Agenda Emergency PreparednessEmergency Preparedness Probabilities / HVA’s and ThreatsProbabilities...

AgendaAgenda

• Emergency Preparedness Emergency Preparedness

• Probabilities / HVA’s and ThreatsProbabilities / HVA’s and Threats

• Active ShootingActive Shooting

• Bombing / Blast Injuries Bombing / Blast Injuries

• Emerging & Re-emerging Infectious DiseasesEmerging & Re-emerging Infectious Diseases

• Medical Surge Medical Surge

• Discussion GAPSDiscussion GAPS

DRS 2007

Storms are still the biggest threat!Storms are still the biggest threat!

• FY 2014 Preparedness PlanFY 2014 Preparedness Plan

Potential Probability vs. ImpactPotential Probability vs. Impact

POTENTIALIMPACT

PROBABILITY/LIKELIHOOD

NUCLEARWEAPON

IMPROVISEDNUCLEAR

DEVICE

RADIOACTIVEMATERIAL

CHEMICAL AGENTOR TOXIC

INDUSTRIALCHEMICAL

BIOLOGICALAGENT

Human Hazards - RISKHuman Hazards - RISK

Natural Hazards - RISKNatural Hazards - RISK

The ThreatThe Threat

• ““Why hunt tigers when there Why hunt tigers when there are so many sheep” – from al are so many sheep” – from al Qaeda training manual Qaeda training manual captured in Afghanistancaptured in Afghanistan

Aurora ShootingsAurora Shootings

Primary Attack Location of 140 Active Shooter Incidents from 2000 to 2014Primary Attack Location of 140 Active Shooter Incidents from 2000 to 2014

Police Response in HospitalsPolice Response in Hospitals

Core Capabilities Trend AnalysisCore Capabilities Trend Analysis

Active Shooter Hazard ZonesActive Shooter Hazard Zones

• Hot Zone: Hot Zone: Unsecured area Unsecured area where threat remains active. Law where threat remains active. Law enforcement (LE) responsible for enforcement (LE) responsible for neutralizing shooter(s). neutralizing shooter(s).

• Warm Zone: Warm Zone: Area swept for Area swept for immediate threats. LE provides immediate threats. LE provides force protection for medical force protection for medical personnel responding in this personnel responding in this zone zone

• Cold Zone: Cold Zone: Secured area Secured area outside of immediate threat. This outside of immediate threat. This is the personnel standby zoneis the personnel standby zone. .

THREAT THREAT

• T - Threat suppressionT - Threat suppression

• H - Hemorrhage controlH - Hemorrhage control

• RE - Rapid Extrication to safetyRE - Rapid Extrication to safety

• A - Assessment by medical A - Assessment by medical providersproviders

• T - Transport to definitive careT - Transport to definitive care

Skewed PrioritiesSkewed Priorities

• U.S. schools extensively guard against fire:U.S. schools extensively guard against fire:

– –Fire drillsFire drills

– –Sprinkler systemsSprinkler systems

– –Building codes, etc.Building codes, etc.• Yet not one child has died from fire in any U.S. Yet not one child has died from fire in any U.S.

school in over 25 years (excluding dorm fires).school in over 25 years (excluding dorm fires).• Well over 200 deaths have occurred by active Well over 200 deaths have occurred by active

shooters in the same period here.shooters in the same period here.• But training and preparation for these events meets But training and preparation for these events meets

with stiff resistance and denialwith stiff resistance and denial

Response IssuesResponse Issues

• Remember that there is a difference Remember that there is a difference between “law enforcement on scene” and between “law enforcement on scene” and “scene is secure”.“scene is secure”.

• Fire and EMS should remain in staging Fire and EMS should remain in staging areas areas until the scene is secured by law until the scene is secured by law enforcement when possibleenforcement when possible. This process . This process may take several hours.may take several hours.

EMS response issuesEMS response issues

• EMS may need to utilize “scoop EMS may need to utilize “scoop and scoot” and “load and go” and scoot” and “load and go” from the incident.from the incident.

