Anesthesia Support of Mass Casualty Incidents

COL Paul C. Reynolds, M.D.

Mass Casualty Incidents

• A disaster is an emergency that disrupts normal community function and causes concern for the safety, property, and lives of its citizens.

• An MCI is a medical disaster that is associated with the production of human injuries.

MCI Levels

• MCI Level 1 - manageable

• MCI Level 2 - multi-jurisdictional mutual aid

• MCI Level 3 - overwhelming, requiring state or federal aid

Philosophy of Disaster Care

• Normally - maximal time and resources devoted to individuals

• MCI - greatest good for the greatest number• Expectant category• CPR• Acceptable results

Unaltered Precepts

• ABC’s• Systematic assessment• Triage and re-triage• Patient dignity• Pain Control

The Plan

• Plan / Practice

• Organization

• Communication– internal– external

• Execution / Evacuation

• Debriefing

JCAHO

• A plan must be formulated

• The plan must be written down

• The plan must be disseminated

• The plan must be practiced

Mass Casualty(examples)

• Gallant Eagle

• Beirut, Lebanon

• Urgent Fury

• Bhopal, India•Gander, Newfoundland •Desert Storm•Ft Bragg, NC•Shemaya, Alaska•Tokyo, Japan

Gallant Eagle ‘82(30 March 1982)

• Parachute Operation: Ft Irwin, CA

• 158 injuries

• 6 deaths

• On-site Physicians Assistants

• Community Hospital - 10 miles

• 93rd Evacuation Hospital

Gallant Eagle(continued)

• Prior coordination

• Planned & practiced

• Communication

• Situation driven decisions- DZ evac - Individual intiative- Referrals - Hospital expansion- X-rays - Accountability

Beirut, Lebanon(23 October 1983)

• 234 immediately killed

• 96 seriously injured

• Medical officer killed

• On-site coordination

• USS Iwo Jima

• British Royal Hospital

Beirut(continued)

• Planned / practiced

• Assessment / treatment / recording

• Evacuation

• Coordination

Urgent Fury - Grenada(24 October 1983)

• USS Guam

• 76 casualties

• Initial triage staffing

• Surgical team

• Role of ATLS

• “Walking blood bank”

Urgent Fury - Grenada(USS Guam)

Overflow207 beds

Starboard

Port

Urgent Fury - Grenada(nature of wounds)

• Traumatic– Orthopedic 66

– Head & face 19

– Chest 16

– Back & neck 11

– Penetrating• Abdomen 10

• Soft tissue 10

• Burns 2

• Genital 1

• ARDS 1

•Non-traumatic– Heat exhaustion 5– Cellulitis 1– Battle fatigue 1– Unstable angina 1– Post-partum hemorrhage 1

Bhopal, India(3 December 1984)

• 100,000 casualties in the first 24 hours

• 500 deaths - prior to treatment

• 6,000 severe injuries - 2,000 died in the first week

• 150,000 - 200,000 some injury

Gander, Newfoundland(12 December 1985)

• 256 deaths

• Radiologic support

• Pathologic support

• FBI support

8th Evacuation Hospital(21 January 1991 - Desert Storm)

• Mass casualty situation in garrison

• Anti-tank weapon in billeting area

• Evac hospital

• 14 casualties arrived during mass casualty exercise

• 4 immediate, 1 delayed, 9 minimal

Pope Air Force Base(23 March 1993)

• F-14 crashes into group of paratroopers

• 104 casualties arrive within 5 minutes

• 13 dead

• 20 operative procedures

• 25 intubations

Pope Air Force Base(C141 at Green Ramp)

On-site

• Triage

• Treatment

• Evacuation

Intubations & evacuation

Transport

• Local EMS

• Anything that rolls

• Walking wounded

Initial Assessment

• Airway

• Breathing

• Circulation

• Airway management team / expertise

Outside the Operating Room

• Unfamilar– support– personnel– terminology– timing

• Rounds

• Consultation

Traige(intubations)

• Morphine

• Lidocaine

• Succinylcholine

Problematic Intubation

“Our (unpublished) data suggest that in military trauma, the first-attempt failure rate [of intubations] could exceed 40%, although it is less for experienced medical officers. The rate of field-executed cricothyroidotomies also suggests a high occurrence of failed intubations.”

