocardium
in Radiation–Burn
The myocardial systole is closely related to the intracellular
Ca 2+ level. The normal myocardial function depends on the
internal stability of calcium ions. The calcium ions in myo-
cardium are mainly stored in the mitochondria and myo-
plasm reticulum. In fact, the overload of the calcium in
myocardial cells means calcium overload in the mitochon-
dria. Mitochondria are the places that produce energy; thus,
the overload of calcium in mitochondria will affect their
function. Verapamil is an antagonist of calcium ions.
Therefore, in radiation–burn, taking verapamil for preventive
treatment has the evidently protective effect on the respira-
tory function of the myocardial mitochondria.
The concentration of calcium ions in normal myocardial
mitochondria is (0.051±0.009) nmol Ca 2+ /mg protein. After
radiation injury, the concentration of Ca 2+ was reduced,
while after burn and combined radiation–burn injuries, the
concentration of calcium ions in mitochondria was increased
markedly. If verapamil was used by the subject for preven-
tion, the concentration of Ca 2+ would be still somewhat
increased, but when verapamil was used by the subject for
treatment, the Ca 2+ concentration would always be main-
tained at a normal level. Treating the subject with fl uid infu-
sion could also maintain the Ca 2+ concentration.
The rate of absorbing Ca 2+ of the myocardial mitochon-
dria was reduced in the radiation injury group. In the burn
and combined injury groups, the rate of absorbing Ca 2+
reduced slightly, and the reduction of Ca 2+ absorbance rate
could be prevented by administering fl uid infusion and vera-
pamil for prevention and treatment.
The basal Ca 2+ discharge rate was reduced after radiation
injury. In the burn and combined injury groups, the basal
Ca 2+ discharge rate was several times higher than the normal
value. Using verapamil for prevention and treatment could
also prevent any increase in the basal Ca 2+ discharge rate.
Mitochondria kept Ca 2+ function at reduced level, which
would lead to an increase in the intracellular Ca 2+ , and
showed that after radiation injury the Na + -dependent Ca 2+
discharge rate was reduced. In the burn and combined radia-
tion–burn groups, the Na + -dependent Ca 2+ discharge rate was
several times higher than the normal value. Using verapamil
for prevention and treatment could prevent any increase in
the Na + -dependent Ca 2+ discharge rate.
13.2.2.3 The Changes in the β-Adrenergic
Receptor Density on the Myocardial Cell
Membrane
After the single 6 Gy radiation injury, single 30 % third-
degree burn, or radiation–burn, the density of the β-adrenergic
receptor (β-AR) on the myocardial cell membrane was
decreased, which manifested a reduction in the maximum
combined volume ( B max ), and continued from 1 to 24 h after
injury without restoration, which indicated that β-AR was
sensitive to burn and radiation injury. The reduction in the
β-AR density in myocardial cells may be one of the main
causes of the myocardial function being inhibited after radia-
tion injury, burn or radiation–burn.
13.2.2.4 The Effect of Nitrogen Monoxide
on the Inhibition of Myocardial
Function in Radiation–Burn
After whole-body radiation injury with 6 Gy, 30 % third-
degree burn, or radiation–burn, the early change in the nitro-
gen monoxide (NO) synthesis and its effect on myocardium
had been observed. We found that NO synthesis and the
activity of induced nitrogen monoxide synthetase (iNOS) in
myocardium were markedly increased in the burn and radia-
tion–burn groups, while there was no change in the radiation
only group. After having been treated by NO donator SIN-1
(1 μmol/kg or 10 μmol/kg, i.p.), the myocardial cGMP syn-
thesis increased, while the activity of Na + -K + -ATPase decreased.
Dexamethasone had a distinct inhibitory effect on the
changes mentioned above, which showed at an early stage in
the burn group and radiation–burn group. The increase in
myocardial NO synthesis was mainly due to the excess of
induced nitrogen monoxide synthetase, and further caused
the changes in the amount of cGMP and the activity of Na + -
K + -ATPase in the myocardium.
To sum up the opinions mentioned above, this research
compared the changes in myocardial function in the three
injuries—radiation injury, burn injury, and radiation–burn—
all sides, mainly with regard to blood fl ow dynamics at the
shock stage in radiation–burn, dysfunction of the myocar-
dium, myocardial mechanics, the changes in potassium–
sodium ion channels in myocardial cells, the dysfunction of
energy metabolism in myocardial mitochondria and its pro-
tective measures, the change in β-adrenergic receptor density
in myocardial cells, the change in myocardial NO quantity,
etc.—and through different levels—the whole body, organ,
cell, and subcell levels. Although the causes of myocardial
dysfunction at the shock stage in radiation–burn were multi-
factorial, the main causes included the effects of energy
metabolism, calcium ion channel, and the effects of serum
components on the change in myocardial systolic function,
the change in the β-adrenergic receptor of the myocardial
cell membrane after injury, and the inhibitory effect of
endogenous NO after injury on the myocardial function. The
research also analyzed in depth the mechanism of changes in
myocardial systolic function from many aspects. In the three
injuries, the inhibitory effect of radiation injury was slight,
and it was far slighter than that in burn and the combined
injury groups with the same dose of irradiation, but the con-
dition of the wound in the combined injury group was more
severe than the condition of the wound in the same burn
13.2 Protection of Heart Function and Anti-shock in Combined Radiation–Burn Injury

322
injury, which on the one hand indicated that the change in the
condition of the wound in the radiation–burn group under the
6-Gy whole body irradiation depended mainly on the rules of
burn injury; on the other hand it also indicated that the condi-
tion of the wounds of the radiation injury and burn injury
might affect each other and be worse.
13.2.3 The Early Anti-shock in Radiation–Burn
In general, few single radiation injuries directly caused
shock; shock-like changes may occur only after irradiation
with large doses. However, in radiation injury combined with
a burn, shock happened early and easily. The higher the irra-
diation dose, the more severe the condition of wound would
be, and the higher the incidence of shock, the more serious
the course of the wound.
In radiation–burn, the nervous system, endocrine system,
circulatory system, and the metabolic function of the organ-
ism had all seriously broken down because of the severe
effects of the combined injury factors; among them the
reduction in the effective circulatory blood volume was usu-
ally the key link in developing shock. Therefore, in fact, in
severe radiation–burn, the early stage after injury was the
shock stage. The clinical manifestations were: mental excite-
ment, moving restlessly and uneasily, soon turning to inhibi-
tion, dull response, apathetic expression, even to dim
consciousness. Meanwhile, there were corresponding time
phasic changes in respiration, pulse, and blood pressure. The
blood became concentrated, the blood volume reduced, and
changes in the biochemical metabolism occurred rapidly.
In war-time, the functions of the main organs were often
normal at the beginning of the shock phase caused by a sin-
gle injury. However, in the early stages of a combined injury,
there may be injuries of functions in one or more of the main
organs, and then the injuries grew day by day as the course
developed, which not only caused the clinical changes and
injury types to appear greatly different, but also markedly
affected the prognosis. The temperature and blood pressure
in the subject with radiation–burn were often simultaneously
markedly decreased. If the subject was not treated effectively
in time, the prognosis would be bad and the mortality was
very high.
Through experiments on 390 mice, measuring the blood
pressure in each one, and combining the general condition
after injury, setting the blood pressure at ≤6.6 kPa (50 mmHg)
as the critical value for developing severe shock, we found
that with a single dose of irradiation with 12 and 16 Gy, a
single third-degree burn of 5,10, 15, and 25 %, and after the
injuries caused by the above two irradiation doses respec-
tively, then combining the four degrees of burn, the early
incidence of shock was raised and the burn wound was
worse, also having certain relationship between the irradia-
tion doses and the incidence of shock. For example, the inci-
dence of shock incidence in a single 15 % burn and a 25 %
burn were 20 and 40 %, after combining with an irradiation
dose of 12 Gy they were increased to 50 and 80 %, while
after combining with an irradiation dose of 16 Gy the inci-
dence was even increased to 70 and 90 %. The results also
showed the signifi cant difference between the mild intestinal
type of radiation–burn and the single radiation injury, which
was also one of the important characteristics of the combined
effect of the combined injury, i.e., there appeared to be two
peaks of death in animals after radiation–burn: the cause of
the fi rst death peak was the early shock of the burn about
24 h after injury; using fl uid infusion for the prevention of
shock would basically avoid early death, enabling the ani-
mals to proceed to the stage of regeneration of the intestine
epithelium. One of the effects of burn shock on the intestinal
epithelium was the effect of DNA synthesis; before distinct
morphological changes appeared in the intestinal epithelium
in animals with shock, changes in increasing permeability
had occurred. These results expounded the signifi cant char-
acteristics of the early combined effect in radiation–burn of
an intestinal type, and provided the direct experimental basis
for preventing early death.
13.3
Controlling Infection and Adjusting
Immunity for Radiation–Burn
Infection in radiation sickness only and burn only was rela-
tively prominent, while in radiation–burn, infection hap-
pened earlier, more severely, and in many more subjects, and
at a critical stage in particular, pyemia often occurred. As for
radiation–burn, not only exogenous infection in the burn
wound, but also endogenous infection of the intestinal tract
and respiratory tract occurred, the immune function of the
general anti-infection was reduced; thus, the infection hap-
pened early, often following early shock, or it even occurred
simultaneously with shock, and was more severe. Therefore,
infection became the main direct cause of death.
13.3.1 The Manifestations of Infection
in Radiation–Burn
The results of early research showed that injured dogs all
died 6–15 days after injury (on average they survived for
10.2 days), with 400R X-rays irradiating the whole body
once combined with a 25 % third-degree burn. After injury
the dogs all suffered from general and local infection to dif-
ferent extents. The research also analyzed the manifestations
of the complicated infection, the etiology, the mechanism of
the disease onset, and the signifi cance of infection in the
development of the disease. The research proved that the
13 Combined Radiation–Burn Injury

