Presentation on theme: "Mass Casualty Respiratory Failure"— Presentation transcript:
1 Mass Casualty Respiratory Failure Lewis RubinsonDisaster Medicine DirectorPublic Health- Seattle & King County
2 ObjectivesList the medical response circumstances anticipated for mass casualty respiratory failure.List the benefits of repurposing hospital wards rather than “non-medical” areas such as gymnasiums for augmenting critical care treatment space.Describe crucial characteristics for surge positive pressure ventilation equipment.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 eventsCritically injured survivors may stress local receiving facilities critical care capabilityRequires organized, optimal local/institutional critical care response
4 Localized Events and Critical Care Needs Immediate to ICU 12%3.4 ± 3.0 /eventIntensiveCare unitImmediatesurgery 36%Post-opICU 31%2.3 ± 2.5 /eventEmergencydepartmentOperatingroomOthersurgery 25%CT scan 40%4.0 ± 3.2 CT/eventEinav et al, Ann Surg 2006; 243:
10 Critical Care DemandNumber of critically ill and injured victims surviving initial eventRate of development of critical illness and injuryDuration of critical illness and injurySpecialized needs (e.g. renal replacement therapy, burn care)
11 Disasters May Cause Critical Illness and Injury in Survivors Estimated Maximal Critically Ill and Injured Patients Needing CareMultiple ShootingsConventional ExplosionsOpen-spaceClosed spaceDensely-populated structure fireLarge-scale toxic inhalationsSerious natural disastersEpidemic with serious pathogenLarge nuclear detonation1-1010’s100’s1000’s10,000’s
15 ICUs Have Limited Reserve Space 87,400 ICU beds in non-federal US hospitals~3600 acute care hospitals13% of total hospital beds (most countries have fewer ICU beds)ICU occupancy 65-80%
16 ICUs Have Limited Reserve Equipment Just-in-time purchasingBreadth of ICU meds and equipment create financial barriers to building reserve ICUsMaintenance/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 shortageWill add Groeger graph slide
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:Spectrum of critical care interventionsMedical equipmentTriageStaffingProvide circumscribed set of key critical care interventions to many patients rather than maximal critical care to far fewerDerived 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 ventilationVasopressor infusionLarge volume blood product transfusionsIntra-arterial blood pressure monitoringContinuous renal replacement therapyIntra-aortic counter-pulsation deviceICP monitoringHigh-frequency oscillatory ventilationActivated protein C infusion
23 Emergency Mass Critical Care Interventions Supports the organ systems most likely to cause deathDemonstrated effectiveness or best professional judgment to improve survival in similar clinical conditionsDo not require prohibitively expensive equipmentNot staff or resource intensive
24 Emergency Mass Critical Care Interventions Mechanical ventilationBasic mode(s)Hemodynamic supportIV fluids, vasopressor(s)Set of prophylactic interventionsThromboembolism prophylaxis, elevation of head of bed and ? GI prophylaxis
25 Positive Pressure Ventilation Capability DemandResourcesRoughly one full-feature mechanical ventilator per ICU bed in countries with widespread critical care availabilityMASS CASUALTY RESPIRATORY FAILURE
26 Mass Respiratory Failure Surge Capability SpaceWhere should patients receive sustained mechanical ventilation when ICUs are full?StuffWhich respiratory equipment is necessary for mass casualty respiratory failure?StaffWho can help care for surge of patients with respiratory failure?
27 SpaceWhere should patients receive sustained mechanical ventilation when ICUs, EDs and PACUs are full and timely evacuation is not possible?
