Upload
thomas-johnson
View
137
Download
1
Embed Size (px)
Citation preview
Objectives
Be able to differentiate types of disasters
Be able to list the types of man-made disasters
Be able to manage a blast-lung injury
Be able to list the most likely natural disasters
Be able to describe mass-critical care
Be able to describe the preparation to mitigate the impact of a disaster on the hospital
Be able to describe the management of blast lung injuries
Be able to describe the management of an infectious pandemic
Limitations on Resources
Human Resources: Numbers, types, skill-sets, physical limitations, and …
Physical Plant Resources, esp. HVAC, electricity, suction, oxygen, etc.
Durable Equipment Resources, e.g. ventilators, monitors, beds, surgical suite equipment
Medical Supplies: OXYGEN, PPE, medications, IV fluids and tubing, surgical supplies, catheters and other tubes,
Food: patients and staff (spoilage)
Water (potable or non potable)
Hygiene and Sanitation
Can We Master the Chaos or will Chaos Prevail?
T H E F A I R A N D E Q U I T A B L E A L L O C A T I O N A N D R A T I O N I N G O F S C A R C E C R I T I C A L C A R E R E S O U R C E S I N A D I S A S T E R R E Q U I R E S
T H A T C L I N I C I A N S A N D I N S T I T U T I O N S P L A N I N G O O D F A I T H , B E T R A N S P A R E N T I N T H E P L A N N I N G P R O C E S S .
CHAOS: Crisis Overwhelms Hospital, Municipality or Region and Nation
Potential for chaotic, inequitable/ unfair, unethical and possibly illegal provision of ‘care’.
Both patient and care providers needs must be anticipated and prepared for.
PPE
Changes in scope of practice and responsibilities
Training / Drills *
Supervisory systems (both during and after the crisis)
*Drills should be ruthlessly evaluated for opportunities to improve and fix.
ICU RTs: 2 Questions
1. DO YOU DO DAILY SEQUENTIAL ORGAN FAILURE ASSESSMENTS (SOFA)?
2. ARE YOU A REGULAR PARTICIPANT AT THE CRITICAL CARE ETHICS AND TRIAGE COMMITTEE?
Sequential Organ Failure Assessment (SOFA) Components
PaO2 / FIO2
SaO2 / FIO2
Platelets
MAP
GCS
Creatinine
Get this app: Clincalc.com/IcuMortality/SOFA
ICU Triage in Disasters: Triage Officer & Triage Team
Team Shift Duration: < 16 hours Triage Officer : Highly Experienced SurgeonManages clinical activities during a crisisAssesses all patientsAttends the High Priority PatientsDirects Logistics of resources and patient
transfers Team Composition: Experienced Critical Care NurseRespiratory Therapist and / orPharmacist
Duration of the Emergency Mass Critical Care
(EMCC)
“Hospitals should prepare to deliver
EMCC for 10 days without sufficient
external assistance.”
Emergency Department (ED) response can
vary from hours (RI nightclub fire and London
bombings-3 h 14 m)
Critical Care LOS: average 21days (RI) to
12.4 [range 6 to 22 days] (London bombing)
Devereaux A, Christian MD et. al. Summary of Suggestions from the Task Force for
Mass Critical Care Summit January 26-27, 2007 Chest 2008; 133:1S-7
Blast Lung Injury
Potential to produce large number of victims
Nature of the blast: HE, Low order, etc.
Location: indoor, outdoor, reflective surface
Victim Severity: Location, Shielding, Distance
Overpressure of >15 psi (>100 kPa) Effects
Secondary Effect: Shrapnel, Thrown victims, body parts
Signs & Symptoms of BLI
Hypoxemia (P/F <200)
“Butterfly” pattern on CXR
Tachypnea
Low Vt
Restrictive defect
Low Compliance
R/O Hemothorax/pneumothorax
Wheezing
CMV for BLI
Intubate using RSI and cervical neck immobilization
Mechanically ventilate
Mode of choice: keep PIP <40 and Vt ~6 ml/kg PBW
f <22 to keep pH >7.20 (after that consider HFPPV/HFOV)
PEEP up to 15 cm H2O then consider iNO
Monitor ET CO2 for increased VD due to emboli
Limit Fluids to prevent alveolar flooding