1997年 · 第17卷第01期

目的 通过对1996年1月5日吉林市发生的一起辐射事故病人 "文" 的救治，对急性放射病合并局部极重度放射性损伤诊断与救治提供新经验。 方法 通过物理模拟试验、染色体畸变分析、淋巴细胞微核率及局部组织ESR的检测，估算全身受照射剂量及局部不同部位受照射剂量，并通过临床症状、造血系统等临床资料综合分析，确定了损伤程度。 结果 全身受照后吸收剂量（红骨髓干细胞存活计权等效剂量）为2.9±0.3Gy，右下肢最大吸收剂量达3737.8Gy。照后2小时50分出现频繁的恶心呕吐。照后第1～2天淋巴细胞计数为0.9～0.4×109/L，为保全生命，于照后第8天行右大腿及左手腕截肢术。白细胞、血小板计数于照后第17天降至最低值（分别为0.65×109/L及19×109/L）照后4～23天应用rhG-CSF，极期仅持续5天便进入恢复期。 结论 本例为中度骨髓型急性放射病合并局部极重度放射损伤，后者又会加重全身急性放射病的病理改变，在治疗中不能忽视对局部损伤的及时处理，早期应用rhG-CSF有助于造血功能的恢复，心肌酶的检测有助于局部严重放射损伤的判定。

目的 对1例192Ir极不均匀外照射局部极重度放射损伤病人进行临床观察。 方法 系统观察了病变的临床过程和应用红外线热成像技术测定了损伤部位的温度变化。 结果 照射后2小时出现肢体麻木、抽搐，最早照后4小时出现红斑、肿胀，54小时出现水疱，第5天出现坏死和剧痛，最晚出现红斑、肿胀是照射后41天，47天出现水疱和糜烂创面。红外线热成像显示：损伤早期温度升高，水疱、坏死区和损伤后期温度降低，温度升高越早，损伤越重，温度改变区域与损伤范围相一致。 结论 大剂量极不均匀外照射放射损伤的初期反应早，放射病与局部损伤相互加重病情，症状先后不一，轻重不等，致残率高和疼痛剧烈，红外线热成像温度变化可以作为临床诊断的指标之一。

目的 观察一例大剂量全身极不均匀照射急性放射损伤患者数处局部病理改变。 方法 病理常规切片染色，光镜检查。 结果 吸收剂量右下肢为3738Gy，左手掌为830Gy，于照射后第8天行右下肢、左前臂截肢术。右手、左膝照射剂量相对较小但难以准确估计，红斑、水肿、水疱、溃疡出现相对较晚，于第55天行右手指、左膝清创植皮术。镜下：右小腿局部皮肤和皮肤附属器官、皮下组织和骨胳肌广泛地坏死和弥漫性出血，但真皮中的立毛肌尚存；左手指、手掌皮肤表皮细胞空泡变性、坏死，并形成大小不一的囊泡，致使表皮与真皮分离，真皮弥漫性出血、中性粒细胞浸润，汗腺上皮细胞变性、坏死，皮下组织内弥漫性出血，少数脂肪细胞坏死。胫骨、腓骨上端和股骨、桡骨、尺骨下端处骨髓腔内造血组织各系细胞均消失。左膝、右手拇指、食指、中指皮肤示急性放射性溃疡。 结论 大剂量照射导致的急性放射损伤造成大面积、深达肌肉的软组织坏死及骨髓造血细胞消失。

目的 观察病人血浆造血活性，了解其与照后造血功能变化的可能关系。 方法 以MTT法测病人血浆对NFS-60、TF-1和BET-2细胞因子依赖细胞株在有或无相应细胞因子存在时的吸光度（492 nm）。 结果 患者血清有类似GM-CSF、IL-3和EPO的刺激活性。血浆加入含rhG-CSF和EPO的培养体系中可使NFS-60和BET-2细胞增殖受抑。上述变化与病人外周血白细胞、红细胞及血红蛋白的变化有相关之处。 结论 吉林辐射事故病人血浆中有粒系和红系造血抑制活性。

