©2002  J  Dietrick  CRNA  

Hospital  Emergencies  and  

Anesthesia  

Joe Dietrick, CRNA, M.A. Have A Nice Day Anesthesia Associates, LLC

Chillicothe, MO

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  

Declarations  No  conflict  or  affiliation  to  report  No  discussion  of  off-­label  use  of  medications  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  

Objectives  The  participant  will  understand  the  four  facets  of  emergency  management  personal,  organizational,  &  anesthetic  response  to  emergencies  concepts  of  triage  mechanisms  of  injury  in  terrorism  anesthetic  considerations  in  disasters    

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Planning

What  is  a  Disaster?  Facility  emergency    Operations  altered  Most  likely  

Facility  disaster    Operations  overwhelmed  Most  extreme  

Both  require  adequate  Emergency  Plan  Mandated  by  JCAHO  E.C.  1.4,  2.4,  &  2.9.1  Plan  execution  twice  per  year  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Planning

Four  Facets  of  Planning  1)  Mitigation  Threat  risk  assessment  Strategy  to  minimize  vulnerability  

2)  Preparedness  Building  organizational  capacity  

3)  Response  Implementation  of  some  phase  of  plan  Tracking  &  modifying  activities  

4)  Recovery  Restoration  of  essential  service  Restoration  of  normal  service    

©2002  J  Dietrick  CRNA  Mitigation

Risk  Assessment  Hazard  Vulnerability  Analysis  tool  Likelihood  of  event  occurring  Anticipated  severity  if  event  occurs  

Types  of  emergency  categories  Internal  External  

       -­  Many  emergencies  result  in  a  combination     -­  All  are  Security  events  as  well  

  Must  develop  plans  to  respond  to  each  threat  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Mitigation

Types  of  Emergencies:  Internal  Safety  Facility  damage  Inadvertent  HazMat  release  

Operational  Utility  or  Communication  Disruption  Impaired  services  

Security  Fire/smoke  Hostile  party  /  disturbance  Implied  /  explicit  threats  

©2002  J  Dietrick  CRNA  Mitigation

Types  of  Emergencies:  External  Mass  Casualty  Incident  (MCI)      Types  Natural  or  man-­made  cataclysmic  event  Weather,  earthquake,  nuclear  or  explosive  event  

Cyber  Terrorism:  CBRNE  Chemical  Biological  Radiological  Nuclear  Explosive  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Mitigation

Terrorism  Definition  of  terrorism  (28  CFR  Section  0.85)  Terrorism  is  the  unlawful  use  of  force  or  violence  against  persons  or  property  to  intimidate  or  coerce  a  government,  the  civilian  population,  or  any  segment  thereof,  in  furtherance  of  political  or  social  objectives.  

Goals  of  terrorists  Mass  casualty  generation    Lethality  Disruption  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Preparedness - ICS

Building  Organizational  Capacity  Ability  to  respond  Expand  resources  Anesthesia  normally  1:1  patient  care  Minimal  primary  responsibilities  outside  OR  May  be  responsible  for  triage  &  immediate  stabilization  May  have  to  care  for  multiple  patients  

Requires  organized  system  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Preparedness - ICS

Incident  Command  System  (ICS)  Designed  to  provide  organized  and  flexible  response  Originated  in  the  Fire  Service  Successfully  used  by  most  Public  Safety  agencies  HEICS  -­  Hospital  Emergency  ICS  

ICS  creates  a  dependable  chain  of  command  flexibility  in  activation  &  expansion  of  response  prioritization  of  duties    

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Preparedness - ICS

ICS  Assigns  roles  rather  than  individuals  Mission  Duties  Priorities  

Incident  Command  Center      

Purpose  maintain  optimal  hospital  operation  during  a  threat  (actual  or  perceived)  by  being  a  central  point  of  coordination,  contact,  and  resource  management  in  support  of  other  departments.    

Bottom  up  structure  All  roles  provide  support  to  those  below!  

