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FILOTEO C. FERRER, MD Section of Nephrology Makati Medical Center

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Presentation on theme: "FILOTEO C. FERRER, MD Section of Nephrology Makati Medical Center"— Presentation transcript:

1 LEARNING FROM DISASTERS (Focus on Nephrology Experience on Crush Syndrome)
FILOTEO C. FERRER, MD Section of Nephrology Makati Medical Center March 24, 2011 I 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.

2 Lessons from past disasters
Outline Lessons from past disasters (Objectives) Be aware Understand Prepare It 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 everybody Will be aware,understand a little and prepare for crush injury in case an earthquake happens

3 SCIENTIFIC METHODOLOGY
So how do we learn from diasaters, normally

4 NO EXPERIMENTAL MODEL OF DISASTERS
Only way to collect information and draw conclusions is by: Retrospective analysis of past disasters And have a good understanding of these lessons Unfortunately there is no experimental model of diasters…

5 NO EXPERIMENTAL MODEL OF DISASTERS
Lessons learned from these unfortunate experiences can contribute Minimize number of mistakes Implement an effective response Decrease death toll in future catastrophes Apply whatever lessons to avoid same mistake or at least decrease number of mistakes Use these lessons to Plan and implement an effective response And hopefully decrease death toll in future catastrophes

6 MAJOR EARTHQUAKES DURING THE LAST 50 YEARS
Location Date Magnitude Number of Injured Deaths Crush Syndrome Dialyzed Tangshan, China 1976 8.0 165,000 255,000 2.5% ? Southern Italian, Italy 1980 6.8 202 19 7 Tyre,Lebanon 1982 - 80 1 Spitak,Armenia 1988 25,000 600 Northern,Iran 1990 >40,000 156 Kobe,Japan 1995 5,530 372 123 Chi-Chi,Taiwan 1999 2,405 52 32 Marmara,Turkey 7.6 17,000 639 477 Bam,Iran 2003 >20,000 26,000 124 96 Kashmir,Pakistan 2005 >100,000 >80,000 118 65 Sichuan,China 2008 7.9 69,000 Haiti 2010 7.0 220,000 92 62 Busy 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.

7 INCIDENCE OF CRUSH INJURY AFTER DISASTRERS
Intensity of the disaster Population density of the region Structural characteristics of the buildings Timing of disaster Efficacy of rescue 11M in 636 sq KM = 17,000 plus per Km2 as compared to Sendai 1, persons per km².

8 Crush 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..

9 Crush 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 injury Sepsis acute respiratory distress syndrome diffuse intravascular coaugulation Bleeding hypovolemic shock cardiac failure arrhythmias electrolyte disturbances.

10 Crush syndrome Second most frequent cause of disaster related mortality after earthquakes (after direct trauma) Incidence may increase up to 2-5% overall in disaster victims But 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 practice NDT (2009)

11 Crush Syndrome (CS) It takes a lot of effort to extricate victims from the rubble Hence, it would be deplorable and even counter productive if proper therapeutic possibilities would not be prepared and offered But come to think of it …regrettable kkahinayang buhay So lets us try to understand the complicated pathophysiology of CS Sever M.S., et al Renal disaster relief; from theory to practice; NDT (2009)

12 Bywaters 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 ju British Medical Journal 1941 March

13 Pathophysiology 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 reactions Extreme tension Inc Symp activity Inc cathecholamines RHABDOMYOLYSIS Release of pressure on the limb (rescue) F A S C I O T M Y So 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 deterioration Hypovolemia Cardiac arrest Hyperkalemia Hypocalcemia ARF DIC,SIRS/MOF Interstitial edema/cell swelling Compartment syndrome myoneuroopathy JMAJ July 2005-Vol 48. 7

14 Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis
Consequences Influx from extracellular compartment into muscle cells Water,NaCl,and Calcium Hypovolemia and hemodynamic shock,pre-renal and ATN,hypocalcemia,aggravated hyperkalemic cardiotoxicity;increased cysolic Ca++, activation of cytotoxic proteases Much 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

15 Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis
Consequences Efflux from damaged muscle cell potassium hyperK and cardiotoxicity aggravated by hypocalcemia and hypotension purines from disintegrating cell nuclei Hyperuricemia,nephrotoxicity Phosphate Hyperphosphatemia,aggravation of hypocalcemia and metastatic calcification

