Medical Response to Major Incidents and Disasters: A Practical Guide for All Medical Staff

Medical Response to Major Incidents and Disasters Sten Lennquist Editor Medical Response to Major Incidents and Disa...

Author: Sten Lennquist

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Medical Response to Major Incidents and Disasters

Sten Lennquist Editor

Medical Response to Major Incidents and Disasters A Practical Guide for All Medical Staff

Editor Sten Lennquist Ängslyckestigen 4 614 32 Söderköping Sweden [email protected]

The artwork in this book is, when not otherwise indicated, done by Typoform, Stockholm, Sweden

ISBN 978-3-642-21894-1 e-ISBN 978-3-642-21895-8 DOI 10.1007/978-3-642-21895-8 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2011940865 © Springer-Verlag Berlin Heidelberg 2012 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

To all those who, with never-ending energy and enthusiasm, devote themselves to education and training of medical staff for the response to major incidents, including not only the challenge of performing effective and accurate training for this difficult task, but also the equally large challenge of getting decision makers on all levels to understand their responsibility to supply such training to staff of all categories – all for the benefit of the continuously increasing number of victims of such incidents.

Preface

It is today clear that the incidence of major incidents – situations where available resources are insufficient for the immediate need of medical care – has increased significantly parallel to the technical and economical development in the world. To maintain and continuously improve our standard of living requires continuous development of advanced technology, and the price we have to pay is the risks connected to this development. Our technical development has also generated changes in nature and climate, leading to an escalation of what have been called natural disasters, but which have been, to an increasing extent, caused by man. The increasing global population and the remaining, and in some areas even increasing, differences in the standard of living between poor and rich countries creates political tensions, leading to armed conflicts and terrorist actions from which no place in the world is safe. Parallel to this, and as a paradox, the vulnerability of our health care system to such situations has increased: Increasing demands on efficiency reduce or eliminate the “reserve capacity” for high loads of casualties; we are increasingly dependent on vulnerable technical systems; and continuing subspecialization reduces our ability to deal with emergencies outside our own narrow specialties. Decision makers in health care and education have a heavy responsibility to act in accordance with this – a responsibility that not is taken everywhere, especially on the educational side. Medical personnel of all categories and on all levels have the responsibility to prepare situations like this so that we can handle them in the best possible way, eliminating or reducing loss of life and health, as well as physical and psychological suffering, consequential to such incidents as much as possible. This requires planning and preparedness, but it also has been clearly shown that the most important thing is that staff of all categories are accurately trained to meet these situations. It is not enough to “continue to do the normal work and do it more efficiently”; additional skills are needed for accurate management and performance in these difficult situations: • Make decisions with regard to priority when the need of care extensively exceeds available resources and accurately adapt these decisions to the situation; this does not only include priority among patients (triage), but also the priority in performing diagnostic and therapeutic measures, i.e., it involves all medical staff. • Primarily treat emergencies with injury/disease outside our own specialties because the access to specialists will not be sufficient. • Use simplified methods for diagnosis and treatment because the access to advanced technology will be limited. • Handle reserve systems as back-up for our vulnerable technical systems. • Work as an integrated part of a prepared alert and response process, which requires knowledge of this process. vii

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None of this is possible without education and training. Different from most clinical specialties, training cannot be done in the “real situation” (the major incident) but has to be done with the use of simulation techniques, which puts high demands on those responsible for the training. By far the best way to perform such training is by the use of interactive models – “learning by doing” – where all participants are trained in decision making on all levels, from command and coordination down to the level of patient management: what to do with patients in this particular situation, the priority in which to do it, for the best use of and how to do it, for the best possible use of available resources. This requires training models that supply information detailed enough to serve as a basis for decisions and that show the results of the decisions with regard to outcome in mortality and complications. To allow enough space for interactive training, traditional lectures should be reduced, which requires textbooks that help students prepare themselves for the training. Textbooks within this field so far have been either directed toward planners or managers or deal mainly with basic trauma management. Based on experiences from the interactive European courses in medical response to major incidents (MRMI), this book has been created to fill the apparent need for a practical guide for all medical staff that covers the whole spectrum of required knowledge from the level of command and coordination to the practical management of casualties in these difficult situations, thereby collecting all the basic knowledge required into one comprehensive and easily accessible format. Variations exist between countries with regard to both terminology and organization. The international group behind this book has put much effort in adapting the text and content to what we have identified as a common standard for most European countries. We will always have slight differences in terminology and organization, based on differences in health care systems, culture, economy, and traditions, but we consider the principles described here simple to adapt to the standard of any European country and probably to most countries outside Europe. This book has been created by the members of the core faculty of the MRMI courses, all of whom are highly devoted to this task, with the help of an international group of experienced specialists within different sectors of major incident response. As editor and coordinator of the book, I want to express my sincere gratitude to all those who have put time and effort into contributing to it, all for the benefit of the continuously increasing number of victims of incidents of this kind in all parts of the world. Söderköping, Sweden

Sten Lennquist

Contents

1

2

3

Major Incidents: Definitions and Demands on the Health-Care System .................................................................................. 1.1 Terminology ....................................................................................... 1.2 When, and by Whom, Is a “Major Incident” Declared? .................... 1.3 The Risk for Major Incidents in the Modern Community.................. 1.4 Demands on Health Care During Major Incidents ............................. 1.4.1 The Need for Planning and Preparedness .............................. 1.4.2 The Need for Education and Training ................................... 1.4.3 The Need for Development and Research ............................. Further Reading ..........................................................................................

1 1 2 2 3 3 4 6 6

Major Incidents: Examples and Experiences ......................................... 2.1 Terminology ....................................................................................... 2.2 Incidents That Occur as a Consequence of Technical Development .................................................................. 2.2.1 Transports .............................................................................. 2.2.2 Accidents Caused by Hazardous Material ............................. 2.2.3 Accidents Caused by Radiation ............................................. 2.2.4 Accidents Caused by Fire ...................................................... 2.2.5 Accidents During Public Gatherings ..................................... 2.2.6 Collapse of Buildings and Constructions .............................. 2.3 Disturbances in Technical Systems .................................................... 2.4 Intentionally Caused Incidents ........................................................... 2.4.1 Armed Conflicts ..................................................................... 2.4.2 Terror Actions ........................................................................ 2.5 Incidents Consequent to Changes in Nature and Climate .................. 2.5.1 Sudden-Onset Incidents ......................................................... 2.5.2 Slow-Onset Incidents ............................................................. 2.6 Conclusions ........................................................................................ References to Major Incidents and Disasters..............................................

9 9 9 10 16 18 19 20 21 21 22 22 22 24 24 31 31 31

The Prehospital Response ........................................................................ 3.1 Structural Variations Between Countries ........................................... 3.2 Terminology ....................................................................................... 3.3 First Unit on Scene ............................................................................. 3.3.1 The First Report ..................................................................... 3.3.2 Taking Command ................................................................... 3.3.3 Contact with the Rescue Incident Commander .....................

33 33 33 34 34 34 34 ix

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3.3.4 3.3.5 3.3.6 3.3.7 3.3.8 3.3.9

Safety ..................................................................................... Overview of the Scene ........................................................... Second Report ........................................................................ Covering the Need for Medical Staff on Scene ..................... Decision of Strategy for the Medical Work ........................... Establishing Continuous Contact with the Regional Medical Command Center...................................... 3.3.10 Continued Coordination of the Medical Response on Scene ................................................................ 3.3.11 Major Incident Stand Down ................................................... 3.4 Building Up the Structure on Scene Step by Step .............................. 3.4.1 The Need for Simplicity ........................................................ 3.4.2 The First Step: Starting Triage and Transport ....................... 3.4.3 The Second Step: Completing the Casualty and Ambulance Loading Zones .............................. 3.4.4 The Third Step: Completing the Organization on Scene ..................................................... 3.5 Equipment .......................................................................................... 3.5.1 Ambulance Equipment Vehicles ............................................ 3.5.2 Special Equipment Supplied by the Rescue Service ............................................................ 3.6 Who Is Responsible for What?........................................................... 3.6.1 Medical Staff on Scene .......................................................... 3.6.2 Military Staff.......................................................................... 3.6.3 Voluntary Organizations ........................................................ 3.6.4 Voluntary Medical Staff ......................................................... 3.7 Triage on Scene .................................................................................. 3.7.1 General Principles .................................................................. 3.7.2 Overview Before Starting Triage ........................................... 3.7.3 Triage in Different Zones of the Scene .................................. 3.7.4 Indicating Priority .................................................................. 3.8 Treatment: How Much Should Be Done? .......................................... 3.9 Transport of Casualties ....................................................................... 3.9.1 Alert of Ambulances .............................................................. 3.9.2 Alert of Helicopters ............................................................... 3.9.3 Alert of Other Transport Facilities ......................................... 3.9.4 Leading and Coordination of Transport................................. 3.9.5 Ambulance Service ................................................................ 3.10 Registration on Scene ......................................................................... 3.10.1 Medical Documentation......................................................... 3.10.2 Identification and Destination ................................................ 3.11 Communication .................................................................................. 3.11.1 Problems and Limitations ...................................................... 3.11.2 The Telephone Net ................................................................. 3.11.3 The Mobile Telephone Net .................................................... 3.11.4 The Radio Net ........................................................................ 3.11.5 Other Communication Systems ............................................. 3.12 Special Considerations in Terrorist Actions in Areas of Violence.............................................................. Further Reading ..........................................................................................

35 36 37 37 37 38 38 38 38 38 39 39 41 43 43 43 45 45 46 47 47 48 48 48 51 51 51 53 53 53 54 54 57 58 58 58 59 59 59 59 59 60 60 60

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4

Triage ....................................................................................................... 4.1 The Term Triage ................................................................................. 4.2 Demands on Triage............................................................................. 4.2.1 Categories of Priority ............................................................. 4.2.2 Indication of Priority.............................................................. 4.3 Methodology of Triage ....................................................................... 4.3.1 Anatomical Triage ................................................................. 4.3.2 Physiological Triage .............................................................. 4.3.3 Physiological Triage .............................................................. 4.3.4 Anatomical Triage ................................................................. 4.4 Outcome Related to Method of Triage ............................................... 4.5 Triage in Children............................................................................... 4.5.1 Pediatric Triage Tape ............................................................. Further Reading ..........................................................................................

63 63 63 64 64 67 67 67 68 70 73 74 74 74

5

The Hospital Response ............................................................................. 5.1 The Need for Planning ....................................................................... 5.2 The Disaster Plan: Goals and Structure.............................................. 5.2.1 Demands on a Functioning Plan ............................................ 5.2.2 The Need for Simplicity ........................................................ 5.2.3 Functions of Critical Importance for the Capacity of the Hospital ........................................................ 5.2.4 The Content of the Disaster Plan ........................................... 5.2.5 What Every Staff Member Should Know .............................. 5.2.6 The “All Hazard” Concept ..................................................... 5.3 The Alert Process ............................................................................... 5.3.1 Who Alerts? ........................................................................... 5.3.2 Receiving the Alarm .............................................................. 5.3.3 Decision About the Level of Alert ......................................... 5.3.4 Further Processing of the Alarm ............................................ 5.3.5 Where to Go When Alerted ................................................... 5.3.6 What to Do When Alerted ..................................................... 5.3.7 Canceling the Alert ................................................................ 5.4 Levels of Alert .................................................................................... 5.4.1 Green Alert (“Stand by”) ....................................................... 5.4.2 Yellow Alert (“Partial Mobilization”).................................... 5.4.3 Red Alert (“Full Mobilization”) ............................................ 5.4.4 The Need for Three Levels .................................................... 5.5 Coordination and Command .............................................................. 5.5.1 Within the Hospital ................................................................ 5.5.2 Command on Regional Level ................................................ 5.5.3 Command an National Level ................................................. 5.6 Action Cards ....................................................................................... 5.7 Preparing the Hospital ........................................................................ 5.8 Receiving Casualties .......................................................................... 5.8.1 Primary Triage ....................................................................... 5.8.2 Severely Injured Victims........................................................ 5.8.3 Less Severely Injured Victims ...............................................

77 77 77 77 78 78 78 79 79 79 79 80 80 81 81 81 81 81 81 82 82 82 83 83 85 85 87 88 89 89 89 92

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5.8.4 Noninjured Victims ................................................................ 5.8.5 Dead Victims ......................................................................... 5.9 Continued Treatment of Injured Patients ........................................... 5.9.1 Patients Who Need Immediate Surgery and/or Intensive Care ............................................... 5.9.2 Patients Needing In-Patient Care ........................................... 5.10 Registration of Patients....................................................................... 5.11 Hospital Information Center............................................................... 5.12 Management of Media........................................................................ 5.13 Supplies .............................................................................................. 5.14 Technical Functions ............................................................................ 5.14.1 Electrical Power ..................................................................... 5.14.2 Water ...................................................................................... 5.14.3 Computer Support .................................................................. 5.15 Communication .................................................................................. 5.16 Psychosocial Support ......................................................................... 5.17 Incidents Primarily Involving the Hospital ........................................ 5.18 Special Types of Incidents .................................................................. 5.19 The Recovery Phase ........................................................................... Further Reading ..........................................................................................

92 92 92 92 93 93 93 94 95 95 95 96 96 96 96 97 97 97 98

6

Management and Identification of Dead Victims................................... 6.1 Introduction ........................................................................................ 6.2 Care of the Deceased on the Scene .................................................... 6.2.1 Packing, Labeling, and Transport .......................................... 6.2.2 Preliminary Storage ............................................................... 6.2.3 Delivery and Funeral.............................................................. 6.2.4 Local Instructions .................................................................. 6.3 Identification of the Deceased Under Normal Conditions ................. 6.4 Identification During Major Incidents with Many Deceased ............. 6.4.1 Final Identification ................................................................. 6.4.2 Identification Teams............................................................... 6.4.3 Methods for Identification of the Deceased ........................... 6.4.4 Forensic Autopsy ................................................................... 6.4.5 DNA Investigations................................................................ 6.5 International DVI Work ...................................................................... Further Reading ..........................................................................................

99 99 99 99 99 100 100 100 100 101 101 101 102 103 106 110

7

Incidents Caused by Physical Trauma .................................................... 7.1 Different Mechanisms of Injury in Different Kinds of Incidents ....... 7.2 Effects of Different Kinds of Physical Trauma .................................. 7.3 Penetrating Injuries............................................................................. 7.3.1 Wounds Involving Skin and Subcutaneous Tissues ............... 7.3.2 Missile and Fragment Injuries ............................................... 7.3.3 Other Wounds Penetrating into Body Cavities ...................... 7.4 Nonpenetrating Injuries ...................................................................... 7.4.1 Blunt Trauma ......................................................................... 7.4.2 Blast Injury ............................................................................ 7.4.3 Crush Injury ...........................................................................

111 111 111 112 112 113 115 115 116 116 117

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7.5 Primary Management of the Injured .................................................. 7.5.1 The Importance of Time ........................................................ 7.5.2 The Importance of a Standardized Methodology .................. 7.5.3 Action Plan for Primary Management ................................... 7.5.4 Primary Survey with Elimination of Threats Against Vital Functions ........................................ 7.6 Triage on Scene .................................................................................. 7.7 Decision with Regard to Continued Prehospital Treatment ............... 7.8 Prehospital Fluid Resuscitation .......................................................... 7.8.1 Vascular Access ..................................................................... 7.8.2 Different Kinds of Fluids: Advantages and Disadvantages.............................................. 7.8.3 Recommended Guidelines for Use in Major Incidents.......... 7.9 Prehospital Pain Relief ....................................................................... 7.10 Prehospital Stabilization of Limb Injuries ......................................... 7.10.1 The Importance of Accurate Stabilization Before Transport .................................................................... 7.10.2 Open Fractures ....................................................................... 7.10.3 Closed Fractures and Dislocations......................................... 7.11 Priority for Transport.......................................................................... 7.12 Transport............................................................................................. 7.13 Primary Triage and Management in the Hospital............................... 7.13.1 Primary Triage at the Hospital Entrance................................ 7.13.2 Major Incident Resuscitation Teams...................................... 7.13.3 Primary Management of Severely Injured Patients ............... 7.13.4 Additional Investigations ....................................................... 7.14 Continued Treatment in the Hospital ................................................. 7.15 Damage Control ................................................................................. 7.15.1 Indications for Damage Control ............................................ 7.15.2 Results of Damage Control .................................................... 7.16 Injuries to Different Organ Systems ................................................... 7.16.1 Head Injuries .......................................................................... 7.16.2 Maxillofacial Injuries............................................................. 7.16.3 Eye Injuries ............................................................................ 7.16.4 Injuries to the Ears ................................................................. 7.16.5 Injuries to the Neck ................................................................ 7.16.6 Chest Injuries ......................................................................... 7.16.7 Abdominal Injuries ................................................................ 7.16.8 Injuries to the Urinary Tract .................................................. 7.16.9 Pelvic Injuries ........................................................................ 7.16.10 Spinal Injuries ........................................................................ 7.16.11 Limb Injuries ......................................................................... 7.17 Special Injuries Commonly Occurring in Major Incidents ................ 7.17.1 Missile and Fragment Injuries ............................................... 7.17.2 Amputations ........................................................................... 7.17.3 Crush Injury and Compartment Syndrome ............................ 7.17.4 Blast Injury ............................................................................ 7.17.5 Special Categories of Injured................................................. Further Reading ..........................................................................................

118 118 118 119 119 135 136 136 136 137 137 138 139 139 139 139 144 144 144 144 145 146 148 148 149 150 150 151 151 153 156 157 157 160 163 175 175 178 179 183 183 186 187 189 191 192

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8

Incidents Caused by Fire and Toxic Gas................................................. 8.1 Treatment Strategies for Burns ........................................................... 8.1.1 Extent of Injury ...................................................................... 8.1.2 Surface Area .......................................................................... 8.1.3 Burn Wound Depth ................................................................ 8.1.4 Fluid Treatment...................................................................... 8.1.5 Inhalation Injuries and Facial Burns ...................................... 8.2 Modern Treatment Strategy ................................................................ 8.2.1 Acute Burn Life Support ....................................................... 8.2.2 Modern Burn Treatment: The Three Phases .......................... 8.3 Burn Care During Major Incidents..................................................... 8.3.1 Care Level A .......................................................................... 8.3.2 Care Level B .......................................................................... 8.3.3 Care Level C .......................................................................... 8.3.4 Transport of Patients .............................................................. 8.4 National and International Burn Care Societies ................................. Further Reading ..........................................................................................

197 197 197 198 199 199 200 201 202 202 204 205 207 208 208 209 209

9

Incidents in Cold and Wet Environments ............................................... 9.1 Hypothermia ....................................................................................... 9.1.1 Effects of Cooling .................................................................. 9.1.2 Predisposing Factors of Hypothermia.................................... 9.1.3 Effects on Different Organ Systems ...................................... 9.1.4 Clinical Signs and Symptoms ................................................ 9.1.5 Protection from Further Cooling ........................................... 9.1.6 Positioning, Evacuation, and Transport ................................. 9.1.7 Triage ..................................................................................... 9.1.8 Criteria to Declare Death ....................................................... 9.1.9 In-hospital Management ........................................................ 9.2 Results of Treatment of Hypothermia ................................................ 9.3 Cold Injuries ....................................................................................... 9.3.1 Risk for Cold Injuries in Traumatized Patients...................... 9.4 Avalanche Incidents............................................................................ 9.5 Drowning ............................................................................................ 9.5.1 Definitions.............................................................................. Further Reading ..........................................................................................

211 211 211 212 212 213 215 216 216 217 217 220 220 220 224 225 225 226

10 Incidents Caused by Hazardous Material .............................................. 10.1 Introduction ........................................................................................ 10.2 The Prehospital Response .................................................................. 10.2.1 Activities En Route to the Incident Site................................. 10.2.2 Arrival at the Incident Site ..................................................... 10.2.3 Treatment of Victims ............................................................. 10.2.4 Transportation of Victims ...................................................... 10.2.5 Management of Fatalities....................................................... 10.3 The Hospital Response ....................................................................... 10.3.1 The Alert Process ................................................................... 10.3.2 Coordination and Command .................................................. 10.3.3 Preparing the Hospital ........................................................... 10.3.4 Receiving Casualties ..............................................................

229 229 231 231 231 233 236 237 237 237 237 237 238

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10.4 Personal Protective Equipment and Training ..................................... 10.4.1 Recommendations.................................................................. 10.5 Decontamination and Decontamination Triage .................................. 10.5.1 Decontamination of Children ................................................ 10.5.2 Decontamination Triage ........................................................ 10.5.3 Nonambulatory Victims ......................................................... 10.6 Role of the PCC in Chemical Incidents ............................................. 10.6.1 Operational Activities of the PCC in a Chemical Incident Response.................................................. 10.6.2 Monitoring Possible Delayed Effects .................................... 10.6.3 Cooperation When Preparing Rescue Management Plans ................................................................. 10.6.4 Laying Down Recommended Procedures and Guidelines for the Response to Chemical Incidents ................................ 10.6.5 Rational Antidote Supply ...................................................... 10.6.6 Providing Training for Medical Personnel and Other Rescue Workers Assigned to Respond to Chemical Incidents ............................................................ 10.6.7 Cooperating in Preparing Analyses and Follow-Up Studies of Chemical Accidents and Proposing Improvements ............................... 10.7 General Approach to Toxic Trauma Treatment .................................. 10.7.1 Identifying the Name of Chemicals and Hazard Recognition ........................................................ 10.7.2 Exposure, Poisoning .............................................................. 10.7.3 Toxicokinetics, Toxicodynamics............................................ 10.7.4 Toxicologic Sample Analysis ................................................ 10.7.5 Documentation ....................................................................... 10.8 Antidotes ............................................................................................ 10.8.1 Antidote Within the Poisoning Treatment Scheme................ 10.8.2 Contraindications for Antidote Administration ..................... 10.8.3 Antidotes for Use in Chemical Incidents ............................... 10.9 Toxic Trauma Treatment of the Most Common Toxic Injuries .......... 10.9.1 Irritant Gases (Irritants) ......................................................... 10.9.2 Asphyxiants ........................................................................... 10.9.3 Organic Solvents .................................................................... 10.9.4 Acetyl Cholinesterase Inhibitors (Nerve Agents) .................. 10.9.5 Blister Agents (Vesicants)...................................................... 10.9.6 Chemicals Used for Temporary Incapacitation (Lachrymators) ............................................... Further Reading .......................................................................................... 11 Incidents Caused by Irradiation .............................................................. 11.1 Different Types of Incidents ............................................................... 11.2 Examples of Incidents with Release of Radioactive Material ...................................................................... 11.2.1 Reactor Breakdowns .............................................................. 11.2.2 Accidents with Lost or Unknown Irradiation Sources ................................................................. 11.2.3 Accidents in Nuclear Industry ...............................................

240 241 242 244 244 244 246 246 246 246 247 247

247

247 247 248 249 250 250 250 251 251 251 252 255 255 258 261 264 267 272 274 275 275 275 275 277 277

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11.2.4 International Spread of Radioactive Material and Use of Nuclear Reactions ................................. 11.3 Basic Radiation Physics ..................................................................... 11.3.1 Different Types of Ionizing Radiation ................................... 11.3.2 Natural and Artificial Ionizing Radiation .............................. 11.3.3 Dose and Activity .................................................................. 11.3.4 External and Internal Radiation ............................................. 11.3.5 External and Internal Contamination ..................................... 11.4 The Effects of Ionizing Radiation ...................................................... 11.4.1 Biological Effects of Ionizing Radiation ............................... 11.4.2 Medical Effects of Ionizing Radiation ................................... 11.4.3 Acute (Deterministic) Radiation Injuries............................... 11.4.4 Stochastic Effects of Radiation .............................................. 11.4.5 Prenatal Exposure Effects ...................................................... 11.5 Medical Response to Nuclear and Radiological Incidents ................. 11.5.1 Planning and Organization..................................................... 11.5.2 Risk Zones ............................................................................. 11.5.3 Decontamination .................................................................... 11.5.4 Triage ..................................................................................... 11.5.5 Diagnosis ............................................................................... 11.6 Treatment............................................................................................ 11.6.1 Treatment of Whole-Body Radiation .................................... 11.6.2 Treatment of Internal Contamination .................................... 11.6.3 Initial Treatment of Internal Contamination .......................... 11.6.4 Specific Treatments: Blocking, Dilution, and Displacement Agents ...................................................... 11.6.5 Chelating Agents ................................................................... 11.6.6 General Recommendations for the Treatment of Internal Contamination (TIARA, EC) ............................... 11.6.7 Surgical Treatment ................................................................. 11.6.8 Psychological Aspects and the Necessity of Information ........................................................................ 11.7 Planning and Preparedness ................................................................. 11.7.1 Local Level ............................................................................ 11.7.2 Regional Level ....................................................................... 11.7.3 National Level........................................................................ 11.7.4 International Level ................................................................. 11.8 Global International Organizations .................................................... Further Reading .......................................................................................... 12 Infectious Diseases and Microbiological Threats ................................... 12.1 Introduction ........................................................................................ 12.2 Classification of Microbiological Incidents ....................................... 12.2.1 Incidents Consequent to Technical Development .................. 12.2.2 Incidents Intentionally Caused by Man ................................. 12.2.3 Incidents Consequent to Changes in Climate and Nature ............................................................ 12.3 Terminology and Characteristics of Infectious Disease Incidents ................................................................................

278 279 279 280 280 280 281 281 281 281 281 283 283 284 284 285 285 286 286 287 287 288 288 288 289 289 289 290 290 291 291 291 291 291 292 293 293 294 294 295 296 296

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12.4 Routes of Transmission for Communicable Diseases ........................ 12.4.1 Infection Control and Personal Protection ............................. 12.5 Personal Protection Through Medical Interventions .......................... 12.6 Bioterrorism ....................................................................................... 12.6.1 When to Suspect an Intentionally Caused Incident? ............. 12.7 Conclusions ........................................................................................ Further Reading ..........................................................................................

298 299 301 302 302 303 303

13 Incidents Caused by Changes in Nature and Climate ........................... 13.1 Introduction ........................................................................................ 13.2 Epidemiology of Natural Disasters .................................................... 13.3 The Short- and Long-Term Consequences of Natural Disasters ........ 13.4 Vulnerability and the Ability to Recover Varies Between Communities ............................................................ 13.5 Seismic Natural Disasters................................................................... 13.5.1 Earthquakes............................................................................ 13.5.2 Tidal Waves (Tsunamis) ........................................................ 13.6 Meteorological Natural Disasters ....................................................... 13.6.1 High Wind Speeds ................................................................. 13.6.2 Floods .................................................................................... 13.6.3 Extreme Temperature Conditions .......................................... 13.7 Natural Disasters Indirectly Caused by Environmental Impact ......... 13.8 National and International Disaster Medicine .................................... 13.9 Needs Assessment .............................................................................. 13.10 Local and National Relief Operations .............................................. 13.11 International Humanitarian Relief .................................................... 13.12 Vital Relief Needs............................................................................. 13.13 The Earthquake and Tsunami in Japan, March 11, 2011 ................. Further Reading ..........................................................................................

305 305 305 305 307 308 308 309 309 309 311 311 311 311 312 313 313 315 317 318

14 Combat Casualty Management ............................................................... 14.1 Definition ............................................................................................ 14.2 Combat Casualty Care Approach ....................................................... 14.2.1 Level 1 ................................................................................... 14.2.2 Level 2 ................................................................................... 14.2.3 Evacuation to Levels 3, 4, and 5 ............................................ 14.2.4 Additional Trauma Management Issues ................................ 14.2.5 The CNN Effect ..................................................................... 14.3 Civilian Application of C3 Principles for Major Incidents ................ 14.4 Conclusions ........................................................................................ Further Reading ..........................................................................................

321 321 322 322 325 326 328 329 329 333 334

15 Terrorist Attacks on the Civilian Community........................................ 15.1 Introduction ........................................................................................ 15.2 The Strategy of Terrorism .................................................................. 15.2.1 The Structure of Terrorist Organisations ............................... 15.2.2 Stages of Terrorist Activity .................................................... 15.2.3 Techniques, Tactics, and Procedures of Terrorists ................ 15.3 Terror Medicine ..................................................................................

337 337 337 338 339 339 342

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15.4 Impact of Terrorism on the Prehospital Organization ........................ 15.4.1 Police ..................................................................................... 15.4.2 Fire Brigade/Rescue Service.................................................. 15.4.3 Ambulance/Medics ................................................................ 15.4.4 Military .................................................................................. 15.5 The Hospital Response to Terrorist Incidents .................................... 15.5.1 Importance of the Planning Process ...................................... 15.6 Impact of Terrorism on Hospitals ....................................................... 15.6.1 Security of the Hospital ......................................................... 15.6.2 Security of the Patients .......................................................... 15.6.3 Security of Ambulance Vehicles Parked at the Entrances ...................................................................... 15.6.4 Issues Regarding Ethnic Groups Within the Hospital ................................................................ 15.6.5 Issues with Telephone Communication ................................. 15.6.6 Impact of Police and Security Services ................................. 15.6.7 Issues with the Media ............................................................ 15.6.8 Issues with Foreign Embassies .............................................. 15.6.9 VIP Visits ............................................................................... 15.7 Conclusions ........................................................................................ Further Reading ..........................................................................................

343 343 345 346 347 347 348 348 349 349

16 Scoring Systems Related to Outcome in Severe Injuries....................... 16.1 Anatomical Scoring Systems ............................................................. 16.1.1 Abbreviated Injury Scale ....................................................... 16.1.2 Injury Severity Score ............................................................. 16.1.3 Anatomical Profile ................................................................. 16.1.4 New Injury Severity Score (NISS)......................................... 16.1.5 ICISS (ICD-9 Injury Severity Score)..................................... 16.2 Physiological Scoring Systems .......................................................... 16.2.1 Revised Trauma Score (RTS) ................................................ 16.2.2 Triage Revised Trauma Score (T-RTS) .................................. 16.3 Combined Scoring Systems ............................................................... 16.3.1 The Probability of Death Score ............................................. 16.3.2 TRISS (Trauma Score, Injury Severity Score) ...................... 16.3.3 A Severity Characterization of Trauma (ASCOT)................. 16.3.4 Polytrauma Score ................................................................... 16.3.5 Base Excess Injury Severity Scale (BISS) ............................. 16.3.6 Pediatric Trauma Score .......................................................... 16.3.7 Other Combined Systems ...................................................... 16.4 Outcome ............................................................................................. 16.4.1 Survival .................................................................................. 16.4.2 Long-Term Outcome and Consequences of Injuries ............. 16.4.3 Organ-Related Outcome Scores............................................. 16.4.4 Universal Outcome Scales ..................................................... 16.4.5 Psychologic Outcome ............................................................ 16.4.6 Problems and Pitfalls ............................................................. 16.4.7 Summary and Conclusions .................................................... References...................................................................................................

353 353 353 354 354 355 355 355 355 356 356 356 356 357 357 357 358 358 358 358 358 359 359 360 360 360 361

349 349 349 349 350 350 350 350 351

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17 Psychological Crisis Support in Major Incidents .................................. 17.1 Introduction ........................................................................................ 17.2 Historical Background........................................................................ 17.3 Crisis Support: Background ............................................................... 17.3.1 Holistic View ......................................................................... 17.3.2 Major incidents ...................................................................... 17.3.3 Survivors ................................................................................ 17.3.4 Relatives and Friends ............................................................. 17.4 Stress Reactions After Major Incidents .............................................. 17.4.1 What Do We Mean by Reactions After Traumatic Stress? ......................................................... 17.4.2 How to Recognize Traumatic Stress Reactions ..................... 17.5 More Severe Symptoms ..................................................................... 17.6 Posttraumatic Stress Disorder ............................................................ 17.6.1 Risk Factors for Posttraumatic Stress Reactions ................... 17.6.2 Resilience ............................................................................... 17.6.3 Trajectories ............................................................................ 17.7 Crisis Support ..................................................................................... 17.7.1 On Site ................................................................................... 17.8 Psychological First Aid ...................................................................... 17.8.1 Contact and Engagement ....................................................... 17.8.2 Sense of Safety and Comfort ................................................ 17.8.3 Calming and Stabilizing ........................................................ 17.8.4 Positive Coping ...................................................................... 17.8.5 Connectedness and Social Support ........................................ 17.8.6 Hope ....................................................................................... 17.8.7 Follow-Up .............................................................................. 17.8.8 When Do Survivors Need More Extended Support? ............. 17.8.9 Support for Special Groups ................................................... 17.8.10 Cultural and Religious Diversity .......................................... 17.8.11 Rites and Customs ........................................................... 17.8.12 Seeing Deceased Loved Ones .............................................. 17.9 Treatment............................................................................................ 17.9.1 Psychological Treatment........................................................ 17.9.2 Pharmacological Treatment ................................................... 17.10 Self-Care ........................................................................................... 17.10.1 Taking Care of Oneself......................................................... Further Reading .......................................................................................... 18 Education and Training ............................................................................ 18.1 The Need for Education and Training ................................................ 18.2 Education on Different Levels............................................................ 18.2.1 Basic Education ..................................................................... 18.2.2 Specialist Training ................................................................. 18.2.3 Postgraduate Training ............................................................ 18.2.4 Repeated Training .................................................................. 18.3 Methodology of Training ................................................................... 18.3.1 Problems with Training and How to Cope with Them .................................................

363 363 363 364 364 364 364 365 365 365 366 366 367 368 368 368 369 369 369 369 370 370 371 371 371 372 372 372 373

374 374 374 374 375 375 376 376 379 379 379 380 380 381 381 381 381

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Contents

18.3.2 Demands on Training in Decision Making, the Keystone of Major Incident Response ............................. 18.3.3 Validation of Educational Models ......................................... 18.4 Models for Interactive Training .......................................................... 18.4.1 Practical Field Exercises ........................................................ 18.4.2 Table Top Exercises ............................................................... 18.5 Course Models.................................................................................... 18.5.1 Undergraduate Training ......................................................... 18.5.2 Specialist Training ................................................................. 18.5.3 Postgraduate Training ............................................................ 18.6 Who Should Deliver the Training? ..................................................... Further Reading ..........................................................................................

382 382 383 383 385 389 389 390 390 393 397

19 Further Methodological Development and Research ............................ 19.1 The Science of Disaster Medicine ...................................................... 19.2 Historical Background........................................................................ 19.3 The Need for Research ....................................................................... 19.3.1 Research Covering the Whole Field of Major Incident Response ................................................... 19.3.2 Research Within Specialties Involved in Major Incident Response ....................................................... 19.4 Future Perspectives ............................................................................. Further Reading ..........................................................................................

399 399 399 400

Index .................................................................................................................

407

401 403 405 405

Presentation of Authors

Editor and Principal Author Sten Lennquist, M.D., Ph.D., Professor Emeritus at the University of Linköping, Sweden, is surgeon and former Chief of Surgery, University Hospital, Linköping. His involvement in Disaster Medicine originates from international humanitarian missions as a young surgeon and has been a part of his surgical career. He has served as a consultant to the Swedish Board of Health and Welfare in Disaster Preparedness, organized and led numerous national and international courses in Disaster Medicine, and has had educational missions in this field for the World Health Organization (WHO), the European Union commission, and several countries in different parts of the world. In 1991 he was appointed as the first Professor of Disaster Medicine in Scandinavia and initiated and founded the Center for Research and Education in Disaster Medicine, University of Linköping. He has published more than 200 original articles, chapters, and textbooks within the fields of Trauma and Disaster Medicine. He is an Honorary Member of the European Society for Trauma and Emergency Surgery, of which he was President 2007–2008; the Scandinavian Surgical Society; the American Association for the Surgery of Trauma; The French Academy of Surgery; the Swedish Society of Disaster Medicine; and the Hungarian Society for Military and Disaster Medicine. [email protected]

Authors of Chapters Howard R. Champion, M.D., FRCS, FACS, is Professor of Surgery and Senior Advisor in Trauma at Uniformed Services University of the Health Sciences, Washington, D.C., and has been involved in the training of military personnel in trauma management for more than 30 years. He has authored numerous chapters and articles on combat injury, including the chapter on Injuries from Explosions in the Seventh Edition of the Prehospital Trauma Life Support Manual (Mosby 2010). His company has a number of grants and contracts to bring technology-assisted training to the domain of combat casualty care and surgical training. [email protected]

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Robert Dobson, F(ass)RCS(Ed) (United Kingdom), is a Registered Paramedic and has been a Senior Training Officer at the Department for Education and Development, London Ambulance Service, and at the Regional Training Center, Surrey Ambulance Service, for nearly 35 years. He also has acted as an advisor to Special Operations and Special Forces and as an Instructor at the Combat and Tactical Life Saver Course. He served with the Army in Northern Ireland in 1973–1975. He is member of ESTES (European Society for Trauma & Emergency Surgery) Section for Disaster and Military Surgery and the Croatian Urgent Medicine and Surgery Association. He is also Medical Advisor and Associate Director of Hanover Associates (UK), Ltd., and one of the initiators of the MRMI courses, where he is a faculty member and also member of the Board of MRMI. [email protected] Boris Hreckovski, M.D., FICS (Croatia), is a general surgery and trauma care specialist and Major in the Croatian Army Reserve. He served as army physician 1991– 1994 during the war in Croatia and Bosnia. Currently he is head of the Department of Trauma, Slavonski Brod General Hospital. He is President of the Croatian Urgent Medicine and Surgery Association and the Croatian Section of International College of Surgeons, Vice-Chairman of ESTES Section for Education and Training, and a national representative in ESTES Section for Disaster and Military Surgery. He is Vice-President of the International College of Surgeons, 2011–2012, Vice-President of the MRMI board, and a lecturer at the MRMI courses since 2009. [email protected] Kerstin Bergh Johannesson, Ph.D., is a Licensed Clinical Psychologist and Senior Supervisor in Psychology at the University Hospital in Uppsala, Sweden. She specialises in the treatment of trauma-related psychological disorders and holds a position as a researcher in this field at the Swedish National Center for Disaster Psychiatry, Uppsala. She is Director of the Psychosocial Emergency Team at the University Hospital of Uppsala and for many years has been a lecturer in psychotraumatology. [email protected] Siegfried de Joussineau, M.D., Ph.D., is currently the Surgeon General of the Swedish Armed Forces and has a long experience in the field of Radiation Emergency Medicine, being a member of the Expert Group for Nuclear and Radiation Incidents of the Swedish National Board of Health & Welfare. He is a former Senior Consultant at the Center of Radiation Medicine, Karolinska University Hospital, Stockholm, and has been active in the international cooperation within the International Atomic Energy Agency and the WHO (Radiation Emergency Medical Preparedness and Assistance Network), as well as European Community joint projects. He also has been an organizer and lecturer for national and international specialist courses in Radiation Medicine. [email protected] Robert A. Leitch, MBE, RN, Colonel (Ret), has more than 30 years’ experience in military medicine during peace and conflict as an enlisted Special Forces medic, a noncommissioned officer in charge of an airborne Field Surgical Team, and as a Royal Military Academy Sandhurst graduate responsible for the development of education and training for combat medics and the development and implementation of

Presentation of Authors

Presentation of Authors

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military medical policy at the highest levels. He has served in Northern Ireland, the Falklands War, the first Gulf War, and a number of other military operations around the world. [email protected] Bertil Lindblom, Ph.D., is Professor in Forensic Genetics and adjunct at the University of Linköping, Sweden. He has long experience with DNA investigations regarding family and kinship. He was responsible for the Department of Forensic Genetics at The National Board of Forensic Medicine at the time when DNA analyses were introduced for routine family investigations in Sweden. He also participated for several periods in the disaster victim identification work in Thailand after the tsunami on December 26, 2004. [email protected] Tom Lundin, M.D., Ph.D., is Professor in Disaster Psychiatry at the University of Uppsala, Sweden, and Senior Consultant at the Department of Psychiatry, Uppsala University Hospital. He is a former Director of the National Center for Disaster Psychiatry at Department of Neuroscience, Uppsala University, and has published more than 140 publications within the field of Disaster Psychiatry. [email protected] Per-Olof Michel, M.D., Ph.D., is Associate Professor of Psychiatry and former Director of Psychiatry of the Swedish Armed Forces (Lt. Col., Ret.). He currently holds a position as Director of the Swedish National Center for Disaster Psychiatry, University of Uppsala, Sweden. In addition to his academic work he has experiences of field conditions as a military psychiatrist and in civilian disaster operations. [email protected] Kristina Lennquist Montán, RN, BC l, Ph.D.-Cand., is an instructor in Disaster Medicine at the Center for Prehospital and Disaster Medicine, Gothenburg, Sweden. She has been working with the development of simulation systems for education and training in disaster medicine as the Emergotrain and MACSIM systems and has served as course assistant at the WHO International Diploma courses in Emergency Preparedness and Vulnerability Reduction and the European Union courses for instructors in Disaster Medicine. She is an instructor at the MRMI courses and currently works with a PhD research project on methodology of triage at the University of Gothenburg. [email protected] Per Örtenwall, M.D., Ph.D., is Associate Professor of Surgery and head of the Division of Trauma, Sahlgrenska University Hospital, Gothenburg, Sweden. He is an instructor and Research Director at the Center for Prehospital and Disaster Medicine, Gothenburg. He is also a Medical Officer in the Nordic Battlefield Group, with experiences from international missions in Afghanistan and the Middle East. He has published a large number of original articles and chapters within the fields of Trauma and Disaster Medicine and is one of the initiators of the MRMI courses, where he is an instructor and member of the MRMI board. [email protected]

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Lennart Rammer, M.D., Ph.D., is Professor Emeritus of Forensic Medicine, University of Linköping, Sweden. He is a forensic pathologist and was previously the head of the Department of Forensic Medicine in Linköping at the National Board of Forensic Medicine. He was also previously scientific adviser in forensic medicine at The National Board of Health and Welfare. [email protected] Louis Riddez, M.D., Ph.D., is Associate Professor of Surgery and Head of the Section for Trauma and Emergency Surgery at the Karolinska University Hospital, Stockholm. For more than 24 years he has worked in disasters worldwide, doing a large number of missions for the International Committee of the Red Cross, The Federation of the Red Cross, and Médecins Sans Frontières (MSF). He is also a teacher in disaster medicine at the Karolinska Institute, Stockholm. [email protected] Lucija Sarc, M.D., Ph.D., is a specialist of internal medicine. Since 1995 she has held a position as clinical toxicologist in the National Poison Control Center at the University Medical Center, Ljubljana, Slovenia. She leads the project “Chemical Incidents Preparedness” and is actively involved in the educational MRMI program by Ministry of Health, Slovenia. She is the author of various publications on the field of toxicology and of the national guidelines on emergency medical services team response in the event of chemical incidents. She was expert adviser in the European Union project “Transitional Facility – Chemical Safety 3.” [email protected] Johan von Schreeb, M.D., Ph.D., is a specialist in general surgery and has for more than 20 years worked in disasters worldwide, mainly for MSF. In 1992 he set up the Swedish branch of MSF. He currently leads a research group at the Karolinska Institute, Stockholm, that is focused on health challenges in disasters, developing evidence for surgical practices in resource-scarce disaster settings while maintaining regular fieldwork in disasters. [email protected] Folke Sjöberg, M.D., Ph.D., is Professor of Anesthesiology and Intensive Care, University of Linköping, Sweden, and head of the Burn Center, University Hospital, Linköping, where he heads a research group that focuses on burns, critical care, and outcome. He is Past President of the European Burns Association and has been engaged in producing the Swedish disaster plan involving burns. Furthermore, he is the author of more than 150 articles in the field of Burns and Critical Care. [email protected] Martin Wahl, M.D., Ph.D., is Associate Professor of Infectious Diseases with more than 25 years of clinical experience, including service and teaching positions in lowincome countries. He has been working with communicable disease control and prevention in the regional, national, and international arenas. He has been involved in disaster and relief work for 20 years and is currently Senior Consultant at the Center for Prehospital and Disaster Medicine in Gothenburg, Sweden. [email protected]

Presentation of Authors

1

Major Incidents: Deﬁnitions and Demands on the Health-Care System Sten Lennquist

1.1

Terminology

Within the health-care system, a major incident is defined as “a situation in which available resources are insufficient for the immediate need of medical care.” It is not related to any specific number of critically ill or injured individuals, or to any specific level of resources, but to the balance between resources and need. The term is used only for the acute situation where a lack of resources may cause immediate loss of life or severe impairment of health. “Chronic” discrepancy between resources and need, which is increasingly present within today’s health-care system, is not classified as a “major incident.” The terminology in this book is based on three levels of major incidents: 1. Major incident level 1: By adjusting organization and methodology, we can maintain the level of ambition for our medical care and save all normally salvageable patients. Alternative terminology includes major incidents or major accidents, major emergencies, and compensated incidents. 2. Major incident level 2: The load of casualties is so high that even by adjusting organization and methodology we cannot maintain the level of ambition (all normally salvageable patients cannot be saved). Alternative terminology includes mass-casualty incidents, disasters, or decompensated incidents.

S. Lennquist e-mail: [email protected]

3. Major incident level 3: Level 3 is similar to level 2 but includes destruction of the infrastructure in a region or in a country. This means even higher demands on triage and other kinds of support besides medical, usually requiring external assistance. Alternative terminology includes complex emergencies or compound incidents. The advantage of this terminology is that it provides a direct practical base for decisions in response to the alert: Level 1 usually means that the disaster plans should be activated and the methodology of working adjusted to implement them, and level 2 means upgrading the degree of alert and preparedness to give lower priority to casualties with very low chances of survival to be able to save patients who are more likely to survive. Level 3 means mobilizing external resources, from other regions or from other countries, and other support functions of the community to ensure the supply of water, electricity, food, temporary accommodation, and transport facilities both for evacuation of casualties and delivery of personnel and material resources. Even if an internationally uniform terminology was desirable, we will probably have to live with variations in definitions between countries because of differences in resources, potential scenarios, structure of the communities, cultures, and traditions. Regardless of terminology, it is important that the definitions used are not only a theoretical construction of words, but also practical and useful as a base for decisions and performance in these situations; they must be well known by health care staff on all levels.

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_1, © Springer-Verlag Berlin Heidelberg 2012

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S. Lennquist

1.2

When, and by Whom, Is a “Major Incident” Declared?

As mentioned, the medical definition of a major incident is not related to any specific number of casualties or any specific level of resources, but to the balance between immediate needs and immediate access to resources for those needs. For example, a bus accident with 40 injured passengers might not require a classification of a major incident if all casualties have minor injuries and do not require ambulance transport but can be transported with another bus to the nearest hospital, where the casualty load caused by the accident “disappears” among the 200 patients daily treated at that hospital’s emergency department. On the other hand, a maniac shooting in a school or shopping center who injures five to ten people who need immediate surgery for missile injuries might need to be declared a major incident if it happens in area where such things are not daily routine.

A golden rule is that it is better to declare major incident one time too much than not to declare it one time when it is needed.

Consequently, it has to be the task of a responsible medical officer to decide – on the basis of available information –when a major incident should be declared, and that decision should be rapidly mediated to all organizations and units involved. Who has this responsibility varies among countries and regions. In some places it is the crew of the first ambulance on the scene; in other places it is a coordinating center –an alarm center, ambulance dispatch center, or regional medical command center – that can declare a major incident based on either an incoming alarm or on the report from the first unit on the scene.

Regardless of who has this responsibility, it must be clearly stated in the disaster plan for a region to which position this decision is connected, and the person who has this responsibility must be immediately available and well trained to make such decisions.

The level of a major incident is, in the majority of cases, difficult to immediately determine because the first report usually contains very little information and different units have to decide their level of alert based on the limited information available. In some cases it is apparent from the beginning that a higher level alert is valid; in other cases the level can be upgraded or downgraded when more information has been made available. The level can be different for different parts of the chain of management and can vary during the response. It is important to consider that it is difficult or even impossible for the staff on the front line, who are often fully occupied taking care of patients, to get an overview of the total need for care or the expected access to resources. It is therefore an important task for the responsible coordinators/commanders at all positions to continuously disseminate the information about the declared level to their staff because it influences both the triage process and selection of treatment.

1.3

The Risk for Major Incidents in the Modern Community

During the last decades, it has been clearly shown that the risk of situations in which available resources are insufficient for the immediate need of medical care has increased significantly and continues to increase parallel to the development of the community: • The global population has increased from 1.6 to 6 billion during the last century, and, with the present annual population increase of 1.33%, the calculated figure for 2050 is 8.9 billion, which is a risk factor in itself. • The continuing urbanization means increasing numbers of people in crowded areas, both for permanent living and gathering together for public events. Such areas are also potential targets for terrorist attacks. • Increasing movement of people, either permanent or by traveling. For example, of Sweden’s nine million inhabitants, in average more than 400,000 are in other countries during the entire year; in the majority of cases they are tourists in areas known to be vulnerable to natural disasters and/or terrorist activity. • Production, transport, and use of hazardous material has highly increased during the last decades. In

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Major Incidents: Definitions and Demands on the Health-Care System

Sweden, 18 million tons of flammable, explosive, chemical, or toxic agents are transported on roads every year, and an additional 3 million tons are transported on railroads. • Hazardous material includes radioactive substances, which the modern community has been increasingly dependent on for the supply of energy, and where we have a recent example of that it involves risks that not can be neglected. • Global terrorism has apparently come to stay, partly replacing armed conflicts. This means that, at any time, in any place, regardless of active involvement in any conflict, and without warning, we can be faced with large numbers of severely injured people. The goal of the terrorist is to get attention for his or her own interests, and the terrorist kills where it is easiest and has the biggest effect, regardless if totally innocent people are killed. • Even if the risk for a global war temporarily has decreased, history speaks for itself, and armed conflicts are continuously ongoing in several places around the world; they probably will continue to go on in response to increasing political tensions and accelerated by increasing clefts between poor and rich populations. • There is today agreement that ongoing climatic changes have generated an escalation of so-called “natural disasters” and that the effects of such disasters with regard to loss of health and life have a potential to increase because of the increase in the global population, increased concentrations of people in limited areas, and building influenced more by economy than security. The World Disaster Report 2007 showed a 60% increase in the occurrence of incidents defined as disasters during the decade 1997–2006. During this period, the reported deaths from such incidents increased from 600,000 to more than 1,200,000, and the number of affected people increased from 230 to 270 million. Paradoxically, in addition to this comes an increased vulnerability of our health care system to these kinds of situations: • Reduced reserve capacity because of increasing demands on efficiency with continuous optimal utilization of all available resources • Increased dependence on advanced technology • Increased specialization with reduced ability to deal with conditions outside one’s own specialty

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An overview with examples and experiences from different kinds of major incidents will be given in the following chapter of this book and will show clearly that, wherever we live or work in the world and how safe and peaceful this area may seem, we can at any time face a situation that requires the knowledge and preparedness described below to be able to reduce the loss of health, life, and suffering for people who depend on and trust our competence in this field.

1.4

Demands on Health Care During Major Incidents

The goal of the health care system during major incidents is to reduce or eliminate loss of life and health, and subsequent physical and psychological suffering, to the greatest extent possible. Achievement of this goal requires two things: 1. Relocating available resources to where they are most needed and rapid mobilization of additional resources (personnel and materials). 2. Optimal utilization of available resources through accurate priorities between patients and between measures and through the use of simplified methods for diagnosis and treatment. Relocation and mobilization of resources requires planning and preparedness, including a prepared structure of coordination and command that defines the positions responsible for decisions on different levels. Optimal utilization of available resources requires education and training of all staff involved in the response to the incident. As in all other fields of medicine, planning and education and training require basic development and research.

1.4.1

The Need for Planning and Preparedness

Do we need special plans for dealing with major incidents? It is not better just to continue working with the organization we already have and are familiar with instead of building up a new organization? All available experience tells us that we need plans to be able to deal with these situations with optimal efficiency, and there are actions of critical importance that have to be prepared before an incident occurs to

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have any chance to work. However, two things have to be clearly emphasized: 1. The goal should not be to build up a new organization but to make necessary adjustments to the already existing organization to divert resources to where they are insufficient, i.e., to the treatment of victims. The plan we create should be one that can be activated in a few minutes, on any day and at any time of the day, regardless of who is on duty. This requires that the plan is simple: Simplicity is the key to realistic and accurate planning. 2. Planning cannot replace education and training. Even the best plan is of limited value if those who are expected to work as an integrated part of it have no knowledge about the plan or the knowledge and skills listed below that are necessary for accurate performance during these difficult situations. Even if the plan must be simple, and even if staff has to be trained, we still need planning. When the alarm comes, there is little time to decide: Whom should I call? Whom should I alert? What kind of steps should I take? Answers to these questions should be clearly stated in prepared action cards for all staff involved, which list steps to take in chronologic order. As a basis for this, there must be clearly defined levels of alert, including the level of increased preparedness that is decided by the (also clearly defined) responsible person in charge when the alarm comes – that person has to be immediately available at any time. Knowing the level of alert, responders follow the action card for that level, and the alerted unit will automatically be prepared for action. A common mistake is to make the planning too complex and “burden” the plan with a lot of unnecessary information for the steps described above. This can happen when administrative staff too far from the “working floor” are making the plan (“a thick plan looks good and indicates good preparedness,” but that plan might be too complex to ever be activated). Therefore, planning should be done by, or at least in close collaboration with, staff on the “working floor.” This requires that all staff involved have a basic knowledge of the principles of planning for major incidents and disasters, which, consequently, is an important part of the education in this field. In hospitals there are a number of things that need to be prepared for an accurate response. For example: • A room prepared for the hospital command group with separate external communication lines and equipment needed for coordination of the response

S. Lennquist

• Prepared areas in, or in connection to, the emergency department for triage and primary treatment of a large number of casualties • Decontamination unit in connection to the emergency department to eliminate the risk that patients who have been contaminated by hazardous material or irradiation enter the hospital • Prepared rooms that can serve as extra theaters for minor surgery; available theaters can be a limiting factor for the surge capacity of a hospital • Ventilators in reserve, or a planned strategy for extra ventilator support, because ventilator capacity is another major limiting factor • Stocks of supplies for mass-casualty management and a planned strategy to get extra supplies because many supplies are limited to the normal immediate need • Reserve systems for electricity, water, communication, and computer support • Equipment for prehospital teams to be deployed to the scene if needed • A system for simple registration of casualties None of this can be done when the alarm comes, and the absence of any of these components can cause a collapse of the whole chain of response, for which the patients will have to suffer. So, certain steps of preparedness and planning are needed. Both planning and preparedness must be based on analysis of experiences from previous major incidents and disasters, and planning is a part of the methodology in the response to major incidents and disasters that has to be continuously developed and critically evaluated. The principles for planning and preparedness in different components of the chain of management will be dealt with in the chapters specifically describing these components.

1.4.2

The Need for Education and Training

To cope with these kinds of situations, it is not enough that we as medical staff do our ordinary job and continue to do it as efficiently as possible. We need additional knowledge and skills of different kinds to be able to respond accurately to the specific demands in these situations. Health care has undergone rapid and extensive development during the last decades. This has resulted in improved treatment results, and many diseases or

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Major Incidents: Definitions and Demands on the Health-Care System

conditions without a cure a few years ago can now be treated successfully. Simultaneously, the development in the community has led to justified demands for increased quality and security. This has generated new and advanced technologies and an increase in specialization, with extensive knowledge restricted to narrow fields of competence. Today’s medical staff often works in limited sectors with access to advanced techniques for diagnosis and treatment. This development is seen not only in highly technologic countries but, to a varying extent, all around the world. Advanced technology and increasing possibilities to cure diseases and conditions generates increasing costs. This leads to increasing demands on efficiency, where every resource must be optimally utilized. However, this means reduced reserve capacity for unexpected high loads of casualties and critically ill patients, which is a globally recognized problem. To summarize this development: • The vulnerability of our health care system to major incidents and disasters is increasing, parallel to a continuously increasing risk for such events caused by the development of community. • This has increased the demands on specific knowledge and skills, in addition to the competence required for daily medical care, to be able to work in an efficient way during major incidents.

1.4.2.1 Knowledge and Skills Requested for Accurate Response to Major Incidents and Disasters A major incident or disaster can hit any time, at any place, and without warning, as has been well illustrated by the development of global terrorism. When we suddenly are faced with the demand to cope with a large number of injured or critically ill patients, we may not have: • Access to, or time to use, the advanced techniques we are used to have at our disposal; • access to specialists to deal with things that normally are handled by such experts; • the possibility to treat all patients with the quality and security that we are used to; • access to theaters or ventilators “in reserve” since every resource is already optimally utilized; • supplies for heavy loads of casualties because many supplies are refilled on day-to-day basis; • the computer support on which all daily routines are based; and/or

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• functioning telecommunication, since modern systems are vulnerable to overloads and technical disturbances. This requires knowledge and skills to: • use simplified methods for diagnosis and treatment; • primarily treat emergencies outside our own specialty, at least those commonly occurring in these situations; • perform triage and make rapid and accurate decisions with regard to priority between patients and between diagnostic and therapeutic measures; • work as an integrated part of an organization when resources must be redistributed rapidly depending on need, which requires knowledge about the organization; • work with limited supplies and know how to get additional supplies; and • use reserve systems if computer or telecommunication systems, or other advanced technical systems, fail. In addition, specific types of incidents require special knowledge, such as management of patients contaminated by hazardous material, biological agents, or irradiation, or who have specific injuries that rarely occur during daily care, such as high-energy missile or fragment injuries, blast injuries, and severely contaminated injuries. Working under austere conditions in areas with highly limited resources or in “chronic” disaster zones with severe public health problems requires specific knowledge in fields such as nutrition, infectious diseases, and management of refugees and displaced populations. All of this requires specific education and training for those deployed to serve in such areas.

1.4.2.2 Methodology of Training Education and training in this field is demanding. Different from other parts of medicine, problems and the methods to deal with them can to a limited extent be demonstrated on patients, and the real incident is no place for education or training. This requires simulation models of different kinds. Practical field exercises have been the most common way to teach and train responders, but they have a tendency to become spectacular events, possibly fulfilling the purpose of illustrating chaotic situations but giving limited feedback to the trainee, which may cause them to question: In reality, what would my decision and performance had led to?

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S. Lennquist

The key-element in education and training in disaster medicine is decision making. Correct decisions have to be made under pressure and in limited amounts of time on all levels, from coordination and command: Which resources to alert? How to use them best?

to individual patient management: What to do with this patient in this particular situation, when and how to do it, and with which priority?

Characteristically, in this field the patient may not get another chance if the wrong decision is made even once. We act as computers: we receive a large amount of information (input data), analyze it, and deliver the decision, which leads to a result (output data). To train and evaluate decisions, all information on which the decision is based and all consequences of the decision must be illustrated. This requires advanced simulation models that illustrate all components in the chain of management (scene, transport, hospital, coordination, and command) because they are linked to each other when determining the outcome. The need for such models has been recognized during the recent years, and they are often replacing the old-fashioned and more expensive form of training with field exercises and figurants. Then, who should be trained? Because any medical staff, regardless of specialty, at any time may be faced by a large number of severely injured or critically ill patients with no specialists or expertise available, the basic principles for working in major incidents have to be taught in special courses during the basic training of doctors and nurses. With few exceptions, this is the case today in Europe. Training is the responsibility of universities and nursing academies and is a requisite for a good standard of training. Staff specializing in emergency disciplines need additional training in their positions, which usually is the responsibility of hospitals, often, in some countries, counties, or regions, with governmental support because it is a matter of security for the population. Staff expected to get leading or coordinating roles need even further training in these difficult tasks, which usually is done by a few regional training centers in every country. Chapter 18 is devoted to the methodology in education and training.

1.4.3

The Need for Development and Research

It has already been emphasized that the development and evaluation of methodology is as necessary in this field as in all other fields of medicine. Examples of important scientific areas include: • Analysis of risks for major incidents and disasters as a basis for planning and preparedness • Continuous and subsequent collection and analysis of experiences and results from major incidents and disasters as a basis for development and evaluation of methodology • Development and evaluation of simplified methods for diagnosis and treatment to be used during these situations • Development and evaluation of reserve systems for technical support, communication, and information technology • Development and evaluation of criteria on good preparedness for quality assurance • Development, evaluation, and validation of educational methods Chapter 19 is devoted to areas and methods for development and research in this field.

Further Reading Aylwin CJ (2006) Reduction in mortality in urban mass casualty incidents – analysis of triage, surgery and resources use after the London bombings on July 7, 2005. Lancet 368:2219–2225 Frykberg ER (2002) Medical management of disasters and mass casualties from terrorist bombings – how can we cope? J Trauma 53:201–212 Gelling J (ed). (2002) Fundamental disaster management. Society of Critical Care Medicine, Mount Prospect Hodgetts T, Mackway-Jones K (eds) (2002) Major incident management and support – the practical approach. BMJ Publishing Group, London Hogan DE, Burstein JL (2007) Basic perspectives of disasters. In: Hogan DE, Burstein JL (eds) Disaster medicine, 2nd edn. Lippincott Williams & Wilkins, Philadelphia Klyman Y, Kouppari N, Mukhier M (2007) World disaster report 2007. International Federation of Red Cross and Red Crescent Societies, Geneva Lennquist S (2003a) Promotion of disaster medicine to a scientific discipline – a slow and painful but necessary process. Int J Disaster Med 2:95–99 Lennquist S (2003b) Education and training in disaster medicine time for a scientific approach. Int J Disaster Med 1:9–15

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Major Incidents: Definitions and Demands on the Health-Care System

Lennquist S (2003c) The importance of maintaining simplicity in planning and preparation for major incidents and disasters. Int J Disaster Med 2004:5–9 Lennquist S (2005) Education and training in disaster medicine. Scand J Surg 94:300–310 Liberman M, Branas CC, Mulder DS et al (2004) Advanced versus basic life support in the prehospital setting – the controversy between the “scope and run” and the “stay and play” approach to the care of the injured patient. Int J Disaster Med 2:9–17 Noji E (ed) (1997) The public health consequences of disasters. Oxford University Press, Oxford O’Neill PA (2005) The ABCs of the disaster response. Scand J Surg 4:259–266 Powers R, Daily E (eds) (2010) International disaster nursing. Cambridge University Press, Cambridge Shapira SC, Hammond J, Cole LA (2009) Essentials of terror medicine. Springer, New York Smart CJ (2008) How and what do you declare a major incident? Prehosp Disaster Med 23:70–75

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Smith E, Waisak J, Archer F (2009) Three decades of disasters – a review of Disaster-specific literature from 1777–2009. Prehosp Disaster Med 24:306–311 Sundness KO, Birnbaum ML (2003) Health disaster management guidelines for evaluation and research in the Utstein style. Prehosp Disaster Med 17(Suppl 3):1–177 Turegano F, Perez-Diaz D, Sans-Sanchez M et al (2008) Overall assessment of the response to the terrorist bombings in trains in Madrid, March 11 2004. Eur J Trauma Emerg Surg 34: 433–441

Websites World Health Organization, International Strategy for Disaster Reduction Report, 2008–2009. World Disaster Reduction Campaign: http://www.unisdr.org/eng/public_aware/world_ camp/2008-2009world_health_day20090407/enindex.html

2

Major Incidents: Examples and Experiences Sten Lennquist

2.1

Terminology

Traditionally, major incidents and disasters have been classified as (1) those caused by human beings or by the development caused by human beings, referred to as “man-made disasters,” and (2) those caused by changes in nature or climate, referred to as “natural disasters.” To the first category have belonged incidents that occur as a consequence of technical failures within, for example, industry or transportation; to the latter category belong events such as earthquakes, volcanoes, hurricanes, and floods. Such classification is not totally relevant because many of the so-called “natural disasters” are consequences of human activities. During recent years the theory that climate changes caused by man indirectly have increased the risk for certain types of natural disasters, like hurricanes and floods, has gained support. The “starvation disasters” witnessed today are to a significant degree the effect of an inaccurate distribution of resources between poor and rich countries, overutilization of nature, and political actions. On the other hand, incidents classified as “man-made” may have been caused by climatologic changes, for example, airplane and ship accidents caused by heavy winds. A more relevant classification may be the following: • Incidents that occur as a consequence of technical development • Incidents intentionally caused by man • Incidents that occur as a consequence of changes in climate and nature S. Lennquist e-mail: [email protected]

2.2

Incidents That Occur as a Consequence of Technical Development

Human beings have always promoted technical development, but development has never gone so fast or been so extensive as it has during recent decades. Thanks to advanced techniques, we have gained a successively increasing standard of living, but through this way of living we consume resources with little attention paid to how this influences nature, climate, and the needs of coming generations. The demands of a continuously increasing standard of living has generated dramatically accelerating industrial production and increased traveling, with faster and bigger transport facilities. Because economic interests often are stronger than concerns about security, the risk for accidents with many people involved, both directly through technical development and indirectly by the influence on nature and climate, is increased. Incidents that occur as a consequence of this development are those caused by: • transport– in the air, at sea, on rails, and on roads; • hazardous material – production, transport, and use of flammable, explosive, chemical, and toxic substances or substances causing irradiation; • fires in buildings, industries, and transport systems; • public and political events – gathering many people together in limited areas; for example, sporting events, festivals, political meetings, or demonstrations; • the collapse of buildings or construction projects where economical interests have been given priority before security; and

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_2, © Springer-Verlag Berlin Heidelberg 2012

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• disturbances in technical systems, such as computer and telecommunication systems, on which we are increasingly dependent in all functions of the community and that are vulnerable to disturbances and overload during critical situations. Incidents in these categories can be caused by mistakes in construction and management, the socalled “human factor” that never can be eliminated completely by security systems. They can also be caused by underestimation of or disregarding risks; for example, as a consequence of economic interests or competition. The Estonia ferry disaster in the Baltic in 2004 (described below), where 852 people died, is a tragic example that we are exposed to risks that are well known but neglected. No responsible professional could be unaware of the risks connected with ferries constructed like the one lost, or that safer constructions are possible but with somewhat reduced capacity related to size. This is may be an example that shows we have to pay a price for our way of living; however, that price should include increased efforts in preparedness to handle incidents like this. However, this is not always the case: After the Estonia disaster, in which the majority of the survivors (97 of 137 people) where saved by helicopters, access to helicopters has not been increased but reduced. Military helicopters are now less available in an attempt to save money and have not been replaced by any alternative. There are, unfortunately, many similar examples.

2.2.1

Transports

Never before in history have so many people and so much material been transported between different parts of the world. Incidents consequent to this are: • airplane accidents; • ship accidents; • accidents on rail; and • accidents on road.

2.2.1.1 Airplane Accidents The intensity of air traffic is continuously increasing. For example, the number of air passengers in the United States was estimated to exceed 985 million in 2009 compared with 580 million in 1995 – almost double over 15 years. Through each of the big airports

in Europe pass between 50 and 100 million passengers every year. The number of accidents during the last years has been low in relation to the intensity of traffic. According to the latest available statistics from the US Aviation National Transportation Safety Board, the frequency of incidents was 0.223 of a total of 11,200,000 takeoffs; of those, 0.018 had a fatal outcome. This means that the risk of being exposed to an incident is 1 in every 500,000 takeoffs, with a fatal outcome of 1 in every 5,500,000 takeoffs, which statistically makes traveling by air by far the safest method of transport. Even if incidents are rare, they do occur. Increased competition between airlines has led to increasing demands on efficiency, which can be a threat to security and is now focus of debate. The continuously increasing traffic density around major airports also involves a risk. Of all incidents, 15% occur in connection to takeoff, 55% in connection to landing, and the rest during flight. In accidents occurring close to airports, effective and fast rescue actions in combination with construction of safer airplanes have increased the number of surviving casualties, a significant trend during recent years. One such example is the 1989 airplane crash in East Midlands, United Kingdom, when a Boeing 737 did an emergency landing close to the airport because of engine failure. The airplane was heavily destroyed (Fig. 2.1), but because of rapid and effective fire secure and rescue, 87 of the 118 passengers survived initially, but 16 died later. Many had severe injuries, and the load on the medical care was heavy. The experiences have been carefully reported in a separate publication (Wallace et al. 1994). Incidents can also occur in areas far from available roads, which means difficult problems for rescue and primary medical care. One of the most tragic examples of this is the jumbo jet crash in Japan in 1985, which was caused by a construction error in the airplane and lead to the death of more than 500 people. The rescue and medical staff did not reach the aircraft until after 14 h, and a few survivors witnessed that many more had survived the crash but died waiting for help. There are other examples of similar delays, emphasizing the importance of faster localization and faster transport of medical staff to the scene during such situations.

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Fig. 2.1 The 1989 airplane crash in East Midlands, United Kingdom. A Boeing 737 crashed during an emergency landing close to the airport because of engine failure. Despite extensive destruction of the aircraft, 87 of the 118 passengers initially survived the crash. Sixteen of these died after primary treatment. The photograph illustrates a clear trend in airplane crashes:

Because of faster and more effective actions during rescue and fire control, as well as improved airplane construction, the chances of surviving an air crash have increased, but this also increases the load on health care with many severely injured survivors (Photo Scanpix, with permission)

One type of incident that has increased in frequency during recent years is airplane crashes in buildings or crowded areas. Surprisingly often, flights to big airports pass over densely populated areas. One example is the an airplane crash in Amsterdam in 1991 (Arturson et al. 1994), where a jumbo jet flew straight into a high building (Fig. 2.2a, b). Miraculously only 50 people were killed; this was a transport flight with only crew on board, and many people living in the houses were outdoors on that occasion. However, it is easy to imagine what the outcome could have been if the airplane had been full of passengers and everyone was at home inside the houses (Arturson et al. 1994). Another example of crashes in densely populated areas is the air show in Ramstein, Germany, in 1988, where an airplane, after a collision, crashed in the middle of the crowd of spectators, resulting in 43 dead and more than 400 injured (Brismar and Lorin 1990). In Sweden in 1993, during an air show over the center of Stockholm, a new military airplane crashed only 100 m from a long bridge crowded with spectators, which easily could have generated a similar scenario.

To this kind of scenario we today have to add airplane crashes caused intentionally in densely populated areas (see below in the section “Terrorist Actions”). Increased traffic intensity also has led to an increased risk for accidents on the ground. The most severe incident of this kind to date was the collision between a Dutch and an American aircraft at the airport of Tenerife in March of 1977; 581 were killed and more than 60 were severely injured. In October 2001, at the Linate air port in Italy, a collision occurred on the ground between a Scandinavian passenger aircraft and a private aircraft, which was caused by a mistake made by the airport flight control and resulted in the death of 118 passengers. The psychological management of relatives of victims killed in a foreign country, a common situation in air crashes, was evaluated after this accident in a special report (Berg-Johannesen et al. 2006). The scenario of injuries in airplane crashes is dominated by blunt trauma and has a pattern of injury similar to that seen in road traffic accidents. The majority (60– 65%) have multiple injuries. Burns have been registered in 8% of injured survivors, where the dominant cause of

12 Fig. 2.2 The 1991 airplane crash in Amsterdam. A jumbo jet coming in for a landing crashed straight into a high-rise apartment building, causing severe destruction and fire. Because this was a transport flight with only crew on board, and because very few of those living in the houses were there at the moment of the crash, the number of casualties was limited, but could have been much higher if the aircraft had been full of passengers and everyone at home in the buildings. (a) Almost 70 tons of fuel caused a violent fire. (b) The site of the crash in the middle of a living area. Today, many flights pass today over crowded cities or other densely populated areas on the way to airports, involving a risk of incidents during which the outcome of dead and injured can be extremely high (Photo Scanpix, with permission)

S. Lennquist

a

b

death has been inhalation of smoke. One such example is the airplane crash in Manchester, United Kingdom, in 1985, where a passenger aircraft caught fire during takeoff and resulted in 55 dead, of whom 80% had cyanide levels in the blood that exceeded the level that causes unconsciousness (O’Hickey et al. 1987; Fries 1991).

A specific injury pattern is seen in helicopter crashes, in which fires are rarely reported because of safer fuel systems. Blunt trauma dominates, with a high in incidence (>60%) of head injuries, and many vertebral injuries are caused by the deceleration trauma (Bledsoe and Smith 2004).

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Major Incidents: Examples and Experiences

13 Table 2.1 Major incidents with ferries during the last 20 years

Airplane Crashes: Summary of Experiences

• Even if airplane crashes are rare in relation to the intensity of traffic, the continuously increasing traffic and demands for efficiency involve potentially increasing risks. • Because of more rapid and effective rescue actions at airports, the number of injured survivors after airplane crashes has increased, thereby increasing the need for and importance of immediate and accurate medical response. • Airplane crashes during flight are rare but can put high demands on rescue service and medical care if they occur far from available roads. • Crashes into buildings or in densely populated areas may result in extensive casualties. • Crashes caused intentionally is a new scenario that must be included in calculated risks.

2.2.1.2 Ship Accidents The development of sea travel includes bigger ships with increasing numbers of passengers, higher speeds, and higher demands on keeping to schedules regardless of weather conditions. Between Sweden and its surrounding coasts, 39 million people are transported every year – four times the population of the country – indicating the frequency of travel by sea. Many ferries can today take more than 2,500 passengers with simultaneous transports of cars and trucks with any kind of material. The loss of the passenger ferry Estonia in the Baltic Sea in September 1994, which resulted in the deaths of 852 people (Brandsjö et al. 1997), is one of the bigger disasters at sea during recent years and is of interest because it was not an overloaded ship run without attention to security, but a modern, high-technology ferry cruising in an area with a normally high standard of security. For many, this was a wake-up call from believing that “such things cannot happen.” Still, this was not the first ferry accident of this kind (Table 2.1). Ferries of this kind have a big open cavity inside, which is separated from the water outside by rather thin walls and by a big front door wide enough for trucks and trains to pass through. If water comes into this cavity, a level up to 10–15 in. is enough to make the ferry roll around; if the water (by the movement of the sea) collects on one side, there is nothing between to stop it. This process can happen fast, so

Year 1987

Ship Donna Paz

Position Philippines

1988

Belgium

1991

Herald of Free Enterprise Scandinavian Star Salem Express

1993 1993 1994

Jan Hewelius Ferry Estonia

1990

Sweden Red Sea Baltic Sea South Korea Sweden/ Estonia

Cause Collision, fire Technical failure Fire Ground strike Storm Storm Technical failure

Number of dead 2,000 188 158 480 55 292 859

Table 2.2 Examples of major incidents in sport arenas during the last 15 years Year 1985 1985 1988 1989 1991 1991 1996

2001 2001 2010

Place Bradford, UK Brussels, Belgium Katmandu, Nepal Hillsborough, UK Orkney, South Africa New York, USA Guatemala City, Republic of Guatemala Johannesburg, South Africa Ghana, India Phom Phen, Cambodia

Cause Fire Congestion Congestion Congestion Congestion

Dead 55 39 80 96 40

Congestion Congestion

8 84

28 147

Collapse

43

250

Congestion Collapse

123 349

Injured 200 437 700 400 50

Unknown Unknown

there may not be enough time to evacuate passengers or to launch lifeboats; this was exactly what happened to the Estonia after a leak through the big frontal doors, the cause of which is still unknown but probably it was caused by a combination of high speed and heavy waves. This was not the first time this happened: In 1987, the ferry “Herald of Free Enterprise” rolled around just after departure from the harbor in Zeebrügge, Belgium, this time because someone had forgotten to close the front doors. More than 200 passengers died, and the outcome would have been even worse if it had not occurred in shallow water with parts of the ferry still above the surface (Lorin and Norberg 1998). Similar accidents have been described before that of the Estonia (Table 2.2).

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other reasons for leakage remain in these crowded ferries, which run with high speed in heavy traffic and bad weather conditions. Examples of learning and disregarding the lessons learned is not unusual in this field. Accidents at sea have moved toward an increasing number of dead with every incident, probably because the ships have become bigger and the number of passengers higher. Of 353 registered accidents between 1970 and 1985, 50,000 people died, whereas the 20 biggest accidents during 1980–1995 caused only 15,400 deaths. The largest accident at sea during peace time so far is the collision between a Philippine passenger ferry and an oil tanker in 1987, which resulted in the loss of more than 2,000 lives. Fire on board ships is another cause of death at sea. The fire on board the passenger ship Scandinavian Star off of the Swedish coast in 1990 caused the deaths of 159 people. This incident describes the importance of collaboration between countries and organizations in these complex rescue actions (Almersjö et al. 1993). Ship Accidents: Summary of Experiences Fig. 2.3 Ninety-seven of the 137 survivors of the Estonia ferry disaster were saved by helicopters with surface rescuers that could pick up survivors from the water. This work was demanding and risky in heavy wind and waves. The rescuers had no chance to pick up all passengers, but gave priority to those showing signs of life. This included a risk of leaving hypothermic victims with a possibility of survival on the rafts, but it was probably the best possible triage under these difficult circumstances (Photo Scanpix, with permission)

Of the 989 registered passengers and crew on board the Estonia, 852 drowned, probably because most of them never had time to get out. Of the 137 survivors, only 40 could be picked up by other ships that were available quickly but were not prepared to pick up people from the water in heavy waves. Ninety-seven survivors were picked up by helicopters from Finland and Sweden (Fig. 2.3). The helicopters arrived late: the first, 2 h after the incident, and the majority arrived after several hours. In water this cold – 10°C (50°F) – the chance of surviving more than 3 h is less than 50% and falls rapidly as time spent in the water increases. In other words, rapid access to helicopters is vital. Still, no steps have been taken to increase access to helicopters; on the contrary, access has been reduced significantly by the removal of military helicopters on the Swedish side. The ferries themselves look the same, and although some strengthening of the front gates has occurred,

• Bigger ships, higher numbers of passengers, higher speeds, and competition along with demands to keep time tables independent of weather conditions have increased the number of incidents, with many dead. • The construction of big ferries, where economical interests are given priority before safety, accelerates this risk. • Rescue actions at sea put big demands on collaboration between countries and organizations and require training for good preparedness. • Rapid access to helicopters can be of vital importance for survival in heavy weather and/ or low water temperatures and must be included in planning and preparedness. • Hypothermia and drowning are conditions outside normal routines for most medical staff, and both require increased knowledge and training.

2.2.1.3 Accidents on Rail The total number of dead in train crashes may seem limited compared with those dead in road traffic incidents, but when train accidents occur, the number of simultaneously injured can be high, putting demands on preparedness and response.

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Major Incidents: Examples and Experiences

Fig. 2.4 (a, b) The high-speed train incident in Eschede, Germany, in June 1998. An overheated wheel locked and cut the rail off, and the wagons behind it derailed and crashed into a concrete bridge, which collapsed and crushed parts of the train. One hundred one people died and 87 were severely injured. The pictures illustrate the difficult and time-consuming work to rescue many trapped patients (From Hülse and Oestern 1999 with permission)

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a

b

The speed of trains has increased greatly during the last decades. How much this influences the risk for incidents remains unknown. In Japan, one of the leading countries in fast train travel, more than 10,000 persons have been injured in more than 80 registered train crashes during the last 2 decades. A well-documented example of an accident with a high-speed train was the derailment in Eschede, Germany, in June 1998 (Hülse and Oestern 1999). The cause was overheating in a wheel, which caused it to “lock” and thereby cut off the

rail, which led to the subsequent wagons in the train being derailed. This was just before the train was to pass under a concrete bridge. Instead, the derailed wagons crashed into the bridge (Fig. 2.4) which collapsed and caused extensive damage. One hundred one people died and 87 were severely injured, and many were trapped, which required an extensive rescue action. The value of helicopters for transport and bringing resources to the scene was clearly demonstrated during this incident. Overheating in wheels, resulting

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in damage to the rail and derailment, is a well-known phenomenon that has been reported both before and after the Eschede derailment but with less severe consequences. The biggest incident on rail with regard to the number of dead and injured happened in Bashkira, Ukraine, in 1989. Leaking gas from a gas line caught fire in the same moment as two trains, on their way to and from a tourist resort, met, which probably induced the fire. Eight hundred people, of whom many were children, were treated for burns, and a large number of people died (calculations say more than 2,000, a figure that never was confirmed). Rescue and medical teams from many countries participated in the rescue operations (Kulaypin et al. 1990; Becker et al. 1990). Incidents on rail also include trams and underground trains in major cities. In Gothenburg, Sweden, in March 1992, a tram without a driver ran downhill in the center of the city after the breaks failed when it was parked on top of the hill. With increasing speed, the train crushed everything in its way, resulting in 42 injured and 13 dead (Almersjö and Kulling 1994). Special problems are connected to incidents occurring in tunnels: trapped passengers and difficulties with gaining access to and evacuating casualties. The collision of two trains in the London subway in 1964 that left 30 dead and 150 injured, and a fire in King’s Cross subway station (also in London) in 1987 that left 31 dead and 60 injured (Hallén and Kulling 1990), are examples on this. In the terror attacks in London in July 2005 (further described below), three of the simultaneous attacks were directed at the London subway (Aylwin 2006). The Sarin gas attack in Tokyo in 1995 (Kyriacou

Accidents on Rails: Summary of Experiences

• Increasing speed on our railroads has increased the risk of incidents with many injured. • Special problems during rescue actions include trapped patients and difficulty gaining access to and evacuating the injured, resulting in timeconsuming operations with demands on treatment on-site and during extrication. • These problems increase further when incidents occur in underground railways or tunnels, which also have been targets of terrorist attacks during recent years.

2006), also described below, is another example of a terror attack directed at an underground railway.

2.2.1.4 Accidents on Roads Serial collisions on highways during darkness, fog, or in slippery conditions can result in many injured and dead, and several such incidents have been described during recent years, a consequence of increasing traffic intensity in urban areas. Trapped patients and traffic jams reducing access to the scene are problems described in connection to such incidents. An important lesson is that road traffic accidents under special circumstances can justify major incident response. A more common cause of major incidents in road traffic is bus crashes. The size and speed of buses have increased, and the use of buses in the tourist industry has also increased. In Sweden, where buses are frequently used in charter traffic, 15 major incidents with buses have been reported during the last 2 decades, with more than 500 injured and 50 dead. This has resulted in efforts to increase security by better construction and seatbelts as standard. Figure 2.5 shows one of the latest incidents, a collision between two buses on a slippery road in the north of Sweden, far from the nearest hospital, with six dead and 62 injured, many of them severely. Another reminder that bus crashes can lead to a heavy load on local hospitals in rural areas. Road Trafﬁc Accidents: Summary of Experiences

• Serial collisions on highways during high traffic intensity and bad weather conditions can cause major incidents. Care of trapped patients before they reach a hospital may be needed during time-consuming extrications. • Bus crashes with many injured and dead have increased with increasing use of high-speed tourist buses and are another cause of major incidents on roads; the resultant load on medical care in rural areas can be considerable.

2.2.2

Accidents Caused by Hazardous Material

Next to terror actions, accidents caused by hazardous material have increased most during recent years. The risks are apparent: In Sweden (nine million inhabitants),

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Major Incidents: Examples and Experiences

17

Fig. 2.5 The bus crash in Rasbo close to Uppsala, Sweden, in February 2007 resulted in six dead and 62 injured, many severely. The picture illustrates the difficult and time-consuming rescue operation of many trapped patients (Photo Scanpix, with permission)

every year 18 million tons of flammable, explosive, chemical, and toxic substances are transported on our roads, and an additional 3 million tons are transported on rails, often passing through densely populated areas. The most serious incident with flammable and explosive substances to date is the propane explosion in San Juanico, Mexico, in 1984 (Arturson 1987). A series of explosions after a leakage in a propane depot in a densely populated area close to Mexico City resulted in more than 7,000 burn-injured casualties; 600 of them died. The use of propane is increasing, and the San Juanico disaster is only one of many incidents of this kind. If stored propane is leaking (for example, because of deficiency of a valve or collision) and starts to burn, the storage tank is heated and the liquefied propane starts to boil and becomes vaporized to gas under pressure, which finally ruptures the tank. This leaking gas is highly flammable and can cause an explosive fireball several hundred meters in diameter, burning everything in its way. This phenomenon is called BLEVE (boiling liquid vapor explosion). The relatively low mortality among those who were severely burned in San Juanico was probably because of the extensive resources for treating burn injuries in Mexico City. In several places in Europe the same incident would have demanded international collaboration to care for all the burns. The large number of injured in San Juanico was partially caused by the fact that homes had been built quite close to the propane depot. A BLEVE disaster

more representative of European conditions was the propane explosion in Los Alfaques, Spain, in 1978. A truck with propane containers refilled the supplies in a camping area close to a popular swimming resort. The truck ran into a stone wall; there was a leakage and fire resulting in a BLEVE that caused more than 100 immediate deaths and 140 burn injuries, many of which were severe. The triage and primary management of the injured, following different treatment lines with different strategies, has been carefully analyzed and significantly contributed to the knowledge in this field (Arturson 1981). Several other BLEVE disasters have occurred both before and after San Juanico, and the risk of other remains considering the frequent, extensive, and increasing transportation of propane. Accidents with leaking gas may demand evacuation of large numbers of people from the risk zone. An example of this was the train crash in Missisauga outside Toronto, Ontario, Canada, in 1979. The train was carrying a variety of hazardous material, among them propane and chlorine gas. The propane exploded in the crash, causing damage to the chlorine gas wagon, where leakage occurred. More than 210,000 people had to be evacuated from the disaster zone. However, injuries were limited thanks to well-performed rescue and evacuation processes (Baxter 1990). To date, the worst disaster caused by toxic substances happened in Bhopal, India, in 1984. Through a failure in a safety valve, leakage occurred and released 43 tons of methyl isocyanate, an intermediate product

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in the production of pesticides. Five hundred twenty thousand (520,000) people were exposed; of those, 8,000 died during the first week, and another 8,000 died later. Ten thousand were treated for symptoms caused by the exposure, and they may still have symptoms or impairment as a consequence of the disaster. The disaster has been carefully retrospectively analyzed and the long-term effects followed up (Eckerman 2005). The terror attack with the nerve gas Sarin in Tokyo’s underground railway in 1995 (already mentioned and described in detail below) is another example illustrating the large number of injured and dead that can be a consequence of incidents of this kind. The management of incidents that include hazardous material is dealt with in detail in a separate chapter of this book. Accidents Caused by Hazardous Material: Summary of Experiences

• Incidents caused by hazardous material can result in numbers of dead and injured widely exceeding those caused by mechanical violence. • The risk of such incidents is increasing parallel to increased production, transport, and use of such substances. • Preparedness must include plans for decontamination and evacuation of large numbers of people. • Staff within risk zones should not work without personal protection equipment, which must be clearly defined, and special staff must be trained to use such equipment. • Antidotes for substances used in or transported through an area must be stored and rapidly available in that area.

2.2.3

Accidents Caused by Radiation

Nuclear plants are needed for the supply of enough energy to permit our present standard of living. Even if safety protocols are rigorous and the technology advanced, they are operated by human beings, and human beings can and do make mistakes. Nuclear plants also may be potential targets for terrorism, and they are vulnerable to natural disasters that we cannot control. This means risks, and if incidents occur, the consequences can be severe and extensive.

Incidents so far have been few and mainly caused by technical failures. One example is the Chernobyl disaster in Ukraine in April 1986 (Brandsjö et al. 1992). The reactor exploded after security systems had been disconnected for a test. In a subsequent violent fire, a large part of the radioactive content of the reactor was released and spread over a wide area. The number of immediate deaths was limited to 31 (reactor and rescue staff). More than 100 were treated for irradiation injuries. The long-term consequences for the contaminated areas have been difficult to determine. A change in the pattern of malignant tumors, especially among children, has been registered in areas close to the disaster. One lesson to be learned, in addition to matters of reactor safety, was the need for better preparedness to determine contamination and inform about risks. Just when the manuscript for this book was delivered to the publisher, Japan was hit by the one of worst earthquakes ever registered (9.1 on the Richter scale). It occurred off the coast of Sendai and created a tsunami wave that hit the coastline with devastating effects (Fig. 2.10). Several of the Japanese nuclear plants are located along this coastline and were hit by the wave. Reserve electricity and cooling systems were destroyed, leading to overheating of the plants with a risk of meltdown and severe leakage of radiation (Fig. 2.11). At the time of this writing, the consequences of this are difficult to overview, and information available at the time of printing will be summarized in Chap.11 on irradiation incidents. Our standard of living requires more energy than we can produce with conventional techniques without destruction of nature, and of alternative sources of energy, nuclear power has been considered the only one available today that has sufficient capacity to fill our needs. To believe that we can master this advanced technology with total elimination of risks is, of course, not realistic. What is happening in Japan right now is an example that to live the way we do requires acceptance of risks. This, however, also means a responsibility to inform people about these risks and take all steps we can take to prepare ourselves to handle them. On this point, our political leaders on all levels still have a long way to go. Irradiation injuries are not restricted only to nuclear plants; they have occurred as long as radiation has been part of our technology. During the last few decades, more than 3,000 accidents with radiation have been reported to the International Atomic Energy Association, many of them severe and leading to death or severe diseases. Therefore, knowledge about triage,

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Major Incidents: Examples and Experiences

diagnosis, and primary treatment of such injuries should be included in disaster medicine education. This is dealt with in chap. 11. Accidents Caused by Radiation: Summary of Experiences

• Nuclear power will, for the near future, be necessary to maintain our present standard of living, and, even with rigorous security, risks for incidents can never be eliminated completely. • Such incidents may lead to contamination of wide areas, and consequences are difficult to overview. • This requires prepared systems for rapid determination of irradiation, information, decontamination, and evacuation, which have to be included in disaster preparedness and in education and training in disaster medicine. • In addition to nuclear plants, substances causing irradiation are used in many areas of our community, and many incidents are reported every year, requiring the same kind of attention and preparedness as for other types of incidents.

2.2.4

Accidents Caused by Fire

The fire brigade in a country like Sweden (nine million inhabitants) is involved in 30,000–40,000 missions every year because of fire. Burn injuries are registered in 20,000 people every year, but only 10–15% of these need hospital care, of which only 1% (approximately 200 people) need treatment in a specialized burn unit. Fires inside buildings or ships usually do not cause a high number of burn casualties because most of those injured by fire usually die from inhalation of toxic gases. For example, the fire in the ferry Scandinavian Star (described above) left 159 dead, but only 4% of those died from burn injuries. The rest died because of lack of oxygen in combination with inhalation of gases as carbon dioxide, carbon monoxide, and cyan hydrogen. Fires outdoors, on the other hand, can cause extensive numbers of burns. One example is the propane explosion in San Juanico, Mexico (described above), which resulted in more than 7,000 burn casualties. Another example is the intentionally caused fire in the Bradford (UK) football stadium in 1985, which left 50 dead and several hundred survivors with burn injuries.

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Fire in high buildings is a special and increasing problem for rescue services. An example of such an incident in a modern hotel is the fire in the MGM hotel in Las Vegas, Nevada (USA) in 1980, with 84 dead and more than 700 injured (Buerk et al. 1982). Another more recent example is the World Trade Center disaster in Ney York City in 2001, which is described in further detail below under “Terror Actions.” Public events seem to include an increased risk for large numbers of burns, often by intentionally caused fires. One of many examples is the discotheque fire in Gothenburg, Sweden, in November 1998, which resulted in 63 dead and 182 injured. One hundred fifty of the injured needed in-hospital care and 74 required intensive care because of severe burns and/or smoke inhalation (Cassuto and Tarnow 2003). Because the number of beds in specialized burn units is limited and usually not adapted to major incidents, these kinds of incidents require national and possibly international collaboration, with distribution of patients requiring special burn care over a wide area, even if the primary treatment and triage has to be done on site as much as possible with support from burn specialists. At the Gothenburg fire, all specialized burn units in Sweden were involved, and some patients needing special burn care had to be transferred to Norway. Fires in industries may have severe consequences depending on the products produced. One example is the fire in a pyrotechnic industry that produced fireworks in Enschede, the Netherlands, in May 2000, which resulted in 20 dead and more than 200 injured (Fig. 2.6). A chapter in this book is devoted to the special problems connected to management of large numbers of burns and describes principles of triage and primary treatment.

Accidents Caused by Fires: Summary of Experiences

• Fires may cause large numbers of burn casualties, many of which will require special resources for successful outcomes. Special burn care facilities in most countries are not adapted for mass-casualty situations, which require planning and preparedness for national and international collaboration for management of many injured, including transportation.

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Fig. 2.6 Explosion in a pyrotechnical industry in the center of a densely populated area in Enschede, the Netherlands, in May 2000, resulting in 20 dead and more than 200 injured (Photo Scanpix, with permission)

• Primary management and triage has to be done at the primary receiving hospital because of the time factor, and, as an important part of preparedness, this requires knowledge about principles both for triage and primary treatment in all hospitals receiving trauma patients. • The major cause of death in fires occurring indoors or inside transport units is smoke inhalation. Diagnosis and treatment of inhalation injuries is therefore an important part of this knowledge.

2.2.5

Accidents During Public Gatherings

Public gatherings such as sporting events, political meetings, concerts, and shows, involve a risk in themselves because many people are collected in limited areas, which can be difficult and time-consuming to evacuate. Examples of the effects of fire during such events have been described above. But such gatherings can turn into disasters without fire: Only 1 month

after the fire in the Bradford football stadium in England, 40 people were killed and 400 were injured in a football stadium in Brussels after a confrontation between supporter groups, leading to the mass movement of spectators that crushed many to death and injured even more. There are many similar examples of mass-casualty situations caused by panicked movement in crowded sport arenas or stadiums (Table 2.2). Mass gatherings of any kind are a potential target for terrorism because it is an easy way to cause the biggest possible numbers of dead and injured and at the same time attract attention and glamor for the terrorist group behind the attack. Accidents Connected to Public Gatherings: Summary of Experiences

• Large gatherings of people, regardless of purpose, constitute a potential risk for masscasualty situations that justifies attention and accurate preparedness within the medical care system.

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Major Incidents: Examples and Experiences

• Panic movements alone, without additional causes of injury, are enough to kill and injure large numbers of people. • Restrictions on the number of people needed to enforce rules, secure evacuation lines, barriers reducing the effect of panic movements, and sufficient numbers of security guards are safety measures that should not be limited by economic interests.

2.2.6

Collapse of Buildings and Constructions

Experiences show that both old and new buildings can collapse without external violence, just because of failures in construction – perhaps a combination of human errors and/or lowering priority of safety because of economic interests. One example is the collapse of the Ronan Point Apartment Tower in London in 1968 (Lee and Davis 2006). This totally new building was 70 m high, with more than 100 fashionable apartments into which people just had moved. A small gas explosion on the top floor resulted in a domino effect causing total collapse of the whole building down to the bottom floor – similar to the collapse of the World Trade Center buildings but without external cause. Miraculously, the majority of the 260 people in the building managed to get out because the collapse proceeded slowly, but this and other incidents illustrate that even modern buildings can have fatal errors in the construction. The scenarios in these incidents are similar to that during earthquakes: The least severely injured come out first; the more severely injured, who technically require extrication first, come out later, often with complex and severe injuries. Blunt trauma dominates the pattern of injuries. Bridges can also collapse, with fatal consequences. An example is the collapse of the Sunshine Skyway Bridge in Tampa Bay, Florida, in 1980 (Melville and Rahman-Kahn 2006), which was caused by a tanker that because of reduced visibility ran into one of the pillars. The whole central part of the bridge that was full of traffic collapsed. Thirty-five people died and many were injured.

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Collapse of Buildings: Summary of Experiences

• Collapse of old and new buildings and buildings under construction can occur without, or with only minimal, external violence, and this should be taken into consideration during disaster planning in urban areas. • The scenario and pattern of injuries is similar to that caused by earthquakes. and experiences from such disasters should be considered in the planning.

2.3

Disturbances in Technical Systems

This type of risk has been added recently to the bank of potential scenarios. Technical development has facilitated our lives in many ways, but it also has made us highly dependent on this technique working properly. Many people are most likely unaware of how vulnerable we will become if these systems fail. Many functions in our community – telecommunication, transport systems, industry – are totally based on such techniques and because they usually work under normal conditions, limited efforts to create reserve systems have occurred. In the event of major incidents and disasters, there is a high risk that these systems will fail – either damaged by the cause of the incident, intentionally destroyed (as in terrorist actions), or just overloaded. One example is the breakdown of the central computer systems during the World Trade Center disaster in 2001 (Connocenti and Azima 2003). This clearly illustrates the need for reserve and backup systems as an important part of preparedness for major incidents. Unfortunately, this is one part of our planning where much remains to be done. The health care system has, during the last few years, been dependent on computer techniques to an extent that not everyone is aware of or considers. Anyone that has experienced a collapse in the central computer system in a big hospital has had that frightening experience: practically every function in the hospital is paralyzed – results of laboratory tests cannot be provided, necessary supplies cannot be delivered, technical functions fail, and telecommunication fails. If this happens during a major incident, the consequences might be fatal if reserve and backup systems are not prepared as part of the disaster planning.

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To these potential risks we must add the risk of intentional attacks on our computer systems. In the summer of 2007, the country of Estonia was exposed to a cyber attack, i.e., large numbers of e-mails were simultaneously sent to the central severs of the country, which led to a temporary but illustrative breakdown. The attack was interpreted as a political action. Our preparedness for such attacks is limited, which further emphasizes the need for reserve systems for critical functions, such as health care. Vulnerability of Technical Systems: Summary of Experiences

• The dependence on advanced technical systems has increased the vulnerability of the community, including the health care system, to technical disturbances. • Experiences show that such systems may fail during major incidents and disasters. • To avoid fatal consequences of system failure, preparedness must include backup and reserve systems for critical functions, an area where much remains to be done.

2.4

Intentionally Caused Incidents

2.4.1

Armed Conﬂicts

Even if the current risk for a global war according to political experts seems to be small, armed conflicts are going on in many places in the world, as they have done as long as human beings have existed, and most likely will continue. Unfortunately development has gone toward an increasing involvement of civilian populations. To take care of those injured in armed conflicts – military as well as civilians – is an important task for medical staff. These are often situations in which available resources are insufficient for the immediate need of medical care, which by definition makes this field a part of major incident response. From an organizational point of view, there is a difference between medical care during armed conflicts and medical care during “civilian” incidents: Armed conflicts rarely occur without warning, which gives time to plan and build up a good organization. On the other hand, this organization has to be in action for a

long time, months or even years. In “civilian” incidents, there is often no warning at all and a community can be faced with a heavy load of severely injured only a few minutes after an alarm; however, the inflow of patients, in most cases, does not last more than 24 h, with the exception of a major incident level 3. This difference requires different organizations, and a common mistake has been to build planning for major civilian incidents on military experiences, which not is relevant because it leads to an organization that takes too long to activate and includes components rarely needed in civilian major incident response. However, with this exception, military experiences are valuable for the management of “civilian” major incidents disasters, and research, education, and training in these fields should be closely linked. Armed forces also have good resources that should be prepared and available for use during major civilian incidents, which should be part of the planning on national and regional levels. There are differences in the pattern of injuries between military and civilian trauma, but with global terrorism as the new threat, many injures traditionally considered to be military are seen after terror attacks and have to be treated by civilian staff. The principles for primary management of such injuries should, therefore, also be a part of education in disaster medicine. The characteristics of war injuries and the principles of combat casualty management are described in a separate chapter in this book.

2.4.2

Terror Actions

Many consider the global terrorism as “the modern form of war,” replacing the traditional armed conflicts. The tragic thing about terrorism is that it strikes blindly, with the aim to cause as much death and suffering as possible, regardless of whether those killed and injured are in any way involved in, or even aware of, the conflict behind the attack. This means that we as medical staff, wherever we live and work, at any time and without any warning can be faced with the task of taking care of large numbers of injured from a terror attack. Knowledge of the common pattern of injury in such incidents and how to deal with it is today an important part of education in disaster medicine. Today we have to face the fact that it is possible for groups of people who want to cause biggest possible damage, death, and suffering to come into possession

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Major Incidents: Examples and Experiences

of harmful agents as weapon systems, chemical and toxic agents and microorganisms that can cause extensive damage even without access to advanced techniques of dispersion. Global terrorism was forecasted to be the major disaster risk of the new millennium. Still, the World Trade Center disaster on September 11, 2001 (Pryor 2009) was a shock to many. It was a well-organized action with a global network and strong economy behind it. Three simultaneous attacks were performed, all using hijacked passenger aircrafts with innocent people aboard who were used as human missiles toward selected targets. The attack toward the World Trade Center in central Manhattan, New York, was successful, leading to 2,762 deaths when both towers collapsed. One thousand one hundred three injured needed hospital care; 29% of these were rescue staff and police that performed heroic efforts to save people from the inferno. The load of casualties on the extensive medical resources in New York was high, but not as high as expected because most of the severely injured died when the towers collapsed. The central computer systems in New York City collapsed subsequent to the incident (Connocenti and Azima 2003), which seriously affected the involved hospitals, illustrating again the vulnerability of the health care system to technical disturbances (Fig. 2.7). One of the three attacks, probably directed toward the White House in Washington, D.C., failed because the airplane crashed before reaching the target. However, the aim to kill all innocent passengers and crew on board was successful. The third attack, directed at the Pentagon, hit the target but did not get the desired effect because it hit a part of the building occupied by few people. September 11 was the introduction to a series of extensive terrorist attacks in different parts of the world, and some of them deserve further description. In March 2004, a series of simultaneous bomb explosions hit four commuter trains in the center of Madrid, Spain (Turegano et al. 2008). Ten different bombs had been placed in backpacks or hand luggage in the different train wagons and were successively released by mobile telephones during a 3 min time period to create the biggest possible chaos. One hundred seventyseven people were instantly killed. Seven hundred seventy-five injured were taken to the largest hospitals in Madrid; 263 of these had minor to moderate injuries whereas 512 needed more extensive treatment (Turegano et al. 2008).

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Fig. 2.7 Two hijacked passenger aircraft operated by suicide pilots fly almost simultaneously into the two towers of World Trade Center in New York, New York on September 11, 2001. These crashes resulted in the death of more than 2,700 people, and more than 1,000 were injured and required hospital care (Photo Scanpix, with permission)

The terrorist attack in Madrid is still described as the most severe attack of this kind that has hit Europe, which is correct with regard to the number of dead. In July 2005 the next simultaneous attack hit London and has been described as the most extensive mass-casualty scenario in the United Kingdom since World War II (Aylwin 2006). In July 2007, in the middle of the time with the highest traffic intensity, three bombs were released simultaneously in three underground trains in central London. At the same moment, a fourth bomb was released on a bus close to a bus station. The total number of injured exceeded 750, but the number of dead was less than in Madrid. As in Madrid, those who died did so in immediate connection to the incident and the late mortality was quite low, probably because of good primary treatment and good triage. The experiences from these two attacks, which have much in common, illustrate: • Problems in communication, both within the prehospital organization and between the scene and the hospitals

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• Initial “over-triage,” with many patients in the prehospital phase given too high a priority • Initial maldistribution of patients between hospitals because of failure in communication • Initial deficits in security, with too many volunteer helpers initially involved • Lack of knowledge about blast injuries among medical staff Both of these incidents happened in major cities with good access to medical facilities of all kinds and staff with a high level of competence, probably contributing to the low rate of late mortality. The London and Madrid attacks are examples of scenarios caused by physical violence. Terrorists also use other mechanisms of injury. In an attack on Tokyo’s underground in March 1995, containers with the nerve gas sarin were placed in five wagons in three of the underground lines (Kulling 1998). The gas spread quickly, and within a short time alarms came from 15 different underground stations. A total of 6,000 people were exposed to the gas. Of these, 3,227 were taken to hospitals, altogether 493 were hospitalized in Tokyo’s 41 hospitals. Twelve people died, ten as a direct consequence of the exposure and two from secondary brain injury. An additional number of patients developed secondary brain damage. Many of the rescue staff, working without personal protection, also developed symptoms after the exposure but had no fatal or persistent injuries. Another terrorist scenario is the use of biologic agents. Soon after September 11, anthrax bacteria were intentionally spread in the US mail system. The consequences were able to be limited, but the treatment of bioterrorism is taken seriously all over the world. There are indications that cultures of bacteria against which we have no immunity are kept somewhere, and if organisms that cause diseases with relatively long incubation periods are taken into a country, they will have spread beyond control by the time they are discovered (Kyriacou 2006). The possibility that countries supporting terrorism will produce and use nuclear weapons has also been discussed as a possible disaster scenario. In some countries, terror attacks are a part of the daily routine, with hundreds of people killed and even more injured every month. Because this is something that can happen any time in any part of the world, it is important that experiences from such countries is used for preparedness, education, and training in countries where terrorism is less frequent.

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Terror Actions: Summary of Experiences

• Today, global terrorism constitutes perhaps our biggest risk for major incidents and disasters next to the big “natural disasters” and can, in contrast to natural disasters, occur at any time at any place in the world. • It is today possible even for small groups of people to come into possession of systems or products with great potential to cause extensive damage, resulting in high numbers of dead and injured. • Terrorism strikes with the aim to cause as much suffering and death as possible, regardless of whether the victims are totally innocent and not involved in, or even aware of, the reason behind the attack. • This requires preparedness for these scenarios in all parts of the world as well as knowledge about the specific characteristics of these injures and their management as a part of education and training in disaster medicine.

2.5

Incidents Consequent to Changes in Nature and Climate

Incidents caused by changes in nature or climate can be categorized according to how quickly they hit us: • Sudden onset: Incidents that hit us quickly with little or no warning, such as earthquakes, volcanoes, floods, and heavy winds (hurricanes, cyclones, tornadoes) • Slow onset: Incidents that hit us more slowly and gradually, such as drought, starvation, and pandemics

2.5.1

Sudden-Onset Incidents

2.5.1.1 Earthquakes During the last decades, almost 500,000 people have been killed and approximately three times as many have been injured in the most affected zones in the world. Examples of major earthquakes are Guatemala in 1970 with 67,000 dead and 143,000 injured, and China in 1976 with more than 200,000 dead. Usually the number of injured are three to four times the number of dead; for example, in Kobe, Japan, in 1995,

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Major Incidents: Examples and Experiences

Fig. 2.8 The earthquake in the Sichuan Province in central China hit a densely populated area with extensive material destruction (a), including hospitals, which is why the initial medical resuscitation had to be performed under primitive conditions (b) (a Photo Scanpix, with permission; b from Wang et al. 2011, with permission)

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a

b

5,300 were killed and 27,000 injured (Lorin et al. 1996). However, there are exceptions. In Armenia in 1988, 25,000 died, whereas the number of registered injured only was 30,000. These differences can be influenced by geographic differences but may reflect differences in the quality of primary management and triage. Of major earthquakes during the last decade should be mentioned the one in Bam, Iran, in December 2003, which was caused by a shockwave of 6.5 on the Richter scale. More than 40,000 people were killed, approximately 30,000 were injured, and approximately 75,000

were left homeless. International assistance was provided by more than 60 countries from all parts of the world. One of the most severe earthquakes in modern times occurred in May 2008 when the Sichuan province in China was hit by a shockwave of 7.8 on the Richter scale (Fan et al. 2011; Wang et al. 2011). Seventy thousand people died and more than five million lost their homes (Fig. 2.8). In January 2010 the capital of Haiti, Port au Prince, was struck by a shockwave that measured 7.0 on the Richter scale (Missair et al. 2010). This earth quake

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affected a low-income country with a weak government and a weak infrastructure in the community. The most affected areas were densely populated, which resulted in a very high mortality. The estimated number of dead was approximately 200,000, and far more were injured. The already insufficient health care system could not cope with the extensive number of injured, and deficiencies and destruction of infrastructure (damaged roads and airports) made international support missions difficult. However, the international assistance was massive and approximately 50 foreign field hospitals arrived during the first 2 weeks. The United Nations cluster system was activated to coordinate the more than 300 health agencies active in the disaster zone. The lack of coordination was, as in all previous similar events, criticized, which illustrates the well-known need for better synchronization between supporting agencies based on need assessment and communication with the region receiving the support. This requires planning and preparedness on an international level “before it happens,” which is a continuous challenge for coordinating organizations (Missair et al. 2010). Also, many of the support actions during the aftermath of the Haiti earthquake have been criticized for insufficient attention to specific needs, both with regard to the situation in general and the pattern of injuries; the expression “disaster tourism” has been launched on the presumption that missions may be done with the aim to “learn and watch” more than to help. Even if such things may occur, it has to be emphasized that the vast majority of efforts are done with the best intentions to support suffering people. However, knowledge about how to handle the specific patterns of injuries met in these situations, and problems connected to this, is necessary for successful support missions, and this is an important part of education and training within this field. This is also the reason why a considerable part of this book is devoted to the primary management of injuries met in these situations. It has been debated how big the need really is for urgent surgical procedures – for example, surgical teams or a field hospital – in situations like this, and many experiences indicate that such efforts almost always come too late to be of help during the acute phase. It is beyond doubt that most important are the resources already available on site and that external support must come quickly to be of value during this first phase. However, international support is of great

S. Lennquist

value during the later subacute phase, with need for evacuation; protection; supplies of water and food; and to continue normal delivery of health care and replacing lost facilities and staff. International support is also needed during the recovery phase with rebuilding of the infrastructure and for education and training of local resources to increase the preparedness in zones hit by these kind of disasters. The strategy of working in the acute phase, according to experience, should be a well organized response rather than rapid and poorly planned raids into the area with the risk of causing injuries to both rescue staff and victims. The scenario is often characterized by a primary flow of minor to moderate injuries first followed by the severe injuries that require time-consuming extrication.

2.5.1.2 Volcanoes Volcano eruptions have hit human beings in all eras, and there are still active volcanoes in many places in the known risk zones for this type of disaster, including parts of Southern Europe and the United States. During recent decades, the population density around these areas has increased and buildings have gotten closer. For example, a new eruption of Mount Vesuvius in Italy is forecasted within the near future, and the difficulties of evacuating large populations from the risk zone is apparent because eruption can occur with little or no warning. The scenario during volcano eruptions includes a broad spectrum of causes of injuries: different kinds of lava flow, some with high temperatures; landslides; toxic gases; secondary earthquakes; and floods. High doses of radiation (radon gas) have been registered in ash from volcanoes. All this means high demands on planning and preparedness in areas known as risk zones for eruptions. The volcano eruption in Iceland in the early spring of 2010 illustrated a new problem that may occur during situations like this: the blocking of air traffic by clouds of volcano ash, which may have a devastating effect on international support actions when they are needed. 2.5.1.3 Tsunamis When the tsunami disaster in December 2004 hit Southeast Asia, one of the biggest incidents in modern time, “tsunami” was for many an unknown term. This is remarkable because more people have died in floods

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Major Incidents: Examples and Experiences

and tsunamis than in earthquakes during the last part of the 20th century. Statistically, six major floods occur every century subsequent to earthquakes or landslides. Simultaneously, building activity increases close to the coasts; 35% of the world’s population is today living within 100 km of a coastline. In the risk zones for floods, building has increased most. What happened December 26, 2004, at 7:58 a.m. local time was that an earthquake, registering 9.3 on the Richter scale, occurred 30 km below the surface of earth, with an epicenter 240 km from the coast of Sumatra, Indonesia. The shockwave generated a flood with a maximal speed of 800 km/h, which hit the coasts of eight countries around the epicenter of the quake. The effect on the coasts varied with the distance and with the depth close to the coastline: In shallow waters, the wave could rise up to 10 m, thereby destroying everything up to several kilometers from the coast. In total almost 300,000 people died in the affected countries. In many countries, the infrastructure was totally destroyed and numerous people lost their homes and possibilities to earn their living. For European countries, the effects in Thailand came into focus because many Europeans traditionally spent their Christmas holidays there. For example, 25,000 Swedish citizens were in Thailand at the time for the disaster. Five hundred forty-three of those were killed and 1,500 were injured. This created a new dimension of problems: taking care of large numbers of citizens who were injured and dead in a country far from home, which puts specific demands on authorities and health care; support of the host country in mediating contacts between victims and local health care; and evacuation of the injured to release pressure being placed on the local health care system (Fan et al. 2011). Previous experiences from such situations (Tran et al. 2003) have illustrated the importance of rapid deployment of assessment teams to the affected country to support these functions. Sweden was among the countries that did this much too slowly because of inability to make a rapid decision at a central level, which was heavily criticized in a parliamentary report (Lennquist and Hodgetts 2008). As a consequence, a special force is now always prepared to go instantly if something similar happens, and that has worked well in similar events after the 2004 tsunami. Because of increased traveling, many countries now have significant numbers of citizens who spend time in other countries. For Sweden, this has been calculated to be

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400,000 at any time, which is between 4% and 5% of the whole population. Preparedness for scenarios like this is therefore mandatory. This is one lesson from the 2004 tsunami disaster, but there is much more to learn from the experiences in Thailand that have been carefully evaluated. The load of casualties on the Thai hospitals was huge: the six hospitals in the Phuket and Phang Nga provinces received during the first 3 days more than 11,000 patients, 3,000 of whom needed in-hospital care (total capacity of beds in these hospitals was 1,500). In the 33 surgical theaters in these hospitals, 1,700 operations were performed during the first 5 days (Lennquist and Hodgetts 2008). In spite of this, the in-hospital mortality could be kept low. The major contributing factor to this was good preparedness for major incidents and disasters. An air bridge with supplies of materials and staff from Bangkok to Phuket was planned and could start immediately at the time of the disaster. Casualties were evacuated to Bangkok on returning flights. All hospitals had functioning and recently tested disaster plans, including prepared areas for primary triage, triage tags, prepared rooms for coordinations and command on both hospital and regional levels. The number of surgical theaters was extended by using prepared rooms for minor surgery with local anesthesia (Lennquist and Hodgetts 2008). With regard to hospital beds, the experiences confirmed what has been shown in many major incidents and disasters during recent years: The beds are not the limiting factor; room to place patients can always be found if all staff is mobilized. Limiting factors for surge capacity are ventilators, operation theaters, and supplies. One initial mistake occurred: the primary closure of wounds. The majority of surviving injured had wounds, and these were caused by considerable energy (Fig. 2.9a, b), were severely contaminated, and came late to treatment, indicating that they should have been treated like war injuries and primarily left open for delayed primary closure. Because staff of all categories had to be involved in wound treatment, this was not generally understood from the beginning, and the incidence of infections, many severe, was high. When this was discovered, the policy was immediately changed and infections went down. This illustrates one important thing: The principles for primary management of injuries should be known by all medical staff, and this

28 Fig. 2.9 The Tsunami disaster in Southeast Asia in December 2004 hit many countries, among them Thailand, where many European tourists spend their Christmas holidays. Many families with children were living in resorts close to the waterfront (a). In this area, because of the shallow water outside the beaches, the tsunami waves reached a height of 10 m, and because of the flat land in some places they reached more than 4 km from the waterfront, destroying everything in their way (b). In total, 300,000 people died in the eight countries hit by the Tsunami; of those, more than 8,000 were dead or missing in Thailand, many of them tourists

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a

b

is an important part of education in disaster medicine (Edsander-Nord 2008; Kespechara et al. 2005). On March 11, 2011, Japan was hit by the worst disaster since World War II. An earthquake with the magnitude of 9.1 on the Richter scale occurred in the ocean outside the city of Sendai at the northwest coast of Oshus. The earthquake was of the same magnitude as the one outside the cost of Sumatra in December 2004 and was one of the five biggest ever registered. A tsunami wave, growing to at least 10 m in height as it approached the coastline, was generated by the earthquake and had a devastating effect on the cities and villages along this coastline (Fig. 2.10). In spite of a good tsunami warning system and extensive work on

protective walls, the tsunami wave caused the loss of at least 10,000 lives; the confirmed number of dead when at the time of this writing was approximately 8,500, but almost 10,000 people are still registered as missing and the rescue work in the affected areas is difficult because of the extensive destruction. As already mentioned in the section “Accidents Caused by Radiation,” some of the nuclear plants at the coastline were hit by the wave, resulting in the destruction of the reserve system for cooling the plants in case of an incident. This resulted in overheating, with potential meltdown and leakage of radiation (Fig. 2.11), and more than 200,000 people had to be evacuated. As mentioned above, both short-term and

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Fig. 2.10 (a, b) On March 11, 2011, Japan was hit by an earthquake with a magnitude of 9.1 on the Richter scale off the coast of Sendai. The earthquake generated a tsunami wave rising up to a height of 10 m or more when it hit the coastline with devastating effects. Despite a good tsunami warning system and protection walls, the wave took at least 10,000 lives (preliminary figure; the final death toll is expected to be double this) (Photo Scanpix, with permission)

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a

b

long-term consequences of this are at the present time difficult or impossible to estimate, but they may influence both economy and public health not only in Japan but also in other countries.

2.5.1.4 Floods Floods constitute more than 50% of all incidents caused by changes in nature and climate and cause more deaths than any other type of such incidents.

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Fig. 2.11 Some of the nuclear plants at the coastline were hit, and the reserve system for cooling in case of an incident was destroyed, leading to overheating of the plant and leakage of radioactive material. Picture from Fukushima nuclear plant (Photo Scanpix, with permission)

Including floods caused by tsunamis and heavy winds, these kinds of disasters are responsible for 75% of all disaster-related deaths. The major cause of death is drowning, and the number of survivors is small in comparison to the number of dead. Secondary injuries and diseases subsequent to contaminated water and toxic substances, on the other hand, commonly occur after major floods. That was also shown clearly after the tsunami disaster (Edsander-Nord 2008; Kespechara et al. 2005). The rescue actions during these types of disasters are demanding and require preparedness for evacuation of large numbers of people and management of problems related to impaired or destroyed infrastructure in the affected communities. An example of such an incident hitting a technically advanced community, leading to severe consequences, is the flood after the hurricane Katrina in the United States in 2005; New Orleans, Louisiana was hit especially hard (Zoraster 2010; Condon et al. 2010). The hurricane itself caused rather moderate damage to the city of New Orleans. However, the water in the Mississippi River rose and broke the walls protecting large parts of the area around the city, resulting in flooding of large parts of living areas. Many people died by drowning, but many also died waiting for help, sitting on roofs without electricity and water in the high temperature and humidity. Because this happened

in one of the richest and technically best developed countries in the world, it caused severe criticism against the way it was handled by the authorities responsible. Hesitation to send rescue units into the area because of the risk of losing them has been reported as one of the reasons for the delay in rescue operations. With the expected global elevation of water levels, floods like Katrina can in the future be a potential threat in many parts of the world.

2.5.1.5 Heavy Winds There is today an increasing agreement that climatic changes caused by the human influence on nature have generated an increased risk of atmospheric disturbances in the form of cyclones, hurricanes, and tornadoes. This also means that countries that so far have not been hit by this kind of phenomenon are at increased risk in the future. Incidents caused by heavy winds induce the most extensive material destruction and the biggest risk for disturbances in infrastructure (roads, water, electricity, and telecommunication). However, the number of dead and injured directly caused by the influence of wind is often limited. The most important with regard to health care planning is good preparedness to maintain function for long periods of time without external supplies of water and/or electricity, which means accurate and sufficient reserve systems.

2

Major Incidents: Examples and Experiences

2.5.2

Slow-Onset Incidents

2.5.2.1 Drought and Starvation As mentioned above, the global population has increased from 1.5 to 6 billion during the last century and continues to increase. This increase occurs most often in countries and regions that already have difficulties feeding their existing populations. Drought and dearth of foodstuffs can have fatal consequences for large populations in such areas, of which the starvation disasters in Africa during recent decades are terrifying examples. It is the obligation of rich countries to assist economically and technically, but armed conflicts and political tension can make this difficult. It is important that international relief operations are well coordinated and are adapted to the real needs of the suffering populations. This is a field in which much still remains to be done. 2.5.2.2 Pandemics “Incidents caused by nature” can also be defined those caused by the spread of contagious diseases. Sudden spread of microorganisms against which we have no immunity or resistance have occurred throughout history at regular intervals and have caused large numbers of deaths, and this remains a potential threat. With the increased global population, increased concentrations of people in limited areas, and increased global travel, such pandemics are likely to cause even more fatal effects than those previously. This requires preparedness to prevent the spread of such pandemics through early diagnosis and preventive measures such as information and vaccination. Chap. 12 in this book is dealing specifically with this part of disaster medicine. 2.5.2.3 Complex Emergencies Slow-onset incidents, including many of the components above (political or armed conflicts, refugees, displaced populations, lack of food and water, pandemics), have been defined as complex emergencies, requiring a multidisciplinary approach, special organization, and special knowledge. This is outside the scope of this book, but literature for further reading in this field is given below (see also Chap. 13).

2.6

Conclusions

This overview, with examples of major incidents and disasters during recent decades and examples of what we can learn from them, clearly illustrates what also has

31

been shown statistically: we are faced with increasing risks of such events. A significant part of this is the price we have to pay to live in the way we do. It should then also be our obligation to, as much as possible, reduce the consequences of this – death, illness, and suffering. All experiences show that we can do that in many ways: • Identification of risks • Prevention • Planning • Preparedness • Education and training • Development and research Awareness of the importance of these measures has increased worldwide, mostly because of development during recent years. The scientific field of major incidence response, Disaster Medicine (Chap. 19), is still a young field within medicine, but is today recognized and established in most countries with major emphasis on education and training at all levels. However, we also need methodological development and research, a field in which we are still only at the beginning. Methodology in education and training, and important fields for scientific development and research, is dealt with in Chap. 18 in this book.

References to Major Incidents and Disasters The references below refer in alphabetic order to the examples of different major incidents described in this chapter to facilitate further studies for those interested. Some of these references refer to Kamedo reports. “Kamedo” is the Swedish Disaster Medicine Organization Committee with the task of sending observers to the sites of major incidents to collect information as a basis for published reports. The reports listed below are all printed in English, some them only as extended summaries, but upgrading is planned. They can be downloaded free of charge and are available in printed form and can be acquired from the Swedish National Board of Health and Welfare’s website: http://www.socialstyrelsen.se. Search “English - Kamedo” and then search for the publication number only or from the given list. Almersjö O, Kulling P (1994) The tram accident in Gothenburg, March 12, 1992. Kamedo report 62, 2 Almersjö O, Ask E, Brandsjö K et al (1993) The fire on the passenger liner Scandinavian Star, April 7, 1990. Kamedo report 60, 3 Arturson G (1981) The los Alfaques disaster: a boiling liquid expanding vapor explosion. Burns 7:233–251 Arturson G (1987) The tragedy of San Juanico – the most severe LPG disaster in history. Burns 13:87–102

32 Arturson G, Lorin H, Olofsson P et al (1994) The Jumbo jet crash in Amsterdam, October 4, 1992. Kamedo report 64, 16 Aylwin CJ (2006) Reduction in mortality in urban mass casualty incidents – analysis of triage, surgery and resources use after the London bombings on July 7, 2005. Lancet 368:2219–2225 Baxter PJ (1990) Review of major chemical incidents and their medical management. Royal Society of Medicine Services, Ltd., London, pp 7–20 Becker WK, Waymack JP, Mc Manus AT et al (1990) Bashkirian train pipeline disaster: the American military response. Burns 16:325–328 Berg-Johannesen K, Stefanini S, Lundin T et al (2006) Impact of bereavement among relatives in Sweden and Italy after the Linate airplane disaster. Int J Disaster Med 4:110–117 Bledsoe B, Smith M (2004) Medical helicopter accidents in the United States – a 10-year review. J Trauma 56:1325–1328 Brandsjö K, Reizenstein P, Walinder G (1992) The nuclear power plant accident in Chernobyl, April 26, 1986. Kamedo report 59, 4 Brandsjö K, Häggmark T, Kulling P et al (1997) The Estonia disaster: the loss of the M/S Estonia in the Baltic, September 28, 1994. Kamedo report 68, 15 Brismar B, Lorin H (1990) The accident at the Ramstein Base Air Show, August 28, 1988. Kamedo report 57, 31 Buerk CA, Batdorf JW, Cammack KW et al (1982) The MGM Grand Hotel fire – lessons learned from a major disaster. Arch Surg 117:641–644 Cassuto J, Tarnow P (2003) The discotheques fire in Gothenburg 1998 – a tragedy among teenagers. Burns 29:405–416 Condon S, Savoia E, Cardigan RO et al (2010) “Operation helping hands” – Massachusetts’ health and medical response to Hurricane Katrina. Prehosp Disaster Med 25:80–86 Connocenti P, Azima C (2003) Computer vulnerability, consequences and preparedness – experiences from the World Trade Center disaster. Int J Disaster Med 1:69–73 Eckerman I (2005) The Bopal Saga – causes and consequences of the world’s largest industrial disaster. Universities press, India Edsander–Nord Å (2008) Wound complications from the Tsunami disaster – a reminder of indications for delayed closure. Eur J Trauma Emerg Surg 34:457–464 Fan Z, Li A, Lian B et al (2011) Injury type and victims in the 12 May 2008 Wenchuan earthquake: analysis of 1,038 patients in Jiangyou City. Eur J Trauma Emerg Surg 37:3–7 Fries H (1991) The airplane fire in Manchester, August 22, 1985. Kamedo report 58, 14 Hallén B, Kulling P (1990) The fire at the King Cross underground station, November 18, 1987. Kamedo report 56, 30

S. Lennquist Hülse E, Oestern HJ (1999) Die ICE Katastrophen von Eschede – eine interdisciplinäre analyse. Springer, Berlin Kespechara K, Koyosombat T, Pakmol S et al (2005) Infecting organisms in victims from the Tsunami disaster. Int J Disaster Med 1:66–70 Kulaypin AV, Sakhautdiov VG, Temerbulatov VM et al (1990) Bashkiria train – gas pipeline disaster: a history of the joint USSR/USA collaboration. Burns 16:339–342 Kulling P (1998) The terrorist attack with Sarin in Tokyo, March 20, 1995. Kamedo report 71, 20 Kyriacou DN (2006) Anthrax – from antiquity and obscurity to a front runner in bioterrorism. Infect Dis Clin North Am 20(2):227–235 Lee CY, Davis T (2006) Building collapse. In: Ciottone GR et al (eds) Disaster medicine, 2nd edn. Kluwer/Lippincott, Hingham/Philadelphia, pp 842–845 Lennquist S, Hodgetts T (2008) Evaluation of the response of the Swedish Health Care System to the Tsunami disaster in Southeast Asia. Eur J Trauma Emerg Surg 34:465–485 Lorin H, Norberg KA (1998) The ferry accident at Zeebrügge, March 6, 1987. Kamedo report 55, 17 Lorin H, Unger H, Kulling P et al (1996) The great Anshin-Awaji (Kobe) earthquake, January 17, 1995. Kamedo report 66, 12 Melville LD, Rahman-Kahn N (2006) Bridge collapse. In: Ciottone GR et al (eds) Disaster medicine, 2nd edn. Kluwer/ Lippincott, Hingham/Philadelphia, pp 846–849 Missair A, Gebbard R, Pierre E et al (2010) Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake. Prehosp Disaster Med 25:487–493 O’Hickey SP, Pickering CA, Jones PE et al (1987) Manchester air disaster. Br Med J 294:1663–1667 Pryor JP (2009) The 2001 World Trade Center disaster – summary and evaluation of experiences. Eur J Trauma Emerg Surg 3:212–224 Tran M, Garner A, Morrison I et al (2003) The Bali bombing – civilian aeromedical evacuation. Med J Aust 179:335 Turegano F, Perez-Diaz D, Sanz-Sanchez M et al (2008) Overall assessment of of the response to the terrorist bombings in trains in Madrid, March 11, 2004. Eur J Trauma Emerg Surg 34:433–441 Wallace AW, Rowles JM, Colton CL (1994) Management of disasters and their aftermath. BMJ Publishing Group, London Wang Z, Sun Y, Wang Q et al (2011) Anesthetic management of injuries following the 2008 Wenchuan earthquake. Eur J Trauma Emerg Surg 37:9–12 Zoraster RM (2010) Vulnerable populations: Hurricane Katrina as a case study. Prehosp Disaster Med 25:74–79

3

The Prehospital Response Sten Lennquist and Robert Dobson

3.1

Structural Variations Between Countries

The organization on the scene naturally varies between countries depending on structural differences between communities with regard to involved actors and their responsibilities, national traditions, geography, culture, economy, and political system. However, the basic principles are the same and will be described based on what is common practice, at least in most European countries, but with emphasis on where alternative ways of organization may exist. Some basic rules that are important to follow regardless of type of organization will be emphasized, as will the most common mistakes. A concept that occasionally will be referred to because it is frequently used in European courses in this field, is the Major Incident Medical Management and Support (MIMMS) concept, which originates in the United Kingdom. It is influenced by the British organization, which differs somewhat from the organization in Central Europe, but parts of it are valid for any organization and it is educationally well presented, using acronym-based poems to support the memory in critical situations. It is important that all medical personnel who might be deployed for work on the scene during major incidents are familiar with their own local organization, and a prerequisite for that is postgraduate education and training of all staff in the positions they can be expected to have during a major incident.

3.2

Because some areas of the on-scene organization vary between countries, there are also variations in terminology. With the aim to avoid continuous repetition of alternative terminology, which may cause confusion, we will in this chapter use only one terminology, explained below with existing alternatives. With regard to organization, it is important for all medical personnel to learn and use the terminology adopted in their own country; hopefully, at some point in the future, it will be possible to come to an agreement on an internationally uniform terminology. MI MIC

RIC

PIC TRO ALO

RMC

RVP S. Lennquist • R. Dobson e-mail: [email protected]; [email protected]

Terminology

Major Incident Medical Incident Commander. Leads and coordinates the medical work on scene. Alternative term: Ambulance Incident Officer. Rescue Incident Commander. Leads and coordinates the rescue work on scene. Alternative term: Fire Incident Officer. Police Incident Commander. Leads the police work on scene. Triage Officer. Medical officer responsible for the primary triage. The term is not used in all organizations. Ambulance Loading Officer. Leads and coordinates transport of casualties from the scene. Alternative terms: Transport Officer, Transport Leader, Chief of Transport. Regional Medical Command Center. Leads and coordinates the whole medical response to the incident. In some countries, this is a specially prepared function staffed by medical and administrative officers. In other countries, this function is covered by other organizations, such as an Alarm Center, Ambulance Dispatch Center, or a defined hospital in the area, and in some countries it does not exist. Rendezvous Point. Point to which all incoming units in the rescue action are directed to stand by for access to the scene. Alternative terms: Check Point, Break Point.

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_3, © Springer-Verlag Berlin Heidelberg 2012

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3.3

First Unit on Scene

3.3.1

The First Report

The first unit on scene has an important role, even more so in major incidents. Regardless of which kind of information that already has been mediated to the coordinating center, this will be the first report from medical staff, which is of critical importance for the further activation of the whole chain of medical response: Mobilization of transport facilities, equipments and prehospital teams, and alerting hospitals. Delay in this report will cause a delay in the response that may have fatal consequences for the victims of the incident. The first report is commonly referred to as “Window report,” which should not have the aim of being complete, but a primary indication of how big the need of medical care is expected to be, and therefore in many cases can be based on what can be seen through the window of an arriving vehicle. Possible information at this stage may be restricted to something like “many injured, probably many dead, big need for both medical support on scene and transport facilities” – enough to pull the trigger for a declaration of a major incident and activation of the medical response. According to the MIMMS concept, the acronymbased poem for the first report is METHANE: Major incident declared (or standby) Exact location Type of incident Hazards Access Number of casualties Extra resources This is standard in some countries, but is not always easy to transfer to other languages. It is based on the British system, where the first ambulance crew may declare a major incident, whereas in many countries this is the responsibility of a coordinating medical center. The difference may be of theoretical interest; no coordinating center would probably object if the first arriving ambulance evaluates the situation as a major incident. However, it is important that it is clearly stated in the disaster plan to which position the authority (and responsibility) to declare

a major incident is connected, so confusion on this point does not delay the decision and thereby the alerting of resources. If a major incident is apparent and immediate contact cannot be established with the coordinating center, the first ambulance crew on scene should act according to the action cards until contact has been established.

3.3.2

Taking Command

When a major incident is declared, the first arriving ambulance will not be involved in transport of casualties, but will stay on scene. One of the officers takes the role of Medical Incident Commander (MIC) and the other (usually the one with the best medical competence, if there is a difference) takes the primary role as Triage Officer (TRO) and immediately starts to prepare the ambulance loading zone and triage the first casualties so they are ready for transport in the first available ambulances. In some organizations with good access to ambulances, both officers in the first ambulance take administrative roles, but with an urgent need for medical care at this stage it is often difficult to afford two administrators. In most organizations, the ambulances are equipped with tabards labeled with the positions referred to above (Fig. 3.1). The labeling may vary between countries, but the most generally internationally accepted colors for medical staff are green and yellow. The MIC should have a prepared action card for MIC stating what steps to take and in which order (see Table 3.1 for an example). Such action cards should also be included in the equipment of all ambulances. To summarize the contents of the action card, the acronym-based poem used for the MIMMS concept is CSCATTT, which stands for “Command, Safety, Communication, Assessment, Triage, Treatment, Transport.” This may be a good support for the memory if the action card is lost or not found.

3.3.3

Contact with the Rescue Incident Commander

The leader of the rescue operation is, in most countries, the officer in charge of the first arriving fire brigade, the Rescue Incident Commander (RIC); in some

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a

b

Fig. 3.1 The crew in the first ambulance on the scene of a major incident takes on the roles Medical Incident Commander (MIC) and Triage Officer (TRO).They take on tabards with these markings, which are available in all ambulances (a); unload medical equipment needed on the scene (b); and follow the action cards

for these positions, also available in all ambulances (Tables 3.1 and 3.2). This ambulance is not used for transport but stays on the scene as a command ambulance; in some countries this is indicated by keeping the blue light on (Photo: Kjell Eriksson)

countries the leader is the officer in charge of the first arriving police unit, the Police Incident Commander (PIC). In some countries, the rescue leader has the overall command of rescue operations, whereas in other countries every involved organization works on its own responsibilities. This difference is mainly theoretical because no chief of rescue or police would give orders with regard to medical care, and medical staff naturally respect the advice of police and fire brigades with regard to security matters. Regardless of the organization, the RIC is the one who has authority to require any kind of resource needed for the rescue work, including private property (even if he or she has to explain why afterward). If the RIC (in most places with a clear marking on tabard and/or helmet; see Fig. 3.2a, b for examples) has arrived on the scene before the first ambulance, one of the first steps is to establish contact, request available information (see Table 3.1), request resources of benefit for medical care, and agree on a location for triage and ambulance loading zones that should be as close together as possible but outside potential risk zones. The RIC, PIC, and MIC normally constitute the command group on scene. In complex incidents, or incidents over an extended time, a place of command is established from which this group can coordinate the operation.

3.3.4

Safety

The MIC is responsible for the safety of the medical staff, and a dead or injured medical officer is of no benefit to the victims. Communication with the RIC with regard to possible risks in the area (Table 3.1) is mandatory as a basis for dispatching medical staff to the scene. The rescue service commonly uses the terminology hot, warm, and cold zones: Such high risks to life and health that only rescue staff with special equipment and training should go in (fire, smoke, or high concentrations of hazardous material). Warm zone Medical staff can go in, but only if they have protection equipment and are trained for it (smoke or hazardous material in concentrations low enough that simple protection equipment is sufficient). Cold zone No risks requiring special equipment or training (not excluding other risks). Hot zone

In some countries, the RIC decides who is allowed to enter warm or hot zones; in other countries the MIC decides for medical staff, but regardless should respect the advice of the RIC. During incidents caused by or involving criminal activity like terrorist attacks, riots, or gunfire, the police

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Table 3.1 Example of an action card for a medical incident commander, MIC (the content should be adjusted to national and local standards) 1. Deliver window report to alarm center (rough estimation of number of casualties, estimated need of transport and medical care on scene)a 2. Confirm MI. If MI is not already declared but is apparent upon arrival, inform alarm center and act according to MI until contact from RMC.b 3. Park ambulance, take on tabards for MIC and (other crew member) TRO. 4. Contact the RIC (if arrived) direct or by channel X • Require information about: – Estimated number of injured and dead – Risk zones (hot, warm) and other risks on scene – The most urgent need for care – Required and expected resources from rescue service • Decide with RIC the location of casualty clearing and ambulance loading zones 5. Decide if incoming ambulance crews should be kept on scene for medical support, and if so, how may and for which tasks 6. Dispatch TRO to start primary triage according to action card 7. Make quick survey of the scene and: • Estimate again number and severity of casualties • Need for support in injury zone (trapped)? Identify urgent needs! 8. Decide Level of MI as a guideline for medical work, inform all staff, and re-evaluate this level continuously 9. Contact RMC via channel X (if no contact with RMC, contact alarm center or ADC), and: • Deliver second report based on the information above • Request prehospital teams to scene if needed • Request available ambulance-helicopters if needed and not already alerted • Request distribution key for transports to hospital 10. Start transport of patients triaged by TRO. Until distribution key is provided, start to send severely injured according to: • Six to Major City University Hospital • Four to Sea Town Regional Hospital • Two to Small Town County Hospital 11. Organize casualty clearing and ambulance loading zones for primary and secondary triage and dispatch teams according to that, as well as teams to the injury zone when needed (do not send to risk zone without communication with RIC) 12. Appoint ALO for transport coordination 13. Repeat contact with RMC, update reports from scene, request updated distribution keys, request additional support and equipment as necessary 14. Maintain contact with RIC and PIC; during large incidents establish command location 15. Decide “MI Stand Down” on scene in agreement with RMC when all injured are evacuated. Inform RIC, PIC, and all medical staff on scene. Lead debriefing for all medical staff before departure from scene. a

If “METHANE” is used as guideline for this report, insert it here In some countries, a major incident is declared by the first ambulance to arrive on the scene RMC Regional Medical Command Center, MIC medical incident commander, TRO triage officer, RIC rescue incident commander, MI major incident, ADC ambulance dispatch center, ALO ambulance loading office, PIC police incident commander

b

are also responsible for security and to make decisions with regard to which zones can be entered by rescue and health care staff without risk of being injured from such activities.

3.3.5

Overview of the Scene

Before delivering the next report, the MIC should make a quick scene reconnaissance (2–5 min) to get the first medical overview of the scene and identify urgent

needs for care, such as the need for medical support for extrication of trapped victims, and make a preliminary estimation of the number of severely injured victims. This gives personal knowledge of the conditions on scene, valuable as a basis for leading the work and for dispatching medical staff within the area. In bigger incidents, the RIC usually organizes the scene in sectors (part of a building, one or more train cars), with a rescue officer responsible for each sector. If there is a need for medical support on scene, it would be wise to dispatch medical staff to make contact with

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a

b

Fig. 3.2 (a) Police Incident Commander (left), Rescue Incident Commander (middle), and Medical Incident Commander (right). These officers constitute the command group on the scene and keep up continuous communication during the response. A

command location is usually established, which can be at a vehicle (b) or, in extensive incidents, in a special command wagon (Photo: Kjell Eriksson)

the responsible rescue sector officers to get information and establish collaboration.

evacuation. Necessary treatment can in such cases be given by the ambulance crews to their own patients before departure. However, when the evacuation is delayed, which is the case in the majority of major incidents, the need for triage and treatment on scene will increase, which means a need for more medical staff. The only such staff available in the beginning might be the crews of incoming ambulances. Whether, and to what extent, these crews should be used for work on scene or for transport is a decision of critical importance to be made early by the MIC. For every ambulance crew kept on scene, a transport resource will be (temporarily) lost. It is also important that the MIC recognizes this need as early as possible and requests medical staff to the scene. This can be prehospital teams from hospitals or primary care centers (see below), or off-duty ambulance crews, mobilized according to the disaster plan. Voluntary medical staff on scene can be used under certain conditions (see below). A trick that is used in some countries is to let rescue or police officers drive the ambulances to “save” one ambulance crew member on scene.

3.3.6

Second Report

The second report is the confirming report, occurring after the first “window report.” It is important that this report is delivered as soon as possible. At this stage, the whole medical organization, trigged by the first alert, is waiting for more information as a basis for a decision about the level of alert and steps to be taken within every unit. So, again, no details and no attempts to give the anatomical distribution of injuries are necessary, just the information that can be extracted from communicating with other units on scene and from the rapid reconnaissance of the area.

3.3.7

Covering the Need for Medical Staff on Scene

In major incidents of limited extent, with good and rapid access to ambulances and short distances to hospitals, there may be limited need for medical work on the scene. In such cases there might be no need to keep additional ambulance crews on the scene for triage or medical treatment and it may be better to use every available ambulance for transport, where the MIC can also function as a transport coordinator (see below) and the TRO performs the necessary triage before

3.3.8

Decision of Strategy for the Medical Work

At this stage the MIC should be able to estimate the relationship (or discrepancy) between the need for medical care on scene and available resources. Based

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on this, decision about strategy has to be made. Consider, is this a situation where: • The normal level of ambition for medical care can be maintained with the steps taken as above (major incident level 1: all potentially salvageable patients can be saved, also called compensated incident)? • The load of casualties is so high that the ambition and standard of care has to be lowered to be able to save as many as possible ( major incident level 2, also called decompensated incident)? It is difficult for medical staff on scene to get the overview needed to make such judgments, and this is therefore the task of the MIC. Decisions with regard to strategy should be clearly given to all staff involved as a guideline for the triage and can be changed during the response depending on incoming resources or initially undiscovered need for care.

3.3.9

Establishing Continuous Contact with the Regional Medical Command Center

After these first steps, following the action card, the MIC should take a position where he or she is not involved in medical care or decisions with regard to triage and should establish repeated contacts with the regional medical command center (RMC) to: • Request information about hospital capacity • Request additional support on scene if needed (transport resources, equipment, staff) • Report casualty load on scene and departed transports

As already mentioned, in complex or in extended incidents, the primary MIC might be replaced by a medical officer with special training and more experience. The primary MIC then usually stays as a support person (staff) to the new MIC or takes the role of Ambulance Loading Officer (ALO; see below). In the same way, the TRO can be replaced by senior medical officer with more clinical experience.

3.3.11 Major Incident Stand Down The MIC should liaise with the PIC and RIC to confirm that there are no more casualties before reporting that the medical element of the incident has concluded. Only the MIC can report the major incident stand down on scene. This information should be forwarded to all staff and to the RMC and Ambulance Dispatch Center (ADC). The medical staff should not leave the scene without a debriefing, led by the MIC or another experienced person on scene. This may be repeated in ambulance stations and hospitals before leaving shifts. These are always shocking events, even for experienced personnel; thoughts about the incident may come afterward, and it is important to get the opportunity to discuss impressions and experiences with other participating staff in immediate connection to the response. We have now gone through the points in the action card for MIC (Table 4.1), which illustrates that there a lot of things to do and decisions to make within a short time, demonstrating the need for a prepared action card for this purpose.