©2002  J  Dietrick  CRNA  Preparedness - ICS

©2002  J  Dietrick  CRNA  

Four  Sections  Logistics  Things    

Planning  Foresight  People  

Finance/Admin  Pay  for  it,  or  get  paid    

Operations  Whoever  has  the  expertise  &  capability  to  manage  event  and  mitigate  hazards  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - ICS

Operations  Medical  Operations    primary  design  of  HEICS  Internal  Emergencies  Primary  Operations  Section  branch:    Facilities  or  Security  

Medical  Operations  branch  in  addition  

Divisions:  Care  &  Support  Care  areas  In-­Patient:          early  discharge  Out-­patient:      augmentation  ED:                              triage,  critical  care  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - ICS

Incident  Commander  Overall  responsibility  Set  objectives  according  to  priorities  

Obtain Incident Summary understand the situation Identify objectives & prioritize (life, then property)

Establish an Incident Action Plan (IAP) to accomplish objectives Communicate IAP Re-evaluate IAP frequently, and consider:

worst-case scenario secondary threat/consequences

Level of response Level of service

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Disaster  Notification  Obvious  a  disaster  has  occurred  (earthquake)  Patients  start  arriving  at  your  facility  Unusually  similar  illnesses  appear  Prehospital  /  Public  Safety  Telephone  Radio  Network  

Number  of  casualties  &  resources  required,  almost  always  overestimated.  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Disaster  Scene  Operations  Search  Rescue  Triage  Initial  Stabilization  Transport  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Your  Response    

Problems  Not  accountable  to  anyone  Not  accounted  for  by  anyone  Not  trained  in  scene  safety  (safety  over  care)  Secondary  events  are  likely  

Goal:  Rapid  removal  to  higher  level  of  care    

Victims  often  arrive  at  facility  quickly  

Consider  searching  all  victims    

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

GO  TEAM  External  response  team  Medical  care  above  the  level  of  prehospital  /  EMS  providers  Attributes  Planned  Organized  Equipped  Trained  

May  be  useful  in  rural  areas  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Internal  Facility  Damage  Scene  safety  first    observe  for:  Electrical  hazards   -­    Broken  glass  Fire  danger     -­    Jagged  metal  Unstable  objects   -­    Toxic  substances  Adverse  environmental  conditions  

Do  not  enter  until  hazards  are  secured  and  scene  is  safe  

 

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Protect  Yourself  NFPA  704:  system  for  identifying  hazards  &  severity  in  a  simple  format  Not  a  DOT  placard  Identifies  on  a  scale  of  0    4       Health        Flammability        Instability/  Reactivity  Fourth  indicator:  special  hazards  Water  reactivity  &  oxidizing  agents  

 Source:  NFPA  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Mass  Casualty  Incidents  (MCI)  Three  levels      I:  Local  resources  adequate    II:  Pooling  of  resources  necessary  III:  State/  Federal  assistance  required  

Level  III  resources  include  National  Guard  /  Military  FEMA  Disaster  Medical  Assistance  Teams  (DMAT)  Urban  Search  &  Rescue  (USAR)  

Augmented  medical  sources  Medical  Reserve  Corps  Emergency  System  for  Advance  Registration  of  Volunteer  Health  Professionals  (ESAR-­VP)  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Triage

Triage  MCI  =  [demand]  >  [resources]  Everyone  has  to  be  on  the  same  page  Terminology  Urgency  those  who  need  rapid  medical  attention  to  save  life/limb  those  with  minor  injuries  

Level  of  care  to  provide  

Improve  distribution  of  casualties  among  available  hospitals  Often  keeps  hospitals  below  MCI  levels  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Triage

Triage  Categories  Immediate  Require  immediate  treatment  for  life/limb  for  which  survival  likely  with  initial  stabilization  

Delayed  Not  likely  to  die  if  treatment  delayed,  but...  Will  require  definitive  treatment  

Minimal  Minor  injuries  requiring  no  or  minimal  treatment  

Generally  performed  by  most  senior  physician  

©2002  J  Dietrick  CRNA  

A  MASS  START  to  a  good  finish  Quickly  group  large  number  of  victims  MASS  Move  Ambulate?  Move  an  extremity?  Nothing  

Assess  Individual  START  assessment  

Sort  Send  

 

Simple  Triage  And  Rapid  Treatment  Three  assessments  Respirations    Pulse  Mental  Status  

Immediate  if  any  RPM  abnormal  Three  treatments  Open  Airway  (may  insert  OAW)  Stop  bleeding  Elevate  extremities  

 

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Triage

START  Triage  Algorithm      

YES NO

NO YES

< 30 > 30

< 2" > 2"

NO YES

NO YES

Delayed

Expectant Immediate

Open AirwayVentilation Present?