OR Support

The Next Day

• Continuing operations– other ongoing operations– planning for secondary

interventions– evacuation stabilization

• Rationing personnel

• Rest cycles

Personal Experience

• “How did we do that?”

• What went well?

• What went badly?

• Psychological after effects

• Planning the next one!

China Eastern MD-11(5 April 1993)

• Shemaya Island - Aleutian chain

• Medical clinic

• One staff physician

• 3 hours until first medical reinforcements

• 64 litter evacuations

• 93 ambulatory evacuations

Tokyo Subway Sarin Gas Attack

• Methyl phosphonofluoridic acid 1-methylethyl ester (Sarin)

• Sarin is an organophosphate nerve agent.

• Dilute solutions in containers hidden on three different commuter train lines.

• 5,500 patients

EMT limitations

• Japanese emergency life-saving technicians– Combitube– Laryngeal Mask Airway– Intravenous line– Cardioversion

• Cannot be carried out without physician orders

Communications

• Tokyo Metropolitan Ambulance Control Center (TMACC) “was in total confusion”

• Incoming information exceeded ability to manage communications

• Lack of cooperation and communication between agencies involved

Hospital response

• Cessation of normal operations

• Change to disaster response

• Triage

• Lack of decontamination

• Supply redistribution

National response

• Japanese Self Defense Forces

• Planning was centered on local threats

• Acceptance of international help– Especially regarding nerve agent treatment

“Although some knowledge exists of the long-term effects of sarin on animals, there is little information about its effects on humans. Follow-up of the victims of this large-scale exposure is essential for that purpose.”

Mass casualty incidents

• Summary

Doyle, CJ. Mass Casualty Incidents, Integration with Prehospital Care. Emergency Medicine Cliics of North America. 1990; 8: 163-175.Timboe HL. Mass Casualty Situation: Gallant Eagle 82 Airborne Operations: A Case Report. Military Medicine. 1988; 153: 198-202.Frykberg ER, et al. Diaster in Beirut: An Application of Mass Casualty Principles. Military Medicine. 1987; 152: 563-566.Lorin HG, et al. The Bhopal Tradgedy-What has Swedish Disaster Medicine Planning Learned from it? The Jouranl of Emergency Medicine. 1986; 4: 311-316.Walsh DP, et al. The effectiveness of the Advanced Trauma Life Support System in a Mass Casualty Situation by Non-trauma Experienced Physicians: Grenada 1983. The Journal of Emergency Medicine. 1989; 7: 175-180.Mulligan ME, et al. Radiographic Evaluation of Mass Casualty Victims: Lessons from the Gander, Newfoundland, Accident. Radiology 1988; 168: 229-233.Satava RM, et al. A Mass Casualty While in Garrison during Operation Desert Storm. Military Medicine. 1992; 157: 299-300.Towne LE. China Eastern MD-11 Mass Casualty-Expect the Unexpected: A Case Report. Aviation, Space, and Environmental Medicine. 1995; 66 (10): 998-1000.

Bibliography

Shalev AY. Editorial: The Role of Mental Health Professionals in Mass Casualty Events. Israeli Journal of Psychiatry Related Sciences. 1994; 31(4): 243-245.Rozin RR, et al. Integration of Military Unit and Civilian Hospital during Mass Casualty Situation: Experience during the 1982 Lebanon War. Military Medicine. 1986; 151: 580-582.Durham TW, et al. The Psychological Impact of Disaster on Rescue Personnel. Annals of Emergency Medicine. 1985; 14: 664-668.Phillips WJ, et al. Anesthesia during a Mass Casualty Disaster: The Army’s Experience at Fort Bragg, North Carolina, March 23, 1994. Military Medicine. 1997; 162: 371-373.Abraham RB, et al. Problematic Intubation in Soldiers: Are there Predisposing Factors? Military Medicine. 2000; 165: 111-113.Leibovici D, et al. Prehospital Cricothyroidotomy by Physicians. American Journal Emergency Medicine. 1997; 15: 91-93.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 1: Community Emergency Response. Academic Emergency Medicine. 1998; 5(6): 613-617.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 2: Hospital Response. Academic Emergency Medicine. 1998; 5(6): 618-624.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 3: National and International Responses. Academic Emergency Medicine. 1998; 5(6): 615-628.

Bibliography