323
complicated infection was the key problem of the mutually
aggravating symptoms in radiation–burn. The most severe
infection was on the skin wound surface. The other local
infections occurred in the oral cavity, lung, and intestinal
tract. General infections included bacteremia, septicemia,
pyemia, and “toxemia.” There were two sources of bacteria
exogenous (wound surface) and endogenous. The anti-
infection function of the organism was reduced—except for
the breaking down of the barrier ability, with regard to anti-
bacterial function, and the factors of the cells, tissues, and
body fl uid were also reduced, the cell factor being the main
one. The body fl uid factors of anti-Gram-negative bacteria
(the ability to kill E. coli and the complement amount in
serum) were not markedly reduced. With regard to the anti-
toxin ability, we found that the properdin was decreased,
obviously when “toxemia” was occurring, considering that
this was indirectly refl ecting the increase in “toxic sub-
stances” in the blood and the decrease in the anti-toxic func-
tion in the organism. The reduction of functions of the
barrier, anti-bacteria, and anti-toxin in the organism formed
the basis of the complicated infection. At the critical stage
and in the early stages of recovery, complicated infection
was the main cause of death.
Taking the infection of the skin wound surface as an
example, during the early stages after injury the eschar ha
not softened and lysed, and a large area of eschar on the
surface was fairly intact, infection could occur under the
eschar. At that time, there were usually few bacteria within
the eschar layers, and the bacterial colonies could only be
found in the inter-follicular space and the tissue clefts of the
eschar. Sometimes the bacterial colonies could be linked to
the infected area under the eschar. In general, the eschar
began to lyse about 7–10 days after injury, then split and fell
off, and the lysing course would reach its peak at the end of
the second week. At this time, just during the critical stage,
the general condition was worse, the necrotic tissue of the
wound surface continued to develop, and the infection
became worse and worse each day. The wound surface was
then covered with pieces of the bacterial layers. The bacteria
in the necrotic tissue spread widely; some bacteria could
invade the blood vessels and lymphatics. In a subject with
severe infection, the bacteria could spread along the collag-
enous fi bers to other places. Apart from a demarcating
infl ammatory zone in the early stages, few neutrophils infi l-
trated. Whether the subject was treated or not, the infi ltrat-
ing cells were mainly monocytes, sometimes the cells
proliferating actively could be seen, but with little or no
phagocytosis. Bacteria could be cultured from the inguinal
or axillary lymphatic nodes near the wound surface.
Bacterial colonies and necrotic tissue were growing in some
of the marginal sinuses, even in the medulla of the lym-
phatic nodes. Bacteria were also found in some of the lym-
phatic nodes and the cavities of the blood vessels.
The research, besides giving a detailed description of the
characteristics of pathological changes in local and general
infection, also put forward the characteristics of the reaction
of infl ammatory cells, of which the monocytes were the main
elements of the infection (with other infectious conditions,
granulocytes were frequently the main elements). Linking to
the fi ndings in other severe injuries the research especially
pointed out that such a peculiar infl ammatory cell reaction
was not caused by certain specifi c harmful or stimulating
factors, but were probably common features after changes in
response occurred during multiple severe injuries.
13.3.2 The Characteristics of Infection
Induced by Bacterial Invasion
After Radiation–Burn
From experiments on the healthy adult hybrid male domestic
dogs, the whole body was irradiated once with 4 Gy by 60 Co
γ-rays combined with 20 % skin burn (third-degree 8 %,
second-degree 12 %), we found that the incidence of fever
3 days after injury was 100 % in the radiation–burn group
and radiation only groups, which was higher than that in the
burn only group (70 %). The fever began on the 4.9th day
after injury in the combined injury group, which was earlier
than in the radiation only group (7.9th day) and the burn only
group (5.7th day), while fever in the combined injury group
continued for 2.0 days, which was shorter than in the radia-
tion only group (3.0 days) and in the burn only group
(4.4 days). The bacterial incubations from the burn wound
surface 4 days after injury were all positive; most of them
were mixed bacterial infections. Among the bacteria, the
Staphylococcus aureus positive accounted for 90.0 %, beta
streptococcus for 54.1 %, alpha streptococcus for 30.0 %,
and Staphylococcus candicans for 16.4 %. There was no dif-
ference between the radiation–burn group and the burn only
group; the positive rates of bacterial quantitative incubation
from the tissue under the burn eschar were 80.0 % in the
radiation–burn group, 63.8 % in burn only group. The bacte-
rial numbers were 1.8 × 10 6 /g and 1.4 × 10 6 /g respectively.
Most of the bacteria were Staphylococcus aureus and bacil-
lus diphtheroid; the positive rate of blood bacterial incuba-
tion was 70 % in the radiation–burn group, which was higher
than in the burn only group (20 %) and in the radiation only
group (40 %). The bacterial incubation positive in the radia-
tion–burn group began on the 7th day, which was earlier than
in the radiation only group (the 10th day) and in the burn
only group (the 8th day). Thus, the day of when bacterial
incubation positive fi rst occurred in the radiation–burn group
was 3–6 days later than at the burn wound surface, while the
infective bacteria coincided with that of the burn wound sur-
face; the cases of infective focus on the body surface (except
for the burn wound surface) and in the viscera of the
13.3 Controlling Infection and Adjusting Immunity for Radiation–Burn

324
radiation–burn group were similar to those in the radiation
only group, which were higher than those in the burn only
group.
After rats were underwent whole-body irradiation with
6 Gy by 60 Co γ-rays combined with 15 % third-degree burn
for 24 h, the bacteria were only limited on the eschar and
within the eschar. Bacteria had invaded under the eschar by
3 days after injury, the positive rate of bacteria cultured was
44 % Seven to ten days after injury, the bacteria under the
eschar had reproduced in a large number (>10 6 CFU/g), the
positive rate of bacteria cultured reached 100 %, but by
15–30 days after injury, the infective extent under the eschar
or on the wound surface of the survivors had reduced.
Moreover, by incubating bacteria for blood in the cardiac
cavity and tissues, and linking to the pathological features,
the bacterial infection rate and the severity of infection in
viscera showed lung–liver–heart blood, and the kinds of bac-
teria coincided with the bacterial infection under the eschar.
However, when removing the eschar for skin transplantation,
the animal survival rate increased from 30 % of the control
group to 90 % because the bacterial infection on the wound
surface and viscera had been removed. These results
expounded the time characteristics of infection induced by
bacterial invasion on the wound surface in severe radiation–
burn, which provided important evidence for choosing the
opportunity for suitable operation.
13.3.3 The Onset and Adjustment
of Enterogenous Infection
in Radiation–Burn
The intestinal tract has the function of being a complete bar-
rier under normal physiological conditions, especially the
immune barrier of the intestinal mucosa, which is composed
of lymphatic tissues of the intestine, such as lymphocytes in
the intestinal epithelium, lymphocytes in the lamina propria,
and Peyer’s lymph nodes, etc. Thus, the bacteria and toxins
in the intestinal tract are not harmful to the organism. During
radiation–burn, as the epithelium of the intestinal mucosa,
particularly the stem cell pool of the crypt, is quite sensitive
to radiation, the epithelium is easily damaged. After radia-
tion–burn, the bacteria in the intestinal tract move their habi-
tat early, but the amount of E. coli , which had been large and
had settled in the intestinal tract, entering into the tissue, did
not quite coincide with the time the peak value was reached.
For example, 4 h after injury, the bacteria in the intestinal
tract had moved their habitat both in the radiation–burn
group and in the burn only group. Migration of the intestinal
bacteria in the radiation–burn group would involve the mes-
enteric lymph nodes and spleen, while in the burn only group
the bacteria were only limited to the mesenteric lymph nodes,
at this moment the moving habitat of the intestinal bacteria
in the radiation only group was not obvious. Until 6 h after
injury, the fact that the bacteria were moving their habitat
was obvious in all the three groups, reaching its peak value
in the burn only group and the radiation–burn group, the
most severe in the radiation–burn group, where the 3 H-TdR
count of the number of the marked bacteria was higher than
that in both of the other groups, but less than the sum of the
two groups; namely, “1 < 1 + 1 < 2”; in radiation only injury
group, the time of peak value of the moving of the bacterial
habitat was at the 12th hour after the injury; after 96 h, the
moving of the bacterial habitat in the burn only group was
markedly reduced, while those in the single radiation group
and radiation–burn group were somewhat reduced, yet they
were still distinctly different from the normal control group
( p < 0.01). After injury, the amount of moving of the intesti-
nal bacterial habitat was not identical in every visceral organ;
the mesenteric lymph nodes were the fi rst to be attacked,
while the spleen and liver were second.
Taking an animal model such as 8-Gy whole-body irradia-
tion in mice combined with 15 % third-degree burn, by using
the methods enzyme linked immunosorbent assay (ELISA),
immunohistochemistry, and bacteria culture, the adjusting and
controlling effects of recombinant human interleukin-4 (rhIL-
4) on the immunity of intestinal mucosa were observed. Four
control groups of normal, radiation only, burn only, and com-
bined radiation–burn injuries and three groups of prevention
for radiation only, burn only, and combined radiation–burn
injuries were designed in the experiments. There were two
phase points designed at 6 and 72 h in each group. In the pre-
venting groups during 6 h of taking samples, each mouse was
injected IL-4 0.05 ml (6,000 U) once subcutaneously in the
inguinal region on 2 days, 1 day before injury and on the day of
sample-taking respectively, while in the 72 h of taking samples,
each mouse was injected once with a continuous dose 3 days
after injury. In the normal control groups, the mice were
injected with the same amount of normal saline. The experi-
ments showed that after treatment with rhIL-4, the number of
bacteria moving habitat was markedly lower than that in the
untreated control group ( p < 0.01), which indicated that rhIL-4
may effectively reduce the amount of bacteria moving habitat
in the intestinal tract. Six and 72 h after injury, the OD value of
SIgA in the mucus of the small intestine was reduced, com-
pared with the control groups, the difference between them
being quite distinct ( p < 0.01), while after treatment with rhIL-
4, the OD value of SIgA was clearly increased compared with
that in each control group ( p < 0.01). When using IgA monoclo-
nal antibody with the specifi c ability to show plasma cells
secreting IgA, the number of plasma cells clearly decreased 6
and 72 h after radiation–burn. After using IL-4 for treatment,
the number of secreting IgA plasma cells in the lamina propria
of the small intestine markedly increased ( p < 0.01), which
increased the amount of SIgA in the mucus, and reduced the
incidence of enterogenous infection, reducing the infection to
13 Combined Radiation–Burn Injury

325
some extent, all of which showed that rhIL-4 may improve and
restore the immune ability of the damaged intestine mucosa,
and reduce the incidence of enterogenous infection.
13.3.4 Changes in the Macrophages
in the Peritoneal Cavity After
Radiation–Burn
The percentage of macrophages (MΦ) in the cellular elements
of the peritoneal cavity of mice after whole-body irradiation
with 8 Gy by 60 Co γ-rays combined with 10 % third-degree
burn for 1, 3, 5, and 10 days, had the tendency to decrease,
increase, and decrease again (the percentages were 29.4, 54.9,
63.5, and 43.7 respectively, normal control group was
52.3 ± 2.2), while the tendency of neutrophils and eosinophils
was to increase, decrease, and increase again (for neutrophils
65.7, 14.8, 25.5, and 44.7 respectively, normal control was
44.1 ± 2.2, and eosinophils 2.2, 5.3, 15.7, 17.0 respectively,
normal control group 1.3 ± 0.3). Eosinophils always main-
tained a higher level, all of which showed that after radiation–
burn, several cellular elements in the peritoneal cavity had
changed signifi cantly. The changes in MΦ types (%) and their
phagocytic function showed that after radiation–burn for 1, 3,
5 and 10 days, the original MΦ (3.5, 1.0, 1.6 and 2.7 respec-
tively) and young MΦ (6.9, 4.3, 4.6 and 9.3 respectively) were
obviously reduced compared with the normal controls (origi-
nal 10.1, young 11.3), while matured MΦ increased, the
phagocytic rate was maintained at a higher level. However, the
digestive rates (47.9 and 43.6) and the phagocytic indices (2.6
and 2.9) 1 and 3 days after injury were reduced (average val-
ues of the normal control groups were 51.0 and 3.2). Although
on the 5th day they were restored to 53.1 and 3.7, by the 10th
day they were reduced again (39.6 and 2.7). All of which
showed that the changing characteristics of phagocytes in the
peritoneal cavity of mice in radiation–burn were that MΦ
matured rapidly and their phagocytic rates were markedly
raised; the digestive rates, namely the ability to kill bacteria,
and phagocytic indices had a tendency toward reduction, the
causes of which were the emergency response of the organism
to the burn factors after the radiation–burn; the reduction in the
MΦ digestive rate indicated that the MΦ could not kill the
pathogenic bacteria; however, the wandering of MΦ may
become a bacterial transmitter, which was an important factor
for the aggravated infection in radiation–burn.
13.3.5 Changes in Immune Function
After Radiation–burn
The immunity of the intestinal mucosa has been mentioned
above; the changes in immune cells in the blood, thymus,
and spleen are described in detail here. When the rats
underwent whole-body irradiation with 5 Gy by 60 Co γ-rays
combined with 15 % third-degree burn, the phagocytic activ-
ity of neutrophile granulocytes in the peripheral blood was
obviously inhibited, the ability of the opsonin in the serum
was markedly reduced, mainly because of the inhibitory fac-
tor of phagocytes appearing in the blood after combined
injury. After irradiation with a larger dose, the necrosis of
immune lymphocytes was one of the developing dysfunc-
tional factors of immune ability; when irradiated with a dose
range below 4–6 Gy, the function of the survival lymphocytes
broke down. As for the T cells, the active elements on the
cell surface, especially the number of TCR/CD3, decreased,
and their functions were reduced, which caused the cells not
to fulfi ll their effectively active function. Under the action of
ionizing radiation, the rearrangement and mutation of TCR
genes occurred, which was the molecular basis for TCR/
CD3 changes. Through observation of the immune activity
of thymic cells, which is closely related to the immune reac-
tion and the ability to form antibodies in splenic cells, we
found that in the 15 % third-degree burns the spontaneous
incorporating rate of thymic cells was reduced 24 h after
injury, and began to restore after 72 h; the cell number of the
thymus and spleen and several immune targets of peripheral
blood were also reduced 72 h after injury, and began to be
restored after 7 days; they were higher than the normal level
after 10 days. All of this indicated that the immune function
of cells during the early stages of a burn was inhibited, while
at the later stage the immune function had a strengthening
effect. When the whole body was irradiated with 6 Gy by
60 Co γ-rays, the cell number of the thymus and spleen and
their cellular reaction activity, and the changing trend of sev-
eral immune targets in the peripheral blood were more
strongly inhibited than in the burn only group, were main-
tained for a long time, and were restored later; among them,
B cells and T H cells were inhibited most markedly. Compared
with the single injury, the features of whole-body irradiation
with 6 Gy combined with 15 % third- degree burn had the
following characteristics:
1. The inhibiting extent of the thymic cells during the early
stage of radiation–burn was similar to that of the radiation
only group, but heavier than that in both the single injury
groups, and the inhibitory extent at the time of cellular
restoration was also heavier than that of both single injury
groups. For example, the spontaneous incorporating rate
of thymic cells in the combined injury group 72 h after
injury was decreased by 10.3 % of that before injury,
which was similar to that of the radiation only group
(10.2 %), while in the burn only group it increased from
41.4 % of that 24 h after injury to 69.4 %. Seven and ten
days after injury, in the two single injury groups it was
nearing or reached the normal level, while in the combined
injury group it had the lowest value; later on it was obvi-
ously lower than the normal level. The changing trend in
13.3 Controlling Infection and Adjusting Immunity for Radiation–Burn

