The Rhode Island Nightclub Fire One Hospitals Response

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The Rhode Island Nightclub FireOne Hospitals
Response

• Michael Dacey, M.D.
• Director, Intensive Care Unit
• Kent Hospital

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Outline

• History of nightclub fires
• Timeline of events
• Types of injuries
• Triage issues
• Communication issues
• Airway management
• Lessons learned

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History

• 1942 --- Cocoanut Grove nightclub fire in Boston
• 491 victims died
• Many died from smoke inhalation alone and CO
  toxicity
• 1979 --- MGM Grand hotel fire in Las Vegas
• 84 died, many from CO intoxication at the scene
• 1981 --- Stardust Nightclub fire in Dublin
• 48 died
• Scene meticulously reconstructed

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Dublin Reconstruction

• Visibility reduced to less than 1 meter
• Ambient temperatures can reach 1160 degrees C
  (2120 F)
• Oxygen reduced to less than 2
• CO increased to greater than 3
• HCN 250 ppm
• HCl 8500 ppm

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Timeline

• 2230 first notification to hospital of fire
• 2245 told it was a gas station fire
• 2255 no wait, its the station nightclub
• 2300 two of our MDs at scene and call disaster
  code (but not the right one)
• 2310 first patients arrive via POV
• 2315 first EMS transports arrive
• 2340 first of 4 helicopters land at hospital

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Timeline cont.

• 2345-0130 most critically injured arrive
• 2345-0130 least severely injured arrive (POV)
• 2400-0300 stabilization of critically injured
• 0130-0400 EMS delivers less severely injured
• 0400 most dispositions made

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Types of Injuries

• First 6 were in coma
• 21 required intubation
• Severity of burns varied but of the initial 25
  patients, most had 2nd and 3rd degree on face,
  hands and trunk
• CO intoxication in 19 4 patients
• 4 with broken ribs, no other Fx.
• Only 8 had blood ETOH levels gt0.10

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Internal Set-up Plan

• E.R. (65K per year, built for 30K) most
  seriously injured
• E.R. Waiting room and radiology (adjacent) less
  serious patients
• Families sent to cafeteria some distance away
• Admissions to Recovery room O.R. as 15 ICU beds
  already full

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Equipment Shortages

• Ventilators
• Suction tubing set-up for ventilators
• Central lines (most with hand/arm burns)
• Large volume IV tubing (too many micro-drip sets)
• Laryngoscope blades (disposable?)
• Lactated Ringers solution (had just enough)
• AVG volume 6 liters

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Station Fire Triage

• Triage by paramedics Firefighters at scene was
  outstanding
• Communication between scene and hospitals was
  extremely poor during first few hours
• Device failures
• Poor information about remaining capacity at
  hospitals
• Reasonably good communication between hospitals
• Crowd control at scene --- so many left on their
  own ---can you really hold them?

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What we saw at Kent Hospital

• 64 patients in first 6 hours, 84 total
• 22 critically ill
• 21 intubated in E.D. (none of our patients
  intubated in field)
• 6 patients in coma upon arrival
• Too many patients taken by POV to hospital which
  almost overwhelmed our capacity

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Staffing

• Timing of fire at change of shifts helped a lot
  as we were able to effectively have double normal
  workforce
• Total of 7 respiratory therapists
• Physicians 4 ER / 2 internists/ 1 ICU MD / 1
  surgeon / 2 PAs. Staffs, not physicians win
  these battles

10 ER / 5 internists / 3 surgeons / 2 anesth / 2
ICU/ 4 PAs
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Communication with Site

• Very poor
• Almost no notice of what casualties were in-bound
• Hand held walkie-talkie like cell phones did not
  work well for us (volume too low)
• We sent two M.D.s to scene but should have sent
  more per first responders
• We heard more about what was happening at scene
  via radio, TV, but had limited interaction with
  site itself

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Communication cont.

• As receiving hospital, our E.D. physicians, staff
  felt that our capacity was overestimated thru-out
  the first few hours
• Probably due to influx of victims arriving in
  POVs unaccounted for by managers at scene
• Some mis-information about remaining capacity at
  other hospitals

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Communication cont.

• Arrival of senior leadership was both good and
  bad
• Senior leadership took the point on communication
• Usual staff was actually more capable re
  communication as they do it day to day
• Many of first responders we talked to were
  unfamiliar to us
• Had to give directions even though we were only 2
  miles away --- one unit lost briefly

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Communication with other hospitals

• Biggest problem for us was finding who had
  capacity
• Capacity in E.D.s, ICUs, burn ICUs
• Later, managing family members became a problem
  re location of patients
• Faxing patient lists back and forth
• Must be a better way, web sites, etcprior to
  states central coordination site standing up

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Airway Management

• Not routine airways
• Time critical
• Risk of death high
• Route of intubation?
• Standard, fiber-optic, surgical?
• Sedation?
• Paralyze?

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Are Burn Patients Different?

• Yes
• Upper airway burns/edema may obscure usual
  landmarks making intubations difficult
• Time essential complete upper airway obstruction
  may develop quickly
• Therefore greater risk of CVCI scenario
• Limited respiratory reserve
• Surgical airways always difficult --- more so in
  this population with face/neck burns
• Large volume little time per patient
• Volume depleted patients greater risk of
  hypotension

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How to intubate?

