Presentation on theme: "FILOTEO C. FERRER, MD Section of Nephrology Makati Medical Center"— Presentation transcript:
1LEARNING FROM DISASTERS (Focus on Nephrology Experience on Crush Syndrome) FILOTEO C. FERRER, MDSection of NephrologyMakati Medical CenterMarch 24, 2011I decided to change the title of my talk. I think this is more appropriate as im still learning. I have never been part of an actual rescue operation during disaters.
2Lessons from past disasters OutlineLessons from past disasters(Objectives)Be awareUnderstandPrepareIt is not my objective to make everyone here to be part of a rescue team or become expert in disaster preparedness in case, I my self have no experience also in disaster rescue, I am only a member of the disaster committe formed by our society the PSN. At the end of my talk I hope everybodyWill be aware,understand a little and prepare for crush injury in case an earthquake happens
3SCIENTIFIC METHODOLOGY So how do we learn from diasaters, normally
4NO EXPERIMENTAL MODEL OF DISASTERS Only way to collect information and draw conclusions is by:Retrospective analysis of past disastersAnd have a good understanding of these lessonsUnfortunately there is no experimental model of diasters…
5NO EXPERIMENTAL MODEL OF DISASTERS Lessons learned from these unfortunate experiences can contributeMinimize number of mistakesImplement an effective responseDecrease death toll in future catastrophesApply whatever lessons to avoid same mistake or at least decrease number of mistakesUse these lessons to Plan and implement an effective responseAnd hopefully decrease death toll in future catastrophes
6MAJOR EARTHQUAKES DURING THE LAST 50 YEARS LocationDateMagnitudeNumber of InjuredDeathsCrush SyndromeDialyzedTangshan, China19768.0165,000255,0002.5%?Southern Italian, Italy19806.8202197Tyre,Lebanon1982-801Spitak,Armenia198825,000600Northern,Iran1990>40,000156Kobe,Japan19955,530372123Chi-Chi,Taiwan19992,4055232Marmara,Turkey7.617,000639477Bam,Iran2003>20,00026,00012496Kashmir,Pakistan2005>100,000>80,00011865Sichuan,China20087.969,000Haiti20107.0220,0009262Busy slide.. But will just These are the major earthquakes for the last 50 years with good published data on CS as you can see incidence of Crush injury/syndrome varies.
7INCIDENCE OF CRUSH INJURY AFTER DISASTRERS Intensity of the disasterPopulation density of the regionStructural characteristics of the buildingsTiming of disasterEfficacy of rescue11M in 636 sq KM = 17,000 plus per Km2 as compared toSendai 1, persons per km².
8Crush injury is defined as a direct injury caused by collapsing material and debris resulting in manifest muscle swelling and/or neurological disturbances in the affected parts of the body.So what is crush injury..
9Crush Syndrome on the other hand is defined as patients with crush injury and systemic manifestation due to muscle cell damage which would include:acute kidney injurySepsisacute respiratory distress syndromediffuse intravascular coaugulationBleedinghypovolemic shockcardiac failurearrhythmiaselectrolyte disturbances.