3.4

Building Up the Structure on Scene Step by Step

3.3.10 Continued Coordination of the Medical Response on Scene

3.4.1

The Need for Simplicity

It is important to give clear tasks and responsibilities to all staff on scene and to define clearly who is in command of different positions. This is a tough situation, and it may be necessary to exchange staff that not is functioning properly. During extended incidents, it is important to plan the release of staff after a certain amount of time. The medical work must also be coordinated with the work of rescue service and police, with requires close collaboration with the RIC and PIC (Fig. 3.2).

As stated in Chap. 1, simplicity is the key to successful management of major incidents, and this is valid for the organization on scene as well. It has to be remembered that the majority of major incidents occur in densely populated areas with good access to ambulances and short distances to hospitals. The first ambulance is often on scene within 5–15 min after the alarm and then the medical work starts; with many ambulances within close range, the evacuation from the scene can (and should) start only a few minutes after that.

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This does not give time to build up a complex organization. Schedules of organization that are too complex with too many boxes, too many levels of command and decision, and too many ranks and titles will involve a risk that “the war is over” before the organization is built up.

It is an understandable temptation to transfer experiences from the military organization to the civilian because military personnel are (and have to be) good organizers, using a clear and strict hierarchy. However, there are significant differences between the civilian major incident and the combat situation with regard to (a) time for preparation and (b) demands on endurance. • A war rarely starts without warning, which gives a long time for preparation. However, the organization must have the ability to run at a high capacity for a long time – days, weeks, months, or even years. • A major incident during peace time in a civilian community, on the other hand, occurs at any time without any warning at all, and in only a few minutes an organization fully occupied with routine medical care must have the ability to deal with a number of severely injured victims far exceeding available capacity, regardless whether none of the available staff has any experience with such situations. However, the peak of the casualty load is usually past within a few hours (of course, exceptions exist). This means much higher demands on simplicity than the combat situation. There is no time to build up a new organization, only to adapt the normal organization to the specific demands of the major incident.

3.4.2

The First Step: Starting Triage and Transport

The tasks of the first medical unit on scene have already been described, illustrating that one of the officers in the first unit will be fully occupied with the important role of MIC. At the same time, it is of critical importance that the transports to hospitals start as soon as

39

possible – “no fully staffed ambulance should be standing waiting,” and the sooner they get moving, the sooner they come back. Therefore, the triage process has to start as soon as there are ambulances on scene, and this is the reason for the strategy to use the second officer in the first ambulance as primary TRO. The first step in building up the scene, based on the presence of only one ambulance, is illustrated in Fig. 3.3. The TRO sorts the patients into three routes of evacuation: (1) should go with the first available ambulance, (2) needs an ambulance but can wait, and (3) injured but does not need ambulance transport. A simple system should be used for this primary triage, e.g., triage sieve (see Chap. 4). An example of an action card for the TRO is illustrated in Table 3.2. In this initial phase the MIC also has the role of transport coordinator and directs available (staffed) ambulances to hospitals. The principles for the distribution between hospitals are described below under “Transport of Casualties”. As soon as casualties en route (2) begin to accumulate or need surveillance, additional medical staff on scene is mandatory, and that is the task of the MIC (see above). Thereby the organization is transferred into the next step.

3.4.3

The Second Step: Completing the Casualty and Ambulance Loading Zones

We have now access to additional medical staff on scene – either ambulance crews from arrived ambulances or deployed prehospital teams, which usually take longer to get to the scene. This means that the second route of evacuation goes to one or more teams for secondary triage, including measures of resuscitation needed before transport (Fig. 3.4). Two staff members in each such team are preferred, e.g., one ambulance crew or a prehospital team with a physician and a nurse. A system with better discriminative capacity than triage sieve is recommended for this secondary triage, e.g., triage sort (Chap. 4). If there is congestion in the evacuation and no immediate access to ambulances for high-priority patients, staff needs to attend to and survey casualties waiting for transport (Fig. 3.4). At this stage, evacuation also should be prepared for casualties that do not need ambulance transport,

40 Fig. 3.3 The organization on scene is built up step by step. The first step is based on the presence of only one ambulance crew on the scene, with the aim to start transport as soon as possible for utilization of available ambulances. The Triage Officer (TRO) makes only a simple primary triage and sorts the patients according to three routes: (1) severely injured, who can go with an available ambulance, with necessary resuscitation to be done by the ambulance crew; (2) needs ambulance transport but can wait; (3) does not need ambulance transport. The Medical Incident Commander(MIC) has at this stage the role of transport coordinator and decides the destination of the first patients (Artwork: Lais-Ake Peterson)

S. Lennquist and R. Dobson

RVP

MIC

TRO

1 2 3

Table 3.2 Example of an action card for a triage officer (the content should be adjusted to national and local standards) 1. Take on tabard “TRO,” bring handheld radio and equipment, including triage cards, from the ambulance 2. Make a quick survey of patients already in the casualty clearing zone to identify and eliminate immediate threats to life 3. Start primary triage according to triage sieve (see back side of action card) and separate those who do not need ambulance transport from those who do need it, and indicate priority with SMART tag,a only color marking 4. Inform MIC (channel X) when the first casualties are ready for transport and distribute them between available ambulances. MIC gives destination (before an ALO is appointed) 5. Continue with primary triage in the casualty clearing zone 6. When teams for secondary triage are available, distribute patients who need ambulance transport between them for necessary resuscitation or treatment before transport and secondary triage and surveillance before departure 7. When more staff arrive, deploy another ambulance officer for primary triage and take overall command of the casualty clearing zone with continuous control of patient flow (at this point the role of TRO may be taken over by a more senior or qualified medical officer on the scene and the original TRO continues with primary triage). a

SMART tag is an example of a system for combined indication of priority and registration (see Chap. 4). Some countries have other systems MIC medical incident commander, TRO triage officer, ALO ambulance loading officer

and they have to be seen and re-triaged by medical staff before departure (Fig. 3.4). The MIC should be released from the position as transport coordinator as soon as possible and replaced by another ambulance officer (ALO; Figs. 3.4 and 3.5). Shown in Fig. 3.4 is the now-completed structure of the casualty clearing zones and ambulance loading zones, even if these zones with expanding needs may

include more staff for secondary triage and surveillance before transport. The setup in Fig. 3.4 is consuming eight medical officers (ambulance crews or prehospital teams) on scene, but this is what is needed in situations with many injured when there are no ambulances available for all casualties who need them. Still, this only includes medical staff in the casualty clearing zone,

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41 RVP

ALO MIC

TRO

1 2 3

Fig. 3.4 When it is apparent that there are more patients who need ambulance transport than there are available ambulances, the organization is extended with a second step: Patients who are not ready to depart or cannot depart because of the lack of available ambulance, now follow line 2 (from Fig 3.3) to teams devoted to necessary resuscitation/treatment and secondary triage before transport. An additional medical officer/team surveys

patients waiting for transport, and another is dispatched for secondary triage/survey of patients who have been estimated to not need ambulance transport. This requires more medical staff on the scene, either by keeping crews of incoming ambulances or bringing in other staff (see the text for further discussion) (Artwork: Lais-Ake Peterson)

Eight medical officers working on scene is equal to four ambulances that cannot be utilized. This emphasizes the importance that the MIC: • Immediately calls for additional medical staff to the scene when the need for medical support is apparent or expected • Continuously surveys the situation and, as soon as ambulance crews can be released from the scene, dispatches them to their ambulances. The trick of using police or rescue staff as ambulance drivers, mentioned above and used in some countries, is one way to solve this problem.

3.4.4 Fig. 3.5 The MIC is now replaced by another ambulance officer, who has the role of Ambulance Loading Officer (ALO) (Photo: Kjell Eriksson)

and there might also be a need for medical staff in the injury zone (see below), e.g., for support during the extrication of trapped patients.

The Third Step: Completing the Organization on Scene

3.4.4.1 The Injury Zone As mentioned above, the need for medical support during major incidents is usually not restricted to the casualty clearing and ambulance loading zones, even if the work, as a general principle, should start here to get the transport going as soon as possible. There may be

42 Fig. 3.6 The organization completely built up on the scene in a bigger incident (see the text for further explanation)

S. Lennquist and R. Dobson

Hot zone

Scene

Warm zone Collection point, dead bodies

Collection point, victims property Casualty Clearing zone Primary triage

Non-injured

Less severely injured

Helicopter landing

Secondary triage

TRO

Command place

MIC ALO

Ambulance loading zone

= Rescue

= Rescue area

= Health care

MIC = Medical Incident Commander TRO = Triage Officer

= Police

ALO = Ambulance Loading Officer

an urgent need for resuscitation and triage where the casualties are located immediately after the injury – the injury zone (Fig. 3.6) – which can be in the wreck after an airplane, rail, or bus crash, in a collapsed building, or trapped in an area of explosion. One of the intentions of the rapid overview of the scene done by the MIC immediately upon arrival is to identify such needs and deploy staff there as soon as possible. Note that there can be risk zones (see above) within the injury zone – do not deploy staff to suspected risk zones without communicating with the RIC.

3.4.4.2 Noninjured Victims People who survive a major incident without physical injuries are also victims. Exposure to a situation like this means for most people a severe psychological shock and, even if the reactions are not apparent immediately, they may appear later. In addition, many of the noninjured victims may have lost contact with friends and relatives or have seen them killed or injured, or they may have lost their property and/or be far from

Rendevouz-point (parking zone)

home. This is a group of people that not just can be sent away but needs to be taken care of. Also, the same considerations with regard to potential severe injuries are valid for the group primarily triaged as “less severely injured” (see below). They should, if possible, be seen by a medical officer before departing from the scene. The police have the responsibility to take care of the noninjured victims. They have to be registered and taken to a prepared zone where they can be given protection and then get transport to a place where they can get psychosocial support, information about lost friends and relatives, and help with further transport (Fig. 3.6). Chapter 17 deals specially with the psychological management of both injured and noninjured victims.

3.4.4.3 Dead at the Scene The management of dead patients on the scene is the responsibility of the police. In most countries, only doctors are allowed to declare patients dead unless death is apparent, as when the head has been separated from the

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The Prehospital Response

rest of the body or the patient is totally crushed or burned. Patients that are apparently dead should be left where they are to facilitate the work of identification and investigation by the police. Other casualties without any signs of life should be labeled as low-priority patients (see Chap. 4) until they can be examined by a doctor and death can be confirmed. Note the hazard of differentiating between hypothermia and death (Chap. 9): In a cold environment, no one should be declared dead until he or she is warm and dead! For further management of dead victims in major incidents, see Chap. 6.

3.4.4.4 Helicopter Landing Area Helicopters are a useful resource during major incidents, not only for evacuation of casualties (see below under “Transport of Casualties”), but also for transport of equipment and staff to the scene. In incidents where the benefit of helicopters is apparent and there is access to helicopters, they should be alerted early for this purpose, and a helicopter landing area must be prepared and clearly marked. It should be located on such a distance from the casualty clearing zone that ambulance transport to helicopters not is needed, but not so close that it disturbs the work in the casualty clearing zone (a distance of approximately 50 m is recommended for ordinary helicopters).

43

ing zone. The figure illustrates a scene with immediate access to a road, which is the case in most, but not all, major incidents. A long distance from the injury zone to a road requires off-road transport between casualty clearing and ambulance loading zones, which puts even higher demands on the rescue organization.

3.5

Equipment

3.5.1

Ambulance Equipment Vehicles

Some countries have special ambulance equipment vehicles that carry extra equipment for major incidents, such as: • Oxygen • Oxygen masks • Entonox (for pain relief; see Chap. 7) • Burn dressings • Dressing for extensive wounds and other trauma • Intravenous fluid and needles • Protection gloves and sterile gloves • Oral and nasal airway sets • Glow sticks Extra safety equipment (helmets, high-visibility jackets)

3.5.2 3.4.4.5 Cordoning Off and Trafﬁc Control The first task of the police is to cordon off the area to prevent all traffic in and access to the area for vehicles not involved in the rescue action. If all arriving rescue and transport vehicles arriving at the area should proceed into it, they would soon create a congested and chaotic situation where no vehicle could move. One of the first tasks of the incoming rescue leader is, in communication with the police, to decide on a check point or rendezvous point (RVP) – a place that is easy to identify on the map, well connected to routes for both entrance and evacuation, and with space enough to park waiting vehicles. This point is often decided before the arrival of rescue units and is based on local knowledge of the area, and information about it should be forwarded to all alerted units. Traffic control at this point should be handled by the police. Figure 3.6 illustrates the principles for a fully developed organization on scene during a major incident with many injured and the need for medical support in the injury zone, the casualty clearing zone, and the ambulance load-

Special Equipment Supplied by the Rescue Service

In some countries, the rescue service/fire brigades have special preloaded trucks or wagons with equipment for bigger incidents with special demands. Because time is important, this resource should be alerted as soon as a potential need is identified. This equipment may include: • Stretchers and/or simple boards used to protect from the cold ground • Blankets • Extra illumination • Simple splints for fracture stabilization • Inflatable tents that can be set up quickly to protect casualties in a cold or hot climate (Fig. 3.7a) • Simple stretcher stands for positioning patients for shock prevention or elevating them into a better position for required treatment (Fig. 3.7b) Inflatable tents can be life saving in severe climatic conditions with delayed evacuation, but they involve a potential risk for congestion: It gives the impression of being in a field hospital, with a temptation to extend

44

a

Fig. 3.7 (a) Inflatable tent for protection of casualties in difficult climatic conditions (severe cold or severe heat). This model is inflated by a diesel compressor, which can function as an air conditioner for heat or cold, and generates currency for illumination. This tent takes only a few minutes to inflate and is usually stored

S. Lennquist and R. Dobson

b

in a rescue unit, but it is mainly used in big incidents with time-consuming evacuation. (b) Inside of the tent in (a), showing simple stands for stretchers included in the equipment (Photo: University Hospital, Linkoping)

Fig. 3.8 Even if tents shown in Fig. 3.7 are used, it is important to maintain the simplicity of the structure and not fall for the temptation to overdo treatment with the feeling of being in a field hospital. What is illustrated in this figure could also be the effect of exercises performed without real times, giving the impression that everything can be done without consuming any time (see Chap. 18 on education and training) (Artwork: Lais-Ake Peterson)

the treatment to more patients than absolutely necessary before transport, which may create a congestion of waiting patients and unused ambulances (Fig. 3.8).

If tents are used, it is of vital importance that the structure and principles of working are maintained as described above.

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3.6

Who Is Responsible for What?

Staff from different organizations are involved in the work on scene: medical staff, rescue personnel, police, and perhaps military and voluntary organizations. It must be absolutely clear who is responsible for what to avoid duplication of some decisions and the lack of others, and to avoid arguments between officers in command. The medical staff under the leadership of the MIC is responsible for: • Triage of casualties • Resuscitation and necessary treatment of casualties before evacuation • Surveillance of casualties before evacuation • Medical registration of casualties before departure (medical report) • Evacuation of casualties who need ambulance or helicopter transport • Distribution of casualties between hospitals in communication with the RMC • Survey of noninjured victims before departure The rescue service, under the leadership of the RIC, is responsible for: • Securing the scene from additional damage and injuries • Defining and indicating risk zones (hot and warm zones) • Evacuating casualties from those zones as fast as possible • Performing simple, immediately needed life-saving procedures when there is a lack of medical staff • Supporting medical staff in getting access to casualties • Extricating injured in collaboration with medical staff The police, under the leadership of the PIC, are responsible for: • Securing the scene from threats by criminal elements (for example, in terrorist actions) • Cordoning off the scene and, when needed, evacuating people who are not involved in the rescue work • Traffic control, including organizing and monitoring of the RVP • Taking care of victims who are apparently dead or declared dead • Searching the area for additional casualties • Registering all victims of the incidents (injured and noninjured) before departure from the scene

45

• Securing documentation for legal investigations • Taking care of victims property Other personnel on the scene work under the responsibility and leadership of one or more of the organizations above, depending on to which task they are devoted. To this list should be added the overall responsibility for the rescue operation, which, as previously stated, varies between countries and between different types of incidents. The rescue service (most common) or the police could have overall responsibility, or in some countries it could be that every organization is responsible for their own activities, as listed above.

3.6.1

Medical Staff on Scene

3.6.1.1 Ambulance Service The important roles of the ambulance staff during major incidents have been described above. The need for special training for these difficult situations hardly needs to be emphasized, and it should be included in the basic training for all ambulance staff. This should include training in triage and training in roles as the MIC, TRO, and ALO because any ambulance crew can be placed in the situation to take on one of these roles. Because major incidents in most countries during peace time are relatively rare and the time between the basic training and such events can be long, the training should be repeated at regular intervals; this is the responsibility of every ambulance organization. A major incident is a tough situation in which to work, psychologically as well as physically. All medical staff deployed to such tasks should have access to equipment for personal protection, including helmets and climate resistant clothing. In some countries, especially those with a cold climate, the ambulance crews have the same personal equipment as the prehospital teams, also including helmets with lamps. All ambulances should be equipped with triage cards equal to those used by prehospital teams (see Chap. 4) and action cards for leading positions like MIC, TRO, and ALO. Ambulance officers are used to working on scene and are therefore a potentially useful resource in major incidents, even when they are not on duty. Planning and preparedness should include a system

46

S. Lennquist and R. Dobson

for rapid alert of off-duty ambulance crews, including continuously updated alarm lists, as are used for hospital staff.

3.6.1.2 Prehospital Teams from Hospitals or Primary Care Centers The need for medical staff on the scene of major incidents has been illustrated above. Even if the ambulance crews are an important resource for this – especially in the early phase of the response – the importance of getting them back to their major task – evacuating patients from the scene – as soon as possible has also been illustrated. Planning for major incidents should include plans to send prehospital teams from the hospitals and from primary care centers far from hospitals in sparsely populated areas. This requires preparedness. • It must be clearly stated in the disaster plan which category of staff should go, on which indications, and to which position this decision is connected. • The staff deployed must have personal and medical equipment for work on the scene. • They must be trained for this work – to send a person to the scene without training for it is unethical and unfair both to the staff deployed, the victims, and other staff working on scene. Figure 3.9 shows an example of personal equipment designed for use on scene: protective clothes with high visibility, boots, helmets, and headlamps. Figure 3.10a, b, shows an example of medical equipment for use on scene, and Fig. 3.10b shows additional equipment for use in incidents caused by hazardous material. Figure 3.11 shows the storing of this equipment, kept in the emergency department, from which the teams are deployed upon alert. A big hospital should have equipment for deployment of at least five teams. The size and composition of teams varies between countries. A recommendation is to have small teams, with one doctor and one nurse in each. If the alert comes during non-office hours, it is difficult and time consuming to collect big teams; in most cases one or maybe two such teams can go instantly on alert, and more may come later. If there are many hospitals within close range, a good rule is to take teams from

Fig. 3.9 Protection clothes for prehospital medical teams, designed for use in rough conditions on the scene and in a cold climate (example from Sweden). The ambulance service has the same equipment available in ambulances (Photo: Kjell Eriksson)

the most distant ones because the others will get pressure from casualties earlier. As mentioned above, prehospital teams from primary care centers with long distances to hospitals can be of benefit in this situation, which, however, requires training and supply of equipment to such centers. In some countries, prehospital medical teams are provided by Helicopter Emergency Medical Services. These teams work in both prehospital and hospital environments and therefore have a clear understanding of both sets of needs.

3.6.2

Military Staff

Most military units have, even during peace time, prepared staff, which can be requested by the RIC. Even nonmedical military staff can be of benefit in a civilian incident; there are always arms needed to carry stretchers, and the military is well organized and used to working in the field under difficult conditions. Military units also have equipment that can be valuable, including stretchers, blankets, tents, vehicles, and perhaps medical equipment like mobile medical units, ambulances, and helicopters. To get rapid access to such

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The Prehospital Response

a

47

b

c

Fig. 3.10 (a) Medical equipment for use at the scene. This equipment is easy to carry, gives good exposure, and is designed for two to four severely injured patients. (b) The equipment in ambulances includes portable oxygen bottles. In the front,

laryngeal masks of different sizes are seen. (c) Incidents involving hazardous material require special equipment, which has to be easily available (see Chap. 10, which deals with such incidents) (Photo: Kjell Eriksson)

equipment requires planning, and such plans should be made wherever military resources of this kind are available.

3.6.4

3.6.3

Voluntary Organizations

Voluntary organizations like the Red Cross and voluntary military organizations can be of benefit in incidents with many casualties or that are extended in time, but the access to such organizations varies widely between countries. Usually the response time is too long to use such staff in a civilian major incident. If they can be used, they should have trained with the ordinary staff on scene so that they are familiar with the organization and methodology of the work.

Voluntary Medical Staff

It is not unusual that doctors, nurses, and other medical staff happen to be on or close to the scene of a major incident. It is a natural ambition to help, which also is included in the ethical rules for medical staff: To do the best to support when life and health is in danger. However, there are certain prerequisites for utilization of such staff: • Contact with the MIC should occur prior to participation (with the exception of immediate life-saving procedures), and the involvement in the work should be approved by the MIC. The MIC should request identification if the person is not known (it has happened that “false” doctors or nurses have started to work on scene).

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S. Lennquist and R. Dobson

Fig. 3.11 In hospitals deploying prehospital medical teams to major incidents, equipment shown in Figs. 3.8–3.9 is usually stored at the emergency departments in the hospitals where the teams collect on alert. A big hospital can have personal and medical equipment of this kind for four to five teams, with two persons (physician and nurse) in each. The composition and equipment of these teams varies between countries, but should be nationally uniform (Photo: University Hospital, Linkoping)

• Even if the voluntary staff is a senior and experienced person, he or she is under the leadership of the MIC and should respect decisions and instructions from him or her. The question of whether noninjured persons who have been involved in the incidents should be used for such tasks is controversial. Some organizations say no, but others say yes presuming that the MIC evaluates the person’s physical and mental condition accurately. It might be worse to be there and have survived but not be allowed to help. In big incidents like natural disasters, where there is an immense need for medical help, it is natural that everyone who is able to help does so.

3.7

Triage on Scene

3.7.1

General Principles

“Triage” is originally a translation of the French expression for “sorting” and means from a medical point of view sorting patients into categories of priority, i.e., in which order they should be treated and/or evacuated. Because triage should be done at all levels in the chain of medical management, the methodology is described in detail in Chap. 4, and in the present chapter only the general principles for triage on scene are described.

• Triage is a dynamic process, which means that the priority should be re-evaluated at each level in the chain of management and adjusted according to: – The patient’s condition – Effects of resuscitation/treatment – Where in the chain the patient is (injury zone, casualty clearing zone, or ambulance loading zone) – Available resources • Standardized systems for triage based on simple physiologic criteria can be used and may have limitations, but they make the triage less dependent on competence, which makes them especially suitable for triage on the scene. Different systems may be suitable for different levels in the chain. • The priority given should be clearly indicated on the patient using a standardized system. The system used must make it possible to easily upgrade as well as downgrade the priority.

3.7.2

Overview Before Starting Triage

As medical staff facing a severely injured patient in our daily routine, it is natural to pay attention only to that patient and do whatever we can to support him or her; if someone has a more urgent need there is usually somebody to tell us that. It is not so in the major incident:

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The Prehospital Response

Fig. 3.12 No triage or treatment should start without first getting an overview and assessment of immediate needs. The figure illustrates the temptation to stay at the first patient, with the consequence that others may be lost because of the lack of simple but immediately needed life-saving procedures (see the text for further explanation) (Artwork: Lais-Ake Peterson)

49

B D C E F

G A

Paying attention only to the first patient we see may cost the life of patients with better prospects of cure. Therefore, always get an overview of the whole area for which you are responsible before starting any triage or treatment. This may seem so evident that it should not need to be emphasized. However, all practical experience tells us that this is among the most difficult things to learn with regard to the methodology in major incidents. We are not used to “passing on” a severely injured patient, but now we have to overcome our normal pattern of action. Experience also shows that medical staff who work in these kinds of situations as an almost daily routine (as in armed conflicts or areas hit by terrorism) can learn to act this way, which is necessary to avoid losing patients who have a chance of survival. For those who are not used to this in their daily work, the importance and benefit of training is evident. Figures 3.12–3.14 illustrate these principles. The first patient (A) met by the responder on this scene has an open arm fracture. There is moderate bleeding, but the patient has pain, is scared, and cries for help. The responder stays with this patient without noticing that patient B has severe bleeding and is (wrongly) kept on her feet and is on her way into severe shock; patient D is unconscious and lying flat on his back, resulting in blocked airway; patient E has a blocked airway because of bleeding; patient F is losing his blood from an arterial bleed; and patient G has respiratory distress from an open chest wound.

The correct way to act (which requires training) is to make a quick tour to get an overview of the situation and do a rapid assessment of the need for care, only using a few seconds (not minutes!) for each patient (Fig. 3.13). “Diagnosis at a distance” can be used for many patients: Those in danger are the silent ones, not the screaming ones. This is referred to as “the first round” or the “Overview round.” The second round is “the life-saving round” (Fig. 3.14). Immediate threats to life are dealt with in the first round, doing only what is necessary to save the life: • Patients A, with the arm fracture, and C, who is apparently awake and breathing, have to wait. • Helpers are instructed to position patient B in the shock position. • Patients D and E are placed in the drainage position after rapid clearing of airway. • A helper applies pressure to the bleeding in patient F; when necessary, a tourniquet should be applied. • Patient G has an immediately life-threatening condition and has to be given high priority for evacuation. The third round is the “triage round,” during which priority for further treatment or evacuation is decided upon and indicated based on the two first rounds.

To summarize, the overview and life-saving procedures should occur before triage.

50

S. Lennquist and R. Dobson

Fig. 3.13 The “first round”: a quick overview – only a few seconds (not minutes!) for each patient – to identify immediate threats. This is not as easy as it looks and requires training (see the text for further explanation) (Artwork: Lais-Ake Peterson)

C B

D

E

F

A G

C D

E B Fig. 3.14 The “second round”: Doing what is necessary to (if possible) eliminate immediate threats to life, but not more than that; then the patients can be triaged for further treatment and evacuation (see the text for further explanation) (Artwork: Lais-Ake Peterson)

F

A

G

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The Prehospital Response

3.7.3

Triage in Different Zones of the Scene

3.7.3.1 Injury Zone Any kind of triage in the injury zone may be difficult; casualties may have to be evacuated in the order in which they are found just to get further access. As a general rule, treatment in this zone should be restricted to only necessary life-saving procedures, and the casualties should be evacuated to the casualty clearing zone as soon as possible, where both the overview and the conditions to perform triage as well as treatment are far better. However, trapped patients may need treatment before and during extrication. If several casualties are trapped, the decision has to be made which ones to free first. In such cases the principles illustrated in Figs. 3.13–3.14 should be followed: Get an overview of the area or the sector before starting triage. 3.7.3.2 Casualty Clearing Zone In many cases there is already an accumulation of casualties in what is going to be the casualty clearing zone when medical staff arrive, and triage and resuscitation have to be started in the face of a large number of casualties awaiting attention. If this is the case, follow the principles outlined in Fig. 3.13–3.14. When the casualty clearing zone is organized (see Fig. 3.4), triage should occur in two steps: Primary triage by the primary TRO (or team) with the aim to: • Sort out those who do not need ambulance transport • Give those who need ambulance transport priority for either – Resuscitation on the scene and secondary triage, or – Resuscitation and departure in an immediately available ambulance For this primary triage, a system based on simple criteria of the patient’s condition (“physiological triage”) is sufficient, e.g., triage sieve (Chap. 4). This can be done quickly by a person with limited medical experience if experienced staff not is available. Secondary triage by the next triage team(s) with the aim to: • Make a secondary examination and evaluation of the patient’s condition

51

• Perform resuscitation and treatment considered necessary before transport • Confirm or adjust priority based on the results of the steps above and considering access to transport facilities and estimated time to hospitals At this level, a triage system with a higher discriminative capacity is preferred, e.g., triage sort, a physiological triage system based on the Revised Trauma Score (Chap. 4), if possible combined with “anatomical triage,” based on diagnosed injuries.

3.7.4

Indicating Priority

There is unfortunately still no internationally uniform system for indication of priority, even if we are approaching an international consensus on colors for different levels. Neither is there an internationally uniform system for marking priority, which should be highly desirable because much of this work requires international collaboration. Different triage systems, levels of triage, and systems for indicating priority are described in Chap. 4, with emphasis on the systems most commonly used today.

3.8

Treatment: How Much Should Be Done?

How much medical treatment should be done on the scene? Is it not better to get the injured to the hospitals as soon as possible, where the facilities for diagnosis and treatment are far better than those in the field? There is an old, and still ongoing, debate with regard to which is the best strategy during major incidents. • Load and go (or “Scope and run”): Transport the patient from the scene without any delay caused by treatment that not is immediately necessary to save his or her life • Stay and stabilize (or “Stay and play”): Perform not only life-saving procedures on scene, but also more advanced procedures with the aim to – Get the patient in the best possible condition before transport – Make it possible to give lower priority to some patients, saving transport facilities for those with more urgent needs.

52

As in other fields of medicine, the truth is not black or white: The selection of strategy must be adapted to the situation, and what is right in one situation might be totally wrong in another. Factors that influence the strategy during major incidents are (in addition to the patient’s condition): • Time to the hospital • Access to transport facilities • Access to resources on scene The need for simple, life-saving procedures, such as clearing and securing the airway, stopping major external bleeding, simple shock prevention and immobilization of fractures before transport is apparent and not controversial. The controversies apply to more time-consuming procedures such as placing an intravenous line, providing intravenous fluid, and performing a tracheal intubation. Analysis of when and from what patients die after accidents have shown that approximately 40% of those who die consequent to injuries die on the scene, and approximately10% die during transport. The majority of those who die on scene die within the first hour. Between 10% and 20% (the number varies in different studies) of those could initially have been saved by measures taken on the scene – often simple things like clearing and securing the airway and stopping external bleeding. This figure must be considered with the background that we do not know how many of these initially salvageable patients would have been able to be definitely saved. However, avoidable deaths have occurred on scene and continue to occur even after single accidents. Analyses of causes of death after head injuries have also shown that up to 30% do not die from the head injury itself, but from the lack of an unobstructed airway; for example, by staying unconscious flat on their back, something that can be easily prevented. It is important to realize that prevention of these initially avoidable deaths in the majority of cases only requires simple procedures, but they have to be done soon after the injury. The best way to achieve this is better training of people in general in basic first aid procedures, especially if staff who are commonly first on the scene, such as rescue personnel. The importance of widespread knowledge of basic first aid has also clearly been shown in major incident levels 2 and 3. The possible indications for more advanced procedures on scene that require qualified medical staff must also be evaluated with consideration of the continued

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course and final outcome for the severely injured patient. Approximately 30% of patients with severe injuries develop delayed reactions to trauma such as hepatorenal failure because of prolonged shock, respiratory distress syndrome (“shock lung”), multiorgan failure, or sepsis. Our natural defense mechanisms against trauma gets over-triggered into negative effects. Of that 30%, up to one-third still die during posttraumatic intensive care. However, recent research in trauma has shown that these delayed and often fatal reactions can be reduced or eliminated by early treatment such as: • Effective ventilation and oxygenation; • Effective prevention and treatment of shock, including early control of bleeding; • Effective immobilization of fractures as a measure to reduce secretion of metabolic products from injured tissue; and • Pain relief as shock prevention in reducing catecholamine secretion. The delay of these actions increases the risk for delayed reactions to trauma, generating an increased load on intensive care and increased morbidity and mortality. A severely injured patient who reaches the hospital alive may still be lost if he or she comes to the hospital after prolonged shock with insufficient ventilation and oxygenation and nonstabilized fractures. This means that qualified treatment before and during transport can be both justified and of critical importance when: • Expected transport time to hospital is long (>30 min as a guideline) • Delayed evacuation from the scene (trapped patients and/or many injured) • Limited access to transport facilities (waiting time for ambulance/helicopter) When transport time is <30 min, prehospital intravenous fluid hardly has any effect, and it is better to get the patient to the hospital quickly. Overuse of fluid, such as crystalloid solutions, can also have negative effects (see Chap. 7 for further discussion of injuries caused by physical violence). In case of extensive internal bleeding, the only possibility to save the patient’s life may be to get rapid surgical control of the bleeding in the hospital, and any delay might be fatal. However, as stated above, even in the “normal” accident there are situations where more advanced prehospital treatment is justified. Increasing the competence of ambulance crews and making them better

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equipped has made that possible. Equally as important as skills to perform treatment in these situations is the ability to make accurate decisions about what to do and not to do. A good rule to follow is: “The hospital is always the best place for the severely injured patient, and if you stay out there to do things before transport, you must have a good reason for it.” During major incidents, on the other hand, many of the indications for more extensive prehospital treatment listed above may be present: • The transport times to the hospital are longer because it may be necessary to send patients to hospitals that are a longer distance from the scene because of a lack of capacity at hospitals that are closer. • The evacuation from the scene is delayed because patients are trapped, there is limited access to the scene, or there is a high number of casualties in relation to available staff. • The available transport facilities are insufficient in relation to the need. Therefore, preparedness for major incidents should include preparedness for treatment of casualties on scene with regard to both competence and equipment. Good medical competence is also of critical importance for triage of casualties to ensure the most effective utilization of available resources. The indications and principles for prehospital treatment of casualties are discussed in detail in the chapters dealing with different mechanisms of injury: physical violence (Chap. 7), fire (Chap. 8), hypothermia (Chap. 9), hazardous material (Chap. 10), and irradiation (Chap. 11).

3.9

Transport of Casualties

3.9.1

Alert of Ambulances

Ambulances are usually alerted by the ADC as a response to an incoming alarm, which also is valid during major incidents. The alarm center also alerts the RMC when a major incident is evident or suspected. The ADC makes a decision about alerting ambulances based on the information given in the alarm and the first reports from the scene. The RMC can ask the ADC for more ambulances based on communication with the MIC, but usually does not have the authority or task to alert them.

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The question of how many ambulances to alert has been subject of debate. In some major incidents, an over-alert has been registered and has become the focus of criticism. One example is an airplane crash in Amsterdam, where a jumbo jet crashed into a building during flight into the airport (Chap. 2). All available ambulances were alerted, but only a few were needed because the aircraft was a transport carrier with only crew on board, and most of the people in the crushed houses were not in their homes. However, none of this was known at the time for alert. It could well have been a scenario with several hundreds of injured. Based on this and other experiences, attempts have been made to construct formulas to help determine how many resources should be alerted, but these are all theoretical constructions. The principle must be to “over-alert rather than under-alert”: Over- alert may cost money, but under-alert may cost lives. As a principle, an area should never be completely drained of ambulances. Other emergencies can happen, or ambulances may be needed for secondary transport. An exception is if the neighboring area can simultaneously release ambulances that can replace some of the ambulances alerted to the scene.

3.9.2

Alert of Helicopters

Ambulance helicopters staffed and equipped for medical transport are available in many counties and are usually hospital based. They are often alerted by the same unit that alerts the ambulances. Their ability to fly in darkness or severe weather conditions varies between countries. If the helicopters are hospital based, they should be remembered as a resource to bring prehospital medical teams and medical equipment to the scene. Other helicopters (e.g., military) are usually requested by the RIC during major incidents. If they do not have equipment prepared for advanced medical surveillance, they should not be used for this purpose; bringing in such equipment that has not been tested and approved for flight security may expose patients and staff to risks. However, they can still be a valuable resource for bringing staff and equipment to the scene and transport of patients who do not need advanced equipment for surveillance or treatment.

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The most efficient use of helicopters is for transport of patients to hospitals a long distance from the scene, gaining transport time. They should, if possible, only go to hospitals with helipads because they otherwise consume ambulances for transport from landing areas.

3.9.3

Alert of Other Transport Facilities

Buses might be needed for transport both of less severely injured and noninjured victims. The RIC has the authority to request these resources during a major incident. Also, other transport facilities can be requested under certain conditions, including bandwagons, boats, trains, or airplanes. Less severely injured patients should not be transported without attendance of medical personnel – even if they are seen by medical staff before departure, some of them may have undiagnosed severe injuries primarily missed in a severe scenario.

3.9.4

Leading and Coordination of Transport

With regard to evacuation of casualties from the scene of a major incident, there is an old misconception that the only important thing is to get all patients evacuated as soon as possible: “The hospital is always a better place that the scene,” and when all patients are in a hospital, all problems are solved. This kind of thinking does still exist. One reason for it is that exercises often stop at the hospital entrance because of practical problems of bringing figurants into the hospital. This means that nobody knows what would have happened to all these patients if they really had been brought to hospitals according to the distribution in the exercise. Another reason is that the development within the health care system during the last decades not has been recognized by the prehospital organization. Going back 20–25 years, the situation in hospitals with regard to capacity for unexpected high loads of casualties was different. It was much easier to find available theaters and ventilators, and many patients in the wards were in the condition that they could be

sent home earlier if needed. The increasing demands on efficiency (parallel to increased costs for health care) has led to every resource being optimally utilized: During office hours every operating theater in a big hospital it occupied, often for time-consuming, in-depth surgery; every ventilator in the intensive care unit is occupied; and hospital beds are used only for those who need advanced care or surveillance.

If a patient who needs immediate surgery or a ventilator comes to a hospital with no operating theater or ventilator available, the patient may be lost – even in a big hospital – because there is neither time nor immediately available resources for secondary transport to another hospital.

This can never be understood if exercises are limited to the prehospital part of response. Every exercise should illustrate the whole chain of management, which never can be achieved without using simulation systems, which is the only way to illustrate the full hospital response. Live field exercises might be justified, but should always include simulation of transport and hospital response with real times and real resources.

To summarize, as a consequence of the development within the health care system, it is today of critical importance that the patient comes to the right hospital – one where immediately needed resources are immediately available – from the beginning.

Figure 3.15 illustrates what can happen if this is not properly understood. The incident has occurred in an area with four hospitals within a relatively close range; all hospitals are alerted and activate their plans. The ALO wants to use his ambulances in the most efficient way and sends all of them to the nearest hospital, thereby getting them back quickly, and the scene can

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Fig. 3.15 An example of “maldistribution” of patients between hospitals. Instead of distributing the patients between the hospitals in the area of the incident with consideration of hospital capacity, all ambulances are sent to the nearest hospitals to get them back faster. Because “reserve capacity” for sudden high loads of casualties in today’s hospitals is limited, this will lead to mortality that could have been avoided (see the text for further discussion)

be evacuated in short time – therefore the problem for the transport officer is over. However, the nearest hospitals in this case do not have operating rooms or ventilators for all patients who need them, patients are lost while all ambulances are circulating between this hospital and the scene, and the other hospitals are not utilized. Such a “maldistribution” of patients is one of the most common recently reported errors during major incidents. To achieve an accurate distribution of patients between available hospitals with regard to their immediate capacity requires establishment of communication between the scene and the receiving hospitals as quickly as possible. Communication between the scene and every hospital is not realistic, considering the wellknown difficulties of establishing functional communication under these circumstances. The communication has to be mediated by a coordinating center that is well equipped with communication lines and staffed by medically competent people. From this coordinating center it is easier to establish communication with the command groups of the hospitals involved (see Chap. 5). This coordination is schematically illustrated in Fig. 3.16. As previously mentioned, this function may be organized differently in different countries. It can be connected to or located with the Alarm Center, the Ambulance Dispatch Center, the Rescue or Police Command Center, or to one of the hospitals in the region. In this book it is referred to as the Regional Medical Command Center.

Regardless of where it is located, the RMC must: • Be staffed by persons who are immediately available by pager on a 24-h basis • Have medical competent staff • Be functioning within 15–20 min after the alarm • Be well equipped with communication lines (radio, direct telephone lines to hospital command groups, alternative communication systems) • Be independent of electricity through connection to reserve power systems. These are high demands and require an on-call system for at least two persons in each region: one senior medical officer and one administrative officer. To respond to the demands of rapid alert and access to facilities, it is an advantage to locate the RMC with one of the organizations mentioned above. The staff should be specially trained for this purpose and have action cards to follow. The tasks of the RMC are to: • Declare a major incident when justified (in some countries this can also be done by the first ambulance crew on scene) • Inform and alert hospitals and other resources for medical care according to estimated and expected needs

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• Coordinate distribution of casualties between hospitals in communication with hospital command groups and the ALO on scene • Coordinate information to other agencies (rescue service, police, military), regional and national authorities, media, and (when necessary) foreign embassies • Make the decision to cancel major incident (see “Major Incident Stand Down”) with information provided to all organizations involved

Even with immediate access to the RMC officer on call, and even with the demand that hospitals report immediate critical capacity within 15 min of the alert (see Chap. 5), it cannot be expected that this information is available on the scene when the first transports are ready to go, especially in an urban area with short distances to hospitals and good access to ambulances. However, ambulances should not stand waiting for this information. In the action cards for the MIC and ALO on scene should be rules for how patients can be initially distributed before access to information about capacity. Some countries use the “rule of four,” presuming that every hospital can receive up to four severely injured patients without having any plan activated. Other countries have this given in the action cards, considering size and normal capacity of hospitals (Table 3.1). The capacity report from hospitals at this early stage should only include information of critical functions: immediately available operating rooms and ventilators (see Chap. 5). Based on this, the RMC gives a “distribution key” to the ALO, for example: Hospital A: four patients for immediate surgery (one for general, two for orthopedic, and one for neurosurgery), two ventilators Hospital B: two patients for immediate surgery, one ventilator Hospital C: three patients for immediate surgery, two ventilators

If the distribution key still is not provided when the first patients have been distributed according to the above, the ALO should request it urgently and, while waiting for it, continue to distribute patients according to the same principles as above. This distribution key is continuously updated parallel to the hospital’s continuous capacity reports based

RMC

HCG 1

HCG 2

HCG 3

MIC ALO

TRO

Fig. 3.16 Schematic illustration of the medical “command structure” and coordination of transports to a hospital. The Ambulance Loading Officer (ALO) has radio- communication with the Regional Medical Command Center (RMC), which in its turn has telecommunication with the Hospital Command Groups (HCGs; see Chap. 5). One of the tasks of the HCG is to report the capacity for immediate treatment (in the operating rooms or intensive care unit) at the most 15 min after the alert, then continuously after activating the disaster plan. Based on this, the RMC gives a “distribution key” for distribution of casualties between hospitals (see the text for further details). A prerequisite for this is that both the RMC and HCG comprise staff on call on a 24-h basis

on activation of plans with redistribution and mobilization of resources, taking into considering what already has been sent to them. Decisions by the ALO about where to send patients is based on the distance to hospitals, the patient’s condition, and also the preliminary diagnosis; some

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Table 3.3 Example of an action card for an ambulance loading officer (the content should be adjusted to local organization) 1. Take on tabard “ALO,” bring handheld radio and triage cards from the ambulance for needed re-triage. 2. Make contact with the RMC (channel X) and ask for present distribution key and distribute patients between hospitals according to that, with consideration of normal rules for specific injuries (head injuries, burns) Waiting for distribution key to be given, follow the rule: • Six severely injured patients to Major City University Hospital • Four severely injured to Sea Town Regional Hospital • Two severely injured patients to Small Town County Hospital 3. Check, or let check, that registration is done before departure (SMART tag completed) 4. Report, or let report, departed patients (time of departure and estimated types of injuries) to receiving hospitals (channel X) 5. Report estimated need of ambulances to MIC (channel X) 6. Keep contact with TRO (direct or via channel X) and request information on coming needs for transport 7. Discuss use of helicopters individually with RMC (channel X) 8. Report lack of ambulances leading to delay in evacuation, or staffed and waiting but not used ambulances, to MIC (channel X) RMC Regional Medical Command Center, MIC medical incident commander, TRO triage officer, ALO ambulance loading officer

injuries/patients should be sent to hospitals with special facilities, if available: Head injuries. These patients should be sent to hospitals with neurosurgical unit. Even if all surgeons dealing with trauma can do a trepanation in an emergency situation, these patients consume more effort and time without access to neurosurgically competent staff and might require secondary transport. Major burn injuries. If possible, these patients should be sent primarily to a burn center. However, primary treatment (large-volume resuscitation) can also be done in intensive care units without specific burn facilities and burn specialists can be transferred there for support during triage and treatment; secondary transport can occur later. Eye injuries. These patients should be sent to a unit with ophthalmologic surgery capabilities; when possible secondary transfer can occur later (<12–24 h) because these are not life-threatening conditions. Children. Young patients should, if possible, already primarily be transferred to pediatric units with staff used to taking care of children. All other injuries can primarily be taken care of in surgical and orthopedic units. An example of an action card for an ALO is given in Table 3.3.

3.9.5

Ambulance Service

3.9.5.1 Tasks The ambulance service has, as already illustrated, many important functions during major incidents:

• Command and coordination on scene, taking on roles as MIC, with overall responsibility for the medical work at the scene, ALO, and primarily TRO • Triage and treatment on scene, perhaps supported later by prehospital medical teams • Transport of casualties from the scene • Surveillance and treatment during transport

3.9.5.2 Competence The competence of the ambulance staff varies between countries. A uniform development during recent years has been to increase the medical competence, and, in many countries, every ambulance has at least one nurse with special training in prehospital and emergency medicine. Some countries have paramedics with special training, and other countries have physicians in certain ambulances. There are now special, internationally uniform training programs for ambulance staff, such as Prehospital Trauma Life Support, which teaches the same principles as Advanced Trauma Life Support, as well as other programs (see Chap. 18). Increased medical competence does not mean that an ambulance crew shall do more advanced procedures on scene, but it increases their ability to make accurate decisions regarding what to do and not to do and decisions with regard to patient priority. In addition, in most countries today ambulance staff receives special training in major incident response, which is a prerequisite to be able to cover

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the functions listed above. They have experience working in the field from their daily routine, which, combined with their medical competence, makes them a valuable resource on scene, and it is important that this is recognized and respected by other medical staff. Exactly what kinds of treatment the ambulance officers are trained and authorized to do varies within countries and within regions. In areas where it is justified because of long distances to hospitals, ambulance staff may have a permanent (but restricted by time) delegation to do things normally not connected to their formal professional competence, but then a seniorlevel medical officer has to be responsible for the delegation and the training necessary for it.

3.9.5.3 Ambulance Equipment The equipment in ambulances also varies between countries, and there is no uniform international standard. Equipment that can be much needed during major incidents, and therefore as a step of preparedness should be brought as more than one unit, includes: • Splints for all kinds of fractures. In most scenarios, approximately 70% of injuries are limb injuries. Simple splints that consume minimum space and can be adjusted to different types of fractures are valuable, as are extension splints for femur fractures. • Boards for stabilization of the cervical and thoracolumbar spine • Equipment for establishing intraosseous infusion • Portable oxygen bottles see also “Ambulance Equipment Vehicles,” above. In a cold or rough environment, protective clothing for ambulance crews and equipment to keep intravenous fluid warm is important. The equipment should also include a sufficient number or triage and registration cards and, as already mentioned, major incident action cards. Because of wide variations between countries, it is outside the scope of this book to describe existing models of vehicles. Medical staff that can be deployed for prehospital work should, during their postgraduate training, become acquainted with the models and equipment used in their own region.

3.10

Registration on Scene

All major incident victims should be registered as injured, noninjured, or dead before they depart the scene. How this is done, and which organization has the responsibility for it, varies between different countries.

3.10.1 Medical Documentation Within the health care system, there is in most countries a legal obligation to document treatment and decisions made by medical staff outside hospitals, and this is an important part of patient management. There is still no internationally uniform system, and many countries do not even have a nationally uniform system. Examples of registration cards developed for this purpose, which also function as triage cards, are given in Chap. 4. The medical registration is a balance between the ambition to evacuate the patient from the scene as soon as possible and the ambition to document as much information as possible. As a principle, registration should not cause any unnecessary delay in evacuation; many of the cards in use give space for a lot of information, and it must not be a self-purpose. Medication given, including analgesia, must always be documented, and certain data are important for diagnosis and decision making later in the chain (such as level of consciousness of patients with head injuries; see Chap. 7), but everything in the card does not need to be filled in if it will delay transport.

3.10.2 Identiﬁcation and Destination A part of the medical registration card that always should be filled in is the destination of the patient, which also is the basis for information provided to relatives. Every card usually has a registration number, so if the patient’s name not can be identified or given, the destination can be connected to the registration number. However, it is desirable for many reasons that as many patients as possible are identified by name before departure from the scene so that information about which patient goes to which hospital (or other destination) is available as soon as possible. In a heavy load of casualties, it is questionable to give this task to medical staff. In most countries, this is done by the police. A common registration system for police and medical

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staff should be a natural goal, but has so far been possible to achieve in few countries. The police also have the task of registering uninjured victims and those dead at the scene. Whichever system is used for this, it is of critical importance that the registration does not delay the evacuation from the scene; the organization responsible for this must devote sufficient resources to it to avoid congestion at departure.

3.11

Communication

3.11.1 Problems and Limitations Functional communication is an absolute prerequisite for a successful major incident response, and this is valid for all organizations involved in the response. At the same time, the most commonly reported problems during the evaluation of major incident response are failures in communication. These failures are of three different kinds: 1. Deficient function of available communication systems, e.g., insufficient coverage, overload of systems, or technical failures 2. Deficiencies in how these systems are handled(human factor), e.g., lack of training of medical staff in the use of communication devices, or charging of batteries has been forgotten 3. Deficiencies in communication technique: forget to report (common), unnecessary or unnecessarily long communication, deficiencies in verbal technique The most commonly used systems today are the telephone net, mobile (cell phone) net, and radios.

3.11.2 The Telephone Net The telephone net is usually not available directly at the scene of an incident, but can be made available by connecting to it through the rescue service; then it works as long as the net is intact. However, even modern digital nets can be overloaded by high traffic intensity, such as that which occurs during major incidents. In hospitals, it is important to have direct lines (that do not pass through any switchboard) for critical functions such as the HCG command room (Chap. 5), information center, and emergency department.

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3.11.3 The Mobile Telephone Net The mobile telephone net is an excellent tool for communication – as long as it works. However, this net is sensitive to disturbances in the infrastructure and especially sensitive to overload, when it can be impossible to get through. On few occasions are as many calls placed as are during the major incident. As a rule: Bring a cell phone with you, and if it works, fine, but never rely on it. In some countries, it is possible – by request from the police or rescue service – to institute an overload control, which means that only telephones equipped with specific software modifications will continue to function in an overload situation, thereby securing communication for vital functions. This requires preparation and decision regarding which functions should be supplied with such equipment, which should include important functions within health care. One disadvantage with the use of mobile phones, even if they work, is that the communication not can be heard and documented on a central level.

3.11.4 The Radio Net The radio net is the by far safest method of communication during a major incident, even if this technique has restrictions in the form of limitations in coverage. Communication can be done according to a single or double frequency system. Single frequency means that every user can talk to any other user, and everything is heard; double frequency means that every user can talk only to a central control, but the central control can talk to every user and mediate calls between users by “talk through.” Radios operate either on a very high frequency (VHF) or ultra-high frequency (UHF). The VHF has the longer range and can be used both for communication within the scene of an incident and from the scene to regional centers and hospitals, as is commonly used by rescue services, police, and the health care system. Usually, every service has its own channel(s), which should be known in advance by all services. The UHF has a shorter range and is suitable mainly for communication within the scene and can be used by the rescue service or police.

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Because the space on the net is limited (only one person can talk at one time), it is of vital importance to keep a strict radio discipline: • Do not talk if you have nothing important to say • Keep messages short, providing only necessary information • Identify yourself and the receiver clearly • Indicate clearly when the message is over This requires training on the handling of the radio sets. Rescue service, police, and ambulance staff have this training and use it on a daily basis. Doctors and nurses in prehospital teams do not have it in their regular training and are mostly not used to it, which means that this should be included in the training of potential prehospital teams. Staff who are not trained for it should not use radios on a scene.

3.12

3.11.5 Other Communication Systems

Further Reading

3.11.5.1 Satellite Systems Different such systems have recently been developed for international telecommunication for military and maritime use. The access to them varies between countries, and they have so far been used in civilian incidents only to a limited extent, but may have great potential in this area in the future.

Aylwin CJ, König TC, Brennan NW et al (2006) Reduction in mortality in urban mass casualty incidents: analysis of triage, surgery and resources use after the London bombings on July 7, 2005. Lancet 368:2219–2225 Bernard SE (2006) Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emerg Med Australas 18: 221–226 Bloch YH (2007) Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of densely populated area – lessons learned from the medical management of a terrorist attack. Prehosp Disaster Med 22:186–191 Clawson D (ed) (2001) Principles of emergency medical dispatch, 3rd edn. Priority Press, Salt Lake City Garshnek V, Nurkle FM (2006) Communication and information technology tools for disaster response and medical assistance. In: Hogan DE, Burstein JL (eds) Disaster medicine, 2nd edn. Wolters Kluwer/ Lippincott Williams & Wilkins, Philadelphia, pp 158–172 Hodgetts T, Mackway-Jones K (2002) Major incident management and support: the practical approach. BMJ Publishing Group, London Hogan DE, Burstein JL (2007) Basic perspectives of disasters. In: Hogan DE, Burstein JL (eds) Disaster medicine, 2nd edn. Lippincott Williams & Wilkins, Philadelphia Hülse E, Oestern HJ (1999) Die ICE Katastrophe von Eschede 1998. Springer, Berlin Laaksonen MI (2006) Effect of physician-staffed helicopter emergency medical service on blunt trauma patient survival and prehospital care. Eur J Emerg Med 13(6):335–339 Lam D (2006) How to collect and transmit data from the site to hospitals during a disaster response. Int J Disaster Med 4:144–151 Lee A (2003) Level of prehospital care and risk of mortality in patients with and without severe blunt head injury. Injury 34(11):815–819

3.11.5.2 Runners People who can deliver messages by foot or by vehicle are an alternative if other communication systems fail. At the millennium shift, when it was feared that all computer technology could shut down and thereby the communication based on it, the use of runners was planned in disaster preparedness in many countries. They can be used both within the scene, within hospitals, to pick up staff on alert, and for communication between hospitals and the scene, but is has to be planned; this can be an important task for voluntary organizations. 3.11.5.3 Media Media should not be forgotten as an instrument for information and for alert of staff if telecommunication fails. Information about risk zones (incidents involving hazardous material), evacuation, traffic restrictions, the number to call for information about missing relatives, and recruitment of blood donors are examples where collaboration with media is important.

Special Considerations in Terrorist Actions in Areas of Violence

In civilian incidents caused by terrorist actions in regions with political tensions and continuous violence, there may be threats remaining on the scene immediately after the incident: Casualties, rescue staff, and medical staff may be exposed to threats even during the response (shooting or explosions). In such cases, safety must have priority, and casualties may have to be evacuated as quickly as possible, even without triage and with minimal resuscitation on the scene. The principles in such situations are similar to those in combat casualty management and are described in Chaps. 14 and 15.

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Lennquist S (2003) The importance of maintaining simplicity in planning and preparation for major incidents and disasters. Int J Disaster Med 2004:5–9 Lennquist S (2005) Education and training in disaster medicine. Scand J Surg 94:300–310 Liberman M, Branas CC, Mulder DS et al (2004) Advanced versus basic life support in the prehospital setting – the controversy between the “scope and run” and the “stay and play” approach to the care of the injured patient. Int J Disaster Med 2:9–17 McSwain NE, Frame S, Salome JF (eds) (2006) Basic and advanced prehospital trauma life support, 5th edn. St Louis, Mosby O’Hickey SP, Pickering CA, Jones PE et al (1987) Manchester air disaster. Br Med J 294:1663–1667 O’Neill PA (2005) The ABCs of the disaster response. Scand J Surg 4:259–266 Pryor JP (2009) The 2001 World Trade Center disaster – summary and evaluation of experiences. Eur J Trauma Emerg Surg 3:212–224

61 Salomone JP (2005) Opinions of trauma practitioners regarding prehospital interventions for critically injured patients. J Trauma 58(3):509–515 Schou J (1996) Major interventions in field stabilization of trauma patients: what is possible? Eur J Emerg Med 3(4): 222–224 Soreide L, Grande CM (eds) (2001) Prehospital trauma care. Marcel Decker, Inc., New York Turegano F, Perez-Diaz D, Sanz-Sanchez M et al (2008) Overall assessment of the response to the terrorist bombings in trains in Madrid, March 11, 2004. Eur J Trauma Emerg Surg 34:433–442 Wallace AW, Rowles JM, Colton CL (1994) Management of disasters and their aftermath. BMJ Publishing Group, London Zoraster RM (2007) Field triage and patient maldistribution in a mass-casualty incident. Prehosp Disaster Med 22: 224–230

4

Triage Kristina Lennquist Montán

4.1

The Term Triage

The word “triage” is derived from the French word trier, which means “sort” or “sift.” It is today a globally accepted term for the method used to identify those in greatest need of care when faced with a large number of severely injured or critically ill patients. The name of this method originates from the French language because the first to initiate triage was Baron Dominique Jean Larrey, chief surgeon to Napoleon Bonaparte. He introduced triage as a method to sort casualties into priority groups for evacuation from the battlefield. In fact, he initially used this method to identify the less severely injured, who could be returned to the battlefield quickly after treatment. Today, the aim of triage is different; it is used to identify the most severely injured and give them priority for evacuation and treatment at all levels along the chain of medical care.

4.2

Demands on Triage

Triage is the part of the methodology of major incident response that differs most from the methodology used in daily medical care. In routine medical care we have to set priorities, especially with regard to more advanced and expensive methods for diagnosis and treatment, which have become available as a consequence of technical development, and in situations where some part of our medical care system is temporarily overloaded. However, such decisions K.L. Montán e-mail: [email protected]

about priority can usually be referred to staff with high competence and experience, with good access to information, and without the time pressure that characterizes an MI. In the latter situation, triage must – especially at the front line of the response – be done by responders with limited experience, limited access to information, and under heavy time pressure. This raises the demand on simple standardized systems, which can be learned and trained relatively easily. Triage during MIs has to meet the following requirements: • Triage is, and has to be, a dynamic process, which means that it can and should be re-evaluated at every stage in the chain of the response and adjusted to: – The patient’s condition; – Effects of performed treatment; and – Position in the chain of response (prehospital, transport, different levels in the hospital response). This means that a patient may be prioritized differently at different levels of the chain of management. • Standardized systems for triage make the triage more independent of the level of competence of the staff doing it, and may thereby be the method of choice in the front line of response, where senior competence in most cases is not available. • The system used must be adapted to: – The level of the chain of management on which it is done; and – The competence of the responder doing it. This means that different systems may be used at different levels of the response. • The categories of priority must be clearly defined and a uniform terminology used by all staff involved in the same incident. An international uniform terminology should be desirable.

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_4, © Springer-Verlag Berlin Heidelberg 2012

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Table 4.1 Triage classifications used by the North Atlantic Trade Organization (NATO)a Priority Immediate Urgent Delayed Expectant Dead

Color Red Yellow Green Black/green White/black

Label P-system P1 P2 P3 T4 T0

T-system T1 T2 T3

a

The P-system is used in level 1 major incidents, and the T-system is used in incidents corresponding to major incident levels 2 and 3

• The priority given must be clearly marked on the patient and be able to be changed quickly and simply according to the demand that triage has to be a dynamic process.

4.2.1

Categories of Priority

Casualties are traditionally referred to categories based on the priority given. Unfortunately, the number of categories used, as well as how they are defined, varies between countries and there is still no uniform international terminology. Even within the same country, different terminology may be used. This may cause dangerous confusion, especially during international rescue missions, where health care staff from different countries and different regions must work together and communicate. The categories introduced by the North Atlantic Treaty Organization (NATO), used today in most European countries, are described in Table 4.1. Two different systems are used depending on the level of MI: The P-system corresponds to a MI level 1 and the T-system is used in incidents corresponding to MI levels 2 and 3. The P-system includes three categories: • P1: Immediate treatment is required to save a life • P2: Severely injured, but can wait for a limited time (30–60 min) • P3: Can wait without risk of life and/or health The T-system includes five categories of priority: • T1: Same as P1, with the difference that patients whose possibilities to survive are considered limited now are referred to category T4 (see below). • T2: Same as P2 • T3: Same as P3

• T4: Shall wait (“expectant”); patients with severe injuries where the possibility to survive is considered so limited that the resources they would consume for treatment instead should be used for those who are salvageable. • T0: Dead The aim must be to agree on a uniform international system for defining categories for triage, at least a uniform system for Europe. Because the use of the NATO system is already widespread in Europe, it may be reasonable to establish it as the European system.

4.2.2

Indication of Priority

For indication of priority there is a lack of agreement on an international uniform system, and a wide variety of colors and symbols are used. This can be dangerous because the same color can have different meaning in different countries. For example, is in some countries black is used for the category “expectant,” whereas it in other countries is used only for casualties declared dead by a doctor. The consequences of misinterpretation are easy to recognize. Because triage is a dynamic process, which means that the priority must be re-evaluated – and changed when justified – at all stages in the chain of response. The system for indicating priority must then be possible to change in both directions: upgraded or downgraded. There are still systems in use in Europe in which this is not possible and because of that the triage process cannot be dynamic, which interferes with optimal utilization of resources. Most systems for indicating priority are based on colors. At the first congress of the World Association for Disaster and Emergency Medicine in Mainz, Germany, in 1977, the following colors were agreed upon after a workshop: Red Yellow Green Black

Immediate treatment Urgent but can wait Shall wait Dead

Since that congress the need for a fifth category has been increasingly recognized, especially during MI levels 2 and3: casualties with such a small possibility of survival that the resources they would consume for treatment should be used for those who are salvageable. In the NATO system these patients are categorized as

4

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“T4” and are labeled with black and green. In the British system, they are categorized as “expectant” and labeled with blue. Most European countries have adapted the British color system, partially influenced by the Major Incident Medical Management and Support courses, but also because blue provides a better contrast to the other colors. The introduction of this fifth category is not without controversies, and many countries have still not introduced it. However, it has gained increasing support during recent years and been considered justified, especially during level 2 or 3 MIs. A reasonable European standard would, therefore, be to add this fifth category: Blue: Expectant (shall wait as long as resources do not permit the curative treatment of all casualties) How these color indications are practically applied to casualties also varies widely among countries and regions. From this aspect, an international uniform standard would be desirable. As already mentioned above, it should be a system that permits easy change of priority, both upgrading and downgrading. That disqualifies many systems used today. One example of a system that permits easy change of priority is the SMART-tag® system (Fig. 4.1a–c). It is a combined triage and registration card with space for patient identity and for notes about clinical findings during examination, preliminary diagnosis, and treatment given, with additional space that can be used if and when time permits; medication must, of course, always be registered. The card can be folded so that only one color at a time is visible, and it is easy to refold it to upgrade or downgrade priority and still keep the same registration card. A separate card is used for indication of death because it should not be possible to mistakenly fold up the card to show black. Before evacuation, the patient identity portion of the card should be filled in; the destination should be indicated and one part of it removed and kept for documentation in the ambulance loading zone. The SMART-tag® system also includes special cards for use during incidents caused by chemical, radioactive, and biologic agents (Fig. 4.2a, b). Another alternative for indication of priority is that used by the Norwegian Air Ambulance (Fig. 4.3a, b) based on a color strip, which is simply squeezed around the arm of the patient and easy to change. An ordinary ambulance record is then used for registration.

65

a

b

c

Fig. 4.1 (a) The SMART®-tag (http://www.tsgassociates.net) system is a combined triage and registration card. Priority is indicated by folding the card so that only one color can be visible at a time. This makes it possible to upgrade or downgrade the priority without changing the card. Small picture to the right: expectant (blue) can be indicated by folding the red tag so that the blue color appears in the corner. (b) The registration portion includes on the left a table with the algorithm for triage sort to fill in, with space for repeated examinations. In the center there is space for simple indication of injuries and to the right a “tear-off” tag to keep on scene to record evacuated patients and their destination. (c) On the back of the card is space for a more detailed description of injuries and treatments, which can be filled in depending on time available. It is mandatory to register given drugs of any kind

66 Fig. 4.2 Front (a) and back (b) of SMART@-tag (http:// www.tsgassociates.net) cards to use for patients contaminated with chemical, biological, or radioactive substances

K.L. Montán

a

b

a

b

Fig. 4.3 Priority indication system used by the Norwegian Air Ambulance. A metallic priority-bar is slashed around the limb (a), automatically folds around it and remains safely attached

(b), but can also easily be removed by the responder, permitting easy change of priority (Photo: Yvonne Bäckstedt)

There are also other systems similar to the SMART-tag® system and based on similar principles, with the same color system, in use in Europe today. Whichever system is used, it is important to include a sufficient number of triage cards in the equipment at

all positions where the cards potentially may be used as well as in ambulances. If the organization suddenly runs out of cards, a chaotic situation may arise, and this has happened in some major incidents during recent years.

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4.3

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Methodology of Triage

Yes

Walking

There are many different methods of triage, according to two different main principles: (1) “anatomical” and (2) “physiological” triage.

Yes

Injured

Delayed priority 3

No

No

Assembly area for non-injured Dead

4.3.1

No

Anatomical Triage

No

Breathing

Anatomical triage is based on the injuries that are identifiable during clinical examination, and the decision about the patient’s priority is made according to this examination and based on knowledge about the clinical course of such injuries and the risks connected to them. For example: • Penetrating chest injury: high priority • Uncomplicated closed fracture of the lower limb: low priority This requires: • The possibility to do a reasonably accurate clinical examination, which may be difficult depending on light, temperature, and geographic conditions. Some injuries are difficult to diagnose during primary evaluation. • Experience and competence enough to evaluate the potential clinical course of the injury and potential risks. The advantages of this method are that it takes into consideration: • Not only the present condition of the patient, but the potential change of condition that can be expected based on knowledge about the clinical course; and • The potential effect of treatment; patients with a small possibility to be saved can be given a lower priority in situations with a heavy load of casualties, as in MI levels 2 and 3. The disadvantage of anatomical triage is that it requires staff with sufficient clinical knowledge and experience to evaluate the injuries properly; these people are not always available in the first line of triage.

4.3.2

Physiological Triage

Physiological triage is based on simple physiological parameters, for example, breathing, circulation, and neurological response. The decision about priority is made by inserting these parameters into an algorithm that automatically gives the priority (e.g., Fig. 4.4).

Open airway

Yes

Yes

Respiratory rate 10–29 Pulse rate

Breathing

< 10 or ≥ 30

Immediate priority 1

20

≥1

< 120

Urgent priority 2

Fig. 4.4 Algorithm for triage sieve, modified with pulse rate instead of capillary refill) (From TSG associates with permission)

The advantage of physiological triage is that it can be done by responders with limited clinical knowledge and experience. The disadvantages are that it is only based on the condition of the patient at the time of the triage, not the potential condition to which the injury can lead. In addition, it gives automatically high priority to patients who have such severe injuries that they are likely to die even if given such high priority. The practical implication of the different advantages and disadvantages of these two principles of triage is a combination of the two methods: On scene, especially during the initial stage of the response, physiological triage may be the preferable method because more experienced and competent responders usually are not available at this stage. In a level 2 MI, where some patients with severe injuries and small prospects of survival may justify a lower priority, anatomical triage may be performed as a complement to determine the priority for evacuation and transport to a hospital. In the hospital, physiological triage may initially also be the method of choice with heavy loads of casualties, as in MIs of levels 2 or 3, but then it should be changed to anatomical triage when setting priorities for surgery, intensive care, or other advanced treatments, where also the potential access to more experienced staff is better.

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Table 4.2 The most common physiological triage methods Geographic use Method of primary triage Triage United sieve Kingdom/ Australia START

North America

Care Flight

Australia

Sacco Triage Method

North America

Jump start

North America

Pediatric United Triage Kingdom/ Tape Australia Method secondary triage Triage United Sort Kingdom / Australia

SAVE Triage

North America

Basis Ability to walk, presence of breathing, airway patency, respiratory rate, capillary refill, or radial pulse rate Ability to walk, airway patency, respiratory rate, presence of radial pulse or capillary refill, ability to follow simple commands Glasgow Coma Scale score, presence of breathing, palpable radial pulse; used on both adults and children Mathematical model based on the probability of survival related to ventilatory rate, pulse rate, and best motor response; requires software support Used in conjunction with START in mass casualty incidents involving children up to 8 years of age Modification of the triage sieve, adjusted for parameters of children Used as secondary triage after triage sieve. Based on Revised Trauma Score including the criteria of Glascow Coma Scale, respiratory rate, and systolic blood pressure Used as secondary triage after START. Detailed guidelines for prehospital personnel in situations when the evacuation of injured will be prolonged

An alternative is to move more experienced staff toward the “front line” of the response to be able to earlier combine anatomical and physiological triage. However, preparedness and access to sufficient senior staff is required to justify this step.

4.3.3

Physiological Triage

There are many methods for physiological triage and the most common are listed in Table 4.2, which also illustrates that different methods dominate in different parts of the world. The most commonly used methods

in European countries are triage sieve and triage sort. Triage sieve is mainly used for triage on scene or primary triage in the casualty clearing zone, whereas triage sort mainly is used for secondary triage in the casualty clearing zone (see Chap. 3).

4.3.3.1 Triage Sieve As mentioned above, triage sieve is mainly intended for primary triage, which in most cases is done by the first responders on the scene, who often have limited experience. Because of this, and because triage on this level in most cases has to be done under heavy time pressure, this method is based on simple criteria: • Can the patient walk? • Is the patient breathing? • What is the patient’s respiratory rate? • How is the capillary refill? (alternative: pulse rate) The findings according to these criteria are transferred into an algorithm (Fig. 4.4). Capillary refill: Using finger pressure, the blood is removed from the nail bed for 5 s, and the time to complete refill of the bed is counted. A time of 2 s or more should correspond to a pulse of 120 beats per min or higher. This method is not entirely easy to perform, especially in bad light or cold climate, and some countries have selected to use pulse rate instead of capillary refill. Thus, this system is simple but at the same time is open to error: • Even a patient with threatening internal bleeding, for example a liver or splenic injury, may initially be walking. • A deeply hypothermic patient can be alive even if breathing or pulse cannot be registered. In addition, it is not always easy to register respiratory rate on the scene, especially in darkness and with noise from the rescue work. Some of the risk for error can be reduced by: • Repeated and frequent evaluations • Never declaring a cold patient dead until he or she has been warmed in the hospital (see Chap. 9). Responders using triage sieve should not totally disregard the character of the injury, but maintain some “anatomic thinking,” though it not should be allowed to interfere with simplicity and speed. For example, a patient with a penetrating chest injury initially may not have any impairment of circulation and breathing. However, if and when a cardiac tamponade or tension pneumothorax develops, it may quickly turn into a

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Table 4.3 Triage sort scores related to respiratory rate (RR), systolic blood pressure (SBP), and Glasgow Coma Scale (GCS) (After Champion et al 1989) GCS

Respiratory rate

Heart rate

13–15 9–12 6–8 4–5 3 10–29 >29 6–9 1–5 0 ³90 76–89 50–75 1–49

Score 4 3 2 1 0 4 3 2 1 0 4 3 2 1

life-threatening situation. Thus, the type of injury itself may justify high priority even in simple physiological triage (see Chap. 7). Triage sieve has been widely used internationally both in major incidents and armed conflicts. However, it has never been critically scientifically evaluated, which unfortunately applies to most triage methods used today. With the considerations above, triage sieve seems to be a reasonably good instrument to use in primary triage in the front line of the response. For secondary triage, however, methods based on more information are recommended.

4.3.3.2 Triage Sort One such method is triage sort, based on revised trauma score (RTS), which is a scoring system that aims to make an early classification of the severity of an injury (see Chap. 16). The criteria used are: • Respiratory rate • Systolic blood pressure • Neurologic response according to the Glasgow Coma Scale (GCS ; see Chap. 7) Adding the values from these criteria gives a scoring point (Table 4.3) as a base for the priority (Table 4.4). Triage sort gives a safer and more differentiated evaluation of circulatory and neurological condition. The first is important for early detection of internal bleeding in the trunk, the latter for following a course where changes can be a signal of life-threatening intracranial bleeding.

Table 4.4 Triage sort with scores converted to priorities Triage revised trauma score 4–10 11 12 1–3 (Hospital only) 0

Triage group or priority T1 T2 T3 T4 Dead

Triage sort has the same limitations as triage sieve with regard to the risk of missing bleeding in the trunk or inaccurately declaring a deeply hypothermic patient dead. Therefore, as in triage sieve: • Some attention must be paid to the type of injury • Repeated evaluations have to be done. As illustrated in Fig. 4.4, the card for triage sort included in the SMART-tag® system also encourages this by providing space for repeated evaluations. • Special rules must be valid for hypothermic patients (see Chap. 9). Another potential risk connected to triage sort is that a drop in systolic blood pressure, especially in young patients, may be a late sign on circulatory impairment. Young patients have an ability to maintain blood pressure longer through extensive vasoconstriction because a higher flexibility of the vascular bed. Clinical signs can show an experienced clinician that the patient has an ongoing bleed before a fall in blood pressure is registered. Some of the risks with this system can, as with triage sieve, be overcome by proper education and training. A potential advantage of these systems compared with anatomical triage (see below) is that they are reported to give less “over-triage” (setting priorities of patients too high) than anatomical triage. However, this is based only on anecdotal reports or personal views and remains to be better evaluated scientifically.

4.3.3.3 Other Methods of Physiological Triage As illustrated in Table 4.2, a wide variety of methods for physiological triage has been described. Only the most frequently used will be described here. START Triage START (Simple Treatment And Rapid Transport) is based on the following criteria: • Ability to walk • Airway • Respiratory rate

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• Heart rate • Ability to follow command It originated in and is mainly used in the United States. Care Flight Care flight is based on same criteria as in triage START except respiratory rate, which means that it goes considerably faster; this method is used mainly in Australia. Sacco Triage Method (STM) Sacco Triage Method (STM) uses mathematic calculations based on empirical data of the probability for survival related to physiological parameters. It is one of the few systems that has been prospectively evaluated in simulation models. It is used mainly in the United States. Physiological Triage Methods for Children See below under pediatric triage.

4.3.4

Anatomical Triage

The major advantages of anatomical triage are, as mentioned initially in this chapter, that it is based not only on the condition of the patient at the time of triage, but it also takes into consideration the type of injury and the potential change of condition to which this injury will lead. This requires clinical knowledge and experience. Another advantage is that anatomical triage makes it possible to evaluate the patient’s chance to survive with accurate treatment. Especially in level 2 and 3 MIs, this makes it possible to identify casualties with such limited prospects of being saved that the resources required for attempts to save them could be better used for patients with better chances to survive with treatment. This is the base for a special form of anatomical triage: effect-related triage (ERT).

4.3.4.1 Effect-Related Triage ERT means simply to give high priority to diagnostic and therapeutic measures that have the greatest effect on maintenance of health and life and to give low priority to those that have low effect. The effect of a treatment is defined as the difference in outcome between performing and not performing this treat-

ment. The natural aim of daily medical care is to give patients the highest possible quality of care delivered with highest possible safety. This often means that: • All available diagnostic and therapeutic methods are used, some of them with limited additional effects on the outcome. • The most advanced technology is used even if it would be possible to reach the same, or at least nearly the same, end result with simpler methods. • Advanced curative treatment is given to patients with limited possibilities of being saved or with limited chances of prolonging their lives. This is acceptable as long as it does not lead to the loss of life and/or health of other patients because lack of recourses that could be caused by such a strategy. However, in a MI, defined as insufficient resources related to the need of medical care, this strategy has to be changed if the overall goal of the medical response is to be achieved: To reduce or eliminate to the extent possible the loss of life and health, and physical and psychological suffering, incurred as a consequence of MIs. This is the background of the ERT concept, as described above. It requires, however, not only sufficient clinical knowledge and experience to identify and evaluate different injuries, but also knowledge of the real effects of different treatments on the outcome with regard to life and health. To identify such effects requires scientific studies of series of patients both from daily trauma care and from MIs, i.e., research projects in collaboration between clinical medicine and disaster medicine (see also Chap. 19). One example is given in Fig. 4.5, from a study of burn injuries from the propane fire in Los Alfaques, Spain, in 1978. The two curves illustrate the mortality related to full-thickness burned body area: the red curve indicating those who received immediate fluid resuscitation and the black curve indicating those who received fluid resuscitation after a delay of 24 h. For example, for a 40% burn injury the mortality of patients given immediate fluid resuscitation was between 5% and 10%, whereas the corresponding mortality for patients given delayed treatment was close to 90%. This illustrates that immediate fluid resuscitation of patients with this extent of injury has a high effect on the outcome and thereby should be done with high priority.

4

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71

Mortality (%)

Mortality (%)

100

100 Immediate i.v. fluid

No surgery Surgery

50

50

i.v. fluid, 24 h delay 0

0 0

20

40

60

80

100

Full thickness burned surface (%)

Fig. 4.5 Illustration of the effects of early fluid treatment in burn injuries of different severities (see the text for more information) From the Swedish Defence Research Agency (FOI) with permission

However, corresponding treatment of injuries below 25% or above 55% resulted in a limited outcome or no difference in outcome, in the first group because they could go for some time with no or only oral fluid supply, and in the second group because of the bad prognosis regardless of treatment. These groups of patients should thus have low priority for immediate fluid resuscitation. This is one example of how data from major incidents can be used to identify effects of treatment as a base for anatomical triage according to the ERT concept. Such curves can be created for all kinds of injuries and can be based on clinical experience. Figure 4.6 illustrates how a similar curve can be done for abdominal injuries. Recent clinical studies of large series of patients have shown that many injuries, if the patient has stable circulation, do well without surgical treatment, but patients who do not have stable circulation require hemostatic intervention. In fact, the highest effect of treatment is achieved in the group with unstable circulation, a group that in older literature was recommended to be given low priority because of small prospects of cure related to high consumption of resources. However, modern techniques (damage control, noninterventional techniques) has made it possible to treat this group with limited consumption of resources and return them to full health. Making a similar schematic curve for head injuries illustrates an entirely different pattern: The highest

Circulatory stable

Circulatory unstable

Fig. 4.6 Effects of surgery in abdominal injuries related to circulatory condition (see the text for more information) (From Lennquist S. Katastrofmedicin, Liber, Stockholm 2009 with permission)

effects of treatment are achieved in the less severe injures, where alertness in discovering and treating an intracranial bleed by accurately securing the airway and, when needed, simple trepanation can return a patient to full health. Those with lower scores on the GCS often have a brain injury that means small possibilities for survival or at least return to a life of reasonable quality. These are examples showing three different patterns with regard to effect of treatment related to severity of injury. Corresponding graphs are possible for all kinds of injuries using data both from clinical series and MI situations. In the future, such data may for clinical use include not only therapeutic, but also diagnostic measures, the effect of which on the outcome widely varies. Figure 4.7a–c is a schematic illustration of how ERT can be applied based on estimated effects on survival. (a) Illustrates a number of casualties in a situation where available resources (the red column) are insufficient to perform all possible treatments (represented by the grey columns above the patients). (b) Optimal treatment has been given to the first two patients who have a Revised Trauma Score of 9 and 6, respectively, and therefore should have priority red according to physiological triage (triage sort). The third patient has unstable circulation and

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Fig. 4.7 Schematic illustration of how effectrelated triage (EFT) can be applied based on estimated effects on survival. (a) A number of casualties in a situation where available resources (red column) are insufficient to perform all treatments normally possible (grey columns above patients). (b) All possible treatment has been given to the first two patients with a revised trauma score (RTS) of 9 and 6, respectively, which according to triage sort means red priority. Remaining resources (red) are not sufficient to save the other (potentially salvageable) patients who are lost, giving a total mortality of 100% for these patients. (c) The potential effects of treatment have here been considered according to EFT. The first two patients with very small chances to survive in spite of treatment are here given blue priority regardless of RTSs. The resources that thereby can be devoted to patient 3 mean the difference between death and full recovery, and there are resources enough left over for the less extensive but life-saving treatment of the last two patients (From Lennquist S. Katastrofmedicin, Liber, Stockholm 2009 with permission)

a Possible medical care with available resources

Available capacity Possible care for each patient

Full thickness Head injury Abdominal injury Maxillofacial Open chest injury burn 90% GCS 13 GCS 3 GCS 15 injury GCS 12 GCS 15 SBT 85, RR > 30 SBT 95, RR 9 SBT 80, RR > 30 SBT 120, RR 25 SBT 100 RR > 30

b Triage according to physiological criteria without attention to potential effects of treatment. Survival = 0 %.

†

†

Full thickness burn 90% GCS 13 SBT 85, RR > 30

†

Head injury GCS 3 SBT 95, RR 9

†

Abdominal injury GCS 15 SBT 80, RR > 30

†

Maxillofacial injury GCS 12 SBT 120, RR 25

Open chest injury GCS 15 SBT 100 RR > 30

c Effect-related triage

†

Effect + 1%

†

Effect + 3%

DC-surgery effect + 50%

Resuscitation effect + 50%

Full thickness burn 90% GCS 13 SBT 85, RR > 30

Head injury GCS 3 SBT 95, RR 9

abdominal injury, and the remaining red color (available resources) are not sufficient to save him, so he is lost. The last two last patients are also lost because there are no resources at all left for them.

Abdominal injury GCS 15 SBT 80, RR > 30

Additional primary treatment, effect + 10% Chest drain + resuscitation effect + 90% Secure of airway effect + 90%

Maxillofacial injury GCS 12 SBT 120, RR 25

Open chest injury GCS 15 SBT 100 RR > 30

This makes a mortality of 100% for this group of patients –not a very successful result. (c) In this triage, the potential effects of the treatment have been considered. The chances of survival

4

Triage

with a 90% full-thickness burn injury (patient 1) or a head injury with GCS score of 3 (patient 2) are as close to zero as they can come and they are therefore given blue priority in spite of the RTS scores. High priority for patient 3 for transport, shock treatment, and surgery consumes resources but returns the patient to full health. We can now still afford the limited primary treatment required to save patients 4 and 5 and return them to full health. The latter approach has reduced the mortality by 80%. Of course, this is a hypothetical example, but it cannot be disregarded that a physiological triage based on RTS scores without knowledge of the injuries and consideration of the potential effects of treatment could have led to the outcome illustrated in Fig. 4.7b.

4.3.4.2 Anatomical Triage on Scene For primary triage on scene, physiological triage will, in most cases, probably be the method of choice because of the time pressure and lack of access to staff with knowledge and experience of trauma sufficient to perform anatomical triage. During secondary triage, which should precede transport whenever possible, physiological triage also may be the principal method of choice depending on the load of casualties and access to experienced staff. However, with a lack of transport resources for evacuation from the scene, it is of critical importance that the right patients go first and to the right destination, which has to be based on consideration of the character of the injuries. This requires anatomical triage, or at least a combination of physiological and anatomical triage, with an experienced medical officer using “anatomical thinking” when rechecking priority before transport. The principles for anatomical triage in incidents with many injured are described in Chap. 7. 4.3.4.3 Anatomical Triage in a Hospital Physiological triage may be needed during primary triage in the hospital in MI situations with a high load of casualties. If used, such primary physiological triage should be replaced as soon as possible by anatomical triage, which is needed for optimal utilization of hospital resources. This requires experienced staff on the front line of the chain of triage, as described in Chap. 5. The principles for in-hospital triage of injured and critically ill patients are illustrated in Chaps. 7–11.

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4.4

Outcome Related to Method of Triage

As illustrated in Table 4.2, few studies have been done with the aim of critically evaluating the accuracy of the different methods of triage: How much time do they really consume under field conditions? How accurate are they? How do they affect the outcome? The reason for this lack of evidence-based information is probably the difficulty of evaluating these methods in retrospective analysis from major incidents, and prospective studies are difficult to perform because many factors influence the outcome, which makes it hazardous to compare different incidents with regard to the result of triage. One way to evaluate different methods is to use simulation models that give input and output data reliable enough to permit different methods to be compared, if all parameters except the one studied are standardized. During recent years, such methods have become available (see Chaps. 18 and 19). In a recent study with the use of such a model, the results from anatomical and physiological triage (triage sort) were compared, using three test groups with different medical competence: • Nurse students after disaster medicine course • Ambulance nurses after postgraduate training in disaster medicine • Surgeons with trauma experience The participants in the test got the task of performing triage on a group of injured patients, first with physiological triage (triage sort) and then with anatomical triage. Only data required for the method used were given, and the patients were mixed so they not could be recognized between the sessions. The results were compared to the result of an expert group with access to all clinical data and clinical course for these patients. There was no significant difference between the two methods for the first two groups, but for the more experienced group, the difference compared with the expert group was significantly less for anatomical triage (p < 0.001). This indicates that, for less or moderately experienced medical staff, physiological triage may be equally as good as anatomical, whereas for more experienced staff, anatomical triage is better. When using the simulation model to predict the outcome with regard to potential preventable mortality in this study, anatomical triage gave better results for all groups (Lennquist-Montán K et al, Am J Disaster Med in press (2012).

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These results illustrate the need for further scientific evaluation of available triage methods. Hopefully, this can lead to recommendations with regard to which method to use and when. The potential advantages of anatomical triage also can be an argument to move experienced staff closer to the front line of response, both on scene and in the hospital.

4.5

Triage in Children

Children younger than age 10 normally have a higher pulse, higher respiratory rate, and lower blood pressure than adults, as illustrated in Table 4.5. If physiological triage is based on these criteria according to the methods described above, it would lead to overtriage, i.e., patients given too high a priority. In incidents with a limited number of children, this may not be a major problem; it may also be justified by humanitarian reasons to give children a relatively high priority. However, in incidents with great numbers of children involved, for example terror actions against schools, such over-triage can lead to nonoptimal utilization of available resources. For this reason, special methods have been developed for triage of children.

4.5.1

Pediatric triage tape (PTT) is based on the fact that the body length (in centimeters) is proportional to physiological parameters (Table 4.5). A module consisting of a water-proof plastic strip (tape) is rolled out along the child. The triage algorithm closest to the heels of the patient is applied (Fig. 4.8). The module is then reused on other patients. This method originated in the United Kingdom and is used in many European countries.

Table 4.5 Normal values for respiratory rate (RR) and heart rate (HR) related to body length in children younger than 10 years of age Respiratory rate (breaths per min) 20–50 15–40 10–30

From Studentlitteratur with permission

4.5.1.1 Jump START This method is based on triage START (see Table 4.2) but with the physiological parameters adjusted for pediatric use. The method is mainly used in the United States.

Pediatric Triage Tape

Length (cm) 50 80 100

Fig. 4.8 Pediatric triage tape designed to compensate for the differences in physiological response to trauma between adults and children younger than age 10. The tape is rolled out alongside the child with the arrow at the level of the head. The table at the level of the foot plant is used to calculate the RTS (From TSG Associates with permission)

Heart rate (beats per min) 90–180 80–160 70–140

Further Reading Armstrong JH, Frykberg ER, Burris DG (2008) Toward a national standard primary mass-casualty triage. Disaster Med Public Health Prep 2(Suppl 1):S8–S10 Arturson G (1981) The los Alfaques disaster – a boiling liquid expanding vapor explosion. Burns 7:233–251 Ashkenazi I, Kessel B, Kashan T et al (2006) Precision of inhospital triage in mass-casualty incidents after terror attacks. Prehosp Disaster Med 21:20–23 Aylwin CJ, König TC, Brennan NW et al (2006) Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge and resource use after the London bombings on July 7, 2005. Lancet 368:2219–2225 Bielajs I, Burkle FM, Archer FL et al (2008) Development of a prehospital, population-based triage management protocol for pandemics. Prehosp Diaster Med 23:420–430 Bond WF, Subbarao I, Schwid H et al (2006) Using screenbased computer simulation to design and test a civilian, symptom-based terrorism triage algorithm. Int Trauma Care 16:19–25

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Triage

Bond WF, Subbarao I, Kimmel SR et al (2008) Testing the use of symptom-based terrorism triage algorithms with hospitalbased providers. Prehosp Disaster Med 23:234–243 Champion HR, Sacco WJ, Copes WS et al (1989) A revision of the trauma score. J Trauma 29:623–629 Cone DC, MacMillan DS (2005) Mass casualty triage systems – a hint of science. Acad Emerg Med 12(8):739–741 Demetriades D, Kuncir E, Brown CV (2006) Early prediction of mortality in isolated head injury patients: a new predictive model. J Trauma 61:868–872 Domres B, Koch M, Manger A et al (2001) Ethics and triage. Prehosp Disaster Med 16:53–58 Einav S, Feigenberg Z, Weissman C et al (2004) Evacuation priorities in mass casualty terror-related events. Implications for contingency planning. Ann Surg 239:304–310 Frykberg ER (2005) Triage: principles and practice. Scand J Surg 94:272–278 Garner A, Lee A, Harrison K et al (2001) Comparative analysis of multiple-casualty incidents triage algorithms. Ann Emerg Med 38:541–548 Gebhart ME, Pence R (2007) START triage: does it work? Disaster Manag Response 5:68–73 Hodgetts TJ Triage; A position, European union core Group on Disaster Medicine, 2001 Husum H, Gibert M, Wisborg T et al (2003) Respiratory rate as a prehospital triage tool in rural trauma. J Trauma 55:466–470 Jenkins JL, McCarthy ML, Sauer LM et al (2008) Mass-casualty triage: time for an evidence-based approach. A comprehensive review. Prehosp Disaster Med 23(1):3–8 Kahn CA, Schultz CH, Miller KT et al (2009) Does START triage work? An outcome assessment after a disaster. Ann Emerg Med 54(3):425–430 Khorram-Manesh A, Lennquist-Montán K, Lennquist S, Örtenwall P (2011) Triage: an important part of the response to the major incidents. ICU Manag 10(4):6–7 Kilner T, Hall J (2005) Triage decisions of UK police firearm officers using a multiple-causality scenario paper exercise. Prehosp Disaster Med 20(1):40–46 Lennquist S (2007) Management of major accidents and disasters: an important responsibility for the trauma surgeon. J Trauma 62:1321–1329 Lennquist-Montán K, Khorram-Manesh A, Örtenwall P et al (2012) A comparative study of physiological and anatomical triage in major incidents using a new simulation model. Am J Disaster Med in press Lerner EB, Schwartz RB, Coule PL (2008) Massasualty triage: an evaluation of the data and development of a proposal for national guidelines. Disaster Med Public Health Prep 2(Suppl 1):S25–S34 Lieberman JD, Paquale MD, Garcia R et al (2003) Use of admission Glasgow Coma Score, pupil size, and pupile reactivity to determine outcome for trauma patients. J Trauma 55:437–443 Mulholland SA, Cameron PA, Gabbe BJ et al (2008) Prehospital prediction of the severity of blunt anatomic injury. J Trauma 64:754–760 Navin M, Sacco W, McGill G (2009) Application of a resourceconstrained triage to military-aged victims. Mil Med 174: 1247–1255 Navin DM, Sacco WJ, Waddell R (2010) Operational comparison of the Simple Triage and Rapid Treatment Method and the

75 Sacco Triage Method in mass casualty exercises. J Trauma 69:215–225 Neal DJ, Barbera JA, Harrald JR (2010) PLUS prehospital masscasualty triage: a strategy for addressing unusual injury mechanisms. Prehosp Disaster Med 25(13):227–236 Okumura T, Kondo H, Nagayama H et al (2007) Simple triage and rapid decontamination of mass casualties with colored clothes pegs (STARDOM-CCP) system against chemical releases. Prehosp Disaster Med 22(3):233–236 Owens K (2008) EMS triage. Sorting through the maze. Fire Eng 161:155–160 Pinkert M, Lehavi O, Goren OB et al (2008) Primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals – lessons learned from a suicide bomber attack in downtown Tel-Aviv. Prehosp Disaster Med 23(4):337–341 Risava BL, Salen PN, Heller MB et al (2001) A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 5:197–199 Romig LE, Team Life Support Inc (2011) The Jump START pediatric MCI triage tool and other pediatric disaster and emergency medicine resources. Available at http://www. jumpstarttriage.com/JumpSTART_and_MCL_Inage.php Acceesed Feb 20, 2011 Ryan M (2008) Triage principles and pressures. Eur J Trauma Emerg Surg 34:427–432 Sacco WJ, Navin DM, Fiedler KE et al (2005) Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med 12(8):759–770 Sacco W, Navin M, Waddel RK et al (2007) A new resourceconstrained triage method applied to victims of penetrating injury. J Trauma 63:316–325 Sapp RF, Brice JH, Myers JB et al (2010) Triage performance of first-year medical students using a multiple-casualty scenario, paper exercise. Prehosp Disaster Med 25(3):239–245 Skaga NO, Eken T, Søvik S et al (2007) Pre-injury ASA Physical status classification is an independent predictor of mortality after trauma. J Trauma 63:972–978 Subbarao I, Johnsson C, Bond WF et al (2005) Symptom-based, algorithmic approach for handling the initial encounter with victims of a potential terrorist attack. Prehosp Disaster Med 20(5):301–308 Subbarao I, Bond WF, Johnson C et al (2006) Using innovative simulation modalities for civilian-based, chemical, biological, radiological, nuclear, and explosive training in the acute management of terrorist victims: a pilot study. Prehosp Disaster Med 21(4):272–275 Torkki M, Koljonen V, Sillanpää K et al (2006) Triage in a bomb disaster with 166 casualties. Eur J Trauma 32:374–380 Turégano Fuentes F, Pérez-Díaz D, Sans-Sánchez M et al (2008) Overall assessment of the response to terrorist bombings in trains, Madrid, 11 March 2004. Eur J Trauma Emerg Surg 34:433–444 Vincent DS, Berg BW, Ikegami K (2009) Mass-casualty triage training for international healthcare workers in the AsiaPacific region using Manikin-based simulations. Prehosp Disaster Med 24(3):206–213 Wallis LA, Carley S (2006) Comparison of pediatric major incident primary triage tools. Emerg Med J 23:475–478 Zoraster RM, Chidester C, Koenig W (2007) Field triage and patients maldistribution in a mass-casualty incident. Prehosp Disaster Med 22(3):224–229

5

The Hospital Response Sten Lennquist

5.1

The Need for Planning

In technically developed countries, such as most countries in Europe, there is today a high standard of medical care and it is easy to believe that, with all the resources these countries have, they can at any time and without preparedness cope with a sudden high load of casualties from a major incident. However, as a paradox, the development within the health care system has significantly increased vulnerability to major incidents – parallel to a continuous increase of the risk for such events, as illustrated in Chap. 2. Technical development has supplied us with diagnostic and therapeutic tools that make it possible to do things that were impossible a few decades ago. Simultaneously, the aging population, with a higher rate of morbidity, increases the demands on medical care, and we are rapidly approaching a situation where we cannot afford to do everything we are technically able to do without consuming a too big part of our national budget. This has led to continuously increasing demands on efficiency: Every resource has to be optimally utilized. This means that the “reserve capacity” for a suddenly increased load of casualties has been reduced: all surgical theaters in a big hospital are, through computerized planning, occupied by heavy surgery during office hours; every ventilator is used; and every bed is occupied by a patient who needs in-patient care. This problem is well recognized globally.

S. Lennquist e-mail: [email protected]

The increasing dependence on high technology has also significantly increased the vulnerability of the health care system to technical disturbances, of which there is an increasing risk during a major incident. When the incident has occurred, it is too late to start to prepare back-up systems. To summarize, the need for planning and preparedness of the medical response to major incidents is today bigger than ever before. Chapter 1 has already illustrated a number of things that have to be prepared before the incident occurs and that lack of planning and preparedness on these points may lead to collapse of the whole chain of response, for which our patients will have to suffer.

5.2

The Disaster Plan: Goals and Structure

5.2.1

Demands on a Functioning Plan

In most countries today there is a legal obligation of all hospitals responsible for and authorized to receive patients within the fields of trauma, emergency surgery, and medicine to have a functioning disaster plan. “Functioning plan” means not only that there should be a written plan somewhere in an office, but that there exists a plan that is continuously updated, tested, and known by all staff potentially involved in the response to major incidents. In some countries, the government has appointed an authority (normally within the health sector) that has the responsibility to supervise and control the plans and ensure their quality by regular formal inspections; this should be the case in every country; otherwise,

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_5, © Springer-Verlag Berlin Heidelberg 2012

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there is a risk that this preparedness is not given the priority it should have in competition with daily resource-consuming activities. To meet the demands of a functioning plan requires: • A responsible committee within the hospital with authorization to request the involvement of and contributions from all units in the hospital with regard to planning, preparedness, and education • Information of all staff about the plan as a part of the employment process • Systematic and repeated training of staff about important functions during major incident response

5.2.2

The Need for Simplicity

As already illustrated in Chap. 1, equally important as having a plan is to avoid “over-planning”: The goal should not be to build up a new organization, only to make necessary adjustments to the already existing organization to divert resources to where they by definition are insufficient, e.g., to the treatment of victims. The plan has to be one that can be activated in a few minutes, on any day of the year, at any time of the day regardless of who is on duty; then, it has to be simple.

Simplicity is the Key to Accurate and Realistic Planning

A disaster plan should not be a “monument of words” built up by administrative ambitions. There are, unfortunately, many examples of plans that have been so extensive and complex that nobody has taken time to read them, and then they cannot work. During evaluations after major incidents, it can sometimes be heard: “Yes we had a plan, but we did not use it,” and when you see the plan, you easily realize why.

5.2.3

Functions of Critical Importance for the Capacity of the Hospital

The capacity of the hospital to receive casualties from a major incident is often referred to as the surge capacity, the capacity to receive a certain number of injured or critically ill per time unit. Which are the most common factors that limit this capacity?

The continuously reduced number of beds in our hospitals, parallel to more efficient use of available beds, is often referred to as a limiting factor for this capacity. However, all available experience shows that the number of beds is rarely or never the limiting factor – there is always space, there are often extra supplies of beds, and patients can even sleep on the floor on mattresses, if needed. Alerting staff who are not on duty will in most cases allow for a sufficient number of staff to – for a limited time – take care of a high load of extra patients who need in-patient care. Neither is the emergency department a limiting factor. For the severely injured or ill, the emergency department is just a transfer station through which the casualties should pass as quickly as possible on their way to surgery, intensive care, or a ward. The triage and primary treatment here should be led by staff with highest possible clinical competence within the actual field; for example, trauma should be treated by specialists within surgical and anesthesiologic disciplines. For less severely injured patients, on the other hand, the emergency department is in many cases the final destination, but this category demands fewer resources and is not a critical capacity-limiting factor. Factors of critical importance for the capacity of the hospital are, instead, surgical and intensive care unit (ICU) capacity: the number of available surgical theaters and ventilators and the staff to handle them. As already mentioned, during office hours in a big hospital, every available theater is occupied by (often time-consuming) surgery, and it can be difficult to find a single ventilator for a patient who needs it unexpectedly. If these resources are not available for an injured patient in urgent need of them, the patient may be lost. Planning and preparing the hospital response must be based on awareness of the actual critical functions, and the staff who represent these functions must have a major role in the planning process as well as in leading the hospital response.

5.2.4

The Content of the Disaster Plan

Plans may look different in different hospitals depending on the hospital size and capacity, geographic conditions, and local traditions, and there is not, and probably should not be, any uniform “standard plan.” However, the structure of the plan should be as uniform as possible, at least within the same country, both for educational

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reasons (staff move between hospitals) and to facilitate collaboration between hospitals during a response – everyone should use the same terminology. Involvement of many hospitals, perhaps from different regions, during a response has been increasingly necessary because of the reduced reserve capacity mentioned above. The following structure is recommended: 1. General information This part should be read and known by all staff and therefore restricted to a maximum of five to ten pages. It should include: • Alerting the hospital – How the hospital is alerted – What to do when receiving the alarm – Where to go when alerted – What to do when alerted – Canceling the alert • Levels of alert Definitions and indications – when to use which level • Coordination and command – Overall (regional) command of the response – Hospital command: who is responsible for which decision? 2. Action cards Action cards should be prepared and available for all staff involved in the response. Every staff member has to know his or her own action card, but all action cards may be attached to the plan for informational purposes. 3. Information about special types of incidents, or incidents only involving specific categories of staff • Incidents involving hazardous material • Incidents involving irradiation • Incidents involving infectious diseases or biological agents • Incidents involving large numbers of burns • Incidents primarily involving the hospital – Threats – Fire – Technical disturbances

5.2.5

What Every Staff Member Should Know

As already mentioned, Part 1, “General information” should be known by every staff member, and it is recommended that this portion is included in the

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orientation connected to employment. It is thereby important that this part is not burdened with information that not is absolutely necessary for all staff. The next part, Part 2, “Action cards,” indicates that every staff member should know is his or her own action card (see below for examples). The action card for a certain position can be put in a visible place in the office, or – as some hospitals do –laminated “pocket format” action cards can be given to staff members with key positions. All staff should also know where to find information about special types of incidents, including those primarily involving the hospital. Some categories of staff need specific training: • Those included in the hospital command group (HCG) • Those that might be deployed to prehospital teams (see Chap. 3) • Those responsible for decontamination of victims from incidents involving hazardous material or irradiation

5.2.6

The “All Hazard” Concept

Even if the plan has to include certain information about specific types of incidents, this does not mean that there should be specific plans for these types of incidents – this would make the planning too complex. Instead, the same structure of plan should be used in every kind of incident: alert process, levels of alert, and coordination and command. However, staff with special functions in specific types of incidents (e.g., decontamination) needs special action cards for those types of incidents.

5.3

The Alert Process

5.3.1

Who Alerts?

How the hospital is alerted varies between countries. In some countries it is the Regional Medical Command Center (RMC; see Chap. 3), in others it is the national/ regional Alarm Center, and in yet other countries it is the Ambulance Dispatch Center (ADC). The first alternative requires immediately available staff on call 24 h/day, but this is recommended because of the advantage of having medical staff with a high

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Table 5.1 Example checklist for the receiver of a major incident alarm • Who alerts?……………………………………………………………………………………………………………………… • Time of alert?…………………………………………………………………………………………………………………..... • What has happened (type of incident)?………………………………………………………………………………………….. • When did the incident occur?……………………………………………………………………………………………………. • Where did the incident occur?………………………………………………………………………………………………….... • Hazardous material involved? (Yes/no/not known)…………………………………………………………………………….... • Estimated number of casualties?……………………………………………………………………………………………….... • Of those, estimated severely injured?……………………………………………………………………………………………. • Other hospitals alerted?…………………………………………………………………………………….……………………. • Need for prehospital teams from this hospital?………………………………………………………………………………….. ➣ Transfer this information to the senior surgeon on duty immediately (beeper….) for decision regarding activation of plan and level of alert

level of competence, and with good knowledge about the situation in hospitals, involved in the coordination of medical resources from the beginning. Whichever local organization initiates the alert, the following must be clearly stated in the disaster plan: • Who has the authorization and responsibility to alert the hospital? • Who decides the level of alert (see below)? If the hospital is alerted in a way other than those stated above, e.g., by a private person watching the incident, contact should immediately be made with the unit normally responsible for the alert.

5.3.2

Receiving the Alarm

An incoming alarm should immediately be connected to a defined position in the hospital, which should be clearly described in the plan; it is usually the senior nurse on duty in the emergency department who always is available. His or her tasks are: • To collect and register information • To transfer this information to the person (position) responsible for making the decision about the level of alert and to take the primary command In this situation it is easy to miss information of critical importance. Therefore, the person who receives the alarm should have a checklist for receiving the alarm (see Table 5.1 for an example). If the receiver is the senior nurse on duty in the emergency department, this checklist should be on the wall in his or her office, together with the action card for this position. Using the Major Incident Medical Management and Support (MIMMS) concept, the same acronymbased poem as on scene is recommended (METHANE;

see Chap. 3). That can be used instead of a checklist, but is not entirely adapted to the information needed by the hospital, which is why a checklist as in Table 5.1 is recommended.

5.3.3

Decision About the Level of Alert

It has to be clearly stated in the plan which person (position) has the authorization/responsibility to decide the level of alert for the hospital (see below). In some countries, the alerting organization (RMC or an Alarm Center) has this responsibility and, if so, it should be included in the message of alert, and thereby included in the checklist of the person who receives the alert. In other countries, this decision is made by the medical officer primarily in charge in the hospital. This model is recommended because this person has the immediate overview of the present situation in the hospital. For example, if a major incident occurs during office hours when all staff is in the hospital and a number of theaters and ventilators happen to be available, a lower level of alert may be sufficient; in another situation outside office hours and with all available theaters and ventilators occupied, the same incident may require a higher level of alert.

Regardless of to which position this responsibility/ authorization is connected, it has to be clearly stated in the plan which it is and must be included in the action card for that position.

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5.3.4

Further Processing of the Alarm

An alarm is spread within the hospital according the principle “rings on the water” – the primarily alerted staff alerts other staff/positions, with all alerted units finally alerting or calling in their own staff. For this purpose, regularly updated files with home telephone numbers and alternative numbers should be available in all units. To avoid misuse of such lists, they can be kept safe (in a sealed envelope) until they are needed for this purpose. To make this processing of the alarm possible, it has to be clearly stated in the action card for each position whom to alert further, with pager and telephone numbers given (for example, see Table 5.3). An absolute prerequisite is that everyone knows where to find his or her action card, which is a keystone in preparedness and education. Just for information, it should also be stated in the action card from whom the alert should come. If there are indications that an alarm process is going on and you have not been alerted, it should be possible to call and ask the person who should have alerted you, because mistakes can happen in this situation. With action cards following this structure, an “alarm schedule” saying who should alert whom is not necessary, but should be attached as an appendix to the plan for informational purposes.

5.3.5

Where to Go When Alerted

For staff on duty in the hospital, where to go when an alert occurs should be clearly stated in the action cards. For staff who are alerted at home, this must be known as a part of preparative education. Usually, staff in the emergency department and nursing staff in an operating room, anesthesiology, ICU, and wards go to their ordinary positions, whereas other categories of staff (including alerted physicians) register at a special area for arriving staff. The advantage with this is that the staff in charge in this area will be able to: • Get an overview of available staff • Inform them collectively about the situation • Deploy staff to where they are needed, in communication with the HCG (see below) • Keep some of the arriving staff on “standby” • Send those who are not needed home to rest and be prepared to release the staff who are on duty initially if the response is extended in time

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5.3.6

What to Do When Alerted

Having received information about the level of alert (see below), all staff involved in the response should follow their action card (see below) for that level step by step.

5.3.7

Canceling the Alert

The alert can only be canceled by the HCG, which has the responsibility to inform all positions and staff involved in the response.

5.4

Levels of Alert

To have just one level of alert (which still is the case in some countries) might seem to be the most simple. However, this would mean that a lot of steps should be taken as soon as there was a suspicion of a major incident. The consequences of this should be either a number of “over-alerts,” e.g., initiation of a lot of procedures that would turn out to not be needed, or the absence of an alert when it really is needed because of fear of over-alert. To avoid this requires a system based on different levels of alert. There is still no internationally uniform standard. The system presented here is an example, originally developed by the author, which has been used for many years as the national system in Sweden and introduced in an increasing number of countries. It is used as a model in the Medical Response to Major Incidents courses organized by the European Society for Trauma and Emergency Surgery. This system is based on three levels of alert:

Green alert: “Stand by” Yellow alert: “Partial mobilization” Red alert: “Full mobilization”

5.4.1

Green Alert (“Stand by”)

5.4.1.1 Used When The green alert is used when an accident has happened or a threat has come up, but it is yet not known whether or to what extent the hospital will receive casualties.

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5.4.1.2 Alert Means • Activation of the HCG (see below) • Information given to critical functions in the hospital, simultaneous investigation of present capacity • Report of present capacity to the RMC (see below) • Consideration of “freezing” planned treatments that can wait (done if something has happened, not when there are only threats)

5.4.3

Red Alert (“Full Mobilization”)

5.4.3.1 Used When The red alert is used when it has been confirmed or suspected that the hospital will receive a large number of casualties within short time, requiring its full capacity.

5.4.3.2 Alert Means Green alert is minimally resource consuming but increases the preparedness significantly and should be used for a wide range of indications.

5.4.2

Yellow Alert (“Partial Mobilization”)

5.4.2.1 Used When The yellow alert is used when it has been confirmed that the hospital will receive casualties, but within a limit that does not require full response.

Those items listed for the green and yellow alerts, plus automatic alert of all available staff within emergency and supporting disciplines according to a prepared alarm schedule (“rings on the water” system).

In a major hospital, red alert is a level to be used only on rare occasions, when a high load of casualties is expected and there is only a short distance to the scene.

5.4.4 5.4.2.2 Alert Means Same as those listed for the green alert plus: • “Freezing” of all nonstarted treatments that can wait • Alert of a (defined in the plan and limited) number of emergency room nurses, emergency physicians, surgeons, orthopedic surgeons, anesthesiology teams (physician and nurse) and operating room nurses • Alert of HCG support group (see below under Coordination and Command) The second item listed above depends on the size and location of the hospital and should be clearly defined in the plan. An example from a medium sized hospital without emergency physicians in the organization (as in many places in Europe) specifies: • • • • •

6 Emergency room nurses 4 Surgeons 2 Orthopedic Surgeons 6 Anesthesiology teams 6 OR nurses

Yellow alert is sufficient to cope with the majority of major incidents during peace time (additional staff in key functions can be mobilized later, within this level, by decision of the HCG).

The Need for Three Levels

Green alert is needed as a level to activate on wide indications, as soon as there is even a small suspicion of a major incident, and therefore it should remain as a level that consumes minimal resources. A common mistake is to “burden” this level with additional steps, but that might create a hesitation to activate it and then the intention with it is lost. The steps included above significantly increase the preparedness for response by having: • The HCG group in place and activated • Critical functions (emergency department, OR, ICU) informed • Capacity of critical functions investigated and ready to report to RMC Yellow alert is clearly justified as being enough to cope with the vast majority of major incidents during peace time. Red alert, even if indicated only on rare occasions in a major hospital, is needed in situations where the hospital is expected to be flooded by casualties within a short time; there is not time to think of what to alert or not, and red alert means automatic mobilization of large numbers of staff and other resources. It has to be considered, however, that taking care of all incoming staff also consumes resources, and preparedness for this should be reflected in the action cards for red alert.

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5.5

Coordination and Command

5.5.1

Within the Hospital

5.5.1.1 Demands on a Clear Command Structure The hospital response to a major incident means that, with short notice and within a short time, an organization fully busy with routine care of patients has to be adapted to receive a number of casualties far exceeding the resources normally devoted to this. This requires rapid relocation and diversion of resources to where they are needed. The need for firm leadership and rapid decisions on all levels is apparent. Other organizations involved in major incident response – fire brigade, police, military – understandably have a more clear and hierarchical command structure and always working within that structure; therefore, it is always clear who is in command and who is responsible for the decisions on all levels. It is not so in the health care system. During office hours it is clear who the leaders are, but these leaders are mainly responsible for strategic and economic decisions, whereas operative decisions often are made on an individual basis. Management of conditions requiring involvement of several different specialties, such as trauma, illustrates this issues and has led to the demand for the appointment of only one “captain.” However, this has not been a painless process, and has not been equally successful everywhere. During nonoffice hours, the strategic leaders are rarely in the hospital and mostly are not available within the first critical hour(s) of the response. It is quite apparent that leadership for the initial response not can be connected to such persons. Why is it so urgent? Does it not often take time from the first alarm until casualties reach the hospital? Most major incidents occur in urban and densely populated areas with short distances to hospitals and good access to ambulances. The first ambulances are on scene often 5–10 min after the alarm and the transport of casualties to hospitals can start. Chapter 3 has already emphasized the importance of quickly getting the patient to a hospital where requested resources are immediately available. This means that immediate transport of patients must be based on capacity reports from the hospitals. The HCG collects and delivers these reports. The demand on the HCG should be that it is in action within 15 min after the alarm has reached the hospital.

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To summarize, the hospital response to major incidents requires a well-prepared leadership structure based on staff who • Are immediately available during nonoffice hours; • Have a clearly defined responsibility as well as authorization to make the necessary decisions during the initial phase of the response; and • Are trained specifically for this difficult task.

5.5.1.2 The Medical Ofﬁcer in Charge Immediately available on a 24-h basis at a senior level are the senior physicians on call within surgical specialties, anesthesiology, or the emergency department (if the hospital has emergency physicians). Which of these should be the primary Medical Officer in Charge (MOC) is not important. However, it is, important that: • It is clearly stated in the disaster plan to which position this task is connected • Everyone who holds this position should have special training for this difficult and important task Many hospitals use the senior surgeon on call for this task, for several reasons: • He or she automatically has an immediate overview of the critical functions (operating room and ICU). • The senior anesthesiologist is needed to make priorities in the ICU, the senior emergency physician is needed to prepare the emergency department, and the senior orthopedic surgeon is more likely to be involved immediately in patient management. We are now talking about the initial (primary) phase of the response. When more staff are called in, a senior physician with more experience and more training for this purpose often takes over the difficult role of MOC, especially if the response is extended in time.

5.5.1.3 The Hospital Command Group The MOC should be the operative leader of the HCG. The HCG also should include administrative staff for support and decisions regarding economy and hospital security. Usually this administrative officer in charge (AOC) is a senior administrative officer available on call, who later may be replaced by the ordinary director/manager of the hospital. However, to make purely administrative staff responsible for the primary operative decisions is not realistic, considering the usually much longer response times for this category of staff. Because of the many tasks connected to the HCG during the first critical 15–30 min of the response, it is preferable to dispatch more medical staff to this group

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whenever possible. This can include senior medical officers on call within other specialties and varies between hospitals but, again, this should be clearly stated in the plan. Later during the response when more staff is available, it is natural that the HCG is staffed by the most senior physicians in the specialties mainly involved in the response; for example, for trauma the senior physicians in charge within surgery, anesthesiology, and orthopedic surgery as well as the senior emergency physician, if the hospital has this specialty, would be included in the HCG. Secretarial staff specially trained for this purpose should also be connected to this group as soon as possible.

5.5.1.4 The Major Incident Command Room It is mandatory that the HCG has a specially prepared room to go to, equipped with: • Telephones for each staff member, both internal and direct external lines • Communication – radio with channels for communication with the RMC, the MOC on scene, and the ambulance service (see Chap. 3) • Radio and television sets to allow them to follow information being provided by the media • Maps • Disaster plans for hospitals in the region • Prepared whiteboards for continuous documentation of information • Computers See Fig. 5.1 for a example of such a room. It is important that the HCG staff goes to this room immediately after the alarm. A lot of questions come up in the hospital, and there is a need for a place to which these calls can be directed, and many calls will come to the HCG room within the first minutes after the alarm. That emphasizes the need for secretarial staff to be available as soon as possible. 5.5.1.5 The HCG Support Group The HCG group responsible for the operative decisions should not be too large; it should be made up of the MOC, the AOC, if possible one or two additional senior physicians, and two-three secretaries. Too many people and too much telephone communication in this room will disturb the important immediate decisions that have to be made. However, there are a lot of functions in the hospital that will be involved during a major incident response, and these functions need coordinating staff that should fill the function as a support group to the HCG.

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Fig. 5.1 Example of a hospital command room. This room should be located centrally in the hospital, close to the emergency department, and should always be prepared for action. The equipment should include telephones (internal lines and direct external lines); a radio for communication with the ambulance services, and, in case of failure in telephone communication, with the regional command center; computers; a radio and television receiver to record media broadcasts; plotting boards with maps and disaster plans for the region and the hospital (see the text for further description) (photo: University Hospital Linkoping, Sweden)

Examples of administrative and medical officers in such a group are: • Security manager (security control of hospital entrances) • Technical manager (technical support and reserve functions) • Communication manager (telecommunication and computer technology) • Information officer (responsible for hospital information center and media contacts) • Transport manager (porter service, traffic control within hospital) • Catering manager (kitchens and restaurants and food for staff, patients, and relatives) • Supply manager (overall responsibility for supplies including beds, linen, drugs, fluid, and disposable supplies) • Hospital staff manager (all staff matters, including unit for child care for called-in staff) • Secretarial manager (coordinator of administrative support) • Psychosocial support coordinator (psychosocial support to victims, relatives, and staff) It is not a self-purpose to collect this entire staff in one room, but they should be available online as soon as possible after the alarm so that they easily can be reached by the HCG. Usually it is the task of the hospital telephone board to follow the alarm lists until

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they find and can call in staff in all of these categories. Many of these functions (in some hospitals all of them, which is preferred) are covered by staff who are available on call on a 24-h basis, even if they have a longer response time than medical staff.

5.5.1.6 Medical Staff on site in Charge of Different Functions During the major incident response, it must be clear who has the coordinating responsibility on site for all critical functions in the hospital. It is one of the initial tasks of the HCG to define or appoint the leaders for different functions – in some cases a nurse, in some cases physician and a nurse. This staff should be clearly labeled with tabards or arm bands. 5.5.1.7 Action Card for Hospital Command Group An example of an action card for the HCG is given in Table 5.2.

5.5.2

Command on Regional Level

The need for coordination and command on regional level is described in Chap. 3, where it also is mentioned that this function can be connected to different organizations in different countries. In this book this is referred to as the Regional Medical command Center (RMC). Regardless of where this unit is located, or who is responsible for it, it has to • Be staffed by persons who are immediately available through a pager on a 24-h basis; • Include staff who are medically competent • Be functioning within 15 min after the alarm • Be well equipped with communication lines (radio, direct telephone lines to HCGs, alternative communication systems) • Be independent of electricity, i.e., connected to reserve power systems As also mentioned in Chap. 5, the tasks of the RMC are to: • Declare Major incident (in some countries this can also be done by the first ambulance crew on the scene) • Inform and alert hospitals and other resources for medical care according to estimated and expected needs • Coordinate distribution of casualties between hospitals in communication with HCGs and the ALO on scene

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• Coordinate information to other agencies (rescue service, police, military); regional and national authorities; media; and (when needed) foreign embassies • Make the decision to cancel Major incident with information sent to all agencies involved To be able to fulfill the function in the second item listed above, the RMC needs to receive reports of hospital capacity (critical functions like the operating rooms and ICU) as soon as possible, which is the reason behind the demands on HCGs to be activated and report less than 15 min after the alarm. HCGs then have to update and extend these reports continuously, based on the hospital’s mobilization and redistribution of resources (see Table 5.1). The importance of an accurate distribution of casualties between hospitals has been emphasized above and in Chap. 3, and a prerequisite for this is an organization that fulfills the demands listed above for an RMC. Without such an organization, the ALO or MOC should have to contact all involved hospitals directly. Considering the problems with communication in these situations, such a policy is not realistic and has been abandoned almost everywhere based on experience.

5.5.3

Command an National Level

Major incidents may require national coordination, e.g., incidents involving hazardous material and the need for a large number of ventilators, or incidents with many severe burn injuries that require involvement of all specialized burn units not only in the affected country but also in other countries. This is facilitated by a coordinating authority on national level, which can be connected to the Department of Health or to a National Board of Health Care. The prerequisite for this is an officer on call 24 h a day, however not with the same demands on response time as above. In Sweden, such a function was established after the Chernobyl nuclear plant disaster where the need for better and nationally coordinated information was recognized. It has turned out to be helpful in incidents occurring after that – such as the Estonia ferry disaster and the tsunami with many Swedish victims from all parts of the country (see Chap. 2) – and is recommended based on this experience. It has to be emphasized that this is only a coordinating support function. The operative decisions are still made by the different regional centers.

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Table 5.2 Example of action card for hospital command group (HCG) The initial HCG is staffed by the: • Senior surgeon on call (responsible for medical decisions, including level of alert), alerted by the surgeon on duty • Senior manager on call (responsible for administrative decisions), alerted by the hospital telephone operator • Senior anesthesiologist on call, alerted by the anesthesiologist on duty If the senior surgeon or anesthesiologist on call not is immediately available, the surgeon or anesthesiologist on duty has to cover these positions until the senior colleagues are available The officers in the HCG should, when alerted, immediately go to the hospital command center The officers in the initial group may be replaced later by officers specially trained for this function, when available Green alert 1. Inform hospital telephone operator that the command center is open and staffed 2. Inform the RMC that the command center is open and staffed, inform about the decided level of alert, and ask for available new information. Document information on the prepared whiteboard 3. Request report of immediately available capacity in OR (theaters available now and within 1 h) and ICU (available ventilators) with a response <10 min. Report this information to RMC <15 min from the alarm 4. Consider if planned surgery and other treatments that can wait should be “frozen” to await further information. This is not a mandatory part of “green alert” but can be used when it is likely that the hospital will receive casualties. If so, inform senior nurse, OR 5. Based on information from the RMC, consider if the level of alert should be changed. If so, inform: • Senior nurse in the EMD • Hospital telephone operator • Surgeon, anesthesiologist, and orthopedic surgeon on duty • The RMC 6. Define/appoint staff in command of critical functions, and register name/telephone: • EMD • OR • Postoperative/preoperative preparation • ICU • Coordinators of wards 7. Give a short press release to the hospital telephone operator that can be given to media to release the pressure on the HCG. Consider the questions, What do we know? What have we done? Have any casualties been received or are any under way? What is the time of the next press release? 8. If “green alert” is cancelled, inform of, according to (5)above. Yellow alert As under “green alert” points 1–8 with the addition of: 9. Request continuous reports from OR, ICU, EMD, and coordinating senior nurses in wards about available capacity, updated reflected by arriving staff, possible evacuation of patients, and redistribution of resources. If information is missing, search for it. Report capacity to RMC continuously 10. Consider if more staff should be alerted than the minimal level automatically connected to “yellow alert” (six emergency teams in EMD, six OR teams, six anesthesiologists, and six nurses of anesthesia, four surgeons, and two orthopaedic surgeons). Alternatively, consider increased level of alert and inform according to point (5) for “green alert” 11. Collect the now-mobilized HCG support group for briefing and report. Check that all tasks connected to this group have been initiated. Make plan for staff meetings with regular interval for exchange of information Red alert As under “yellow alert” with the addition of: 12. Staff and organize room for arriving staff with responsible senior manager, senior physician, senior nurse, and secretarial support. Coordinate distribution of arriving staff to fill needs reported to the HCG. Give information to arriving staff and consider coming need of replacements (it might be necessary to send some staff home for rest but being available for call). Give this information to units with an expected heavy workload within the coming 24 h EMD emergency department, ICU intensive care unit, OR operating room, RMC Regional Medical Coordination Center

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Table 5.3 Example of action card for surgeon on duty Alarm received by: senior nurse, EMD When receiving alarm: Contact senior surgeon on call; report the content of the alarm and the present situation in the hospital with regard to surgery, anesthesiology, and ICU. Senior surgeon on call makes decision about the level of alert If the senior surgeon on call not is immediately available, the surgeon on duty can make this decision Green alert 1. Inform senior nurse in the EMD (beeper/telephone) that “green alert” is activated 2. Inform senior anesthesiologist on duty (beeper/telephone.) that “green alert “is activated 3. Inform hospital telephone board that “green alert “is activated 4. Inform senior nurse in the OR (beeper/telephone) that “green alert” is activated. Simultaneously, investigate the present situation in the OR. Are theaters available for surgery? If not, until when will they be occupied? 5. Inform senior orthopedic surgeon on duty (beeper/telephone.) that “green alert” is activated 6. If the senior surgeon on call is not in the hospital or not immediately available, go to HCG and follow action card for HCG until senior surgeon on call is available for this position. When and if senior surgeon on call is available, go to EMD and accelerate treatment and evacuation of surgical patients Yellow alert As under “green alert” 1–5 with the addition of: 7. Request senior nurse in the OR to: • “Freeze” all nonstarted surgery that can wait • Call four OR teams from staff who are not currently on duty • Call four surgeons from staff not on duty according to alarm list Red alert As under “yellow alert” with the addition of: 8. Request senior nurse in the OR to alert all surgeons and all OR staff whoa re not currently on duty according to alarm list EMD emergency department, HCG home command group, ICU intensive care unit, OR operating room Telephone/beeper numbers should be included in the action card

The most important tasks for a national coordinating authority are on the level of planning and preparedness, to promote a nationally uniform structure in: • Planning and organization • Terminology • Equipment • Education and training Other important tasks are funding for development and research and quality assurance of preparedness by regular inspection of hospitals.

5.6

Action Cards

As already emphasized above, the most important components in a hospital’s preparedness for major incidents are the action cards for all positions involved in the response.

What staff members need to know is: • Which level of alert is activated: green, yellow, or red? • Where is your action card?

Knowing this and having your action card, you can follow it step by step, in chronologic order. The telephone and pager numbers you need should be there. By following this procedure, you cannot fail to fulfill your task during the alert and preparatory phase of the response (simplicity is the key to a functioning disaster plan). Examples of action cards for staff in the front line of the response are given in Tables 5.3 and 5.4. These action cards must be designed with great care and effort and in close collaboration with all units involved. They are the basic element in the chain of alert and after every re-organization, it is important to make an alert test to ensure that no function has been missed. Many hospitals attach the action cards for all involved positions to the disaster plan. This is a balance: It might be an advantage to see the action cards for other functions, but it also makes the plan thick and frightening. However, information provided to staff about what they have to know as a minimum (“general information” and the action card for their own position) may eliminate this risk.

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Table 5.4 Example action card for anesthesiologist on duty Alarm received by: Surgeon on duty Green alert 1. Inform senior anesthesiologist on call (beeper.) that “green alert” is activated. If the senior anesthesiologist on call is not immediately available, cover his or her function in the HCG until arrival (go to the HCG) 2. Inform senior nurse of anesthesia (beeper/telephone) that “green alert” is activated and request report of immediate capacity for anesthesia 3. Inform senior nurse in the ICU (beeper/telephone.) that “green alert” is activated and request report of immediately available ICU capacity (beds, ventilators, staff) 4. Report the information above to the HCG (telephone) <10 min after receiving the alarm 5. Go to the ICU. Investigate possibilities to move ventilator patients to wards. If so possible, report to HCG Yellow alert As under “green alert” 1–5 with the addition of: 6. Stop nonstarted surgery and anaesthesia that can wait 7. Request senior nurse of anaesthesia (beeper/telephone) alert six nurses of anaesthesia and six anesthesiologists from staff not currently on duty 8. Start to evacuate patients from ICU to wards 9. Report again the capacity of anesthesiology and ICU to HCG (telephone) Red alert As under yellow alert 1–9 with the addition of: 10. Request senior nurse of anaesthesia (beeper/telephone) initiate alert of all available staff of anesthesia according to alarm plan for red alert HCG home command group, ICU intensive care unit Telephone and beeper numbers included should be in the action card

It is also a recommended policy to print the action cards separately, put them on the wall in offices, and laminate them in a pocket format for key staff.

5.7

Preparing the Hospital

We have so far mainly dealt with the alarm-phase of the response: How the alarm should be received and forwarded, how a command structure is established and how all involved staff should start taking action following their action cards. Transferring from a structure designed for ordinary patient care to a structure designed to receive a large number of casualties from a major incidents is a process that has to occur quickly; therefore, this is a process for which staff must be prepared and trained. The action cards, which tell all staff members what to do and in which order, is a help in this process. However, other forms of preparation are equally necessary: • Rooms in the emergency department where patients should be received, triaged, and primarily treated must be prepared and all equipment needed for this stored in places known by everyone and easy to access. • Special materials needed, such as cards/records for registration of victims, triage tags, and tabards/arm

bands for staff in charge and in key functions must be prepared and easily accessible. • Signs for identification of different zones and pathways in the hospital must be prepared and set up according to a prepared schedule, usually a task for porters. • Extra supplies for fluid, disposable supplies, and beds must prepared and easily accessible. • A room for the HCG must be prepared (see above). • A room and organization for the hospital information center (see below) must be prepared. All of these points are examples of things that have to be well prepared before the incident occurs, otherwise it will not work. Preparing the hospital on alert is done according to the action cards for all involved functions. Examples are provided below. Emergency Department • Appoint staff in charge of key functions, including – primary triage, secondary triage, and treatment of severely injured – secondary triage and treatment of less severely injured • Transfer all “ordinary” patients either further into the hospital, or dismissed after treatment, as soon as possible, which requires reinforcement of mobilized additional staff

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Surgery • Appoint physicians and nurses in charge of operating rooms and anesthesia • Finalize ongoing operations as soon as possible, which may require support from experienced staff • Organize a preoperative zone – usually the ordinary postoperative unit that is evacuated of ordinary patients as soon as possible – and appoint staff in charge in this zone • Report to HCG about how many theaters that can be made available and when with mobilized staff. Intensive Care • Appoint physician and nurse in charge • Review all patients. Which patients can/should be transferred to wards for continued treatment? • Report to HCG about how many ventilators that can be made available and when with mobilized staff. Wards • Appoint physician and nurse in charge for every involved department • Transfer patients from emergency ward(s) to regular wards as soon as possible • Dispatch staff to review all wards. How many additional patients can be taken in? • In communication with the HCG, decide which wards should be used primarily for patients from the incident (see below) The intention of this overview was to illustrate the principles for preparing the hospital and not to go into detail in every function. As illustrated above, appointing staff in charge of key functions is an important first step; this staff then has the responsibility for preparing, staffing, and running the different functions. Clear labeling of this staff so they can be easily identified is also an important step.

5.8

Receiving Casualties

5.8.1

Primary Triage

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quickly upon alert (Fig. 5.2). This area will function as the zone for primary triage and be supplied with: • Experienced staff responsible for the initial triage, with the aim of: – Separating the less severely injured, who are transferred to the zone for this, usually waiting rooms and offices ordinarily used for ambulatory care of emergency patients – Setting priority for the severely injured to be given primary treatment and secondary triage by prepared teams (see below) • Staff responsible for registration of all arriving casualties During level 2 and 3 major incidents, a big entrance hall may be too small for all casualties awaiting triage. This should be considered during the planning and an adjacent area should be prepared. In countries with a warm climate, this can be an outdoor area; in countries with a rougher climate some kind of indoor facility should be prepared for this (dotted line in Fig. 5.2). A “must” for all major hospitals receiving emergency and trauma patients is a decontamination unit in the hospital for decontamination of patients who have been exposed to hazardous material or irradiation. Theoretically, all such decontamination should be done on the scene before evacuating the casualties for transport to hospitals. In practice, however, there is no guarantee that this always is done. Patients may evacuate themselves spontaneously before rescue and before health care staff has arrived and taken control of the scene; this has happened in major incidents during recent years. To bring a single contaminated patient into the emergency department may paralyze not only the emergency department but many other critical functions in the hospital as well. Therefore, a decontamination unit should be prepared in connection to, but with ventilation separated from, the hospital (Fig. 5.2), and the staff should be trained to perform decontamination and work in protective clothing (Fig. 5.3; see also Chaps. 10 and 11, dealing with incidents caused by hazardous and radioactive materials).

5.8.2 As a general rule, all casualties should enter the hospital at the same place – a prerequisite for accurate registration. This is usually the ambulance entrance of the emergency department. It is important that the hospital is prepared so that there is a wide open area available in the immediate vicinity of this entrance, used for another purpose under normal conditions but possible to evacuate

Severely Injured Victims

The management of the severely injured has to run through several parallel lines; otherwise the emergency department will be a key hole that creates congestion. For this purpose, the staff has to be organized in teams, working parallel in areas prepared for this (Fig. 5.2).

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Prepared waiting area 1

Primary triage

2

Secondary triage, severely injured

3

Secondary triage, less severely injured

4

Triage for surgery Press Physician Nurse, Emergency Department

Information center

Registration

E Psychosocial support groops

Nurse anesthesiology

Secretary/administrative assistant

2

3

Nurse other

Decontamination 1

EMD teams

A EMD coord team w w

w w B MIR teams

Staff coord team

Hospital security Police EMD Emergency Department OR ICU

Surgery Intensive care

D Arriving staff

Decontamination team

Ward coord team

Preop

OR coord team

4

C w

w

w

ICU coord team

OR Wards

HCG support group

HCG

OR teams

ICU

ICU teams

HCG Hospital Command Group W

Waiting zone Dead victims

Fig. 5.2 Schematic illustration of the organization of the hospital during major incident response. Areas normally used as the entrance hall (A), emergency department (B) and postoperative unit (C) are now – according to a prepared plan – quickly transformed into areas for receipt and triage of casualties (A), management of severely and less severely injured casualties (B), and a preoperative zone with triage/waiting area for surgery (C). Offices and meeting rooms (D, E) are also transformed into command

rooms and an area for arriving staff (D) and an information and media center and center of psychosocial support functions (E). Coordinating staff are appointed to all of these functions and are responsible for their preparation and staffing. The red triangles indicate primary triage upon arrival (1), secondary triage of severely injured (2), secondary triage of less severely injured (3), and triage for surgery (4). The arrows indicate the flow of casualties (see the text for further description)

It is important that these teams are well staffed. Normally, severely injured patients are taken care of by trauma teams; such a team usually consists of two or three physicians and three or four nurses (all

are well needed) responsible for different functions. With a heavy load of casualties and the need for many parallel teams, we cannot afford so many staff on every team. On the other hand, a single physician

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Fig. 5.3 Decontamination unit in a major hospital. This unit should be located in connection to, but with a ventilation separate from, the rest of the hospital, with special evacuation routes for decontaminated air and water. The staff who may have to work here must be specially trained in how to perform decontamination and how to use the special protection equipment, based on overpressure of air into the suites (photo: Disaster and Emergency Medical Center, Södersjukhuset, Stockholm, Sweden)

and nurse are not enough for this task, which is the background of the organization described below.

have prepared space for at least six to eight such teams, including the ordinary trauma bays, which are quite suitable for this purpose.

5.8.2.1 Major Incident Resuscitation Teams A recommended model is special major incident resuscitation (MIR) teams for severely injured or critically ill victims with a minimum staff of four persons: two physicians and two nurses. In a major incident caused by trauma, at least one of the physicians should have clinical experience with trauma (a specialist or senior resident in surgery, orthopedic surgery, or anesthesiology, or an emergency physician with training in trauma) and at least one of the nurses should have trauma experience (emergency room or anesthesia). In this situation the rest of the team may be available physicians and nurses in any specialty. The first task of the staff in charge of this position is to recruit staff to these MIR teams and appoint team leaders according to the principles above. Some hospitals label these teams with numbered arm bands so they can be identified easily. The areas/rooms where these teams should work should be defined as a part of the planning process and supplied with necessary equipment, including suction, oxygen, sufficient illumination, and trays with necessary instruments and material. A bigger hospital should

5.8.2.2 Primary Management and Secondary Triage The task of the MIR teams is to make a complete survey of the patient according to the ATLS principles, perform necessary resuscitation, perform investigations necessary for decision and immediately necessary treatment, re-evaluate priority (secondary triage), and then transfer the patient as soon as possible to the next destination, which might be the preoperative zone, the ICU, or in some cases a ward (Fig. 5.2). 5.8.2.3 X-Ray Examinations X-ray examinations should in this situation be used very restrictively. Even if computed tomography is available in the emergency department, it cannot be used for all patients and in many cases has to be replaced by more simple investigations (see Chap. 7). Plain x-ray of fractures can be done later with mobile units in the preoperative zone or in wards. The principles for the primary management and secondary triage for different kind of incidents are described in Chaps. 7–11.

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5.8.3

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Less Severely Injured Victims

Also those categorized as less severely injured have to be carefully and systematically examined; even a walking patient can have an internal bleeding. The staff devoted to this should have access to staff with competence in trauma which can be consulted when necessary. Some of these patients may be transferred to wards for observation or later surgery (e.g., fractures that can wait after temporary reduction and stabilization). Others may be ready to be dismissed after treatment. However, it has to be considered that these patients, even if they have minor injuries, have gone through a shocking experience and cannot just be sent home. They have to get the opportunity to meet psychosocial support staff (see below), during which time contact for future needs can be established. These patients may have lost relatives or friends, they may have relatives among the severely injured, or they may be far from home and having lost their personal property or clothes. Therefore, an organization to take care of them has to be prepared (Fig. 5.2). Patients in this category who have received some form of treatment also must have a plan for follow-up in their local hospital if they are far from home.

5.8.4

Noninjured Victims

Noninjured victims may also come to the hospital, either accompanying injured relatives or friends, as psychologically shocked, or just because they are far from home and have nowhere else to go. A special area must be prepared for this category of patients, separated from the emergency department and with access to psychosocial support staff and to information that allows them to search for relatives and friends (Fig. 5.2). Voluntary organizations such as the Red Cross often play an important role in the support of this category of victims.

5.8.5

Dead Victims

Patients who have died during transport or after arrival to the hospital should be transferred to an area prepared to receive dead victims, usually connected to the

department of pathology (Fig. 5.2). It is important that this area has rooms where relatives can see their dead in a calm and harmonic atmosphere, and have access to staff from the psychosocial support group. Management of the dead is dealt with further in Chap. 6.

5.9

Continued Treatment of Injured Patients

5.9.1

Patients Who Need Immediate Surgery and/or Intensive Care

These patients are transferred to the preoperative zone, which, as mentioned above, usually is the unit used for postoperative care and surveillance from which ordinary postoperative patients have now been evacuated, and transformed into an area for preoperative treatment and surveillance of patients who need immediate surgery and/or intensive care (Fig. 5.2). Patients transferred here are often critically ill, and this unit must be well supplied with intensive care and anesthesiology staff. Decisions regarding priority for surgery and/or ventilator treatment should be made by an experienced team comprising a senior surgeon and anesthesiologist, with continuous contact with the OR and ICU staff. Ventilators and mobile units for plain x-ray should be included in the equipment of this area. The access to operating theaters can be a temporary limiting factor, especially if the incident occurs during office hours when all theaters may be heavily occupied. Experiences from major incidents and disasters show that many operations can be done with local or regional anesthesia, e.g., debridement of wounds and minor fractures. This type of surgery can be done in rooms normally used for ambulatory surgery or outpatient clinics to release the pressure on the ordinary surgical theaters, and this should be included in the planning and preparation process. Access to ventilators is often the most critical limiting factor for the capacity of the hospital, and triage places many demands on this function. Some hospitals have ventilators in reserve for major incidents, which is justified in areas at high risk for such incidents. A possible solution is temporary use of ventilators from operating theaters if and when the load on surgery so permits. Ventilators also can be moved between hospi-

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tals, which might be easier than transporting a critically ill patient who needs ventilatory support.

5.9.2

Patients Needing In-Patient Care

As already mentioned, all recent experience shows that beds rarely, if ever, are a limiting factor for the surge-capacity of the hospital. This might seem strange, considering the everyday struggle to find beds for emergency patients under ordinary conditions. However, mobilizing staff who are not currently on duty increases the capacity of the wards; there is often space somewhere, and most hospitals have supplies of extra beds and mattresses. With access to staff, it is also possible to open up temporarily closed wards. There is rarely any need to dismiss in-patients from the hospital, and with the short times for in-hospital care today, patients who are there really need a bed and are not so easy to dismiss without special measures, which consume resources. A good strategy for in-patient care of victims from major incidents is to devote one or more wards exclusively to the care of such patients by moving existing patients from these wards to empty spots in other wards. This “principle of centralization” gives the advantage of having all patients from a major incident collected together and allows for resources especially needed for this (e.g., higher density of staff, psychosocial support) to be concentrated in such wards.

5.10

Registration of Patients

To avoid congestion when a high number of casualties arrive to the hospital within a short time, a simple and rapid system for registration and documentation is needed. This is best achieved by using already prepared “fill-in” documents. Many hospitals use the same registration for trauma patients, which works well for incidents caused by physical trauma but not for other types of incidents (hazardous material, irradiation). Other hospitals have a special registration system for major incidents covering all types of incidents and including additional information valuable for evaluation of the response. From a scientific point of view, an internationally uniform system should be a goal to work toward.

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Regardless of which system is used, it must be one that meets the demands of simplicity and speed; all staff involved in registration must be familiar with the system, and it must be prepared so that the needed documents are available in sufficient number. It is important that the registration documents from the scene are kept together with the hospital registration documents; they may contain valuable information, and as medical documents also they have to be preserved for medicolegal reasons. Parallel to the individual patient registration, files with identification data for all incoming patients must be filled in upon arrival, with the patient’s next destination within the hospital noted. These files are continuously copied to the hospital information center (see below) and provide the base for information provided to people calling to search for injured relatives or friends. For this reason it is important that such continuous documentation also is mediated from the zones for less severely injured and noninjured.

5.11

Hospital Information Center

After a major incident, there is large need for information provided to relatives and friends of people that have been involved, or may have been involved, in the incident. Many call just because they believe that their relatives have been in the area of the incident; others know that their relatives were, for example, on the plane, or in the train, that crashed. The total number of calls is much too high to be handled by the hospitals, and another organization is needed to sort out those who are registered as casualties and to which hospital they have been taken, so that those calls than be referred to the appropriate hospital. This primary information is in most countries handled by the police, who, as soon as possible after the incident, open a police information center well supplied with staff that can take all these calls, which can number in the hundreds, sometimes even several thousand, within short time after the incident. This requires a well-prepared organization. The number(s) to call are usually given by the media at an early stage after the incident. When such calls come to the hospitals, the operator should confirm that the questioning person first has been in contact with the police information center and, if not, refer them there. If contact has been made with

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the police information center and it has been confirmed that the person asked for has been taken to the hospital, the operator should forward the call to the hospital information center, which is a necessary function in the hospital and has to be prepared for as an important part of the planning process. This unit should be located in a place that is well supplied with telephones and staffed by persons who have received special training for this purpose. A common way to staff this center is by using secretaries working together with nurses from out-patient clinics that not are medically involved in the incident; this staff works in teams of two – one answering the call and one searching for the patient, following the files continuously delivered from the registration. Calculating three to five calls per patient, a major incident can easily generate 300–500 calls within a few hours. Five teams (ten persons) is a minimum to take care of this task, and more may be needed. If the patient: • Has been transferred to a ward or to the ICU, the call is connected to that unit. • Is undergoing resuscitation in the emergency department or is waiting for or undergoing surgery, contact details are registered so that responsible staff can call back when the condition of the patient is stabilized. • Is in the zone for less severely injured or noninjured victims, information about this is given, and the patient is expected to make contact. This is valuable information for worried relatives, which emphasizes the importance that also these patients be registered as soon as possible. • Is dead, such information should never be given by telephone. Contact details are registered and relatives will be contacted at their homes by the police together with psychosocial support staff. The question often comes up whether the information center can give information, without securing the identity of the person asking. That would consume time during this heavy load of calls and is usually not considered necessary. Exceptions are official persons or persons attractive to the media; it has happened that media pretends to be relatives to get information. For such persons it is therefore a wise strategy to call back. A senior manager or physician should be appointed in charge of this information center if delicate questions arise.