326
thymic cell number basically coincided with the reactive
characteristics of the cellular activity mentioned above.
2. The inhibitory time for the reaction of forming antibody
cells in the spleen during the early stages of radiation–
burn was similar to that in the radiation only group, but
in the former, because of combination with a burn, it
appeared to have an aggravated effect. For example,
24–72 h after injury, both the reduced extent of the reac-
tive activity of the splenic cells and the number of
splenic cells were markedly lower than in the radiation
only group, while in the burn only group they fl uctuated
from the normal level; 7–20 days after injury, the reac-
tive activity of the splenic cells increased from 49.6 to
102.5 %, which was similar to that in the radiation only
group (102.1 %), while in the burn only group it showed
a strengthened effect. All of this indicated that after
combined injury the inhibitory function of the splenic
cells was aggravated, and was mainly occurring during
the early stages. Compared with the functional changes
of thymic cells the inhibitory effect occurred with sever-
ity at an early stage, while during the later stages it
restored rapidly.
3. The changing features of several immune targets in
peripheral blood after radiation–burn were different from
those of single radiation injuries. Several immune targets
of the peripheral blood in both groups were inhibited
severely only 3 days after injury; 7 days after they began
to increase in the combined injury group, there was
clearly more time beforehand than in the radiation only
group. During the later stages of combined injury (15–
20 days), the restoration of the total number of lympho-
cytes, and the numbers of B cells, T cells, and T H cells
were all inhibited, in particular the T H cells. On the other
hand, the number of T s cells increased markedly and the
T s /T H ratio appeared to be raised. Meanwhile all of the
targets in the burn only group had a strengthened effect.
The fact that several immune targets after combined
injury were raised again ahead of time, that the restora-
tion of T H cells at the later stage was inhibited severely,
and that the number of T s cells increased may result from
the effect of cellular stimulating and inhibitory factors
forming after the burn. When cells began to be restored
after combined injury, the burning factors in the serum-
stimulated cells proliferated, which caused several
immune targets of peripheral blood to increase temporar-
ily. After that, since the inhibitory factors, such as necrotic
tissue of the burn wound surface, degenerated protein,
histotoxic factor, bacterial infection, toxin entering into
the blood, etc., accumulated unceasingly, occupied a
dominant position, and directly inhibited T H cells and
activated T s cells, the inhibition of the immune function
for restoration in the organism was more severe than that
in the single injury groups.
13.3.6 The Changes in the Immune Function
After Autotransplantation of Skin
and Eschor-Protection
in Radiation–Burn
After the rats, which had undergone whole-body irradiation
with 6 Gy by 60 Co γ-rays combined with 15 % third-degree
burn for 24 h, had the eschar removed and underwent auto-
transplantation with skin. The results showed the spontane-
ous incorporating rates of the splenic cells, the extent of the
reaction of antibody cell formation in the spleen, that the
reduction in the number of thymic and splenic cells in the
animals with eschar removal and skin transplantation were
lower than that in the animals without eschar removal and
skin transplantation, and that the time at which restoration
began was earlier, and that the extent of the restoration was
obviously greater than in the control groups ( p < 0.01). When
using Zn(SD) 2 only to protect eschar, in contrast, the changes
in several immune targets were basically similar to those of
the control group. In the several immune targets of the
peripheral blood, the restoration of the number of T H cells
slowed down, while the number of T s cells increased mark-
edly. The survival rate for 30 days in the animals that had
whose eschar had been removed following skin grafting dur-
ing the early stages increased from 32 % of the control group
to 95 %. These results indicate that the main effect of cutting
eschar following skin grafting at an early stage after com-
bined injury was extremely advantageous to the restoration
of function of the thymic and splenic cells, which to a certain
extent represented the state of the immune function of the
organism at that moment. However, at 30 days after injury
the number of T H cells in the peripheral blood was still lower
than normal values, while the number of T s cells was greater
than the normal level, which showed after combined injury
the complete restoration of the immune function in the
organism, even if it took a long time. Meanwhile, the inhibi-
tion of the restoration of function of the thymic and splenic
cells after combined injury was mainly due to the effects of
the burn wound surface; it was probable that inhibitory fac-
tors from the burn resulted in the damage of the restoration
of the function of the cells in immune organs.
13.4
Dysfunction and Reconstruction
of Hematopoiesis in Radiation–Burn
The hematopoietic tissues are especially sensitive to radia-
tion. The pathological changes of hematopoiesis after radia-
tion injury appeared early, and the extent of the changes was
great; after a severe burn, the burn toxins or infection also
affected the hematopoietic function. After radiation–burn,
the changing rules of radiation injury often played a leading
role in the changes in the hematopoietic system, the
13 Combined Radiation–Burn Injury

327
hematopoietic tissue in the bone marrow suffered severely,
the hematopoietic stem cells/progenitor cells decreased, the
microcirculation of hematopoiesis suffered markedly, and
the total number of blood cells in the peripheral blood
decreased. Thus, the dysfunction of hematopoiesis was the
most fundamental pathological change of the radiation–burn.
The extent of changes always infl uenced the degree of the
wound severity, which would decide the prognosis of the
course; thus, further study of the changing rules of hemato-
poiesis in a combined injury will have an important theoreti-
cal and practical signifi cance for profoundly realizing the
characteristics of the combined injury, and seeking a way to
promote the healing of a combined injury.
13.4.1 Dysfunction of Hematopoiesis
in Radiation–Burn
13.4.1.1 Radiation–Burn Affecting
the Erythrocytic System More
Severely Than the Granulocytic System
After the rats underwent whole-body irradiation with 5 or
6 Gy by γ-rays combined with 15 % third-degree burn,
either the total number of white blood cells in peripheral
blood and the total number of nuclear cells in bone marrow,
or the targets of granulocytic and erythrocytic hematopoie-
sis in bone marrow were reduced signifi cantly, the extent
inhibition was obviously more severe than that in both sin-
gle injury groups, but in the combined injury group the
effect on the erythrocytic system was markedly more severe
than that on the granulocytic system. The dysfunction of
granulocytic hematopoiesis mainly resulted from the inhibi-
tion of granulocytic young cells before the neutrophilic
myelocytes, which had the ability to divide. The example of
inhibition of the erythrocytic system being more severe than
that of the granulocytic system was 3 days after injury, the
ratio of young cells before neutrophilic myelocytes hemato-
poiesis to the nuclear cells in bone marrow was only 2.7 %
in the erythrocytic system compared with that before injury,
while in the granulocytic system it was 6.6 % compared
with that before injury.
13.4.1.2 The Characters and Causes
of Anemia in Radiation–Burn
After radiation injury combined with a burn, the mean red
cell hemoglobin (MCH) showed no remarkable change,
which illustrated that the amount of hemoglobin in each red
cell was normal, but after 1 week the mean red cell volume
(MCV) was visibly increased, the mean red cell hemoglobin
concentration (MCHC) was markedly reduced, which
showed that the anemia was macrocytic with low hemoglo-
bin, and that it was probably caused by a reduction in the
folic acid, vitamin B 12 , a decrease in the amount of iron
taken, and a metabolic disorder of vitamin C after severe
injury. Anemia after a radiation–burn was mainly caused by
the effect on the stem cells of the erythrocytic system and
the young red cells in the bone marrow, which had the abil-
ity to divide, and interference with the metabolism of hemo-
globin in which iron participated. The speeding up of the
destruction of mature red cells also had a certain effect.
13.4.1.3 The Mechanism of Destruction
of Mature Red Cells in Peripheral
Blood During Radiation–Burn
When the red donor cells marked with either 59 Fe in vivo or
51 Cr in vitro 5 days after burn only, radiation injury only or
radiation–burn were transfused into normal recipients, the
half-life times of the red cells were 15.6, 13.7, and 14.1 days
respectively, which were not different from the result of
being transfused with red cells of normal donors (14.1 days).
These results indicated that burn, radiation injury, and com-
bined injury had no directly damaging effects on red cells.
However, when the red cells of normal donor were trans-
fused into recipients with burn, radiation injury, and radia-
tion–burn, the half-life times of the red cells were 11.7, 8.4
and 4.7 days respectively, which were markedly shorter than
that of normal recipients (14.1 days). This explained why the
destruction of red cells was mainly affected by the intracor-
poral environment of the recipients with burn, radiation
injury, and radiation–burn. These results were also supported
by using the saline permeable fragility test of red cells.
13.4.1.4 Rules of Metabolic Disorders of Nucleic
Acid in Hematopoietic Tissues During
Radiation–Burn
Forty-eight hours after radiation–burn, the hematopoietic tis-
sue and the amounts of DNA and RNA in peripheral blood
were clearly reduced following the increase in irradiation
doses. When irradiation of different doses was used (0, 2, 4,
6 and 8 Gy), the extents of reduction were less than that in
the radiation only group or in the burn group with the same
doses. DNA was reduced much more severely than
RNA. DNA was most visibly reduced in bone marrow, which
only accounted for 0.5 % of the normal amount; while RNA
was most clearly reduced in lymphonodus, accounting for
29.4 % of the normal amount.
13.4.1.5 Effects of Trace Element Preparations
on the Hematopoietic Function During
Radiation–Burn
The comprehensive preparations of trace elements with the
amount of physiological need for trace elements of zinc,
copper and iron, lysine, vitamins B 1 , B 2 , C, and D, folic acid,
and millet sprouts, etc., mixed with principal forage (millet
power) were in the proportion 1:9, the animals were fed with
this forage 6 days before the combined radiation–burn injury
13.4 Dysfunction and Reconstruction of Hematopoiesis in Radiation–Burn