Immediate Delayed

Follows simpleCommands?

Immediate

ControlBleeding

Capillary Refill Immediate

AssessRespiratory Rate

VentilationPresent?

Able to Walk?

FEMA/EMI  CERT  Field  Operating  Guide  http://training.fema.gov/EMIWeb/downloads/fog.PDF  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Triage

Triage  error  Under-­triage  Assignment  of  immediate  victim  to  delayed  Must  be  avoided  

Over-­triage  Assignment  of  immediate  care  when  not  critically  injured  (delayed)  Common  

In  true  MCI,  over-­triage  is  directly  proportional  to  mortality  rate  of  critical  injuries  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Injuries

 Not  all  terrorism  is  BIOterrorism:  CBRNE  CDC  has  outstanding  website  Ideally,  mass  effect  by  delayed  recognition  of  undetectable  (to  senses)  agent  Wisconsin  Statewide  Health  Information  Network  (WISHIN)  

ABSOLUTE  RULES:  Contaminated  victims  must  be  prevented  from  entering  your  facility  Decontaminate  outside  to  protect  your  facility,  patients,  &  staff  

©2002  J  Dietrick  CRNA  

CBRNE  Chemical  Pulmonary  /  Choking  agents:  Pulmonary  edema  Phosgene  

Blood  agents  Cyanide-­based  

Blister  agents:  Respiratory  tract  &  skin  Mustard,  Lewisite,  Phosgene  Oxime  

Nerve  agents:  Inhibit  Ach-­ase  cholinergic  activation  Sarin,  Tabun,  Soman,  VX  

 Decontaminate  as  for  biological  exposure  

 

Biological    More  toxic  by  weight  than  chemicals  Dissemination  

Inhalational,  ingestion,  dermal  contact  

Category  A  agents:  Anthrax  (95%  mortality  inhaled  Plague  Smallpox  (30%  in  unvaccinated)  Tularemia    Viral  Hemorrhagic  Fever  Botulism  

 Decontamination  (warm  water!):  

Wet  victim,  strip  clothing,  flush  with  water,  cover  Use  soap/water  &/or  Bleach/Water  (10:1)  

 

©2002  J  Dietrick  CRNA  

CBRNE  Radiological  Dirty  Bomb  Conventional  explosive  used  to  disseminate  radiological  agent  Good  news  Limited  exposure  to  care  providers  Do  not  delay  critical  care  to  decontaminate  

Nuclear  Good-­bye  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Injuries

CBRNE:  bombs/blasts  Most  common  deliberate  cause  of  mass  disaster  Primary:  2º  shockwave  Creates  high:  pressure,  temperature,  speed    Air-­tissue  interfaces  disrupted:  Ears,  Lung  

After  overpressure  Negative  pressure/implosion  Then  air  movement:  blast  wind    secondary/tertiary  

Secondary  Debris  set  in  motion  Blown  or  collapse  

Tertiary  Body  set  in  motion  Crashes  into  other  objects  

 

©2002  J  Dietrick  CRNA  

Effects  of  blasts  Casualty  generation  Magnitude  Human  proximity  

Lethality  Magnitude  Indoor  location  Building  collapse  

Study  of  fatalities  in  N.  Ireland        Head  injuries    Most  are  non-­critical  

Non-­critical  injuries  Soft-­tissue  &  skeletal  injuries  (contaminated)  Burns  usually  superficial  

 

Injury  (N=305)   %  

Primary  blast  lung   47  

Abdominal   34  

Other  chest   25  

©2002  J  Dietrick  CRNA  

Primary  Blast  Lung  Injury  Most  victims  killed  immediately  Proximity  to  explosion  Secondary  &  tertiary  injuries  

Cerebral  &  coronary  air  embolus  

Among  few  survivors  Acute  respiratory  failure  with  pulmonary  edema  Classic  triad    apnea    bradycardia    hypotension  