10Crush syndromeSecond most frequent cause of disaster related mortality after earthquakes (after direct trauma)Incidence may increase up to 2-5% overall in disaster victimsBut according to general perception:they constitute a relatively minor group requiring a complex labor- intensive therapeutic measures and are rarely included in governmental or local disaster plans (emergency teams concentrate on housing and primary health )Sever M.S., et al Renal disaster relief: from theory to practiceNDT (2009)
11Crush Syndrome (CS)It takes a lot of effort to extricate victims from the rubbleHence, it would be deplorable and even counter productive if proper therapeutic possibilities would not be prepared and offeredBut come to think of it …regrettable kkahinayang buhaySo lets us try to understand the complicated pathophysiology of CSSever M.S., et al Renal disaster relief; from theory to practice; NDT (2009)
12Bywaters described four(4) cases in 1941 1st case seen on Sun. Sept. 16, 1940 at Hammersmith Hosp. 17 yr, old girl with crush injury involving L leg. Initially responded to fluid but became oliguric with rising urea, died suddenly on the 8th day with K 34 mg% (8.7 mEq/L).It was first described by bywaters juBritish Medical Journal 1941 March
13Pathophysiology of CS Prolonged pressure on the limbs Ischemic insult(endothelium)Stretch insult(myocytes)Ischemia reperfusion injury-oxygen free radicals-Leukocyte activation-calcium influx-Other body reactionsExtreme tension Inc Symp activityInc cathecholaminesRHABDOMYOLYSISReleaseof pressureon the limb(rescue)FASCIOTMYSo what could have caused the death of this patient, as you can see from diagram the trigger would be pressure on the affected limbs syndrome starts immediately upon compression of a skeletal muscle and becomes a cycle or continous even after release of the pressure and its is not purely due to rhabdomyolyis or release of myoglobin, oxygen free radicals, leukocyte activation and the calcium influx into the cell plays a major role resulting into furher damage of the myocytes.Systemic deteriorationHypovolemiaCardiac arrestHyperkalemiaHypocalcemiaARFDIC,SIRS/MOFInterstitial edema/cell swellingCompartment syndromemyoneuroopathyJMAJ July 2005-Vol 48. 7
14Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis ConsequencesInflux from extracellular compartment into muscle cellsWater,NaCl,and CalciumHypovolemia and hemodynamic shock,pre-renal and ATN,hypocalcemia,aggravated hyperkalemic cardiotoxicity;increased cysolic Ca++, activation of cytotoxic proteasesMuch of events leading to full blown syndrome happens upon release of the pressure on the affected limbs, immidiately after the release of the pressure there will be influx of water and Na into the muscle cells leading to …. Clinical swelling erythema …JMAJ July 2005-Vol 48. 7
15Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis ConsequencesEfflux from damaged muscle cellpotassiumhyperK and cardiotoxicity aggravated by hypocalcemia and hypotensionpurines from disintegrating cellnucleiHyperuricemia,nephrotoxicityPhosphateHyperphosphatemia,aggravation of hypocalcemia and metastatic calcification
16Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis ConsequencesEfflux from damaged muscle cellLactic and other organic acidsMetabolic acidosis and aciduriamyoglobinNephrotoxicity,particularly with co-existing oliguria,aciduria and uricusuriaThromboplastinDisseminated intrvascular coagulationCreatinineElevated creatinine
17Crush SyndromeSo a patient with CS may become hyperkalemic,hyperuricemic,hyperphosphatemic, hypocalcemic with swollen affected limb and some may have renal failure, late stage if left untreated they usually develop sepsis DIC and eventually death.So how do we treat them or avoid further complication… what have learned from previous diasters
18MAJOR EARTHQUAKES DURING THE LAST 50 YEARS LocationDateMagnitudeNumber of InjuredDeathsCrush SyndromeDialyzedTangshan, China19768.0165,000255,0002.5%?Southern Italian, Italy19806.8202197Tyre,Lebanon1982-801Spitak,Armenia198825,000600Northern,Iran1990>40,000156Kobe,Japan19955,530372123Chi-Chi,Taiwan19992,4055232Marmara,Turkey7.617,000639477Bam,Iran200326,00012496Kashmir,Pakistan2005>100,000>80,00011865Sichuan,China20087.969,000Haiti20107.0220,0009262Busy slide
19TANGSHAN (CHINA) EARTHQUAKE Year: 1976 Intensity 8 Deaths 242K injured 165K CS 2-5 % Any patient with crush injury is a major casualtyCS patients may suddenly die hyperkalemia
20SOUTHERN ITALIAN EARTHQUAKE Year 1980 Intensity 6.8 Deaths 202 CS 19 Acute Kidney injury was not necessarily observed in all CS victims (12/19= 63%)Rescued victim who were seemingly well under the rubble deteriorated or even died as soon as after extricationRescueDeathSevere metabolic acidosisFatal hyperkalemiaSantangelo et al Surg and Gyne 1982
