management of mass surgical emergencies

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MANAGEMENT OF MASS SURGICAL EMERGENCIES

By;Col. Abrar Hussain Zaidi

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• INTRODUCTION / back ground• PRINCIPLES OF MANAGEMENT >TRAUMA CARE SYSTEM

SEQUENCE

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Your view ?

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1-INTRODUCTION

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INTRODUCTION

What constitutes a surgical emergency-?

A patient who requires :

an immediate,urgent,early surgical operative intervention [ of any

extent] to either save his life OR to prevent a

disability

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INTRODUCTION

Primary considerations ‘Life’ and ‘quality of life’

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INTRODUCTION

What constitutes Mass surgical

causalities Or emergencies ?

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INTRODUCTION

Any time /situation/occurrence when there are ‘more Patients than Rescuers and immediately available resources’

A major incident An event whose impact cannot be handled within

routine service and arrangements. It requires the implementation of special procedures by one, or more, of the Emergency Services.

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INTRODUCTION

levels /spectrum of major incident

• LEVEL I INCIDENTS multi-vehicle road traffic accidents, tens of casualties

• LEVEL II - Much larger scale events affecting potentially hundreds, rather than tens, of people,

possibly also involving the closure or evacuation of a major facility or persistent disruption over many days. This level of incident will require a collective response by several, or many, Trusts.

• LEVEL III INCIDENTS - Events of potentially

catastrophic proportions that severely disrup thealth and social care services and other functions (power, water, etc)and that exceed even collective capability.

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INTRODUCTION

Major Incidents of recent past

>9/11 >Kashmir earth quake >Frequent bomb blasts

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INTRODUCTION

What particularly differentiates a situation of mass causalities than ordinary circumstances

• Chaos and panic• Disorder• Difficult to define priorities• On going disaster• Destruction of Infrastructure

–road/rail/Hospitals• Limitation of available resources• Numerous others

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INTRODUCTION

Types of major incidents Special ground situations

• A-When the humans are responsible

• B-When The Nature Goes Wild

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A-HUMANS RESPONSIBLE [PRIMARY ROLE OF PREVENTION – STRESSED BY DISASTER MANAGEMENT TEAMS] • Air disaster• Road and Rail Accidents • Fire Emergencies• Industrial accidents /Hazardous Materials• Nuclear Accidents and Radiation• Building collapse • Explosion • Riots / insurgencies• Terrorism• wars

INTRODUCTION

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B-NATURE GOING WILD [PREVENTION NOT POSSIBLE – STRESS IS ON PREPARATION TO FIGHT] • Air/Environment [storms, inf. outbreaks[• Mountains• Planes• Desert• Waters• Combined e.g. Earth quakes

INTRODUCTION

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INTRODUCTION

Special Ground situationsSpecial Ground situations

Civilian vs. Army Mixed

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INTRODUCTION

Nature of mass surgical emergencies

Most of the mass surgical emergencies are Traumatic in nature >Physical Mechanical-RTA Fire/heat - burns Fire arm injuries –Wars/terrorisms

>Chemical >Others

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INTRODUCTION

AIMS OF MANAGEMENT

Minimize human mortality and morbidity

with Best use of available resources and

expertise

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INTRODUCTION

AIMS OF MANAGEMENT Save as Many Lives

as Possible Prevent as much disability as possible with best use of available

resources

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How to achieve the goals--?

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Answ. A Rationale,systematic,well structured,

coordinated and well organized approach in patient care.

The ‘theme’ in development of ‘principles of management’ of mass surgical emergencies and the ‘Trauma care system’

i.e. ‘a system approach in patient care’

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2-PRINCIPLES OF MANAGEMENT Differences from

ordinary trauma management-- ?

One casualty vs tens reporting simultaneously

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In ordinarily situations there are: tens of service men to attend a single causality

In mass casualty incident there are: Tens of casualties to be attended by

only a few service men

PRINCIPLES OF MANAGEMENT

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Mass casualty management poses challenges that are distinct from routine surgical practice.

WE NEED TO BE SELECTIVE As services can not be extended equally to every

one


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‘‘Trauma care system’Trauma care system’ A system approach in patient careA system approach in patient care that comprises;that comprises;

• Pre hospital care/scene of Pre hospital care/scene of accidentaccident• Evacuation systemEvacuation system• Hospital care . level 1, 11,111. Hospital care . level 1, 11,111.

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>Stress on a uniform approach of management >Developed with common consensus of world

bodies

-ATLS -PTC -BlS -Others


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TRIMODAL PATTERN OF DEATH:

• Immediate death - first peak within seconds of the injury, massive head injury, heart injury, or aortic injury. cannot be prevented.