S. Lennquist

5.12

Management of Media

There are many reasons to establish a constructive collaboration between health care and media in these situations. The health care staff are interested in the delivery of information, for example, request for staff of certain categories to go to the hospital, request for blood donors, request that people who do not absolutely need to go to the hospital either wait or go to primary care stations. Media representatives should – as all other responders in the community – see as their task to give support in this difficult situation and understand that they have a responsibility to mediate correct information. Unfortunately, this collaboration sometimes is ruined by “hunting a scope,” when media try to get sensational pictures from wounded casualties or crying relatives. However, it is the responsibility of the health care staff to protect patients and relatives in this situation. Even if they agree to be in pictures, this can cause considerable psychological harm during the aftermath. This means a potential conflict between health care staff and media. The best ways to cope with this are: • Discussions with media representatives before an incident allow both sides to understand each other. Some hospitals organize regular seminars with their local media representatives concerning matters in the daily routine, including major incidence response and problems connected to that. This is an effort that usually pays back well. • A senior person (information officer) responsible for media contacts who takes active care of journalists, informs them, shows them around in an organized way, and gives them the facilities they require, such as a press room with access to telephones where they also can be continuously informed. Staff who could potentially fill the role of information officers should go through special training in media management. As a general rule, press conferences should be given exclusively by the RMC in collaboration with command centers for rescue service and police, which gives the best overview of the incident and the response to it. The RMC should take the initiative for such conferences and announce them to the media in advance. However, media will still call, and appear in, the

5

The Hospital Response

hospitals that receive patients, and it is not a good policy to try to close the door to them. This should be the task of the information officer responsible and all questions should be referred to him or her. Other staff cannot be prohibited from giving individual interviews, but they should be recommended not to do so. There are many traps into which hospital staff can fall, and it does not give an impression of confidence if the information given is wrong or contradictory. All staff should also be aware of that they are responsible for not allowing the media to take pictures of casualties or relatives without permission. A good strategy during the initial phase after the alarm is to give a press release to the hospital telephone operator (see Action Card for HCG, Table 5.1). It might seem strange that this measure is given such a high priority during the critical phase immediately after the alarm. However, as soon as information about the incident reaches the media (which happens quickly today), they will call the nearest hospital and ask for information, and it is not only one call, but dozens of calls within a few minutes. The hospital operator has to transfer these calls to the HCG – unless he or she has a short written message to read, for example: “The hospital received an alarm at 10.25 a.m. informing about a train crash between [city A] and [city B], with many injured. We have activated the plan for major incident response and are preparing the hospital according to that, but we have still not received any casualties. The next press release will be available at 11 00 a.m.” This simple step “protects” the HCG from a flood of incoming calls, and later the information officer can take care of this.

5.13

Supplies

Most hospitals today run with limited supplies because it is considered an economic advantage not to have big stores in the hospital, and some of the material also have expiration dates. With today’s technology, it is also easy to refill supplies continuously, according to expected needs. However, this creates new problems during major incidents, when the need of specific types of supplies can reach high volumes within a few hours, perhaps during non-office hours. Especially sensitive areas are disposable material, fluids, and drugs. For disposable material, many hospitals have supplies only for a few

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days of routine activity and that will run out quickly during a major incident. Preparedness for this must include: • Reserve supplies of certain materials of critical importance (such as fluid and certain drugs), even if it is connected to additional costs. • Agreements with suppliers of material (fluids, drugs, disposables) to provide access to supplies in case of emergency, even within a short time or outside office hours. • A stock of certain nondisposable material that can be sterilized and reused, e.g., syringes, scalpel blades, and linen. During a major incident response, a supply manager should have the overall responsibility for supplies and should be included in the HCG support group (see above). In major incident levels 2 and 3, supplies can be flown in by helicopters or airplanes to hospitals on the front line. This was done during the tsunami disaster in Thailand, where an air-bridge flying material from Bangkok to Phuket was started immediately after the alarm, thanks to good planning. Such needs also can appear in more limited incidents: at the discotheque fire in Gothenburg, Sweden, helicopters returning after transport of burned casualties to hospitals all over Scandinavia were filled with supplies to be delivered to the big Gothenburg hospitals, which had quickly become short of fluids and disposables.

5.14

Technical Functions

Hospitals today are highly dependent on technology, and the more advanced the technology is, the more sensitive it is to disturbances. Unfortunately, such disturbances are likely to occur in connection to major incidents, either because of simultaneous damage to the infrastructure of the community or by overloading. Preparedness for this is, therefore, an important part of the planning and preparedness process.

5.14.1 Electrical Power Every hospital today has reserve power systems that automatically take over if the supply by the ordinary net is interrupted. However, it is important that:

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• These systems are regularly tested. • They cover all functions necessary for an major incident response, such as the areas prepared for receiving casualties in the emergency department, and administrative functions such as the HCG command room and the information center. During a major incident, the interruption of currency can be long-lasting. Supplies of flashlights and battery-operated headlamps in designated areas are also part of the preparedness for this.

5.14.2 Water Few hospitals have reserve functions for water supply and, because this is dependent on electrical power, longlasting disturbances are a serious threat. Generally, this is something that should be better reviewed. A simple step is to maintain reserve tanks for storing water for use during a threatening, long-lasting lack of electricity.

5.14.3 Computer Support Most medical staff today have experienced a failure of the hospital’s central computer system and know what happens: The hospital becomes totally paralyzed. It is suddenly not possible to get answers to laboratory tests; in some cases it is not even possible to require fluids or blood, take samples or perform diagnostic procedures such as x-rays. In addition, the whole system of patient registration fails. During routine medical care, such failures are often corrected within a few hours, but in connection to major incidents they may be long-lasting and can be fatal to the hospital’s ability to respond. Backup and reserve systems are mandatory as a part of the process of major incident planning and preparedness. This may be the weakest point of the planning in today’s hospitals, and few have such systems, perhaps because the consequences of failure are yet not fully understood (technical development within this field has occurred quickly).

5.15

Communication

Well-functioning communication is of vital importance for a hospital’s major incident response. Historically, hospital switch boards were sensitive to overloading

and could collapse because of a heavy influx of calls. After some incidents where this happened, it was able to be solved technically and the problem was forgotten, until the new digital, computer-based systems were introduced a few years ago and the same problem appeared again – this time on a central level and outside the control of the hospitals. This issue still has not been solved and has been reported during a number of recent major incidents. The hospital is suddenly isolated from telephone contacts both to and from the world outside. This is also something that has to be included in the process of planning and preparedness. Access to cell phones for all key staff is good as long as they work, but this system can collapse as well because of the overloading in these situations. One possibility is to secure certain cell phones for key functions (see Chap. 3), but this has to be done during the planning stage. For communication within the hospital, internal lines can be used, as can runners who transfer information in written or oral form, something for which voluntary organizations can be used if it is planned in advance. For external communication, the HCG must have access to a radio and be trained in the use of it (see Chap. 3). A (perhaps extreme) solution for external communication is runners who can deliver messages between the scene and the hospital and may be to the RMC, depending on distance. Runners with cars can also pick up key staff at their homes if the incident occurs at a time of the day when people are not normally listening to the radio or watching television. This organization was prepared in many hospitals before the new millennium, when it was forecasted that all telecommunication could be blown out: A number of minibuses were rented and porters were prepared to drive them, ready to pick up key staff at their homes according to prepared maps.

5.16

Psychosocial Support

The need for psychosocial support is large both before and after the response to a major incident, and many different categories may need such support, including: • Injured patients • Noninjured victims who were affected by the incident • Relatives/friends of injured patients • Relative/friends of dead victims • Staff of all categories Such support, therefore, has to be available at many positions in the chain of management:

5

The Hospital Response

• In the assembly area for patients that have received ambulatory treatment and are ready to be dismissed • In the assembly area for noninjured but psychologically shocked victims • In wards where casualties from the incident are treated • In the ICU (waiting room for relatives) • In the area for management of dead victims for support to relatives/friends • In the hospital information center Staff of all categories should have the opportunity to receive psychological support, but the primary support should always be given by the staff’s own unit. Persons in charge should have a responsibility to collect all staff before leaving after a response and discuss what happened, what was bad and what was good in the response, and what has been learned for the future. This primary debriefing is not a task for psychologists, but everyone should be made aware that their reactions and feelings are natural and not pathologic. However, it is also important to identify any staff member who at this point needs psychological support and to ensure that it is provided. All staff should be aware that such support can be given later if necessary, and whom they should contact to get it. Responsible for the psychosocial support functions in the hospital is the coordinator of psychosocial support, who can be a psychiatrist or a psychologist, or even social workers or priests. Psychological problems in connection to major incidents and the methodology to deal with them are described in Chap. 17.

5.17

Incidents Primarily Involving the Hospital

In the description above of the contents of the disaster plan was also included a separate part dealing with incidents primarily involving the hospital. These can be: • Fires, either accidental or intentional • Threats • Collapsed buildings, as occur as a result of earthquakes • Incidents involving hazardous material or irradiation • Floods

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• Terrorist actions • Armed conflicts that may expose the hospital to gun-fire Several fires in hospitals have been reported during the last years. It is mandatory that the hospital has special plans for this, including evacuation lines, and that everyone knows where to find them, but staff should be regularly trained together with the fire-brigade. The staff has a responsibility to save not only themselves, but the patients including those who are severely ill and receiving ongoing treatment. Threats to hospitals, for example bomb threats by maniacs, have been reported with an increasing frequency and should always be taken seriously. A special action card for dealing with threats should be included in the plan. Plans for evacuation of the hospital for the above or other reasons should also be included as an appendix to the plan.

5.18

Special Types of Incidents

The description of the hospital response to major incidents in this chapter has been mainly focused on incidents caused by physical trauma. As mentioned initially, the plan structure and organization of the hospital should be the same for all kinds of incidents (the “all-hazard” concept). The principles of medical management are, of course, different and are described in the Chaps. 7–11.

5.19

The Recovery Phase

A hospital’s response to a major incident involves many functions in the hospital and sometimes means maximal utilization of all available resources during a usually limited time period (during peace time). However, the response is not over because all patients have left the emergency department. Primary surgery may continue for 24–48 h or longer, operating on casualties who initially were given low priority. Primary surgery is often damage-control surgery – temporary live-saving procedures followed later by definitive surgical repair (see Chap. 7). This “secondary surgery” is done one or several days after primary surgery unless the patient not is transferred to another hospital. This means that the surgical activity, with all that is connected to it, may fully occupy available

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operating room facilities several days after the incident. During this period, everything in the normal routine that had to be postponed during the incident must be dealt with. It also takes time to restore supplies, and the staff needs rest. All this means that it will take several days after a major incident response until the hospital can go back to normal routines. It is important that staff who need it get the opportunity to receive psychological support during this phase (see above). During this phase, it is also extremely important to start the evaluation process, which is a part of the debriefing of the staff on all levels. It is important to have the opportunity to discuss how the response fulfilled its goals and what could be planned better for the future. This is also the perfect occasion to put together a report of the response from which others will benefit. To make possible scientific evaluation and comparison of such reports, they should be standardized to the extent possible, i.e., they should follow the same protocol. Efforts to come to an agreement on such protocols are currently ongoing, for example, in the Section of Disaster and Military Surgery within the European Society of Trauma and Emergency Surgery.

Further Reading Adini B, Goldberg A, Lace D et al (2006) Assessing levels of hospital preparedness for emergencies. Prehosp Disaster Med 21:451–457 Arnold JL, Demby LM, Tsai MC et al (2005) Recommended modifications and applications of the hospital emergency incident command system for hospital emergency management. Prehosp Disaster Med 20:290–300 Aylwin CJ, König TC, Brennan N et al (2006) Reduction in critical mortality in urban mass-casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 368:2219–2225 Bloch YH, Schwartz D, Pinkert M et al (2007) Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of a densely populated area – lessons learned from the medical management of a terrorist attack. Prehosp Disaster Med 22:186–193 Concenti P, Azima C (2003) Computer vulnerability, consequences and preparedness – experiences from the World Trade Center disaster. Int J Disaster Med 1:69–75 Cushman JG, Pachter HL, Beaton HL (2003) Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 54:147–154

S. Lennquist Davis DP, Poste JC, Hicks T et al (2005) Hospital bed surge capacity in the event of a mass-casualty incident. Prehosp Disaster Med 20:169–176 Debacker M (2003) Hospital preparedness for incidents with chemical agents. Int J Disaster Med 1:42–50 Frykberg ER (2002) Medical management of disasters and mass casualties from terrorist bombings – how can we cope? J Trauma 53:201–212 Hirschberg A, Stein M, Walden R (1999) Surgical resource utilization in urban terrorist bombing: a computer simulation. J Trauma 47:545–550 Hirschberg A, Holcomb JB, Mattox KL (2001) Hospital trauma care in multiple casualty injuries – a critical review. Ann Emerg Med 37:647–654 Hirschberg A, Bradford SG, Granchi T et al (2005) How does casualty load affect trauma care in urban bombing incidents? J Trauma 58:686–695 Holmes A (2004) System issues for psychiatrists responding to disasters. Psychiatr Clin North Am 27:541–548 Klein KR, Rosenthal DO, Klausner HA (2005) Blacout 2003– preparedness and lessons learned from the perspective of four hospitals. Prehosp Disaster Med 20:343–349 Leiba A, Ashkenasi I, Nakash G (2006) Response of the Thai hospitals to the tsunami disaster. Prehosp Disaster Med 21(1):32–37 Lennquist S (2004) The importance of maintaining simplicity in planning and preparation for major incidents and disasters. Int J Disaster Med 2:5–9 Lennquist S (2008) Protocol for reports from major incidents and disasters. Eur J Trauma Emerg Surg 5:486–492 Lennquist S, Hodgetts T (2008) Evaluation of the response of the Swedish health care system to the tsunami disaster in South East Asia. Eur J Trauma Emerg Surg 5:465–485 Marres G, Bemelman M, van der Eijk J (2009) Major incident hospital development of a permanent facility for management of incident casualties. Eur J Trauma Emerg Surg 3: 203–211 Marres GMH, van der Eijk J, Bemelman M et al (2011) Evaluation of admissions to the major incident hospital based on a standardized protocol. Eur J Trauma Emerg Surg 37: 19–29 Pryor JP (2009) The 2001 World Trade Center disaster – summary and evaluation of experiences. Eur J Trauma Emerg Surg 3:212–224 Schmidt PJ (2002) Blood and disaster – supply and demand. N Engl J Med 34:6617–6620 Schultz CH, Koenig KL, Auf der Heide E et al (2005) Benchmarking for hospital evacuation – a critical data collection tool. Prehosp Disaster Med 20:331–342 Turegano-Fuentes F, Pérez-Diaz D, Sans Sanchez M et al (2008) Overall assessment of the response to terrorist bombings in trains, Madrida, 11 March 2004. Eur J Trauma Emerg Med 5:433–441 Zane RD, Prestipino AL (2004) Implementing the hospital emergency incident command system – an integrated system’s experience. Prehosp Disaster Med 19:311–317 Zoraster RM (2007) Field triage and patient maldistribution in a mass casualty incident. Prehosp Disaster Med 22:224

6

Management and Identiﬁcation of Dead Victims Bertil Lindblom and Lennart Rammer

6.1

Introduction

aspect to certify where the different deceased and their belongings have been found. Bodies also can be mutilated or in separate parts, and it can facilitate the work to match different parts of the body, leaving as much of the material as possible untouched.

In incidents with many people involved, care and identification of the dead bodies is an important task for the rescue organization. From a humanitarian point of view it is of utmost importance that deceased persons are taken care of in a dignified way, that people are informed of whether or not their relatives have died in the incident, and that the family has the possibility to have the body for a funeral. In many developing countries, the authorities do not have the resources or competence for such identification, and many bodies are buried in mass graves as unidentified. The methods for identification in incidents with many victims are the same as in incidents of single deaths. The procedures may, however, be different depending upon the number of cases and the practical difficulties and circumstances that often exist at the scene of the event.

Bodies should be placed into special plastic transport bags that can be sealed with a zipper so that body fluids cannot escape. Both the body and the bag have to be marked clearly with the common marking system for the incident (see Chap. 3). If separate parts of a body are found, they are put in separate packages that also are marked. It is important that the handling and transport of the deceased to the first storage place is performed in an ethically acceptable way and in as dignified a form as possible.

6.2

6.2.2

Care of the Deceased on the Scene

The work of the rescue personnel naturally is focused on saving lives, and injured people are resuscitated, triaged, and evacuated as quickly as possible. There is no rush to evacuate apparently dead casualties; however, there is difficulty in evaluating the criteria of death in severe hypothermia (see Chap. 9). Criminal investigators in the police force have the responsibility to investigate and document the scene of an incident, and it can be of great value from that B. Lindblom • L. Rammer e-mail: [email protected]; [email protected]

6.2.1

Packing, Labeling, and Transport

Preliminary Storage

Preferably, the bodies should be kept cold at a couple of degrees Celsius and not in a deep freeze. Because of the lack of suitable storage facilities in many developing countries difficulties with the storage of bodies after disasters can be encountered. In a short period of time after death – often within 24 h – because of the influences of heat, insect attacks, and purification, bodies are subject to severe changes – such as impaired quality of body samples and sanitary problems for the personnel handling the bodies – which means that the deceased cannot be identified by recognition alone.

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_6, © Springer-Verlag Berlin Heidelberg 2012

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It is therefore desirable that identification of the deceased be given a high priority by local authorities. Possible solutions are to use trucks with cold containers otherwise used for alimentation transportation; place artificial ice around the bodies; or, as a last alternative, cover the bodies with sand after they have been placed into the marked plastic bags to keep down the surrounding temperature. It also is important to arrange for close surveillance and control of admission to the scene to prevent uncontrolled searching among the deceased by desperate relatives.

6.2.3

Delivery and Funeral

After the final identification (described in detail below), the body can be delivered to the family for interment or cremation. If the catastrophe has occurred in a foreign country, the body normally is transported to the home country by air freight. It is important that the delivery and transport is preformed with dignity. According to the will of the relatives, a minor memorial ceremony with or without religious elements can be arranged before transportation of the body. At the place of residence an undertaker cares for the body and arranges a funeral.

6.2.4

Local Instructions

As a part of local disaster planning, it is desirable that each country and each community indicates which cold storage facilities at hospitals, forensic institutes, and cemeteries are available in the case of a major incident.

6.3

Identiﬁcation of the Deceased Under Normal Conditions

Normally the doctor that confirms death makes the official declaration of the death by signing a death certificate. The legislation concerning these matters differs from country to country (we refer to relevant national laws for details). The death certificate also is used for statistical purposes concerning causes of death according to the International Classification of Diseases (ICD) system. In the majority of cases identification is based upon a statement by a relative or medical person-

nel about the identity of the person, and any additional investigations are not performed or considered necessary. An identification tag with the name and personal code number is fixed at the wrist of the deceased, and this tag follows the body to the mortuary, into the coffin, to the crematory, and into the grave. In most countries, if the identity of the deceased cannot be determined by recognition, the case has to be reported to the police, and the police order a medicolegal examination. If a missing person has not been found or identified, inheritance cannot be shifted and insurance cannot be paid to the surviving relatives. Legislation about this also differs among countries. Furthermore, it is a great psychological trauma to lose a relative and not have the death objectively confirmed.

6.4

Identiﬁcation During Major Incidents with Many Deceased

This section presents the process of indentifying deceased in incidents with many casualties. In such situations, it is often not possible or desirable to identify the deceased only by recognition because this procedure could increase the risk of false identification and poor handling of dead bodies. Therefore, it is highly recommended that, in bigger incidents, all identifications are performed with objective and reproducible methods. To perform a safe and objective identification, material for comparison is needed from all missing persons. Information collected about missing persons is called antemortem (AM) information. Without AM information it is not possible to identify the bodies. Therefore, one of the most important processes in identification work is to collect and document such information about missing persons. The reporting follows the Disaster Victim Identification (DVI) form published by Interpol. It contains distinguishing marks, information from dental records, other medical information such as operation scars and implants, and DNA profiles from close relatives who can be used as a reference. Information obtained in association with the examination of the dead body and that describes its characteristics is called postmortem (PM) information. During the examination of the body, samples of DNA are taken for examination. The PM result is documented in an identification sheet that follows the same structure as the AM document.

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Management and Identification of Dead Victims

6.4.1

Final Identiﬁcation

When the AM and PM results agree and the information about other facts of the missed person and the recovered body has been controlled, there are requirements for a final identification of the body. An expert group calculates and judges the degree of certainty of the identification, which is the basis for their decision.

6.4.2

Identiﬁcation Teams

Many countries have teams organized in advance for identification purposes in case of a severe catastrophe within the country or abroad in which many citizens are killed. Such a team may consist of police personnel, forensic odontologists, forensic pathologists, and forensic genetic experts. Such teams may also cooperate with each other, as occurred during the Southeast Asia tsunami disaster, where many people from various countries were killed during the same incident.

6.4.3

Methods for Identiﬁcation of the Deceased

There are certain and uncertain identification methods. The certain identification methods are: • Recognition: certain in single deaths under normal conditions, but should not be used in mass catastrophes) • Forensic odontologic examination • Forensic genetic examination and • Fingerprint examination The uncertain identification methods consist of various technical examinations, which can contribute to supportive evidence; only in exceptional cases can they constitute the basis for identification. Such information can include: • Personal belongings on or close to the body, such as rings, jewelry, keys • Tattoos, scars, birthmarks, and other external signs • Height, weight, sex, and ethnic characteristics; and • Implants or other medical findings

6.4.3.1 Recognition This method is used when relatives or medical personnel identify the deceased in ordinary cases of death. The method also is routinely used by the police during

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investigations of unknown or questioned identity. A relative, coworker, or someone who knows the missing person well views the body under the supervision of the police. It is important that the person who leads the confrontation is convinced that the person who performs the identification has looked carefully at the body and is sure about the conclusion. This procedure normally is considered safe; however, it has its limitations in cases of facial injuries, incipient purification, and children, and it cannot be controlled afterward. It should, therefore, not be used as the single method of identification in catastrophes with many victims. A number of false identifications in such situations have occurred. An identical tattoo was present on the arm of two women killed in a bomb attack in Bali in 2002. As friends they had been to the same tattooer a couple of years previously. In addition, resemblance to an image in a photograph should not be used as the basis of identification.

6.4.3.2 Forensic Odontologic Identiﬁcation Forensic odontologic identification is the method that has long been used to identify unknown victims. Each of the 32 teeth in the oral cavity has five surfaces, giving rise to a huge number of possibilities in the form of fillings, extractions, and reconstructions. The number of combinations is large enough to make a safe identification or exclusion possible. The dental status of the deceased is registered and x-ray pictures are taken, preferably using a digital technique. The findings are compared to the dental records and x-rays recovered from the dentist of the missing person. The result can be put into a computer to facilitate the interpretation of a great number of cases. The final decision of identity must, however, always be based upon an expert interpretation of the results (Figs. 6.1 and 6.2). 6.4.3.3 Fingerprint Examination In criminal cases the police take fingerprints for comparison with fingerprints recovered from the scene of a crime (dactyloscopy). Such recordings can be compared with those taken from unidentified bodies. Comparisons also can be made with fingerprints lifted from the belongings of the deceased or from objects in the home environment such as glass. Forensic technicians can recover fingerprints from the deceased by painting the fingertips with carbon dust, lifting it with adhesive tape, and mounting it on a

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6.4.3.5 Technical Examination The police register information about a missed person such as age, sex, height, weight, hair color, eye color, scars, birthmarks, clothes, identification papers, keys, jewelry, and rings. Such information cannot be the basis of a safe identification but can contribute as supporting evidence. Prostheses or pacemakers with serial numbers registered in the medical records can sometimes constitute a safe identification. This also is valid for wedding or engagement rings with an engraving of a name and date.

Fig. 6.1 Antemortem dental x-ray provided by a dentist

Fig. 6.2 Postmortem dental x-ray taken at autopsy

plastic sheet. Even in cases of advanced putrefaction or submersion in water, the fingerprints of the deceased can be recorded, either from the loosened skin or from the underlying exposed fingertips with visible papillary lines. In cases of dry putrefaction with hard skin, dipping the fingers in hot water can soften the fingertips. They then can be expanded by an injection of water under the skin.

6.4.3.4 Forensic Genetic Examination Identification based on DNA analysis has become more commonly used and has increased the possibility of identifying deceased individuals. DNA identification includes a comparison of the victim’s DNA profile with a reference profile from either a direct reference sample taken before death or samples from close relatives such as parents, children, or siblings. This method of identification is described in more detail below.

6.4.4

Forensic Autopsy

Normally, the examination of a dead body is part of a forensic medical examination. The legislation about forensic examinations differs greatly between various countries (refer to national laws for a closer study). The decision about a forensic examination is made by a police authority, a magistrate, a coroner, or a medical examiner. The examination may be performed as a full autopsy or as only an external medicolegal examination; in both cases the examination is combined with sampling of biological specimens and an odontologic examination. Ideally, specialists in forensic medicine and forensic odontology, working at forensic institutes, should perform the work. The mandatory authority decides the extent of the examination as well as the sampling procedure. This should depend upon the type of event and the questions that need to be answered. In some instances – e.g., a driver of a bus or train or a pilot of an aircraft – a full autopsy is needed, combined with an extensive toxicologic examination and, if possible, a computed tomographic scan of the body. A toxicologic examination is recommended, especially in cases of burns and suspected intoxications. The purpose of the forensic autopsy, apart from identification, is to determine the cause of death, which may be of importance for the payment of insurance and for statistical purposes. The most important purpose is to clarify the course of events of the catastrophe and to elucidate what happened. A driver or a pilot may have suffered from an acute disease or may have been intoxicated. After an air crash, the results of the autopsy may be of importance for assessment if the victims have died from crush injuries or from a supervening fire.

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Management and Identification of Dead Victims

6.4.5

DNA Investigations

The first major incident where analysis of DNA was applied was a fire in the ferry Scandinavian Star in 1990. The victims were identified after analysis of variable number of tandem repeat polymorphisms, a state-of-the-art procedure at that time. Since then, DNA investigations have been used in many disaster victim identification (DVI) operations (Alonso et al. 2005). Today, DNA analyses are performed using the polymorphisms of approximately 15 short tandem repeat (STR) markers. These markers are DNA segments with repeated nucleotide sequences; often four nucleotides (GATA) repeated a varying number of times. The markers used are spread over the genome to ensure random and nonlinked inheritance. All markers are analyzed simultaneously. Extracted DNA or DNA on FTA™ Cards (Whatman, US) is amplified by primer pairs in commercial kits and analyzed by capillary electrophoresis. One of the primers in each primer pair is labeled, which gives a possibility to visualize the amplified DNA fragments as individual peaks (Fig. 6.3). Comparisons of DNA profiles, fingerprints, and dental characteristics are accepted as primary methods for identifying deceased. DNA has been proven to be an important and efficient method, especially when identifying children who may not have any individual dental characteristics recorded or any fingerprints left behind. Comparing DNA profiles is also an efficient method for assembling body parts from different bodies (Fig. 6.4).

6.4.5.1 Antemortem DNA Samples and Analyses Early in the process it is important to decide what kind of AM DNA information and samples are needed as references. This information should be given to the local AM commissions (local police) or, if it is an international operation, to the home country commissions. The DNA analysis can be performed on: • Direct samples from national bio banks and originating from the missing persons themselves; • Samples from close relatives (parents, children, or siblings), if possible from at least two individuals; and • Samples from personal belongings, if possible supplemented with a sample from a close relative to ensure the relation. Samples from close relatives can be taken as buccal swabs. The samples can be collected by a police officer

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who is collecting other information concerning the missing person and securing fingerprints. In international operations, the DNA analyses of AM samples might be performed at laboratories in the missing persons’ home countries. Thus, participating laboratories should be accredited for forensic DNA analysis according to ISO/IEC 17025 or similar international standards. All analysis should be performed with negative and genomic controls and checked for peak height and peak balance. The DNA profiles should be transferred electronically as XML files adapted for Interpol’s “Antemortem Victim Identification Form,” page E4, or as Excel files according to given information. Complementary information, such as a copy of the continuity documentation, and a family tree (pedigree) showing relations between the persons investigated and the missing person or persons, should be transferred to the identification center. In some situations, raw data from the analyses may be requested. If no other information is given, the analyzing laboratories should file and store AM samples and documentation about these samples for the duration of the operation.

6.4.5.2 Postmortem DNA Samples PM samples should be collected according to the best practices for the kind of disaster and environmental conditions at the site of the disaster. Experiences from the Southeast Asia tsunami showed that femur samples worked well. If there is a risk for decomposition, a 5- to 8-cm femur sample or a tooth (molar) is recommended. If there is no risk for decomposition, a PM blood sample or a piece of muscle can be taken. It is important to label samples taken for DNA analysis with specific sample numbers that can be traced back to the individual bodies. A system for labeling bodies and samples should be established before anything is moved at or from the scene of the disaster. Every sample that is taken has to be documented. From the documentation it should be possible to trace from which body or body part a sample is taken; what kind of sample it is; when and where (and at which site, if more than one) it was taken; where it is stored; when and where it has been sent for analysis; and, later, the date when the DNA result is received. All PM samples should be placed in a test tube or container labeled with the sample number and should be stored securely but easy to find and at a low

Fig. 6.3 A DNA profile of a sample taken from an unknown man on an FTA card and analyzed with the AmpFℓSTR Identifier PCR Amplification kit (Applied BioSystems)

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Management and Identification of Dead Victims

Fig. 6.4 The number of deceased children younger than 16 years old who died in the tsunami, identified with different methods or a combination of methods

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temperature to protected from decomposition. When transported, the samples should be protected from decomposition and maintained in a way that the chain of custody is obtained.

6.4.5.3 Postmortem DNA Analyses Laboratories accredited for DNA analysis of PM samples according to ISO/IEC 17025 or similar international standards should perform the analyses. If the number of samples is high, it might be wise to use more than one laboratory to analyze the samples. Agreements should be made with the laboratories before samples are sent. From the tsunami operation, it was found that the most rapid input of PM profiles was during the time when the Beijing Genome Institute in China; the Department of Forensic Genetics in Sweden; and the International Commission of Missing Persons did the analyses and delivered DNA profiles from May to August 2005. Routine PM analysis should include documentation of when the samples arrive, the kind of sample, and a photo of the sample that shows the original test tube with label, local laboratory number, and a size standard. All DNA profiles should be analyzed with negative and genomic controls and checked for peak height and

peak balance. The DNA profiles should be transferred electronically as XML files adapted for the Interpol’s “Postmortem Victim Identification Form,” page E4, or as Excel files according to given information. Complementary information, such as continuity documentation and information about quality checks, should be transferred to the identification center at the same time.

6.4.5.4 DNA Markers Analyses of AM and PM samples must be done with the same DNA marker kit. The markers must be internationally known and provided as commercially available kits. In the work after the tsunami, most of the samples were analyzed with one sex and 15 autosomal markers included in the AmpFℓSTR Identifier PCR Amplification kit (Applied BioSystems). In some cases, complementary analyses with Y-chromosome short tandem repeat (STR) markers, single nucleotide polymorphism markers, or mitochondrial DNA sequences might be needed. The analyzing laboratories must have the marker kits implemented in their routines and be familiar with the use of them. Peerreviewed DNA marker frequencies for the actual population must be available for statistical evaluation.

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6.4.5.5 Matching With AM and PM results present, the comparison (matching) between DNA profiles can be done. Before the profiles are accepted for matching they should be checked for quality. If an AM profile is obtained from a stored sample from the missing person, a direct match should be found as identical PM profiles. With AM samples from close relatives, the comparison of AM and PM profiles has to be analyzed according to the biological inheritance of the markers (see Fig. 6.5). A statistical likelihood ratio should be calculated comparing the hypothetical family relation against a random hit. It might happen that some profiles will be incomplete, with dropouts of one or both alleles in one or more marker systems. This will probably occur more often in PM profiles than in AM profiles, depending on the increased risk of DNA degradation in the PM samples. The risk of losing fragments, allelic dropouts, also increases with increased fragment length. The STR marker polymorphism depends on spontaneous modifications of the fragment lengths, which normally occur as a mutation. In family matches, the occurrence of single mutations has to be handled in the matching process and introduced into the likelihood calculations. A report should be written for each AM–PM match found. This report should include the PM number, the PM sample number, the AM number, the name and date of birth of the deceased, as well as a statement about how the match was recognized and the likelihood of the identification. It should also be stated in the document that the continuity of all samples and the family tree for the case has been checked.

6.5

International DVI Work

At international DVI operations, with several teams from different countries working together, it is necessary to keep in mind that the work has to be performed based on decisions made by the authorities of the country in which the disaster has occurred. The DVI guide and the DVI forms developed by Interpol, listed on Interpol’s homepage (http://www.interpol.int) under the shortcut “Disaster Victim Identification,” are good standards for the work, as are the recommendations given by the International Society of Forensic Genetics (Prinz et al. 2007).

The initial work after an incident naturally is focused on rescuing wounded and homeless people. An early assessment of the disaster is essential to estimate the requirement of recourse available to the rescue teams. It will also provide an overview of the number of victims, their origins and family relations, the sex and age fractions, and the condition of bodies and body parts. In addition, it will give an idea of the environmental conditions such as temperature, humidity, and other circumstances that might influence the decomposition of bodies, body parts, and biological samples. An inventory must be taken of the possibilities for handling and storing bodies for the necessary autopsy investigations, and samples for DNA analysis must be taken. In disasters with high numbers of deceased victims from many countries, the DVI work will most probably comprise personnel from around the world. The DVI operation in Thailand after the Southeast Asia tsunami in 2004 is an example of such an international cooperation. It is to date the largest international DVI operation, which employed identification teams from 31 nations. The tsunami hit the west coast of Thailand, and more than 5,000 people were reported dead or missing in Thailand alone. Some of the areas hit worst along the coast were popular tourist resorts full of families on vacation from northern Europe. More than 2,500 tourists were expected to be among the deceased. The DVI operation started in the last days in December 2004, with DVI teams coming from Australia, Asia, Europe, and the United States. The Thai Tsunami Victim Identification (TTVI) was established January 13, 2005. A shared understanding between the Thai authorities and the international community supporting the operation resulted in common statements for the work, presented in Fig. 6.6. Once fully established, the work was organized as shown in Fig. 6.7. The importance of an early collection of AM information for the outcome was obvious from the TTVI work. Dental AM information was available from most of the European countries shortly after the tsunami, which resulted in the quick identification of many Europeans, as shown in Fig. 6.8 for the Swedish victims. Dental information was not available for the Thai victims to the same extent, and it took much longer to collect AM information for them, which resulted in delayed identification, which is obvious from the curves in Fig. 6.9.

Fig. 6.5 The inheritance of four short tandem repeat systems representing antemortem results from a mother and a child for a missing father. The DNA profiles from two postmortem samples are compared

6 Management and Identification of Dead Victims 107

108 Fig. 6.6 Mission and values developed by Thai authorities and the international community for the work in Thai Tsunami Victim Identification

B. Lindblom and L. Rammer

MISSION AND VALUES developed by Thai authorities and the International community for the work in Thai Tsunami Victim Identification (TTVI) TTVI MISSION To identify the victims of the Thai Tsunami and release these identified deceased for repatriation to their families, in accordance with Thai law, the INTERPOL DVI Guidelines and TTVI Protocols. TTVI VALUES Commitment Members engaged in TTVI operations will be characterised through their dedication, application, perseverance and a belief in their personal capacity to achieve and add value to the operation. Equity Every deceased person will be treated equitably to ensure there is no discrimination based upon age, race or ethnicity. Transparency

Complete openness and availability of all information and documentation generated through the TTVI operation will be maintained to all persons with a genuine right to such information. Spirit of Cooperation There will be complete co-operation between the Thai authorities and the international community, and between individual countries within the international community, to achieve operational objectives. Accountability All members of TTVI operations accept responsibility for the consequences of their efforts and any associated outcomes. Integrity All members of TTVI operations will display complete honesty and forthrightness in all their actions whilst engaged in the operation. (From: INTERPOL Tsunami Evaluation Working Group. The DVI Response to the South East Asian Tsunami between December 2004 and February 2006)

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Management and Identification of Dead Victims

Fig. 6.7 Organization chart for the identification operations in Thailand after the tsunami in 2004. The Thai Tsunami Victim Identification was established January 13, 2005, as a branch of the Thai police to implement the international commitment to identify the dead found in Thailand

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Fig. 6.9 Thai victims from the tsunami were identified with different techniques. The image shows the results of the various techniques and a combination of these techniques when each technique is not produced satisfactory basis for a decision on identification (Data from Thai Tsunami Victim Identification data from 2006)

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Further Reading Alonso A, Martin P, Albarrán C, Garcia P, Fernandez de Simon L, Jesús Iturralde M, Fernández-Rodriguez A, Atienza I, Capilla J, García-Hirschfeld J, Martinez P, Vallejo G, García O, García E, Real P, Alvarez D, León A, Sancho M (2005) Challenges of DNA profiling in mass disaster investigations. Croat Med J 46(4):540–548 http://www.interpol.int/Public/DisasterVictim/Guide/Guide.pdf August 20, 2011

B. Lindblom and L. Rammer http://www.interpol.int/Public/DisasterVictim/TsunamiEvaluation20100330.pdf August 20, 2011 Prinz M, Carracedo A, Mayer WR, Morling N, Parsons TJ, Sajantila A, Scheithauer R, Schmitter H, Schneider PM (2007) DNA Commission of the International Society for Forensic Genetics (ISFG): recommendations regarding the role of forensic genetics for disaster victim identification (DVI). Forensic Sci Int Genet 1:3–12

7

Incidents Caused by Physical Trauma Sten Lennquist

7.1

Different Mechanisms of Injury in Different Kinds of Incidents

The previous chapters in this book have dealt with the principles for organization and methodology in the response to major incidents. Different mechanisms of injury are dominant in different kinds of incidents: • Physical trauma, as in incidents involving transport facilities, collapsed buildings or constructions, changes in nature and climate, and intentional violence such as armed conflicts or terrorist actions • High temperature and toxic gases, as in fires and explosions • Low temperatures, as in ship accidents and cold climate • Hazardous material in connection to production, transport, or industrial use • Irradiation in connection to production, transport, and use of radioactive material • Microorganisms, as in pandemics and biologic warfare or terrorism As mentioned in the introductory chapters, during major incidents there will not be enough specialists available to take primarily take care of all injuries that, in today’s routine health care, normally are primarily treated by specialists. This means that all staff involved in a major incident response will have to, at least primarily, take care of injuries outside their own specialty. Knowledge about the principles for primary management and triage of the most commonly occurring injuries in major incidents is, therefore, a part of the training in disaster medicine for all medical staff. S. Lennquist e-mail: [email protected]

One good example of the need for this knowledge is the tsunami disaster that occurred in Thailand in 2004, where the six major hospitals in the disaster zone received 11,000 casualties during the first 3 days. The majority of those casualties had wounds and fractures that had to be primarily dealt with by all doctors and nurses, regardless of specialty. The importance of knowledge about how to primarily deal with severely contaminated wounds and to avoid severe and even life-threatening complications was clearly illustrated; however, today, such knowledge is not included in the training of medical staff everywhere. In the following sections, the basic principles for triage and primary management of different injuries will be illustrated, starting with injuries caused by physical trauma, which so far has been the dominating mechanism of injury in major incidents.

7.2

Effects of Different Kinds of Physical Trauma

Physical trauma that affects living tissue has different effects: • Direct visible effects where the trauma occurs (blunt injury by crushing, tearing, or compressing the tissue; penetrating injury as stabbing or missile or fragment wounds) • Indirect effects of energy from the trauma, which is transferred to surrounding tissue and also to other parts of the body • Secondary effects on different organ systems by products generated from injured tissue, circulatory shock or pain; effects primarily intended to protect the body, but by severe trauma they are over-trigged and cause an adverse effect

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_7, © Springer-Verlag Berlin Heidelberg 2012

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What we see on our first assessment of the injured are the direct visible effects, e.g., a hole in the skin caused by a missile or fragment. It can be difficult, especially for a less experienced responder, to evaluate whether this hole is caused by a low-energy trauma with minimum damage to the underlying tissues, or if it is caused by a high-energy trauma with extensive underlying tissue injury. In the first case, the risk for indirect or secondary injuries is small, and minimal treatment is required. In the second case, indirect or secondary effects can be life-threatening and require extensive and accurate primary treatment, local as well as systemic.

In the examples above caused by low energy, there is a minimal risk for indirect and secondary effects, and primary surgical repair can in most cases be done without risk of local complications. In the examples of injuries caused by higher energy, the risk for both indirect and secondary effects is significant and increases with the amount of energy transferred to the tissues. The indirect effects to surrounding tissues require a different treatment strategy, and the secondary effects increase the risk of adding surgical trauma by primary surgical repair of the injury.

7.3 Therefore, evaluation of an injury and decision with regard to treatment should never be based solely on the appearance of the injury, but on all available information with regard to the type of violence that has caused the injury. This is important in the treatment of all injuries, but it is especially important in major incidents where • many injures are caused by higher energy than in a “normal” situation, and • primary treatment may have to be done by staff with less experience with trauma. Below are listed examples of differences with regard to the energy in the trauma. • A fracture caused by a collision at a high speed can on x-ray look similar to a fracture caused by rotation violence during fall down a staircase or during skiing, but it means entirely different demands of treatment with regard to indirect and secondary effects of the trauma. • A missile or fragment injury caused by high energy (high impact velocity or heavy retardation in the body) can have a similar external appearance as an injury caused by low energy (low impact velocity or low retardation), but requires an entirely different approach to the wound with excision of devitalized tissue and delayed wound closure. The same is valid for heavily contaminated wounds, which also are common in major incidents. • An intestinal penetration or hematoma consequent to high intra-abdominal pressure caused by severe blunt trauma, blast, or penetrating missile or fragment can look similar to a lesion caused by a fall or a stab wound, but requires entirely different considerations with regard to treatment.

Penetrating Injuries

Penetrating injuries in major incidents include: • “Superficial” wounds limited to the skin and subcutaneous tissues • Wounds caused by missiles or fragments, penetrating deeper into the body • Other wounds caused by intentional or accidental penetration of objects into the body cavities. All these types of wounds are common in major incidents, where they are characterized by being caused more often by higher trauma energy and being more contaminated, and treatment often is delayed and done with fewer resources than under ordinary conditions. This means that they require special considerations with regard to the methodology of treatment, which on some points is different from the methodology used in routine medical care.

7.3.1

Wounds Involving Skin and Subcutaneous Tissues

In major incidents wounds involving the skin and subcutaneous tissues are naturally considered minor injuries, which often means delayed treatment and treatment by nonsurgical specialists. As mentioned above in the example from the tsunami disaster in Thailand, where more than 90% of the survivors had wounds – in most cases multiple – it is important that all medical staff involved in the treatment of casualties have knowledge about the principles for primary management of wounds under these circumstances. They often: • Are caused by considerable energy, with more tissue damage than what is seen on the first inspection • Are contaminated by dirt and microorganisms from damaged material

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Fig. 7.1 In situations with many injured, wounds involving skin and subcutaneous tissues have to be handled by staff with limited surgical experience. However, this requires the ability to evaluate the character of the injury (trauma energy? decontamination? devitalization?) as a basis for the selection of treatment. The picture shows an injury from the tsunami disaster that, based on such evaluation, should have been left open for delayed primary closure, but was primarily closed and now has severe infection and delayed healing as a consequence. To mediate such knowledge to all medical staff is an important part of major incident preparedness (From Keschpera et al., Int J Disaster Med 2005;1:66, with permission)

• Arrive late to treatment because of low priority compared with other injuries Wounds suspected to be caused by strong violence or severely contaminated should be treated according to the same principles as war wounds (see below), which means thorough cleaning, irrigation, and excision of dead tissue; even if they after that are considered clean, they are primarily left open based on liberal indications for delayed primary closure (see below). When in doubt, it is never wrong to leave a wound primarily open, but it might be terribly wrong to close a wound that should have been left open. Figure 7.1 shows an example of a wound fulfilling the criteria above, which should have been primarily left open but now was primarily closed, resulting in severe and long-lasting infection. Figure 7.2a, b shows long-term consequences of primary closure of wounds that should have been left open for delayed primary closure.

7.3.2

Missile and Fragment Injuries

Penetrating missiles or fragments transfer energy to the tissues, generating both indirect injury to

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surrounding tissues and secondary injury to different organ systems. The amount of energy varies widely, from those that transfer minimal energy, causing minor injury and requiring minimal treatment, to those that transfer massive amounts of energy, causing life-threatening injuries and requiring accurate local as well as systemic treatment. The energy transferred to the tissues is determined by: • The impact velocity of the missile/fragment • The mass (weight) of the missile/fragment • The retardation in the tissues, which is determined by: – The stability of the missile/fragment – The density and elasticity of the tissue The energy at impact (E) increases in direct proportion to the mass (M), but in square proportion to the velocity (V), according to the formula E = (M × V2)/2, which is the basis for the modern weapons technology. Increasing the velocity of a missile increases its impact energy even if the mass (weight) is reduced. This is the rationale behind high-velocity weapons and what has been called “high-velocity missile injuries.” However, it has to be considered that factors other than the velocity determine the impact energy and thereby the extent of the injury. For example, the retardation in the tissues can be increased by prefragmentation of the missile or by preparing it so it becomes unstable along its course before it hits the target. A “low-velocity missile” that hits bone will be retarded and thereby deliver energy comparative to that from a “high-velocity missile” only passing through soft tissues. Better terminology than “high- or low-velocity injuries” would therefore be “high- or low-energy injuries.” Missiles or fragments that transfer low energy to the tissues may penetrate the body without causing more injury than a stab wound, and if the missile track does not go through any vital structures, no treatment at all may be needed and the entrance and exit wounds can be left open for delayed closure or, under certain conditions, be primarily closed (see below). However, when the energy transferred to the tissues exceeds a certain level, the effect will be different. The missile or fragment causes a pressure wave, generating a temporary cavity around the missile track. Highspeed film recordings can illustrate that this cavity expands and collapses intermittently, like a “pulsating wound” sucking contaminated material into the cavity (Fig. 7.3). In the zone of this temporary cavity, a

114 Fig. 7.2 (a, b) Patients from the tsunami disaster upon arrival in Sweden after evacuation from the disaster zone. The pictures show deep infections with all criteria of inflammatory reaction in these initially severely decontaminated wounds, which were primarily sutured. Many of these wounds required a long healing process with repeated wound excisions, and in some cases amputation. Comparison with wounds that in the same disaster were primarily left open for delayed primary closure showed significantly lower infection rates in the latter group (From Edsander-Nord et al., Eur J Trauma Emerg Surg 2008; 5:457, with permission)

S. Lennquist

a

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varying amount of tissue will be irreversibly devitalized (Fig. 7.4), which, in combination with the decontamination illustrated in Fig. 7.3, will provide a basis for infection.

The extent of this temporary cavity and the amount of devitalized tissue are dependent on where the missile hits. Tissues with higher resistance, such as muscles and parenchymatous organs, as well as organs

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a b

b c

Fig. 7.3 When a missile or fragment passes through human tissue, it induces a temporarily expanding cavity (a) caused by the pressure wave. This expanding cavity generates an underpressure and contaminated particles are “sucked” into the injured tissues (b). Note the laceration around the exit wound (c), characteristic of (but not always occurring in) high-energy wounds

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Then, how to differentiate between a low- and high-energy missile (or fragment) wound? The external appearance might be the same: an entrance and an exit hole. Usually, high-energy missiles cause the skin to tear around the exit hole (Fig. 7.4), but this does not always occur. This emphasizes the importance of knowing which weapon that caused the injury. It is sometimes possible to see the cavity on plain x-ray, if available. If a high-energy injury is suspected, it is wise to make a small incision over the entrance and exit wounds, which will reveal devitalization of underlying tissues that requires excision (see below under “Surgical Treatment”). As high-velocity weapons are classified modern military weapons such as M16 (exit velocity 850–1,000 m/s) and AK-47 (exit velocity 935 m/s). As a comparison, ordinary handguns, rifles, and shotguns have exit velocities between 200 and 400 m/s. Diagnosis and surgical treatment of missile injuries to different parts of the body and different organ systems will be described below.

Visible missile track

7.3.3 Fig. 7.4 High-energy wound through which the missile or fragment has passed. Around the remaining visible missile track (a) there is a zone of devitalized and/or contaminated tissue (b) corresponding to the extent of the temporarily expanding cavity (c). The treatment must focus on minimizing infection by removal of devitalized and contaminated tissue, combined with effective drainage by leaving the wound primarily open for delayed primary closure (see Fig. 7.64 below)

partly filled with fluid (abdomen, cranium, big vessels), offer more favorable conditions for cavitation than organs with higher elasticity such as the lungs. The pressure wave can also generate indirect injuries to surrounding organs. For example, a high-energy missile wound in the thigh can be combined with pressure-induced injuries in the abdomen. Fragments from bone can also act as secondary missiles. Finally, release of products from injured, devitalized, or dead tissue generates secondary effects on different organ systems and plays an important role in the systemic response to trauma. These effects on circulation, respiration, metabolism, and coagulation are generated through several parallel routes. For a description of the mechanisms in detail is referred to the trauma literature.

Other Wounds Penetrating into Body Cavities

Wounds that penetrate body cavities can be either intentional (stab wounds) or unintentional penetrations by piling objects in connection to accidents; the latter are not uncommon in major incidents. When evaluating the depth of a penetration, e.g., in the abdomen or chest, it must be considered that the patient was most likely in another position during the trauma than he or she is during investigation, which means that a penetrating channel into the body cavities can be easily missed. If the penetrating object still is place at primary resuscitation, it should remain so until the patient is in the operating room, because removal of it can start a bleeding that is difficult to control from outside the body. Diagnosis and management of such wounds will be described under injuries to the different organ systems below.

7.4

Nonpenetrating Injuries

Nonpenetrating injuries include injuries caused by blunt trauma (beating, collision, fall), pressure waves (blast injury), and crushing (crush injury).

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a

When the speed at the moment of collision exceeds a certain level, the energy transferred to the tissues can cause indirect and secondary effects similar to those caused by missile injuries, i.e., devitalized tissue involving risks for both local complications and secondary effects of products from injured tissue on different organ systems. Studies of anaesthetized pigs exposed to blunt trauma as well as penetrating missile trauma to the trunk with different impact velocities showed that the borderline for pressure-induced intramural hematomas in the intestinal wall – some of them leading to necrosis and secondary perforation – corresponds to a speed at collision of 35 km/h for blunt trauma and an impact velocity of 300 m/s for missile trauma, both of which generate a similar pattern of pressure-induced injury. This emphasizes the importance of considering this mechanism of injury in a patient exposed to severe trauma.

b

7.4.2

Fig. 7.5 (a) Injuries to the trunk by direct violence hit mainly parenchymatous organs such as the liver, spleen, pancreas, and kidneys. (b) Rapid compression of an enclosed space, such as the abdominal cavity, generates an increase of the intra-abdominal pressure, causing injuries to organs at a distance from the impact site, which is why abdominal injuries after trauma often are multiple. Missiles or fragments that pass through the trunk can generate a pressure wave similar to that caused by severe blunt trauma; thus, the mechanisms of injury can be similar in blunt and penetrating traumas. The extent of injury is related to the character of the organ. In cavities filled with fluid, such as the abdomen or the cranium, the damage can be extensive; in cavities with more homogenous and elastic tissue, such as the lungs, the damage is significantly less

7.4.1

Blunt Trauma

The most common cause of unintentional blunt trauma is collisions with or between vehicles, also a common trauma in major incidents. Collisions at a high speed cause, in addition to direct injuries where the trauma hits, compression of the body, generating pressureinduced injuries in the body cavities (Fig. 7.5a, b). Whereas the first effect is apparent, the second effect is often forgotten and requires diagnostic observance.

Blast Injury

Pressure waves from explosions cause more complex and multiple forms of extensive damage to the body than any other wounding agent and therefore they are popular among terrorists. Terrorist bombing incidents have risen more than tenfold during the last decades and account today for more than 60% of terrorist attacks. Because this threat is directed toward innocent civilian citizens and can hit anywhere in the world at any time, it is important that all medical staff are aware of the pathophysiology of this kind of trauma and of the principles for diagnosis, triage, and primary treatment. There are several types of explosive devices: “conventional,” including bombs, artillery shells, grenades, landmines, and fuel-air explosives, all used for both military purpose and terrorist activities. More common in terrorist actions today are improvised explosive devices, which are simple and cheap to manufacture (detailed information is available on the Internet; see Chap. 15). All explosions generate an expansive shock wave that radiates out from the explosive source (Fig. 7.6). This blast wave has two components: (1) an initial high-pressure shock wave, followed by (2) a phase of negative pressure or “blast wind” caused by air being drawn back to the point of detonation. The initial shock wave causes injuries to the body at the air-liquid

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Fig. 7.6 Morbidity and mortality as a function of distance from open-space detonation of a 155-mm (100-kg) shell. Distances are in proportion from ground zero to 40 m. The interval between 40 and 549 m is too large to allow proportional spacing (From Champion et al. (2007), with permission)

117 Injury from fragments; temporary hearing threshold shift Death from fragments Injury from fragments only

Death from primary blast and fragments; eardrum rupture

> 549 m No discernable physical injury Ground Zero 15 m

24 m

interface, whereas the blast wind generates fragments from crushed material, resulting in secondary injuries. In enclosed rooms or spaces, the shock wave is reflected from solid surfaces, causing further damage, and the scenario resulting from blasts occurring in such enclosed or confined areas is generally worse than that resulting from explosions in open areas. As illustrated in Table 14.2 (Chap. 14), blast injuries can be classified into five different categories, depending on whether they are caused by the primary shock wave, by fragmentation or displacement of damaged material, explosion-related effects like fire or toxic gas, or by additives to the bombs such as bacteria or irradiation (“dirty bombs”). These effects are dominant at different distances from the explosion (Fig. 7.6). The lungs are especially sensitive to pressure waves because of their high content of air. The rise in pressure causes tearing of lung tissue and alveolar ruptures, with local bleeding from damaged capillaries and leakage of blood and fluid into the tissues and the bronchial tree. The capillary damage can generate an air embolism that can be immediately fatal or result in varying degrees of neurologic injuries. Primarily, the blood flow to the injured segment(s) is reduced by local vasoconstriction and direction of the blood supply to intact parts of the lung. This compensatory mechanism can make it possible to primarily maintain oxygenation, which can give the impression that the patient does not need ventilatory support. After some time, however, this vasoconstriction will diminish, and nonoxygenated blood will be shunted through the lungs and generate an accelerating respiratory insufficiency. Awareness of this initial compensatory mechanism is important when evaluating a casualty that has been exposed to pressure waves.

40 m

549 m

In summary, evaluation of casualties exposed to pressure waves requires special attention because: • The body can appear intact in spite of severe internal damage • Clinical symptoms of even severe internal injuries can be delayed by temporary respiratory and circulatory compensatory mechanisms. Understanding this is especially important because a prerequisite for survival in some of these injuries is high priority for treatment, and wrong treatment can be fatal (e.g., uncritical heavy fluid resuscitation to patients with pulmonary blast injuries). Diagnosis, triage, and treatment of blast injuries will be dealt with below under “Injuries to Different Organ Systems.”

7.4.3

Crush Injury

When a limb is trapped under material from collapsed buildings or other constructions, the compression leads to a combination of ischemia because of reduced vascular supply and direct injury to the muscular cells, especially the cell membranes. This leads to a change in the cation pump that finally leads to death of the cell. The cell membrane becomes permeable and unable to maintain the osmolal gap and the anion/cation differences between the intra- and extracellular environment. This causes a shift of fluid into the cell, swelling of the cells, and increase of the pressure in the muscular compartments. Depletion of fluid from the vascular system, reflected in a rise of hematocrit, can induce or aggravate circulatory shock. The muscular necrosis causes a release of electrolytes, such as potassium, calcium, magnesium, and phosphorus, and products from the muscular cell

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breakdown, such as myoglobin, into the circulation (rhabdomyolysis). This, together with other substances from injured tissues, generates a series of systemic disturbances: metabolic acidosis, coagulopathy, circulatory impairment, and renal failure. Potassium levels can be high and induce malignant arrhythmias. These systemic effects occur mainly when the circulation to the trapped limb is restored (reperfusion injury). Because every muscular compartment of the limbs is surrounded by rigid fascia, the increased pressure leads to a further reduction in vascular supply, increasing the muscular necrosis in a vicious circle (compartment syndrome). This can be diagnosed by palpation by an experienced clinician and confirmed by simple pressure determination in the different compartments of a limb (see below under 7.17.3). Treatment is urgent and should focus on: • Active resuscitation at the time of reperfusion to counteract the systemic effects of reperfusion injury, involving effective shock treatment and correction of metabolic disturbances • Release of pressure in the affected compartment(s) as soon as possible by opening of the fascia in all these compartments Some authors differentiate strictly between crush syndrome and compartment syndrome, considering them to be two separate entities – crush syndrome including muscular cell death by pressure and compartment syndrome being mainly swelling because of sequestration of fluid in the compartment – and recommend restrictiveness with fasciotomy in “pure crush injury” because the cells already are dead. However, clinically it is difficult to separate these entities, especially because increased compartment pressure also is a result of muscular necrosis, generating further necrosis in a vicious circle. Therefore, it is better to make one unnecessary fasciotomy than not doing it when it could have saved a limb and perhaps a life. Diagnosis and treatment of crush injury and compartments syndrome is further described under “Hospital Treatment of Limb Injuries.”

7.5

Primary Management of the Injured

The principles for primary management of injured patients are the same whether the injury occurs on the scene, in an ambulance, or in the emergency room in

the hospital. In some major incidents, even the basic primary management has to be done in the hospital because casualties come there with little or no preceding investigation or treatment, e.g., in incidents that occur a short distance from the hospital and where there is good access to transport resources. On the other hand, in incidents with a long distance to hospitals, lack of transport resources, or time-consuming evacuation from the scene, even advanced primary management may have to be done on the scene. To summarize this, a dogmatic split between what can and should be done at the scene and in the hospital might seem theoretically justified but is not in accordance with practical reality. Decisions about where to do what must be made during, and adapted to, every situation.

7.5.1

The Importance of Time

There are few fields in medicine where the time factor is as important as in the management of the severely injured patient. Ventilatory failure because of a blocked airway or injury to the respiratory organs must be dealt with within a few minutes if the patient is to survive. Bleeding from major vessels can, if not rapidly controlled, drain the patient of blood in a short time. Prolonged impairment of oxygenation or circulation may generate systemic effects on different organs that can be fatal or irreversible, even if the patient reaches the hospital alive. These examples emphasize the importance of rapid and correct decisions with regard to what to do and not to do and with which priority to do it. Characteristic of major incidents is that the patient may not get another chance if the wrong decision is made only once.

Therefore, to train responders in decision making for these specific situations is a responsibility that our patients have right to request from us.

7.5.2

The Importance of a Standardized Methodology

As stated above, management of severely traumatized patients means a number of steps that have to be taken and critical decisions that have to be made within a

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limited period of time. Especially for medical staff who are not involved in primary management of trauma in their daily routine, it is important to follow a strictly standardized and well-trained schedule to minimize the risk that important steps and considerations are missed. A standardized concept of primary management of traumatized patients that has gained acceptance in many countries in the world, and in most countries in Europe, is the Advanced Trauma Life Support (ATLS) concept. This concept, originating in the United States, is primarily intended for physicians, but is in modified editions also used for training nurses and paramedics (e.g., Prehospital Trauma Life Support). Because it is today widely used as the standard concept for primary management of traumatized patients, it is reasonable that it also is used as a basis for trauma management during major incidents. The following survey of the primary management of injured patients in major incidents is not intended to replace or repeat the ATLS concept, but to illustrate the application of the ATLS principles in these specific situations.

7.5.3

Action Plan for Primary Management

The three main steps of primary management in the ATLS concept also are valid for the major incident: • Primary survey with the aim to identify and eliminate immediate threats to vital functions • Secondary survey to get a detailed overview of the types and extent of injuries • Repeated and additional examinations with simultaneous support of vital functions until definite treatment Remember: • A complete or confirmed diagnosis is not a prerequisite for starting life-saving resuscitation. • Examination and treatment should be done simultaneously and a life-threatening condition should be dealt with immediately when it has been identified. • After every treatment, the effect of that treatment should be controlled with repeated evaluation.

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7.5.4

Primary Survey with Elimination of Threats Against Vital Functions

This is, according to the ATLS concept, expressed with the first five letters of the alphabet, ABCDE: Airway Breathing Circulation Disability Exposure

The ABCDE concept is easy to memorize but is not entirely consequent with regard to the often most lifethreatening condition in severe trauma – severe external bleeding –which can drain the patient of blood in a few minutes and always should be dealt with first without any delay. This is common sense for most responders, but some military organizations use as alternative the concept CABCDE, where the initial C stands for “Catastrophic bleeding,” indicating that this should be taken care of first (for control of bleeding, see below under “Circulation”). With this important exception, the alphabetic order is in accordance with the priorities in numerical order: 1. The airway must be secured immediately (within a few minutes) if the patient is to survive 2. Breathing must be established to secure oxygenation, especially of the brain 3. Circulation must be secured to maintain the blood supply to vital organs 4. Neurologic/mental dysfunction (disability) must be identified to exclude/deal with intracranial bleeding 5. Other injuries that can be a potential threat to vital functions have to be identified by systematic examination of the whole body (exposure)

7.5.4.1 Airway The airway can be blocked by: • A retracted tongue caused by reduced muscular tension in unconscious patients. Note that this is one of the most common causes of avoidable death on scene in major incidents! • Blood, secretion, aspirated gastrointestinal content, dislocated teeth or dental prostheses, or foreign material • Edema caused by strong heat or toxic gases; may not be present early after exposure but can progress rapidly with time if the patient is left without close observation, which is a risk during major incidents with a lack of resources

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a

Fig. 7.7 (a) In the unconscious patient, the airway can be blocked only because the patient is lying flat on his or her back and the tongue falls backward because of reduced muscular tonus. (b) Pulling the chin forward can be enough to open the airway in such a patient. Note the risk of bending the neck for-

b

ward – head injuries may be combined with fractures of the cervical spine, where especially flexion movements might promote dislocation and injury to the spinal cord. The head can be stabilized by the other hand as the figure indicates, or stabilized by a helper until more permanent stabilization can be achieved

Diagnose • Communicate with the patient: “How are you? Where does it hurt?” If the patient responds, it gives immediate information about airway, breathing, oxygen supply to the brain, and mental function. If the patient does not respond or responds inaccurately: • Listen with the ear close to mouth/nose for breath sounds • Palpate the chest: are there breath movements? • Listen over the lungs Signs of a blocked airway are: • Gurgling breathing sounds, blood or secretion in the upper airways • Sucking for air • Reduced/absent breath sounds Treatment • Urgent! A clear airway must be established within a few minutes if the patient is to survive! • Pull the mandible forward either by lifting the chin (chin lift; Fig. 7.7) or by pulling the jaws forward (jaw thrust) but without bending the neck forward in case of possible cervical injury (see below). This simple measure can be enough to establish a clear airway in a patient with reduced consciousness. • Clean the mouth and upper airway of blood, secretion, or other blocking material (Fig. 7.8). A pack-

Fig. 7.8 The upper airways can be cleaned with the fingers if portable suction not is available. A bunch of disposable gloves in the pockets should be mandatory for all medical staff on the scene

age of gloves is an important part of the equipment in incidents with many injured, as is a simple manual suction device.

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In every patient with impaired consciousness, consider the risk of injury to the cervical neck, which is not uncommon in patients with head injuries! Careless handling of a patient with a cervical neck injury can lead to dislocation of a fracture, with consequent irreversible spinal cord injury. In such patients, the cervical spine should be immobilized (stabilized) as soon as possible. The measures described above are life saving when the airway is blocked and must be done first, but always with consideration of possible cervical spine injury. As a general principle: • Try to get help from an assisting person who can keep the head stable while you clear the airway • Do not bend the neck forward because this movement involves a risk of dislocating a fracture, whereas keeping the head stable with the neck extended minimizes this risk

Continued treatment: If the patient is breathing spontaneously after the airway has been cleared, as above, proceed according to alternative A, below. If NOT, go immediately to alternative B.

Alternative A: Spontaneous Breathing After Clearing of Airway Even if the breathing is satisfactory after the measures described above, do not leave the patient lying flat on his or her back without continuous observation because that means a risk for repeated blocking of the airway. Instead: • Position the patient in the drainage (“recovery”) position (Figs. 7.9 and 7.10) • If the patient has a reduced level of consciousness with a difficulty maintaining the airway, secure it with a nasopharyngeal tube (Fig. 7.11) or, upon suspicion of maxillofacial or skull base fracture, use an oropharyngeal tube As mentioned above, a blocked airway in unconscious patients who are lying flat on their backs is one of the most common causes of death on the scene during major incidents. In these situations it will not be possible to continuously observe all patients with reduced consciousness, and liberal use of the drainage position in patients who are waiting for transport or further triage is potentially lifesaving. There are many alternative ways to position a patient than the drainage position, and only one example (Fig. 7.9) is shown

Fig. 7.9 An unconscious or severely injured patient should never be left lying flat on his or her back in situations where continuous surveillance not is possible because of lack of staff (see Fig. 7.7a). The same is valid for all severely injured: potential shock with reduced consciousness, aspiration, missed head injury. There are several different models for positioning patients to keep the airway open and drained, and the figure shows the one used in most countries for cardiopulmonary resuscitation, which means that most medical staff are familiar with it. As a general rule, use the position you are used to – the differences are mainly academic, but learn to do it quickly and correctly! Optimally the neck should be stabilized before positioning, which in most major incidents is not realistic, but use common sense and be careful with the neck, as described in the text

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Ca 30°

Fig. 7.10 An alternative when the injuries make it difficult or even impossible to position the patient as described in Fig. 7.9. The patient is placed on a stretcher remaining on his or her back, but the stretcher is supported in semirotation and the head is rotated to the side, permitting airway drainage

traumatized patients in major incidents. A severely injured patient can, even if he or she is awake during the primary evaluation, aspirate, go into shock with reduced consciousness, or have an expanding intracranial hematoma. In the original ATLS concept, it was emphasized that all patients with reduced consciousness should be equipped with a neck-stabilizing device before any other measures were done. As mentioned above, lifesaving procedures to clear the airway must have higher priority. Even if the aim is to stabilize the neck of such patients as soon as possible (preferably before they are placed in drainage position), this is not realistic in mass-casualty situations: application of a neck collar (Fig. 7.12) consumes time, staff, and equipment. As an alternative, an assisting person can keep the head stable during this procedure (as described above), strictly avoiding bending the neck forward. Fear of moving the neck must not risk the life of the patient! Even if correctly applied, a stiff collar on the neck (Fig. 7.12) does not give complete stability. In cases of manifest – or strong suspicion of – injury to the cervical spine, positioning on a spine board (Fig. 7.13) or, alternatively, a whole-body vacuum splint, is preferred. Alternative B: The Patient Is NOT Breathing After Clearing the Airway Blow air into the patient (mouth-to-mask or bag-tomask) and check the movement of the chest wall to confirm a clear airway. If the airway is still blocked, there are three alternatives to get air into the patient: • Tracheal intubation • Cricothyroidotomy • Jet-insufflation through the cricothyroid membrane

Fig. 7.11 Securing an upper airway with a nasopharyngeal tube. The figure shows a tube with adjustable collar (Rüsch®), adaptable to the size of the patient. Note the risk in maxillofacial or skull base fractures where an oropharyngeal tube is a better alternative (see text)

here – that used during cardiopulmonary resuscitation and which is, therefore, well known to all medical staff. As a general rule, use the position you are trained to use. An alternative to the regular drainage position for patients who cannot turn around (e.g., with certain fractures) is the “semi-drainage position” (Fig. 7.10). Liberal use of the drainage position is valid not only for primarily unconscious patients, but for all severely

Tracheal Intubation

Tracheal intubation outside the hospital should be restricted also in “normal” situations, and even more so during major incidents. It is difficult to do under these circumstances, it consumes time and resources, and an intubated patient requires qualified staff for surveillance and transport. Failed attempts to intubate cause delay and can also worsen the patient’s condition. Practically the only remaining indication for intubation on the scene of a major incident is when there is no other way to establish airway in a patient who can otherwise reasonably be saved. When indicated, intubation should as far as possible be done by staff with continuous experience of doing it.

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a

b

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• All necessary equipment, including suction and drugs, should be easily available Orotracheal intubation with a laryngoscope is normally the first alternative. The normal size of the tube is for women 7.0 and for men 8.0. For induction (if the patient is not deeply unconscious), propofol or ketamine can be used, combined with a muscle relaxant with short duration. Note that there are conditions in which muscle relaxants are contraindicated, such as neck injuries, which makes intubation even more difficult. Because intubation in these situations should be done by those with previous experience, for further description of the technique is referred to textbooks in traumatology and anesthesiology. An alternative for adult patients that has gained increased use during recent years is fast-track intubation via a laryngeal mask (see below), which is an easier and faster method under correct indications, but it is not recommended for those without any experience with conventional tracheal intubation. Cricothyroidotomy

Fig. 7.12 Application of a stiff collar to protect the cervical spine. A helper is supporting the neck during application. It is necessary to use either a collar of the correct size or a collar that can be adjusted to the size of the patient. Even then, a stiff collar does not provide complete stabilization (Photo: Karl-Ake Jansson)

The general principles for intubation are: • The patient should, if possible, be preoxygenated (oxygen by mask) 3–5 min with the goal of 100% saturation • The neck should be stabilized by an assisting person who keeps the head firmly in place with light traction in the neck – no anterior flexion!

Cricothyroidotomy (coniotomy or “emergency tracheotomy”) is an alternative when: • Tracheal intubation fails • Severe maxillofacial injury or prominent edema (e.g., inhalation injury) makes regular intubation hazardous or impossible • Equipment for and/or competence for intubation is missing Regular tracheotomy (an incision of the trachea below the laryngeal cartilage) has no place in this situation (blocked airway) because it is too time consuming. Cricothyroidotomy (Fig. 7.14a, b) means an incision through the cricothyroid membrane (“cona elastica”) between the thyroid and laryngeal cartilages. The place for the incision is easy to identify with palpation when the neck is extended; the way into the tracheal lumen is here short and, if the incision remains in the midline, the risk of bleeding is minimal. Prepared “kits” are available with a trocar and tube, but a person with some surgical experience can do this easily with a knife or any other cutting device. It is important to make a horizontal, not vertical, incision in the membrane – a vertical incision involves a risk of interfering with the laryngeal cartilage, and that means a risk of causing a laryngeal stricture (note the difference compared with regular tracheotomy, which cuts below the laryngeal cartilage and always is done with vertical

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Fig. 7.13 The best alternative for stabilization of a suspected or manifest cervical spine injury is the spine board, available in most ambulances today (Photo Kjell Ericsson)

Fig. 7.14 Emergency tracheotomy, cricothyroidotomy, or coniotomy. Establishment of a clear airway by incision of the membrane (cona elastica) between the cricoid and laryngeal cartilages. With the head extended backward, it is easy to palpate the oval groove between these cartilages, where it also is

easy to identify the midline. There are no major vessels in the midline and the airway is close to the skin here. No advanced equipment is required, and this can be done with any knife or even with scissors, and any available device can be used to keep the airway temporarily open

incision in the tracheal wall). Tracheal tubes 5.0–6.0 can be used, but in an emergency use whatever you have available to keep the airway open. Cricothyroidotomy is considered contraindicated in children younger than age 13. On the other hand, insertion of an ordinary intravenous needle at the same location is in such patients often sufficient to temporarily secure the airway and can be used for jet-insufflation (see below).

continuously. The treatment should not be extended more that 45 min because of the risk of carbon dioxide retention, but it is still a useful way to gain time when waiting for access to medically competent staff and/or equipment to permanently secure the airway.

Jet-Insufﬂation

Jet-insufflation means insertion of an intravenous needle through the cricothyroid membrane and connecting it by a Y-connection (Fig. 7.15) to oxygen with a flow of 12–15 l/min. Insufflations are done with duration of 1 s, followed by 4 s of expiratory phase, repeated

7.5.4.2 Breathing If the patient does not have spontaneous breathing after clearing and securing the airway, check circulation (see below). In a “normal” situation, if the patient has a detectable pulse and an open airway but no spontaneous breathing, it means that ventilatory support should be started immediately. In a major incident, STOP and evaluate the injuries: Is this a patient who has a reasonable chance to survive in this situation? Consider that

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because they can be combined with intrathoracic and intra-abdominal injuries. However, multiple rib fractures, where several ribs are fractured at two locations, can result in flail chest with an unstable thorax (Fig. 7.16), which is a serious but not immediately lifethreatening condition. Diagnosis • Multiple fractures felt during palpation (Fig. 7.11). Part of the chest wall does not follow the breathing but moves paradoxically in the opposite direction (“paradoxical breathing”)

Fig. 7.15 A needle is placed through the cricothyroid membrane connected to oxygen (via Y-connection) for jet-insufflation (see the text for further description). A Venflon® syringe may be sufficient to maintain airway in children, for whom regular cricothyroidotomy is considered contraindicated

continuous ventilatory support will consume resources that perhaps could be used for patients with better prospects of being saved. If the decision is to continue resuscitation, start bag-to-mask ventilation, give oxygen (10–12 l/min), and make a rapid but systematic examination of the chest. • Inspection: Penetrations? Contusions? Respiratory movements? • Palpation: Rib fractures? Paradoxal ventilation? • Percussion: Hemothorax or pneumothorax? • Auscultation: Breath sounds? Respiratory rate? Irregular breathing? Injuries to the Chest That May Cause Impaired Breathing • Injuries to the chest wall: multiple rib fractures with unstable chest • Pneumothorax: Air in pleura or mediastinum because of injury to the chest wall, diaphragm, bronchial tree, or lung tissue • Hemothorax: Blood in pleura or mediastinum because of injury to the chest wall, mediastinum, intrathoracic vessels, or lungs • Injuries to the lungs: Contusion, blast injury Injuries to the Chest Wall

Simple rib fractures usually do not cause impaired breathing, but they are important to discover

Treatment • Flail chest with impaired ventilation requires ventilatory support. With a long distance to hospital, tracheal intubation before transport should be considered if medically competent staff and equipment are available. As alternative, provide ventilation via a laryngeal mask (Fig. 7.21), oxygen, and pain relief. Flail chest may be combined with a closed pneumothorax (see below). When starting prehospital ventilation, observe for signs of tension pneumothorax, which, if present, must be dealt with immediately (see below). In the trauma room, before ventilation of a patient with flail chest is started, the pneumothorax should be excluded by x-ray or a chest drain should be applied. Pneumothorax

Pneumothorax means leakage of air into the pleura or mediastinum because of an open injury to the chest wall (open pneumothorax) or injuries to the lungs or bronchial tree (closed pneumothorax). The lung is no longer expanded by the normally negative pressure within the chest cavity, but collapses (Fig. 7.17). A valve mechanism can occur, with the consequence that air can enter the pleura but cannot come out (tension pneumothorax). Continued collection of air leads to increased pressure in the pleural cavity with a dislocation of the mediastinum toward the unaffected side (Fig. 7.18). This will, in the end, cause compression of the mediastinal veins, leading to circulatory impairment. This is an immediately life-threatening condition if not properly and quickly managed. Diagnosis • Diagnosis of an open pneumothorax is easy: penetration of the chest wall (do not forget the back side of the patient) and sucking/gurgling sounds connected to respiratory movements.

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Fig. 7.17 Pneumothorax: air leakage into the pleura caused by injury to the chest wall (black arrow) or to the lung (blue arrow). The negative pressure in the pleura, which normally keeps the lung expanded, is reduced or eliminated and the lung “collapses,” leading to impaired respiratory function

A closed pneumothorax is more difficult to diagnose. As a general rule, always suspect pneumothorax after heavy violence on the trunk and always in the presence of rib fractures, especially multiple fractures. Signs that indicate pneumothorax are: • Reduced respiratory sounds or impaired respiratory movements on the affected side • Tympanic sound during percussion of the affected side • Subcutaneous emphysema (single cases) • Respiratory insufficiency despite a clear airway Signs of a tension pneumothorax are: • Rapidly progressing respiratory insufficiency • No respiratory movement on the affected side that can give the impression of being extended • Anxiety, sucking for air • Cyanosis • Dislocation of heart sounds because of dislocation of mediastinum • Circulatory impairment with rising pulse, drop in blood pressure (late sign) • Expanded cervical veins (late sign)

Fig. 7.16 Flail chest. Multiple rib fractures where the ribs are broken on two locations (arrows) means that a part of the chest wall does not follow the breathing movements but moves in the opposite direction (“paradoxal breathing”). This impairs the respiratory capacity. Extensive flail chest leads to respiratory insufficiency and requires ventilatory support for survival. Note the risk of concomitant lung injury with pneumothorax

The greatest danger in this condition is not the respiratory insufficiency but the compression of the mediastinum causing reduced refilling of the heart, which can end in circulatory collapse.

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Fig. 7.18 Tension pneumothorax, a feared and immediately life-threatening complication of pneumothorax. At the site of the lung injury, a valve mechanism occurs so that air leaks out but not back in. In a closed pneumothorax (intact chest wall) this leads to an increase of intrapleural pressure. The mediastinum is pushed toward the unaffected side, leading to ventilatory insufficiency on that side. The most threatening consequence of this condition is the pressure on the large chest veins with impairment of the refilling of the heart, which can lead to a rapidly progressing circulatory collapse. Immediate normalization of the pressure with needle thoracotomy is a prerequisite for survival

Treatment • If a tension pneumothorax is clear or strongly suspected it is urgent, and treatment should be provided with highest priority and (if the clinical signs above are apparent) before the patient is transferred to the next position in the chain of management • Perform needle thoracocentesis in the second intercostal space in the medioclavicular line. If the

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diagnosis is correct, air will come out and the patient will show rapid improvement. This is a measure that can be done in the prehospital setting by a person with experience and competence enough to make the diagnosis. However, it is a measure that, even if it gains valuable time, is helpful only temporarily because the pressure will rise again if permanent drainage not is achieved. Therefore, as the next step: • Insert a chest drain (Fig. 7.39a–e) connected to a closed suction system with a pressure corresponding to 20 cm H2O as soon as possible. In the trauma room, an experienced team can insert a chest drain directly when a tension pneumothorax is apparent, and a preceding x-ray, even if it is normally done in the trauma room, is not mandatory in situations with insufficient resources. In major incidents with delayed evacuation and/or long transport times to hospitals, chest drains can be inserted on the scene, either connected to temporary suction or to a Heimlich valve (Fig. 7.19), letting the air out but not in. A simple substitute for a Heimlich valve is to use the finger of a surgical glove with a hole cut in it tied over a cannula (Fig. 7.20). Open pneumothorax is best treated with a chest drain (Fig. 7.39a–e) combined with an air-tight occlusive bandage. An occlusive bandage should not be applied before a chest drain can be inserted because this involves a risk of turning the open pneumothorax into a tension pneumothorax. Temporarily, the open wound can be covered with a semiocclusive bandage to let air out but not in. Such bandages are available on the market but can also easily be achieved by a dressing taped on three sides and left open on one side. A closed pneumothorax without suspicion of tension pneumothorax can be observed by repeated X-ray if it is minimal (< 2–3 cm); however, if it is larger it should be treated with a chest drain. Before starting ventilatory support in the trauma room, It is important to exclude closed pneumothorax because ventilation can transform it into a tension pneumothorax, and a larger pneumothorax should always be drained before ventilation starts. Hemothorax

Hemothorax means collection of blood in the thoracic cavity because of injuries to the chest wall or to the intrathoracic vessels or organs. Up to 0.5 l of blood may induce minimal symptoms, but more than that impairs respiratory function by compressing the lung.

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Fig. 7.19 Thoracocentesis for normalization of intrapleural pressure should be followed as soon as possible by the insertion of a chest drain connected to permanent suction. If there is no access to permanent suction, the drain can temporarily be con-

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nected to an external valve. The figure illustrates an example of this – the Heimlich valve, a simple mechanism that permits air to go out but not in

Pulmonary Contusion and Blast Injury

Pulmonary contusions can be caused by severe blunt trauma or by a pressure wave resulting from an explosion (blast injury), and the mechanisms have been described above.

Fig. 7.20 Without access to either a permanent suction or to a Heimlich valve, a temporary “homemade” valve can be achieved by tying a finger from a surgical glove over a needle and cutting a small hole in it

Diagnosis Penetrating or heavy, blunt trauma to the chest combined with: • Impaired circulation • Impaired breathing • Reduced or eliminated respiratory sounds upon auscultation on the affected side • “Dumb” percussion tone on the affected side Treatment • Prehospital: Transport to the hospital with high priority. This is not a condition that can be treated during the prehospital phase because drainage must be combined with effective shock treatment, usually (and when possible) including blood transfusion. For in-hospital treatment of hemothorax, see below under “Thoracic Injuries.”

Diagnosis Signs of pulmonary contusion are: • Chest pain and respiratory insufficiency, often after a primary symptom-free interval • Cyanosis (severe cases) • Petechia (minor bleeding) around the nose and mouth, hemoptysis (severe cases) Consider that severe pulmonary contusion also can be present • With few or no external signs • With primarily limited symptoms depending on primary compensatory mechanisms (see above) Especially in patients exposed to explosions, be aware of the risk for blast injury and observe for the symptoms listed above, which justifies high priority for oxygen and ventilatory support, and high priority for transport to a hospital. Treatment • Early supply of oxygen and effective ventilation • Restrictive fluid resuscitation • Diuretics, when possible albumin, to reduce alveolar edema For further diagnosis and treatment in hospital, see below under “Thoracic Injuries.” Other Causes of Impaired Breathing In addition to the injuries to the respiratory organs described above, there may be other reasons for impaired respiratory function in an injured patient. • Lung injury caused by toxic gases from fires or hazardous material

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Fig. 7.21 The laryngeal mask is a good alternative in patients with a clear airway who need ventilatory support, and the procedure can be learned quickly by staff with limited experience with airway management. It requires access to masks of different sizes. It does not protect against aspiration and it is not considered suitable for use in children (Photo Kjell Ericsson)

• Injury to the respiratory center of the brain caused by severe head injury • Injury to the respiratory center consequent to longlasting circulatory shock and/or lack of oxygen • Intoxication Indications for Ventilatory Support An indicator of ventilatory function is respiratory rate (RR). RR can be: • Low (<12 breaths/min) • Normal (12–30 breaths /min) • High (>30 breaths /min) Low RR is an indicator of cerebral ischemia (impaired oxygen supply to the brain). • Treatment: Ventilatory support + oxygen. Investigate cerebral and circulatory functions. High RR is an indicator either of increased accumulation of carbon dioxide or impaired oxygen saturation with secondary retention of carbon dioxide. • Treatment: Ventilatory support + oxygen. Investigate the reason for insufficient oxygenation (circulatory impairment?) Indications for Tracheal Intubation The traditional indications for tracheal intubation of traumatized patients are: • Blocked airway that is impossible to secure with other methods

• Airway threat from burn injuries through inhalation of hot air and/or toxic gases with risk of progressing edema ending in blocked airway. It is important that the airway is secured before this process goes too far • Direct lung injury, such as blast injuries or severe pulmonary contusion • Unstable chest with respiratory insufficiency • Reduced consciousness leading to insufficient spontaneous ventilation • Circulatory shock • Major trauma with a high risk of secondary respiratory, circulatory, and metabolic effects The first two indications are not controversial and are valid also for major incidents, and tracheal intubation is indicated when the competence and equipment required for it are available. If not, some of the alternatives described above under “Airway” have to be used. With regard to the other indications listed above, delay in intubation means no immediate threat to life, and it is better to wait until staff with continuous experience with intubation are available, which usually is in the hospital and not in the prehospital setting. Intubation on scene can considerably delay the transport to a hospital, and failed attempts to intubate under nonoptimal conditions can worsen the patient’s situation. An alternative to intubation with the latter indications is ventilatory support by laryngeal mask (Fig. 7.21). Application of a laryngeal mask can be

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learned quickly, and can be done by staff with limited routine practice in airway management. It requires access to masks of different sizes, and it is not considered suitable for children. It does not prevent aspiration, which is why preparedness with suction is mandatory. The laryngeal mask can also be a support during tracheal intubation (“fast track”). Oxygen Oxygen is widely indicated to all severely injured patients and and should be given to all patients with circulatory impairment. Extra supply of portable oxygen bottles to the scene in major incidents is, therefore, an important part of preparedness and puts special demands on transportation and storage.

7.5.4.3 Circulation After securing the airway and breathing, circulation is controlled on the scene primarily by palpation of peripheral, radial, femoral, or carotid pulse. Carotid pulse may be the most easy to palpate but this must be done with great caution and never with long-lasting compression to avoid vasovagal stimulation, and it is contraindicated in hypothermia because of the risk of inducing arrhythmia. If the carotid pulse is the only one that can be palpated, systolic blood pressure (SBP) can be estimated to around 50–50 mmHg. Absence of Pulse Absence of pulse means cardiac arrest – except in cases of hypothermia, which is not uncommon in major incidents; peripheral pulse can be difficult to palpate even if the hypothermic patient has circulation (see Chap. 9). Cardiac arrest means risk of irreversible brain damage after approximately 4 min at normal body temperature; in hypothermia it is longer (varies with body temperature; see Chap. 9). If the airway has been blocked, the circulatory arrest can have been caused by a lack of oxygen. An initial short attempt to restart circulation in such cases can be justified if it not is apparent that the injuries not are compatible with continued life. However, there are two exceptions to this: • In situations with many injured, where a strategic decision has been made by the persons in charge that not under any circumstances should cardiopulmonary resuscitation be performed in patients without vital signs

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• Hypothermia, where unjustified or incautious resuscitation can initiate irreversible arrhythmias (see Chap. 9). If a short attempt to restart circulation is done and is not immediately successful, STOP and consider the resources continued resuscitation would consume related to the total need for medical care. The chances of saving a patient with circulatory arrest caused by severe trauma are close to zero on the scene and are small also in the hospital, even if in the normal situation chances are somewhat better for penetrating than blunt trauma. Circulatory Shock Circulatory shock – impaired function of vital organs because of impaired perfusion with a consequent lack of oxygen – can be caused and/or aggravated by trauma through several different pathways: loss of blood, loss of other fluids (severe burns), extensive tissue injury with release of products from dead and injured tissue, and increased catecholamine secretion caused by pain and stress. The systems involved in this complex process and the pathways through which they are mediated are outside the scope of this book, and reference is made to basic text books in traumatology. Diagnosis • In modern medical care, we are spoiled with advanced technical facilities for surveillance and monitoring of vital functions. In the primary assessment of severely injured patients in major incidents, we have to make decisions without access to such facilities, which means that we have to rely more on clinical findings, an art that partly has been forgotten in today’s health care. Clinical signs of circulatory shock are: • The skin is pale, humid, and cold (“diaphoretic”), especially peripherally on the extremities • The veins are partly collapsed • The pulse is fast, and can become weak and “thin” over time • The ventilation is superficial and fast • The patient falls into a stage of apathy and responds slowly; lack of oxygen can also cause anxiety Rise in pulse rate (heart rate) related to blood loss is illustrated in Table 7.2. It must be noted that children younger than the age of 10 normally have higher heart

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Table 7.1 Estimation of blood loss based on clinical criteria Corresponds in ml (adult) Approx. 750 Approx. 1,500

Mental state

Skin

RR/min

HR/min

SBP (mm Hg)

Blood loss (%) 10–15 15–30

Unaffected Anxious

15–20 20–30

<100 >100

>120 <120

30–40

1,500–2,000

Confused

30–40

>120

<90

>40

>2,000

Lethargic

Pale Pale CR delayed Pale and cold CR delayed Pale and cold CR delayed

30–40

>140

<70

From Riddez L: Bleeding and shock. In: Lennquist S (Ed): Traumatologi. Liber, 2007 (with permission) RR respiratory rate, HR heart rate, SBT systolic blood pressure, CR capillary refill

rates than adults, as illustrated in Chap. 4, which is something to be considered during the triage process. For adults, a pulse rate exceeding 120 beats/min and no immediate response to shock treatment, is considered one of the criteria for being defined as circulatory unstable. Systolic blood pressure related to blood loss is also illustrated in Table 7.1. However, blood pressure is an unreliable parameter for early diagnosis of shock. Especially young patients have an ability to compensate for blood loss and maintain blood pressure by vasoconstriction for rather long time – but when it suddenly drops, it goes down quickly. A good rule to follow is, “circulatory shock should be detected and prevented before blood pressure falls.” Capillary refill is another parameter for evaluation of circulation used in some of today’s existing triage algorithms. Using a finger, pressure is applied to the patient’s nailbed for 5 s. The time for the bed to refill is determined. More than 2 s is considered to correspond to a pulse rate of 120 or above. This is not entirely simple to do on the scene, especially in darkness or difficult climatic conditions. Treatment In a patient with circulatory shock caused by bleeding, the most important step is to stop the bleeding as soon as possible: • Control of external bleeding has the highest priority in prehospital management • Control of internal bleeding should be done in a hospital as often as possible, which means that the patient should be transported to the hospital with the highest priority and without any unnecessary delay caused by measures on the scene

The major risk in circulatory shock is impaired oxygenation of vital organs caused by impaired perfusion of oxygenated blood. Replacing lost blood by intravenous infusion of other fluids can temporarily increase perfusion and thereby be of temporary benefit. Currently, synthetic oxygen-carrying solutions have been used in clinical trials and may be used clinically in the near future to enhance organ oxygenation. However, a major drawback with these solutions is their lack of coagulation factors. This means that blood transfusion is the only effective way to treat circulatory shock after (or parallel to) control of bleeding. Because blood transfusion (with rare exceptions) is not done in the field, this further emphasizes the importance of getting the patient to a hospital unit as quickly as possible. If the expected transport time to a hospital is 30 min or less, there is no indication to delay transport by giving intravenous fluid on the scene or during transport, and the effect of such treatment during such a short time is only marginal. If the expected transport time is longer or evacuation from the scene is delayed because of patients being trapped, large numbers of casualties, and/or lack of transport resources – which might be the case in major incidents – there are indications to give prehospital intravenous volume replacement: • If the patient is in severe shock (SBP <90 or heart rate >120 and clinical signs of shock listed above) • If there is a concomitant head injury where impaired perfusion involves a risk of permanent brain damage Techniques and guidelines for fluid resuscitation are described below under “Prehospital Fluid Resuscitation.”

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a

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b

Fig. 7.22 External arterial bleeding should be controlled as soon as possible. (a) Elevation of the bleeding site, firm pressure either on the artery proximal to the wound or directly into the

wound – no panic clamps! (b) Compression bandage with available material. The vast majority of external (including arterial) bleedings can be controlled this way

External Bleeding Stopping major external bleeding is dealt with here because it is a measure to prevent shock included under “circulation” in the ATLS concept. However, major external bleeding should be controlled as part of the immediate primary management of the injured, which is presumed to occur in parallel with the life-saving procedures described above. As mentioned above, in some military organizations the concept CABCDE is used as an alternative to the conventional ABCDE, with the first “C” standing for catastrophic bleeding (life-threatening external bleeding that must be stopped as the first step of the primary resuscitation; a major arterial bleeding can rapidly drain the blood volume).

bandage (Fig. 7.22), which is sufficient to stop the majority of bleedings. • When it not is possible to stop the bleeding with the measures above (e.g., in traumatic amputations where the artery often is retracted), apply a tourniquet (Fig. 7.23). This is often the first choice in battle-field conditions where time and blood cannot be lost during attempts to apply a compression bandage. In the absence of prepared tourniquets, other kinds of materials (belts, ropes) can be used with a similar effect. A tourniquet should always be applied as peripherally as possible, but at a level where the arterial circulation can be compressed. It should be intermittently released and as soon as possible changed to a compression bandage or surgical control of the bleeding.

Treatment • The first alternative (when possible) is to apply direct pressure on the artery proximal to the wound; if this is not effective, compress the wound with the fingers or apply pressure direct on the bleeding source (always wear gloves when dealing with injured patients, and change gloves between patients). If the bleeding stops with this, maintain the pressure and wait for material to apply a compression

Never apply vascular clamps blindly in a bleeding wound! A special challenge is injury to the carotid artery, where neither a compression bandage nor tourniquet is allowed. Control the bleeding with finger pressure until the patient is in surgery. An alternative in penetrating injuries with severe bleeding is to insert a Foley catheter into the

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a

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b

Fig. 7.23 In some cases, a compression bandage is not sufficient or is not possible to apply, such as in the case of limb wounds with severe laceration or traumatic amputations, i.e., injuries common in armed conflicts and terrorist actions. The alternative in these cases is a tourniquet that should be included

in the equipment for all such incidents. The picture shows a model of tourniquet used by the military. (a) The wounded can apply the tourniquet around the limb himself and, (b) by rotating the handle, induce enough pressure to stop the bleeding

wound and, by inflating it, temporarily occlude the bleeding vessel; multiple catheters can be used for this purpose.

and inaccurately to talk and pain, respectively, is missed, and this is an important basis for triage. Attempts have been made to solve this by splitting up the categories V (verbal) and P (pain) in two levels each: V1: Responds accurately to talk, fully oriented in time and room V2: Responds to talk but gives confused answers, not oriented P1: Responds to pain by accurate retraction movements, localizes pain P2: Responds to pain by inaccurate extension movements This makes the scale slightly more complicated, but gives a better basis for decisions with regard to triage (see below under “Head Injuries: Priority”). A more detailed scale, used for triage algorithms in the triage system sort (see Chap. 4), among others, is the Glasgow Coma Scale (GCS; Table 7.2) Signs indicating a rise in intracranial pressure: • Impaired response to talk and pain. Inaccurate response to pain is connected to a poor prognosis; no response to pain means (if not caused by other reasons) minimal chance of survival under these conditions. • Contracted pupil(s) can be a sign of pressure on cranial nerves. With increasing pressure, the pupil(s) become dilated and do not respond to light, which is a late and serious sign

7.5.4.4 Disability In the ATLS concept, evaluation of neurological condition is the first step after securing vital functions. The rationale for this is that an expanding intracranial bleed after a head injury is a potentially life-threatening condition that can occur and progress rapidly after the trauma. Evaluation of mental and neurological status, initially and repeatedly, is therefore an important part of the primary management of the severely injured. Diagnosis • Early and repeated determination of the level of consciousness is important to identify changes that indicate intracranial bleeding. Different scales are used to register this level. The most simple, widely used in the USA, is the AVPU(Awake, Verbal, Pain, Unresponsive) scale, which has four levels: 1. Awake (fully awake) 2. Verbal (responds to talk) 3. Pain (responds to pain but not to talk) 4. Unresponsive (does neither respond to talk nor pain) The groups at risk for intracranial bleeding are those in categories 3 and 4. The advantage of the AVPU scale is its simplicity. On the other hand, the discrimination between those who respond accurately

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Table 7.2 Glasgow Coma Scale Points Eye opening Spontaneous To speech To pain None Verbal response Oriented Confused Inappropriate words Incomprehensible sounds None Motor response Obeys commands Localizes pain Withdraws on pain Abnormal flexion Abnormal extension None Totally

4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 3–15

• Falling pulse rate and increased blood pressure are other late signs of rising intracranial pressure with cerebral incarceration. Note the difficulties of interpreting these signs in a patient with simultaneous circulatory shock because of bleeding. In patients with head injuries it is especially important to do repeated examinations: An intracranial bleeding expands successively and progress of any of the signs above has to be registered. Patients who develop intracranial hematomas often have a “free interval” of temporary improvement followed by recurrent impairment, which is of special importance to register (see below under “Head Injuries”). Treatment • Patients in categories A and V of the AVPU scale are considered for the moment not at risk, but those in category V should be observed with repeated investigations. • Patients in categories P and U should normally be taken to hospital immediately, when possible to a hospital with neurosurgical unit. In major incidents, the poor prognosis for patients in category U must be considered during triage (see below under “Head Injuries: Priority”). In these situations it may not be possible to bring all patients with

head injuries to neurosurgical units, but the aim should be to do so as many patients as possible because they will consume more resources and efforts in other hospitals. If there are long transport times or signs of circulatory impairment: • Use intravenous fluid to secure the cerebral perfusion • Keep SBP on a level between 90 and 100 mmHg, if possible, for the same reason See further under “Injuries to Different Organ Systems: Head Injuries”

7.5.4.5 Exposure The primary evaluation includes a rapid, systematic whole-body examination to evaluate the type and extent of injuries. In major incidents, the vast majority of patients have multiple injuries, and it is easy to focus the action on the most visually apparent injuries, which involves the risk of disregarding injuries that may be even more threatening and urgent to deal with. On scene in cold environment, this examination is done without removing the clothes more than absolutely necessary because of the risk of inducing or aggravating hypothermia. In the hospital, all clothes should be removed so that the whole body can be thoroughly inspected, front and back. Hypothermia is avoided by keeping rooms used for primary treatment of severely traumatized patients at a higher temperature. A systematic schedule should be followed, according to the ATLS concept, starting with the head followed by neck, chest, abdomen, pelvis, spine, and limbs. An alternative is to start with the trunk, where the potentially most life-threatening conditions can be expected, then proceed to the chest, abdomen, and pelvis, followed by the head, spine, and limbs. This primary survey has to be done quickly, and the important thing is to use a learned and trained schedule. • Communicate with the patient (if awake): Where does it hurt? Can you feel? Can you move? • Inspect: Cyanosis? Skin penetrations? Bruises? Hematomas? Asymmetries? Apparent dislocations? • Feel: Palpate and register tenderness, skin temperature and moistness, and peripheral pulse; move limbs. • Listen: Check breath sounds, bruits over vessels? Tone when percussion over lung fields and abdomen?

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Clinical signs for different injuries are described under “Different Organ Systems,” below. The review given here of the primary survey, focusing on what is specific during the major incident, might give the impression that this is a time-consuming process. However, in reality it occurs (and must occur) quickly, especially in major incidents where each responder has many patients to survey. The clinical signs and symptoms described above can be registered quickly by experienced staff, and responders trained to do this can register a large amount of information simultaneously. For patients who are awake and do not have serious impairment of vital functions, this primary survey can be done in a few seconds, for others may be minutes, depending on the need for simultaneous resuscitation. Because the process has to be described in “linear format” starting with A and ending with E, it may also give the impression that the action always strictly follows this linear structure and that the next step not can be started before the previous is finished. In the trauma room, several teams work in parallel with defined responsibilities and do things simultaneously. Also, prehospital responders often work in teams doing things in parallel. Even if some of the measures in the primary resuscitation described above can be done in a few seconds, other measures are time consuming. Therefore, training for this should be done with real times so that it provides a basis for decision making (what to do and not to do) in the real situation.

7.5.4.6 Repeated Surveys The primary survey with identification and elimination of threats to vital functions, which, as emphasized above, has to done quickly, should in the severely injured be followed by a secondary survey where the effects of the primary resuscitation are confirmed and where also a more thorough systematic examination is done under continuous observation of vital functions. The first two surveys should be followed by frequent repeated surveys. The development of local as

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well as systemic reactions to major trauma is a dynamic process requiring continuous attention of the patient through the whole chain of management!

7.6

Triage on Scene

The principles for triage on scene have been described in Chap. 4 and are related to the primary management as follows: 1. Primary triage is done as a first step before the primary management described above, with the aim to: • Sort out those who are evaluated as not in need of resuscitation on the scene or ambulance transport from the scene • Give those who need resuscitation on the scene or ambulance transport priority for either: – primary management on the scene and secondary triage, or – resuscitation and departure in an immediately available ambulance. For this primary triage, a system based on simple criteria of the patient’s condition (“physiological triage”) is sufficient, e.g., triage sieve (Chap. 4). This can be done quickly and by a person who has limited medical experience if experienced staff not is available. 2. Secondary triage is done with the aim to re-evaluate priority after primary management and resuscitation according to the principles described above; it usually is done by the team responsible for this primary management. At this level, a triage system with a higher discriminative capacity is preferred, e.g., triage sort, a physiological triage system based on a Revised Trauma Score (Chap. 4). As illustrated in Chap. 4, the advantage of a triage system based on physiological criteria is that it can be used by staff who have limited clinical experience. However, there are some limitations on the use of such systems with traumatized patients: • It may lead to over-triage of patients with severe injuries and small possibility of saving, who, as long as they have vital signs, will be given a high priority and consume resources that may be used for patients with better prospects of cure. This is especially valid for level 2 major incidents,

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i.e., where all patients who normally can be saved are not possible to save because of the high load of casualties related to available resources. • In may lead to under-triage of patients with injuries that are potentially life threatening but show minor to moderate initial symptoms, for example: – Blast lung injuries, where the patient initially can appear to be in a satisfactory condition because of shunting and other compensatory mechanisms – Intra-abdominal injury with bleeding, where the initial symptoms can be modest even with ongoing bleeding Especially in level 2 major incidents, the aim should be to have experienced staff doing either secondary triage entirely based on the anatomy of injuries or physiologic triage followed by a re-evaluation of the patient with consideration of the anatomical findings: potential dangers of different injuries, chances of survival. 3. Patients under surveillance waiting for transport should be continuously re-evaluated with regard to priority. Triage is a dynamic, not static, process and has to be continuously adjusted both to the patient’s condition and available resources. If possible, this evaluation should focus on the character of the injuries, which gives a better basis for optimal use of transport facilities (see below under “Priority for Transport”).

7.7

Decision with Regard to Continued Prehospital Treatment

The level of ambition for the treatment on scene, and the balance between “load and go” and “stay and stabilize,” has already been discussed in Chap. 3. The strategy has to be adjusted to the situation, and what is right in one specific situation might be totally wrong in another. As a general principle, the patients should never be kept on the scene longer than necessary, and, in situations with good access to transport resources and short times for transport to hospitals, treatment on the scene should be restricted to mandatory life-saving procedures before transport. However, in major incidents with time-consuming evacuation, lack of transport resources in relation to the load of casualties, and/

or long distances to hospitals, it may be necessary to extend the prehospital treatment on the scene to include measures that are normally restricted among injured patients, such as: • Ventilatory support and oxygen • Tracheal intubation or cricothyroidotomy • Intravenous fluid treatment • Decompression of tension pneumothorax This requires experienced staff on scene and perhaps even more important than having the skills to perform these measures is the ability to make correct decisions with regard to what to do and not to do. Training for medical response to major incidents must include training in decision making, which has to be done in such a way that the trainee realizes the consequences of his or her decisions, with regard to both consumption of time and resources and the influence of the decision on the outcome of the individual patient.

7.8

Prehospital Fluid Resuscitation

The indications for prehospital fluid treatment are given above under “Primary Management: Circulation.”

7.8.1

Vascular Access

Venous access in the prehospital setting is best achieved with a minimum of two cannulas, the wider and shorter the better, in the veins of the upper limbs; infusion in the lower limbs is of limited value if there is bleeding in the trunk. In penetrating injuries, the wound should never be between the intravenous catheter and the heart. The external jugular vein is an alternative for staff with experience using it. Central intravenous lines have no place in the prehospital setting, not even in the “normal” trauma situation. When it is difficult to achieve venous access through intraosseous infusion, alternatives are either use of a battery-operated drill (today available in many ambulances) in the proximal tibia or humerus (Fig. 7.24), or with a sternal intraosseous device. Some military organizations use a special bone injection gun, which is difficult and risky to handle for the less experienced. In a situation with a lack of equipment, a simple manual intraosseous needle with a handle can be used. The

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Fig. 7.24 Intraosseous infusion is an alternative when it is difficult to establish an intravenous line. The needle is drilled into the bone and can be directly connected to an infusion line. The most common location is the proximal tibia; an alternative location is the proximal humerus. This needle is also a safe line during transport (VIDACARE/IM-medico, with permission)

intraosseous route is not recommended for hypertonic solutions.

7.8.2

Different Kinds of Fluids: Advantages and Disadvantages

There are different kinds of fluids available for temporary or supplementary volume replacement in patients in shock: • Isotonic crystalloid solutions • Hypertonic solutions • Synthetic colloid solutions Isotonic crystalloid solutions are effective as volume expanders during a short period of time, increasing cardiac output and organ perfusion (without supplying tissues with oxygen). However, 1 h after administration, only about one-third of the fluid remains in the intravascular space, which means that three times the volume of lost blood must be given to restore perfusion. Advantages are that they can be stored for a long time and cause minimal adverse reactions. The most commonly used isotonic crystalloid solution is the Ringer lactate, which has a composition most similar to the electrolytes in plasma. Hypertonic solutions have higher concentrations of electrolytes and thereby higher osmolality, which makes them more effective volume expanders:

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250 ml of a hypertonic saline solution gives the same volume replacement as 2–3 l of isotonic crystalloids. However, in spite of this theoretical advantage, no clinical trial has proven them superior to isotonic crystalloids. Disadvantages are shorter storage time and higher costs, and they are not recommended to be given through the intraosseous pathway, which is increasingly used in these situations. One indication where they should be considered is in patients with concomitant head injuries, when it is of vital importance to maintain cerebral perfusion and minimize extravascular edema. The most commonly used of these is hypertonic saline 7.5% sodium chloride solution. Synthetic colloid solutions draw fluid from the interstitial and intracellular spaces into the intravascular space, thereby inducing expansion of intravascular volume. Disadvantages are adverse reactions (which can be minimized by the addition of anti-immunoreactive components), higher costs, and limited storage capability. As for hypertonic crystalloid solutions, no clinical trial has so far proven them superior to crystalloid solutions. Examples of such solutions are Dextran®, Macrodex®, Voluven®, and Venofundin®. There are also combinations of crystalloids and synthetic colloids like Hyper-Haess® (based on Ha Es starch) and RescueFlow®, based on Dextran. A volume of 250 ml of those corresponds to a volume of 3,000 ml of crystalloids.

7.8.3

Recommended Guidelines for Use in Major Incidents

Indications for intravenous fluid infusion in the prehospital setting in major incidents are described above under “Circulation.” Even if selection of fluid in some parts is a continuous target for controversial opinions, the vast majority is in agreement that infusion in adults, when indicated, may start with a bolus dose of 2,000 ml of crystalloids (e.g., Ringer lactate, as the most commonly available in the first line of treatment in these situations [see below for exceptions]). The corresponding dose for children is roughly 20 ml solution/kg bodyweight. Exceptions to the rule to start with crystalloids are: • Concomitant head injuries, where is it of critical importance to avoid progression of tissue edema;

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hypertonic solutions could be considered if available (see below) • Treatment in combat conditions, where some military organizations use hypertonic saline as an initial alternative on the battlefield for logistical reasons – it means less volume to carry to achieve effects in volume replacement equal to those of crystalloids (see Chap. 14, “Combat Casualty Management”). Infused solutions should, if possible, be heated to 39°C (102°F) before infusion. In cold environments (outdoor temperature lower than room temperature) intravenous infusion should never be given without the ability to keep both the fluid bag and the fluid tube warm; equipment for this should be mandatory in every prehospital unit. Fluids lose temperature quickly in such environments, and infusing cold fluids, thereby inducing hypothermia, could be deleterious for the trauma patient (see also Chap. 9, “Incidents in Cold and Wet Environments”). The goal of the infusion should be to keep SBP between 80 and 90 mmHg Noncritical and uncontrolled infusion to a higher blood pressure involves a risk of inducing or restarting bleeding. The recommendation for major incidents is to stick to the protocol normally used in the organization, and if crystalloids are the only available solution (which might be the case in these situations regardless of normal routines), continue with crystalloids as an emergency measure. Continued high volumes of crystalloids involve a risk of causing impairment to the coagulation system, which has to be kept in mind. Head injuries require special considerations. Head injuries in themselves rarely lead to circulatory shock, but a trauma patient with other causes of severe bleeding might have a concomitant head injury. In patients with head injuries with increasing intracranial pressure, it is of critical importance to maintain cerebral perfusion and oxygenation by keeping a sufficient mean arterial pressure. In addition, it is important to avoid tissue edema, which is one negative effect of volume replacement with fluids with low osmolality, such as some of the crystalloids. In situations where access to surgery is delayed, the use of hypertonic saline combined with colloids (if available) should be considered for maintenance of perfusion in patients with persistent shock and concomitant head injury.

S. Lennquist

7.9

Prehospital Pain Relief

The prehospital need for analgesia is less than generally believed. There is often a period of relative analgesia immediately after the trauma, partially mediated by endorphin secretion and partially because muscular contractions in injured limbs appear after a varying delay after the trauma. An important part of pain relief on the scene of an incident is handling the patient with proper consideration of the type of injuries. Side effects of analgesia, such as impaired ventilation and vasodilatation, with aggravation of hypoxia and hypotension, have also led to restricted use of pharmacological analgesia in severely traumatized patients. However, this should not prevent the use of analgesia when it really is needed, e.g., in trapped patients where the extrication in itself can be painful. In patients with manifest or potential shock (all severely injured), analgesia should be given intravenously if possible. In circulatory impairment, analgesia administered in other ways (orally, subcutaneously, intramuscularly) acts too slowly and provides an insufficient effect, and repeated injections are accumulated on the site of administration to be released when circulation improves, when they can have a suppressive effect on the ventilation. The drugs given should be effective but at the same time have minimal inhibitory effects on ventilation. Repeated small doses are preferred to one larger dose. The dose should be selected with consideration of the patient’s age, bodyweight, circulatory and respiratory condition, and the type of injury. For example, morphine sulphate 2–2.5–5–10 mg slowly administered intravenously until pain relief is achieved. Staff with anesthesiologic competence/experience may use ketamine 0.25–0.5 mg/kg bodyweight when more complete analgesia is needed, e.g., during extrication. The use of ketamine in patients with head injuries is controversial; some consider it contraindicated, but others consider it useful in cases of simultaneous circulatory shock, where it has many advantages – securing circulation always has a high priority in an injured patient. Entonox (The Linde Group) or Medimix®, a mixture of 50% oxygen and 50% nitrous oxide for selfinhalation, is used on scene and during transport in some countries, especially in patients with severe burn injuries.

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7.10

Prehospital Stabilization of Limb Injuries

7.10.1 The Importance of Accurate Stabilization Before Transport In major incidents caused by physical trauma, limb injuries almost always dominate the scenario, often with an incidence of between 60% and 70%. Even if these injuries (with a few exceptions) not are life threatening, insufficient primary management can lead to both local complications and severe systemic complications that can be life threatening. Accurate primary management of limb injuries is, therefore, an important part of the primary management of trauma. A fracture that not is accurately stabilized before transport of the patient can lead to: • Dislocation or increase of dislocation • Secondary injuries to skin and soft tissues, to the extent that a closed fracture can be transferred into an open fracture • Edema with risk of secondary effects on vessels and nerves • Continuous pain that may induce or aggravate shock, and systemic reactions to trauma • Continuous release of products from injured tissues, with the same effects as those listed above Therefore: • Moving a patient with a fracture must always be done with proper consideration of the injury. • Transport of a patient with a fracture must never be done without appropriate immobilization before transport.

7.10.2 Open Fractures Minimize contamination of the wound. Cut clothes and cover the wound with a sterile dressing as soon as possible. To achieve accurate immobilization, it might be necessary to re-locate an exteriorized fracture end into the wound and, if so, this should be clearly registered in the triage card or in some other way.

7.10.3 Closed Fractures and Dislocations Immediately after the trauma, there is usually an interval of between 10 and 30 min of reduced muscular

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tonus before pain-induced muscular contraction starts. Reduction of major dislocation during this interval can be done with minimal or no pain relief, presumed that it is done correctly by an experienced person. Reduction after this interval requires pharmacological analgesia and perhaps muscle-relaxing agents.

7.10.3.1 Principles for Reduction Before Stabilization The aim should at this stage not be to achieve an exact anatomical reduction of dislocation, just to make it possible to apply accurate stabilization: • Move slowly and carefully, paying continuous attention to the patient’s reaction (if he or she is awake). Collaborate with the patient. • Keep continuous, firm traction in the longitudinal direction of the limb, which prevents fracture ends from being crushed against each other or crushing surrounding tissue. Always work with an assistant, who should apply traction in the opposite direction of the limb (Fig. 7.25a) • Eliminate first angular, then rotational, dislocation (Fig. 7.25b) • Keep the traction firm (Fig. 7.25c) until the limb is placed in a splint (this is best done by a third person) 7.10.3.2 Principles of Immobilization Immobilization: • Should include the joints on both sides of the fracture (may seem self-evident, but for some reason this is often disregarded) • Must never cause injuries to the skin (dress and pack carefully!) • Must never interfere with peripheral circulation (check peripheral circulation during transport!) 7.10.3.3 Principles for Management of Different Fractures Ankle A closed ankle fracture with dislocation of the ankle can rather quickly turn into an open fracture because of necrosis of the skin. Especially in cases of total dislocation, reduction should always be done before longer transports, and it is easily done within a short time after the injury, without the need for anaesthesia. Immobilize with a lower-leg splint (Fig. 7.26).

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a

b

c Fig. 7.27 Vacuum splint used for fracture stabilization in many ambulances. These kinds of splints consume space and are less suitable for use in major incidents. If used, they should be inflated with caution because too aggressive inflation can cause skin injury (Photo Kjell Ericsson)

Fig. 7.25 Principles for reduction of major dislocation of fractures. The reduction should be done with a helper who keeps a firm and careful contraction. Move slowly, paying attention to the patient’s reaction. Reduction with no or minimal pain (which is possible for a short time after the trauma) reduces the risk of additional tissue injury. Eliminate first angular (a), then rotational dislocations (b), and keep the traction (c) while a third person applies the splint

Lower Limb Reduction, as shown in Fig. 7.25a–c, should include the whole leg, including the ankle. This can be achieved by putting two simple splints (Fig. 7.26) together, or by using a vacuum splint, which are usually available in ambulances (Fig. 7.27). Knee Fractures are immobilized in a whole-leg splint (as above) with light flexion. Dislocation of the knee joint as an effect of severe trauma involves risk of vascular injury; provide close observation of distal circulation and, on suspicion of vascular injury, high priority for transport.

Fig. 7.26 A simple flat splint for limb immobilization, which can be bent from the sides and secured by a bandage. Adding two together makes a splint for the whole limb, as would be needed for tibial shaft fractures. Such splints are cheap and can be stored in large amounts, e.g., at the rescue service, to be brought to the scene in major incidents (after all, approximately 70% of patients in such incidents have limb injuries) (Photo Karl Markluna)

Femur Fracture of the shaft of the femur is usually an effect of severe violence and combined with extensive soft-tissue injury. Even without major vascular injury, 1–1.5 l of blood can be lost in surrounding soft tissues without prominent external signs. Manual reduction is difficult because of muscular contraction. The only effective way to immobilize is with a traction splint (Figs. 7.28–7.30). An alternative, however less effective, is a whole-body vacuum splint.

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Fig. 7.28 Effective stabilization of femur fractures requires traction, and there are several different devices that have been developed for this purpose, and different types are used in different ambulanceorganizations. The figure shows one example, the Quicksplint®, which can be used both with and without traction and for bilateral fractures of the lower limbs. The handle facilitates lifting of the patient. Note the traction device at the foot (Photo Kjell Ericsson)

Fig. 7.29 CT-6 Carbon Traction Leg Splint® used by the US Army is light and easy to carry in the field and is designed to give a precise adjustment of the amount of traction (Fare Tec, Inc., Painesville, OH, with permission)

a

Fig. 7.30 This figure illustrates how two simple flat splints of the model described in Fig. 7.26 can be used as a traction splint by being equipped with burdock tape (the Holmström splint). This is a cheap alternative when there is a lack of devices. It does not give

b

the same effective and precise traction, but is better than no traction at all (Centre for Education and Research in Disaster Medicine & Traumatology, Linköping, Sweden, with permission)

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Because of the extensive tissue damage in femur fractures caused by severe violence, they involve a high risk of systemic effects of trauma and patients should, therefore, have a higher priority for transport than other closed fractures. Hip Fractures to the femoral neck often occur in elderly patients after minor to moderate trauma. Typical signs are shortening and lateral rotation of the leg. A regular stretcher is sufficient for immobilization, and these patients have a low priority for transport. However, dislocation of the hip is an effect of severe trauma, not uncommon in major incidents. The leg can be shortened in medial rotation (posterior dislocation), rotated laterally in abduction (anterior dislocation), or shortened and fixated in a neutral position (central dislocation into the acetabulum). Posterior and anterior dislocation should be reduced as soon as possible because of the risk of permanent nerve damage. Reduction requires general anesthesia, which means a relatively high priority for transport to hospital (not life threatening, but there is a risk of persistent disability). Pelvis Even if the pelvis only partly belongs to the extremities, it is dealt with here because stabilization of the pelvis before transport is an important (in some cases life-saving) procedure, which, according to clinical experience, too often is disregarded or forgotten. The pelvis should be regarded as a ring with several components: the sacrum and the two pelvic halves, posteriorly connected by the sacroiliac joints and anteriorly by the symphysis. If the ring is ruptured at only one site, it still stays together (the fracture is stable). If the ring is ruptured at two or more sites, however, the halves of the rings can be moved away from each other (the fracture is unstable). The instability can be vertical or lateral depending on the type of fractures. Stable pelvic fractures are minor injuries, are rarely connected to injuries of other organs, require no stabilization other than a stretcher, and justifies only low priority for transport. The unstable fractures, however, reflect major trauma, are often connected to injuries of surrounding tissues and organs, such as the big vessels, urogenital,

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and gastrointestinal organs. There is often massive bleeding from the venous plexa in the pelvis and a high potential risk of shock, even without major vascular injury. Such a patient must be effectively stabilized before transport for several reasons: • Compressing the pelvic halves together is in itself a hemostatic procedure that can be life saving. • Transport of an unstable pelvic fracture without effective stabilization means risk of induction or aggravation of injuries to adjacent organs. • It also means severe pain and release of products from injured tissue, inducing or aggravating shock and systemic reactions to trauma. Diagnosis • To discriminate between a stable and unstable pelvic fracture on the scene is not entirely easy (except in severe cases with apparent dislocation) and requires experience. If the fracture is caused by severe trauma, like collision at a high speed, it should always raise the suspicion of instability from tenderness on palpation on more than one site of the pelvic ring. Pain reaction to (gentle) attempts to move the pelvic halves from each other is also an indicator of instability. Treatment • The only accurate immobilization of an unstable pelvic fracture is compression of the pelvic halves toward each other. Predesigned girdles for this (Fig. 7.31a, b) should be included in the equipment of every ambulance. Without access to such devices, a sheet can be used to pull together the pelvic halves as an emergency procedure. A whole-body vacuum splint, which in some places traditionally has been used for this purpose, does not give enough compression but can be used as a complement during transport. Shoulder Fractures to the clavicle or humeroscapular joint can be stabilized simply with the arm in a sling (mitella) or fixed to the body by the clothes (Fig. 7.30). Dislocations should, if possible, be reduced as soon as possible before muscular contraction starts and can easily be made on scene with the patient flat on his or her back, traction in the longitudinal direction of the arm, lateral rotation, abduction and then medial rotation, followed by stabilization as described above. If the reduction is not easily done, do not make repeated attempts.

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Fig. 7.31 Pelvic girdle type T-pod (Pyng Medical, Richmond, Canada, with permission). A girdle of this type has to be adjusted so it gives a firm compression of the pelvic ring and is the most effective way to stabilize unstable pelvic fractures during trans-

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port. Without access to this kind of device, a sheet firmly wrapped around the pelvic ring can also provide fairly good stabilization

Upper Arm Fractures on the medial or distal humerus always involve a risk of vascular injury, which is why peripheral circulation always should be checked and, if impaired, be given high priority. If it is not impaired, fixation to the body with a sling or as described in Fig. 7.32 is sufficient. Elbow Fractures of the elbow can be treated upper arm, with registration of peripheral circulation. Elbow dislocations, like shoulder dislocations, usually can be easily reduced soon after the trauma: place the elbow in 90°, use traction in the longitudinal direction of lower arm applied by an assistant, and pull the hands around the elbow joint with forward compression of the thumbs on the olecranon.

Fig. 7.32 Immobilization of upper limb fractures can easily be achieved by using the clothes of the injured

Lower Arm and Hand Injuries to vessels and nerves are relatively uncommon in the lower arm and hand and reduction can wait until the patient arrives at the hospital, where it can be done with x-ray control, and surgery can be considered if it is not entirely successful. Fixate during transport as shown in Fig. 7.32.

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Priority for Transport

It may sometimes be necessary to base this triage on a standardized triage algorithm, but whenever available medical competence and time permit, decisions about the priority for transport should be done with consideration of the potential clinical course for the specific injuries, which provides a better basis for optimal utilization of transport resources. As a general principle, patients who have responded satisfactorily to resuscitation and treatment can wait, whereas those who do not respond are given continued high priority. Exceptions are patients with manifest or suspected internal bleeding, who should have a high priority for transport even if they have responded to treatment on the scene. Highest priority (immediate transport) • Not possible to eliminate threat to the airway on the scene • Impaired ventilation that requires immediate ventilatory support • Tension pneumothorax, if decompression cannot be done on the scene • Patients in severe circulatory shock (heart rate >120, SBP <90 mmHg) • Penetrating injuries to the trunk • Blunt injuries to the trunk with suspicion of internal bleeding (including unstable pelvic fractures) • Penetrating head injuries1 • Head injuries with clear signs of expanding intracranial hematoma1 Priority after those above (urgent but can wait for limited time) • Open fractures of long bones • Crush injuries, compartment syndrome • Vascular injuries with impaired peripheral circulation • Severe multiple injuries • Other patients with circulatory and respiratory impairment • Full-thickness burn injuries > 30%1 • Hypothermia with a body temperature <28°C (when possible to determine on scene) Lower priority (shall wait): • Closed fractures (with the exception of unstable pelvic fractures, femur fractures after severe blunt trauma) 1

In major incidents levels 2 and 3, some of these patients can be considered as “expectant” (see below).

• Rib fracture without respiratory impairment and without suspicion of internal bleeding • Spinal injuries • Eye injuries • Wounds and soft tissue injuries • Burn injuries <30% • Hypothermia with a body temperature >28°C (when possible to determine) Expectant (patients with small prospects of cure who, in major incident levels 2 or 3, should be made to wait to save resources for those with a higher possibility of survival): • Open head injuries with either GCS score <8, RR < 10, wide dilated pupils, or bihemispheric missile track • Blunt head injuries with no or inaccurate response to pain, wide dilated pupils, or RR < 10 • Burn injuries with full-thickness burned surface >60%

7.12

Transport

The principles for transport of casualties, including facilities for transport, their equipment, and competence of the staff as well as the methodology for accurate distribution of patients between hospitals, has been described in Chap. 3. Here should again be emphasized that the time during which the patient is being transported does not mean an interruption of treatment. Surveillance, treatment, and re-evaluation of priority continues all the way into the hospital, and the transfer of the patient to the hospital staff is an important part of this process, where information of critical importance from the prehospital phase is delivered to and recorded by the receiving hospital staff. As mentioned in Chap. 3, the registration documents from the scene and transport should be attached to the patient’s hospital record.

7.13

Primary Triage and Management in the Hospital

7.13.1 Primary Triage at the Hospital Entrance The general principles for reception and primary triage of casualties in the hospital have been described in Chap. 5.

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It is emphasized again that triage is a dynamic, not a static, process and the patient’s priority has to be re-evaluated at each step in the chain of management. A priority that was valid on the scene or during transport might not be valid for continued treatment. The primary triage in the hospital has to be done quickly in an open space that has been prepared to receive a large number of casualties (see Chap. 5), and it should be done by experienced staff, when necessary along several parallel lines to avoid congestion. The aims of this triage are to: • Separate the less severely injured (potential ambulatory cases) from the severely injured (requiring resuscitation or with potential need of surgery or in-hospital care) • Set the priority for the severely injured to be taken care of by prepared teams (modified trauma teams or “major incident resuscitation [MIR] teams”)

7.13.2 Major Incident Resuscitation Teams 7.13.2.1 Background and Aims The reasons behind this concept are that: • Severely injured patients require a certain number of qualified staff for primary management to avoid mortality and complications on this level, but also to minimize the time spent in the emergency room, which is important in these situations • To dispatch the same number of staff for this task as for primary management of severely traumatized patients in “routine” medical care will, in most major incidents, not be possible • Therefore, we have to find a balance with the aim to get the best possible staff for this purpose without consuming too many staff resources. In routine medical care, severely traumatized patients are usually taken care of by special trauma teams. In hospitals with high loads of trauma, as in major trauma centers, these teams can be composed by staff who work exclusively with trauma, generating a high level of experience and training. In other hospitals, they are composed of staff who also work with other tasks: surgical disciplines, anesthesiology, or emergency medicine. A trauma team can include six to eight experienced persons, all of whom have specific tasks, e.g., the anesthesiology team (physician and nurse) are at the head of the patient securing airway and ventilation, one team (usually

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emergency nurses) is securing vascular access and drawing blood samples, a physician is responsible for the exposure and a nurse for the registration, and some distance from the table the “captain” of the team (usually a surgeon) is responsible for decisions with regard to further investigations and treatment. To the team can be connected other specialists (orthopedic surgeon, neurosurgeon, radiologist); in some hospitals these other specialists are routinely included. Few hospitals outside the major trauma centers can staff more than two to four such teams within short notice, and for most major incidents that will not be sufficient. On the other hand, to dispatch a physician alone, or with a nurse, for primary management of a severely traumatized patient on the hospital level would be a wrong utilization of resources.

7.13.2.2 Composition of Major Incident Resuscitation Teams The MIR team means a minimal level of staffing of four persons, usually two physicians and two nurses, of whom at least one physician should have clinical experience with trauma (surgical or orthopedic specialty, anesthesiology, or emergency medicine) and at least one nurse should have experience with trauma, anesthesiology, or emergency medicine. One should be responsible for the airway and breathing; one for vascular access, sampling, and intravenous fluid; one for registration (trauma record); and one for exposure thorough systematic examination. One of these team members should have a clearly defined role as team leader or “captain of the team,” be clearly labelled as such (with an arm badge or tabard), and be responsible for decisions about investigations, treatment, action plan, and priorities. One or more mobile anesthesiology teams and (if available) neurosurgeon(s) and radiologist(s) should be common resources for support of the MIR teams. Coordinator of and in charge of all the teams should be a senior clinician, assisted by a senior nurse, none of them practically involved in the management process. An important part of the preparatory phase in the hospital on alert is to appoint: • The coordinating staff in charge of the MIR teams (senior clinician and nurse)

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• The team leaders • The staffing of the teams, utilizing available staff according to requirements listed above The tasks of the team leaders are then to prepare their working area, distribute the different tasks within the teams, and repeat the strategy of working within the teams.

7.13.2.3 Tasks of MIR Teams The tasks of the MIR teams are: • Primary management of severely injured casualties in the hospital, including primary survey and resuscitation according to the same principles as described for the prehospital phase, with certain extensions based on increased access to the resources in the hospital • To decide about further management, clearly described in an action plan for each patient with given priorities • Transfer of the patient to the next position in the chain of management The last point consumes time for the teams but is necessary, e.g., a patient with ongoing ventilatory support and/or fluid resuscitation cannot be transported by a porter without medical competence, and it is valuable that the team reports all information to the next station in the chain. 7.13.2.4 The Importance of Time With a heavy load of casualties, the emergency department can easily become a “keyhole” that creates congestion. This can be avoided by: • Establishing as many parallel MIR teams as possible (which also requires prepared working areas) • Shortening the time spent with each patient as much as possible, only doing what is absolutely necessary with regard to resuscitation and decision making In routine trauma care, generally accepted goals for maximum times in the trauma room are 15 min for circulatory unstable patients and 30 min for circulatory stable patients. The longer time for circulatory stable patients is because there is more time for investigations if the patient does not have ongoing bleeding. This is not valid in the major incident, where timeconsuming investigations (such as computed tomography [CT]) have to be restricted to a minimum, and

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where many investigations can be done at the next position in the chain, e.g., x-ray of fractures by mobile units in the wards or in the preoperative zone. In major incidents, therefore, the goal should be a maximum of 15 min for both categories of patients, a goal that should not result in a loss of patients because things that have be done not are done. This emphasizes the importance of basic education in trauma for staff who do not normally work with trauma.

7.13.3 Primary Management of Severely Injured Patients The primary management of severely injured patients in the hospital follows the same principles as those described for the prehospital management and is done according to the ATLS principles, which will not be repeated here. However, on some points the increased access to equipment and competence permits extended resuscitation and additional investigations and treatment.

7.13.3.1 Airway • Tracheal intubation in all patients with the potential need for ventilatory support, including circulatory unstable patients and patients exposed to major trauma with potential systemic circulatory, respiratory, and metabolic effects. If attempts to intubate fail, cricothyroidotomy is an alternative in the hospital. Depending on access to medically competent staff and equipment, other alternatives are also available in the hospital, such as fiberoptic and video-assisted intubation. 7.13.3.2 Breathing • Give oxygen to all severely injured patients • Apply a chest drain in cases of clinically significant pneumothorax and hemothorax (see below under “Chest Injuries”) 7.13.3.3 Circulation • Intravenous lines, if possible parallel lines on upper extremities, should be placed in all severely injured patients with simultaneous blood samples (see below). If it is difficult to establish intravenous access, intraosseous infusion can be used initially (Fig. 7.26). The femoral vein is an alternative, but it

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is less effective when there is bleeding in the trunk. Another alternative is to cut down to get vascular access. Central venous catheters have limited use in major incidents. • Intravenous fluid is initiated or continued according to the same principles described above under “Prehospital Fluid Resuscitation.” It is important not to “over-resuscitate” with fluid. The aim should be a SBP between 70 and 90 mmHg; higher levels can increase bleeding, and lower levels give too low organ perfusion. Acidosis should be corrected, as should hypothermia (see Chap. 9). On the hospital level, continued recording of urine flow via a bladder catheter should be initiated with the goal to keep urine flow on a level of: – 0.5 ml/kg bodyweight/h in adults – 1 ml/kg bodyweight/h in pediatric patients older than 1 year of age – 2 ml/kg bodyweight/h in pediatric patients younger than 1 year of age • When there is suspicion of major bleeding, blood should be given as soon as possible, if and when it is available – blood is so far the only fluid that can transport oxygen, but blood should only be given parallel to efforts to identify and control the source of bleeding. Massive transfusions during ongoing bleeding have negative effects on both the coagulation and immune systems. Blood grouping and blood-matching test should be included in the primary laboratory tests in the hospital whenever possible (see below). In life-threatening bleedings, it is possible to give blood group 0 (Rhesus negative), while waiting for group-specific blood and parallel to fluid infusion. Blood in the form of erythrocyte concentrate, the most common transfusion product in trauma, has a good oxygen-binding capacity but lacks coagulation factors, which are destroyed by storing. In massive transfusions, it is therefore important to add coagulation factors in the form of fresh-frozen plasma, fresh plasma, or platelet concentrate. Such transfusions should be done according to established tranfusion protocols and in collaboration with transfusion units or centers when possible. Specific coagulation-stimulating factors, like factor VIIa, are under evaluation and are expected to become of importance in normal trauma management, but the

147 Table 7.3 Laboratory tests normally mandatory in the primary survey of patients after major trauma In major incidents, resources may be insufficient to analyze all of these primarily, but sampling costs minimal extra time and it may later be of value to know original status to identify the clinical course Blood status: hemoglobin, hematocrit, white blood cell count Coagulation: prothrombin time (PT), partial prothrombin time (PTT), platelet count Blood gases: PO2, PCO2, pH, lactate Amylase Blood typing and cross-matching Urinary status: red cell count

treatment is still expensive and today is hardly an alternative for use in major incidents. Auto-transfusion with reinfusion of the patient’s own blood is a technique highly justified in these situations, e.g., in a patient with a hemothorax and ongoing bleeding, noncontaminated blood from the pleural cavity can be reinfused into the patient. Simple systems for this, prepared against coagulation, are available on the market and should be included in the preparedness for every hospital involved in major incident response.

7.13.3.4 Disability Initial careful registration of neurological status according to (for example) the GCS (Table 7.3) is important to be able to register changes in response, which can be an indicator of intracranial bleeding. Therefore, for every patient with manifest or suspected head injury, such a protocol should be started at this point. 7.13.3.5 Exposure Removing the patients clothes on the scene or at the casualty clearing station is not recommended and usually is not done because of the risk for hypothermia, a risk that has to be considered in all traumatized patients when the outdoor temperature is at or below the level of normal room temperature (see Chap. 8). This means that the emergency room is the first place where the patient can be examined without clothes, and it has to be consequently and systematically done: “From top to toe, with a finger in each hole,” to quote an expression from the ATLS concept. A tool for rapid cutting of even thick clothes and belts is a valuable component of the equipment for the MIR team (Fig. 7.33).

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Fig. 7.33 A tool for rapid cutting of thick clothes and belts is a valuable component in the equipment of the major incident team (ES Equipment, Gothenburg, with permission)

7.13.4 Additional Investigations 7.13.4.1 Laboratory Tests Table 7.3 shows the laboratory tests usually ordered automatically in routine trauma care, called “trauma lab tests” (may vary somewhat between hospitals). In major incidents there may not be enough laboratory resources to analyze all these tests initially, but when blood is being drawn, it is a small extra effort to draw samples for all these tests, and it can later be of value to know the original levels for different tests. 7.13.4.2 Body Temperature Body temperature is normally determined in all severely traumatized patients and should have high priority also in major incidents where the risk of hypothermia may be higher because of a prolonged prehospital phase. Thermometers able to determine temperatures blow 35°C should be included in the equipment in the emergency department (see Chap. 9).

7.13.4.3 X-ray Normally, pulmonary x-ray is done on all severely injured patients in the trauma room that often also is equipped for skeletal x-ray for primary diagnosis of fractures. In this situation neither time nor resources may allows for this. Pulmonary x-ray may have to be replaced by clinical diagnosis and thoracocentesis if there is suspicion of pneumothorax or hemothorax, and skeletal x-ray should be replaced by temporary

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reduction and immobilization for later x-ray at the next destination (preoperative unit, intensive care unit [ICU], or regular ward). An increasing number of emergency departments are equipped with computer tomograph in immediate connection to the trauma room, which is a big advantage in trauma management: Moving the patient to a radiology department or laboratory in another place will consume time and tie up the resuscitation team for a long time, something we can afford to a limited extent (maybe not at all) during a major incident. However, even if CT is available in the hospital, the number of tomographs is limited even in big hospitals; simpler diagnostic methods may have to be used in the majority of cases (see below under “Diagnosis and Treatment of Injuries to Different Organ Systems”). Ultrasonography (USG) is a good diagnostic tool in these situations because it can be done quickly and can give immediate information needed to make a decision, e.g., with regard to the source of bleeding. However, it requires access to (a) equipment and (b) medically competent staff. In hospitals where the staff on duty normally do USG and have equipment on site, it can be used for diagnostic screening, but in hospitals where this requires special staff, it will be of limited value.

7.13.4.4 Diagnostic Thoracocentesis and Laparocentesis Equipment for these methods, done to a limited extent in today’s daily routines because of access to other diagnostic methods, should be available in the equipment of the MIR teams as a part of preparedness for major incidents (see below under “Diagnosis and Treatment of Injuries to Different Organ Systems”).

7.14

Continued Treatment in the Hospital

We have now dealt with the primary (immediate) management of injured patients, which may be done either on the scene, during transport, or in the emergency room. “Where to do what” is dependent of many factors: the situation at the scene, available transport resources, available prehospital staff, distance to hospitals, the type of injury, and the patient’s condition. An increased demand on prehospital measures may

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occur based on variations in the factors above. This must be prepared for through training and equipment of prehospital teams that can be sent from either hospitals or other organizations to support ambulance staff on the scene (see Chap. 3). The continued triage, diagnosis, and treatment is now done in the hospitals (sometimes in field hospitals during armed conflicts or under austere conditions). On this point, the situation varies widely, for obvious reasons. Even in major incidents with a large number of injured victims, there may be good access to resources in an area with normally good access to health care, maintained infrastructure, and short distances between hospitals – presuming that the injured are correctly distributed between hospitals (see Chap. 5). A major incident, therefore, does not always mean primitive or insufficient medical treatment. However, it requires knowledge about the character of injuries occurring in these situations – they are often caused by a higher energy than in “normal” accidents, often severely contaminated, and often have a longer delay from injury to treatment. In modern war, good logistics and organization can get injured soldiers to advanced medical care in a fairly short time. Therefore, war surgery does not always mean primitive surgery, even if it requires knowledge about the character of injuries caused by weapons and explosives. Injuries from major incidents and armed conflicts have many things in common, even if the effects of war weapons may differ from “daily trauma” and the effects of major incidents. Based on these similarities, it is justified to use similar principles for treatment, influenced by the fact that both situations are characterized by a lack of resources in relation to the need for medical care: major incidents by definition, and armed conflicts as a natural consequence of the conditions, even if the aim is to supply personnel on the front lines with optimal care. Here, the guidelines for further management of injuries caused by violence mainly focus on situations in which there is a clear discrepancy between the available resources and need for care, which means a need to use simplified principles and methods to save life and health for as many people as possible. Because this book deals primarily with major incident levels 1–2, where the infrastructure of the community is maintained and there still is access to surgical care, this part does not deal with situations without any (or with extremely limited) access to medically competent

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staff and equipment for surgery, where other principles for triage and management may have to be applied.

7.15

Damage Control

A strategy for surgical treatment that has developed during the last decades, originating from the management of severely injured patients in “normal” trauma care but applicable also in situations with limited resources, is damage control. Because this will be referred to repeatedly in the following guidelines for management of injuries in different organ systems under these conditions, the background and principles of this strategy will be presented for those who are not yet fully familiar with it. The term damage control originates from the US Navy. Instead of trying to repair an injured vessel at sea, the principle is to keep the vessel afloat using the simplest measures possible until it reaches the harbor, where complete repair can be done under far better conditions. The initial reason to apply this strategy in traumatized patients was because the severely injured patient – like a “sinking ship” – is in a situation of circulatory and metabolic impairment, perhaps also hypothermia and impaired coagulation after extensive blood loss, which makes him or her extremely vulnerable to the additional trauma caused by an extensive surgical procedure. Therefore, primary surgical repair was replaced by simple, temporary life-saving procedures: • Temporarily controlling bleeding by simple measures, like packing • Maintaining necessary organ perfusion with shunt procedures • Limiting contamination by temporary intestinal ligation instead of anastomosis • Evacuating major leakage and contamination by drainage procedures In patients with abdominal injuries, on whom this strategy was first applied, the abdomen was after the procedures above only temporarily closed (or left open) and the patient was transferred to the ICU for respiratory, circulatory, and metabolic monitoring, with the aim being to restore normal functions and simultaneously correct coagulopathy and body temperature to the extent possible. When this had been done, the patient was taken back to the operating theater for reparative surgery, after a time interval sufficient to permit recovery

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but short enough not to increase the risk of complications after primary surgery (usually 24–48 h). Based on positive experiences, this strategy has now become established, the indications have been defined and also extended (see below), and the methodology has been developed.

7.15.1 Indications for Damage Control Indications related to the condition of the patient • Pronounced hemodynamic instability • Pronounced metabolic acidosis • Coagulopathy • Hypothermia Indications related to the type of injury • High-energy abdominal trauma • Multiple penetrating injuries to the trunk • Abdominal injury with involvement of major vessels, or multiple organ injuries • Multiple severe injuries with competing priorities • Injuries that require time-consuming reparative surgery (relative indication) Indications related to limited resources • Primary surgery has to be done by staff with limited competence and experience with trauma • Major incidents where the immediate need of surgical resources exceeds available capacity

The last group of indications has been added based on the positive experiences in using this methodology.

Whether damage control should be used in major incidents has become a controversial matter. In the Handbook in War Surgery, published by the International Committee of the Red Cross (ICRC) in March 2009, it is stated that “Damage control is obviously restricted to the very severely injured, a small minority. It is a much individualized form of management, requiring many resources, and may not be compatible with a situation of triage in mass casualties.” Others describe both civilian major incidents and armed conflicts as “the indication for damage control at its essence.”

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The reason for this controversy is probably a mixture of the indications for damage control and a lack of understanding that the techniques used vary with and are dependent on the indications. Damage control today includes a wide variety of techniques: • Packing solid organ bleedings instead of repairing them • Temporary vascular shunting of arteries necessary for maintaining critical organ perfusion instead of primary anastomosis or graft • Temporary bowel ligation instead of primary anastomosis • Temporary colostomy instead of primary anastomosis • Drainage instead of primary repair • Nephrostomy instead of primary renal or ureteral repair • Cystostomy instead of urethral repair • Delayed wound closure • Simple external fixation of fractures instead of primary osteosynthesis For the original indications, the severe condition of the patient, and also some measures like packing extensive organ injuries and temporary bowel ligation, requires intensive care. Applying this during major incidents might transfer the problem from the operating room to the ICU, and in major incidents the ICU bed with a ventilator is often an even more exclusive resource than the operating theater. Therefore, applying this to very severely injured patients – which is justified in the “normal” situation where it can save lives – may be questioned in the major incident, where it may consume resources that should be better used for simpler life-saving procedures. However, for the extended indication (lack of resources), some of the simpler methods can be used in less severely impaired patients who have a good chance of survival without treatment in an ICU, and many of the procedures in the list above do not require an ICU. Damage control with these indications can save patients who, prior to the introduction of this concept, had to be given low priority because traditional surgical repair consumed too many resources.

7.15.2 Results of Damage Control When the concept was introduced, a mortality of 50–70% was described with the original indications, but this was a group that had an even higher mortality before the application of damage control. Since then,

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the indications, the criteria for selection of patients, and the methodology have been developed and during recent years has been reported a mortality between 10% and 20%, which is significantly lower than mortality after conventional surgery used for this group. The number of prospective randomized studies has been limited to date. However, the morbidity in the form of complications seems to be higher than that after conventional techniques, which has to be taken into consideration, but it may be a price worth paying during major incidents to save lives that otherwise would be lost because of low priority.

7.16

Injuries to Different Organ Systems

7.16.1 Head Injuries Head injuries can be either penetrating (with penetration of the skull bone from the outside or through the sinuses) or blunt (without such penetration).

