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
Incident Command System
- Needs to start early before an incident gets out of control
- Medical responder must adhere to the structure of ICS
- A unified command is important
- The structure of the ICS must be the ***same
- The key personnel may be ***different (depend on nature of injury / disaster)
Roles:
- Incident commander (IC) (Hospital CE / COS of AED)
- sets objectives + priorities
- maintains overall responsibility
- often the disaster commander - Public information officer (PIO)
- Liaison officer
- Safety officer
Responsible for:
- Operations
- Planning
- Logistics
- Finance / Admin
Good outcome in disaster management
- Adequate preparation
- Rapid logistical response
- Short transport time
- Immediate access to operating rooms
- Multidisciplinary care delivery
- Luck
Emergency surgery: Damage control surgery
- Arrest of bleeding
- Completion of amputations
- Placement of external fixators
- Soft tissue debridement
- Removal of foreign body
4 phases of disaster response
- Response
- decrease morbidity, mortality, and property damage after a disaster has happened - Recovery
- actions taken to return to normal after a disaster - Mitigation / Prevention
- reduce the negative consequences of a disaster / decrease the probability of it happening - Preparation
- plan, train, educate for events that cannot be prevented
Summary
- Key to succeeding in responding to a catastrophic event is to ***anticipate the event, plan the response, practise the plan
- Paradigm change from the application of unlimited resources for the greatest good of each individual patient, to the allocation of limited resources for the greatest good of the greatest number of casualties
- Physician must possess sufficient familiarity with the incident command system and the community resources