• later death - second peak hemorrhage or direct organ compromise, deaths begins an hour or two after the injury- “golden

hour. subdural and epidural hematomas, hemo-pneumothorax, organ rupture, or blood loss. These deaths are often preventable • Delayed death –third peak due to complications and organ failure. due to sepsis or multi-organ failure. Prompt treatment of shock and hypoxemia during the “golden hour” can reduce these

deaths

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TRIMODAL PATTERN OF DEATH:

Sec to min 1-2 hrs [golden hour] weeks late

Immediate deaths Preventive measures

Early deathsUrgent treatment

Late deathsGood prolonged care

The main target for care

50%

30%

20%

Preventable

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Second peak death prevention

By benefiting from- “golden hour” is the

main target of trauma care services

[Subdural and epidural hematomas, hemo-

pneumothorax, organ rupture, or blood loss. deaths are preventable]

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‘Trauma care system’ A well coordinated,organized system of trauma

care services ‘operating in a specified geographical zone’ parallel to the administrative zone

Zones of operation A county A town A city A province A country

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PRINCIPLES OF MANAGEMENT Some Considerations

• Mass casualties are characterized by such numbers, severity,

and diversity of injuries that can overwhelm the ability of local

medical resources to deliver comprehensive and definitive medical care to all victims. • Surgeons play the pivot role BUT every one in the system has a unique contribution

• The training and skills of doctors is important

• Resources and infrastructure of trauma centers and trauma

systems should be suited for the logistical demands

• Rapid decision making required by large casualty burdens

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WHO GUID LINES

Disaster planning [preparedness]

• Local

• Regional• National


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‘Trauma care system’

Regional Mass Casualty Support Units

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WHO GUID LINES

• Project definition: determines the aim, objectives and scope of an emergency plan

• Planning group: to gather information and to gain the commitment of people and organizations, which will contribute .

• Potential problem analysis: develop strategies, • Resource analysis: resources available, discrepancy between requirement and availability, and responsibility.• Designation of roles and responsibilities to individuals

and organizations.• Management structure concerning the command of

individual organizations and control across organizations.• Systems development -actual medical aid for specific response and recovery

.• Documentation: The written emergency plan w

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THE BASIC PRINCIPLES

Actual treatment is done on the same principles as in usual victims of trauma –but with greater speed and on priorities

1- Triage and early transportation 2- Primary survey & resuscitation identification

& treatment of immediate life threat] 3- Secondary survey [ detailed examination, assessment and definitive subsequent Damage control surgical treatment and]

4- Continued care 5- Rehabilitation/follow up

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1-Triage

Selection/prioritization of cases on the ‘merit of the severity of their conditions’ to establish priorities for care -- based on available resources

See who needs attention first Based on quick Primary survey

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1-Triage • Proirity-1 / Red –- highest priority need immediate care (usually circulatory or respiratory]

• Proirity-2 / Yellow -second highest priority able to wait longer before transport (45 minutes)

• Proirity-3 / Green- walking - able to wait several hours

• Proirity-4 / White- Expectant-where out come is gloomy –

severe head injury, spinal cord injury• Proirity-5/ Black – Dead

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1-TriageProirity-1 / RedSeverely injured but able to be saved with

relatively quick treatment and transport– Examples:

° Severe bleeding, ° Severe Shock, ° Open Chest or Abdominal Wounds, ° Unconscious but has pulse and is breathing, ° Several Major Fractures

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1-TriageProirity-2 Yellow – Delayed• Stable but unable to walk on their own• Examples:

– severe burns but no respiratory distress, – spinal injuries – moderate blood loss – conscious with head injuries

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1-Triage

Proirity-3 / Green- walking - able to wait several hours

Minor injures that need to be assessed or

treated but not right away.

Ex: Minor fractures, minor bleeding

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1-Triage

Proirity-4 / Expectant-

where out come is gloomy – severe head injury, spinal cord injury

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1-Triage –points to remember• It is primarily based on quick and orderly primary

survey• It’s a dynamic process –i.e sorting & resorting May be repeated at different levels of care

Because • A bulk sorted at the scene of accident and

moved to Tauma ctr when RE_SORTED and re examined –may differ and change in poirities

• Sorting station at trauma ctr may be first triage site

• Actual condition of the victim may change with time and during transportation

• Initial assessment may be false –under/over

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1-Triage –points to remember Primarily concentrate on selection of severely injured

who has a good chance of survival

if treated well in time OR who will die if not treated in time

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1-Triage –points to remember The Criteria of selection : Severity of injury and chance of

survival

Search for: Seriously injured but with a good chance of survival

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2-Primary survey & Resuscitation