7.16.1.1 Blunt Injuries A blunt injury means injury to the brain or its vessels without penetration of the bone. The trauma causes a primary focal brain injury that can be a concussion (minor injury with only a short – usually less than 30 -min – loss of consciousness) or a contusion (more severe injury with longer or persistent loss of consciousness). After a certain amount of time, this primary focal brain injury can develop to a secondary brain injury with edema or bleeding that can be located outside the dura (epidural hematoma) or inside the dura (subdural hematoma). The brain injury and/or the bleeding can lead to reduced consciousness and give focal neurological symptoms depending on its location, including impaired pupil reactions, paralysis or muscular weakness on the contralateral side, uncontrolled extension movements, aphasia, or dysphasia. Bleeding in the posterior part of the brain can induce headache, nausea, and generally increased muscular tonus. Nonreactive pupils and impairment of ventilation and circulation also can occur in an early stage of bleeding in this localization. The bleeding or the edema can cause a rise in the intracranial pressure (ICP), a life-threatening condition because it leads to reduced perfusion and thereby reduced oxygenation, to which the brain is sensitive. In addition, this leads to further edema and further reduc-

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tion of oxygenation, a vicious circle that has to be broken if the patient is to survive. Between the reduction in consciousness caused by the primary brain injury and that caused by the rise in ICP can occur a period where the patient is relatively awake, the so-called free interval, which is of diagnostic value to register. Continuous registration of level of consciousness is important after trauma to the head and should be done as far as possible, even in major incidents, and also prehospital records should have a prepared protocol for that. Free intervals occur in 60–70% of patients with epidural hematomas (duration from a couple of hours up to 24 h) and in 20–30% of patients with subdural hematomas (duration usually 24–72 h). However, in the major portion of severe head injuries there is no free interval. The rise of ICP can lead to an incarceration of the brain, an immediately life-threatening situation where the brain becomes compressed toward the bottom of the cranium, blocking the flow of cerebrospinal fluid, which leads to a further dramatic increase of ICP. Symptoms of this are: • Rapid fall in consciousness ending in coma • Wide and nonreactive pupil (usually on the same side as the bleeding) • Rising blood pressure and falling heart rate (note the hazard of diagnosis with simultaneous circulatory shock) • Extension movements (late sign) • Periodically impaired breathing (Cheyne Stoke) and finally respiratory arrest

7.16.1.2 Penetrating Injuries The severity of penetrating injuries varies widely. The risk of a rise in ICP in these injuries is less than with blunt injuries, but there is still a risk. However, the mortality among those with reduced consciousness is lower than among those with blunt injuries, which is important to know in the triage process. Diagnosis In addition to inspection and palpation of the skull and maxillofacial skeleton, examination of patients with head injuries in the emergency room should include a more thorough neurological examination than that performed on the scene, with the use of a standard scale, e.g., GCS (Table 7.2). Because of the importance of registering changes, this investigation must be repeated with registered times.

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Symptoms and clinical signs must be related to other injuries – simultaneous circulatory shock, injury to the respiratory organs leading to lack of oxygenation, and injuries to the spine and limbs – which can cause diagnostic difficulties. Patients with persistent reduction of consciousness or other signs of a rise in ICP should have priority for CT, if it is available. CT can eliminate the need for resourceconsuming observation as well as unnecessary surgery; if life-saving surgery is indicated, CT can give information that can facilitate and shorten surgery. However, with regard to whether head injuries should have priority in these situations – and if so, which – see below under “Indications for Surgery.” If CT not is available, indications for surgery have to be based on clinical diagnosis (see below). In the Emergency Room • Secure the airway. In an unconscious patient, intubate endotracheally. • Provide ventilatory support when needed, give oxygen. • Provide intravenous fluid when there are signs of circulatory impairment to maintain cerebral perfusion. Note the risk with low osmolal (isotonic) solutions: This is a situation where hypertonic solutions should be considered (see above). • In an unconscious patient, insert a gastric tube and urinary catheter. • Restrict analgesia in patients with a suspected head injury because it makes neurological observation difficult. • For penetrating injuries, administer antibiotics.

Note that very severe head injuries have a poor prognosis regardless of treatment, and this must be considered when making the decision of priority for treatment when resources are limited. Indications for Surgery With this consideration in mind, the following indications for immediate surgery are valid when resources so permit: • Penetrating injuries with external penetration • Blunt injuries with – hematomas (epidural or subdural) shown on CT, if available

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– falling consciousness after free interval – persistent consciousness combined with focal neurological symptoms – signs of a rise in ICP (described above) • Blunt injuries combined with impression fractures of the skull are normally indications for surgery if the impression exceeds the thickness of the bone. However, in the absence of the indications listed above, such patients can wait until later in situations with limited resources. Priority for Surgery Factors connected to poor prognosis of penetrating injuries regardless of treatment are: • GCS score <8: A marked fall in survival rate below this level on the GCS has been registered among patients with penetrating injuries, with mortality rates between 60% and 100% in a “normal” situation • Bilaterally dilated and rigid pupils: This is only when connected to low GCS scores because changes in pupil reaction also can be caused by ocular injury • RR <10 at admission • Bihemispheric injuries, which generally are associated with poor prognosis Patients who fulfill one or more of these criteria should, when resources are limited, be considered for the category “expectant” to offer better access to surgical treatment for patients with better prospects of cure. Factors connected to poor prognosis of nonpenetrating injuries regardless of treatment are: • Absent or inaccurate response to pain: There is an almost linear correlation between mortality and declining motor response in these patients, with high mortality (³60%) at these levels of response in the “normal” trauma situation. In major incidents or combat situations, small survival rates at this level of response have been reported, with even less chance to recover to a normal life • Bilateral dilated and rigid pupils combined with low GCS score – the same as for penetrating injuries • RR <10 • Circulatory chock caused by other severe injuries Patients who fulfill one or more of these criteria should, when resources are limited, be considered for

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the category “expectant” to offer better access to surgical treatment for patients with better prospects of cure. An additional factor that influences the priority for surgery for these patients is the access to: • CT for preoperative localization and characterization of the injury • Neurosurgical competence and equipment Even if it is possible to operate based on clinical diagnosis, and even if primary surgery in emergency situations can be done by surgeons without such competence, it makes it hazardous and potentially more resource consuming, and this should be included in the decision process. Also, the access (or lack of access) to postoperative ventilator treatment should be included in the decision. Patients with penetrating injuries and patients with suspicion of a rise in ICP consequent to expanding intracranial bleeding should, with the exceptions given above under “Indications for Surgery,” be given high priority for surgery. These injuries can be operated on simultaneously with other injuries with high priority. Every surgeon involved in trauma care should be able to perform a damage control procedure (drill a hole and release the pressure) in an emergency situation. Patients with a suspected rise in ICP should not be moved to other hospitals because surgery should be done without delay. Principles for Primary Surgical Treatment Penetrating injuries are treated with the control of bleeding and the removal of contaminated and devitalized tissue according to the same principles as in other penetrating injuries (see below under “Wound Treatment”). The head is shaved, the wound is irrigated, and devitalized tissue and loose bone fragments are removed. Easily accessible foreign, nonorganic material (fragments) is removed, but the operation should not be extended to remove material deeper in the wound. Hemostasis is achieved with the head elevated, meticulous ligation, and local hemostatics, and bone wax on the fracture edges. The dura should be closed to the extent possible, and defects in the bone should always be covered with skin, if necessary with a rotation flap. Expanding intracranial hematomas are evacuated with trepanation. If CT has not been available for localization, diagnostic trepanation is done on the clinically suspected side. The technique for trepanation is illustrated in Fig. 7.34a–d. If trepanation on one side is negative, trepanation is done at the corresponding location on the other

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side. If an epidural hematoma is identified, the hole is widened to an approximate diameter of 5 cm and the hematoma evacuated. After hemostasis, a drain is inserted and can be removed after 24 h. If hemostasis is impossible to achieve, the wound is left open, covered by sterile dressing according to damage control principles, and the patient is transferred to a neurosurgical unit if possible, or to a unit with better surgical resources. If no epidural hematoma is identified, the intracerebral expansion can be caused either by a subdural hematoma (can be seen through the dura) or a focal cerebral contusion. These conditions should not be dealt with without neurosurgical experience. For treatment is referred to textbooks about neurosurgery. Postoperative Care • Antibiotics should be given to all patients with penetrating injuries and injuries that leak cerebrospinal fluid. • Elevating the head reduces cerebral venous pressure. Diuretics can be considered for the same reason, presuming that the patient is circulatory stable. • Restrict fluid replacement (unless the patient is circulatory unstable by other reasons). • Administer anticonvulsants when needed. • Continuously control consciousness. Falling level requires re-exploration upon suspicion of a new expansion or clot.

7.16.2 Maxillofacial Injuries Maxillofacial injuries can be life threatening if they interfere with the airways, and in such situations the highest priority is to secure the airway. After that, patients with these injuries have no high priority for primary surgery.

7.16.2.1 Diagnosis Examination of patients with maxillofacial injuries in the emergency room should include: • Inspection: Asymmetry? Mimics? Bleeding in the mouth or pharynx? • Palpation: Fractures? Mandibular mobility? Maxillary stability upon traction? • Eyes: Penetration? Movements? • Palpation of neck: Edema or crepitations around the larynx?

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Fig. 7.34 (a) Recommended site for trepanation upon suspicion of intracranial bleeding. (b) Through a 3- to 4-cm-long incision, the temporal muscle is incised in a longitudinal direction and the periost is dissected free from the underlying cranium. (c) A hole is drilled with the trephine and widened with

tongs of forceps to a diameter of 2.5–3 cm. If an epidural hematoma is present, it is carefully sucked out, followed by meticulous hemostasis. (d) Without access to an electric trephine, a simple hand-driven device can fulfill the same function

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Fig. 7.35 Posterior packing of nasopharyngeal bleeding with the use of a Foley catheter, inflated with 5–10 ml and fixated with light traction, combined with anterior packing. Note the risk with this method in patients with fractures to the skull base, where this procedure requires careful control of the positioning of the catheter, but it might be the only alternative to achieve hemostasis during primary management

a

Clinical examination is often sufficient for a primary diagnosis and x-ray can wait until more resources are available.

7.16.2.2 In the Emergency Room • Secure the airway. In patients with minor injuries, cleaning and suction, if needed combined with a naso- or oropharyngeal tube, is often sufficient. Note the risk of inserting tubes in patients with simultaneous fractures of the skull base, where a tube may go wrong. If this not is sufficient to maintain the airway, do a tracheal intubation or, in difficult cases, a cricothyroidotomy (see above under “Primary Management of Airway”). • Control bleeding. Bleeding from maxillofacial injuries is rarely life threatening in itself, but it may be a risk for airway obstruction and can also cause secondary airway problems from vomiting swallowed blood and aspiration. Hemostasis may require combined anterior and posterior nasopharyngeal packing, which is best done with prepared gauze sponges. If such supplies are not available, a Foley catheter can be used, inflated to 5–10 ml, with the application of light traction combined with anterior packing (Fig. 7.35). Note the risk with simultaneous skull base fractures, which require careful attention during such a maneuver!

b

7.16.2.3 Priority for Surgery • Skin and soft-tissue injuries can be dealt with and even closed up to 12 h after injury because of the good vascular supply. Major injuries require meticulous cleaning and repair, which is best done in an operating theater after primary covering with a sterile dressing in the emergency room. • Fractures that require surgery – which in “normal” trauma management often are dealt with primarily simultaneously with other primary surgery – can in these situations wait until better access to surgical resources is available. It is also an advantage to get an exact diagnosis (CT) before surgery, for which there may be limited or no resources in the first phase of the response.

7.16.2.4 Principles for Primary Surgery • Skin and soft-tissue injuries: Careful wound cleaning, and excision when necessary. In most cases good vascular supply makes it possible to do primary closure (without tension!), but it is never wrong to leave a facial wound open for delayed primary closure in case of extensive contamination and devitalization. For closure of eyelids, see “Eye Injuries”. Injuries to the facial nerve should be diagnosed but repaired at a later stage of secondary surgery.

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• After mandibular fixation, continuously be prepared to cut the wires in the case of aspiration or other reasons for airway obstruction.

7.16.3 Eye Injuries

b

Eye injuries are common after exposure to explosions and are caused by penetrating fragments, blasts, or burns. The aim should be to have all such injuries treated by an ophthalmologist, even if this means a delay of 12 h or more. This is usually possible except under extreme conditions (war or an austere environment). Therefore, the following only deals with nonsurgical primary management.

7.16.3.1 Diagnosis

Fig. 7.36 Interdental fixation with noncorrosive wires is a good temporary fixation in mandibular fractures. (a) From above: The ends of the wires are passed between the teeth with the pretwisted part on the buccal side. The ends are pulled through the “eye” and twisted. (b) From the front: Thinner wires join the upper and lower “eyes”

• Fractures: As stated above, most fractures can wait and are better dealt with at a later stage, when additional resources are available. Unilateral mandibular fractures can be treated with just an elastic bandage, whereas bilateral fractures may have to be dealt with if there is a long delay or long transport times to secondary surgery. Interdental fixation with noncorrosive wires is a simple way to stabilize (Fig. 7.36a–c). Simple devices for external fixation of maxillofacial fractures are available today, but because this usually is done at a later stage, reference is made to textbooks about trauma or maxillofacial surgery.

7.16.2.5 Postoperative Care • Administer antibiotics to all patients with open maxillofacial fractures.

Examination should be done with retracted eyelids, which may require eye drops of local anesthetic. It is of critical importance that no pressure is applied to the eye – even a slight pressure on the globe in a penetrating injury may cause irreversible loss of vital contents. • Visual ability can be graded by the patient’s ability to: – Read print – Count fingers – Perceive hand movements – Perceive light • The eyelids, cornea, conjunctiva, and sclera are inspected with a lamp or flashlight. Visualization may require irrigation with isotonic saline.

7.16.3.2 In the Emergency Room • Irrigate with sterile isotonic saline and carefully remove all loose foreign material without applying any pressure to the eye. • Apply a fresh solution of ophthalmic antibiotics (e.g., chloramphenicol 1%) to be renewed every 4 h if possible, and cover with sterile gauze dressing (not a pressure bandage). Cover the contralateral eye to minimize eye movement. • Administer systemic antibiotics. With regard to indications and priority for surgery and techniques for primary surgery in penetrating injuries, see textbooks about ophthalmologic surgery or traumatology – all of these patients should whenever possible be treated by a specialist in ophthalmology, even if this means a delay in treatment. Also, the repair of eyelids, which should be done in layers with fine, absorbable sutures, requires meticulous

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technique and fine instruments and should be done in an operating theater, preferably by an eye or plastic surgeon, even if it means a delay in treatment.

7.16.4 Injuries to the Ears 7.16.4.1 External Ear Precise technique for repair is important to avoid deformities and should, if possible, be done in a surgical theater. It is important to retain good apposition of the cartilage. Hematomas should be aspirated or evacuated under sterile conditions. Bandages should be replaced daily to discover and evacuate recurrent hematomas. Injuries in the external canal should be repaired precisely and the meatus should be left open for observation with regard to stenosis.

7.16.4.2 Middle and Inner Ear Injuries to the middle and inner ear are common after explosions and in armed conflicts and can be caused by: • Blast with a sudden compression of air, which can cause rupture of the tympanic membrane and sometimes dislocation of the ossicles • Penetration by fragment • Fracture of the skull base • Symptoms are reduced hearing and often bleeding from the ear. Injuries to the inner ear may lead to total loss of hearing, severe vertigo, and nystagmus. • The primary treatment should be conservative, only covering the ear with sterile dressing and giving instructions to the patient to avoid contamination: totally protect the ear from water, do not blow the nose, see a medical provider in case of suppuration or fever. Antibiotics should be given in case of suppuration or leak of cerebrospinal fluid. Most tympanic ruptures heal spontaneously, but some require repair, which is done at a later stage. Patients with injuries to the inner ear should be referred to a specialist team as soon as possible.

7.16.5 Injuries to the Neck Significant injuries to vital structures occur in 30–35% of penetrating gunshot wounds and 20–25% of penetrating stab wounds of the neck. However, only 15–20% of unilateral gunshot wounds and only 10% of unilateral stab wounds are today explored in routine trauma

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care, mainly depending on access to better diagnostic tools as CT angiography. Therefore, the conventional strategy of mandatory exploration has been replaced by increasing use of selective nonoperative management. These diagnostic tools cannot be expected to be available to the same extent in major incidents, which means wider indications for exploration of these wounds, but it may be important to know that all of them will not require extensive surgical repair.

7.16.5.1 Diagnosis The optimal diagnostic tool is CT angiography. Additional diagnostic methods (conventional angiography for vascular injuries, laryngoscopy/tracheoscopy for laryngeal injuries, esophagoscopy for oesophageal injuries) are equally resource-consuming, less accurate, and probably less available during major incidents. Because observation of these patients also is resource-consuming, surgical exploration may be the alternative diagnostic method in situations with limited resources.

7.16.5.2 In the Emergency Room • Injuries with suspected bleeding or expanding hematoma: orotracheal intubation whenever possible. Restrict the use of paralytic agents that can lead to the loss of an airway that is already partly obstructed because of reduced muscular tonus. • Do not continue to try too long if intubation fails. Repeated failed attempts can lead to an increase in ICP consequent to increased venous pressure and can end in incarceration and fatal outcome. The surgeon should not leave the patient but be on standby for immediate cricothyroidotomy when needed (see below). • If intubation fails, do cricothyroidotomy (Fig. 7.14a, b). The hematoma rarely proceeds so far proximally so it causes problems when trying to get a tube through the cricothyroid membrane. • Control external bleeding with finger compression (no blind clamping). 7.16.5.3 Indications for Surgery • Immediate surgical exploration is indicated, regardless of access to diagnostic facilities, when there is: – Air bubbling through the wound – Severe external bleeding – Rapidly expanding hematoma – Circulatory instability without other cause – Absence of radial pulse

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Fig. 7.37 The traditional three zones of the neck: zone I, distal to the cricothyroid cartilage; zone II, between the cricothyroid cartilage and the mandibular angle; zone III, proximal to the mandibular angle. (1) Mandibular angle, (2) Laryngeal cartilage, (3) Clavicle, (4) Internal carotid artery, (5) External carotid artery, (6) Vertebral arteries

1

5

4

Zone III

Zone II 2 Zone I

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• In other cases, CT angiography should be done if it is immediately available because it can prevent unnecessary surgery and be a valuable guide for surgical strategy. If it is not available (which might be the case in a major incident), all patients with penetrating injuries and significant hematomas have to be surgically explored.

7.16.5.4 Priority for Surgery These patients should always have high priority for surgery because injuries to the neck are potentially immediately life threatening and many of them can be successfully cured by simple measures. 7.16.5.5 Principles for Primary Surgical Treatment Traditionally, the neck has been divided in three zones (Fig. 7.37). Injuries in zone 2 are the most easy to access; those in zone 1 might require sternotomy for access; and those in zone 3 are the most difficult, where experience and knowledge of the neck anatomy is especially valuable and the assistance of a head-andneck surgeon is desirable, if possible.

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General principles: • Achieve optimal access by bending the head backward with a pillow under the shoulders (Fig. 7.38a). • Incise along the frontal border of the sternocleidomastoid muscle (Fig. 7.38b). For bilateral injures, the same incision is done on both sides, and they are connected caudally horizontally. • If the hematoma is caused by venous bleeding, try to get both proximal and distal control by vascular strips before opening it. • The carotid arteries are located under the jugular vein and can be reached through this incision by ligating and dividing the facial and medial thyroid veins (Fig. 7.38c). • Do not do any surgery “blind” (without identification of anatomic structures). • Maintain simplicity and avoid procedures you are not familiar with.

7.16.5.6 Venous Injuries All veins in this area (except the superior caval vein) can be unilaterally ligated without any persistent impairment – do not waste time on venous repair.

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Fig. 7.38 Standard approach to vascular injuries in the neck. (a) Position the patient with his or her neck extended, a pillow (if possible a vacuum splint) under the shoulders, and the head rotated from the side of the injury. (b) Incise along the medial boarder of the sternocleidomastoid muscle. In bilateral injuries, the same incision is done on the other side and the incisions are

connected horizontally a couple of fingerbreadths above the clavicles. (c) The internal jugular vein (1) is first visualized and has to be mobilized laterally to get access to the underlying carotid artery (2). For this maneuver the facial vein (3) and the (more irregular) medial thyroid vein (4) have to be ligated and divided

7.16.5.7 Arterial Injuries The external carotid artery can be ligated without persistent impairment and this should be done for all threatening bleeds in zone 1 or from facial arteries. Note that the bifurcation is rather high up at the level proximal to the notch of the laryngeal cartilage (Fig. 7.37). The difference between the external and internal carotid (which cannot be ligated without the risk of damage to the brain) is that the external carotid has branches whereas the internal carotid does not (Fig. 7.37).

The internal carotid has to be restored to secure the vascular supply to the brain. Ligation involves a high risk of brain infarction and stroke. Simple closure or a patch is sometimes (but rarely) possible and should only be done for minor injuries. Repair with a graft requires an external shunt that (even if it is available) is not recommended for those who are not familiar to it. An alternative is simple temporary vascular shunting with whatever material is available (Fig. 7.50). The temporary shunt should be replaced by a permanent

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graft as a secondary surgical procedure as soon as possible. The present recommendation is to heparinize the patient, which might be a problem in the case of simultaneous injuries with a potential risk of bleeding (such as brain injuries). Recent experimental data indicate that vascular shunting with a high patency rate is possible even without heparinization, but it remains to be clinically proven. Also, the vertebral artery (Fig. 7.37) can be ligated, but proximal control of it inside the vertebral arches may be difficult. Percutaneous embolization is the method of choice if available; if not, packing with bone wax or local hemostatic agents is an alternative. For access to arteries in zone 2, the brachiocephalic and subclavian arteries require sternotomy, and a total midline sternotomy is the method of choice and gives good access, even if this is not a procedure that should be used in primitive conditions. More distal injuries to the subclavian arteries require even more complex procedures to get access (division of clavicles), and, if available, percutaneous embolization is the method of choice. Temporary hemostasis can be achieved through the use of inflatable balloon catheters until more competent staff/resources can be made available.

7.16.5.8 Esophageal Injuries Esophageal injuries are difficult to diagnose and dangerous to miss because of the risk of infection. Using a gastric tube during exploration of the neck helps to localize the esophageal wall (beware of the recurrent laryngeal nerves). The wall is difficult to close tightly and a drain is mandatory. Catheter esophagostomy may be an alternative for major injuries.

7.16.5.9 Tracheal and Laryngeal Injuries Tracheal injuries can be repaired by strong, resorbable single sutures involving the tracheal rings, and longitudinal defects up to 5 cm can be overcome by mobilization of the trachea. Laryngeal injuries also can be repaired in a similar way. However, without experience in this area, it is better to do a damage control procedure and leave the laryngeal tube in place, secure leakage, insert a drain, and refer the patient for repair as a secondary surgical procedure.

7.16.5.10 Postoperative Care All patients with penetrating injuries should be given antibiotics. Patients who receive vascular repair or

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ligation should be meticulously observed with liberal indications for re-exploration if there are signs of recurrent hematoma or bleeding.

7.16.6 Chest Injuries Injuries to the chest can be immediately life threatening because of impaired ventilation and oxygenation, and some of these injuries have to be treated with high priority already in the primary management (see above). Regardless of what has been done during primary management on the scene or during transport, careful examination of the chest should be repeated in the emergency room according to the same principles and the same considerations as described above under “Primary Management.”

7.16.6.1 Diagnosis • Inspection: Penetration? Contusions? Asymmetry? Breathing movements? Cyanosis? Hemoptysis? • Palpation: Rib fractures? Paradoxical ventilation (part of the chest wall does not follow the breathing but moves paradoxically in opposite direction)? • Percussion: Hemothorax or pneumothorax? • Auscultation: Breath sounds? Respiratory rate? Irregular breathing? In routine medical care, pulmonary X-ray is routinely done in the emergency room for severely traumatized patients, but it may not be possible to do on everyone in this situation. In the absence of this and on suspicion on pneumo- or hemothorax, diagnostic thoracocentesis may have to be done in the emergency room. The use of CT, as stated above, must be restricted in these situations, if it is available at all. If it is available, priority for it should be given to patients who have a widened mediastinum on plain pulmonary x-ray (if such is performed) and to those who have blood in the pleura on thoracocentesis, in which cases it can give valuable additional information for the further strategy. If USG is available (equipment in the emergency room and emergency staff trained to use it), it is a faster sand simpler investigation than CT and is especially valuable for diagnosis of fluid in the pleura (hemothorax) or pericardial sac (cardiac tamponade).

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Fig. 7.39 Insertion of a chest drain. Standard site for insertion is in the fourth to fifth interstitium (“level of the male nipple”) in the anterior axillary line. (a) Small skin incision followed by blunt dissection with hemostatic forceps, passing just over the rib in the selected interstitium to avoid injury to intercostal vessels and nerve. (b) Finger dissection to secure entrance in the

pleural sac above the diaphragm. (c) The finger is removed and the drain inserted in the pleural sac with the help of a hemostatic forceps. (d) The drain is advanced posteriorly and upward to drain air as well as blood. (e) The drain is securely anchored and sutures are tied around it. Upon removal, the skin incision should be closed

7.16.6.2 In the Emergency Room

• If there is blood in the drain, insert a drain of sufficient diameter to evacuate blood and clots (F36–F40), connect to an underwater seal, suction at the level given above, and start transfusion, if possible autotransfusion. These measures are sufficient for treatment of the majority of patients with hemothorax (see below for indications for surgery). • If there are large volumes of air in the drain, suspect bronchial rupture. Keep the drain with suction and, when possible, further diagnosis with bronchoscopy, when and if is available.

Measures to be taken in cases of immediately threatening respiratory insufficiency have already been described under “Primary Management,” above. Additional measures in the emergency room include: • In the case of suspected or confirmed pneumothorax, insert a drain on the affected side (Fig. 7.39a–e). Connect to an underwater seal with suction corresponding to 15–20 cm H2O.

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7.16.6.3 Indications for Surgery As stated above, an accurately inserted and functioning chest drain is sufficient in the overwhelming majority of patients with hemothorax. Approximately 90% of penetrating chest injuries in armed conflicts are treated in this way, combined with volume substitution. In most cases, the bleeding is stopped by the expanding lung. Indications for surgery in “normal” trauma care are: • Massive bleeding when inserting the drain (1,000–1,500 ml) • Ongoing bleeding >300 ml/h for >4 h • Increasing amount of blood in the pleura despite accurate drainage • Circulatory impairment because of the bleeding that is not normalized by initial shock treatment In a situation with circulatory instability and bleeding both in the chest and in the abdomen, the reasonable priority is to trust the chest drain and do a laparotomy because severe bleeding in the abdomen cannot be managed by drain. In a situation with a severe lack of resources consider treating bleeding in the chest with a drain only because: • It is sufficient in the majority of cases. • Cases where the drain alone not is sufficient are likely to require considerable surgical resources that could be used for a larger number of patients.

7.16.6.4 Priority for Surgery As stated above, consider not operating on patients with chest injuries in situations with a severe lack of resources. However, “major incidents” include a wide spectrum of events, even those with relatively good surgical capacity when resources have been fully mobilized and re-distributed, and it should be remembered that even severe bleeding in the chest – bleeding from the chest wall that can be considerable, or minor myocardial lesions that can be easily closed but otherwise will be fatal – can be easily managed with thoracotomy. This has to be decided based on the actual situation. Emergency room thoracotomies for patients with minor or no vital signs should be avoided during major incidents. Even if a single patient can be saved, especially after penetrating trauma, it consumes a lot of emergency room resources and may turn the whole emergency unit upside down for a period of time. In addition, the potential gain of this does not stand in proportion to what it costs in energy, resources, and emotions. Patients in such a condition that they cannot wait for an available theater may have to be sacrificed in this situation.

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7.16.6.5 Principles for Primary Surgical Treatment The standard approach to emergency surgery of the chest is anterolateral thoracotomy in the fifth or sixth interstitium (Fig. 7.40a–e). This is an incision that all surgeons on duty or on call should be able to master. It gives good access to bleedings from the chest wall, such as from an intercostal or mammary artery, which may be the only cause of the bleeding and can be ligated easily. Complex bleedings from the chest wall can be packed as a damage control procedure, and the packs can be removed after 48 h. A left anterolateral thoracotomy also gives good access to the heart, where minor penetrating injuries like fragment and stab wounds can be easy to deal with. The pericardial sac is opened in the front between the phrenic nerves and the blood, that does not clot spontaneously, is evacuated. A minor penetration of the myocardium can easily be closed by sutures anchored by patches of synthetic graft (Fig. 7.41a, b), and a temporary passive drain is left in the pericardial sac. Injuries to the lungs rarely require resection. Most injuries can be managed with simple suture-ligation combined with suction drainage, as described above. Major lung injuries with bleeding that involve the major lung vessels may require an emergency pulmectomy. In this case, the pulmonary hilus is compressed by the fingers until a broad vascular clamp can be applied and the whole lung removed en bloc (Fig. 7.42). This involves a risk of bronchial fistulas, but they can be treated later. Injuries to the trachea and esophagus have been described above under “Neck Injuries.” Injuries to the major vessels (in those patients who survive until they arrive at the hospital under these circumstances) require vascular or cardiothoracic surgical competence; see textbooks about cardiovascular surgery or traumatology. 7.16.6.6 Postoperative care Drains should be maintained until the bleeding or secretion stops and pulmonary x-ray has confirmed full expansion of the lungs that remains after the suction has been replaced by clamping. Additional x-ray after the removal of drains should be done to confirm lung expansion. Antibiotics should be given to all patients with penetrating chest injuries. Early mobilization and physiotherapy is important for these patients.

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Fig. 7.40 Anterolateral thoracotomy in the fifth interstitium. The incision is made over a rib (a) and the chest wall opened along the upper margin of the rib (b) to avoid injury to the inter-

costal vessels and nerve. To clamp the thoracic aorta, the pleura is opened (c) and the aorta compressed with the fingers (d) until a vascular clap can be applied (e)

7.16.7 Abdominal Injuries

• Other more apparent injuries (to the head or limbs, major wounds) may attract more attention in the primary survey An abdominal injury that has been primarily disregarded can rapidly lead to major loss of blood with a fatal outcome, and such missed injuries belong to the most

Injuries to the abdominal organs are easy to miss in the primary examination of the injured for two reasons: • Even severe injuries may have minimal initial symptoms and signs

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Fig. 7.41 Penetrating fragment injuries to the heart are life threatening because without treatment they lead to a pericardial tamponade; on the other hand, they can rather easily be surgically treated whenever available resources so allow. They can be approached either by an anterolateral thoracotomy (Fig. 7.40) or a complete midline sternotomy. The pericardial sac is opened

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anteriorly by a vertical incision between the (easily visible) phrenic nerves, and the hole in the myocardium is controlled by finger (a) and closed by an U-suture anchored with “buttons” of vascular graft (b). Drainage should be put into the pericardial sac before closure

common causes of “avoidable deaths” in normal trauma care. Even if the outcome not is fatal, delayed diagnosis is a common cause of late complications from trauma. On the other hand, accurate and rapid management of such an injury can restore the patient to full health, sometimes with only simple surgical treatment. This leads to some basic rules in the management of the severely injured patient: • Even if initial symptoms are minor or missing, suspect injury to the trunk in the severely injured patient until the opposite has been proven. • In circulatory impairment without major external bleeding, always suspect bleeding in the trunk and give priority to the search for such a bleeding.

7.16.7.1 Diagnosis

Fig. 7.42 Emergency pulmectomy in major lung bleeding with involvement of the big vessels. The pulmonary hilus is compressed by the fingers until it can be clamped by a broad vascular clamp (Satinsky) and the lung, with its vascular stalk, is removed en bloc (see the text for further explanation)

Findings during the clinical examination that immediately should lead to suspicion on abdominal injury are: • Penetration of the abdominal wall • Hematoma/contusion of the abdominal wall • Fractures of the lower ribs • Pelvic fracture, especially unstable (see below) • Distinct tenderness or muscular defense • Expanding abdomen During normal trauma management in most hospitals today, all patients with suspicion of abdominal

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Fig. 7.43 Diagnostic peritoneal lavage to detect blood or fluid in the abdominal cavity. (a) A 2- to 3-cm skin incision is made in local anesthesia immediately below the umbilicus. (b) Blunt dissection down to the peritoneum. (c) Peritoneum is lifted up so that it can be opened without risk of injury to underlying abdominal organs. (d) A catheter is inserted and directed toward the pelvic region. (e) Five hundred to 1,000 ml of isotonic saline is rapidly infused through the catheter. (f) The infusion bag is lowered and the return fluid inspected. Clear and continuous blood in the return flow indicates intra-abdominal bleeding

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injury are referred to CT. Exceptions to this are circulatory unstable patients, usually characterized as patients with a heart rate >100, SPB <90 mmHg, RR <12 or >30, and no (or only temporary) response to shock treatment. These patients are bleeding and should go immediately to the operating room; there is no time for CT, unless it can be done in a few minutes in the trauma room, which is rarely the case. Still, it is of value to localize the source of the bleeding before surgery if possible. That can be done by USG (“FAST”: Focus Assessment Sonography in

Trauma, according to a standardized screening procedure), presuming that equipment and competence for this is immediately available in the emergency room, which is not always the case and can be difficult to achieve in the major incident. The remaining alternative is diagnostic peritoneal lavage (DPL) (Fig. 7.43a–f), a method that was frequently used before the introduction of CT and FAST. It is simple to perform, can be done in the emergency room with minimal equipment, and only takes a few minutes. It is not accurate for specific organ diagnosis because

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it only gives information about whether the source of bleeding is in the abdomen or not, but that is valuable information in this situation.

7.16.7.2 Indications for Surgery Circulatory unstable patients in whom FAST or DPL have shown blood in the abdomen should be immediately operated on without further delay. The statement above is in some situations a matter of controversy. As late as 2001, in the ICRC Handbook in War Surgery, it was suggested that circulatory unstable patients with abdominal injuries should be considered to be given low priority in these situations because they consume too many resources. This may be correct under austere conditions with no or limited access to surgical facilities. These patients will die without surgery, and they can often be saved by minimal primary surgery according the new principles for damage control (not identical to the need for intensive care). Therefore, this can be an effective use of resources. Management of circulatory stable patients is depending on whether it has been possible to visualize the injury on CT, which is not always the case in these situations – there is a limited number of computer tomographs even in bigger hospitals and other injuries, e.g., head injuries, have a higher priority for CT. With access to CT, nonoperative management in circulatory stable can be considered if: • There is no contrast leakage because of ongoing bleeding (“contrast blush”) • There is no significant amount of blood in the abdomen • There is no continuous need for transfusion because of bleeding These recommendations are based on the latest year’s accumulated experience from a large series of patients who received nonoperative management. In these series, more than 90% of patients with documented injuries to the liver or spleen have been possible to treat nonoperatively, and in children these figures are even higher. In a series of 1,800 patients with penetrating abdominal injuries, 28% of those with penetrating stab wounds and 40% of those with penetrating low-energy missile wounds could be managed nonoperatively (Velmahos 2001). However, this requires careful continuous clinical observation and the question is if this is possible or if it should be recommended in situations with limited resources. On the other hand, it saves surgical resources (in addition to the advantage for the patient to avoid unnecessary surgery). There is probably no place for a

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uniform recommendation, but the decision of strategy has to be made by the medical officer in command for every specific situation, taking into consideration the balance between resources for surgery and resources for clinical observation. Access to CT is also important for this decision. Without access to CT, nonoperative management requires even more careful clinical observation and diagnostic surgical exploration on wider indications. FAST (if available) and DPL can be used as substitutes for CT, but FAST has a limited accuracy for organspecific diagnosis and DPL does not exclude intraabdominal injuries that will require surgery.

7.16.7.3 Priority for Surgery As already stated above, circulatory unstable patients should have the highest priority for surgery because the bleeding has to be surgically controlled and that can be lifesaving, sometimes even with simple surgical measures (see above under “Indications for Surgery”). Circulatory stable patients with signs of peritonitis should also have high surgical priority because delayed surgery increases the complication rate considerably. Other abdominal injuries should have priority depending on clinical and radiologic findings; diagnostic laparotomy according to the principles described above should not necessarily justify high priority if the patient is stable. 7.16.7.4 Principles for Surgical Treatment The standard incision for abdominal trauma is a long midline incision (Fig. 7.44a, b). The whole abdomen, front of the chest, and front of the thighs should be sterile for potential access to the chest (aortic clamping) or the groin (vascular access). The patient should have gastric tube and urinary catheter (an exception is a suspected urethral injury; see below) and good intravenous lines in the upper limbs. Surgical strategy • Be prepared to meet a major bleeding when the compressing effect of the abdominal wall is removed during a laparotomy. This bleeding must be controlled instantly because it may turn quickly into a circulatory unstable situation. • If such a bleeding is met, pack the four quadrants of the abdomen and keep the incision closed with towel clips until the anesthesiologist has “caught up” with volume replacement. • Remove the packs one by one, starting with the lower quadrants and ending with the right upper

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Fig. 7.44 Laparotomy in trauma. (a) The whole abdomen, the anterior chest wall, and both groins down to the proximal femur should be sterilized to allow rapid extension of the operation into the chest or vascular access in the groins. (b) The standard

incision is a long midline incision from the xiphoid process to the symphysis (exception is when pelvic bleeding is suspected, the peritoneum below the umbilicus should then be kept intact to allow preperitoneal packing; see Fig. 7.58)

quadrant, and control bleeding as described below. If there is difficulty controlling the bleeding, re-pack and try to get more qualified assistance. Long failed attempts to control bleeding cost time and blood. If there is severe bleeding from the aorta or its major branches, it is difficult or impossible to get control by packing. The only alternative may be temporary clamping of the aorta, which can be done immediately below the diaphragm (Fig. 7.45a, b) or by an anterolateral thoracotomy (sometimes even better; see Fig. 7.40). Temporary control, until clamping can be done, can be achieved by compression of the aorta proximal to the injury with the fist or by firm pressure with an inverted retractor (Fig. 7.46).

Pack major venous bleedings, such as those from the liver, instead of resection or repair. There is practically no bleeding from the liver that not is possible to pack, especially with the help of today’s potent local hemostatics, which have made it possible to get control of combined lesions to the liver and the inferior caval vein, which previously was a great surgical challenge (and still can be in major injuries). Temporary control of bleeding before packing can be achieved by compressing the hepatoduodenale ligament with the fingers (Fig. 7.47) and then applying a tourniquet (as illustrated in Fig. 7.49). Packing requires mobilization of the liver, which can be achieved by division of the anterior ligament, and in posterior injuries also the dorsal ligament. However, in injuries to the retrohepatic caval vein it is important not to mobilize the liver so much that it is lifted forward by the packing, thereby loosing its compressing effect on the vein. The principles for packing are illustrated in Fig. 7.48a, b. The packs are removed after 1–3 days, and in most cases this is sufficient treatment.

The primary surgical treatment of severe abdominal injuries should in these situations be done according to the principles of damage control.

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Fig. 7.45 Clamping of the aorta below the diaphragm. (a) The muscle fibers of the diaphragm (1) are opened carefully with blunt finger dissection to avoid injury to the phrenic nerves. (b) Esophagus (2) is held aside with fingers or a retractor so that the

aorta (3) is visualized and clamped with a straight (or straight angled) vascular clamp. An alternative is to clamp the aorta above the diaphragm via an anterolateral thoracotomy (Fig. 7.40)

Injuries that penetrate the liver (as missile injuries) can be “packed” by an intrahepatic balloon catheter, either a predesigned one if available, or simply produced by a Penrose drain filled with saline and with the ends tied (Fig. 7.49). Do not spend time and blood to repair or preserve a ruptured spleen in these situations – splenectomy is a simple and fast procedure that should be mastered by every surgeon. Most vessels in the abdomen can be ligated without persistent impairment, but there are some exceptions other than the aorta and the caval vein. These include the celiac trunk and superior mesenteric artery, the external femoral artery and the renal arteries (if the kidney should survive), the hepatic artery (trunk), and

the portal vein (trunk). Primary repair requires time and experience, but an alternative is vascular shunting as described in Fig. 7.50. Injuries to the stomach can occur both in penetrating injuries and after severe blunt trauma caused by a pressure wave. It is important to inspect the dorsal side of the stomach, which is done by opening the lesser sac, a mandatory step in laparotomy for trauma because it is the only way to inspect the pancreas and exclude pancreatic injuries (see below). Injuries to the stomach can, in most cases, easily be repaired by a single-layer continuous suture with serosal invagination. Injuries to the duodenum are easy to overlook because of its partly retroperitoneal location. Retroperitoneal hematomas in this region should be explored and if there

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Fig. 7.47 The Pringle maneuver. Temporary control of bleeding from the liver by compression of the hepatoduodenal ligament. With the index finger inserted through the foramen of Winslow, the ligament can be compressed by the two-finger grip, as illustrated in the picture, until a vascular clamp or (better) a tourniquet can be applied (see Fig. 7.49). The clamp or tourniquet should be opened with an approximately 20-min interval for temporary vascular supply to the liver

Fig. 7.46 Temporary control of bleeding by compression of the aorta with the back side of a retractor (special devices for this are also available)

is suspicion of duodenal or pancreatic injury (see below), a blunt mobilization of the duodenum and the pancreatic head should be performed (Kocher mobilization). As a damage control procedure, duodenal injuries can be treated with gastrotomy and closure of the pylorus from inside (pyloric exclusion), then connecting the gastrotomy to jejunum as a temporary gastroenterostomy, combined with accurate drainage (Fig. 7.51a, b). Damage control for pancreatic injuries means consequent replacement of primary repair with only drainage combined with secondary repair. However, leakage from this area may be fatal and appropriate drainage is mandatory. A simple method is to use wide Penrose drains that can be cut with the distal end in a colostomy bag; such drains are rarely occluded and active suction is not necessary. This technique has been used as a damage control procedure in injuries to the

pancreatic head with duct involvement, where extensive primary surgery previously was advocated. Injuries to the small bowel are often multiple, especially after penetrating missile injuries or severe blunt trauma, and a mandatory procedure in laparotomy for trauma is careful systematic inspection of the whole intestine from the ligament of Treitz to the ileocecal valve. As a part of the damage control concept, simple ligation (Fig. 7.52) has been proposed instead of resection and anastomosis. This can be debated: Resection and anastomosis (layer continuous suture with serosal invagination) is a quick procedure for a trained surgeon, even if there might be a need for several resections to save as much intestine as possible. Ligation means bowel distension with promotion of intraabdominal pressure, which may lead to intra-abdominal compartment syndrome and end up in a patient with an open abdomen who requires intensive care (see below). It has also been shown experimentally to induce metabolic changes, promoting acidosis. Based on all this, it is not a recommended procedure in these situations. However, this is a controversial matter about which different opinions exist.

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Fig. 7.48 Packing of liver injury with bleeding. The liver is mobilized by division of the anterior (falciform) ligament to the abdominal wall. In more posteriorly located bleedings, the posterior ligaments also must be partly divided (exception is when there is bleeding from the retrohepatic caval vein; see the text). The bleeding is temporarily controlled as much as possible with the Pringle maneuver (Fig. 7.47) and “sandwiches” of big,

Fig. 7.49 Penetrating injuries to the liver (such as missile or fragment wounds) may be difficult to control by packing as described in Fig. 7.52. An alternative is to insert an inflatable balloon catheter (e.g., the Sengstaken model) through the missile or fragment track. If no such catheters are available, a Penrose drain, cut and tied at both ends and inflated (after Pachter & Hofstetter, 2000) may fulfill the same function (see also Fig. 14.4)

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folded laparotomy packs are applied, first toward the posterior/ anterior surfaces of the liver (a) and then toward the caudal surface (b). The packs should be applied on the surface, not into the liver parenchyma, because then they cannot be removed without initiating a new bleed. Pack so much that the bleeding is controlled, but do not “over-pack” (too massive packing involves a risk of abdominal compartment syndrome)

Injuries more common in major incidents than in routine medical care are intramural hematomas of the intestinal wall, which are induced by pressure waves, caused most frequently by blasts, but also by penetrating missiles and fragments or severe blunt trauma (see Fig. 7.5a, b). These intramural hematomas often do not primarily break through the intestinal wall and are therefore not possible to find without surgical exploration; in these cases these are also easy to overlook during a laparotomy for trauma. They can have a rather innocent appearance on the surface of the intestinal wall and look like a contusion induced by a retractor, but the mechanisms are entirely different. These pressure wave–induced hematomas involve the whole intestinal wall and some of them develop into necrosis and intestinal perforation (Fig. 7.53a–c). If every intramural hematoma should be treated with resection or invagination, it would consume considerable time and involve a risk of complications. On the other hand, if a hematoma with a potential risk of secondary perforation is left untreated, it means a risk of delayed peritonitis.

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Fig. 7.50 Temporary vascular shunt (TVS) as a damage control procedure in vascular injuries requiring repair for maintained circulation. (a) Distal embolectomy. (b) Tube of appropriate diameter, from whatever sterile material available, is inserted through the proximal lumen and (c) finally through the distal lumen. The TVS should be replaced by permanent repair with a vascular graft as soon as possible (see the text for further explanation)

In studies with long-term observation of such hematomas, attempts have been made to identify those that involve a risk for secondary perforation. The results are as follows: • Palpable defect in the intestinal wall • Visible serosal lesion

Fig. 7.51 Exclusion of the pylorus as a damage control procedure in duodenal injuries. Through a gastrotomy, the pylorus is closed from the inside with continuous resorbable suture (a). The gastrotomy is then used to make a temporary gastrojejunostomy (b)

• Diameter exceeding 15 mm of the small intestinal or 20 mm of the colonic wall, or more than half of the circumference of the intestinal wall

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Fig. 7.52 Simple temporary closure of the intestine according to the damage control concept is suggested as an alternative to resection and anastomosis (see the text for further discussion). Diverging opinions exist with regard to this method

Also, intramural hematomas that do not fulfill these criteria and thereby are left in situ should be documented as a basis for exploration in case of secondary peritonitis. With regard to colon and rectal injuries, the trend in normal trauma care has gone strongly toward resection and primary closure on wide indications. The situation in major incidents may be different, often with higher energy, more contamination, delayed surgery, limited resources and staff with limited experience/ competence. The emphasis here has to be put on safety, and a safer procedure under these circumstances, especially for the less experienced, is colostomy, which could be considered a damage control procedure: Even if it may be – as many damage control procedures are – connected to higher morbidity, it can be a price worth paying to save a life. This should not prevent the experienced surgeon from doing a primary repair if he or she makes a proper evaluation of the nature of the injury and if time in the operating room is available. The traditional approach to “exteriorize” the injured part of the colon has more or less been abandoned today. To resect the injured part and exteriorize the ends is a quick and simple procedure (Fig. 7.54). Whether the ends should be located close to each other or at a distance is a matter of debate. Close location facilitates secondary repair and the risk of contents “passing over” between ends is minimal. Injuries to the rectum are easily overlooked because of its partly retroperitoneal location. Preoperative rectal examination is important to discover a hematoma or even a perforation. During a laparotomy, the prerectal space should be carefully palpated and inspected.

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Fig. 7.53 Intramural hematomas of the intestinal wall after trauma. (a) In spite of an innocent appearance on the serosal side, this hematoma involves the whole intestinal wall and is a potential risk for later perforation. (b) Large intramural hematoma in a patient exposed to severe blunt trauma. (c) The hematoma in (b) during a secondary look 2 days later, when resection was decided. Microscopic examination of the specimen showed extensive necrosis, indicating that this lesion should have lead to perforation if it had not been resected

In case of injury, Hartman’s procedure with end sigmoidostomy and closure of the distal sigmoid (Fig. 7.55) is the procedure of choice, combined with presacral drainage, which is best achieved with broad Penrose drains.

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Fig. 7.54 Colostomy after resection of injury to the colon (see the text for further explanation)

Fig. 7.55 Hartman’s procedure for management of an injury to the proximal rectum where exteriorization of the distal end not is possible. Instead, the distal end is closed and the sigmoid end used for colostomy. Appropriate presacral drainage is essential

All laparotomies for abdominal trauma should include a careful systematic inspection of the whole abdomen before closure. Abdominal injuries are often multiple (see Fig. 7.5), and the team taking over for the next phase of treatment trust that the current team has registered everything: the whole intestine, duodenum and pancreas (open the bursa for inspection), retroperitoneal space around the rectum, and

diaphragm. Retroperitoneal hematomas in upper abdomen should be explored, but exploration of hematomas in the lower abdomen should be avoided unless they are expanding rapidly. Injuries to the diaphragm are also easily overlooked because they are not always visible on a primary pulmonary x-ray, and identification during laparotomy requires palpation of the diaphragm from

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below. Injures identified during a laparotomy can be repaired from below with broad, resorbable mattress sutures, in longer ruptures combined with additional continuous closure of the suture line. In central ruptures, careful attention must be paid to the phrenic nerves, the large vessels, and the pericardium. With limited experience of this region, in this situation it might be better to just diagnose the injury and leave it for secondary repair.

7.16.7.5 Closure of the Abdomen When damage control was applied on its initial indications in routine trauma care, a common component of this strategy was to leave the wound open until the next exploration. These patients had severe injuries combined with severe circulatory and metabolic impairment and required postoperative ventilator treatment in the ICU; when this occurred, an open abdomen did not mean so much additional surveillance and could have advantages in minimizing the risk of abdominal compartment syndrome (see below) and facilitate secondary surgery. When applied based on the indication “lack of resources,” damage control is also performed in patients with less severe injuries and with the use of procedures that do not require, or even justify, leaving the abdomen open. This means fewer demands on postoperative monitoring. Because ICU beds and ventilators are a critical capacity-limiting factor in major incidents, the abdomen should be primarily closed as much as possible. This requires strict attention to the postoperative intra-abdominal pressure, but this can be followed simply and without the need for any sophisticated equipment (see below). The faster and simpler the procedures are during laparotomy, the easier it is to primarily close the abdominal wall. Broad “retention sutures” should be avoided because they involve a risk of intestinal injuries. Normal techniques can be used, and there are prefabricated girdles that facilitate stepwise adaptation of the abdominal wall if necessary. 7.16.7.6 Postoperative Care Severe abdominal trauma involves a risk of inducing an increase of the intra-abdominal pressure, especially after major surgery, but also because of hematomas and edema, sequestration of fluid, or reperfusion injuries to the intra-abdominal organs. This is summarized as the intra-abdominal compartment

Fig. 7.56 Percutaneous nephropyelostomy is a damage control alternative to primary ureteral or renal repair

syndrome, creating a vicious circle in further impairment of intra-abdominal circulation and leading to a further rise in pressure. It also has negative effects on other organ systems: the lungs with impaired ventilation, the heart with impaired refilling, the kidneys with reduced perfusion, and the venous system in general, with an influence on the central nervous system as well. It can be fatal if the pressure is not released by opening of the abdomen. All patients in whom the abdomen is closed after major trauma surgery should therefore be followed with repeated determinations of intra-abdominal pressure. This can be done simply with connection of the urinary catheter to a vertical tube at the level of the symphysis and, with the patient in supine position, infusion of 50 ml saline and determination of the pressure by measuring the saline level in the tube (1 cm saline or water corresponds to 1 mmHg). Levels >25 mmHg are an absolute indication for surgical decompression (laparotomy); levels between 15 and 25 mmHg are an indication for surgery if combined with signs of elevated pulmonary pressure, reduced cardiac output, or oliguria (if there is a lack of resources for monitoring, use wider indications). Antibiotics should be given to all patients with penetrating abdominal injuries or injuries to the gastrointestinal organs.

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Fig. 7.57 Suprapubic cystostomy as a damage control alternative to primary urethral repair. This is also an alternative to prefer instead of traditional bladder catheter in patients with

unstable pelvic fractures or other situations where urethral injury is suspected

7.16.8 Injuries to the Urinary Tract

Urethral injuries (which should always be suspected in unstable pelvic fractures; see below) should not be primarily repaired in these situations but treated with cystostomy (Fig. 7.57) for later repair.

The principles for primary management of urogenital injuries do not differ from those used in abdominal injuries with application of the damage control concept. Hematomas around the kidneys should be opened restrictively because this can lead to accelerated bleeding that requires resection of nephrectomy; the vast majority of renal injuries heal with conservative management. An exception is a rapidly expanding hematoma, which can indicate a rupture of the renal artery. Bleeding with an intact arterial supply can be treated with packing; in case of urinary leakage or ureteral injury, treat with a pyelostomy (Fig. 7.56).

7.16.9 Pelvic Injuries Pelvic fractures can be categorized as stable, when the pelvic ring is broken only on one site and the ring still is kept together, and unstable, when the ring is ruptured at more than one site, splitting the ring into two parts that moves independently of each other. The rupture can be either a fracture or a rupture of a ligament, such as symphysis of sacroiliacal ligament. The instability can be horizontal (like “opening a book”

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from the front) or vertical (the halves of the ring can be dislocated in vertical direction). The latter involves the highest risk for severe bleeding and injuries to other organs. Stable pelvic fractures are rather harmless injuries with a small risk of severe bleeding or injuries to other organs, whereas the unstable pelvic fractures are lifethreatening injuries that require high priority and for which the treatment both in prehospital and hospital setting is a challenge.

7.16.9.1 Diagnosis Because of the difference in severity – and thereby in triage and management – between stable and unstable fractures, it is important to discriminate between them as soon as possible. Primarily this is done by palpation, which not is entirely easy because these patients, especially those with unstable fractures, have pain and muscular contraction. Asymmetry is significant for unstable fractures, and signs of more than one fracture should always raise the suspicion of instability. Attempts to move the two pelvic halves in relation to each other might reveal instability, but that has to be done carefully because even slight movements can increase bleeding. Palpation of the sacroiliacal joint from behind is important: Ruptures here may be a component of an unstable fracture. Examinations in the emergency room, in addition to those that can be done in the prehospital phase, are: • Plain x-ray if available in the emergency room (do not remove wrapping or compression bandage for x-ray at this point – it can start a bleeding that tips the patient over the edge) • Palpation of the rectum (bleeding or hematomas?) 7.16.9.2 Treatment in the Emergency Room In confirmed or suspected unstable fractures: • If compression bandage or wrapping of the pelvis not already has been applied, do it now. Compression of the pelvis is the best way to stop bleeding and can be done simply with a sheet. • Start aggressive volume replacement and consider blood transfusion (depending on access to blood and the patient’s circulatory condition, but these patients have often lost significant volumes of blood when they reach hospital). • If there is a suspicion of urethral injury, perform a cystostomy (Fig. 7.57).

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7.16.9.3 Indications for Surgery A stable pelvic fracture is rarely an indication for surgery, and there is no indication for primary surgery under these circumstances. An unstable fracture has a high priority for stabilization of the pelvic ring, which can be a life-saving procedure because it: • Stops or reduces bleeding • Reduces systemic reactions to trauma caused by shock, pain, and factors resulting from continuously injured tissue Stabilization of the pelvis can be done by external fixation (see below) if equipment and competence for this is immediately available. In most cases a highly functional alternative is firm wrapping of the pelvis with a sheet. If the patient is circulatory unstable and/or has signs of ongoing bleeding, exclude the possibility of simultaneous intra-abdominal bleeding (simultaneous abdominal injury is common) either by FAST or DPL. If there is no intra-abdominal bleeding, consider extraperitoneal packing of the pelvis (see below). This can be combined with angiography and percutaneous embolization if competence and equipment for this is available in this situation. If there is intra-abdominal bleeding, perform a laparotomy to control the intra-abdominal bleeding. If the pelvic hematoma not has broken through the peritoneum, stay outside this hematoma and do prepelvic packing (if and when possible followed by angiography). If it has broken through the peritoneum, do intraperitoneal packing of the pelvis, which can be combined with ligation of the internal iliac artery on one or both sides as a further hemostatic measure. 7.16.9.4 Priority for Surgery Patients with unstable pelvic fractures with circulatory instability and/or signs of ongoing bleeding should have high priority for immediate surgery. 7.16.9.5 Principles for Primary Surgical Treatment Stabilization of the pelvis: As stated above, the simplest way to achieve such stabilization is wrapping, which is used in many hospitals today as the standard procedure, even in the “normal” trauma situation. However, if competence and equipment is available (which it can be even in this situation) the so-called “C-clamp” is the device that gives the best stabilization.

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Fig. 7.58 Technique for extraperitoneal packing of the pelvis in unstable pelvic fractures with severe bleeding. (a, b) Lower midline incision without opening the peritoneum. (c) Preperitoneal

dissection in lateral direction on both sides. (d) Packs placed extraperitoneally on both sides

However, it is recommended to be used only by surgeons with continuous experience working with it. Stabilization with conventional external frames gives only partial (anterior) stabilization and requires also experience to use, which is why simple wrapping remains a good alternative in these situations. Pelvic packing: If there is not a peritoneal breakthrough of the bleeding, extraperitoneal packing (Fig. 7.58a–d) is the method of choice; opening a retroperitoneal pelvic hematoma might cause acceleration of the bleeding when the compressing effect of the

peritoneum is released. In such cases it is important not to open the abdominal wall all the way down to the symphysis, as in a regular trauma laparotomy, but instead bluntly dissect anterior to the peritoneum and apply packs preperitoneally. This method has been described during recent years and has been evaluated as superior to conventional intraperitoneal packing, for the reasons mentioned above. If the bleeding has penetrated into the peritoneal cavity, the reason may be major vascular injury. The internal iliac artery can be ligated (which also is a

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measure that can achieve hemostasis in severe cases), but the external iliac artery has to be restored, which in these situations can be done with a temporary shunt (see Fig. 7.50). After control of major vascular bleeding, the prevesical, prerectal, and presacral spaces are firmly packed, when and if possible followed by angiography and embolization.

7.16.9.6 Postoperative Care Patients with unstable pelvic fractures are at a high risk of developing systemic reactions to trauma, such as ARDS, and should have priority for postoperative ventilator treatment.

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Examination of a patient with suspected spinal injuries should include: • Inspection and palpation of the vertebral spine: asymmetry, hematomas, tenderness? • Passive and active mobility? • Ability to move limbs? • Sensibility? In a patient with a suspected injury, primary determination of the upper level of sensibility is of clinical importance. • In patients with suspected cervical spine injuries, get a plain x-ray of the cervical spine as soon as possible after primary stabilization (see below). If fracture is confirmed, further examination with CT and/or magnetic resonance imaging should be done as soon as resources allow.

7.16.10 Spinal Injuries Blunt injuries to the spinal cord are often caused by indirect violence with hyperextension and/or rotation, leading to vertebral compression. Severe violence may cause fragmentation with penetration of fragments into the spinal cord. Fractures of the vertebral arches may lead to instability with a risk of tearing the cord. Injuries involving the spinal cord are relatively rare, but the risk for such injuries increases with the severity of the violence. A complete transection of the spinal cord results in a complete loss of both motor and sensory functions. Cervical or high thoracic spinal injuries may lead to impaired respiratory function. High cervical injuries may lead to circulatory shock consequent to the loss of vasomotor function. The initial clinical symptoms may be aggravated because of bleeding or edema, and compression in the case of unstable fractures. Penetrating injuries have consequences similar to those caused by blunt injuries, but they more frequently involve the spinal cord.

7.16.10.1 Diagnosis Injuries to the spinal cord in unconscious patients are also difficult to diagnose in the hospital. On the same time, moving or manipulating a patient with an unstable spinal fracture without proper attention paid to or unawareness of the injury can lead to additional injury to the spinal cord and may result in severe persistent disability. This is especially valid for injuries to the cervical spine, which are common in major incidents.

7.16.10.2 In the Emergency Room Injuries to the cervical spine: • Every patient with reduced consciousness should have his or her neck stabilized by a stiff collar as soon as possible, however, this does not provide full stability, which means that all transfer and manipulation of the patient has to be done with strict attention paid to the cervical spine. When securing the airway, the head of the patient should be kept stable by an assistant (see above under “Prehospital Management”). Avoid bending the neck forward! • Patients with confirmed unstable or dislocated fractures should be stabilized with cervical traction as soon as possible, which can be done with local anesthesia (Fig. 7.59a, b). Other injuries to the spine: • Stable injuries without neurological symptoms or signs: Pain relief and mobilization as soon possible • Unstable injuries or injuries with neurological signs: Perform every transfer, movement, and manipulation with extreme care! No flexion or rotation of the spine! As soon as possible, stabilize in plane and supine position. • Penetrating injuries: Administer antibiotics and refer to surgical treatment, whenever possible in a spinal surgical unit (see below).

7.16.10.3 Indications for Surgery Penetrating injuries should whenever possible be operated on a spinal surgical unit. If this not is possible within 24 h, closure of the dura should be done on site because of the risk of infection.

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Fig. 7.59 Cervical traction. Symmetric incisions at the level of the “equator” (the widest part of the cranium) above the ears and behind the temporal muscle

a

Surgical treatment of blunt injuries requires specialist experience and is connected to a poor prognosis with regard to neurological function even with optimal technique. If access to a specialist team is available, laminectomy can be considered on the following indications: • Incomplete lesion of the spinal cord with decreasing neurological function • Complete or incomplete lesion with spinal block (cerebrospinal fluid flow blocked by the injury • Impression of fragments into or through the spinal cord

7.16.10.4 Priority for Surgery Considering the poor prognosis with regard to neurological function, these injuries should be given low priority in a situation with limited resources. The neurological impairment registered after 24 h can be considered persistent. An exception may be injuries on the level between the thoracic and lumbar spine, where a certain recovery can be seen even after a longer time. Cervical spine injuries at a high level (C1–C4) have a generally poor prognosis.

b

7.16.10.5 Principles for Primary Surgical Treatment Because this surgery should be done by specialists (with simple closure of the dura as a possible exception; see above), we refer the reader to literature specific for this field.

7.16.11 Limb Injuries Limb injuries constitute, as mentioned above, the dominating part of injuries caused by physical violence – approximately 60–70% in most scenarios. The importance of adequate prehospital management of these injuries has also been emphasized, and this also is valid for primary management in the hospital.

7.16.11.1 Diagnosis Clinical examination of the extremities in the emergency room should include: • Inspection: Wound? Hematoma? Visible dislocation?

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• • • •

Palpation: Tenderness? Crepitations? Mobility: Passive and active movement? Sensibility? Circulation: Differences in temperature? Peripheral pulse? Equipment for plain x-ray is normally available in the emergency room but may be an examination that requires too must time and resources in major incidents. Primary reduction and stabilization may have to be based on clinical evaluation and x-ray done at the next destination (preoperative unit, ICU, or ward).

7.16.11.2 In the Emergency Room Skin and soft-tissue injuries should not (with the exception of minimal injuries that can be treated ambulatory) be finally dealt with in the emergency room in this situation, but at the next destination: Major injuries in the operating room, minor injuries in the ICU or ward. Primary treatment in the emergency room should include cleaning with rigorous irrigation and covering with sterile towels and application of a compression bandage in cases of major bleeding. Patients with wounds with considerable contamination and devitalization (such as missile and fragment wounds) should have antibiotics at this stage, if not already given. Closed fractures and dislocations should be reduced and temporary stabilized as soon as possible according to the same principles as described for prehospital management. Within a half to 1 h after the injury, such reduction of dislocations can usually be done without the need for anesthesia, presuming that it is done carefully while the patient’s reaction is being observed. When there are signs of vascular or nerve injury, the patient should have a high priority for surgical exploration. Open fractures should be covered by a sterile dressing and carefully reduced and stabilized according to the same principles as above. Early antibiotics should be given; priority for surgery is high, but comes after life-threatening injuries (see below). 7.16.11.3 Indications for Surgery Major skin and soft-tissue injuries should be surgically treated as soon as possible. Because these injuries in these situations, with wide indications, should be treated with primary cleaning and wound excision followed by delayed primary closure, they do not need to “compete” with more severe injures about access to surgical theaters, but can be treated in rooms equipped

S. Lennquist Table 7.4 Incidence of gangrene requiring amputation after ligation of major arteries Ligated artery Axillary Brachial Common femoral Superficial femoral Popliteal

Incidence of amputation (%) 45–55 25 80 55 75–100

for minor surgery and often under local or regional anesthesia. Compartment syndrome caused by crush injury or trapping (see above under “Prehospital Management”) that requires fasciotomy should be treated with the highest priority, but this does not require surgical theatres for treatment and can be treated in the same facilities as major wounds (see above) or in the emergency room when the indication is considered urgent. Vascular injuries that require vascular repair for limb preservation (see Table 7.4) should be operated either by primary vascular repair, if time and access to competence so permits, or by temporary vascular shunt according to the damage control concept (Fig. 7.50). According to recent reports from armed conflicts (US Forces in the Middle East), today approximately 25% or vascular limb injuries are primarily repaired with a temporary vascular shunt, replaced by definite repair within 12–24 h, with a good patency rate. Traditionally, these patients should be heparinized, which is a dilemma with regard to concomitant injuries with a risk of bleeding (cerebral injuries, injuries to parenchymatous organs). Recent experimental studies indicate that a temporary shunt also can be used with good patency without heparinization; however, at the time of publication this has not been finally clinically confirmed. Whichever method is used, vascular repair requires at least temporary stabilization of simultaneous fracture on the affected limb. Open fractures should be operated at soon as possible because of the risk of infection. A traditional treatment in war surgery was previously to primarily stabilize with plaster after wound cleaning and excision, even when this meant covering open wounds with plaster. With increased access to simple methods of external fixation, such devices have been increasingly used (see below). Because wound excision and external fixation neither consume many resources nor

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time, this can be done under simple conditions and does not need to compete with major surgery. Closed fractures • without dislocation OR • dislocated but reduced to acceptable position AND • without major vascular or nerve injury can be primarily stabilized with plaster or a splint. Plaster is often used when the patient needs to be transported, e.g., under combat conditions, but circular plaster, if applied, should always be cut before transport and kept together with an elastic bandage because of the risk of edema. Some fractures involving or close to joints are normally primarily operated for the best possible preservation of ligament and articular structures, but in these situations can receive delayed treatment presuming that they are reduced to an accurate position, stabilized, and treated with an elevated limb to reduce the risk of edema and skin problems. Fractures of the femoral shaft are difficult to stabilize with plaster or a splint. The alternatives are either operation with external fixation or simple traction (Fig. 7.60), which however makes transport difficult. Fractures of the femoral neck, which today are normally primarily operated, can wait and be treated with simple traction in these situations. Other fractures that are difficult to stabilize with a splint are supracondylar fractures of the humeral shaft, which primarily can be treated with traction in these situations, presuming that the peripheral circulation is intact (Fig. 7.61).

7.16.11.4 Priority for Surgery Highest priority: • Fasciotomy in compartment syndrome with impaired peripheral circulation (can be done quickly and with minimal resources) • Vascular injuries, which, if possible, should be operated within 6 h after the injury • Nerve injuries should be operated early with diagnostic exploration and release of pressure, whereas nerve repair in these situations can be done as a secondary procedure • Dislocations involving risk of vascular and/or nerve injury, e.g., hip, knee, and elbow, should be reduced as soon as possible High priority but can wait: Open fractures, not included in the categories above

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Fig. 7.60 Traction by application of a pin through tuberositas tibiae can be used as temporary treatment during a major incident as an alternative to immediate surgery in patients with fractures of the femoral neck and the femoral shaft

Fig. 7.61 Traction by application of a pin through the olecranon can be used as temporary treatment of supracondylar fractures of the humeral shaft during a major incident; however, suspicion of vascular or nerve injury is an indication for immediate surgery

Lower priority: Closed fractures that require surgery but primarily can be reduced and stabilized in an acceptable posi-

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tion and without vascular or nerve injury can, in these situations, wait for treatment until resources are available

7.16.11.5 Principles for Surgical Treatment Skin and soft-tissue injuries which in these situations often are caused by considerable violence, are significantly contaminated, and often arrive late to treatment should be treated according to the same principles as described here for missile and fragment injuries: • Thorough wound cleaning • Excision of devitalized tissue • Delayed primary closure on wide indications (see below under ”Missile and Fragment Injuries”) Compartment syndrome with threatening or confirmed impairment of peripheral circulation should be treated by opening all involved compartments (fasciotomy); for technique see below under “Crush Injury.” Vascular injuries that require vascular repair for limb preservation (see above) can either be primarily repaired by suture, patch, or graft when time, resources, or the patient’s condition so allow, or by temporary vascular shunt (Fig. 7.50 above). In severely contaminated wounds, use of synthetic grafts can be a hazard because of the risk of infection, even if modern antibiotics have made the indications for this more liberal in experienced hands. Use of autologous grafts is time consuming because it often requires longitudinal duplication of the graft to achieve the correct diameter. Temporary vascular shunt (Fig. 7.50 above) as a damage control procedure is an alternative that has been increasingly used. Recent publications from combat surgery report up to 25% of vascular limb injuries successfully treated by temporary vascular shunt, presuming that it is transferred to a definite repair within 24–48 h. Heparin has traditionally been given to all these patients, which is a disadvantage in the presence of other bleeds (e.g., intracranial). As already mentioned, recent experimental data indicate that shunting can be done without heparinization with good patency rates, but this remains to be clinically proven. Nerve injuries should be carefully explored and pressure on the nerve released, but in these situations they should not be primarily repaired. The position of the nerve ends could be labeled by clips or sutures in close connection to, but not on, the nerve.

Fig. 7.62 Example of a simple device for external fixation of fractures (Hammerfix®, Swemac Orthopedics, Linköping, Sweden, with permission). This system is used in many military organizations, but many other similar systems exist. Every surgeon who deals with trauma should master the system used by his or her organization

Tendon injuries should be handled according to the same principles as nerve injuries. Open fractures are treated with thorough wound cleaning reduction and stabilization with external fixation. Simplified instruments (Fig. 7.62) for this are available today and should be mastered by all surgeons who deal with trauma. An alternative for external fixation, if complete instruments for this not are available, is illustrated in Fig. 7.63. Another alternative is the use of simple plaster or plaster slabs, as described above; however, this provides less effective stabilization and makes wounds more difficult to observe. Internal fixation should be strictly avoided under these circumstances, unless primary treatment is done in a well-equipped specialist unit by experienced staff, but, even then, the character of the injury should be carefully considered. Open-joint injuries are treated with wound excision, thorough irrigation under strictly sterile conditions, antibiotics, and as much closure of the joint capsule as is possible; the rest of the wound can be left open for delayed primary closure. Closed fractures that require surgery can wait until later presuming that they are primarily reduced to an acceptable position and accurately stabilized. For methodology, the reader is referred to textbooks in trauma and orthopedic surgery.

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resources and cause considerable suffering, sometimes loss of limbs and even lives.

7.17.1.2 Mechanisms of Injury The pathophysiology and mechanisms of injury of missile and fragment wounds has been thoroughly described in the beginning of this chapter under “Effects of Different Kinds of Physical Trauma.” 7.17.1.3 Prehospital Management

Fig. 7.63 A simple alternative for external fixation if instruments as in Fig. 7.62 are not available. Pins or wires are drilled through the bone distal and proximal to the fracture and connected with whatever is available, e.g., longitudinal poles or plaster splints

7.17

Special Injuries Commonly Occurring in Major Incidents

7.17.1 Missile and Fragment Injuries 7.17.1.1 A Model for Treatment of Wounds in Many Major Incidents Injuries from missiles and fragments not only occur during armed conflicts but also in major incidents in the civilian community, e.g., terrorist attacks with the use of explosives, weapons used in political conflicts or riots, mass shootings by maniacs, and criminal actions. The wounds caused by missiles or fragments have much in common with wounds seen in the majority of major incidents. Such wounds: • Are often caused by higher energy than wounds dealt with in daily medical care • Are often severely contaminated • Often come late to primary treatment • Often have to be dealt with under time pressure and/ or with limited resources Because of this, the principles for primary treatment of wounds caused by missiles and fragments – which is today well established and based on extensive experience from armed conflicts – can be used as a model for the treatment of wounds in major incidents that fulfill the criteria above. If these principles had been better followed, in many major incidents they may have reduced or eliminated avoidable complications like severe wound infections, which consume additional

The prehospital management of these injuries follows the same principles as those for other injuries to different organ systems. For special considerations in combat casualty care, the reader is referred to Chap. 14, which deals specifically with this.

7.17.1.4 Clinical Assessment of Injuries It is important to do a complete and careful inspection of the whole body, front and back, in the emergency room. It is easy to miss minor fragment penetrations, especially in areas covered with hair or in connection to normal body entrances. Consider the risk of secondary injuries caused by fragmentation and/or a pressure wave: A missile injury to a limb may be combined with secondary injuries to the trunk (see under “Mechanisms of Injury”). Note that, upon inspection, the absence of skin penetration does not exclude internal injuries. A highenergy missile or fragment that passes close to the body’s surface can cause internal damage through the pressure wave. Missiles with low energy transfer to the body often have small and identical entrance and exit wounds. Missiles with high energy transfer often have a larger exit wound with rupture of the skin’s edges (Fig. 7.64). These signs are, however, not totally reliable; a highenergy injury may have a small exit wound, depending on the degree of retardation of the missile. In addition, information is often lacking with regard to the type of weapon. Therefore, a wise policy is to make at least a minimal exploration of all missile wounds as far as resources permit. In the Emergency Room The management of missile and fragment injuries in the emergency room follows the same principles as other injuries to different organ systems. Do not fall for the temptation to close minor wounds in the emergency room “to have it done.” These wounds should be treated

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a

c

b

Fig. 7.64 Principles for wound excision (“debridement”) in high-energy missile and fragment injuries. (a) Liberal skin incisions in the longitudinal direction of the limb. However, minimal excision of skin. (b) Liberal incision of fascia, extended subcutaneously. Minimal excision of fascia. (c) Excision of all

devitalized muscle is the most difficult part of this procedure and requires practical training. This excision is best done with scissors, step by step until all devitalized tissue is removed. See the text for criteria for devitalization. It is as wrong to remove too much muscle as too little

in a theater for at least minor surgery, where careful wound cleaning and, if needed, excision can be done. Most of these injuries are best treated with delayed primary closure (see below). Antibiotics and tetanus prophylaxis should be given to all patients with penetrating

missile or fragment wounds. Traditionally, high-dose penicillin has been recommended with special consideration of the risk for gas-gangrene – a risk that has decreased parallel to more effective surgical wound management. Today, a third-generation cephalosporin

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is mostly the antibiotic of choice, with the addition of amino-glycosides and/or metronidazole in cases of heavy contamination and open fractures.

7.17.1.5 Indications for Surgery For treatment of penetrating missile and fragment injuries to the head, neck, chest, and abdomen: See above under the respective organ system. Surgical treatment of penetrating missile and fragment injuries to the limbs is controversial. In countries or regions with a high incidence of gunshot wounds, many of these are left untreated as a resource-saving measure; the vast majority of these injuries are caused by low energy and thereby may heal reasonably without treatment. However, in major incidents, including armed conflicts and terrorist attacks with explosives, the majority of the injuries may be high-energy injuries, which means entirely different demands on treatment to avoid infection. If resources permit, it is a wise policy to make a minor diagnostic exploration of all these wounds – it does not require much effort to see if there is devitalized tissue under the skin; if so, a thorough wound cleaning and excision of devitalized tissue should be done and the wound left open for delayed primary closure (see below). 7.17.1.6 Priority for Surgery For surgical priority of missile and fragment injuries to the head, neck, chest, and abdomen see the different organ systems discussed above. When dealing with missile and fragment injuries to the limbs, injuries with confirmed or suspected vascular or nerve damage should have high priority for surgical exploration; open fractures come next in priority. Other wounds can wait, but if such resources are available, they can be treated in rooms for minor surgery and with local or regional anesthesia, thereby not “competing” with major and life-threatening injuries. However, it is important that they are not left to staff who have no knowledge of the principles for treatment of these wounds. 7.17.1.7 Principles for Primary Surgical Treatment The goal of primary surgical treatment is to prevent infection by removing all devitalized tissue by excision (“debridement”) and to establish sufficient drainage by leaving the wound open for later closure within the normal period of healing (delayed primary closure). All loose organic material is removed and the wound is thoroughly irrigated. Nonorganic material

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(such as metal fragments) is removed when it is easily available in the wound, but the operation is not extended to reach material that is difficult to access – nonorganic material is itself not a source of infection. Hemostasis should be achieved with minimal foreign material, if possible with diathermy. Debridement should always be done from both the entrance and exit wounds so that the missile track can be followed with (careful!) blunt finger dissection. The principles for debridement, described in Fig. 7.64a–c, are the following: Skin: Restrictive excision, only a few millimeters around the edges of the wound, but (as soon as highenergy injury is confirmed) liberal incision, which should be done in a longitudinal direction for best access to the underlying devitalized soft tissues (Fig. 7.64a). Incisions should be made through both entrance and exit wounds, and the wounds should be connected in a transverse direction only if they are very close to each other. Make curved incisions over joints. Subcutaneous fat: Liberal excision of all devitalized and contaminated tissue. Fascia: Liberal incision of fascia, both for access to underlying muscle and for prevention of compartment syndrome (see below). Muscle: Sufficient excision of muscle (all devitalized) is the most essential component in this procedure and may be the most difficult for the less experienced. Devitalized muscle can be identified by the four Cs: • Darker Color than vital muscle (Fig. 7.64c) • Looser Consistency (easy to recognize if the excision is made with scissors) • Reduced Contractility • Reduced Capillary bleeding The excision is technically best done with scissors step by step until viable tissue is reached (different color and consistency, capillary bleeding from the line of excision). Avoid extensive en bloc excisions: it is equally wrong to remove too much as to leave too much. Bone: Fragments with periostal attachment can be left in place, but loose fragments should be removed. All internal osteosynthesis is contraindicated, and when there is a need for surgical fracture stabilization it should be done with external fixation (see Figs. 7.62 and 7.63). Vessels: Vessels that require repair (see Table 7.4) can be primarily repaired with grafts if medically competent staff are available and time permits, but because synthetic grafts involve a risk of infection and autologous grafts are time consuming, a better option may be

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vascular shunting as described above under “Limb Injuries” (Fig. 7.50). Nerves and tendons: Diagnostic exploration and, if possible, labeling of the ends as described under “Limb Injuries,” but no primary repair in these wounds. After the procedure above the wound is left open and covered (not packed!) by a fluffy absorbant bandage. Drains are usually not necessary. The bandage can be left in place until the time for delayed primary closure after 4–7 days. If the wound excision has been accurate there is no need for daily re-dressing. If not, there will be suppuration and fever and the patient has to return to the operating room for additional wound excision. At the time of delayed primary closure, the wound is inspected and closed if it is free of devitalized or contaminated tissue – if not, re-excision has to be done and delayed closure made at a later stage. Wound closure should never be done by tension – if there are remaining skin defects, skin grafting should be used. However, it is surprising to realize how even seemingly wide wounds fall neatly fall together after proper primary wound excision. At certain locations, such as the face and inside of the hand, good vascular supply makes primary closure possible after accurate cleaning and wound excision. However, when in doubt, it is never wrong to leave a wound in these regions primarily open. The scrotal skin can and should whenever possible be closed to protect the testicles. Common errors in the debridement procedure are: • Undiscovered wounds (body entrances, axillae, hair, perineum) • Debridement only from one direction • Insufficient excision of muscle • Too extensive excision of skin

7.17.1.8 Can Missile Wounds Be Primarily Closed? After the last decades’ war experiences with the introduction of high-velocity missiles, the general recommendation has been that all missile wounds should be treated with debridement and delayed primary closure according to the principles described above. This has been a successful strategy, saving life and health in an immense number of wounded. The results have also been well documented. During later years, reports have come from civilian areas with a high incidence of missile injuries, mainly from handguns, consequent to a high

S. Lennquist

criminality and easy access to such weapons. Good results have been reported for primary closure and also from conservative management of such wounds. The issue has been raised of whether this strategy should be generally recommended. It must, however, be considered that these injuries have been caused by low-energy missiles with entirely different effects than high-energy missiles or fragments. Such injuries require no or minimal excision (an exception is when bone is hit, which means higher retardation and higher transfer of energy). Whether such injuries at all need to be explored has even been questioned, and in areas with high incidence of such injuries, routine exploration should be resource consuming, which is why an understandable strategy could be a conservative approach and acceptance of a certain number of failures. Whether such a strategy should be transferred to major incidents and armed conflicts, where in most cases the majority of missile and fragment injuries are high-energy injuries, is highly controversial. Liberal exploration consumes few resources if it really is a minimal exploration, interrupted in cases without signs on devitalization of underlying tissues, and it can easily be extended in cases where the need for excision is apparent. That is a strategy of safety in accordance with the general surgical principles in these situations and it will certainly reduce complications as well as loss of health and life.

7.17.2 Amputations Amputations can be either traumatic, which means that the amputation is already completed and the limb lost when the patient arrives for treatment, or surgical, which means that the limb is still attached to the body but the decision is made to amputate it, either because the chances to preserve it with maintained function are small or none, or because removal of it is considered necessary to save the life of the patient.

7.17.2.1 Traumatic Amputations Traumatic amputation of limbs can be caused by blasts (see below), by missiles, by trapping, or by other forms of severe trauma in major incidents. During the primary management, control of bleeding is essential, as already described under “Prehospital Management.” The use of a tourniquet, which during one period of time was

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banned by the ATLS group, is now accepted and even recommended as a life-saving procedure in the field, but it should not be used longer than necessary, and these patients should have high priority for surgery. The principles for primary surgical treatment are the same as for missile and fragment injuries described above. It should not be done as a planned amputation to primarily achieve an amputated end that fits well into a prosthesis, but conservatively with preservation of all viable tissue (even if it does not look cosmetically accurate from the beginning) because such tissue can be needed during secondary surgery. Devitalized tissue should be removed according to the same principles as described for “debridement” under “Missile Injuries,” and the wound should be left open on wide indications for delayed primary closure. The bone should always be cut proximal to the skin edges and slight traction on the skin can, if needed, be applied to avoid skin retraction. Final revision can be done either at delayed primary closure or later as a secondary procedure, depending on available resources and the appearance of the wound.

7.17.2.2 Surgical Amputations All efforts should be made to preserve an injured limb whenever it is considered possible to restore acceptable function. However, attempts to preserve a limb that is so severely damaged that it still will be lost in the end, or that perhaps can be preserved but without any function, may lead to unnecessary and prolonged suffering, complications, and even preventable loss of life. Primary surgical amputation, therefore, can be the correct procedure in cases of severe limb injuries. Decision about amputation is difficult and should be done by the person with the highest available competence and experience (if resources so permit, by two persons with independent evaluation). Primary evaluation of circulation, and especially nerve function, is difficult. The principle should be “life before limb.” Factors of importance are time without (or with significantly impaired) circulation and signs of severe nerve injuries. An example of a scoring system as a support for the decision is shown in Table 7.5. In a level 3 major incident with an extreme lack of not only resources for primary surgery, but also resources for postoperative care and secondary surgery, preservation of limbs with severe injuries may not even be possible, even if the limb would have a small chance of survival under more optimal conditions. However, decisions to widen the indications for primary amputation under these cir-

187 Table 7.5 Scoring system for amputation according to Nerve injury Ischmia Soft-tissue injury Skeletal injury Shock Age patrent (NISSSA) Score Nerve injury Sensate Loss of dorsal Partial plantar Complete plantar Ischemia None Mild Moderate Severe Soft-tissue injury/contamination Low Medium High Severe Skeletal injury Low energy Medium energy High energy Very high energy Shock/blood pressure Normotensive Transient hypotension Persistent hypotension Age (years) <30 30–50 >50

0 1 2 3 0 1a 2a 3a 0 1 2 3 0 1 2 3 0 1 2 0 1 2

Mc Namara MG et al. Severe open fractures of lower extremity – a retrospective evaluation of the Mangled Extremity Severity Score. J Orthopaedic Trauma 1994; 8:81, with permission A NISSSA score >11 predicts amputation a Double value if duration of ischemia exceeds 6 h

cumstances are delicate and should be done through the collaboration of experienced medical leaders and with consideration of the situation in total; it has to be considered that people in regions where these situations are most likely to occur may have a small or no possibility to survive with a lost limb. These are situations for which no general policy can be recommended, but decisions have to be made for every specific situation.

7.17.3 Crush Injury and Compartment Syndrome Crush injury is a specific type of injury commonly seen in major incidents, both in patients exposed to

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severe blunt trauma and patients trapped with compression of the limbs or other parts of the body. The mechanisms of injury and the pathophysiology are described in the beginning of this chapter under “Effects of Different Kinds of Physical Trauma: Nonpenetrating Injuries.” Here is also emphasized the importance of starting effective fluid resuscitation early during prehospital management, and at least by the time extrication occurs because that is when the dangerous reperfusion injury starts: Systemic metabolic effects like acidosis, coagulopathy, and circulatory impairment induced by the release of products from muscular cell breakdown. This fluid resuscitation has to continue (or, if not already started, initiated) with high priority in the emergency room, including counteraction of the systemic effects of muscular breakdown by: • Forced diuresis to prevent renal failure, which means placement of a urinary catheter and continuous recording of urine flow, aiming at a urinary flow of 200–300 ml/h, if needed supported by diuretics and/or Mannitol. • Alkalinization of the urine by adding bicarbonate to the intravenous fluid, aiming at a urinary pH >6.5. Effective fluid resuscitation and maintenance of diuresis can be achieved in major incidents, whereas monitoring of pH and electrolytes requires resources (e.g., for determination of electrolytes and blood gases) that are not always available in these situations. Crush injury may lead to edema consequent to cell death. Because every muscular compartment of the limb is surrounded by rigid fascia, this might lead to increased pressure in the compartments with reduced vascular supply and further increase of cell death in a vicious cycle: compartment syndrome. The only way to break this cycle is to release the pressure by liberally opening the fascia in all involved compartments (see below under “Surgical Treatment”). Some authors have proposed that crush syndrome and compartment syndrome are two totally different entities that should be treated differently. In a crush injury, the cell death caused by the injury is the primary condition, leading to edema and high compartment pressure, whereas in compartment syndrome, the primary condition is increased pressure by the trauma (e.g., being trapped), leading to cell death as a secondary effect. The therapeutic implication of this philosophy should – hypothetically – be not to perform a fasciotomy in a crush injury because the cells are

S. Lennquist

Fig. 7.65 Determination of the pressure in the fascial compartments can be done simply with a needle and a tube connected to it by a Y-connection. Normal pressure is less than 10 cm H2O. A pressure >25–30 cm means a risk of impaired peripheral circulation and additional tissue damage

already dead, and unnecessary fasciotomy might cause unnecessary morbidity. However, it is difficult under these conditions to separate clinically these two entities, and regardless of the initiating factor, they may coexist in a viscous cycle where increased compartment pressure continues to generate cell death. Therefore, the recommendation is to perform fasciotomy in all situations where increased compartment pressure is confirmed or clinically suspected. It is better to do one fasciotomy too many than not doing a fasciotomy when it was needed to save a limb or even a life. An unnecessary fasciotomy may cause some morbidity (in most cases minimal) but it does not cost a limb or a life. A simple diagnostic tool to determine compartment pressure is described in Fig. 7.65. However, the hand and eye of an experienced clinician are in most cases sufficient tools to confirm edematous limb with stretched and shiny skin; in some cases peripheral pulse is impaired or difficult to palpate (persistent pulse can, however, often be confirmed by Doppler because the edema is not able to totally block vascular flow).

Incidents Caused by Physical Trauma

b al

dial

a

Fibula

rome

later

Po s t e

Fig. 7.66 Fasciotomy in compartment syndrome of the lower limb. It is vital that all compartments are opened. The two anterior compartments are best reached by anterolateral incision (a), and the two posterior compartments (b) by posterolateral incision

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Antero

7

Skin incision

Access by anterolateral incision (a)

7.17.3.1 Surgical Treatment The technique for fasciotomy is described in Fig. 7.66, with the lower limb as an example. It is of critical importance that all compartments are opened. Opening of the fascia should be liberal and can be extended subcutaneously beyond the edges of the skin incisions. After opening, it looks like the skin edges could never approach each other again, but when the edema has gone, secondary skin closure is in most cases no problem. Special devices are available for stepwise adaptation of the skin edges.

Access by posteromedial incision (b)

evaluation of casualties exposed to pressure waves requires special attention because: • The body can appear intact during external inspection in spite of severe internal damage. • Clinical symptoms of even severe internal injuries can be delayed by temporary respiratory and circulatory compensatory mechanisms, such as the direction of blood from injured parts of the lung, making it possible to maintain oxygenation temporarily. Because of these difficulties, it is important to have guidelines for the primary in-hospital triage of casualties exposed to blasts, as described below.

7.17.4 Blast Injury 7.17.4.1 Primary Triage in the Hospital The mechanisms and pathophysiology of blast injury are described in the beginning of this chapter under “Effects of Different Kinds of Physical Trauma: Nonpenetrating Injuries” and in Chap. 14, “Combat Casualty Management.” Here is also emphasized that

In major incidents caused by or involving explosions and pressure waves, it is important during the triage process to identify those who are at risk of having or develop blast injuries to the internal organs; these injuries might be immediately life threatening and require prompt

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attention. The following categories have been listed as connected to a high risk of significant blast injuries: • Patients with tympanic rupture. Even if the experiences from, e.g., the Madrid bombings showed that many patients with severe blast injuries to the lungs (BLI) did not have tympanic perforations, it remains a useful triage tool to indicate exposure to a significant blast force, and all such patients should (when possible) be admitted for observation, with monitoring of oxygen saturation as a valuable marker for delayed lung injury. • Patients with traumatic amputation of a limb or long-bone fracture have been shown to have a high rate of associated BLI and a high mortality in these situations. • Patients who, upon arrival, have acidosis and hypothermia after exposure to blasts have been shown to be more at risk for BLI. • Factors that predict the need for mechanical ventilation are tachypnea, tachycardia, confusion, multiple penetrating wounds, and multiple areas of soft tissue damage (Almogy et al. 2004). In high loads of casualties (level 2 major incidents) it might be necessary to categorize patients with small chances of survival as expectant, e.g., patients with amputated body parts and who are unresponsive to pain. It should be remembered, however, that the mortality in patients with blast injuries who arrive at the hospital alive in most series is relatively low, which justifies efforts in resuscitation and treatment of these patients.

7.17.4.2 Treatment of Speciﬁc Blast Injuries The mechanisms of BLI have been described initially in this chapter under “Effects of Physical trauma” where the delay in clinical signs and symptoms because of temporary direction of the blood to noninjured parts of the lungs was described, emphasizing the need of being clinically observant of patients exposed to blasts. Signs of BLI are: • Reduced arterial oxygen saturation (early sign) • Bihilar opacities (“butterfly pattern”) on chest x-ray. This is also an early sign that may be seen before clinical symptoms, which emphasizes that all patients exposed to significant blasts, if and when possible, should be referred for chest x-ray. The treatment of BLI is supportive: • Drainage of pneumothorax (in tension pneumothorax preceded by immediate thoracocentesis for pressure release). Note that pneumothorax is a common finding in BLI.

S. Lennquist

• Ventilatory support by mechanical ventilation. The recommendation is to avoid high-peak inspiratory pressure to not cause secondary lung damage or air embolism. Note the risk for bronchopleural fistula that may require independent lung ventilation. • Restricted fluid to not cause or increase pulmonary edema. Factors that indicate a poor prognosis in patients with BLI are low PaO2/FiO2 ration (<60) and the occurrence of bronchopleural fistula, as well as other concomitant severe injuries. Abdominal blast injuries: Intra-abdominal organs are sensitive to blasts and the mechanisms have already been described under “Effects of Different Kinds of Physical Trauma.” A lesion that commonly occurs as a result of blast injuries, but also in penetrating missile injuries and severe blunt trauma, is an intestinal intramural hematoma, the pathophysiology and principles of management of which have been described above under “Abdominal Injuries.” The indications and principles for surgical treatment of other intra-abdominal blast injuries are also the same as those described above under “Abdominal Injuries.” Musculoskeletal blast injuries should be treated according to the same principles as high-energy missile and fragment injuries. Liberal fasciotomy is recommended. Peripheral thrombosis, sometimes delayed, is commonly seen in blast injuries and might increase the amount of devitalized tissue, which is why patients with these wounds should be carefully observed for the need for re-debridement. Antibiotics and tetanus prophylaxis is mandatory, as in high-energy missile injuries and according to the same principles. Head injuries are common after exposure to a blast. In the Madrid scenario, 52% of the victims referred to hospital had head trauma. In addition to injuries also seen after other kinds of blunt and penetrating trauma, head injuries after blasts include systemic arterial gas embolism from lung barotraumas, which cause damage that is difficult to separate from direct brain trauma, and secondary shock waves from the trunk or extremities that may cause a variety of injuries, leading to chronic postconcussional symptoms, a phenomenon observed in military personnel exposed to blasts in the Middle East. Blast injuries to the head are often combined with severe injuries to the ears and eyes. The principles of surgical treatment of blast head injuries include – if resources are available – liberal craniotomy, evacuation of hematomas, removal of

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devitalized brain and fragments, and postoperative monitoring of intracranial pressure. The principles for trepanation for evacuating epidural hematomas have been described above under “Head Injuries.” More extensive procedures should only be done by staff with neurosurgical experience and reference is made to literature about neurosurgery and head trauma.

Because of this, and because of the special demands on psychological management of children and their parents, when resources allow it is desirable to centralize the treatment and care of children to special units/ departments staffed by personnel with pediatric experience. Staff from hospitals with such experience can also be sent to hospitals without such units.

7.17.4.3 Postoperative Management Postoperative management of blast injuries is, as is the surgical treatment, resource consuming and difficult to achieve in level 3 major incidents, as well as in level 1 or 2 incidents, if not resources for postoperative surveillance and secondary surgery can be mobilized after the initial load of casualties, or the patients rapidly transferred to such resources. Special attention must be paid to the risk of postoperative embolism. Prophylaxis against deep vein thrombosis should be given to these patients as soon as possible, but it is – as always – a balance with regard to the risk of continued or recurrent bleeding from internal injuries. A temporary filter in the inferior caval vein is recommended in patients with injuries that require longer bed stay, but that may be difficult to achieve in these situations.

7.17.5.2 Pregnant Women Anatomical and physiologic changes during pregnancy can lead to different modes of reaction to trauma and treatment. Therefore it is important to find out if the injured woman is pregnant, if necessary with a pregnancy test.

7.17.5 Special Categories of Injured 7.17.5.1 Children Some differences between adults and children are important to consider in the primary management of injured: • Children have a different pattern of response in physiologic parameters to trauma, which requires adjusted algorithms for physiologic triage, as described in Chap. 4, and requires attention in any form of triage • They are sensitive to cold and lose temperature quickly • Small children also are sensitive to minor loss of volume • Older children, such as young adults, on the other hand, have an ability to compensate (and thereby mask) loss of volume longer through extensive vascular contraction, which means that a decrease in blood pressure in these patients is a late sign of circulatory shock • Injuries to parenchymatous organs in children can be nonoperatively treated on wider indications because of a higher resistance to trauma and better prospects of spontaneous healing

Physiological Changes During Pregnancy Blood volume increases up to 40–50%, and this occurs during the first trimester. Heart rate increases by 10–15 beats per minute and cardiac output increases. At weeks 20–24, a slight decrease in blood pressure is usually registered. The number of red cells increases, but the relative increase in plasma volume causes a dilution, which is the reason for the decrease in hemoglobin normally seen in pregnant women: hemoglobin >100 g/l is acceptable and hemoglobin >100 g/l is rarely an expression of anemia during pregnancy. Changes in coagulation factors occur with an increase in fibrinogen and factors VIII, IX, and X. In the supine position (flat on the back), the uterus can compress the caval vein, resulting in reduced return flow to the heart and decreased blood pressure. This should be taken into consideration during transports, especially in women in the late stage of pregnancy (>week 26). Abdominal viscera are dislocated upward, which means an increased risk for gastrointestinal perforations in patients with both penetrating and blunt abdominal injuries. The abdominal cavity becomes less sensitive for peritoneal inflammation, which may make clinical diagnosis of peritonitis more hazardous. Special Diagnostic Measures During Pregnancy The size, length, and shape of uterus is inspected. The distance in centimeters between the symphysis and the top of uterus, minus 1 cm, usually corresponds to the length of the pregnancy in number of weeks. After weeks 24–26 of pregnancy, the fetus is considered to have good chances of survival. Contractions of uterus and fetus movements should be registered. Vaginal examination should be

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done to check for blood or fluid. Fetal heart sounds, usually detectable after the 12th week, should be registered. If the uterus has been exposed to violence, USG (if available) is the best way to achieve a diagnosis of the extent of injury. Treatment If pregnancy is confirmed, all treatment should, if and when possible, be done with fetal monitoring and in collaboration with a gynecologist. Direct injuries to the uterus can usually be repaired during a Caesarean section, simultaneously saving the fetus if it is viable. As a principle, the life of the mother should have higher priority than the life of the fetus since it often is a prerequisite for the survival and well-being of the baby. Different religions, however, may have different opinions about this. If it is not possible to save the mother, it may be possible to save the fetus via Caesarean section if it is done within short time (<5 min) after the death of the mother.

7.17.5.3 Elderly Older individuals have fewer physiological reserves and a reduced capacity to compensate for the loss of volume and hypoxia. A decrease in blood pressure may occur after moderate or minor bleeding. The increase in pulse rate is, on the other hand, slower, which means less pronounced tachycardia in major bleeding. It also has to be considered that many patients in this group are taking medication for cardiovascular disease, e.g., with b-blocking agents, that can maintain a low pulse in spite of considerable bleeding. Therefore, recording the medical history of these patients is important even under these conditions. The wide and increasing variations in the relation between numerical and biological (true) age in this group of patients should be considered during the triage process.

Further Reading The recommended literature for further reading is in this chapter divided in: • Overview literature • Updated/relevant literature within the different sub-topics

S. Lennquist

Overview Literature American College of Surgeons Committee on Trauma (2004) Advanced trauma life support program for physicians. American College of Surgeons Committee, Chicago Asensio JA, Trunkey D (eds) (2008) Current therapy of trauma and surgical critical care. Mosby/Elsevier, Philadelphia Boffard K (ed) (2007) Manual of definite surgical trauma care, 2nd edn. Hodder-Arnold, London Driscol P, Skinner D, Earlam R (2000) ABC of major trauma, 3rd edn. BMJ Publishing Group, London Eastern Association for the Surgery of Trauma. Practice management guidelines. Available at www.east.org Hirschberg A, Mattox K (2005) Top knife – the art and craft of trauma surgery. TFM Publishing, Nr Shrewsbury Husum H, Gilbert G, Wisborg T (2000) Save lives, save limbs: life support for victims of mines, wars and accidents. Third World Network, Penang Ivatury RR, Cayten CG (eds) (1996) The textbook of penetrating trauma. Williams & Wilkins, Baltimore Lennquist S (2007) Traumatologi. Liber, Stockholm (for Scandinavian readers) Moore EE, Feliciano DV, Mattox KL (eds) (2004) Trauma, 5th edn. McGraw Hill, New York Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TM (2002) The trauma manual, 2nd edn. Lippincott-Raven, Philadelphia Shapira SC, Hammond JS, Cole LA (eds) (2009) Essentials of terror medicine. Springer, New York Sing RF, Reilly PM (2001) Initial management of injuries. BMJ Publishing Group, London Smith J, Greaves I, Porter KM (2011) Oxford desk reference to major trauma. Oxford University Press, Oxford Talving P, DuBose J, Barmparas G et al (2009) Role of selective management of penetrating injuries in mass-casualty incidents – a review. Eur J Trauma Emerg Surg 35: 225–239 Wyen H, Jakob H, Wutzler S et al (2010) Prehospital and early clinical care of infants, children and teenagers compared to an adult cohort. Eur J Trauma Emerg Surg 36: 300–307

Prehospital Management Bunn F, Trivedi D, Ashraf S (2008) Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 23(1):CD001319 Champion HR (2003) Combat fluid resuscitation – introduction and overview of conferences. J Trauma 54(5 Suppl):S7–S12 Dunham CM, Barraco RD, Clark DE et al (2003) Guidelines for emergency tracheal intubation immediately after traumatic injury. J Trauma 55:162–179 Irvin CB, Szpunar S, Cindrich LA et al (2010) Should patients with Glasgow Coma Score 3 be intubated prior to hospital arrival? Prehosp Disaster Med 25:541–546 Jokela J, Nurmi J, Genzwuerker HV et al (2009) Laryngeal tube and intubating, laryngeal mask insertion in a manikin by first responder trainees after a short video-clip demonstration. Prehosp Disaster Med 24:63–67

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Kragh JF, Walters TJ, Baer DG et al (2008) Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 64:538–550 Kwan I, Bunn F (2005) Effects of prehospital spinal immobilization – a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med 20(1):47–53 Mahajan R, Nazir R, Mehta S (2010) An overview of intraosseous access. Anesth Analg 111(3):825–826 McIntosh SE, Swansson ER, Barton ED (2008) Cricothyroidotomy in air medical transport. J Trauma 64:1543–1547 McSwain NE, Champion HR, Fabian TC et al (2011) State of the arts of fluid resuscitation 2010: Prehospital and immediate transition to hospital. J Trauma 70(5) suppl: 2–10 Morrison CA, Carrick MM, Norman MA et al (2011) Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock – a randomised trial. J Trauma 70:652–663 Perel P, Roberts I (2007) Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 17(4):CD000567 Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Care (USA) and the American College of Surgeons Committee of Trauma (2003) PHTLS – basic and advanced pre-hospital trauma life support, 5th edn. Mosby, Missouri Stockinger ZT, Mc Swain NE Jr (2004) Prehospital endotracheal intubation for trauma does not improve survival over bagvalve-mask ventilation. J Trauma 56:531–536 Vandromme MJ, Griffin RL, Kerby JD et al (2011) Identifying risk for massive transfusion in the relatively normotensive patient utility of the Prehospital Shock Index. J Trauma 70:384–390

Damage Control Barker DE, Kaufman HJ, Smith LA et al (2000) Vacuum pack technique of temporary abdominal closure. J Trauma 8:201–207 Bashir MO, Abu-Zidan F, Lennquist S (2003) Will the damage control concept influence the principles for setting priorities for severely traumatized patients in disaster situations? Int J Disaster Med 2:97–102 Hoey BA, Schwab CW (2002) Damage control surgery. Scand J Surg 91:92–103 Holcomb JB, Jenkins D, Rhee P et al (2007) Damage control resuscitation directly addressing the early coagulopathy in trauma. J Trauma 62:307–310 Johnson JW, Gracias VH, Schwab CW et al (2001) Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 51:261–269 Loveland JA, Boffard KD (2004) Damage control in the abdomen and beyond. Br J Surg 91:1095–1101 Miller RS, Morris JA, Diaz JJ et al (2005) Complications after 344 damage-control open celiotomies. J Trauma 59:1365–1374 Shapiro MB, Jenkins DH, Schwab CV et al (2000) Damage control – a collective review. J Trauma 49:969–978

Head Injuries Carney NA, Chesnut R, Kochanek PM (2003) Guidelines for the acute management of severe traumatic brain injuries in infants, children and adolescents. J Trauma 54(Suppl 65):S235–S310

193 Cernak I, Wang Z, Jiang J et al (2001) Ultra-structural and functional characteristics of blast-injury-induced neurotrauma. J Trauma 50(65):695–706 Demetriades D (2006a) Early prediction of mortality in isolated head injury patients: a new predictive model. J Trauma 61(4):868 DuBose JJ, Barmparas G, Inaba K et al (2011) Isolated severe traumatic brain injuries sustained during combat operations – demographics, mortality outcomes and lessons to be learned from contrasts to civilian counterparts. J Trauma 70:11–18 Gerhart KA, Mellick DC, Weintgraum AH (2003) Violencerelated traumatic brain injury – a population based study. J Trauma 55:1045–1053 Gröbe A, Klatt J, Heiland M et al (2011) Diagnostic and therapeutic aspects in the treatment of gunshot wounds of the viscerocranium. Eur J Trauma Emerg Surg 37:41–47 Howard JL, Cipolle MD, Anderson M et al (2008) Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury. J Trauma 65:380–386 Kim TW, Lee JK, Moon KS et al (2007) Penetrating gunshot injuries to the brain. J Trauma 62:1446–1451 Martin EM, Lu WC, Helmick K et al (2008) Traumatic brain injuries sustained in the Afghanistan and Iraq wars. J Trauma Nurs 15:94–99 Muller K, Waterloo K, Romner B, Wester K et al (2003) Mild head injuries: impact of a national strategy for implementation of management guidelines. J Trauma 55:1029–1034 Okie S (2005) Traumatic brain injury in the war zone. N Engl J Med 352:2043–2047 Oncei D, Demetriades D, Gruen P et al (2007) Brain lobectomy for severe head injuries is not a hopeless procedure. J Trauma 63:1010–1013 Rudehill A, Bellander BM, Weitzberg E et al (2000) Outcome of traumatic brain injuries in 1508 patients – impact of prehospital care. J Neurotrauma 19:855–864 Rutland-Brown W, Langlois JA, Nicaj L et al (2007) Traumatic brain injuries after mass-casualty incidents – lessons from the 11 September 2001. Prehosp Disaster Med 22:157–164 Zafonte RD, Mann NR, Millis SC et al (1997) Functional outcome after violence related traumatic brain injury. Brain Inj 2:403–407 Zafonte RD, Woods DL, Harrison–Felix CL et al (2001) Severe penetrating head injury – a study of outcomes. Arch Phys Med Rehabil 82:306–310

Neck Injuries Demetriades D, Theodorou D, Cornwell E et al (1997) Evaluation of penetrating injuries of the neck – prospective study of 223 patients. World J Surg 21:41–47 Demetriades D, Salim A, Brown C (2007a) Neck injuries, a review. Curr Probl Surg 44(1):13–85 Demetriades D, Salim A, Brown C et al (2007b) Neck injuries. Curr Probl Surg 44:13–85 Du Bose J, Resinos G, Teixeira PGR et al (2008) Endovascular stenting for the treatment of traumatic internal carotid injuries – expanding experience. J Trauma 65:1561–1566 Feliciano DV (2001) Management of penetrating injuries to the carotid artery. World J Surg 25:1028–1035

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Chest Injuries Asensio JA, Arroyo H Jr, Veloz W et al (2002) Penetrating thoracoabdominal injuries: ongoing dilemma – which cavity and when? World J Surg 26:539–543 Bass C, Rafaels KA, Salzar RS (2008) Pulmonary injury risk assessment for short duration blasts. J Trauma 65:604–615 Bilello JF, Davis JW, Lemaster DM (2005) Occult traumatic hemothorax. Am J Surg 190:841–844 Bokhari F, Brakenridge S, Nagy K et al (2003) Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 54:1255–1256 Huber-Wagner S, Korner M, Ehrt A et al (2006) Emergency chest tube placement in trauma care – which approach is preferable? Resuscitation 72:226–233 Hunt PA et al (2006) Emergency thoracotomy in thoracic trauma – a review. Injury 37(1):1–12 Kurimoto V, Hase M, Nara S et al (2006) Blind subxiphoid pericardiotomy for cardiac tamponade because of acute hemopericardium. J Trauma 61:582–585 McPherson JJ, Feigin DS, Bellamy RF (2006) Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma 60:573–578 Reed AB, Thompson JK, Crafton CJ et al (2006) Timing of endovascular repair of blunt traumatic thoracic aortic transections. J Vasc Surg 43:684–688

Abdominal and Urogenital Injuries Burch J, Moore E, Moore F et al (1996) The abdominal compartment syndrome. Surg Clin North Am 76:833–842 Demetriades D (2006b) Selective non-operative management of penetrating abdominal solid organ injuries. Ann Surg 244(4): 620 Ivatury RR, Cheatham ML, Malbrain ML et al (2006) Abdominal compartment syndrome. Landes Biosciences, Georgetown Ivatury RR, Malhotra AK, Aboutanos MB et al (2007) Duodenal injuries – a review. Eur J Trauma Emerg Surg 33: 231–237 Kaplan M, Banwell P, Orgill D et al (2005) Guidelines for the management of the open abdomen – recommendations from a multidisciplinary expert panel. Wounds 3(Suppl 1):1–23 Kirkpatrick AW, Baxter KA, Simons RK et al (2003) Intraabdominal complications after surgical repair of small bowel injuries – an international review. J Trauma 55:399–406 Malbrain ML, Cheatham ML, Kirkpatrick A et al (2006) Results from the international conference of experts on intraabdominal hypertension and abdominal compartments syndrome. Intensive Care Med 32:1722–1732 Navsaria PH et al (2007) Non–operative management of abdominal stab wounds – an analysis of 186 patients. S Afr J Surg 45(4):128–136 Plackett TP, Fleurat J, Putty B et al (2011) Selective non-operative management of anterior abdominal stab wounds 1992– 2008. J Trauma 70:408–414

S. Lennquist Reilly PM, Rotondo MF, Carpenter JC et al (1995) Temporary vascular continuity during damage control: intraluminal shunting for proximal superior mesenteric artery injury. J Trauma 39:757–760 Ruesseler M, Kirschning T, Breitkreutz R et al (2009) Prehospital and emergency department ultrasound in blunt abdominal trauma. Eur J Trauma Emerg Surg 35:341–346 Suliburk JW, Ware DN, Zsolt B et al (2003) Vacuum assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 55:1155–1160 Thai ER, O’Keefe T (2007) Operative exposure of abdominal injuries and closure of the abdomen. ACS surgery: principles and practice. Web MD Publishing, New York, Section 7, Chapter 9 World Society for Abdominal Compartment Syndrome. www. wsacs.org Zengerink I, McBeth PB, Zygun DA (2008) Validation and experience with a simple continuous intraabdominal pressure measurement technique in a multidisciplinary medical/ surgical critical care unit. J Trauma 64:1159–1164

Pelvic Injuries Cothren CC, Osborn PM, Moore E (2007) Preperitoneal pelvic packing for haemodynamically unstable pelvic fractures – a paradigm shift. J Trauma 62:834–842 Eastridge BJ, Starr A, Minel JP et al (2002) The importance of fracture pattern in guiding therapeutic decision making in patients with haemorrhagic shock and pelvic ring disruption. J Trauma 53:446–450 Ertel W, Keel M, Eld K et al (2001) Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 15:468–474 Lehnen LPH (2010) Pelvic fractures – soft tissue trauma. Eur J Trauma Emerg Surg 36:117–123 Pohleman T, Bosch U, Gränsslen A et al (1994) The Hannover experience in managing pelvic fractures. Clin Orthop 305: 69–80 Rommens PM, Hofmann A, Hessman MH (2010) Management of acute hemorrhage in pelvic trauma – an overview. Eur J Trauma Emerg Surg 36:91–99 Routt ML Jr, Nork SE, Mills WJ (2002) High-energy pelvic ring disruptions. Orthop Clin North Am 33:59–72 Tötterman A, Dormagen JB, Madsen JE et al (2006) A protocol for angiographic embolisation in exsanguinating pelvic trauma. Acta Orthop 71:462–468 Tötterman A, Madsen JE, Skaga NO et al (2007) Extraperitoneal pelvic packing – a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 62:843–852

Injuries to the Spine Browner L, Levine S (2003) Skeletal trauma – basic science, management and reconstruction, 3rd edn. Saunders, Philadelphia

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Eastern Association for the Surgery of Trauma (2000) Determination of spine stability in trauma patients. EAST, Winston-Salem. www.east.org Fehlings MG (2006) The timing of surgical intervention in the treatment of spinal cord injury – a systematic review of recent clinical evidence. Spine 11:528–535 Morris CG (2004) Spinal immobilisation of unconscious patients with multiple injuries. BMJ 329:495–499

195 Taeger G, Ruchholz S, Waydhas C (2005) Damage control orthopedics in patients with multiple injuries is effective, time saving and safe. J Trauma 59:409–416 Taller J, Kamdar JP, Greene JA et al (2008) Temporary vascular shunt as initial treatment of extremity vascular injuries in combat surgery – the new standard of care? J Trauma 65: 595–603 Wang Z, Sun Y, Wang Q et al (2011) Anaesthetic management of injuries following the 2008 Wenchuan (China) earthquake. Eur J Trauma Emerg Surg 37:9–12

Limb Injuries Ball CG, Wyrzykowsky AD, Nicholas JM et al (2011) A decade’s experience with balloon catheter tamponade for the emergency control of haemorrhage. J Trauma 70:330–333 Covey D (2002) Blast and fragment injuries to the musculoskeletal system. J Bone Joint Surg Am 84:1221–1234 Fox CJ, Gillespie DL, Cox ED et al (2008) The effectiveness of damage control resuscitation strategy for vascular injury in a combat support hospital. J Trauma 64:99–107 Gifford SM, Eliason JZ, Clouse WD et al (2009) Early versus delayed restoration of vascular flow with TVS reduces circulating markers of injury. J Trauma 67:259–265 Hoff WS, Bonadies JA, Cachelo R (2011) Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 70:751–754 Langworthy MJ, Smith JM, Gould M (2004) Treatment of mangled extremity after terrorist blast injury. Clin Orthop 422:88–96 Mc Rae R (1999) Pocket book of orthopedics and fractures. Churchill Livingstone, Edinburgh Murray CK, Hsu JR, Solomkin JS (2008) Prevention and management of infections associated with combat-related extremity injuries. J Trauma 64:239–251 Newton EJ (2007) Acute complications of extremity trauma. Emerg Med Clin North Am 25(3):751 Rasmussen TE, Clouse WD, Jenkins D et al (2006) The use of temporary vascular shunts as damage control in wartime vascular surgery. J Trauma 18:91–99 Reis ND, Better OS (2005) Mechanical muscle-crush injury and acute muscle-crush compartment syndrome. J Bone Joint Surg 87:450–453 Rhee P, Nunley MK, Shapiro MB et al (2005) Tetanus and trauma – a review and recommendations. J Trauma 58:1082–1088 Ritenour AE, Dorlac WC, Fang R et al (2008a) Complications after fasciotomy – revision and delayed compartment release in combat patients. J Trauma 64:153–162 Ruedi TP, Murphy WM (eds) (2001) Principles of fracture management. Thieme, Stuttgart/New York Shimazu T, Yoshioka T, Nakata Y et al (1997) Fluid resuscitation and systemic complications in crush syndrome. J Trauma 42:641–646 Subramania A, Vercruysse G, Dente C et al (2008) A decades experience with temporary vascular shunts in a civilian level I trauma center. J Trauma 65:316–326

Missile and Fragment Injuries Dubose J (2007) Selective non-operative management of solid organ injury following abdominal gunshot wounds. Injury 38(9):1084 Luchette FA, Borzotta AP, Croce MA et al (2000) Practice management guidelines for prophylactic antibiotics in penetrating trauma. J Trauma 48(3):508–518 Murano T (2005) Civilian craniocerebral gunshot wounds: an update in predicting outcome. Am Surg 71(12): 1009–1013 Omoshoro-Jones JA (2005) Selective non-operative management of liver gunshot injuries. Br J Surg 92:890–896 Peleg K (2004) Gunshot and explosion injuries: characteristics, outcomes and implications for care of terror-related injuries in Israel. Ann Surg 239(3):311–317 Salim A (2002) When to operate on abdominal gunshot wounds? Scand J Surg 91(1):62–67 Velmahos GC (2001) Selective non-operative management of 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 234(3):395

Blast Injuries Almogy G, Luria T, Richter E et al (2005) Can external signs of trauma guide management? Lessons learned from suicide bombing attacks in Israel. Arch Surg 140: 390–393 Arnold JL, Tsai MC, Halpern P et al (2003) Mass casualty terrorist bombings – epidemiological outcomes, resource utilization and time course of emergency needs. Prehosp Disaster Med 18:220–234 Champion HR, Holcomb JB, Lee Ann Young MA (2009) Injuries from explosions – biophysics, pathology and required research focus. J Trauma 66:1468–1477 De Palma RG, Burris D, Champion HR (2005) Blast injuries. N Engl J Med 352:1335–1342 Neuhaus SJ, Sharwood PF, Rosenfeldt JV (2006) Terrorism and blast explosions – lessons for the Australian surgical community. ANZ J Surg 76:637–644

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Ritenour AE, Wickley A, Ritenour JS (2008b) Tympanic membrane perforation and hearing loss from blast overpressure. J Trauma 64:174–178

Molde Å, Navein J, Coupland R (2001) Care in the field for victims of war. International Committee of the Red Cross, Health and Relief Division, Geneva

War Surgery

Pediatric Trauma

Dufour D, Kromann Jensen S, Owen-Smith M et al (1998) Surgery for the victims of war. International Committee of the Red Cross, Geneva Giannou C, Baldan M (eds) (2009) War surgery – working with limited resources in armed conflicts and other situations of violence. International Committee of the Red Cross, Geneva Husum H, Ang SC, V E (1995) War surgery field manual. Third World Network, Penang

Advanced life support group (2001) Advanced paediatric life support. BMJ Publishing group Ong A, McKenney MG, McKenney KA et al (2003) Predicting the need of laparotomy in pediatric trauma patients on the basis of ultrasound score. J Trauma 54:503–508

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Incidents Caused by Fire and Toxic Gas Folke Sjöberg

8.1

Treatment Strategies for Burns

The strategies for dealing with major burn injuries follow the same rules and overlying principles as the treatment of other kinds of trauma and are in accordance with the advanced trauma life-support guidelines described in Chap. 7. There are, however, some components of this care that have to be specially adjusted to burn trauma victims, and this has implications and consequences for the planning for major burn incidents. Major burn injuries constitute one of the most resource-demanding medical conditions involving patients. The consequence of this is that the need for extra resources during major fire incidents often becomes significantly larger than anticipated at the beginning. For example, Sweden, a state hosting ten million inhabitants, only hosts eight critical care beds particularly aimed at treating burn injuries, which means that a major burn incident will quickly consume all available specialist resources. Both knowledge and actual resources to treat burns have diminished in the ordinary health care system as burn care has been increasingly centralized to burn centers. This is a general phenomenon in Europe as well as in the United States. In parallel, the incidence of burns has been decreasing in these countries because of better prevention strategies. As an example, the incidence in Sweden has declined by approximately 25% and the length of stay for these patients has been reduced by 50% compared with what was registered at the end of the 1980s. F. Sjöberg e-mail: [email protected]

Furthermore, the ambition to save even severely burned patients has increased significantly parallel to a reduction of mortality. For example, in Sweden, the hospital mortality for patients who arrive at the hospital alive has been reduced by 70% during the last 25 years. This means that older guidelines and treatment algorithms need to be adjusted accordingly. The international cooperation between burn care facilities has increased, and burn injuries are not only transported within countries for final treatment, but also internationally. This has consequences for the treatment strategy because transport techniques and resources have become better and more effective. An example of this is the transportation of victims of the Bali fire incident in 2002 to final treatment in Australia and other countries. Also on the horizon of planning and management, the international cooperation guidelines are under development; this will have implications for major burn incidents in the near future (see the special section on planning management principles and guidelines for major burn incidents at the end of this chapter).

8.1.1

Extent of Injury

A burn injury occurs when the quantity of absorbed thermal energy absorbed into human tissue exceeds the tolerability of the particular tissue. The energy absorbed depends mainly on two factors: (1) the temperature and (2) the duration of the exposure. For exampled, deep dermal burns are caused by exposure to flames (high temperature) within seconds, whereas exposures to temperatures of 43–44°C will require

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18 (+18)

9

For small children: Subtract 1% from the head and add half percent for every year up to 10

19 1 Rule of nine 18

18

Adult

Head

9%

Upper limb

9%

9

18 (+18) 9

Rule of nine Head

1 13

13

Upper limb

Children age 1 to 10 19% 9%

Anterior trunk

18%

Anterior trunk

18%

Posterior trunk

18%

Posterior trunk

18%

Perineum

1%

Perineum

Lower limb

18%

Lower limb

1% 13% Plus half of age (years)

100%

100%

Fig. 8.1 The rule of nine is a technique used to facilitate the determination of burn size compared with the total body surface area. The human body is, for simplicity, divided into multiples of 9%. When the burned areas are dispersed on a skin surface,

the size of the palm (including the fingers) can be used as an 1% total body surface estimate (using the hand of the injured person). Note the relatively larger head in the infant compared with the adult

several (2–6) hours before deep dermal injuries occur. Another important factor for the depth of the injury is the thickness of the skin, which is thicker on the back and thinner in children and the elderly. An additional factor of importance is the blood flow in the tissue, which reduces thermal exposure by transporting the thermal energy away from the exposure site. A practical and relevant definition of a burn injury is the one used by the American Burn Association (http://www.ameriburn.org/): “a thermal injury to the tissue caused by one or more of the following mechanisms: • Fire or hot liquids • Corrosive chemicals • Radiation or electric current” Most important for the severity and prognosis of the burn is the extent of the skin burned, which usually is described as skin surface area burned (total burn surface area [TBSA], represented by a percentage) and the depth of the injury. These two factors are important for treatment strategies. Another important factor for the outcome is the age of the victim. Children younger than 1 year and elderly older than 60 years are more at risk and have less chance for successful treatment and survival in

the case of severe burns. The survival prognosis for burns often is defined as the LD50 value, i.e., the extent of an injury that has a 50% survival chance (or e.g., lethal dose [LD]). Improvements in care have lead to an increase in the LD50 value from 45% TBSA in a 21-yearold adult in 1975 compared with the corresponding value of approximately 85% TBSA today.

8.1.2

Surface Area

When confronted with the need to depict and assess the surface area burned, the rule of nines is usually the technique chosen. This technique is based on that the body, for simplicity, can be divided into multiples of 9%, where each arm constitutes 9%, each leg 18% (two times 9%), the front and back of the torso each 18%, and the head 9% (Fig. 8.1). In cases of a dispersed picture of skin injuries, the palm of the hand of the victim may be used as measure of skin surface extent because it usually constitutes 1% of the total surface area of that individual. A good approach to reduce the risk of any miscalculations is to count both the areas burned and the uninjured areas and add them

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Incidents Caused by Fire and Toxic Gas

199

Section of skin

Depth of burn

Epidermis Dermis Blood vessels Nerves Hair follicles Sebaceous glands

Receptors Itch Pain Pressure Touch Temperature

1st degree

Epidermal superficial

2nd degree

Superficial second degree

Partial thickness

Deep Second degree

Subcutaneous tissue

Full thickness

3rd degree

Deep tissue (muscles, tendons, nerves, bone)

4th degree Injuries to deep tissues

Fig. 8.2 Determination of burn depth

together to get the anticipated 100%. Any deviations from 100% would signal an error. It is important to stress that assessing both extent and depth is considered difficult because it is regularly found that errors occur despite extensive experience and expertise. This fact underlines the problems that may occur in a major incident, where the available knowledge of the investigator during triage may be significantly less and the numbers of victims may be large, in conjunction with possibly primitive circumstances under which the responders must work. Other complicating circumstances that may make the triage even more difficult include situations where the wound may become worse because of insufficient fluid treatment, bleeding from other injuries, local wound infections, or combinations of these.

injury a partial thickness injury (first degree and less pronounced second degree), which heals spontaneously within 2 weeks, or a full-thickness burn (deep second and third degree); the latter requires surgery to treat it. For these injuries, the healing time is long if the patient is not subjected to surgery because the healing process has to evolve from the edges and slowly reach the center of the wound. During burn surgery, the injured skin is surgically excised and the area is covered by autologous skin taken from other uninjured areas on the victim. For the long-term outcome, it is important that skin is healed in superficial injuries before 14 days after the burn because longer healing times lead to a more complicated wound healing course, with lower functional and poorer cosmetic outcomes (Figs. 8.2 and 8.3).

8.1.3

8.1.4

Burn Wound Depth

As mentioned, the depth of the wound depends on the thickness of the skin, its blood flow, and not least, the amount of thermal energy transmitted (the latter usually is assessed by details of the accident). From a historical point of view, a three-level grading of skin burn depth has been used (first-, second-, and third-degree burns). Today, a more pragmatic scale is used, dividing the old second-degree burn in two, instead calling the

Fluid Treatment

What is unique for the burned patients is their extensive need for fluid treatment to avoid the development of “burn shock.” If they are not treated accordingly, patients are at risk of significant mortality as soon as the burn extent exceeds a TBSA of 20%, above which fluid treatment is mandatory. The development of burn shock is the first general challenge for treatment teams during a major burn incident. The underlying

200

F. Sjöberg

a

b

c

Fig. 8.3 (a) Partial thickness burn. (b) Full-thickness burn. (c) Mixture of both partial and full-thickness burns

mechanisms for the fluid needs faced by burn victims are caused by different factors. First, and most important, is the development of a strong negative hydrostatic tissue pressure (negative imbibition pressure) in the burned injured tissue, which may reach levels as low as −50 mm Hg within 2 h. This effect usually declines during the following 4–6 h. This leads to rapid loss of fluid from the circulation into the injured tissue, which, if not treated adequately, will cause the patient to go into shock because of a low circulating blood volume. This effect is further aggravated by the general fluid loss caused by the permeability change that occurs in all of the vasculature, which is due to the inflammatory response secondary to the burn and is propagated by the inflammatory cascades. The fluid volume needed during these circumstances can be predicted by the size of the burn injury (percent of TBSA) and the weight of the patient. As a guide, the Parkland formula (from Parkland Memorial Hospital in Dallas, Texas, USA, where it was invented) can be used, which

states that 2–4 mL/kg and burned surface percent is to be provided for the first 24 h. Half of the volume (50%) should be given during the first 8 h, when the fluid loss is the largest, followed by the other half of the volume during the ensuing 16 h. This can be exemplified by a 70-kg man with an burn injury of 70% TBSA who should be given 19,600 mL (70 × 70 × 4), i.e., close to 20 L of fluid during the first 24 h. The goal of the treatment is that the patient shall have a mean arterial blood pressure of more than 70 mmHg and a diuresis of between 50 and 100 mL/h. If the blood pressure or the urine production is less, the infusion rate should be increased (usually by approximately 30%).

8.1.5

Inhalation Injuries and Facial Burns

Other important aspects of burn treatment that need early attention are inhalation of toxic gases (carbon monoxide and cyanide); facial burns with risk for

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Incidents Caused by Fire and Toxic Gas

upper airway obstruction; restrictions in the compliance of the thorax caused by the burn and fluid accumulation in the wound, leading to breathing problems; and circulation deficits for the same reason in circumferential injuries in the extremities. The thermal injury and especially smoke inhalation may elicit injuries to the airways. These injuries are usually divided into those above (upper) or below (lower) the glottis, respectively. Thermal injury may affect the upper airway, but this is uncommon because the airway has an excellent capacity for heat dissipation. Therefore, swelling and edema at the level of the vocal cords is uncommon if the victim not has been specifically exposed to inhalation of hot steam under pressure. During such conditions, the patency of the airway may be at risk and there is a threat of an upper airway obstruction. More important from a treatment perspective is the risk of smoke-induced effects on the airway, which, besides its direct irritant and toxic effects, elicits a generalized inflammatory response in the lung with deleterious consequences for the lung tissue and its function. The latter leads to the feared smoke-induced respiratory failure, which at times is difficult to differentiate from a regular acute respiratory distress syndrome, which it will eventually lead to if not successfully treated. Inhalation injuries affect the whole burn injury process and lead to higher morbidity and mortality, even though these effects seem to be less pronounced today than 15 years ago. From a general perspective, it is assumed that approximately 10–20% of patients with major burns also have inhalation injuries. These effects lead to increased duration of ventilator use as well as increased length of stay in the hospital, which is of particular importance because it complicates the course during major incidents, when resources may be insufficient. Another important component that affects breathing and circulation is the effect of carbon monoxide and cyanide exposure. Carbon monoxide interferes with oxygen transport and cyanide interferes with the cellular combustion of oxygen, both leading to a generalized oxygen deficit (hypoxia). Such effects are important, as illustrated by the discotheque fire in Gothenburg, Sweden, in 1998, when 62 young persons died at the site of the fire and where the vast majority of deaths were caused by the effects of carbon monoxide and cyanide. Another often neglected effect related to oxygen under these circumstances is a rapid and pronounced oxygen deficit in the vicinity of the vic-

201

tim; as oxygen is rapidly consumed by a fierce fire, the individual can be rendered hypoxic and finally unconscious. This explains why some fire victims are found dead at the center of rooms without obvious signs of attempts to escape the fire through potential exits. Interventions • Provide 100% oxygen in a nonrebreathing circuit to the victim because it significantly eliminates carbon monoxide (shortens its half-life). • Provide a cobalamin-based antidote to cyanide. The latter treatment is essentially without risk, which is why it can be administrated based on wide indications. Be aware, however, that the cobalamin discolors the urine (makes it red), which may falsely lead to the suspicion of hemoglobin and myoglobin production in the urine, not uncommon in patients with major burns as a consequence to tissue injury.

8.1.5.1 Facial Burns Facial burns constitute an emergency because they may involve the risk of an upper airway problem. Furthermore, they potentially can lead to cosmetic deficiencies. The often pronounced swelling around the eyes may lead to difficulties with opening the eyes and can reduce eyesight. The primary intervention is to ascertain the patency of the airway, which often is done by tracheal intubation. In most cases this is not a technical problem early during the treatment course, which it rapidly may develop into as swelling increases already within the first hours and reaches its maximum 1–2 day after the injury.

8.2

Modern Treatment Strategy

Complete burn care treatment, from early fluid resuscitation, surgical excision, grafting, and critical care, followed by reconstructive surgery and possibly aggressive rehabilitation, obviously has many dimensions. During the early phase, the patient is cared for using the basic principles for trauma care similar to those described in Chap. 7 and below under “Primary Survey.” This early phase is followed by extensive fluid therapy and, for major injuries, surgery during critical care– like conditions. The goal during this stage is to maintain physiological body functions and at the same time reduce the risk of complications, mainly in the form of infections and organ dysfunction/failure. The latter is the most common cause of death in modern burn care.

202

F. Sjöberg

After this stage, aggressive mobilization and rehabilitation begins and may continue over weeks or months, during which further surgical procedures may be required to improve cosmetics as well as function. The total chain of events incorporates quite different treatment approaches, which depict the multifaceted pathophysiology in the treatment of burns. This is the background for the need of treatment teams made up of multiple professionals, which have made modern burn care develop so rapidly and have accomplished successful end results, all in favor of the burned patients. During the last 15 years of burn injury care, many improvements have been made, all of which together have changed the outcome significantly for the better. It is difficult to isolate specific procedures, but the following may be claimed to be especially important in the advancement of modern burn care: • The early and, most importantly, total surgical excision of deep burn injured tissue. Early in the history of burn care, extensive and early excisions were not feasible because of extensive intraoperative blood loss, among other things. These are better dealt with today. The excision of dead tissue eliminates unviable tissue, which may host a growth of bacteria and lead to serious infections. This approach also has reduced the pronounced trauma-induced hypermetabolic response in burns that could lead to an extensive catabolism. A dramatically reduced length of stay was one of the consequences of early excision, observed during the late 1980s and beginning of the 1990s. • Improved critical care, including more advanced respiratory and metabolic support, as well as new and more effective antibiotics. • Improved wound care, utilizing new dermal substitutes and biological and synthetic dressings; the latter also incorporates newer antimicrobials. In conclusion, all of these changes have led to a mortality reduction of approximately 70% and significantly shorter hospital stays.

8.2.1

Acute Burn Life Support

Acute burn life support (ABLS®), constitutes guidelines for the early (first 24 h) evaluation and treatment of burns. The ABLS concept is in accordance with the advanced trauma life support (ATLS) guidelines developed by the American College of Surgeons

(see Chap. 7). The ABLS guidelines were developed by the American Burn Association (http://www.ameriburn.org) and aim to provide evaluation and treatment algorithms that standardize and harmonize the early care of burned patients. This is especially important in the major incident, during which many individuals with different backgrounds and training may come together to treat many and extensive burns. ABLS courses are provided at several sites in Europe, including Germany and Sweden. A similar teaching program is also provided by the British Burn Association (http:// www.britishburnassociation.co.uk).

8.2.2

Modern Burn Treatment: The Three Phases

This section describes general burn treatment principles, and the latter part of this section will address the treatment and handling of specific issues in situations involving many burn injured victims. There are a number of ways to present burn care principles to make them easily understandable and comprehensive, and the most commonly used is to divide the treatment process into three separate phases: • Initial acute care and fluid resuscitation • Burn wound care with excision and grafting • Rehabilitation, including reconstructive events This scheme also is suitable for the planning and treatment of many victims at once, such as may occur in a major incident. In such scenarios, it is important to add an extra phase – first triage – at the site of the accident or in its close vicinity.

8.2.2.1 Initial Acute Care and Fluid Resuscitation (The First 2 Days After Injury) The initial acute care and fluid resuscitation phase starts from the period of the injury and includes the first 2 day. The aim of the treatment is to reduce the pathophysiological effects of the burn injury, i.e., to reduce, if possible, the tissue injury and, most important, to reduce the effects of the fluid loss from the vascular space on circulation. The goal is to ascertain vital functions and start the fluid treatment. During this period, the patient is examined regularly and the injuries are dealt with according to ATLS/ABLS principles. The fluid treatment is evaluated regularly and adjusted according to patient needs until the end of the period. During major incidents, this part may be

8

Incidents Caused by Fire and Toxic Gas

performed in the first casualty clearing zone or, alternatively, in the primary hospital with emergency and intensive care facilities; the burn centers at this time may be heavily burdened by acute admissions and not able to accept additional patients. Furthermore, experience tells us that this phase also can be successfully handled at the non–burn center level. On the scene, it is important to address the following issues rapidly: • Put out any fire in the patient’s clothing. Flush/ rinse, roll, and extinguish the fire. Thereafter, eliminate clothing and other items that may retain heat. Rinse/flush with water all areas exposed to heat, if possible. Cool the wound, but be aware of the risk for hypothermia by extensive cooling. Flushing/ rinsing is especially important if chemicals are involved. Remove rings, watches, and jewelry that may cause ischemia to extremities as they become swollen. • Take precautions not to become infected by contagious diseases because there is an increased risk of transmission of diseases such as hepatitis A and B, as well as HIV, through wound fluid and blood. Such precautions include gloves and wearing a visor that protects the mouth and eyes. These precautions have to be taken by all personnel who may come in contact with patients. Primary Survey The primary survey includes assessment according to the ABLS concept. Fluid treatment is added at this point compared with the common ATLS guidelines because it is considered important to start this treatment early during the care of burns.

203

Fig. 8.4 Localization of escharotomies is performed as shown by the lines in this figure. Especially over the large joints, as suggested in the figure, attention is needed to ascertain the correct depth of the cut. This often fails because the subcutaneous tissue is more difficult to ascertain at these locations

monoxide or cyanide intoxication is suspected. Be aware of circular burn injuries around the thorax because they may reduce thoracic compliance and have a constrictive effect as the edema progresses during treatment, thereby reducing the patient’s ability to breathe. This is most important for children who have a higher thoracic compliance and are more prone to be affected by this. Do not forget to stabilize the spine in patients with a suspicion of spinal injuries (see Chap. 7).

Airway

The airway needs immediate attention. Often a compromised airway can be secured by simply bending the neck back and pushing the jaw forward so that the tongue does not fall toward the throat and occlude the airway. Intubation may be indicated in the case of a threatening airway obstruction (see above). Breathing

It is important to assess breathing by examining the chest and listening to breath sounds corresponding to the border of the lungs. Note breathing depth and frequency. Provide oxygen at a high rate (15 L/min) through a nonrebreathing system to obtain high levels of FiO2. This is especially important when carbon

Circulation

Evaluation of circulation is best made by examining and assessing the circulatory status of the skin, its color, sensitivity, peripheral pulses, and capillary perfusion and refill after external compression. The latter often is affected in circular burns with an increasing local edema secondary to fluid resuscitation. In these situations, with acute pressure relieving incisions, escharotomies are mandatory and are important for tissue survival and to maintain extremity function. Suggested lines for escharotomies are shown in Fig. 8.4. At the marked areas over the major joints (marked by thick lines) are areas of special importance where there is a risk of insufficient incision depth when

204

performing the escharotomies because the evaluation here of the result is more difficult. Disability

Normally, the burn injured patient in the acute phase should be awake, alert, and readily responsive almost irrespective of the size of the burn injury. If that is not the case, in a major incident it should raise suspicion of an underlying complication such as other trauma, hypoxia, carbon monoxide intoxication, or other complicating medical condition such as diabetes. The disability should be rated according the Glasgow Coma Scale. Exposure

The examiner should remove clothing and inspect the wounds. However, be aware of the risk for hypothermia and counteract/treat such tendencies. Also remove rings and jewelry that may cause ischemia as the extremities swell and edema progresses. Clothes that are stuck to the skin may be left in place during acute triage. Fluid Treatment

Start fluid treatment with Ringer acetate solution 2–4 mL/kg/% TBSA and adjust the infusion rate to the urinary output, aiming at 30–50 mL/h. In cases of larger burns, insert a urinary catheter as soon as possible to estimate urine production. Secondary Survey The secondary investigation of the patient is performed just after the primary investigation (survey) and is made to examine in detail the patient from head to toe to rule out other important injuries that might have been foreseen during the first examination and may have importance for the final outcome. The burn injury is often the most eye-catching injury and there might be a risk that other important but less obvious injuries may be overlooked. A thorough secondary investigation reduces the risk of missing other injuries that may have significant effects on outcome. Additional Medical History It is important to gather as much information as possible regarding the injury and the underlying injury mechanisms; the treatment strategies planned will, to a large extent, depend on factors such as the injury mechanisms, time, and severity of the injury.

F. Sjöberg

8.2.2.2 Burn Wound Care with Excision and Grafting The initial acute care and fluid resuscitation phase is followed by the burn wound care period. This period is characterized by confirming the extent and depth of the injuries, surgically excising all full thickness injuries, and autologously transplanting the corresponding areas. This phase starts at the third day after the burn and continues until the wounds are covered by the patient’s own transplanted skin, which may take several weeks. During this period, repeated surgeries with skin transplantation activities are performed. Temporal wound coverings often are used based on biological materials such as porcine and donor skin; for large burns, cultured skin cells from the patient also are used during the transplantation process. It is preferable during this period that the patient be treated at burn centers by burn specialists if possible, even when connected to major incidents. 8.2.2.3 Rehabilitation and Reconstructive Surgery Even though the hospital length of stay for burn injuries today is approximately of one third of what it was in the early 1980s, it is still significant and is estimated at 1 day per percent TBSA. This means that a patient with a 70% TBSA burn will remain in the hospital for 70 days, i.e., more than 2 months. During this time, attempts are made to help the patient regain his or her preinjury physical and psychological functions. This is achieved with the help of advanced and aggressive physio- and occupational therapy. Scar compression therapy is another cornerstone in the treatment at this point. At this stage, reconstructive surgery may be needed, but such surgery also is used later in the rehabilitation course. It is also important at this point to stress the good functional and healthrelated quality of life outcome, which may be reached with modern burn care and which supports the active treatment approach. In previous times, the rehabilitation phase was considered to be an isolated entity at the end of the treatment chain. With modern care, this phase is becoming more integrated into the earlier phases of care.

8.3

Burn Care During Major Incidents

This section describes the principles for how the care of large numbers of burn victims can be undertaken and how the different levels of care can be organized

8

Incidents Caused by Fire and Toxic Gas

and operated. The description is based on the guidelines worked out by the International Society of Burn Injuries (ISBI), which is the combined and superimposed organization for the regional association in the world: American Burn Association; European Burn Association (EBA); Asian Burn Organization; South American Burn Association; and other national organizations. These guidelines were published in Burns in 2006 (see reference list). Most important in such planning is to clarify: • The different levels of care that have to be constructed and operational, and • How the patients should be cared for at these levels, as well as how the transport between these levels should be administered. In the ISBI guidelines, the three phases presented above are used. To these phases is added a first care level at the site of the incident, defined as follows: • First care, including primary triage, located at or close to the incident site, depending on local circumstances • Initial acute care and fluid resuscitation, including secondary triage • Burn wound care with excision, grafting, and infectious control • Rehabilitation and reconstructive surgery The planning and structure suggested above should not be regarded as fixed without possibilities for modifications. In this sense it is important to stress that local specifics, such as access to well trained staff, play an important role in the planning. Other incident specifics such as transport capabilities may significantly affect the planning. With increasing international cooperative measures as presently experienced, a level B facility may rapidly be turned into a level C by transporting the necessary staff and other resources provided by international support to this site. The transport of an injured patient starts at the site of the incident where the first care measures are made and primary triage is done. A flow chart is presented in Fig. 8.5.

8.3.1

Care Level A

A first aid station in a protected place, or an emergency department, may serve as a level A facility. It is important that this point can be reached by foot or is a short distance away from the incident site. Some units at level A may serve as triage stations, offering only lim-

205 Major Burn Incident

Primary triage and resuscitation

National/ international help Material, Staff, Burn specialists, Transport facilities, Rescue staff

Health care level 1 (primary care center, small hospital)

Health care level 2 (bigger hospital)

Health care level 3 ( major hospital, burn center)

Fig. 8.5 Flow chart of patient transports during the first days (1–3) after a major fire incident (After Haberal 2006, with permission) From the three burn care phases or periods suggested, the following care levels (hospitals and other facilities with specific resources and competences) may be defined: • Level A: Deals with the initial care, including classification, triage, and the start of fluid treatment. • Level B: Initial care and fluid treatment but also management of the second phase: “burn wound care with excision, grafting, and infectious control.” • Level C: Handles all phases of care but in the major incident setting, not least because of capacity reasons, engages mostly in the second and third phases: “burn wound care with excision, grafting, and infectious control” and “rehabilitation and needed reconstructive surgery.” These units are normally the tertiary-level burn centers. This level may well be units in other regions or, when there is international cooperation, units in other countries or possibly on another continent

ited medical aid and support. Others may, if the resources permit, function as level B stations (see below). There may even be mobile teams that can be transported into the incident area to perform triage and/or provide level A care. All burn injured victims that are taken care of at level A are thereafter sent either to care level B or C. The main object at level A is to perform triage, start treatment as soon as possible, then send the patients to the next care level, where they will be treated further.

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F. Sjöberg

8.3.1.1 Primary Treatment

8.3.1.2 Classiﬁcation of Casualties

The primary treatment is performed on scene or in its vicinity. In the major burn incident setting it is important to evacuate the wounded from the area quickly because it may be dangerous to remain. At this location it is important to: • Extinguish ongoing fire in clothing (roll and suffocate the fire); if water is available, flush to cool the wound, but be aware of the risk for hypothermia! • Perform triage and interventions previously described and within the ABLS treatment algorithms. • If there is scalding, try to get rid of the heat that is contained within the clothing. Do not hesitate to cut the clothing if it is difficult to remove. • Provide respiratory and circulatory support. • Be careful when manipulating the injured because there may be injuries other than the burn.

At care level A, patients are classified according to the severity of the injury and the future need for care. This classification can be performed according to a threelevel care scale that depicts the prognosis and the potential resource needs of the patient.

