MANAGEMENT OF MASS SURGICAL EMERGENCIES

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MANAGEMENT OF MASS SURGICAL EMERGENCIES

• By
• Col. Abrar Hussain Zaidi

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SEQUENCE

• INTRODUCTION / back ground
• PRINCIPLES OF MANAGEMENT
• gtTRAUMA CARE SYSTEM

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Your view ?
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• 1-INTRODUCTION

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INTRODUCTION

• What constitutes a surgical emergency-?
• A patient who requires
• an immediate,urgent,early
• surgical operative intervention of any
  extent
• to either save his life OR to prevent a
  disability

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INTRODUCTION

• Primary considerations
• Life and quality of life

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INTRODUCTION

• What constitutes Mass surgical
• causalities Or emergencies ?

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INTRODUCTION

• Any time /situation/occurrence when there are
  more Patients than Rescuers and immediately
  available resources
• A major incident
• An event whose impact cannot be handled
  within routine service and arrangements. It
  requires the implementation of special procedures
  by one, or more, of the Emergency Services.

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INTRODUCTION

• levels /spectrum of major incident
• LEVEL I INCIDENTS
• multi-vehicle road traffic accidents, tens
  of casualties
• LEVEL II - Much larger scale events affecting
• potentially hundreds, rather than tens, of
  people, possibly also involving the closure or
  evacuation of a major facility or persistent
  disruption over many days. This level of incident
  will require a collective response by several, or
  many, Trusts.
• LEVEL III INCIDENTS - Events of potentially
  catastrophic proportions that severely disrup
  thealth and social care services and other
  functions (power, water, etc)and that exceed even
  collective capability.

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INTRODUCTION

• Major Incidents of recent past
• gt9/11
• gtKashmir earth quake
• gtFrequent bomb blasts

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INTRODUCTION

• What particularly differentiates a situation of
  mass causalities than ordinary circumstances
• Chaos and panic
• Disorder
• Difficult to define priorities
• On going disaster
• Destruction of Infrastructure
  road/rail/Hospitals
• Limitation of available resources
• Numerous others

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INTRODUCTION

• Types of major incidents
• Special ground situations
• A-When the humans are responsible
• B-When The Nature Goes Wild

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INTRODUCTION

• A-HUMANS RESPONSIBLE
• PRIMARY ROLE OF PREVENTION
• STRESSED BY DISASTER MANAGEMENT TEAMS
• Air disaster
• Road and Rail Accidents
• Fire Emergencies
• Industrial accidents /Hazardous Materials
• Nuclear Accidents and Radiation
• Building collapse
• Explosion
• Riots / insurgencies
• Terrorism
• wars

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INTRODUCTION

• B-NATURE GOING WILD
• PREVENTION NOT POSSIBLE
• STRESS IS ON PREPARATION TO FIGHT
• Air/Environment storms, inf. outbreaks
• Mountains
• Planes
• Desert
• Waters
• Combined e.g. Earth quakes

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INTRODUCTION

Special Ground situations
Civilian vs. Army Mixed
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INTRODUCTION

• Nature of mass surgical emergencies
• Most of the mass surgical emergencies
• are Traumatic in nature
• gtPhysical
• Mechanical-RTA
• Fire/heat - burns
• Fire arm injuries
  Wars/terrorisms
• gtChemical
• gtOthers

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INTRODUCTION

• AIMS OF MANAGEMENT
• Minimize human mortality and morbidity
• with Best use of
• available resources and expertise

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INTRODUCTION

• AIMS OF MANAGEMENT
• Save as Many Lives
  as Possible
• Prevent as much disability
• as possible
• with best use of available resources

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• How to achieve the goals--?

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• Answ.
• A Rationale,systematic,well structured,
  
• coordinated and well organized
• approach in patient care.
• The theme in development of principles of
  management of mass surgical emergencies and the
  Trauma care system
• i.e. a system approach in patient care

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• 2-PRINCIPLES OF MANAGEMENT
• Differences from
• ordinary trauma management-- ?
• One casualty vs tens reporting
  simultaneously

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PRINCIPLES OF MANAGEMENT

• In ordinarily situations there are tens of
  service men to attend a single causality
• In mass casualty incident there are
• Tens of casualties to be attended by only a
  few service men

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PRINCIPLES OF MANAGEMENT

• Mass casualty management
• poses challenges that are distinct
• from routine surgical practice.
• WE NEED TO BE SELECTIVE
• As services can not be extended equally to
  every one

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PRINCIPLES OF MANAGEMENT

• Trauma care system
• A system approach in patient care
• that comprises
• Pre hospital care/scene of accident
• Evacuation system
• Hospital care . level 1, 11,111.

