Transcript מצגת של PowerPoint - The Centre for Excellence in

Mass Chemical Incidents:
Principles of Hospital
Management
P. Halpern, MD
Chair, Emergency Department
Tel Aviv Medical Center
Granitville NC, Jan 2005,
0200am
The rail crew that parked 2 cars on the
side rail by the Avondale Mills facility
had not switched the diversion switch
back and had gone home hours before
an oncoming train with the chlorine
railcars arrived.
The event killed nine and temporarily
displaced thousands in Graniteville.
Responders from the local volunteer
fire department responded to the train
crash and subsequent chlorine release
without first donning personal
protective gear.
Neither law enforcement personnel
nor emergency responders seemed
trained/drilled/prepared for this
scenario.
 The area of evacuation was
insufficient. A woman who lived 2.5
miles downwind was not evacuated.
She awoke that morning feeling weak,
and noticed “a strange fog” outside.
 She learned about the disaster on TV.
When her husband came home later,
they left their home and went to
relatives, but the chlorine came there
also, so they went back home.
The woman did not go to an ED until
4 days after the incident.
There was no notification to her or
others about health effects to watch
out for. The hospital diagnosed her
with pneumonia and gave her
antibiotics, which did not help at all.
Conclusions
When a moderate-sized chemical event
occurred in the US, appropriate
procedures and capacity were in hand
locally or in relatively close proximity,
yet much of the available capacity was
never or sub optimally employed.
Why Should Civilian Doctors
Know About Chemical Weapons ?
Agents potentially used by terrorists are
involved in industrial and in transportation
accidents (e.g. cyanide, acids, phosgene).
Some agents are generated in fires.
Organophosphate insecticides act very much
like military nerve gases.
The risk of terrorist incidents involving
chemical weapons is now considered
substantial.
Why should hospitals prepare
for chemical mass incidents?
 It may never happen, but probably
WILL.
 It is the hospital’s ethical duty to
community to prepare;
 It is an effective way to upgrade
the entire system!
The Level of Awareness is Increasing
Current State of Preparedness
Data from 30 hospitals FEMA Region III
• 100% of sites not fully prepared for a
biological incident
• 73% not prepared for a chemical
incident
• 73% not prepared for a radiological
incident
Treat K.N. Hospital preparedness for weapons of mass destruction incidents:
An initial assessment. Annals of Emergency Medicine Nov. 2001
Current State of Preparedness
73% would set up a “single room”
decontamination process.
13% had no decontamination process.
Only 3% (1 hospital) had chemical
antidote stockpile
0% had prepared media statements
25% had “some” training in WMD
incidents
Poll of all 135 US anesthesiology programs;
37% had any form of training, most did not
repeat training after initial sessions.
28% of programs east of the Mississippi
reported some training, whereas only 17% of
programs west of it reported training available.
The majority of anesthesia residency programs
in the US provide little or no training in the
management of patients exposed to WMD 27
KA Candiotti: Anesth Analg 2005;101:1135-1140
The Differences between nonconventional & conventional MCI
 Number of casualties X 10, 100.
 Event may be overt or covert.
 Requirements for decontamination, staff
protection and site contamination disrupt
normal facility response.
 Disruption of external support may impede
response (e.g. traffic jams).
 Psychological effects on staff & victims.
Time course of ED presentation
after Tokyo subway sarin attack
Process
Travel from
attack site
to ED
Time for first
Time for 500
Time for first
victim to
more victims
walk-in victim
arrive by
to arrive
to arrive (min) ambulance
(min)
(min)
33
48
48-108
Vast majority of victims arrived within 2 hr
Okumura T, et al: Report on 640 victims of the Tokyo Subway
Sarin Attack. Ann Emerg Med 1996;28:129-135.
Tokyo Sarin event
Total
5,510
Critically ill
17
Severely ill
37
Moderately ill
Required Mechanical Ventilation
984
54
Considerations for Hospital
Preparedness Plan
 Obtain commitment from management. It costs
money, nobody likes the drills. Without
authority and funding nothing will happen!
 Designate a clear chain of command.
 Personnel must have incentives to train.
 Include field personnel in planning - not just
managers.
 Ensure continuing education for retention.
 Review plan periodically for changing threats,
environment, staff, equipment, concepts of
care, hospital capabilities, funding.
Types of chemical events
 By advance notice:
 Advance notice sufficient for organized
response
 Advance notice sufficient for gate control
 No advance notice
 By type of agent:
 Known vs Unknown
 Persistent vs Non-persistent
 Dangerous (requiring protection) vs
Non-dangerous
Level of complexity of response
Volatile,
Persistent,
dangerous
dangerous
agent
agent (VX)
(sarin)
No advance
notice
Short
advance
notice
Sufficient
advance
notice
Volatile,
nondangerous
agent (Cl)
Steps in response:




