Surgery SC032: A Bus Hit A Train: Multiple Trauma, Disaster Management Flashcards
Disaster
- A sudden event e.g. Accident / Natural catastrophe, that causes great damage / loss of life
- Event / Fact that has unfortunate consequences
2 components:
- Hazards
- Flood
- Cyclone
- Earthquake
- Tsunami
- Volcanic eruption
- Drought
- Landslide
- Biological - Vulnerability component
- Livehood + its resilience
- Base-line status well-being
- Self-protection
- Social protection
- Governance
Classification:
- Natural
- typhoons, earthquakes, flood, landslide, forest / hill fire - Manmade
- war, transportation, industrial accidents, terrorism, technological disasters - Disease
- cholera, ebola, influenza
Mass Casualty Incident (MCI)
Needs > Resources
Disaster care vs Conventional medical care:
- High threat level
- Severely limited resources
- Fixed and limited personnel
- Limited supplies of equipment, resupply significantly delayed
- No subspecialty services immediately available
- Maybe no option for transfer
4 phases of MCI response:
- Search + Rescue (e.g. by fire service in HK)
- Triage + Initial stabilisation
- Definitive medical care
- Evacuation
Trimodal death distribution of trauma
- Immediate deaths (death at scene)
- most patients
- **airway compromises, **C-spine injuries, ***breathing: pneumothorax, haemothorax, hypoxia
- need prevention from policies - Early deaths (2 hours after injury)
- ***bleeding: “Blood on the floor and Four more”
—> On the floor: Bleeding from visible wound
—> Four more: Chest, Abdomen, Pelvis, Fractured long bone (e.g. femur)
- preventable by early transfer to appropriate care - Late deaths (A few weeks later)
- usually due to surgical complications e.g. pneumonia (preventable by ICU care), renal failure, sepsis, UTI, aspiration, post-op complications
Triage + Initial stabilisation
Basic life support at scene: ABC
Aims of on-site triage:
- Safety (victims / medical staff) is first concern
- Provide maximum outcome benefit for the majority
- Identify, provide initial treatment, transfer victims with life / limb threatening conditions to the appropriate hospital
Triage = Sort out, To prioritise
Type:
- Field triage (in Disaster)
- do the greatest good for the greatest number - AED triage
- most seriously injured has highest priority - Military triage
- mildly injured treated first —> so that soldiers can go back to battlefield asap - Civilian triage
- severely injured + high chance of survival treat first
Levels of triage
On-site triage (Level 1 triage)
- Victims designated as “Acute” / “Non-acute”
—> Acute = Red
—> Non-acute = Green
Medical triage (Level 2 triage)
- Rapid categorisation of victims at casualty site by experienced medical personnel with a knowledge of various injuries (e.g. blast, crush, biological, radiological, chemical, burns)
- Cruciform triage tag (top priority, 2nd priority, walking wounded, dead)
Casualty collection
A site identified to collect all victims:
- easy visible to disaster victims
- big sign post
- convenient exit routes for air / land evacuation
Concepts of ATLS
Advanced trauma life support
- Treat the ***greatest threat to life first
- Definitive diagnosis should NOT impede the application of an indicated treatment
- Detailed history is NOT essential to begin the evaluation
- ABCDE approach
Primary survey:
- patients assessed + treatment priorities established based on injuries, vital signs, injury mechanisms
ABCDE:
- Airway + ***C-spine protection (presumed until proven otherwised)
- Breathing + Ventilation
- Circulation + ***Haemorrhage control
- Disability + Neurologic status
- Exposure + Environmental control
Initial assessment
Preparation (equipment) + Primary survey + Resuscitation + Adjuncts (X-ray, ECG, FAST etc.) + Re-evaluation
—> Secondary survey (head to toe examination) + Adjuncts (CT, X-ray) + Re-evaluation
—> Definitive care (surgery, embolisation, ICU care) + Re-evaluation
Evacuation
Means:
- Ground transport
- Helicopters
- Small fixed-wing aircraft
- Large fixed-wing aircraft
Indications:
- Decompress disaster area
- Improve care for critical casualties
- Provide specialised care to specific casualties (e.g. burn, crush injuries)
Trauma centres
5 Trauma centres in HK
- QMH
- QEH
- PMH
- PWH
- TMH
Primary trauma diversion
Severe trauma patients —> Require direct transfer to Trauma centre
Contraindications: Cardiac arrest / Airway difficulties —> Stabilise patient first in nearest hospital —> Transfer to Trauma centre
Anatomical criteria:
- Flail chest
- Lower limb fracture involving 2 long bones
- Amputation proximal to wrist / ankle
- All penetrating injuries to head, neck, torso
- Limb paralysis
- Pelvic fracture
- Combined trauma + burns (>2nd degree / >20%)
Physiological criteria:
- GCS <14
- SBP <90
- RR <10 / >29
Airport contingency plan
CLK airport has its own stand alone contigency plan with a different preset diversion
- Ambulance: PMH, YCH, CMC
- Helicopter: PYNEH
- Boat: TMH
- MTR +/- Ambulance (green cases): QEH, KWH
Burn units and Burn facilities
Burn units:
- QMH
- PWH
Burn facilities:
- KWH
- QEH
- TMH
Burn triage:
- First 2 patients —> PWH / QMH
- 3rd / 4th patients —> QMH / PWH (send to opposite hospital)
- 5th, 6th, 7th —> 1 each to KWH / QEH / TMH (in order of vicinity)
- 8th onwards —> repeating the receiving arrangement
Major Incident Response Plan / Disaster Plan in QMH
Activation of Major Incident Response Plan / Disaster Plan considered when:
- QMH is informed of an accident on HK island, involved >=8 victims
or
- RH / PYNEH declares full disaster activation
Trauma management team
- Surgeons
- AED doctors
- Orthopaedic surgeons
- Neurosurgeons
- Anaesthetists
- Intensivist
- Nurses
- Other paramedics
Leadership:
- successful disaster response requires well-defined leadership role
- those in charge require
—> clinical expertise to treat the injured
—> an understanding of hospital triage principles
—> experience in caring for patients when resources are scarce