328
until 8 days after injury. When fed 1 day after injury the for-
age appeared to have a distinctly protective effect on the
stem cells of the granulocytic hematopoietic system and
8 days after injury, the forage still had the effect of promot-
ing restoration of hematopoiesis. One day after injury the
total number of leukocytes was still maintained at a higher
level. The benefi cial effect of the trace element preparation
on hematopoiesis in radiation–burns was probably due to the
stimulating action of zinc, copper, iron, etc., trace elements
on the hematopoietic stem cells.
13.4.2 Mechanism of Hematopoietic
Dysfunction and Reconstruction
of Hematopoiesis in Radiation–Burn
13.4.2.1 The Causes of Dysfunction of
Hematopoietic Parenchymal Cells
in Bone Marrow Suffering from Severe
Damage During Radiation–Burn
The combined effect of hematopoietic dysfunction in radia-
tion–burn was quantifi ed by using crossing joint culture for
stromal cells and hematopoietic parenchymal cells in bone
marrow. The radiation–burn severely affected the number of
progenitor cells of the granulocytic and monocytic systems
in bone marrow and/or their reproductive abilities. Apoptosis
of cells was an important way in which radiation damaged
the hematopoietic function, and the apoptosis of cells
induced by irradiation was markedly related to the effective-
ness for a given period of time and dosage of irradiation. The
genes involved in the apoptosis of cells clearly changed dur-
ing radiation injury: the Bcl-2 gene showed a reduction,
GADD45 and p53 genes showed an increase. Meanwhile,
the DNA damage of hematopoietic cells in bone marrow was
the direct cause of the decreasing number of S stage cells
during the cell cycle. Irradiation not only inhibited the ability
to proliferate but also killed the cells within the cell cycle.
Changes in the Generating Ability of Colony-Forming
Units (CFU-GM) in the Granulo-Macrophage System
After radiation injury and radiation–burn, we found the
inhibition of forming CFU-GM in the bone marrow cells of
mice, which was particularly severe 3–5 days after injury.
The formation of CFU-GM was reduced by 90 % in radia-
tion–burn, after 7 days it would gradually restore, until
10 days after injury in both the radiation–burn and radiation
only groups it was still lower than in the normal control
group. After that the restoration of hematopoiesis appeared
to be better in the combined group than in the radiation only
group. In the burn group 3–5 days after injury, it was
reduced, while later on it restored rapidly and was clearly
higher than in the normal control group. Two days after
injury, the number of antigen-positive (Sca-1 + ) cells in the
stem cells of the bone marrow and the colony forming abil-
ity of the granulocytic and erythrocytic systems were
signifi cantly reduced.
Combined Effects of the General Damage
of Hematopoietic Function in Radiation–Burn
Taking crossing joint culture with normal or injured tropho-
blast of stromal cells in bone marrow and normal or injured
hematopoietic parenchymal cells as a simulated hematopoi-
etic condition of bone marrow in vivo, we found when trans-
planting bone marrow cells of radiation–burn on the parietal
layer of normal stromal cells, the number of CFU-GM
decreased markedly; when transplanting bone marrow cells
of normal or radiation–burn rats on the stromal cells of the
bone marrow of radiation–burn, the formation of CFU-GM
was reduced, which was most obvious 3–5 days after injury,
e.g., only 25 % of the normal value. It still did not restore
until 10 days after injury. When transplanting injured hema-
topoietic parenchymal cells on the injured stromal cells, the
damaged trend of hematopoietic ability was the same as
above, but more severe, only one tenth of the normal value
3–5 days after injury.
The Apoptosis of Hematopoietic Cells Induced by
Irradiation and the Changes in the Genes Concerned
The high value of terrace of developing apoptosis of hemato-
poietic cells in bone marrow after irradiation with 4–8 Gy
was 30 %, and the time needed to reach the high terrace
value would gradually go up with the increase in the irradia-
tion doses; the earliest time might be 4 h after injury. The
apoptosis of cells mainly occurred within 24–48 h after irra-
diation. The incidence of apoptosis after irradiation with a
10-Gy dose was similar to that with a 4-Gy dose; necrosis
was the main form of cell death. After irradiation with
4–10 Gy, the Bcl-2 gene of the bone marrow cells had
reduced expression, while the GADD45 and p53 genes had
increased expression, but the GM-CSF gene maintaining the
normal lower level of expression.
Determining DNA and Protein in Hematopoietic Cells
with Flow Cytometry
After radiation–burn, the percentage of the cells at the S
stage refl ecting the ability of cell proliferation in bone mar-
row and spleen and their proliferating index were always at
a lower level, and after injury the DNA and protein level in
the cells of the bone marrow and spleen were remarkably
lower than in the normal group. The change in DNA in
bone marrow was more obvious than that in the spleen. By
using Brd U marked cells, after irradiation with 4–10 Gy
for 4 h, the proliferating indices of hematopoietic cells of
the bone marrow in every dose group were signifi cantly
reduced, and they were always at the lower level 48 h after
irradiation, which was only less than 20 % of the normal
13 Combined Radiation–Burn Injury

329
value; most of the cells that were in cyclic stage were dead
within 12 h after injury.
The Number of Megakaryocytes and Blood
Platelets Decreased
Eight hours after radiation–burn, the number of megakaryo-
cytes and blood platelets clearly decreased; 3–15 days after
injury they always stayed at the lower level, the number
most markedly reduced in the combined group and these
were the slowest to be restored. Different from the granulo-
macrophagocytic system, the number of megakaryocytes
continuously decreased in the burn injury group, and
reached the lowest level on the 13th day after injury (simi-
lar to the lower value in the radiation only group), which is
probably related to megakaryocytes in bone marrow being
phagocytosed. The number of blood platelets in the radia-
tion only group and in the radiation–burn group was signifi -
cantly decreased.
13.4.2.2 The Damage of the Adhesive Function
of Bone Marrow Stromal Cells
Was the Main Mechanism
of Dysfunction of Hematopoiesis
in Radiation–Burn
During radiation–burn, the fi broblasts increased, appear-
ing to be maldeveloped, their mitochondria swelled, and
their structure was disordered. The ability of colony for-
mation of bone marrow stromal cells was clearly reduced,
the proliferative ability was inhibited, the cell number at
the G 2 +M stage decreased, the DNA amount in the stromal
cells was reduced, all of which developed “G 1 stage retar-
dation.” During radiation only injury and radiation–burn,
the ability to support and adjust hematopoiesis of bone
marrow stromal cells was markedly destroyed, and its res-
toration was slowed down. Research proved that the vascu-
lar adhesive molecules (VCAM-1), fi bronectin (Fn),
laminin (Lm), and type IV collagen (Co1 IV) of the bone
marrow stromal cells played an important role in the adhe-
sive location of the hematopoietic parenchymal cells.
However, during radiation–burn and radiation only injury,
these adhesive molecules were decreased, which would
certainly affect the ability to proliferate and differentiate
hematopoietic parenchymal cells, and prevent normal
hematopoiesis. Thus, the notion was proposed that damage
of the adhesive function of the stromal cells in the bone
marrow microenvironment might be one of the important
mechanisms in the development of hematopoietic dysfunc-
tion in radiation–burn.
Observing Stromal Cells of Bone Marrow Under
Optical and Electron Microscopes
There are fi broblasts, multipolar or multigonal reticulum
cells, squamous epithelial cells, and round cells in the parietal
stromal cells of bone marrow. After radiation injury, the cell
bodies of the fi broblasts were smaller, the cytoplasm was
smaller, the number of multigonal reticulum cells increased,
the surface of the round cells was not smooth, with many
folds appearing petaliform; after burn injury, the fi broblasts
were fewer, the number of reticulum cells had increased sig-
nifi cantly, there was foam in the cytoplasm; after radiation–
burn, the fi broblasts increased, with less cytoplasm, a slender
form, on the surface there were longitudinal shallow grooves
showing maldevelopment, the surface was uneven, and the
round cells appeared “caulifl ower-like.” Under transmission
electron microscopy we that found the matrix of mitochon-
dria in the stromal cells of bone marrow after radiation injury
became pale, their cristae became shorter, the endoplasmic
reticulum expanded; in the burn group the mitochondria of
stromal cells increased, swelled, and the cristae became
thick, while after radiation–burn, the stromal cells showed
changed hollow spaces, swollen mitochondria, and disor-
dered structure.
The Proliferative Dynamics of Stromal Cells
in Bone Marrow
The ratio of cells at the G 2 +M stage, which refl ected the
proliferative ability of the cells, and the amount of DNA
in the stromal cells of bone marrow 14 days after injury in
the radiation injury group and the radiation–burn group
were lower than those in the normal and burn only groups.
The changes in the colony formation ability of stromal
cells in bone marrow 1, 3, 5, 7, 10, and 14 days after
injury in the radiation only injury and radiation–burn
groups were obviously lower than those in the normal
control group and single burn group, and were the lowest
3–7 days after injury. They were more markedly reduced
in the radiation injury group than in the combined injury
group; in the burn group 3 days after injury they were
lower than in the normal group. Afterward, they were
gradually restored.
The Effect of Stromal Cells of Bone Marrow
on Formation of CFU-GM
The trophoblast of normal stromal cells in bone marrow
cultured at different times had different abilities and forms
to support hematopoiesis. When cultured for less than
14 days, the main effect was the direct effect between the
stromal cells and the hematopoietic parenchymal cells,
while after culturing for 21 days, the stimulating activity
of the supernatant of the culture was greater. When trans-
planting bone marrow cells of normal or radiation–burn
rats on the stromal cells of bone marrow in radiation–
burn, the formation of CFU-GM 3–5 days after injury was
reduced markedly, i.e., only 25 % of the normal value. By
10 days after injury it had still not been restored to the
normal condition.
13.4 Dysfunction and Reconstruction of Hematopoiesis in Radiation–Burn

330
The Expression of Adhesive Molecules of Bone
Marrow Stromal Cells
After radiation–burn, the effect of stromal cells on the
adhesive ability of mononuclear cells of bone marrow was
reduced, particularly severely reduced 3–7 days after injury,
and was more obvious than that in the radiation only injury.
After burn injury the adhesive ability was strengthened.
After adding VCAM-1, Fn, Lm, Co1-IV respectively into
the cultured stromal cell system to treating monoclonal
antibodies, the effect of normal stromal cells on the sup-
porting ability of normal CFU-GM in bone marrow was
clearly reduced, most distinctly in the VCAM-1 monoclo-
nal antibody group, where it was reduced by 54.43 %. In
radiation–burn, the expression levels of VCAM-1, Fn, Lm,
and Co1-IV clearly decreased, most markedly 3–7 days
after injury. After that they gradually increased again, but
they still had not reached normal levels by the 28th day. The
mRNA level of VCAM-1 in bone marrow stromal cells was
clearly increased 1 day after a burn, but in the radiation only
injury and radiation–burn they were markedly reduced. The
changes in the protein level showed a similar trend.
13.4.2.3 The Gene of Hematopoietic Cells
Expressing Maladjustment Is Also
an Important Mechanism
of Hematopoietic Dysfunction
in Radiation–Burn
During radiation–burn, the extent of inhibition expressed by
the gene of interleukin-3 ( IL-3 ) was between the radiation
injury and the burn injury; inhibition expressed by the IL-3
gene may be one of the causes of dysfunction induced by radia-
tion–burn. Under the action of irradiation, the fact that the IL-3
receptor ( IL-3R ) gene of nuclear cells in bone marrow changed
and that a great many hematopoietic stem/progenitor cells rich
in IL-3R died were the possible causes of IL-3R positive and
IL-3R average amounts of expression in every cell decreasing
during radiation–burn. After radiation injury the hematopoietic
inhibition activity in serum was strengthened, the hematopoi-
etic inhibiting factor TNF-α was markedly reduced, while
TGF-β increased at fi rst, and then decreased.
The Change in IL-3 Gene Expression
After radiation injury, the IL-3 expression of nuclear cells in
bone marrow was clearly inhibited; 3 and 14 days after irra-
diation, the inhibition rates of the transcriptional level were
77 and 21 % respectively; the inhibition rates of translational
level were 88 and 36 % respectively; while the effect of burn
on the expression of IL-3 gene was inhibited at fi rst and then
strengthened; during radiation–burn the inhibitory extent of
IL-3 gene expression was between the radiation only injury
and the burn only injury.
The Change in Expression of the IL-3 Receptor
After radiation injury and radiation–burn, the positive ratio
of the IL-3R α subunit in nuclear cells of bone marrow and
the average expressing amount of the IL-3R α subunit in
every cell were rapidly reduced. They would be somewhat
restored by 14 days after injury, but would still not reach
the normal level, and were positively related to the number
of nuclear cells of bone marrow. There was no distinct dif-
ference between the burn only group and the normal con-
trol group.
The Level of Inhibitory Hematopoietic
Active Substance
The cultured supernatant of normal macrophagocytic strain
(Ana-1) had an inhibitory effect on the formation of CFU-E
and CFU-GM; after irradiation with 6 Gy this inhibitory
effect was strengthened. In the serum of mice undergoing
whole-body irradiation with 6 Gy, the supporting activity
of CFU-E was reduced, but the supporting activity of
CFU-GM was strengthened; both CFU-E and CFU-GM
induced by stimulating factor had a marked inhibitory
activity; the inhibiting activity of the serum after deactiva-
tion was reduced. One to 3 days after radiation injury, the
level of TNF-α in serum was clearly reduced. It restored to
normal level on the 7th day; 1–3 days after injury, the
TGF-β level in the serum was raised markedly. It was
clearly reduced by the 15th day.
Change in TPO Expression
Three to 13 days after radiation only injury and burn only
injury, the mRNA level of thyroid peroxidase (TPO) was sig-
nifi cantly lower than that of normal controls, while in radia-
tion–burn it was markedly increased.
Research into the effect of the serum on the erythrocytic
and granulocytic hematopoietic systems of bone marrow and
hematopoietic regulating factors erythropoietin (EPO),
GM-CSF after a burn found that after 6–20 days, the nuclear
cells in the bone marrow, CFU-GM, colony-forming unit-
fi broblasts (CFU-F), the parietal cells in the bone marrow,
and the WBC in peripheral blood were all clearly raised; in
the early stages of a burn, the stimulating activity of the
serum erythrocytic and granulocytic systems was markedly
higher than in normal serum, of which the increase in the
stimulating activity of the erythrocytic system in serum was
obviously related to the increase in EPO concentration in
serum after injury. After a burn injury the expression of EPO
mRNA in the kidney and liver was strengthened, while
GM-CSF mRNA was only strongly expressed in liver. This
result clearly explained the possible mechanism that the res-
toration of hematopoietic function in radiation–burn was
faster than that in radiation only injury.
13 Combined Radiation–Burn Injury