Most Common Fatal InjuriesMost Common Fatal Injuries

• Major Hemorrhage: commonly known as Major Hemorrhage: commonly known as blood lossblood loss

• Tension Pneumothorax: improper breathing Tension Pneumothorax: improper breathing due to sustained chest traumadue to sustained chest trauma

• Airway Obstruction :physical blockage or Airway Obstruction :physical blockage or trauma of the respiratory airwaytrauma of the respiratory airway

Physical Results of an Explosion

Imagine this apple as an arm, leg, or torso struck by shrapnel.

London BombingsLondon Bombings

Boston BombingsBoston Bombings

Texas Fertilizer Plant ExplosionTexas Fertilizer Plant Explosion

Alfred P. Murrah Building, Alfred P. Murrah Building, Oklahoma City, April 19, 1995Oklahoma City, April 19, 1995

ObjectivesObjectives

• Explain various types of explosive devices Explain various types of explosive devices

• Describe physical elements of blast / explosion eventsDescribe physical elements of blast / explosion events

• Discuss physiological effects of blast / explosion eventsDiscuss physiological effects of blast / explosion events

• Address potential injuries associated with bomb / blast eventsAddress potential injuries associated with bomb / blast events

DefinitionsDefinitions

• Explosives:Explosives: A chemical material capable of very rapid burning and A chemical material capable of very rapid burning and

production of high volumes of heated gasesproduction of high volumes of heated gases

• Shrapnel:Shrapnel: Small fragments of material (usually from a bomb Small fragments of material (usually from a bomb

casing or other container) thrown away from an casing or other container) thrown away from an explosion at high velocitiesexplosion at high velocities

• Shock / Blast Wave:Shock / Blast Wave: A wave of pressure resulting from an explosion; travels A wave of pressure resulting from an explosion; travels

in excess of 700mphin excess of 700mph

DefinitionsDefinitions

• TBITBI or or MTBIMTBI TTraumatic raumatic BBrain rain IInjury or njury or

MMild ild TTraumatic raumatic BBrain rain IInjurynjury

• TMTM TTympanic ympanic MMembrane – embrane –

damage to TM results in damage to TM results in hearing losshearing loss

Types of Explosives / BombsTypes of Explosives / Bombs

Truck / Car BombsTruck / Car Bombs• Vehicle loaded with explosivesVehicle loaded with explosives• Driver usually committed to mission / suicideDriver usually committed to mission / suicide• Vehicle adds to shrapnel damageVehicle adds to shrapnel damage• Can result in large scale explosions based on explosive cargoCan result in large scale explosions based on explosive cargo

Types of Explosives / BombsTypes of Explosives / Bombs

Suicide / Homicide BombsSuicide / Homicide Bombs• Strapped to body of individualStrapped to body of individual

• Usually covered with heavy clothingUsually covered with heavy clothing

• Can also appear as a suitcase, briefcase, or backpackCan also appear as a suitcase, briefcase, or backpack

• Activated either by remote control or a hand-held switchActivated either by remote control or a hand-held switch

• To increase injuries, some bombs also include:To increase injuries, some bombs also include:– Bolts, nuts, or washersBolts, nuts, or washers

– Nails or screwsNails or screws

– Other metals to add shrapnelOther metals to add shrapnel

Terrorist Use of ExplosivesTerrorist Use of Explosives

• Most post-9/11 terrorist events have involved:Most post-9/11 terrorist events have involved:• Car or truck bombsCar or truck bombs• Emergency vehicles or others disguised as normal Emergency vehicles or others disguised as normal

traffic in the areatraffic in the area• Large amounts of explosivesLarge amounts of explosives

Bomb / Blast InjuriesBomb / Blast Injuries

Four categories of injuries:Four categories of injuries:• PrimaryPrimary

• SecondarySecondary

• TertiaryTertiary

• QuaternaryQuaternary


CategoryCategory CharacteristicsCharacteristicsBody Part Body Part AffectedAffected

Type of InjuryType of Injury

PrimaryPrimary

Unique to high Unique to high explosivesexplosives

Results from Results from impact of impact of shock waveshock wave

Gas filled Gas filled structures:structures:

•LungsLungs

•GI tractGI tract

•Middle earMiddle ear

• Blast Lung Blast Lung (pulmonary(pulmonary barotrauma or barotrauma or rapid change in pressure)rapid change in pressure)