• Should sedation be used?
• Should intubation be done while awake?
• Should muscle relaxant medications be used?
• Are these patients fundamentally different than
  other EMS patients?

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Initial Assessment

• Heat and smoke injury and extensive facial burns
• Intubate quickly
• Deep facial burns but no smoke injury
• Difficulty controlling secretions and high risk
  for progression to airway obstruction ---
  intubate early
• Heat and smoke injury but no facial burns
• Observe carefully and intubate at earliest sign
  of airway edema

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Diagnosis of Smoke Inhalation

• Singed nasal hair
• Hoarseness
• Stridor
• Dyspnea
• Wheezing
• All the above are unreliable signs of serious
  smoke inhalation (i.e. may often be absent)
• Carbonaceous sputum is a reliable sign

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Chest Films

• Chest films are unreliable signs of serious smoke
  inhalation injury
• ARDS may eventually develop but not immediately
• Pulmonary edema rare during resuscitation phase
  (pulmonary vascular resistance elevated and
  protective)
• Often films are normal

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• Bronchoscopy is also a reliable test
• Common F.O.B. findings include
• Carbon particles in airways
• Mucosal ulcerations
• Inflammatory airway changes

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Upper Airway Injury

• Rapid edema formation and burn itself preventing
  access to mouth
• Rapid tongue swelling
• Supraglottic edema
• Vocal cord edema
• Infraglottic edema

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Wilkinson, Norman Advanced airway management and
intubation, 2002
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Normal Airway Appearance
Cole, Steve Advanced airway management, 2003
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Supraglottic Edema at 12 Hours
Burnsurgery.org 2004
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Sedation?

• Yes --- for most patients
• Etomidate (20 - 30 mg)
• Morphine (large doses early for pain)
• Midazolam
• Propofol

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Muscle Relaxants?

• TNTC studies supporting the use of RSI protocols
  in E.D.s by experienced physicians
• increased success rate first attempt
• decreased aspiration risk
• less airway trauma
• Studies done in field, in transport helicopters
  and by non-physicians have suffered from poor
  design with some raising concerns while others
  suggest RSI preferable
• No studies limited to burn patients although
  trauma literature generally supports RSI in E.D.
  setting
• Succinylcholine OK in first few hours after burn

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Recent RSI Field Study

• San Diego paramedics
• Trauma patients
• RSI protocol using midazolam and succinylcholine
  after 60 sec pre-oxygenation
• Study stopped early as outcomes worse in RSI
  group
• Apparently due to prolonged oxygen desaturation
  in 57

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Conclusion about RSI

• Caution advised
• Advantages to the spontaneously breathing patient
• We intubated 21 patients in first 2 hours
• 7 RSI with etomidate and succinylcholine
• 5 awake using topical anesthesia and laryngeal
  nerve blocks
• 1 fiber-optic
• 8 with just etomidate/morphine/midazolam
• MANY patients had already developed upper airway
  edema as seen on laryngoscopy
• 0 missed airways or esophageal intubations
• Frequent hypotension that responded to fluids in
  all cases
• Central access in more than 1/2 given arm burns

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Inhalation Injury By Site of Inflammation
From Parrillo and Dellinger Critical Care
Medicine, 1485, 2002.
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CO Intoxication Diagnosis

• High Index of Suspicion
• Carboxy-Hgb level gt 10
• Unexplained metabolic acidosis
• Confusion, agitation, coma
• Measurement of PO2 or O2 saturations not useful
• 60 of all deaths from house fires are from CO
  intoxication

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Demling RH. Pulmonary Problems in the Burn
Patient (A Leading cause of Morbidity and
Mortality in the Burn Patient). J Burns
Surg Wound Care serial online 20043(1)5.
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20 Feb 03

• 44 COHgb tests at Kent Hospital
• 19 gt 10
• All had clinical evidence of CO intoxication
• Not including 4 patients transported to
  Boston/UMass during first hour via helicopter

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Treatment of CO Intoxication
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Demling RH. Pulmonary Problems in the Burn
Patient (A Leading cause of Morbidity and
Mortality in the Burn Patient). J Burns
Surg Wound Care serial online 20043(1)5.
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Pain Treatment

• All of the first 35 patients required intravenous
  pain control
• We used over 1 gram of morphine in about 5 hours
• Typical dose for the 21 intubated patients was
  15 20 mg initially
• Anxiety a big problem IV midazolam or lorazepam
  in dose averaging 5 mg to start

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Dealing with Press

• Keeping press away from patients in hospital and
  families waiting to hear during emergency itself
• Three press conferences, starting next morning
• Interviews coordinated by public relations
• Very large press area set up across street from
  fire site
• Attitude of press shifted 24 hours later

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Lessons Learned

• Airway management key to survival early on
• Disaster drills paid big dividends throughout
  night at all levels of care
• Communication between hospitals and scene very
  poor
• What is the current capacity that each has left?
• Communication between hospitals could be improved
• Need an immediate way to identify victims in
  hospitals before central state agency up and
  running
• State wide and regional resources and expertise
  were adequate
• I.D. of victims who died went very well
• Simple names for disaster codes
• Be careful with the media

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