Medical Aspects ofMedical Aspects ofUrban Search & RescueUrban Search & Rescue

David C. Cone, MDDavid C. Cone, MDAssociate Professor and ChiefAssociate Professor and Chief

Division of EMSDivision of EMSSection of Emergency MedicineSection of Emergency Medicine

Yale University School of MedicineYale University School of Medicine

Medical Team ManagerMedical Team ManagerConnecticut Urban Search & Rescue Task ForceConnecticut Urban Search & Rescue Task Force

ObjectivesObjectives

1. Introduce the U.S. federal 1. Introduce the U.S. federal response system for US&R incidentsresponse system for US&R incidents

2. Introduce confined space medicine2. Introduce confined space medicine

US&R: DefinitionUS&R: Definition

””The process of locating, extricating, The process of locating, extricating, and providing medical treatment to and providing medical treatment to victims trapped as a result of victims trapped as a result of structural collapses and other natural structural collapses and other natural or man-made catastrophes.”or man-made catastrophes.”

US&R Definition: Contd.US&R Definition: Contd.

““US&R also has application toward a US&R also has application toward a wide range of other advanced wide range of other advanced technical rescue incidents such as technical rescue incidents such as rescuing victims from rescuing victims from floods, swift-floods, swift-water, high-rise fire incidents and water, high-rise fire incidents and cave-inscave-ins; as well as rescuing survivors ; as well as rescuing survivors of of confined space, trench collapse, confined space, trench collapse, mass-transportation, climbing and mass-transportation, climbing and industrial machinery accidentsindustrial machinery accidents””

CSM: DefinitionCSM: Definition

““An emerging body of knowledge An emerging body of knowledge concerned with treatment and rescue concerned with treatment and rescue of victims in a collapsed structure” of victims in a collapsed structure” with limited access and egress, and with limited access and egress, and unfavorable environmental unfavorable environmental conditions.conditions.

Part 1:Part 1:U.S. US&R SystemU.S. US&R System

I am I am notnot trying to “sell” this system trying to “sell” this system

I am I am notnot trying to suggest that the trying to suggest that the U.S. system is better than any other U.S. system is better than any other systemsystem

I’m just describing it as it currently I’m just describing it as it currently existsexists

FEMA US&R Task ForcesFEMA US&R Task Forces

28 teams – variability in structure, 28 teams – variability in structure, composition, policies, etc.composition, policies, etc.

Fully self-sufficient for first 72 hoursFully self-sufficient for first 72 hours• Food, potable water, shelter, etc.Food, potable water, shelter, etc.

Functional for at least 10 daysFunctional for at least 10 days

Task Force StructureTask Force Structure

Incident Command SystemIncident Command System 62 persons (+ canines) in two shifts62 persons (+ canines) in two shifts Five componentsFive components

• Medical: 2 physicians, 4 medics/nursesMedical: 2 physicians, 4 medics/nurses• Search: canines, specializedSearch: canines, specialized• Rescue: 4 squads of six, heavy riggingRescue: 4 squads of six, heavy rigging• Logistics: communications, logisticsLogistics: communications, logistics• Planning: hazmat, structural, law Planning: hazmat, structural, law

enforcement, informationenforcement, information

Equipment CacheEquipment Cache

60,000 pounds60,000 pounds Pre-packaged on palletsPre-packaged on pallets www.fema.gov/pdf/usr/www.fema.gov/pdf/usr/

tfcache2000.pdftfcache2000.pdf

Task Force MissionsTask Force Missions

Recon: assess damage, determine Recon: assess damage, determine needs, survey hazmat and structuralneeds, survey hazmat and structural

Physical search & rescuePhysical search & rescue Emergency medical care for response Emergency medical care for response

personnel and limited # of victimspersonnel and limited # of victims• 10 critical, 15 moderate, 25 minor10 critical, 15 moderate, 25 minor

Communications support (military Communications support (military compatible equipment)compatible equipment)

Caring For Our OwnCaring For Our Own

Providing for the health and medical Providing for the health and medical needs of the team is the #1 priority needs of the team is the #1 priority of the medical component of the of the medical component of the teamteam

We do this by ensuring that We do this by ensuring that allall aspects of medical care are provided aspects of medical care are provided by usby us

““Prospective” RolesProspective” Roles

Health and fitness standardsHealth and fitness standards ImmunizationsImmunizations Medical recordsMedical records TrainingTraining Medical cache maintenanceMedical cache maintenance Medical check-in before departureMedical check-in before departure Medical intelligence gatheringMedical intelligence gathering