If  breathing:  provide  oxygen,  avoid  PPV  if  possible  

 

Response - Injuries

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Injuries

Crush  Syndrome  Local  &  systemic  injury  Traumatic  rhabdomyolysis  Common  in  collapse  with  masonry  Release  of  myoglobin,  potassium,  uric  acid,  and  lactic  acid  Metabolic  acidosis  &  renal  impairment  

Hypovolemia  &  coagulopathy  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Disaster  Anesthesia  Avoid  contamination  from  CBR  agents  Prepare  &  have  supplies  for  most  likely  critical  injuries  Hypovolemia        Head  injury  Airway  management      Hypothermia  Cervical  spine  injury      Pneumothorax  

During  MCI,  conventional  level  of  care  may  not  apply  Pain  control:  a  priority  in  all  clinical  situations    

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Disaster  Anesthesia  Options  dependent  on  environmental  situation  Can  you  use  the  OR?  Other  locations?  

Can  you  use  your  machine?  Electricity  Pipeline  oxygen  

Do  you  have  adequate  oxygen  supply?  Source:  King  Systems  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Oxygen  Supply  Hospital  liquid  oxygen  requires  electricity    Alternatives  Cylinders:  E  660  liters,  H  6900  liters  Concentrators  Unlimited  supply,  reliable,  economical  Require  electricity  lpm,  FiO2  =  0.85  -­  0.95  

Generally  accepted  as  best  disaster  source  

Portable  liquid  oxygen  tanks  No  electricity,  heat  ,  or  noise  20  -­  60  liter  liquid    17k  -­  50k  liter  gas  0-­15  lpm  

 

Source:  CAIRE,  Inc.  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Monitors  Pulse  Oximeter  Oxygenation  Pulse  rate  &  rhythm  Peripheral  perfusion  

Blood  Pressure  Manual  cuffs  available?  

Temperature  Hypothermia  is  common  

Capnometry?  Relative  cardiac  output,  RR,  pulmonary  dynamics    

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Anesthesia  Techniques  IV  Sedation  minimal  anesthesia,  monitoring  necessary  

Regional  Anesthesia  Once  block  established  care  may  be  reduced  Good  prolonged  pain  control  Reduces  systemic  medications  &  side  effects  

General  anesthesia  (inhalation  or  TIVA)  Maintain  spontaneous  ventilation  Maintain  CV  stability  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Intravenous  Agents  Long-­acting  rather  than  short  Diazepam  >  Midazolam  Morphine  >  Fentanyl  

Minimize  respiratory  depression  NSAIDs  >  Mixed  Opioid  Ag/Antag  >  Opioids  

Cardiovascular  stability  Etomidate  /  Ketamine  (±)  >  Thiopental  /  Propofol  

Agent  with  multiple  routes  of  administration  Ketamine  Fentanyl  Midazolam  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response - Anesthesia

Blood  Consider  autotransfusion  techniques  In  OKC  bombing  >  300  units  blood  administered  Regional  blood  center  had  adequate  supplies  on  the  shelf  

In  OKC  tornado  <  100  units  given  Problem:  distributing  blood  due  to  traffic  

Decision  to  transfuse:  demand  vs.  resources  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  

Altered  Standards  of  Care?  Standard  of  care  

 What  a  reasonable  person  would  do  in  similar  circumstances  

Resource  allocation  does  change  

Schultz  &  Annas  

allocate  scarce  resources  maximizing  patient  outcomes  is  a  necessary  and  appropriate  goal  for  those  engaged  in  disaster  preparedness  and  

 

Altering  the  Standard  of  Care  in  Disasters Unnecessary  and  Dangerous.  Ann    Em  Med  2012  

©2002  J  Dietrick  CRNA  ©2002  J  Dietrick  CRNA  Response

Media:  Releasing  Information  ICS  always  appoints  Media  role  early  Guidelines  published  by  American  Hospital  Association:  Any  inquiry  must  contain  name  of  the  patient  Unless  patient  has  requested  information  withheld  Location  One-­word  description  of  condition  

Conditions  Undetermined      Serious  Good        Critical  Fair