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Mass Casualty Respiratory Failure Lewis Rubinson Disaster Medicine Director Public Health- Seattle & King County.

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Presentation on theme: "Mass Casualty Respiratory Failure Lewis Rubinson Disaster Medicine Director Public Health- Seattle & King County."— Presentation transcript:

1 Mass Casualty Respiratory Failure Lewis Rubinson Disaster Medicine Director Public Health- Seattle & King County

2 Objectives 1.List the medical response circumstances anticipated for mass casualty respiratory failure. 2.List the benefits of repurposing hospital wards rather than “non-medical” areas such as gymnasiums for augmenting critical care treatment space. 3.Describe crucial characteristics for surge positive pressure ventilation equipment. 4.List recommended ancillary respiratory equipment for mass casualty critical care.

3 Localized Events and Critical Care Conventional traumatic emergencies: –Multiple shooting victims, conventional explosions, limited natural disaster (tornado) Most frequent events –Critically injured survivors may stress local receiving facilities critical care capability –Requires organized, optimal local/institutional critical care response

4 Localized Events and Critical Care Needs Einav et al, Ann Surg 2006; 243: Immediate surgery 36% CT scan 40% 4.0 ± 3.2 CT/event Other surgery 25% Immediate to ICU 12% Post-op ICU 31% 2.3 ± 2.5 /event Operating room Intensive Care unit 3.4 ± 3.0 /event Emergency department

5 Recent Lessons

6 Plausible Future Events United States Congress, Office of Technology Assessment

7 National Planning Scenarios Catastrophic numbers of critically ill and injured

8 Chlorine Tanker Explosion US Dept of Homeland Security National Planning Scenarios 2005

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10 Critical Care Demand 1.Number of critically ill and injured victims surviving initial event 2.Rate of development of critical illness and injury 3.Duration of critical illness and injury 4.Specialized needs (e.g. renal replacement therapy, burn care)

11 Disasters May Cause Critical Illness and Injury in Survivors Multiple Shootings Conventional Explosions Open-space Closed space Densely-populated structure fire Large-scale toxic inhalations Serious natural disasters Epidemic with serious pathogen Large nuclear detonation ’s 100’s 1000’s 10,000’s Estimated Maximal Critically Ill and Injured Patients Needing Care

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14 DemandResources Critical Care Capability

15 ICUs Have Limited Reserve Space 87,400 ICU beds in non- federal US hospitals –~3600 acute care hospitals –13% of total hospital beds (most countries have fewer ICU beds) –ICU occupancy 65-80%

16 ICUs Have Limited Reserve Equipment Just-in-time purchasing Breadth of ICU meds and equipment create financial barriers to building reserve ICUs Maintenance/storage of reserve ICU equipment very expensive

17 ICUs Have Limited Reserve Staff Shortages of critical care nurses, pharmacists, respiratory therapists and intensivists in most communities –> 10% of ICUs have beds closed due to nursing shortage

18 What should you do if the previous critical care surge processes do not provide enough additional critical care capability?

19 Emergency Mass Critical Care Caring for critically ill/injured patients whose needs far exceed traditional, available hospital critical care capacity and when timely evacuation is not available?

20 Emergency Mass Critical Care Emergency changes in: 1)Spectrum of critical care interventions 2)Medical equipment 3)Triage 4)Staffing Provide circumscribed set of key critical care interventions to many patients rather than maximal critical care to far fewer Derived from recommendations of a working group of 33 North American experts

21 Which critical care interventions should be provided if resources are limited and usual critical care cannot be provided to all in need?

22 Frequently Used ICU Interventions Conventional mechanical ventilation Vasopressor infusion Large volume blood product transfusions Intra-arterial blood pressure monitoring Continuous renal replacement therapy Intra-aortic counter-pulsation device ICP monitoring High-frequency oscillatory ventilation Activated protein C infusion

23 Emergency Mass Critical Care Interventions 1.Supports the organ systems most likely to cause death 2.Demonstrated effectiveness or best professional judgment to improve survival in similar clinical conditions 3.Do not require prohibitively expensive equipment –Not staff or resource intensive

24 Emergency Mass Critical Care Interventions Mechanical ventilation –Basic mode(s) Hemodynamic support –IV fluids, vasopressor(s) Set of prophylactic interventions –Thromboembolism prophylaxis, elevation of head of bed and ? GI prophylaxis

25 DemandResources Positive Pressure Ventilation Capability Roughly one full-feature mechanical ventilator per ICU bed in countries with widespread critical care availability MASS CASUALTY RESPIRATORY FAILURE

26 Mass Respiratory Failure Surge Capability 1.Space –Where should patients receive sustained mechanical ventilation when ICUs are full? 2.Stuff –Which respiratory equipment is necessary for mass casualty respiratory failure? 3.Staff –Who can help care for surge of patients with respiratory failure?

