Disaster Medicine: Impact on Critical Care Operations

Chapter 74 Disaster Medicine


Impact On Critical Care Operations



John R. Benjamin, MD, MSc , Edward E. George, MD, PhD


Disaster medicine encompasses extraordinarily wide and disparate scenarios. Despite the heterogeneity of scope and nature, many components are common to virtually all situations. The impact on health care resources at all levels of care most often requires adjusting the routine manner(s) of delivering care in response to these challenges. Better appreciation of the generic components of disaster medicine may help individuals involved in critical care medicine prepare and optimize response to these challenging situations.




1 What are the two general categories of disasters?


Natural and manmade



2 What are the most commonly encountered disasters?


Hurricanes, earthquakes, industrial accidents, acts of terror



3 How does the public health sector plan for disaster medicine–related events?


The Department of Homeland Security (DHS) in conjunction with the Department of Health and Human Services (HHS) bears a prominent role in the National Response Plans of the federal government. In the National Preparedness Guidelines issued by the DHS are listed 15 National Planning Scenarios (Box 74-1).



Box 74-1 United States National Planning Scenarios




Improvised nuclear device


Aerosol anthrax


Pandemic influenza


Plague


Blister agent


Toxic industrial chemicals


Nerve agent


Chlorine tank explosion


Major earthquake


Major hurricane


Radiological dispersal device


Improvised explosive device


Food contamination


Foreign animal disease


Cyber attack


From Department of Homeland Security: National Preparedness Guidelines September 2007: www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf.


In reviewing the various situations listed by government agencies exercising oversight for the public welfare, it is apparent that many of the envisioned scenarios could or would result in victims requiring medical care in facilities ranging in echelon from community hospitals to tertiary-level academic institutions.


For a comprehensive discussion of disaster planning from the level of the federal government please refer to the National Preparedness Guidelines website: www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf.



4 What mechanisms are commonly employed in acts of terror?


Explosives, chemical agents, biologic agents



5 What are common categories of injuries encountered in the disaster victim?




image Burns


image Crush


image Fractures


image Cardiopulmonary: Commonly seen with inhalation agents such as mustard or blistering agents causing both a direct insult to pulmonary tissue(s) and indirect as a result of marked pulmonary edema with potential compromise of cardiac function.


image Systemic (biologics or chemicals): Infectious agents, such as anthrax and smallpox, present obvious systemic effects, with an appreciable delay between exposure and manifestation of systems, thereby presenting a further challenge in timely therapy. Chemical agents (e.g., cyanide) with direct effects on cellular respiration and nerve gases (e.g., sarin) by inhibition of acetylcholinesterase exhibit systemic effects ranging from respiratory collapse to paralysis.



6 What are the four phases of disaster response?


See Table 74-1.



Table 74-1 Four Phases of Disaster Response

image

Personnel responding to disasters vary in training and experience, in part as a function of the phase of response. After the chaotic component, initial response is almost exclusively local personnel. Specifically police, fire, and emergency medical assets (emergency medical technicians and paramedics) will be the first trained personnel arriving at the scene. As on-scene assessments are conducted and contingency plans engaged, the process of bringing additional specially trained personnel and equipment into the area and establishing a coordinated process of command and control for triage and evacuation relies more heavily on teams trained in the management of disaster scenes, as well as coordination with evacuation centers. Training and exercise for such contingencies are ongoing at the municipal, state, and federal level with guidance and oversight provided by numerous federal agencies to include the Federal Emergency Management Agency, as well as the DHS and HHS. With training directed and coordinated at the national level, personnel from every tier of the response system benefit from understanding the overall approach to a specific disaster, as well as expectations and capabilities of support at and from all levels.



7 What are the four categories of blast injury?




image Primary: Injuries resulting from the overpressurization wave that affects gas-filled structures such as the lungs, gastrointestinal tract, and middle ear


image Secondary: Injuries resulting from flying debris affecting any body part


image Tertiary: Resultant injuries from personnel being thrown by the blast wind


image Quaternary: Exacerbations from existing conditions (i.e., chronic obstructive pulmonary disease exacerbations, myocardial infarctions) or complications from blast injuries (i.e., burns, crush injuries, closed head injuries)



8 Describe blast lung.




image Lung injury is a result of a blast wave passing through lung tissue, causing tissue disruption at the capillary-alveolar interface. Effectively a pulmonary contusion caused by the traversing of a shock wave (associated with a blast) through the various structures of the lung, the process can be magnified as a result of the blast occurring in a confined structure thereby magnifying the effect with the pressure wave rebounding from the walls, floor, and ceiling. This type of injury may be mimicked by a shotgun blast to the thorax; however, injuries associated with high-velocity projectiles and knives do not present a similar pattern of injury.


image Blast lung is clinically diagnosed by the presence of respiratory distress, hypoxia, and butterfly or batwing infiltrates (perihilar infiltrates caused by the reflection of the blast wave of mediastinal structures).


image If patients require mechanical ventilation, the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol is appropriate.

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Disaster Medicine: Impact on Critical Care Operations

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