331
13.4.2.4 Ways of Promoting the Reconstruction
of Hematopoiesis in Radiation–Burn
Treatment with cellular factor is a new form of therapy that
has developed in recent years. Research into the effect of
several cellular factors on preventing and treating the radia-
tion–burn has been probed. The research found that IL-3
had a good effect on curing the dysfunction of hematopoi-
esis caused by radiation injury and radiation–burn.
Reconstructing the colony-stimulating factor of the granu-
locytic and monocytic systems (rhGM-CSF) could promote
the restoration of hematopoietic function in radiation–burn
on several levels. Tumor necrosis factor (TNF-α) had a pro-
tective effect on the hematopoietic damage caused by irra-
diation, and could stop the bone marrow cells at the resting
stage from entering the proliferating stage. Spirulina is a
monocellular plant. A study proved that spirulina platensis
polysaccharide (SPP) can promote proliferation and differ-
entiation of hematopoietic cells. It had the effect of protect-
ing and promoting repair of the hematopoietic damage
caused by irradiation. As for the hematopoietic reconstruc-
tion of hematopoietic cells after amplifi cation in vitro, the
study proved that the amplifi cation in vitro that was sup-
ported by stromal cells may clearly improve the transplant-
ing ability of cells after amplifi cation.
Interleukin-3
Canavalin A (Con A), which may induce expression of
IL-3, phorbol esters, and calcium ion guiding agent
A23187 had to be used jointly; when using the above
three jointly, the effect would be strengthened by three to
four times that of using Con A alone; and the effective
expression of IL-3 depended on the two ways in which
PKC and Ca 2+ increased in cells. Animals with radiation
alone injury and radiation–burn may use genes to reorga-
nize IL-3 for prevention and treatment, the promoting
effect of which on the restoration of hematopoiesis was
better than that in the single prevention and single treat-
ment groups. This favorable stimulating effect was repre-
sented both on the hematopoietic parenchymal cells and
the stromal cells of hematopoiesis.
Colony-Stimulating Factor of the Granulocytic
and Monocytic Systems
After radiation–burn, we were immediately able to inject
colony-stimulating factor of the granulocytic and mono-
cytic system (rhGM-CSF) intraperitoneally with a dose of
10 μg/(kg·day), once daily, continuously for 10 days, which
would obviously increase the number of WBCs in periph-
eral blood, and nuclear cells of bone marrow, and the num-
ber of progenitor cells of the granulocytic and phagocytic
systems.
Tumor Necrosis Factor
Injecting TNF-α 100,000 U/mouse into the peritoneal cav-
ity 20 h before irradiation would clearly increase the sur-
vival rate of the mice irradiated with a lethal dose to 30 days
and increase the number of WBCs in the peripheral blood,
nuclear cells in the bone marrow, and the progenitor cells of
the granulo-phagocytic systems. TNF-α could also could
hinder the bone marrow cells at G 0 /G 1 stages entering into
the S stage. Using 5 × 10 4 to 1 × 10 5 U TNF-α in vivo may
increase CFU-GM 3 H-TdR participation, while using
1 × 10 4 U TNF-α would cause the expressing density of
IL-3R to increase, but the positive rate was not changed.
We should pay attention to the fact that the individual cell
number of bone marrow was reduced at that time. In the
cultured system in vitro the inhibitory effect of TNF-α on
CFU-GM was dependent on the dose injected. The differ-
ent effects of TNF-α in vivo and in vitro showed that it did
not have a simple direct effect. It may have an effect on the
network of cellular factors; thus, we have to use it cau-
tiously in the clinic.
Spirulina Platensis Polysaccharide
Injecting SPP 125 mg/(kg·day) into the peritoneal cavity con-
tinuously for 5 days, the number of colony-forming unit- spleen
(CFU-S) increased by 88 % compared with that in the control
group, signifi cantly increasing the number of nuclear cells in
bone marrow and CFU-GM of the mice after irradiation.
Amplifi cation of Hematopoietic Cells In Vitro
After amplifi cation in vitro of mononuclear cells of bone
marrow induced by single cellular factor, the reconstructive
ability of hematopoiesis of hematopoietic cells would be
damaged; in particular, the long-term reconstructive ability
of hematopoiesis would be signifi cantly damaged. However,
amplifi cation in vitro supported by stromal cells may mark-
edly improve the transplantation ability of the cells after
amplifi cation, and they were better than the imported uncul-
tured cells in respect of promoting hematopoietic restoration
and short-term hematopoietic reconstruction. Building three-
dimensional bone marrow structure in vitro could be used in
the relevant research.
Phytohemagglutinin-Mononuclear Cells
Conditional Medium
Phytohemagglutinin-mononuclear cells conditional medium
(PHA-MNCCM) and phytohemagglutinin-splenic cells con-
ditional medium (PHA-SCCM) had the clear effect of stimu-
lating activity on CFU-F. The best reaping time for conditional
medium was on days 7–12. The conditional medium without
being stimulated by PHA would have a markedly reduced
effect on the stimulating activity of CFU-F.
13.4 Dysfunction and Reconstruction of Hematopoiesis in Radiation–Burn

332
13.5
The Application of Anti-radiation
Drugs to the Radiation–Burn
Radiation injury has often played a leading role in radiation–
burn; thus, we have to devote much attention to the applica-
tion of anti-radiation drugs. As a general rule, several
anti-radiation drugs that were effi cacious for radiation sick-
ness only also have a fundamental effect on radiation–burn,
but attention should be paid to the characteristics of radia-
tion–burn, which are different from the radiation only injury.
13.5.1 The Protective Effect of WR2721
on Radiation–Burn
S-2-(3-amino-alanine) ethyl thiophosphate (WR2721), is
defi nitely a better protective drug for chemo-irradiation.
Research showed that WR2721 might markedly increase the
survival rate of the mice suffering from radiation–burn, and
prolonged the survival time of the dying animals. After using
WR2721 for prevention, the LD 50 of the mice with radiation–
burn was increased from 5.10 Gy in the control group to
9.53 Gy; dose reduction factor (DRF) was 1.84. The preven-
tive effect of WR2721 on the mice with radiation–burn was
best when the mice were given 200 mg/kg of WR2721 before
irradiation. In mice with radiation–burn after using WR2721
for prevention, the number of WBCs in the peripheral blood
and nuclear cells in the bone marrow were reduced less and
restored more rapidly compared with the control group. The
number of granulo-monocytic system progenitor cells in
bone marrow 1 and 7 days after injury and the number of
hematopoietic stem cells of bone marrow 7 and 14 days after
injury were signifi cantly higher than in the control group,
which indicated that the preventive effect of WR2721 on the
mice with radiation–burn was realized at least partly through
the protection of hematopoietic function.
Taking mice that underwent whole-body irradiation with
8 Gy to cause radiation injury combined with 10 % third- degree
burn as the models, only 20 % of mice of the untreated group
survived for 10 days after injury, when the mice with combined
injury that were intramuscularly (i.m.) injected with estriol
(1 mg/mouse) 30 min before irradiation, the survival rate was the
same as that in combined injury, but when WR2721 (10 mg/
each) was injected (i.m.) into the mice, the survival rate was
higher than that in the former two groups by 65 %; the protective
index was 5.3. If WR2721 was injected into the irradiated mice
(i.m.), it would increase the survival rate of the mice to 8 days
after injury by 86.9 % compared with that in the uninjected
groups. The weight of the spleen increased from 19 to 32 mg, the
number of polydirectional hematopoietic stem cells would
increase from 16.0 (number of each spleen) of the control group
to 49.7 ± 8.0. These results indicated that WR2721 had a better
protective effect on the radiation injury and radiation–burn. The
mechanism of protection was mainly through reducing the irra-
diation damage to the splenic tissue and polydirectional hemato-
poietic stem cells, to protect the hematopoietic function of the
organism, and to increase the resistance of the organism, thereby
increasing the survival rate of the animals.
One, 3, 5, and 10 days after radiation–burn, the neutrophils,
eosinophils, and macrophages in the peritoneal cellular ele-
ments were markedly changed, the trend of change in the
groups using estriol was similar to that in the combined groups,
while the WR2721 group 5 days after injury showed a statisti-
cally signifi cant difference (the fi rst cell elements of the three
were increased by 55.1 % compared with the combined group;
the other two cell elements decreased by 15.7 and 35.7 %
respectively). In the WR2721 group, the mitotic cells in the
macrocytic system had been restored 3–10 days after injury to
the normal level before injury (0.1 % ± 0.1 %), while in the
combined group 1, 3, and 10 days after injury, they were all
zero, which showed that WR2721 had a promoting effect on
the restoration of mitotic cells of the macrocytic system in the
peritoneal cavity of mice with radiation–burn.
The primary, young, mature MΦ, and MΦ phagocytic rates
in the WR2721 group 1 day after injury were 3.8, 11.3, 85.0,
and 44.0 % respectively. Ten days after injury they were 4.8,
9.5, 85.8, and 54.7 % respectively; the changing rule was simi-
lar to that in the combined group, but the digestive rates in
every time phase (for example, 3 days after injury, it was
58.4 %, after 10 days it was 53.3 %) were higher than that in
the combined group (3 days after injury it was 43.6 %; after
10 days it was 39.6 %), and they always remained above the
normal level (average value 51.0 %). The phagocytic indices
5–10 days after injury (3.3 and 3.8 respectively) had already
been restored to normal (average value 3.2), which showed in
the WR2721 group, except for the fact that it retained in the
combined group the increasing maturity of MΦ and the phago-
cytic rate; it could also clearly increase the phagocytic diges-
tive function of MΦ in the peritoneal cavity and promote the
restoration of the phagocytic indices.
The experiments also observed that if the mice that had
undergone irradiation with 6 Gy by γ-rays combined with
10 % third-degree burn were injected (i.m.) with WR2721
(6 mg/mouse) 30 min before irradiation, this may effectively
reduce the effect of lipid peroxidation caused by radiation–
burn, to clearly reduce the amount of malondialdehyde
(MDA) in bone marrow and spleen, to raise the activity of
SOD, and to increase the amount of DNA by 56–98 %.
13.5.2 The Preventive and Curative Effect
of E838 on Radiation–Burn
E838 is an estrogen-like protective agent against radiation. It
has been synthesized using an artifi cial method in recent
years, and is a derivative of ethinylestradiol. It is a new drug
13 Combined Radiation–Burn Injury