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PRINCIPLES OF MANAGEMENT

• gtStress on a uniform approach of management
• gtDeveloped with common consensus of world bodies
• -ATLS
• -PTC
• -BlS
• -Others

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PRINCIPLES OF MANAGEMENT

• 
  TRIMODAL PATTERN OF DEATH
• Immediate death - first peak
• within seconds of the injury,
• massive head injury, heart injury, or
  aortic injury.
• cannot be prevented.
• later death - second peak
• hemorrhage or direct organ
  compromise,
• deaths begins an hour or two after
  the injury- golden hour.
• subdural and epidural hematomas,
  hemo-pneumothorax,
• organ rupture, or blood loss.
• These deaths are often preventable
• Delayed death third peak
• due to complications and organ failure.
  due to sepsis or
• multi-organ failure.
• Prompt treatment of shock and
• hypoxemia during the golden hour can
  reduce these deaths
•         

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TRIMODAL PATTERN OF DEATH

Immediate deaths Preventive measures
The main target for care
Early deaths Urgent treatment
Late deaths Good prolonged care
50 30 20
Preventable
Sec to min 1-2 hrs golden hour
weeks late
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• Second peak death prevention
• By benefiting from- golden hour is the
• main target of trauma care services
• Subdural and epidural hematomas, hemo-
  
• pneumothorax, organ rupture, or blood
  loss.
• deaths are preventable

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PRINCIPLES OF MANAGEMENT

• Trauma care system
• A well coordinated,organized system of trauma
  care services operating in a specified
  geographical zone parallel to the
  administrative zone
• Zones of operation
• A county
• A town
• A city
• A province
• A country

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PRINCIPLES OF MANAGEMENT

• Some Considerations
• Mass casualties are characterized by such
  numbers, severity,
• and diversity of injuries that can
  overwhelm the ability of local
• medical resources to deliver
  comprehensive and definitive
• medical care to all victims.
• Surgeons play the pivot role BUT every
  one in the system
• has a unique contribution
• The training and skills of doctors is
  important
• Resources and infrastructure of trauma
  centers and trauma
• systems should be suited for the
  logistical demands
• Rapid decision making required by large
  casualty burdens

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PRINCIPLES OF MANAGEMENT

• WHO GUID LINES
• Disaster planning preparedness
• Local
• Regional
• National

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PRINCIPLES OF MANAGEMENT

• Trauma care system
• Regional Mass Casualty Support Units

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PRINCIPLES OF MANAGEMENT

• WHO GUID LINES
• Project definition determines the aim,
  objectives and scope of an emergency plan
• Planning group to gather information and to gain
  the commitment of people and organizations,
  which will contribute .
• Potential problem analysis develop strategies,
• Resource analysis resources available,
  discrepancy
• between requirement and availability, and
  responsibility.
• Designation of roles and responsibilities to
  individuals and organizations.
• Management structure concerning the command of
  individual organizations and control across
  organizations.
• Systems development -actual medical aid
• for specific response and
  recovery .
• Documentation The written emergency plan w

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PRINCIPLES OF MANAGEMENT

• THE BASIC PRINCIPLES
• Actual treatment is done on the same
  principles as in usual victims of trauma but
  with greater speed and on priorities
• 1- Triage and early transportation
• 2- Primary survey resuscitation
  identification
• treatment of immediate life threat
• 3- Secondary survey detailed examination,
• assessment and definitive subsequent
• Damage control surgical treatment and
• 4- Continued care
• 5- Rehabilitation/follow up

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Selection/prioritization of cases on the
  merit of the severity of their conditions
  to establish priorities for care -- based on
  available resources
• See who needs attention first
• Based on quick Primary survey

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Proirity-1 / Red - highest priority need
  immediate
• care (usually
  circulatory or respiratory
• Proirity-2 / Yellow -second highest priority able
  to wait
• longer before
  transport (45 minutes)
• Proirity-3 / Green- walking - able to wait
  several hours
• Proirity-4 / White- Expectant-where out come is
  gloomy
• severe head
  injury, spinal cord injury
• Proirity-5/ Black Dead

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Proirity-1 / Red
• Severely injured but able to be saved with
  relatively quick treatment and transport
• Examples
• Severe bleeding,
• Severe Shock,
• Open Chest or Abdominal Wounds,
• Unconscious but has pulse and is breathing,
• Several Major Fractures

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Proirity-2 Yellow Delayed
• Stable but unable to walk on their own
• Examples
• severe burns but no respiratory distress,
• spinal injuries
• moderate blood loss
• conscious with head injuries