21Lebanon Experience Year 1982 Deaths 80 CS 7 Dialysed 1 Archives of Int Med 1984 : 144 : p# PXs with Crush Injuryunder the rubble (hours)Time to IV fluids (hours)AKIFasciotomyFluid balance in 60 hrs712.5Opositive 12.5 kg15.524Sudden collapse of building due to bombing19797126-105Positive 11 kg
22Lebanon Experience Year 1982 Deaths 80 CS 7 Dialysed 1 Immediate fluid resuscitation is of vital importance to prevent crush syndrome complications
23ARMENIAN EARTHQUAKE Year: 1988 Intensity 6 ARMENIAN EARTHQUAKE Year: 1988 Intensity 6.8 deaths 25K- 150K CS 600 Dialysis 225600 cases of AKI, 225 cases of which needed dialysis created second catastrophe/disaster(“RENAL DISASTER”)Despite availability of 36 tons of dialysis supplies, 100 dialysis machines and volunteer personel from many countries the response was ineffectiveoverwhelming medical need of the victims led to another disaster what is now known as renal disaster but despite international relief efforts because there was no locally organized relief structure plus poorly organized international effort it worsened the chaosWorsened the chaos“Third disaster “
24ARMENIAN EARTHQUAKE Year: 1988 Intensity 6 ARMENIAN EARTHQUAKE Year: 1988 Intensity 6.8 deaths 25K- 150K CS 600 Dialysis 225“Disaster within in a disaster”No organized international structure with appropriate training and deployment strategiesDisappointing experienceThis disappointing experiences of armenian earthquake convinced the ISN to organize this RDRTF
25International Society of Nephrology Logistic organization to avoid similar problems in the future disastersHeadquarters are informed immediately of all disastersLogistic support from NGOs such as Medicins Sans Frontieres (MSF)Since the organization, it had intervened in several disasters (Marmara,Bam,Kashmir,Kobe)
26Disaster Chief Disaster Relief Coordinator US Geological Survey detects earthquakeVisiting disaster areaAssessing extent of the problemChairperson of RDRTF is informedAsking for Global SupportEstimation of the needs for support (i.e., medications, blood products)Decision to interveneAsking for local supportDispatching of scouting teamSince its org they have been following this steps in doing their relief efforts, but any relief effort to be effective there should be preparation …Support offeredAccessing of local conditionsDISASTER RESPONSEGLOBAL COORDINATIONLOCAL COORDINATIONMajor Steps in Global and Local Coordination of Renal-Disaster Relief EffortsNDT (2009) 24 :
27Renal Disaster Response PREPARATIONS BEFORE DISASTERComposing Disaster Response TeamDirectorsAssessment team membersRescuers and medical personnelOrganizing Educational activities forPublicRescue teamsNon-nephrological medical personnelNephrological (para) medical personnelChronic dialysis patientsPlanning the interventionsExternal planning and preparationsLocal planningOverall disaster planningMaterial planningPlanning of dialysis servicesCollaboration with external bodiesMEASURES AFTER DISASTERExternal InterventionLocal InterventionThe acute phase (action plan)The maintenance phaseAnd as you can see part of preparing for disater is public awareness and The philipiine Society of Nephrology has been preparing this module recommendations for crush sydrome since November for this purpose, actually even earlier na overtake lang ng Ondoy, need for algo re Leptospirosis … Is there a need for it here??Major Steps in Renal Disaster ResponseNDT (2009) 24 :
28PSN DISASTER RESPONSE TO CRUSH INJURY/CRUSH SYNDROME The Philippines being situated in the Pacific ring of fire is at increased risk of major earthquakes.Situated in a geotectonically active region
29PSN DISASTER RESPONSE TO CRUSH INJURY/CRUSH SYNDROME The1,200-km-long Philippine fault zone (PFZ) is a major tectonic feature that transects the whole Philippine archipelago from northwestern Luzon to southeastern Mindanao. This arc-parallel, left-lateral strike slip fault is divided into several segments and has been the source of large-magnitude earthquakes in recent years, such as the 1973 Ragay Gulf earthquake (M 7.0), 1990 Luzon earthquake (Mw 7.7) , and 2003 Masbate earthquake (Ms 6.2).go to philvolcs website . What have we learned from our own experince… the killer earthquake
32Northern Luzon Earthquake Year 1990 Intensity 7. 7 Deaths > 1000 CS Northern Luzon Earthquake Year Intensity 7.7 Deaths > 1000 CS ?? AKI ??Doctors working under umbrellas and sheets of plastic had treated nearly 800 of the injured? Medical publications/experiencePhilvolcs and DOST has been mapping the 1200 Km fault zoneGreatly improved earthquake monitoring system from 12 stations now we have 66 seismic stations nationwide,release announcement in less than 10 minutesUnfortunately we were not get any medical publication related to this earthquake. The only thing positive that happened out of this is that philvolcs and dost has ….