• Starts Starts beforebefore departure departure

Medical Intelligence GatheringMedical Intelligence Gathering

Likely numbers and types of victimsLikely numbers and types of victims WeatherWeather Hazardous materialsHazardous materials Status of local medical resourcesStatus of local medical resources

• Is the EMS system intact?Is the EMS system intact?• Are the hospitals and ED’s intact?Are the hospitals and ED’s intact?• Can we re-stock our suppliesCan we re-stock our supplies

Arrival On SceneArrival On Scene

Quickly establish and staff a Quickly establish and staff a dedicated medical area, and be sure dedicated medical area, and be sure everybody knows where it iseverybody knows where it is

Establish and staff a “forward” Establish and staff a “forward” medical area, once it is known where medical area, once it is known where the team will be operatingthe team will be operating

On-Scene Medical DutiesOn-Scene Medical Duties

Up-front care for team membersUp-front care for team members Enforcing hydration, hygiene, rehabEnforcing hydration, hygiene, rehab Ensuring shelter, sanitation, foodEnsuring shelter, sanitation, food Care for victimsCare for victims Care for team’s search dogsCare for team’s search dogs Media relationsMedia relations Relations with local medical Relations with local medical

resources (if any)resources (if any)

Interaction with local EM/EMSInteraction with local EM/EMS

Availability of EMS resourcesAvailability of EMS resources• is there somebody to hand patients off is there somebody to hand patients off

to?to?• hand-off to less sophisticated level of hand-off to less sophisticated level of

care is FEMA policy, to maintain integrity care is FEMA policy, to maintain integrity of medical team and equipment at siteof medical team and equipment at site

Availability of ED/hospital resourcesAvailability of ED/hospital resources

““Retrospective” RolesRetrospective” Roles

Injury and exposure follow-upInjury and exposure follow-up Medical cache reconstitutionMedical cache reconstitution Paperwork, paperwork, paperworkPaperwork, paperwork, paperwork

Part 2:Part 2:Confined Space MedicineConfined Space Medicine

CSM and the treatment of victims is CSM and the treatment of victims is a a very smallvery small part of US&R medicine part of US&R medicine

Care of the team must be the Care of the team must be the primary function of the medical primary function of the medical component of US&R task forcecomponent of US&R task force

CSM: Two general categoriesCSM: Two general categories

A confined space that is intact: A confined space that is intact: power vaults, grain silos, sewerspower vaults, grain silos, sewers• 35% of victims are would-be rescuers35% of victims are would-be rescuers

A structural collapse: building, A structural collapse: building, trench, highwaytrench, highway

Why is it hard to operate?Why is it hard to operate?

Poor lighting, ventilation, Poor lighting, ventilation, temperature controltemperature control

Exposure to blood/body fluids, liquidsExposure to blood/body fluids, liquids Tight spacesTight spaces Need for PPENeed for PPE Crime sceneCrime scene

Situational ConsiderationsSituational Considerations

Atmosphere: (90% of non-collapse Atmosphere: (90% of non-collapse injuries and deaths)injuries and deaths)• Oxygen-deficientOxygen-deficient• CO from fires and toolsCO from fires and tools• Broken gas linesBroken gas lines• Hazardous materialsHazardous materials

Risk of secondary collapse / deviceRisk of secondary collapse / device• shoring, stabilizingshoring, stabilizing

Basic CSM PrinciplesBasic CSM Principles

Forget “scoop and run”Forget “scoop and run”

Prevention of renal failure secondary Prevention of renal failure secondary to crush syndrome is the biggest to crush syndrome is the biggest advance in reducing morbidity and advance in reducing morbidity and mortality in urban search & rescuemortality in urban search & rescue

Team must expect to spend Team must expect to spend hourshours “in “in the hole” with the patientthe hole” with the patient

Anticipate prolonged mgmtAnticipate prolonged mgmt

Expect hypothermia, dehydrationExpect hypothermia, dehydration Possible blood loss, third spacingPossible blood loss, third spacing Patient may be contaminated with Patient may be contaminated with

own urine and stoolown urine and stool Complications not typically seen in Complications not typically seen in

the pre-hospital setting may have the pre-hospital setting may have already begunalready begun

Limited ExamLimited Exam

May begin assessment before patient May begin assessment before patient is reachedis reached

May begin treatment with only part May begin treatment with only part of the victim accessibleof the victim accessible

How we decrease M&MHow we decrease M&M

Rapid stabilization in the holeRapid stabilization in the hole Expedite extricationExpedite extrication