• TM ruptureTM rupture

• Middle ear damageMiddle ear damage

• Abdominal hemorrhageAbdominal hemorrhage

• Abdominal perforationAbdominal perforation

• Globe (eye) ruptureGlobe (eye) rupture

• Concussion (TBI without Concussion (TBI without physical signs of head injury)physical signs of head injury)




SecondarySecondaryResults from Results from flying debris and flying debris and bomb fragmentsbomb fragments

Any partAny part

• Penetrating ballistic injuriesPenetrating ballistic injuries

(fragmentation) (fragmentation)

• Blunt trauma injuriesBlunt trauma injuries

• Eye injuries (can be occult)Eye injuries (can be occult)

TertiaryTertiary

Results from Results from individuals being individuals being thrown by the thrown by the blast windblast wind

(shock wave)(shock wave)

Any partAny part

•FractureFracture

•Traumatic amputationTraumatic amputation

•Closed & open brain injuryClosed & open brain injury




QuaternaryQuaternary

• All explosion All explosion related injuries, related injuries, illnesses, or illnesses, or diseases not due diseases not due to primary, to primary, secondary, or secondary, or tertiary tertiary mechanismsmechanisms

• Includes Includes exacerbation of exacerbation of existing existing conditionsconditions

Any partAny part

• Burns (flash, partial, & Burns (flash, partial, & full thickness)full thickness)

• Crush injuriesCrush injuries

• Closed & open brain Closed & open brain injuryinjury

• Asthma, COPD, or other Asthma, COPD, or other breathing problems from breathing problems from dust, smoke, or toxic fumesdust, smoke, or toxic fumes

• AnginaAngina

• HyperglycemiaHyperglycemia

• HypertensionHypertension


Lung InjuryLung Injury• Direct result from shock wave impactDirect result from shock wave impact

• Most common fatal injuryMost common fatal injury

• Usually present at initial triageUsually present at initial triage

• Can present up to 48 hours laterCan present up to 48 hours later

Eye InjuryEye Injury• 10% of all survivors will have significant eye injuries10% of all survivors will have significant eye injuries

• Will involve perforations from projectilesWill involve perforations from projectiles

• Can present for care days, weeks, or months after eventCan present for care days, weeks, or months after event


EarEar InjuryInjury• Easily overlookedEasily overlooked

• Signs of injury are usually present at initial triageSigns of injury are usually present at initial triage

• Blast injuries to auditory system cause significant fatalitiesBlast injuries to auditory system cause significant fatalities

• Injury dependant on orientation of the ear to the blastInjury dependant on orientation of the ear to the blast

• TM perforation is most common TM perforation is most common

• Should be suspected for patients complaining of:Should be suspected for patients complaining of:— Hearing loss, tinnitus (ringing ears) or otalgia (ear pain)Hearing loss, tinnitus (ringing ears) or otalgia (ear pain)

— Vertigo or bleeding from external canal, Vertigo or bleeding from external canal,

— TM rupture or mucopurulent otorhea (mucus discharge)TM rupture or mucopurulent otorhea (mucus discharge)


Abdominal InjuryAbdominal Injury• Gas containing sections of GI tract are most vulnerableGas containing sections of GI tract are most vulnerable• Can cause:Can cause:

— Immediate bowel perforation Immediate bowel perforation && solid organ lacerations solid organ lacerations— Hemorrhage Hemorrhage && mesenteric shear injuries mesenteric shear injuries— Testicular ruptureTesticular rupture

• Suspect in patients presenting with:Suspect in patients presenting with:— Abdominal pain, nausea Abdominal pain, nausea & & vomitingvomiting— Hematemisis (bloody vomit), rectal pain Hematemisis (bloody vomit), rectal pain oror tenesmus tenesmus && testicular testicular

painpain— Unexplained hypovolemia (decrease in blood volume) Unexplained hypovolemia (decrease in blood volume) oror anything anything

indicating an acute abdomenindicating an acute abdomen


• Brain InjuryBrain Injury• Blast / shock waves can cause concussions or mild Blast / shock waves can cause concussions or mild

traumatic brain injury (MTBI) traumatic brain injury (MTBI) withoutwithout a direct blow to a direct blow to the headthe head