Notification
Confirmation
Activation (by senior management)
Activation of plan: decide if event requires
decontamination and staff protection or not
 Establish command structure, based on
available personnel
 Agent recognition:
 Initially clinical by medical staff and specialists
 Then by specialized local or regional or
national, civilian or military staff
Identifying a Chemical Event
Victim characteristics:
Minimal wounds
Strong odors
Unidentified liquids on body
Respiratory complaints
Eye or mucous membrane complaints
Chemical burns
Neurologic complaints
Rapidly decreasing LOC or unconsciousness
Cardiac arrest
Identifying a Chemical Event
Event characteristics:
 Easy (!) chemical container event
recognized
 Minor explosion
 Multiple victims
 Odors noted
 Immediate complaints by initially
uninjured victims
 Victims come from large area
Hospital Deployment Scheme
for Chemical Events
Flow Control Site
Initial Triage
Immediate Casualties
Walking Casualties
Intubation
Decontamination
Disrobe
Secondary Triage
Resuscitation
Severe
Mild
Pediatric
Moderate Combined
Worst Case Scenario: no advance
notice, persistent, hazardous agent
 Decision making (senior staff +/- in
consultation with expert):
 Chemical event ? (event and victim
characteristics)
 Dangerous chemical ?
 Persistent chemical (e.g. chlorine vs
terrorist release)?
 Specific therapy exists for chemical (e.g.
organophosphates)?
 Declare chemical event in the ED and
activate emergency plans.
Activities in the Hospital
 Hospital and ED perimeter control (gate
triage: allow in immediate ALS only);
 Activate decontamination facility;
 Call up staff;
 Coordinate with EMS etc.
 Request support (antidotes, ventilators,
secondary transfers);
Activities in the ED
 Continue life-saving procedures by
unprotected staff;
 Initiate ED evacuation of “regular pts”;
 Disrobe all event casualties;
 Mark and isolate contaminated area;
 Protected personnel to relieve non-protected
teams;
 Contaminated staff – to self
decontamination;
 Staff call-up
Activities in the ED
 Deploy ventilators (human or mechanical).
 If antidote or specific meds available for
specific agent, bring forward.
 Deploy O2 masks, IVs, intubation kits, meds.
 Deploy and ensure staff read treatment cards
or computer messages for specific agent.
 Use public address system to communicate
patient care and staff protection policy.
Medications and specific
equipment:
 Nerve agent meds:






Atropine
Pralidoxime
Scopolamine
Benzodiazepines
Eye drops
β1 agonist, inhaled
 Cyanide meds:
 Na nitrite
 Na thiosulfate
 Bicarbonate
 Mustard:
 Burn care meds and
dressings
 Eye drops
 β1 agonist, inhaled
Factors influencing
medical management
 Is the agent identified?
 Type of agent (toxicity, aging, persistence, specific
Rx availability).
 Route of exposure: inhalation/percutaneous.
 Presence and severity of clinical disease.
 Elapsed time after exposure.
 Number of victims and rate of arrival.
 Advance notification.
 Available resources (i.e. AM/PM, level of
preparedness of facility, available external support).
Decontamination of Victims:
Principles
Decon site should be close to ED.
Decon site should be operative within 20
min of event recognition.
Clear demarcation and physical barriers
between “hot” and “cold” zones.
Strict patient, staff and crowd control is
essential.
Single-channel, one-way patient flow is
essential.
Ready stores
 Coherently arranged,
clearly labeled, ready
to use equipment,
close to ED site
Decon area at the TASMC
Decontamination site during drill
“Yellow
line”
Decontamination procedure
Triage carried out by Level C-protected senior
personnel:
Dead or dying
Non-ambulatory, requires emergent
intubation
Non-ambulatory, does not require emergent
intubation
Ambulatory
Patients NOT requiring
ventilatory support
Placed on wire-mesh gurneys
Given IM antidote (if nerve gas)
Decontaminated
Taken to “yellow line” and handed over as
above
Ambulatory pt decon
Disrobe down to underwear.
No decontamination is performed,
except for vesicant agents.
Anxiety victims are reassured and
discharged.
Non-ambulatory pt decon
 Full disrobing;
 Privacy provided as best possible;
 Warm water + liquid soap: head to toe, toe to
head x2, or 6 minutes.
 Bleach (0.5%) controversial (open wounds,
eyes).
 Decon staff wear Level C PPE.
 Decon staff are nurses or paramedical
personnel, who can recognize patient
deterioration during decon.
Decontamination for Vesicants
Initial “dry decontamination”
No scrubbing of skin
Followed by wet decontamination
Emphasis on irrigation of the eyes
Consider using dilute bleach for
extreme skin exposure.
Care of Multiple VentilatorDependent Patients
Large numbers of ventilated pts anticipated
Designate alternate Intensive Care areas
Ensure O2 supply
Ensure supply of mechanical ventilators
and/or manual resuscitators
Train personnel to care for ventilated
patients and to ventilate manually
Care of Multiple VentilatorDependent Patients
 Identify and designate MD & RN trained in
mechanical ventilation.
 Ensure supplies of disposables and drugs (e.g.
HMEs, tubing, sedatives, paralytics).
 Prepare data management system (appropriate
forms or computerized system).
 Standardize care! Disallow multiple protocols
and experimental or unproven therapies.
 Ensure staff coordination and information
dissemination (daily meetings, bulletins etc.)
Summary
Preparing medical centers for chemical
mass events is critical to successful
event management, but also ethically
and practically correct.
The unique features of a chemical
attack make it probably the most
challenging event any hospital may ever
face.
Addendum: Hospital oxygen supplies:
 Assume victims=50% of hospital capacity; 25%
ventilated, i.e. for 1,000 bed hospital 500 victims, 125
ventilated pts.
 Assume 15 lpm/pt, 21,600 liters/24hr/pt, 2,700,000
liters/24 hr/hospital.
 Assume 50% require O2 by mask at 10 lpm/pt, i.e.
250x10x60x24=3,600,000 liters/24hr.
 Assume 2,000,000 for rest of hospital use.
 Total: 8,300,000 liters/24 hr.
 My hospital’s total storage capacity: ______
Addendum: Hospital oxygen supplies:
 Assume 40-bed ward, 20 ventilators @ 15lpm.
 Assume ventilators require pressure > 3.5 Atm.
 Assume 18 mask O2 pts @ 10 lpm.
 Assume 2 CPAP pts @ 100 lpm.
 Assume 100 lpm surge flow (sudden opening of flow
meter, new patient connected to CPAP)
 Total required FLOW: 680 lpm.
 Assume pressure drop along tubing and check most
distant room!