• immobilize immobilize onlyonly as needed as needed• provide pain controlprovide pain control• improve patient cooperationimprove patient cooperation• anatomic / physiologic advice for anatomic / physiologic advice for

disentangling and moving patientdisentangling and moving patient• prepare patient for hand-off to EMSprepare patient for hand-off to EMS

Unusual medical problemsUnusual medical problems

Crush injury / crush syndromeCrush injury / crush syndrome Dust airway impactionDust airway impaction Hazmat exposure / injuryHazmat exposure / injury Traumatic amputationsTraumatic amputations Blast injuryBlast injury Dehydration/starvationDehydration/starvation Hypothermia/hyperthermiaHypothermia/hyperthermia

DustDust

Building materials contain silica, Building materials contain silica, calcium, asbestos, wood, mineral calcium, asbestos, wood, mineral fibersfibers

Masonry, sheet rock, plaster, tiles, Masonry, sheet rock, plaster, tiles, insulationinsulation

Impair both ventilation and gas Impair both ventilation and gas transfertransfer

Major cause of death in Kobe Major cause of death in Kobe earthquakeearthquake

Respiratory ProblemsRespiratory Problems

Airway obstruction (blood, teeth, Airway obstruction (blood, teeth, vomitus, etc)vomitus, etc)

Airway contamination (dust)Airway contamination (dust)• Provide all patients with dust masksProvide all patients with dust masks

Ventilation problems (debris limiting Ventilation problems (debris limiting chest wall expansion, pneumothorax, chest wall expansion, pneumothorax, hemothorax, pulmonary contusionhemothorax, pulmonary contusion

Inhalation InjuriesInhalation Injuries

Displacement/consumption of oxygenDisplacement/consumption of oxygen• e.g. methane from ruptured gas linee.g. methane from ruptured gas line

Thermal injury - hot gases > edemaThermal injury - hot gases > edema

Noxious gases / particulatesNoxious gases / particulates

Cellular toxins (CO, cyanide)Cellular toxins (CO, cyanide)

Blast InjuryBlast Injury

Air-filled organs at Air-filled organs at greatest risk (lungs, greatest risk (lungs, stomach, intestines, stomach, intestines, tympanic tympanic membranes)membranes)

Blast injuryBlast injury

Significantly higher morbidity and Significantly higher morbidity and mortality if occurs in an enclosed mortality if occurs in an enclosed space than if out in the openspace than if out in the open

Frequent complications:Frequent complications:• air embolismair embolism• ARDSARDS• splenic rupturesplenic rupture• pneumoperitoneumpneumoperitoneum• ocular injuryocular injury

Infection ConsiderationsInfection Considerations

Open wounds: sepsis and wound Open wounds: sepsis and wound infectioninfection

Contamination with air- and water-Contamination with air- and water-borne agents, as well as own stool borne agents, as well as own stool and/or vomitusand/or vomitus

Pulmonary coccidiomycosis following Pulmonary coccidiomycosis following Northridge earthquakeNorthridge earthquake

Field Considerations for IDField Considerations for ID

Drain abscesses if delay in Drain abscesses if delay in extricationextrication

Local wound care and antibiotics for Local wound care and antibiotics for other infectionsother infections

Oral, IM, or IV antibioticsOral, IM, or IV antibiotics

Orthopedic InjuriesOrthopedic Injuries

All open fractures get splints and IV All open fractures get splints and IV antibioticsantibiotics

Be generous with pain medsBe generous with pain meds

Immobilize spine only if necessaryImmobilize spine only if necessary

Field amputation is a last resortField amputation is a last resort

Crush SyndromeCrush Syndrome

Post-extrication deterioration and Post-extrication deterioration and death from treatable mechanismsdeath from treatable mechanisms

Essential to begin treatment before Essential to begin treatment before the crush is relievedthe crush is relieved

Death by hypovolemia and Death by hypovolemia and arrhythmia (early), renal failure and arrhythmia (early), renal failure and infection (late)infection (late)

Cellular effects of crushCellular effects of crush

Local arterial blood flow interruptedLocal arterial blood flow interrupted Cells switch from aerobic to Cells switch from aerobic to

anaerobic, produce lactic acidanaerobic, produce lactic acid Cell membrane disruptedCell membrane disrupted

• Cellular contents leak Cellular contents leak outout (potassium, (potassium, CK, myoglobin, phosphorous, CK, myoglobin, phosphorous, leukotrienes)leukotrienes)

• Calcium leaks Calcium leaks inin• Capillaries leak, causing edemaCapillaries leak, causing edema

