Treatment of injuries in catastrophes

Béla TurchányiBéla TurchányiHead of Trauma and Hand DepartmentHead of Trauma and Hand Department

Debrecen UniversityDebrecen University

Individual treatment?-Mass treatment?

• Individual treatment = dg-th in order of arrival /?/• Mass-treatment = disproportional

between number of patient – treatment providers

» Does not depend on quantity-quality!

• Can be resolved with local forces

• HAS (hungarian ambulance service): number of injured ≥ 5 = mass injury

» Severe? Minor?

Combined injuriesCombined injuriesOne patient One patient

One time One time

Injuries of different origins and Injuries of different origins and

mechanismsmechanisms( eg. mechanical, thermic, chemical, radiationeg. mechanical, thermic, chemical, radiation)

Catastrophe treatment=

Mass treatment is not possible with local forces

T 1 Severe, life-threatening immediate treatmentT 1 Severe, life-threatening immediate treatment

T 2 Serious, delayable treatmentT 2 Serious, delayable treatment

T 3 Minor injuriesT 3 Minor injuries

T 4 Moribund groupT 4 Moribund group

Napoleon’s Head surgeon, Dominique Larray

Military Triage categories:

• medical service on the basis of a hierarchy•company / regiment medical station - mobile camp hospitals

• Corpsmen began treatment on the battlefield

Approach to categorization in WWII:

Introduction of rapid rescue:

• Korean air rescue, •stretcher attached to the outside of the helicopter

• Vietnam rapid air transport

Korean and Vietnam Wars

• World war II 4.7 %

• Vietnam 1.0 %

Mortality rate(USA data)

• World war II 12-18 hours

• Korean war 2- 4 hours

• Vietnam < 2 hours

Time until treatment(USA data)

"The result of a vast ecological breakdown in the relations between man and his environment, a serious and sudden (or slow, as in drought) disruption on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.„ WHO

Disaster Disaster

Technological and medical aid !!!

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Disasters

NaturalNatural

• Meteorological

(storms, tornados, avalanche)• Earthquake• Landslide• Volcanic eruption• Flood

• Revolution, affair, violence

• Wars (with conventional weapons)• Escaping mass, panic• Mass accidents• Terrorism• industrial

Human

Epidemics11

Disasters, mass injuries

- Terrestrial

- Aviation

- Nautical

- Explosion

- Fire in buildings, hotels

- Radioactivity

- Gas intoxication- Terrorism- Intoxication

Traffic accidentsTraffic accidents

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The last years disasters estonished people

indepedently if it had been natural or civilization

• New York• Haiti• Indonesia• ChinaChina• JapanJapan

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Oct. 04. 2009.

1 400 000 m3 red mad

10 Death More than 200 injured 38 000 000 000 Ft ˂ loss

• Catastrophe is like radiation injury, • first we estimate• later we know

–how large it was.

Rate of demolition, number of victims

World wide comprehensive planning

In the healthcare:Personal: doctors, nurses, assistants

Institutions: in organization

Preparedness

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Limitation in disaster managementLimitation in disaster management

Lack of information

unpreparedness

disorder

Insufficient personal and material background

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- plan!

- prepare!

-control!

-be ready!

- practice!

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Number of injured peopleUncertainty

LowLow < 50 Local forces

50 < Middle < 150 Regional forces

High> 150150 National or international forces

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Extra > 1000 International aid

In disaster

Number of injured people is highNumber of injured people is high

But not everey mass injury is disaster

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Catastrophy treatmentCatastrophy treatment

Catastrophic treatment

≠≠

AIM:AIM:

Do the absolute most for Do the absolute most for the absolutely most needythe absolutely most needy

We are forced to compromise

In the examination of the victim in the field

In the preparation for transport

In the choice of transport vehicle

In the method of treatment

( because of the large discrepancy between the numbers because of the large discrepancy between the numbers of injured and care providersof injured and care providers)

Primary questions:

• What happened ???

• Utilities?

• Provision of energy?

• Communication?

• Access?

• Health care institutions?

• Storage facilities?