To Be Noted

At this early stage, it is important to be aware of the risk involved with facial burns and thermal injuries to the upper airways because they may, together with the effect of the fluid resuscitation, cause an upper airway obstruction. Such a situation is life threatening, even in conditions with good resources available. Before beginning transport of a patient with such a threat, the airway should be secured with oral intubation. Intubation should be performed for variable indications to avoid the risk of development of an upper airway obstruction during transport – something that may jeopardize the life of the patient. The patient should be covered with clean sheets and blankets to avoid hypothermia after the clothes have been removed. When evacuation from the injury zone has occurred, the focus should be directed toward the treatment of the burn and evaluation of the extent of the burn injury. At this point, the fluid resuscitation should be started if equipment and time is available. The extent of the injury should be established and a preliminary treatment plan scheduled (including recognition of the potential need for intensive care). The aim of this stage is to take initial care of the patients and protect them from further injury or complications in a safe place where the vital organ functions also can be secured and stabilized. After this initial care and triage, the patient is transported to the next level of care (Fig. 8.5).

Patients in Care Classiﬁcation Level 1: Major Burn Injuries The patients belonging in this category are those who have significant burn injuries, i.e., those with more than 20% TBSA full-thickness injuries. If possible, this category of patients should be referred to burn care specialists. Often a critical care facility is required, in some cases including ventilator treatment. Furthermore, the fluid treatment for these patients is more demanding. The airway is secured at this care level (A); at times, intubation is needed and ventilatory treatment is started. As mentioned above, it is important that the airway is secured before transportation. Good intravenous lines are important and they are inserted here if they are not already in place. When needed and if possible, central venous lines are administered here. A urinary catheter should be inserted and urine output closely monitored. If the airway is secured by intubation, a nasogastric tube also should be in place so that enteral nutrition can be started early. Close surveillance and monitoring of the patient is important, and he or she should be kept normothermic before transport to the next level (B). Patients in Care Classiﬁcation Level 2: Moderate Burn Injuries Patients with moderate burn injuries are those with less than 20% TBSA burned. These patients do not need intravenous fluid resuscitation. They obtain their first care at level A, and thereafter they are transported to assembly locations where patients with smaller injuries are gathered. They may personally take responsibility for further burn care as they are asked to contact level B and C later for further treatments and advice. If treatment is more urgent or needed earlier, the patient is referred to level C or, if such care is not presently available, to level B. Patients in Care Classiﬁcation Level 3: Small Burn Injuries Patients in this category (level 3) are examined and, if needed and if possible, are treated at care level A and

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Incidents Caused by Fire and Toxic Gas

207

Table 8.1 Guidelines for triage during major burn incidents Age (years) <2 2–5 5–20 20–30 30–40 40–50 50–60 60–70 >70

Total body surface area (%) 1–10 11–20 21–30 High High High Amb High High Amb High High Amb High High Amb High High Amb High High Amb High High High High Medium High High Medium

31–40 Medium High High High Medium Medium Medium Medium Low

41–50 Medium Medium Medium Medium Medium Medium Medium Medium Low

51–60 Medium Medium Medium Medium Medium Medium Medium Low Pall

61–70 Low Medium Medium Medium Medium Medium Low Low Pall

71–80 Low Low Medium Medium Medium Low Low Low Pall

81–90 Low Low Medium Low Low Low Pall Pall Pall

>90 Pall Low Low Low Low Low Pall Pall Pall

Modified from Saffle and Gamelli (2005), with permission Please note that this table only shall be used during major incident levels 2 and 3, when treatment resources are significantly reduced and there is a shortage of transport possibilities Priorities: High: A good resource:outcome ratio, good survival chances; high probability for good treatment outcome; often short length of stay (<14 days); reduced resource needs (one or two surgical procedures) Medium: A decent resource:outcome ratio, acceptable survival chances (>50%); needs aggressive fluid treatment and is resource demanding; longer length of stay (>14 days); need of several surgical procedures Low: Lower resource:outcome ratio, lower survival chances (<50%) despite extensive treatment attempts; high resource needs Pall: Palliative; poor resource:outcome ratio, high mortality (>90%) despite extensive treatment Amb: Ambulatory (outpatient care); good end results without inpatient care

thereafter referred to outpatient care by the ordinary care system, e.g., a general practitioner. The patient may be transported to an assembly area where further transportation is provided.

8.3.1.3 Triage As has been stressed earlier, large burn injuries are demanding on resources, and this has consequences for the care system during major incidents, when resources are scarce. On most occasions, the majority of the injuries are moderate or small; A “rule of thumb” is that approximately 80% of the injuries have a TBSA of less than 20%, and most often these can be taken care of as described above without major problems. A common finding is that the mean TBSA of the victims generally is larger in outdoor fires than in indoor fires. In the case of indoor fires, usually more patients are affected by inhalation injuries with a corresponding higher death rate. As a consequence it is more common with larger patient numbers and patients with injuries with a larger percentage of TBSA in large outdoor fire incidents. For patients with larger injuries (>20% TBSA), the resource consumption increases exponentially with the size of the injury. For extensive injuries, especially among the elderly, a high mortality rate can be anticipated. An predictable deadly outcome

may be identified irrespectively of the available treatment resources. In general, it can be stated that there is a 50% survival chance for victims younger than 60 years of age, given that the injury is less than 80% TBSA. The effect of age on the survival is significant; an 80% burn injury in a 20-year-old person is comparable to a 20% burn injury in an 80-year-old individual. Another important factor to be stressed in this triage is the exponential resource increase with increasing burn injury size. An example of guidelines for such occasions is presented in Table 8.1.

8.3.2

Care Level B

Early after the incident, care level B is engaged for the primary management and the start of fluid treatment. During the second week after the incident, the main task at this level is to deliver advanced burn care with a focus on skin transplantation, infectious surveillance, and care. Most patients at this level of care have been transferred from level A or, alternatively, come from other hospitals with care level B but have treatment capacities that have been overwhelmed. During the first week, it is important that these level B facilities have received specially trained burn care doctors and

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nurses with experience of treatment of major burns (burn surgeons, intensivists, and special burn care nurses). From the beginning of the second week, it is important that this care level also receives complementary support through the addition of plastic and general surgeons with burn care experience. An important part of the major incident planning and management is to ensure that these structures can maintain enough expertise, numbers, and resources and be supplied by other resources needed, such as psychologists and social workers. National and international burn associations and interest groups may at these occasions provide valuable support and aid. This may encompass aid in planning, organization, teaching, and training as well as providing burn care materials. If there is a burn center in the area or vicinity of the incident, it operates initially as a level B unit and it may, because of its expertise, handle larger numbers of victims. However, it is important that plans for further transportation of victims to care levels C locations are made at an early stage because the burn center will, as time progresses, be overwhelmed with patients and become short of resources.

8.3.3

Care Level C

This is the final care level and constitutes the hospitals that provide the treatment for the largest burns. In these settings, the burn-specific treatments for the larger injuries are started during the second week after the incident. It constitutes mainly continued wound care by continuous wound revisions, débridements, and skin transplantations to cover the wounds. This care level is based on regular burn centers with burn care specialists and complete burn care programs. If the incident is extensive, these centers need to be supported by resources from outside. These level C care centers may be situated within the incident area, but they may be located quite far from it. If the incident is of a large dimension, there might be a need for international cooperation with units located in other countries. The planning of international cooperation at this level should be undertaken with national and international burn care organizations as well as international aid organizations and military resources. Such planning should been done before an incident happens and should include plans for transport.

8.3.4

Transport of Patients

In Fig. 8.5, the transport processes are scheduled for the time period after the incident. In the early phase, i.e., during the first week, the main flow of patients will be between care levels A and B and between the different level B care facilities, with the latter depending on the resources available at each unit. From the second week on, there will be transportations mainly according to two routes, depending if the choice is: • To reinforce and provide extra resources at levels B and C, in or close to the incident area, or • To transport patients to units further away from the incident area with the available transport systems. It is important that there strategic decisions are made and a corresponding plan in place so that the process is optimized, i.e., all resources are used in the most effective way possible. In the first alternative listed above, specialists and resources are moved into the area and, for the second alternative, the strategy is based on the transport of patients out of the incident region. It is important to stress that, depending on the underlying situation, the choice as well as the outcome with regard to these alternatives may be significantly different.

8.3.4.1 Reinforcements of Different Care Levels As stated previously, the models presented above serve to show how the rescue work may be organized and conducted. It is important to underline that the specifics details and backgrounds for each incident will affect what the alternatives will be and what they will look like. These specifics will, to a significant degree, facilitate certain solutions and lead to the ruling out of others. One central aspect is to decide which parts of the scheduled operations will need early support and where to allocate the available resources. Although obvious, it needs to be stressed that, unless extensive resources are available and easily moved into the area, the scenario will be that of a significant shortage at almost all levels. Therefore, as fewer personnel and resources become available, a major task will be to strengthen all levels with national and possibly international resources and aid. Units at Care Level A The need to strengthen the units at care level A may be dependent on several factors. First and most important is the magnitude of the incident, the time perspective,

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Incidents Caused by Fire and Toxic Gas

and the available resources. Most often the main care at this level will be early triage and stabilization, and it may be assumed that the patients will stay at this location for shorter periods of time. In such cases, it is advantageous if burn care specialists can participate in this process. A prerequisite is that such resources are available and that they can be positioned at this location. If resources are limited, the specialist can contribute more at treatment levels B and C. If, on the other hand, the level A process is located at a hospital of a relevant size, the goal may be instead that the fluid treatment is started and optimized at this location and the patient is stabilized further for transport to the next care level. At this point, intubation may be performed in patients needing it. In cases of sufficient resources and time, a first and more extensive wound cleaning and care may be performed. This is particularly advantageous in situations where care levels B and C are becoming saturated. Then it could be advantageous to support level A with further expertise and materials. One important function that is essential at level A is its close link and relation to transportation facilities. Most commonly, level A serves as the admittance level and first aid activities before transport to levels B and C, and this process is urgent. It is then obvious that the transport capacities at this point will be crucial for these activities and the possibility of moving patients to the next level. Therefore, during the early planning phase it is important to have knowledge of the total transport capacity of the organization, i.e., how many vehicles are available and what possible organizations may participate in the process (e.g., rescue services, military, and volunteers). For example, these transport activities are often hampered by long distances or difficult terrain, which may call for helicopter transportation or aircraft support. Units at Care Levels B and C At levels B and C, during the early phase after the incident there are usually sufficient resources and expertise, at least in the beginning. The need for further resource support will depend on the total number of injured and the normal size of the units. In cases of an extensive incident, the need for further support is obvious and may encompass both resources and staff/ expertise. At this point, when the resources become saturated, there is a need to make a strategic decision about whether to strengthen the units at this level or to

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increase the transportation to other level B and C units located farther away. It is important to be aware of the longer treatment periods often called for by large/ extremely large burns, which may wear out the capacity of the units if they have to perform at supranormal levels for extended periods of time.

8.4

National and International Burn Care Societies

In countries that do not have a plan for fire incident management, help can be obtained by cooperating with national or international burn care societies, such as the ISBI (http://www.worldburn.org/) or the EBA (http://www.euroburn.org/), which can contribute their expertise. Most major burn centers are known to the officials in these organizations, and this knowledge can be of value for incident planning in connection to a major event. Other important functions that can be of value include provision of: • A list of nearby burn centers and their capacity and organization; • Contact information and help with the transport process by assessing the present workload and capacity of the units; • The number of burn care specialists that may be available and who are possible to recruit; • Resources for the planning of the long-term work by assessing the future resource need and possible alternative solutions; • Rapid teaching and training of staff and burn care personnel; • Help with delivering information to both media and the press and, not least, to provide expertise and advice to local authorities; and • Continuous flow of information between burn centers, authorities, and the media.

Further Reading American Burn Association. ABA website: http://www.ameriburn.org/ August 20, 2011 Arturson G (1987) The tragedy of San Juanico – the most severe LPG disaster in history. Burns Incl Therm Inj 13:87–102 Barillo DJ (2006) Burn centers and disaster response. J Burn Care Res 27(5):558–559 Barillo DJ, Dimick AR (2006) The Southern region burn disaster plan. J Burn Care Res 27(5):589–595

210 Broeze CL, Falder S, Rea S et al (2010) Burn disasters – an audit of the literature. Prehosp Disaster Med 25:555–579 Cairns BA, Stiffler A (2005) Managing a combined burn trauma disaster in the post-9/11 world: lessons learned from the 2003 West Pharmaceutical plant explosion. J Burn Care Rehabil 26(2):144–150 Cancio LC (2008) Invited critique: bridging the gap between disaster plan and execution. J Burn Care Res 29(1):166–167 Cancio LC, Pruitt B (2004) Management of mass casualty burn disasters. Int J Disaster Med 2:114–129 Frantz RR (2007) Firestorms and wildfires. In: Hogan DE, Burstein JL (eds) Disaster medicine, 2nd edn. WoltersKluwer/ Lippincott Williams & Wilkins, Philadelphia Greenfield E, Winfree J (2005) Nursing’s role in the planning, preparation, and response to burn disaster or mass casualty events. J Burn Care Rehabil 26(2):166–169 Haberal M (2006) Guidelines for dealing with disasters involving large numbers of extensive burns. Burns 32:933–939 Hogan DE (2007) Fires and mass burn care. In: Hogan DE, Burstein JL (eds) Disaster medicine, 2nd edn. Wolter Kluwer/ Lippincott Williams & Wilkins, Philadelphia Jordan MH, Mozingo DW (2005) Plenary session II: American Burn Association disaster readiness plan. J Burn Care Rehabil 26(2):183–191 Kennedy PJ (2005) The Bali burn disaster: implications and lessons learned. J Burn Care Rehabil 26:125–131

F. Sjöberg Mackie DP, Koning HM (1990) Fate of mass burn casualties: implications for disaster planning. Burns 16:203–206 Mozingo DJ, Barillo DJ (2005) The Pope Air Force Base aircraft crash and burn disaster. J Burn Care Rehabil 26(2):132–140 Saffle J, Gamelli RL (2005) Invited articles: Disaster Management and the ABA plan. J Burn Care Rehabil 26(2):183–197 Schenker JD, Goldstein S (2006) Triage accuracy at a multiple casualty incident disaster drill: the Emergency Medical Service, Fire Department of New York City experience. J Burn Care Res 27(5):570–575 Wachtel TL, Cowan ML (1989) Developing a regional and national burn disaster response. J Burn Care Rehabil 10(6):561–567 Wachtel TL, McQeen KAK (2007) Burn management in disasters and humanitarian crises. In: Herndon DN (ed) Total burn care, 3rd edn. Saunders Elsevier, Philadelphia, pp 43–67 Welling LA (2006) Consensus process on management of major burns accidents: lessons learned from the cafe fire in Volendam, the Netherlands. J Health Organ Manag 20:243–252 Yurt RW, Bessey P (2005) A regional burn center’s response to a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil 26(2):117–124 Yurt RW, Bessey PQ (2006) Burn-injured patients in a disaster: September 11 revisited. J Burn Care Res 27(5):635–641 Yurt RW, Lazar EJ (2008) Burn disaster response planning: an urban region’s approach. J Burn Care Res 29(1):158–165

9

Incidents in Cold and Wet Environments Sten Lennquist

The temperature levels in this chapter are given according to the Celsius scale (°C). For conversion to the Fahrenheit scale, the following formulas can be used: Celsius = 5/9 × (°Fahrenheit – 32); Fahrenheit = 9/5 × (°Celsius + 32)

9.1

Hypothermia

Hypothermia is defined as a body temperature 35°C or lower. Depending on how quickly the drop in body temperature has occurred, hypothermia is classified as: Acute: Rapid fall of body temperature, as occurs after falling into extremely cold water Chronic: Slow fall in body temperature, as when being lost or injured in a cold outdoor climate. Injured patients are usually hit by the chronic form, i.e., the cooling has occurred over a relatively long period of exposure. Long exposure has effects on different organ systems, such as a shift of body fluids and electrolytes and impairment of the coagulation system. These changes must be known and taken into consideration during treatment of such a patient. It is also important to know the duration of cooling for appropriate selection of treatment, e.g., the method of rewarming, which differs somewhat between the acute and chronic forms.

S. Lennquist e-mail: [email protected]

9.1.1

Effects of Cooling

For an injured patient lying on the ground because they became trapped, unconscious, or unable to move because of an injury, outdoor temperature below 0°C is not a prerequisite for becoming hypothermic. Hypothermia can in such a patient occur at several degrees above 0°C, especially if the injured is dressed to sit inside a warm transport facility (bus, train, airplane). In addition, the risk of hypothermia in an injured patient increases because of a rise in catecholamine secretion and/or circulatory shock. Certain injuries specifically promote hypothermia, such as a head injury with damage to the vasomotor center of the brain or a spinal injury with spinal cord transection. Hypothermia in the injured patient involves a risk for increased morbidity and mortality and requires special considerations during treatment to avoid further increase of this risk. It is therefore important that hypothermia is not overlooked, but always considered during treatment of injured who have been exposed to cooling, have been picked up from water, have spent a long time on the scene, or have been trapped. For the same reason, it is important to prevent hypothermia in the injured by protecting them from cooling from the ground, surrounding air, and wet clothes. Another reason not to overlook cooling and its effects is the difficulty to differentiate between death and hypothermia, a problem that previously has been, and in many areas still is, underestimated (see below). A nightmare for medical staff is to declare a hypothermic (but alive) patient dead, which has happened during recent years because of a lack of knowledge. This is the background of the rule that never must be

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_9, © Springer-Verlag Berlin Heidelberg 2012

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forgotten: “No one is dead until warm and dead”; i.e. the patient must be rewarmed before he or she can be declared dead.

9.1.2

Predisposing Factors of Hypothermia

Predisposing factors of hypothermia are: • High age, reducing the ability to maintain temperature by shivering • Young age, newborn and small children, in whom the skin surface is large related to the body core, thereby promoting cooling • Alcohol and drugs, which among noninjured is a common cause of hypothermia • Endocrine disorders (e.g., hypothyroidism, diabetic neuropathy) • Medication, for example b-blocking agents, which are commonly used today • Trauma (as described above)

9.1.3

Effects on Different Organ Systems

9.1.3.1 The Respiratory System During rapid cooling, the respiratory rate automatically increases and can at an early stage induce respiratory alkalosis, leading to convulsions, semiconsciousness, and even ventricular fibrillation. The respiratory rate decreases proportional to falling body temperature in individuals with a body temperature below 30°C, the respiratory rate can go down to 5–10 breaths per minute and breathing is shallow. If the temperature declines further, respiratory regulation by the central nervous system is affected. The impaired ventilation leads to carbon dioxide retention and respiratory acidosis. Pulmonary hypertension with fluid retention in the pulmonary capillaries appears subsequent to the vasodynamic effects described below and may, with further decrease in temperature, induce respiratory insufficiency and eventually respiratory arrest. 9.1.3.2 The Circulatory System The Heart Fall in body temperature leads to bradycardia, with a 50% reduction of heart rate, which can be even less at body temperatures of 28°C and lower. This bradycardia is resistant to atropine. Blood pressure declines and

cardiac output is reduced to approximately 50% at body temperatures of 28°C and lower. Electrocardiography (ECG) shows a prolonged PR interval, followed by widening of the QRS and QT intervals. A so-called “J-wave,” a positive deflection in the QRS-ST transmission, can appear when body temperature falls below 32°C. The size of this J-wave increases with falling temperature. A similar J-wave can occur during myocardial infarction, causing problems with differential diagnosis. Risk for arrhythmias occurs at a body temperature of 32°C. First extrasystoles occur, which with falling temperature can transfer into auricular fibrillation, followed by ventricular extrasystoles and ventricular fibrillation upon further decline of temperature. At temperatures of 28°C and below, the risk for ventricular fibrillation increases significantly, and at temperatures below 25°C the risk for asystole arises. Hyperkalemia and intracellular hypocalcemia aggravate this situation further. Resuscitation and ventilatory support – for example, with precordial stimulation and endotracheal intubation – has previously been considered to induce ventricular fibrillation and asystole. Recent experiences indicate that endotracheal intubation, when the patient’s condition so requires, can be performed with reasonable caution. However, it is of utmost importance always to pay attention to body temperature during the management of injured patients and not to forget that the hypothermic patient is sensitive to all manipulations and must be handled with great care. Blood Vessels A pronounced increase in catecholamine secretion contributes to the maintenance of core temperature and induces peripheral vasoconstriction. Initially, temporary vasodilatation protects peripheral parts of the body against cold injuries, but this effect disappears with further reduction in temperature and the risk for such injuries increases.

9.1.3.3 Renal Function and Fluid Balance During early hypothermia, the peripheral vasoconstriction caused by increased catecholamine secretion, as described above generates an initial increase in central blood volume, which leads to increased diuresis. This cold-induced diuresis begins 10–20 min after exposure to cold and may cause involuntary urination. It previously has been interpreted as an aqueous diuresis

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caused by reduced secretion of antidiuretic hormone. However, it has been shown experimentally that cold diuresis is an osmolar diuresis, with sodium and chloride as its main components. The underlying mechanism is increased catecholamine secretion, leading to peripheral vasoconstriction, increased central blood volume, and increased renal artery perfusion pressure. A rise in capillary pressure, secondary to increased renal artery perfusion pressure, increases the hydrostatic gradient against which sodium is transported, which leads to reduced sodium reabsorption. Sodium is therefore lost in the urine, with accompanying fluid losses. This cold-induced diuresis causes progressive hemoconcentration and reduced blood volume. In addition to urinary fluid loss, a pronounced extravasation of fluid into the interstitial space further reduces the blood volume. These effects of cooling occur before development of hypothermia and may lead to considerable loss of fluid and reduced blood volume. This means that the hypothermic patient can be expected to be hypovolemic, especially those with “chronic” hypothermia. The handling of a hypothermic patient without knowledge and consideration of this – for example, moving a hypothermic patient from a surface in a vertical instead of a supine position – may lead to a drop in blood pressure sufficient enough to induce cardiac arrhythmia.

9.1.3.4 The Central Nervous System Body temperatures falling to moderately lowered levels may induce confusion with inaccurate patterns of action, reducing the ability of the hypothermic patient to protect himself or herself from further cooling. At temperatures of 30–32°C, a hallucinatory state may occur. At 30°C, most patients become unconscious, but exceptions occur; some patients have the ability to react down to levels of 28°C. Below 32°C, peripheral reflexes decline and finally disappear (at approximately 27°C). This is also valid for the corneal reflexes. The pupil reaction to light ceases at approximately 33°C.

To be aware of:

Knowledge of these neurologic consequences of hypothermia is of critical importance when differentiating between a dead and a deeply hypothermic patient.

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At body temperatures of 25–35°C, the metabolism of the brain is linearly reduced. Electroencephalography (EEG) shows abnormalities at body temperatures below 33°C and no activity below 19–20°C. This means that the absence of registered activity on EEG below this body temperature should not be interpreted as brain death!

9.1.3.5 The Coagulation System Hypothermia at temperatures below 33°C induces a coagulopathy equivalent to significant factor deficiency states under normothermic conditions, despite the presence of normal clotting factor levels. Thrombocytopenia caused by bone marrow depression and sequestration of platelets in the spleen and liver may also cause bleeding. Hypercoagulation may occur because of the release of factors from hypothermic tissue and increased catecholamine secretion, inducing a clinical picture resembling disseminated intravascular coagulation.

9.1.4

Clinical Signs and Symptoms

• Skin is pale and cold, especially at the periphery of the limbs • Respiration becomes shallow and slow and can, at low temperatures, be difficult to register • Heart rate becomes slow and weak, and at low temperatures may be difficult to register • Blood pressure becomes difficult to determine at temperatures below 31°C • Consciousness declines gradually and is totally lost at varying temperatures (between 30°C and 26°C) • Reflexes decline at 32°C and disappear at 27°C, as does the corneal reflex, and at this level pupil reactions also disappear Table 9.1 summarizes these findings on a falling temperature scale. This means that the hypothermic patient may be alive despite being cold and stiff, missed detectable signs of breathing and circulation, and missed detectable reflexes and peripheral as well as corneal and pupil reactions. This is the base for the implementation of the rule: “Nobody should be declared dead until warm and dead.”

9.1.4.1 Determination of Body Temperature The simplest method to use in the prehospital setting is determination of tympanic temperature. This requires

214 Table 9.1 Symptoms and clinical findings related to body temperature Temperature (°C) Symptoms/clinical findings 36 Increased metabolic activity, shivering 35 Maximal metabolic activity, hyperventilation 33 Shivering declines; abnormalities can be seen on EEG 32 Progressing confusion; appearance of (initially innocent) arrhythmias 31 Blood pressure difficult to register 30 Declining respiratory rate down to 5–10 breaths per min 28 Declining heart rate; risk of arrhythmias that may be difficult to control 27 Reflexes, even corneal reflex, disappear; the pupils’ response to light disappears 26 Unconsciousness; poikilothermia (the inability of the body to maintain temperature) 25 Risk for spontaneous ventricular fibrillation and asystole 19–20 EEG shows no activity, even if the patient is alive EEG electroencephalogram

special thermometers that can record low temperatures. Tympanic thermometers for normal indoor use, using infrared techniques, are not totally reliable for outdoor use; most of them lose some reliability when the surrounding temperature goes below 16°C. The most reliable tympanic thermometer on the market is the Metraux thermometer, which shows accurate values in the interval of –16°C to +60°C (accuracy ±0.5%). However, the most reliable method of measuring body temperature is determination of esophageal temperature, which should be used when hypothermia is suspected. The method is available today in many, but not all ambulances, which varies between countries. It is the method that should be used primarily in hospitals in cases of confirmed or suspected hypothermia (see below for further description of methodology).

9.1.4.2 Prehospital Management The primary management of a hypothermic patient follows the same principles as for other injured patients, according to the advanced trauma life support (ATLS) concept. The following recommendations deal only with what is specific for hypothermia, and they are important to consider during the management of these patients during a major incident.

S. Lennquist

Airway Securing the airway may be difficult in the unconscious and hypothermic patient because of rigidness and difficulty with opening the jaws. Previously, the restrictiveness of tracheal intubation in hypothermic patients had been recommended because of the risk to induce arrhythmias. The dominating opinion today, based on extensive experience of intubation of hypothermic patients, is that the same indications for intubation valid for other forms of trauma also should be valid for hypothermia. However, it is again emphasised that all handling of a hypothermic patient must be done with great care. If the patient has stiff jaws, making an oral intubation difficult, nasal intubation may be an alternative. However, note the risk of bleeding because of fragile mucosa in the hypothermic patient. Breathing The extremely slow and shallow breathing in a deeply hypothermic patient can be difficult to register (Table 9.1). If no spontaneous breathing can be detected, the patient has to be ventilated carefully (see below). As soon as possible and if possible, all hypothermic patients should be given oxygen (4–6 L/ min with a bridle or 40–60% with a mask), if possible slightly heated to reduce the risk of further heat loss. Circulation Note the difficulties in registering the pulse of a deeply hypothermic patient (Table 9.1). If the radial pulse is undetectable, try the groin, then the carotid artery; the latter must be used with great care to avoid vagal stimulation and a further decrease in blood pressure and arrhythmia. On suspicion of circulatory arrest, cardiopulmonary resuscitation (CPR) with compression of the heart should not be done until asystole has been confirmed with ECG. Starting external compression of the heart when the heart still is functioning, albeit with a slow and weak pulse, may induce a lethal arrhythmia. However, pulmonary ventilation may be of benefit and should start even without ECG monitoring. ECG monitoring of the deeply hypothermic patient in the prehospital setting may be difficult, and needle electrodes should be included in the equipment for a cold environment because normal electrodes can be difficult to attach to the skin of these patients.

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Confirmation of cardiac arrest is, in a “normal” situation, a clear indication to start CPR; a deeply hypothermic patient can survive and return to full health after a period of asystole. In a major incident, this is a matter of priority (see Sect. 9.1.7). CPR can be difficult during deep hypothermia because of the rigid chest wall, but there are many examples of deeply hypothermic patients who have survived after such treatment. There are diverging opinions as to whether CPR should be done at “half speed” because the need for oxygen is reduced, and some authors propose that CPR at slow speed might be sufficient and less traumatizing. Others suggest that CPR should not necessarily be given at a slower rate than that use for the normothermic patient. The compression rate chosen should allow for maximum filling of the left ventricle, and that rate is difficult to calculate because stiffness of the chest wall might reduce the output. To summarize, the condition of the chest wall should be taken into consideration when selecting strategy. Because many hypothermic patients have survived several hours of CPR, it should (in the normal situation) continue until the patient is in the hospital, and then proceed further until the patient is rewarmed. If there is no cardiac response at a temperature of 33°C, the patient can be declared dead. Intravenous infusion (or intraosseous, which is the alternative when there is a lack of identified veins; see Chap. 7) should be given as early as possible. However, an absolute prerequisite for this is access to preheated fluids (37–40°C) and equipment to keep not only the fluid warm during storage, but also the fluid bag and tube during infusion (Fig. 9.1). The temperature of unprotected bags and tubes falls quickly in cold environments, and infusion of cold solutions will aggravate the patient’s condition in inducing vasoconstriction, cardiac depression, hypoxia, and acidosis. In “pure” hypothermia, glucose solutions 5% heated to the level given above is a good alternative to start with. In hypothermia combined with trauma, the principles described in Chap. 7 are valid. Disability Reduced consciousness can be an effect of hypothermia. Consider the temperatures at which the response to different stimuli disappears consequent to the hypothermia (Table 9.1). As in trauma, it is important to register continuously the level of

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Fig. 9.1 Equipment for keeping the fluid bag as well as the tube warm is an absolute prerequisite for giving intravenous fluid to patients in a cold environment

consciousness and the response to talk and pain, which can be done according the principles described in Chap. 7.

9.1.5

Protection from Further Cooling

It has been emphasised that external rewarming of a hypothermic patient opens peripheral shunts, thereby redistributing cold blood and fluids to the still-warm body core, with a drop in core temperature as a consequence, as well as risk for arrhythmias connected to that. This is valid mainly for those exposed to cold for a long time (chronic hypothermia). The risk is probably overexaggerated also for those exposed for a long period of time, but there is still reason to be careful and avoid massive external heating without simultaneous rewarming of the body core. However, this does not mean that the patient should not, as soon as possible, be placed in an environment that prevents further cooling: remove wet and cold clothes carefully, insulate the patient with dry clothes and blankets, and place him or her in an environment that maintains body temperature. This means a surrounding temperature of 25–30°C and should not be confused with active rewarming. All possible rewarming of the body core in the prehospital setting is always indicated in cases of hypothermia, using methods such as infusion of heated fluid, as mentioned above, as well as heated oxygen from a bridle or mask. Conscious patients are allowed to drink hot fluid if they do not have injuries preventing this.

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a

b

Fig. 9.2 (a) Moving a hypothermic patient from the ground or water surface, for example, into an helicopter, should never be done with the patient in a vertical position; these patients are hypovolemic and moving them in such a position may cause a drop in blood pressure sufficient to induce arrhythmia. Stretchers

for moving patients in horizontal position should be included in equipment, especially in cold environments. (b) In the absence of such a stretcher, a double sling around the patient’s knees and shoulders can be used

9.1.6

9.1.7

Positioning, Evacuation, and Transport

All handling of hypothermic patients should be performed with great care because all manipulations at low body temperatures involve a risk for impaired circulation and arrhythmias, as has been emphasized. When a hypothermic patient is taken up from the ground or water surface in, for example, a helicopter, the vertical position of the patient should be avoided because this can induce a decrease in blood pressure in an already hypovolemic patient. A special stretcher for this, with possibility of moving the patient in horizontal position and simultaneously protecting against further cooling, should be included in equipment used during rescue missions over water or in cold environments (Fig. 9.2a). In the absence of this, a “double sling” can be placed under the shoulders and knees of the patient during movement (Fig. 9.2b).

Triage

Because the body temperature influences and partly determinates the priority, the principles for triage in the prehospital situation depend on the possibilities of determining body temperature. This varies and is dependent on (1) access to equipment and (2) access to time and staff, as during a major incident. Two different triage models are discussed here according to these different conditions.

9.1.7.1 Triage Without Determination of Body Temperature Immediate (Red) • Patients with injuries involving threat against vital functions, or in whom the injury itself justifies high priority (see Chap. 7) • Cold patients who are unconscious (no response to talk) • Apparently deeply hypothermic patients without signs of life

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Incidents in Cold and Wet Environments

Can or Shall Wait (Yellow or Green, Depending on the Scenario) • Cold patients who are conscious and have no threat to vital functions and who have no injuries justifying high priority • Apparently deeply hypothermic patients who have been under water or buried in snow for long time (see below) With regard to the latter category, a time limit of 15 min has been recommended previously. However, during recent years a number of hypothermic patients have survived even longer under water, which makes recommendations with regard to time difficult (see Sect. 9.5).

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that shows no activity (“nobody is dead until warm and dead”). This means that declaration of death for patients who have confirmed or suspect hypothermia not should be done in the field. There are two exceptions to this: • The patient’s airway is completely filled with snow, ice, or water (found during attempted intubation) • The patient has apparently fatal injuries (e.g., “head separated from body”) These rules may seem to be strict and rigid. However, declaration of death by mistake has occurred under these circumstances, and it has been proposed that it most likely has happened more often than it has been discovered. This is not acceptable and justifies strict rules for declaration of death, as listed above.

9.1.7.2 Triage with Determination of Body Temperature

9.1.9 Immediate (Red) • Injuries involving threat against vital functions or injury that in itself justifies high priority • Unconscious (does not respond to talk) • Body temperature below 28°C Urgent but Can Wait (Yellow) • No threat to vital functions and no injury justifying high priority and • Conscious (responds to talk) and • Body temperature between 28°C and 32°C Shall Wait (Green) • No threat to vital functions and • Conscious (responds to talk) and • Body temperature above 32°C The temperature limit of 28°C – determining the borderline between red and yellow – is based on the risk for poikilothermia appearing at that level, i.e., the ability of the body to maintain temperature declines and the body temperature starts to decrease rapidly, which means a life-threatening condition; it is not possible to define this without determining body temperature in the field.

9.1.8

Criteria to Declare Death

A cold, unconscious patient without apparent signs of life should never be declared dead before rewarming to a body temperature 32°C and an ECG at this temperature

In-hospital Management

9.1.9.1 Determination of Body Temperature If determination of temperature not has been possible during prehospital management, this may be the first stage at which the diagnosis of hypothermia can be confirmed and/or the body temperature determined. The importance of control of body temperature in all severely traumatized patients is emphasized, especially after a long prehospital phase, which often is the case in major incidents. The safest and most accurate method during initial management in the hospital is measuring esophageal temperature – a probe is inserted in the middle part of the esophagus, where it gives the temperature corresponding to the left atrium of the heart. If the probe is inserted too high in the esophagus, it will be influenced by the tracheal temperature. However, this method requires equipment with a probe and recorder. In the absence of that equipment, rectal temperature can be used, but regular rectal thermometers are to inaccurate; thermometers for routine use are unable to record low temperatures. Accurate determination of body temperature through the rectum of a hypothermic patient also requires a probe, inserted to a level of 10 cm above the sphincter. A probe in the urinary bladder is another alternative. Tympanic temperature can also be used and, for indoor use, tympanic thermometers based on infrared techniques have acceptable accuracy with the presumption that they are able to record low temperatures (which routinely used tympanic thermometers are not).

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9.1.9.2 Primary Management of the Hypothermic Patient in Hospital As in the prehospital setting, the primary management of the hypothermic patient in the hospital follows the same principles as for other injured, according to the ATLS concept. The following recommendations only deal with what is specific for hypothermia and are important to consider during the management of these patients in a major incident. Airway The same rules for tracheal intubation as those for other injured patients are valid (referring back to the considerations regarding the risk of intubation at low body temperature). The patient should, if possible, be connected to a saturation monitor and liberally oxygenated before intubation (4–6 L/min with a bridle or 40–60% with a mask). A gastric tube is recommended. Oral intubation is the first alternative; if this is difficult because of rigid jaws, nasal intubation can be considered, again with attention paid to the risk of bleeding from fragile nasal mucosa. Breathing Note the difficulty of registering the slow and shallow respiration of a deeply hypothermic patient. When the absence of spontaneous breathing is suspected, ventilatory support should be provided and the patient should be intubated, according to the guidelines above. Circulation • Connect the ECG for continuous surveillance. • If possible, insert an arterial line to register blood pressure, which in a deeply hypothermic patient may be difficult to register with a noninvasive technique. • Establish a venous line, which might be difficult and require cut- down. Use of a central venous line should be restricted initially because a catheter in the right atrium or in the pulmonary artery might mean a risk of inducing arrhythmia. • Insert a bladder catheter for continuous registration of urinary flow. • Start or continue intravenous fluid with heated solutions: 37–40°C, 5% glucose with the addition of electrolytes according to laboratory findings. Some changes in acid-base and electrolyte balance are caused by the hypothermia itself and will normalize when the patient is rewarmed; this is

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why “over-correction” has to be avoided (see Sect. 9.1.9.2.6). Ringer’s acetate should be used restrictively because of difficulties the hypothermic liver has when metabolizing lactate. Otherwise, shock treatment can be given according to the same principles as those used with other injured (see Chap. 7). Disability In the hospital, it is time for a more thorough neurologic examination according to the Glasgow Coma Scale. Consider the effects of body temperature on different neurological findings according to Table 9.1. In a patient with deep hypothermia and weak or absent signs of life, EEG should, if possible, be connected, but consider that EEG stops showing activity at body temperatures below 19–20°C even if the patient still is alive. Safe registration by EEG can be done after first rewarming the patient to a body temperature above this level. Exposure All clothes must now be removed and a thorough clinical investigation performed, after which the patient should be insulated with dry and warm blankets. Laboratory Findings Many laboratory tests are affected by the cold temperature itself, which has to be taken into consideration when evaluating the laboratory results of a severely hypothermic patient. Blood Status

Haematocrit and haemoglobin levels rise as a result of cold diuresis, which makes it difficult to evaluate blood loss based on those values. Platelet count as well as white cell count decline in lower temperatures after long exposure because of bone marrow depression and sequestration of cells in the spleen and liver. Acid-Base Balance

Initial respiratory alkalosis, which is specially pronounced in acute hypothermia caused by hyperventilation, is later transferred into respiratory acidosis because of respiratory depression. This is accompanied by a metabolic acidosis caused by lactate formation during shivering, impaired circulation with tissue hypoxia, and ketogenesis in the liver. How active one should be in correction of this acidosis is controversial: It is a natural consequence of the cooling, it will spontaneously be corrected upon rewarming, and attempts

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Incidents in Cold and Wet Environments

to correct it that are too active can instead lead to pronounced metabolic alkalosis, which not is desirable. This should be considered during the treatment of the hypothermic patient, which should be done under careful clinical surveillance and repeated controls with regard to acid-base balance. Electrolytes

Potassium has to be carefully checked because hyperkalemia, which may occur in chronic as well as acute hypothermia and is a bad prognostic sign, increases the risk for ventricular fibrillation. The risk of hyperkalemia increases in combination with crush injuries or renal failure caused by other reasons. For initial treatment of hyperkalemia, intravenous fluid for dilution is recommended; if insufficient, the effect can be enhanced with the addition of glucose and insulin. A potassium level higher than 10 mmol/L is a very poor prognostic sign. Sodium is often low, especially in patients with chronic hypothermia, and is caused by osmolar diuresis with the loss of sodium occurring through the renal tubules. Blood Glucose

In acute hypothermia, blood glucose is usually raised through catecholamine-induced glycogenolysis. In chronic hypothermia, prolonged exposure to cold with shivering, fatigue, and exhaustion of glycogen stores leads to hypoglycemia. Persistent hyperglycemia during rewarming can be caused by hemorrhagic pancreatitis as a complication of hypothermia, trauma, or diabetes. Insulin has no effect at body temperatures below 30°C. Repeated doses can instead lead to severe hypoglycemia during rewarming.

9.1.9.3 Rewarming Passive Rewarming At a body temperature of 32°C, so-called passive rewarming is usually sufficient; the patient is isolated in blankets (or other isolating material) in a room at a temperature of approximately 25°C and is allowed to drink hot fluid with nutritional supply (if the patient is fully awake and has no other injuries preventing this). This passive rewarming is a slow process and allows for a rise in body temperature of 0.5–2°C/h. If faster rewarming is required, e.g., for acute surgery, other methods of rewarming must be considered (see below).

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However, even if it is slow, this passive rewarming is a simple and safe method and can, in situations with limited resources such as major incidents, be used even in patients with body temperatures below 32°C. Active Rewarming When resources and experienced professionals are available, active rewarming can be used for patients with body temperatures below 32°C. Such rewarming can be either external, warming from outside the body, or internal, warming of the body core. Before active rewarming is started, the patient should have secure intravenous lines and be connected to an ECG monitor. Infusion should have been started with warm solutions (5% glucose at 37–40°C) to provide simultaneous warming of the body core. External Rewarming

There are many methods for external rewarming: • Hot blankets and water bottles • “Warming roof” of an intensive care unit model • “Bair Hugger,” which are sets of perforated wrappings through which hot air is blown • The “Vanguard” technique, which heats the venous blood in the limbs • Chemical heat pads • Hot water bath at a temperature of 40–42°C Warm material of any kind applied to the cold skin of a hypothermic patient with impaired circulation involves a risk for local burn injuries, which has to be considered if an alternative like hot blankets, bottles, or heat pads are used. A hot-water bath interferes with CPR in cases of ventricular fibrillation and should therefore only be used when there is access to special equipment and experienced staff. The Bair Hugger technique may be the safest and most widely used technique for external rewarming. Internal Rewarming

Several methods have been used for internal rewarming: • Inhalation of heated air • Peritoneal lavage with heated solutions • Thoracic lavage in the pleural sac • Extracorporeal circulation Inhalation of heated air can be used with air temperatures up to 40–45°C; higher temperatures involve a risk of burn injuries in the airways. It can also be used in the prehospital setting. The effect is higher if

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the patient is intubated (heating effect of 1.2°C/h compared with 0.7°C/h using a ventilation mask). Thus, the method is slow but has the advantage of simultaneously securing good oxygenation. Peritoneal lavage with irrigation of the abdomen with isotonic saline 40–45°C is a simple and safe method. Two liters of fluid is infused every 20 min, which is replaced by two new, heated liters; this exchange goes on until the patient’s temperature is normalized. The rewarming effect is 1–3°C/h. Thoracic lavage with infusion of heated fluid in one or both pleura is a somewhat more dramatic method, used for hypothermic patients in cardiac arrest. Two drains are inserted: one in the medioclavicular and one in the posterior axillary line (the latter for evacuation), and 1–3 L of isotonic saline solution heated to 40–42°C is infused. Extracorporeal circulation has during recent years been used whenever available for treatment of deeply hypothermic patients. This method makes it possible to maintain circulation even during temporary cardiac arrest. A “complete” (via sternotomy) or “partial” (femorofemoral bypass) approach can be used. The rewarming effect is 1–2°C/5 min, which means a quick and safe method. It does, however, consume resources, and there may be no or limited access to it during major incidents. One disadvantage of internal rewarming in trauma patients has been the need for complete heparinization. However, new methodology with preheparinized perfusion catheters without systemic heparinization has been used recently in patients with hypothermia and simultaneous intracranial trauma, which may open new possibilities of using this method in trauma patients, with minimal risk of inducing bleeding.

9.1.9.4 Selection of Rewarming Method When selecting the rewarming method, several factors must be taken into consideration. If the patient has an injury requiring or that is expected to require surgery, a faster way of rewarming is preferred. Even if the patient has a severe trauma that does not require surgery, the hypothermia is a complicating factor that must be corrected as soon as possible (see Chap. 7). The fastest method – extracorporeal circulation – requires rapid access to special resources that may not be available or not can be given priority in a major incident. In addition, this method has effects on coagulation and respiration similar to those caused by trauma, and the additive effects of this must be taken

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into consideration if selecting this method, which from other points of view has apparent advantages. With a lack of resources, the disadvantages of a slower but safe method may be a price worth paying for limited consumption of resources when the patient’s condition does not require rapid normalization of body temperature.

9.2

Results of Treatment of Hypothermia

To date, the lowest temperature registered in accidental hypothermia and followed by survival is in an adult (13.7°C) and a child (15°C). However, it must be considered that intentional cooling in connection with open heart surgery is routinely done at a body temperature of 25°C in adults and 15°C in children, with excellent results and few complications. This illustrates that even deep hypothermia is a condition compatible with survival. This makes it important not to overlook or disregard hypothermia and to have knowledge about the risks connected with it and the available diagnostic and therapeutic methods for the management of hypothermic patients. Mistakes can lead both to incorrect declaration of death (which should be a nightmare for every medical responder) and to preventable death caused by inaccurate management. Most likely, the risk for and incidence of hypothermia is still underestimated today because of insufficient awareness of this serious, but in most cases curable, condition.

9.3

Cold Injuries

9.3.1

Risk for Cold Injuries in Traumatized Patients

A traumatized patient who has been exposed to cold runs an increased risk for cold injuries because the increased catecholamine secretion caused by trauma is added to the trauma caused by cold exposure itself. This can be futher added to by psychological stress, which is common in major incidents. As described above (see Sect. 9.1.1), catecholamine secretion induces a peripheral vasoconstriction to preserve the temperature of the body core. The peripheral parts of the body are initially protected by an intermittent peripheral vasodilatation, but this effect declines as body temperatures decrease and the risk for peripheral cold injuries increases.

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Table 9.2 The influence of wind speed on the cooling effect at different temperatures Temperature (°C) Wind velocity (m/s)

0

−5

−10

−15

−20

−25

−30

Corresponding effect on unprotected skin in calm weather

Calm (0)

0

−5

−10

−15

−20

−25

−30

Slight wind (0−3,5)

−4

−14

−20

−23

−26

−28

−33

Moderate wind (3,5−8)

−10

−21

−25

−32

−38

−45

−52

Fresh wind (8−14)

−15

−25

−28

−36

−48

−56

−63

Strong wind (14−20)

−18

−27

−33

−38

−51

−57

−57

Half gale (21−25)

−19

−28

−36

−43

−52

−60

−68

After Siple and Passel (1945)

Cold injuries can be categorized as: • Frostbite, which occurs at external temperatures below 0°C, where the dominating factor is the direct effect of cold on the cells • Nonfreezing cold injury (NFCI), which occurs above external temperatures of 0°C and is caused by a combination of cold and damp environment and long periods of immobilization The major incident involves a high risk not only for the first category, but also for the second category, which is easily overlooked because it may occur at temperatures far above 0°C, in which cases rescue and medical staff may be less observant of the risk. Knowledge and awareness about it is, therefore, important for all medical responders.

9.3.1.1 Frostbite Pathophysiology Frostbite occurs when the local loss of heat increases above the ability of the body to maintain temperature. Loss of heat can occur through: • Conduction through air, ground, water, snow, or ice or through metal or other materials with a high conduction capacity • Convection through air or water • Irradiation of heat, especially from naked skin

• Evaporation by transfer of water to steam, mainly via respiration The ability of the peripheral parts of the body to maintain temperature can be reduced through: • Peripheral vasoconstriction (as mentioned above), especially when the protective intermittent vasodilatation declines with falling temperature • Immobilization (e.g., by an injury or being trapped), which reduces heat production via reduced muscular activity The risk for frostbite is naturally higher when the body surface comes into contact with media with higher conductive capacity. Water, and wet clothes, conducts heat 25 times better than dry air. Snow and ice conduct heat 70 times better than air, iron and steel approximately 1,800 times better, and metals, such as copper and aluminium, conduct heat approximately 10,000 times better than air. Factors other than external temperature influences the risk of frostbite, including: • Wind speed: Table 9.2 illustrates the influence of wind speed at different temperatures. For example, a temperature of 10°C in calm weather corresponds to a temperature of –33°C at a wind speed of 15 m/s, which means a high risk for frostbite

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Fig. 9.3 Superficial frostbite. Pale skin with a wax-like appearance, which in superficial injuries is still soft and malleable against underlying tissues. This injury returns to normal after thawing

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Fig. 9.4 Deep frostbite that, after thawing, turns into a reaction phase with red and edematous skin with blisters that can be filled with clear fluid or blood. Blood-filled blisters are a poor prognostic sign

• Humidity: as mentioned above, water and damp clothes conduct temperature better than air, and the risk for frostbite increases significantly with higher humidity in the air The duration of exposure also influences the risk for frostbite. Symptoms and Clinical Findings Frostbite often begins with a stabbing local pain that quickly is replaced by complete local anaesthesia, which means that the injury can be overlooked easily. The skin becomes pale white with a wax-like appearance (Fig. 9.3). Initially, the skin is soft and malleable against the underlying tissues, which means that the frostbite still is superficial, and the skin returns to normal after thawing of the injury (see below). If the injury is overlooked and the exposure continues, the skin becomes hard and fixed against the underlying tissues (deep frostbite). When this deep injury is thawed, the skin becomes red and edematous. Blisters filled with fluid may appear within a few hours (Fig. 9.4). Vesicles filled with clear fluid are a good prognostic sign, whereas blisters filled with blood indicate a higher risk of loss of body tissue. The most severe degree of deep frostbite is that which, upon thawing, not develops flush or vesicles but remains cold and cyanotic. Such tissue will be mummified within a few days (Fig. 9.5). After an interval of up to 3 months, a line of demarcation appears between healthy and dead tissue and can lead to spontaneous amputation (Fig. 9.6). This spontaneous line of demarcation usually occurs more distally than the initial clinical evaluation indicates, which is the reason for surgical expectancy in the treatment (see below).

Fig. 9.5 Severe deep frostbite that upon thawing does not transfer into the reaction phase (as described in Fig. 9.4), but instead moves directly into a gangrenous phase. This injury will lead to considerable loss of tissue

Prehospital Treatment Frostbite that is thawed and thereafter is refrozen immediately or within a short period of time involves a risk for a more severe injury. In the past this has been the basis for a strategy of restrictiveness in thawing frostbites in the field. However, the longer an injury remains unthawed, the bigger the risk for deeper tissue involvement. Thus, frostbite injuries should be thawed as soon as possible (in the prehospital setting), and these patients should be protected from further cold exposure to the extent possible. In the prehospital treatment of frostbites, it is important to treat the whole patient: Protect him or her from cold, humidity, and wind and supply him or her with warm, dry clothes and hot beverages (if the patient is conscious).

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Incidents in Cold and Wet Environments

Fig. 9.6 A line of demarcation between healthy and damaged tissue often appears spontaneously after an interval of up to 3 months and may lead to spontaneous amputation

Outdoors or under field conditions, the simplest way of thawing is to use the rescuer’s own body heat, for example, by putting the frozen hand or foot inside the clothes of the rescuer. Rubbing with snow, which was done in the past, only gives a false feeling of heat and involves the risk of worsening the injury; it is therefore contra-indicated. Deep injuries may require analgesia because thawing can be painful. If parts of the clothes are frozen and firmly attached to the skin, they should not be removed until indoor thawing in a water bath can be performed. In-hospital Treatment In the hospital (or if the transport time to hospital is long, as soon as the patient can be taken indoors), thawing is best done in water in a whirlpool bath or bathtub at a temperature of 40–42°C. It is preferable to have the whole patient immersed in the bath. An ordinary bathtub can be used, but units in areas with a high risk of cold injuries are often equipped with special bathtubs with lifts, thermostats, large water flows, and constant circulation. After thawing, anti-inflammatory drugs (for example ibuprofen 600 mg/day for 6–7 days) are recommended. Patients with superficial frostbites (full recovery after thawing) or less severe deep frostbites (only flushing after thawing) can be discharged and checked ambulatorily. If edema or blisters occur after thawing,

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observation in the hospital should be considered; this is always indicated in cases of blood-filled blisters and in patients in whom the injury remains cold and cyanotic without a reaction phase. Such injuries should be treated with elevation of the injured limb, which should be carefully protected from all kinds of trauma or pressure. Analgesia may be required for a considerable length of time. Epidural pain relief has the advantage of improving microcirculation. The patient should be observed with regard to compartment syndrome: if compartment pressure is suspected and the limb has been elevated, fasciotomy should be considered (see Chap. 7). Blisters filled with clear fluid can be unroofed and treated with a mild prostaglandin inhibitor, such as aloe vera ointment. Blood-filled blisters should be left intact and allowed to shrivel naturally and, if they burst, should be dressed with antibiotic ointment. The injured limb can be treated with a whirlpool bath at 40–42oCa, with antiseptic solution added, twice daily for 20–30 min to remove loose tissue and bacteria. If not contraindicated by other injuries, acetylic acid can be given as prophylaxis against thromboembolism. No effect of heparin has been proven. However, infusion of dextran 40 (25 mL/h as infusion) has been shown to improve the result in some cases. The effect of hyperbaric oxygen, which if used should be administered early, has not been convincing in these cases. However, early physiotherapy is important and there may be a need for early psychological support. As mentioned above, it may be difficult during the initial stage to evaluate where the final demarcation against healthy tissue will be located. Technetium scanning has been shown to be of value in this evaluation during recent years, as has magnetic resonance angiography, if such resources are available. Clinical experiences have shown that this demarcation in most cases will be more peripherally located that initially assessed. Amputation should not, therefore, be considered until the demarcation has been clearly indicated, which may take a long time. There is an old saying: “frozen in January, amputation in July,” which probably should be revised, but a period of at least 3, perhaps 6, weeks should be recommended to avoid too proximal of an amputation. In case of infection, it may be justified to create drainage with wound revisions, but this should be done with care so it does not lead to unnecessary loss of tissue.

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Long-Term Sequelae After Frostbite Pain on exposure to cold is the most frequent sequelae and may last throughout life. Other long-term complications are hyperhidrosis and fungal infections. Arthritic changes can be seen in children who have frozen before the epiphyses have fused. Patients exposed to deep frostbite have a persistent increase in sensitivity to new frostbites and should avoid being exposed to cold to avoid risk for repeated injuries.

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Also as in frostbite, the patient should be carefully observed with regard to compartment syndrome. Long-Term Sequelae The same types of sequelae seen in patients with frostbite can occur after NFCI injuries and should be managed in the same way.

9.4 9.3.1.2 Nonfreezing Cold Injury Different from frostbite, temperature is not the critical factor for the risk of NFCI injuries. They often occur after exposure of a limb to a moist and cool environment for 2–3 days, and may occur in temperatures several degrees above 0°C. Considering the length of exposure needed, these are injuries that mostly are seen under extreme circumstances, such as those that occur during major incidents. In armed conflicts, these injuries have been seen among soldiers who have endured long exposure to wet and cold environments in trenches (“trench foot”) or in life boats (“immersion foot”). Symptoms and Clinical Findings The most common first sign is a swollen, numb, and edematous foot. With time, the leg becomes painful and sensitive, which prevents walking. Initially the skin is red, transferring into a pale and then cyanotic color. Peripheral pulse may be difficult to palpate because of swelling. Treatment As in frostbite, it is important to treat the whole patient: provide protection from further exposure to cold and wet surroundings, warm and dry clothes, and hot beverages. Continued treatment indoors or in a hospital includes careful drying and washing and elevation of the affected limb to diminish swelling. Keeping the limb cool reduces the metabolic requirements while the body supplies oxygen and nutrition. Analgesia should be given, if possible as an epidural block. Antibiotics are given upon suspicion of infection. Dextran 40, given in the same dose as that for frostbite (see above), might also have a beneficial effect on these injuries. Surgical revision may be indicated if infection occurs and should be done with care, as in frostbite.

Avalanche Incidents

During the last 20 years, approximately 150 people have been killed in avalanche incidents every year in Europe and the United States together. The main causes of death in avalanches are: • Acute asphyxia, where the victims are trapped without an air pocket (65%) • Prolonged asphyxia combined with hypothermia, where the victims are trapped within an air pocket (25%) • Injuries caused by the avalanche (10%) This illustrates the importance of an air pocket for the probability of survival. “Air pocket” is defined as situations in which a cavity is open in front of the nose and mouth; “no air pocket” is defined as situations in which the mouth and nose of the victim are tightly blocked from air by avalanche snow or debris. Approximately 8% of victims in an avalanche incident die within the first 15 min, often because of lethal injuries. The likelihood of survival then declines from 92% at 15 min to only 30% 35 min after the incident. Survival after this time means that the victim has an air pocket, and the chances of survival decline rather slowly to 27% 90 min after the incident. One hundred thirty minutes after the incident, the survival rate is only 3%. However, the survival chances are significantly better for victims trapped in buildings, cars, or trains. The longest documented survival times for completely buried avalanche victims to date are in an open field (44 h) and in a building (13 days). These figures, used as a base for setting priorities in search and rescue, illustrate the importance of speed during the extrication process. The present goal with regard to time is extrication of all victims within 90 min, but as many as possible within 15 min after the incident. Safety equipment for skiers that make it possible to create an artificial air pocket and avoid carbon monoxide poisoning have been introduced.

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The treatment of hypoxia, hypothermia, and associated injuries among extricated victims does not differ from the principles already discussed in this and previous chapters.

9.5

Drowning

With water temperatures dominating in the major part of the world, the risk of drowning is in most cases combined with the risk of hypothermia, and it is therefore natural to deal with these risks together. However, that these risks are connected actually increases the possibilities of survival of those who accidentally fall into water: hypothermia lowers our metabolic activity and thereby reduces the need for oxygen. During recent years, deeply hypothermic patients have been saved after having spent more than 1 h under water. This is important to know and consider because it affects both triage and treatment, for example, the indications to start or interrupt CPR in these patients.

9.5.1

Deﬁnitions

Immersion means that a person has gone into the water but the airway is still above the water surface. Submersion means that a person is completely under water, including the airways. There are significant differences in pathophysiology between submersion in fresh water and salt water because of the differences in the osmolarity of the water.

9.5.1.1 Pathophysiology Immersion in cold water leads to hyperventilation that can be so pronounced it generates tetany by decreasing PaCO2. Peripheral vasoconstriction leads to a decrease in muscular blood flow, and systolic blood pressure increases because of increased catecholamine secretion. There is a pronounced increase in cardiac output, which, in combination with hypoxia and rapid changes in acid-base balance, can induce ventricular fibrillation and cardiac arrest. Immersion in cold water also leads to a gasp reflex, and if the person sinks rapidly, this may lead to aspiration, the effect of which is different in salt and fresh water. However, in some cases laryngeal

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spasm prevents aspiration, and 10–15% of submersion victims have dry lungs, which probably is a combined effect of laryngeal spasm and rapid absorption of water. Fresh water is hypotonic in relation to plasma. Consequent to the osmolar difference, fluid passes from the alveoli to the blood, increasing the intravascular volume and the risk of overloading of the heart. Also a consequence of the osmolar gradient, fluid passes into the red cells, with hemolysis and hyperkalemia as consequences. Salt water has, compared with fresh water, an osmolarity three to four times higher then plasma, which means that fluid instead is transferred from the vascular bed to the alveoli. This leads to pulmonary edema, with the alveoli filled with thick, foamy, protein-rich fluid, ending in respiratory insufficiency. This condition can appear or progress at a secondary stage after resuscitation, which means that the patient should be under surveillance for a period of time (at least 4–6 h) after such an incident. The end result of both fresh water and salt water submersion is progressive hypoxemia.

9.5.1.2 Prehospital Treatment If the submerged victim has spent less than 1 h under water, CPR should always be initiated. There are single case reports where the patient has survived after even longer times under water, but in these cases the risk of severe persistent neurologic impairment increases. Airway Clean the upper airway, according to the ATLS principles described above, with suction if possible. Note the risk for aspiration consequent to vomiting water. Also note the risk for concomitant cervical spine injury, which is common among submerged victims, and act accordingly (see Chap. 7). Breathing As soon as possible, start ventilatory support with 100% oxygen and positive end-expiratory pressure. The difference between fresh and salt water submersion is that the fresh water victim may have a limited amount of fluid in his or her respiratory tract, whereas the salt water victim has a thick, foamy sputum consequent to alveolar edema, which makes a suction device almost mandatory.

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Circulation Even in the case of no palpable pulse and suspicion of cardiac arrest, CPR should be started when the victim not has been under water longer than 1 h (see above). Disability Make a rapid evaluation of neurologic status according to the AVPU (Alert, Voice, Pain, Unresponsive) scale (see Chap. 7): is there a response to talk and pain? Exposure Check for signs of exposure to trauma. Determine (if equipment for this is available in the prehospital setting) body temperature to confirm or exclude hypothermia. It is of great importance that complete information is delivered to the hospital for a decision about continued treatment, including the type of water (salt water or fresh water and extent and type of contamination), water temperature, suspicion of trauma, length of time submerged, time of and findings upon extraction from the water, and time when CPR was started.

9.5.1.3 In-hospital Treatment Diagnosis Investigations of all submerged patients should include: • Body temperature (esophageal temperature in patients with confirmed or suspected hypothermia) • Pulmonary x-ray (all patients) • X-ray of cervical spine (in all unconscious patients and patients with clinical suspicion of cervical spine injury) • Connection to ECG monitor • Monitoring of saturation • Monitoring of urinary flow • Laboratory tests: blood gases, electrolytes, and blood status; on suspicion of intoxication, relevant intoxication tests. Treatment • Impaired respiration: oxygen 10–15 L/min • Unconscious patients: tracheal intubation • Gastric tube because of risk for aspiration • In cases of continued asystole: continued CPR with 100% oxygen with positive end-expiratory pressure. In hypothermic patients: continue until body temperature is 35°C. If there is no effect after 30 min of CPR at or above this level, the chance of

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survival without severe neurologic impairment is almost nonexistent and the treatment can be interrupted. • Submerged victims returning to consciousness without respiratory or circulatory impairment should stay under observation for at least 4–6 h to exclude secondary respiratory complications (see above).

Further Reading Auerbach PS (ed) (2001) Wilderness medicine, 4th edn. Mosby, St. Louis Borms SF, Englelen SL, Himpe DG et al (1994) Bair-Hugger forced air warming maintains normothermia more effectively that thermolite insulation. J Clin Anesth 6:303–307 Brauer A, Pacholik L, Perl T, English MJ et al (1993) Conductive heat exchange with a gel-coated circulating water mattress. Anesth Analg 77:89–95 Carden DL (1983) Intubating the hypothermic patient. Ann Emerg Med 12:124–128 Clifton CL, Miller ER, Choi SC et al (2002) Hypothermia on admission in patients with severe brain injury. J Neurotrauma 19:293–301 Cohen S, Hayes JS, Tordella T et al (2002) Thermal efficiency of pre-warmed cotton, reflective, and forced-air inflatable blankets in trauma patients. Int J Trauma Nurs 8:4–8 Danzl D (2001) Accidental hypothermia. In: Auerbach P (ed) Wilderness medicine, 4th edn. Mosby, St. Louis, pp 135–177 Deakin DC (2000) Forced air surface rewarming in patients with severe accidental hypothermia. Resuscitation 43:223 Foray J (1992) Mountain frost bite – current trends in prognosis and treatment. Int J Sports Med 13:193–196 Giesbrecht CG (2000) Cold stress, near drowning and accidental hypothermia – a review. Aviat Space Environ Med 71(7): 733–752 Giesbrecht CG (2001a) Prehospital treatment of hypothermia. Wilderness Environ Med 12(1):24–31 Giesbrecht G (2001b) Emergency treatment of hypothermia. Emerg Med 13:16–19 Gilbert M (2000) Resuscitation from accidental hypothermia of 13.7°C with circulatory arrest. Lancet 29:375–377 Hayes JS, Tyler-Ball S, Cohen SS et al (2002) Evidence-based practice and heat loss prevention in trauma patients. J Nurse Care Qual 16:13–16 Henriksson O, Lundgren P, Kuklane K et al (2011) Protection against cold in prehospital care – thermal insulation properties of blankets and rescue bags in different wind conditions. Prehosp Disaster Med 24(5);408-415 Husum H, Olsen T, Murad M et al (2002) Preventing post-injury hypothermia during prehospital evacuation. Prehosp Disaster Med 17:23–26 Kempaine RR, Brunette DD (2004) The evaluation and management of accidental hypothermia. Respir Care 49:192–205 Kirkpatrick AW, Garraway N, Brown DR et al (2003) Use of a centrifugal vortex blood pump and heparin-bonded circuit for extracorporeal rewarming in severe hypothermia. J Trauma 55:407–412

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Incidents in Cold and Wet Environments

Kober A, Scheck T, Fulsedi B et al (2001) Effectiveness of resistive heating compared with passive warming in treating hypothermia associated with minor trauma – a randomized trial. Mayo Clin Proc 76:369–375 Lennquist S, Lamke LO, Liljedahl SO et al (1972) The influence of cold on catecholamine excretion and oxygen uptake in normal persons. Scand J Clin Lab Invest 30:57–62 Lennquist S, Granberg PO, Wedin B (1974a) Fluid balance and physical work capacity in humans exposed to cold. Arch Environ Health 29:241–249 Lennquist S, Fröberg J, Karlsson G et al (1974b) Renal and adrenal function – a comparison between responses to cold and to psychological stress ors in humans. Lab Clin Stress Res 40:1–27 Lundgren P, Henriksson O, Widfeldt N et al (2004) Insulated spine board for prehospital care in a cold environment. Int J Disaster Med 2:33–37 Mariak Z, White MD, Lyson T et al (2003) Tympanic temperature reflects intracranial temperature changes in humans. Pflugers Arch 446:279–284 Mills WJ (1992) Field care of the hypothermic patient. Int J Sports Med 13:199–202 Newman AB (2001) Submersion incidents. In: Auerbach PS (ed) Wilderness medicine, 4th edn. Mosby, St Louis

227 Quan L (1993) Drowning issues in resuscitation. Ann Emerg Med 22(2):336 Quarny RG et al (1999) Severe accidental hypothermia – the need for prolonged aggressive resuscitation efforts. Prehosp Emerg Care 3:254 Siple P, Passel F (1945) Proc Am Philos Soc 89–177 Swedish National Board of Health and Welfare: hypothermia, cold injuries and near drowning (2002) 110–14; 7–142. Available at http://www.strd.se/webshop/socialstyrelsen Tisherman SA (2004) Hypothermia and injury. Curr Opin Crit Care 10:512–519 Vangaard L, Eyolfsson D, Xu X et al (1999) Immersion of distal arms and legs in warm water (ava rewarming) effectively re-warms hypothermic humans. Aviat Space Environ Med 70:1081–1088 Wahlpol BH (1994) The Methraux thermometer for reliable determination of tympanic temperature in hypothermic patients. J Clin Monit 10:91–95 Wang HE, Callaway CV, Peitzman AB et al (2004) Admission hypothermia is associated with adverse outcomes after trauma. Acad Emerg Med 11:513–514

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Lucija Sarc

Abbreviations ABGA ARDS BAL CAS

Arterial blood gas analysis Acute respiratory distress syndrome British anti- Lewisite Chemical abstract service (unique registration number) CBC Complete blood count CNS Central nervous system CO Carbon monoxide COPD Chronic obstructive pulmonary disease CPAP Continuous positive airway pressure CRBN Chemical, biological, radiological, or nuclear CVS Cardiovascular system DIC Disseminated intravascular coagulopathy ECG Electrocardiograph ED Emergency department EDTA Ethylenedinitroletetra-acetic acid EEG Electroencephalograph EMS Emergency Medical Service EPA Environmental Protection Agency FFP3 High-capacity filtering face piece GABA Gamma-aminobutyric acid GCS Glasgow Coma Scale GHS Globally Harmonized System GIT Gastrointestinal tract Hazmat Hazardous material HBO Hyperbaric oxygenation

L. Sarc e-mail: [email protected]

ICU IDLH IM IV MetHb MH MIT MSDS OS PAPR PCC PEEP PEF PPE SC SCBA

10.1

Intensive care unit Immediately dangerous to life or health Intramuscular Intravenous Methemoglobin Ministry of Health Major incident team Material safety data sheet Organic solvent Powered air-purifying respirator Poison Control Center Positive end-expiratory pressure Peak expiratory flow Personal protective equipment Subcutaneous Self-contained breathing apparatus

Introduction

Chemical substances and potentially toxic agents are now an integral part of everyday life. However, their use constitutes certain risks, both to the individual and to the society as a whole. The possibility of unintentional or intentional exposure of individuals to toxic substances has rapidly increased during recent years. A chemical incident is not just a sudden unintentional release of or exposure to hazardous material. The definition should also include all intentional releases. We are aware that, besides the unintentional exposure to numerous chemicals in general use, in industry, and during transport, the threat of exposure to chemical weapons is becoming ever more present, particularly with respect to terrorist acts.

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_10, © Springer-Verlag Berlin Heidelberg 2012

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Thus, a chemical incident can be defined as any event in which individuals are or could have been exposed to hazardous materials that may be harmful to their health.

The chemical substances defined as hazardous material in connection with chemical incidents are inorganic or organic substances (including petroleum-based products) that are – because of their physical, chemical, toxicological, and ecotoxicological properties – potentially hazardous to people, animals, and the environment. In accordance with the wise observation by Paracelsus: “All things are poison and nothing is without poison, only the dose permits something not to be poisonous,” a toxic substance can be any substance that is harmful to health in unlimited or uncontrolled conditions. In the case of the release of a substance, the hazard is marked by four main characteristics besides the released quantity of the chemical: • Type of toxicity • Latency of the effect • Persistence of the substance • Transmissibility The toxicity and latency are determined by the toxicokinetic or toxicodynamic characteristics of the substance and denote the hazard it poses to the victims. Its persistence and transmissibility (the possibility of secondary contamination) are determined by the physical and chemical properties of the substance and denote the hazard it poses to rescuers. Some examples of previous chemical incidents are mentioned in Chap. 2. From studying the published reports of such incidents, we can learn some important lessons: • We should identify the hazardous material as soon as possible and adopt all the necessary measures reasonably. • The decontamination of victims prior to leaving (at least) the warm zone is essential to the protection of staff later in the rescue chain and necessary to hinder any spreading of the contamination. • A fear of exposure to hazardous material can cause people to panic as a result of uncertainty; thus, the rescuer can expect an approximately 5:1 ratio of unaffected and affected casualties who require decontamination and medical treatment.

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“If you are ready to manage chemical incidents, you are ready to manage all other incidents.”

The main principles of the rescue activities for chemical incidents are similar to those for all other types of incidents; there are, however, some essential – for the rescue workers possibly critical – specialities: the use of personal protective equipment (PPE), the decontamination of the contaminated victims, and the management of toxic trauma. On the other hand, chemical incidents could also involve an explosion, a fire, or a traffic accident. Consequently, the victims in such incidents not only have toxic trauma, they can also suffer from “conventional” trauma, burns, and other injuries. This is why it can be said that when rescue workers master the rescue activities in the event of a chemical incident, they have also mastered the rescue activities for any other type of incident. The release of a hazardous substance is relatively difficult to predict. For most substances there are no permanent detection systems available, which means the onset of symptoms by the victims can represent the first indicator of a release. According to criteria from the World Health Organization, there are six possible scenarios for hazardous substance release, which are determined by a combination of three variables: 1. Detected release/silent release (suspicion of a release) 2. Known substances/unknown substances 3. From a stationary/dynamic source From the viewpoint of the emergency medical service (EMS) team’s safety, the most hazardous scenario is the silent release of an unknown substance. This scenario is even more treacherous if there is only one victim; in cases where multiple persons are hurt simultaneously without any signs of external injuries, one would consider attributing these effects to toxic injuries much earlier. A chemical incident is often not evident or recognized as such from the beginning, and consequently it is not announced as a chemical incident. Thus, the members of the EMS team should always respect a general, safe approach and keep in mind the possibility of the presence of hazardous material. In general, the rescue principle in chemical incidents is the same as in all other MIs, which is in accordance

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with one of the major themes of this textbook: simplicity. This chapter complements Chaps. 3 and 5 (The Prehospital Response” and “The Hospital Response,” respectively) by discussing specialist measures and other important issues related to chemical incidents.

10.2

The Prehospital Response

10.2.1 Activities En Route to the Incident Site The first information indicating the possibility of a chemical incident can be deciphered from the dispatch call itself, e.g., the presence of unusual signs or symptoms (pungent odor, irritation to the eyes, irritant cough) or the dispatcher provides direct information that this is a situation involving the release of hazardous material. On the way to the incident site, rescue workers must pay attention to all the obvious signs/clues that indicate the potential possibility of a hazardous substance release: • Presence of smoke, vapor clouds • Stains of spilled liquid (e.g., gasoline, corrosive substances) • Unusual odors, signs of irritation to the eyes or respiratory organs • Visual appearance of the site/type of incident (tanker truck, goods train, industrial plant where hazardous chemicals are present, etc.) In some cases there will be no obvious warning signs or symptoms, e.g., in the event of a release of an odorless or radioactive chemical. Sometimes our sensory organs might not perceive the presence of a hazardous substance, which is why the absence of such clues does not mean that the site is actually safe. Before reaching the site of an incident, the rescue workers should try to gather as much information Rescue workers must follow strict safety instructions, especially until the substance has been identified – otherwise they may become victims themselves. as possible about the circumstances of the accident (Table 10.1): • The sort and type of incident • The chemical and trademark name of the chemical present

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• The basic data on the chemicals (gas/liquid/powder, odor, color) • Number and age of the persons exposed to the chemical • Duration of exposure • Signs and symptoms that the exposed victims have developed • Presence of conventional injuries After the basic information has been obtained, the EMS team should consult a toxicologist within the framework of the 24-h information consulting service of the Poison Control Center (PCC), which will give them – on the basis of the data listed above – further instructions and information about (Table 10.2): • the nature and possible types of injuries that can be caused by the chemical(s) present; • possible routes of exposure; • risk of secondary contamination; • required level of PPE; • necessary treatment measures, including administration of an antidote; • the need for decontamination and the type of decontamination procedure; and • the need for biological sample collection for a toxicologic analysis.

10.2.2 Arrival at the Incident Site

Only properly trained and appropriately equipped rescue workers can carry out rescue work in chemical incidents. With the desire to provide the necessary and timely treatment to the victims, rescue workers often overlook or underestimate the risk to themselves. The general rules of safe access to the site of the incident involving a hazardous material are: • Until instructed otherwise, ambulances should be parked upwind (the direction of the wind must always be from the rescue team toward the incident site) at the highest point outside the area of obvious contamination. • Do not enter, either in an ambulance or on foot, the area of obvious contamination (spilled/scattered substance, smoke, vapor).

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Table 10.1 List of additional chemical data required by receiving chemical incident call Obtain as much as possible data about chemical incident Time of incident: Sort/type of incident □ Traffic □ Fire Name of a chemical Trademark name: Basic data of the present chemical □ Gas/vapor Number of victims Adults: Signs/symptoms experienced by victims □ Yes □ No Conventional injuries presence □ Yes □ No

□ Industry release □ Terroristic release Chemical name: □ Liquid Children: If yes, list them please: If yes, list them please:

Others: CAS number: □ Solid □ No data □ No data □ No data

Table 10.2 Checklist of communication with clinical toxicologist Toxicological data for toxic trauma treatment in a chemical incident Name of a chemical Trademark name: Relevant route of exposure □ Inhalation □ Skin/mucous membranes Expected signs/symptoms of exposure Secondary contamination risk □ No □ Yes Decontamination necessary □ No □ Yes Prioritization by triage Required personal protective equipment □ No □ Yes Antidote □ No □ Yes

Symptomatic treatment recommendation Biological samples for toxicology analysis □ None Observation/admission/discharge criteria

• Avoid unnecessary contamination of the equipment. • Avoid exposure when approaching the contaminated area. • Do not approach anyone coming from the contaminated area. • Do not make a rescue attempt until you are properly informed and equipped. • Report any suspicious packaging, parcels, receptacles, containers, or people to the head of the intervention team.

□ Blood

Chemical name: □ Ingestion

CAS number:

Details: Details: Details: Name: Indication: Dosage: Cautions: □ Urine

□ Vomit Details:

safety data sheet (MSDS). (For further information, see item 10.7.1) The labels are, however, often missing or inadequate, which is why the incident site always must be approached with caution. For an intentional release of a hazardous material, the signs and symptoms of the victims are the first help in the identification. The release of a hazardous chemical must be objectified with laboratory help (mobile unit) if there is any uncertainty.

10.2.2.2 Use of PPE 10.2.2.1 Identiﬁcation of the Hazardous Chemicals If the EMS team fails to acquire relevant data about the identity and properties of the hazardous chemical upon their arrival at the incident site, sometimes these data can be obtained at the site of the incident itself, e.g., from transport labels (orange rectangular or white rhomboid panels – respect safe distance, use field glasses) or labels and instructions for use found on the packaging of chemicals or enclosed material

The hazard, or the fact that the hazard is still unknown, must be known before the first rescue worker enters the contaminated area. The available PPE for the EMS staff varies in different countries: from the working uniform only (common) to the highest level of PPE (rare). Consequently, the entrance of the EMS staff into the hot/red zone is not

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permitted in most countries. (For further information, see item 10.4) It is important to gain information about the PPE necessary as soon as possible and prepare it en route to the incident site. The leader of the rescue operation (rescue incident commander [RIC]/police incident commander [PIC]) must be notified of information about the available level of PPE for the EMS because he or she is responsible for the safety of all rescue partners. The rescue workers put on the appropriate PPE, at the latest before entering the warm/decontamination zone, except when they are given an explicit guarantee from the RIC at the site or after consultation with the toxicologist that PPE is not necessary. As soon as circumstances permit, the EMS personnel can reduce the level of PPE and thus facilitate the provision of care/ treatment to the victims.

10.2.2.3 On-Site Organization Do not move victims from the hot zone until appropriately trained rescue workers with appropriate PPE have arrived and a decontamination corridor has been established. In chemical incidents, respect the recommended spatial organization – zones, lines, and corridors – in the scope of which operation sites of various services are established (Fig. 10.1). The hot/red/injury zone must include all of the contaminated area, and access to this zone must be forbidden to all unauthorized persons. Every person leaving the contaminated area is regarded as potentially contaminated and should therefore be subject to appropriate examination procedures and, if necessary, be decontaminated. If the decontamination of victims is necessary, a decontamination corridor should be set up in the warm/orange/decontamination zone and access to check points should be established. The medical treatment of victims takes place in the cold/green/support zone.

10.2.3 Treatment of Victims The main principles for this are illustrated in Fig. 10.2. During a chemical incident, the first aim of the rescue workers at the scene is evacuation – to eliminate

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exposure and to remove victims from the danger zone. The next step is decontamination – to manage the risk of further absorption and the risk of dissemination of contamination. The rescuers must provide treatment to the victims without putting their own safety at risk. In most countries, victims are evacuated from the contaminated/hot/red zone by firefighters or by appropriately trained and equipped members of other rescue services, and then handed over to the EMS in the predetermined casualty clearing zone. Medical treatment takes place in the cold/green/ support zone. The risk of exposure to a hazardous material, fire, or explosion, as well as the reduced operational capability that arises from the use of the PPE, outweigh the advantage in the time that might have been gained if the victims were treated in the hot zone by the EMS staff. Appropriately trained members of the EMS teams protected with PPE (self-contained breathing apparatus [SCBA]/full face mask with filters, suit resistant to splashes of chemicals, nitrile gloves and boots) can join forces in the decontamination zone while respecting certain limitations (chemical hazard and duration of the activity within the zone). Decontamination is not an automatic or obligatory rescue procedure in all chemical incidents. If, when, and to what extent the decontamination procedure should be undertaken depends on the nature of the hazardous material, the assessments made by the rescue workers, and the professional opinion of the PCC/clinical toxicologist. Though not all chemicals pose a risk of secondary contamination, everyone who has been exposed is to be treated as contaminated until the risk is precisely determined. When decontamination is necessary, in most countries it is carried out by firefighters. A member of the EMS team should cooperate in the decontamination of injured victims; if circumstances allow, this can be the doctor or the nurse performing the decontamination triage. During an MI, the triage doctor or another experienced EMS team member classifies the victims according to the level of emergency for priority decontamination, termed decontamination triage. Before at least primary decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and staunch bleeding with compression (for further information, see item 10.5).

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Fig. 10.1 Spatial organization: zones in chemical incidents COLD/ GREN/ SUPPORT ZONE

Crowd Control Line

COMMAND POINT

Safety zone WARM/ ORANGE/ DECONTAMINATION ZONE RED/ HOT/ INJURY/ ZONE

Decontamination line

Hot Line

DECO

NTAMIN ATION CORR IDOR

Acces Control Points

Wind direction

Primary examination of the victim during lifethreatening situations can occur simultaneously with the primary decontamination. Invasive procedures (e.g., intravenous [IV] administration of medications, intubation) are performed for already-decontaminated victims, if possible, because there exists a risk of introducing the chemical directly into the body through such measures. After a properly completed decontamination procedure, the victims are given the

same treatment as those in other incidents. The EMS staff no longer need the PPE, which facilitates and accelerates the management of victims. In an MI, decontamination is followed by the triage procedure (primary triage, secondary triage), which is the same as in other incidents and carried out with the same algorithms. By a process of sorting, we also must consider the severity of clinical signs and symptoms of poisoning.

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HELICOPTER

MIC

T3

4

T1

1

FIELD HOSPITAL

DECO CORIDOR

T2

SECONDARY TRIAGE

DECO CORIDOR

PRIMARY TRIAGE

DECONTAMINATION TRIAGE

CASUALTY ASSEMBLY POINT

1

CASUALTY CLEARING AREA

2

RE-TRIAGE, TRANSPORT TRIAGE

3

2

T4

3 4

SUPPLIES STORAGE

TEMPORARY MORTUARY

Ambulance assembly point

Fig. 10.2 Prehospital response. Organizing scheme of emergency services

The only additional nuisance is a toxic trauma treatment. When using a toxic trauma treatment, respect the procedures that are specific for the actual chemical. Information about these can be obtained from the clinical toxicologist within the framework of the 24-h service by the PCC or from relevant databases (for further information, see item 10.9). In chemical incidents, appropriate observation of the victims and re-triage procedures must be organized frequently because toxicodynamic effects may develop. Follow-up examinations of the patients must be carried out because certain chemicals effects may surface with a delay.

Administer oxygen by a bag-valve-mask. The gas bottles must be wrapped in polyvinyl chloride (PVC) for easier decontamination. Particular attention is required when treating vomiting patients. The vomit itself may be contaminated; there is a risk of secondary contamination by the released gases or from contact with the skin or mucous membranes. For the majority of victims, only a symptomatic treatment is required. If the administration of an antidote is necessary, the condition of the victim, the availability of the antidote, and the distance to the hospital must be taken into account. We must be well acquainted with the antidote being applied (indications, dose,

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Table 10.3 List of antidotes that can be applied on site if necessary Antidote Amyl nitrite amp

Atropine amp

Dimercaprol (BAL) amp.

Calcium gluconate 10% amp. Calcium gluconate 2.5% to 10% gel or solution Hydroxocobalamine amp Methylene blue vials Oxygen

Pralidoxime vials Toxogonin vials

Poisoning with – Cyanides – Nitriles – Sulphides – Organophosphates – Carbamates – Nerve agents – Arsenic – Arsine – Lewisite – Hydrofluoric acid (systemic effect) – Fluorides – Hydrofluoric acid burns – Cyanides – Methemoglobin-forming substances – Simple asphyxiants – Chemical asphyxiants – Methemoglobin-forming substances – Carbon monoxide – Cyanides – Azides/hydrazoic acid – Sulphides – Organophosphates – Nerve agents – Organophosphates – Nerve agents

BAL British anti-Lewisite, amp ampoule

manner of administration, and side effects). We must be particularly careful when dosing an antidote for children because in most cases it will be necessary to adapt the dose to the bodyweight of the child (for further information, see item 10.8) (Table 10.3 and 10.5).

10.2.4 Transportation of Victims Transportation of victims can commence as soon as all the severely injured have been assigned to a team that will be able to provide them with individual treatment as far as possible. The preferred transportation vehicles for chemical incidents are ambulances. The possibility of using helicopters for transportation during chemical incidents is limited because of the risks posed by hazardous materials, including (1) the incomplete decontamination of a patient can possibly cause a

secondary contamination of the crew, and then the crew can develop clinical signs during the flight; (2) the route of the helicopter might lead through an unclean/contaminated area (clouds of smoke, aerosols, vapors); or (3) the landing of the helicopter can cause the dispersion of poisonous gases and vapors. In chemical incidents, the inclusion of helicopters must therefore be approved by and coordinated with the RIC. General rules for the transportation of victims in chemical incidents include the following: • Before transportation, the patient should be decontaminated to the highest reasonable level for the actual chemical. • No patient should be transported unless he or she has been at least primarily decontaminated. • If only primary decontamination has been carried out, the patient must be wrapped in a blanket. Note that the rate of absorption of some chemicals through the skin increases at higher temperatures. • Avoid contact with contaminants; protect the vehicle; wear the appropriate PPE. • Before departure, ensure the treatment to other victims in accordance with the protocol. • Before the departure from the site, take down the name of the chemical(s) involved in the incident and all other available data. • Ensure adequate fresh-air ventilation in the patient and driver compartments of the vehicle. • Establish contact with the target hospital and provide its personnel with as much information as possible about the patient, the treatment given, and data about the chemical. • A bag should be kept ready for intercepting and keeping any vomit; seal the bag tightly to prevent the evaporation of possible toxic gases. • Take note of any breathing distress; administer oxygen by facial mask, except if it is contraindicated (e.g., CO2 narcosis in coronary obstructive pulmonary disease [COPD]). • In the case of exposure of the eyes to a corrosive, flush them with physiological solution/clear water during transportation. • Obtain instructions for accessing and entering the hospital. • Park away from the emergency department (ED) or as close to the allocated decontamination area as possible to reduce the risk of contamination of the emergency ward. • The patient is not to be taken into the ED until permission has been given by the ED personnel.

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• When the patient has been handed over, appropriately decontaminate the vehicle (in accordance with the type of actual chemical and the level of contamination; soap and water will usually suffice) and all the contaminated medical equipment (doublebag it and keep it sealed until further instructions for the decontamination are given). • All exposed staff must also undergo decontamination. It is advisable to use checklists (Table 10.1) during radio communication; these should be available in all ambulances and call or radio communication centers. During communication with the ED, include information about: • The level of decontamination that has already been carried out at the accident site • The estimated arrival time

10.2.5 Management of Fatalities Fatalities are to be handled in accordance with the current forensic medical and ethical principles. Guidelines for preventing secondary contamination should also be taken into account.

10.3

The Hospital Response

In most countries toxic trauma treatment is not the domain of surgeons but of specialists in internal medicine or, rarely, of anesthesiologists. Larger hospitals have specialized toxicology departments with clinical toxicologists; in smaller hospitals poisoned patients are treated in other internal departments. Severely poisoned patients mostly need intensive care with assisted ventilation. That is why the number of ventilators will be a factor of critical importance for the hospital during chemical incidents. In the sense of an “all hazard” concept, the same structure of plan is used for the hospital response during a chemical incident; however, some variations, mostly in required resources and treatment process, are emphasized below.

10.3.1 The Alert Process The alert system must be unified. The only important difference compared with those presented in Chap. 5 is

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in the activation of different nonsurgical but internal medicine resources. Thus, upon receiving an incoming alarm from the senior nurse on duty, in the case of hazardous material involvement, the action card should have additional items (Table 10.1): • The chemical and trademark name of the chemical • The basic data about the chemicals (gas/liquid/ powder, odor) • The number and age of the persons exposed to the chemicals • The route of the exposure (by inhalation, through skin or mucous membranes, etc.) • The duration of the exposure • The signs and symptoms that the exposed have developed • The presence of conventional injuries After receiving an alert of a major chemical incident, the senior nurse on duty must alert the internal medicine specialist on duty instead of the surgeon on duty. From this point on, the same alert system must be triggered in the internal medicine part of the hospital as that described for the surgical one.

10.3.2 Coordination and Command The only important difference compared with those presented in Chap. 5 is staffing by those involved in specialties required for the management of hazardous material, e.g., senior clinical toxicologist, internal medicine specialist, or senior anesthesiologist.

10.3.3 Preparing the Hospital Chapter 5 lists the main measures (surgery is necessary if toxic trauma is combined with classic trauma); however, the hospital also needs to have special preparations for receipt of contaminated victims. Based on experiences from previous chemical incidents, hospitals are not besieged only by on-scene decontaminated and triaged patents, but also by self-evacuated victims/ exposed persons, especially if the hospital is not far from the incident site. Thus, when nondecontaminated victims come to the emergency unit, it is necessary that the decontamination is organized outside the ED (primary decontamination) or in a suitable room that has been specially prepared for this task (a room with negative air pressure and floor drains to contain contaminants; see Chap. 5, Figs. 5.2 and 5.3).

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The specialist on duty has to gather as much information as possible about the chemicals involved, potential victims, and estimated arrival times. Based on the acquired data, the clinical toxicologist of the 24-h information/consultation service of the PCC will provide the specialist on duty with further instructions and advice about the following (Table 10.2): • Expected clinical signs and symptoms • Possible routes of the exposure • Risk of secondary contamination • Required level of PPE • Toxic trauma treatment measures, including the administration of antidotes • Need for decontamination and the appropriate decontamination procedures • Need for biological sample collection for toxicologic analysis Based on the acquired data and considering the risk for secondary contamination, the specialist on duty provides the arriving EMS rescue teams with instructions about access to the ED. He or she also organizes triage and orange/decontamination zones and establishes a visible border between the contaminated and clean areas with checkpoints. Staff who will perform decontamination triage and decontamination must be acquainted with the potential risk of the hazardous material present and must use the required PPE. When arranging the staff, it is important to consider that those who work in the orange/ decontamination zone are considered to be potentially contaminated and can come back into the ED only after a self-decontamination procedure. The medical staff behind the orange/decontamination boundary do not need any special PPE and can use their usual work uniforms.

10.3.4 Receiving Casualties The general principles for victim management are the same as those described in Chap. 5: primary triage, management of the severely injured by MIT, primary management and secondary triage, management of less severely injured, observation or admission and continued treatment of severely injured patients. So, what is different? 1. The most important measure in a chemical incident is the prevention of contamination dissemination; if not, there will be another disaster inside the hospi-

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tal. Although at least a primary decontamination should already have been carried out at the accident site, every victim should be considered potentially contaminated until proven otherwise. Thus, before entering the ED, every victim should be checked to see if the decontamination was properly carried out. If YES, this victim can go to the primary triage area; If NOT, the victim should be directed to the decontamination triage area. Primary decontamination should be performed before entering the decontamination room, but not in the ambulance. Secondary decontamination is performed in the decontamination room, if it exists. If there is no decontamination room, it has to be improvised outside. Otherwise the decontamination procedure in general is the same as on the incident site (for further information, see item 10.5). If necessary, a thorough decontamination of the wounds is to be performed after the procedure has been completed. If contaminants have protruded too deeply, they must be removed by excision. After the decontamination of the victims has been completed, it is necessary to decontaminate the personnel and the equipment. After the decontamination procedure is complete, all the victims are directed to primary triage followed by immediate treatment and secondary triage. 2. At the secondary triage level and primary management, instead of advanced trauma life support principles, toxic trauma treatment should be considered and adapted to the individual chemical (for further information, see items 10.7, 10.8, and 10.9). If the victims need to be hospitalized until they can receive definitive treatment, they are to be admitted to departments where the personnel have more experience with toxic trauma treatment; if intensive treatment is necessary, they have to be admitted to the intensive care unit (ICU) (Fig. 10.3). When conventional/nontoxic injuries or burns are prevalent, the patients should be admitted to the appropriate surgical departments. During an MI, the victims are allocated to departments according to the hospital’s MI plan. The medical personnel are provided with professional support for the toxic trauma treatment at all times by the PCC. The on-call clinical toxicologist can be reached 24 h a day by telephone within the framework of the 24-h information/consultation service of the PCC (for further information, see item 10.6.1).

Fig. 10.3 Hospital response. Organizing scheme of an emergency department

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10.4

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Personal Protective Equipment and Training

PPE is the equipment that is worn by persons at work with the intention of protecting them against one or more risks to their health or safety. It should be used in working conditions in which all available technical safety measures are insufficient. Without doubt, chemical incidents are situations where the risk to the rescuer’s health or even life could be high. The demand for diverse PPE is extensive; however, the exact guidance for its use remains scarce. There have been comprehensive discussions about the advantages and disadvantages of particular PPE without any practical conclusion. The most commonly used classification for PPE is that of the US Environmental Protection Agency (EPA). The EPA has graded PPE into four levels based on the degree of protection provided. Each level of PPE consists of a combination of varying degrees of respiratory, ocular, and skin protection, where “level A” ensures the maximum protection and “level D” minimum protection. Level A consists of a fully encapsulating, vaportight, chemical-resistant suit, chemical-resistant boots, chemical-resistant inner and outer gloves, and a SCBA. This protection should be worn when the highest level of respiratory, skin, eye, and mucous membrane protection is needed. Level B protection should be selected when the highest level of respiratory protection is needed but a lesser level of skin and eye protection is sufficient. It differs from level A only in that it provides splash protection by the use of chemical-resistant clothing (overalls, long sleeves, jacket) or fully encapsulating, non-vapor-tight, chemical-resistant suit and SCBA. Level C protection should be selected when the type of airborne substance is known, the concentration has been measured, the criteria for using air-purifying respirators are met, and skin and eye exposures are unlikely. This involves a full-face respirator with an air-purifying canister and chemical-resistant clothing. It provides the same level of skin protection as level B, but a lower level of respiratory protection. Level D is primarily a work uniform. In hospitals it consists of standard work clothes, a surgical mask, and latex gloves. It should not be worn on any site where respiratory or skin hazards exist. It provides no respiratory protection and minimal/no skin protection.

The available PPE for EMS staff varies in different countries, from the working uniform only (common) to the highest level of PPE (rare); consequently, the entrance of the EMS staff in the hot zone is, in most countries, not permitted. The leader of the rescue operation – the RIC or PIC – must be notified with information about the available PPE level of the EMS because he or she is (in most countries) responsible for the safety of all rescue partners. For a chemical incident this is important information for scene organization and for the evacuation of victims. The rescue workers put on the appropriate PPE (at the latest before entering the warm/decontamination zone), except when they are given an explicit guarantee from the RIC at the site or by toxicologic consultation that PPE is not necessary. Many highly toxic substances have no transmissibility potential (e.g., the highly toxic gases carbon monoxide [CO] and arsine). Once the victim is out of the injury/hot/red area, such substances in gaseous form pose no risk of secondary contamination. The amount that is found in/on a patient does not pose a risk of poisoning others (secondary contamination), especially if the contaminated clothes have been removed. Even with substances that have a high transmissibility, the potential risk of secondary contamination decreases significantly after the primary decontamination has been carried out. In such cases, the EMS personnel can reduce the level of PPE and thus facilitate the provision of care/treatment to the victims. There are several important things to consider with regard to PPE: • PPE selection should be made on the basis of the planned activities and the guidance for the EMS in a chemical incident. Thus, the potential route of exposure, the degree of contact, and specific tasks assigned to the user must be defined. • The potential leader of the rescue operation (firefighters, in most countries) must be informed about the selected PPE level for EMS staff. • All potential users of PPE performing rescue activities during a chemical incident must be properly trained in the appropriate use of the PPE before taking part in an intervention. Such training must include the proper donning and doffing procedures and acquaintance with potential problems and reactions in such conditions. • Using PPE with the highest level of protection is not always the best solution; it might even be the

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Fig. 10.4 Personal protective equipment level C

worst. It brings a lot of problems and obstacles, including limited visibility, reduced dexterity, restricted movement, claustrophobia, insufficient air supply, dehydration, and heat and cold effects. It is not suitable for everyone, and one must be in a good condition to wear it. Donning and doffing PPE are time-consuming procedures.

10.4.1 Recommendations • If the medical personnel do not enter the hot/red/ injury zone, they do not need level A protection. • For performing the decontamination triage and collaborating in the decontamination process outside the hot zone, level C (Fig. 10.4) protection is sufficient for most hazardous materials. Only in

241

Fig. 10.5 Personal protective equipment (disposable chemicalresistant suit, chemical-resistant gloves, high-capacity filtering face piece, respirator, and safety goggles)

the case of an incident with a highly toxic chemical and a high level of transmissibility potential (e.g., nerve agent, cyanide) should SCBA be used, especially for the management of the victims who have a large contaminated body surface. Such a level of PPE should also be used for medical staff in the ED in the case of the arrival of self-evacuated victims and victims who have not been properly decontaminated. • If the decontamination on the scene was not completed for various reasons and the chemical poses a risk of contamination through direct contact, the medical staff should at least use a disposable, chemical-resistant suit, chemical-resistant gloves, highcapacity filtering face piece respirator, and safety goggles with indirect ventilation (Fig. 10.5).

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• When treating the properly decontaminated victim, medical staff do not need any special PPE; they can use their usual work uniform. All those who take part in providing EMS services, either full time or part time, must complete a basic training course that consists of both a theoretical and a practical part and a final examination to confirm the success of the training. The aim of the training for medical staff participating in EMS services is to instruct them on the risks posed by hazardous chemicals, how to identify them, and how to appropriately respond to exposures/toxic injuries. Rescuing and providing treatment to the victims of chemical accidents requires additional knowledge, both in the field of PPE as well as the treatment of patients who have been exposed to hazardous material. A refresher/follow-up training course, approximately once every 3 years, is also anticipated for all those who provide EMS services.

10.5

Decontamination and Decontamination Triage

Decontamination of the victims of a chemical incident is a procedure of safely removing the hazardous material prior to its absorption. It poses at least two important benefits: 1. The rapid physical removal of the hazardous material is the most important measure in the chemical incident management rescue chain immediately after basic life support. The removal of hazardous material from the skin and visible mucous membranes hinders further local tissue damage and stops the systemic absorption of chemicals. 2. Decontamination prevents the dissemination of hazardous material and secondary contamination. Even though not all chemicals pse a risk of secondary contamination, everyone who has been exposed needs to be treated as contaminated until proven otherwise! Decontamination is not an automatic or obligatory rescue procedure in all chemical incidents. If, when, and to what extent the decontamination procedures should be undertaken depends on the nature of the incident, an assessment made by the rescue workers,

and the professional opinion of the PCC/clinical toxicologist. The basic requirements for every decontamination procedure are: • Provision of a secure area for decontamination • Appropriate PPE for the personnel performing decontamination • Knowledge of the methods for removal of the contaminant from the victims • Availability of a rinsing agent • Provision of towels and clean garments/gowns • Appropriate disposable medical equipment or equipment that can be cleaned When decontamination is necessary, it is carried out by firefighters. A member of the EMS team may also cooperate during decontamination of the injured victims; if circumstances allow, this can be the doctor or the nurse performing the decontamination triage. In the event of a mass casualty accident, the triage doctor or another experienced EMS team member classifies the victims according to the level of emergency for priority decontamination and decontamination triage. Before decontamination, only the most urgent firstaid measures should be carried out: secure the airway, protect the cervical spine, and control severe bleeding If a patient has not been secondarily decontaminated, he or she must be wrapped in a blanket in the fashion of a cocoon before transport. Decontamination washing is carried out using warm/cold water, a soft brush or sponge, and mild soap. Depending on the type of contamination, in view of toxicodynamics, cold water is the most appropriate, but it should not be used in low temperatures when it can cause hypothermia, a highly undesired effect for a severely injured patient. The use of hot water is, however, contraindicated because it increases absorption. • Cold water – Advantages: readily available, expeditious start of the decontamination, vasoconstriction (sealing of the skin pores, reduced absorption) – Disadvantages: hypothermia, thermal shock • Warm water – Advantages: decreases the risk of hypothermia and the resulting shock – Disadvantages: lack of immediate availability, increases absorption, does not dissolve certain types of chemical weapons well It is difficult to assess the effectiveness of decontamination objectively; such assessments are most often based on a clinical opinion/evaluation. Thus, the effectiveness

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of the decontamination must be assured by the procedure itself. Objective detectors are – apart from those for radioactive contamination – mostly not available. The decontamination area should be fitted with an appropriate contaminated-water outlet to prevent environmental pollution. Primary decontamination denotes the removal of contaminated/potentially contaminated clothes, including jewelery and watches. When undressing a victim, attention must be paid so noncontaminated areas do not become contaminated. All the removed articles are stored in a double PVC bag, which is then sealed and labeled. With properly performed undressing, contamination can be reduced by up to 80%. Brush or wipe every evidently contaminated part of the skin, then rinse each contaminated area of the body with running water for 1 min in the head-to-toe direction. If the substance in question reacts with water, a longer flushing period with a greater amount of water is required. Protect open wounds from contaminants using a waterresistant dressing/bandage. All the contaminated clothes and patient’s other belongings must remain in the decontamination zone and must not accompany the patient in the ambulance, unless this has been explicitly approved by the head of decontamination or security. Secondary decontamination denotes the removal of contaminants to the greatest possible extent. If circumstances (personnel, equipment, water, weather) allow, secondary decontamination is performed on every victim before he or she is transferred to the cold/green/ support zone. Secondary decontamination is carried out by organized and meticulous individual washing with soap and water. After this stage, no risk of contamination, either for the patient or for the rescue worker, should remain. Begin the secondary decontamination at the face and continue in the direction toward the legs. Take special care around any wounds and the eyes, which are particularly sensitive to some hazardous substances. Wounds are to be cleaned first and protected against further decontamination using a water-resistant dressing/bandage. In case of contamination with certain chemicals, such as corrosive materials, rinse the exposed parts of the skin or eyes for at least 20 min. Emergency decontamination is a physical procedure for the immediate removal of the hazardous material from contaminated victims in a potentially lifethreatening situation. It is applied when the assessment of the nature of the incident has indicated that

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decontamination should occur as soon as possible. Improvised equipment can be used to perform this procedure. Because this type of decontamination poses a greater risk for the weak and the injured, the presence of an EMS team member must be ensured. Wound decontamination is needed when an open wound is contaminated by a chemical agent (e.g., nerve agents, vesicants). When undressing a victim, attention must be paid so wounds are not contaminated further. Thoroughly irrigate wounds with a 0.9% NaCl solution, wipe, and protect the wound using a water-resistant dressing/bandage. In a hospital, if necessary, a thorough decontamination for the wounds needs to be performed as soon as possible. If contaminants have protruded too deeply, they must be removed by wound excision. Mass decontamination is needed when the number of people exposed or suspected of being exposed to chemicals is significant. Appropriate triage for priority for decontamination of the most threatened must be carried out. The ambulatory victims can be included in a guided, simultaneous decontamination procedure of several people at once. The immediate commencement of at least the primary decontamination of an unsettled crowd is the best method to prevent secondary contamination and to reduce morbidity, mortality, and panic. To ensure this, large quantities of water and soap as well as towels and spare clothes are needed. If possible, decontamination areas for men and women should be set up separately; religious habits should also be respected, if possible. After decontamination, the individuals are directed into the cold/green/support zone. Enable controlled and guided self-decontamination for the victims who are able to perform such a procedure; this significantly speeds up the decontamination and requires fewer personnel. In such cases, clear instructions in plain language must be given, along with a presentation of how important this – to most victims probably unpleasant – procedure is for the preservation of their health and even their lives. The decontamination of nonambulatory victims is more problematic. During the decontamination procedure, the victim’s back, buttocks, armpits, hair, and genitals must be carefully cleaned. The stretcher, the cervical collar, and all other medical equipment must also be either decontaminated or changed before entering the cold/green/support zone. If the patient is severely injured, it is sometimes necessary to provide breathing support or to administer medications during the decontamination procedure, even though invasive

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methods, e.g., intubation, should generally not be done in the decontamination zone unless they are urgent.

10.5.1 Decontamination of Children Decontamination is even more problematic if there are children involved in an accident. If PPE must be used during the decontamination procedure, this stirs up even more fear in children and results in them being less cooperative and causes them greater psychological trauma. If at all possible, their parents or guardians/ acquaintances should stay with them during the decontamination, medical treatment, and transportation to the hospital. We must give a calming and emphatic impression at all times – even more so when the children are not accompanied by their relatives – and strive to reunite them with their parents as soon as possible. Older children are usually more adaptable and cooperate well during decontamination; however, they are still particularly susceptible to mass hysteria and it is therefore important to give them timely and satisfactory explanations and information and to keep them calm. Children are susceptible to hypothermia, which is why they should – especially in unfavorable weather conditions – be subjected only to primary decontamination and then be transported wrapped in a blanket to the hospital or other heated area where secondary decontamination can be carried out.

10.5.2 Decontamination Triage Decontamination triage is the process of the victim selections – choosing those who need decontamination and then sorting among them for the decontamination order/priority. In a chemical incident, the number of apparent victims may exceed capabilities for effective rescue, decontamination, and treatment of the victims. The main aim of each triage is to provide the greatest benefit for the greatest number. When decontamination is required, it is performed at the casualty assembly point in the orange/warm zone. Decontamination triage must make the following decisions: Who needs decontamination? Who needs it first? Who needs urgent treatment prior to decontamination? This is decided by the triage doctor in the decontamination zone. These triage decisions must be made by an experienced medical rescuer who can make the correct decisions about triage priority in the shortest possible

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time. If there is no doctor available to perform the decontamination triage or if it is more rational way to proceed, it can also be carried out by another experienced member of the medical team. Medical procedures within the contaminated area are generally limited only to opening blocked airways, controlling bleeding, and protecting the cervical spine (and, as an exception, applying any antidote). Physiological models of triage algorithms are generally used for early triage; they are fairly simple to use and focus only on vital functions. The triage algorithm sieve (see Chap. 4) is also useful in a chemical incident. Victims should first be sorted into ambulatory and nonambulatory groups (Fig. 10.6). Among the ambulatory victims (tagged green) a further prioritization should be made respecting (1) the proximity to the source of the release, (2) exposure to gas vapor or aerosol, (3) evidence of liquid deposition on the skin or clothing, (4) the presence of clinical signs and symptoms (cough, choking, chest tightness), and (5) the presence of conventional injuries. • First priority should be given to victims who were closest to the source of the release, were exposed to gas vapor or aerosol, have liquid deposition on their skin or clothing, or have serious clinical signs and symptoms. • Second priority should be given to victims who were not as close to the source of the release and may not have evidence of liquid deposition but do have clinical signs or symptoms. • Third priority should be given to victims with conventional injuries. Lower priority should be given to victims who were far away from to the source of the release and who do not have any clinical signs and symptoms. A victim who has trouble with breathing (obstructed airways) or circulation problems (bleeding) must be given immediate assistance; unconscious victims are to be positioned lying on their left side.

10.5.3 Nonambulatory Victims • First priority are the red/immediately tagged victims with breathing or circulatory problems. If such a state is the consequence of poisoning, these casualties are the highest decontamination priority. For example, with nerve agent or cyanide poisoning, such victims are candidates for urgent antidote application; if this is not possible they should be considered to be tagged as priority 4 (see below).

NO

NO

UNDER 120/min

OVER 120/min

BREATHING after AIRWAY CLEARED

Fig. 10.6 Decontamination triage

PULSE RATE

YES

RESPRIRATORY RATE 11-29

YES

BREATHING

NO

WALKING

YES

NO

YES

URGENT T2

IMMEDIATE T1

DECEASED T4

DELAYED T3

N A ON M B U LA TO R Y

B

AM

RY

TO

A UL

CONSIDER

• T2 tagged victims, WITH CONVENTIONAL INJURIES without CLINICAL SIGNS / SYMPTOMS OF POISONING • low EXPOSURE TO VAPOURS / AEROSOL / LIQUID • T4 tagged victims • T1 tagged victims WITH CONVENTIONAL INJURIES and PRESENCE OF very severe CLINICAL SIGNS / SYMPTOMS OF POISONING • grossly CONTAMINATED AND THOSE WHO DID NO RESOPOND TO EMERG. ANTIDOTE APPLICATION

4

• T2 tagged victims, WITH CONVENTIONAL INJURIES and PRESENCE OF moderate CLINICAL SIGNS / SYMPTOMS OF POISONING • moderate EXPOSURE TO VAPOURS / AEROSOL / LIQUID

• T1 tagged victims, specially, IF SUCH STATE IS CONSEQUENCE OF SEVERE POISONING

CONSIDER

• FAR AWAY FROM THE RELEASE SOURCE • NO CLINICAL SIGNS / SYMPTOMS OF EXPOSURE

• VICTIMS WITH CONVENTIONAL INJURIES

• NOT AS CLOSE TO THE RELEASE SOURCE • NOT LIQUID DEPOSITION ON SKIN / CLOTHING • PRESENCE OF CLINICAL SIGNS / SYMPTOMS

• CLOSEST TO THE RELEASE SOURCE • EXPOSED TO GAS VAPOURS / AEROSOL • LIQUID DEPOSITION ON SKIN / CLOTHING • PRESENCE OF SEVERE CLINICAL SIGNS/SYMPTOMS

3

2

1

PRIORITY

4

3

2

1

PRIORITY

10 Incidents Caused by Hazardous Material 245

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CLINICAL TOXICOLOGIST 1

Fig. 10.7 Clinical toxicologists organizing the scheme

− consultant to the MOC, HCG, RMC − coordination of toxicologists’ work

246 CLINICAL TOXICOLOGIST 2

− consultant to the Pre-hospital EMS tearms and to the MIC − consultant to the ED triage doctor and specialist on duty in ED

CLINICAL TOXICOLOGIST 3 − providing treatment to the victims admitted to the PCC

CLINICAL TOXICOLOGIST 4 − consultant to the physicians carriing for poisoned victims admited to other departments of the hopital

• Second priority are the yellow/urgently tagged victims. Conventional injuries aside, they may also have minimal to moderate symptoms and signs of poisoning, mild exposure to hazardous chemicals, gas vapor, or liquid but not at life-threatening levels. • Third priority are the yellow or green tagged victims without clinical signs or symptoms of exposure and minimal exposure to hazardous chemicals, gas vapor, or liquid at non-life-threatening levels. • Forth priority are the victims tagged as priority 4 (see Chap. 4). Conventional injuries aside, they have serious signs and symptoms, are grossly contaminated, and have not responded to an antidote. If possible, two decontamination corridors should be organized; the first for the nonambulatory victims and the second for the ambulatory victims. In case of only one corridor, the nonambulatory victims with first priority should be decontaminated first, followed by the ambulatory first-priority victims, followed by nonambulatory second-priority victims, and so on.

10.6

Role of the PCC in Chemical Incidents

10.6.1 Operational Activities of the PCC in a Chemical Incident Response The on-call clinical toxicologist can be reached 24 h a day by telephone within the framework of the 24-h information/consultation service of the PCC. In the event of a chemical incident, rescue workers will give him or her information about the type of accident, the potentially hazardous substances involved, their quantity, the circumstances, and the potential number

of persons exposed. On the basis of this information, the toxicologist shall provide basic instructions about the potential risk of poisoning to the exposed, instructions for the protection of rescue workers, the decontamination procedures, the triage recommendation for the exposed, and the basic information about the treatment, including administration of antidotes. If the clinical toxicologist is in the hospital, her or she also coordinates the further treatment of the exposed; for all other hospitals, the toxicologist shall provide such instructions to the responsible treating medical doctor of the particular hospital (Fig. 10.7).

10.6.2 Monitoring Possible Delayed Effects Using the system of toxicovigilance, the PCC also monitors delayed signs of poisoning or effects of a long-running exposure to a polluted environment or food-chain resources. A release of hazardous substances can severely pollute the environment, contaminate food and water, and enter the food chain. Signs of this type of exposure can develop with both a temporal delay as well as a spatial disparity. The PCC strives to detect them and attribute them to individual chemical incidents using the system of toxicovigilance.

10.6.3 Cooperation When Preparing Rescue Management Plans The PCC cooperates with services that take action in the event of chemical incidents with regard to preparing rescue management plans at both the regional and the national levels.

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10.6.4 Laying Down Recommended Procedures and Guidelines for the Response to Chemical Incidents The PCC prepares and follows new developments in the field of decontamination, first aid, emergency medical assistance, and hospital treatment procedures in chemical incidents. The main toxicologic properties of the hazardous substances, signs and symptoms of poisoning, decontamination procedures, the toxic trauma treatment during the chemical incidents for some of the most common and the most “suspicious” chemicals are presented in item 10.9.

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on the effectiveness of the suggested management schemes, from the points of view of both the organization as well as the doctrine itself. The main assessment categories are the quickness, rationality, and safety of the procedures and whether the first-aid measures actually reduced the exposure to harmful substances, alleviated the progression of poisoning, and prevented the worst consequences the chemical accident could have caused. The PCC shall submit proposals for improvements to the response plans and, if necessary, for amendments to the regulations.

10.7

General Approach to Toxic Trauma Treatment

10.6.5 Rational Antidote Supply The PCC should be involved in rational antidote supply planning at the national level. This should also cover the planning for chemical incidents. What the stock volumes are and where they will be stored – especially some of the rarely used antidotes – are a matter of agreement at the national level, taking into account certain potential natural predispositions of the chemical incidents (industry, transport) in an individual region.

10.6.6 Providing Training for Medical Personnel and Other Rescue Workers Assigned to Respond to Chemical Incidents The PCC should collaborate in organizing a professional training program in toxic trauma treatment. The aim of the training program is to teach EMS services personnel how to identify the potential hazards streaming from a chemical accident, how to use PPE correctly, and what the particularities of the treatment for some of the most important toxic substances are. Practical workshops must be part of the training.

10.6.7 Cooperating in Preparing Analyses and Follow-Up Studies of Chemical Accidents and Proposing Improvements Analyses of the organization and first-aid and treatment procedures following the completion of a chemical incident are the only sources of relevant feedback

Patient treatment guidelines are written as a guiding thread, covering the treatment of victims from the incident site to definitive hospital care. Although chemical incident measures are, in terms of organization, divided into prehospital and hospital measures, we should at all times strive to treat victims comprehensively and to ensure that the transition from the evacuation to the provision of definitive treatment in a hospital is as smooth as possible (Fig. 10.8). These guidelines are prepared in line with this principle. All people in the EMS rescue chain must always keep in mind the fundamental postulates of rescue activities in the event of chemical incidents. • The rescue workers’ safety always comes first (using the appropriate PPE and determining a suitable treatment area). • Timely identification of the involved hazardous substances ensures safer and more rational rescue activities. • Decontamination of the victims must be timely and thorough. • Before decontamination, only the most urgent firstaid measures are provided: clear airways, protect the cervical spine, and control bleeding by applying compression. • Resuscitate and maintain the victims’ vital functions as soon as possible. • As a rule, only symptomatic treatment is provided in the field to the degree allowed by the circumstances. Urgent specific antidotes that are administered on site, if indicated, are oxygen, atropine, toxogonin/pralidoxime, amyl nitrite/hydroxocobalamin, methylene blue, calcium gluconate, and British anti-Lewisite (BAL).

248 Fig. 10.8 Rescue chain during chemical incidents

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Safety!

Identification of Hazardous Chemical PPE usage Decontamination Triage Toxic trauma treatment Transportation Definitive victims’ management in a hospital

• Good tissue oxygenation and sufficient circulation are the preliminary conditions for successful antidote treatment. In line with these principles, after each phase it is important to check which of the prescribed victim treatment measures have already been carried out and which are still to be performed, complemented, or repeated. Because of the related toxicokinetic and toxicodynamic processes, patients suffering from toxic trauma must be monitored particularly carefully, i.e., frequent re-triages.

10.7.1 Identifying the Name of Chemicals and Hazard Recognition The names of chemicals are usually complicated and long, whereas their trivial names, which are often used in practice, may be misleading. The only reliable means of identifying a chemical is its Chemical Abstract Service (CAS) index number, which can be regarded as the identification number of any given substance. By using CAS numbers communication can be facilitated and the risk of fatal misunderstandings reduced. It is required by law that the CAS number of a hazardous substance be printed on the label next to the name of the substance; it must also be provided in section 2 or 3 of the MSDS of the chemical. Correctly compiled safety MSDSs represent an important source of first information for the rescue workers, providing information about the health hazards of actual hazardous chemical as well as the required personal protection, firefighting, and first-aid measures. We should always strive to gather as much information about a chemical as possible: its name, common name, CAS number, physical state, color, smell, irritation

Hospital

properties, water solubility, boiling point, vapor pressure, explosiveness, flashpoint, self-ignition temperature, immediately dangerous to life or health (IDHL) value, possible routes of exposure, protective measures, signs and symptoms of poisoning, decontamination procedure, and treatment guidelines. In an incident in which cargo vehicles are involved, transport labels (orange rectangular or white rhomboid panels) are an important source of information (Fig. 10.9). People who have been exposed to a hazardous material will not necessarily develop symptoms of poisoning. These symptoms appear after a significant exposure to hazardous substances labelled with the letters Xi, Xn, C, T, or T+ and the associated hazard symbols. With substances that are hazardous because of their physicochemical properties and are labelled only with E, O, F, or F+, mostly conventional injuries can be expected, whereas substances marked with N can have an adverse effect on the environment (Fig. 10.10). The abovementioned symbols indicate only the highest possible level of risk and can be found on the label and (if applicable) in section 15 of the MSDS. More detailed information about all the relevant hazardous properties are provided in the form of standard risk, or “R,” phrases, which warn us about the hazardous routes of exposure (e.g., toxic by inhalation, harmful if swallowed). Standard safety, or “S,” phrases give information about storing, obligatory protective measures, first-aid measures, and measures for protecting the environment. These phrases are printed both on the labels and in section 15 of the MSDS. At the present time many countries are in phase of adopting the Globally Harmonized System, which brings a new classification and labeling of hazardous chemicals. It will take some time during the transitional period to become familiar with them.

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249

33

Number of hazard (e.g. 3 - flammable; duplication of number means hazard gradation)

1203

UN numbers are four-digit numbers that identify hazardous substances in the framework of international transport (e.g. 1203 means gasoline or petrol)

Class 1: Class 2: EXPLOSIVES GASES

Class 3: FLAMMABLE LIQUIDS

Class 4: Class 5: FLAMMABLE OXIDISING AGENTS AND SOLIDS ORGANIC PEROXIDES

Class 6: Class 7: Class 8: Class 9: TOXIC and RADIOACTIVE CORROSIVE MISCELLANEINFECTIOUS SUBSTANCE SUBSTANCE OUS SUBSTANCE

Fig. 10.9 Labeling of hazardous substances in transport

E EXPLOSIVE

O OXIDISING

F FLAMMABLE

T TOXIC

F+ EXTREMELY FLAMMABLE

T+ TOXIC FLAMMABLE

C CORROSIVE

Xi IRRITANT Xn HARMFUL

N DANGEROUS FOR THE ENVIROMENT

Risk phrases (R), defined in Annex III of EU Directive 67/548/EEC give us more information on nature of special risks attributed to particular harmful substances and preparations e.g.: R26/27/28: Very toxic by inhalation, in contact with skin and if swallowed R36/37/38: Irritating to eyes, respiratory system and skin R41: Risk of serious damage to eyes R42/43: May cause sensitization by inhalation and skin contact Safety phrases (S), defined in Annex III of EU Directive 67/548/EEC advice concerning harmful substances and preparations e.g.: S38: In case of insufficient ventilation wear suitable respiratory equipment S36/37/39: Wear suitable protective clothing, gloves and eye/face protection S50: Do not mix with ... (to be specified by the manufacturer)

Fig. 10.10 Labeling of hazardous substances in accordance with EU Directive 67/548/EEC

10.7.2 Exposure, Poisoning When assessing the significance of exposure and predicting the severity of poisoning, we must take into account not only the toxicity of the hazardous substance but also its physicochemical properties (physical form, solubility, volatility, and viscosity), the route of exposure, the protective equipment that may have been used, and the duration of the exposure. During chemical incidents a hazardous material can enter the human body by inhalation, through the skin

or mucous membranes, and – less commonly – by ingestion or injection. Secondary poisoning can also occur via the ingestion of contaminated food or water. Inhalation is the most common route by which chemical substances enter the human body. Gases, fumes, vapors, and aerosols with liquid or solid particles (mist, smoke, dust) enter the body in this way. The effect that the inhaled substance will cause depends on its toxicity and physicochemical properties, which present as different signs and symptoms:

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• Substances that dissolve well in water cause immediate irritation to the eyes and respiratory mucous membrane, which serves as a warning for the victim to retreat. Substances that do not dissolve well in water cause delayed irritation and can protrude into the lower parts of the respiratory tract; in cases of significant exposure, both types of substances may cause toxic pneumonitis. • Substances consisting of particles of less than 5 mm in diameter may enter all the way into the lung alveoli. • Some substances diffuse through the alveolar-capillary membrane and cause signs of systemic toxicity. Some hazardous materials may cause only local effects on the eyes, on the skin (irritate or defeat it or cause depigmentation), whereas others (e.g., organophosphates, toluene, phenol, aniline, carbon tetrachloride) may enter the body through the skin and cause signs of systemic toxicity. Skin and mucous membranes cover relatively large surfaces and present a wide window of opportunity for substances to enter the body. If the skin or a mucous membrane is damaged, substances can enter the body all the more easily.

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through the skin, mucous membranes, and breast milk. Toxicodynamics refers to the molecular, biochemical, and physiologic effects of toxicants or their metabolites in the organism. All of the above-mentioned elements of toxicokinetics must be taken into account before any inferences can be made about the toxicodynamic effects of an actual hazardous substance.

10.7.4 Toxicologic Sample Analysis Samples of biological material for a toxicologic analysis are to be taken as soon as the situation allows it – ideally before the treatment has commenced, but never at the cost of the patient’s health. Before taking the sample, the patient should already have been decontaminated. When taking the sample, also bear your own safety in mind – always use appropriate PPE. Never clean the puncture site with alcohol. Use sterile water/0.9% NaCl solution instead. If it is possible collect two tubes (one with heparine and one with ethylenedinitroletetra-acetic acid) and urine in a small plastic pot.

10.7.3 Toxicokinetics, Toxicodynamics

10.7.5 Documentation

Substances that absorb into the body must reach a certain concentration within the organism to cause toxic effects. The rate of absorption depends on the chemical properties of the substance; e.g., substances that dissolve well in water are rapidly absorbed through mucous membranes and more easily reach the toxic concentration in the organism. Fat-soluble substances (organophosphates, organic solvents) can reach significant concentrations within the body by absorption through the skin. Once absorbed, these substances follow different patterns of distribution within the body. Some of them accumulate only in particular bodily organs; others are distributed evenly throughout the whole organism. The toxicity threshold of a substance within an organism is also determined by its metabolic pathway. Substances are excreted from the organism either unchanged or – having been metabolised – in the form of other, mostly less dangerous substances. There are also certain materials that are not hazardous as such, but at a certain stage of the metabolic process form toxic metabolites (bioactivation). Some examples of such substances are methanol, ethylene glycol, and parathion. According to their respective properties, substances can be excreted from the organism via the respiratory system, kidneys, and liver, as well as

When the situation allows it, try to record answers to as many of the following questions as possible: • Which chemical (technical substance, purity, formulation/concentration, presence of solvents or other additives, physical state [solid, liquid, gas], combined effect of several chemicals)? • What is the route of exposure (through skin, by inhalation, by ingestion)? Different ways of introducing of a chemical into the organism may cause the same symptoms, but toxic effects of the substance may, on the other hand, also occur in organs or systems that are not connected to the point of entry. • Where did the poisoning occur (circumstances, e.g., fire, ambient temperature)? • What was the duration of the exposure (single [minutes/hours], repeated, chronic)? • How much time has passed since the most recent exposure? • Have any means of protection been used during the exposure and, if so, which? • How have the symptoms of poisoning changed since the beginning of exposure? • How was the victims previous health condition? After the victim has been treated, fill in the Chemical Exposure Report (Table 10.4).

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Table 10.4 Sample of chemical exposure report (fill in and send to the Poison Control Center) DATA ON THE VICTIM/INSTITUTION Institution: Department: Surname: □ Male Address: Postal code: EXPOSURE and DECONTAMINATION Location of the exposure: Route of exposure: Chemical name and form: Decontaminated at the incident site?

Date of arrival:

□ Inhalation □ Solid

Has the victim been decontaminated in the ED? Did the victim showed any signs/symptoms of exposure List the signs/symptoms: Time of the onset of signs/symptoms Triage category at the incident site: □ T1 Triage category in the ED: □ T1 TREATMENT Had the victim received an antidote? Name of given antidote: Symptomatic treatment:

Oxygen: □ Yes, □ No □ Blood

Taken samples for toxicologic analysis: OUTCOME Was the victim admitted to a hospital? Was the victim discharged? Was the victim scheduled a follow-up examination? Has the patient transferred elsewhere? Has the patient died? Name, surname, signature:

10.8

Time:

□ Female

Name: Date of birth/age:

Nationality:

Phone:

Date: □ Skin □ Liquid □ Yes, partly □ Yes, completely □ Yes □ Yes

Time: □ Ingestion □ Vapour/gas □ No

□ No data □ No data □ No data

□ No □ No

Time: □ No data

Date: □ T2 □ T2

Time: □ T3 □ T3

□ Yes Dose:

□ No □ IM, □ IV, □ SC, □ Inh;

IV Fluids: □ Yes, □ No □ Urine

Bronchodilat. Inh. □ Yes, □ No □ Vomit

Name of the department: □ Yes □ Yes Name of the hospital: Date: Doctor ID:

□ No □ No Date: □ No Time: Date:

Antidotes

Antidotes are medications that, according to a known mechanism, modify the toxicodynamics and/or toxicokinetics of a poison and have proven clinical effect. Here we focus only on antidotes that can be administered in the event of a chemical incident (Table 10.5).

GCS: GCS:

□ No data □ No data □ No data Repeated: □ Yes, □ No Other medicines: □ None

□ No data □ No □ No

Sufficient oxygenation, blood pressure, heart rate, and adequate body temperature must be ensured when applying an antidote. An urgent symptomatic treatment also includes the treatment of convulsions, toxic pneumonitis, and pulmonary edema.

10.8.2 Contraindications for Antidote Administration 10.8.1 Antidote Within the Poisoning Treatment Scheme In cases of poisoning, the first question that springs to mind is probably the antidote; however, compared with the number of poisons, the number of antidotes is actually small. Without an effective symptomatic treatment the effectiveness of the antidote is questionable.:

An absolute contraindication for the administration of a specific antidote means that this antidote is not to be administered under any conditions. This is, for example, an anaphylactic reaction mediated via immunoglobulin (Ig) E (type 1 sensitization), which occurs independently of the dose, concentration, or the manner of administration of the substance.

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A relative contraindication to the administration of an antidote is an anaphylactoid reaction (e.g., sensitization that is not mediated via IgE). The signs and symptoms are similar to that of the anaphylactic reaction; however, in this case sensitization can be avoided by slower administration, by administering a lower concentration or a smaller dose, or by using a different route, e.g., orally instead of intravenously. Specific contraindications associated with an individual antidote must also be considered.

10.8.3 Antidotes for Use in Chemical Incidents Amyl nitrite induces a low-level methemoglobinemia. Methemoglobin binds free cyanides. It is possible that it is also effective through nitric oxide synthetase. It is used as first aid for evident acute poisoning with cyanides, cyanogenic substances, or possibly with sulphides (H2S) in the first 30 min after exposure. The contents of a crushed ampoule are to be inhaled for 30 s, followed by a 30-s pause, which is necessary to achieve better oxygenation, then the procedure is repeated; 1 ampoule suffices for 2–3 min of use and causes an approximately 5% methemoglobinemia. When sodium nitrite has been administered intravenously, administration of amyl nitrite is ceased. Amyl nitrite is extremely volatile and explosive, and is used only as a quick first aid. A more effective antidote that forms methemoglobin is sodium nitrite. The relative contraindications for administering amyl nitrite are severe hypotension, methemoglobinemia of >40%, or CO poisoning. Adverse effects include headache, hypotension, reflex tachycardia, hypoperfusion, and shock. Atropine is a competitive antagonist of cholinergic muscarinic receptors (but not of the nicotinic ones). It is effective in all cases of poisoning in which cholinergic syndrome occurs (poisonings with cholinesterase inhibitors, such as organophosphorous insecticides and N-methylcarbamates, cholinergics, nerve agents). Because of the inhibition of acetylcholinesterase, unmetabolized acetylcholine starts to build up in the cholinergic synapses, which causes the typical clinical presentation of an excited cholinergic system. The starting dose of atropine for adults is 1–5 mg intravenously in bolus (depending on the bronchial secretion rate), for children, 0.02–0.05 mg/kg of bodyweight; doses are administered repeatedly every 5 min until the clinical

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picture of severe poisoning has improved. Atropine can also be administered by infusion at 0.02–0.08 mg/kg bodyweight/h. In a mass-casualty situation IM atropine can be given. Sufficient oxygenation must be provided to the patient because atropine can trigger heart rhythm disturbances in hypoxemic patients. The most important sign of adequate atropinization is the cessation of bronchial hypersecretion, whereas less significant signs include mydriasis, dry mouth, and tachycardia. Dimercaprol (BAL, 2,3-dimercaptopropanol). Dimercaprol binds with arsenic, arsine, and lewisite to form complexes. The lewisite and arsenic toxicity is based on the interaction with essential sulphydrile groups (-SH) of enzymes. Dimercaprol has two -SH groups, with which it builds a strong mercaptide ring after binding with metal ions. The dimercaprol-metal complex is secreted through the kidneys and with bile. Dimercaprol is the most toxic antidote still in use. Urine alkalization reduces the nephrotoxicity of the above dimercaprol-metal complex. The adverse effects of dimercaprol include nausea, vomiting, stomach pain, dose-dependent hypertension, tachycardia, a squeezing pain in the chest, headache, perspiration, lacrymation, salivation, muscle pain, burning sensation in the mouth, throat, and eyes, and, in the case of an overdose, possibly convulsions and unconsciousness. It diffuses through cell membranes quickly; therefore, the concentration in tissues is up to five times higher than in the blood. In cases of arsenic poisoning, dimercaprol is administered during the first 2 days at 3 mg/ kg of bodyweight, deeply IM every 4–6 h, then every 12 h for a further 7–10 days; in cases of arsine poisoning and systemic effects of lewisite (shock or significant pulmonary toxic injury), it is administered only on the first day after the exposure, at 3 mg/kg bodyweight. Consultation with a toxicologist is recommended. In the event of kidney insufficiency, the complex is effectively removed using hemodialysis or hemodiafiltration. It is contraindicated by an allergy to peanuts. Hydroxocobalamin is a synthetic precursor of vitamin B12 (cyanocobalamin), which is used for the treatment of pernicious anemia. In high doses it is also used to treat cyanide poisonings. Hydroxocobalamin binds with free cyanide radicals in the plasma to form the nontoxic cyanocobalamin. It is indicated with poisoning or a suspicion of poisoning with cyanides, especially in the event of a fire, when the use of nitrites is contraindicated because of a high possibility of carboxyhemoglobinemia in cases of contemporary CO

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Table 10.5 The most urgent antidotes for administration in chemical incidents, with indications and dosage for adults and children Antidote Atropine sulphate amp of different volume

Poisoning with – Organophosphates – N-methylcarbamates – Nerve agents

Calcium gluconate 10%, amp of 10 ml

– Hydrofluoric acid (systemic effect) – Fluorides – Hydrofluoric acid burns

Calcium gluconate 2.5% to 10% gel or solution Amyl nitrite amp of 0.3 ml

Hydroxocobalamin two vials of 2.5 g Sodium nitrite 3%, amp of 10 ml Sodium thiosulphate 25%, amp of 50 ml

– – – –

Cyanides Nitriles Sulphides (H2S) Cyanides

– – – – –

Cyanides Nitriles Sulphides (H2S) Cyanides Nitriles

Methylene blue 1% vial

– Methemoglobin-forming substances

Oxygen

– Simple asphyxiants – Chemical asphyxiants – Methemoglobin-forming substances – Carbon monoxide – Cyanides – Azides/hydrazoic acid – Sulphides – Organophosphates – Nerve agents

Obidoxime 250 mg vial of 1 ml

Pralidoxime 1 g, vial of 1 ml

– Organophosphates – Nerve agents

Dimercaprol (BAL) 10%, amp – Arsenic of 3 ml – Arsine – Lewisite

Dose – adults Starting dose 1–5 mg IV/IM in bolus; repeated doses every 5 min according to the clinical effect 10–20 ml IV in bolus over 5 min; if necessary, repeat it every 10 min

Dose – children 0.02–0.05 mg/kg IV/IM in bolus, repeated doses every 5 min in accordance with the clinical picture 0.2–0.3 ml/kg IV in bolus over 5 min; if necessary, repeat it every 10 min

Local application

Local application

Inhalation (1 amp, inhaling for 30 s, followed by a 30 s pause; procedure can be repeated) 5 g infusion IV in 30 min 10 ml IV in 5 min

50 ml infusion IV in 10–20 min

1–2 mg/kg IV in 5 min, if necessary, repeat it every 30–60 min 100% via NRB mask, HBO in case of CO poisoning

– 250 mg/kg IV/IM – Repeat dose in 2 h – Repeated every 6–8 h until there is an effect – Can be administered via continuous infusion 1–2 g IV in 10 min/IM/SC, then 200–500 mg/h via continuous infusion until there is an effect

70 mg/kg infusion IV in 30 min 0.15–0.33 ml/kg IV in 5 min, to maximum of 10 ml 1.6 ml/kg infusion IV in 10–20 min, to maximum of 50 ml 1–2 mg/kg IV in 5 min, if necessary, repeat it every 30–60 min 100% via NRB mask, HBO in case of CO poisoning

4–8 mg/kg IV/IM (maximum, 250 mg) – Repeat the dose in 2 h – Repeated every 6–8 h until there is an effect – Can be administered via continuous infusion 20–40 mg/kg IV in 10 min/ IM/SC, then 5–10 mg/kg/h via continuous infusion until there is an effect

3 mg/kg deeply IM every 4–6 h (in case of arsenic 2 days, in case of arsine or Lewisite 1 day), in case of arsenic then additional 7–10 days every 12 h

BAL British anti-Lewisite, amp ampoule, IV intravenously, IM intramuscularly, HBO hyperbaric oxygenation, NRB nonrebreather mask, CO carbon monoxide, SC subcutaneous

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poisoning. It is also used to prevent toxic effects of sodium nitroprusside. The average dose for adults is 5 g of hydroxocobalamin diluted in at least 200 ml of 0.9% NaCl solution via a 30-min infusion. The pediatric dose is 70 mg/kg bodyweight. Simultaneous administration of sodium thiosulphate causes a synergistic effect, to be administered in a dose of 8–12.5 g IV (32–50 ml of 25% solution). The antidotes must not be mixed in an infusion because the thiosulphate forms an inactive complex with hydroxocobalamin. If the clinical state does not improve after 15–30 min, repeat the doses of hydroxocobalamin and sodium thiosulphate. The possible adverse effects are nausea, vomiting, hypertension, muscle convulsions, or spasms. The antidote must be stored at standard room temperature. Calcium gluconate is a physiologic antagonist in poisonings with fluorides, hydrofluoride, magnesium, or potassium. In cases of percutaneous hydrofluoric acid (HF) poisoning, calcium gluconate is infiltrated subcutaneously into the affected area (0.5 ml of 5–10% solution/cm2; not more than 0.5 ml per finger). In cases of significant systemic absorption with hypocalcemia, the systemic administration of calcium gluconate is also indicated. The starting dose for an adult is 10–20 ml IV in 5 min (for children, the dose is 0.2–0.3 ml/kg bodyweight); if necessary, the dose can be repeated every 10 min. In cases of hydrofluoric acid ingestion, calcium gluconate is administered orally at 10–20 g (10–20 ampoule) in 250 ml of water. As a first-aid measure 0.5–1 dl of milk or CaCO3 can be drank. For an inhalation exposure to HF, the use of 2.5% calcium gluconate by nebulization is recommended. Oxygen is a competitive antagonist in CO poisonings. Hyperbaric oxygenation (treatment with oxygen in special chambers, where the pressure equals 2–3 atm) is indicated for CO poisoning; its effectiveness has not been proven in poisonings with cyanides and hydrosulphide or in methemoglobinemia. Methylene blue is a reducer of ferrihemoglobin (Fe3+), which it reduces to ferrohemoglobin (Fe2+). In cases of toxic methemoglobinemia, administer 1–2 mg/kg bodyweight, it is administered slowly intravenously in the form of a 1% solution. Doses for adults and children are the same. After the bolus, administer 15–30 ml of physiologic solution or 5% glucose to reduce the local pain. The dose can be repeated after 30–60 min, and the maximum effect is expected within 30 min. Doses can be repeated up to a total of maximum 7 mg/kg bodyweight.

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Sodium nitrite is used in cases of acute poisoning with cyanides or possibly with sulphides (H2S) in the first 30 min after exposure. This antidote oxidizes the hemoglobin into methemoglobin, which binds free cyanides. The therapeutic dose for adults is 300 mg of sodium nitrite (10 ml of a 3% solution), administered slowly intravenously (5 min). Such a dose raises the concentration of methemoglobin by 20–30% within 30 min. If the desired rise in methemoglobin level does not occur, an addition half of the dose can be administered. The dose for a child is 0.15–0.33 ml/kg bodyweight up to a maximum of 10 ml; however, this depends mostly on the concentration of hemoglobin. In cases of anemia and hypotension, we must reduce the dose accordingly, dilute the antidote in 50–100 ml of physiological solution, and inject it slowly (at least 5 min). After the administration of the sodium nitrite, sodium thiosulphate should always be administered, too. The thiosulphate is, however, not to be administered in poisonings with sulphides (H2S) because sulphmethemoglobin degrades spontaneously. In cases of simultaneous CO poisoning, e.g., in fires, do not administer nitrites – use hydroxocobalamin instead. Sodium thiosulphate transforms cyanides into thiocyanates (rhodanide) that differ from cyanides in that they diffuse slowly through cell membranes. In cases of cyanide poisoning, a combination of sodium nitrite and sodium thiosulphate is to be administered. The dose is 12.5 g (50 ml 25% solution) via intravenous infusion in 10–20 min. The dose for a child is 400 mg/ kg bodyweight (1.6 ml 25% solution), up to a total of 50 ml of 25% solution. An additional half of the dose can be administered after 30–60 min. Obidoxime is a reactivator of acetylcholinesterase. It is the most effective if administered as soon as possible, while the bond of the poison with acetylcholinesterase is still reversible (with nerve agent weapons this can be up to a few minutes, and with organophosphorous insecticides up to 24 h after the poisoning, or until acetylcholinesterase is successfully reactivated). It is administered intravenously or intramuscularly. The starting dose for adults is 250 mg, and this can be repeated after 2 h, then 250 mg every 6–8 h. The dose for children is 4–8 mg/kg bodyweight but not more than 250 mg. The duration of the infusion depends on the effectiveness of acetylcholinesterase reactivation. Pralidoxime is a reactivator of cholinesterase. It is most effective if administered as soon as possible,

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while the bond of the poison with acetylcholinesterase is still reversible (with nerve agent weapons this can be up to a few minutes, and with organophosphorous insecticides up to 24 h after poisoning, or until acetylcholinesterase is successfully reactivated). The starting dose is 1–2 g, slowly intravenously (over 10 min) or by a short infusion of 100 ml of physiologic solution in 15–30 min. Children are administered 20–40 mg/kg bodyweight, slowly intravenously up to 1 g. IM or subcutaneous administration should be used if IV access is not immediately available. Continue by infusing 200–500 mg of pralidoxime per hour (children 5–10 mg/kg/h) for at least 24 h. Treatment with the antidote may last several days, particularly in cases of poisonings with the lipophilic types of organophosphates. The duration of the treatment depends on the clinical picture, the activity of the acetylcholinesterase, and the type of organophosphorous compound in question.

10.9

Toxic Trauma Treatment of the Most Common Toxic Injuries

The guidelines for the treatment of victims in a chemical incident offer EMS teams basic knowledge and instructions about how to treat different types of chemical injuries. Certainly, this is not a chapter of a clinical toxicology textbook. Laying down separate guidelines for each of thousands of existing chemicals would be absolutely impossible and preposterous. These guidelines, therefore, focus on the commonly used substances and those substances that have – according to the available data – already been involved in chemical incidents. To present the basic information in as simple terms as possible, and to make it easier to use, a relatively large number of chemicals are divided into categories based on the similarities of clinical signs they evoke, and the similarities in the required treatment. We must stress, however, that each incident involving hazardous chemicals is unique and calls for an individual risk assessment, as well as for specialized, precise guidelines in terms of both the safety of rescue workers and providing treatment to the victims. These guidelines should thus be regarded merely as the starting point for facilitating communication between the EMS teams and the clinical toxicologists within the framework of the 24-h information/consultation service of the PCC and other rescue services.

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The toxic trauma treatment of a specific hazardous material or a group of similar substances is written in a manner that is the best for a victim exposed to this substance. The number of such victims, the demand for medical resources, and the circumstances of the incident will together influence in what manner and to what extent it will be carried out. For example, during an MI with a large number of victims, it is unrealistic to expect a 20-min irrigation of contaminated eyes. In an MI it is better to decide on a 1-min eye irrigations for 20 victims. The health care rescuer must know in which direction they can improvise and what the costs to the victims are.

10.9.1 Irritant Gases (Irritants) Irritants react in contact with moist surfaces of the mucous membranes and skin, causing local tissue irritation as well as corrosive injuries. The effects depend on the concentration and the duration of the exposure. Thus, they cause irritation to the eyes (conjunctiva, cornea), the nasal mucous membrane, the mouth, the throat, the epiglottis, the larynx, the trachea, the bronchi, the bronchioli, and the alveolarcapillary membrane. The exposure poses a higher risk to victims with a pulmonary disease (asthmatics, COPD) and smokers. An exposure to the high concentrations can be fatal. In general, irritant gases do not absorb into the organism and do not cause direct systemic toxicity. Because of the airway injury (mucous membrane edema, bronchospasms, noncardiogenic pulmonary edema) the diffusion of oxygen from the lungs into tissues is disrupted, which causes hypoxemia and hypoxia of the organs (heart and/or brain). The development of clinical signs and symptoms after exposure to irritants also depends on their solubility in water. The highly water-soluble gases have a good warning property; they cause an upper respiratory system irritation even at low concentrations in the air. According to their solubility in water, irritant gases are classified into: • Gases with a high water solubility: NH3, SO2, HCl, HF, formaldehyde, HBr, sulphur chloride, vapors of overheated Teflon • Gases with a moderate water solubility: Cl2, fluorine, acrolein

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• Gases with a low water solubility (soluble in the fats): nitrous gases (NO2, N2O4), phosgene, ozone, nickel carbonyl Chlorine is often involved in chemical incidents. It is known as a yellow-green gas or a clear yellowishbrown liquid (liquefied gas) with a characteristic odor usually associated with swimming pools or bleaching agents. Chlorine is used in the chemical industry as a bleaching agent, disinfectant, and for the disinfection of pools. Chlorine gas is heavier than air – it stays in the lower layers. Chlorine forms hydrochloric and hypochlorous acid upon contact with a moisture surface/water. It is highly reactive with air and can also form an explosive mixture. Ammonia is a colorless gas or a liquid (liquefied compressed gas or aqueous solution). It is a strong alkali with a pungent characteristic odor of drying urine. It is lighter than air. It is used as a refrigerant, a bleaching agent, in explosives, and in some household cleaners. In laboratories it is commonly supplied as a 35% aqueous solution. Phosgene synonyms are carbonyl chloride, COCl2, and CG. It is colorless gas or white vapor at room temperature and may have the odor of the moldy hay or fresh-mown grass (it is odorless in low concentrations).