• Consider proximity of victim to the blast given Consider proximity of victim to the blast given complaints / observations of headache, fatigue, poor complaints / observations of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptomsor other constitutional symptoms


• Other Common InjuriesOther Common Injuries• Sprains / Strains from attempting to Sprains / Strains from attempting to

escape, falling, being thrown or escape, falling, being thrown or pushed down by force, or from pushed down by force, or from carrying other victimscarrying other victims

• Scraping against debris or sharp Scraping against debris or sharp objects can cause lacerations, objects can cause lacerations, wounds usually require thorough wounds usually require thorough cleaningcleaning

Medical Management of Bomb / Blast Victims

Medical Management of Bomb / Blast Victims

New RealitiesNew Realities

• Blast injuries no longer confined to military battlefieldsBlast injuries no longer confined to military battlefields• Should be considered for any victim exposed to an explosive forceShould be considered for any victim exposed to an explosive force

• Wounds can be grossly contaminatedWounds can be grossly contaminated• Consider careful decontamination, delayed primary closure, and Consider careful decontamination, delayed primary closure, and

assess tetanus statusassess tetanus status

• Close follow-up of wounds; head, eye, and ear injuries; and stress Close follow-up of wounds; head, eye, and ear injuries; and stress related complaintsrelated complaints

Surge Capacity NeedsSurge Capacity Needs

• 50% of survivors will present at 50% of survivors will present at

ED for treatment within 1 hour ED for treatment within 1 hour

of eventof event

• Remainder will present within Remainder will present within

next 6 hoursnext 6 hours

• Rapid surge capacity response Rapid surge capacity response

needed to handle patient volumeneeded to handle patient volume

Source: CDC website

Medical Management OptionsMedical Management Options

• Penetrating & blunt trauma injuries are most commonPenetrating & blunt trauma injuries are most common

• Highest mortality is primary blast lung & abdomen injuriesHighest mortality is primary blast lung & abdomen injuries

• Blast Lung is most common fatal injury in initial survivors Blast Lung is most common fatal injury in initial survivors


““Blast Lung” presents soon after exposureBlast Lung” presents soon after exposure• Confirmed by finding a “butterfly” pattern on X-rayConfirmed by finding a “butterfly” pattern on X-ray

• Prophylactic chest tubes recommended prior to general Prophylactic chest tubes recommended prior to general anesthesia and / or air transportanesthesia and / or air transport

Air embolism is commonAir embolism is common• Can present as stroke, MI, acute abdomen, blindness, Can present as stroke, MI, acute abdomen, blindness,

deafness, spinal cord injury, or claudication (limping)deafness, spinal cord injury, or claudication (limping)

• Hyperbaric oxygen therapy effective in some casesHyperbaric oxygen therapy effective in some cases


Clinical signs of blast-related abdominal injuries:Clinical signs of blast-related abdominal injuries:• Are initially silentAre initially silent

• Can be missed until acute abdomen or sepsis are advancedCan be missed until acute abdomen or sepsis are advanced

Traumatic amputation of any limb indicates Traumatic amputation of any limb indicates potential for multi-system injuriespotential for multi-system injuries

• Compartment syndrome, rhabdomyolysis Compartment syndrome, rhabdomyolysis (muscle tissue breakdown), and acute renal (muscle tissue breakdown), and acute renal failure are associated with structural failure are associated with structural collapse, prolonged extrication, severe collapse, prolonged extrication, severe burns, and some poisoningsburns, and some poisonings

• Always consider possibility of exposure to Always consider possibility of exposure to inhaled toxins and poisonsinhaled toxins and poisons

Medical Management Options

• Auditory system injuries are Auditory system injuries are often overlookedoften overlooked• Symptoms of mild TBI and post-Symptoms of mild TBI and post-

traumatic stress disorder can be traumatic stress disorder can be identicalidentical

• Isolated TM rupture is Isolated TM rupture is usually non-fatalusually non-fatal


• Communications Communications with patients may with patients may need to be written need to be written due to tinnitus and due to tinnitus and sudden temporary sudden temporary or permanent or permanent deafnessdeafness


Helping Patients Cope with a Traumatic Event

Helping Patients Cope with a Traumatic Event

What is a Traumatic Event?What is a Traumatic Event?