FogadótérReception area

Classification areaClassification area

Treatment areaTreatment area

Site /safety of care providers?/

Rescue:Fire Department

PoliceCatastrophe defense

Military

Lay downLay down

casualtiescasualties

OrganizationOrganization( with the guidance of an experienced doctor)

On the accident site (together with the rescue team)

- in classification- in preparation for transport- in choice of transport vehicle

At the primary treatment location

At the final treatment location

Treatment of Group injuries

Compromiseexamination, diagnostics

Uniform treatment principles

3TTriage

Transport

Treatment

Similarities in treatment of mass accidents and catastrophies

1. Organized, methodical rescue

2. Compromise

3. Uniform treatment principles

Appropriate victimAppropriate victim

Appropriate time frameAppropriate time frame

Appropriate placementAppropriate placement

3 A

Classification(triage) is a

continual process, all

alterations can cause its

continual change.

Continuous re-evaluation

is necessary.

Why classify?Why classify? Because:

- many victims are in need of care at once

- few personel are available

- field aid is not appropriate

How long do we classify?

- until the possibility for individual diagnosis and treatment arises…

Victims can only enter

the treatment system

following prior

classification!

Victims can only enter

the treatment system

following prior

classification!

Execution of classificationExecution of classification

How: Depending on the situation and location

When: Continually and dynamically changing

Where: In a previously determined classification area

Whom: Everyone!!

Who: A doctor or paramedic experienced in classification

Classification time2 - 4 minutes

diagnosis

Designation of treatment area

Basic documentation

I. priority: Immediate care (red)

II. priority: Delayed urgent care (yellow)

III. priority: Minor delayed care (green)

IV. priority: Dead or mortally

Classification categories of catastrophe victims:

Chance for survival in %

time between accident & resustitation (min)

Abbreviated Injury Scale

• The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in 1969.

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AIS Score Injury

1 Minor

2 Moderate

3 Serious

4 Severe

5 Critical

6 Unsurvivable

Organ Injury Scales of the American Association for the Surgery of Trauma.

 

Injury Severity Score

• The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score.

• Head,• Face, • Chest, • Abdomen, • Extremities (including Pelvis),• External (skin).

• The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity.

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AIS Score Injury

1 Minor

2 Moderate

3 Serious

4 Severe

5 Critical

6 Unsurvivable

Example

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• Cerebral contusion (3 - 4 )

• HPTX with serial rib fx (3 – 4 )

• Pelvic ring Type A fracture (2)

• Wrist fracture (2)

• Contusions and abrasions (1)

ISS ═ 9 + 9 + 4 ═ 22 ( 36)

(polytrauma ═ ISS > 18

AIS Score Injury

1 Minor

2 Moderate

3 Serious

4 Severe

5 Critical

6 Unsurvivable

Polytrauma

Severe injury of two or more organ systems, when at least one of them or the combination is life threatening.

(Tscherne)(Tscherne)

ISS above 18ISS above 18

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Age ISS value

 15-40 40

45-64 29

65-< 20

Age ISS value

 15-40 40

45-64 29

65-< 20

Relationship between a 50 % risk of mortality and ISS

Relationship between a 50 % risk of mortality and ISS

Glasgow Coma Score • Best Eye Response. (4) • No eye opening 1 • Eye opening to pain. 2 • Eye opening to verbal command. 3 • Eyes open spontaneously. 4

• Best Verbal Response. (5) • No verbal response 1• Incomprehensible sounds. 2• Inappropriate words. 3• Confused 4• Orientated 5

• Best Motor Response. (6) • No motor response. 1• Extension to pain. 2• Flexion to pain. 3• Withdrawal from pain. 4• Localising pain. 5• Obeys Commands. 6

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Revised Trauma Score The Revised Trauma Score is a physiological scoring system, with high inter-rater reliability and demonstrated accurracy in

predictng death. It is scored from the first set of data obtained on the patient, and consists of GCS, Systolic Blood Pressure and

Respiratory Rate.