16 Flow of Solutes and water across Skeletal – Muscle- Cell membrane in Rhabdomyolyisis
Consequences Efflux from damaged muscle cell Lactic and other organic acids Metabolic acidosis and aciduria myoglobin Nephrotoxicity,particularly with co-existing oliguria,aciduria and uricusuria Thromboplastin Disseminated intrvascular coagulation Creatinine Elevated creatinine

17 Crush Syndrome So 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

18 MAJOR EARTHQUAKES DURING THE LAST 50 YEARS
Location Date Magnitude Number of Injured Deaths Crush Syndrome Dialyzed Tangshan, China 1976 8.0 165,000 255,000 2.5% ? Southern Italian, Italy 1980 6.8 202 19 7 Tyre,Lebanon 1982 - 80 1 Spitak,Armenia 1988 25,000 600 Northern,Iran 1990 >40,000 156 Kobe,Japan 1995 5,530 372 123 Chi-Chi,Taiwan 1999 2,405 52 32 Marmara,Turkey 7.6 17,000 639 477 Bam,Iran 2003 26,000 124 96 Kashmir,Pakistan 2005 >100,000 >80,000 118 65 Sichuan,China 2008 7.9 69,000 Haiti 2010 7.0 220,000 92 62 Busy slide

19 TANGSHAN (CHINA) EARTHQUAKE Year: 1976 Intensity 8 Deaths 242K injured 165K CS 2-5 %
Any patient with crush injury is a major casualty CS patients may suddenly die hyperkalemia

20 SOUTHERN 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 extrication Rescue Death Severe metabolic acidosis Fatal hyperkalemia Santangelo et al Surg and Gyne 1982

21 Lebanon Experience Year 1982 Deaths 80 CS 7 Dialysed 1
Archives of Int Med 1984 : 144 : p # PXs with Crush Injury under the rubble (hours) Time to IV fluids (hours) AKI Fasciotomy Fluid balance in 60 hrs 7 12.5 O positive 12.5 kg 1 5.5 24 Sudden collapse of building due to bombing 1979 7 12 6-10 5 Positive 11 kg

22 Lebanon Experience Year 1982 Deaths 80 CS 7 Dialysed 1
Immediate fluid resuscitation is of vital importance to prevent crush syndrome complications

23 ARMENIAN EARTHQUAKE Year: 1988 Intensity 6
ARMENIAN EARTHQUAKE Year: 1988 Intensity 6.8 deaths 25K- 150K CS 600 Dialysis 225 600 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 ineffective overwhelming 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 chaos Worsened the chaos “Third disaster “

24 ARMENIAN 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 strategies Disappointing experience This disappointing experiences of armenian earthquake convinced the ISN to organize this RDRTF

25 International Society of Nephrology
Logistic organization to avoid similar problems in the future disasters Headquarters are informed immediately of all disasters Logistic support from NGOs such as Medicins Sans Frontieres (MSF) Since the organization, it had intervened in several disasters (Marmara,Bam,Kashmir,Kobe)

26 Disaster Chief Disaster Relief Coordinator
US Geological Survey detects earthquake Visiting disaster area Assessing extent of the problem Chairperson of RDRTF is informed Asking for Global Support Estimation of the needs for support (i.e., medications, blood products) Decision to intervene Asking for local support Dispatching of scouting team Since 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 offered Accessing of local conditions DISASTER RESPONSE GLOBAL COORDINATION LOCAL COORDINATION Major Steps in Global and Local Coordination of Renal-Disaster Relief Efforts NDT (2009) 24 :

27 Renal Disaster Response
PREPARATIONS BEFORE DISASTER Composing Disaster Response Team Directors Assessment team members Rescuers and medical personnel Organizing Educational activities for Public Rescue teams Non-nephrological medical personnel Nephrological (para) medical personnel Chronic dialysis patients Planning the interventions External planning and preparations Local planning Overall disaster planning Material planning Planning of dialysis services Collaboration with external bodies MEASURES AFTER DISASTER External Intervention Local Intervention The acute phase (action plan) The maintenance phase And 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 Response NDT (2009) 24 :

28 PSN 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

29 PSN 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

30

31 Show pictures 1 by 1

32 Northern 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/experience Philvolcs and DOST has been mapping the 1200 Km fault zone Greatly improved earthquake monitoring system from 12 stations now we have 66 seismic stations nationwide,release announcement in less than 10 minutes Unfortunately 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 ….