It is heavier than air – it accumulates in the lower levels, degrades slowly, and can contaminate a large area. In contact with water from the mucous membranes or skin it forms hydrochloric acid. It is used in industry for the production of isocyanates, polyurethane, polycarbonate resins, pesticides, herbicides, and dyes. It is formed through the process of chlorinated hydrocarbon combustion.

10.9.1.1 Acute Signs and Symptoms of Exposure to Irritant Gases Acute signs and symptoms of exposure to irritant gases are first of all the local irritating signs. • Eye: burning pain, stinging, watering, blepharospasm • Respiratory system: sneezing, coughing, upper airway edema, disphonia, wheezing, dyspnea, bronchospasm, pneumonitis or noncardiogenic pulmonary edema (possible delayed onset after exposure: up to 24 h for chlorine and up to 48 h for phosgene), the signs of a hypoxemia and cardiac arrest • Skin: irritation, erythema, and signs of burns or frostbite after contact with compressed liquid gasses

10.9.1.2 Prehospital Management Evacuation Persistence/ transmissibility Information Primary examination Decontamination

Toxic trauma treatment

Antidote

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. Low risk of secondary contamination to health care rescuers; it is possible only with irritants in liquid form. Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots). Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. • The decontamination of the victims exposed to gaseous irritants is not mandatory; however, undressing is recommended because some gases are trapped in clothes. • Victims exposed to irritants in liquid or aerosol form should be primarily decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: thoroughly irrigate affected areas with water; for corrosive substances, prolong the irrigation of affected areas. • Examine all victims who show symptoms of exposure. • Treatment is symptomatic. • Maintain an open airway, consider early intubation (edema!), administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. There is no specific antidote.

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• Examine all victims who showed or still show symptoms of exposure; all victims who have a history of any pulmonary disease and all who still show symptoms at the time of the examination are to be admitted for a 24-h observation after the exposure to irritant gases with moderate water solubility, e.g., chlorine, and for a 48-h observation after exposure to gases with a low water solubility, e.g., phosgene. • All victims who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • If signs of corneal injury are present, or in the case of contact with a liquefied gas, an examination by an ophthalmologist is required. • Fill in the chemical exposure report.

10.9.1.3 Emergency Department/Hospital Management Persistence/transmissibility Information Primary examination Decontamination

Toxic trauma treatment

Antidote Admission/discharge criteria

Low secondary contamination risk to health care rescuers; it is possible only with irritants in liquid form. Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots). Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. • The decontamination of the victims exposed to gaseous irritants is not mandatory; however, undressing is recommended because some gases are trapped in clothes. • Victims exposed to irritants in liquid or aerosol form should be primarily decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: irrigate affected areas thoroughly with water; for corrosive substances prolong the irrigation of affected areas. • The treatment is symptomatic. • Maintain an open airway, consider early intubation (edema!), administer supplemental oxygen if necessary. • Inhalation exposure: take blood for arterial blood gas analysis (ABGA), chest x-ray, measure peak expiratory flow (PEF); repeat the tests if necessary. In the case of a bronchospasm administer bronchodilator (inhaled or systemic) and inhaled steroid. • Ventilation may be necessary (positive end expiratory pressure [PEEP], continuous positive airway pressure [CPAP]). • Monitor the possibility of secondary infection or acute respiratory distress syndrome (ARDS) and act accordingly. • In severe exposure to, e.g., chlorine or phosgene, consider early systemic administration of corticosteroids to prevent pulmonary edema. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution. If signs of corneal injury are present or they eyes were in contact with the liquefied gas, examination by an ophthalmologist is required. • Skin exposure: irrigate affected areas thoroughly with water. Burns/frostbite treat symptomatically, consider surgical treatment. There is no specific antidote. • Examine all victims who showed or still show symptoms of exposure; all victims who have a history of any pulmonary disease and all who still show symptoms at the time of the examination are to be admitted for a 24-h observation after the exposure to irritant gases with moderate water solubility, e.g., chlorine, and for a 48-h observation after exposure to gases with a low water solubility, e.g., phosgene. • All who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • If signs of corneal injury are present, or in the case of contact with a liquefied gas, an examination by an ophthalmologist is required. • Fill in the chemical exposure report.

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10.9.2 Asphyxiants Asphyxiants are chemicals that interfere with the body’s mechanisms that perform aerobic metabolism. They have similar clinical effects regardless of the level at which they disrupt oxygen supply or its utilization, and the onset of symptoms varies. Asphyxiants are divided into the simple and the chemical. Simple asphyxiants displace oxygen from the surrounding atmosphere so that there is less oxygen in the inhaled air. Chemical asphyxiants are substances that interfere with the oxygen transport system (hemoglobin) or mitochondrial cytochrome oxidase in the process of oxygen utilization.

10.9.2.1 Sources of Possible Unintentional Exposure and Use of Asphyxiants • Simple asphyxiants: Carbon dioxide (CO2): byproduct of combustion, fire extinction Methane: swamps, sewage, chemical synthesis, mines Propane: liquefied gas, chemical synthesis • Chemical asphyxiants: Methemoglobin (MetHb)-forming substances: antidotes (nitrites), production of dyes, tire vulcanization CO : incomplete combustion of charcoal, kerosene, or gas fuel, smoke inhalation during fires, methylene chloride (CH3Cl) Cyanides and cyanogenic substances: Hydrogen cyanide (HCN) is used in chemical industry in the production of plastics and nitrites. Other cyanide compounds are used in painting, dyeing, photographic industry, cleaning, and metal production. HCN is a colorless gas or a pale blue, highly volatile liquid, whereas cyanogens and cyanide salts are colorless gases or white, solid substances. Their odor may resemble that of bitter almonds; perception of the odor depends on an individual’s genetic predispositions. HCN acid is highly volatile and can form an explosive mixture Sulphides: anaerobic degradation of biological material, chemical synthesis, production of rubber Azides: production of explosives, chemical synthesis Arsine: metallurgy, chemical industry, and microelectronics

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10.9.2.2 The Routes of Exposure Simple asphyxiants enter the body by inhalation. Chemical asphyxiants can enter the body by inhalation (CO), but also through the skin and mucous membranes or by ingestion (cyanides, cyanogenic substances, sulphides, azides, and substances that form methemoglobin [MetHb]). Effects depend on the concentration and the duration of exposure; with ingestion, effects appear with a delay. 10.9.2.3 Toxicity Mechanism A decrease in the partial oxygen pressure in the alveoli (simple asphyxiants); disrupted transportation of oxygen to tissues (caused by MetHb-forming substances, CO, arsine); disrupted utilization of oxygen in the cells respiratory chain system (CO, cyanides, azides, sulphides).

10.9.2.4 Acute Signs and Symptoms Reﬂect Various Degree of Exposure to Asphyxiants • Central nervous system (CNS): headache, confusion, nausea, agitation, convulsions, impaired consciousness, coma • Respiratory system: dyspnea, gasping, tachypnea/ bradypnea, apnea • Cardiovascular system (CVS): tachycardia, signs of myocardial ischemia, arrhythmia, cardiac arrest, hypotension (nitrites, nitrates, azides) • Gastrointestinal tract: metallic taste in mouth caused by cyanides, nausea, vomiting • Skin/mucous membrane: pale, cold/sweaty, cyanotic (simple asphyxiants, MetHb-forming substances), bright red (CO) • Eyes: watering, blepharospasm (H2S) Exposure to a high concentration of H2S can cause a characteristic rapid loss of consciousness (“knock-down”). In cyanide exposure there is rapid effect (seconds to a few minutes) on the CNS; death occurs because of cardiopulmonary arrest. Some cyanides (e.g., cyanogen chloride) are also irritants and cause cough, choking, and noncardiogenic pulmonary edema; sodium cyanide may damage skin and eyes.

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10.9.2.5 Prehospital Management Evacuation

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. Persistence/ Gaseous asphyxiants do not pose any risk of secondary contamination. A secondary contamination risk to transmissibility health care rescuers is possible with asphyxiants in either liquid or solid form. Information Health care rescuers who collaborate in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect the limitations (e.g., cyanide exposure) if they are not equipped with SCBA. Primary Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, examination protect the cervical spine, and stop severe bleeding with compression. In the case of cyanide poisoning, if there is respiratory depression/impaired consciousness (Glasgow Coma Scale [GCS] score < 8), give an antidote immediately! When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). Decontamination • The decontamination of victims exposed to gaseous asphyxiants is not mandatory; however, undressing is recommended. Undressing is mandatory if it is suspected that vapors are trapped or have been absorbed in clothes. • Victims exposed to asphyxiants in liquid or solid form should be properly decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: irrigate thoroughly with water; for corrosive substances, prolong the irrigation of affected areas. Toxic trauma • Examine all victims who show symptoms of exposure. treatment • Maintain an open airway, 100% oxygen with a bag-valve-mask; if necessary, intubate and ventilate. • In clinically significant MetHb consider methylene-blue administration. • In severe sulphide (H2S) poisoning, consider amyl-nitrite administration in the first 30 min after exposure. • In cyanide inhalation exposure: do not administer an antidote if the patient is breathing normally and is still fully conscious 5 min after the evacuation; once the oxygen therapy has been administered and the patient has calmed down, he or she will recover spontaneously. • If respiratory depression/impaired consciousness (GCS score < 8), give an antidote immediately. • In the case of bronchospasm (e.g., sulphides) administer inhaled bronchodilatator and inhaled steroid. • Burns/frostbite is treated symptomatically. Antidotes • In CO poisoning: 100% oxygen. • In MetHb-forming substances poisoning: in s symptomatic victim with MetHb value > 20% administer methylene blue. For asymptomatic patients with MetHb < 20%, treatment with methylene blue is not necessary. Hyperbaric oxygenation [HBO] could be applicable only in cases of severe poisoning if treatment with methylene blue was not successful. • In sulphide poisoning, treat with amyl nitrite or sodium nitrite. • In cyanide poisoning, if respiratory depression/impaired consciousness (GCS score < 8), give an antidote immediately: – Amyl nitrite is also suitable for on-field administration, particularly in an MI. – A combination of sodium nitrite and sodium thiosulphate, which is, however, less appropriate for on-field administration because it does not allow for the monitoring of the MetHb level; the administration itself is also more complicated. – For on-field application, hydroxocobalamin is therefore more appropriate because it can be used in the case of cyanide poisoning in the event of a fire, where simultaneous poisonings with CO are not uncommon. For further information, see item 10.8.3. Observation/ • All victims showing any signs of poisoning are to be admitted for a 24-h observation. Rest is indicated for discharge criteria poisoning with chemical asphyxiants. • If signs of corneal injury are present, or for contact with a liquefied gas, an examination by an ophthalmologist is required. • All those who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • Fill in the chemical exposure report.

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10.9.2.6 Emergency Department/Hospital Management Persistence/transmissibility

Information

Primary examination

Decontamination

Toxic trauma treatment

Gaseous asphyxiants do not pose any risk of secondary contamination. A secondary contamination risk to health care rescuers is possible with asphyxiants in either liquid or solid form. Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect the limitations (e.g., cyanide exposure) if they are not equipped with SCBA. Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression.. In the case of cyanide poisoning, if there is respiratory depression/impaired consciousness (GCS score < 8), give an antidote immediately! When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). • The decontamination of victims exposed to gaseous asphyxiants is not mandatory; however, undressing is recommended. Undressing is mandatory if it is suspected that vapors are trapped or have been absorbed in clothes. • Victims exposed to asphyxiants in liquid or solid form should be properly decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: irrigate thoroughly with water; for corrosive substances, prolong the irrigation of affected areas. • Examine all victims who show symptoms of exposure. • Inhalation exposure: maintain an open airway, administer 100% oxygen with a bag-valve-mask; if necessary, intubate and ventilate. Check oxymetry and ABGA, chest x-ray, PEF; repeat the tests if necessary. • Apply a large-bore IV cannula, perform electrocardiograph (ECG), correct acidosis by administering sodium hydrogen carbonate. • In the case of bronchospasm (e.g., sulphides) administer bronchodilatator (inhaled or systemic) and inhaled steroid. • Ventilation may be necessary (PEEP, CPAP). Monitor the possibility of secondary infection or ARDS and act accordingly. • In clinically significant MetHb consider methylene blue administration. • In severe sulphide poisoning consider amyl nitrite or sodium nitrite administration in the first 30 min after exposure. • In cyanide inhalation exposure: do not administer an antidote if the patient is breathing normally and is still fully conscious 5 min after the evacuation; once the oxygen therapy has been administered and the patient has calmed down, he or she will recover spontaneously. • If there is respiratory depression/impaired consciousness (GCS score < 8), give an antidote immediately. • Before antidote administration, a sample of 5–10 ml of blood has to be taken in a lithium-heparin or plastic tube for the determination of the serum cyanide level. • In the case of cyanide ingestion: do not induce vomiting in patients with impaired consciousness; conscious patients must be administered activated charcoal (1 g/kg bodyweight) as soon as possible. If less than 1 h since ingestion, perform gastric lavage (note: use PPE, properly dispose of the contaminated contents of the stomach), and administer a sufficient quantity of activated charcoal. • Burns/frostbite treat symptomatically, consider surgical treatment.

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• In CO poisoning: 100% oxygen, HBO therapy should be considered. • In MetHb-forming substances poisoning: in symptomatic victim with MetHb value >20% administer methylene blue. For asymptomatic patients with MetHb < 20%, treatment with methylene blue is not necessary. HBO could be applicable only in the case of severe poisoning if treatment with methylene blue had not been successful. • In sulphide poisoning: amyl nitrite or sodium nitrite. • In cyanide poisoning, if respiratory depression/impaired consciousness (GCS score < 8), give immediately an antidote: – Amyl nitrite suitable also for on-field administration, particularly in the MI. – A combination of sodium nitrite and sodium thiosulphate, which is, however, less appropriate for on-field administration because iwt does not allow for the monitoring of the MetHb level; the administration itself is also more complicated. – Hydroxocobalamin can be used in the case of cyanide poisonings in an event of fire, where simultaneous poisonings with CO are not uncommon. For further information see item 10.8.3. • All victims showing any signs of poisoning are to be admitted for a 24-h observation. Rest is indicated for chemical asphyxiants poisoning. • All those who have been given an antidote must be admitted to an ICU. • In case of ingestion, all victims must be admitted for a 24-h observation and be treated appropriately if their conditions have deteriorated. • Asymptomatic patients with normal basic laboratory results including ABGA and oximetry can be discharged. • If signs of corneal injury are present or in case of contact with the liquefied gas, examination by an ophthalmologist is required. • All those who have not been admitted are to be instructed, in writing, that must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • Fill in the chemical exposure report.

10.9.3 Organic Solvents According to their chemical structures, this is a heterogeneous group of chemicals; the majority of them are hydrocarbons. Their common property is their ability to dissolve organic compounds. They are often found in the form of mixtures of several hydrocarbons (e.g., nitro solvent). According to their chemical structure, organic solvents (OSs) can be categorized into the following groups: • Petroleum products: petroleum ether, gasoline, oil, white spirit, kerosene, diesel oil, mineral oil, paraffin • Aromatic organic solvents (compounds with a benzene ring): benzene, xylene, toluene, styrene, phenol • Halogenated organic solvents (organohalides): trichloroethylene, trichloroethane, tetrachlorocarbon, methylene chloride, ethylene chloride, methyl chloride, freons • Turpentine: essential oil • Alcohols: methanol, ethanol, propanol • Other compounds: glycols, aldehydes, esters, ethers, benzyl benzoate

10.9.3.1 Toxicity Mechanism OSs are locally irritant or corrosive and could also pose a systemic effect. Thus, they irritate skin, eyes, and respiratory and intestinal mucous membranes; higher concentrations cause burns, and prolonged exposure defeats the skin. Among nonspecific systemic effects they could have effects on the CNS, including depression of the CNS (via the GABAA receptors), high concentrations of the vapor cause similar effects to those of simple asphyxiants, and effects on the heart, including sensitization of the myocardium to endogenous catecholamines and lower threshold for ventricular fibrillation. 10.9.3.2 The Routes of Exposure OSs are absorbed by inhalation of vapors and/or aerosol, through contact with the skin and eyes, and by ingestion; aspiration of a solvent is also possible. The effects depend on a concentration and duration of the exposure, as well as on the type of the OS. Onset of the effects can be immediate, from within a couple of seconds to a couple of minutes (depending

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on the type of solvent and the route of exposure), or delayed (systemic effects of the OS or impurities, e.g., aniline or metabolites of OSs). Besides their toxicologic properties, their physical properties, surface tension, and volatility should also be taken into account.

10.9.3.3 Acute Signs and Symptoms of Exposure to OSs • Local effects: burning sensation, irritation and corrosive effects on the eye and skin; sneezing, cough, chemical pneumonitis, dyspnea, tachypnea/bradypnea/apnea

• CNS: headache, nausea, confusion, agitation, convulsions, anesthesia, narcosis, coma • CVS: heart rhythm disturbances, tachycardia caused by hypoxemia, myocardial ischemia and myocardial arrest, possibly direct cardiotoxic effect • Special systemic effects of individual OSs: pentachlorophenol; dinitrophenol (disruption of oxidative phosphorylation and hyperthermia); phenol (corrosive effect, multiorgan failure); methylene chloride (metabolizes into carbon monoxide, signs of carbon monoxide poisoning); benzene (carcinogenic); n-hexane (onset of peripheral neuropathy in cases of prolonged exposure).

10.9.3.4 Prehospital Management Evacuation Persistence/ transmissibility Information

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. A secondary contamination risk to health care rescuers is possible with OS in either liquid or solid form.

Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots). Primary Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, examination protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (possible risk of secondary exposure). Decontamination • The decontamination of victims exposed to vapor of an OS is not mandatory; however, undressing is recommended. Undressing is mandatory if it is suspected that vapors are trapped or have been absorbed in the clothes. • Victims exposed to an OS in liquid or solid form should be properly decontaminated using water and soap (low water solubility). • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: irrigate thoroughly with water and soap; for corrosive substances prolong the irrigation of affected areas. Toxic trauma • Examine all victims who show symptoms of exposure. treatment • Maintain an open airway, 100% oxygen with a bag-valve-mask; if necessary, intubate and ventilate. • Treat convulsions. • Be cautious of the use of any adrenergic agents (e.g., epinephrine, albuterol) because of the possibility of myocardial sensitization with OSs. • Burns/frostbite: treat symptomatically. Antidotes • In exposure to methylene chloride it is necessary to administer 100% oxygen as an antidote because of CO formation. • If aniline is present in the solvent as an impurity, methylene blue is indicated; in the case of clinically significant MetHb > 20% administer methylene blue. For asymptomatic patients with MetHb < 20%, treatment with methylene blue is not necessary. HBO would be applicable only in severe poisoning if a treatment with methylene blue was not successful. For further information, see item 10.8.3. Observation/ • All victims showing any signs of poisoning are to be admitted for a 24-h observation. discharge criteria • If signs of corneal injury are present, or in contact with a liquefied gas, examination by an ophthalmologist is required. • All those who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • Fill in the chemical exposure report.

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10.9.3.5 Emergency Department/Hospital Management Persistence/transmissibility Information Primary examination

Decontamination

Toxic trauma treatment

Antidotes

Admission/discharge criteria

A secondary contamination risk to healthcare rescuers is possible with an OS in either liquid or solid form. Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots). Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (possible risk of secondary exposure). • The decontamination of victims exposed to vapour of an OS is not mandatory; however, undressing is recommended. Undressing is mandatory if it is suspected that vapors are trapped or have been absorbed in the clothes. • Victims exposed to an OS in liquid or solid form should be properly decontaminated using water and soap (low water solubility). • Eye exposure: remove contact lenses and be careful, not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Skin exposure: irrigate thoroughly with water and soap; for corrosive substances prolong the irrigation of affected areas. • Examine all victims who show symptoms of exposure. • Inhalation exposure: maintain an open airway, administer 100% oxygen with a bag-valvemask; if necessary, intubate and ventilate. • In inhalation and/or aspiration/ingestion of an OS: check oximetry and ABGA, chest x-ray, perform ECG; repeat the tests if necessary. • Ventilation may be necessary (PEEP, CPAP). Monitor the possibility of secondary infection or ARDS and act accordingly. • Be cautious with use of any adrenergic agents (e.g., epinephrine, albuterol) caused by a possibility of myocardial sensitisation with OSs. • In exposure to methylene chloride, administer 100% oxygen as an antidote because of CO formation. • If aniline is present in the solvent, methylene blue is indicated in the clinically significant MetHb; for asymptomatic patients with MetHb < 20%, treatment with methylene blue is not necessary. • Burns/frostbite: treat symptomatically, consider surgical treatment. • If signs of corneal injury are present, or in the case of the contact with the liquefied gas, examination by an ophthalmologist is required. • In exposure to methylene chloride, it is necessary to administer 100% oxygen as an antidote because of CO formation. • If aniline is present in the solvent as an impurity, methylene blue is indicated; in the case of clinically significant MetHb > 20% administer methylene blue. For asymptomatic patients with MetHb < 20%, treatment with methylene blue is not necessary. HBO would be applicable only in severe poisoning if treatment with methylene blue was not successful. For further information see item 10.8.3. • Observe all victims with signs of systemic poisoning and those for which suspicion of aspiration or ingestion exist; if their conditions have deteriorated, treat them appropriately. Check for toxic pneumonitis development. If they are completely asymptomatic after 6 h, discharge the patients. • All who have been given an antidote must be admitted to an ICU. • If signs of corneal injury are present, or in the case of contact with a liquefied gas, an examination by an ophthalmologist is required. • Asymptomatic patients with normal, basic laboratory results, including PAAK and oximetry, can be discharged. • All those who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms associated with the respiratory organs appear. • Fill in the chemical exposure report.

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10.9.4 Acetyl Cholinesterase Inhibitors (Nerve Agents) This is a rather diverse group of substances that use the same toxicity mechanism. They inhibit the activity of the enzyme acetylcholinesterase (AChE); however, they do differ from one another in terms of their physicochemical properties and consequently in their levels of toxicity. The bond or inhibition of AChE can be reversible, which is the case with, e.g., N-methylcarbamates, or irreversible with some other substances, e.g., organophosphorous insecticides (OPIs) and certain chemical warfare nerve gases such as Tabun, Sarin, Soman, GF, and VX; this is a so-called “enzyme aging” process. The time required for this process to complete aging ranges from only a couple of minutes with certain warfare agents to several hours or even days with OPIs. Some nerve agents can be used for chemical warfare – a small drop on the skin can be fatal. There are two known cases of intentional release of Sarin, which took place in Japan in 1994 (Matsumoto) and 1995 (Tokyo subway station), causing 18 fatalities in total; several cases of secondary contamination of the medical personnel who did not wear appropriate PPE were also recorded. At room temperature, nerve agents are colorless to brown liquids; some have a fruity smell, but others are odorless. Pesticide products usually smell predominately of solvents. They have different levels of volatility; they can be dispersed, prepared as an aerosol, and inhaled. Their vapors are heavier than air – they accumulate in the lower levels and confined spaces. Under certain conditions, some warfare agents degrade into toxic products: Tabun can form hydrogen cyanide and CO; Sarin and Soman form hydrogen fluoride in an acidic environment; VX forms EA2192 in the process of alkaline hydrolysis.

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Gastroenteritis, Emesis) and nicotine receptors (MTWHP: Mydriasis, Tachycardia, Weakness, Hypertension, Fasciculations), as well as receptors in the CNS (3C: Confusion, Convulsions, Coma). They can cause death from respiratory depression, from depression of the CNS, and from respiratory muscle paralysis.

10.9.4.2 Route of Exposure They are absorbed through the skin (through clothing) and eyes, and by inhalation and by ingestion. 10.9.4.3 Acute Signs and Symptoms of the Exposure to Nerve Agents Effects depend on the concentration, as well as the duration and route of exposure. Local effects occur immediately, whereas systemic effects may occur with as much as an 18-h delay: • Mild symptoms: rhinorrhea, pinpoint pupils, pain in the eyes, salivation, chest tightness, dizziness, headache • Moderate symptoms: increased eye symptoms/ blurred vision, drooling and excessive sweating, increased chest tightness, difficulty breathing, nausea, vomiting, abdominal cramps, diarrhea, muscle weakness, headache, confusion, drowsiness • Severe symptoms: moderate symptoms plus involuntary defecation/urination, copious secretion, seizures, flaccid paralysis, coma, respiratory failure, death • Delayed effects: 1–4 days after an exposure to nerve agents can occur acute respiratory insufficiency and flaccid paralysis. In the case of a so-called “intermediate syndrome” (irresponsive to pralidoxime), artificial ventilation is required. Other delayed effects include permanent peripheral neuropathy, changes in the electroencephalograph (EEG), difficulties with concentration, memory disruptions, posttraumatic stress disorders

10.9.4.1 Toxicity Mechanism/Toxic Dynamics Both OPIs and warfare nerve agents inhibit the enzyme acetylcholinesterase and cause acetylcholine accumulation in nerve and neuromuscular synapses. They consecutively stimulate muscarine receptors (SLUDGE: Salivation, Lacrimation, Urination, Defecation,

Muscle fasciculations and abundant bronchial secretions are what differentiates poisoning by nerve agents from poisoning by cyanides!

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10.9.4.4 Prehospital Management Evacuation

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. Persistence/ Secondary contamination is possible by direct contact with the clothing or contaminated skin of victims or by vapors transmissibility trapped in their clothing. Clothing can trap and release nerve agents after contact with vapors. Information Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect limitations (e.g., chemical warfare nerve agents) if they are not equipped with SCBA. Primary Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, examination protect the cervical spine, and stop severe bleeding with compression. In the case of severe or moderate poisoning, administer antidotes atropine and obidoxime or pralidoxime intramuscularly as soon as possible! When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). Decontamination • Emergency decontamination is essential after either vapor or liquid exposure. • Clothing can trap and release nerve agent for 30 min after contact with vapours. Secondary decontamination procedure with water and soap should be carried out as soon as possible after the skin exposure. • Eye exposure: remove contact lenses and be careful, not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • No transfer to cold/green zone until victims have been completely decontaminated! Toxic trauma • Examine all victims who show any symptoms of exposure. treatment • Maintain an open airway and suction secretion; administer 100% oxygen with a bag-valve-mask; if necessary, intubate (avoid administering succinylcholine) and ventilate. • Check which therapy has already been given during the primary survey and decontamination (application of an antidote). • Apply a large-bore IV cannula. • In severe or moderate poisoning administer antidotes atropine and obidoxime or pralidoxime intravenously/ intramuscularly as soon as possible. • Hypoxia must be corrected before atropine administration (heart rhythm disturbances). • Treat convulsions/fitting with diazepam. • In the case of no or a weak response to the antidote, consult a toxicologist. • In the case of pain in the eyes or blurred vision, administer a drop of atropine or 0.5% tropicamide locally. Antidotes There are specific antidotes available that can save lives if applied in a timely manner. For severe or moderate poisoning, administer atropine and obidoxime or pralidoxime. • Atropine: the starting dose of atropine for adults is 1–5 mg intravenously in bolus (depending on the bronchial secretion rate), for children 0.02–0.05 mg/kg bodyweight; doses are administered repeatedly every 5 min until the symptoms improve. Atropine can also be administered by infusion at 0.02–0.08 mg/ kg bodyweight/h. The most important sign of a sufficient atropinization is the cessation of bronchial hypersecretion; do not rely on mydriasis, dry mouth, and tachycardia. • Obidoxime: administer intravenously or intramuscularly. The starting dose for adults is 250 mg, and this can be repeated after 2 h, then 250 mg every 6–8 h in continuous infusion. The dose for children is 4–8 mg/ kg, but not more than 250 mg. The duration of the infusion depends on the effectiveness of the acetylcholinesterase reactivation. • Pralidoxime: the starting dose is 1–2 g, slowly intravenously (10 min) or by a short infusion of 100 ml of physiological solution in 15–30 min. Children are administered 20–40 mg/kg bodyweight, slowly intravenously up to 1 g. Continue by infusing 200–500 mg of pralidoxime per hour (children 5–10 mg/ kg/h) for at least 24 h. For further information, see item 10.8.3. Observation/ • Observe asymptomatic victims exposed to liquid agent for at least 18 h. discharge criteria • Observe victims with mild symptoms (ocular signs without bronchorrhea, bronchospasm, or any data on spasms) for 8–12 h after the exposure and completed decontamination; victims whose symptoms have not aggravated can be discharged. • All who have been given an antidote should be admitted to the ICU. • Fill in the chemical exposure report.

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10.9.4.5 Emergency Department/Hospital Management Persistence/ transmissibility Information

Primary examination

Decontamination

Toxic trauma treatment

Antidotes

Secondary contamination is possible by direct contact with the clothing or contaminated skin of victims or by vapors trapped in their clothing. Clothing can trap and release nerve agents for about 30 min after contact with vapours. Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect the limitations (e.g., chemical warfare nerve agents) if they are not equipped with SCBA. Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. In the case of severe or moderate poisoning administer antidotes atropine and obidoxime or pralidoxime intramuscularly as soon as possible! When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). • Emergency decontamination is essential following either vapor or liquid exposure. • Clothing can trap and release nerve agent after contact with vapors. Secondary decontamination procedure with water and soap should be carried out as soon as possible after the skin exposure. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution; for corrosive substances, irrigate for at least 20 min. • Do not enter the emergency department until completely decontaminated! • Examine all victims who show any symptoms of exposure. • Maintain an open airway and suction secretion; administer 100% oxygen with a bag-valve-mask; if necessary, intubate (avoid administering succinylcholine) and ventilate. • Check what therapy has already been given during the prehospital treatment (application of an antidote). • Check oxymetry and ABGA, chest x-ray, red blood cell count, and plasma cholinesterase level; repeat the tests if necessary. • In severe or moderate poisoning apply a large-bore IV cannula and administer atropine and obidoxime or pralidoxime intravenously as soon as possible! • Hypoxia must be corrected before atropine administration (heart rhythm disturbances!). • In the case of no or a weak response to the antidote, consult a toxicologist. • Treat convulsions/fitting with diazepam. • Muscle paralysis may cover up seizures – perform EEG. • Ventilation may be necessary (PEEP, CPAP). Monitor the possibility of secondary infection or ARDS and act accordingly. • Progression of symptoms indicates that the exposure is still present, that the decontamination was insufficient, or that the treatment has been inappropriate. • In the case of pain in the eyes or blurred vision, administer a drop of atropine or 0.5% tropicamide locally. There are specific antidotes available that can save lives if applied in a timely manner. In severe or moderate poisoning, administer atropine and obidoxime or pralidoxime. • Atropine: the starting dose of atropine for adults is 1–5 mg intravenously in bolus (depending on the bronchial secretion rate), for children 0.02–0.05 mg/kg bodyweight; doses are administered repeatedly every 5 min until the symptoms improve. Atropine can also be administered by infusion at 0.02– 0.08 mg/kg bodyweight/h. The most important sign of a sufficient atropinization is the cessation of bronchial hypersecretion; do not rely on mydriasis, dry mouth, and tachycardia. • Obidoxime: administer intravenously or intramuscularly. The starting dose for adults is 250 mg, and this can be repeated after 2 h, then 250 mg every 6–8 h in continuous infusion. The dose for children is 4–8 mg/kg, but not more than 250 mg. The duration of the infusion depends on the effectiveness of the acetylcholinesterase reactivation. • Pralidoxime: the starting dose is 1–2 g, slowly intravenously (10 min) or by a short infusion of 100 ml of physiologic solution in 15–30 min. Children are administered 20–40 mg/kg bodyweight, slowly intravenously up to 1 g. Continue by infusing 200–500 mg of pralidoxime per hour (children 5–10 mg/ kg/h) for at least 24 h. For further information, see item 10.8.3.

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• Observe asymptomatic victims exposed to a liquid agent for at least 18 h; those who have been exposed to a vapors only can be discharged • Victims with mild symptoms (ocular signs without bronchorrhea, bronchospasm, or any data on spasms) are to be kept under observation for 8–12 h after the exposure and completed decontamination; victims whose symptoms have not aggravated and have normal basic laboratory results including PAAK and acetylcholinesterase level can be discharged. • All who have been given an antidote must be admitted to an ICU. • In case of ingestion, all victims must be admitted for a 24-h observation and appropriately treated if their conditions have deteriorated. • All who have not been admitted are to be instructed, in writing, that they must return for a check-up immediately if any symptoms appear. • All victims with severe and moderate exposure schedule for a follow-up examination after 6 weeks. • Fill in the chemical exposure report.

10.9.5 Blister Agents (Vesicants) Blister agents cause blisters and are severe irritants, particularly to the skin, eyes, and respiratory organs. Mustard gas and Lewisite were the most commonly mentioned compounds of this group. They are both cytotoxic and alkylating agents, and they absorb rapidly through the skin (even through clothes) and eyes or by inhalation and ingestion (contaminated food or water). The onset of signs and symptoms and the treatment are different, which is why they are presented separately here. Other corrosive substances cause burns, edema, and loss of tissue fluid; however, blistering is not characteristic of them.

10.9.5.1 Mustard Gas Its chemical name is 2, 2¢-di(chloroethyl) sulphide; synonyms are HD, H, S-yperite, sulphur mustard, Yperite. It is an oily, volatile liquid (colorless or pale yellow, brownish) and can smell of mustard, horseradish, garlic, or leek. Its vapor is heavier than air – it accumulates in the lower levels and confined spaces, and transfers well with the wind. In moderate climate conditions it stays in the environment for 1–2 days; in cold weather it can persist for several weeks or even months. S-yperite was used as a chemical weapon in World War I, where the mortality rate was 2–3%. Similar compounds were produced later, namely the nitrogen mustards: 2,2-dichlorotriethylamine; 2,2-dichloro-N-methyldiethylamine; and 2,2,2-trichlorotriethylamine, which have, however, never been used as chemical weapons.

Mustard gas is absorbed rapidly through the skin (even through the clothes) and the eyes or by inhalation and ingestion (contaminated food or water). Although tissue damage commences immediately, clinical signs often appear with delay (except in cases of contact with liquid mustard gas) until the skin/ mucous membrane has come into contact with water (sweat, humidity). The clinical signs gradually intensify within hours or days after a 1- to 24-h latent period. Clinical effects depend on the concentration and the duration of exposure; the effects are worse in hot and humid conditions. A liquid mustard gas is more toxic than the gaseous form, and the more excessive is the exposure, the shorter is the latent period. The delay in clinical signs help to distinguish between mustard gas and Lewisite exposure; with exposure to Lewisite, clinical effects appear immediately.

Acute Signs and Symptoms of Exposure to Mustard Gas The sooner after exposure symptoms occur, the more likely they are to progress and become severe. • Eyes: low exposure (latent period, 4–12 h): watery eyes/lachrymation, scraping sensation in the eyes, pain, mild periorbital edema; medium to severe exposure (latent period, 1–3 h): painful blepharospasm, blindness (usually temporary), corneal damage • Inhalation: if eyes are afflicted, expect an effect on the respiratory system. Low exposure (latent period, 6–24 h): rhinorrhea, sneezing, nosebleed, hoarseness, hacking cough. Medium to severe exposure

268

L. Sarc

(latent period, 2–6 h): like at low exposure, cough becomes more productive (necrotic slough) • Skin: warm and moist areas are affected the most (groin, genitals, armpits, perineum). Low exposure (latent period, 2–24 h): raised erythema (“sunburn”). Medium to severe exposure (latent period, 2–24 h): blisters filled with clear to yellow liquid, the effect reaches its maximum extreme in 48–72 h; blisters may rupture (they do not contain mustard gas)

• Systemic effects: medium exposure: nausea, vomiting, diarrhea. Severe exposure: nausea, vomiting, diarrhea, bradycardia, heart rhythm disturbances, depression of the CNS, depression of the bone marrow (leucopenia) • Long-term effects: visual disturbances, permanent loss of sight, keratitis (may appear after several years), bone marrow displasia, vitiligo, scarring (more frequent in cases of secondary infection), chronic respiratory disorder

Prehospital Management Evacuation

Persistence/transmissibility

Information

Primary examination

Decontamination

Toxic trauma treatment

Antidote Observation/discharge criteria

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. A secondary contamination is possible by direct contact with the contaminated clothing or skin of victims or by vapors trapped in their clothing. Clothing can trap and release mustard gas for 1–2 days after contact with vapors. Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect limitations if they are not equipped with SCBA. Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one way valve (risk of secondary exposure). • Emergency decontamination is essential after mustard exposure! • If available, first decontaminate with paraffin or with plenty of water because mustard gas is only slightly soluble in water. • A secondary decontamination procedure, with water and soap, should be carried out as soon as possible after skin contact exposure. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution for 5 min. If signs of corneal injury are present examination by an ophthalmologist is required. • No transfer to cold/green zone until completely decontaminated. • Examine all the exposed victims. • Maintain an open airway and administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Eyes exposure: do not patch, place the victim in a dark room (or shade their eyes with dark glasses); use a sterile Vaseline or a 5% boric acid ointment to prevent the eyelids sticking. • Because of severe pain, redness, and blisters in the eyes, systemic analgesia may be necessary (opiates); avoid administering local anesthetics (e.g., eye drops). • Skin exposure: 1% hydrocortisone ointment; for itching, give oral antihistamine. • Fluid resuscitation. There is no specific antidote available. • Asymptomatic patients should be observed for 8 h; if there are no signs of injuries on the skin and eyes, discharge the patients and give them further instructions in writing. • If low exposure signs are present on the eyes/skin, keep under observation for a further 24 h. If the clinical state does not deteriorate and only mild redness and small blisters and mild irritation to the eyes/conjunctivitis are present, discharge the patients, give them further instructions in writing, and schedule them for a follow-up examination in 3–5 days. • After severe exposure, victims will need hospitalization in a burn unit. • Fill in the chemical exposure report.

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Emergency Department/Hospital Management Persistence/transmissibility

Information

Primary examination

Decontamination

Toxic trauma treatment

Antidote Admission/discharge criteria

A secondary contamination is possible by direct contact with the contaminated clothing or skin of victims or by vapors trapped in their clothing. Clothing can trap and release mustard gas for 1–2 days after contact with vapors. Health care rescuers collaborating in the decontamination should use PPE (SCBA/ full-face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and should respect limitations if they are not equipped with SCBA. Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one way valve (risk of secondary exposure). • Emergency decontamination is essential after mustard exposure! • If available, first decontaminate with paraffin or with plenty of water because mustard gas is only slightly soluble in water. • A secondary decontamination procedure, with water and soap, should be carried out as soon as possible after skin contact exposure. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with lukewarm water (if possible) or 0.9% NaCl solution for 5 min. If signs of corneal injury are present examination by an ophthalmologist is required. • Do not enter the emergency department until completely decontaminated. • Examine all the exposed victims. • Maintain an open airway and administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Sample blood for the initial hemogram, and sample urine for mustard or its methabolite thiodiglycol assessment. • Eye exposure: do not patch, place the victim in a dark room (or shade their eyes with dark glasses); use sterile Vaseline or a 5% boric acid ointment to prevent the eyelids sticking, use cycloplegic drops to prevent synechia, atropine, or homatropine. • If blepharospasm is evident, consult an ophthalmologist. • In case of severe pain, redness, and blisters in the eyes, systemic analgesia may be necessary (opiates); avoid administering local anesthetics (e.g., eye drops). • Skin exposure: 1% hydrocortisone ointment; in case of itching, oral antihistamine; clean damaged blisters with 0.9% NaCl solution, cover smaller areas with Vaseline gauze and the larger ones with 1% silver sulphadiazine; consult a plastic surgeon. • Fluid resuscitation. • Severe cases require care in a burn unit. • After severe exposure, monitor the blood count: if the leucocytes were high at admittance and appear low on days 3–5, this could be a result of bone marrow depression. There is no specific antidote available. • Asymptomatic patients observe for 8 h; if there are no signs of injuries on the skin and eyes, discharge the patients and give them further instructions in writing. • If low exposure signs are present on the eyes/skin, keep under observation for a further 24 h. If the clinical state does not deteriorate and only mild redness and small blisters and mild irritation to the eyes/conjunctivitis are present, discharge the patients, give them further instructions in writing, and schedule them for a follow-up laboratory evaluation, pulmonary function tests, and bone marrow toxicity tests in 3–5 days. • If signs of corneal injury are present, an examination by an ophthalmologist is required. • Fill in the chemical exposure report.

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10.9.5.2 Lewisite Its chemical name is chlorovinyl dichloroarisine (L). It is an oily, volatile, liquid arsenic-chlorine compound (colorless or bluish black) with an odor of geraniums. Its vapors are heavier than air – they accumulate in the lower layers and confined spaces. At extremely low or extremely high temperatures Lewisite can persist longer in the liquid form. Lewisite is fat soluble; it is rapidly absorbed through the skin and mucous membranes (3–5 min!), and absorption is accelerated by heat and humidity. Tissue damage by alkylation aside, in extensive exposure, systemic signs of arsenic poisoning could appear. Clinical effects depend on the concentration and the duration of the exposure; the effects are worse in hot and humid conditions; liquid Lewisite is more toxic than the gaseous form. Clinical signs occur immediately, as opposed to mustard gas, where these are delayed.

L. Sarc

Acute Signs and Symptoms of Exposure to Lewisite • Local effects: immediate burning pain at the sites of exposure, irritation and swelling of the eyelids, eye damage or blindness can occur in minutes (temporary/permanent), progressive pain at exposure sites, skin redness and blistering in 8–12 h, severe rhinorrhea and sneezing, productive cough, progressive development of severe pulmonary edema/chemical pneumonitis; ARDS and secondary bacterial infection are the main causes of death • Systemic effects: liver failure and signs of arsenic intoxication: nausea, vomiting, diarrhea, general weakness, muscle spasms, red or green urine, neuropathy, nephritis, hemolysis, encephalopathy, unconsciousness and “Lewisite shock” (hypotension, atrioventricular block, cardiac arrest), restlessness, weakness • Long-term effects: visual disturbances and chronic pulmonary disorder may occur; no changes in pigmentation remain

Prehospital Management Evacuation

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. Persistence/ A secondary contamination is possible by direct contact with the contaminated clothing or skin of the victims or by transmissibility vapors trapped in their clothing. The clothing can trap and release Lewisite for a long time after contact with vapors. Information Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and must respect the limitations if they are not equipped with SCBA. Primary Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, examination protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). Decontamination • Emergency decontamination is essential after Lewisite exposure. • If available, first decontaminate with paraffin or copious amount of water because Lewisite is only slightly soluble in water. • A secondary decontamination procedure with water and soap should be carried out as soon as possible after skin contact/exposure. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with water or 0.9% NaCl solution. • No transfer to cold/green zone until completely decontaminated! Toxic trauma • Examine all the exposed victims. treatment • Maintain an open airway and administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Eyes exposure: do not patch, place the victim in a dark room (or shade his or her eyes with dark glasses); use sterile Vaseline or a 5% boric acid ointment to prevent the eyelids sticking. • Because of severe pain, redness, and blisters in the eyes, systemic analgesia may be necessary (opiates); avoid administering local anesthetics (e.g., eye drops). • Skin exposure: 1% hydrocortisone ointment; in case of itching, oral antihistamine. • Fluid resuscitation. • Consider a systemic BAL administration.

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Antidote

• Dimercaprol (BAL) is the specific antidote. Administer 3 mg/kg bodyweight deep IM every 4 h up to the total of four doses. • Systemic BAL administration is indicated in shock or with signs of significant pulmonary injury, with burns covering a surface exceeding the size of a palm, if the patient has not been decontaminated within 15 min, if more than 5% of the skin’s surface has been exposed, and if changes in the skin’s coloration appear within 30 min. For further information, see item 10.8.3. Observation/ • Asymptomatic patients observe for 2 h; if there are no signs of injuries on the skin and eyes, discharge the discharge criteria patients and give him or her further instructions in writing. • If low-exposure signs are present on the eyes/skin, keep under observation for a further 18–24 h. If the clinical state does not deteriorate and only mild redness and small blisters and mild irritation to the eyes/ conjunctivitis are present, discharge the patients, give them further instructions in writing, and schedule them for a follow-up pulmonary function, renal/hepatic function, and complete blood count evaluation in 3–5 days. • If signs of corneal injury are present, an examination by an ophthalmologist is required. • For severe exposure, victims will need hospitalization, most likely in an intensive burn unit. • Fill in the chemical exposure report.

Emergency Department/Hospital Management Persistence/ transmissibility Information

Primary examination

Decontamination

Toxic trauma treatment

A secondary contamination is possible by direct contact with the contaminated clothing or skin of the victims or by vapors trapped in their clothing. The clothing can trap and release Lewisite for a long time after contact with vapors. Health care rescuers collaborating in the decontamination should use PPE (SCBA/full face mask with filters, suit resistant to chemical splashes, nitrile gloves and boots) and must respect the limitations if they are not equipped with SCBA. Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. When resuscitating, do not use the mouth-to-mouth technique, use a mask with a one-way valve (risk of secondary exposure). • Emergency decontamination is essential after Lewisite exposure. • If available, first decontaminate with paraffin or copious amount of water because Lewisite is only slightly soluble in water. • A secondary decontamination procedure with water and soap should be carried out as soon as possible after skin contact/exposure. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with water or 0.9% NaCl solution. • Do not transfer into the emergency department until completely decontaminated! • Examine all the exposed victims. • Maintain an open airway and administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Sample blood for the initial hemogram, and sample urine for arsenic assessment. • Eye exposure: do not patch, place the victim in a dark room (or shade his or her eyes with dark glasses); use sterile Vaseline or a 5% boric acid ointment to prevent the eyelids sticking, use cycloplegic drops to prevent synechia – atropine or homatropine. • If blepharospasm is evident, consult an ophthalmologist. • In the case of severe pain, redness, and blisters in the eyes, systemic analgesia may be necessary (opiates); avoid administering local anesthetics (e.g., eye drops). • Skin exposure: 1% hydrocortisone ointment; in case of itching, oral antihistamine; clean damaged blisters with 0.9% NaCl solution, cover smaller areas with Vaseline gauze and the larger ones with 1% silver sulphadiazine; consider a BAL ointment using but not together with sulphadiazine (chelation of silver!); consult plastic surgeon. • Fluid resuscitation. • Severe cases require care in an intensive burns unit. • Consider systemic BAL administration. In the case of severe exposure, monitor the blood count: if leucocytes are high upon admittance and leucopenia appears in 3–5 days, this may be a result of bone marrow depression.

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Admission/ discharge criteria

L. Sarc • Dimercaprol (BAL) is the specific antidote. Administer 3 mg/kg bodyweight deep IM every 4 h up to the total of four doses. • Systemic BAL administration is indicated in shock or with signs of significant pulmonary injury, with burns covering a surface exceeding the size of a palm, if the patient has not been decontaminated within 15 min, if more than 5% of the skin’s surface has been exposed, or if changes in the skin’s coloration appear within 30 min. For further information, see item 10.8.3. • Admit the victims with the significant exposure with the skin, eye, and airway symptoms. • Asymptomatic patients observe for 2 h; if there are no signs of injuries on the skin and eyes, discharge the patient and give him or her further instructions in writing. • If low-exposure signs are present on the eyes/skin, keep under observation for further 18–24 h. If the clinical state does not deteriorate and only mild redness and small blisters and mild irritation to the eyes/ conjunctivitis are present, discharge the patients, give them further instructions in writing, and schedule them for a follow-up laboratory evaluation of pulmonary function, renal/hepatic function, and complete blood count in 3–5 days. • Admit victims with significant exposure with skin eye and airway symptoms. • Fill in the chemical exposure report.

10.9.6 Chemicals Used for Temporary Incapacitation (Lachrymators) Lachrymators are chemical substances that temporarily incapacitate people by causing irritation of the eyes, mouth, throat, lungs, and skin. The availability of these products varies on different markets: OC pepper spray (capsaicin) and CS spray (chlorobenzylidene malononitrile) are available generally in smaller packages and low concentrations. For military purposes, more dangerous substances are used, e.g., CN (chloroacetophenone), CR (dibenzoxazepine); these produce a more severe clinical effects. For military purposes, DM (Adamsite) was also used and does not cause irritation only to the eyes and respiratory mucous membranes, but also induces vomiting. Lachrymators are white or yellow, sometimes crystalline solid substances; some may smell of apple blossom or pepper. Generally they are in a form of liquid or solid particles in a spray, which can contaminate the mucous membranes, eyes, or skin. The particles may also settle on clothing and surrounding objects; movement may re-disperse particles, which

can cause further problems. Lachrymators are used by the police, security guards, and the military in riot control operations and for other purposes (in training); they are also used for self-defense.

10.9.6.1 Acute Signs and Symptoms for Exposure to Lachrymators Effects occur immediately – within the timeframe of a few seconds to a few minutes. Effects depend on the concentration and the duration of the exposure. • Eyes: stinging, burning, painful blepharospasm, lacrimation; blurred vision, possible ulcerations of the cornea after severe exposure; there is improvement 15–30 min after exposure has ceased • Inhalation: painful secretion from the nose, burning sensation in the throat, hoarseness and loss of voice, excessive salivation; in long-lasting exposure (in poorly ventilated small spaces) noncardiogenic pulmonary edema may occur with a 12- to 24-h delay; ARDS and pulmonary arrest also occur • Skin: burning sensation, redness, after a longer severe exposure possible burns and blisters

10.9.6.2 Prehospital Management Evacuation Persistence/ transmissibility Information

Victims should be evacuated from the contaminated/hot/red zone as soon as possible by properly trained and equipped (level A PPE) rescuers; in most countries an evacuation is the domain of firefighters. A low secondary contamination risk to health care rescuers is possible with liquid or solid particles that settled on the skin and clothing. Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to splashes, nitrile gloves and boots).

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Toxic trauma treatment

Antidote Observation/ discharge criteria

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Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. • The decontamination of victims exposed to gaseous substances is not mandatory; however, undressing is recommended because some gases can be trapped in clothes. • Victims exposed to substances in liquid form should be primarily decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with water or 0.9% NaCl solution for 15 min. • Skin exposure: irrigate affected areas thoroughly with water. • Examine all victims who show symptoms of exposure. • The treatment is symptomatic. • Maintain an open airway, and administer supplemental oxygen if it is necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Eye exposure: if 2 h after decontamination the pain in the eyes still persists, examination by an ophthalmologist is required. • Skin exposure: a solution of sodium hydrogen carbonate can neutralize the effects and soothe the irritation. Locally apply 1% hydrocortisone ointment, and administer an oral antihistamine in case of severe itching. There is no specific antidote. • If the signs are mild, keep the patients under observation for 2 h. If the patient’s condition has not deteriorated, discharge the patient and give him or her further instructions in writing. • Admit all victims who show severe respiratory signs and those whose condition has not improved satisfactorily after 2 h of observation. • If signs of corneal injury are present, examination by an ophthalmologist is required. • Fill in the chemical exposure report.

10.9.6.3 Emergency Department/Hospital Management Persistence/ transmissibility Information Primary examination Decontamination

Toxic trauma treatment

Antidote

A low secondary contamination risk to health care rescuers is possible with liquid or solid particles that settled on the skin and clothing. Health care rescuers collaborating in the decontamination should use PPE (full face mask with filters, suit resistant to splashes, nitrile gloves and boots). Before decontamination, only the most urgent life-saving procedures should be carried out: clear airways, protect the cervical spine, and stop severe bleeding with compression. • The decontamination of victims exposed to gaseous substances is not mandatory; however, undressing is recommended because some gases can be trapped in clothes. • Victims exposed to substances in liquid form should be primarily decontaminated. • Eye exposure: remove contact lenses and be careful not to cause further damage. Irrigate eyes thoroughly with water or 0.9% NaCl solution for 15 min. • Skin exposure: irrigate affected areas thoroughly with water. • The treatment is symptomatic. • Maintain an open airway; administer supplemental oxygen if necessary. • In the case of bronchospasm, administer inhaled bronchodilator and inhaled steroid. • Inhalation exposure: take blood for ABGA, chest x-ray, measure PEF; repeat the tests if necessary. • Ventilation may be necessary (PEEP, CPAP). Monitor the possibility of secondary infection or ARDS and act accordingly. • Eye exposure: if 2 h after decontamination the pain in the eyes still persists, examination by an ophthalmologist is required. • Skin exposure: a solution of sodium hydrogen carbonate can neutralize the effects and soothe the irritation. Locally apply 1% hydrocortisone ointment, and administer an oral antihistamine in case of severe itching. There is no specific antidote.

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L. Sarc • If the signs are only mild, keep under observation for 2 h. If the patient’s condition has not deteriorated, discharge the patient and give him or her further instructions in writing. • Admit all victims who show severe respiratory signs and those whose condition has not improved satisfactorily after 2 h of observation. • If the respiratory signs have disappeared and only mild signs on the eyes/skin remain, discharge the patient, give them further instructions in writing, and schedule them for a follow-up laboratory evaluation of pulmonary function. • If signs of corneal injury are present, examination by an ophthalmologist is required. • Fill in the chemical exposure report.

Further Reading Augustine JJ (2003) Decontamination packs, Atlanta, Georgia; Emory University Department of Emergency Medicine, presented at the 2nd international congress of Hamburg Fire Department: “Moderne Gefahrenabwehrsysteme”, Hamburg Fire Department, October 1–2, 2003 Baker DJ (1996) Advanced life support for acute toxic injury (TOXALS). Eur J Emerg Med 3(4):256–262 Baker D (2004) Civilian exposure to toxic agents: emergency medical response. Prehosp Disaster Med 19(2):174–178 Chemical Incident Surveillance Review (January 2006–December 2007) Available at: http://www.hpa.org.uk/web/HPAwebFile/ HPAweb_C/1211184033548 http://www.hpa.org.uk/publications/2007/chemical_incident_05/chemical_incidents_05.pdf Cone DC, Davidson SJ (1997) Hazardous materials preparedness in the emergency department. Prehosp Emerg Care 1(2):85–90 Cox RD (1994) Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med 23(4):761–770 DHHS: US Department of Health and Human Services (2000) Managing hazardous materials incidents, volume I, II, III emergency medical services. A planning guide for the management of contaminated patients, vol I. Public Health Service and Agency for Toxic Substance and Disease Registry, Atlanta Domres B, Manger A, Brockmann S, Wenke R (eds) (2005) Dekontamination und Notfallversorgung Verletzter bei Zwischenfällen mit chemischen Gefahrstoffen [Decontamination and emergency care for victims in chemical incidents]. Bundesamt für Bevölkerungsschutz und Katastrophenhilfe [Federal Office for Population Protection and Disaster Relief], Bonn Farrow C, Wheeler H, Bates N, Murray V (2000) Chemical incident management handbook by medical toxicology unit

Guy’s and St Thomas’ Hospital Trust. The Stationery Office, London Heptonstall J, Gent N (2006) CRBN incidents: clinical management & health protection. Health Protection Agency, London Home Office (2004) Strategic national guidance – decontamination of people exposed to CBRN. Home Office, London Koenig KL (2003) Strip and shower: the duck and cover for the 21st century. Ann Emerg Med 42:391–394 NFPA: National Fire Protection Association (2002) Recommended practice for responding to hazardous materials incidents, NFPA 471, 2002nd edn. NFPA, Quincy, MA OBFV: Österreichischer Bundesfeuerwehrverband [Austrian Federal Fire-Fighters Association] (1997) Gefährliche Stoffe, Strahlenschutz; Ausbildungsunterlage für Gruppenkommandanten [Haz-Mat and radiation protection – course materials for group commander course]. ÖBFV, Vienna OBFV: Österreichischer Bundesfeuerwehrverband [Austrian Federal Fire-Fighters Association] (2003) Personendekontamination und Einsatzhygiene, Information des Sachgebiets “Gefährliche Stoffe” [Body decontamination and hygiene measures, information of ÖBFV advisory group “Haz-Mat”]. Vienna, ÖBFV OSHA: Occupational Safety and Health Administration (2005) Best practices for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances. Department of Labour, Washington, DC Scottish Ambulance Service (2003) Guidance for the emergency services on decontamination of people exposed to hazardous chemical, biological or radioactive substances, Edinburgh Vereinigung zur Förderung des Deutschen Brandschutzes e.V. (VFDB,10/04) [Association for the Promotion of Fire Protection in Germany] (1998) Dekontamination bei Feuerwehreinsätzen mit gefährlichen Stoffen und Gütern [Decontamination in fire departments response to Haz-Mat incidents], VFDB-Richtlinie 10/04. VFDB, Munich

Incidents Caused by Irradiation

11

Siegfried de Joussineau

11.1

Different Types of Incidents

Major irradiation incidents cause acute injuries and induce health risks among the population in large geographic areas, for example, severe nuclear reactor technology failures in nuclear power plants. Reactor failure might cause acute irradiation-induced traumas as well as physical traumas, or the combination of both, to persons in the vicinity of the reactor. Radioactive material might be released from the reactor and spread over large geographic areas, and the radioactive downfall can be a serious danger to the health of the population and can cause severe environmental pollution in the affected areas, with long-lasting effects. Nuclear-powered ships and submarines can sustain reactor breakdowns with the consequences of irradiation traumas, surgical traumas, and combined traumas as well as the release of radioactive material over large areas with the same effects as those mentioned above. Nuclear-powered satellites, which re-enter the atmosphere and break up, can cause a spread of radioactive material over large areas, and the environmental contamination might become a threat to the health of the affected the population. Minor irradiation incidents are incidents that cause acute irradiation traumas and other traumas limited to the workers at the site of the accident. The release of the radioactive material is usually limited to a smaller area, and the danger to the health of the population and environmental contamination is only local, for example, in industries that handle radioactive material, hospitals, and transportation units for nuclear material. S. de Joussineau e-mail: [email protected]

11.2

Examples of Incidents with Release of Radioactive Material

11.2.1 Reactor Breakdowns 11.2.1.1 Wind Scale, UK, 1957 A graphite-moderated reactor overheated, fire began in the graphite, and large quantities of radioactive material were released and spread out to the neighbourhood because of the lack of reactor containment. There was such extensive ground contamination in the neighborhood by radioactive iodine that milk from the cows grazing the local pastures had to be condemned for consumption as food. No acute radiation injuries were reported from the accident.

11.2.1.2 Harrisburg, PA, USA, 1979 This incident was caused by the breakdown of the cooling system and mismanagement by the operators so that the reactor became overheated, leading to a core meltdown and a breach of the fuel elements. However, the robust containment around the reactor functioned, so there was only a limited release of radioactive noble gases. The individual doses measured were low and no injuries caused by radiation exposure were reported; neither were there any environmental consequences.

11.2.1.3 Chernobyl, Ukraine, 1986 On April 26, 1986, an experiment was performed to find out if it was possible to enhance the effect and power production of this graphite-moderated reactor. The operators disconnected some of the security systems and the pressure rose in the core, which caused an explosion, and a ravaging fire broke out. The reactor

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was destroyed and 3% of the fuel was released, along with 100% of the radioactive noble gases, 20% of the radioactive iodine-131, and approximately 10% of the radioactive caesium-137 from the reactor. A plume of radioactive material rose into the atmosphere to an altitude of approximately 1 km and initially was carried by the winds in a northwest direction toward Poland and Scandinavia, and later in a southerly direction toward the Balkans and Greece, with downfall of radioactive isotopes, especially iodine-131 and Caesium-137, over the areas mentioned. The area around Chernobyl was heavily contaminated with radioactive isotopes that fell to the ground, and approximately 100,000 persons who lived within a radius of 30 km were evacuated. The rescue personnel who took part in the initial rescue work were exposed to significant radiation doses – 2 Gy or more – and 135 fire fighters and rescue workers from the reactor plant suffered from acute radiation syndrome. Some of the rescue personal were not only exposed to ionizing radiation, they suffered from combined trauma, physical trauma such as fractures and burns, as well as irradiation. There was a great need for intensive care in combination with other specialist and radiation medicine expert care. Within 3 months, 28 persons were dead as a cause of the radiation exposure. Several of the survivors still suffer from chronic complications in the skin, local defects in the limbs, and eye cataracts. During the first years after the incident, many prognostications were made about the future illnesses that would be caused by the accident, and a significant increase in the incidence of cancer among rescue workers and the populations living in the vicinity of the reactor and the areas exposed to downfall was foreseen. Large national and international clinical and epidemiological studies have been done and some are still ongoing. The international reports from the United Nations Scientific Committee of the Effects of Atomic Radiation (2000) and the World Health Organization (WHO 2006) are continuously reporting the results of the international expert consensus. So far there has been reported a significant increase of thyroid cancer among those who were newly born up to the age of 17 years at the time of the accident and who were living in areas in Ukraine, Russia, and Belorussia that were exposed to increased levels of

S. de Joussineau

radioactive iodine131 released from the reactor and, by 2006, 4,837 cases had been reported. No increased incidence of other solid tumors has been shown, either among the population in the affected areas or among the rescue personnel or those workers (liquidators) who were used to decontaminate and to build the containment (sarcophagi) covering the contaminated rests of the reactor. So far, there have not been any reports of an increased incidence of blood- or bone marrow– related cancer among the population of the affected areas. Liquidation workers’ initial studies revealed a small increase in the incidence of leukemia associated with Chernobyl radiation exposure. However, the most recent studies suggest a twofold increase in the incidence of non-chronic lymphocytic leukemia between 1986 and 1996 among Russian liquidators exposed to more than 150 mGy (external dose). Ongoing studies are expected to provide additional information. Among the noncancer diseases, an increased incidence of cataracts has been observed among children and liquidators whose eye lenses were exposed to doses exceeding 250 mGy. There also has been observed an increased incidence of cardiovascular disease among the rescue workers and liquidators exposed to significant doses of radiation. No congenital malformations or changes in fertility caused by exposure to radiation among the affected population have been proven. However, an increase of mental health and psychosomatic disorders has been reported within the population and among the liquidators, which still puts an increased demand on the health care services in the affected areas.

11.2.1.4 Fukushima, Japan, March 11, 2011 At the time of delivery of this manuscript, Japan was hit by what has been considered to be the worst disaster in this country since World War II. An earthquake with the magnitude of 9.1 on the Richter scale occurred in the ocean outside the city of Sendai at the northwest coast of Oshus. A tsunami wave, growing to a height of more than 10 m, was generated by the earthquake and hit the coastline, causing extensive material damage (Fig. 2.10a–c). Among the structures damaged by the wave were some of the Japanese power plants located along the coastline, among those Fukushima, which were built to be earthquake safe but not to resist a tsunami wave of this magnitude. One of the effects was that the reserve electricity and cooling systems

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were destroyed, leading to overheating of the reactors. This resulted in meltdown and overheating of the spent reactor fuel, stored in water basins near the reactors within the nuclear power plant, leading to severe leakage of irradiation. Both the short- and long-term consequences of this are at the present moment difficult to foresee; so far, 200,000 people have been evacuated out of the risk zone and radioactive contamination has been confirmed both on the ground and in the sea far outside the coastal area. The authorities have recommended intake of iodine prophylaxis within the risk zone. Food such as milk and vegetables grown in the Fukushima and neighboring prefectures has been reported contaminated and the authorities have forbidden the sale of such food. Water from open sources also has been reported contaminated and the authorities have put restrictions on the use of such water. It is already apparent at this stage that this will affect the entire country of Japan for a long time and may have an influence on the global economy. Our current standard of living requires more energy than we can produce with available methods without destruction of nature, and without alternative sources of energy, nuclear power is considered the only method available today that has a capacity sufficient to cover our needs. What is happening in Japan is an example that to live the way we do means acceptance of risks. This also means a responsibility to inform communities about these risks and take all necessary steps to prepare ourselves to handle them, including planning, preparedness, education, and training.

11.2.2 Accidents with Lost or Unknown Irradiation Sources 11.2.2.1 Goiania, Brazil, 1987 A therapeutic device with a powerful radiation source (51 Tbq caesium-137) had been abandoned upon the closure of a radiation therapy clinic in the town of Gioania. Two men, who were searching for valuable metal scrap, found the device, dismantled it, and brought the radiation source to a local scrap dealer. The metal capping was broken and the source was liberated. The caesium-137 powder had a beautiful blue, luminous sheen, which fascinated the scrap dealer, so he kept the source and gave some of the powder to his family and neighbors. The caesium-137 powder was used to color the skin and via the contaminated hands

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it was ingested. This behavior caused both an external as well as an internal contamination. The scrap dealer, his coworkers, and his daughter became ill with acute radiation sickness. The symptoms were similar to and initially mistaken for acute gastroenteritis – nausea, vomiting, and diarrhea – which caused a delay in the diagnostic process. The search for the radiation source involved a whole district in the town of Goiania, and soon a significant part of the town’s population was involved. More than 100,000 persons were screened during the first days after the discovery of the radioactive source. About 250 of them were heavily contaminated and needed decontamination. Twenty persons were sick from acute radiation sickness caused by internal contamination and they were brought to the Navy’s hospital in Rio de Janerio for special treatment. Four of these persons died, amongst them the scrap dealer and his daughter. The entire block on which the scrap dealer had lived had to be demolished because of the radioactive contamination; the contaminated material has since been contained.

11.2.3 Accidents in Nuclear Industry 11.2.3.1 Tokaimura, Japan, 1999 This accident occurred at a Nuclear Fuel Conversion factory during the production of nuclear fuel. Three workers were to mix a solution of enriched uranium. They were short on time, so they mixed approximately eight times more of the enriched uranium solution than what was specified as safe; thus, a critical mass was made and an uncontrolled nuclear reaction was initiated. The three workers were exposed to high doses of mixed irradiation. They were swiftly brought to the local hospital in Tokaimura with symptoms of acute radiation sickness. Because of an initial misunderstanding, there was a delay in the diagnostics, and the workers were believed to be externally contaminated. A couple of hours later, they were referred to specialist clinics in the Tokyo area for further diagnosis and treatment. The diagnosis was confirmed as irradiation and the doses estimated were, for the two workers most heavily exposed, equivalent to 17.8 and 9.3 Sv mixed gamma and neutron radiation, respectively. The third worker had received a dose equivalent of 3.5 Sv mixed gamma and neutron radiation. They were all given the most advanced intensive care and expert treatment available. However, the two most

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heavily exposed died within 7 months; the third worker survived. Other workers, rescue personnel, and people living within a radius of 350 m from the factory were exposed to low doses of radiation – all of them were evacuated and there were no radiation injuries reported. The local authorities issued a recommendation to the population living within a 10-km radius to stay indoors. This affected 300,000 persons and caused a lot of anxiety.

11.2.4 International Spread of Radioactive Material and Use of Nuclear Reactions 11.2.4.1 Armed Conﬂicts So far, nuclear weapons have only been used on two occasions: in 1945 at the end of World War II when the United States attacked the Japanese cities Hiroshima and Nagasaki using one nuclear bomb for each of the cities. The nuclear bombs (weapons of mass destruction) had a devastating effect in the Japanese cities, in which most of the houses were constructed of bricks, wood, and paper. The nuclear weapon’s effects of shockwave, fireball, and heat irradiation in combination with ionizing radiation and radioactive downfall ruined the cities and caused mass death and mass casualties – a situation that the rescue services and the health care system could not handle. During the “Cold War” there was a nuclear arms race between the USA and the USSR. During the last decades there have been agreements of nuclear disarmament between the USA and Russia; however, the proliferation and development of new nuclear arms systems is still in progress.

11.2.4.2 Terrorist Actions Terrorist attacks using explosive materials in bombs are frequent occurrences nowadays. There has been evidence that terrorists have been planning to build bombs made of explosives mixed with radioactive material to create a “dirty bomb.” A dirty bomb would not only cause the “normal” bomb traumas but with induce a situation with wounded radioactivecontaminated persons and radioactive contamination spreading through area around the bomb. There have also been plans to set up a hidden radioactive source that irradiates person within the area around the

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source, with the only aim being to spread radioactive material into the environment. These types of actions might not cause only acute trauma, they would create a lot work for the health care system, the radiation protection authorities, the police, and the joint command systems.

11.2.4.3 Criminal Actions (London, UK, 2006) The former KGB Lt. Colonel Alexander Litvinenko, who was living in exile in London, was poisoned in November 2006 with polonium-210, a radioactive isotope that emits alpha particles. It is dangerous and even small doses can cause death when ingested. Litvinenko’s initial symptoms were similar to acute gastroenteritis: nausea, vomiting, diarrhea, and general fatigue. Litvinenko was initially in contact with his general practitioner, but after a couple of days he was hospitalized and put on antibiotics because of the suspicion of generalized gastrointestinal infection. His hemoglobin and white blood cell levels were falling, and this was initially diagnosed as a bone marrow depression as a side effect of the antibiotic treatment. Litvinenko’s condition worsened and he was put into the intensive care unit. A group of medical experts examined him, and it took almost a month to find the right diagnosis: poisoning by polonium-210. By this time, Litvinenko was out of the reach of effective treatment and he died shortly afterwards. The British authorities had found traces of polonium-210 at different places in London: hotels, bars, restaurants, and on board some airplanes. An international warning was sent to ensure that the persons who might have been exposed to the polonium-210 could be checked by the health care and radiation protection authorities. All over the world, radiation protection authorities in cooperation with the health care sector and police checked the persons affected. For example, in Sweden, ten persons who might have been exposed were checked, but none were affected. The mass media inflated the situation, and during the first days there was common anxiety and increased demand on the health care system in Sweden. However, the situation calmed down after a mutual official statement from the radiation protection authority and the National Board of Health and Welfare, combined with a press conference with complete information about how the situation was being handled and the status of the Swedes who were suspected to have been contaminated.

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This information had a positive effect and the anxiety went away. However, one should notice how a rather limited nuclear incident can have a large impact on the public, causing a lot of anxiety. Therefore, it is most important to have a communication plan in place for all sorts of such incidents, from the minor to major, and to have joint radiation emergency management plans prepared, including the coordination of radiation protection expertise, radiation medicine expertise, and command units on the local, regional, national, and international levels.

11.3

Basic Radiation Physics

11.3.1 Different Types of Ionizing Radiation Radioactive nuclides are made of elements with unstable atomic nuclei, which can lose their surplus energy in the form of alpha, beta-, or gamma radiation (ionizing radiation), which forms a new element. This new element can be unstable and continue to lose energy (degradation) by emitting ionizing radiation, or it may no longer have any surplus energy and does not emit any ionizing radiation – it is then a stable element and no longer radioactive. The energy of the radiation is measured in electron volts (eV). Usually the surplus energy of the radioactive nuclides is within the range of thousands to millions eV. The radiation is ionizing when it has enough energy to push electrons from their orbits around the atomic nucleus; thus, an electrically charged atom, an ion, has been formed. The transition of atoms to ions in biological tissues can cause a break up of the proteins and the nucleic acids in the cells. This changes the homeostasis of the cells, which can lead to dysfunction, malformations, and apoptosis. Changes in the structures of the nucleic acids might cause cancer. In a radiation emergency incident, one must take into account the qualities of the ionizing radiation (Fig. 11.1): • Alpha radiation is a positively charged particle composed of two protons and two neutrons (helium nucleus). Alpha radiation generally carries more energy than gamma and beta radiation and deposits the energy quickly when passing through the tissue, referred to as high linear energy transfer (LET). It has a short range – some centimeters in air – alpha radiation even with high energy can be

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α β γ η

Paper

Aluminium

Lead

Fig. 11.1 Different types of ionizing radiation

stopped by a paper or the upper layers of the epidermis. Alpha radiation is only harmful to humans if the alpha-emitting nuclides come into the body via inhalation or ingestion or via open wounds, termed internal contamination. • Beta radiation is made of negatively charged electrons, and the range is dependent on the amount of energy. Highly energetic electrons have a range of several meters in air and can penetrate from 5 to protective clothing 10 mm into body tissues, are not stopped as quickly as alpha particles within tissue, and produce less damage per cell (low LET). Thick protective clothing, inhalation masks, and protective goggles provide sufficient protection. • Gamma radiation is like light and x-ray beams composed of electromagnetic waves with energy quanta and photons, and it has no charge. It has a short wavelength and a high energy and can pass through the body. The range of gamma radiation is dependent on its energy and it can reach up to several hundred meters in air. It penetrates lead to the thickness of tens of centimeters. Thick, heavily armed concrete walls reduce the radiation, but not completely. Gamma radiation is of great risk to humans because it is so penetrative. • Neutron radiation is a particle radiation composed of noncharged particles and neutrons, and it is emitted by nuclear fission, e.g., reactors or nuclear bombs. Neutron radiation has high penetration and range, but can be stopped effectively by materials with a high percentage of hydrogen atoms, such as water.

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11.3.2 Natural and Artiﬁcial Ionizing Radiation

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People living on Earth are exposed their entire life to ionizing radiation, the amounts of which vary depending on where one lives and his or her activities. The following calculations are from Sweden. Persons in Sweden are exposed to natural ionizing radiation from the environment and space, approximately 0.3 and 0.5 mSv/year, respectively. Human beings are also made of radioactive isotopes such as carbon and potassium; they add approximately 0.2 mSV/year. X-ray diagnostics and other medical treatment that uses ionizing radiation adds another 0.8 mSv/year. A normal lung x-ray means an effective dose of 0.2 mSv, and a computed tomography scan of the stomach is approximately 8 mSv. It is estimated that the average person in Sweden receives an average dose of about 4 mSv/year.

of the radiation in causing stochastic health effects. This effectiveness is sometimes called “radiation quality.” The unit of equivalent dose is the Sievert (Sv). Rolf Sievert was a Swedish physicist who worked at the Karolinska Institute (Stockholm, Sweden) and was a pioneer in the radiation protection field, being one of the founders of the International Commission on Radiological Protection (ICRP) in 1928. Physical half time decay is the time it takes to reduce the activity of a radioactive isotope to half of its initial level. Biological halftime decay is the time it takes for the body to eliminate a radioactive isotope so only half of the original activity of the isotope is left in the body. Effective half time decay is the combination of the physical and biological times for halftime decay so only half of the original activity of the radioactive isotope is still in the body.

11.3.3 Dose and Activity

11.3.4 External and Internal Radiation

Activity is the physical unit used to measure the rate of radioactive decay per time unit. The unit is a Becquerel (Bq) and corresponds to one atomic disintegration per second. It is used as a measure of the amount of radioactive material. The name Becquerel comes from the French physicist Henri Becquerel, who discovered natural radioactivity. Absorbed dose is the amount of energy deposited by ionizing radiation in a mass of tissue, expressed in units of joules per kilogram, which is given the name of gray (Gy). The name comes from the British radiation biologist Louis Harold Gray, who did important research on the radiation sensitivity of tumor tissues. The distribution of radiation energy in the body is not always even; for example, in a situation in which rescue service personnel was exposed to heavy beta radiation because they lacked sufficient protective clothing, they would receive a high dose absorbed into the skin, resulting in severe skin injuries (beta burns), whereas the dose absorbed into the bone marrow would be moderate. The mean value of the absorbed dose in different organs or in the whole body can be estimated as the mean absorbed dose, or whole body dose. Equivalent dose is the absorbed dose averaged over a tissue organ, with the contribution from each radiation type (alpha, beta, gamma, neutron, etc.) weighted by a “radiation weighting factor” that reflects the effectiveness

When a radioactive source outside the body emits ionizing radiation that directly hits a person it is called external radiation. This can happen by accident, by direct radiation from the source, or from radioactive material that has been spread out from the source, e.g., in the air or on the ground. A irradiated person may get injuries and cancer might be induced from the direct external radiation, but the person cannot transfer this radiation, or the resultant injuries, to other persons. Irradiated persons are not “contagious,” and it is not dangerous for health care personnel to take care of these patients; several thousands of patients who have been treated with external radiation for cancer are nursed everyday in oncology departments without any risks to the personnel. If a radioactive isotope has entered the body via the respiratory and/or gastrointestinal tracts and/or through a wound, the person affected is hit by radiation from a radioactive isotope inside of the body, called internal radiation. Internal radiation might cause acute radiation injuries and local injuries in the organs where the radioactive material is deposited and later absorbed; cancer might also be induced. The person who has the radioactive isotope inside the body is internally contaminated, and the radioactive substance may be excreted via the urine, stool, other body liquids, or the breath. The activity is usually so low that there should

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not be any risk for the health care personnel if special safety measures are used. Several thousands of patients are treated every day in oncology departments with internal radioactive isotopes without any harm to the health care personnel.

11.3.5 External and Internal Contamination External contamination refers to radioactive material in the form of dust, solid particles, aerosols, or liquid that is attached to a person’s skin or clothes. External contamination should be monitored for individuals who might have been contaminated using a determination of the amount of radioactive material deposited on the skin or the clothing. Externally contaminated individuals should be decontaminated as soon as possible. Internal contamination refers to radioactive material incorporated within the body as a result of inhalation, ingestion, or direct absorption trough open wounds, intact skin, or mucosa. Radionuclides that have been incorporated via one organ (e.g., the gastrointestinal tract) might be transferred to other organs such as the bone marrow, where, for example, plutonium, strontium and uranium are deposited. Light solvable uranium elements might in a couple of hours be deposited in the kidneys and there cause local toxic damage. Medical treatment is usually indicated for the treatment of internal contamination, sometimes in combination with surgical intervention to remove radioactive material from wounds or incorporated radioactive fragments.

11.4

The Effects of Ionizing Radiation

All viable tissue can be affected by ionizing radiation; the radiation has general biological effects. Here we will focus on the medical effects in the human being.

11.4.1 Biological Effects of Ionizing Radiation The negative effects of ionizing radiation are that the ionizing can induce, or directly cause, damage in the cell, including in the membrane, cytoplasm, and the nucleus with the DNA molecules.

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The cell has a capacity to repair DNA damage, and the probability is fairly low that both DNA strands are damaged at low doses; a single strand break is frequently correctly repaired. High-dose radiation and a high dose rate might cause more severe damage, such as DNA double strand breaks, and the cell might not repair the damage, which leads to apoptosis. If a lot of cells die, it might lead to organ impairment or death. An alternative is incorrect reparation of the damage, which might lead to dysfunction, cancer, or hereditary effects. Cells are especially vulnerable during the replication of DNA, so cell systems with high replication kinetics, for example the hematopoiesis in the bone marrow or the gut epithelium, are more sensitive to radiation. The fetus and children are also more sensitive than adults because of their growth.

11.4.2 Medical Effects of Ionizing Radiation Today’s knowledge of the medical effects of ionizing radiation is primarily based on situations with high radiation doses in combination with a high dose rate, including, the atomic bomb cohorts from Japan, the reactor disaster in Chernobyl, and other accidents through which a limited number of persons have been exposed, such as nuclear industry and health care accidents. This has given us information about both acute radiation injuries and the late effects. The negative effects of radiation at low doses and dose rates are more uncertain and difficult to estimate even though large studies and experiments have been done, especially concerning the development of malignancies. One reason is that the effects of low-dose radiation and low dose rates are difficult to isolate from other risk factors.

11.4.3 Acute (Deterministic) Radiation Injuries Acute radiation injuries might cause symptoms within the first hour (extremely high doses), within the first couple of days (high doses), or within a couple of weeks (moderate doses) after an instant whole-body radiation. Symptoms and clinical findings in humans related to the absorbed dose are shown in Table 11.1 Two decades ago, a whole-body dose of more than 3–4 Sv was considered to have a 50% mortality risk

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Table 11.1 Symptoms and clinical findings in humans related to instant whole-body doses Dose (Gy) Symptoms and clinical findings <0. 5 Usually no clinical symptoms 0.5–1 Fatigue and a slight decrease in the white blood cell and platelet counts 1–6 Moderate to severe ARS, dose-dependent increase of nausea, vomiting, bone marrow depression with leucopenia, thrombocytopenia, and increased infectious sensibility, bleeding, and cutaneous erythema >6 Severe ARS; the same as above in combination with radiation injuries to the gastrointestinal tract with severe diarrhea and bleeding, loss of fluids and electrolytes, and nutritional disturbances; few patients survive >15 Lethal radiation syndrome as above, but the central nervous system is also damaged with loss of consciousness and decreased blood pressure, which progresses rapidly to death Adapted after IAEA/WHO and Metrepol ARS acute radiation syndrome

because of bone marrow depression. It is therefore important to follow the leukocyte and thrombocyte kinetics (Fig. 11.2). Modern treatment modalities such as hematopoietic growth factors and stem-cell transplantation in combination with intensive care and the improved treatment of infections has raised the level for lethal doses. The success of treatment is dependent on an early precise diagnosis for each individual and the close cooperation between radiation emergency medicine expertise and expertise from each clinical speciality that might be involved, such as hematology and intensive care.

Platelets, percent of normal

Leucocytes, percent of normal Normal

100

In some cases the radiation dose is not homogenously distributed all over the body but is concentrated in some local part or organ, and this can cause special injuries and problems. The thyroid can take up radioactive iodine-131, for example, after a release from a nuclear reactor accident via inhalation or ingestion. This might cause a decrease in the function of the thyroid or complete nonfunction. It also increases the risk of getting thyroid cancer, specially among children and young adults. The intake of stable iodine reduces the uptake of the radioactive iodine, if it is done before the exposure to the iodine. The stable iodine blocks the uptake of radioactive iodine and the thyroid is protected; however, to achieve as much protection as possible, the iodine has to be ingested before exposure to radioactive iodine to achieve an early intervention. There has to be a pre distribution of stable iodine to achieve a good prophylactic level. Tablets with stable iodine have been distributed to the population living within the safety zones around nuclear power plants. The lungs may be injured not only by direct radiation but also through the inspiration of radioactive material, which may be deposited in the lungs and can cause local radiation injuries. A dose of 6–8 Sv may cause a serious type of damage to the lung – radiation pneumonitis – which might occur after a time lag of several weeks. If the skin is exposed to radiation, a local erythema arises within a couple of days (Fig. 11.3). Cutaneous erythema is induced by a radiation dose of 6–8 Gy. These skin injuries might heal, but it takes usually several weeks to months (Fig. 11.4). The affected skin

Normal

100 Mild

Mild Severe 2–5 Gy

<1 Gy

Moderate 1–2 Gy

50

Moderate 1–2 Gy

50 Very severe > 5–6 Gy Letal

Critical period

Very severe

Infections, Fever

> 5–6 Gy Bleeding, Death

Lethal

Infections, Fever, Death

0

<1 Gy

Severe 2–5 Gy Bleeding

0 0

5

10

15 20 25 30 35 40 45 Time after exposure, days

50

180

0

5

10

15 20 25 30 35 40 45 50 Time after exposure, days

Fig. 11.2 Development over the time of leukocytes and platelets in humans after exposure to radiation

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If corrective measures are not taken by a surgeon (excision and debridement), radiation doses above 25 Gy are difficult to heal because the skin and deeper tissues are severely damaged – blood perfusion is knocked out and a local proliferating inflammatory process is induced, followed by local infection. Rapid surgical intervention in cooperation with radiation emergency medicine specialists is needed. Local doses of 50 Sv or more indicate vital surgical resection and/or amputation of the affected parts. Fig. 11.3 Local erythema 5 days after irradiation

11.4.4 Stochastic Effects of Radiation Radiation effects generally occur without a threshold level of dose, the probability of which is proportional to the dose and the severity of which is dependant on the dose. A risk estimate for the probability of dying of radiation-induced cancer when exposed to low radiation doses is about 5% per Sievert. Large studies of people exposed to radiation in Hiroshima and Nagasaki (Japan) as well as Chernobyl (USSR) have shown that malignancy usually manifests within a couple of years of the latency period, e.g., leukemia in Japan and later for other types of cancers.

Fig. 11.4 Skin damage several weeks after irradiation

11.4.5 Prenatal Exposure Effects

Fig. 11.5 Skin damage with imperfect healing

area is more sensitive to new traumas. At a dose of 10–15 Sv, imperfect atrophic healing is the result (Fig. 11.5). At doses of 15–20 Sv, spontaneous healing is not successful and has to be supported by surgical techniques to achieve skin enclosure. Not only the skin but more deeply located tissues might have been damaged, which can lead to fibrotization and necrosis.

Prenatal exposure gives deterministic and stochastic effects of radiation to the embryo and fetus. The effects of radiation exposure depend on the developmental stage during which the exposure occurs. Because of the high radio sensitivity and possible death of the embryo, significant prenatal exposure in the first 2 weeks after conception is not likely to result in other effects. During the period of organogenesis, malformations may be caused in the organ under development at the time of exposure. The effects are deterministic, with a threshold of approximately 100 mSv. During the whole pregnancy, it is likely that radiation exposure can cause a stochastic effect in the embryo and fetus, expressed in an increased probability of cancer over the lifetime. The ICRP has noted that prenatal exposure should not require specific levels of protection in situations of prolonged exposure where the annual dose is well below 100 mSv.

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11.5

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Medical Response to Nuclear and Radiological Incidents

11.5.1 Planning and Organization • It is most important to have an accurate program for emergency preparedness on the international, national, regional, as local levels in the case of a nuclear or radiologic emergency. We will initially focus on the regional and local levels of the health care system, where the hospital and the prehospital medical management, as well as the primary health care services and family doctors, must be involved in the emergency preparedness. There is a strong need for joint operational planning and emergency preparedness between the regional and local authorities, rescue services, police, military, nongovernmental organizations, and the radiological and nuclear industries, e.g., nuclear power plants and fuel factories. Planning for the emergency and medical preparedness for a nuclear or radiologic emergency must take into account the main principles of the planning for other emergencies. However, there are some important distinctions and special requirements to which attention must be paid: • Radiation protection expertise and radiation emergency medicine expertise should be on hand for the assessment of the emergency situation and to give advice. • The presence of radiation protection staff specially trained in radiation monitoring and in the use of monitoring equipment is necessary at the site of the incident, as well as at hospitals and other medical units in charge of receiving patients from the incident. • It is important to have access to monitoring and decontamination facilities for both injured and noninjured persons who are or might be contaminated. • The risk of not having enough radiation protection specialists, radiation emergency medicine expertise, monitoring and decontamination equipment, as well as medical emergency capabilities must always be considered in the case of major nuclear or radiological emergencies. • It is necessary to contain the spread of radioactive material from the area of the emergency and the monitoring of radioactive material within that area. Restrictive measures such as cordons, the monitoring of all persons within the area, and, when needed,

•

• •

•

• •

•

•

•

•

•

decontamination of the contaminated persons are necessary. Timely and correct information provided to the rescue workers and the public is most important. There is a need for radiologic protection expertise and monitoring equipment within the health care services to assess the contamination and for clinical diagnostics. The clinical findings of patients may be difficult to assess, and providing a correct diagnosis and prognosis can be difficult as well – the patient might have been exposed to both external and internal radiation. The progress of the symptoms can be delayed hours up to days or weeks. There may be a situation with combined injuries, such as physical trauma in combination with radiation injuries. This complicates the medical management of the patients and means a greater demand for specialized treatment facilities. There might be a great demand for laboratories with good analyzing capacities for blood cell analysis and, in the case of internal contamination, facilities that can scan patients for internal contamination and assess the excretion of radioactive materials in urine and/or stool. There is a great need for knowledge and understanding of how to treat patients with internal contamination. There is great demand for information about the accident and the medical consequences of it from both the public and the health services staff. The information has to be coordinated between the authorities and the experts. Planning for the use of urgent population-protective actions such as providing shelter, evacuating the population, and providing iodine prophylaxis and personal protective equipment should be undertaken. Special planning should consider the requirements for workers and rescue and health services participating in the intervention. Special planning should be made for the medical and epidemiological follow up of the persons and population exposed to radiation and/or radioactive material during the emergency situation. Plans must be made regarding how to take care of the persons who were not exposed during the emergency but are worried. This group of persons can be large and will seek advice from health care services. Plans for a joint command on the strategic and tactical levels are needed.

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• There is a need for continuous education, training, and exercise for all health care services involved in the emergency preparedness for nuclear and radiological emergencies.

11.5.2 Risk Zones The area of the risk zone is dependent on the type of incident – a radiation accident, an accident that releases radiologic material, or a nuclear accident – as well as the type of radiation source and or radioactive materials. In a transportation accident with a radiation source that does not release any radioactive material, the risk zone is limited and easily defined by monitoring. Medical services are usually not involved in this type emergency. However, if there has been a release of radioactive material, a smaller or larger area may have been contaminated, and this contaminated zone has to be defined by monitoring and sealed off. Persons who have to go into the contaminated zone (assuming the radiation exposure is not too high) must wear protective equipment adapted to the situation and a personal dosimeter that monitors the dose exposure. This also applies to persons from health services who might enter the zone. Pregnant women should be exempted from the type of tasks where they might get exposed to radiation or radioactive material. Examples of accidents with larger risk zones – up to quadrates of kilometers – may be nuclear incidents and those that spread radioactive substances, e.g., a critical reaction in a fuel factory or the detonation of a dirty bomb. Reactor breakdowns that release large amounts of radioactive material or any nuclear detonation may have as a consequence a vast contaminated zone (tens or hundreds of square kilometers). The spreading of the radioactive material is dependent on the climate for that day (winds and rain) and interventions such as sheltering and evacuation in combination with the intake of iodine prophylaxis.

11.5.3 Decontamination Decontamination of injured persons should be done as soon as possible to reduce exposure to further radiation and to avoid spreading the radioactive material.

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This means that the decontamination usually starts at the incident site, close to the risk zone. Note

Life- and limb-saving medical interventions should have priority before decontamination. Rescue and medical personnel should be properly equipped with: • Protective clothing; • Inhalation protective mask; and • Protective gloves and boots. • Personal dosimeters monitor to the radiation dose. The decontamination of radioactive material is different from the decontamination of chemicals. It usually is possible to monitor the external radioactive contamination with special equipment with the help of radiation protection staff and the risk of rescue- and medical-services receiving a high dose from contaminated patients is low. The decontamination continues by removing the clothes and further monitoring to find any contaminated portions of the skin. If there is some contaminated skin, it should be cautiously washed with water so that the contamination and the water does not spread the radioactive material (as could occur during the cleaning of a wound). The cleaning of the mouth, nose and nostrils, eyes, ears, and open wounds should be prioritized to prevent and/or reduce internal contamination. Samples should be taken with a swab from the parts mentioned above and sent in a test tube for radiophysical and radiochemical analysis. The mouth should be rinsed and the water spit out to avoid internal contamination, and it is also important to rinse the eyes. The cleaning of wounds is most important, and surgical revision should be used as necessary to remove contamination, and local application of antidotes should occur as soon as possible, preferably within 2 h, to reduce the uptake of radioactive material and reduce internal contamination. The hair and nails could be cut short to facilitate decontamination. New monitoring should be done after decontamination, and the decontamination should continue until there is no radioactive material left or the effect of further decontamination is less than a reduction of 10% of the activity left on the body surface. It is recommended that the remaining activity be <10 Bq/ cm2 or any other level recommended by the radiation protection authorities.

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Table 11.2 Triage scheme for acute radiation syndrome Symptom Priority group 1 Symptoms within 30 min Loss of conscience + (coma) Asthenia/poorly unwell +++ Nausea ++++ Vomiting/24 h >10 frequent Diarrhea >10 watery Dermal erythema +++ within 3 h Blood pressure Systolic <80 mmHg Body temperature >40°C Lymphocyte count in peripheral blood After 24 h <500/mL After 48 h <100/mL Dose estimation Whole body >4 Sv Form of illness Severe to lethal acute radiation syndrome; high risk of multiorgan failure Medical management Intensive care, alternative palliative care; individual assessment by radiation emergency medicine experts in cooperation with other medical experts

Priority group 2 5h 0 ++ +++ 1–10 2–9 +/− Normal or intermittently low 38–40°C

Priority group 3 12 h 0 + + £1 Occasionally 0 Normal <38°C

<1,500/mL <1,500/mL

>1,500/mL >1,500/mL

Approximately 2–4 Sv Moderate ARS

£2 Sv Mild

Hospitalization for curative care

Ambulatory care

Joussineau S, modified after IAEA, EBMT and Metrepol

Special decontamination facilities should be prepared at the hospitals receiving contaminated patients because of the need to give them proper medical treatment as soon as possible. The ambulances can be covered with plastic sheets or blankets to reduce contamination during transportation, and the contaminated waste and clothing should be collected and handled according to the recommendations of the radiation protection authorities.

11.5.4 Triage The basic principles for triage should be applied in nuclear and radiologic incidents. Severe acute radiation syndrome (ARS) manifests relatively early (within an hour), with nausea and vomiting. However, these signs might be difficult to recognize as radiationinduced symptoms. It is therefore important to evaluate the clinical symptoms as soon as possible and to cooperate with radiation protection expertise to get an estimation of the radiation dose. Life-threatening radiation-induced injuries usually manifest after a couple of days or weeks, but for high lethal doses, radiation-induced loss of conscience occurs within the initial 15 min, and palliative treatment of these patients might be advised in a triage situation.

In a major incident with a lack of sufficient treatment facilities, triage is necessary. Table 11.2 presents a clinical approach to the different groups of ARS and can be used as guidance for triage.

11.5.5 Diagnosis Clinical diagnosis is of great importance. The assessment of the symptoms together with the clinical findings in combination with the laboratory findings constitute the basic guidance for the medical management. The analysis of the radiation and dose estimates in cooperation with radiation physics expertise is necessary to find out if it is a case of external radiation, internal radiation, or a combination of both. The analysis comprises the parts of the body and organs that have been exposed to radiation and the cause of exposure – only external radiation and/or internal radiation through inhalation or ingestion. It is important to know the type of radiation and the dose as well as whether there is internal contamination. The choice of monitoring methods is dependent on the radionuclide and might be performed as whole-body scan or more selectively combined with the analysis of radionuclides in the urine, feces, or blood and from local swabs of the mouth, nose, eyes, ears, gastric probes, hair, and nails.

11 Incidents Caused by Irradiation

• Anamnesis: It is important to try to estimate the time when the radiation began, the duration of the radiation, and when the cardinal symptoms were manifested. One should ask about the type of exposure, type of radiation, dosimeter values, and if there is or has been some contamination or risk of contamination. • Symptoms: When symptoms started, their duration, and their frequency are all important parameters to know. The cardinal symptoms are loss of conscience, nausea, vomiting, and diarrhea. • Clinical findings: These include general status, blood pressure, body temperature, and skin erythema (time of onset, localization, and duration). • Laboratory findings: These include peripheral blood status and neutrophil, lymphocyte, and platelet counts at admission and after 24 and 48 h; specific patterns develop related to the radiation dose (see Table 11.2 and Fig. 11.2), electrolytes, kidney-liver tests, and urine tests. • Biological dosimetry: A peripheral venous blood sample in heparinized test tubes should be sent to special laboratories (WHO’s Radiation Emergency Medical Preparedness and Assistance Network and IAEA Response Assistance Network can be contacted for the actual addresses) for the cytogenetic analysis of lymphocytes, which can give an estimation of the exposure. This method is officially recognized and accredited. • Physical dosimetry: In cooperation with radiation physicists, this includes monitoring radiation and analysis of tests from different localities such as the mouth, nose, gastric fluid, blood, excretion of radionuclides in urine and feces, and dose estimates. • Human leukocyte antigen typing: Samples should be taken as soon as possible if an exposure to highdose radiation is suspected; a stem-cell transplant might be a possible form of treatment.

11.6

Treatment

11.6.1 Treatment of Whole-Body Radiation Patients who have been exposed to low whole-body radiation do not become ill with acute radiation sickness; they do not need any specific therapy and can be cared for in ambulatory units, e.g., those in local health centers, or by family doctors. However, there is always a risk for stochastic effects. The increased risk for

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cancer can be estimated by the radiation dose, but it is fairly low. The dose can be estimated by biological dosimetry. The patients need information and follow up within the ambulatory care system. Patients who have been exposed to whole-body radiation doses of 0.5–2 Sv develop mild acute radiation sickness during the first days, with symptoms of fatigue, nausea, loose stools, and occasionally vomiting. A slight decrease in the cell counts of lymphocytes, neutrophils, and platelets may occur after the first weeks, and these changes remain along with the fatigue for a couple of weeks. The patients usually do not need any specific therapy, but some individual cases may need treatment for infection. These patients usually can be cared for as outpatients with regular checkups. Patients who were exposed to a whole-body dose of about 2–4 Sv develop moderate acute radiation syndrome within 5 h after exposure, with symptoms of nausea, vomiting, diarrhea, and increased body temperature. They become sensitive to infections within 10–14 days and develop a tendency to bleed because of bone marrow depression caused by the radiation, which can be aggravated for up to 5–6 weeks. These patients need to be hospitalized, preferably in an hematologic or oncology clinic experienced with the management of patients blood and bone marrow depression. Cooperation with the intensive care clinic might be needed if the patients are critically ill due to life-threatening infections and bleeding. It is important to support patients throughout the period of bone marrow depression with treatment of the infections, anemia, and bleeding and to provide nutrition, fluids, and electrolytes. To enhance the recovery of the bone marrow with hematopoietic growth factors can be used until the bone marrow is recovered. The prognosis for recovery is good. Patients who have been exposed to high (>4 Sv) or extremely high (>6 Sv) whole-body radiation doses develop within the first half hour symptoms of severe or very severe ARS. Severe nausea and frequent vomiting are the typical symptoms. Loss of consciousness might occur, and coma indicates exposure to a lethal dose (>15 Sv). The body temperature rises to above 40°C and systolic blood pressure falls to below 80 mmHg. Blood and bone marrow depression occurs during the first week, as do injuries to the gastro-intestinal tract, with symptoms of frequent watery diarrhea combined with large losses of fluids and electrolytes. Multiorgan injuries occur involving the skin, the lungs, and the circulatory system, and these injuries can

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progress to multiorgan failure and death. The patients need to be managed in an intensive care unit supported by all modern treatment modalities. They usually suffer from severe pain, which has to be specially treated. At whole-body radiation doses of approximately 6 Sv or greater, the damage to the bone marrow is usually so severe and large that a spontaneous restitution, even with the enhancement of growth factors, is not possible. An allogeneic stem-cell transplantation may then be a possibility for survival. These treatments have to be performed in specialized clinics. Even if the stemcell transplantation is successful, the issues with a seriously injured gut can cause such problems that the outcome cannot be certain. In a disaster situation with mass casualties, the access to intensive care units must be considered. Patients exposed to a lethal dose of whole-body radiation (>15 Sv) usually die within a week or two. The treatment to consider is palliative, using sedatives, analgesics, antiemetics, and high doses of glucocorticoids.

11.6.2 Treatment of Internal Contamination Internal contamination is present when a radionuclide has entered the body via the airways, gastrointestinal tract, the skin, or open wounds. The treatment is basically in line with the treatment of chemical intoxications. The first step is to identify which radionuclide(s) may be involved in the incident. Monitoring of the patient is done by a radiation protection specialist; it is necessary to find out which nuclides are involved for a primarily dose assessment and to administer the best medical treatment. Samples from the nose, mouth, gastric fluids, urine, and stools should be analysed to identify the radionuclides involved. The treatment is directed primarily toward the reduction of the resorption of radionuclides to promote the excretion of the radionuclide, to dilute the radionuclide with stable analogs, or to create complex bindings of the radionuclides to enhance the excretion of them. The treatment should be done by radioemergency medicine specialists in cooperation with toxicologic expertise because some nuclides can cause both a radiation-induced injury as well as a chemical or toxic effect caused by the physical and/or chemical forms of the nuclide involved.

S. de Joussineau

Please Note

The time factor is of great importance because injuries can be induced within a short time by internal contamination. Therefore, it is vital to start adequate therapy as soon as possible. It is recommended that medical staff (prehospital and hospital) is educated, equipped, and trained to take care of patients with internal contamination, especially in places where such incidents might happen, e.g., around nuclear industries. Joint planning and exercises with recue services is also important.

11.6.3 Initial Treatment of Internal Contamination 11.6.3.1 Airways Rinsing of the mouth and nose – avoiding swallowing the water – can be done on scene.

11.6.3.2 Gastrointestinal Tract • Rinsing of the mouth and nose – avoiding swallowing the water – can be done on scene. • Immediate administration of absorption-reducing agents such as antacids (for example alu-hydroxide), can be done on scene. • Gastric lavage • Oral administration of laxatives, for example, magnesium sulphate 15 g in 100 mL water, which enhances the fecal excretion of radionuclides, especially radium and strontium. • Oral administration of ferric ferrocyanide (Prussian blue) 1 g × 3/day traps caesium in the gut, interrupts its reabsorption from the gastrointestinal tract, and thereby increases fecal excretion.

11.6.4 Speciﬁc Treatments: Blocking, Dilution, and Displacement Agents • Radioactive iodine: Oral administration of stable iodine (potassium iodide), blocks the uptake of radioactive iodine. If it is administrated 6 h before the exposure it can block 98% of the intake; there is a 90% reduction of the intake if given at the time of exposure, and about 50% reduction if given within

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4–6 h after the exposure. The administration can be done in the prehospital setting. • Tritium: Isotopic dilution is achieved by the administration of large quantities of water; a high level of water intake will increase the excretion of tritium and may possibly enhance diuresis as well. • Radioactive strontium: A displacement agent is the administration of calcium to increase the urinary excretion of radioactive strontium. Strontium gluconate (600 mg intravenously per day) can also be used to enhance the urinary excretion of radioactive strontium. • Radioactive phosphorous: Oral administration of calcium phosphate reduces the absorption of the radionuclide.

time. For treatment periods longer than 2 days, treatment with ZnDTPA is recommended in the same doses as for CaDTPA, but ZnDTPA treatment should not be inhaled. • Open wounds contaminated with plutonium: CaDTPA can be administrated directly into wounds in the form of solution mentioned above. • Treatment for radioactive lead (Pb) and polonium (Po): DMPS capsules 100 mg × 3–4 times daily, given orally. • Uranium: Contamination with soluble forms of uranium should be treated as soon as possible with 1.4% sodium bicarbonate buffer 250 mL intravenously to avoid kidney damage; the hazard is more chemical than radiological.

11.6.5 Chelating Agents

11.6.6 General Recommendations for the Treatment of Internal Contamination (TIARA, EC)

Chelating agents are compounds that increase the natural turnover process, thereby effectively eliminating radionuclides from the body tissues. They enhance the formation of soluble complexes with the radionuclides, and the complexes are excreted by the kidneys in the urine. Because chelating agents cannot penetrate cells, their use is most effective when treatment is commenced immediately after exposure, while the ions of the radioactive material are still in circulation and before their incorporation into cells in the target organs, e.g., bone and liver. Diethylene triamine penta-acetic acid (DTPA) is the most common form of chelating agent and has shown its effectiveness in the treatment of contamination by transuranics such as plutonium, americium, curium, and lanthanides such as cerium, yttrium. • Treatment suggestion for plutonium and other transuranics or lanthanides: 1 g CaDTPA per day intravenously, alternatively, 1 g CaDTPA in 250 mL isotonic sodium chloride; infusion time 30 min. In aerosol for nebulization, 1 g CaDTPA in 10 mL isotonic sodium chloride; inhalation time 10–20 min. Treatment should be initiated immediately upon confirmed or suspected contamination to reduce the incorporation of the plutonium into the bone or liver. Patients should undergo an initial 2-day treatment. Treatment may be prolonged to 5 consecutive days per week for several weeks; however, the monitoring of urinary excretion of the radionuclide is the guide for the treatment

• Assessed effective dose below 1 mSv: Minimal risk; provide information to affected persons • Assessed effective dose 1–20 mSv: New monitoring and dose assessment; if the dose is within the same limits, there is no risk for deterministic injury and a limited increased risk for a stochastic event; provide information to the patient; no treatment • Assessed effective dose 20–200 mSv: New monitoring and dose assessment; if the dose is within the same limits, medical assessment for the benefit of treatment. Even if acute injuries are not likely, the benefit of an initial short treatment to reduce the dose burden should be considered • Assessed effective dose more than 200 mSv: Indication for treatment; however, the benefit of a longer period of treatment should be assessed

11.6.7 Surgical Treatment 11.6.7.1 Open Wounds Open wounds that are contaminated or suspected to be contaminated should be cleaned as soon as possible; if necessary, surgical revision should be performed. The wounds should not be closed until monitoring of any remaining radionuclides has been done, and the result should be assessed by radiation emergency medicine expertise.

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11.6.7.2 Shrapnel Any radioactively contaminated shrapnel/splinter from a bomb or explosion that has entered the body should be removed as soon as possible. Monitoring of any remaining radioactive shrapnel/splinter should be performed and assessment done in cooperation with radiation emergency medicine experts before closing the wound(s). For a limb containing large amounts of radioactive shrapnel/splinter, one should consider amputation.

S. de Joussineau

tissues, and some positive outcomes have been reported. The healing process of localized radiation injuries is slow and protracted. Insufficient healing with blood perfusion problems, recurrent ulcerations, and fibrosis is common. The treatment of radioactively contaminated wounds, combined traumas, and localized radiation injuries put extra strain and demands on the surgical resources during both the acute phase and the followup period of a nuclear and/or radioactive emergency.

11.6.7.3 Combined Injuries All patients exposed to severe physical trauma should be stabilized (see Chap. 7) before radiation injuries are dealt with. Exposure to ionizing radiation should not delay life- and limb-saving procedures, but one must be aware that the patient might have a worsened prognosis because of the ionizing radiation. One must especially consider complications caused by bone marrow depression and gastrointestinal impairment. A joint assessment with radiation emergency medicine experts is advised. The surgical interventions should be performed and completed within the first 36 h to avoid complications caused by the radiation. Open wounds should be revised and closed and fractures reduced and stabilized. If gut surgery has been performed, a stoma should be done on wide indications. Amputations are preferred before large reconstructive interventions in these patients. The healing of fractures demands 25–50% longer time compared with a normal situation.

11.6.7.4 Local Radiation Injuries Persistent local tissue injuries and necrosis can arise after local radiation doses of more than 12–20 Sv and are most likely to occur from doses above 25 Sv. Initially, it is important to define the affected area by dose reconstruction in cooperation with radiation experts. The border of the area with normal blood perfusion also must be defined. The damaged tissue is then surgically removed with an accurate margin around the area with normal blood perfusion. The wound must be protected from infections and further trauma. Repeated resections of damaged tissue and amputations might be needed over time. Skin grafts to cover the damaged areas are often necessary, preferably flaps of skin with their own blood perfusion. During recent years, local injections of mesenchymal stem cells have been used in combination with stimulating growth factors to regenerate damaged

11.6.8 Psychological Aspects and the Necessity of Information A nuclear or radiation emergency causes a lot of distress, fear, and anxiety among the affected persons and their relatives, the society, and the rescue and health care services. Therefore, it is important during the management planning to prepare and train personnel about the distribution of relevant information and medical advice to the different groups mentioned above. It is important that the information be coordinated between the responsible authorities. Many persons will, however, seek help for their anxiety and fear from health services, and therefore it is important to plan for and organize a structured system for psychosocial support on regional as well as local community levels. More facilities to take care of psychiatric reactions are needed. The rescue and health care services staff that has been on duty during the emergency needs extra support and follow up. A major nuclear and/or radiologic incident affects the whole society for a long period of time, both psychologically and physically. This implies great expectations and demands on the health care services: comprehensive planning, organization, equipment, education, training, and regular exercises are needed to be prepared.

11.7

Planning and Preparedness

As mentioned above, it is vital to have comprehensive planning and organization to be prepared for a nuclear and/or radiation emergency. A major nuclear and/or radiation emergency may affect not only the local community, but regions, nations, and the international community.

11 Incidents Caused by Irradiation

11.7.1 Local Level Every person or institution (individuals and private or public organizations) that possesses and handles radioactive substances and radiation sources have the responsibility to plan for the management of nuclear and/or radiation emergencies. The local rescue and health care services at the local level must have adequate equipment and training to manage an emergency situation in cooperation with other local authorities. An analysis of different local scenarios that might happen should support the planning and local organization.

11.7.2 Regional Level If a major nuclear or radiation emergency occurs – for example, a reactor breaks down with a subsequent major release of radioactive material – it is not only a local emergency, but a regional one. Many countries have a regional authority that plans and coordinates the management of the nuclear and/or radiation emergency in cooperation with other authorities on the regional level, such as rescue and health services, police, and military. The Rescue Incident Commander (RIC) should have a special staff for support that is located in a special command center. It should also be staffed with medical specialists and radiation protection specialists. The RIC makes decisions about shelter, evacuation, and intake of stable iodine (in some other countries, stable iodine is predistributed to the population living in the risk zone of a nuclear power plant). The regional health authorities support the RIC and are responsible for disseminating medical information to the medical services and the population. The rescue leader coordinates all public information on the regional level. The RIC reports to the coordinating authority on the national level and the radiation protection authority, which support the regional authorities with expertise.

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advice about radiation protection issues and for the coordination of the monitoring of an emergency on the national level. It is also responsible for the international contacts within the radiation protection field, EC, and IAEA. The National Board of Health and Welfare supports the SSM with medical expertise (The Nuclear Medical Expert Group with experts on radiation emergency medicine, hematology, oncology, nuclear medicine, and health physics). The Board is responsible for the provision of medical information to the health care services and the public and can be empowered by the government to coordinate the work of the regional health services. It is also a contact point for international cooperation within the health care field with EC and WHO. The National Authority for the Management of the Rescue Services (MSB) plans and coordinates the rescue services. It is also the government’s national coordinator and is responsible for the international contacts with the EC and the United Nations. Other countries have different organizations, but regardless of type of organization, it must be well prepared.

11.7.4 International Level A major nuclear and/or radiation emergency may not just affect one country, but other countries as well. Therefore, there is a continuous work needed to maintain and improve cooperation among the international community. In different parts of the world exist bilateral and multilateral agreements of cooperation. Within the European community, the European Commission has the responsibility to maintain its preparedness to forward radiation alert messages and additional information to European Community Urgent Radiological Information Exchange member states. It also exists as a mechanism for cooperation within the rescue services field and a monitoring and information center for the health services, located in Luxembourg.

11.7.3 National Level

11.8 Most countries have specially designated authorities on the national level who are responsible for the planning and management of nuclear and/or radiation emergencies both on a national level and during international cooperation. Sweden is presented here as an example. In Sweden, the Swedish Radiation Security Authority (SSM) has the national responsibility for giving expert

Global International Organizations

The International Atomic Energy Agency (IAEA) in Vienna is authorized under its statutes to establish standards of safety for protection of health.

The IAEA is the depository of the Convention on Early Notification of a Nuclear Accident and the

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Convention on Assistance in the case of a nuclear accident or radiologic emergency, and it has specific obligations with regard to preparedness actions, namely to collect and disseminate to state parties and member states information concerning experts, equipment, and materials that could be available in the event of nuclear accidents and radiologic emergencies. The IAEA has established a special Incident and Emergency Center (ERC) on duty 24 h a day 7 days a week to carry out the specific responsibility for the response preparedness and a special emergency response network, ERNET. In Geneva, Switzerland, the WHO has the statutory general responsibilities relevant to emergency response. The Radiation and Environmental Health Program (RAD) is a key unit in the area of radio-nuclear emergency response by the WHO. RAD works closely with IAEA and ERC to maintain and mobilize its international response system. Coordinated by RAD, the Radiation Emergency Medical Preparedness and Assistance Network provides access to a large number of specialized facilities and equipment to the WHO collaborating institutions in member states for consultation, diagnostics, and treatment of radiation injuries and delayed health consequences of radionuclear accidents.

Further Reading Bennet B, Repacholi M, Carr Z (2006) Health of the Chernobyl accident WHO. WHO, Geneva Berger ME, Christen DM, Lowry PC et al (2006) Medical management of radiation injuries: current approaches. Occup Med (Lond) 56:162–172 Blakely W, Carr Z, Chin-May Chu M (2009) Meeting report: WHO 1st consultation on the development of a global biodosimetry laboratories network for radiation emergencies (BioDoseNet). Radiat Res 171(1):127–139 Carr Z (2006) The role of the WHO in strengthening capacity of the Member States for preparedness and response to radiation emergencies. Acta Med Nagasaki 50(Supplement 2):37–40 Daniak N, Berger P, Albanese J (2007) Relevance and feasibility of multiparameter assessment for management of mass casualties from a radiological event. Exp Hematol 35:17–23 Der Strahlenunfall, Strahlenschutzkommission, Band 32, Berlin 2007 Germany EBMT (eds) (2007) European approach for the medical management of mass radiation exposure – the first 48 hrs. Ulm University, Institut de Radioprotection et de Surete Nucleaire IRSN Fontenay aux -Roses, France

S. de Joussineau Fliedner TM, Friesecke I, Beyrer K (2001) Medical Management of radiation accidents: manual on the acute radiation syndrome. The British Institute of Radiology, London Gorin NC, Fliedner TM, Gourmelon P et al (2006) Consensus conference on European preparedness for hematological and other medical management of mass radiation accidents. Ann Hematol 85:671–679 Gourmelon P, Marquette C, Agay D et al (2005) Involvement of the central nervous system in radiation induced multiorgan dysfunction and/or failure. Br J Radiol Suppl 27:62–68 Gourmelon P, Benderitter M, Bertho JM et al (2010) European consensus on the medical management of acute radiation syndrome and analysis of the radiation accidents in Belgium and Senegal. Health Phys 98(6):825–832 Gusev I, Guskova A, Mettler F (2001) Medical management of radiation accidents. CRC Press, New York IAEA EPR-JPLAN (2006) Vienna Austria ICRP Publication 103 (2007) The 2007 recommendations of the international commission on radiological protection. Ann ICRP 37(2–4):1–332 ICRP Publication 96 (2005) Protecting people against radiation exposure in the event of a radiological attack. Ann ICRP 35(1):1–110 Joussineau S, Riddez L (2003) KAMEDO report 78 (The nuclear technology accident in Tokaimura, Japan 1999) SoS Socialstyrelsen, Stockholm Sweden Lataillade J, Doucet C, Bey E et al (2007) New approach to radiation burn treatment by dosimetry-guided surgery combined with autologous mesenchymal stem cell therapy. Regen Med 2(5):785–794 Lewensohn R, Stenke L, Joussineau S (2002) Management of radiation injuries new organisation, new guidelines. J Swedish Med Assoc (Läkartidningen) 99:1453–1455 Lloyd DC, Edwards AA, Moquet JE et al (2000) The role of cytogenetics in early triage of radiation casualties. Appl Radiat Isot 52(5):1107–1112 Meineke F (2005) The role of damage to the cutaneous system in radiation induced multi-organ failure. Br J Radiol Suppl 27:95–99 Menetrier F, Berard P, Joussineau S et al (2007) TIARA: treatment initiatives after radiological accidents. Radiat Prot Dosimetry 127:444–448 Menetrier F, Hodgson A, Stradling N et al (2007) Dose assessment of inhaled radionuclides in emergency situations. Health Protection Agency, Didcot Ricks RC, Berger ME, O’Hara FM (2002) The medical basis for radiation accident preparedness: clinical care of victims. Proceedings of the 4th International REAC/TS conference. Parthenon Publishing, New York Rojas Palma C, Liland A, Jerstad AN et al (2009) TMT handbook: triage, monitoring and treatment of people exposed to ionising radiation following a malevolent act. Norwegian Radiation Protection Authority, Norway Waselenko JK, MacWittie TJ, Blakely WF et al (2004) Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med 140:1037–1051

Infectious Diseases and Microbiological Threats

12

Martin Wahl

12.1

Introduction (Fig. 12.1)

Hardly a day passes without new headlines concerning infectious disease threats. The time is far from near to “close the book on infectious disease.” Not all infectious disease threats evolve into outbreaks or major incidents, and all threats concerning suspected infectious diseases do not turn out to have infectious causes. Initially, the cause of major incidents often is not clearly identified. This holds true especially for incidents in which symptoms of the affected persons are diffuse, the conditions are undiagnosed, or the hazardous materials involved are not clearly identified. Many incidents caused by material other than biological con-

Fig. 12.1 The international symbol for biohazards

M. Wahl e-mail: [email protected]

taminants are often initially classified as suspected infectious incidents but, when the full picture becomes clear, they are found to have other causes for example, intoxication by chemical or radiological agents. One reason for this is that most societies have surveillance systems that most of the time direct their major interest toward the more common entity: infectious diseases. Infectious diseases can constitute major incidents alone or as a part of or consequence of an incident having a non-infectious cause. The infections that follow as a part of or a direct consequence of a disaster may have several different causes, and they can differ depending on what type of primary incident they are secondary to. The primary incident can lead to disruption of the infrastructure in the affected society; which secondary can result in increasing biological incidents through, for example, increased crowding; collapse of water, deteriorating sanitation and hygienic conditions; drought or famine. Secondary effects can even be seen within medical institutions for example as a consequnce of a lessened capacity to isolate infected individuals. Because of some of these circumstances, infections can change in both clinical presentation as well as increase in virulence of the microorganism – the ability of the microorganism to cause disease. Certain communicable diseases are more prone to cause outbreaks than others and can cause disasters independently. Examples of infectious diseases causing disasters independently are pandemics caused by microorganisms, such as influenza or cholera. Before the outbreak in 2003 of severe acute respiratory syndrome (SARS), it was an unknown type of infection and is another example of infection constituting a major incident independently. SARS also gives us a serious example of how emerging infections can be included in the term

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_12, © Springer-Verlag Berlin Heidelberg 2012

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biological major incidents. The term “emerging infections” sometimes covers both new and previously unknown contagions as well as reappearing older contagions or re-emerging infections. Humanitarian emergencies caused by conflict or natural disasters are frequently characterized by the displacement of large numbers of people. The populations affected are often resettled in temporary locations with high population densities, inadequate food and shelter, unsafe water, and poor sanitation. These conditions can increase the risk of transmission of communicable diseases and other conditions and lead to increased mortality, particularly from diseases prone to outbreak. To address this increased risk, specialized systems for disease surveillance and response are often set up in the affected areas during the acute phase of emergencies by national ministries, often with support from the World Health Organization (WHO) and other agencies. These early-warning disease surveillance and response systems are designed to detect and respond rapidly to outbreaks and disease clusters in populations affected by humanitarian emergencies. Major incidents caused by a microorganism or its toxins also should be considered as possible bioterrorism incidents, and they are more often suspected as such than what they turn out to be in reality. Several myths are circulating about natural disasters and their possible direct cause of outbreaks. One is that natural disasters themselves cause epidemics. Outbreaks are, however, usually secondary to the displacement of people and disruption of infrastructures, as mentioned above. The appearance of infections after a disaster is therefore usually of the same type of infections that are present in the area before the incident but with a possible increase in numbers. A resent example of this is the situation in Haiti after the extraordinarily devastating earthquake that occurred in January 2010. Another common myth is that dead bodies spread epidemics. Carcases smell and are generally unpleasant to see and to handle. They are, however, more of a sanitary problem but, in most circumstances, if handled properly they are not dangerous. It is only in large-scale cholera epidemics or outbreaks of viral hemorrhagic fever (VHF), such as the Ebola virus, when bodies might be a direct threat to public health. Those who have survived a natural disaster are usually more likely to spread diseases than are dead bodies.

M. Wahl

12.2

Classiﬁcation of Microbiological Incidents

Major incidents and disasters caused by a microorganism or its toxins can be classified in the same way as major incidents of other causes, including the relevant classification suggested in Chap. 2: • Incidents consequent to technical development • Incidents intentionally caused by man • Incidents subsequent to changes in climate and nature

12.2.1 Incidents Consequent to Technical Development Microbiological incidents consequent to technical development can be caused by, for example, failing systems for the supply of water, sanitation, and ventilation. These incidents can happen in a community, a building, or a transport facility. Many recent food- or waterborne outbreaks are consequences of mistreatment in the modern chains of distribution of food or water. Crowding of people as well as animals constitute examples of technical development that can lead to infectious incidents, such as highly pathogenic avian influenza, which appears mainly in densely populated poultry farms. Another example is the increased risk of epidemic meningitis that occurs when extreme crowding of people takes place, as it does during the pilgrimage to Mecca, Hajj. A well-known incident with spread of contagious spores over a large surface area happened in Sverdlovsk, former Sovietunion, in 1979. Several cases of anthrax occurred among humans as well as livestock downwind from a microbiology plant (Fig. 12.2). The cause was revealed several years after the incident as an accident after the misuse of filters, which led to the dissemination of anthrax spores into open air. Incidents consisting mainly of primary physical trauma can have secondary results of infectious disease incidents, such as a sharp increase in the number of wound infections or a shortage of isolation facilities. Hospital-acquired infectious diseases are another increasing form that is directly related to technical development in hospital settings and the development of medical techniques.

12 Infectious Diseases and Microbiological Threats Fig. 12.2 Six villages (A–F) with fatal animal anthrax after an accidental release of anthrax spores from a ventilation outlet of an industrial plant in Sverdlovsk, in April 1979 (Source: Meselson et al. 1994)

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12.2.2 Incidents Intentionally Caused by Man Microbiological incidents intentionally caused by man are often termed bioterrorism. They can be used intentionally during war as well as in other situations. An international agreement against the use of biological weapons was achieved under the United Nations in 1975 at the Biological and Toxin Weapons Convention (BTWC). The production and spread of biological agents requires both knowledge and resources to produce

sufficient amounts of the agent along with methods to weaponize the material. The latter problem is often underestimated and is why attempts of biological warfare often have failed. However, in spite of the 1975 BTWC agreement, several attempts have been made to use biological weapons, e.g., during the Iraq–Iran war in the 1980s. An attempt to spread anthrax spores to the public in Japan by the terror group Aum Shinrikyo in 1995 failed mainly because of the use of the wrong source of microbiological material. A nonpathogenic vaccinederived strain was used, causing no harm at all!

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The first time a successful intentional spread of anthrax was confirmed was in 2001 after the World Trade Center attack on September 11. The attack was followed by an intentional spread of anthrax through the mail system in the United States, with several fatalities caused by the most serious and well-weaponized form of anthrax. A man-made disaster that was presumably not caused directly or intentionally by man but could still rather easily have been foreseen or predicted as a direct consequence was the extensive outbreak of cholera in Zimbabwe and adjacent countries in 2008–2009. In spite of intense efforts from the international society, the outbreak did not cease until approximately 100,000 people where affected; an unusually high case fatality rate clearly indicated a society under misadministration with failing infrastructure and a health system in ruins.

12.2.3 Incidents Consequent to Changes in Climate and Nature At present, the largest threats to the infectious disease arena is probably microbiological incidents consequent to changes in climate and nature. Infectious diseases re-emerge in areas where they previously have been eradicated or spread to new regions because of changes in climate. For example, climate change has the potential to increase substantially the presence of malaria in areas where it previously has been eradicated. The spread of dengue fever and the appearance of the viral infection Chikungunya in Southern Europe are examples of incidents that most likely have one cause in ongoing climate change. Climate change also can lead to increased drought and possibly famine, displacement of populations, shortage of water, floods, storms, and tsunamis, all of which can secondarily lead to and increase in infectious disease incidents. There is an obvious difference in potential microbiological hazards when, for example, a flood is caused by sea water or fresh water. The sharp increase in numbers of cases with severe leptospirosis in the Philippines in 2009, after the heaviest rains and fresh-water floods in modern history, presented problems with different pathogens than what occurred after the salt-water floods in the Southern United States in 2005 after hurricane Katrina.

M. Wahl

The increasing problem with antimicrobial resistance is another change by nature that is considered to be one of the strongest disease threats at present. “The bugs are fighting back,” and the situtation as it was before antibiotics were available seems to be returning quicker than anyone could expect.

12.3

Terminology and Characteristics of Infectious Disease Incidents

Infectious disease incidents have certain characteristics that differentiate them from most other types of major incidents. The dissemination of or exposure to an infectious agent usually is not noticed until after some latency because the substance is not noted in any obvious way when the incident itself occurs – it is not seen or heard, has no smell, and is first noticed only when the exposed persons develop symptoms. The number of affected can rise sharply, even logarithmically, if the agent involved is communicable with a high reproductive rate (the potential for the contagion to spread from person to person). The large number of people who possibly can be affected during a large-scale communicable disease incident is exemplified with recent epidemics in Table 12.1. There is almost always a delay between when the incident occurs until it is discovered or revealed as such, and may take even longer to be identified as a specific infectious disease incident. The detection of infectious disease incidents relies mostly on different surveillance systems. Different methods of surveillance constitute the basis for the detection of infectious disease incidents. An outbreak or an epidemic is by definition when more cases of a certain infection are noted or diagnosed than what is expected. Terminology common for biological incidents are stated in Table 12.2. An outbreak can be obvious or insidious depending on the symptoms present and how well surveillance is conducted. Most countries have national surveillance systems for a number of different infectious diseases. The national authorities are linked and report to each other through different networks or organizations; e.g., globally through WHO, within the European Union through the European Centre for Disease Prevention and Control, and through disease-specific networks such as ENTER-NET (international surveillance network for enteric infections) and The European Working Group for Legionella Infections.

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Table 12.1 Examples of recent large-scale communicable disease incidents Infection Severe acute respiratory syndrome Cholera Pandemic flu Leptospirosis Dengue fever

Year 2003 2008–2009 2009–2010 2009 2008

Localization Multinational Zimbabwe Global Philippines Brazil

Number affected >8,000 cases >98,000 cases >200 nations >3,000 cases >530,000 cases

Case fatality rate (% or n) 9.6% 4.3% >15,000 >250 0.1%

Table 12.2 Terminology for biological incidents Term Biological incident Infectious disease Communicable disease Contagious disease Epidemic Outbreak Pandemic Surveillance

Description Threat of or actual incident with accidental, intentional, or natural release of a biological toxin or microorganism with the potential of causing extensive harm All diseases caused by microorganisms or their toxins Infectious diseases that can be transmitted from one infected person to another person A more vague term often used to describe a highly infectious disease When a disease occurs in a community or a population with a frequency that clearly exceeds what it is normally expected A milder, more neutral term for epidemic; often used on a smaller scale When an epidemic disease spreads globally or at least to several continents A system covering certain areas, populations, or periods with the aim of detecting sudden changes in incidence, i.e., outbreaks or epidemics of a certain disease or condition

International surveillance reporting and responding is coordinated through WHO and its member states. Global roles have been implemented through WHO and its International Health Regulations (IHR) to enhance public health security at all levels: global, national, as well as regional. The IHR is an international legal instrument binding 194 countries, including all the member states of WHO. The aim of the IHR is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. In the globalized world, diseases can spread far and wide via international travel and trade. A health crisis in one country can impact livelihoods and economies in many parts of the world. Such crises can result from emerging infections like SARS or a new human pandemic influenza. The IHR can also apply to other public health emergencies such as chemical spills, leaks and dumping, or nuclear meltdowns. The IHR aim to limit interference with international traffic and trade while ensuring public health through the prevention of the spread of disease. The IHR, which entered into action on June 15, 2007, requires countries to report certain disease outbreaks and public health events through focal points to WHO. Building on the unique experience of WHO in

global disease surveillance, alert, and response, the IHR define the rights and obligations of countries to report public health events and establish a number of procedures that WHO must follow in its work to uphold global public health security. The IHR also require countries to strengthen their existing capacities for public health surveillance and response. WHO is working closely with countries and partners to provide technical guidance and support to mobilize the resources needed to implement the new rules. The overall aim is that timely and open reporting of public health events will make the world more secure in this aspect. WHO also coordinates a global network of experts – The Global Outbreak Alert and Response Network (GOARN) – that can step into action on request. GOARN is a technical collaboration of existing institutions and networks that pool human and technical resources for the rapid identification of, confirmation of, and response to outbreaks of international importance. Detection of an infectious disease incident depends largely on how sensitive and rapid a surveillance system is. Parallel to traditional surveillance, systems are implemented to get early warnings for infectious disease incidents through, for example, syndromes, health-related information activities within the population, figures of absentees, or crude mortality data. All

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Table 12.3 Characteristics of infectious disease incidents Causative agent Mode of transmission Incubation period Index case Primary case Secondary case Reproductive rate Immunity Herd immunity Prophylaxis Attack rate Case fatality rate

Microorganism or its toxin causing the disease The route through which transmission of a communicable disease can occur from one host to another susceptible individual The period of time from exposure and getting infected to onset of symptoms The first case diagnosed with the infection concerned during an outbreak The individual that introduces the infection into a group or population The individuals infected by the index case. Secondary cases can generate further waves or generations of infection in the affected, exposed population The average number of secondary infectious cases that are produced by a single index case in a completely susceptible population When an individual, in the clinical context, does not develop a disease after exposure to the specific infection The level of immunity against an infection in a population that will prevent an outbreak of the infection Efforts to prevent transmission or development of a disease before or after exposure to a causative agent The proportion of a population that will become ill after being exposed to the specific causative agent The proportion of all who became ill that will die of the infectious disease concerned, i.e., lethality

surveillance data are meant to give alerts and, if needed, result in different levels and types of response, i.e., they provide the data needed for action. Syndromic and similar methods for surveillance can be more open to unknown changes in the panorama of diseases as well as the appearance of previously unknown contagions. Many new, emerging infections as well as the re-emergence of previously known pathogens have occurred during the last decades. Wellknown examples are HIV (AIDS), Helicobacter pylori as a causative agent for duodenal peptic ulcers, Borrelia burgdorferi as the cause of different manifestations of borreliosis, and Coronavirus causing SARS. Surveillance for emerging infections also needs to cover areas outside human medicine. Zoonotic infections are infections that can spread from vertebrate animals to humans and vice versa. Surveillance for zoonotic infections thus needs to cover both public and animal health communities to increase the surveillance for emerging diseases that have a potential for widespread and serious transmission. The flu pandemic of H1N1 in 2009–2010 is one example of this, where the new viral strain actually had been circulating in pigs for almost a decade and probably jumped to humans only months before it was detected in Mexico in the spring of 2009. The time period from dissemination of or exposure to an infectious agent and onset of the first clinical symptoms varies depending on what type of microorganism is involved and the susceptibility of those exposed to the agent of concerned. The time period from exposure and infection to onset of symptoms is the incubation period. The incubation period usually

varies within a certain time range and is dependent on several factors, such as infectious dose, mode of transmission, and susceptibility of the exposed. Lack of susceptibility to a specific agent can have immunity as one explanation among many. Immunity can be genetically determined (congenital) or acquired after exposure or immunization. Several infectious diseases can be treated with antimicrobial agents either prophylactic i.e. before or curative i.e. after symptoms have occurred. The first case diagnosed/detected with the infection in question is named the index case, whereas the first case in an outbreak or an incident, i.e., the case that brought the contagion into a population or group of people, is the primary case. An infectious disease can spread among a group or a population at different speeds depending on factors such as mode of transmission, frequency and type of contact, grade of exposure, immunity among the population, and the potential for the contagion to spread from person to person, which is termed the reproductive or transmission rate. Relevant characteristics of infectious disease incidents are summarized in Table 12.3.

12.4

Routes of Transmission for Communicable Diseases

An infectious microorganism can spread to and between humans via several different routes. It is important to know by which modes different contagions

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Table 12.4 Modes of transmission for infectious diseases Mode Airborne Droplet Contact Sexual Bloodborne Fecal-oral Vector-borne

Description Requires relatively small particles that can be suspended in the air and spread by wind or ventilation systems Larger particles than airborne particles that do not suspend in the air for more than a short distance (meters) from an infectious person Can be direct between persons or indirect via contaminated objects Contact transmission via sexual contact which includes transfer of body fluids Inoculation of infected blood or blood products Ingestion of contaminated material, usually food or water

Example Morbilli, varicellae, legionella, spores of anthrax Influenza, tuberculosis, smallpox Influenza, skin infections HIV, chlamydia HIV, hepatitis, malaria Norovirus, salmonella, cholera, anthrax Infectious organism spread via insects or larger animals from reservoir to a host Malaria, borrelia, plague

are transmitted to be able to respond to a threat, incident, or outbreak in an appropriate way. The most relevant modes of transmission of infectious diseases are listed in Table 12.4.

12.4.1 Infection Control and Personal Protection Knowledge about how to limit the spread of infections is as important as knowledge about transmission routes for different pathogens. Because most pathogens and conditions are unknown in the individual contact situation, some basic rules are important to know and to practice from a general point of view. Steps to be taken to achieve adequate personal protection depend on the outcome of the risk assessment conducted for each specific situation. The appearance of an infectious agent or disease at a certain place or at a certain time can be part of the natural occurrence of the microorganism concerned, but it also can be a consequence of environmental contamination, either accidental or intentional. Each individual has physiological barriers such as skin and mucous membranes that function fairly well, at least as long as the barriers are intact. The barrier effect can be much improved and risks of exposure limited by introducing hygienic routines that are practiced at each level of contact between staff and potentially affected persons, i.e., every patient in a treatment or nursing situation. Basic hygienic routines include disinfection of hands with alcohol-based items before and after each physical contact; the use of disposable gloves when in contact with secretions or for investigations; and the use of disposable aprons and eye and mouth protection when there is a risk of fluid splash.

Fig. 12.3 Medical staff equipped according to basic hygienic routines, including for procedures for handling secretions such as the possibility for splash of secretions (Source: National Board of Health and Welfare, Sweden)

Point disinfection is added for environmental use, e.g., on surfaces once splash has occurred. Figure 12.3 shows medical staff equipped according to these principles. Personal protective equipment (PPE) varies from situation to situation as a consequence of several factors, such as the contagiousness of the suspected

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Fig. 12.4 Personal protective equipment for first responders dealing with hazardous material at an incident site. The equipment is disposable and is commonly used for several emergency services in Sweden (Source: National Board of Health and Welfare, Sweden)

pathogen, its routes of transmission, and the severity of the condition concerned. An increasing level of personal protection can be achieved through adding face masks or respiratory protective gear to the basic hygienic routines stated above and into the full PPE recommended for use when there is, for example, a suspicion of the presence of VHF pathogens, as illustrated in Figs. 12.4 and 12.5. The infectious agents causing VHF can serve well as a model situation when it comes to the use of PPE. The VHF agents can be transmitted by all known modes of transmission and the conditions hold a high fatality rate once transmission has occurred. Decontamination is seldom used environmentally for biological agents, apart from in the medical setting for individual patients and for material and surfaces. The communicable disease most often subject to more extensive decontamination of the environment and

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Fig. 12.5 Personal protective equipment for medical staff dealing with hazardous material in hospital settings, including the procedures for decontamination and initial medical care (Source: National Board of Health and Welfare, Sweden)

contaminated individuals is anthrax. Decontamination of the environment can be difficult, time consuming, extensive, and extremely costly because of the ability of the anthrax bacteria to form extremely viable spores. Each decontamination plan has to be tailored to the unique situation concerned. For anthrax, this has been shown both historically and recently, in spite of the presence of modern techniques, equipment, and resources. In 1942, during the Second World War, the small island of Gruinard off the northwest Scottish coast was the site of a biological warfare test performed by British military scientists (Fig. 12.6). Decontamination attempts on the island after the biological warfare testing were unsuccessful because of the durability of anthrax spores. As a result, Gruinard Island was quarantined for many years afterwards. Visits to the island were strictly prohibited, except by personnel checking the level of contamination. In 1986, a decontamination

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Fig. 12.6 The island of Gruinard, off the northwest coast of Scotland, was used for biological warfare testing by British military scientists in 1942. The island was announced safe after

extensive decontamination 48 years later in 1990 (Source: http:// w w w. d r o o k i t a g a i n . c o . u k / c o p p e r m i n e / d i s p l a y i m a g e . php?pid=2856 Photographer: Donald Whannell)

effort was started using several hundred tons of formaldehyde solution diluted in seawater and sprayed all over the island together with removal of the worst contaminated topsoil around the dispersal site. A flock of sheep was then placed on the island and remained healthy. Not until 1990, after 48 years of quarantine, the island was announced safe for habitation. The spread of Anthrax by mail in the United States after the World Trade Center attack on September 11, 2001, killed five people, closed down a Senate office building, nearly paralyzed the US postal system, and caused national and international panic. The environmental decontamination methods used on this occasion were chlorine gas and other decontaminants. The Senate building could reopen 3 months after the contamination occurred. The investigation of this incident (the “Amerithrax investigation”) was conducted by the Federal Bureau of Investigation (FBI) and lasted for 6 years. It was thereby the largest and most extensive inquest in the history of the FBI. The incident was finally assessed as an intentional criminal activity without connection to any political activities. However, complete resolution was never achieved because the main suspect committed suicide before the investigation could be finalized. Personal protection is more than physiological and biological barriers. Immunity needs to be considered as part of personal protection. Immunity can be congenital or acquired. Acquired immunity can follow natural

exposure with or without obvious disease followed by recovery or can be induced through immunization. Passive or, preferably, active immunization (vaccination) is possible for many infectious diseases. The duration of the protection achieved depends on the type of immunizing agent used and if the response is upheld naturally or if it is boosted through concomitant doses. The possibility of using immunization during an infectious disease outbreak, however, is often limited because of factors such as delay in identification of the microorganism concerned, delay in the development of an immune response in the immunized individual, difficulties in defining a target population for directed immunization, and, in some instances, the cost of the vaccine as well as availability of the vaccine concerned.

12.5

Personal Protection Through Medical Interventions

Immunization is one active way of providing protection on an individual as well as on a population basis. The level of immunity in a defined population that prevents the occurrence of epidemics is known as herd immunity. The herd immunity varies with the transmission rate of the disease concerned. A high transmission rate takes a higher degree of herd immunity to prevent occurrence of an outbreak. For most communicable diseases, the herd immunity lies between 75% and 85%.

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In most circumstances, achievement of immunity through immunization has the drawback that it requires some time to develop. The length of time needed to develop immunity depends on what type of vaccine is used and the number of doses and dose-intervals needed to achieve full protection. The duration of immunity achieved through vaccination also varies correspondingly, depending on the type of vaccine and the number of doses given. Personal protection can in certain instances also be achieved through prophylactic medication. Such prophylaxis can be administered before or after exposure (preexposure and postexposure prophylaxis) and needs to vary in length depending on the organism concerned, its incubation period, and possible ongoing exposure. Prophylactic medication with antimicrobials is seldom justified. Exceptions include exposure to anthrax material; when several cases of meningococcal disease have occurred in a closed population; malaria, and specific situations with HIV exposure. The final measure to stop transmission of a contagion and its course once the disease has developed in an infected individual is treatment.

12.6

Bioterrorism

Biological weapons or agents are relatively easy to produce, but their use must include knowledge of methods of dispersion. Even though an international agreement against the use of biological weapons was achieved by the UN in 1975, several attempts have been made since then to use such weapons. The potential for the use of biological weapons is reduced through several factors, such as difficulties in controlling the extent of the use, including contamination of affected areas and the possibility of negative effects on the user themselves. Intentionally caused biological incidents can and have occurred both during warfare and as part of separate terrorist actions. The level of public health preparedness needed for possible bioterrorist incidents is not static but varies with several factors. The necessary preparedness depends on the continuous evaluation of threats and their changes over time. The suspicion of an intentionally caused incident is more common than the actual intentional use of biological agents. The level of suspicion depends on the evaluation of threats as well as how the threats are perceived.

To face biological threats, public health preparedness must include plans that are adaptable to change in threats overtime as well as practical issues. Practical issues that need to be included are to what extent protective equipment, vaccine, and antimicrobials are needed as well as their storage. To what extent materials need to be decentralized depends on type of threats and the assessment of such threats. Facilities for isolation and the capacity to increase such facilities depending on possible scenarios also need to be included in such planning. The use of biological agents, and even just the threat of their use, has been shown to cause immense psychological effects. Preparedness thus needs to include detailed strategies for how information is to be handled and disseminated and how to deal with the possible psychological effects of these threats. Several organizations have produced lists of possible biological agents. The most critical agents for public health preparedness are those that are supposed to have the highest overall public impact; these are listed in Table 12.5.

12.6.1 When to Suspect an Intentionally Caused Incident? An intentionally caused incident can be suspected when either the number of cases or crude mortality show a rapid increase, the cases have an unusual presentation only in numbers or in clinical symptoms, or a different attack rate can be observed, i.e., indoors or at another distinct location. An unusual presentation of a known disease or contagion that show an unusual pattern of sensitivity and solitary cases of a condition with high potential for use as bioterror agent are other situations that should increase the suspicion of having an intentional cause. The importance of a broad surveillance system covering both known and unknown conditions is crucial to enable an early alert and the possibility of responding to what is unexpected but suspected. During the last four decades, the emergence of new diseases has given us approximately 40 new infectious diseases. Such rapid development provides both good and strong reasons to keep and continuously develop an “open-minded” surveillance system for infectious diseases. The expression “expect the unexpected” applies more to infectious disease preparedness than any other area within disaster medicine.

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Table 12.5 Biological agents with high potential for use in bioterrorism Biological agent Bacillus anthracis

Comment Three clinical forms depending on mode of transmission: cutaneous, gastrointestinal, or pulmonary; little risk of secondary transmission Variola Smallpox Extinct viral disease, but the agent is present in laboratories Plague Three clinical forms depending on mode of transmission: Bubonic, septic, or Yersinia pestis pulmonary; high risk of secondary transmission Tularemia Disease with low infectious dose; several clinical forms depending on mode of Francisella tularensis transmission: ulcero/oculoglandular, oropharyngeal, pneumonic, or septic Botulism Spore-forming bacteria producing heat labile potent neurotoxin with a short Clostridium botulinum incubation time; transmission mainly via aerosol or ingestion; no secondary transmission; antitoxin is available for treatment Arenavirus (Lassa virus); Viral Serious, highly contagious diseases caused by several groups of viruses with Filovirus (Ebola, Marburg); hemorrhagic limited geographical spread; little specific treatment and high mortality; Bunyavirus (Congo-Crim HF), fever transmission can occur via all known modes for most groups etc.