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Mangled Extremity Severity Score (MESS)

• - from Johansen et.al. 1990 - anatomical & functional Skeletal / soft-tissue injury      Low energy (stab; simple fracture; pistol gunshot wound):  1      Medium energy (open or multiple fractures, dislocation):  2      High energy (high speed MVA or rifle GSW):  3      Very high energy (high speed trauma + gross contamination):  4 Limb ischemia      Pulse reduced or absent but perfusion normal:  1*      Pulseless; paresthesias, diminished capillary refill:  2*      Cool, paralyzed, insensate, numb:  3* Shock      Systolic BP always > 90 mm Hg:  0      Hypotensive transiently: 1      Persistent hypotension:  2 Age (years)      < 30:  0      30-50: 1      > 50:  2

* Score doubled for ischemia > 6 hours

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• MESS ˂ 6 chance for limb salvage

MESS = 5

• MESS > 7 consider amputation

• MESS = 10

Compromise

Medical forcesMedical forces

Technical supportTechnical support

Number of injured peopleNumber of injured people

Technical requirementsTechnical requirements

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Rapid Assesment

• Skin colour• Carotid pulse palpable (systolic blood

pressure>60 mm Hg)• Femoral pulse palpable (syst. blood

pressure>70 mm Hg)• Radial pulse palpable (syst. blood pressure>80

mm Hg)

Changes in the central venous pressure are more important than individual measurements!

Primary survey and resuscitation• Airway and cervical spine control

• Breathing

• Circulation and hemorrhage control

• Dysfunction of central nervous system

• Exposure

• Secondary survey• Definitive management (DCS)

Bleeding control!

CACBCD stammering ABC

Prevention of death can only occur with

rapid professional care,

Substitutional treatment is necessary

during time of examination.

I.Priority: Immediate emergency

II. Priority: delayed urgent care II. Priority: delayed urgent care

possibility of bleeding

organ injuries

spinal cord injuries

facial and eye injuries

extensive, mangled limb injuries

stabilized polytrauma

III. Priority: minor injuryIII. Priority: minor injury

- not life-threatening injuries

- smaller soft-tissue injuries

-closed fractures

- not dangerous functional disturbances

probablilty of survival even with

optimal care is unlikely

should be separated from the rest of the

injured

cannot leave them alone

observation is done by less care takers

IV. Moribund group

Grouping of victims according to classification

Necessity of shock treatment Necessity of shock treatment 10-20 %10-20 %

Undelayable operative treatment Undelayable operative treatment 25-50 %25-50 %

Intensive care Intensive care 10-20 % 10-20 %

Delayable treatment, placing in ward Delayable treatment, placing in ward 20-40 %20-40 %

Minorly injuredMinorly injured 30-40 %30-40 %

Pediatric victims Pediatric victims 10-20 %10-20 %

Triage categories in emergency treatment

• 1. immediate care – GCS ≤ 12– polytrauma, – shock, – Chest injury with respiratory insufficiency

Triage categories in emergency treatment

• 2. critical, not delayable medical examination within 15 minutes – Unstable chest– Progresszive mental disturbances– Uncertain abdominal injury, with unstable

circulation– Open fracture/bleeding wound– Fracture or luxation with large dislocation,

circulatory deficiency or possiblity of nerve damage

Triage categories in emergeny treatment

• 3. rapid, medical examination within 30-40 minutes – Child injured under 8 years of age– Hip fracture– Fracture of long bones– Open wounds without significant bleeding– Head injury GCS ≥ 14– Under influence of alcohol but not unconscious

head injury

Triage categories in emergency treatment

• 4. minor, medical examination within 2-3 hours - Closed fracture in wrist or ankle region

without significant dislocation- fractures distal to wrist and ankle - contusions- superficial, banal wounds

Triage categories in emergency treatment

• 5. delayable, when their turn arrives – Closed injuries of several days with a good soft

tissue cover– Patients called for follow-up…– Non-accident limb complaints without circulatory or

nerve disturbances

Primary tasks:Primary tasks: laying, resting

airways

stop bleeding

pain control

thermal protection

clothing

Primary medical tasks:Primary medical tasks:breathing airways

breathing supportventilation

circulation bleeding control /bandage

fluid replacementinfusion

Stabilization immobilizationfracture fixationthermal protectionmental guidance

Path of patients in hospital

triagetriage

Staff/work stationStaff/work station

Triage 1 doctor, 1 assistant, 1 administrator

Shock room  3 - 5 injured 1 trauma workgroup

OP 1 work group/OP

Ambulances 1 doctor,  2 nurses

Suturing room1 doctor, 2 asstintants

Plastering room 1 doctor, 1 assistant

Exact documentation!