33PSN DISASTER RESPONSE TO CRUSH INJURY/CRUSH SYNDROME Most doctors and even nephrologists have no regular experience with CSThus, there is a need for guidance“recommendations only” due to lack of evidencePsn disaster guide hopefully would serve as a campaign tool to enhance awareness and as guide for paramedical non paramedical personnels
34PRE-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM Immediate fluid resuscitation is of vital importance to prevent crush syndrome complicationsAs we have learned from past disasters there is a need to hydrate all potential crush injury victims as this would prevent crush syndrome complications so even before the patient is exctricated from the rubblePSN Disaster Response to CRUSH Injury
35POST-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM (PRE-HOSPITAL PHASE) Any patient with crush injury is a major casualtyCS patients may suddenly dieAvoid K containing fluid !!!Once the a victim is extricatedinitial evaluation should be done and be hydrated accordingly , ECG may be done in the field to check for hyperK ecg changes and hyper K regimen be given eevn before trasport of patient.PSN Disaster Response to CRUSH Injury
36VICTIM MAY BE DISCHARGED WITH PROPER ADVICE Victims who are deemed stable with no signs of dehydration, and without significant risk for crush injury/crush syndrome may be discharged or sent home due to limitation of hospital beds should be instructed to:watch for their color of urine (dark-colored or reddish-colored urine)monitor the volume of urine (Note for oliguria <400 ml/24 hours)Watch-out-for symptoms of crush syndrome such as acute weight gain, edema, dyspnea,Seek medical care as soon as possible
37POST-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM Once the victim is admitted to the hospital, a thorough ‘comprehensive secondary survey’ is done which includes complete history taking, detailed physical examination and reassessment of all vital signs.(HOSPITAL PHASE)PSN Disaster Response to CRUSH Injury
38POST EXTRICATION MANAGEMENT (HOSPITAL PHASE): Continue Hydation: May shift NSS to Alkaline saline hydration: 1L half-isotonic saline with 50 meqs NaHCO3 every 2nd or 3rd cycle of 1L isotonic saline at 0.5 – 1L/hr-theoretically ideal fluid to use as alkalinization of plasma may reduce plasma K and eventually the urine to promote uric acid excretion and increase solubility of myoglobin- but may also promote calcium phosphate deposition inducing or worsening manifestation of hypocalcemia0.5 l per hour that is 500 ml/hr damiClosely monitor patients and adjust IVF rate accordingly
39POST EXTRICATION MANAGEMENT (HOSPITAL PHASE): Continue Hydation:OR May just continue NSS lit/day( If laboratory monitoring is not possible and HCO3 solution is not available)Due to theoretical drawback of alkainization of urine it is recommended that this should only be done if close monitoring is possible.But you may ask how much is too much or how much is enough … so we go back to our 50 year Hx…Closely monitor patients and adjust IVF rate accordingly
40MAJOR EARTHQUAKES DURING THE LAST 50 YEARS LocationDateMagnitudeNumber of InjuredDeathsCrush SyndromeDialyzedTangshan, China19768.0165,000255,0002.5%?Southern Italian, Italy19806.8202197Tyre,Lebanon1982-801Spitak,Armenia198825,000600Northern,Iran1990>40,000156Kobe,Japan19955,530372123Chi-Chi,Taiwan19992,4055232Marmara,Turkey7.617,000639477Bingol, Turkey20036.4177164Kashmir,Pakistan2005>100,000>80,00011865Sichuan,China20087.969,000Haiti20107.0220,0009262These are the major earthquakes for the lasat 50 years with good published data on CS as you can see incidence varies.