29 Challenges of Critical Care Mgmt Outside of Hospitals Expensive hospital bedsDifficult to manage pts on cots for sustained periodsOxygen!!SuctionInfection controlBroad diagnostic capabilitySpecialty consulation
30 Oxygen May be a Crucial Scarce Resource Non-medical spaces likely to require compressed oxygen sourceRequire numerous tanks to support pts 24 hrs/day on oxygenPortable oxygen generation systems and port. liquid oxygen systems cost prohibitive for most communities to manage many critically ill/injured patients for days outside of hospitalsHospital liquid oxygen best optionCapacity is largeOne caveat is dependent on distribution by vendor
32 Emergency Mass Critical Care Beds ICUs usually 5-15% of total inpatient bedsIn past, hospitals have made approximately 20% inpatient beds available within 24 hours by recalling staff, canceling surgeries, expedited dischargesWithin 24 hrs increase hospital total critical care space by 2-4 fold if critically ill/injures given admission priorityFor 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 Many sick patients will die without sustained PPVHypoxemic respiratory failure, hypercapnic ventilatory failure, or airway protection/ pulmonary toiletAnticipated PPV needs > 12 hrsLimited specialized staffOxygen may be limited resourceNot provided with US SNS vent stockpile? consistent electrical supply, medical equipment distribution systemPossible secondary disease transmission
35 Manual vs Mechanical Ventilation InexpensiveAvailableEasy to useDifficult to use wellRequires operator with patientNot oxygen conservingInconsistent minute ventilationMechanicalAlarms allow mgmt of multiple ptsConsistent minute ventilationOxygen conservingMore expensiveMore complex to operateMaintenanceAcceptable short term strategyBetter long-term strategy (hrs, days or weeks)
36 AUGMENTING POSITIVE PRESSURE VENTILATION Reserve full-feature ventilatorsVentilator rental supplyMany hospitals dependent on the same vendorsAnesthesia machinesCannot be repurposed for long responseNiPPV equipmentStockpiled PPVMay be used earlier if rapidly deployableIncreasing numbers of victims needing PPV and timely evacuation not possible
37 PPV CATEGORIES Sophisticated Transport Vents Full-feature vents EMS transport ventsManual ventiatorsAutomatic resuscitators
38 Optimal PPV Equipment for Mass Respiratory Failure * Operating CharacteristicsVolume control mode (needs to work for most respiratory failure but simple to use)Internal PEEP w/ PEEP compensationFlow > 70 L/min and < 10 L/minPediatric approvedFiO2 range (~.21 to ~1.0) on 50 psi oxygen sourceOperates w/ low pressure oxygen sourceCapable of battery operationControl of RR, VT, flow (or I:E), PEEPDisplays delivered VTStudy 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 * PerformanceRuggedized (can withstand fall from 4 feet)Minimization of oxygen consumptionEngineered so circuit and all connections cannot be attached incorrectlySafetyAudible/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 PanelImpact Uni-vent 754 (2001) and Puritan Bennett LP-10 (2002)2004 Working Group on Emergency Mass Critical CareSociety of Crit. Care Med (SCCM) and Center for Biosecurity of UPMCAll survivable pts with resp failure should get at least basic mode of mech vent2004 Study Group on Mass Casualty Mechanical VentilationCDC’s Strategic National Stockpile, SCCM, and Center for Biosecurity of UPMCRecommended sophisticated transport vents2005 Guidelines for Acquisition of Ventilators to Meet Demands for Pandemic Flu and Mass Casualty IncidentsAmerican Association of Respiratory Care
41 PPV Equipment Stockpile: The US National Example
45 US SNS Included PPV Equipment w/ Ventilators Ancillary ItemsIMPACT Uni-Vent 754LP10Adult CircuitPediatric CircuitBacterial FilterHeat and Moisture ExchangerOxygen Reservoir KitPEEPbuilt inOxygen Enrichment KitOxygen elbow for FiO2<40%NACarrying case
46 US SNS Mechanical Ventilators As a critical care provider, you cannot directly request equipment from the SNS!Process SummaryLocal emergency management (EM) State EM Governor Federal approvalDistributed to state from Managed InventoryDistributed to local facilityWill be delay from need determination locally to arrival of equipmentFor multiple regions concurrently involved, total numbers of ventilators may be insufficient to meet surge need
47 Investigate Your Local PPV Surge Preparation Is stockpiled PPV equipment available?Which PPV equipment and ancillary respiratory equipment is provided?What is process to request and receive?How long to receive and how many will be provided?What may be logistical barriers to delivery?What is the oxygen surge and backup plan?
48 Minimum Recommended Ancillary Respiratory Equipment AirwayManual ventilator with face mask (adult and peds sizes)External PEEP valveEndotracheal intubation equipmentEndotracheal tubes (ETT)(7.5 or 8.0 mm for most adults, peds sizes)ETT securing deviceNiPPV not recommended for most victims of mass casualty respiratory failure unless experienced staff available to closely monitor patientsClosed 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 SNSStudy Group on Mass Casualty Mechanical Ventilation and US Homeland Security Council Action ID Mass Casualty Respiratory Failure Panel
49 Minimum Recommended Ancillary Respiratory Equipment CircuitsVentilator circuits (1 per pt, adult and peds)Must work with surge PPV equipmentIf using heated humidifier w/ or w/o wire must have appropriate circuit and additional equipment *Humidification and FiltrationHME for most ptsHeated 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 equipmentStudy 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 DeliveryMDI adapter *Patient monitoringPulse oximeter (may use one device for multiple pts) *Disposable probes (for each pt) ** Not provided w/ SNS equipmentStudy 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 transportRCP staff gain experience w/ equipmentProcess 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 Deployable respiratory care professional (RCP) teamsOffice of Preparedness and Emergency Operations in US Depart of Health and Human Services200 respiratory care professionalsAdvantage: practicing RCPs with training for deployed roleDisadvantage: Lag time to arrive on site, less likely to deploy in geographically expansive event (e.g. severe influenza pandemic)
54 Augmenting Staff Project Xtreme Just-in-time DVD-based training for non-respiratory care professionalsairway care (e.g. suctioning), basic operations of SNS vents, and infection controlAvailable in near future from US AHRQ from