333
with a low level of toxins, a widely effective dose range of
anti-radiation, and has a better effect on increasing leuko-
cytes. In the experiments taking animals that had undergone
whole-body irradiation with 7 Gy by 60 Co γ-rays combined
with 15 % third-degree burn as models, oil was used as a sol-
vent to prepare the E838 injection, 1.25 mg/kg body weight
was injected into the peritoneal cavity, and the animals were
divided into fi ve groups, i.e., 1, 2, and 3 days before irradia-
tion, on the day of irradiation, and 1 day after irradiation. The
survival rates (%) of the fi ve groups in the radiation–burn
group and the average survival times were 77.19, 78.69,
37.93, 22.00, and 10.42 % and 11.63, 12.01, 10.55, 10.23,
and 9.53 days respectively. In the group without E838 injec-
tion, they were 7.46 % and 7.94 days. The survival rates of the
fi ve groups in the radiation only group (%) and the average
survival times were 84.85, 85.29, 50.00, 30.00, and 20.69 %,
and 12.55, 12.76, 11.48, 10.88, and 9.53 days respectively. In
the group without E838 injection they were 19.05 % and
8.61 days. The above results showed that the effect of E838
on prevention in the radiation–burn and radiation only groups
was signifi cantly better than that in the control group without
E838 injection. The effect was best when injecting the drug
2 days before irradiation; injecting 1 day before irradiation
was the second best, while the effect was worst when inject-
ing on the day of irradiation and 1 day after irradiation.
Therefore, in the follow-up experiments we adapted the
method to injecting the drug 2 days before irradiation.
After radiation injury and radiation–burn, the number of
WBCs in the peripheral blood and nuclear cells in the bone
marrow was rapidly decreased, CFU-GM and CFU-S were
always at the lower level; although they were somewhat
reduced in the E838 prevention group, they still remained at
a higher level, restoring quickly, and reaching or nearing the
level of the normal value 14 days after injury, which showed
the good protective hematopoietic effect; compared with the
control group, there was a distinct difference. The result
showed that E838 not only had a better preventive effect on
radiation injury alone and radiation–burn, but also had an
obvious protective effect on the hematopoietic function of
injured mice. The pharmacological and toxicological experi-
ments indicated that E838 was no remarkable toxic reaction
when using 50 times the effective dose once and six times the
effective dose for a long time; only when using 50 times of
the effective dose for a long time did there the side effect of
estrogenic activity appear. Observing the curative effect on
fi ve groups using the drug before and after radiation injury
alone and radiation–burn showed that E838 had the same
characteristics as other estrogenic irradiation- protective
agents; namely, the preventive effect was satisfi ed (had a
good protective effect when using the drug 1–3 days before
irradiation), while the curative effect was worse (using the
drug after irradiation was a little better than in the control
group).
13.5.3 Preventive and Curative Effects
of the Combined Use of Several
Anti- radiation Drugs
Taking the use of whole-body irradiation of 7 Gy by 60 Co
γ-rays combined with 15 % third-degree burn injury as a
model, the preventive and curative effects and the synergetic
effect on mice of four anti-radiation protective drugs were
compared—E838, WR2721, cystine hydrochloride, and
ethinylestradiol—on radiation injury alone and radiation–
burn. The drugs for prevention used as follows:
1. E838: injected intraperitoneally (1,250 μg/kg, 0.2 ml/
mouse; E838 ground powder suspended in medical oil)
2. WR 2721: injected intraperitoneally (200 mg/kg, 0.5 ml/
mouse)
3. Ethinylestradiol treated by gavage (0.1 mg/ml/mouse)
4. Cystine hydrochloride: injected intraperitoneally (2.5 mg,
0.5 ml/mouse)
Drugs were given before irradiation for 2 successive days.
The drugs for used for treatment were: E838 (0.2 ml/mouse);
estriol (1 mg/0.1 ml/mouse); WR2721 (0.5 ml/mouse). All
drugs were injected intraperitoneally twice, 1 and 24 h after
irradiation.
After using E838, WR2721, cystine hydrochloride, and
ethinyloestradiol as preventive drugs before irradiation in the
groups undergoing whole-body irradiation with a 7-Gy dose
combined with a 15 % three-degree burn injury, the survival
rates (%) for 30 days were 78.69, 79.56, 70.46, and 62.24 %
respectively, and were higher than in the control group
(8.28 %) by 70.41, 71.28, 62.18, and 53.96 %; the average
numbers of survival days were 12.01, 10.92, 10.53, and
10.11 days, while it was 8.91 days in the control group; the
protective indices were 2.455, 2.449, 2.263, and 2.160. There
appeared to be a good protective effect in every preventive
group. The protective effects achieved using WR2721 and
E838 were best, using ethinylestradiol was the second best,
while cystine hydrochloride was a little worse. The preven-
tive effect of using drugs in the radiation injury only group
was basically identical to the effect in the radiation–burn
group.
In view of the curative effect, E838, WR2721, and estriol
were given 1 h after irradiation, E838 was effective either in
the radiation–burn group or in the radiation only group
30 days after injury; the survival rate was 25.53 %, and it was
32.94 % in the radiation only group. Estriol and WR2721 did
not show a clear curative effect.
Using WR2721 for prevention plus fetal liver cell suspen-
sion for treatment may markedly reduce the mortality of ani-
mals with radiation–burn, and prolong the average survival
time of dying animals. Compared with the control group, the
WBCs in the peripheral blood, the total number of nuclear
cells in the bone marrow, and the hematopoietic stem cells of
the granulocytic system in bone marrow (GM-CFU-C) of the
13.5 The Application of Anti-radiation Drugs to the Radiation–Burn

334
preventive and curative groups were damaged slightly, but
they restored rapidly. The effect of WR2721 for prevention
plus fetal liver treatment on the severe radiation–burn sur-
passed the effect of using WR2721 alone or using fetal liver
suspension alone. During radiation–burn, when adopting a
compatible program for using WR2721 for prevention plus
E838 for treatment, using WR2721 for prevention plus
estriol for treatment, and using E838 for prevention plus
WR2721 for treatment, the survival rates (%) of the animals
surviving for 30 days after injury were 82.65, 80.44, and
67.82 (%) respectively. Compared with the control group
(9.03 %) they were raised by 73.62, 71.41, and 58.79 %; the
average survival times of each compatible group were 13.12,
12.89, and 10.12 days, while in the control group it was
8.24 days. The protective indices were 2.653, 2.612, and
2.313. Either use of two anti-radiation drugs for compatibil-
ity or mixed use of different anti-radiation drugs for preven-
tion and treatment, and either the effect on the radiation–burn
group or the effect on the radiation injury only group, all
showed good protective effects. In particular, the survival
rates for 30 days after injury and their protective indices in
the radiation–burn group were better than in the single radia-
tion group with the same dose. The effect in the group using
WR2721 for prevention plus E838 for treatment was the
best.
These results showed that WR2721 and E838 had relative
ideal protective effects from irradiation compared with other
anti-radiation drugs. E838 also had a certain curative effect,
if the two drugs were used compatibly and reasonably, they
would play an active role in coordinated treatment.
13.6
Treatment of Wound Surface
for Combined Radiation-Burn Injury
There is much mature experience of treating the wound sur-
face for a single burn injury, but treating the wound surface
under the conditions of a radiation–burn is much more diffi -
cult. During the severe radiation–burn, the infl ammatory
reaction was reduced; thus, there were a few leukocytes infi l-
trating and a little exudate on the local wound surface, while
the wound hemorrhaged widely, necrotic tissues increased
and fell off slowly, the granulation tissue was delayed in
growing to maturity and was malformed, the course of the
covering epithelium was delayed, and the wound surface
healed slowly. After radiation–burn, the immunity of the
whole body was inhibited because of the break down of the
hematopoietic function, infection under the eschar occurred
quite early, and when entering the terminal stage, the wound
surface was more easily severely infected and hemorrhaged,
which caused the wound condition of the whole body to fur-
ther worsen, and was diffi cult to cure. Therefore, in radia-
tion–burn we have to fully consider that it is not only different
from radiation sickness alone (with wound surface injury),
but also different from a burn injury alone (with radiation
injury). We have to draw the treatment experience and mea-
sures in the single injury and actively apply them to the com-
bined injury.
13.6.1 Protecting Eschar and Skin Autograft
As for treating the wound surface of the burn, iodine agent is
mainly used during the early stages to protect the eschar,
which was adopted in the research of previous years. After
reaching the terminal stage the operation of removing eschar
and the autograft was carried out, which had the effect of
seven out of ten dogs undergoing whole-body irradiation
with 400 roentgens by γ-rays combined with 25 % third-
degree burn surviving, while at the same time showing that
hemorrhage and infection at the terminal stage always
affected the survival of the main factors of the skin autograft.
Pathological examination found that after removing eschar
and the autograft, although the grafts had been adhered by
original fi brin and survived by the following vessels and
fi broblasts growing into the wound. After about 1 week
entering into the terminal stage, part of the grafts that had
survived fell off because of secondary infection and necrosis,
or because of the hemorrhage between the grafts and the
receiving skin area. In another group of experimental dogs,
irradiation of a lower dose (reduced to 300 roentgens whole-
body irradiation) combined with 15–30 % third-degree burn
injury was adopted, and 24 h after injury, eschar and auto-
graft were removed, or the autograft at the recovery stage
after the eschar fell off naturally. The effect was better than
in the former group.
When taking whole-body irradiation for rats with 6 Gy by
60 Co γ-rays combined with a 15 % third-degree burn injury
as a model, and divided them into groups of different schemes
for treating the wound surface: such as removing eschar and
autograft 24 h after injury, removing the eschar and autograft
7 days after injury, applying AgSD or Zn(SD) 2 to the wound
for 15 days after injury and then removing the eschar and
autograft, and a hydropathic compress with bFGF after
injury. The results showed as follows:
1. There appeared to be a distinct curative effect of removing
eschar and autograft 24 h after injury. The survival rates of
animals surviving for 30 days increased from 32 % in the
control group to 95 %, the grafts all survived, and new hairs
were growing. The wound surfaces had healed completely,
subcutaneous hemorrhage and infection were not found,
the immune function and blood cells were restored rapidly.
The main reasons were that the wound surface was removed
before the bacterial infection under eschar, thus avoiding
infection, which was extremely advantageous to the recov-
ery of the organism, thus increasing the curative effect.
13 Combined Radiation–Burn Injury

335
2. If removing eschar and autograft 7 days after injury, the
condition of wound was worse, and the curative effect
was reduced. Most of the animals died 1–3 days after
operation; the animals’ survival rate for 30 days was obvi-
ously lower (0 %) than that in the control group (32 %).
On the day after operation there was a wide area of sub-
cutaneous hemorrhage, the grafts became black after
3 days, and then necrosed. During the operation we dis-
covered that the bacteria positive rate under the eschar
was 100 %; the number of bacteria was more than
10 7 CFU/g in the tissue. The animals were autopsied after
death and infectious foci were found in the lungs and liver
with lesions of congestion, hemorrhage, and accumulated
fl uid in the pleural cavity. The main reasons were that
operating at the terminal stage had caused a large amount
of bacteria on the wound surface to spread, aggravating
the general infection, and increasing the hemorrhaging of
the wound surface and viscera, which caused the animals
and grafts to die rapidly.
3. When applying silver sulfadiazine (Ag-SD) and zinc sul-
fadiazine [Zn(SD) 2 ] to the wound surface after injury,
despite using anti-infection and anti-shock measures at an
early stage and supporting the treatment for a long time,
the animals’ survival rate of 50 % for 30 days was still
lower than that in the group with early operation (95 %).
The other (50 %) of animals all died of infection and
hemorrhage of the lungs. In the Ag-SD group, the ani-
mals surviving for 15 days were autografted, the success-
ful rate of operation was high, the wound surface healed
and new hairs grew, the recovery extent and time of
immune function and blood cells were higher and faster
than in the unoperated groups, which indicated during the
use of drugs on the wound surface and comprehensive
treatment of the whole body, it was diffi cult to avoid vis-
ceral infections; however, operation at the recovery stage
was also feasible.
4. Using phenytoin sodium combined with iodophor may
both improve healing of the wound surface and prevent
infection; the two drugs had no antagonistic effect. Taking
whole-body irradiation for animals with 4 Gy by 60 Co
γ-rays combined with a 15 % three-degree burn injury as
the model in the experiments, 5 % iodophor was applied
to the burn wound of rats after injury; 30 min later 20 %
solution of phenytoin sodium was applied to the wound
surface again, once a day and for 10 days. The results
showed that either simply using iodophor or using it com-
bined with phenytoin sodium had obvious anti-infection
effects and promoted the healing of the wound surface;
therefore, the chance of infection of the wound surface,
the number of bacteria of the tissue, and how much of the
wound remained 30 days after injury were all lower than
those in the control group. However, the protein in the
granulation tissue, the amount of hydroxyproline, and the
blood vessel density count were all higher than those in
the control group after drugs had been used for 7–24 days
in succession. When the combined drugs were used, there
was no antagonistic effect, and the effect of using the
combined drugs was better than using them singly.
5. Using a bFGF wet compress on the wound surface could
promote the healing of the wound. After rats underwent
irradiation with 5 Gy combined with a 15 % third-degree
burn injury, the eschar was removed 24 h after injury, and
normal saline was applied containing 0.4 μg of recombi-
nant basic fi broblast growth factor (bFGF) for a gauze
wet compress. After 60 days the percentage of the wound
surface that had completely healed had increased by
28.5 % compared with that of the control group, the heal-
ing time of 50 % of the wound surface was 9 days earlier
than that of the control group. Histological examination
proved that bFGF may stimulate fi broblasts to proliferate
and synthesize collagen, promote hyperplasia of capillar-
ies, and form granulation tissue, which showed that bFGF
had a promoting effect on the repair of skin wound in
severe radiation–burn, the mechanism of which was
mainly that bFGF played a role in adjusting the synthesis
of DNA in cells, and sped up cell division and prolifera-
tion. It also took part in adjustment of the synthesis of
collagen and formation of the collagenous matrix; it stim-
ulated proliferation of the endothelial cells and their
migration, and had the effect of inducing the endothelium
of blood vessels growing into the collagenous matrix to
form capillary cavities, promoting the healing of the
wound surface in radiation–burn.
In another experimental batch the rats underwent whole-
body irradiation with 5 Gy by 60 Co γ-rays combined with a
5-kW bromine tungsten light irradiating to induce a 10 %
third-degree burn injury as a model. After injury they were
divided into four groups at random:
1. The group undergoing eschar removal and wound sutur-
ing: 24–48 h after injury, the animals were put under the
combined anesthesia of ketamine and sodium hydroxy
succinate (the ratio: 1:1–1:0.75). The burn eschar was
then removed and both sides of the eschar were sutured.
Within 3 days of the injury normal saline i.v., 3 ml every
day to avoid shock to death; on the 3rd–13th days after
injury 20,000 U of penicillin and ampicillin 0.025 g,
twice a day, and 14th–to the 22nd days after injury genta-
micin i.m., 4,000 U, was injected twice a day to resist
infection.
2. The group with eschar removal, but not suturing of the
wound. After removing the burn eschar and unsuturing
the wound, the wound is then covered with petrolatum
gauze, and the wound is bound up.
3. The group in which the eschar was not removed. A 2.5 %
tincture of iodine was applied to the wound surface, when
the eschar was falling off, dripping on the wound with
13.6 Treatment of Wound Surface for Combined Radiation-Burn Injury