Quick appraisal : >what the person is suffering from >Is there an acute but treatable problem >What immediate measures are required >Does he need immediate shifting to OT

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• Wherever the patient is first seen –at the triage area

Or at the Trauma center• Examination time --seconds • Objective -Identify the immediate threat to life

and do an immediate measure -Assign the priority of case

Sequence of Resuscitation - ABC- of trauma care

Airways, Breathing, circulation, Disability, Exposure

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2-Primary survey & Resuscitation ABCDE of Trauma

The ‘primary’ survey, should identify such life-threatening injuries such as:

• airway obstruction• chest injuries with breathing difficulties• severe external or internal haemorrhage• abdominal injuries.

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Sequence of Resuscitation -ABCDE- of trauma care

AirwayAssess the airway. Can patient talk and breathe freely? If

obstructed, the steps to beconsidered are:• chin lift/jaw thrust (tongue is attached to the jaw)• suction (if available)• Insert airway/nasopharyngeal airway• Intubation. NB keep the neck immobilised in neutral

position.BreathingBreathing is assessed as airway patency and breathing

adequacy are re-checked. Ifinadequate, the steps to be considered are:

• Decompression and drainage of tension pneumothorax/haemothorax

• Closure of open chest injury• Artificial ventilation.• Give oxygen if available.

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Sequence of Resuscitation -ABCDE- of trauma care

Circulation• Assess circulation, as oxygen supply, airway patency

and breathing adequacy are re-checked. If inadequate, the steps to be considered are:

• Sstop external haemorrhage• Establish 2 large-bore IV lines (14 or 16 G) if possible• Administer fluid if available. Disability• Rapid neurological assessment (is patient awake,

vocally responsive to pain or unconscious). There is no time to do the Glasgow Coma Scale so a

• Awake A• Verbal response V• Painful response P• Unresponsive UExposure• Undress patient and look for injury e.g spinal injury,

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Reassessment of ABC’s must be undertaken

if patient is unstable

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2-Primary survey & Resuscitation Summary

• Check and establish airways – chin lift, jaw thrust, intubate.

e.g. Oropharyngeal /neck/chest injuries• Check and restore breathing –

Manual,mechanical,intubate. e.g. Haemopneumothorax• Check &R circulatory shock – stop visible bleeding, i/v

line balanced salt solution e.g. major vascular injuries• Check for neurological deficit.• Stabilize neck –manually/with collar supports

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Remember that:• Primary survey and immediate

therapeutic measure go side by side• A life saving procedure done by one

person /team may be supplemented by examination by other person/team and may draw attention to an associated serious condition [ex-4]

• Try to minimize the chance of missing any important feature

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Triage Primary survey &

resuscitation

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EXERCISE-1In a mass emergency situation you happen to

see twoMen; Make a choice / select one person

for Immediate help /resuscitation &

transfer

1-Young man with 5x5 inch burst in Rt.chest wall, pale and in shock.

2-Young man with bullet inj lt.chest with tense abdomen, conscous and maintaining vital signs Remember the Criteria —Severity and chance of

survival

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EXERCISE-2 Make a choice / select one person for Immediate help /resuscitation & transfer

A young man with Haemopneumothorax vs A young man with compound Fracture tibia

and fibula Mind that both are-priority one cases But –

Remember the Criteria —Severity and chance of survival

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EXERCISE-3 select one person for Immediate

esuscitation & transfer: young man with head and neck and chest

injury and coma vs A young man with absent femoral artery

pulsation and bluish discoloration on lower abdominal wall, conscious and stable

Traveling distance is of 2 hours Think - how much is chance for survival

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EXERCISE-4 A young officer, victim of a terrorist attack on GHQ is

brought to trauma ctr. First look /exam. He has visible 1-2 cm size wounds on fore head,

face and right arm. His clothes are grossly stained with blood. Has tachycardia. Blood pressure is normal. Very caring staff immediately attends and treat. Mean while 5-6 more injured persons are brought,

they are crying with pain and need attention. Officer cont to c/o pain and points to Right lower chest area

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A senior doctor comes and inquires

Staff reports: His condition is stable Emergency treatment/analgesia

given What should you do ? Feel satisfied OR else ? Resurvey

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Triage Primary survey &

resuscitation

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Evacuation /Transportation

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3- Secondary survey

At the trauma ctr/hospital

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3- Secondary survey

• History • Physical Exam • Laboratory Tests • X-rays • Special Surgical Procedures • Monitoring of Resuscitation • Consultation and Disposition

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3- Secondary survey

Decision for surgical intervention

Damage control surgery

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• Resources are limited • Aim is to save maximum number of cases• we have to be Selective• Rationalize the use of resources for the best deserving ; So- Choose; Those with serious but a treatable condition and treat expeditiously Important for all doctors to attain an

appropriate level of education and training in the unique principles and practice of mass casualty management, and to serve as role models in this field.