Releasing compression:Releasing compression:Early effectsEarly effects

Capillary leak > hypovolemia, shockCapillary leak > hypovolemia, shock Metabolic acidosis > ventr. fibrillationMetabolic acidosis > ventr. fibrillation Increased serum potassium > various Increased serum potassium > various

arrhythmiasarrhythmias

Serum hypocalcemia and Serum hypocalcemia and hyperphosphatemia contribute to hyperphosphatemia contribute to cardiac instabilitycardiac instability

CalciumCalcium

Serum calcium level fallsSerum calcium level falls Intracellular calcium rises in the Intracellular calcium rises in the

injured muscle tissueinjured muscle tissue Increased mitochondrial calcium Increased mitochondrial calcium

impairs cellular respiration and ATP impairs cellular respiration and ATP productionproduction

Activation of phospholipase AActivation of phospholipase A22, , causing activation of leukotrienes, causing activation of leukotrienes, prostaglandins, & lysophopholipaseprostaglandins, & lysophopholipase

Should you give calcium?Should you give calcium?

Not unless absolutely necessary to Not unless absolutely necessary to treat ventricular ectopy:treat ventricular ectopy:• will only transiently correct will only transiently correct

hypocalcemiahypocalcemia• will be deposited in the injured musclewill be deposited in the injured muscle

Late effects: renalLate effects: renal

““Traumatic rhabdomyolysis”Traumatic rhabdomyolysis”

1. Ferrihemate and other 1. Ferrihemate and other decomposition products of myoglobindecomposition products of myoglobin

2. Direct tubule obstruction by CPK, 2. Direct tubule obstruction by CPK, myoglobin, and uric acid crystalsmyoglobin, and uric acid crystals

3. Hypovolemia3. Hypovolemia

MyoglobinMyoglobin

Overflow appears in urine - Overflow appears in urine - red/brown colorred/brown color

At high levels, myoglobin precipitates At high levels, myoglobin precipitates in kidney tubulesin kidney tubules

Detect with urine “dip-stick”Detect with urine “dip-stick” Solubility in urine is pH-dependentSolubility in urine is pH-dependent

• 0% precipitates at pH > 7.50% precipitates at pH > 7.5• 73% precipitates at pH < 5.073% precipitates at pH < 5.0

Post-release signs of troublePost-release signs of trouble

AgitationAgitation Severe painSevere pain Paralysis of affected limbParalysis of affected limb Progressive, marked swellingProgressive, marked swelling

These should all be prevented with These should all be prevented with adequate pre-release care!adequate pre-release care!

HypovolemiaHypovolemia

Have good IV access in place before Have good IV access in place before releaserelease

Use normal saline (lactated Ringer’s Use normal saline (lactated Ringer’s contains potassium and lactate)contains potassium and lactate)

Carefully monitor fluid status: vital Carefully monitor fluid status: vital signs, urine output, chest sounds, signs, urine output, chest sounds, edema, etcedema, etc

Hyperkalemia & AcidosisHyperkalemia & Acidosis

Sodium bicarbonate IVSodium bicarbonate IV

Insulin & dextroseInsulin & dextrose

Beta-2 agonistsBeta-2 agonists

Renal InjuryRenal Injury

Maximize renal perfusion with IV Maximize renal perfusion with IV fluidsfluids

Carefully alkalinize urine with sodium Carefully alkalinize urine with sodium bicarbonate or acetazolamidebicarbonate or acetazolamide

Monitor both amount and pH (prefer Monitor both amount and pH (prefer >6.5)>6.5)

““Crush Injury Cocktail”Crush Injury Cocktail”

500 cc crystalloid per hour (after 500 cc crystalloid per hour (after initial bolus, if needed)initial bolus, if needed)

Add 1 amp NaHCOAdd 1 amp NaHCO33 per liter per liter

Give mannitol if UO < 300 ml/hrGive mannitol if UO < 300 ml/hr

Give acetazolamide if pH < 7.45Give acetazolamide if pH < 7.45

Care of the compressed limbCare of the compressed limb

Protect open woundsProtect open wounds Non-compressive splintNon-compressive splint Monitor for signs of compartment Monitor for signs of compartment

syndromesyndrome Provide adequate pain controlProvide adequate pain control

Contact InformationContact Information

david.cone@yale.edudavid.cone@yale.edu

Yale Emergency MedicineYale Emergency Medicine Suite 260Suite 260 464 Congress Avenue464 Congress Avenue New Haven CT 06519-1315 USANew Haven CT 06519-1315 USA