336
0.1 % chlorhexidine glycerine solution. The other treat-
ments in the eschar removal group without suturing and
the group in which the eschar was not removed were the
same as in the group with eschar removal and suturing.
4. Control group in which no treatment was given after
injury. The experiments also obtained good results: the
surviving rate in the group with eschar removal and
suturing reached 78 % surviving 60 days, which was
obviously 40 % higher than that in the group in which
the eschar was not removed ( p < 0.05). It was even 15 %
higher than that in the eschar removal group without
suturing ( p < 0.01), and 10 % higher than that in the con-
trol group ( p < 0.01). The average healing time of the
wound was 19.5 days ± 6.6 days in the eschar removal
and suturing group, which was 20.5 days shorter than
that in the group in which the eschar was remove and not
suture (40.0 ± 3.6 days), and 27.5 days shorter than that
in the control group, while it was even 35.7 days shorter
than that in the group in which eschar was not removed.
However, the latest death time of every rat group
occurred before the earliest healing time; namely, when
the burn wound was removed, the animals had been out
of danger. The experiments also indicated when apply-
ing tincture of iodine to the eschar in the group in which
the eschar was removed, all of the eschar was not
infected, gradually dried up, and then fell off about
1 week later than the time at which the eschar fell off in
the control group. In the eschar removal without sutur-
ing group, in the group in which eschar was not removed,
and in the control group, as the granulation tissue of the
wound contracted, and caused both sides of the wound
medially to close up, then formed a linear scar for heal-
ing. In the eschar removal group, in 85 % of the animals,
both incisal sides were sutured and were not infected,
the wound had healed by 16 days after injury. Only 15 %
of the incisions were cleft because one or two stitches of
the suture thread had loosened; thus, the healing time
was prolonged slightly.
By comparing the above results, the following princi-
ples for treating the wound surface were put forward: in
severe radiation–burn, we have to work hard to remove the
eschar and autograft before bacterial infection under the
eschar. If applying drugs to the wound surface appropri-
ately, after entering into the recovery stage, removing
eschar and autograft are also feasible; however, the opera-
tion is not recommended at the terminal stage. When
adopting combined anesthesia of ketamine and sodium
hydroxysuccinate, the animals were both induced and
revived rapidly, easy to nurse, favorable to feeding; mean-
while, the drugs were safer to store, but the dose of anes-
thetic drugs used differs greatly in rats, especially in rats
of lower weight and with low drug- tolerance; thus, during
anesthesia we have to avoid a drug overdose, causing
death. Moreover, applying bFGF to the wound surface of
radiation–burn is successful, which lays a foundation for
the application of growth factors of other cells.
13.6.2 Skin Autograft
Although there is no rejection of the foreign body reaction
to autograft in the wound of a radiation–burn and it is easily
successful; yet, taking an autograft, especially a large area
of autograft, aggravates the condition of the injury. During
the terminal stage the wound caused by removing skin for
the autograft is diffi cult to heal, and remains a future prob-
lem; thus, hetero-dermal grafting is chosen as an signifi cant
treatment method. We consider that although radiation
injury inhibits the immune function and is unfavorable to
the organism, during the radiation–burn the repelling for-
eign body reaction of the hetero-dermal graft is reduced,
which may change the disadvantage into an advantage, and
prolong the survival time. Using a hetero-dermal graft to
cover the wound early, and do all one can to change the
combined injury into single injury, which will be much
more advantageous to the general treatment and gain time to
tide over the terminal stage after entering the recovery stage
to further deal with the wound (for example, changing over
to transplantation of an autograft).
In the experiments taking animals undergoing whole-
body irradiation with 5 Gy by 60 Co γ-rays combined with a
15 % third-degree burn injury as a model, 3 h after injury
1 ml of heterogenic irradiated blood was transfused. Twenty-
four, 48, and 72 h after injury the eschar and transplant allo-
dermal graft should then be removed. The results showed
that 24 h after injury, the effect of an allo-dermal graft was
the best, the survival rate of the animals for 30 days was
increased from 32 % in the control group to 71 %; 20 days
after operation, the survival rate of the graft was 100 %,
while in the groups with allografts 48 and 72 h after injury,
the grafts were all rejected 20 days after operation (the sur-
vival rate of the grafts was 0 %). Histological examination
showed that in the allo-dermal grafting group 24 h after
injury, the epithelial cells and collagenous fi bers in the grafts
had degenerated 1–4 days after transplantation; the blood
circulation had better reconstruction 9–14 days after trans-
plantation, the epithelium proliferated. Twenty-four to
29 days after transplantation, the epithelium and appendages
of the graft were shown basically as a normal structure, and
grew new hairs. At the same time, in the group without blood
transfusion and allograft 24 h after injury, the survival rate of
allo-dermal grafts 10 and 15 days after operation were 64
and 50 % respectively; they were also clearly higher than
that in the burn only with allo-dermal grafting group (0 %).
The wound surfaces in most of the animals were well healed,
and the blood cells and immune function restored rapidly.
13 Combined Radiation–Burn Injury

337
Which factors affect the survival of the allo-dermal grafts?
Comparing the irradiation dose, the timing of skin transplan-
tation, and the types of transfusing blood were studied, and
the results were as follows:
1. Irradiation dose: by a radiation–burn with a 15 % third-
degree burn combining irradiation with 3, 4, 5, and 6 Gy
by 60 Co γ-rays and a burn only injury after allo-dermal
grafting, examining the survival rate of the grafts day by
day, and combining with the healing of the wound, the
change in the grafts and their changes under light micros-
copy, we determined that combined whole-body irradia-
tion with over 5 Gy affected greatly the survival of
allo-dermal grafting, and that the survival time of allo-
dermal graft was markedly prolonged with the increase in
the irradiation dose.
2. Time of skin transplant: after irradiation with 5 Gy com-
bined with a 15 % third-degree burn, blood with 20 Gy irra-
diation in vitro is transfused, then allo-dermal grafts are
transplanted 24, 48, and 72 h after injury respectively. The
survival rates of the grafts in the three groups were 100, 0
and 0 %. In the former group the wound healed completely,
and new hairs grew on the grafts, while in the latter two
groups 0–3 days after operation, a large area of bleeding
appeared, blood accumulated with infection of the wound;
later, the grafts necrosed with edema, turned black, dried up,
and fi nally fell off, which developed after combined injury
as the transplant time went on, hemorrhage and infection
under the wound skin. The main reason was destruction of
the blood circulation between the donor and recipient grafts,
causing the grafts on the wound surface to die early.
3. Transfusion of blood treated using different methods: in
the combined injury with 5 or 6 Gy irradiation combined
with a 15 % third-degree burn, we found that transfusion
before skin transplant had a signifi cant effect on the sur-
vival of the allo-dermal graft. By examining the survival
rates of grafts every day after injury in the three groups
with transfusion of fresh blood, irradiated blood (20 Gy
in vitro), and stored blood (at 4 °C for 7 days) respec-
tively, and combining the comparison with the healing of
the wound, changes of the grafts, and histopathological
observation, it was further proved that transfusion of
stored blood or irradiated blood after injury had a defi nite
effect on prolonging the survival of allo-dermal grafts,
while transfusion of fresh blood would increase the reac-
tion of the repelling foreign body and cause death, all of
which indicated that transfusing different blood after
combined injury was a vital factor affecting the survival
of allo-dermal grafts.
The immunological meaning of transfusion in the survival
of allo-dermal grafts was shown in the following two aspects:
1. Through experimental research, the immune cells and the
relation between their activities with dynamic character-
istics and the survival of the allo-dermal graft after
transplantation in a 15 % third-degree burn injury and
combined injury with irradiation of 5 Gy were put for-
ward. In the single burn with transplanted graft group, the
immune activity of the thymic cells 3 and 7 days after
injury reached 118.4 and 190.7 % of the normal level
respectively, the ability of the splenic cells to form anti-
bodies was 203.2 and 170.9 % respectively, and reached
326.4 % on the 15th day. The grafts were dead within
7 days because the allo-dermal grafts were rejected,
which indicated that the heterogenic gene of the skin cells
stimulated the thymic T cells to proliferate strongly, caus-
ing a series of reactions, thus making the ability of to
form antibodies become fast and beyond the normal level,
and destroyed the target cells to cause acute rejection
reaction. In combined injury 3 days after skin transplant,
the immune cellular elements and their immune activity
were completely inhibited, but after 7 and 15 days, the
proliferating abilities of thymic cells were 152.9 and
119.0 % respectively, while the strengthening time of the
ability of splenic cells to form antibodies was delayed
until the 30th day; on the 10th day, the survival rate of the
grafts increased to 62.5 % of that of a single burn graft
(0 %), which proved in the combined injury that the sur-
vival time of allo-dermal grafts was prolonged because of
the irradiating factor, causing inhibition of the recipient’s
immune reaction.
2. Transfusion before allo-dermal grafting in radiation–burn
markedly affected the immune reaction. By comparison
of the dynamic changes in immune cell activity in each
group with different blood transfusion with a transplant-
ing graft after injury and the survival rate of allo-dermal
graft, we found that cell immune activity in irradiated
blood transfusion and transfusion of stored blood groups
after injury was inhibited and the inhibitory time was long
without seeing a strengthened course. On the 15th day the
survival rates of allo-dermal grafts were 73 and 100 %
respectively, while in the group with fresh blood transfu-
sion after injury the course of cell immune activity
appeared stronger, causing the survival rate of the allo-
dermal grafts to clearly reduce compared with those in
the two former groups, and also lower than in the non-
transfusion group. Moreover, the reductive effect of trans-
fusing stored blood before skin transplant in burn injury
on the extent of cell immune activity strengthening was
also found. The survival rate (50 %) of allo-dermal graft-
ing for 7 days was somewhat higher than that in skin
transplanting in the burn only group (0 %).
These results indicated after skin transplant in the single
burn group the intense strength of the immune cell activity at
an early stage was the main cause of the transplant causing
acute repulsion; after radiation–burn, the immune function
reduced rapidly because of irradiation; thus, the survival
time of allo-dermal grafting was prolonged. When entering
13.6 Treatment of Wound Surface for Combined Radiation-Burn Injury