27 Space Where should patients receive sustained mechanical ventilation when ICUs, EDs and PACUs are full and timely evacuation is not possible?

28 Mass Casualty Respiratory Failure

29 Challenges of Critical Care Mgmt Outside of Hospitals 1.Expensive hospital beds –Difficult to manage pts on cots for sustained periods 2.Oxygen!! 3.Suction 4.Infection control 5.Broad diagnostic capability 6.Specialty consulation

30 Oxygen May be a Crucial Scarce Resource Non-medical spaces likely to require compressed oxygen source –Require numerous tanks to support pts 24 hrs/day on oxygen Portable oxygen generation systems and port. liquid oxygen systems cost prohibitive for most communities to manage many critically ill/injured patients for days outside of hospitals Hospital liquid oxygen best option –Capacity is large –One caveat is dependent on distribution by vendor

31 ICU, ED, PACU Step-down and telemetry units General hospital wards Pts w/ resp failure Least sick pts Non-hospital sites Nursing homes Home Health Alternate care facilities Usual step- down & tele pts

32 Emergency Mass Critical Care Beds ICUs usually 5-15% of total inpatient beds In past, hospitals have made approximately 20% inpatient beds available within 24 hours by recalling staff, canceling surgeries, expedited discharges Within 24 hrs increase hospital total critical care space by 2-4 fold if critically ill/injures given admission priority –For sustained events likely increase critical care space 5-10 fold over traditional ICU capacity.

33 Stuff Positive Pressure Ventilation (PPV) and ancillary respiratory equipment for mass casualty respiratory failure

34 Mass Respiratory Failure Situational Context 1.Many sick patients will die without sustained PPV –Hypoxemic respiratory failure, hypercapnic ventilatory failure, or airway protection/ pulmonary toilet 2.Anticipated PPV needs > 12 hrs 3.Limited specialized staff 4.Oxygen may be limited resource –Not provided with US SNS vent stockpile 5.? consistent electrical supply, medical equipment distribution system 6.Possible secondary disease transmission

35 Manual vs Mechanical Ventilation Manual Inexpensive Available Easy to use Difficult to use well Requires operator with patient Not oxygen conserving Inconsistent minute ventilation Mechanical Alarms allow mgmt of multiple pts Consistent minute ventilation Oxygen conserving More expensive More complex to operate Maintenance Acceptable short term strategy Better long-term strategy (hrs, days or weeks)

36 AUGMENTING POSITIVE PRESSURE VENTILATION Reserve full-feature ventilators Ventilator rental supply –Many hospitals dependent on the same vendors Anesthesia machines –Cannot be repurposed for long response NiPPV equipment Stockpiled PPV –May be used earlier if rapidly deployable Increasing numbers of victims needing PPV and timely evacuation not possible

37 PPV CATEGORIES Automatic resuscitatorsEMS transport ventsSophisticated Transport VentsFull-feature vents Manual ventiators

38 Optimal PPV Equipment for Mass Respiratory Failure * 1.Operating Characteristics –Volume control mode (needs to work for most respiratory failure but simple to use) –Internal PEEP w/ PEEP compensation –Flow > 70 L/min and < 10 L/min –Pediatric approved –FiO2 range (~.21 to ~1.0) on 50 psi oxygen source –Operates w/ low pressure oxygen source –Capable of battery operation –Control of RR, V T, flow (or I:E), PEEP –Displays delivered V T Study Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel

39 Optimal PPV Equipment for Mass Respiratory Failure * 2.Performance –Ruggedized (can withstand fall from 4 feet) –Minimization of oxygen consumption –Engineered so circuit and all connections cannot be attached incorrectly 3.Safety –Audible/visible alarms (disconnect, high pressure, low source gas pressure) Study Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel

40 US Consensus for Sophisticated Transport Vents for Disasters 2000 US CDC National Stockpile Advisory Panel –Impact Uni-vent 754 (2001) and Puritan Bennett LP-10 (2002) 2004 Working Group on Emergency Mass Critical Care –Society of Crit. Care Med (SCCM) and Center for Biosecurity of UPMC –All survivable pts with resp failure should get at least basic mode of mech vent 2004 Study Group on Mass Casualty Mechanical Ventilation –CDC’s Strategic National Stockpile, SCCM, and Center for Biosecurity of UPMC –Recommended sophisticated transport vents 2005 Guidelines for Acquisition of Ventilators to Meet Demands for Pandemic Flu and Mass Casualty Incidents –American Association of Respiratory Care –Recommended sophisticated transport vents

41 PPV Equipment Stockpile: The US National Example

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43 LP10 Ventilator and IMPACT Eagle 754

44 IMPACT Eagle 754-kitted

45 US SNS Included PPV Equipment w/ Ventilators Ancillary ItemsIMPACT Uni-Vent 754LP10 Adult Circuit Pediatric Circuit Bacterial Filter Heat and Moisture Exchanger Oxygen Reservoir Kit PEEPbuilt in Oxygen Enrichment Kitbuilt in Oxygen elbow for FiO 2 <40%NA Carrying case

46 US SNS Mechanical Ventilators As a critical care provider, you cannot directly request equipment from the SNS! Process Summary Local emergency management (EM) State EM Governor Federal approval Distributed to state from Managed Inventory Distributed to local facility Will be delay from need determination locally to arrival of equipment For multiple regions concurrently involved, total numbers of ventilators may be insufficient to meet surge need

47 Investigate Your Local PPV Surge Preparation 1.Is stockpiled PPV equipment available? 2.Which PPV equipment and ancillary respiratory equipment is provided? 3.What is process to request and receive? –How long to receive and how many will be provided? –What may be logistical barriers to delivery? 4.What is the oxygen surge and backup plan?

48 Minimum Recommended Ancillary Respiratory Equipment Airway –Manual ventilator with face mask (adult and peds sizes) External PEEP valve –Endotracheal intubation equipment –Endotracheal tubes (ETT)(7.5 or 8.0 mm for most adults, peds sizes) ETT securing device NiPPV not recommended for most victims of mass casualty respiratory failure unless experienced staff available to closely monitor patients –Closed circuit suction catheter * –Single use suction catheters (if required after extubation) –Vacuum source, suction regulator, suction trap and hoses ** * Not provided w/ SNS equipment ** Limited quantities in SNS Study Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel

49 Minimum Recommended Ancillary Respiratory Equipment Circuits –Ventilator circuits (1 per pt, adult and peds) Must work with surge PPV equipment If using heated humidifier w/ or w/o wire must have appropriate circuit and additional equipment * Humidification and Filtration –HME for most pts –Heated humidifier w/ or w/o circuit wire (and addl equipment such as chambers, sterile water) * –Filter for expiratory limb (can be HMEF rather than separate HME and filter) * Not provided w/ SNS equipment Study Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel

50 Minimum Recommended Ancillary Respiratory Equipment Respiratory Medication Delivery –MDI adapter * Patient monitoring –Pulse oximeter (may use one device for multiple pts) * –Disposable probes (for each pt) * * Not provided w/ SNS equipment Study Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel

51 Training and augmenting respiratory care professional staff for mass casualty respiratory failure

52 PPV Equipment Training Consider pre-deploying 1 or 2 surge ventilator(s) in hospitals for intra-hospital transport –RCP staff gain experience w/ equipment Process to request, distribute and set-up for patient care should be part of regional exercises (if region has PPV stockpile)

53 Augmenting Staff US Examples 1.Deployable respiratory care professional (RCP) teams –Office of Preparedness and Emergency Operations in US Depart of Health and Human Services –200 respiratory care professionals –Advantage: practicing RCPs with training for deployed role –Disadvantage: Lag time to arrive on site, less likely to deploy in geographically expansive event (e.g. severe influenza pandemic)

54 Augmenting Staff 2.Project Xtreme –Just-in-time DVD-based training for non-respiratory care professionals –airway care (e.g. suctioning), basic operations of SNS vents, and infection control –Available in near future from US AHRQ from

55 Questions ?


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