41Bingol (Turkey) Earthquake Year 2003 Intensity 6 Bingol (Turkey) Earthquake Year 2003 Intensity 6.4 Deaths 177 CS 16 Dialysis 4Non DialyzedVictims (12 Px)Dialyzed Victims(4 Px)Mean +/- SDP valueVolume of fluids (L)Day 121.8 +/- 2.711 +/- 2.50.002Day 220 +/- 7.69 +/- 11NSDay39.2 +/- 5.84 +/- 0.70.05Urine output (L)8.8 +/- 2.31.8 +/- 2.410.2 +/- 2.90.7 +/- 1.30.0018.1 +/_ 3.20.11 +/- 0.16Here they use mannitol plus alkaline as you can see as much as 21 liter may be infused on then first day
43Bam Iran Earthquake Year2003 Intensity 6.6 Deaths 25K Injured 30K AKI defined as crea > 1.6 mg/dl or dialysis need
44Mortality in patients with AKI Kobe (Hanshin-Awaji) Japan Earthquake Year 1995 Intensity 7.2 Deaths 5325 CS 372 AKI 202 Dialysed 123Mortality in patients with AKIOverall % (50 deaths out of 202)Mortality in patients with AKI and dialysed41% ( 50 out of 123 needed dialysis)Most of these patients received only 2 to 3 liters per day during the initial 3 daysThe journal of trauma 42 (3) March 1997
45Survivors vs. non survivors: NS Dialyzed: 5407+/- 1623 ml Marmara Earthquake Year 1999 Intensity 7.4 Deaths 17K Injured 44K AKI 639 Dialysed 477Mean volume of fluid given on the first day of admission : 5109+/ mlSurvivors vs. non survivors: NSDialyzed: 5407+/ mlVS.Non dialyzed : 3825+/ mlP=.01
46Marmara Earthquake Year 199 Intensity 7 Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 Dialysis 477Many victims were admitted to reference hospitals may have already established ATNConservative fluid management for late rescued victims to avoid fluid overload and need for dialysis
47POST EXTRICATION MANAGEMENT (HOSPITAL PHASE): Conservative Hydration: if close monitoring is impossible late rescued victims as ATN have developed alreadyBased on these there is no substitute for close monitoring ,will not go into the details of our guideline but we are open for you suggestions and comments later;Would like to continue with our preparations…
48The following factors should be considered in hydration age(Caution should be exercised in the elderly.)body mass index(More fluid is needed for the victims with larger body mass.)trauma pattern(More fluid is needed in patient with third spacing)Edema due to compartment syndrome does not necessarily reflect fluid overload.)amount of presumed fluid loss(More fluid should be given to victims with bleeding, and in those in hot climates)position of the victim(Those who are on upside down or in a prone position are at higher risk of developing respiratory difficulties following aggressive fluid resuscitation.)
49Renal Disaster Response PREPARATIONS BEFORE DISASTERComposing Disaster Response TeamDirectorsAssessment team membersRescuers and medical personnelOrganizing Educational activities forPublicRescue teamsNon-nephrological medical personnelNephrological (para) medical personnelChronic dialysis patientsPlanning the interventionsExternal planning and preparationsLocal planningOverall disaster planningMaterial planningPlanning of dialysis servicesCollaboration with external bodiesMEASURES AFTER DISASTERExternal InterventionLocal InterventionThe acute phase (action plan)The maintenance phaseMajor Steps in Renal Disaster ResponseNDT (2009) 24 :
50Marmara Earthquake Year 199 Intensity 7 Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 C Dialysis 477No of patients dialyzed477Total HD sessions5137HD sessions per patient who required HD11.2 =/- 8No of blood transfusions2981No. of FFP transfusions2594No. of human albumin transfusionsRatio of dialysis sessions required over all patient8.2 +/-10.3Ratio of blood transfusion requiring patient over all patient4.6=/- 9No. of days a patient with ARF needed dialysis13-18 daysSever MS, et al, NEJM 2006;354:
51For each potential patient with crush syndrome Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 C Dialysis 47For each potential patient with crush syndrome8 to 10 sets of dialysis equipmentAt least 5 liters of non K containing crystalloids15 grams of polysterene or equivalent K binder4 to 5 units of blood
52Scenario : 1000 crush injury victims 1000 x 5 liters NSS x 7 days = 35,000 Liters1000 x 15g x 7 days = 105,000 grams kayexalate or equivalent1000 x 5 = 5000 units of blood1000 x 1o= 10,000 sets of HD needsPlus antibiotic , surgical , mechanical ventilator needsBefore we all get overwhelmed by all these needs would like to share other lessons learned from past disaster that may be eqaully important before ending this talk
53Other lessonsNot to do Fasciotomy routinely to prevent compartment syndromeIncreases risk for sepsisAvoid administration of succinylcholine during operation/procedures as it may exacerbate hyperkalemia causing cardiac arrest.