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Proirity-3 / Green- walking - able to wait
  several hours
• Minor injures that need to be assessed or
  treated but not right away.
• Ex Minor fractures, minor bleeding

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PRINCIPLES OF MANAGEMENT

• 1-Triage
• Proirity-4 / Expectant-
• where out come is gloomy
  severe head injury, spinal cord
  injury

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PRINCIPLES OF MANAGEMENT

• 1-Triage points to remember
• It is primarily based on quick and orderly
  primary survey
• Its a dynamic process i.e sorting resorting
• May be repeated at different levels of
  care
• Because
• A bulk sorted at the scene of accident and moved
  to Tauma ctr when RE_SORTED and re examined
  may differ and change in poirities
• Sorting station at trauma ctr may be first triage
  site
• Actual condition of the victim may change with
  time and during transportation
• Initial assessment may be false under/over

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PRINCIPLES OF MANAGEMENT

• 1-Triage points to remember
• Primarily concentrate on
• selection of severely injured
• who has a good chance of survival
• if treated well in time
• OR who will die if not treated in time

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PRINCIPLES OF MANAGEMENT

• 1-Triage points to remember
• The Criteria of selection
• Severity of injury and chance of survival
• Search for Seriously injured
• but
• with a good chance of survival

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• Quick appraisal
• gtwhat the person is suffering from
• gtIs there an acute but treatable problem
• gtWhat immediate measures are required
• gtDoes he need immediate shifting to OT

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• Wherever the patient is first seen at the triage
  area
• Or at the Trauma center
• Examination time --seconds
• Objective -Identify the immediate threat to life
  and
• do an immediate measure
• -Assign the priority of case
• Sequence of Resuscitation - ABC- of trauma
  care
• Airways, Breathing, circulation, Disability,
  Exposure

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• ABCDE of Trauma
• The primary survey, should identify such
  life-threatening injuries such as
• airway obstruction
• chest injuries with breathing difficulties
• severe external or internal haemorrhage
• abdominal injuries.

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PRINCIPLES OF MANAGEMENT

• Sequence of Resuscitation -ABCDE- of trauma care
• Airway
• Assess the airway. Can patient talk and breathe
  freely? If obstructed, the steps to beconsidered
  are
• chin lift/jaw thrust (tongue is attached to the
  jaw)
• suction (if available)
• Insert airway/nasopharyngeal airway
• Intubation. NB keep the neck immobilised in
  neutral position.
• Breathing
• Breathing is assessed as airway patency and
  breathing adequacy are re-checked. Ifinadequate,
  the steps to be considered are
• Decompression and drainage of tension
  pneumothorax/haemothorax
• Closure of open chest injury
• Artificial ventilation.
• Give oxygen if available.

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PRINCIPLES OF MANAGEMENT

• Sequence of Resuscitation -ABCDE- of trauma care
• Circulation
• Assess circulation, as oxygen supply, airway
  patency and breathing adequacy are re-checked. If
  inadequate, the steps to be considered are
• Sstop external haemorrhage
• Establish 2 large-bore IV lines (14 or 16 G) if
  possible
• Administer fluid if available.
• Disability
• Rapid neurological assessment (is patient awake,
  vocally responsive to pain or unconscious). There
  is no time to do the Glasgow Coma Scale so a
• Awake A
• Verbal response V
• Painful response P
• Unresponsive U
• Exposure
• Undress patient and look for injury e.g spinal
  injury,

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• Reassessment of ABCs must be undertaken
• if patient is unstable

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• Summary
• Check and establish airways chin lift, jaw
  thrust, intubate.
• e.g. Oropharyngeal /neck/chest injuries
• Check and restore breathing Manual,mechanical,int
  ubate.
• e.g. Haemopneumothorax
• Check R circulatory shock stop visible
  bleeding, i/v line
• 
  balanced salt solution
• e.g. major vascular injuries
• Check for neurological deficit.
• Stabilize neck manually/with collar supports

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PRINCIPLES OF MANAGEMENT

• 2-Primary survey Resuscitation
• Remember that
• Primary survey and immediate therapeutic measure
  go side by side
• A life saving procedure done by one person /team
  may be supplemented by examination by other
  person/team and may draw attention to an
  associated serious condition ex-4
• Try to minimize the chance of missing any
  important feature

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PRINCIPLES OF MANAGEMENT

• Triage
• Primary survey resuscitation
• ?