目的 早期快速对遭受192Ir源局部大剂量外照射一例病人的病情作出判断。 方法 利用组织-空气比方法计算躯干内及手部、腿部受照部位及其周围组织的剂量分布，并计算全身剂量。利用手表红宝石作为事故剂量计测量手部剂量。 结果 给出了手部、腿部受照部位及其周围组织的剂量分布，全身造血干细胞活存计权等效剂量为2.9Gy。病人手腕处红宝石剂量为14.2Gy。 结论 病人全身剂量在中度骨髓型放射病范围内，手部、腿部受到局部大剂量照射。

目的 用染色体畸变分析方法对一例192Ir源辐射事故病人进行生物剂量估计。 方法 照后72小时取血培养，分析M1细胞双着丝粒加环畸变频率作为生物剂量估算依据，并于照后31天，66天追踪观察。同时用双+环畸变在细胞间的泊松分布统计检验，以示照射的均匀性。 结果 根据照后72小时双+环频率估算个体辐射剂量为2.9Gy，这一剂量与物理方法测定的剂量比较接近，与临床放射损伤的诊断也是一致的。事故后31，66天又取血培养，分析双+环畸变数与照后72小时差别不大。同时用双+环畸变数在细胞间的泊松分布统计检验，证实偏离泊松分布。 结论 这是一例高度不均匀照射病例。

ObjectiveAfter the medical handling of a patient exposed to extremely uneven total body irradiation from an 192Ir source （the activity was 2.765 TBq）on January 5, 1996 in Jilin Province，we will provide new successful experience for medical support in future nuclear accident and to the security of peaceful uses of nuclear energy. MethodsThe dose distributions in the local tissues and the whole body were estimated by calculation. The biological doses were estimated by lymphocyte chromosome aberrations and micronuclei. In order to save the life，eradicate the focus of infection and avoid the impending acute renal failure （a lesson learned from the Estonia radiation accident）, his right lower extremity was amputated at the level of about 23cm above the knee on day 8 and his left wrist amputated on the same day. 145 days after the exposure he had the 2nd amputation of his reserved right leg because of intolerable pain and failure of healing. Pathological exmination of the amputated parts was made and dose （Gy） to the parts was estimated by electron spin resonance （ESR）. The enzymes for muscle injury and HPRT gene mutation frequency （mf）were determined. The hemopoietic activity in the patient's sera was monitored. The treatment consisted of strict isolation in laminar air flow room （LAFR），antibiotics，radioprotective agent，measurcs improving the microcirculation and administration of rhG-CSF from day 4-23 with early recovery of leucocytopenia. ResultsThe hematopoietic stem cell survival weighted whole body dose was 2.9Gy，and the maximal skin surface dose estimation at the right lower extremity was 3737.8Gy. The biological doses were consistent to the dose estimated by physical measurement. The local tissue absorbed dose estimated by ESR （Gy）at 1st amputated sites of femur were 45.4Gy and 38.4Gy respectively and at the 2nd amputated sites of femur were 9.1Gy，8.7Gy，6.6Gy and 6.5Gy respectively. There were GM-CSF-like，IL-3-like and Epo-like activities in the plasma of the patient and were consistent with the changes of WBC，RBC and Hb in the patient's blood. The HPRT gene mf was determined to be 30×10-8，comparable to that of 3Gy 60Co　γ-rays in vitro and also consistent with the physical dose of 2.9Gy. Masssive necrosis of the cells of the epidermis, appendages of the skin，hypodermis，skeletal muscles were seen microscopically in the heavily irradiated part of the right shank. ConclusionThe authors emphysize the early amputation as the key to success，the importance of rhG-CSF effect and the significance of rational nutrition for the support of the patient, who had total body irradiation，massive local radiation injury and extensive surgical intervention to sustain.