54Other lessonsA higher mortality rate was observed in the patients who were treated in hospitals of affected area compared with those transferred to undamaged hospitals.
55Renal Disaster Response PREPARATIONS BEFORE DISASTERComposing Disaster Response TeamDirectorsAssessment team membersRescuers and medical personnelOrganizing Educational activities forPublicRescue teamsNon-nephrological medical personnelNephrological (para) medical personnelChronic dialysis patientsPlanning the interventionsExternal planning and preparationsLocal planningOverall disaster planningMaterial planningPlanning of dialysis servicesCollaboration with external bodiesMEASURES AFTER DISASTERExternal InterventionContact list?(RDRTF)? MilitaryLocal InterventionThe acute phase (action plan)First 3 daysThe maintenance phaseFirst monthSo let us continue preparing as Disasters can happen anytime, we have to know when to ask for help but before we ask for help we should also be ready to accept it and as even accepting help needs planning and coordination.Major Steps in Renal Disaster ResponseNDT (2009) 24 :
56And hopefully not be announced in an international convention that they had chaotic time helping the philippines …
57There is no substitute for public awareness and preparedness as Diasaters can rarely be anticipated, much less prevented.
58“The Children of Adam are limbs of each other Having been created of one essence.When the calamity of time afflicts one limbThe other limbs cannot remain at rest.If thou hast no sympathy for the troubles of othersThou art unworthy to be called by the name of a man”Saadi ( Persian poet)But lets us not be helpless in time of disasters as we Filipinos are known for this… the Filipino value of communal effortIn times of disaster it is a universal instinct of a man to be of help.
59Let me leave you with this ….Your choice stay under
60"Triangle of Life": OR Try the triangle of life either way let us all be safe
61References PSN disaster response guide THANK YOU!!!ReferencesPSN disaster response guideSever and Vanholder Lecture ASN 2010A combination of pictures shows earthquake survivor, middle school student Liao Bo under the rubble in Beichuan County, Sichuan Province, May 13, 2008, left, and in a hospital in Chongqing Municipality, on his 17th birthday, May 24, right. Liao Bo lost his left leg in the earthquake.
64by: Bernardo C. Cueto,MD ( Emergency Preparedness Officer) EMERGENCY PREPAREDNESS AND TRANSPORT OF THE SICK AND INJURED (Patient/ Casualty Handling)by:Bernardo C. Cueto,MD( Emergency Preparedness Officer)
65PURPOSEThe purpose of this lecture is to orient MMC medical personel how to prepare for possible emergencies that may occur in the hospital. It also intends to inform the participants how to properly transport patients
66OBJECTIVES Describe the Hospital Emergency At the end of this module, participants willbe able toDescribe the Hospital EmergencyPreparedness Committee StructureEnumerate the Hospital EmergencyCodesEnumerate the Hospital Evacuation Code
67OBJECTIVES Define Emergency Rescue and Transfer Demonstrate technique of EmergencyTransferDescribe the hospital plan for the differentpossible disasters
68Emergency Preparedness Officer PUBLIC INFORMATION OFFICER DEPUTY EP OFFICERCOMMUNICATIONDETAILFIRE SAFETY OFFICERFLOOR BRIGADEMANAGERFOODCLEARING OPERATIONUTILITYBFP / DILG / PNPSECURITYOFFICEREmergency Preparedness OfficerFACILITIESUNIT BRIGADE MANAGEREVACUATIONFIREEXTINGUISHER DETAILMANPOWER&TRACKINGPUBLIC INFORMATION OFFICERTRAUMA TEAM 1TRAUMATEAM 2MEDICALFINANCEFIREBRIGADEFIRE SUPRESSIONSEARCH AND RESCUE
69Floor brigade managerOrganizes and coordinates emergency response in their area of responsibility.DUTIES AND RESPONSIBILITIES:1. Responsible for matters relative to Emergency Preparedness in his/her floor.2. Responsible for the enforcement of safety rules and regulations in his/her floor3. Organizes Floor Brigade in his/her floor composed of unit brigades in the different areas of the front rectangular ,rear rectangular, wing and circular. ( The new building will have a different set of Floor Brigade Manager)
70Floor brigade managerActs as incident commander in his area of responsibility when an Emergency Incident arises.a) Directs fire fighting and if necessary direct initialevacuationb) Assures and calms down and assists patients andvisitors in her floor to avoid panicc) Supervises the evacuation of his/her floor when soordered and return his/her evacuees in accordancewith the established procedure.5. Communicates and updates Emergency IncidentCommander during an incident.