CONCLUSION MASS EMERGENCY MANAGEMENT

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DAMAGE CONTROLE SURGERY

Head Injury • General Approach Establish diagnosis, Assessment• Stabilization • Skull Fractures • Epidural Hematoma • Subdural Hematoma • Cerebral Contusion • Parenchymal Hemorrhage • Penetrating Injury Neck and Airway Trauma• General Approach Establish diagnosis, Assessment• Indications for Intubation • Laryngeal Injury • Airway Burn • Facial Trauma • C-spine Injury Chest Trauma• Approach to the Chest Establish diagnosis, Assessment• Myocardial Contusion • Flail Chest • Open Chest Wounds • Pulmonary Contusion • Hemothorax • Pneumothorax • Cardiac Tamponade • Aortic Rupture Abdominal Trauma • Approach to the Abdomen Establish diagnosis, Assessment• Liver Injury • Spleen Injury • Kidney Injury • Bowel Rupture • Pancreatic Trauma Trauma in Pregnancy Establish diagnosis, Assessment• Changes in Pregnancy • Stabilization • Uterine Rupture • Abrupted Placenta Pelvic Organ Injury • Approach to the Pelvis Establish diagnosis, Assessment• Ureteral Injury • Urethral Injury • Bladder Injury • Pelvic Fractures Orthopedic Trauma • Evaluation Establish diagnosis, Assessment• Stabilization The Burn Victim • General Approach to Burns Establish diagnosis, Assessment• Fluid Resuscitation Formula • Calculation of Burn Area • Referral Criteria

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References

• Mass Casualty Management Systems Strategies and guidelines for building health sector capacity by WHO.

• Major incident/mass casualty plan general plan and generic response for the Lincolnshire health community In managing major/mass casualty incidents February 2005

• ST-42 Statement on disaster and mass casualty management by the American College of Surgeons[The statement was

developed by the College's Ad Hoc Committee on Disaster and Mass Casualty Management of the Committee on Trauma, and was approved by the Board of Regents at its June 2003 meeting.]

• REVIEW ARTICLE : MK Joshipura, HS Shah, PR Patel, PA Divatia Trauma care systems in India - An overview2004 | Volume : 8 | Issue : 2 | Page : 93-97

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References• Moles TM.Emergency medical Med. 2003 Oct-Dec; 18(4):372-84. experience. Gen

Hosp psychiatry.

• C a r t e r W Ni c k . Di s a s t e r disasters. Acad Emerg Med 2004 A Feigenberg Z, Statnikovitz R,

• Gofin R, Shapira SC. A multiMa n a g eme n t . A Di s a s t e r Nov; 11(11): 1229-36. • Prasad. K.H, Nagarasad Y.R, GM, Cantrill S. Health Care facility Acad Emerg

Med.2004 Oct,;

• Murthy.P.N: Disaster Management. and Community strategies for 11(10):1102-4.

• Parmar N.K. Disaster Management 61. and Disaster preparedness in level I• in Metropolis: A thesis Submitted to 09. Lillibridge SR, NOJI EK, Burkle Trauma

centers in the U.S. AcadAIIMS, New Delhi, 1989. FM Jr. Disaster assessment : the Emerg Med 2003 May; 10(5): 529-

• Amin Tabish. Endangered future of emergency health evaluation of a 30. humans. The Future of Health. Paras population affected by a disaster. 13. Sweeney

B, Jasper E, Gates E.Publication. 2004 First Edition 235- Ann Emerg Med.1993 Nov; Large-scale Urban disaster drill 274. 22(11):1715-20. involving an explosion; Lessons

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Conclusion

The management of mass casualties is only one of many critical functions

involved in the overall response to a disaster.

Education training and rehearsal are especially important • Disaster planning and Integration of local, regional, and

national levels .• Hospital Emergency Incident Command Systems (HEICS).• Communications and security.• Media relations.• Protection of health care delivery personnel and facilities.• Detection and decontamination of biological, chemical, and

radiation exposure.• Triage principles and implementation.• Logistics of medical evaluation, stabilization, disposition,

and treatment of victims.• Record-keeping and postdisaster debriefing, critique, and

reporting.• Critical incident stress management (CISM).• Published research and experience in disaster

management.

management of mass surgical emergencies

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