12.7

Disease Anthrax

Conclusions

Infectious diseases are unique in many ways when causing major incidents. Microorganisms are part of our daily life, and they can cause severe disease as well as large outbreaks and epidemics. Below are listed examples summarizing how infectious disease and microbiological threats are unique. • The onset of an infectious disease incident is usually gradual but can rapidly increase and even reach logarithmic proportions. • The base of the detection of infectious disease incidents are well-developed and functioning surveillance and response systems. Such systems also need to include mechanisms to detect emerging infections. • There is often a delay between the incident itself and its detection. Once an incident is detected, most traces of it source are usually gone, and the base of its detection is mainly through indirect epidemiological evidence. • There are several ways to protect target populations and to stop an ongoing outbreak. • The strongest medical threats at present are not bioterror activities; instead they are an increase in resistance to antimicrobials – infections are becoming more and more untreatable.

Further Reading CDC (2011) Emerging infectious diseases. Available at: http:// www.cdc.gov/eid ECDC (2011) Eurosurveillance. Available at: http://www.eurosurveillance.org/ Fong A, Alibek K (2005) Bioterrorism and infectious agents: a new dilemma for the 21st century. Springer Science and Business Media Inc., New York Giesecke J (2001) Modern infectious disease epidemiology, 2nd edn. Arnold, London Heymann D (ed) (2008) Control of communicable diseases manual, 19th edn. American Public Health Association, Washington, DC International Society for Infectious Diseases: ProMED mail. http://www.promedmail.oracle/ Menne B, Ebi KL (eds) (2006) Climate change and adaptation strategies for human health. Springer, Darmstadt Meselson M, Guillemin J, Hugh-Jones M, Langmuir A, Popova I, Shelokov A, Yampolskaya O (1994) The Sverdlovsk anthrax outbreak of 1979. Science 266(5188):1202–1208 National Research Council (US). Committee on Standards and Policies for Decontaminating Public Facilities Affected by Exposure to Harmful Biological Agents: How clean is safe? (2005) Reopening public facilities after a biological attack: a decision-making framework. Board on Life Sciences, Washington, DC Physicians for Human Rights (2009) Health in ruins: PHR reports on the man-made health crisis in Zimbabwe. Physicians for Human Rights, Cambridge Swiderski R (2004) Anthrax: a history. McFarland and Co, Inc, Jefferson World Health Organization (2011) Global alert and response (GOAR) – Disease outbreak news. Available at: http://www. who.int/csr/don/en/

Incidents Caused by Changes in Nature and Climate

13

Louis Riddez and Johan von Schreeb

13.1

Introduction

A “natural disaster” has been defined as a serious disruption triggered by a natural hazard causing human, material, economic, or environmental losses, which exceed the ability of those affected to cope (the United Nations Development Programme). Such incidents may have a sudden onset, for example, during an earthquake, flood, or typhoon, but they may also take a slower course, for example, during a drought, a hunger crisis, or an epidemic. There are many different systems used to classify natural disasters, and the one we believe to be the most appropriate is presented in Chap. 2. The Centre for Research on the Epidemiology of Disasters (CRED) has been systematically documenting the world’s natural disasters since 1973. CRED uses a definition for natural disaster similar to the one presented above, but to be included CRED’s database at least one of the following criteria must be fulfilled. • Ten or more people reported killed • One hundred or more people reported affected • Declaration of a state of emergency • A call for international assistance

13.2

Epidemiology of Natural Disasters

Data indicates that since 1987 there has been an increase in the number of natural disasters throughout the world. Between 1996 and 2006, the number of natural disasters has more than doubled (Fig. 13.1).

L. Riddez • J. von Schreeb e-mail: [email protected]; [email protected]

This increase can be partially explained by improved reporting procedures, but also by a marked increase in the number of meteorological natural disasters (Fig. 13.2). This includes floods, landslides, high wind speeds, extreme temperatures, and wildfires. In 2007 alone, in 133 countries there were 414 natural disasters, which together affected 211 million people and killed almost 17,000 people. Flooding represented more than half the number of natural disasters. In Chap. 2 there are further examples of different types of disasters caused by the climate and environment.

13.3

The Short- and Long-Term Consequences of Natural Disasters

Climate change increases the risk of meteorological disasters. At the same time, the population growth in urban slums increases the risk of people being affected by these events and aggravates the consequences of such disasters. In these risky environments, it is the poorest segment of the population that runs the greatest risk of being affected. The increase in the number of meteorological natural disasters during recent years consequently has led to more people being affected. It has, to a certain extent, been possible to limit the damage through improved warning systems, shelter, and emergency preparedness plans (Fig. 13.3). Because natural disasters encompass a range of events that differ both in the nature and degree of severity and that affect vastly different social structures, the effects will also be different. In high-income and certain medium-income countries, the effects of a natural disaster often can be mitigated and handled because the infrastructure is adapted to cope with

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natural hazards, although the economic consequences can be serious. Moreover, in this context, national emergency plans including capacities for rescue services and health care resources exist. Even when a state of emergency is declared (“a situation in which there is a lack of control and that requires urgent

action”), it is often short-lived. The effects of the disaster can be dealt with and normal structural/civic functions can resume quickly. This is especially true when a disaster develops over a couple of days and there is time to prepare, for example, during flooding, but it might also apply to more extensive disasters that

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Fig. 13.3 The increase in the number of meteorological natural disasters in recent years has consequently led to more people being affected (Source: Centre for Research on the Epidemiology of Disasters)

have a rapid onset. For instance, during the earthquake in Bam in Iran on December 26, 2003, regional and local action quickly organized mass evacuation of the injured by road and air to other cities in Iran. The international emergency relief that was provided later had only marginal effects. In low-income countries and many medium-income countries, resources are limited. Geographical factors and lack of access may complicate relief efforts and entail more long-term effects. This was the case during the earthquake in Kashmir in 2005, which is estimated to have affected three million people. The affected area was large, equivalent to two-thirds the size of Switzerland, and was mainly inaccessible.

13.4

Vulnerability and the Ability to Recover Varies Between Communities

Both vulnerability and the ability to recover after a natural disaster vary depending on the socioeconomic level of the area. Moreover, the consequences of a disaster are dependent on the type of natural disaster, the size of the population in the area, the number of people affected, the geography of the area, and the amount and type of assistance provided by other sources.

One important aspect when it comes to recovery is the national, local, and individual ability to cope with the effects of the disaster. This ability often is underestimated, primarily in those countries that are regularly hit by natural disasters, such as Bangladesh, where regular flooding has forced the population to develop coping mechanisms. Based on previous experience the population knows what they need to do to survive. The government has systematically introduced warning systems. Through loudspeakers the at-risk population is informed about approaching tropical storms. High concrete platforms have been constructed in lowland areas to give the population shelter. This has reduced mortality from flooding. In 1971, more than 300,000 people were killed in a tropical cyclone. In 1990, the figure was 142,000, whereas only 4,000 people were killed in the cyclonic storm Sidr in November 2007 because almost 200,000 people has been evacuated to emergency shelters before Sidr hit. This new development means that the impact of a tropical storm now is more related to inducing poverty. The people survive but they lose their livelihoods because of the destruction of livestock and arable land. The top priority in the aftermath of a natural disaster in countries with wellfunctioning disaster preparedness is to define strategies to help people rebuild houses and fight poverty. There are several examples of it taking many years to recover from a natural disaster. Studies following

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Hurricane Mitch in 1998 showed that there were longterm effects on society for close to 10 years after the storm. In Bam and Kashmir, the natural disasters created deep wounds, and controversies arose over land ownership that took years to solve.

13.5

Seismic Natural Disasters

Seismic natural disasters include earthquakes, tsunamis, and erupting volcanoes.

13.5.1 Earthquakes Earthquakes are caused by faults in the Earth’s crust and are a common occurrence in certain countries. A seismic map of the world shows that there are two large regions over which 90% of all earthquakes occur. One of these regions, known as the Pacific Ring of Fire, circles the entire Pacific Ocean (not including Antarctica) and includes the Indonesian archipelago. The second region stretches from the Canary Islands to the Mediterranean Sea, North Africa, the Middle East, Northern Pakistan and India, the Himalayas, Tibet, and large parts of China. Despite enhanced knowledge of the occurrence and geography of earthquakes, there are no warning systems today that are able to sense when an earthquake is going to occur. Thus earthquakes occur without warning, which is why there generally is not enough time to evacuate people or get them to safety. The strength of the earthquake is measured using the Richter scale, and the strength and epicenter of an earthquake have a decisive impact on the amount of material and human damage it causes. In addition, the way buildings are constructed and a city’s architecture have an enormous impact on the amount of damage caused by an earthquake. Thus, in regions badly affected by earthquakes, people have started to build according to new building standards; materials and the reinforcement of walls and roofs mean that the buildings are better able to withstand side movements and thus more powerful earthquakes. This was noted after the earthquake in Kobe, Japan, on January 17, 1995, where the earthquake measured 7.2 on the Richter scale and where buildings that had been constructed according to 1981 building standards were not as badly damaged as other

buildings. In this highly populated area, however, 10,000 buildings were damaged by the earthquake as well as by the fires during the aftermath of the quake. The number of people affected was huge – more than 300,000 were left homeless, almost 35,000 were injured, and more than 5,000 were killed. This can be compared to the 2003 earthquake in Bam in Iran, which measured 6.5 on the Richter scale and extensively damaged older buildings, leading to 26,000 lost lives and a large part of the population left homeless. The situation was similar in Kashmir, where the earthquake caused extensive damage to homes and people over large and inaccessible areas. The main problem in this case was that rescue operations had major difficulties reaching the affected population. On May 12, 2008, the Sichuan Province in central China was hit by an earthquake that measured 7.8 on the Richter scale. Geographically, the region hit measured the size of France and more than five million people were left homeless. Despite the more than 100,000 military personnel and volunteers who were brought into action immediately, it was not possible to reach everyone who needed help. Just as with other earthquakes, it proved difficult to help those buried under the rubble in time. After 3 days the chances of finding survivors under the rubble are small, and during the following days only few people are rescued. It has proved to be difficult to get foreign rescue workers to a region in time. It is difficult to evaluate the extent to which foreign search and rescue teams, with, for example, specially trained dogs used to look for survivors, might have helped in this particular instance, but as a rule the outcome of this type of rescue operation is disheartening. On January 12, 2010, Port au Prince, the capital of Haiti, was struck by a strong earthquake (7.0 on the Richter scale). The effects of this earthquake were defined by the context, which was different thank that of previous earthquakes. It affected a low-income country with weak governance and limited infrastructure. The most affected areas were densely populated. The death toll is estimated to be more than 200,000 people. The number of injured who required immediate medical/surgical care was considerable, and the already failed health system could not cope with the needs. International assistance was needed. Aid started to arrive quickly despite logistic challenges; for example, the airport was small and damaged and roads were destroyed. At least 50 foreign field hospitals arrived

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Fig. 13.4 Choscal hospital in Port-au-Prince, Haiti, supported by Médecins sans Frontières (Photo: L. Riddez)

during the first 2 weeks. Support was provided to local health structures early on by nongovernmental organizations to start up activities (Fig. 13.4). The United Nations (UN) cluster system was launched to coordinate the activities. The health cluster coordinated 314 health agencies during 1 month. There will be need for long-term medical and surgical support during the years ahead.

already existed in the Pacific, but which at that time did not exist in the Indian Ocean, would probably not have saved the lives of the people of Aceh Province. However, this type of warning system would have meant that many people would have left other coastal regions to seek shelter and could have avoided the tidal waves.

13.6

Meteorological Natural Disasters

13.5.2 Tidal Waves (Tsunamis) 13.6.1 High Wind Speeds The 2004 tsunami in the Indian Ocean is one of the more devastating in recent times. The huge waves were caused by an earthquake that measured over 9.0 on the Richter scale, the epicenter of which was on the ocean bed off the west coast of Sumatra. The waves hit coastal regions tens of thousands of miles apart. Altogether, several million people were left homeless and more than 230,000 people were killed. The coastal region hit worst was in the province of Aceh on the island of Sumatra, which lies in Indonesia (Fig. 13.5). There, the earthquake itself caused a great deal of damage, first to buildings, many of which were subsequently destroyed when the coast was hit by the waves about 15 min later. The biggest of these waves was 20 m high. The warning system that

Storms, hurricanes, cyclones, and typhoons have different types of high wind speeds that hit large populations around the world every year. During the year 2006, for example, these types of violent storms with high wind speeds caused five of the top ten natural disasters measured in the number of people affected (Table 13.1). As Table 13.1 indicates, during that particular year China was worst hit. Europeans were given little information about this, which was probably partly because of the difficulty of getting information from China; however, to a large extent it was because of the dependency of Europe and the USA on what the media believes is of interest.

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Fig. 13.5 Banda Aceh after the tsunami in 2004 (Photo: L. Riddez)

Table 13.1 The top 10 natural disasters of 2006 in the number of people affected Type of natural disaster 1. High wind speeds (Typhoon Bilis) 2. Drought 3. High wind speeds (Typhoon Prapiroon) 4. High wind speeds (Cyclone Kaemi) 5. High wind speeds (Typhoon Saomai) 6. Drought 7. Floods 8. Floods 9. Floods 10. High wind speeds (Typhoon Milenyo)

Country China

Number affected 29,622,820

China China

18,000,000 10,000,089

China

6,531,109

China

5,921,791

Malawi China China India The Philippines

5,100,000 4,600,045 4,120,030 4,000,415 3,842,634

Source: Centre for Research on the Epidemiology of Disasters

In contrast, it was easier to follow the effects of the extremely powerful Hurricane Katrina that hit the southern parts of the USA at the end of August 2005. Hurricane Katrina formed as tropical depression 12 in that hurricane season and built up out at sea on August 24, becoming increasing powerful over the days that followed and reaching an average wind speed of more than 250 km/h (a storm is classified as a hurricane at half this wind speed). When the center of the hurricane, or the “eye,”

reached the mainland just east of New Orleans, Louisiana, on the afternoon of August 29, it caused a tidal wave that broke the levee system and led to extensive flooding. The coastal areas of Mississippi and Alabama were hit by widespread material damage because along with the gales there was a great deal of rainfall. Despite the warning system and evacuation of large populations, more than 1,830 people lost their lives and approximately one million were left homeless. After the event the material damage was assessed at more than $100 billion and highlighted how the worst type of hurricane can create havoc and destruction even in a highly technological country like the USA. The major difficulties encountered both during the early rescue operations and later in the subsequent reconstruction work have revealed how, in the aftermath of a disaster, deep wounds, delays in reconstruction, and both social and political conflicts may arise even in a high-income country. On May 2, 2008, the cyclone Nargis came in over the Burmese coast and left in its wake floods and destroyed buildings, homes, networks of roads, and farmland in most of the country. More than 130,000 people lost their lives and 18 days after the disaster the fatalities were expected to continue to rise because the country’s leadership had not started any worthwhile relief operations. Moreover, initially, little international emergency relief was allowed into the country despite that the international community repeatedly urged the country to accept help.

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13.6.2 Floods Floods are the most common natural disaster in the world. The health effects of floods vary depending on the context, type, location, and intensity of flooding. Floods may arise in conjunction with a cyclone, as occurred after Hurricane Katrina in 2005 or Cyclone Nargis. However, the most common type of flooding is that caused by heavy rainfall. This was the case in Pakistan during July–August 2010, where more than 20% of the country was flooded and approximately 14 million people were affected. The need for safe water, sanitation, food, and shelter were raised but the workers helping faced large logistical difficulties when trying to reach the people affected. Health intervention in these situations should be focused on preventive rather than curative activities. The risk of epidemics increases when displaced people are gathered without proper living conditions. In richer parts of the world, damage caused by the water can be limited to mainly material damage. This was the case during the floods in Poland in 1997, in Sweden in 2000, and in the Czech Republic and eastern Germany in 2002.

13.6.3 Extreme Temperature Conditions Extreme temperature conditions include both cold and heat. However, extreme cold does not generally lead to a disaster according to the accepted definition, even if vulnerable people in every country of the world die from cold exposure each year. Extreme heat, on the other hand, may cause drought, lost harvests, and indirectly a lack of food and hunger. This type of natural disaster is in general complex because it usually affects countries that have been affected by dry periods for a long time and which for that reason also suffer from domestic conflicts and wars over water assets. Emergency relief for this particular type of disaster differs enormously from other emergency medical assistance because it: • Has to be provided for long periods of time • Is often provided in conflict conditions • Is difficult to provide without affecting the infrastructure of the country Extreme temperatures may also cause another form of heat disaster like the one in Europe in August 2003. The heat wave that affected France and all neighboring countries in southern Europe caused the deaths of

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approximately 35,000 people. It also had a negative impact on agriculture, leading to smaller harvests. In France alone, 14,802 people died because of temperatures higher than 40°C that lasted for more than a week. Weaknesses in the health care system, particularly during the holiday period, became apparent. Above all, people for the first time became aware of how important it is to take care of the elderly and the weak in this type of situation. Other countries like Great Britain, Italy, and Germany were affected and between 2,000 and 7,000 people – mainly the elderly – died as a result of the high temperatures.

13.7

Natural Disasters Indirectly Caused by Environmental Impact

The border between what is directly caused by the force of nature and indirectly caused by environmental impact is often unclear. This applies to some of the natural disasters described above, but it primarily applies to drought, desertification, earth erosion, landslides, wildfire, and health-related epidemics. These different types of natural disasters are often complex, vary in severity, have enormous differences in the devastation caused, and develop at different rates. Their common denominator is that, in all probability, they could have been avoided – or at least their extent could have been limited – if the environmental impact had not been so great. This applies, for example, to landslides, which often occur in overpopulated areas where agriculture or buildings on slopes combined with heavy rainfall or other weather changes may contribute to a landslide. They also occur along coasts and may in certain cases also cause tsunamis. Between 800 and 1,000 people have died in landslides every year during the last 20 years.

13.8

National and International Disaster Medicine

The most important dimension of disaster medicine is disaster preparedness, which involves the planning of the swift reallocation of resources after a disaster event. It requires regular exercises involving large parts of the health service system. The group of professionals involved in disaster medicine goes beyond the emergency room doctors, surgeons, and anesthesiologists. It includes fire fighters, ambulance drivers,

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administrators, and logistics and transport officers, as well as professionals who care for psychological, social, and spiritual needs. In lower- and low middleincome countries there is less capacity for governmental agencies to be prepared for a disaster even though disasters occur more often. In low-income countries in particular, the resources to adequately and sufficiently provide relief during a disaster may be insufficient or even nonexistent. Sufficiently sized countries are able to handle local disasters using national resources in spite of a relatively low gross national income/capita. The massive impact of the 2005 earthquake in Kashmir, however, made the Pakistani government request international assistance, although a considerable amount of national resources, both military and civilian, had first been made available for the relief work. Bangladesh, a low-income country, has managed to systematically bring down casualties after typhoons and flooding through consistent disaster preparedness. Warning and alert systems have been established in coastal areas and high concrete platforms have been erected on which people can seek protection when the water rises. Middle-income countries that are regularly confronted by natural disasters, such as Indonesia, the Philippines, and Iran, have considerable experience with both disaster preparedness and response. Disasters are to a large extent managed by domestic relief capacities.

13.9

Needs Assessment

A needs assessment (NA) is a broad term that refers to the systematic collection of information that describes the severity of a disaster and the human needs that require immediate action. Ideally it is based on surveys that use qualitative and quantitative methods. In reality, an NA done during the first weeks are “quick and dirty” and include rough estimates based mostly on observations. To plan assistance there is a need for information. The outcome of a disaster will be determined by a combination of factors that are interlinked and include the context before the disaster, the direct disaster effect and size of population affected, as well as the type and quantity of assistance provided. The context includes information about pre-existing vulnerabilities and capacities. A main determinant is the socioeconomic status of the affected country. The likelihood that a disaster will develop in a low-income country is

Textbox 13.1 Form for initial remote needs assumption Assessment of the disaster: Time: Place: Reporters: Report nr: Summary of the situation, scenario, and possible action as well as dependability of information and analysis: Type of disaster: Context (political, financial, geographical, health, and economic background): The number of people in the area; the number of people affected/injured/missing/dead: Current resources (number of hospitals with intensive care facilities, other resources and capabilities): Appreciation of the type and quantity of vital needs and their prioritization (water and sanitation, food, roof over heads, health and medical care, security): If there is a need for medical care, state type of needs and how they will vary over time: How might any needs be satisfied and by whom? (Locally? Nationally? Regionally? Internationally?): Has the disaster-afflicted country requested assistance? What type of assistance? Are there other players in the area? What type of assistance might they provide? Scenario (threats, risks, and time aspect): Legal, logistical, linguistic, cultural, and transportation aspects of a possible operation: Proposals regarding action required/or not and, if so, type, quantity, and length: When should the next needs assessment be carried out? Is a more detailed needs assessment required on site? Sources of information used:

significantly higher than in middle- and high-income countries. As with child survival, there is an almost linear relationship between disaster vulnerability and the community’s socioeconomic status: higher risk in poor settings. It also is important to document the burden of disease before the disaster and the capacities of the health system in the affected area. This type of analysis has been coined “remote magnitude assumption.” Such rapid analysis can be done in a few hours and, beside defining the context, should also estimate the extent of disaster and the number of affected (Textboxes 13.1 and 13.2). The results are analysed based on the mandate and capacities of the implementing agency to help guide the type and quantity of potential relief. It also is important to note that different disasters create different types of health needs. The Pan American Health Organization has compiled

13 Incidents Caused by Changes in Nature and Climate Textbox 13.2 Web sources of information for initial remote needs assumption internet ReliefWeb World Health Organization AlertNet Google British Broadcasting Company Google Blog search

http://www.reliefweb.int http://www.who.int http://www.alertnet.org http://www.google.com http://www.bbc.com http://blogsearch.google.com

experience from different types of natural disaster (Table 13.2). Before a decision is made with regard to whether assistance shall be provided or not, a number of other considerations must be taken into account; for instance, the mandate of humanitarian organizations, the current security situation, whether or not there are resources available for the operations, how quickly assistance can be provided, and the extent to which other players will provide assistance. A more systematic and detailed NA should be carried out on site within the first few days to help direct the operational strategy of the assistance and to improve the target of the assistance to better adapt the operations to the current situation and the most urgent needs of those affected by the disaster. NAs on site should be combined with information gained from remote sensing, using satellite images and computer programs to analyse the devastation and possible evacuation of people. The NA should be seen as the first step in the retrieval of information that must be regularly repeated to follow the development of the situation. As the situation gradually stabilizes, the assessment is replaced with regular monitoring through the collection and analysis of data from, for instance, health care facilities. There are a number of initiatives to increase the use of NAs and to make such information readily available via the Internet by, for example, entering the information into Google Earth. One of the tasks of the World Health Organization is to ensure that NA data is available. Below we provide a summary of adequate medical assistance after natural disasters in resource-scarce environments. The summary does not include assistance in complex chronic disasters that have a gradual onset and include complex factors besides the disaster. It requires an in-depth knowledge and experience, for example, how to prevent a hunger crisis from developing. Studies have shown that the direct cause of hunger

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is rarely the lack of food. Instead it is usually other complex problems that lie behind it. Combating hunger and malnutrition cannot be resolved by only sending food – a more long-term strategy is required. Assistance provided in conjunction with that type of chronic disaster could therefore be regarded as lying outside the area of direct disaster medicine.

13.10 Local and National Relief Operations The most important initial assistance after a disaster is provided by the local population and local rescue services. They will save lives and rescue people during the first few minutes, hours, and days before any form of outside assistance arrives. With growing wealth, the risk of disasters decreases while the ability of the state to organize rescue services and provide relief increases. When disaster events occur in high- and upper-middle-income countries, sufficient assistance in most cases will be provided by the local and national rescue services and, if necessary, by complementary actions implemented by the national military, police, and health service as well as national voluntary rescue services. In high-income countries and upper-middle-income countries the discipline of disaster medicine is well developed despite low disaster risks. The focus of disaster medicine in resourcerich contexts is on site care, predisaster planning, and the rapid transportation of those injured to hospitals. After typhoons and floods a similar situation arises: rescue services must be provided immediately by those already in the area to be able to save those who are most injured. Therefore, support of national rescue services is of the utmost importance. However, international health and medical assistance is required for the needs that dominate after a few days, when the ordinary health and medical structures have either been destroyed or are overstretched by all the people who require medical care.

13.11 International Humanitarian Relief International humanitarian assistance is based on the humanitarian imperative, an unselfish and ethical obligation to assist people in need with the aim of protecting lives and alleviating suffering. The term is

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Table 13.2 Likely effects of various natural hazards Effect Loss of lives Severe injuries requiring complex treatment Major risk of communicable diseases Damage to health facilities Damage to water supply systems Food scarcity Large migrations

Earthquakes High High

Strong winds Low Moderate

Tsunamis and flash floods High Low

Ordinary floods Low Low

Volcanic Landslides and lava activity High High Low Low

Potential risk after all significant phenomena (likelihood increases with crowding and the degradation of sanitary conditions) Severe Severe Severe but Severe Severe but (structure localized (equipment only) localized and equipment) Severe Light Severe Light Severe but localized Infrequent (generally caused by Common Common Infrequent economic or logistical factors) Infrequent (common in severely Common (generally limited) affected urban areas)

Severe (structure and equipment) Severe Infrequent

Source: Pan American Health Organization (2002)

widely used but rarely defined. It refers to the provision of resources and/or expertise to save lives and relieve human suffering in populations that have been overwhelmed by a disaster. Humanitarian health assistance is one part of this and involves public health interventions aimed at preventive services and more curative, health facility–based medical and surgical services. International humanitarian assistance has developed from largely charity-driven aid activities to a profession employing and engaging thousands of trained people in hundreds of organizations with a multitude of mandates. Funding for humanitarian assistance has increased significantly during the last 20 years. The architecture of international humanitarian assistance will vary from disaster to disaster. The main actors involved in providing assistance are the UN organizations with a humanitarian mandate. Those that are active after natural disasters in resource-scarce environments include the World Health Organization, The United Nations Children’s Fund, the World Food Program, United Nations High Commissioner for Refugees, and the Organization for the Coordination of Humanitarian Assistance. A large proportion of international humanitarian assistance is delivered by a group of international organizations referred to as nongovernmental Organizations (NGOs). A key aspect that separates the different actors is their different mandates. While the UN and the Red Cross/Crescent organizations have a legally defined mandate, the NGOs define their own mandates. The

number of NGOs active in humanitarian disasters has increased substantially during the last 20 years. After the 2004 tsunami in the Indian Ocean, more than 300 international NGOs were active in Aceh Province. In Haiti after the 2010 earthquake, more than 400 relief agencies, mainly NGOs, were recorded. Government agencies, including the military in high- and middleincome countries, are becoming increasingly active in the delivery of assistance during disasters. The multitude of actors and their different mandates makes it difficult to regulate and coordinate assistance. During the last 5 years, significant work has been put into ensuring efforts to try to better coordinate assistance. However, the lack of a legal framework to regulate and control humanitarian assistance remains a critical problem that needs to be resolved to improve coordination. After the earthquake in Bam, Iran, in 2003, it was neighbors and the local Red Cross groups (the Iranian Red Crescent Society) that saved the lives of thousands of people; the 34 rescue teams sent to the area from 27 countries only managed to rescue 22 people. After the 2010 earthquake in Haiti, the largest-ever search and rescue team was deployed. A total of 211 people were rescued by 53 foreign teams. These poor outcomes are the result of the international rescue teams taking far too long to arrive. Experience from many earthquakes has shown that after 3 days only a few people can be saved from the rubble, and it is rare that international assistance is provided within that time.

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13.12 Vital Relief Needs Human survival depends on the availability of the five main groups of health determinants: (1) water and sanitation, (2) food, (3) shelter, (4) health care, and (5) protection/security. The operational focus of humanitarian assistance is to ensure that the affected population has access to all of these vital needs. In environments with limited resources, disaster medicine operations must take a broader responsibility and be more focused on public health than on individual curative care. To reduce mortality, it is often necessary to prioritize preventative health measures, for example, ensuring access to water or over-operating on injured people. Preferably, these different types of measures should go hand-in-hand and be integrated. Médecins sans Frontières, which is an organization with a great deal of experience in disaster medicine, has developed a list of the ten most important activities in the aftermath of an event that has forced people to leave their homes and end up in a refugee camp (Textbox 13.3). Apart from ensuring that the most important vital health care functions are re-established, it is also important to quickly establish a system of medical care facilities geared toward both preventative and curative measures. Health and medical care operations should be geared toward providing care for the injuries caused by the disaster and preventative measures against the diseases that risk occurring because of the situation at hand. Systems to collect data and monitor the situation must be put in place quickly. Within a few weeks, the most important medical care needs will be dominated by the normal burden of disease. In a low-income country, this will include infectious diseases, malnutrition, and problems arising during childbirth. The main surgical need will be Caesarean section. Measles is one of the most serious and common diseases in a refugee camp in low-income countries. If children are not vaccinated, they will quickly become infected. If those infected suffer from malnutrition, there is a risk that they will die from complications of measles. There are several studies from refugee camp settings that have documented a 30% case-fatality rate with measles and complications of this disease. It is therefore important to introduce preventative measures like vaccinations as quickly as possible. The most common diseases are often easily treated, such as pneumonia, diarrhea, and malaria. However, these

315 Textbox 13.3 The top ten most important activities when people are assembled in a refugee camp 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Needs assessment Mass immunization against measles Water and sanitation Food adapted to needs Roof over heads, planning, and building Curative basic medical care focusing on diarrhea, respiratory infections, and malaria Keeping infectious diseases and epidemics in check Monitoring and collecting health data Managing staff – management and training Coordination work

Source: Médecins sans Frontières (1997)

diseases may increase in number and become more serious because of the difficult circumstances. Cholera and other spectacular epidemic diseases are rarely a major problem if the preventative measures with regard to water supply and sanitation are implemented adequately. Despite regular media alerts regarding outbreaks of epidemics after flooding, there have been no documented large-scale epidemics recorded after flooding. The massive 2010 earthquake in Pakistan created large-scale suffering, but no major epidemics were recorded. Thus, it is important to note that the risk of epidemics does not increase significantly until people have been forced together in a camp that lacks safe water and latrines. When people are forced to live in a crowded space with a lack of safe water and sanitation there is risk of epidemic outbreak. Surveillance of communicable diseases must be established quickly to prevent such outbreaks. Risks for cholera and other epidemic diseases should be taken seriously and special systems to handle outbreaks of such epidemics must be established. A main factor is to limit displacement and avoid crowding. There is no risk that dead bodies will spread disease, even if such rumors often circulate after a disaster. In other words, what is required is solid experience and knowledge of disaster medicine that is adapted to the situation to be able to maximize the use of resources. When a natural disaster leaves devastation and seriously damaged medical care structures in its wake, it is possible to prioritize the purely medical and surgical operations. This applied to the situation in the Aceh Province in Indonesia after the tsunami in 2004. However, the problem with erecting international field hospitals is that it takes time and

316 Fig. 13.6 A conceptual model describing hospital needs after a sudden-onset disaster (SOD Sudden Onset Disaster)

L. Riddez and J. von Schreeb

Hospital resources (need/use)

1 1. Direct SOD caused trauma 2. Trauma complication 3. Indirect caused infectious diseases 4. Accumulated elective care needs

3

2 Non-trauma Emergency 4 Trauma

Elective

Days after SOD SOD event

is costly. A recently published study of four major natural disasters came to the conclusion that it took more than 3 days for an international field hospital to be erected. None of the 43 field hospitals sent to the different areas were up and running in time to save the lives of those who were seriously injured. Nevertheless, some of the field hospitals did play an important role when it came to treating those less seriously injured and especially the treatment of the dominant everyday diseases. The 2010 earthquake in Haiti was massive and affected the densely populated capital of a country with limited resources and political instability. An estimated three million people were directly affected and more than 200,000 people died. International response was massive and the initial focus was trauma surgery. An estimated 30–40 foreign field hospitals were deployed. There is limited information available about their activities but it is clear that the first 2 weeks were totally dominated by surgical care for trauma patients. A conceptual model that describes hospital needs after such a sudden-onset disaster is presented in Fig. 13.6. Soon after the earthquake normal urgent medical problems such as complicated deliveries

requiring Caesarean section, children with pneumonia, traffic accidents, as well as injuries caused by violence were mixed with the injuries caused by the disaster. Therefore, it is essential that a foreign field hospital be multidisciplinary and offer professional capacities to cover all different types of health care. Anyone who is interested in working with international emergency relief operations must be well prepared. Today almost all medical universities provide courses in global health, a recently developed field that covers how the burden of disease varies globally and how to effectively prevent and treat diseases in different contexts. In addition to disaster medicine skills, these courses teach the understanding of and respect for other cultures, how to work with a team, etc. There are a number of training courses today that are focused mainly on the practical nature of the work. These courses also include training on how to quickly build latrines, how to organize mass vaccination against measles, how to erect and run a medical center, and how to set up different types of medical care facilities. Table 13.3 lists the main humanitarian NGOs that recruit staff for missions during disasters.

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Table 13.3 The main humanitarian nongovernmental agencies Agency name Medical Emergency Relief International (MERLIN) Médecins Sans Frontières (MSF; Doctors Without Borders) Médecins du Monde (MDM; Doctors of the World) International Committee of the Red Cross (ICRC) International Federation of Red Cross and Red Crescent Societies (IFRC) Oxfam The International Rescue Committee Action Against Hunger (ACF International)

Relief focus Medical assistance during protracted disasters Medical assistance Medical assistance Assistance to victims of armed conflict Humanitarian assistance Water and sanitation Humanitarian assistance Food and nutrition

13.13 The Earthquake and Tsunami in Japan, March 11, 2011 On March 11, 2011, an earthquake and tsunami struck Japan. At the time of writing the effect of this incident is not yet fully known, but it seems clear that the magnitude and effects of it have historical proportions. Although we have limited information we can, based on experience from other sudden-onset disasters, make some comments that also summarize the content of this chapter. The outcome of a disaster is defined not only by the type and intensity, but also the socioeconomic context before the disaster as well as the capacities to respond after the disaster. The March 11 disaster involved not only an earthquake that measured 9.0 on the Richter scale, but a devastating tsunami and threats of nuclear power plant meltdown. This adds complexity. A key component of this disaster is the context that it affected a high-income country. Japan has the world’s third largest economy, with more than 127 million inhabitants and a 250,000 medical doctors. Not only is it a rich country with a functional and decisive government, but it has a population that has been trained in how to protect itself in case of an earthquake, which reduces vulnerability. A key characteristic of the Japanese population is that 28% is older than 60 years of age, whereas the corresponding figure for Haiti was 6%. This is important to know when planning medical relief because chronic diseases will constitute a significant part of the burden of disease in combination with trauma. A tsunami affects coastal, low-level areas and is characterized by quite clear demarcation between affected and unaffected areas. At the time of this writing more than 4 months have passed since the tsunami struck the coast, data about how many people have been affected are scarce and every day the number of

Web address http://www.merlin.org.uk http://www.msf.org http://www.mdm-international.org/ http://www.icrc.org/ http://www.ifrc.org/ http://www.oxfam.org.uk http://www.theirc.org/ http://www.actionagainsthunger.org/

reported dead is increasing, which is similar to what was seen in Aceh Province in 2004 after the South Asian tsunami. In contrast, in Haiti in 2010, mortality estimates were already quite accurate 3 days after the earthquake. Despite the presence of new technologies it seems to be harder to estimate the magnitude of this type of disaster. The complexity of the Japanese earthquake and tsunami may be specific for a highly technologically developed country. The disruption and major risks of radiation from the nuclear plants not only cause fear and displace parts of the population, they also create an insufficient power supply that affect a large part of the population. The role of international medical relief after a disaster in a high-income setting is limited. Responding to this disaster requires massive access to large ships and helicopters, lots of staff, and a well-functioning organization. In the context of the Japanese earthquake and tsunami, the military is the main group with such capacities and organization. There could be a few areas in which specialized technological support from outside the country can fill a role, but most resources can be mobilized within Japan. The basic human needs after such a large-scale disaster is the same for a low- and high-income country and include access to water and sanitation, shelter, food, security, and health care. However, there will be additional needs in a high-income country that international humanitarian assistance has limited experience dealing with, e.g., dealing with chronic diseases and the expectations of the population. We have yet to await the full impact of the Japanese disaster and to what extent the threats of nuclear power plant collapse will materialize. Nevertheless, basic training in disaster medicine provides essential tools to

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better analyze this type of disaster, assuring that the medical response is based on the needs of the affected population.

Further Reading Books and Reports Canny B (ed.) (2005) A review of NGO coordination in Aceh post earthquake/tsunami. International Council of Voluntary Agencies (ICVA) Darcy J, Hofmann C (2003) According to need? Report 15. H. P. Group, London, Overseas Development Institute, 74, 2003 De Ville de Goyet M (2006) Evaluation of the adequacy, appropriateness and effectiveness of needs assessments in the international decision making process to assist people affected by the tsunami. Tsunami Evaluation Coalition (TEC) 2006:1–104 Lorin H (ed.) (1996) Jordbävningen i Kobe, Japan tisdagen den 17 januari 1995. Kamedo SoS-rapport rapport 66, 1996;1–81 Médecins Sans Frontières (1997) Refugee health: an approach to emergency situations. Macmillan Education, Ltd., London, Epicentre Red Cross Federation World Disasters Report 2004; www.ifrc. org/en/publications-and-reports/world-disasters-report/ report-online/ Riddez L (ed.) (2001) Översvämningarna i Polen 1997 och i Sverige 2000, Kamedo SoS rapport 76, 2001; 1–77 United Nations Development Programme, Bureau for Crisis Prevention and Recovery. Reducing disaster risk: a challenge for the future 2004; Available at: http://www.undp.org/bcpr Von Schreeb J (2007) Needs assessment for international humanitarian health assistance in disasters, Thesis for doctoral degree, Akademisk doktorsavhandling, Karolinska Institutet Willitts-King B (2007) Allocating humanitarian funding according to need: towards analytical frameworks for donors. G. H. Donorship, 12 March 2007

Original Articles Abolghasemi H et al (2006) International medical response to a natural disaster: lessons learned from the Bam earthquake experience. Prehosp Disaster Med 21(3):141–147 Akbari ME, Farshad AA, Asadi-Lari M (2004) The devastation of Bam: an overview of health issues 1 month after the earthquake. Public Health 118(6):403–408 Alexander D (1996) The health effects of earthquakes in the mid-1990s. Disasters 20(3):231–247 Bissell RA (1983) Delayed-impact infectious disease after a natural disaster. J Emerg Med 1(1):59–66 Canny B (ed.) (2005) A review of NGO coordination in Aceh post earthquake/tsunami. International Council of Voluntary Agencies (ICVA) De Ville de Goyet C (2000) Stop propagating disaster myths. Lancet 356(9231):762–764

L. Riddez and J. von Schreeb De Ville de Goyet C (2007a) Myths, the ultimate survivors in disasters. Prehosp Disaster Med 22(2):104–105 De Ville de Goyet C (2007b) Health lessons learned from the recent earthquakes and tsunami in Asia. Prehosp Disaster Med 22:15–21 Floret N, Viel JF, Mauny F, Hoen E, Piarroux R (2006) Negligible risk for epidemics after geophysical disasters. Emerg Infect Dis 12(4):543–548 Gautschi OP, Cadosch D, Rajan G et al (2008) Earthquakes and trauma – review of triage and injury-specific immediate care. Prehosp Disaster Med 23:197–201 Holian AC, Keith PP (1998) Orthopedic surgery after the Aitape tsunami. Med J Aust 169:606–609 Jonkman SN, Kelman I (2005) An analysis of the causes and circumstances of flood disaster deaths. Disasters 29(1):75–97 Kondo H et al (2002) Post flood-infectious diseases in Mozambique. Prehosp Disaster Med 17(3):126–133 Kunii O, Nakamura S, Abdur R, Wakai S (2002) The impact on health and risk factors of the diarrhea epidemics in the 1998 Bangladesh floods. Public Health 116(2):68–74 Malilay J (2000) Public health assessments in disaster settings: recommendations for a multidisciplinary approach. Prehosp Disaster Med 15(4):167–172 Mohammad Naghi T et al (2005) Musculoskeletal injuries associated with earthquake: a report of injuries of Iran’s December 26, 2003, Bam earthquake casualties managed in tertiary referral centers. Injury 36(1):27–32 Morgan O, De Ville de Goyet C (2005) Dispelling disaster myths about dead bodies and disease: the role of scientific evidence and the media. Rev Panam Salud Publica 18(1):33–36 Natural Disasters. Protecting the Public’s Health; Pan American Health Organization publ.2000 Vigilancia Epidemiológica Sanitaria en Situaciones de Desastre, guía para el nivel local Noji EK (2005) Public health issues in disasters. Crit Care Med 33(1, Suppl):S29–S33 Prasartritha T, Tungsiripat R, Warachit P (2008) The revisit of 2004 tsunami in Thailand: characteristics of wounds. Int Wound J 5(1):8–19 Redmond A (2005) Needs assessment of humanitarian crises. BMJ 330(7503):1320–1322 Riddez L et al (2006) The surgical and obstetrical activity at the ICRC Field Hospital in Banda Aceh in the aftermath of the tsunami 2004. Int J Disaster Med 3(1):55–60 Roberts L, Hofmann CA (2004) Assessing the impact of humanitarian assistance in the health sector. Emerg Themes Epidemiol 1(1):3 Schnitzer JJ, Briggs SM (2004) Earthquake relief: the US medical response in Bam, Iran. N Engl J Med 350(12):1174–1176 Schultz CH, Koenig KL, Noji EK (1996) A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 334(7):438–444 Schwartz BS et al (2006) Diarrheal epidemics in Dhaka, Bangladesh, during three consecutive floods: 1988, 1998, and 2004. Am J Trop Med Hyg 74(6):1067–1073 Siddique AK, Baqui AH, Eusof A, Zaman K (1991) 1988 floods in Bangladesh: pattern of illness and causes of death. J Diarrhoeal Dis Res 9(4):310–314 Sur D, Dutta P, Nair GB, Bhattacharya SK (2000) Severe cholera outbreak following floods in a northern district of West Bengal. Indian J Med Res 112:178–182

13 Incidents Caused by Changes in Nature and Climate Tahmasebi MN (2005) Musculoskeletal injuries associated with earthquake: a report of injuries of Iran’s December 26, 2003, Bam earthquake casualties managed in tertiary referral centres. Injury 36(1):27–32 Taylor PR, Emonson DL, Schlimmer JE (1998) Operation Shaddok – the Australian defense force response to the

319 tsunami disaster in Papa New Guinea. Med J Aust 169: 602–606 Von Schreeb J et al (2008) Foreign field hospitals in the recent sudden impact disasters in Iran, Haiti, Indonesia, and Pakistan. Prehosp Disaster Med 23(2):144–151

Combat Casualty Management

14

Howard R. Champion and Robert A. Leitch

How wide and varied is the experience of the battlefield and how fertile the blood of warriors in raising good surgeons.1

Present conflicts are characterized by smallforce ambushes, remotely detonated improvised explosive devices (IEDs), and suicide bombers carrying explosive devices (Eastridge et al. 2006; Champion et al. 2010).

— Sir Clifford Albutt, Crimean War Surgeon

14.1

Deﬁnition

Current generations of civilian emergency medical services (EMS) systems largely rely on care delivery capabilities and organizations developed during combat (e.g., World War II, Korea, Vietnam); however, their training focus and practice is still largely geared toward emergencies most commonly encountered dayto-day, such as cardiac disease and vehicular trauma. Assumptions upon which civilian trauma care protocols are based include ready availability of diagnostic and therapeutic equipment, short evacuation times to definitive and specialty care, and a nonvolatile environment in which to render care. By the mid 1980s, the applicability of these protocols for patient management in the resource-constrained and chaotic environments of combat – the dangers of enemy fire, transportation delays, and lack of equipment and supplies (Butler 2000) – was frequently being called into question (NAEMT 2003).

H.R. Champion • R.A. Leitch e-mail: [email protected]; [email protected]

The protocols, developed from civilian EMS practices that required medics to stabilize fractures and establish intravenous (IV) therapy in inappropriate environments, often within range of enemy fire, were re-examined in detail after the first Gulf War in 1992. In 1996, a trauma management strategy tailored specifically for the combat environment was developed (Butler et al. 1996). The new strategy included using tourniquets for severe limb hemorrhage, delaying IV infusions, establishing expedient-only airway management, and abandoning the standard trauma protocol of cervical spine immobilization and backboards. These tactical combat casualty care (TC3), guidelines embody the principle of providing the right intervention at the right time and identify three distinct stages of combat casualty care (C3), (NAEMT 2003) as follows: 1. Care under fire Care is provided at the point of wounding while both medic and casualty are under hostile fire, there is a high risk of additional injuries, and medical equipment is limited to that carried into the field by mission personnel.

1

Quoted in Cantlie N (1974) A History of the Army Medical Department. Vol 2. London: Churchill Livingstone

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_14, © Springer-Verlag Berlin Heidelberg 2012

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2. Tactical field care Care is provided after the casualty is no longer under hostile fire, medical equipment is limited to that carried by mission personnel, and the time to evacuation may range from minutes to hours. 3. Tactical evacuation care (TACEVAC) Care is provided during evacuation to a higher echelon of care, additional medical personnel and equipment should be prestaged and available (TACEVAC includes casualty evacuation [CASEVAC] and medical evacuation [MEDEVAC]). The three primary goals of TC3 are to reduce/eliminate preventable deaths, prevent additional casualties, and complete the mission, all within the context of enemy fire, limited resources, and often lengthy evacuation times. Incorporation of TC3 into US military medical training within the past 15 years has resulted in improvements in readiness and subsequent improved outcomes and marked increased survival from battlefield injury (Goldberg 2010; Lechner et al. 2010; Kelly et al. 2008a; Holcomb et al. 2006a).

14.2

Combat Casualty Care Approach

In 2001, the US military medical leadership through the Committee on Tactical Combat Casualty Care put in place a formal system of trauma care in the theater of war to improve care and outcomes of combat casualties. The system was based upon the US trauma system model but adapted to the realities of combat (Eastridge et al. 2006). Implemented in 2004, the Joint Theater Trauma System incorporated the precepts of TC3 and put in place the following five-level continuum of care (known by the North American Treaty Organization [NATO] as roles 1–5) (Champion et al. 2010) spread over three continents: Level 1. The casualty (self), buddy or medics render immediate basic medical care at the point of wounding Level 2. Forward surgical teams– small mobile facilities in which surgeons provide initial resuscitation and damage control surgery Level 3. Combat support hospitals – fully equipped field hospitals where resuscitation, damage control surgery, and definitive care occur before evacuation from the combat zone Level 4. Further, definitive care provided out of the combat theater before evacuation to the United States (e.g., at Landstuhl Regional Medical Center in Germany)

Level 5. Definitive and rehabilitative care provided in the continental United States (e.g., at Walter Reed Army Medical Center or National Naval Medical Center in the Washington, DC area, or at Brooke Army Medical Center in San Antonio, TX) (Champion et al. 2010). Implementation of this system is credited with reducing the number of US combat deaths, (Borgman et al. 2007; Holcomb et al. 2007; Holcomb 2005; Ennis et al. 2008; Eastridge et al. 2010) illustrated by a case fatality rate of 9.4 in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), which was down from 15.8 in Vietnam (Holcomb et al. 2006b). The evidence that these outcomes are a direct result of improvements in C3 at every point along the continuum of care is compelling. The first and most fundamental improvements instituted were far forward at the level of close combat. In the broad TC3 initiative, the emphasis by the US Navy SEALs 75th Ranger Regiment on saving lives under fire required all combatants to be trained in first aid, to be able to treat themselves and their fellow combatants, and to prevent the injured from bleeding to death or dying of airway obstruction before they could be evacuated out of harm’s way and sent to a facility that could begin to repair the damage. The Ranger Regiment case fatality rate is 7.6 (Kotwal et al. 2011). As simple as this sounds, it necessitated a major shift in the mindset of many in the military medical system. Not least, it required abandoning the near total reliance of the warfighter on the designated medic to administer sophisticated first aid under fire. Self aid and buddy aid are now common practices in many units during modern conflict. The US model of TC3 and a continuum of care from the point of wounding through damage control and stabilization and lengthy evacuation to definitive care has now been adopted by a number of NATO nations and is rapidly spreading across the international military arena. TC3 is currently instantiated in the 2010 military edition of Prehospital Trauma Life Support (NAEMT 2010).

14.2.1 Level 1 14.2.1.1 Care Under Fire The major cause of preventable combat deaths is hemorrhage (US Casualty Status 2010; Bellamy 1984), followed by tension pneumothorax and, less frequently, airway obstruction when facial trauma is present. Recommending tourniquets for military

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Fig. 14.1 Care under fire: UH60 medevac helicopter arrives to evacuate wounded from an IED attack on a 10th Mountain Division vehicle, Afghanistan, 2009

use initially incurred considerable resistance from the surgical community, which argued that a tourniquet applied poorly or unnecessarily could irreparably damage limbs and that the risks outweighed the perceived benefits of tourniquet use by anyone other than an expert (i.e., a surgeon). Today, tourniquets are the first-line treatment for limb hemorrhage control in TC3, particularly in the care under fire phase, because direct pressure is often hard to maintain by combat medical personnel who may be caught up in the firefight or treating multiple casualties. Hemorrhage control using direct pressure is problematic during lengthy evacuation. The debate about whether to use a tourniquet continues, with detractors offering opinions of the risks of poor application or unnecessary use. The evidence from the past 8 years of combat in Iraq and Afghanistan, however, confirm that that the benefits far outweigh the risks, and the key is to

teach warfighters and combat medics to apply tourniquets properly. Used correctly, tourniquets save lives during combat. Currently, individual tourniquets are issued to all US combatants, who are taught to use them. Improved survival outcomes of those with severe limb hemorrhage in OIF and OEF attest to the value of this key C3 tactic (Shown being utilized in Fig. 14.1).

The military point-of-wounding care provider must treat injuries that do not occur in civilian practice, in the dark, under fire, during mayhem, with no easy access to augmentative resources, and with long delays in transport, and they must perform “as advertised” the first time. There is no corollary in the civilian sector.

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14.2.1.2 Tactical Field Care Civilian prehospital trauma life support policy states, “Ensuring a patent airway is the first priority of trauma management and resuscitation” (NAEMT 2003). When both patient and medic are under fire, however, hemorrhage control takes precedence and, in all but the few cases in which an airway is obviously obstructed and the casualty is asphyxiating, airway derangements are not managed definitively until the tactical field care stage. At this point, when the medic and patient are no longer under fire, time may be available for more complex care such as a cricothyroidotomy (Cook 2010). The amount of time available determines whether only rapid wound care or more comprehensive treatment can be given. All resources should be directed to those who have a chance of survival; casualties with catastrophic injuries who are “vital signs absent,” for example, should not be given cardiopulmonary resuscitation. Time permitting, the following diagnostic/therapeutic interventions may be undertaken in addition to judicious attention to hemorrhage control: (1) the ABCs (airway, breathing, circulation) assessment sequence may be performed, and hemostatic dressings may be packed into wounds that cannot be closed with a tourniquet (e.g., to the torso or junctional areas); (2) pressure dressing can be applied to supplement tourniquets; and (3) IVs may be started to secure patent access to a vein only. TC3 precepts do not sanction the use of large volumes of replacement fluids, preferring that blood loss be initially managed with minimal and judicious use of fluids through IV or intraosseous routes. Fractures may be splinted and other actions can be taken in readiness for evacuation. Analgesia, in the form of intramuscular morphine, and/or fentanyl in “lollipop” form are commonly administered at this point. British medical doctrine recommends ketamine as the analgesic of choice at this juncture. The management of close and penetrating chest injuries requires particular attention during the tactical field care stage. Open chest injuries are closed with specifically built occlusive dressings. All warfighters are taught how to manage this type of wound. Combat medics are also taught how to perform needle thoracentesis to alleviate tension pneumothorax (Fig. 14.2). Equally importantly, all warfighters are taught that patients with chest wounds need to find the position in which they can best relieve respiratory distress, which is most often sitting up. This position is at odds with civilian EMS protocols for cervical spine immobilization.

H.R. Champion and R.A. Leitch

Fig. 14.2 US Army medic performs needle thoracentesis on wounded Afghan soldier

14.2.1.3 Tactical Evacuation Care Perhaps the most variable factor in medical care during combat is the time to evacuation to the next level of expert care, where damage control surgery and stabilization is undertaken. This time may range from minutes to many hours (Chambers et al. 2006). Evacuation is frequently the most problematic aspect of combat casualty care because of the logistical issues involved. Standard litters for patient transport often are not available in the field, and patients sometimes need to be transported on improvised litters or with a shoulder carry (which ranges in difficulty depending on the weight of both the patient and rescuer[s]) (Butler 2000). Evacuation of casualties to the next level of care is driven by time. The relatively crude measure coined during the Vietnam War and introduced to US civilian trauma care shortly afterward, known as the “golden hour,” remains a benchmark even for modern TC3. Current TACEVAC operations are complex and expensive, involving air ambulances, helicopter gunships for close protection, and often AC-130H Spectre gunships, with artillery and fighter-bombers on immediate call for collateral suppression of threat. This level of complexity reflects the recognition that (1) casualty outcomes depend upon speedy evacuation; (2) in modern conflicts, the death of individual combatants can have strategic consequences; and (3) modern enemies, particularly insurgents, consider an attempted medical TACEVAC a potential target to be exploited for strategic propaganda gains. Given the scale of resources used and the often considerable dangers surrounding evacuation sites, TACEVACs are hastily

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Fig. 14.3 Medevac of wounded Afghan National Army soldier from forward operating base, 2009

accomplished once the helicopter is on the ground. Speed is of the essence, and there is opportunity for error and omission during handovers between combat medics and flight medics (Fig. 14.3). In Afghanistan, matters are complicated by the great distances over which casualties must be evacuated by helicopter and the height above sea level, which can severely constrain helicopter performance. After a helicopter has left a location, it may have to refuel before it can return, which often results in long gaps between TACEVAC flights. Where combat takes place in remote areas far from the forward operating bases, TACEVAC is frequently delayed for hours. Militaries often take different approaches to helicopter TACEVAC. The US military uses medium-lift helicopters such as the UH60, which are regularly dedicated as air ambulances. These are staffed with combat medical personnel, whose task is restricted to continuing the initial first aid and stabilization with a focus on speed of evacuation rather than extended treatment. The British deploy heavier helicopters like the CH-47 with a complete medical team onboard, including a doctor, the aim being to enhance treatment en route when and if necessary and to compensate for longer, slower evacuation times. Whatever approach is taken, the reality is often that evacuation time is dictated not by distance but by operational factors such as the intensity of combat and the ability of the combatants to move casualties rapidly to a point from which they can be safely evacuated. The results of a tactical casualty evacuation gone wrong were never more starkly demonstrated than by the US experience in Somalia in 1992 (as

depicted in the movie “Black Hawk Down”), when a short combat operation turned into a prolonged casualty evacuation exercise with the downing of the first rescue helicopter dispatched to recover an injured combatant. The lessons to be drawn from this and similar events is that operational imperatives often dictate the time it takes to evacuate casualties; combat medical personnel must be equipped and trained to sustain casualties, sometimes for lengthy periods; and medical planning and systems must be designed with sufficient flexibility to manage delayed evacuation.

14.2.2 Level 2 In Vietnam, approximately 2.5% of the wounded who arrived at a surgical hospital died (King 2005). Despite rapid helicopter evacuation and the dictum of the “golden hour,” most deaths occurred before the injured were able to receive surgical care. In modern conflicts, the evolution of smaller, more mobile combat units with increased far-forward medical support — particularly combat medics at the subunit level and TC3 training for all warfighters — combined with sophisticated real-time communications down to the subunit level and the availability of on-call TACEVAC, have increased survivability of combat injuries to a certain point. The next step was to push surgical capability to perform damage control and stabilization procedures farther forward, closer to troops in combat. In a move that closely followed the models used by the International Brigade in the Spanish Civil War, the

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British Army in the North African Campaign of World War II, and in the Falklands War and Gulf War, the US Army established a number of forward surgical teams (FSTs) equipped to move directly behind troops. These were functioning surgical facilities with four ventilator-equipped beds and two operating tables, which could be set up within 60 minutes. FSTs travel in a number of Humvees carrying deployable rapid assembly shelter tents. Supplies to immediately resuscitate and operate on the wounded are carried in packs containing sterile instruments, anesthesia equipment, medicine, drapes, gowns, catheters, and handheld devices for measuring hemogram, electrolytes, and blood gases. Additional equipment includes a portable ultrasound, monitors, ventilators, an oxygen concentrator that can provide up to 50% oxygen, 20 units of packed red blood cells, and roll-up stretchers with litter stands. FSTs are estimated to have sufficient supplies to evaluate and/or perform surgery on as many as 30 wounded soldiers and provide approximately 6 hours of postoperative intensive care. FSTs are bound by operational and logistical constraints including limited resources and limited numbers of expert medical personnel. The US Army has approximately 100 general surgeons on active duty and a similar number in the reserves; the US Navy and Air Force have fewer. Deploying large numbers of surgeons and their support staff for long periods to support two wars over the past decade has proved impossible. Thus, the US military reduced its surgical presence to a small number of general surgeons supported by orthopedic and a few other specialists, such as maxillofacial and vascular surgeons, who are considered vital for the innovative and rapidly developing approach to combat trauma management known as damage control surgery (Fig. 14.4). This staged approach to combat injury management is undertaken by the FSTs, which consist of approximately 20 people: usually three general surgeons, one orthopedic surgeon, two nurse anesthetists, and three nurses, plus medics and other support personnel. Other nations have even smaller and more mobile teams; the British and French utilize FSTs that are six-person teams with only one surgeon on each team. Although these FSTs are often used in multiples, they can and do act alone in support of Special Operations forces. The task of the FSTs is to perform the range of damage control surgical procedures needed to stabilize the wounded for evacuation to the next level of care.

H.R. Champion and R.A. Leitch

Fig. 14.4 Damage control surgery – internal tamponade of gunshot wound to liver

Upon arrival of the injured, FSTs carry out standard protocols. However, because of the high incidence of penetrating wounds, life-saving operative management is required far more frequently than in civilian trauma centers. The surgical strategy aims for damage control rather than definitive repair. Liver injuries are packed, perforated bowels are stapled, dirty wounds are lavaged, and all interventions needed to control hemorrhage and contamination while preventing hypothermia and coagulopathy are performed. Surgery, ideally completed in fewer than 2 hours, primarily focuses on stabilizing patients for transport to the next level of care. Abdomens are left open, laparotomy pads are left in, bowels are unanastomosed, vessels are shunted, and the patient is paralyzed, sedated, and ventilated. For this approach to be successful, controlled airspace and dedicated helicopter evacuation with skilled critical care teams aboard are needed.

14.2.3 Evacuation to Levels 3, 4, and 5 The FSTs are supported at the next level by a number of combat support hospitals (CSHs). CSHs are 200bed hospitals with six operating tables, some specialty surgery services, and often sophisticated radiology and laboratory facilities. The role of the CSH is to continue stabilization and damage control as well as to perform definitive surgery when appropriate and necessary. The key to casualty management was to hold a patient only until the casualty management team was reasonably sure the patient would survive a longer evacuation out

14 Combat Casualty Management

of the combat zone to the next stage of care. Initially, hospitals in Kuwait; Rota, Spain; and Landstuhl, Germany were tasked with the role of interim care. Over time, the level 4 role fell solely to Landstuhl. From there, the majority of US casualties from Iraq and Afghanistan are now evacuated directly to level 5 facilities in the continental United States in 1–4 days. This tricontinental system allows casualties to be managed in a comprehensive fashion from the point of wounding to rehabilitation. It is the most formidable and effective trauma system ever created. This novel and innovative system took some getting used to. Surgeons at every level initially tended to hold on to their patients, believing that they could and should provide definitive care themselves. According to US Army Medical Services statistics, during the first few months of the Iraq War in 2003, it took an injured soldier an average of 8 days to move from the point of wounding to a medical treatment facility (MTF) in the continental United States. Gradually, however, surgeons have embraced the wisdom of the system and the average time from the point of wounding in Afghanistan to arrival at a US MTF is now fewer than 3 days, with patients usually having been evacuated directly to a CSH in a secure area for damagecontrol surgery, stabilization, and, when appropriate and necessary, definitive surgery. The key to this successful approach to combat casualty management, created by the US Air Force, is the capability to evacuate critically wounded warfighters over thousands of miles and keep them stable during transport. The Critical Care Air Transport Team (CCATT) is the US Air Force’s vital component in modern C3. CCATTs provide stabilization or advanced critical care of critically ill, injured, or burned patients during either intra- or intertheater air transport to the next level of care, usually the hospital in Landstuhl or an MTF in the continental United States. Each threemember CCATT consists of an intensivist physician, a critical care nurse, and a cardiopulmonary technician. Patients are sometimes transported in a state of dynamic, physiological flux. Intervention by a CCATT team normally begins at the air evacuation staging location. When stabilized patients arrive, the CCATT team prepares them for transport, accompanies them to the aircraft, and monitors and provides intervention care in-flight as necessary. The maximum team-to-patient ratio is one team to three high-acuity patients or to six relatively low-

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acuity, stabilized patients during a realistic duty day of about 16 hours. A high-acuity patient may be one who has suffered significant multiple organ injuries, has not received definitive surgical care but has had life- or limb-saving procedures performed, and requires movement to the next level of care. These patients often present a significant challenge to the CCATT staff and may require substantially more supplies and equipment than a low-acuity patient. High-acuity patients, however, may transition to a lower level of acuity after more definitive procedures are performed. A low-acuity patient may be one who has received multiple injuries to extremities and has had life- or limb-saving procedures performed, but whose internal organs were not injured; these patients may need monitoring but make fewer demands on personnel and inventory than do high-acuity patients. The duration of CCATT missions vary. Both long and short missions are possible. For instance, a stabilized patient received from a staging location in Southwest Asia for transport to Landstuhl may require about 6 hours of flight time, with transport and management before and after the flight extending the mission by 2–4 or more hours. A patient leaving Landstuhl en route to Walter Reed for continued definitive care will require packaging and ground transportation, as well as 8–10 hours of flight time. The transport aircraft for US and other NATO forces is the C17, a large cargo aircraft. Flights of these lengths are frequently stressful for patients, so surgeons must be sure that their patients are stable enough to endure the journey (Fig. 14.5). Late-stage surgical care and long-term care and rehabilitation of US combat casualties almost always continues in one of the three MTFs in the continental United States: Walter Reed in Washington, DC; National Naval Medical Center in Bethesda, MD; (Walter Reed closed in September 2011 and a new Walter Reed Military Medical Center is planned on NNMC grounds as part of the Base Realignment and Closure Plan [BRAC]) or Brooke Army Hospital in San Antonio, TX. Only when a patient is deemed too unstable to manage the whole journey will he or she spend time at Landstuhl. The reasons for this approach are similar to civilian criteria, i.e. that definitive care of severe injury is lengthy, complex, and requires a complete team approach. Because the efforts of combat medics at every level have increased the chance of survival, the numbers of those surviving with multiple

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H.R. Champion and R.A. Leitch

Fig. 14.5 US Air Force C17 with CCATT team flying out of Balad Air Base, Iraq

severe injuries has increased, and the demands on the military health care system to provide state-of-the-art care for the severely injured has risen. The care of patients with traumatic brain injury (TBI), in particular, has made huge demands on military medicine, and there have been major advances in the long-term management and recovery of TBI through the use of a comprehensive team approach, including occupational and speech therapists, among other specialists.

14.2.4 Additional Trauma Management Issues As the competition increases between the military’s ability to protect its combatants through enhanced body armor and vehicles and the enemy’s use of ever more powerful weapons to defeat these protective measures, patterns of wounding have changed. Personal protective equipment (PPE), particularly the ceramic plates that can defeat many fragment and high-velocity small

arms rounds, has proved dramatically effective in preventing torsal injuries. Thus, despite increasing use of IEDs, many patients survive who would otherwise have been killed by torsal fragments from explosions. They often have severe, potentially life-threatening face, neck, and limb injuries, however, including mangled extremities (limbs with combined severe soft-tissue, bone, and vascular damage). Initially, military surgeons relied on civilian trauma criteria in such cases, but this proved inapplicable because combat limb injuries are more extreme and are frequently combined with injuries to other organs. Early attempts to salvage limbs after civilian trauma criteria frequently failed, and life-threatening blood loss ensued. C3 protocols tend toward amputation in these types of wounds. Late complications also have emerged as a substantial management challenge. Surgeons continue to be confronted with pulmonary embolism and deep venous thrombosis, perhaps because of the severity of extremity injuries and the need for long-distance transport in the continuum of management. The solution is not obvious.

14 Combat Casualty Management

Using anticoagulants in patients with fresh wounds and in need of multiple procedures is impractical. Further, injured soldiers from Iraq brought an epidemic of multi-drug resistant Acinetobacter baumanii infection to MTFs (8.4% in 2003–2004, a rate much higher than any before), which caused wounds and prothesis infection as well as catheter-associated sepsis (Gawande 2004). This medical challenge was managed by routinely isolating casualties evacuated from Iraq and screening for the bacteria. It is not known how this epidemic began; no such epidemic occurred among soldiers stationed in Afghanistan.

14.2.5 The CNN Effect Having outlined the operational, logistical, and medical imperatives that shape modern combat casualty management, it is important to mention a fourth, equally key factor that is unique to combat medicine: the CNN Effect. Although it is not strictly medical, it is nevertheless a force that dictates and shapes the continuum of care. The CNN Effect describes the impact of real-time, 24-hour news coverage such as that of the Cable News Network (CNN) (Belknap 2002). For casualties and their families, the CNN Effect comes into play when information about the casualty’s condition is preliminarily disseminated to his or her next of kin. This creates two trajectories: (1) the rapidly changing condition of the patient and (2) the widening circle of distressed relatives demanding information. Although next of kin were notified of patient condition mostly by mail during early conflicts (World War II), by 1982 and the Falklands War, the speed at which the media could report an event required the military to inform next of kin within 10 hours to prevent them from finding out first on television. In modern conflicts, from the first Gulf War to today, protocols have been established that prevent the military from releasing casualty names and details until next of kin are informed, and the media typically honors these agreements. However, mobile telephones and social networking media often broadcast information almost as soon as an injury occurs. The extremely short time between injury and notification during modern operations makes it almost impossible for medical staff in combat zones to provide definite clinical prognoses, comment on evacuation, or keep up with the demand for information (“How badly is he hurt?” “Where is he now?” “When

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can I see him?”), especially as the number of distressed relatives demanding information increases. Before long, the pressure to answer these questions becomes so great that it permeates down to the operational commander and medical staff in the field. When a warfighter is injured, in effect his or her relatives become casualties too, and they remain casualties until their anxieties can be relieved. This phenomenon is also common in civilian medicine, but relatives are usually close by and can reach the patient’s bedside quickly. The most efficient way to reduce the anxiety gap is to evacuate the patient from the combat zone to a location where relatives can be taken to the patient’s bedside. This is common practice in today’s operations in Iraq and Afghanistan and a key driver in establishing an extended continuum of care from the point of wounding to home. In recognition of the positive therapeutic effect of having family close by, relatives are often flown to Landstuhl and to the three major US MTFs as a matter of course (Fig. 14.6). The US facilities have hostels where relatives and significant others can lodge so they can be at the patient’s bedside for long periods and be intimately involved in treatment and rehabilitation from an early stage. Further, patients out of intensive care often are allowed to have their pets with them.

14.3

Civilian Application of C3 Principles for Major Incidents

The clear threat of future terrorist activity and recent experience with natural disasters highlight the need to develop a comprehensive response system based on the integration of civilian and military resources (Champion et al. 2006a; Kapur et al. 2005; Niska and Burt 2003; Mattox 2001)… Terrorist events can involve large numbers of casualties, and the resulting injuries will resemble those being managed every day in Iraq and Afghanistan (Kapur et al. 2005; Aharonson(Daniel et al. 2006); Moore et al. 2007). Although the basic principles of medical care are the same, the circumstances surrounding combat trauma do not resemble those of civilian trauma (National Association of Emergency Medical Technicians (US), Prehospital Trauma Life Support Committee, and

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Fig. 14.6 Wounded soldier at Walter Reed Army Medical Center, Washington, DC

American College of Surgeons Committee on Trauma (NAEMT 2003), nor does the underlying philosophy of care. In civilian trauma often resulting from vehicle crashes or falls and involving one or only a few patients, the primary imperative can be summed up as “do the most for the most.” During combat or major incidents involving many injured patients, however, the guiding principle is “do the best for the most,” i.e., funnel limited resources to salvageable patients, preserve safety, and prevent additional casualties (NAEMT 2003) This necessitates use of a civilian-based model of care for regular trauma cases and adoption of TC3 precepts in major incidents (i.e., those in which care needs outstrip available resources, defined in detail in Chapter 1). Some considerations that differentiate these approaches are given in Table 14.1. Today’s combat casualties typically sustain injuries that are rarely encountered in civilian practice, primarily caused by explosive devices that initiate complex, multisystem derangements (Champion et al. 2010; Kelly et al. 2008b).

Table 14.1 Circumstances determining civilian versus military prehospital care approach Military (combat and major incidents) Often large numbers of patients Predictable and sufficient Extreme difficulties in resources matching resources to unpredictable numbers of casualties Secure environment in which Insecure (frequently hostile) to render care environment Easy access to supplies and Limited supplies; providers medical consults are often isolated Short prehospital phase Extended prehospital phase Short, predictable, and secure Unpredictable evacuation evacuation routes and times times often over insecure routes Civilian (regular trauma) Small number of patients

(NAEMT 2003)

During a terrorist bomb attack, civilian emergency care protocols do not apply well to the combat-like circumstances that may include loss of communications; inadequate resources and personnel to handle large

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Table 14.2 Categories of blast injury Category Primary Blast overpressure

Mechanism of injury Direct tissue damage from blast overpressure. Blast wave interacts with body, especially gas-filled structures. Stress and shear waves injure organs and cause dismemberment/dissemination Primary fragments from exploding weapon and Secondary secondary fragments (such as debris, shattered Propelled fragments glass); the latter is the most common mechanism of injury associated with explosives Propulsion of body or of large fragments into the Tertiary Body propelled onto object/surface body (translational injury) or structural collapse or object propelled onto body Burns, toxic fumes from fuel, metals, septic Quaternary syndromes from soil, environmental contamination Heat and/or combustion fumes Quinary Radiation or chemical additives

Contamination from radiation, chemical agents, bacteria, or human remains

Injuries Pulmonary (blast lung), tympanic membrane rupture, hollow viscus injury Penetrating fragmentation injuries

Penetrating and blunt trauma; crush injuries primarily caused by structural collapse Burns, asphyxiation, inhalation injury Various

Adapted from Champion et al. (2006b)

numbers of casualties; risk of secondary attacks on rescuers and onlookers; dangers from damaged infrastructure; the presence of chemical/biological agents; and that may be packed with nails or other items that increase wounding potential IEDs. Injuries from explosive devices (suicide bombs and IEDs) often consist of massive numbers of combined penetrating, blunt, and burn injuries and are particularly difficult to manage. For the best response in these situations, civilian emergency care providers should be trained to adopt military protocols, i.e., to (1) recognize wounding agents and patterns of injury associated with mass-casualty events and (2) initiate aggressive treatment. In other words, providers must be trained in the differences between civilian and military patient management; be able to recognize the conditions of a tactical scene; and know when to switch to military doctrine for effective scene management, triage, care, rapid removal of the maximum number of injured away from further danger; and the most efficient methods of evacuating those with major but survivable injuries. The [US] military trauma system [the Joint Theater Trauma System] provides a model for our civilian systems… (Eastman 2010). The general term “blast injury” consists of five categories that reflect specific mechanisms and types of injury caused by explosive force, described in Department of Defense Directive 6025.21E (2006) and

summarized in Table 14.2. When an explosive device is detonated, a chain of effects on nearby people and objects ensues (FEMA 2003) that begins with the shock front of the blast wave and then the blast wind, which propels fragments to create multiple penetrating injuries (the predominant cause of explosion-related injury [Wade et al. 2008]) as well as large objects and people, causing whole or partial body translocation, penetrating and blunt injuries, and crush injuries caused by structural collapse (DePalma et al. 2005). Burns, inhalation injuries, and asphyxiation may result from the heat, flames, gas, and smoke generated (DePalma et al. 2005), and additional deleterious health effects may be caused when explosives impregnated with bacteria or radiation are detonated. Primary blast injury may manifest immediately as tympanic membrane rupture, pulmonary damage, and hollow viscus rupture (DePalma et al. 2005). Often the only overpressure injury that occurs is tympanic membrane rupture (Leibovici et al. 1996; Ritenour et al. 2008), which can be caused by pressures as low as 5 pounds per square inch. At higher pressures, the lungs are the organs most susceptible to injury, including pulmonary barotrauma (blast lung), which is usually fatal, especially when the injury occurs in an enclosed space (Nixon and Stewart 2004). After an explosion has occurred, the greatest challenge for care providers is the plethora of casualties and the existence of multiple penetrating injuries (Wade et al. 2008; Beekley et al. 2007) (Fig. 14.7). Modern IEDs are designed to maximize fragmentation

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H.R. Champion and R.A. Leitch

Fig. 14.7 Aftermath of a suicide bombing in Kabul, 2009, leaving 12 dead and at least 60 wounded

injury, with the result that fragments of all types (munitions casing, debris, embedded objects such as bolts or nails) exponentially increase both the range and killing power of these often homemade explosives (Beekley et al. 2007; Linsky and Miller 2005; Champion et al. 2009). Victims of IED attacks can exsanguinate from multiple seemingly small wounds. Thus, surgical teams have learned to pack the bleeding sites before laparotomy or other interventions are performed and to undertake serial operative washouts to ensure adequate removal of infectious debris. The incidence of secondary penetrating injury to abdomens and chests of military personnel has been reduced to a level lower than ever before (and unlike civilians) because they are protected by body armor. However, fragments can enter laterally and below the body armor and in junctions between the torso, arms, neck, and legs. In the absence of body armor, such as in civilian populations, significant fragment injury can occur. It is not uncommon to encounter a casualty with 30–40 fragment wounds, and it is often difficult to ascertain which, if any, of these may have resulted in torsal penetration. Explosions that occur in enclosed spaces (buildings, trains, buses, and other vehicles) inflict more severe injury and are more lethal than those that occur in open spaces (Leibovici et al. 1996) (Fig. 14.8). Detonation of explosive devices in or near structures often causes them to collapse, with resultant injuries to those inside or nearby that result in crush and

compartment syndromes. In the 1995 Oklahoma City bombing, for example, mortality and hospitalization were 5 and 18%, respectively, in the uncollapsed section of the building and 87 and 82% in the collapsed area of the building (Mallonee et al. 1996). Quaternary injuries such as burns and inhalation injury often occur in urban bomb attacks. Burns may be caused by the flame of the explosion itself or by fires caused by the explosion (Stein 2005) and are exacerbated when incendiary agents (e.g., the September 11, 2001, attacks with fuel-filled airplanes [DePalma et al. 2005]) or incendiary explosives are used. Quinary injuries, which are induced by toxic substances released upon detonation, also include the phenomenon of chips of bone being propelled as fragments that cause penetrating injuries (Stein and Hirshberg 2003). In any one casualty of an explosion-related incident, the above injuries may occur alone or in combination. As documented in the Israeli experience with terrorist bombing incidents, explosions produce an injury pattern different from that produced by other traumas (Kluger et al. 2004). After exposure to an explosive device, most of those with lethal injuries die immediately. Although the large majority of survivors do not have life-threatening injuries, approximately 10–15% of casualties will have critical injuries and may be saved with appropriate management (Stein and Hirshberg 1999; Mallonee et al. 1996;

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Fig. 14.8 Suicide bomb attack on an International Security Assistance Force (ISAF) vehicle in Kabul, 2009, leaving 10 killed (6 ISAF) and 40 wounded

Quenemoen et al. 1996). When contrasted with patients with non–explosion-related injury, victims of terrorist bombings were found to have lower states of consciousness (as measured by the Glasgow Coma Scale) and increased hypotension, injury severity, presence of multiple injuries, need for surgery, use of critical care services, length of hospital stay, and mortality (Stein and Hirshberg 1999). Patterns of injury unique to explosive blast include the following (Frykberg and Tepas 1988): • Most are noncritical soft-tissue or skeletal injuries • Head injury predominates among deaths (50–70%) • Most (98.5%) head injury survivors have noncritical injuries • Head injuries are disproportionate to exposed total body surface area • Most blast lung kills immediately • Among survivors, there is a low incidence of wounds to the abdomen and chest, burns, traumatic amputations, and blast lung, although specific mortalities are high (10–40%) Morbidity and mortality generally have a direct relationship to the size of the explosive charge, whether the explosion occurs within a confined space, and whether it causes structural collapse (Phillips and Richmond 1989). Triage decisions are particularly complex in explosive blast incidents, and the scene safety strategy is particularly important because of the possibility of building collapse and the risk of secondary bombs designed to kill and injure response

personnel and onlookers. Further, it must be anticipated that “walking wounded” often arrive at medical centers before critically injured patients for whom resources must be reserved (e.g., by designating a special non–urgent-care area [Mallonee et al. 1996]).

14.4

Conclusions

Perhaps because of the extreme nature of acute surgical care of combat injuries, war has, at least in the past century, produced or consolidated major advances in care of the injured (Champion 2007). Management of the complex, typically multisystemic injuries caused by explosions is a subset of both combat and civilian trauma that requires specific training for maximum performance (Ramasamy et al. 2009). History shows that the battlefield is a fertile ground for advances in the care of the wounded, as illustrated by the many lessons learned from past conflicts. Today’s conflicts in Iraq and Afghanistan have produced a considerable number of substantial advances in care of the injured in the battlefield, and many of these are in the process of being translated into civilian practice. These improvements include not only the use of tourniquets and hemostatic dressings in

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immediate first aid but also management of hemorrhagic shock by hypotensive methods rather than large-volume fluid replacement, management of hypothermia, and changes in early protocols of resuscitation, as illustrated in the following excerpt from War Surgery in Afghanistan and Iraq (Nessen et al. 2008): …they no longer pump saline into a patient with massive trauma to try to get the blood pressure back up to 120, [which results in]… a highly diluted, cold patient with no clotting factors, and the high pressure restarts bleeding… Instead, they try to bring it up to just 80 or 90 with red cells and extra platelets, which encourage clotting. Also, initial surgery even on a severely wounded patient may be brief – just enough to control hemorrhaging and prevent contamination by a torn bowel. Then the patient is returned to intensive care to warm up, raise the blood pressure, and restore the electrolyte balance. The next operation is usually just enough to stabilize the patient for transport to a more sophisticated hospital, perhaps in Baghdad or Kabul, in Germany or the United States (Butler et al. 2007).

The overarching lesson learned between the mid1990s and 2010 is that medical training for C3 must be military-centric and based on the data, experience, insights, knowledge, and institutional memory generated during recent conflicts. The current challenge is the need to train all US troops in TC3 precepts and practices (Butler et al. 2007). This places a heavy demand on training resources, instructors, and equipment, and requires investing considerable resources into the production of new and innovative training technology, such as simulators designed specifically for TC3. The second lesson, yet to be clearly articulated, is how the evidence-based best practices evolving from casualty care in combat can be adapted and adopted for use in the civilian trauma arena, particularly for prehospital trauma care in major incidents and terroristrelated emergencies.

Further Reading Aharonson-Daniel L, Klein Y, Poleg K (2006) Suicide bombers form a new injury profile. Ann Surg 244:1018–1023 Beekley AC, Starnes BW, Sebesta JA (2007) Lessons learned from modern military surgery. Surg Clin North Am 87: 157–184 Belknap MH (2002) The CNN effect: strategic enabler or operational risk? Parameters 32:100–114 Bellamy RF (1984) The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 149:55–62

H.R. Champion and R.A. Leitch Borgman MA, Spinella PC, Perkins JG et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63:805–813 Butler FK (2000) Tactical medicine training for SEAL mission commanders. SpecialOperations.com. 14 July 2000. Available at: http://www.specialoperations.com/Navy/SEALs/SEAL_ Medicine.htm. Accessed 14 Dec 2010 Butler FK, Hagmann J, Butler EG (1996) Tactical combat casualty care in special operations. Mil Med 161(Suppl):1–16 Butler FK, Holcomb JB, Giebner SD et al (2007) Tactical combat casualty care 2007: evolving concepts and battlefield experience. Mil Med 172(11 Suppl):1–19 Chambers LW, Green DJ, Gillingham BL et al (2006) The experience of the US Marine Corps’ surgical shock trauma platoon with 417 operative combat casualties during a 12-month period of Operation Iraqi freedom. J Trauma 60:1155–1161 Champion HR (2007) Lessons learned at war. Surg News 6(2): 80–81 Champion HR, Mabee MS, Meredith JW (2006a) The state of US trauma systems: public perceptions versus reality – implications for US response to terrorism and mass casualty events. J Am Coll Surg 203:951–961 Champion HR, Baskin T, Holcomb JB et al (2006b) Injuries from explosives. In: McSwain NE et al (eds) National Association of Emergency Medical Technicians: PHTLS basic and advanced prehospital trauma life support: military, vol 2. Mosby, St. Louis Champion HR, Holcomb JB, Young LA (2009) Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma 66:1468–1477 Champion HR, Holcomb JB, Lawnick MM et al (2010) Improved characterization of combat injury. J Trauma 68:1139–1150 Cook C (2010) Tactical Combat Casualty Care (TCCC). Undated PowerPoint presentation. Available at: http://www.psow.org/ Tactical%20EMS%20Trends.ppt. Accessed 17 Dec 2010 DePalma RG, Burris DG, Champion HR, Hodgson MJ (2005) Blast injuries. New Engl J Med 352:1335–1342 Department of Defense Directive (2008). Medical research for prevention, mitigation, and treatment of blast injuries. Number 6025.21E. July 5, 2006 [Defense Technical Information Center Web site]. Available at: http://www.dtic. mil/whs/directives/corres/html/602521.htm. Accessed 21 Nov 2008 Eastman AB (2010) Wherever the dart lands: toward the ideal trauma system. J Am Coll Surg 211:153–168 Eastridge BJ, Jenkins D, Flaherty S et al (2006) Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 61:1366–1373 Eastridge BJ, Wade CE, Spott MA et al (2010) Utilizing a trauma systems approach to benchmark and improve combat casualty care. J Trauma 69(Suppl):S5–S9 Ennis JL, Chung KK, Renz EM et al (2008) Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma 64(2 Supp):S146–S151 Federal Emergency Management Agency (2003) Explosive blast. In: Primer to design safe schools projects in case of terrorist attacks. FEMA, Washington, DC, pp 4-1–4-13 Frykberg ER, Tepas JJ III (1988) Terrorist bombings. Lessons learned from Belfast to Beirut. Ann Surg 208:569

14 Combat Casualty Management Gawande A (2004) Casualties of war – Military care for the wounded from Iraq and Afghanistan. N Engl J Med 351: 2471–2475 Goldberg MS (2010) Death and injury rates of U.S. military personnel in Iraq. Mil Med 175:220–226 Holcomb JB (2005) The 2004 Fitts Lecture: current perspective on combat casualty care. J Trauma 59:990–1002 Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF (2006a) Understanding combat casualty care statistics. J Trauma 60:397–401 Holcomb JB, Stansbury LG, Champion HR et al (2006b) Understanding combat casualty care statistics. J Trauma 60:397–401 Holcomb JB, Jenkins D, Rhee P et al (2007) Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 62:307–310 Kapur GB, Hutson HR, Davis MA, Rice PL (2005) The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response. J Trauma 59:1436–1444 Kelly JF, Ritenour AE, McLaughlin DF et al (2008a) Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 64:S21–S27 Kelly JF, Ritenour AR, McLaughlin DF (2008b) Injury severity and causes of death from operation Iraqi freedom and operation enduring freedom: 2003–2004 versus 2006. J Trauma 64:S21–S27 King B, Jatoi I (2005) The Mobile Army Surgical Hospital (MASH): A military and surgical legacy. J Nat Med Assoc 97:648–656 Kluger Y, Peleg K, Daniel-Aharonson L et al (2004) The special injury pattern in terrorist bombings. J Am Coll Surg 199: 875–879 Kotwal RS, Montgomery HR, Kotwal BM et al (2011) Eliminating preventable death on the battlefield. Arch Surg online. Available at http://www.medicalsca.com/files/archsurg.2011.213v1.pdf. Accessed 23 Aug 2011 Lechner R, Achatz G, Hauer T et al (2010) Patterns and causes of injury in a contemporary combat environment. Unfallchirurg 113:106–113 Leibovici D, Gofrit ON, Stein M et al (1996) Blast injuries: bus versus open-air bombings–a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma 41:1030–1035 Linsky R, Miller A (2005) Types of explosions and explosive injuries defined. In: Keyes DC et al (eds) Medical response to terrorism: preparedness and clinical practice. Lippincott Williams & Wilkins, Philadelphia, pp 198–211 Mallonee S, Shariat S, Stennies G et al (1996) Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA 276:382–387 Mattox K (2001) The World Trade Center attack: disaster preparedness: health care is ready, but is the bureaucracy? Crit Care 5:323–325

335 Moore EE, Knudson MM, Schwab CW et al (2007) Militarycivilian collaboration in trauma care and the senior visiting surgeon program. N Engl J Med 357:2723–2727 National Association of Emergency Medical Technicians (2003) PHTLS: Prehospital Trauma Life Support, Revised 5th edn. Mosby, St. Louis National Association of Emergency Medical Technicians (2010) PHTLS: Prehospital Trauma Life Support, Military Edition (NAEMT PHTLS, Basic and Advanced Prehospital Trauma Support). 7th edn. Mosby, St. Louis Nessen SC, Lounsbury DE, Hetz SP (2008) War surgery in Afghanistan and Iraq: a series of cases, 2003–2007. Office of the Surgeon General, Borden Institute, Walter Reed Army Medical Center, Washington, DC Niska RW, Burt CW (2005) Bioterrorism and mass casualty preparedness in hospitals: United States, 2003. Adv Data 364:1–14 Nixon RG, Stewart C (2004). When things go boom: blast injuries. Fire Engineering, May 1, 2004. Available at: http:// www.fireengineering.com/articles/article_display. html?id=204602. Accessed 15 Apr 2008 Phillips YY, Richmond DR (1989) Primary blast injury and basic research: a brief history. In: Bellamy RF, Zajtchuk R (eds) Conventional warfare: ballistic, blast, and burn injuries. Office of the Surgeon General, Department of the Army, Washington, DC, pp 221–240 Quenemoen LE, Davis YM, Malilay J et al (1996) The World Trade Center bombing: injury prevention strategies for highrise building fires. Disasters 20:125 Ramasamy A, Hill AM, Clasper JC (2009) Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps 155:265–272 Ritenour AE, Wickley A, Ritenour JS et al (2008) Tympanic membrane perforation and hearing loss from blast overpressure in Operation Enduring Freedom and Operation Iraqi Freedom wounded. J Trauma 64:S174–S178 Stein M (2005) Urban bombing: a trauma surgeon’s perspective. Scand J Surg 94:286–292 Stein M, Hirshberg A (1999) Medical consequences of terrorism. The conventional weapon threat. Surg Clin North Am 79:1537 Stein M, Hirshberg A (2003) Limited mass casualties due to conventional weapons. A daily reality of a level 1 trauma center. In: Shemer J, Shoenfeld Y (eds) Terror and medicine – medical aspects of biological, chemical and radiological terrorism. PABST Science Publishers, Lengerich, pp 378–393 US Casualty Status (OIF and OEF) (2010). Fatalities as of February October 6, 2010, 10 a.m. EDT. Available at: http://www. globalsecurity.org/military/library/news/2010/10/101006casualty.pdf. Accessed 16 Dec 2010 Wade CE, Ritenour AE, Eastridge BJ et al (2008) Explosion injuries treated at combat support hospitals in the global war on terrorism. In: Elsayed NM, Atkins JL (eds) Explosion and blast-related injuries: effects of explosion and blast from military operations and acts of terrorism. Elsevier Academic Press, Burlington, pp 41–72

Terrorist Attacks on the Civilian Community

15

Boris Hreckovski and Robert Dobson

If you know the enemy and know yourself, your victory will not stand in doubt.

of asymmetric war in which a nonstate actor fights a state, but it must include violence against civilians.

— Sun Tzu, The Art of War

15.2 15.1

The Strategy of Terrorism

Introduction

The term “terrorism” originates from the Greek word “therares,” which means to terrify, or the Latin word “terrere,” meaning frightening. In modern times, the term was first used in the eighteenth century at the time of the French Revolution, when it was used to describe the actions of Jacobins during the “Reign of Terror.” Today there are more than 100 definitions of terrorism. Definitions vary from state to state. The General Secretary of the United Nations has described terrorism as “any act intended to cause death or serious bodily harm to civilians or noncombatants with purpose of intimidating a population or compelling a government or an international organization to do, or abstain from doing, any act.” The Federal Bureau of Investigation defines terrorism as 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.” It is hard to achieve a consensus on one definition because different types of terrorist activity exist. One fact remains, whichever definition of terrorism we use: Terrorists use violence against noncombatants to get publicity for their organization, group, cause, or individuals. Terrorism could also be a form

B. Hreckovski • R. Dobson e-mail: [email protected]; [email protected]

After the 9/11 terrorist attack on the World Trade Center in New York City, our world has not been the same. We have a new bipolarization worldwide. Western countries have developed an Antiterrorist Alliance (ATA) to be more effective in the combat against terrorism. On the other side, we can see transformation of different international terrorist groups or organizations in the Global Terrorist Movement (GTM), causing an increase in the frequency of terrorist attacks. Global knowledge doubles every 3–4 years, which means that new assets are available to everyone and are easily distributed in the era of globalization, which the GTM can also use to further their goals. Terrorists adapt new technologies quickly, showing their capabilities to avoid counterterror measures. In the 2008 attack on Mumbai, India, terrorists used global positioning systems for boat navigation, cells phones for tactical communication, satellite phones for coordination, Blackberries for tactical analysis of media coverage to get information on military and police forces and their activity, and e-mails to communicate with media. The use of new technologies enables terrorists to communicate with their commanders and amongst themselves at different locations during an attack. There has been an increase of more than 500% of terrorist websites in the past 10 years. Online training via the Internet is a method used by terrorist organisations to communicate, recruit new members, collect intelligence, and send encrypted messages. In the

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Al Qaeda training manual, there is a statement: “By using public sources openly and without resorting to illegal means, it is possible to gather at least 80% of all information required about the enemy.” Through the Internet, terrorist organizations can promote their methods, glorify people who have committed terrorist attacks, suggest potential targets, and mislead the young population, even children. Some of them offer sites and links to download games where children can play the role of a terrorist. Also, by using the Internet, terrorists develop worldwide networks based on personal relationships, and it is difficult to discover the chain of command. The efficiency of terrorist activity lies not only in the act itself, but in the public’s and governments’ reactions to the act. An example of changes in political strategy after a terrorist attack is the reaction of the US Congress to and vote after a suicide attack on US Marine barracks in Beirut in 1983. Another important factor is the psychological effect (also a terror), which is an intended result of a terrorist act. Present threats of possible terrorist attacks also produce similar effects. The possibility of kidnapping and taking hostages is a present threat in some countries and produces the same psychological effects. Besides that, this is also a chance for terrorists to gain publicity, earn money, and induce the release of jailed comrades. The hostage is only a tool; the target is the audience concerned about the hostage’s destiny. The material damage after a terrorist attack (e.g., single suicide bomber) may be relatively small, but the political and psychological impact is significant. It could be a case with only a few victims, but with media coverage everyone will see it and react. Terrorists use violence to raise fear in the population. This creates a condition that may lead to social and/or political changes. One of the main goals of terrorists is to use the “weapon of mass media.” Put simply, they rely on mass media to transfer their messages of fear and intimidation to the public. Information about the terrorist attack has to reach the audience. Fear is a potent factor that can lead to public reactions, causing distrust of the system and forcing a government to make social and/or political changes. First responders and medical personnel are at risk during terrorist incidents and are potential targets for secondary devices. The terrorist’s goal is to send a message to the community: If good guys can get hurt, no one is safe. The emergency response at the scene and in the hospitals represents a strong system that terrorists want

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to challenge. With potential secondary devices, which will cause more victims at the scene, during transport, or in emergency departments of hospitals, the terrorist wants to affect the confidence in the emergency response system and disrupt patient care. By raising fear in the population (other than casualties), terrorists create a situation that may lead to social and/or political changes. To be effective against terrorism, we need to have a multiagency approach, training all agencies together. Media coverage of terrorist attacks should be a part of the response to an incident, not to send a message of fear.

15.2.1 The Structure of Terrorist Organisations Terrorist acts can be performed by individuals, organized groups, or a state. The main type of terrorist organization is a secretive cell that consists of members who are highly motivated to perform dangerous and deadly operations. Usually, a terrorist cell consists of two to five members with their own logistics. Each terrorist cell does not have information about the others, which is the main reason why it is hard to penetrate the whole organization. The commander of the cell is the only person who communicates and coordinates with higher levels and other cells. Another fact is that, by using technical tools like the Internet, they do not have to know each other or train together. Terrorist organizations may form only one cell to operate on a tactical level, or they may form many cells that operate locally or internationally. In recent times there has been a new form of terrorist organizations called hybrid cells. Hybrid cells are based on a mixture of religion and ideology with a basic criminal structure. Terrorist organisations can be domestic, international, or transnational. Domestic organisations, such as the Euskadi Ta Askatasuna (ETA), operate within their home country. International organizations such as Hezbollah, operate in multiple countries in one region with goals to induce changes in specific areas. Transnational organizations like Al Qaeda operate internationally and are not focused on a specific region, with goals to affect states with different political systems and national interests throughout the world. Terrorism acts are not reserved only for well-organized groups; terrorism can also be an act of individual citizens. An example of what an individual could do with

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one assistant is illustrated by the Oklahoma City bombings in 1995, caused by Timothy McVeigh; 168 people lost their lives, including 19 children younger than the age of 6, and more than 680 people were injured. Preparation of materials and making a bomb with, for example, 2,000 kg of an ammonium nitrate fertilizer, nitromethane, and diesel fuel mixture costs approximately $5,000 US but may cause $600 million in damage. According to the reports from the University of Maryland’s National Consortium for the Study of Terrorism and Responses to the Terrorism (START), after the Oklahoma City bombings, a much higher percentage of terrorist attacks in the USA have been conducted by unaffiliated individuals than by organized groups. The “lone wolf terrorist” is an enemy that is hard to recognize and understand. The GTM can influence and motivate these lonely individuals to commit terrorist attacks outside any chain of command. Besides individuals, there are new groups of terrorists called self starters or “home-grown” cells, typical in western countries. They do not have direct connections with organisations like Al Qaeda, but they are driven by ideas spread on different websites. Selfstarter cells are usually self-trained and have less experience and knowledge than those who pass Al Qaeda training camps. Self-starters, on the other hand, have more highly educated people in their cell groups. Such self-starters were responsible for both the 2004 Madrid bombings and the 2005 London terrorist attack.

15.2.2 Stages of Terrorist Activity It usually takes years to prepare a terrorist attack, and this preparation can be divided into stages for better understanding and possible countermeasures: 1. Target selection – studies of the vulnerability of protective systems in the target area 2. Collection of material – slow process to avoid attraction 3. Preparation of material (weapons) – need for a hidden space 4. Preparation for the attack – participants are briefed about the plan and timing Why is this important? It illustrates that terrorists are seriously prepared for their aggressive, dangerous, and homicidal intentions. We should never underestimate terrorist preparation (education and training) and intentions. The terrorist McVeigh made his preparations over nearly 2 years, including a test of the first bomb,

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Fig. 15.1 Suicide vest with 4 kg of plastic explosive and nails to produce shrapnel (Courtesy of Police Unit Brodsko-posavska, Croatia)

but he never got any attention by intelligence or the police. A “lone wolf terrorist” is hard to detect. Terrorist attack conduct by A.B.Breivik in Norway includes two almost simultaneous actions: bombing in a centre of the town and mass shooting on a close island what demonstrate how dangerous “ lone wolf terrorist” could be.

15.2.3 Techniques, Tactics, and Procedures of Terrorists The medical doctrine during an MI is to bring the right patient to the right hospital at the right time. The terrorist doctrine (as for suicide bombers) is to bring the right explosive to the right place and detonate it at the right time. Suicide bombers trend is to dress like women and use a sophisticated smart bomb, which is difficult to detect. The suicide bomber vest is usually packed with nails or screws, which upon explosion act like small high-velocity missiles. These projectiles produce a lot of small penetrating wounds. On the scene, it is almost impossible to get an overview of what kind of damage these projectiles have caused to a human body. The depth of penetrating wounds and damage to organs and neurovascular structures is fully identified first in the hospital. First responders and medics on the scene should follow the military doctrine of Catastrophic haemorrhage, Airway, Breathing, Circulation(CABC) (see Chap. 14), especially if they are in the hot zone. Treatment of severe external hemorrhage, airway and ventilatory management, and rapid transport of critically injured casualties from the scene to hospitals is mandatory (Fig. 15.1).

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Database research on suicide bombings, including 400 suicide bomber profiles (Hassan 2001), showed that suicide bombers are highly motivated and, even if they have a chance to inflict the same damage by leaving a bomb behind or using other methods, they will in the majority of cases choose the option of a suicide attack. Suicide attacks produce more panic and fear among the population and terrorists utilize that. Hassan (2001) also found in her research that most terrorist leaders, when asked whether suicide bombings were a tactic or a strategy, answered that Jihad was the strategy and suicide bombings were among many tactics. Because countermeasures against terrorism have been successful in many parts of the world, terrorists now look for so-called “soft targets.” Soft targets are places like supermarkets, night clubs, and hotels because they have low security protection and are easy options for terrorist attacks that require low investment. International airports raised security measures after the 9/11 World Trade Center attacks and became hard targets, but they still have weaknesses because of the large number of visitors and many access points. Performing a terrorist attack on a soft target is an easier and cheaper option and still guarantees media attention and coverage, which is what terrorists are looking for. New procedures will allow terrorists to perform small suicide attacks on different locations. The primary suicide attack is directed at selected targets, usually a place where many people congregate. Among casualties are other suicide bomber(s), who have a duty to activate secondary explosive devices when first responders arrive on the scene or at emergency departments in the hospitals. The primary attack is not the primary goal; with the secondary attack, the terrorists reach the desired goal, especially if they can create confusion and casualties among emergency response personnel. Attempts to describe the profile of a terrorist are not useful because they dress, act, and live like the normal population to avoid any suspicion. Much information can be gained if we more preciously study the characteristics of terrorist cells and do network analysis. Prevention of terroristic attacks could be more efficient with good intelligence work and appropriate education and training of all agencies of the emergency response system. Therefore, terrorist bombings usually occur in places where people congregate, and the weapon of

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choice is an improvised explosive device (IED) in many forms, usually camouflaged. A target that will attract media attention and coverage is selected. Such targets could be places of historical, religious, or social value or infrastructure such as bridges and water supplies. Civilian populations become victims of terrorist attacks simply because they are at the selected place at the wrong time (Fig. 15.2). The most common weapons currently used by the terrorists are IEDs because they are simple to make, easy to hide, and have great potential for destruction. The IED has it origin from military situations. Viet Cong soldiers put IEDs in Coca-Cola or beer cans after that they found that US soldiers liked to kick empty cans during patrol on roads. Today, the most common use of IEDs in Iraqi and Afghanistan is in the form of roadside bombs. They are much stronger, with an enormous potential to destroy. Casualties suffer a combination of thermal, blast, and penetrating injuries caused by the thermal effect from the heat of the explosion, the blast effect from the force of the explosion, and the ballistic effect of flying debris. If the explosion occurs in an enclosed or semienclosed space, the effect will be much greater than in open space. Main factors that influence blast load on the human body are: • The power of the explosion • The medium in which the explosion occurs • The distance of the body from the center of the explosion Even a small amount of explosive can cause a lot of injuries and deaths if it occurs in an enclosed or semienclosed space. Immediate deaths on the scene correlate much more with the medium in which the explosion occurred than with the magnitude of the explosion. The 2011 Moscow terrorist attack demonstrates how an explosion can cause a large number of casualties if it occurs in an enclosed space. The terrorists performing this attack carried only 5–7 kg of explosives, but they carefully selected the place and time for the explosion, and in this way managed to induce a large amount of thermal, blast, and penetrating injuries. A powerful IED in an adequate location can cause a collapse of a structure, with devastating consequences. In the Oklahoma City bombings in 1995, most of the deaths resulted from such a collapse. The blast, caused by an explosion in a truck on a sidewalk in front of the building, damaged more than 300 other buildings in

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Fig. 15.2 (a, b) The suicide vest can be activated by the bomber or by a cell phone (Courtesy of Police Unit, Brodsko-posavska, Croatia)

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a

b

the vicinity and was heard and felt for a long distance. In the case of a collapsing structure, a lot of casualties may be trapped with potential crush injuries. The main components of an IED are: • Batteries for power supply • A trigger, which can be a radio signal. The most popular remote trigger is a cell phone • A detonator, usually electrical • The primary explosive, usually from unexploded landmines • Additional components like nails, fire-starting chemicals, or even toxic or contaminated materials • An envelope, container, or camouflage in which the IED is hidden Methods of using an IED are: • Vehicle-borne IED – a truck filled with camouflaged IEDs, usually parked at or near a designated area or target • Pedestrian-borne IED – suicide bomber (men, women, even handicapped children)

• Packaged IED – camouflaged in bags, dead animals, etc. Terrorists also tend to use liquid explosives for attacks, mainly in airplanes. They can smuggle liquid explosives in standard bottles of hair shampoo or body oil. MP3 players can then be used as detonators. Another possibility for terrorist attacks in airplanes is booby bombs. Explosives such as penta-erythritol tetranitrate in a plastic envelope is implanted by surgical operation into a terrorist’s body. To detonate himself, the terrorist needs a syringe to inject triacetone triperoxide) through the skin into the explosive envelope. In recent times, there has been a lot of speculation that terrorists will use dirty bombs. Dirty bombs are explosive devices made to spread radioactive materials. Dirty bomb are attractive weapons because they contain explosive and radioactive material, and this combination attracts media and spreads fear among the population. For that reason, dirty bombs are called

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in the emergency response system when terrorists combine two or more smaller attacks on different locations simultaneously.

15.3

Fig. 15.3 Improvised explosive devices are today a leading cause of traumatic amputations

“weapons of mass disruption.” Terrorists need to have radioactive material to construct a dirty bomb. Hospitals or pharmaceutical organizations are possible places from which terrorists can steal radioactive caesium-137. Two attempts were made by Chechen separatists using dirty bombs containing caesium, but neither was detonated. Radiological dispersal devices are “high-tech” weapons and are not easy to construct, which is the main reason why they still not have been used by terrorists to the same extent as IEDs. For treatment of injuries caused by IEDs, see Chap. 7 (Fig. 15.3). Mass hostage-taking situations can produce casualties who suffer from different types of penetrating, blunt, and blast injuries. It depends of the amount of explosives and the amounts of small and long-rifle ammunition used by the terrorists and the rescue forces. A new terrorist tactic is to use IEDs as barricades in a mass hostage-taking situation, as occurred in Beslan in 2004 (1,150 hostages), where the terrorists placed explosives around the school and strung them up so they could activate them instantaneously. The terrorists learned a lesson from the Moscow theater attack in 2002: They now broke all the windows and sealed of the plumbing and ventilation systems of the Beslan school to protect themselves from Russian Special Forces. The 2008 mass hostage-taking situation in Mumbai was a step forward in terrorist tactics. Small groups of terrorists perform coordinated attacks with use of hightech technology for communication and tactical advantages. The Mumbai attack illustrated all the problems

Terror Medicine

The global development of terrorism in the twenty-first century establishes the need for a new, distinctive discipline – terror medicine – as a special part of disaster medicine. This new discipline, or special part of disaster medicine, should include medical management of terrorist attacks regardless of the weapons used. It should deal with the whole management, from the scene to posthospital care. In everyday practice, the majority of civilian trauma casualties come from traffic accidents with dominating blunt trauma on different body regions. Penetrating trauma caused by gun fire and stabs occurs less often, especially in European countries. Casualties from terroristic attacks suffer from combination of blunt, penetrating, and blast injuries, which are a different type of trauma. Hospital stays for casualties from terrorist attacks is longer. Severity and types of injury in a typical terrorist attack with an IED is different than those caused by traffic accidents. Societies spend a lot of effort and funds on the prevention of terrorist attacks. Preparation for response and recovery is also important, which means that terror medicine should include the whole spectrum from preparedness and treatment of injuries to psychological effects. Major incidents (MIs) caused by terrorist activity are not easily recognized in their early stages, as incidents caused by climatic changes (hurricanes, tornados, volcanic eruptions) are. Societies also react differently to major incidents caused by terrorism than to those caused by nature. The Global Terrorism Database is available online and could be helpful in the understanding of terrorist tactics. The pre-event phase of a terrorist attack is hard to detect. One possible target for terrorists could be medical personnel. If we consider the levels of protection of hospitals in many parts of the world, we can conclude that they belong to soft targets. It is essential for medical personnel to have basic knowledge about terrorist activities and how to recognize a terrorist event as soon as possible. With appropriate education and training, we can make a shift in our minds that terrorist attacks

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are possible in our environment. That is the first step toward a better response if a terrorist attack happens. After the incident has occurred, an appropriate community emergency plan should be activated and all security measures implemented to ensure safety and prevent additional casualties. We can not achieve 100% security, but we can minimize the security risks. Casualties from MIs caused by terrorist attacks have types of injuries similar to those seen in warfare. There is one great difference between classic warfare and terrorist attacks, which medical personnel and all members of the emergency response system have to carry in their minds: No war starts without a warning. In warfare, there is always enough time to make some kind of preparedness because the pre-event phase usually is long, with clear signs of warning. However, a terrorist attack occurs without any warning; it often happens in the middle of the daily routine with the whole capacity of the hospitals occupied by elective patients, without any pre-event signs, leaving no time to prepare.

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To fight or prevent fire To detect, identify, monitor, and manage hazardous materials To provide scientific advisors To salvage and provide damage control To manage safety within the inner cordon To provide a Fire Incident Officer Ambulance/medical: primary roles To save lives To provide treatment, stabilization, and care for the injured To provide appropriate transport, equipment, and resources To establish effective triage To liaise with the hospital coordinating center To provide a Medical Incident Commander Military aid It must be agreed by each individual country as to what level the military may be involved in a civilian terrorist incident.

15.4.1 Police

15.4

Impact of Terrorism on the Prehospital Organization

It is extremely important that acts of terrorism in the civilian world are dealt with through a multi-agency approach, commonly referred to as the “blue light” services. The categories of terrorism seen within Europe have fallen into three primary styles of attack: • Bomb • Hostage • Active shooter Each requires a different approach from emergency services. Police: primary roles To save lives To coordinate the other emergency services and other agencies involved in the incident To protect and preserve the scene To investigate and secure evidence To collect casualty information To prevent crime To manage safety in the inner cordon in certain cases of terrorism To provide a Police Incident Officer Fire brigade: primary roles To save lives through search and rescue

It is essential that the multiagency approach is adopted within the civilian setting. For example, the police may have intelligence unknown to the other emergency services. Known threats, types of threats, or potential patterns of threats are used by terrorists in other countries. Often, counterterrorist police may have knowledge of the terrorist capabilities; for example, the multibomb attacks in Madrid were followed by multibomb attacks in London. It was common previously for the ETA (Spain) or the Irish Republican Army (UK) to use single bombs, packages, or car bombs as opposed to the attack using multiple bombs or suicide bombers, as occurred in London. Police tactics for terrorist hostage taking will be kept extremely confidential; in many countries this would often be dealt with by specialist firearms officers or special weapons and tactics teams (Fig. 15.4). Some countries may use special forces, who often can provide extra capabilities or have equipment and resources beyond what the ordinary police have. Military assistance is often regarded as the last resort and is rarely available quickly. It is essential that this is discussed within individual countries and practiced before the event.

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Fig. 15.4 Special police have extra capabilities (Courtesy of the Ministry of Interior, Croatia)

Fig. 15.5 The police have to win the fight before medics come on the scene (Courtesy of the Ministry of Interior, Croatia)

In the case of an active shooter or terrorist with guns, such as occurred in the Mumbai attacks, it is again essential that the police have a “STOP” system for the other emergency services. It is widely recognised how difficult this would be because first responders may arrive before receiving the message to stop (Fig. 15.5). Unlike the military, who often treat casualties under fire, the prime goal of the police will be to win the fight before it is safe for the fire brigade or medical services to be allowed to come forward.

One other area for the police is to maintain the link with the other agencies and to make them understand that this is a crime scene. Evidence collected can provide them with a conviction and it can also provide them with information that may lead to a terrorist, the bomber, or even a terrorist cell. In all major incidents it is essential that the police set up the inner and outer cordons to the incident and determine the access to areas with different levels of safety (Fig. 15.6).

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Fig. 15.6 Scene safety is important (Courtesy of Police Unit, Brodsko-posavska, Croatia)

The police will also have to liaise with the ambulance service regarding the routes to and from hospitals. It is essential that the ambulances have a clear route, primarily to get those patients who require surgery to hospitals as quickly as possible and to return to the scene if required.

15.4.2 Fire Brigade/Rescue Service Medical response depends highly on the risk assessment made by the police and the fire brigade. It is generally understood that to allow the “medics” to work in a civilian terrorist attack, it has to be agreed by police and the fire brigade that is it reasonably safe to do so. Both agencies share the similar goal of facilitating this task to allow the medics to get to the scene and treat the patients with the knowledge that their well-being is being looked after. The threat of fire or structural damage during the “blue light” phase of the rescue is generally the responsibility of the fire brigade. They will use detection equipment to assess the risk of any threat from chemicals to give an earliest possible warning as to whether chemical, biological, radiological, or nuclear procedures should be instituted. What the fire brigade offers is extensive knowledge about search and rescue. They will provide cutting

equipment, heavy lifting equipment, and lighting equipment. Another asset they will offer is “people power.” They are used to working alongside doctors and paramedics cutting people out of cars, and it is this teamwork approach in their daily routine that benefits the team during an MI (Fig. 15.7). Medics are also used to working with the fire brigade because they use their equipment. The reality is that everybody will work in small teams coordinated by the forward incident officers from both the fire and medical services. It was quite common during the London bombings to see firefighters carrying patients on stretchers accompanied by a medic and police officer. In the event of a hostage situation, the fire brigade will work under the guidance of the police. They will act as specialist advisors regarding the threat of fire or explosion, and they have experience and special knowledge regarding the stability and structure of buildings. They will also have capabilities to turn off utilities like electricity, gas, or water. Hostage situations are rarely over quickly, and this gives the rescue services the advantage of bringing in structural engineers or people with extensive knowledge of the building. In the event of fire, they will advise on how to fight the fire or advise where the hot spots are developing using their heat-seeking equipment. They will also advise on the probable direction of the fire and the threat to the occupants of the building regarding heat and fumes.

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Fig. 15.7 Medics and firefighters usually work together on the scene (Courtesy of the Fire Brigade, Slavonski Brod, Croatia)

In the event of active shooters, the fire brigade and the medics will be held back by the police until the threat is reduced. Often, fire is caused by tracer rounds fired from weapons or explosive entry techniques. They will be ready to mobilize at the earliest possibility to deal with this. Structural damage may also be an issue, and they will advise on this. In the event of no fire or structural damage, they should always offer lifting and carrying capabilities to the medics.

15.4.3 Ambulance/Medics It is essential that the medics listen to police and fire brigade advice when dealing with terrorist incidents. It is understood that often the first responders will go straight to the scene. It is a first priority in a bomb, hostage, or active shooter incident that the police designate a rendezvous point (RVP) as quickly as possible. The first calls to the emergency services will generally give a clue to the type of incident, and therefore the command and control centres have a responsibility to talk quickly with one another to establish what is jointly known. Whilst the safety on scene primarily sits with the police and fire brigade, personal safety is everyone’s responsibility.

It has happened that well-meaning medics have brought the patients and all their belongings and bags to the hospital, thus circumnavigating any police checks. Current terrorist threats have indicated the potential for secondary devices or, as explained in Chap. 14, a “come on bomb.” Imagine moving a bag into the hospital in good faith without realizing that it contains another bomb! It is therefore essential that medics leave behind bags and packages for police assessment, no matter how much the injured person pleads for it to be brought with him or her. It is also important that the medics realize that this is a crime scene and any evidence removed from the scene may mean that it becomes corrupt and therefore of no use to the police. For medics, a hostage situation can be a long, drawn-out affair, and this is where a Multi-agency Command Group, as used in the UK, is extremely important. Medics here must be involved in the command group meetings, which in the UK generally are held near the Joint Emergency Services Command/ Control area. It is probable that the ambulances at the RVP will be held in a parking area slightly away from the site. The purpose of this is to ensure that the site is clear in the event that police firearms teams, special forces, or the fire brigade require immediate first access should the incident develop unexpectedly. Generally, in hostage

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situations there is an element of time before the release of the hostages, who will be required to be assessed and searched before they are released to the medical services. If the police decide to undertake deliberate action, this is decided on primarily within the command group. The medics are generally informed to go to immediate standby and, if they are too close to the scene, they could alert the terrorists to heightened activity. Therefore, the immediate standby is done in an enclosed, confidential area away from site. Police escort vehicles will bring the vehicles in when requested. It will be for each individual country’s police commanders to decide just how far forward the medic teams can go, and this is dependent on the buildings being safe and secure from further threat. In the UK, medical services work alongside police when they train to clear buildings, and there is a real understanding of how difficult this task is and how long it realistically takes. For the medics to be able to treat a severely injured patient, it is often quicker for the police to evacuate the casualty to a point of safety. The active shooter situation has recently been brought to world attention by the Mumbai incident. Medics have an built-in desire to treat patients as soon as they can. In some countries like the UK, it is not common for the general public to have a full awareness or understanding of weapons or guns. The closest the public gets to this is via Hollywood-style movies in which the hero always wins. This lack of awareness can be a big risk to the medics who only really see the consequences of a bullet when presented with a patient in a safe environment. This is different from their military counterparts, who are trained to use guns and have experience treating patients under fire – a situation that would be extremely rare for a civilian medic. The other major potential issue for medics being so far forward is that they could get themselves involved in the firefight between the terrorist and the police. In such situations, the police need to fully concentrate of winning the fight and not be given the added responsibility of protecting medical staff. It is vital that the medics do as the police command group says, and they should understand that the goal of the police is to get any injured victims to them as soon as possible.

15.4.4 Military In the civilian world, this is not a military incident. The decisions for the use of the military will be decided by

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the senior police officer and government officials up to the level of the President or Prime Minister. Special forces units in most countries are highly secret, as are their capabilities. In the case of hostage taking by terrorist groups they will be instantly involved, unlike the hostage taking of children in a school by a lone gunman. However, they would always advise if requested. In the case of terrorist action, the special forces communities around the world link up and share information. It is extremely likely that they have extensive knowledge and current experience of dealing with these types of terrorist attacks. Most capital cities will have elite police firearms teams, but one advantage of special forces is that they can be deployed in any city or town at request, being neutral to some police politics. Any incident involving special forces will always create a ripple amongst the civilian command groups and takes the incident to another level. These forces must not be treated as competition to the elite police firearms teams. Professor Sten Lennquist is well known for stating “simplicity is the key,” and this is born out by the attitude of most special forces liaison officers. Behind closed doors with senior police officers they simply state their capabilities. It is then the decision of the senior police officer and government to decide on their level of involvement. If handed over to the military, the civilian services step back. Each country will decide how the interaction between the military and the civil services takes place. Once the threat has disappeared, the military will hand the management back to the civilian services. The reason for the step back is to ensure the security of the personnel and the secret tactics of special forces.

15.5

The Hospital Response to Terrorist Incidents

The hospital response is one of the main components of the medical response to MIs. Good and functioning hospital plans for MIs means not only that the hospital should have its own disaster plan, but also that this plan should be properly incorporated in regionalized and national plans and integrated with other components such as prehospital response, transport, communication, coordination, and command.

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15.5.1 Importance of the Planning Process Extensive MIs (levels 2 and 3) are relatively low probability events, and this implicates a problem for hospital planners because it is not easy to find people who have had enough knowledge and experience from such events. Also, too few countries or medical societies, institutions, or individuals so far have been collecting, analyzing, and disseminating experience and knowledge from previous MIs. Hospital planning for MIs needs to have appropriate status, authority, and support from regional and state levels to gain the attention, respect, and cooperation of other organizations and institutions. The process of planning is important, and those who are making the plan should also have a responsibility for the final product. One wrong decision or procedure in these difficult situations may cause loss of many lives. See Chap. 5 for further discussion of hospital response to MIs. Even if communication and coordination is good and the prehospital organization is accurate, overtriage of casualties on the scene can degrade the efficiency of medical care. Frykberg (2002), in his analysis of ten terrorist bombing incidents, showed a linear relationship between over-triage and critical mortality rate. Over-triage of casualties at the scene of an MI is one of the factors that can cause a loss of potentially salvageable lives. In the Madrid terror bombings (2004), the hospital closest to the MI site was filled with over-triaged casualties and the critical mortality rate was 17%. Most reviews of terrorist attacks with IEDs show that the majority of casualties are those with minor injuries, and only about 15–20% have an Injury Severity Score of more than 15. A good example of how to avoid over-triage is the organization of minor injury assessment areas to treat the large number of patients with minor injuries, as was done during the London terror bombings in 2005. This example shows that planners in this case knew some special characteristics that have to be considered when planning the organization of medical care during terrorist attacks. Examples from many past terrorist incidents also show that 30% or more casualties with minor injuries will come to the hospitals without ambulance transport. Usually, nonambulance transport will be toward the closest hospital. Because of that, Israel Ambulance Service aims not to transport noncritical casualties to

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the closest hospitals. According to Shapira in Israel, some hospitals like the Hadassah Medical Center categorize the size of an MI by the number of casualties the hospital receives independent of injury severity. It may be a problem if too many critical casualties are sent to even the largest hospitals. Overloading a large hospital with critically injured casualties may mean serious problems (depending on already ongoing activity) with the delivery of proper care because of today’s minimal reserve capacity, depending on increasing demand for efficiency in medical care. Good coordination, communication, and delivery of information from scene to the hospitals and vice versa through a regional command center is crucial for the organization of an MI response (see Chaps. 3 and 5 on prehospital and hospital response, respectively). Security of the hospital during a terrorist MI is especially important because of the uncontrolled movement of patients, mostly lightly wounded, casualties’ families and friends, the media, freelancers, and possible terrorists. In Israel, ambulance cars are checked in at the entrance of the hospital because they are possible targets of secondary explosive devices. Hospitals are built for patients and to be welcoming, so they are difficult places to secure.

15.6

Impact of Terrorism on Hospitals

Hospitals can be focused on how they treat and triage patients and may miss the fact that they will become the focus of the world – albeit for a short time, but time enough to damage the reputation of the hospital or even the country should things go wrong. Some key issues to consider in MIs caused by terrorist attacks: • Security of the hospital • Security of the patients receiving care • Security of the grounds • Security of ambulance vehicles parked at the entrances • Taking care of different ethnic groups within the hospital • Telephone communication • Taking care of victims’ relatives • Collaboration with police and security services • Collaboration with the media • Communication with foreign embassies • Managing visits by “very important persons” (VIP)

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15.6.1 Security of the Hospital As soon as a terrorist incident is announced, the designated hospital should impose a security clamp down. This will mean closing the hospital’s casualty receiving area, clearing adjacent parking lots of all but essential vehicles, and moving cars that are causing any type of obstruction. All medical staff should display identification cards, and doctors and nurses should not leave white coats or items such as stethoscopes around. Surveys and tests have shown that by wearing these items, non-medical staff can move around freely without being challenged.

15.6.2 Security of the Patients During all MIs, the casualty receiving areas become congested, especially when there is much more movement between cubicles. It is at this time that personal belongings can go missing. Not only is this a concern for the patient, but also a loss of potential forensic evidence for the police. The fact that the person is so seriously injured could indicate this person was near the epicenter of a bomb or near an active shooter. The hospital is expected to be a place of care and safety. It is the hospital’s responsibility to ensure that this is so.

15.6.3 Security of Ambulance Vehicles Parked at the Entrances As ambulances arrive with the injured they will focus on the removal of the casualty from the vehicle into the hospital, often leaving the ambulance doors open and the inside exposed. In Israel, for example, the ambulance vehicles are immediately checked upon arrival, before any personal belongings go into the hospital. Prehospital care workers have been known to transport bags they thought belonged to the patient, which was not the case, and the risk of this has been emphasized above.

15.6.4 Issues Regarding Ethnic Groups Within the Hospital As information filters through regarding what has happened, speculation rises and anger grows amongst

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arriving relatives. Hospitals should be sensitive to the fact that workers within the hospital with different ethnic appearances or faiths may be targeted.

15.6.5 Issues with Telephone Communication Telephone systems into the hospital quickly become overwhelmed. Relatives and friends seeking information regarding the whereabouts or condition of a loved one can often clog the hospital’s incoming call system. Dedicated predetermined phone lines would assist the hospital and enable only essential calls to be made or to come in. This would also assist other hospitals if patients require transfer, thus preventing waiting times on either end of the phone lines. A plan should be in place to call in extra staff for this (see Chap. 5). At the same time that the hospital is becoming overwhelmed, often the emergency services systems are overwhelmed as well. This can become a problem with the hospital maintaining contact with the ambulance service. Some countries like the UK immediately designate the task to hospital liaison officers, who are there to make decisions regarding any ambulance transfers and to update the head of the department on the current situation at the scene. Police have a few roles here as well. They are there to make sure that the hospital is protected and secure. They are there to gain information, such as patient names and nationalities. This information is fed back to a casualty bureau listing known names of the injured. To take the pressure off the medical telephone system, the police should issue a number for the public to call if they wish to locate their potentially missing relatives.

15.6.6 Impact of Police and Security Services Normally hospital staff rule their own areas, but in the case of a terrorist incident they may experience or come into conflict with other agencies’ needs. For example, if the injured person is a terrorist, the police will stay in the room with the injured. Treatment may be given to a patient who is required to be restrained in handcuffs. Security around the treatment area must be heightened as relatives of the injured may become aware of whom the medical staff are treating.

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Medical staff are often unaware of the dangers; even seasoned police officers have been caught out. An example of this is the case of a counterterrorist police officer in the UK who was interviewing a terrorist in his home. The terrorist was not secured because it has been deemed that he was not dangerous. This was a mistake, and the terrorist fatally stabbed the officer with a knife. Another example is a group of terrorists in Turkey that dressed as police officers and attacked an American facility. On arrival at hospital the medical staff was tricked into believing that they were treating real police officers. There may also be occasions where specialist or elite police or special forces are injured. The security of their identities, their equipment, or the clothes they are wearing may need to remain secret. Police and military activity will increase around the individual and special arrangements may be required.

15.6.7 Issues with the Media The media do a great job of letting everyone know what has happened. Major news channels will feed the information about an incident within seconds. One advantage of this from the hospital’s point of view is that the television pictures beamed into the homes of millions also can be available within various departments of the hospital. Doctors and nurses get a view of the incident and the potential mechanisms of injuries they are about to receive. The disadvantage of the media is that they do not hesitate to get a story or a picture that can sell. Wellorganized hospitals have a special media strategy to deal with this. Hospitals should work with the media to try to meet their needs, but in the case of terrorism, the hospitals can inadvertently give out premature information. Countries that are experienced in terrorism always make sure that they confirm with the police what should and should not be released. Police, in turn, will seek confirmation from politicians. Some will say that this is withholding information from the public; others will say that the aim is to protect the hospital or the country’s reputation because the situation will probably be of interest to the world. An example of getting things wrong was during the London bombings, where the media were releasing information that the explosions were caused by a

B. Hreckovski and R. Dobson

series of electrical explosions, when in fact it was an attack on London with the use of multiple suicide bombers. Care must be taken by hospitals, and neither the hospital nor the media want to put out the wrong details. Pictures of injured people always sell papers, and the hospital has a responsibility to protect the dignity and the confidentiality of the patients in its care. Imagine the impact of a photographer showing a picture of a special forces operative injured in the hospital. The picture could have been expose the individual and his or her family to further danger, which potentially could mean the end of his or her career.

15.6.8 Issues with Foreign Embassies To gain maximum publicity in many countries, the terrorist often targets tourist areas; e.g., the bombs in Bali (October 2002) and in Egypt (July 2005). The impact of this is that each country, via their embassy, wants to know if any of their citizens have been killed or injured in the attack. With the police taking control of the names and nationalities of those involved, it makes life easier for embassy staff to deal with one agency. Hospitals must also be aware that they do not hold the master picture because patients could have been taken to multiple hospitals or medical facilities.

15.6.9 VIP Visits VIP visits will occur and will be expected. The hospital will have to cope with these because they are virtually impossible to stop. Who would stop the president of the country with an entire media pack in chase? These must be expected, organized, and facilitated.

15.7

Conclusions

Acts of terrorism will continue to occur around the world. It is up to all agencies to realize that working together in a multiagency approach will save lives. The objective of this chapter is to make people aware that each agency has its own set of ideas, issues, and problems. However, the aim of all agencies is to produce the largest numbers of survivors. Working in “silos” simply does not work and will cost lives.

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Further Reading The lessons learnt from the current conflicts are quite simple: Trauma patients survive because of rapid techniques done effectively, at the earliest opportunity, and without unnecessary delay getting patients to definitive care. There may be cases where the surgeons may come to the patients, but this is extremely rare. Good knowledge of what the surgeons require to save the patient should be filtered down via the ever-growing number of experienced prehospital doctors. In turn, they have a responsibility to advise paramedics, pre-hospital nurses, and ambulance workers. Through training and knowledge of MI response, effective triage, and an understanding of the clinical needs of the patient, medics at all levels must work together. The chain is only as strong as the weakest link. Agencies such as the police and fire brigade understand the need for this and try to balance safety and speed of rescue. At times, their argument for holding back the medical services seems weak. An example of this could be seen during the London bombings, where medics were allegedly held back from going onto the bombed trains because police feared secondary devices. It will always be a difficult decision when people are seriously injured with a risk of dying versus the possible threat of secondary devices. One must ask at what stage the police or fire service could declare the scene totally safe from such threat. The reality is probably not until 1 week later. This can be frustrating for the medics, but it is a judgement call, which is what we ask them to make. MIs caused by terrorist attacks are most challenging for the emergency response system, including prehospital and hospital medical personnel. Our vision is to use the right resources for the right patient at the right time and to bring the right patient to the right medical unit at the right time, no matter under what circumstances we are working.

Abrahams M (2002) What terrorists really want. Int Secur 32(4):86–89 Aharonson-Daniel L, Klein Y (2006) Suicide bombers form a new injury profile. Ann Surg 244(6):1018–1023 Ciottone GR (ed) (2006) Disaster medicine. Mosby Elsevier, Philadelphia Dingle J (2010) Dirty bombs – a real threat? Int Secur 42(4): 48–52 Frykberg ER (2002) Medical management of disasters and mass casualties from terrorist bombings–how can we cope? J Trauma 53:201–212 Musharbash Y (2005) Future of terrorism: what Al-Qaida really wants. Spiegel Online. Available at: www.spiegel.de/international Accessed July 27, 2011 Goldschmitt D (2009) Medical disaster response. CRC Press, Boca Raton Hassan N (2001) An arsenal of believers. The New Yorker, 2001 Hassan N (2004) Al-Qaida’s understudy: suicide terrorism has come to Pakistan. Atlantic Monthly 293:42–44 Hogan ED, Burstein JL (eds) (2007) Disaster medicine, 2nd edn. Lippincott Williams & Wilkins, Philadelphia Horrocks C (2001) Blast injuries: biophysics, pathophysiology and management principles. J R Army Med Corps 147:28–40 Kluger Y, Peleg K (2004) The special injury pattern in terrorist bombings. J Am Coll Surg 199(6):875–879 Lennquist S (2005) Education and training in disaster medicine. Scand J Surg 94:300–310 Lennquist S (2007) Management of major incidents and disasters – an important responsibility for the trauma surgeon. J Trauma 62:1321–1329 London Emergency Services Liaison Panel (2007) LESLP manual. The Stationery Office, London Loretta N (2005) Insurgent Iraq. Seven Stories Press, New York Mayo A, Kluger Y (2006) Terrorist bombings. World J Emerg Surg 13:1–33 Pape RA (2008) Strategic logic of suicide terrorism. Am Pol Sci Rev 97(3):346–361 Peral G, Turegano F, Perez D (2005) Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 33:107–112 Shapira SC (ed) (2009) Essentials of terror medicine. Springer, New York Shapira SC, Shemer J (2002) Medical management of terrorist attacks. Isr Med Assoc J 4:489–492 Wightman J, Gladish S (2001) Explosion and blast injuries. Ann Emerg Med 37:664–678

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Scoring Systems Related to Outcome in Severe Injuries Per Örtenwall

16.1

Anatomical Scoring Systems

16.1.1 Abbreviated Injury Scale A standardized system for anatomical classification of injury severity – the Abbreviated Injury Scale (AIS) – was first presented 40 years ago (Committee on Medical Aspects of Automotive Safety 1971). The AIS system was developed primarily to help analyze the impact of injuries caused by blunt trauma in motor vehicle crashes. The first manual included only 73 injuries and could be used for blunt injuries only. Since then the AIS system has been modified several times. The present (2005) AIS system (with a 2008 update) is applicable to all types of mechanical trauma, including penetrating injuries, as well as physical injuries such as burns, inhalation injuries, high-voltage electrical injuries, and accidental hypothermia. The AIS system, owned by the Association for the Advancement of Automotive Medicine (AAAM) (http://www.carcrash.org; opened April 3, 2011), has become an international (civilian) standard for the classification of trauma severity during the acute phase of virtually all types of accidents. In the military setting, a separate version of AIS has been developed in the United States because of the devastating injuries encountered during modern warfare (Champion et al. 2010). The AIS code system consists of a digit decimal number, the last digit of which (the decimal) defines the severity grade. The other digits define the body region, the type of anatomic structure injured, and the type of injury. In this context, only the severity grade will be discussed. P. Örtenwall e-mail: [email protected]

The severity of the injury – the AIS grade – is defined for each injury according to a seven-grade ordinal scale, including unknown injuries (Table 16.1). Injuries graded as three or less are usually judged as not life-threatening. AIS 4 injuries are judged as lifethreatening but probably survivable. AIS 5 injuries are judged as life-threatening and probably not survivable. AIS 6 injuries are not survivable. An AIS grade of 9 is assigned in those cases where trauma has occurred but no information is available regarding a specific organ or region, such as “blunt abdominal trauma.” There is only a single AIS grade for each injury for any one person at a given age. A correct rating demands precise identification of the extent of the injury. This may only be available after an operation or results from investigations such as a computed tomographic scan or magnetic resonance imaging. If there is any question about the severity of an injury based on all the documented information available, the classification should be “conservative,” i.e., the lowest AIS grade in the specific category should be chosen. The AIS grade is not simply a ranking of expected mortality after an isolated injury, although empirical data show that AIS correlates well with the probability

Table 16.1 The Abbreviated Injury Scale AIS grade 1 2 3 4 5 6 9

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_16, © Springer-Verlag Berlin Heidelberg 2012

Severity Minor Moderate Serious Severe Critical Nonsurvivable Unknown 353

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of death at the serious, severe, and life-threatening levels (AIS grade ³3. Other factors are also considered when determining AIS severity, including the diagnostic certainty, the rapidity, the duration, the complexity, and the expected effectiveness of resolution with or without existing therapy. It is important to note that the AIS grade only assesses the threat to life of an isolated injury and not the combined effects of multiple injuries. The maximum AIS (MAIS), which is the highest AIS grade, given to a patient with multiple injuries, has been used to describe the overall severity in road crashes. In trauma research, the MAIS is insufficient because of its nonlinear relationship with the probability of death. The AIS system, however, is the basis of the Injury Severity Score (ISS; see below). The AIS system is the property of the AAAM. The AIS Committee has put a lot of work into updating the AIS over the years and training health care staff on how to score injuries correctly. The correct use of AIS is fundamental because the severity grades of injuries are squared in ISS and New ISS (see below). Another possible pitfall in comparing trauma scores over time is the possibility that different versions of the AIS may have been used, which is not always evident from published articles. For instance, the number of AIS codes expanded from 1,341 in 1998 to 1,983 codes in 2005 and 1,999 codes in the 2008 update. Because of better treatment, many injuries will have an AIS 2008 code of lower severity compared with the corresponding AIS 1998 code. Although only 4.3% of the injury codes decreased in severity between AIS 1998 and AIS 2008, this decrease had a profound effect on trauma registry. In a recent study comparing 128,000 injuries among 32,000 Australian patients, the number of patients classified as major trauma (ISS > 15, n = 15,471) decreased by 30% when the AIS 2008 codes were applied to the data bank instead of the AIS 1998 codes. (Palmer and Franklyn 2011)

16.1.2 Injury Severity Score The AIS system is the basis of the ISS. The ISS system was described by Baker et al. in 1974 and has been used to predict the outcome of multiple injuries in cases where physiological parameters are missing. The ISS was developed so that there would be a better agreement between the overall severity and the probability of survival compared with the MAIS.

P. Örtenwall Table 16.2 Injury Severity Scale body regions 1 2 3 4 5 6

Head and neck Face Chest Abdominal and pelvic content Extremities and pelvic girdle External

Head and neck injuries include injuries to the brain and cervical spine. Facial injuries include those involving the mouth, ears, eyes, nose, and facial bones. Chest injuries and injuries to abdominal and pelvic contents include lesions to internal organs in the respective cavities. Chest injuries also include those to the diaphragm, rib cage, and thoracic spine. Lumbar spine injuries are included in the abdominal or pelvic areas. Injuries to the extremities include the shoulder and pelvic girdle. External injuries include superficial injuries such as abrasions, contusions, lacerations, and burns independent of their location on the body surface

In the ISS system, the body is divided into six regions (Table 16.2). The ISS score is the sum of the squares of the highest AIS grade in each of the three most severely injured ISS body regions. Any injury coded AIS grade 6 is, by definition, assigned an ISS of 75. The ISS can adopt only 44 of the integer values from 1 to 75. A score of 75 results in one of two assessments: either three AIS grade 5 injuries or with at least one AIS grade 6 injury. The mortality from major trauma increases with age, as shown by Bull in 1975. In Bull’s study, the 50% “lethal dose” was an ISS of 40 for patients aged 15–44 years, 29 for those ages 45–64 years, and 20 for patients age 65 and older. However, the mortality rates do not strictly increase as the ISS values increase (Copes et al. 1988). The mortality rate peaks significantly at ISS values of 16 and 25, respectively. This can be explained by the fact that the AIS scale is not an interval scale and that an isolated AIS 4 injury, amounting to an ISS of 16, may be more life-threatening than a combination of two AIS 3 injuries, amounting to an ISS of 18. In the same way, an isolated AIS 5 injury, amounting to an ISS of 25, can be more life-threatening than a combination of one AIS 4, one AIS 3, and one AIS 2 injury, which equal an ISS of 29.

16.1.3 Anatomical Proﬁle An attempt to overcome some of the shortcomings of ISS was made by introducing the Anatomical Profile (AP) in 1990 (Copes et al. 1990). This was later modified (mAP). The AP, also based on AIS, assigned all

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AIS grades of 3 or higher to one of three body regions: head/brain/spine, thorax /neck, or other. These injuries were weighted and then combined as a sum. However, the AP has not been widely used.

16.1.4 New Injury Severity Score (NISS) The ISS only takes into account the worst injury in each of the six body regions. The New ISS (NISS) was proposed as a solution to the obvious underestimation of injury severity when facing multiple injuries to the same body region: multiple fractures, multiple intrathoracic injuries, or intra-abdominal injuries (Osler et al. 1997). It is calculated as the sum of the squares of the three most severe injuries, regardless of body region.

16.1.5 ICISS (ICD-9 Injury Severity Score) The use of the International Classification of Diseases (ICD) as a scoring tool was proposed by Osler and coworkers in 1996. The ICISS was the product of each individual possibility of survival for every injury sustained. ICD has the advantage of being the coding system used as a standard by most hospitals in their discharge notes and is thus easily accessible from hospital data registries, saving time and money when compared with the use of AIS coding. Software that converts ICD codes into AIS codes are available. However, the number of codes in AIS is much larger than in the ICD. Another weakness is that version 9 (ICD-9) has been used in the United States, whereas many European countries converted to version 10 (ICD-10) a long time ago. Also, it has been reported that many discharge notes are misclassified.

16.2

Physiological Scoring Systems

A number of physiological scoring systems have been proposed over the years. A driving force has been the desire to predict which patients would benefit from being transported directly to a trauma centre, i.e., field triage. The need of endotracheal intubation, the occurence of low systolic blood pressure (<90 mmHg) and tachycardia have been suggested to relate to the need of emergency surgical procedures, care in the ICU, prolonged hospital

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stay as well as mortality. However, most of these parameters are studied upon arrival to the hospital emergency department, and few studies have been conducted using prehospital data. Field triage algorithms are usually based on physiology, obvious injuries, and mechanisms of injury. Assessment of injuries and especially mechanism of injury have a low sensitivity and specificity. To minimize undertriage, over-triage of up to 50% of patients transported to trauma centers has been accepted. In major incidents, the focus shifts from ensuring the best possible outcome for each patient to ensuring optimal outcome for the greatest number of patients. In this situation, decisions must be made quickly, i.e., providers can spend a minimum amount of time on each patient. During such incidents a nearly linear relation between over-triage and poor patient outcome has been reported (Armstrong et al. 2008). Blood pressure is not a typical part of major incident triage systems because it would be difficult and time consuming to measure during an incident that has affected a large number of patients. Instead, palpable radial pulse, or capillary refill of less than 2 s, has been used as surrogate measures to assess perfusion. It is important to recognize that many systems have moved away from using capillary refill time because it is impossible to measure in the dark and it can be inaccurate when the victim is cold. The outcome of trauma is correlated with the age of the injured patient and with the disturbance of vital functions such as consciousness, blood pressure, respiratory rate, and respiratory effort. Since 1974 the Glasgow Coma Scale (GCS) has been accepted worldwide as the fundamental scoring system for brain injuries (Teasdale and Jennet 1974). Interestingly, most of the GCS’s predictive power is related to the motor component of the score. The precision in assessing GCS varies among different prehospital providers and it has been suggested that only the motor score should be taken into account. The Reaction Level Scale (RLS 85), which basically is a motor score, was introduced in Sweden in 1985 (Starmark et al. 1989). It has been used widely in Sweden, but never gained international acceptance.

16.2.1 Revised Trauma Score (RTS) To assess the injury severity from functional variables reflecting dysfunction in the respiratory,

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Table 16.3 Survival probability (Ps) for integer values of Revised Trauma Score (RTS) RTS 8 7 6 5 4 3 2 1 0

Ps 0.988 0.969 0.919 0.807 0.605 0.361 0.172 0.071 0.027

cardiovascular, and central nervous system, Champion et al. (1980) presented the Triage Index. The Triage Index was modified to include systolic blood pressure and respiratory rate, producing the Trauma Score (TS; Champion et al. 1981) and later the Revised Trauma Score (RTS; Champion et al. 1989). From the beginning, the RTS was developed to predict the probability of survival, irrespective of the age of the injured and the pathoanatomical characteristics of the injuries. RTS is the most commonly used system today. It is computed from the coded values (0 – 4) of the Glasgow Coma Scale (GCS), the systolic blood pressure (SBP) and the respiratory rate (RR), all values obtained on admission to an emergency department. The RTS is defined by the following regression formula, using the coded values of these physiological parameters derived from the Major Trauma Outcome Study (MTOS) data (Champion et al. 1990a). RTS = 0.9368 (GCS) + 0.7326 (SBP) + 0.2908 (RR)

The RTS varies from 0 to 7.84 and can have noninteger values. Survival probabilities for integer values of RTS are given in Table 16.3. As can be seen from the formula, level of consciousness and SBP are stronger predictors of survival than RR. However, the reliance of the RTS on GCS data makes evaluation of intubated patients difficult.

16.2.2 Triage Revised Trauma Score (T-RTS) The ordinary values for the GCS, the SBP, and the RR can be coded as defined in Table 16.4. The sum of the coded values (range, 3–12) then forms the Triage-RTS (T-RTS). The T-RTS is normally 12. A T-RTS less than

Table 16.4 Triage Revised Trauma Score (RTS) coded values for the RTS code GCS 13–15 9–12 6–8 4–5 3

SBP >89 76–89 50–75 1–49 0

RR 10–29 >29 6–9 1–5 0

RTS code 4 3 2 1 0

GCS Glasgow Coma Scale, SBP systolic blood pressure, RR respiratory rate

12 has been used as an indication that the injured patient should be given a high priority and/or sent to a trauma center. Examples of other physiological scoring systems are CRAMS (acronym for Circulation, Respiration, Abdomen, Motor, Speech) (Gormican 1982), the Prehospital Index (PHI) (Koehler et al. 1986), the Physiologic Severity Score (PSS) (Husum et al. 2003), and MGAP (acronym for Mechanism, Glasgow Coma Scale, Age, Arterial Pressure) (Sartorius et al. 2010).

16.3

Combined Scoring Systems

16.3.1 The Probability of Death Score In 1983 the Probability of Death Score (PODS) was introduced based on a logistic regression model using the two highest AIS codes taken from a 19-category coding scheme and the age of the patient (Somers 1983). Its use has been rather limited because it requires information about the fatality rate of the actual victim population under study.

16.3.2 TRISS (Trauma Score, Injury Severity Score) A methodology called TRISS, utilizing both the Trauma Score and the ISS, was developed by Boyd et al. in 1987 to estimate the probability of survival. TRISS also incorporates a weighted coefficient for age as an indicator of physiologic reserve. The Trauma Score was used initially in the TRISS methodology, but was later replaced by the RTS. TRISS offers a standard approach for tracking and evaluating the outcome of trauma care. It estimates the probability of survival during the acute phase, with sufficient sensitivity and specificity in most cases, although it has some

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drawbacks. Its main limitations are the failure to account for multiple severe injuries in one body region and failure to give equal weighting to injuries in different body regions. The probability of survival, Ps, is defined by the following function: Ps = 1/(1 + e - b )

where the exponent b is defined by the regression formula: b = b 0 + b1 ( RTS) + b 2 ( ISS) + b3 ( A )

The constant A is zero if the patient is 54 years of age or younger and one if the patient is older than 54 years of age. The regression coefficients b0, b1, b2, and b3 were originally derived from Walker and Duncan’s analysis (1967) and applied to the MTOS data. They are different for blunt and penetrating trauma. The predictive power of TRISS was not exact and was greatly influenced by the case mix. Also, because the coefficients were based on MTOS data, they have been revised after calibration against other patient populations, such as the National Trauma Data Bank in North America (Schluter et al. 2010). In 2004, the Trauma Audit and Research Network (TARN) in the UK developed a new model, omitting patients less severely injured but including sex and replacing the RTS with the GCS score (Bouamra et al. 2006). In 2007 the coefficients for this model were updated (TARN).