338
into the recovery stage, the immune activity of cells appeared
unusual, which caused the transplant to trigger repulsion;
transfusing irradiated blood with few lymphocytes or stored
blood before skin transplant in radiation–burn caused the
inhibitory time of cell immune activity to be prolonged, and
avoid strengthening the course, which was the immunologi-
cal basis of prolonging the survival time of allo-dermal graft-
ing. This fi nding provided an important theoretical and
practical basis for researching into the treatment of allo-
dermal grafting wounds in severe radiation–burn (with third-
degree burn).
13.6.3 Comprehensive Treatments
In the early years the comprehensive treatment for radiation–
burn mostly adopted the “two drugs and one blood” method
(“two drugs” are antibiotics and vitamins, “one blood”
means transfused blood or elements of blood), and treated
with anti-irradiation drugs (such as estrogen and its like, syn-
thetic chemicals, and preparations of Chinese herbs, which
have certain effects on treating radiation only injury), and
combined with the method with which the wound was treated
in patients with a burn in clinical treatment. In experiments
after the dogs had undergone whole-body irradiation with
3.5 Gy by X-rays combined with 10 % third-degree burn,
they were treated with three anti-irradiation drugs and a tinc-
ture of elm bark was applied to the wound surface; all of the
15 dogs survived. In the mouse model of whole-body irradia-
tion with 8 Gy by 60 Co γ-rays combined with a 10 % three-
degree burn, WR2721 was used for prevention before injury
and a suspension of fetal liver cells after injury. After 30 days
of treatment the survival rate of the mice reached 58.7 %,
while that of the control group was only 17.7 %, and the
group in which WR2721 only was used for prevention it was
55.5 %, in the group of using only fetal liver cells for treat-
ment it was 44.6 %. It showed statistically that compared
with the control group the animal mortality from severe radi-
ation–burn in the group using WR2721 for prevention and
adding fetal liver cells for treatment was obviously reduced,
and the average survival time of the dead animals was pro-
longed. The damage of WBC in peripheral blood, nuclear
cells in bone marrow, and hematopoietic stem cells of the
granulocytic system in bone marrow (GM-CFU-C) was
slight, and their restoration was rapid. The therapeutic effect
was much better than in the groups that used WR2721 alone
and fetal liver suspension alone.
At the beginning of the 1980s, with the continuous
renewal of treatment techniques for burn wounds and draw-
ing on the experiences of saving and curing patients with
clinically
acute
radiation
sickness,
research
into
comprehensive treatments with allo-dermal grafting, bone
marrow transplantation (BMT), and transfusion were
adopted for treating the extremely severe radiation–burn,
which was based on the following analyses: although allo-
BMT was one of indications for treating radiation injury, the
low successful transplantation of the bone marrow cells
(BMCs) existed and the phenomenon of repulsion often
occurred after transplantation; if the BMT left the wound
surface after injury, the time of the invading infection would
obviously be moved forward, which would bring a certain
amount of diffi culty to dealing with the wound and treating
the general condition. Therefore, can we use this experience
of treating the wound surface in severe radiation–burn and
the method of transfusion to prolong allo-dermal graft sur-
vival, the experience and method of BMT and transfusion to
treating radiation sickness, and BMT to increase the success-
ful BMC transplantation and general therapeutic effect in
extremely severe radiation–burn? Can we choose allo-der-
mal grafting given the proper opportunity to prolong the sur-
vival time of the allo-dermal graft? If transfusion before
allo-dermal grafting contributed to transplantation of BMCs
in radiation–burn, and further prolonged the survival time of
the allo-dermal graft, this could greatly help local and gen-
eral treatment. In view of this notion, we adopted multiple
combined treatments for the rats undergoing radiation by a
dose greater than 8 Gy to induce extremely severe radiation–
burn through transfusion, BMT, and allo-dermal grafting as
the three therapeutic methods after injury. The results proved
the following:
1. We found after injury that giving transfusion before skin
transplant would contribute to the transplantation of
BMCs, which markedly increased the cure rate. The rats
undergoing irradiation with 8 Gy to induce combined
injury with a 5 % third-degree burn were all dead after
4–20 days, and the number of WBC did not increase.
However, if the rats were transfused with irradiated blood
or stored blood before BMT and allo-dermal grafting, the
characteristics of the transplanting BMCs would be seen
10 days after injury, the survival rate of animals for
100 days raised from that of 33 % in the untransfused
group to 92 and 94 % respectively, which showed that
transfusion contributing to transplanting BMCs was the
fi rst important condition for the survival of the animal;
under the same conditions, without skin implant (transfu-
sion plus BMT), although the transplanting rate of BMCs
for 10 days was 100 %, at the lysing eschar stage (15–
20 days) the cure rate decreased by 60 % because of local
wound infection and general infection, the survival rate of
animals for 100 days was only 20 %, which indicated that
infection was the main cause of the low cure rate. When
the animals underwent irradiation with 8 Gy combined
with 15 % third-degree burn injury, they all died 3–7 days
after injury; the death time moved forward 7 days com-
pared with the radiation only group, the hematopoietic
cells disappeared, the number of WBCs was not increased;
13 Combined Radiation–Burn Injury

339
when transplanting skin after injury and transfusing
stored blood before BMT, the transplantation rate of
BMCs for 7 days reached 100 %, the 30-day survival rate
was increased from that of the nontransfusion blood
group (50 %) to 92 %. All of the above indicated that in
the extremely severe radiation–burn, the transfusion of
stored blood had a good effect on the transplantation
BMCs and on cure.
2. Putting forward the pathological basis of transfusion
before BMT and transplantation for maintaining the long
survival of the transplanted graft. During combined injury
of irradiation with an 8-Gy dose combined with 15 or 5 %
third-degree burn injury, the animals having undergone
transfusion, transplantation, and BMT would have the best
therapeutic effect, and the survival of the animals and the
grafts was completely identical. Sevento 10 days after
transplant, the connected area of the recipient skin and the
donor graft had healed and the wound surface was clean
and without infection, the transplanting graft had survived
well, on the 20th day hairs began to grow, the wound had
completely healed by the 30th day, hairs grew all over the
skin graft, the animals survived and were healthy for more
than 100 and 250 days respectively. Histopathological
observation showed that the blood vessels between the
recipient and the donator graft began to be connected on
the 3rd to 4th days, and on the 5th day blood vessels in the
derma were fi lled with blood, the epithelium began to
regenerate, and there was a little fi brous tissue to be con-
nected in the subcutaneous tissue; 7 days after operation
the graft had grown well, the appendages were normal,
and the small blood vessels were seen clearly in the derma;
10 days after operation the joined point of the graft had
recovered completely; 15–20 days after operation the
dense fi brous tissue had grown into the joining point of the
graft, and the blood vessels and appendages were all nor-
mal; 100 and 480 days after transplantation there was no
difference in the tissue structure of the graft and that of the
recipient skin. This discovery is very important for treat-
ing wounds and increasing the therapeutic effect in
extremely severe radiation–burn.
3. A certain amount of burn factors had a benefi cial effect on
the proliferation and differentiation of the transplanted
BMCs. Under the conditions of skin transplant and BMT
in extremely severe radiation–burn, we chose the changes
in WBC number in the wound without infection as a
model compared with that of the group of radiation only
injury treated with BMT, fi nding that the number of
WBCs 10 days after transplantation was increased by 3.7
times that of the radiation only BMT group, and the WBC
number increased in 20 days to reach the normal level.
The numbers of WBCs 7, 20, and 30 days after transplan-
tation, were increased by 3.5, 3.0, and 1.5 times respec-
tively, and on the 100th day, the numbers of WBCs in
both groups were higher than the normal level. Linking
with the characteristics of self-BMT-restoration in
medium, and severe radiation–burn, we found that the
burn factor in combined injury may stimulate the allo-
dermal graft and self-BMC to proliferate and differenti-
ate, which could cause the number of WBCs in the
peripheral blood to markedly increase, and made the
increasing extent and speed of the WBC number after
transplantation higher and faster.
All of the above results comprehensively indicated the
following: we found that transfusing stored blood or irradi-
ated blood, except for improving blood circulation and pre-
venting
shock,
was
advantageous
compared
with
transplanting BMCs, which was the fi rst important condition
for the survival of the organism; from the time of eschar
removal and skin transplant, the results expounded that the
best time to transplant the skin to maintain the allo-dermal
graft for long survival was 24 h after injury, thereby achiev-
ing the goal of removing and preventing infection of the
wound. From the active relationship of transfusion, BMT,
and allo-dermal grafting, it was proven that the three meth-
ods had a synergistic effect in the treatment for extremely
severe radiation–burn; thus, the new measures and new
schemes were put forward for the treatment of extremely
severe radiation–burn, and the following diagram for effec-
tively curing radiation–burn was also suggested (Fig. 13.1 ).
13.6.4 Treating Effects of Sympathetic
Ganglion Block
After injury the disorder of stress was due to an imbalance in
internal stability in which several factors participated; restor-
ing stability after severe injury might take place through ner-
vous adjustment. From past experiments, we knew that the
excitability of the sympathetic nerves was clearly strength-
ened after severe injury. It might be an effective way of
improving disorder in stress if reducing the excitability of
sympathetic nerves, which would not affect the function of
consciousness. Therefore, we designed a scheme to carry out
cervical sympathetic ganglion block (SB) with lidocaine to
study the relevant treatment for animals with radiation–burn,
and to make sure that SB could be a central adjustment for
the stress in combined injury, thus providing a simple, effec-
tive, safe, and practical method for curing combined injury in
the clinic.
To begin with we had to ensure the basis of SB, which had
a general protective effect similar to that of diazepam-
ketamine on the animals with a burn only injury (reducing
the mortality of rats with 20 % third-degree burn by 33 %),
and studied the curative effect of SB on more complicated,
more severe radiation–burns. The experiments using whole-
body irradiation for mice with 5 Gy by 60 Co γ-rays combined
13.6 Treatment of Wound Surface for Combined Radiation-Burn Injury

340
with 15 % third-degree burn as models (the most prominent
traits of this wound were that the incidence of shock was
high, its extent was severe with very serious damage to
hematopoiesis and tissues of several viscera, and that mortal-
ity was high and it was diffi cult to cure), the injured animals
were treated with SB within 3 h after injury (lidocaine 5 mg/
kg, once daily, continuously for 14 days, without any other
treatment). The results showed that the animals that were
treated with SB did not appear lethargic and reacted well to
the stimuli, the general symptoms were relatively slight, the
mortality clearly reduced; the protective effects particularly
marked during the peak stage of death 7 days after radiation–
burn: the mortalities (%) of the animals treated with SB 7,
10, 15, 20, and 30 days BMC were 16, 22, 28, 34, and 56 (%)
respectively, reduced by 16, 32, 46, 48, and 34 % respec-
tively compared with the control groups (32, 54, 74, 82, and
90 %). This indicated that SB may exactly reduce early mor-
tality after radiation–burn, and had a signifi cantly protective
effect on the animals with radiation–burn. As for the human
body, because the operating method of SB is simple and
easy, as long as the method used is appropriate, there are
almost no negative effects on human body. However, during
the peak stage of death in radiation–burn, although the hema-
topoietic function has failed, the infection is serious, several
visceral functions are severely damaged, and the wound is
diffi cult to cure, the reason why the protective mechanism
and using solely SB for treatment could have such a good
effect is going to be tested simultaneously.
Compared with control groups that were not treated with
SB, SB may cause the RBCs, WBCs, and PLTs in peripheral
blood to clearly increase 7 and 14 days after radiation–burn
( p < 0.01); 21 days after the injury the number of RBCs,
WBCs, and PLTs had also increased signifi cantly ( p < 0.05).
This preliminarily indicated that SB may promote the restora-
tion of hematopoietic function after radiation–burn, which
was the main mechanism of the curing effect of SB on radia-
tion–burn. Meanwhile, treatment with SB may cause the lev-
els of the serum infl ammatory factors TNF-α, IL-1β, and IL-6
3, 6, and 14 days after serious injury to be markedly lower than
those in the control group of being untreated with SB ( p < 0.01).
All of these results showed that SB may precisely inhibit the
excessive infl ammatory reaction after severe injury, and that it
may also promote the restoration of stability of immune func-
tion in organisms was another main mechanism of SB, reduc-
ing the mortality of the animals with radiation–burn.
Experiments also found that SB, just like diazepam-
ketamine, could also adjust the stress function of the organ-
ism during radiation–burn, and clearly inhibit the excessive
improving blood circulation
Hematopoietic
function
and function
of immunity
advantageous
Adjusting immunity, strengthening the
function of Ts cells
Transfusing stored blood or
irradiated blood
Whole body
irradiation ±
III-degree
burn
reduced
or
disappeared
Survival
of
transplanting
heterogeneous
bone
marrow
cells and
auto-donator
skin graft
Prolifer-
ation and
differen-
tiation
of bone
marrow
cells
Keeping
tolerance of
transplan
-tation
Raising
survival of
organism
Preventing infection
to
Burn factors
Fig. 13.1 Diagram of the effective curing effect during combined injury

13 Combined Radiation–Burn Injury