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Updated December 2006 by Charles Gomersall
Trauma
There are no systematic data on which to base recommendations for the
management of multiple casualty events. The content of this page is based on
description of responses to terrorist attacks in Jerusalem, Madrid and New York.
Preparation
- thorough preparation is the key to successful management
- each hospital should have its own disaster plan with plans to deal with
failures in:
- power supplies
- telephone systems
- not only may land phones fail but mobile networks are likely to
be jammed
- computer systems
- water supply
- transport to the hospital
- this will make it difficult for staff to reach the hospital
- may be exacerbated if the hospital lies within the police
security cordon
Note that these are not remote theoretical risks. St Vincent's Hospital
in Manhattan suffered power, telephone, computer and water failures in the
aftermath of the terrorist attack on the World Trade Centre
- coordination between hospitals is vital, particularly to plan for the
possibility of multiple simultaneous attacks. Many hospitals depend on
transfer to other hospitals for surge capacity but this may be more
difficult in the event of multiple attacks.
- physical infrastructure
- a "holding area" needs to be created
- in terrorist incidents it is common for less severely injured
patients to arrive in hospital before those with immediately
life-threatening injuries. It is important that the operating
theatres are not blocked by less severely ill patients by the time
those with life-threatening injuries arrive
- should be equipped to provide basic organ support and
resuscitation
Staffing
- a system of alerting the appropriate staff should be devised with the
relevant back-up systems to deal with the possibility of failure of
communication systems. This is particularly important for incidents that
occur outside normal working hours
- extensive experience at Hadassah Medical Centre in Jerusalem suggests
that the most appropriate response is to alert those who live close to the
hospital first as the time between the incident and arrival of the first
victims is usually short. Staff who live a considerable distance from the
hospital are less likely to be able to arrive in time to deal with the
initial response to the disaster and may be more usefully deployed as relief
staff
- at Hadassah a median of 9 additional staff (range 0-16) were required to
supplement the 7 on-call staff to deal with out-of-hours incidents
Staff roles during an incident
- the model reported by staff at Hadassah is one of "forward deployment"
of anaesthesia and intensive care medical staff
- senior anaesthesia/ICU staff are assigned to the Accident &
Emergency department trauma rooms, holding area, CT and angiography
suites as well the ICU and recovery room
- an anaesthetist is assigned to care for each critically injured
patient from the time of arrival in the trauma room until the time of
admission to ICU. This anaesthetist is not only responsible for the
anaesthetic management in the trauma room and the operating theatre but
is also responsible for their care during transfers and investigations.
In each area there is a senior anaesthetist who can supervise care. This
system ensures continuity of care and minimizes the need for information
transfer. It is particularly useful when the patient requires input from
a variety of different surgical teams.
- the whole operation and the allocation of staff is controlled
centrally by a director who is based in the operating theatre
- coordination of care for all critically injured patients is the
responsibility of the most senior anaesthetist based in the Accident &
Emergency department
- the initial role of those doctors assigned to the ICU is to discharge
all patients who can be safely discharged. This may involve transfer of
patients to other hospitals which may require considerable staff and
equipment resources.
Patients
- the interval between the incident and arrival of the first casualties is
variable but in urban areas is usually of the order of 20-30 minutes
- the long delay between the attack on the World Trade Center and the
arrival of the first casualty may reflect the difficulty of reaching the
initial victims of the attack
- an analysis of 14 incidents at Hadassah indicate that it is unusual for
patients to need to be transferred immediately to the operating theatre and
median time between the incident and the first patient being operated on was
about 2 hours. The equivalent interval for admission to ICU was about 5
hours. However in the Madrid train bombing 7 of 27 critically ill patients
admitted to one hospital required transfer directly from the Accident &
Emergency department to the operating theatres
- the possibility of blast and crush injury and toxin/dust inhalathion
must be considered in addition to more usual patterns of injury
- it is vital not to forget the usual structured approach to multiple
trauma in the chaos of the multiple casualty event
Further reading
Shamir MY et al. Multiple casualty terror events: the
anesthesiologist's perspective. Anesth Analg 2004;98:1746-52
Peral-Gutierrez de Ceballos J et al. 11 March 2004: the
terrorist bomb explosions in Madrid, Spain - an analysis of the logistics,
injuries sustained and clinical management of casualties treated at the closest
hospital. Crit Care, 2005; 9(1):104-111
Kirschenbaum L et al. The experience at St Vincent's Hospital,
Manhattan, on September 11, 2001: preparedness, response, and lessons learned.
Crit Care Med 2005; 33 [Suppl]:S48-S52
Bioterrorism
http://www.bioterrorism.slu.edu/index.html
http://www.bt.cdc.gov/
http://www.fas.org/main/content.jsp?formAction=325&projectId=4
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Topics/Bioterrorism/Bioterrorism.htm
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