71Floor brigade manager6. Informs the EPO, any situation likely to abate the effectiveness and readiness of the operation of the Emergency Preparedness Committee.7. Carries out other responsibilities that may be assigned upon him/her by the Emergency Incident Commander as to aspect of emergency response.
72unit BRIGADE MANAGEROrganizes and directs emergency operations in the unit levelDUTIES AND RESPONSIBILITIES:1. Responsible for enforcing safety rules and regulations in his/her unit.2. Ensures that fire fighting equipments in his/her area of responsibility are in proper condition.3. Ensures that the telephone operators are informed when there is an emergency in his/her area of responsibility.
73unit BRIGADE MANAGER 4. In case of actual Emergency Incident, a) Directs fire fighting and if necessary direct initialevacuationb) Assures, calms down and assists patients and visitors inhis/herunit to avoid panicc) Supervises the evacuation of his/her floor when soordered return his/her evacuees in accordance with theestablished procedure.d) Oversees accounting of evacuated patients
74unit BRIGADE MANAGER5. Informs the Floor Brigade Manager of any situation likely to abate the effectiveness and readiness of the operation of the Emergency Preparedness Committee6. Carries out other responsibilities that may be assigned to him/her in aspect of emergency response.
75Composition of the unit brigade 1. Fire extinguisher detail 2. Evacuation detail A. Personnel evacuation detail B. Property evacuation detail 3. Manpower and tracking
76Guidelines in emergency respoNse PLANGATHER NEEDED MATERIALSFOLLOW THE FOLLOWING INITIAL ACTIONA – ASK FOR HELPI – INTERVENED – DO NOT ADD INJURIES
78Guidelines in emergency RESPONSE SCENE ASSESSMENTELEMENTS OF SCENE ASSESSMENTCHECK FOR SAFETY ?WHAT HAPPENED ?HOW MANY ARE INJURED/SICK ?ARE THERE PEOPLE WHO CAN HELP ?WHAT IS THE MODE OF INJURY/ILLNESS
79Guidelines in emergency respoNse SCENE ASSESSMENTSafety of the rescuer/ responderSafety of the By StanderSafety of the patientCALL FOR HELPLocal Emergency Number : Loc 1000Direct Emergency Number:Makati C3 Number 168
80Guidelines in emergency respoNse HOSPITAL EMERGENCY CODE1. Doctor Red2. Doctor Blue3. Doctor Pink4. Doctor Orange5. Maxicart
81Guidelines in emergency respoNse INITIAL ASSESSMENT – Check for Immediate threats to life R – Responsiveness A – Airway B – Breathing C - Circulation
82Guidelines in emergency respoNse SECONDARY ASSESSMENT – Check for possible threats to life 1. Check Vital Signs 2. Get Patient History 3. Do head to toe assessment (for trauma patient)
83evacuationThe process of moving a persons or things from a place to another, as a dangerous place or disaster area, for reason of safety or protection
84TWO TYPES OF EVACUATION BASED ON AREA OF RELOCATION HORIZONTAL EVACUATION-means moving away from the area of danger to a safe place on the same floor where the individual is, at the time of the alarm or emergency. In this case, the individual should move away from the area of eminent danger.
85TWO TYPES OF EVACUATION BASED ON AREA OF RELOCATION VERTICAL EVACUATION - using a stairway is the preferred method to exit a building. All exit passageways are marked with "EXIT" signs. Stairways can be used by those who are able to evacuate with or without assistance.
86TWO HOSPITAL EVACAUATON CODE E1- is a partial vertical evacuation where the affected area is evacuated to the Emergency room while the adjacent floors evacuates horizontally away from the area of eminent danger. Other floors are on stand by alert.