• Any event, or series of events, that causes Any event, or series of events, that causes moderate to severe stress reactions is called a moderate to severe stress reactions is called a traumatic event.traumatic event.

• Traumatic events are characterized by a sense of Traumatic events are characterized by a sense of horror, helplessness, serious injury, or the threat of horror, helplessness, serious injury, or the threat of serious injury.serious injury.

Who is effected by Traumatic Events?Who is effected by Traumatic Events?

• Traumatic events affect Traumatic events affect survivors, rescue survivors, rescue workers, and friends / workers, and friends / relatives of those relatives of those directly involved.directly involved.

• Can also affect people Can also affect people who witnessed the event who witnessed the event either in person or either in person or through the media.through the media.

Common Responses to Traumatic EventsCommon Responses to Traumatic Events

CognitiveCognitive• Poor concentrationPoor concentration

• ConfusionConfusion

• DisorientationDisorientation

• IndecisivenessIndecisiveness

• Shortened attention spanShortened attention span

• Memory lossMemory loss

• Unwanted memoriesUnwanted memories

• Difficulty making decisionsDifficulty making decisions


EmotionalEmotional• ShockShock• NumbnessNumbness• Feeling overwhelmedFeeling overwhelmed• DepressionDepression• Feeling lostFeeling lost• Fear of harm to self Fear of harm to self

and/or loved onesand/or loved ones• Feeling nothingFeeling nothing• Feeling abandonedFeeling abandoned• Uncertainty of feelingsUncertainty of feelings• Volatile emotionsVolatile emotions


• PhysicalPhysicalNauseaNausea Grinding of teethGrinding of teeth

LightheadednessLightheadedness FatigueFatigue

DizzinessDizziness Poor sleepPoor sleep

Gastro-intestinal problemsGastro-intestinal problems PainPain

Rapid heart rateRapid heart rate Hyper-arousalHyper-arousal

TremorsTremors JumpinessJumpiness

HeadachesHeadaches


BehavioralBehavioral• SuspicionSuspicion• IrritabilityIrritability• Arguments with friends or loved onesArguments with friends or loved ones• WithdrawalWithdrawal• Excessive silenceExcessive silence• Inappropriate humorInappropriate humor• Increased / decreased eatingIncreased / decreased eating• Change in sexual desire or functionChange in sexual desire or function• Increased smokingIncreased smoking• Increased substance abuseIncreased substance abuse

SummarySummary

• Blast injuries no longer confined to military Blast injuries no longer confined to military battlefieldsbattlefields

• Probability of a terrorist event involving Probability of a terrorist event involving explosives higher than other possibilitiesexplosives higher than other possibilities• Currently “significant concern” within Intelligence Currently “significant concern” within Intelligence

community about bomb / blast events in UScommunity about bomb / blast events in US

• Explosions can produce significant traumatic Explosions can produce significant traumatic injuries beyond current ED experienceinjuries beyond current ED experience

SummarySummary

• 50% of all blast / burn victims 50% of all blast / burn victims will present for ED treatment will present for ED treatment within 1 hour of eventwithin 1 hour of event

• Remaining 50% will present Remaining 50% will present over next 6 hoursover next 6 hours

• Above does not account for Above does not account for walking-worried or worried-walking-worried or worried-sicksick

SummarySummary

• Emotional responses to Emotional responses to traumatic burn / blast events traumatic burn / blast events will occur and will will occur and will significantly complicate significantly complicate patient loadspatient loads

• Advanced preparation to Advanced preparation to handle / treat emotional handle / treat emotional casualties is paramountcasualties is paramount

Aerosol / Infectivity RelationshipAerosol / Infectivity Relationship

18-20

15-18

7-12

4-6(bronchioles)

1-5 (alveoli)

Infection Severity

Particle Size (Micron, Mass Median Diameter)

The ideal aerosol contains a homogeneous population

of 2 or 3 micron particulates that contain one or more viable organisms

Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size

Less Severe

More Severe

Antibiotic Resistance ThreatsAntibiotic Resistance Threats

InfluenzaInfluenza

Influenza-like illnessInfluenza-like illness

The public health threat of emerging viral disease.The public health threat of emerging viral disease.