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OP teamOP team

1 chief surgeon (Trauam surgeon, orthopedic surgeon, general surgeon, etc)

1 anaesthesiologist

1 anaesth. assistant

1 - 3 assistant doctor

1- 2 nurses

2 OP aid

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Instruments for patient examination (light stethoscope, blood pressure monitor, reflex hammer, pupil light, basic instruments ) Transport beds, wheelchairsRegister book, booklet, dermographInstruments for reanimationPossibility for preparation of urgent bandagingOutside: cover, tent, indicators for cars

Instruments for patient examination (light stethoscope, blood pressure monitor, reflex hammer, pupil light, basic instruments ) Transport beds, wheelchairsRegister book, booklet, dermographInstruments for reanimationPossibility for preparation of urgent bandagingOutside: cover, tent, indicators for cars

Minimal equipment of triage area:Minimal equipment of triage area:

Time-table in the place of definitive tretmentTime-table in the place of definitive tretment

- Orientational physical examination,

undressing of patient 3-5 min

- Life-saving interventions, intubation op. ven. & bt. 3-6 min

- Continual preparation of basic documentation 3-6 min

- Necessary instrumental examinations:

ECG, X-RAY, UH, CT 30 min

- Start of undelayable surgical interventions max. 1 hour

Visceral operations

Head injuries

Progressive spine injuries

Eye, maxillofacial injuries

Limb injuries: fractures with damage to large vessels open joint injuries open extensive soft tissue injuries compartment syndrome unstable spine fracture of the pelvic ring

Priority of primary surgery following stabilization of circulation

Priority of primary surgery following stabilization of circulation

1. Life-threatening injuries

2. Not life-threatening, but limb-threatening injury

3. Is the injury treatable in a short time span

4. treatment is usually performed in a centrifugal direction.

5. limb treatment is not performed if ISS is over 30

6. MESS (mangled extremity score) can aid in indication

for amputation ( > 7) 7. treatment of open injuries in treatment of open injuries in two stagestwo stages

8. treatment of fractures = EF8. treatment of fractures = EF

Determination of priority in treatment of limb injuriesDetermination of priority in treatment of limb injuries

Tasks for police in mass Tasks for police in mass accidentsaccidents

Tasks for police in mass Tasks for police in mass accidentsaccidents

• Provide accessibility of roads

• Create and uphold possibilites of transport

• Creation of possibility of mobility of medical team

• Aid in the deployment of instrumental infrastructure

• Provision of continual transport in the rescue-treament process

• Provide accessibility of roads

• Create and uphold possibilites of transport

• Creation of possibility of mobility of medical team

• Aid in the deployment of instrumental infrastructure

• Provision of continual transport in the rescue-treament process

1997-year CLIV medical law1997-year CLIV medical law

230.§ (1) Medical attendance in disaster – state aided assigment

230.§ (2) Preparation and execution

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Degree of alarm in our institute(Kenézy Gyula Hospital. Debrecen Plan for Civil Protection)

II. degree. degree 20 vicitims20 vicitims Traumatology departmentTraumatology department

IIII. degree. degree 20 - 40 vicitims20 - 40 vicitims Hospital organizationHospital organization

IIIIII. degree. degree > 40 vicitims> 40 vicitims Inclusion of outside helpInclusion of outside help

The characteristics of the injuries, degree of severity, necessity of treatment can alter the degree of alarm accordingly.

Take home massage

• The key to success is: training and guidanceThe key to success is: training and guidance

• Civil and military cooperationCivil and military cooperation

• Triage, transport, treatmentTriage, transport, treatment, 3 R, 3 R

• special /individual treatment is „a luxury”special /individual treatment is „a luxury”

• Life saving & DCSLife saving & DCS

• Wounds should not closedWounds should not closed primarily primarily

• FE for fracture stabilization FE for fracture stabilization

Thank you for your attention!