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Treatment of injuries in catastrophes
Béla TurchányiBéla TurchányiHead of Trauma and Hand DepartmentHead of Trauma and Hand Department
Debrecen UniversityDebrecen University
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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?
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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)
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Catastrophe treatment=
Mass treatment is not possible with local forces
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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:
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• 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:
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Introduction of rapid rescue:
• Korean air rescue, •stretcher attached to the outside of the helicopter
• Vietnam rapid air transport
Korean and Vietnam Wars
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• World war II 4.7 %
• Vietnam 1.0 %
Mortality rate(USA data)
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• World war II 12-18 hours
• Korean war 2- 4 hours
• Vietnam < 2 hours
Time until treatment(USA data)
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"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
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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
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10 Death More than 200 injured 38 000 000 000 Ft ˂ loss
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• Catastrophe is like radiation injury, • first we estimate• later we know
–how large it was.
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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
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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
≠≠
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AIM:AIM:
Do the absolute most for Do the absolute most for the absolutely most needythe absolutely most needy
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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)
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Primary questions:
• What happened ???
• Utilities?
• Provision of energy?
• Communication?
• Access?
• Health care institutions?
• Storage facilities?
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FogadótérReception area
Classification areaClassification area
Treatment areaTreatment area
Site /safety of care providers?/
Rescue:Fire Department
PoliceCatastrophe defense
Military
Lay downLay down
casualtiescasualties
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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
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Treatment of Group injuries
Compromiseexamination, diagnostics
Uniform treatment principles
3TTriage
Transport
Treatment
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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
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Classification(triage) is a
continual process, all
alterations can cause its
continual change.
Continuous re-evaluation
is necessary.
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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…
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Victims can only enter
the treatment system
following prior
classification!
Victims can only enter
the treatment system
following prior
classification!
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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
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Classification time2 - 4 minutes
diagnosis
Designation of treatment area
Basic documentation
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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:
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Chance for survival in %
time between accident & resustitation (min)
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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.
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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
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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
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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
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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
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• MESS > 7 consider amputation
• MESS = 10
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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!
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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
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Prevention of death can only occur with
rapid professional care,
Substitutional treatment is necessary
during time of examination.
I.Priority: Immediate emergency
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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
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III. Priority: minor injuryIII. Priority: minor injury
- not life-threatening injuries
- smaller soft-tissue injuries
-closed fractures
- not dangerous functional disturbances
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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
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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 %
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Triage categories in emergency treatment
• 1. immediate care – GCS ≤ 12– polytrauma, – shock, – Chest injury with respiratory insufficiency
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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
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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
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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
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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
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Primary tasks:Primary tasks: laying, resting
airways
stop bleeding
pain control
thermal protection
clothing
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Primary medical tasks:Primary medical tasks:breathing airways
breathing supportventilation
circulation bleeding control /bandage
fluid replacementinfusion
Stabilization immobilizationfracture fixationthermal protectionmental guidance
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Path of patients in hospital
triagetriage
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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:
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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
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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
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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
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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
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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.
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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
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Thank you for your attention!
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