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In this calculation GCS is the Glascow Coma Scale, SBP the systolic blood pressure and RR the respiratory rate. The constants A, B, and C summarize all the serious injuries (AIS ³ 3) in the specific body regions defined in the AP (Copes et al. 1990). The AP component A summarizes all serious injuries to the head, brain, and spinal cord. Component B summarizes all serious injuries to the front of the neck and thorax. Component C summarizes serious injuries in all the other body regions. The value of each component (A–C) equals the square root of the sum of the squares of the AIS scores of its associated injuries. Together, the values of A, B, and C correspond to the number, location, and severity of all of a patient’s AIS grade 3, 4, and 5 injuries. From the beginning, the methodology included a component D, consisting of all injuries graded as AIS 1 and 2 in all the body regions. However, this component could be excluded as it did not influence the probability of survival to any significant degree. The age of the patient is modelled more precisely in ASCOT than in TRISS. Age groups are: less than 55 years, by decade from 55 to 84 years and 85 years or older. The coefficients k1–k8 in the equation are, just as in TRISS, different for blunt and penetrating traumas. ASCOT, however, improved only marginally over TRISS regarding discrimination. Because it is somewhat more complicated to use, its usage has been somewhat limited.

16.3.4 Polytrauma Score 16.3.3 A Severity Characterization of Trauma (ASCOT) ASCOT was proposed in 1990 (Champion et al. 1990b) to solve the limitations of TRISS. It incorporated the 1985 AIS and ICD-9 clinical modification (1977) codes as well as more detailed age classifications. The probability of survival according to the ASCOT methodology is defined by the same exponential function as in the TRISS method. Ps = 1/(1 + e - k )

In this case, the exponent k is defined by the following regression formula: k = k1 + k 2 GCS + k 3 SBP + k 4 RR + k 5 A + k 6 B + k 7 C + k g ( Age code)

In 1983 yet another scoring system called Hannover Polytrauma Score was developed in Germany. From a previous analysis of 696 patients, the researchers found the main prognostic factors to be the severity of the injuries along with the age of the patient. The Polytrauma Score was revised in 1989 to incorporate laboratory parameters such as PaO2:FiO2 ratio and base excess.

16.3.5 Base Excess Injury Severity Scale (BISS) In this Dutch model, the RTS in the TRISS equation was replaced by the first base excess (BE) value because BE is accepted as a sensitive parameter that reflects metabolic derangement and is not subject to interpreter bias (Kroezen et al. 2007).

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16.3.6 Pediatric Trauma Score The Paediatric Trauma Score (PTS) was presented in 1987 (Tepas et al. 1987). The PTS grades injury severity by measuring six components, including body weight, airway status, SBP, mental status, the presence of open wounds, and the presence of bony injuries. The maximum PTS is 12. A comparison was made by Tepas et al. (1988) between the PTS and ISS scores for 615 children entered in the National Pediatric Trauma Registry. Inverse linear relationships were demonstrated between the PTS and ISS and between the PTS and the mortality rate. MTOS data have been used to evaluate the need for pediatric-specific injury scales. Although pediatric patients differe substantially from adults (e.g., distributions of causes of injury, mortality rate, and length of hospitalization), MTOS norms for the adult population were found to be reliable outcome predictors for children.

16.3.7 Other Combined Systems A number of other scoring systems have been developed for predicting mortality among stratified patient groups, most commonly patients who require care in the ICU. Some of these have been applied to trauma patients as well. An example of this kind of system is the Acute Physiology and Chronic Health Evaluation (APACHE), which was applied to ICU patients and later revised as APACHE II and APAPCHE III. There are also a number of specific scoring systems for the adult respiratory distress syndrome as well as multiple organ failure.

16.4

Outcome

16.4.1 Survival In 1982, the MTOS was initiated. It was coordinated by the American College of Surgeons Committee on Trauma. The initial objectives of the MTOS were to develop national norms for trauma care that could be used by hospitals for quality assurance and for the management of emergency medical services systems. As a result, MTOS has provided data for prognostic formulae, enabling the probability of survival to be estimated from pathoanatomical descriptions of

injuries and physiological parameters. Similar work has later been conducted and is ongoing in other countries as well (the UK and Germany), providing the community with data that show the present “gold standard” of trauma care; these studies also help with the evolution and adjustment of predictive scores. There are two evaluation methodologies utilizing TRISS through which the outcome can be judged in each case as well as the outcomes of different patient groups, e.g., data from two hospitals can be compared. The first is called the PRE methodology (Preliminary outcome-based evaluation); the second is the DEF methodology (Definitive outcome-based evaluation). However, it is important to note that the statistical methods used to derive the formulae for survival probability described in this chapter are inherently retrospective, and they should not be used for assessing the prognosis of an individual patient during treatment. The methods are completely dependent upon accurate coding of the type and severity of each injury. Thus, comparisons may be completely misleading because of inadequate training of coders or even using different versions of AIS. In the PRE methodology, the RTS and ISS for a trauma case are used to compare the actual outcome (alive or dead) with the expected outcome. The coordinate pairs of the RTS and ISS are plotted for each patient in the PRE chart diagram. Mathematically “unexpected” outcomes merit physicians’ scrutiny and peer review. The DEF methodology is a statistical comparison of trauma care between institutions based on the so-called Z statistics, originally developed for burn patients (Flora 1978). The statistic Z compares the actual number of survivors (A) in a sample to the number expected (E) in relation to a scale factor (S), accounting for statistical variation. The Z value is the ratio (A – E)/S. Absolute values of Z greater than 1.96 indicate that differences between A and E are statistically significant (P < 0.05). In the UK, comparisons of mortality outcomes among trauma patients in different hospitals are posted on the Internet (http://www.tarn.ac.uk).

16.4.2 Long-Term Outcome and Consequences of Injuries According to the Oxford English Dictionary, outcome is defined as a “visible or practical result.” In most studies in the trauma setting, outcome is

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Scoring Systems Related to Outcome in Severe Injuries

expressed as mortality within 30 days after the event causing the injuries. This standard of reporting does not take into account the victims who die during a later phase. It must also be noted that the longterm effects are important for certain injuries, especially serious injuries to the central nervous system and many musculoskeletal injuries (even those with a low AIS grade). When it comes to describing or scoring the long-term consequences after injuries, the situation becomes even more confused compared with mortality, partially because of the lack of ideal scales for outcome measurement but also because of different opinions about how the consequences should be expressed (in monetary or nonmonetary terms). A large number of scales have been developed over the years. These can be divided broadly into those that measure the doctor’s assessment and those that measure the patient’s own assessment of his or her problems. Whereas the first type is usually used by physicians comparing results of specific treatment modalities for specific injuries, the latter (often referred to as health status, functional status, or quality of life measures) is more often used by health economists, managers, and politicians. When discussing the long-term effects or outcome of injuries, it is also appropriate to consider the definitions laid down by the World Health Organization regarding impairment, disability, and handicap. Impairment is defined as a demonstrable anatomical loss or damage, e.g., restricted movement of a joint. Disability is the functional limitation caused by this impairment, interfering with something the person wishes to achieve. Handicap depends on the environment, where different adjustments or adjuncts can reduce or overcome the disability. Different injuries may cause similar impairments. Restriction of movement may result from injuries to the musculoskeletal system, but neurologic injuries may cause exactly the same result. Also, persistent pain or psychological sequelae may cause various difficulties in living a normal life, which are not easily quantified. It is therefore difficult to find a single scale or score that adequately describes health (or the loss of it) and fits all possible conditions. An ideal instrument should include both objective and subjective assessments and still be simple, quick, reliable, reproducible, and cost-effective. In general, such an instrument does not exist, although many measures have come into general use.

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16.4.3 Organ-Related Outcome Scores A large number of organ-related or disease-related quality of life tools are in place. In general, these have been developed to compare therapies for the treatment of certain diseases or injuries. An example of a frequently used and generally accepted outcome measure following head injuries is the Glasgow Outcome Scale (Bond et al. 1979). This scale assesses survival, social integration, and level of care for daily living using five exclusive levels rather than looking specifically at impairment, disability, or handicap. The Disability Rating Scale (DRS) also scores the outcome after head injury, but on a 30-point scale (Rappaport et al. 1982). The DRS was, not surprisingly, found to be more sensitive compared with the Glasgow Outcome Scale because of the more extensive questionnaire that was correspondingly more time consuming. Other examples of assessment tools for use after head injury are the European Brain Injury Questionnaire, Quality of Life after Brain Injury, and the Rivermead Post-Concussion Questionnaire. Confounding factors in measuring outcome after head injury are, apart from age, icentral nervous system disorders present before the injury as well as the timing of assessment after injury. Assessments are usually performed 1 year after injury, but motor skills and cognitive skills can continue to improve for years after injury. Also, the method of gathering data can influence the recorded functional outcome. Neurological outcome scores all rely on the assessment of social function/handicap rather than detailed impairment and disability. Regarding outcome measures related to other organ systems (thoracic, abdominal, muskuloskeletal), a number of different scales are in use. However, in general, these are more related to diseases than injuries.

16.4.4 Universal Outcome Scales Iin 1972, the Committee on Medical Aspects of Automotive Safety proposed the Comprehensive Research Injury Scale (CRIS or CIS), which included a classification of orthopedic injuries. The CRIS classification was based on the AIS system, but its use for predicting permanent impairment has been quite limited. The AAAM later developed the Injury Impairment Scale (IIS) for the same purpose (States and Viano 1990). The IIS is also based on the AIS

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classification, and it is a prognostic scale of the longterm effects of all types of injuries. In the 2005 AIS the Functional Capacity Index (MacKenzie et al. 1996) was intended to assign the outcome 1 year after the injury occurred. A large number of quality of life scales are in use. They span from a Global Quality of Life score, which describes the general life situation in one single measure; to different health-related quality of life scales. In the latter, the intention is to describe the life situation in a multidimensional profile, usually addressing this by the use of questionnaires. A large number of scales are in use; EQ-5D, WHOQOL-100, 36-item Short Form, and the Nottingham Health Profile are just a few examples.

16.4.5 Psychologic Outcome A proportion of persons involved in accidents, major incidents, combat or who experience other types of extreme stress develop psychological symptoms. In its most severe form, this is described as posttraumatic stress disorder (PTSD) and can cause a high grade of impairment in everyday life among those affected. The incidence does not seem to be correlated to the bodily severity of the injury, but rather to the perceived subjective threat to life. Even though most quality of life scales take into account social relationships and psychological well being, specific scales have been developed to describe psychosocial outcome as well as scales to describe the influence of a certain event on the well-being of an affected individual. The Impact of Event Scale is an example of such a scale.

16.4.6 Problems and Pitfalls Injuries that in the acute phase are considered to be “slight” or “minor” can have a huge impact on an individual’s future health. Whiplash-associated disorders (WADs) are a typical example of such a condition. WADs get the lowest score on the AIS (1), but are by far the most expensive condition from the insurance companies’ perspective – at least in certain countries in the European Union. A proportion of patients seeking compensation for WAD, did not even consider the

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condition to be serious enough to warrant medical examination immediately after the injury. The same applies to psychosocial conditions, such as PTSD. As groups, such patients as described above are much less likely to be included in different hospital-based trauma registries. Thus, to describe the total long-term impact or consequences following injuries, conventional trauma registries do not seem to be the solution for gathering data. When describing the total long-term effect of transport-related injuries on society, it is difficult to use multidimensional profiles. Instead, single-value tools such as the Sickness Impact Profile or the EQ-5D are preferred, or the multidimensional profiles gained by the quality of life tools given above can be converted into a single value. This value/index of health status can then be used in economic calculations. The other method is to study people’s preferences of health status using, for example, visual analog scales, time trade off, or willingness to pay methods. The phrase quality-adjusted life year is frequently used. It is the product of life quality (expressed as a value between 0 and 100) for the remaining life-years multiplied by the life expectancy. Disability-adjusted life years combine the time lived with disability and the time lost because of premature death among a population. The measurement is the gap between the situation in the population and an ideal situation where everyone lives into old age free of disease and disability. Cost calculations might refer to direct or indirect costs as well as the comprehensive costs.

16.4.7 Summary and Conclusions The ideal scoring system does not yet exist. In the prehospital setting, decision schemes for triage and the destination of injured patients to different kinds of medical facilities have been used over a long period of time. Since its first publication by the American College of Surgeons in 1986, the field triage decision scheme has been revised four times. A large number of scoring systems to be used in the hospital setting have also been proposed over the years. In general, many of the parameters needed to calculate these scores will not be immediately available at admission. Apart from detailed information of the injuries sustained, information is also needed regarding

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physiological derangement as well as health status before the incident. The long-term consequences after trauma are, to a large extent, unknown. A large number of scales have come into use. An ideal instrument to evaluate the outcome should include both objective and subjective assessments and still be simple, quick, reliable, reproducible, and cost-effective. In general, such an instrument does not exist. There is no agreement on the best scale or score that adequately describes health (or the loss of it) and fits all possible conditions. Cost calculations as well as other methods of describing the burden of injury on society all have their flaws. Thus, it seems reasonable to use several measures in combination to provide relevant information about the different perspectives after injury.

References Armstrong JH, Hammond J, Hirshberg A, Frykberg ER (2008) Is overtriage associated with increased mortality? The evidence says “yes”. Disaster Med Public Health Prep 1:4–5 Baker SP, O’Neill B, Haddon W, Long WB (1974) The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14: 187–196 Bond MR, Jennett WB, Brooks DN, McKinlay W (1979) The nature of physical, mental and social deficits contributing to the categories of good recovery, moderate and severe disability in the Glasgow Global Outcome Scale. Acta Neurochir Suppl (Wien) 28:126–127 Bouamra O, Wrotchford A, Hollis S, Vaila A, Woodford M, Lecky F (2006) A new approach to outcome prediction in trauma: a comparison with the TRISS model. J Trauma 61: 701–710 Boyd CR, Tolson MA, Copes WS (1987) Evaluating trauma care: the TRISS method. J Trauma 27:370–387 Bull JP (1975) The injury severity score of road traffic casualties in relation to mortality, time of death, hospital treatment time and disability. Accid Anal Prev 7:249–255 Champion HR, Sacco WJ, Hannon DS, Lepper RL, Atzinger ES, Copes WS, Prall RH (1980) Assessment of injury severity: the triage index. Crit Care Med 8:201–208 Champion HR, Sacco WJ, Carnazzo AJ, Copes WS, Foulty WJ (1981) Trauma score. Crit Care Med 9:672–676 Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME (1989) A revision of the trauma score. J Trauma 29:623–629 Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW, Flanagan ME, Frey CF (1990a) The major trauma outcome study: establishing national norms for trauma care. J Trauma 30:1356–1365

361 Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, Gennarelli TA, MacKenzie EJ, Schwaitzberg S (1990b) A new characterisation of injury severity. J Trauma 30:539–546 Champion HR, Holcomb JB, Lawnick MM, Kelliher T, Spott MA, Galarneau MR, Jenkins DH, West SA, Dye J, Wade CE, Eastridge BJ, Blackbourne LH, Shair EK (2010) Improved characterization of combat injury. J Trauma 68:1139–1150 Committee on Medical Aspects of Automotive Safety (1971) Rating the severity of tissue damage: I. The abbreviated scale. JAMA 215:277–280 Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW (1988) The Injury Severity Score revisited. J Trauma 28:69–77 Copes WS, Champion HR, Sacco WJ, Lawnick MM, Gann DS, Gennarelli T, MacKenzie E, Schwaitzberg S (1990) Progress in characterizing anatomic injury. J Trauma 30:1200–1207 Flora J (1978) A method for comparing survival of burn patients to a standard survival curve. J Trauma 18:701–705 Gormican SP (1982) CRAMS scale: field triage of trauma victims. Ann Emerg Med 11:132–135 Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M (2003) Respiratory rate as a prehospital triage tool in rural trauma. J Trauma 55:466–470 Koehler JJ, Baer LJ, Malafa SA, Meindertsma MS, Navitskas NR, Huizenga JE (1986) Prehospital Index: a scoring system for field triage of trauma victims. Ann Emerg Med 15:178–182 Kroezen F, Bijlsma TS, Liern MS, Meeuwis JD, Leenen LP (2007) Base deficit-based predictive modelling of outcome in trauma patients admitted to intensive care units in Dutch trauma centers. J Trauma 63:908–913 MacKenzie EJ, Damiano A, Miller T, Luchter S (1996) The development of the Functional Capacity Index. J Trauma 41: 799–807 Osler T, Rutledge R, Deis J, Bedrick E (1996) ICISS: an International Classification of Disease-9–based injury severity score. J Trauma 41:380–386 Osler TM, Baker SP, Long WB (1997) A modification of the Injury Severity Score that both improves accuracy and simplifies scoring. J Trauma 43:922–926 Palmer CS, Franklyn M (2011) Assessment of the effects and limitations of the 1998 to 2008 Abbreviated Injury Scale map using a large population-based dataset. Scand J Trauma Resusc Emerg Med 19:1, http://www.sjtrem.com/content/19/1/1 Rappaport M, Hall KM, Hopkins K, Belleza T, Cope D (1982) Disability rating scale for severe head trauma: coma to community. Arch Phys Med Rehabil 63:118–123 Sartorius D, Le Manach Y, David JS, Rancurel E, Smail N, Thicoïpé M, Wiel E, Ricard-Hibon A, Berthier F, Gueugniaud PY, Riou B (2010) Mechanism, Glasgow Coma Scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients. Crit Care Med 38:831–837 Schluter PJ, Nathens A, Neal ML, Goble S, Cameron CM, Davey TM et al (2010) Trauma and Injury Severity Scores (TRISS) coefficients 2009 revision. J Trauma 68:761–770 Somers RL (1983) The probability of death score. An improvement of the Injury Severity Score. Accid Anal Prev 15:247–257

362 Starmark JE, Stålhammar D, Holmgren E (1989) The Reaction Level Scale (RLS85), manual and guidelines. Acta Neurochir (Wien) 91:12–20 States JD, Viano DC (1990) Injury impairment and disability scales to assess the permanent consequences of trauma. Accid Anal Prev 22:151–160 Teasdale G, Jennet B (1974) Assessment of coma and impaired consciousness. Lancet 2:81–84 Tepas JJ 3rd, Mollitt DL, Talbert JL, Bryant M (1987) The Pediatric Trauma Score as a predictor of injury severity in the injured child. J Pediatr Surg 22:14–18

P. Örtenwall Tepas JJ, Ramenofsky ML, Mollit DL, Gans BM, DiScala C (1988) The Pediatric Trauma Score as a predictor of injury severity: an objective assessment. J Trauma 28:425–429 Trauma Audit and Research Network. An improved approach to outcome prediction: the solutions. http://www.tarn.ac.uk/ Content.aspx?c=1895 Accessed Aug 28, 2011 Walker SH, Duncan DB (1967) Estimation of the probability of an event as a function of several independent variables. Biometrika 54:167–179

Psychological Crisis Support in Major Incidents

17

Kerstin Bergh Johannesson, Per-Olof Michel, and Tom Lundin

17.1

Introduction

The effects of a major incident will depend on to what extent people have been seriously injured or killed. In some situations there will be few survivors with physical injuries. In other incidents, many more will be affected, which will make the situation harder to manage. This will be the case when a lot of survivors are in distress, when collective interventions are needed, when mass media focus their interest on the incident, and if political consequences are at stake. Today we know more about the risk for long-term sequelae after potentially traumatic events and the need for survivors to be met in a flexible way during the initial aftermath of the incident. The term crisis support means all empathic, practical, emotional, and social support that different societal institutions offer when disasters strike communities.

17.2

Historical Background

Since the time of Hippocrates (460–377 B.C.), different constructs have been established within the medical sciences to describe mental deviations. The Swedish scientist Linnaeus made an effort in 1763 to establish a list of mental diseases in his Genera morborum. Among the affect-related states (morbi pathetici), Linnaeus describes nostalgia, or homesickness, as a longing back to the fatherland or to one’s relatives. He also considers other illnesses that might appear after K.B. Johannesson • P.-O. Michel • T. Lundin e-mail: [email protected]; per.olof@[email protected]; [email protected]

an extreme emotional pressure, e.g., melancholia, panophobia, and anxietas. However, the concept of “nostalgia” was described earlier by Johannes Hofer (1678) as a mental disorder in soldiers with strong urges to return to their homes: “The disease rests essentially on a distorted imagination, whereby the part that hosts these imaginations mainly is affected. This is the inner part of the brain, where the spirits of life wave back and fro through the nerve fibers, in which these images are stored. Once these spirits of life have made their way and widened it, it will be easier, just as during sleep, to use the same route over and over again.” In 1871, the American military physician Da Costa described a heart disease in soldiers and named it irritable heart syndrome. The symptoms appeared in soldiers after many months of active duty and developed into the pounding of the heart, chest pain, respiratory distress, irritableness, or diarrhea. Later, mental breakdown among soldiers during or after combat activities was viewed as secondary to infections in the central nervous system, or shell shock. The shockwave of blasting grenades was assumed to generate anatomic changes in the central nervous system without the appearance of any other neurological signs. The concept of “war neurosis” was described later, during World War I. The accumulated knowledge regarding psychiatric conditions in soldiers with combat sequelae, mental disorders in civilian populations that had been exposed to extreme threats (terror bombings or weapons of mass destruction), and late reactions in individuals who had been incarcerated in concentration camps (KZ syndrome) would be integrated in the Diagnostic and Statistical manual of Mental Disorders (the DSM system) for trauma-related disorders

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8_17, © Springer-Verlag Berlin Heidelberg 2012

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40 years after the second world war. Hence, it took until the second half of the twentieth century, especially as a result of the Vietnam War, to acknowledge posttraumatic stress disorder (PTSD) and its neurobiology and treatment.

or other posttraumatic problems so they can get access to psychotraumatological professionals for examination and treatment.

17.3.2 Major incidents

17.3

Crisis Support: Background

It would be unrealistic to expect that societal support, even if well organized and thoroughly conducted, could bring about swift and total recovery from suffering. The main source of support to manage the consequences of hardships derives from, and rests upon, the individual’s social network of relatives, friends, work colleagues, neighbors, or other persons to whom they feel close. Support from society can and should be only a complement to the individual network, not a replacement for it. Societal support could also fill the role of assisting parts of the network to support the fulfillment of its important function. Simultaneously, it must be easy to get access to different forms of societal support. This requires planning and cooperation between important stakeholders in society. Internationally there are reports of positive experiences regarding the establishment of so-called “Information and Advice Centers.” Such centers rest upon the principles of a “one-stop shop,” which means that survivors would need to turn to only one place in their local community to receive support or to be referred to institutions that can meet their needs.

17.3.1 Holistic View Effective support after a potentially traumatic event presupposes a holistic view of human beings. This implies that the efforts have to rely on knowledge from different complementary areas and hence consider biological, psychological, social, sociopsychological, as well as existential and spiritual factors. Such efficient support can reduce the need for later interventions and treatments. Adapted early support can possibly reduce the risk for individuals to develop mental or somatic problems after exposure to difficult circumstances and support the survivor’s recovery process. However, some survivors still will be at risk for developing mental problems in the long term. It is important to identify individuals who develop PTSD

The general term major incident can be defined as an “event that is so extensive or serious that the societal resources need to be organized, led, and managed in a special way.” Major incidents, therefore, could be used as a generic term within health care, health protection, disease protection, and social services regarding different types of events, including risks for or threats about such events. This means that events that are not directly patient related but still have a high impact on the health care system can be viewed as major incidents. Serious events might call for special demands when it comes to leadership and management of local and regional health care systems. This could be exemplified by an accident in which a lot of people have perished or when the serious event constitutes an apparent, immediate threat to the life of human beings without anyone being physically wounded.

17.3.3 Survivors For many years the emphasis in disaster medicine planning was directed toward strict somatic medical measures. Later, focus increasingly expanded to include all those affected, their reactions and abilities to take responsibility for themselves and others, and, for certain groups, to be able to be leaders. Not only those who are directly affected, such as survivors and their relatives, will show different types of reactions. Other groups of indirectly affected, for instance, health care personnel and other rescue personnel, may show different signs of distress. A serious event could imply different meanings to different individuals or groups and lead to varying posttraumatic reactions. A sound preparedness must embrace all affected individuals or groups, and all efforts must be adjusted to meet the different needs of the survivors. In every major incident it is important to identify those who have been affected both directly and indirectly and into which category they fall. Simultaneously, society must demarcate and undramatize the event for the unaffected or less stricken survivors so unnecessary needs are not created.

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17.3.4 Relatives and Friends Sudden serious events leading to consequences for some – either they survive or perish – will ultimately also affect relatives, friends, and work colleagues. Hence, it is important in the planning phase to consider where, how, and when the needs among individuals in these groups should be met.

17.4

Stress Reactions After Major Incidents

A major incident can evoke transient stress reactions in most survivors. However, for some individuals the stress load will eventually lead to posttraumatic stress reactions. Whether or not such reactions follow depends on not only the quality of the stressor to which one is exposed, but also on a combination of how the event affects the individual’s mental ability to understand, manage, and give meaning to the situation. The individual’s interpretation of the situation and his or her opinion about how to manage it will decide if the event is a real stress factor or not. For this reason, events can be considered as “potentially traumatic.” Depending on type of event, the affected group, and degree of exposure, approximately 5–30% of survivors will develop some form of posttraumatic disorder after a potentially traumatic event.

17.4.1 What Do We Mean by Reactions After Traumatic Stress? Potentially traumatic events will shake the foundation of our view of the world as a safe place and our supposition that we can trust our surroundings. Because these kinds of events are beyond what we have expected, reactions could be activated that can seem strange or deviant. Even if these reactions are unusual and disturbing, they are at the same time typical and expectable and can be viewed as normal reactions to abnormal events. The reactions that could surface after traumatic experiences usually are adaptive and are probably originally developed to help us to recognize and quickly avoid other dangerous situations before it is too late. Sometimes these reactions will abate after a couple of days or weeks after a serious event. Reactions of physi-

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cal stress in a biological organism is called general adaptation syndrome and is usually divided into three phases: alarm reaction, resistance, and exhaustion. The alarm reaction is the immediate physiological response of the organism after a physical stressor, mediated by the activation of the sympathetic nervous system. The resistance phase is a way to try to cope with and to counteract the effects of the ongoing stress. In the exhaustion phase the defences are yielding; the powers run short as energy fades. We try to create meaning and comprehension out of the context in which the event occurs. Consequently, there is always a strong subjective component in human beings’ reactions to traumatic experiences. This is most obviously observed in major disasters, when many are exposed to the same kind of experiences. The term trauma means being exposed to a lifethreatening experience. From an evolutionary point of view, such experiences activate the more primitive parts of the human brain as a defense against threat or stress. Simultaneously, many individuals who have been Stress: The Three Phases of General Adaptation Syndrome

• The alarm reaction: the immediate physiologic response of the organism after a physical stressor, mediated by an activation of the sympathetic nervous system. • The resistance phase: a way to try to cope with and to counteract the effects of the ongoing stress. • The exhaustion phase: defenses yielding and power runs short as energy fades.

exposed to assaults from other human beings or groups that they have trusted will also show the same signs of posttraumatic stress, even if such atrocities were not directly life threatening. Deceit from someone who is depended upon for survival, such as children’s relations to parents, can create the same symptoms seen in more classic life threats. Forgetting can contribute to the preservation of an important and necessary attachment (e.g., during childhood) to increase the possibility of maintaining the attachment. A sense of helplessness is a common feature in all kinds of traumatic situations. Traumatic experiences can be shocking and emotionally overwhelming. It is

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natural for exposed individuals to react in different ways. Some of these reactions are characterized by intense fear, horror, disconnectedness, or helplessness. Such events could have implicated actual death or the threat of death, serious injuries, or sexual or other physical assaults. It could also be about other demarcated events such as natural disasters, fires, brutal assaults, or serious traffic accidents. Other events could be ongoing or repeated, such as domestic violence, child abuse, or neglect. Experiences of war, torture, and political violence are especially severe forms of mental trauma. Usually, mental traumas are also associated with different forms of loss. A special form of trauma is the invisible threat, i.e., the threat that cannot be directly detected by our senses, e.g., nuclear radiation. The mental reactions that follow exposure to invisible threats will, to some extent, depend on the activation of an internal threat reaction, meaning that the external threat will attenuate normal psychological defense mechanisms. Such invisible threat is most often harder to cope with and is composed in a considerably more complex way.

and control. Physical health can be affected by symptoms such as fatigue, headache, and uncomfortable feelings of chest pressure. Individuals who have been traumatized earlier in their lives might, if they are traumatized again, develop reactions such as anger, identity disorders, and physical problems of aches and pains. Other reactions could be difficulties controlling impulses and difficulties with trusting other people.

17.4.2 How to Recognize Traumatic Stress Reactions

17.5

Reactions after potentially traumatic events may vary considerably, from relatively mild to severe and disabling. Bodily reactions such as shaking, trembling, and a pounding heart are common, as are mental reactions in the form of anxiety, fear, horror, feeling that the situation is unreal, and feelings of anger, as well as feeling emotionally shut off and feelings of psychological or social disconnectedness. Problems remembering certain parts of what has happened are common among survivors, but they can also be tormented by fragments of memory that return as physical or psychological flashbacks. Nightmares about the event are common, as are depressive and irritable states, sleeping problems, decreased ability to think clearly, exaggerated vigilance, and increased muscular tension. Surviving a disaster in which many people have died can also bring about a complex of existential guilt problems, termed survivor’s guilt. That, in combination with re-experiencing the trauma in the form of flashbacks or nightmares, is probably the most typical sign in the immediate aftermath of a disaster. A potentially traumatic event may be perceived as a threat to the individual’s personal feelings of safety

Common Stress Reactions

• Affective disturbances: anxiety, depression, feelings of guilt • Physical disturbances: trembling, muscle tension, problems talking • Cognitive disturbances: problems thinking clearly, problems with concentration • Physiological changes: increased production of cortisol, a pounding heart, increased blood pressure

More Severe Symptoms

Human beings create meaning with regard to the setting in which an event occurs. Hence, a strong subjective component affects humans’ reactions to traumatic events. Objectively, this becomes apparent in major disasters in which many individuals are exposed to the same event. Differences in individuals’ reactions most probably have an origin in different personalities or previous personal history which can affect how the experience is perceived by the victim. A traumatic stress reaction in the acute phase might, in some individuals, develop into an acute stress disorder (ASD). To fulfill the criteria for this diagnosis, an individual must have suffered for at least 2 days – up to 4 weeks – and the difficulties must have appeared within 4 weeks following a traumatic event. Those in the acute phase who develop more severe reactions, e.g., ASD, will be at a higher risk for suffering from PTSD as well. Hence, it is essential to identify individuals with severe reactions during the acute phase to refer them for professional assistance. ASD is characterised by intense fear, helplessness, or horror in combination with at least three out of the following symptom groups: • A subjective sense of numbing, detachment, or absence of emotional responsiveness

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• A reduction in awareness of his or her surroundings (e.g., “being in a daze”) • Derealization • Depersonalization • Dissociative amnesia (i.e., inability to recall an important aspect of the trauma) ASD also is characterised by a continued recollection of the trauma that evokes memories as well as symptoms of anxiety or arousal.

17.6

Posttraumatic Stress Disorder

The PTSD is a psychiatric diagnosis describing distress following a traumatic event. This is a condition that involves considerable distress and might even turn into a life-limiting handicap for those who suffer from it. International studies show a prevalence that varies between 1% and 9% among a given population. Among exposed groups the risk of being affected is 5–30%. The risk is increased in connection with interpersonal violence, such as physical assaults, but also in the case of traumatic losses of close relatives. There is also a high prevalence of comorbidity with other psychiatric disorders, such as depression, other anxiety disorders, and drug abuse. For the PTSD diagnosis to be applicable, the individual must have been exposed to an event or situation charged with exceptional threat or disastrous elements that most likely would cause serious distress in most human beings. The most common symptoms of PTSD are: • Recollection of recurring, intrusive memories of the traumatic event, either while awake or as nightmares; • Avoidance, meaning that the affected individual tries to avoid all reminders of the trauma, which in turn can lead toward a tendency of isolation from family, friends, or work colleagues; another avoidance aspect is memory loss, either total or more often limited to the time period right before, during, or after the trauma • Hyperarousal, meaning an abnormal startle reaction, being irritable, unjustified outbursts of anger, problems with concentration, or sleeping problems. Anxiety and dissociation are other disorders that could develop after traumatic events, as are psychosomatic conditions or somatic problems such as high blood pressure. In situations of traumatic loss it is important to separate the reaction from the event (posttraumatic stress reaction) from the reaction

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following the loss (grief reaction). Both reactions can occur simultaneously. However, the traumatic experience is considered more detrimental for health than the loss in itself.

Posttraumatic Stress Disorder The person must have been exposed to a stressful event in which he or she experienced, witnessed, or was confronted with actual or threatened death, serious injury, or threat to the physical integrity of self or others. The person’s response involves intense fear, helplessness, or horror.

Persistent Re-experiencing • Recurrent and intrusive recollections • Recurrent distressing dreams • Intense distress when exposed to cues that resemble the trauma • Physiological reactivity when exposed to cues that resemble the trauma Persistent Avoidance • Avoids thoughts, feelings, conversation, activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affects (e.g., unable to have loving feelings) • Sense of foreshortened future Persistent Symptoms of Increased Arousal • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response Duration of the disturbance is more than 1 month and causes clinically significant distress or impairment in social, occupational, or other important areas of function.

368 Processes over time

Chronic 5−30% Delayed 0−15%

Low Function level

Fig. 17.1 Trajectories (freely adapted from Bonanno 2004; Bonanno et al. 2006; Norris et al. 2009, with permission)

K.B. Johannesson et al.

Recovery 15−25% Resilient 30−60% Stress resistant

High

Time

17.6.1 Risk Factors for Posttraumatic Stress Reactions The risk for posttraumatic stress reactions increases with the degree of seriousness of the exposure. In other words, chronic or repeated traumatization is harder to handle than exposure to one limited event. The seriousness of the event, actual life threat, and lack of social support during the aftermath often are seen as the most prominent risk factors for posttraumatic stress reactions. Responding with exaggerated mental reactions during a traumatic event, female sex, and younger age are other examples that are correlated with an increased risk for PTSD. The increased risk for children is sometimes viewed as an effect of lack of knowledge among caregivers about children’s special needs and children’s ways of interpreting the outer world. Children sometimes interpret causal connections between their fantasies and the events they experience. The ability of children to think abstractly is not fully developed and, as a result of less life experience, children do not have the same capacity to perform prospective thinking. During traumatic events children’s basic feelings of safety are threatened. In major disasters there sometimes is a risk of “forgetting” the children – usually because of their quieter reactions. When older adolescents are affected by traumatic events they suddenly and unexpectedly are confronted with the fact that life is not endless. During this development period, fantasies and imaginations about their own invulnerability are not uncommon. Hence, traumatization might cause a more thorough effect on personality. Furthermore, intelligence, level of education, lower socioeconomic status, or minority status are also quoted as risk factors. An increased vulnerability is noted among individuals with a history of earlier exposure to physical assault, neglect, or sexual abuse. Personality

will also affect the acute reaction to trauma. Another factor that might be problematic when experiencing a traumatic event is if the survivor already is dealing with another parallel situation in life that is distressing.

17.6.2 Resilience The focus of the section above was risk and risk factors. About 60–80% of a population will be exposed to a potentially traumatic event during their lifespan. However, it has become understood recently that only a minority of these are at risk of suffering from posttraumatic stress reactions. It has thus been found that a relatively large proportion of survivors will instead show stress resistance or resilience in the face of trauma. Stress resistance means keeping balance through and after a serious event, whereas individuals with resilience may experience a decrease in function from which they recover quickly. Resilient individuals are often equipped with a positive view of their own selfefficacy, which might reflect a stable and safe basic personality that in most cases will be protective. They also seem to have access to social support. Social support alone has in many studies been demonstrated as one of the most important protective factors against PTSD.

17.6.3 Trajectories The knowledge regarding the trajectories over time after disasters has increased during recent years. As mentioned above, a substantial portion of individuals who survive disasters will show stress resistance and resilience (Fig. 17.1). Others will experience different reactions but will recover over a longer period of time. A small proportion will instead develop symptoms

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over time. In addition, some survivors will develop chronic disorders such as PTSD, complicated grief, anxiety disorders, depression, or drug abuse. This knowledge is of great help when organizing support for survivors in the aftermath of disasters.

17.7

Crisis Support

To organize effective support in the aftermath of a disaster, five empirically supported intervention principles have been identified. These principles are applicable on different levels, from health care personnel and the community level to first responders’ measures. The principles are to promote: • A sense of safety • A sense of self- and community efficacy • Connectedness • Calming • Hope Individuals who survive a disaster have different needs. This will be the case in the short and long term, depending on the type of event and the actual circumstances. In the acute situation, which often will be chaotic, and when limited resources are available, it is still possible to identify some needs from the survivor’s point of view. Even if all needs seem to be important, it will become necessary to prioritize the individuals’ different needs. Some survivors also will need help to formulate their specific needs.

17.7.1 On Site The acute situation following a disaster is to a large extent characterized by insecurity and uncertainty. It will sometimes take many hours or even days before correct information is available about what caused the disaster or about identification of perished victims. While waiting for official information, survivors need human support characterized by empathetic closeness and basic safety and security. The main goal for professional first responders during this first stage of support is to form a sound base for continued support over time. The first support response will obviously be performed by other survivors, mainly those who are stress resistant or resilient, by witnesses, and then later by professional responders. All professional first responders

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should be trained in psychological first aid to perform an efficient support. All support on site must be characterized by human decency and a sense of wanting to help survivors with their primary needs of safety, protection from cold or heat, something to drink, or rest. Survivors should continually be updated with correct information presented in a discreet manner. Family members should be kept together. Furthermore, it is essential that survivors are protected from new strong impressions, intrusive mass media representatives, or curious general public. Note

• Move survivors to a secure place • Protect survivors from cold or heat, give them something to drink, and allow them to rest • Provide correct information • Keep families together • Protect survivors from new strong impressions, intrusive mass media representatives, or an inquisitive general public

17.8

Psychological First Aid

Psychological first aid (PFA) is an adjusted way to support survivors after disasters or terrorist attacks. It focuses on safety, the unique needs of the survivors, and social support. PFA presupposes flexible planning and trained health care personnell and community responders . It can be performed on site, in community rescue centers, hotels, airports, or other ad hoc sites. Some core aspects of PFA are discussed below. For more information, see the reference list.

17.8.1 Contact and Engagement The base for support is to establish contact with survivors in an empathetic and discreet way. This contact is essential and might influence the survivors’ view of and acceptance of future support. For personnel, presenting themselves to those they are serving is paramount. It is beneficial for first responders to wear some sort of clothes, signage, or other features that show their status of belonging to an official support organization that is sanctioned by society.

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Sit down while talking or be at the survivor’s eye level to relate in a basic way. Other ways of establishing contact include asking about the individual’s needs or how one can be of service. Responders or personnel who give survivors their full attention, remain calm, use stable eye contact, and avoid distractions when talking to survivors add to the appreciation of contact and engagement. A responder should refrain from being intrusive. For instance, personnel should not pressure survivors to disclose detailed stories about experiences, feelings, thoughts, or losses that she or he is not ready to talk about. However, responders should listen when survivors have the urge to tell about their experiences without being either discouraging or intensely encouraging.

Note

• Present yourself • Ask how you can be of help, not if the survivor needs any help • Give your full attention and stable eye contact • Do not be intrusive, but be ready to listen

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comfort. This will also be supported by access to social support and information about what has happened to other family members and friends that also have been exposed to the disaster. Information must be balanced and well grounded to promote feelings of safety. Such information needs to be repeated because traumatized individuals have a decreased ability to assimilate information. Correct and clear information counteracts a tendency to build up frightening fantasies about what has occurred.

Note

• Promote safety and comfort • Help survivors away from the disaster site to a more comfortable place • Anchor survivors in the “here and now” • Inform survivors about what is known • Repeat information even if there is no new information • Do not promise more than can be delivered

17.8.3 Calming and Stabilizing

17.8.2 Sense of Safety and Comfort To decrease the risk of physical reactions to ongoing fear or distress, it is essential for personnel to promote a sense of safety and comfort. Stress will also affect cognitive functions such as thinking. The traumatic experience will challenge the survivor’s views of the world as safe and the notion that he or she can trust the surroundings. Instead the situation is experienced as threatening or dangerous. Hence, information on different levels – individual, group, and societal – is important. On the individual level, this could, for example, mean that personnel try to help the survivor to identify at least the present situation as stable and safe and remind him or her of functioning coping strategies. Independent of what measures are viewed as adequate, it is paramount to convey a sense of safety and comfort when informing survivors about immediate support, treatment, or continued support. On the group level, the first measure is to get the survivors out of the threatening situation. Support that provides basic needs, protection from heat or cold, food and beverages, or recognition promotes a feeling of safety and

Trauma experiences often activate strong reactions and feelings. Increased tension and vigilance are not uncommon reactions among some survivors, whereas others may react with numbing. During the acute phase such reactions could be viewed as ways to try to adapt. It is important that interventions also emphasize calming and stabilization. Normalizing stress reactions are a central principal to calm and stabilize. Correct information and information about common reactions can reduce the development of negative thinking and rumination. Giving advice about improving sleep habits, eating well, consuming sufficient beverages, engaging in physical activities, and avoiding coffee and alcohol can contribute to stabilization. Simple relaxation techniques such as deep breathing, inner visualisation of calm and safe places, or comforting role models can contribute to a reduction in distress or muscle tension. It also has been shown that reducing the time that is spent watching the news or reading about the traumatic event can lessen the traumatic burden. For children and adolescents, special interventions are needed to stimulate coping strategies to regulate feelings and manage problems. Encouraging return to school work should be high up on the to-do list. In some individuals

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pharmacological interventions might be helpful to increase calmness and stabilization. However, caution is advised when using benzodiazepines; these specific drugs could initially create some calmness but could increase the risk for later PTSD.

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feeling of control. Underestimating needs or problems, formulating unrealistic expectations about recovery, or conveying a lack of trust regarding the survivor’s ability to recover correlates with posttraumatic reactions over time.

Note

Note

• Normalize stress reactions; for instance, confirm common reactions • Give advice about physical activities such as taking walks • Give simple advice about food and beverages and the avoidance of coffee and liquor • Give advice about reducing time spent watching the news or reading about the event • Inform about simple relaxation techniques

• Support survivors’ own abilities • Encourage survivors to be active in supporting others • Support daily routines and the survivor’s own initiatives • Help survivors break down problems into manageable units • Confirm people’s problems seriously • Help form realistic expectations • Convey faith in survivor’s own abilities

17.8.4 Positive Coping

17.8.5 Connectedness and Social Support

Traumatic experiences can make people loose faith in their own ability to manage problems. Such feelings of helplessness are often connected to trauma exposure. Hence, it is important to counteract this by strengthening the survivor’s own abilities by, for example, promoting positive coping strategies. First responders have to try to promote hope and positive expectations despite all the difficulties the survivors are facing. When exposed to threats there are two main ways of coping: emotional and problem-focused coping. With emotional coping, emotional reactions and psychological processing are the dominant ways of managing the threat. With problem-focused coping, the cognitive functions dominate; survivors try to explain what happened in technical terms and strive to solve upcoming problems. Depending on personality traits, one of these models may dominate in an individual. Coping promotes a feeling of control and brings about hope. Successful coping depends on general resources that promote recovery, such as ego strength, material welfare, cultural stability, and social support. These resources enhance power to battle different stress reactions. One way of promoting coping is to maintain daily routines and to take part in usual activities. For some it will help to find ways of supporting others. Problemfocused coping is also about breaking down problems into manageable units, which in turn will increase the

During hardships it is essential to be connected to loved ones and gain the benefits of social support from close relatives. In many studies and in different cultural settings, a lack of social support has been found to be a risk factor for mental illnesses. A helpful idea is to stay in contact with one’s natural daily social context, whether that is family, friends, other relatives, work colleagues, neighbors, associations, or faith communities. Hence, it is important not to separate families after traumatic events. Information given to survivors about society’s responses to an event might reduce a sense of vulnerableness and strengthen the feeling of belonging in a social context. Note

• Keep families together • Help survivors get in contact with their relatives • Inform survivors about what is being done by the society as a response to the traumatic event

17.8.6 Hope Individuals who are able to maintain an optimistic view have a better ability to recover. This will help

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them to retain a reasonable hope about the future. It is crucial to inspire hope because the world view of the survivors might have been crushed, just like their sense of a having any future. This might lead to feelings of despair, meaninglessness, and resignation. Hope can be transmitted in many ways. Personnel should try to keep an optimistic and hopeful attitude when approaching survivors. Many survivors will develop catastrophic cognitions, a thought process pervaded by feelings that everything is meaningless or that nothing will be normal again. To challenge such thinking is important to preserve and repair hope. Catastrophic cognitions are normal reactions about which survivors should be informed. Pointing at realistic possibilities for recovery, however demanding they may be, can have awarding effects. Note

• Convey hope • Support survivors in how to withstand uncertainty • Demonstrate an optimistic approach • Indicate possibilities for a balanced recovery

17.8.7 Follow-Up First responders have an obligation to make sure that those who have been supported will be followed up by societal support organizations. Such follow up could be managed through a responder’s own organization, through special Information and Advice Centers or by survivors own general practitioners. The most important aspect regarding follow up is to clarify the directions of the survivor’s reactions. If initial reactions abate, they will probably diminish by themselves. However, if the reactions remain on the same level, if they increase, or if they are especially problematic, the individual should be assessed for treatment.

17.8.8 When Do Survivors Need More Extended Support? For most survivors reactions will gradually wither. The natural social network – family, friends, and work colleagues – often constitute the best support. For some survivors the reactions will turn into worsening

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symptoms. Hence, some will use strategies that do not promote health: withdrawal, isolation, self-medication with alcohol, or avoiding activities that normally would be stimulating, all of which provide feelings of being in control. A development toward depression, increased anxiety, or extensive alcohol use could be signs that treatment is needed.

17.8.9 Support for Special Groups When managing severe situations certain groups of survivors require special attention, which has to be considered when coming across them as a first responder. These groups include children, adolescents, bereaved relatives and friends, survivors with physical injuries, or people with another cultural background.

Children and Adolescents After disasters, special attention has to be given to the specific needs of children and adolescents. Even in cases where no children or younger people are among the survivors, one has to be aware that there probably will be some among the close relatives. This means that a child’s perspective needs to be present already in the disaster management planning phase. Hence, individuals who are experienced with and competent in dealing with child trauma are necessary in societal support structures. In the immediate aftermath of a disaster it is important to get early overview regarding the following questions: • How many children are involved in the event? • Where are they? • Where are their family members? • Who will take responsibility for a child if both parents have been badly injured or killed? • What information is essential to inform children and adolescents? The principal guidelines for supporting children are essentially the same as for adults: children need security, comfort, and information. If possible, parents or other close relatives are those who will best give this support. Hence, some of those individuals in their turn may need information about how they can care for their children and adolescents. In addition to family support, some children and adolescents might need individual support or support through taking part in group meetings with other children or adolescents. Informational meetings, support engagement, farewell

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or memorial ceremonies, or other gatherings need to be adjusted to the needs of the children and adolescents who are present. It is advisable to have support personnel around who can focus special attention on the needs of these children and adolescents. Furthermore, written information that is specially designed for children and adolescents is needed. Such information should be concrete and practical. Children are more preoccupied with actual problems; not until a later age do they become more aware of the consequences over time.

Relatives and Friends Losing someone close in a traumatic event is a hard emotional experience for anyone. First responders have to be aware that everybody they come into contact with – survivors or deceased – has relatives and friends. It is essential to pay attention to relatives and friends and follow the principals of PFA when supporting them.

Physically Injured Psychological support is an essential part of the management of the physically injured. Severe injuries induce considerable distress and increase the patient’s vulnerability to mental illnesses. In addition to physical pain, the level of stress hormones will be enhanced by uncertainty, insecurity, and fear. To the utmost degree, treatment has to be performed in cooperation with the patient. A calm patient who feels safe will recover more quickly. The start of the recovery and convalescence process is facilitated if it is based upon a comprehensive approach with adequate information provided to the patient and his or her relatives. Familiarity with common reactions after traumatic events is important for concerned personnel, but it can also be of help for the particular patient to get a perspective on his or her healing process. Groups of patients with more complex situations need a long period of rehabilitation. Such groups of patients can be those with severe spine or burn injuries, amputations, or other severe conditions, where the road back to a normalized life can be both long and uncertain. Pain, insecurity about the future, and loss of function can induce serious distress that can lead to the development of PTSD or depression. Sudden losses of close relatives is shocking for survivors. It is an important and responsible task for medical personnel to support bereaved persons by helping them to turn the unreal into something real, e.g., by preparing and

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making it easier to see their deceased loved ones. Access to counselors, psychologists, or representatives of faith communities serving at hospitals is important for the patients but also an important source of support for health care personnel. This applies to both to the acute phase and over time. Other personnel such as physical or occupational therapists are all valuable resources, especially during the rehabilitation phase. The recurrent sessions with, for example, a physical therapist can be more relaxed and undemanding since these meetings do not have the direct aim to disclose feelings about the event.

17.8.10 Cultural and Religious Diversity In many countries nowadays individuals have grown up in or have a cultural background other than that of the country in which they live. Hence, in these societies after traumatic events there will be increased need for different cultural and language competences. Crises that occur in multicultural environments or that in other ways involve different ethnical groups will often demand other ways of management than what has been planned or rehearsed. Primarily, to avoid misunderstandings and mistrust between the survivors and societal institutions or between different groups in society, there will be demands for increased informational activities with regard to both the acute and the followup phases. Lack of knowledge about how society functions and questionable operations of police or rescue services can obstruct the direct rescue operation and the way survivors try to manage the incident. Individuals with immigrant status might also carry experiences from their original countries that will affect their reactions. In different cultures or religions there are different norms and rules for how to react to and behave in critical life situations. This could be the case when it comes to emotional expressions of grief and despair, how to take care of the injured or dead, or how to organize funerals. Therefore it is crucial to incorporate individuals with suitable cultural competence among rescue personnel. When serious events occur in areas densely populated with immigrants, it will also be necessary to produce information in languages other than the official one. Local radio broadcasts and different immigrant associations’ information channels will be important ways to disseminate information. The same goes for different faith communities.

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In these communities there are individuals with language and cultural competencies, and their premises also can be used as places in which to meet or for distributing information. In some places major immigrant groups mainly use news sources distributed by satellite from their original countries and will not have access to national news. In areas that are densely populated with immigrants, access to interpreter services will be crucial for efficient crisis support during the acute phase as well as in the long run.

17.8.11 Rites and Customs In all cultures rites and customs have important functions. Rituals are expressions of needs and defense. At the same time, individual reactions will be influenced by the prevailing cultural patterns. To follow certain customs and rituals will implant feelings of comfort in situations of internal chaos. Rites can decrease anxiety during periods of grief by offering explanation systems. What seems hard to comprehend might, through concrete and symbolic actions, become easier to understand. The ritual may also confirm a development that is predetermined and thereby serves as consolation.

17.8.12 Seeing Deceased Loved Ones It can be important for many relatives to have the possibility to see the deceased. This can help make the unreal more real and thus enhance the relatives’ ability to work through their grief. The imaginations about what the dead body might look like can be more frightening than reality. If the remains are badly injured it is recommended that those parts be covered and only enough of the body be shown to enable the relatives to identify the deceased. Sometimes the remains are in such a poor condition that it is impossible to identify them; then it is proper to advise against any inspection. Children should not be forced to attend, but one should be aware that children’s reactions often mirror those of the adults. Some relatives will need support when they are about to see the deceased, especially in cases of badly injured remains. Those responsible should check the remains beforehand. It is also recommended to inform the relatives about what they are about to see before they enter the show room. Such events should be

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performed in an environment of dignity and with respect for the integrity of the deceased. The arrangements must show consideration of ethical values as well as cultural and religious differences.

17.9

Treatment

There are three treatment orientations to be considered when treating PTSD or other trauma related disorders: psychosocial, psychological, and pharmacological. The focus of the treatment of these conditions can be different. Different aspects for treatment are primarily the psychological consequences; others concern behaviors, unspecific symptoms, or decreased levels of function. Psychotherapy is the primary choice of treatment for PTSD. Among the psychological consequences, the most prominent are the intrusive recollections: memories, thoughts, images, or other sensory impressions (flashbacks). The primary treatment methods for these symptoms, as for recurrent nightmares about the traumatic event, are psychological – sometimes enhanced by pharmacological support. Behavioral symptoms of PTSD primarily depend on an aspiration to avoid the discomfort that is activated by cues that act as reminders of the event. This can be evidenced by numbing – an inability to feel or express emotions. In such cases psychosocial or psychological treatment methods can be used. Pharmacological treatment is primarily focused on unspecific mental symptoms and on comorbid mental illnesses, e.g., anxiety and depression.

17.9.1 Psychological Treatment The most studied treatment models for PTSD and other trauma-related conditions are the trauma-focused therapies, with or without cognitive elements. These treatment methods are ongoing for limited periods of time, normally between eight or 12 sessions. Psychoeducation and techniques for stress management are other components about which clients are informed within the framework of treatment. In behavioral therapy, exposure is an important component. This means that the client is trained, under supervision, to expose him or herself gradually and with support to situations or cues that are reminders of the feared event. Through such

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exposure the distress gradually decreases and becomes manageable. Cognitive behavioural therapy (CBT) was developed in the early 1970s for treating depression and later anxiety conditions. In CBT, behavioral therapeutic techniques, such as exposure, are used, but in addition the negative and unrealistic cognitive patterns that are connected to the trauma-related stress condition are challenged. Doing homework is also an essential part of the treatment. Eye movement desensitization and reprocessing (EMDR) is a psychological treatment method aimed at processing the memories from the traumatic event and thereby relieving the symptoms. This method integrates elements from different psychotherapeutic orientations, such as cognitive, behavioral therapeutic, psychodynamic, as well as body-oriented therapeutic interventions.

ability for psychological treatment. Benzodiazepines should be avoided, in part because of the risk for dependency and in part because the use of such drugs might counteract the possibilities for psychological processing. Serious problems with insomnia or major disturbances in dreaming patterns in acute PTSD may need to be treated before any psychological treatment will be possible. When treating sleep disorders that have a clear connection to a traumatic event, it is important to examine sleep patterns, including dreams and the type of sleep disturbance (e.g., problems falling asleep, disturbed or broken sleep, or shortened sleep/early awakening). When sleep is disturbed or broken, propiomazine could be preferred because it has been shown not to affect normal sleep patterns. Problems falling asleep during the acute phase can be treated beneficially with zopiclone.

17.9.2 Pharmacological Treatment

17.10 Self-Care

The medical drugs that primarily are used in the treatment of unspecific symptoms of PTSD are the same as those used in the treatment of anxiety disorders and depression, e.g., selective serotonin re-uptake inhibitors. In complex PTSD, when there are psychotic symptoms present, common antipsychotic drugs are used. In situations of extreme hyperarousal, favorable effects can be achieved by the use of b-blockers. Pharmacological treatment can also have positive effects on symptoms like avoidance and intrusive memories. In both cases, the drugs can decrease anxiety, which in turn can reduce the “need” for avoidance or reduce emotional pain caused by intrusive memories. This can lead to the increased possibility of psychological processing either spontaneously or within a psychotherapeutic treatment setting. The choice of what medication should be used is primarily determined by what symptoms in particular need to be treated. Important considerations in such cases could be the symptom levels and the necessity of symptom reduction or elimination to facilitate or potentiate psychological treatment. Some symptoms are so painful, especially those that are related to psychophysiological changes and thus part of the normal reaction, that pharmacological treatment is required. In such situations it is imperative to use medication that does not interfere with the

Another aspect of traumatic events is that those who support survivors of disasters also are exposed to traumatic stories. Among this group there are prehospital personnel, physicians, nurses, fire fighters, police and other rescue personnel, as well as psychologists, counselors, and other groups that offer support, counseling, and treatment after the disaster. All these groups are at risk of being exposed to overdoses of human suffering and can be afflicted with secondary traumatization, burn out syndrome, or compassion fatigue. Through their competence, experience, and routine, health care personnel, rescue personnel, police, and other first responders are somewhat protected against major emotional hardships while working with traumatized and injured people. Education and training will also add to such hardiness against stress. Being mentally prepared before exposure to hard and challenging tasks will also armor them before they meet traumatically injured or deceased human beings. Sometimes an overwhelming reality will penetrate even such professional protection. This might happen following an unexpected development in the process or facing some detail that has a personal meaning that makes it difficult to keep a professional distance. Stronger mental reactions might develop after participation in rescue operations. Sequelae can be avoided by training and preparations before such assignments

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and through a well-prepared follow up after the disaster. The risk for secondary traumatization is not limited to groups of professionals among whom exposure is common. Other groups, such as people who work within judicial systems or news reporters and photographers, also are at risk.

17.10.1 Taking Care of Oneself Working with trauma is mentally exhausting, and those who are doing this kind of job need to consider how to take care of themselves. Time for rest, reflection, and recovery are all important during and after such efforts. Physical activity also promotes health.

Before Demanding Operations Preparations through education and training will increase the ability to endure when necessary. Belonging to an efficient organization that utilizes distinct routines can reinforce the sense of control in the presence of serious tasks. Good leadership is especially important in chaotic situations like accidents or disasters. Professional security and safety are enhanced by the sense of belonging to a team of members working together toward common goals. During Operations Being mentally prepared will contribute to safer management of the situation. This means that available facts about the disaster have been presented and discussions about how to deal with the situation have been carried through. Furthermore, responders have thought about their own role and the hardships that lay ahead. To hold back one’s reactions can be helpful for keeping necessary distance to function rationally and stay focused. Limiting one’s exposure is another strategy, as is using self-increasing comments. By staying active, knowing what to do and to performing well will increase a sense of control.

After the Operation A particular and engaging human effort will leave the body and mind in an activated condition. This could lead to a situation where first responders have lowered the need for boundaries for their own workload. The need for rest and recovery are not prioritized. Reactions will most often appear after responders are relieved of their work shift or when the work is

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finished. Such signs can be tension in the body or problems relaxing. Relaxation, physical activity, or training will promote health, as will contact with colleagues and coworkers. It is necessary to create clear borders between what belongs at work and what is private. In many professional groups nowadays, time is spent on informal time-out sessions and/or a formal round-up session to conclude the efforts that have been made. Coworkers who suffer from stress reactions or who have other problems must be followed up individually. Leaders have a crucial responsibility in such cases.

Further Reading Andrews B, Brewin CR, Rose S (2003) Gender, social support and PTSD in victims of violent crime. J Trauma Stress 16(4):421–427 Bergh Johannesson K, Stefanini S, Lundin T et al (2006) Impact of bereavement among relatives in Italy and Sweden after the Linate airplane disaster. Int J Disaster Med 4:110–117 Bergh Johannesson K, Lundin T, Hultman C et al (2009) The effect of bereavement on tsunami-exposed survivors. J Trauma Stress 22:497–504 Bisson J, Brayne M, Ochberg FM et al (2007) Early psychosocial intervention following traumatic events. Am J Psychiatry 16:1016–1019 Bonanno GA, Galea S, Bucciarelli A et al (2006) Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack. Psychol Sci 17(3):181–186 Brewin CR, Andrews B, Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in traumaexposed adults. J Consult Clin Psychol 68:748–766 Bryant RA, Harvey AG, Guthrie RM et al (2003) Acute psychophysiological arousal and posttraumatic stress disorder: a two-year prospective study. J Trauma Stress 16(5):439–443 Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, Watson P, (National Child Traumatic Stress Network and National Center for PTSD), Psychological First Aid: Field Operations Guide, 2nd Edition. http://www.nctsn. org; http://www.ncptsd.va.gov. July 2006 Foa EB, Keane TM, Friedman MJ et al (2009) Effective treatments for PTSD. Practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press, New York Friedman M, Keane TM, Resick PA (2007) Handbook of PTSD. Science and practice. The Guilford Press, New York Galea S, Ahern J, Resnick H et al (2002) Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 346:982–987 Halpern J, Gurevich M, Schwartz B, Brazeau P (2009) Interventions for critical incident stress in emergency medical services: a qualitative study. Stress Health 25:139–149 Hart DS, Orner R (2005) New values in reconstructing early interventions after trauma. ISTSS Trauma Stress Points 19:2–6

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Hobfoll SE, Watson P, Bell CC et al (2007) Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence psychiatry: interpersonal and biological processes. Psychiatry 70:283–315 Lundin T (1994) The treatment of acute trauma. Post-traumatic stress disorder prevention. Psychiatr Clin North Am 17(2): 385–391 Lundin T, Jansson L (2007) Traumatic impact of a fire disaster on survivors – a 25-year follow-up of the 1978 hotel fire in Borås, Sweden. Nord J Psychiatry 61(6):479–485 Michel PO, Rosendal S, Weisaeth L, Heir T Use of and satisfaction with support received among survivors from three Scandinavian countries after the 2004 Southeast Asian tsunami. Eur Psychiatry 2011 Jan 28 (Epub ahead of print) National Institute of Clinical Excellence (NICE) (2005) The management of post-traumatic stress disorder in adults in primary, secondary and community care. Clinical guideline

377 26. National Institute of Clinical Excellence, London, http:// www.nice.org.uk. ISBN 1–84257–922–3 Norris FH, Tracy M, Galea S (2009) Looking for resilience: understanding the longitudinal trajectories of responses to stress. Soc Sci Med 68:2190–2198 Pynoos RS, Goenjian A, Steinberg AM (1998) Strategies of disaster intervention for children and adolescents. In: Hobfoll SE, de Vries M (eds) Extreme stress and communities: impact and intervention. Kluwer, Dordrecht, pp 445–471 Serralta-Colsa D, Camarero-Mulas C, Garcia-Marin AM et al (2011) Functional outcome and quality of life in victims of terrorist explosions as compared to conventional trauma. Eur J Trauma Emerg Med 37:31–36 Shalev AY (1999) Psychophysiological expression of risk factors for PTSD. In: Yehuda R (ed) Risk factors for posttraumatic stress disorder. American Psychiatric Press, Washington, DC, pp 143–161

Education and Training

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Sten Lennquist and Kristina Lennquist Montán

18.1

The Need for Education and Training

Chapter 1 has already given a description of the specific knowledge and skills – in addition to those needed for routine medical care – required for accurate management and performance in the medical response to major incidents (MIs), which includes the ability to: • Perform triage in situations where the immediate need of medical care exceeds available resources even extensively • Primarily treat emergencies also outside our own specialties, which is necessary with high loads of casualties • Use simplified methods for diagnosis and treatment as alternatives to advanced techniques, which not may be available • Work as an integrated part of an organization where resources rapidly must be redistributed depending on need, which requires knowledge of the organization and how to work in it • Be able to handle reserve systems as backup for vulnerable technically advanced systems in all fields of the health care sector If medical staff involved in this response does not have this knowledge and skills, it does not help to have good planning, equipment and organization; the result of the response can never be optimal if the staff has not been trained in how to perform in these specific situations. This means that education and training is equally or even more important than planning, organization,

S. Lennquist • K.L. Montán e-mail: [email protected]; [email protected]

and equipment, something that politicians and administrators are not always aware of or consider as much as they should. This conclusion is repeated in almost every report from a MI response. Such incidents almost always initiate increased efforts in education and training (unfortunately, in most cases only locally). It would be desirable that decision makers, especially within education, broaden their views and try to realize this before lives and health have to be lost because of lack of knowledge and training. However, unfortunately, education and training is still in most places the most neglected and insufficient component of preparedness for MIs.

18.2

Education on Different Levels

All people should know how to act during a MI and how a rescue operation (including medical care) is organized. In natural disasters in areas with limited resources, knowledge and skills in basic first aid among nonmedical personnel has been shown to be of critical importance for the outcome. Teaching this in schools on different levels is important, especially in countries without mandatory military service, which traditionally includes such training. Nonmedical staff involved in MI response, such as rescue service and police, usually have education and training in basic first aid, and in some places primary triage, but to a widely varying extent; in most places this a potential area for improvement. Training together increases knowledge and understanding of the problems that have to be dealt with by all collaborating organizations, and also it has been shown to be of great benefit in the preparedness for MIs.

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Education and training of medical staff in this field is necessary on all levels: • Basic education on an undergraduate level for all medical and paramedic personnel (including ambulance staff) • Specialist training for doctors and nurses • Postgraduate training of all staff involved in the position and role they will have in a MI response • Repeated training as above at predetermined and regular intervals • Additional special training for staff in specific positions (command positions, those who respond to specific types of incidents such as those involving hazardous material, and those sent to international support missions)

18.2.1 Basic Education Education in medical response to MIs is mandatory already in the undergraduate training for both doctors and nurses for several reasons: • The doctor or nurse who has just graduated can at any time, and without any warning or time for preparation, be exposed to an MI with a high number of severely wounded or critically ill patients and may have to take action in the front line, primarily without access to more experienced staff • In contradiction to most other fields in medicine, this is a field where it may not be possible to wait for or refer the patient to a specialist or a senior colleague, and where action (triage, primary management, decision making) has to be taken immediately by the person on the spot to save life and health • Decisions made by staff on the front line can make the difference between life and death, and between full health and persistent disability, for a patient with many years yet to live Knowledge and skills in this field that have to be included in undergraduate training are: • Ability to perform primary triage of injured and critically ill patients • Knowledge about the principles for basic primary treatment of injuries caused by physical violence, fire, cold environment, hazardous material, and irradiation • Ability to perform basic life-saving procedures (resuscitation) for patients exposed to the scenarios above

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• Knowledge about the principles of organizing the work and performance on the scene of an MI, including command, coordination, and communication • Knowledge about the principles of organizing the work and performance in the hospital during an MI • Knowledge about psychological reactions during MIs and how to prevent and deal with them Knowledge and skills required for MI response cover many different fields of medicine, and this education has to be an integrated part of the training in all these fields. However, there is also a need for specific knowledge not included in other fields of education, such as the organization of the work in the field and in the hospital – to work as an integrated part in such organizations requires knowledge about it. Therefore, in addition to the training integrated in other fields of medicine, there is a clear need for a separate course, preferably during the later part of undergraduate training. This training should be mainly practical with the use of field exercises or, even better, realistic simulation exercises (see below under “Methodology of Training”). The length of this separate course should depend on the extent of integrated training in MI response in the rest of the undergraduate training program. Universities and medical schools have the responsibility for this training. Governmental recommendations with regard to the extent of training may, however, be justified because this preparedness is a matter of national security. In many countries, there is competition from an increasing number of subspecialties that all want a part of the educational space. The reason why this kind of education should have a natural priority has been given above.

18.2.2 Specialist Training Training for MI response also must be included in specialist training for doctors and nurses, especially those who will be heavily involved: ambulance and emergency disciplines and surgical, orthopedic, and anesthesiological specialities. In countries where prehospital health care systems are involved in the MI response, this staff should also be included in such training. The length and design of this education naturally varies between specialities. Specialist societies or

18 Education and Training

organization should take the responsibility for including this in the specialist training programs and for designing and supporting the courses.

18.2.3 Postgraduate Training The aim of this training is to secure the ability to function in the specific position or task in the health care system that the specialist nurse/doctor may be required to cover during an MI. This training should also include paramedic and administrative staff with such functions. Basic postgraduate training should be given to practically all staff in the hospital because practically all will be involved in some way in an MI response with a high level of alert. This basic training should include knowledge about the disaster plan and action cards for relevant positions. A part of this can be given as a natural part of the orientation upon beginning employment at the hospital. Special postgraduate training is required for specific positions: • Ambulance staff should have training in command and coordination on scene, adapted to the local organization • Medical and administrative staff with potential responsibility to take command at different positions must be trained in command, coordination, and communication • Medical staff who can be sent out as prehospital teams must be trained for work on the scene • Staff that can be involved in decontamination of casualties must be trained in decontamination and how to use personal protective equipment Parts of this training can be done within the respective department; other parts require field exercises and/ or simulation exercises (specially training in command and coordination). The latter parts require more resources and can be centralized to regional or national training centers with good access to qualified instructors and equipment for simulation exercises.

18.2.4 Repeated Training One single postgraduate training session as above is not enough; it may be a long time between the opportunities to train in MI response, and knowledge that is not used frequently is forgotten. Therefore, repeated

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training sessions are necessary. The length of the intervals between such sessions varies between different countries and organizations, and may also vary between different specialties. Regardless of how long these intervals are, they should be clearly defined and run in a fixed program so every unit can make a plan for them. The obligation to do this should be settled in a contract signed by every chairman of a department/unit to ensure that this training is given accurate priority. The responsibility for the postgraduate training in position, as well as for the repeated training sessions, should be taken by the local hospital or, in some cases, the local region. National recommendations for training should be given by the Departments of Health or Governmental Boards of Health, depending on the national organization.

18.3

Methodology of Training

18.3.1 Problems with Training and How to Cope with Them Education and training for MI response is a challenge for several reasons: • Different from training of skills in clinical disciplines, skills in medical response to MIs (MRMI) cannot be trained in “real” situations. The MI, when it occurs, requires maximal effort of staff in all positions and is no place for training. • The (still) relatively low incidence of MIs means a potentially long interval between the training and its potential application. The knowledge and skills achieved must be practiced so that they remain in the memory. To respond to this challenge, we need good educational methods. The best way of learning skills is learning by doing, and because we cannot train this in a “real” situation, we need good and accurate simulation models for interactive training. A recommendation is to restrict traditional lectures as much as possible, replace them with high-quality literature from which the students can prepare themselves, and then put emphasis on interactive sessions. The best way to achieve this is to use simulation models through which the different components of the chain of management can be illustrated and trained for, first separately and then together to illustrate command, coordination, and communication.

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18.3.2 Demands on Training in Decision Making, the Keystone of Major Incident Response The keystone in knowledge and skills in MI response is the ability to make decisions. Rapid and accurate decisions are of critical importance in the whole chain of management: • On the level of command – which resources to alert and how to use them best • On an organizational level – how to organize the work to best utilize available resources • On the level of individual patient management – what to do with this patient in this specific situation, which method to use and with what priority to do it We can compare the human being with a computer: Certain information goes in (input data), is processed (decision), and comes out as a result of the decision (output data). To train and evaluate the process of decision making requires two things: • All information on which the decision in the real situation should have been based (input data) has to be – Available – Correct in every detail • All consequences of the decision (output data) must be clearly illustrated Examples of input data are: • Available resources of all kinds: staff of different categories; material; transport resources of different kinds; all kinds of hospital resources (beds, operating theaters, ventilators, supplies, etc.); and the times to get access to these resources when the incident occurs, calculating ongoing routine medical care • Transport times to the scene and between the scene and hospital for all available transport facilities • Scenario, i.e., number of casualties and their injuries in detail, including type and severity expressed as a trauma score Examples of output data are: • Mortality related to a trauma score • Preventable mortality: had the patient been possible to save with optimal performance? • Complications of different severities related to a trauma score • Accuracy of the alert process: under-alert or overalert?

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• Efficiency of the alert process: alarm and response times? If these requirements are not met, it is not possible to illustrate whether the decision of the trainee was correct or not. This means that he or she has to leave the training session without objective information about whether the decisions made were correct or not and without the possibility to improve decision making according to that feedback. To express it simply: The most important part of the training has failed. Unfortunately, this is a common situation in the training programs available today. Possible reasons for this are: • To design a training session with complete input data requires a lot of preparatory work • There are still few educational models available that have the ability to give objective, accurate, and reproducible output data This means that education and training in MI response is a field that needs to be developed and that has a great potential for development. A more serious approach to training should increase the motivation of medical staff in all categories to attend training programs as well as make decision makers more motivated to make it a priority to send staff to such programs.

18.3.3 Validation of Educational Models When designing a new educational model or a course, it is of critical importance to ensure that the knowledge and skills given or mediated to the trainee are: • Correct • In accordance with the overall objectives of the course, e.g., to increase the trainee’s ability to make appropriate decisions and perform accurately during an MI In other words, the accuracy of the educational contents should be validated. In the literature today there are many reports about the establishment of new course models or programs within this field, reflecting the increasing interest for education and training. Few of these reports include any validation or even attempt to validate the accuracy of the educational contents. The apparent risk with this is that enthusiastic course organizers or leaders promote what they themselves believe to be correct information, which it in most cases hopefully is, but it can also be entirely wrong.

18 Education and Training Fig. 18.1 The cartoon illustrates the importance of validation of educational content: Are the knowledge and skills delivered accurate and in accordance with the given objectives of the training? The figure shows an unfortunately rather common mistake: teaching an organization that is so complex so it cannot be ready to function until the phase of the response already has passed

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WE DON’T HAVE THE HEART TO TELL THEM, BUT ALL PATIENTS LEFT THE SCENE 5 HOURS AGO... Don’t disturb Medical officer in command staff-wagon

One (too common) example is teaching organizational models that are too complex. The organization the trainees learn will consume so much time and effort to set up that it will not leave any time to triage and treat casualties, and by the time the organization becomes well established, the phase of response has already passed (Fig. 18.1). To validate an educational concept, course, or program for teaching MI response is not easy. Many educational programs in medicine can be validated by showing a statistical improvement of clinical results consequent to the introduction of the program, as has been done, for example, for the advanced trauma life support (ATLS) course in trauma, but that requires a sufficient number of cases or incidents to show statistically significant differences. The number of MIs is fortunately not (yet) large enough to permit such comparisons, and in regions with high numbers of MIs, many different factors influence the outcome, and in most cases one incident is hardly similar to another. The trainee’s perception of the course, which sometimes is reported as a validation, is not sufficient to validate the contents. It can be influenced by many other factors such as enthusiastic faculty, a pleasant atmosphere, or good accommodation, things that are important to evaluate in themselves but that say nothing about the accuracy of the educational content. A pretest can be done before the course and the compared with a similar test after the course, but attention must be paid to the learning effect that occurs just

by repeating the test. That can be compensated for by using tests with minimal methodological learning effects. Another possibility is to let a matching group take the two tests without passing the course. A third possibility is to compare the result of the performance during advanced simulation models with repeated exercises, where participants who pass and fail the course can be compared. Regardless of the methodology used for validation, this should be a request when introducing and reporting new course models.

18.4

Models for Interactive Training

There are two models for interactive training (learning by doing): • Practical field exercises with figurants that simulate injured patients • “Table top” exercises using symbols to illustrate injured patients and available resources of different kinds, presented either by computers or on tables or boards

18.4.1 Practical Field Exercises A problem with traditional field exercises is that they have a tendency to become spectacular events with a lot of energy put into dramatic effects such as dramatically

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painted and screaming figurants. Unfortunately, in many cases, less energy has been devoted to systematic analysis of the decisions made and actions taken by the trainees. According to what has been said above, such a systematic analysis is needed to illustrate the result of the performance of the trainees and how it can be improved. Another problem in many traditional field exercises has been that only a small number of the trainees get the opportunity to train while the others just have to watch. It is better to put less emphasis on the spectacular parts and make the simulations simpler with shorter sessions so that every trainee really gets the opportunity to train and be evaluated. Traditional field exercises usually stop at the point where patients would be evacuated from the casualty clearing station. The disadvantage with this is that the final outcome – the result of the performance and decisions made by the trainees – remains unknown or can be given hypothetically by the instructors, which leaves a lot of questions: • Was the triage correct? • Was the treatment given on the scene accurate related to the final outcome? • Was the distribution of the patients between hospitals optimal? Ambulances and helicopters can do the transport live, but it is expensive and difficult to mobilize units for this for an exercise; there are also matters of security. Extending the exercise into the hospital meets natural resistance in today’s efficiency-dependent health care system. It can be justified as a test of the organization, but hardly for training off staff, for which purpose it also is difficult to make it realistic. However, the biggest mistake during traditional field exercises has been to perform them without realistic timelines. The trainees have been able to simulate that they have done everything with every patient, and it is easy because it has not taken any real time or consumed any real resources. If this is what the trainee learns during the exercise, he or she will act in the same way during the real MI, when suddenly everything takes time, and it will end up in congestion and chaos. Never perform any kind of exercise without realistic (real) times and real consumption of resources (staff, material) for all measures taken! Doing so gives the wrong message and can be even worse than no training

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at all. There are methods available to avoid these potential failures: • Give all trainees complete input data, as described above, as a basis for making and evaluating decisions. This should be available in written form before the exercise. • Use injury cards instead of painting figurants. A card of the model described in Fig. 18.4 below: – Gives more realistic and correct information to the trainee than a painting, regardless of the effort put into making it appear real – Makes it easier to indicate multiple injuries, which is more in accordance with scenarios met today, i.e., provides a more realistic scenario – Gives the condition of the patient expressed in physiologic parameters, which is the basis for the commonly used methods of primary triage – Makes it possible to indicate changes in the patient’s condition easily (by the instructor or by the figurant according to instructions), according to the time that has passed since the injury and measures performed/not performed – Makes it possible to switch easily between trainees and figurants, which may give all trainees the possibility both to act and to function as figurant, increasing the learning effect • Use controllers equipped with a timer and a list with the times it in reality takes to do all potentially possible treatments. If the trainee decides to do a certain treatment, the trainee and the “patient” have to freeze (do nothing) until the time this should have taken in reality has passed. It may be frustrating for the trainee, but it is important for his or her learning. The controller can also check that the equipment needed for the treatment really is (or would have been) available. • Use a transport board of the model described in Fig. 18.9 below, which makes it possible to illustrate: – When the patient departs from the scene, according to the triage done and the (real) access to transport facilities – To which hospital the patients is sent, according to the decision made at evacuation – When the patient arrives at the hospital, according to (real) transport time Adding an instructor to simulate the transport coordinating center (see Chap. 3), with information of (real) available hospital capacity, also makes it possible to illustrate:

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The advantages of table top exercises compared with practical field exercises are: • They are less expensive – the costs for a single practical field exercise that meets the demands described above corresponds to the costs for a large number of table top exercises that can meet the same demands • It is easier to meet the demands listed above during a table top exercise • Every participant can work actively in his or her normal function

• It is possible to run the exercises with a large number of participants with active roles just by expanding the scenario and involve many hospitals • The whole chain of management (scene, transport, hospitals, command/coordination centers) can be trained simultaneously, making it possible to train and evaluate the important functions of command, coordination, and communication • The overall outcome of the response will be clearly illustrated, which is possible only if all components of the chain are trained together. Using a standardized model, this result is reproducible and can be used as a basis for improvement (e.g., through additional training or adjustment of the organization) The disadvantage is that practical field equipment and the use of it not can be trained. This can be compensated for by having separate field exercises that aim to test use of field equipment and using table-top exercises with the main purpose of training staff. There are different models of table top exercises: • Using tables with symbols that are moved on maps that represent the scene or the hospitals. This is the original “table top” model

Fig. 18.2 Older model for table top exercise. The figure shows the model used in the major incident medical management and support prehospital course (MIMMS, see text), with a map on a table and movable symbols illustrating rescue and medical units.

Such a model is accurate to illustrate the organization on the scene but has limited possibilities to illustrate triage and patient management (From Prehospital and Disaster Medicine Centre, Gothenburg, Sweden, with permission)

– The important communication between the scene and the hospitals – The accuracy of the distribution of patients between hospitals – Whether the patient gets access to necessary hospital treatment in time The measures described above are relatively simple and cheap related to the overall costs of a field exercise and should be given priority ahead of the more spectacular components of such exercises.

18.4.2 Table Top Exercises

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• Using boards, e.g., magnetic whiteboards on which symbols are labeled with tags and moved • Using computers, which means that every participant, or group of participants, sits behind a computer, is presented with information, and makes decisions based on that information

All models are good as long as they can fulfill the demands of an exercise listed above. An example of a table top exercise using a map on a table is the one used in major incident medical management and support (MIMMS) courses (Fig. 18.2), which is accurate for the demonstration of the organization on the scene,

a Helicopter landing Commanding place First aid point

Non-injured Dead

b

Minutes Red

4

+2

1

Lying down Abdominal injury Quiet

A − Ok B − Rapid respiratory rate C − HR 130 D − GCS =13 E − Penetrating abdominal injury

+2

+10

+4

Fig. 18.3 The Emergo Train system (ETS). (a) Magnetized symbols on magnetic whiteboards illustrate casualties, staff, and rescue and transport units. The trainees can work with the symbols, moving them and indicating triage and treatment in direct communication with each other. (b) Exercises are run with real times: every indicated treatment is connected to a time. If the trainee indicates a treatment, the patient and the staff are not allowed to move until this time has passed. As the figure illus-

Examination and preliminary diagnosis

+5

Totally

27

trates, a single patient can consume considerable time and resources, which may be accurate when resources and time permit, but is not accurate in situations with a heavy load of casualties where other potentially salvageable patients may be lost because of this. The ETS was the first to introduce the “real-time approach” in these kinds of exercises (From the Centre for Teaching and Research in Disaster Medicine and Traumatology, Linköping, Sweden, with permission)

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and to an extent in the hospital, but offers limited possibilities for interactive training of other parts of the chain of response to MIs. Training with computers requires quality programs, and to illustrate the whole chain of management, including patient management, requires an extensive amount of data. Many attempts have been made, so far with limited success. In addition, the experiences to date have indicated that working with computers does not give the same feeling of interactive involvement as when the participants work with and move symbols by hand and communicate with each other. However, computer technology is continuously developing and the future may open up alternatives that become more successful than what has been the case so far. The first system to use whiteboards with magnetic symbols was the Emergo Train System (ETS; Linköping, Sweden); launched in 1985 and translated into more than ten languages, the ETS still is used in many countries around the world. That this rather simple system, originally developed by the authors of this chapter, has gained such widespread use illustrates the need for such systems in the training of MI response. The system is based on magnetized symbols that represent injured patients, all kinds of staff involved in the response, transport, and hospital resources. The trainees work with these symbols on magnetic whiteboards, where the “patients” can be triaged, treated, and moved along the chain of the response (Fig. 18.3a, b). The system is today owned and commercially marketed by the Center for Education and Research in Disaster Medicine, University of Linköping, Sweden. A similar system, based on the same principles as the ETS but further developed for the scientific evaluation of methodology, is the Mass Casualty Simulation (MACSIM) system, which also was designed by the authors of this chapter and launched in 2009 (www. macsim.se). This system has been used for scientific evaluation and comparison of different triage methods and it has been selected as the educational tool for European courses in MRMI. The key component of the MACSIM system is the injury card (Fig. 18.4a, b) which can be used both for field exercises and table top exercises. The model used for field exercises and for basic training of the methodology is larger and can be attached to figurants for practical, hands-on training. The model intended for table top exercises is smaller and can be magnetized for use on magnetic whiteboards.

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Along the four sides of the front page of the card (Fig. 18.4a) is given information about the condition of the simulated patient according to ATLS principles (airway, breathing, circulation, and disability). These parameters can be changed easily by the instructor – on the big card by movable markers, on the small card by a white-board pen – according to the time that has passed since the injury or measures that were performed/not performed. In the central part of the card, the findings corresponding to “exposure” are indicated with symbols, on the left side are findings at inspection of/communication with the patient, and on the right side are findings of palpation/auscultation. In the left upper corner, the initial position of the patient is given (supine or standing/walking, silent or calling for help). Sex and approximate age is given in the left lower corner. On the back side of the big card (Fig. 18.4b), the different symbols are explained. Symbols for different treatments, which can be attached to the card as stickers, are also given. Each treatment is connected to a time, making it possible to train with real times as described above, and the number of treatment stickers can be adjusted to the number available in reality (Fig. 18.5). The back side of the smaller cards (Fig. 18.4c), intended for table top exercises, contains information for the instructor: • The definitive diagnosis (complete description of injuries) • Times (T > min) above which certain treatments not can be delayed without causing mortality (M), or complications that can be life threatening (CL) or lead to permanent loss of function (CF) • Approximate times for requested surgery (Op/min), which can be adjusted to selection of method • Potential need for a ventilator (V yes or no) • The result with regard to mortality and complications if the patient is given optimal treatment (R/Opt) to permit identification of “avoidable” deaths and complications (some patients will die in spite of optimal treatment because of severity of injuries). L+ indicates that the patient will survive with optimal treatment, L−indicates they will not (the same for function [F+/F−]) • Injury Severity Score based on the summary of injuries (definitive diagnosis, as above) • Revised trauma score based on the patient’s initial condition according to physiological parameters

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a

b POSITION

BREATHING

NORMAL ≥10 - < 30 SLOW > 5 − < 10 VERY SLOW 5

AIRWAY RESPIRATORY RATE

FAST 30

C

A OK

THREAT BLOCKED CIRCULATION < 50

E COMMUNICATION INSPECTION

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MACSIM

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~25 PATIENT NR

SEX/AGE

TENDERNESS, MODERATE

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SCRATCH HEMATOMA, CONTUSION

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BURN, SUPERFICIAL

FRACTURE, DISLOCATED

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< 90 − > 75

EXIT WOUND 75 − 50

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01

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> 100 < 120

≥ 90

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NOT DETECTABLE 0

NOT DETEC -TABLE 0

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50 − 100

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D

ACCURATE INACCURATE ACCURATE INACCURATE NO RESPONSE ALERT RESPONSE RESPONSE RESPONSE RESPONSE TO TALK TO PAIN TO PAIN TO PAIN TO TALK DISABILITY GCS = 13 − 15

GCS = 9 − 12

GCS = 6 − 8

GCS = 4 − 5

c

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STANDING/ STANDING/ SUPINE WALKING, WALKING, POSITION, SILENT CALLING FOR SILENT HELP

SUPINE POSITION, CALLING FOR HELP

1. Cerebral contusion with bleeding and increased ICP, GCS (initially) = 5. 2. Penetrating injury (scrapnel) right thigh, soft tissue injuries 3. Soft tissue injuries left thigh, right arm 4. Rib fractures VII, VIII, IX left, small pneumothorax 5. Splenic rupture OIS IV, bleeding T > min: (1) M: B2>30 Op>120

OP (min): (1) 60

(4) CL: B3>B2

(5) 50

(3) 20

(5) M: Op>120 R/opt L (?), FPatient nr: 01

Vent + ISS: 36 RTS: 6

Fig. 18.4 The key component of the Mass Casualty Simulation (MACSIM) system is the injury card, which can be used both for field exercises and for simulations using the table top model. See the text for a description of the card (www.massim.se), (b) The symbols on the board should be learned by the trainee before the exercise but are also available during the training session, (c) Information for the instructor on the back side of each card:

• Final diagnosis • Times within which different treatment have to be done for survival (using a code system) and • Base for calculation of preventable deaths and complications related to trauma score (Copyright MACSIM, with permission)

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Fig. 18.5 Priority is indicated on the cards with movable stickers (top of cards) in colors described in Chapter 4. Different treatments are also indicated by movable stickers around the margins of the card, corresponding to diagnosis. Such treatmentstickers (with given times requested for every treatment) for all relevant prehospital treatments and also for hospital examinations/ treatments are available for the trainee in numbers corresponding to supplies in reality (Copyright MACSIM, with permission)

All this information may seem extensive, but it is in accordance with the demands of complete input and output data as a basis for both decision making and accurate evaluation of the decisions made at the different levels of the response. The “patients” can be triaged with movable stickers, which have the same colors as those described in Chap. 4 (“Triage”). The MACSIM system and the Emergo Train system both use symbols for all staff included in the response as well as all available transport and hospital resources (for further information, refer to www.macsim.se). Characteristic for the Emergo Train, MACSIM, and other similar systems is the need for magnetic whiteboards to ensure optimal utilization. For limited sce-

narios, the whiteboards available in most lecture rooms today are sufficient, but more extensive training of the whole chain of response requires more space. The best option is to use boards on wheels, but the price of such boards varies and can be high in some countries. The systems can be used on tables; another alternative is to use magnetic films that can be rolled out and temporarily attached to the walls.

18.5

Course Models

18.5.1 Undergraduate Training The training for MI response should be mandatory in all undergraduate medical education programs for the

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reasons discussed earlier in this chapter, and this is a heavy responsibility for universities and medical schools. As mentioned, it should also be a responsibility of Departments of Health because this is a matter of security for the citizens in every county. During recent decades, most countries have established such educational programs, mostly as a consequence of the global terrorism, which illustrates that the need for appropriate response may occur at any time in any country, and educational decision makers on all levels will (and should) officially be held responsible if injured people are exposed to medical staff who have not received such training. Such training programs should be located as late in the undergraduate training program as possible because they are based on knowledge acquired throughout the training for almost every field of medicine. A recommended educational model is to restrict theoretical lectures to an absolute minimum because the students at this level are mature enough to read the literature, and instead focus on interactive training (“learning by doing”) in which all students should be active. This usually provides much-needed repetition in basic practical trauma management and useful training in decision making before taking on professional responsibilities. This interactive training can be done either as practical, “hands-on” exercises or table top exercises, according to the principles described above.

18.5.2 Specialist Training This is a place for exclusive interactive training as a repetition of the knowledge acquired during undergraduate training but now with a focus on a specialty. The extent of such training naturally varies between specialties and depends on the potential role during MI response. The design of standardized programs for this should be the responsibility of the specialist societies, and inclusion of such programs in the specialist training should be a required for specialist certificate.

18.5.2.1 Courses in Trauma and Emergency Medicine Trauma and emergency medicine courses are included in some specialist training programs and are valuable as a part of the training for MI response. Some examples: ATLS is a concept of primary trauma management developed and promoted by the American College of

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Surgeons. It is mainly intended for physicians in surgical, anesthesiologic, and emergency disciplines and is today a mandatory part of specialist examination in some countries. Broad knowledge of trauma among these specialists is also a part of preparedness for MIs. DSTC (Definitive Surgical Trauma Care) goes one step further and deals with the primary surgical treatment of trauma, including damage control principles. It is similar to ATLS, and for the same reasons is a good contribution to the preparedness for MIs. It is mainly intended for general surgeons, but there are similar courses under development for different surgical specialties. TNCC (Trauma Nurse Core Course) is a course concept for nurses similar to the ATLS concept and based on the same principles. PTLS (Prehospital Trauma Life Support) is also based on the ATLS principles and is intended for all categories of prehospital staff ; also, it is a useful course for increasing the preparedness for MI response. These are only a few examples of courses in neighboring fields that can be useful in the composition of specialist training programs for staff involved in MI response.

18.5.3 Postgraduate Training Postgraduate programs should focus on training all medical staff in their real positions and roles during an MI response. This is more demanding because it is difficult to practically train staff in only one specific position. A keystone in the training should be communication and coordination between different positions, and staff with different roles should be trained together. This requires good interactive models.

18.5.3.1 The MIMMS Concept MIMMS is one example of interactive postgraduate training programs. It is based on table top simulation with the model described in Fig. 18.2. There are two main course models: prehospital and hospital MIMMS. Both models deal mainly with organization and little focus is given to individual patient management. They are run as separate courses, which means that only one part of the chain of response is trained at the same time. The prehospital MIMMS gives a good illustration of the organization of the scene during an MI. It is very British in its structure, and the organization is

18 Education and Training Fig. 18.6 Schematic illustration of the setup for an medical response to major incidents (MRMI) course of the model used within the European Society for Trauma and Emergency Surgery. This is an example with four hospitals, but the setup can be done with an unlimited number of hospitals. Around the scene, casualty clearing and transport zones are in the center (see the text), the hospitals (Fig. 18.10), and command centers (Fig. 18.11) are built up in different areas, as in reality, requiring radio or telecommunication between these different components of the chain of management of a major incident

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influenced by the vast experience from armed conflicts and large incidents in the UK, requiring a solid but complex organization. It is, however, important to remember that the major part of MIs require a less complex but rapidly mobilized organization, which makes simplicity important (see Chap. 3). The hospital MIMMS has its main focus on the emergency department with somewhat less attention given to surgery and intensive care, which often are the critical limiting factors during MI response. The simulation model used requires further development.

18.5.3.2 The MRMI Concept MRMI was developed by an international group of specialists within the Section for Disaster and Military Surgery in The European Society for Trauma and Emergency Surgery. The objectives agreed upon when developing this concept were that it should: • Cover the whole chain of management, including the scene, transport, and hospital management as well as communication, coordination, and command • Include patient management with triage and primary treatment • Be fully interactive, with all participants acting in their own roles • Have a strictly standardized design, making it possible to establish in different countries the same

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setup and get reproducible results with regard to illustration of the outcome of the response Of the simulation models discussed, the MACSIM system (see section 18.3.2) was the only one that delivered sufficient input and output data to respond to the demands listed above. The MRMI courses are 3 days: 1 day for preparative training of the different components in groups, and 2 full days of simulation exercises in real time, covering the whole chain of response. The setup is described in Fig. 18.6. All functions and activities are illustrated on magnetic whiteboards with movable magnetic symbols. The big room in the center of the figure represents the scene, where the site of the incident is illustrated by boards with the injury cards placed in the interior or exterior part of, for example, a building. Trapped patients are indicated, with a time requested for extrication. The injuries are taken from real scenarios. Upon arrival on the scene, the ambulance crews and prehospital teams have to take on the functions of medical incident commander, triage office, and ambulance loading officer (see Chap. 3); and organize and coordinate the medical response via radio communication with the coordinating center and in collaboration with the rescue and police incident commanders, as occurs in reality (Fig. 18.7).

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Fig. 18.7 Upon arrival to the scene after the alert, ambulance crews and prehospital teams have to take on different coordinating functions on the scene, indicated by tabards, and, as in reality, they must communicate with each other, with other responding units, and by radio with the coordinating command center. The first rescue-and police units and the first 2 ambulance have arrived. The crew of the first ambulance have taken the roles as MIC and TRO. The majority of the injured Are still inside the building (boards in the back) to which the responders still have no access (photo MACSIM)

From the site of the incident, the trainees work along lines of primary and secondary triage, representing the casualty clearing zone (Figs. 18.6 and 18.8), and end up in the transport zone, where the casualties are distributed to ambulances, helicopters, or other transport facilities. The transport boards (Fig. 18.9) illustrate transport with real times. On another floor, the hospitals are built (Fig. 18.10a–d) with all resources given in detail. The patients are delivered to the hospitals at the time for arrival according to the transport boards. On a third floor, the hospital command centers and regional command centers are built (Fig. 18.11). All communication is, as in reality, done through radio or telephones. The result of the training session is given in terms of preventable mortality and complications related to Injury Severity Score. After thorough evaluation of the decisions made and performance, including an analysis of all preventable deaths, the trainees get a “second chance” with an equally severe scenario, with a possibility to improve their performance. The model may seem complex, but it is still costeffective considering the overall learning effects compared with what can be achieved using more expensive field exercises.

The MRMI course if not the only relevant model for training, but it is described here as an example where all the demands on training have been taken into account. Further information about MRMI courses is available at www.mrmi.org.

18.5.3.3 Special Training Programs for Special Tasks For staff deployed for international relief work in suffering countries or to MIs in countries with limited resources and/or the need of international assistance, special courses are organized by, among others, the International Red Cross and Médecins Sans Frontières. Such courses are strongly recommended for everyone considering deployment for such missions. 18.5.3.4 Extended Training Programs For those who plan an academic or professional career within Disaster Medicine, there are special programs available, such as the European Master Program in Disaster Medicine (available in Europe), which occurs every year in San Marino, Italy. This is a mainly theoretical program, to a large extent based on self-studies, with the result being a Master’s Degree in Disaster Medicine.

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Fig. 18.8 The prehospital staff is working with the injury cards, doing primary triage on the scene followed by secondary triage in the casualty clearing zone, indicating priority and treatment with tags corresponding to their available equipment. Everything is done with real times, which is controlled by the instructors using timers. If the trainee indicates a treatment, the “patient”

and the staff are not allowed to move until that time has passed. On the other hand, if a treatment required within a certain time after the injury not is done within that time, the patient dies or is hit by complications. This applies high pressure on decision making even for experienced staff, identifying the process of decision from the clinical situation (photo MACSIM)

18.6

position of the science of Disaster Medicine, which has the responsibility for education, training, development, and research within the area dealt with throughout this book, is clearly defined in every university and medical school. This is necessary to ensure the competence required for and the coordination of education and training in this field at the undergraduate level. The units or departments described above also should have a natural responsibility of supporting the programs for specialist training because this training requires specific resources and competence, e.g., to run interactive training sessions. The postgraduate training is the responsibility of different hospitals or regions, depending on the organization, and requires involvement of local hospital staff. Every hospital with a responsibility to receive trauma and emergency cases during an MI should have a person or unit responsible for the postgraduate training in MI response, preferably someone or a group connected to the responsibility for the disaster plan of the hospital/region.

Who Should Deliver the Training?

As already stated, undergraduate training is the exclusive responsibility of universities and medical schools. Even if much of this training has to be given as integrated parts of the teaching within many fields of medicine, it requires coordination and support by an overall responsible unit, which also should take the responsibility for the mandatory separate course in this topic during the later part of the undergraduate training programs. This unit should also take responsibility for development and research, which is a prerequisite to ensure and maintain quality in this field, as in all other fields of medicine. Thus, such units ensure the necessary connection between education and research in this area (see Chap. 19). Whether this is a separate academic chair or a unit or division within a university department with involvement in this field might vary between different universities depending on traditions and resources. The important thing is, however, that the academic

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Fig. 18.9 For every ambulance and helicopter, arrival time, patient (injury card), destination, and time of departure and arrival at destination is indicated on the boards, with everything in real time. The staff here communicates by radio with the coordinating center for a decision with regard to patient destinations and with the hospitals to report incoming patients. The patients (injury cards) are delivered to the hospitals at the given

time of arrival. Sending a patient to a hospital without the needed resource (operating theater, ventilator) being available may mean a dead patient, as may selecting a transport that takes too long to permit requested hospital treatment in time. This is tough training in decision making where the results are immediately shown (photo MACSIM)

Postgraduate training programs for staff with special tasks, e.g., command and coordinating positions on different levels, requires special resources both with regard to competence and equipment (as an example refer to the European MRMI course, described above). Such training can be centralized to special regional or national centers for such training to make it cost-effective. Such centers should also have the task of running training programs for teachers and instructors both for universities and medical schools at the undergraduate level and for hospitals and regions.

Such programs are also a guarantee of a common national standard with regard to organization, terminology, and equipment. International collaboration is of special importance in this field, where exchange of experience is mandatory for further development. Scientific and professional societies within this and neighboring fields should be encouraged to organize international courses. The European MRMI courses under the auspices of the European Society for Trauma and Emergency Surgery are an example on this.

Fig. 18.10 The hospitals with all available resources (including available staff) are indicated on the boards. “Nondisaster patients” (patients already in the hospital at the time of the alert) are indicated by special cards. (a) A hospital set up with (from left to right) an area for arrival and primary triage, emergency department, preoperative zone, surgery, and intensive care. Wards are indicated with plastic pouches along the bottom of the boards. (b) The emergency department with zones for severely injured (major incident resuscitation teams) and also less severely injured. As on the scene, everything is done in real time

and according to the decisions made by the trainee. The instructor supervises time keeping and decisions for later evaluation. (c) Surgery with available theaters. Surgery cannot be done without appropriate staff at all positions. Time for surgery can be adjusted by the instructor depending on the method selected and surgical competence. (d) Access to ventilators is a critical factor for determining the surge capacity of the hospital and requires difficult decisions with regard to priority (photo MACSIM)

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Fig. 18.11 The command centers of the hospitals are located on distance from the hospitals so that, as in reality, most of the communication with the departments of the hospital has to be done by telephone. These centers also continuously communicate with the overall coordinating Regional Medical Command Center seen in the figure (photo MACSIM)

Further Reading American College of Surgeons Committee on Trauma (2008) Advanced trauma life support program for physicians, 6th edn. American College of Surgeons, Chicago Archer F, Seynaeve G (2007) International guidelines and standards for education and training to reduce the consequences of events that may threaten the health status of a community. Prehosp Disaster Med 22(2):120–130 Ashkenazi I, Olsha O, Schecter W et al (2009) Inadequate mass casualty knowledge base adversely affects treatment decisions by trauma care providers: survey on hospital response following a terrorist bombing. Prehosp Disaster Med 24(4): 342–347 Cummings GE, Della Corte F, Cummings CG (2006) Disaster medicine education for physicians: a systematic review. Int J Disaster Med 4(3):125–136 Debacker M, Delooz H, Della Corte F (2003) The European master programme in disaster medicine. Int J Disaster Med 1(1):35–41 Duboloz M (2003) WHO international diploma course in vulnerability reduction and emergency preparedness. Int J Disaster Med 1(1):21–24 Fischer P, Kabir K, Weber O et al (2008) Preparedness of German paramedics and emergency physicians for a mass casualty incident: a national survey. Eur J Trauma Emerg Surg 34(5):443–450 Franc-Law JM, Bullard M, Della Corte F (2008a) Simulation of a hospital disaster plan: a virtual, live exercise. Prehosp Disaster Med 23(4):346–353 Franc-Law JM, Bullard M, Della Corte F (2008b) Accuracy of computer simulation to predict patient flow during mass casualty incidents. Prehosp Disaster Med 23(4):354–360

Hodgetts T (2004) Training for major accidents – evaluation and perceived ability after exposure to a systematic approach. Prehosp Immediate Care 4:11–15 Hodgetts T, Mackway-Jones K (eds) (2002) Major incident medical management and support – the practical approach. BMJ Publishing Group, London Jacobs LM, Burns KJ, Kaban JM et al (2003) Development and evaluation of the advanced trauma operative management course. J Trauma 55(3):471–479 Klein RH, Brandenburg DC, Atas JG et al (2005) The use of trained observers as an evaluation tool for a multi-hospital bioterrorism exercise. Prehosp Disaster Med 20(3):159–163 Lehman-Huskamp K, Rebmann T, Walther FG et al (2010) Disaster preparedness education and a Midwest Poison Center. Am J Disaster Med 5:229–236 Lennquist S (2002) Experience from five years international training of Swedish trauma teams. Scand J Trauma Emerg Med 10:200–203 Lennquist S (2003a) Education and training in disaster medicine – time for a scientific approach. Int J Disaster Med 1(1):9–12 Lennquist S (2003b) The emergotrain system for training and testing disaster preparedness: 15 years’ experience. Int J Disaster Med 1(1):25–34 Lennquist S (2005) Education and training in disaster medicine. Scand J Surg 94:300–310 Lennquist S (2007) Management of major accidents and disasters – an important responsibility for the trauma surgeon. J Trauma 62(6):1321–1329 Leroy-Heinrichs W, Youngblood P, Harter P et al (2010) Training health care personnel for mass-casualty incidents in a virtual emergency department: VED II. Prehosp Disaster Med 25(5):424–431

398 Nilsson H, Vikstrom T, Rüter A (2010) Quality control in disaster medicine training – initial regional medical command and control as an example. Am J Disaster Med 5:35–40 Pelaccia T (2009) Can teaching methods based on pattern recognition skill development optimise triage in mass-casualty incidents? Emerg Med J 26:899–902 Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Care (USA) and the American College of Surgeons Committee on Trauma (2003) PHTLS basic and advanced trauma life support, 5th edn. Mosby, St. Louis Rüter A, Nilsson H, Vikström T (2006) Performance indicators as quality control for testing and evaluating hospital management groups. Prehosp Disaster Med 21(6):423–426

S. Lennquist and K.L. Montán Rüter A, Örtenwall P, Vikström T (2007) Staff procedure skills in management groups during exercises in disaster medicine. Prehosp Disaster Med 22(4):318–321 Sapp RF, Brice JH, Myers JB et al (2010) Triage performance of first year medical students using a multiple-casualty scenario, paper exercise. Prehosp Disaster Med 25(3):239–245 Thomas TL, Hsu EB, Kim HK et al (2005) The incident command system in disasters: evaluation methods for a hospital based exercise. Prehosp Disaster Med 20(1):14–23 Vincent DS, Berg BW, Ikegami K (2009) Mass-casualty triage training for international healthcare workers in the AsiaPacific region using Manikin-based simulations. Prehosp Disaster Med 24(3):206–213

Further Methodological Development and Research

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19.1

The Science of Disaster Medicine

As mentioned in Chap. 1, the terminology in this book is based on the term “major incident,” defined as any situation where available resources are insufficient for the immediate need of medical care. Three different levels of major incidents are defined, covering a wide spectrum of scenarios, from incidents where all normally salvageable casualties can be saved by redistribution of resources and adjustment of methodology (MI level 1) to incidents where salvageable casualties with severe injuries have to be given low priority to save others with better prospects of cure (MI level 2). In addition, the infrastructure of the community may be lost, putting extended demands on the relief work (MI level 3). With this terminology, the traditional term “disaster” – for which nobody has succeeded in finding an internationally uniform and generally accepted definition – can, for practical use, be replaced by a terminology with clearly defined levels, which is important if it will be a base for decision making during an incident. The medical response to major incidents is a part of medicine that, like all other parts, also requires a scientific field for development and research. This scientific field has traditionally been defined as the science of disaster medicine. It may seem illogical to use another terminology for the scientific part; however, from a scientific point of view, disaster medicine is well established today as the academic name of this science, and this is no reason to change it.

S. Lennquist e-mail: [email protected]

The overall objectives of the science of disaster medicine are to: “Eliminate or reduce loss of life and health, and physiological and psychological suffering, to the extent possible in every situation where the immediate need of medical care exceeds available resources by • The development and evaluation of methodology and • The education and training of medical staff of all categories.” This means that the science of Disaster Medicine covers a wide spectrum of events, from level 1 to level 3 incidents, according to the definitions above. All these events have in common the basic methodological principles for planning, organization, and performance, even if the decisions naturally have to vary according to the relation between the need of care and available resources. The educational part of Disaster Medicine was dealt with in Chap. 18, and this chapter will focus on development and research.

19.2

Historical Background

The science of Disaster Medicine is a young science and is usually considered to have been established as late as 1975 when the first international scientific society within this field, the International Society for Disaster Medicine (ISDM), was founded. Two years later, in September 1977, the World Association for

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Disaster and Emergency Medicine (WADEM), was founded and has since been the strongest international scientific and professional society for Disaster Medicine. Since that time it has been accompanied by an increasing number of regional and national societies. Simultaneously with the founding of the first international societies, Disaster Medicine began to be recognized at the university level, and education and training was introduced during undergraduate training, first for doctors, then for nurses and paramedic staff. However, methodological development and evaluation has so far been rather limited, and Disaster Medicine has, with few exceptions, developed into and remained a descriptive discipline. Experiences from major incidents have been reported at scientific meetings, including all the difficulties and mistakes natural for those who are hit by such incidents for the first time. However, few attempts have been made to scientifically analyze the methodology and the results of the response. Then, at repeated meetings and congresses, exactly the same mistakes have been reported again and again, with the same expression of surprise every time. One of the reasons for this is that the experiences from major incidents so far only to a limited extent are reported in a way that makes scientific analysis and comparison of results possible. Since the beginning of the new millennium, the interest in Disaster Medicine has significantly increased everywhere in the world, mainly because of the increasing risks for MIs, as illustrated in Chap. 2. The development of global terrorism has, of course, played an important role. Parallel to this increasing interest, the need for a better scientific base both for methodology and education has been increasingly realized. We are hopeful that we can expect extensive and positive development of the scientific part of Disaster Medicine during the years to come.

19.3

The Need for Research

Methodological development and research is a mandatory component of all fields in medicine, and Disaster Medicine is no exception. Disaster Medicine is a multidisciplinary science, covering the major part of medicine: • Surgical disciplines such as trauma, emergency surgery, orthopedic surgery, neurosurgery, plastic surgery, paediatric surgery, and burn management • Anaesthesiology and intensive care

• Internal medicine specialties such as emergency medicine, toxicology, pulmonary medicine, nephrology, paediatric medicine, and nutrition • Primary health care • Prehospital care including ambulance and transport medicine • Infectious diseases, tropical medicine • Nuclear medicine • Forensic medicine • Laboratory medicine • Psychiatry and psychology • Social medicine With all these fields, there is a need for methodological development for the management of situations where the immediate need of care exceeds available resources: • Simplified methods for diagnosis and treatment • Methodology of triage • Injuries/diseases specific to MIs In most of these specialties, the sector of MI response is too small to justify academic positions. However, there is a clear need for a coordinating academic position with the responsibility to: • Identify and define the need for development/ research • Initiate research • Coordinate this research (which often is multidisciplinary) • Mobilize and secure resources for research • Lead, coordinate, and develop education and training within the whole field of Disaster Medicine In addition to this need of research within and in coordination between all fields involved in MI response, there also is a need for development of the coordinating functions covering all these fields: planning and organization of the whole prehospital and hospital responses to MIs, including command, coordination, and communication. This development has to be done with collaborating agencies like rescue service, civil protection, police, and military. All this further emphasizes the need to coordinate academic units with academic positions in Disaster Medicine. Such positions can be staffed by any representative from the involved disciplines described above; because this is mainly a coordinating function, no one person can cover all these fields. Without such positions, however, it will be difficult to achieve any quality or volume of research within this field and to secure quality in education and training.

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Below are described some examples of the need for research common throughout the whole field of MI response and examples of research within different specialties involved in such response.

19.3.1 Research Covering the Whole Field of Major Incident Response Examples on such research fields are: • Scientific documentation and analysis of results from the response at different levels • Quality assurance of planning, preparedness, and performance • Scientific evaluation of methodology of triage at different levels of the response • Quality assurance and validation of educational methodology • Development and evaluation of models for operative command and coordination

19.3.1.1 Documentation and Analysis of Results Consequent reporting of the result of every treatment we do has today become a mandatory and natural responsibility in almost every field of medicine, and it has been an excellent basis both for quality assurance and methodological progress. The science of Disaster Medicine, the academic field of MI response, has so far been an exception to this policy. An increasing number of reports from MIs have been published and that is positive, but these publications have been mainly anecdotal reports, describing the scenario and the difficulties with management and performance. There are so far few national or international standard formats (protocols) for reporting in a standardized way, which is necessary for scientific analysis, comparison of results, and conclusions with regard to the best methodology to use in different situations. If, for example, surgical activities had been reported in a similar way or not reported at all, surgery would probably still be at the same level as it was in the beginning of twentieth century. There are several explanations for this lack of scientific reporting: • Disaster Medicine is still a young science compared with other fields of medicine • It is not even recognized as a science everywhere

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• Reporting results has been politically sensitive because preparedness for MIs is a political responsibility and bad results because of poor or nonexistent planning and preparedness cost votes for politicians. There are recent examples from incidents where all involved staff has been prohibited from reporting any results • There is still no general agreement on how results should be defined and reported It is common, especially because of the second point of those mentioned above, that the official announcement after an MI is that “X number of patients died only because of severe injuries, but the preparedness was good and everyone did an excellent job.” However, there are by now a number of reports where the response, for some reason, has been critically and objectively evaluated after such a statement, showing that practically everything was done wrong and/or the planning and preparedness were totally insufficient. The MI is a difficult situation to cope with, and the incident in which nothing could have been done better has probably not yet occurred. Mistakes in these difficult situations are nothing to be ashamed of, exactly as in the management of severely traumatized patients, but if these mistakes are not reported and analyzed, we will never improve. Standardized reporting of results requires an agreement on how the results should be defined and reported. The result is not the total number of deaths or complications; it is the number of the potentially preventable ones. Because this is not easy to define, an alternative is to give the results as mortality and complications related to (a) the number and severity of injuries (injury severity scores) and (b) available resources. A prerequisite is that these data are included in the protocol used for reporting. Examples of input data in such a protocol include: • The number of injured categorized by trauma score (for example, injury severity score [ISS]) • Available prehospital resources (prehospital teams, transport facilities of different kinds, distances to the scene) • Available hospital resources, surge capacity, and distance from scene Examples on output data include: • Times for alert and response • Mortality • Complications of different severity • Utilization of resources

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Within the section for Disaster & Military Surgery in the European Society for Trauma and Emergency Surgery, just such a protocol has been launched and a number of incidents have been reported according to it. It is still undergoing adjustment to achieve an even wider acceptance if possible, but is available on the website of the forum of the Society, the European Journal of Trauma and Emergency Surgery (http:// www.europeantrauma.net). Other groups in other parts of the world are working with similar protocols, and the optimal outcome would be that all of these groups came together in agreement on the same protocol. To achieve this is a challenge for the international societies in this field. It is important that all staff involved in an MI response realize the importance of this documentation and actively contribute to the registration of data, as described above.

19.3.1.2 Quality Assurance of Preparedness and Response Such quality assurance requires definition of quality indicators: which indicators are relevant to use, how they should be registered, and how the level of quality should be graded. Examples of such quality indicators are: • Alert times (time intervals between the incident and the alert of different units) • Response times (time intervals between alert and response) • Level of alert related to needs (under-alert or overalert) • Triage (percent of accurate/inaccurate priorities; under-triage or over-triage) • Efficiency of prehospital response (time from arrival on the scene until the evacuation is completed) • Efficiency of transport (percent of accurate/inaccurate destinations) • Mortality related to ISS • Complications of different degrees (life-threatening, persistent disability, other) related to ISS Some of these indicators depend on more than one component in the chain of management; for example, the quality of planning and the competence of the responding staff both influence the alert times. This makes the analysis slightly more complex, but it is possible to analyze these components separately. It should be possible to express numerically as figures the quality indicators used. This makes the result of a response or an exercise able to be defined as a base

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for improvement, either by modification of the organization or by repeated training.

19.3.1.3 Quality Assurance of Education and Training The need for validation of programs for education and training has already been discussed in Chap. 18, but it is an important task in the science of Disaster Medicine. 19.3.1.4 Methodology of Triage In the chapter about triage (Chap. 4) the lack of evidence-based data to confirm the validity of or compare the different methods of triage was emphasized. Examples were given about how such data can be acquired by using advanced simulation models, a useful technique for evaluation also of other methods during MI response. As described in Chap. 4, the methodology of triage must be based on data from clinical series of traumatized or critically ill patients. This illustrates the need for and benefit of combining experimental and clinical research as a basis for the development and evaluation of methodology during MI response, which is also valid for fields other than triage. 19.3.1.5 Methodology of Command and Coordination The importance of high quality command and coordination has already been emphasized several times in this book. The need for good structure during MIs is not unique for the health care sector; it is also required among collaborating agencies like rescue service, police, civil defense, and military service. It could therefore be considered natural to use the same leadership structure in the health care sector as that used in the above-mentioned organizations. Attempts have been made to do so, but unfortunately they have not been successful because of significant differences between the health care sector and other organizations: • The organizations referred to above have to use and rely on a well-established operative command structure in their daily work • This is an important part of training for their staff, which, combined with daily practice, means that competence to take command always is available at all levels in the organization • The most important merit for higher positions in these organizations, and a natural part of a professional career, is good leadership capabilities

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In the health care sector, on the other hand, operative leadership is normally used to a limited extent and is not a natural component of the daily work. The formal leaders are administrators who make economical decisions but are not involved in operative leadership and are not available outside office hours. A senior professional position requires high professional competence, but leadership competence in most cases has no merit. These differences make it difficult or impossible to transfer a leadership structure from organizations such as those mentioned above to the health care sector. The health care sector has to develop its own structure of operative command. This structure has to be based on simplicity so that operative leadership can be undertaken by any senior staff member on duty. To train staff for whom such leadership is not included in their daily work or as a part of their professional career requires special training programs. The best way to achieve this is by using advanced simulation models, such as those described in Chap. 16. Training of leaders with such models should be done in collaboration with professionals in leadership from other organizations with understanding both of the structure and of the specific problems in the health care sector. Such training programs require a scientific basis, which is a task for the science of Disaster Medicine.

19.3.2 Research Within Specialties Involved in Major Incident Response In an MI, resources will not allow all injuries or conditions to be treated by specialists, which means that all staff involved in the response have to know the principles of at least primary diagnosis and treatment. Some examples of such injuries/conditions are given below.

19.3.2.1 High-Energy Trauma The effects of high-energy trauma on the human body have been described in Chap. 7. These injuries require special principles of treatment (also described above); if these principles are not followed, preventable loss of health and even life may occur. This requires development and evaluation of methods to treat such injuries, as well as methods to teach and train staff who potentially will be involved in such treatment. Models for high-energy injuries are injuries caused by fragments

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or missiles; modern weapons technology and terrorists have been competing with the aim to injure the human body as much as possible – optimally, they want to tear it into pieces. This has become the basis for a special field of research, wound ballistics, where the effects of this kind of trauma are specifically studied with the aim of developing guidelines for optimal treatment. One positive effect of this sad development is that much of this knowledge can be transferred to daily trauma care because the energy of the trauma we meet in our daily life has increased with the development of the community, e.g., higher speeds during transportation and increasing intentional violence. It is important that this knowledge is transferred to daily trauma care and included in training, not only for trauma specialists, but for all staff potentially involved in the management of such injuries during MIs or armed conflicts.

19.3.2.2 Simpliﬁed Methods for Diagnosis and Treatment The need for simplified methods for diagnosis and treatment during MI response has been emphasised several times in this book. During MIs, resources will not permit the use of all the advanced technology we are used to in our daily medical care. Within surgical specialties, the best example of this is the introduction of the damage control (DC) concept, which is thoroughly described in Chap. 7. The primary temporary treatment uses a simple and quick methodology with the aim to get the patient to survive for reparatory surgery at a later stage, when the patient’s condition has improved and resources so permit. The DC concept includes a wide range of methods involving several surgical specialties, all of which are described in Chap. 7. The problem from a scientific point of view is that many of these methods have been introduced and widely used without being based on evidence. For example, it is possible to close a bowel temporarily instead of performing resection and anastomosis, and it is possible to insert an artificial temporary shunt in an artery instead of doing primary repair; however, there are few – and in many cases none – clinical of experimental studies showing: • The real gain of the procedures (time and resources) • The risks for complications and how to prevent them • Which methodology to use

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This requires either prospective clinical studies or experimental studies. The difficulties in doing prospective clinical studies on these severely ill patients, who are often treated under severe time pressure, are apparent. The problems with transferring the results of experimental studies to the clinical situation are also well known. Basic experimental studies combined with clinical prospective, multicenter studies are required, and this is a challenge for the science of Disaster Medicine in close collaboration with different clinical specialties.

19.3.2.3 Volume Replacement in Bleeding and Shock This is a field for development and research within daily trauma care, but some problems are specific to the MI: • The prehospital phase will in many cases be prolonged, requiring prehospital fluid resuscitation to a larger extent • The access to blood in the hospitals will be limited related to the needs The fluids used for prehospital volume replacement today do not carry oxygen, and they have negative effects on both coagulation and circulation if given in too large amounts. The development and evaluation of oxygen-carrying solutions and solutions with fewer negative effects on coagulation and osmolal balance is a research field that should be given high priority when seen from the perspective of Disaster Medicine; representatives from this science should take part in and promote this development. Auto-transfusion of blood is used to limited extent in daily medicine, but it has a clear role during MIs as a way to save blood, e.g., in a hemothorax with bleeding. The development and evaluation of methodology should be promoted and supported within the science of Disaster Medicine. 19.3.2.4 Extreme Temperatures The effects of low temperature have been described in Chap. 9. There are still many questions about this that remain to be answered and that are of special interest within the field of MI response: • Criteria for the declaration of hypothermic patients as dead • “Full- or half-speed” resuscitation of patients with hypothermia

S. Lennquist

• Risks of rapid rewarming in situations with limited resources Physiologic effects of hypothermia can be studied in connection to the clinical use of hypothermia for surgery and anaesthesia. The effect of cooling can be studied on volunteers, and such studies have been used already to illustrate the role of catecholamines in the effects of cooling, an important issue during MIs, when trauma and cold exposure often are combined. The effect of high temperature is also an important problem during MIs. For example, during the floods following hurricane Katrina in New Orleans, Louisiana, in 2005, one major cause of death was not drowning, but sitting isolated on roofs in high temperatures and humidity without access to airconditioning. Better knowledge about these risks and how to reduce them might have influenced the outcome. Burn injuries also can be categorized as an effect of severe heat. As illustrated in Chap. 8, during major fires there is a high risk that resources will be insufficient to give the same level of treatment to patients with severe burn injuries as they would receive in normal (heavily resource-consuming) burn care. This requires development and evaluation of simplified methods for burn care, another area of focus for the science of Disaster Medicine.

19.3.2.5 Hazardous Materials MIs with hazardous material involve the risk of large numbers of injured requiring resource-consuming treatment, e.g., ventilator treatment after exposure to leakage of toxic gas. Considering that access to ventilators is a critical capacity-limiting factor even in incidents with limited need of such treatment, it is easy to imagine the problems connected with a sudden need of ventilator treatment for perhaps hundreds of patients. This requires planning and preparedness, including the development of alternative methods. An example of such a project is the development of methods for aerosol inhalation to replace ventilator treatment after exposure to chlorine gas, and such projects are needed to prepare for similar scenarios. Development and evaluation of the methodology for decontamination and alternatives for antidotes in mass-casualty-exposure are other fields in this area that should be given priority.

19

Further Methodological Development and Research

19.4

Future Perspectives

As illustrated in this short review, there is a clear need for methodological development and research in many fields within the area of MI response. Without doubt, the low academic activity has so far had a negative influence on development within this field. There are many explanations for this limited activity: This academic field is still young and is not recognized everywhere; there are always difficulties when starting scientific work in areas without scientific traditions, especially with regard to funding; and this field requires a somewhat different methodology compared with that of other medical specialties. It is possible to overcome all of these problems, but most important at the present moment is to get this field better recognized at the university level and get decision makers on this level to realize the apparent need for both research and education. Once this field is established in universities and medical schools – and we are well on our way in this establishment – the scientific activity will increase in many fields waiting to be explored, and that will promote significant development in this area.

Further Reading Birnbaum M (2000) Disaster research – why, how and when? Prehosp Disaster Med 15:88–92 Gryth D, Rådestad M, Nilsson H et al (2010) Evaluation of medical command and control using performance indicators in a

405 full scale major aircraft accident exercise. Prehosp Disaster Med 25:118–123 Jenkins JL, Mc Carthy ML, Sauer LM et al (2008) Mass casualty triage – time for an evidence based approach: a comprehensive review. Prehosp Disaster Med 23:3–8 Jesus JE, Michael GE (2009) Ethical considerations of research in disaster-stricken populations. Prehosp Disaster Med 24: 109–114 Lennquist S (2003) Promotion of disaster medicine to a scientific discipline – a slow and painful but necessary process. Int J Disaster Med 2:95–99 Lennquist S (2008) Protocol for reports from major accidents and disasters. Eur J Trauma Emerg Surg 5:486–492 McManus JG, McClinton A, Morton MJ (2009) Ethical issues in conduct of research in combat and disaster operations. Am J Disaster Med 4:87–94 Neches R, Ryutov T, Kichkaylo T et al (2009) Design and evaluation of evaluation of a disaster preparedness logistic tool. Am J Disaster Med 4:309–320 Nilsson H, Vikstrom T, Rüter A (2010) Quality control in disaster medicine training – initial regional medical command and control as an example. Am J Disaster Med 5:35–40 Rothman RE (2006) Research priorities for surge capacity. Acad Emerg Med 13:1160–1166 Sacco WJ (2005) Precise formulation and evidence based application of resource-constrained triage. Acad Emerg Med 12:759 Sundness K, Birnbaum ML (2003) Health disaster management – guidelines for evaluation and research in the Utstein style. Prehosp Disaster Med 17(Suppl 3):1–177 Talving P, Du Bose J, Barmparas G (2009) Role of selective management of penetrating injuries in mass-casualty situations. J Trauma Emerg Surg 3:225–239 Wang J (2004) Aerosol treatment of chlorine gas induced lung injury. Academic dissertation, University of Linköping, Sweden

Index

A AAAM. See Association for the Advancement of Automobile Accidents ABA. See American Burn Association Abbreviated Injury Score (AIS), 353–354 ABGA. See Arterial Blood Gas Analysis ABLS. See Acute Burn Life Support Action Card, 34, 36, 40, 57, 85, 87, 88 Acute Burn Life Support (ABLS), 202 Acute Physiological and Chronic Health Evaluation (APACHE), 358 Acute stress disorder (ASD), 366–367 Administrative Officer in Command (AOC), 83 Adult respiratory distress syndrome (ARDS), 201, 270, 272 Advanced trauma life support (ATLS), 119, 390 All hazard approach/concept, 79 ALO. See Ambulance loading officer Alpha radiation, 279 AM. See Ante Mortem Ambulance Dispatch Center (ADC), 33 Ambulance equipment vehicle, 43 Ambulance loading officer (ALO), 33 Ambulance loading zone, 40 American Burn Association (ABA), 205 Amerithrax investigation, 301 Amputations, 190 Anatomical profile (AP) (in scoring), 354–355 Anatomical triage, 67 Ante Mortem (AM), 100 Anterolateral thoracotomy, 162 Antidotes, 235, 259 Antimicrobials, 202 Anti terrorist alliance (ATA), 337 AOC. See Administrative Officer in Command APACHE. See Acute Physiological and Chronic Health Evaluation ARDS. See Adult Respiratory Distress Syndrome Arterial Blood Gas Analysis (ABGA), 260 ASCOT. See A Severity Characteristic of Trauma ASD. See Acute stress disorder A Severity Characteristic of Trauma (ASCOT), 357 Association for the Advancement of Automobile Accidents (AAAM), 353 ATA. See Anti terrorist alliance

ATLS. See Advanced Trauma Life Support; Advanced trauma life support Avalanche, 224 Awake Verbal Pain Unresponsive (AVPU)-scale, 133

B Bair Hugger, 219 BAL. See British Antilewisite Barotrauma, 331 Base excess injury severity score (BISS), 357 Becquerel (Bq), 280 Behavioral therapy (BT), 374 Beta-radiation, 279 BIG. See Bone injection gun Biological Toxin Weapons Convention (BTWC), 295 BISS. See Base excess injury severity score Blast injury (BLI), 116–117, 128, 189, 331 Blast lung, 331 BLEVE. See Boiling liquid vapor explosion BLI. See Blast injury Boiling liquid vapor explosion (BLEVE), 17 Bone injection gun (BIG), 136 Booby bombs, 341 Bq. See Becquerel Break point, 33 British Antilewisite (BAL), 236 BTWC. See Biological Toxin Weapons Convention

C CABCD. See Catastrophic Bleeding-AirwayBreathing-Circulation-Disability Cable News Network (CNN), 329 Capillary refill, 68, 131 Cardio-pulmonary resuscitation (CPR), 214 Cardio-vascular system (CVS), 258 Care flight triage system, 70 CAS. See Chemical Abstract Service Casualty clearing zone, 34 Catastrophic bleeding-airway-breathing-circulationdisability (CABCD), 119, 132 CCATT. See Critical care air transport Celsius-Fahrenheit conversion scale, 211 Central nervous system (CNS), 258

S. Lennquist (ed.), Medical Response to Major Incidents and Disasters, DOI 10.1007/978-3-642-21895-8, © Springer-Verlag Berlin Heidelberg 2012

407

408 Centre for Research on the Epidemiology of Disasters (CRED), 305 Check point, 33 Chelating agents, 289 Chemical Abstract Service (CAS), 248 Chest drain, 162 Cheyne-Stoke breathing, 151 Chin lift, 120 Circulation, Respiration, Abdomen, Motor, Speech (CRAMS) scoring system, 356 Circulatory shock, 130–131 CNN. See Cable News Network CNS. See Central nervous system Cognitive behavior therapy (CBT), 375 Cold zone, 35, 233 Collapsed buildings, 21 Colloid solutions, 137 Colostomy, 172 Command safety communication assessment triage treatment transport (CSCATTT), 34 Compartment syndrome, 118, 181 Compensated incidents, 1 Complex emergencies, 1 Compound incidents, 1 Comprehensive Research Injury Scale (CRIS), 359 Computer tomography (CT), 148 Concussion, 151 Continuous Positive Airway Pressure (CPAP), 257 Contusion, 151 CPAP. See Continuous Positive Airway Pressure CPR. See Cardio-pulmonary resuscitation CRED. See Centre for Research on the Epidemiology of Disasters Cricothyroidotomy, 123 CRIS. See Comprehensive Research Injury Scale Crisis support, 369 Critical care air transport (CCATT), 327 Crush injury, 115, 187 Crystalloid solutions, 137 CT. See Computer tomography CVS. See Cardio-vascular system Cystostomy, 150

D Dactyloscopy, 101 DALY. See Disability adjusted life years Damage Control, 149 Debridement, 184, 185 Decompensated incidents, 1 Decontamination, 242, 285 Decontamination triage, 233, 244 Decontamination unit, 89, 285 DEF. See Definitive-outcome-based evaluation form Definitive-outcome-based evaluation form (DEF), 358 Definitive surgical trauma care (DSTC), 390 Delayed primary closure, 185 Diagnostic peritoneal lavage (DPL), 165 Dirty bomb, 278, 341 Disability, 119 Disability adjusted life years (DALY), 360

Index Disability Ranking Scale (DRS), 359 Disaster, 1 Disaster medicine, science of, 1, 399 Disaster plan, 77 Disaster victim identification (DVI), 100 Distribution key, 56 DPL. See Diagnostic peritoneal lavage Drowning, 225 DSTC. See Definitive surgical trauma care DVI. See Disaster victim identification

E Earthquakes, 308 EBA. See European Burn Association ECG. See Electrocardiography ED. See Emergency Department EDTA. See Ethylene dinitrole tetra-acetic acid EEG. See Electroencephalography Effect-related triage (ERT), 70 Electrocardiography (ECG), 212 Electroencephalography (EEG), 213 Electronic volts (eV), 279 EMD. See Emergency Department EMDR. See Eye movement desensitization and reprocessing Emergency Department (ED), 89, 236 Emergency Medical Service (EMS), 230 Emergency Rescue Network within IAEA (ERNET), 292 Emergency Rescue Unit within IAEA (ERC), 292 Emergo Train System (ETS), 385, 387, 388 EMS. See Emergency Medical Service Environmental Protection Agency (USA) (EPA), 240 EPA. See Environmental Protection Agency (USA) Epidural haematoma, 151 ERC. See Emergency Rescue Unit within IAEA ERNET. See Emergency Rescue Network within IAEA ERT. See Effect-related triage Escharotomies, 203 ESTES. See European Society for Trauma & Emergency Surgery Ethylene Dinitrole Tetra-acetic Acid (EDTA), 250 European Burn Association (EBA), 205 European Society for Trauma & Emergency Surgery (ESTES), 391 eV. See Electronic volts External contamination, 276 External radiation, 276 Extraperitoneal packing, 177 Eye movement desensitization and reprocessing (EMDR), 375

F Fahrenheit/Celsius conversion scale, 211 Fasciotomy, 181 FAST. See Focused Assessment Sonography in Trauma FCI. See Functional capacity index Field exercises, 383–385 Flail chest, 125 Floods, 311

Index Focused Assessment Sonography in Trauma (FAST), 165 Forward surgical teams (FSTs), 325–326 Frostbite, 221 FSTs. See Forward surgical teams Functional capacity Index (FCI), 360

G GABA. See Gamma amino butyric acid Gamma amino butyric acid (GABA), 261 Gamma-radiation, 279 GCS. See Glasgow Coma Scale GHS. See Globally Harmonized System Glasgow Coma Scale (GCS), 133, 134 Glasgow Outcome Scale (GOS), 359 Globally Harmonized System (GHS), 248 Global Outbreak Alert and Response Network (GOARN), 297 Global terrorist data base (GTD), 342 Global terrorist movement (GTM), 337 GOARN. See Global Outbreak Alert and Response Network GOS. See Glasgow Outcome Scale Gray (Gy), 280 Green alert, 81 GTD. See Global terrorist data base GTM. See Global terrorist movement Gy. See Gray

H Haemoptysis, 160 Haemothorax, 125, 127, 160 HAPAI. See Highly pathogenic avian influenza Hartman’s procedure, 172 Hazardous material (Hazmat), 238 HBO. See Hyperbaric oxygen HCG. See Hospital Command Group HCN. See Hydrogen cyanide Heart rate (HR), 130 Heimlich valve, 127 Helicopter Emergency Medical Service (HEMS), 46 Helicopter landing area, 43 High capacity filtering face protection (FFP3), 241 Highly pathogenic avian influenza (HAPAI), 294 Hospital Command Group (HCG), 7, 9, 83 Hospital Information Center, 93 Hostage taking, 338 Hot zone, 35, 233 HR. See Heart Rate Hurricanes, 309 Hydrogen cyanide (HCN), 258 Hyperbaric oxygen (HBO), 253 Hypertonic solutions, 137 Hypothermia, 211

I IAC. See Information and Advice Centre IAEA. See International Atomic Energy Agency ICD. See International Classification of Diseases ICD Injury Severity Score (ICISS), 355 ICMP. See International Commission of Missing Persons

409 ICP. See Intracranial pressure ICRC. See International Committee of Red Cross ICRP. See International Commission of Radiological Protection ICU. See Intensive care unit Identification teams, 101 IEDs. See Improvised explosion devices IHR. See International Health Regulations IIS. See Injury Impairment Scale Immediately Dangerous to Life and Health (IDHL), 248 Immersion, 225 Impact energy, 113 Impact velocity, 113 Improvised explosion devices (IEDs), 321, 340 Information and Advice Centre (IAC), 364 Injury Impairment Scale (IIS), 359 Injury Severity Score (ISS), 354 Injury zone, 42 Intensive care unit (ICU), 85 Interactive training, 383 Internal contamination, 281 Internal radiation, 280 International Atomic Energy Agency (IAEA), 291 International Classification of Diseases (ICD), 355 International Commission of Missing Persons (ICMP), 105 International Commission of Radiological Protection (ICRP), 280 International Committee of Red Cross (ICRC), 166 International Health Regulations (IHR), 297 International Society for Burn Injuries (ISBI), 205 International Society for Disaster Medicine (ISDM), 399 Intracranial Pressure (ICP), 151 Intramural haematoma, 170 Intraosseous infusion, 136 Irritable heart syndrome, 363 ISBI. See International Society for Burn Injuries ISS. See Injury Severity Score

J Jaw trust, 120 Jet insufflation, 124 Joint theatre trauma system (JTTS), 322 JTTS. See Joint theatre trauma system Jump START triage method, 68, 74

K Kamedo-report, 31 KZ-syndrome (Concentration camp), 363

L Lachrymators, 272 Landstuhl regional medical centre (LRMC), 322 Laryngeal mask, 129 LET. See Linear energy transfer Linear energy transfer (LET), 279 LRMC. See Landstuhl regional medical centre

410 M MACSIM. See MAss Casualty SIMulation System MAIS. See Maximum AIS Major emergency, 1 Major incident, 1 Major incident command room, 84 Major incident medical management and support (MIMMS), 33, 390–391 Major incident resuscitation (MIR) teams, 91, 142 Major Trauma Outcome Study (MTOS), 356 Man-made disasters, 1 MAss Casualty SIMulation System (MACSIM), 385 Maximum AIS (MAIS), 354 Mechanisms, Glasgow Coma Scale, Age, Arterial pressure (MGAP) scoring system, 356 Médecins Sans Frontières (MSF), 317 Media-management, 94 Medical evacuation-system (MEDEVAC), 322 Medical Incident Commander (MIC), 33 Medical Officer in Command (MOC), 83 Medical relief assistance (MERLIN), 317 Medical response to major incidents (MRMI), 391–392 Medical treatment facility (MTF), 327 MERLIN. See Medical relief assistance Met-Haemoglobin (MetHb), 258 Metraux-thermometer, 214 MGAP scoring system. See Mechanisms, Glasgow Coma Scale, Age, Arterial pressure MI. See Major incident Milli-Sievert (mSv), 280 MIMMS. See Major incident medical management and support MIR. See Major incident resuscitation teams Missile injuries, 113, 183 MOC. See Medical Officer in Command MRMI. See Medical response to major incidents MSF. See Médecins Sans Frontières mSv. See Milli-Sievert MTF. See Medical treatment facility MTWHP. See Mydriasis, Tachycardia, Weakness, Hypotension and Fasciculations Mydriasis, Tachycardia, Weakness, Hypotension and Fasciculations (MTWHP), 264

N NA. See Needs assessment NATO classification for triage, 64 Natural disaster, 1 Needle thoracotomy, 127 Needs assessment (NA), 312 New Injury Severity Score (NISS), 355 NFCI. See Non-Freezing Cold Injury NGOs. See Non-Governmental Organizations NISS. See New Injury Severity Score Non-Freezing Cold Injury (NFCI), 221 Non-Governmental Organizations (NGOs), 284, 314

Index NPP. See Nuclear Power Plant Nuclear energy, 277 Nuclear Power Plant (NPP), 275

O OCHA. See Organization for Coordination of Humanitarian Assistance Operation room/theater (OR), 85 Orange decontamination zone, 238 Organic solvents (OSs), 262 Organization for Coordination of Humanitarian Assistance (OCHA), 314 OSs. See Organic Solvents Over-triage, 348

P Paradoxal ventilation, 160 PCC. See Poison Control Center Peak Expiratory Flow (PEF), 257 Pediatric Trauma Score (PTS), 358 Pediatric triage tape (PTT), 68, 74 PEEP. See Positive end-expiratory pressure PEF. See Peak Expiratory Flow Penta erythro nitrate (implanted explosive device) (PETN), 341 Personal protection equipment (PPE), 230, 328 PHI. See Prehospital Index PHTLS. See Pre-hospital trauma life support Physiological triage, 67 PIC. See Police incident commander Pneumothorax, 125 Poikilothermia, 217 Poison Control Center (PCC), 238 Police incident commander (PIC), 33 Polonium (PO), 278 Polytrauma Score (Hannover) (PTS), 357 Positive end-expiratory pressure (PEEP), 225, 257 Post-mortem examination, 100 Post-traumatic stress disorder (PTSD), 360, 367–369 PPE. See Personal protection equipment Prehospital Index (PHI), 356 Prehospital teams, 46 Pre-hospital trauma life support (PHTLS), 57, 390 Preliminary outcome-based evaluation (PRE-methodology), 358 Preoperative zone, 92 Press release, 95 Priority, categories, 64 Probability Of Death Score (PODS), 356 P-system, 64 PTSD. See Post-traumatic stress disorder Pulmonary contusion, 128

Q QALY. See Quality-adjusted life years QOL. See Quality of life-scale

Index Quality-adjusted life years (QALY), 360 Quality of life-scale (QOL), 360

R Radiation pneumonitis, 282 Radiological dispersive devise (RDD), 342 RDD. See Radiological dispersive devise Reaction level scale (RLS), 355 Recovery position, 121 Red alert, 81 Regional Command/Coordination Centre (RCC), 2 Regional Medical Command/Coordination Centre (RMC), 33 Remote magnitude assumption (RMA), 312 Reperfusion injury, 188 Rescue Incident Commander (RIC), 33 Resilience, 368 Respiratory rate (RR), 356 Revised trauma score (RTS), 69, 355–356 Richter scale, 308 RLS. See Reaction level scale RMA. See Remote magnitude assumption RR. See Respiratory rate RTS. See Revised trauma score Rule of nines, 198

S Sacco Triage Method, 70 Sacco Triage System (STM), 70 SARS. See Severe acute respiratory syndrome SBT. See Systolic blood pressure SCBA. See Self contained breathing apparatus Scope and run, 51 Search and rescue-teams, 308, 343 Self contained breathing apparatus (SCBA), 240 Semi-drainage position, 122 Semi-occlusive bandage, 127 Severe acute respiratory syndrome (SARS), 293 Shell shock, 363 Sickness impact profile (SIP), 360 Sievert (Sv), 280 Simple treatment and rapid transport triage system (START), 69 SIP. See Sickness impact profile SMART® priority & registration card (SMART-tag), 65 START. See Simple treatment and rapid transport triage system Stay and stabilize, 51 STM. See Sacco Triage System Stochastic effects (radiation), 283 Stress syndrome, 365 Subdural haematoma, 151 Submersion, 225 Support functions to HCG, 84 Surge capacity, 78 Systolic blood pressure (SBT), 131

411 T Table-top exercise, 385 TACEVAC. See Tactical evacuation care Tactical combat casualty care (TC3), 321 Tactical evacuation care (TACEVAC), 322 TBI. See Traumatic brain injury TBSA. See Total burned surface area TC3. See Tactical combat casualty care Tension pneumothorax, 126, 127 Terrorism, definition, 337 Terrorist medicine, 342 Thermal injury, 198 Tidal waves, 309 TNCC. See Trauma nurse core course Total burned surface area (TBSA), 198 Toxico-dynamics, 250 Tracheal intubation, 122 Trajectories, 368–369 Transport officer, 33 Trauma Audit Research Network (TARN), 357 Trauma Injury Severity Score (TRISS), 356–357 Trauma nurse core course (TNCC), 390 Traumatic brain injury (TBI), 327–328 Triacetate triple oxide (implanted explosive) (TATPT), Triage officer (TRO), 34 Triage-Revised Trauma Score (T-RTS), 356 Triage sieve, 68 Triage sort, 69 Triage START, 69 TRISS. See Trauma Injury Severity Score T-RTS. See Triage-Revised Trauma Score Tsunami, 26, 309 T-system, 64 Tympanic temperature, 213

U Ultra high frequency (UHF) (communication), 59 Ultrasonography (USG), 148 UNHCR. See United Nations High Commissioner for Refugees United Nations High Commissioner for Refugees (UNHCR), 314 USG. See Ultrasonography

V Vanguard technique for rewarming, 219 Vascular shunt, 171, 180 Vehicle-borne improvised explosive devices (VIED), 341 Very high frequency (VHF) (communication), 59 VIED. See Vehicle-borne improvised explosive devices Vital signs absent (VSA), 324 VSA. See Vital signs absent

W WADEM. See World association for disaster & emergency medicine Warm zone, 35, 233

412 WBC. See White Blood Cell Count WFP. See World Food Program Whiplash associated disorders (WADs), 360 White Blood Cell Count (WBC), 278 WHO. See World Health Organization WHO Radiation Emergency Preparedness and Assistance Network (WHO/REMPAN), 292 Window report, 34

Index World association for disaster & emergency medicine (WADEM), 399–400 World Food Program (WFP), 314 World Health Organization (WHO), 292, 294

Y Yellow alert, 81

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