33 PSN DISASTER RESPONSE TO CRUSH INJURY/CRUSH SYNDROME
Most doctors and even nephrologists have no regular experience with CS Thus, there is a need for guidance “recommendations only” due to lack of evidence Psn disaster guide hopefully would serve as a campaign tool to enhance awareness and as guide for paramedical non paramedical personnels

34 PRE-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM
Immediate fluid resuscitation is of vital importance to prevent crush syndrome complications As 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 rubble PSN Disaster Response to CRUSH Injury

35 POST-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM (PRE-HOSPITAL PHASE)
Any patient with crush injury is a major casualty CS patients may suddenly die Avoid 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

36 VICTIM 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

37 POST-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

38 POST 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 hypocalcemia 0.5 l per hour that is 500 ml/hr dami Closely monitor patients and adjust IVF rate accordingly

39 POST 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

40 MAJOR EARTHQUAKES DURING THE LAST 50 YEARS
Location Date Magnitude Number of Injured Deaths Crush Syndrome Dialyzed Tangshan, China 1976 8.0 165,000 255,000 2.5% ? Southern Italian, Italy 1980 6.8 202 19 7 Tyre,Lebanon 1982 - 80 1 Spitak,Armenia 1988 25,000 600 Northern,Iran 1990 >40,000 156 Kobe,Japan 1995 5,530 372 123 Chi-Chi,Taiwan 1999 2,405 52 32 Marmara,Turkey 7.6 17,000 639 477 Bingol, Turkey 2003 6.4 177 16 4 Kashmir,Pakistan 2005 >100,000 >80,000 118 65 Sichuan,China 2008 7.9 69,000 Haiti 2010 7.0 220,000 92 62 These are the major earthquakes for the lasat 50 years with good published data on CS as you can see incidence varies.

41 Bingol (Turkey) Earthquake Year 2003 Intensity 6
Bingol (Turkey) Earthquake Year 2003 Intensity 6.4 Deaths 177 CS 16 Dialysis 4 Non Dialyzed Victims (12 Px) Dialyzed Victims (4 Px) Mean +/- SD P value Volume of fluids (L) Day 1 21.8 +/- 2.7 11 +/- 2.5 0.002 Day 2 20 +/- 7.6 9 +/- 11 NS Day3 9.2 +/- 5.8 4 +/- 0.7 0.05 Urine output (L) 8.8 +/- 2.3 1.8 +/- 2.4 10.2 +/- 2.9 0.7 +/- 1.3 0.001 8.1 +/_ 3.2 0.11 +/- 0.16 Here they use mannitol plus alkaline as you can see as much as 21 liter may be infused on then first day

42 Bingol (Turkey) Earthquake Year 2003 Intensity 6
Bingol (Turkey) Earthquake Year 2003 Intensity 6.4 Deaths 177 CS 16 Dialysis 4 Early adequate fluid administration helps prevent dialysis

43 Bam Iran Earthquake Year2003 Intensity 6.6 Deaths 25K Injured 30K
AKI defined as crea > 1.6 mg/dl or dialysis need

44 Mortality in patients with AKI
Kobe (Hanshin-Awaji) Japan Earthquake Year 1995 Intensity 7.2 Deaths 5325 CS 372 AKI 202 Dialysed 123 Mortality in patients with AKI Overall % (50 deaths out of 202) Mortality in patients with AKI and dialysed 41% ( 50 out of 123 needed dialysis) Most of these patients received only 2 to 3 liters per day during the initial 3 days The journal of trauma 42 (3) March 1997

45 Survivors vs. non survivors: NS Dialyzed: 5407+/- 1623 ml
Marmara Earthquake Year 1999 Intensity 7.4 Deaths 17K Injured 44K AKI 639 Dialysed 477 Mean volume of fluid given on the first day of admission : 5109+/ ml Survivors vs. non survivors: NS Dialyzed: 5407+/ ml VS. Non dialyzed : 3825+/ ml P=.01

46 Marmara Earthquake Year 199 Intensity 7
Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 Dialysis 477 Many victims were admitted to reference hospitals may have already established ATN Conservative fluid management for late rescued victims to avoid fluid overload and need for dialysis

47 POST EXTRICATION MANAGEMENT (HOSPITAL PHASE):
Conservative Hydration: if close monitoring is impossible late rescued victims as ATN have developed already Based 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…

48 The 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.)

49 Renal Disaster Response
PREPARATIONS BEFORE DISASTER Composing Disaster Response Team Directors Assessment team members Rescuers and medical personnel Organizing Educational activities for Public Rescue teams Non-nephrological medical personnel Nephrological (para) medical personnel Chronic dialysis patients Planning the interventions External planning and preparations Local planning Overall disaster planning Material planning Planning of dialysis services Collaboration with external bodies MEASURES AFTER DISASTER External Intervention Local Intervention The acute phase (action plan) The maintenance phase Major Steps in Renal Disaster Response NDT (2009) 24 :