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• EXERCISE-1
• In a mass emergency situation you happen to see
  two
• Men Make a choice / select one person for
• Immediate help /resuscitation transfer
• 1-Young man with 5x5 inch burst in Rt.chest wall,
  pale and in shock.
• 2-Young man with bullet inj lt.chest with
• tense abdomen, conscous and maintaining
• vital signs
• Remember the Criteria Severity and chance of
  survival

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• EXERCISE-2
• Make a choice / select one person for
• Immediate help /resuscitation transfer
• A young man with Haemopneumothorax
• vs
• A young man with compound Fracture tibia and
  
• fibula
• Mind that both are-priority one cases But
• Remember the Criteria Severity and chance of
  survival

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• EXERCISE-3
• select one person for Immediate
  esuscitation transfer
• young man with head and neck and chest injury
  and coma vs
• A young man with absent femoral artery
  pulsation and bluish discoloration on lower
  abdominal wall, conscious and stable
• Traveling distance is of 2 hours
• Think - how much is chance for survival

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• EXERCISE-4
• A young officer, victim of a terrorist attack on
  GHQ is
• brought to trauma ctr.
• First look /exam.
• He has visible 1-2 cm size wounds on fore
  head, face
• and right arm. His clothes are grossly stained
  with
• blood. Has tachycardia. Blood pressure is
  normal.
• Very caring staff immediately attends and
  treat.
• Mean while 5-6 more injured persons are
  brought, they are crying with pain and need
  attention.
• Officer cont to c/o pain and points
  to
• Right lower chest area

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• A senior doctor comes and inquires
• Staff reports
• His condition is stable
• Emergency treatment/analgesia given
• What should you do ?
• Feel satisfied OR else ?
• Resurvey

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• Triage
• Primary survey resuscitation
• ?

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PRINCIPLES OF MANAGEMENT

• Evacuation /Transportation

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PRINCIPLES OF MANAGEMENT

• 3- Secondary survey
• At the trauma ctr/hospital

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PRINCIPLES OF MANAGEMENT

• 3- Secondary survey
• History
• Physical Exam
• Laboratory Tests
• X-rays
• Special Surgical Procedures
• Monitoring of Resuscitation
• Consultation and Disposition

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• 3- Secondary survey
• Decision for surgical intervention
• Damage control surgery

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CONCLUSION MASS EMERGENCY MANAGEMENT

• Resources are limited
• Aim is to save maximum number of cases
• we have to be Selective
• Rationalize the use of resources for the
• best deserving
• So- Choose
• Those with serious but a treatable condition
• and treat expeditiously
• Important for all doctors to attain an
  appropriate level of education and training in
  the unique principles and practice of mass
  casualty management, and to serve as role models
  in this field.

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Thank you
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DAMAGE CONTROLE SURGERY

• Head Injury
• General Approach Establish diagnosis, Assessment
• Stabilization
• Skull Fractures
• Epidural Hematoma
• Subdural Hematoma
• Cerebral Contusion
• Parenchymal Hemorrhage
• Penetrating Injury
• Neck and Airway Trauma
• General Approach Establish diagnosis, Assessment
• Indications for Intubation
• Laryngeal Injury
• Airway Burn
• Facial Trauma
• C-spine Injury
• Chest Trauma
• Approach to the Chest Establish diagnosis,
  Assessment
• Myocardial Contusion

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References

• Mass Casualty Management Systems Strategies and
  guidelines for building health sector capacity by
  WHO.
• Major incident/mass casualty plan general plan
  and generic response for the Lincolnshire health
  community In managing major/mass casualty
  incidents February 2005
• ST-42 Statement on disaster and mass casualty
  management
• by the American College of SurgeonsThe
  statement was developed by the College's Ad Hoc
  Committee on Disaster and Mass Casualty
  Management of the Committee on Trauma, and was
  approved by the Board of Regents at its June 2003
  meeting.
• REVIEW ARTICLE MK Joshipura, HS Shah, PR Patel,
  PA Divatia Trauma care systems in India - An
  overview2004 Volume 8 Issue 2
  Page 93-97

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Conclusion

• The management of mass casualties is only one of
  many critical functions
• involved in the overall response to a disaster.
• Education training and rehearsal are especially
  important
• Disaster planning and Integration of local,
  regional, and national levels .
• Hospital Emergency Incident Command Systems
  (HEICS).
• Communications and security.
• Media relations.
• Protection of health care delivery personnel and
  facilities.
• Detection and decontamination of biological,
  chemical, and radiation exposure.
• Triage principles and implementation.
• Logistics of medical evaluation, stabilization,
  disposition, and treatment of victims.
• Record-keeping and postdisaster debriefing,
  critique, and reporting.
• Critical incident stress management (CISM).
• Published research and experience in disaster
  management.