87TWO HOSPITAL EVACAUATON CODE E2- is a complete evacuation of the entire hospital (both towers) and the primary evacuation area is Ayala parking . Another evacuation area may be assigned if the primary evacuation area is found not to be safe.
88Emergency rescue and transfer Emergency Rescue – it is the moving of a sick or injured person from unsafe place to a place of safetyTransfer – it is the moving of a sick or injured person after giving treatment
89SELECTION OF TRANSFER METHOD WILL DEPEND ON THE FOLLOWING: Nature and severity of the injury.Size of the victim.Physical capabilities of the responder.Number of personnel and equipment available.5. Nature of evacuation route.6. Distance to be covered.7. Gender of the victim (Last Consideration).
90THINGS TO OBSERVED WHILE CARRYING Victim’s airway must be maintained open.Hemorrhage is controlled.Victim is safely maintained in the correct position.Regular check of the victim’s condition is made.Supporting bandages and dressing remain effectively appliedThe method of transfer is safe, comfortable and as speedy as circumstances permit.
91THINGS TO OBSERVED WHILE CARRYING 6. The patient’s body is moved as one unit.The taller first aiders stay at the head side of the victim.First Aiders/bearers must observed ergonomics in lifting and moving of patient.
96disasterIt is an event resulting in great loss and misfortune. TWO TYPES INTERNAL DISASTER- Is an uncontrollable crisis that originated in the facility. EXTERNAL DISASTER – Is an uncontrollable crisis that happened outside the facility and the hospital is tapped as an emergency facility.
97HOW DO WE IDENTIFY HAZARD HAZARD VULNERABILITY ASSESSMENT A process of identifying all hazards and identifying which one should be given priority in the preparedness planning. It is has three categories namely: 1. Natural Event 2. Human Event 3. Technological event
98DRILLSTo acquaint/refresh the hospital personnel on the correct courses of action under different emergency situation.To achieve an orderly and safe evacuation under proper discipline.To prevent panic, confusion, injury, and loss of life in case of emergency.To monitor the time for evacuation and fire response.To identify training and emergency plan strengths and weaknesses.To test the effectiveness of the alarm system, communication system, and the fire fighting apparatus and other safety equipment.
99Makati med drills Fire Drill(announced or unannounced) Earthquake Drill( announced or unannounced)Hazardous Material Drill (announced or unannounced)Personnel Evacuation and rescue Drill (partial or general)
100Before earthquake CHECK FOR HAZARDS IN THE WORK PLACE BE AWARE OF THE DIFFERENT EXITS IN YOUR AREAIDENTIFY SAFE PLACES INDOOR AND OUTDOOREDUCATE YOURSELF AND YOUR CO – WORKERSPREPARE DISASTER SUPPLIESa) First Aid Kitb) Flashlight and Whistlec) Drinking waterd) Ready to eat food
101during earthquakeDROP to the ground, take COVER and HOLD on until the shaking stopsStay away from glass, windows, outside doors and walls, and anything that could fall, such as lighting fixtures or furniture.Use a doorway for shelter only if it is in close proximity to you and if you know it is a strongly supported, loadbearing doorway.Stay inside until shaking stops and it is safe to go outside. Research has shown that most injuries occur when people inside buildings attempt to move to a different location inside the building or try to leave.DO NOT use the elevators.
102AFTER earthquake Check evacuation route if safe Evacuate and proceed to primary evacuation site for complete evacuation (wait for evacuation order)Stay away from debris and objects that may fallKeep a safe distance away from the buildingDon’t return to area unless ALL CLEAR has been announced and return to work area has been ordered
103Algorithm for bioterrorism Suspected Infectious AgentInfection Control Committee (ICC)Emergency Preparedness Committee (EPC)InvestigateConfirm if true incident of biological agentFALSETRUERecommend clearance to EPCRecommend specific action to EPCContainmentSecurityEngineeringControl access to infected areaShut down ventilation in infected areaWait for advice from EPC for next actionAlgorithm for bioterrorism
104Algorithm for bioterrorism TRUE case of biological agentAdvice from EPC for next actionFALSE case of biological agentContinue containment. Activate Hazmat teamAdvice communication to LGU about incidentNon-medicalMedicalOrder clearance and cleaningAlgorithm for bioterrorism