50 Marmara Earthquake Year 199 Intensity 7
Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 C Dialysis 477 No of patients dialyzed 477 Total HD sessions 5137 HD sessions per patient who required HD 11.2 =/- 8 No of blood transfusions 2981 No. of FFP transfusions 2594 No. of human albumin transfusions Ratio of dialysis sessions required over all patient 8.2 +/-10.3 Ratio of blood transfusion requiring patient over all patient 4.6=/- 9 No. of days a patient with ARF needed dialysis 13-18 days Sever MS, et al, NEJM 2006;354:

51 For each potential patient with crush syndrome
Marmara Earthquake Year 199 Intensity 7.4 Deaths 17K Injured 44K AKI 639 C Dialysis 47 For each potential patient with crush syndrome 8 to 10 sets of dialysis equipment At least 5 liters of non K containing crystalloids 15 grams of polysterene or equivalent K binder 4 to 5 units of blood

52 Scenario : 1000 crush injury victims
1000 x 5 liters NSS x 7 days = 35,000 Liters 1000 x 15g x 7 days = 105,000 grams kayexalate or equivalent 1000 x 5 = 5000 units of blood 1000 x 1o= 10,000 sets of HD needs Plus antibiotic , surgical , mechanical ventilator needs Before 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

53 Other lessons Not to do Fasciotomy routinely to prevent compartment syndrome Increases risk for sepsis Avoid administration of succinylcholine during operation/procedures as it may exacerbate hyperkalemia causing cardiac arrest.

54 Other lessons A higher mortality rate was observed in the patients who were treated in hospitals of affected area compared with those transferred to undamaged hospitals.

55 Renal Disaster Response
PREPARATIONS BEFORE DISASTER Composing Disaster Response Team Directors Assessment team members Rescuers and medical personnel Organizing Educational activities for Public Rescue teams Non-nephrological medical personnel Nephrological (para) medical personnel Chronic dialysis patients Planning the interventions External planning and preparations Local planning Overall disaster planning Material planning Planning of dialysis services Collaboration with external bodies MEASURES AFTER DISASTER External Intervention Contact list ?(RDRTF) ? Military Local Intervention The acute phase (action plan) First 3 days The maintenance phase First month So 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 Response NDT (2009) 24 :

56 And hopefully not be announced in an international convention that they had chaotic time helping the philippines …

57 There 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 limb The other limbs cannot remain at rest. If thou hast no sympathy for the troubles of others Thou 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 effort In times of disaster it is a universal instinct of a man to be of help.

59 Let 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

61 References PSN disaster response guide
THANK YOU!!! References PSN disaster response guide Sever and Vanholder Lecture ASN 2010 A 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.

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64 by: 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)

65 PURPOSE The 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

66 OBJECTIVES Describe the Hospital Emergency
At the end of this module, participants will be able to Describe the Hospital Emergency Preparedness Committee Structure Enumerate the Hospital Emergency Codes Enumerate the Hospital Evacuation Code

67 OBJECTIVES Define Emergency Rescue and Transfer
Demonstrate technique of Emergency Transfer Describe the hospital plan for the different possible disasters

68 Emergency Preparedness Officer PUBLIC INFORMATION OFFICER
DEPUTY EP OFFICER COMMUNICATION DETAIL FIRE SAFETY OFFICER FLOOR BRIGADE MANAGER FOOD CLEARING OPERATION UTILITY BFP / DILG / PNP SECURITY OFFICER Emergency Preparedness Officer FACILITIES UNIT BRIGADE MANAGER EVACUATION FIRE EXTINGUISHER DETAIL MANPOWER & TRACKING PUBLIC INFORMATION OFFICER TRAUMA TEAM 1 TRAUMA TEAM 2 MEDICAL FINANCE FIRE BRIGADE FIRE SUPRESSION SEARCH AND RESCUE

69 Floor brigade manager Organizes 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 floor 3. 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)

70 Floor brigade manager Acts as incident commander in his area of responsibility when an Emergency Incident arises. a) Directs fire fighting and if necessary direct initial evacuation b) Assures and calms down and assists patients and visitors in her floor to avoid panic c) Supervises the evacuation of his/her floor when so ordered and return his/her evacuees in accordance with the established procedure. 5. Communicates and updates Emergency Incident Commander during an incident.