Emerging diseases" are those that either have newly appeared in the Emerging diseases" are those that either have newly appeared in the population or are rapidly increasing their incidence or expanding their population or are rapidly increasing their incidence or expanding their geographic range. Emerging viruses usually have identifiable sources, geographic range. Emerging viruses usually have identifiable sources, often existing viruses of animals or humans that have been given often existing viruses of animals or humans that have been given opportunities to infect new host populations ("viral traffic"). opportunities to infect new host populations ("viral traffic"). Environmental and social changes, frequently the result of human Environmental and social changes, frequently the result of human activities, can accelerate viral traffic, with consequent increases in activities, can accelerate viral traffic, with consequent increases in disease emergence. Host factors, including nutrition, have often disease emergence. Host factors, including nutrition, have often received less attention in the past but are of considerable importance. received less attention in the past but are of considerable importance.

These factors, combined with the ongoing evolution of viral and These factors, combined with the ongoing evolution of viral and microbial variants, make it likely that emerging infections will continue microbial variants, make it likely that emerging infections will continue to appear and probably increase, emphasizing the need for effective to appear and probably increase, emphasizing the need for effective

surveillancesurveillance..

BW - Epidemiologic CluesBW - Epidemiologic Clues

• Large epidemic with high illness and death rateLarge epidemic with high illness and death rate• HIV(+) individuals may have first susceptibilityHIV(+) individuals may have first susceptibility• Respiratory symptoms predominateRespiratory symptoms predominate• Infection non-endemic for regionInfection non-endemic for region• Multiple, simultaneous outbreaksMultiple, simultaneous outbreaks• Multi-drug-resistant pathogensMulti-drug-resistant pathogens• Sick or dead animals Sick or dead animals • Delivery vehicle or intelligence informationDelivery vehicle or intelligence information

Disease Outbreak - CRIDisease Outbreak - CRI

Toxins as Biological AgentsToxins as Biological Agents

• BotulinumBotulinum

• RicinRicin

• Staphylococcal Staphylococcal Enterotoxin B Enterotoxin B (SEB)(SEB)

Three Reports from Institute of MedicineThree Reports from Institute of Medicine

• Guidance for Establishing Crisis Standards Guidance for Establishing Crisis Standards of of Care for use in disaster situations (2009) Care for use in disaster situations (2009)

• Crisis Standards of Care: A Systems Framework for Crisis Standards of Care: A Systems Framework for catastrophic Disaster Response (2012)catastrophic Disaster Response (2012)

• Crisis Standards of Care: Need for a Toolkit for Crisis Standards of Care: Need for a Toolkit for

Indicators aIndicators and Triggers (2013)nd Triggers (2013)

Indicators and TriggersIndicators and Triggers

• Indicators and Triggers Indicators and Triggers help guide operational help guide operational decision making about providing care during public decision making about providing care during public health and medical emergencies and disasters.health and medical emergencies and disasters.

• IndicatorsIndicators are defined as measurements or predictors are defined as measurements or predictors of change in demand for health care services or of change in demand for health care services or availability of resources availability of resources

• TriggersTriggers are defined as decision points about are defined as decision points about adaptations to healthcare services delivery.adaptations to healthcare services delivery.

• Hospitals need to look at their Hospitals need to look at their HVA HVA to decide for to decide for which Scenarios they need to come up with which Scenarios they need to come up with Indicators and Triggers.Indicators and Triggers.

Triggers Triggers

• Conventional Standards →Conventional Standards →

• Contingency Standards →Contingency Standards →

• Crisis Standards of Care Crisis Standards of Care

• Contingency Standards →Contingency Standards →

• Conventional Standards →Conventional Standards →

Crisis Situations Crisis Situations

• Crisis situations may begin Crisis situations may begin with a discrete indicator of with a discrete indicator of excess demand excess demand (ventilators/medications/staff) (ventilators/medications/staff) which can trigger crisis care which can trigger crisis care process.process.

ConclusionConclusion

• Questions?Questions?

• Discussion?Discussion?

• Comments?Comments?

• Critique?Critique?

Agenda Emergency PreparednessEmergency Preparedness Probabilities / HVA’s and ThreatsProbabilities...

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