71 Floor brigade manager 6. 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.

72 unit BRIGADE MANAGER Organizes and directs emergency operations in the unit level DUTIES 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.

73 unit BRIGADE MANAGER 4. In case of actual Emergency Incident,
a) Directs fire fighting and if necessary direct initial evacuation b) Assures, calms down and assists patients and visitors in his/her unit to avoid panic c) Supervises the evacuation of his/her floor when so ordered return his/her evacuees in accordance with the established procedure. d) Oversees accounting of evacuated patients

74 unit BRIGADE MANAGER 5. Informs the Floor Brigade Manager of any situation likely to abate the effectiveness and readiness of the operation of the Emergency Preparedness Committee 6. Carries out other responsibilities that may be assigned to him/her in aspect of emergency response.

75 Composition of the unit brigade
1. Fire extinguisher detail 2. Evacuation detail A. Personnel evacuation detail B. Property evacuation detail 3. Manpower and tracking

76 Guidelines in emergency respoNse
PLAN GATHER NEEDED MATERIALS FOLLOW THE FOLLOWING INITIAL ACTION A – ASK FOR HELP I – INTERVENE D – DO NOT ADD INJURIES

77 Patient Assessment

78 Guidelines in emergency RESPONSE
SCENE ASSESSMENT ELEMENTS OF SCENE ASSESSMENT CHECK FOR SAFETY ? WHAT HAPPENED ? HOW MANY ARE INJURED/SICK ? ARE THERE PEOPLE WHO CAN HELP ? WHAT IS THE MODE OF INJURY/ILLNESS

79 Guidelines in emergency respoNse
SCENE ASSESSMENT Safety of the rescuer/ responder Safety of the By Stander Safety of the patient CALL FOR HELP Local Emergency Number : Loc 1000 Direct Emergency Number: Makati C3 Number 168

80 Guidelines in emergency respoNse
HOSPITAL EMERGENCY CODE 1. Doctor Red 2. Doctor Blue 3. Doctor Pink 4. Doctor Orange 5. Maxicart

81 Guidelines in emergency respoNse
INITIAL ASSESSMENT – Check for Immediate threats to life R – Responsiveness A – Airway B – Breathing C - Circulation

82 Guidelines 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)

83 evacuation The 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

84 TWO 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.

85 TWO 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.

86 TWO 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.

87 TWO 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.

88 Emergency rescue and transfer
Emergency Rescue – it is the moving of a sick or injured person from unsafe place to a place of safety Transfer – it is the moving of a sick or injured person after giving treatment

89 SELECTION 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).

90 THINGS 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 applied The method of transfer is safe, comfortable and as speedy as circumstances permit.

91 THINGS 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.

92 Methods of transfer ASSIST TO WALK CARRY IN ARMS

93 Methods of transfer TWO MAN SIT CARRY EXTREMITY CARRY

94 Methods of transfer BEARERS ALONG SIDE

95 Group carry Bearers along side Blanket carry

96 disaster It 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.

97 HOW 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

98 DRILLS To 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.

99 Makati 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)

100 Before earthquake CHECK FOR HAZARDS IN THE WORK PLACE
BE AWARE OF THE DIFFERENT EXITS IN YOUR AREA IDENTIFY SAFE PLACES INDOOR AND OUTDOOR EDUCATE YOURSELF AND YOUR CO – WORKERS PREPARE DISASTER SUPPLIES a) First Aid Kit b) Flashlight and Whistle c) Drinking water d) Ready to eat food

101 during earthquake DROP to the ground, take COVER and HOLD on until the shaking stops Stay 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.

102 AFTER 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 fall Keep a safe distance away from the building Don’t return to area unless ALL CLEAR has been announced and return to work area has been ordered

103 Algorithm for bioterrorism
Suspected Infectious Agent Infection Control Committee (ICC) Emergency Preparedness Committee (EPC) Investigate Confirm if true incident of biological agent FALSE TRUE Recommend clearance to EPC Recommend specific action to EPC Containment Security Engineering Control access to infected area Shut down ventilation in infected area Wait for advice from EPC for next action Algorithm for bioterrorism

104 Algorithm for bioterrorism
TRUE case of biological agent Advice from EPC for next action FALSE case of biological agent Continue containment. Activate Hazmat team Advice communication to LGU about incident Non-medical Medical Order clearance and cleaning Algorithm for bioterrorism

105 BE SAFE GOOD DAY !!!


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