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Agenda. Emergency Preparedness Probabilities / HVA’s and Threats Active Shooting Bombing / Blast Injuries Emerging & Re-emerging Infectious Diseases Medical Surge Discussion GAPS. Storms are still the biggest threat!. FY 2014 Preparedness Plan. Potential Probability vs. Impact.
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Agenda • Emergency Preparedness • Probabilities / HVA’s and Threats • Active Shooting • Bombing / Blast Injuries • Emerging & Re-emerging Infectious Diseases • Medical Surge • Discussion GAPS
Storms are still the biggest threat! DRS 2007
Potential Probability vs. Impact BIOLOGICAL AGENT NUCLEAR WEAPON IMPROVISED NUCLEAR DEVICE CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL POTENTIAL IMPACT RADIOACTIVE MATERIAL PROBABILITY/LIKELIHOOD
The Threat • “Why hunt tigers when there are so many sheep” – from al Qaeda training manual captured in Afghanistan
Primary Attack Location of 140 Active Shooter Incidents from 2000 to 2014
Active Shooter Hazard Zones • Hot Zone: Unsecured area where threat remains active. Law enforcement (LE) responsible for neutralizing shooter(s). • Warm Zone: Area swept for immediate threats. LE provides force protection for medical personnel responding in this zone • Cold Zone: Secured area outside of immediate threat. This is the personnel standby zone.
THREAT • T - Threat suppression • H - Hemorrhage control • RE - Rapid Extrication to safety • A - Assessment by medical providers • T - Transport to definitive care
Skewed Priorities • U.S. schools extensively guard against fire: –Fire drills –Sprinkler systems –Building codes, etc. • Yet not one child has died from fire in any U.S. school in over 25 years (excluding dorm fires). • Well over 200 deaths have occurred by active shooters in the same period here. • But training and preparation for these events meets with stiff resistance and denial
Response Issues • Remember that there is a difference between “law enforcement on scene” and “scene is secure”. • Fire and EMS should remain in staging areas until the scene is secured by law enforcement when possible. This process may take several hours.
EMS response issues • EMS may need to utilize “scoop and scoot” and “load and go” from the incident.
Most Common Fatal Injuries • Major Hemorrhage: commonly known as blood loss • Tension Pneumothorax: improper breathing due to sustained chest trauma • Airway Obstruction :physical blockage or trauma of the respiratory airway
Physical Results of an Explosion Imagine this apple as an arm, leg, or torso struck by shrapnel.
Objectives • Explain various types of explosive devices • Describe physical elements of blast / explosion events • Discuss physiological effects of blast / explosion events • Address potential injuries associated with bomb / blast events
Definitions • Explosives: • A chemical material capable of very rapid burning and production of high volumes of heated gases • Shrapnel: • Small fragments of material (usually from a bomb casing or other container) thrown away from an explosion at high velocities • Shock / Blast Wave: • A wave of pressure resulting from an explosion; travels in excess of 700mph
Definitions • TBI or MTBI • Traumatic Brain Injury or Mild Traumatic Brain Injury • TM • Tympanic Membrane – damage to TM results in hearing loss
Types of Explosives / Bombs • Truck / Car Bombs • Vehicle loaded with explosives • Driver usually committed to mission / suicide • Vehicle adds to shrapnel damage • Can result in large scale explosions based on explosive cargo
Types of Explosives / Bombs • Suicide / Homicide Bombs • Strapped to body of individual • Usually covered with heavy clothing • Can also appear as a suitcase, briefcase, or backpack • Activated either by remote control or a hand-held switch • To increase injuries, some bombs also include: • Bolts, nuts, or washers • Nails or screws • Other metals to add shrapnel
Terrorist Use of Explosives • Most post-9/11 terrorist events have involved: • Car or truck bombs • Emergency vehicles or others disguised as normal traffic in the area • Large amounts of explosives
Bomb / Blast Injuries Four categories of injuries: • Primary • Secondary • Tertiary • Quaternary
Bomb / Blast Injuries • Lung Injury • Direct result from shock wave impact • Most common fatal injury • Usually present at initial triage • Can present up to 48 hours later • Eye Injury • 10% of all survivors will have significant eye injuries • Will involve perforations from projectiles • Can present for care days, weeks, or months after event
Bomb / Blast Injuries • EarInjury • Easily overlooked • Signs of injury are usually present at initial triage • Blast injuries to auditory system cause significant fatalities • Injury dependant on orientation of the ear to the blast • TM perforation is most common • Should be suspected for patients complaining of: • Hearing loss, tinnitus (ringing ears) or otalgia (ear pain) • Vertigo or bleeding from external canal, • TM rupture or mucopurulent otorhea (mucus discharge)
Bomb / Blast Injuries • Abdominal Injury • Gas containing sections of GI tract are most vulnerable • Can cause: • Immediate bowel perforation & solid organ lacerations • Hemorrhage & mesenteric shear injuries • Testicular rupture • Suspect in patients presenting with: • Abdominal pain, nausea & vomiting • Hematemisis (bloody vomit), rectal pain or tenesmus & testicular pain • Unexplained hypovolemia (decrease in blood volume) or anything indicating an acute abdomen
Bomb / Blast Injuries • Brain Injury • Blast / shock waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head • Consider proximity of victim to the blast given complaints / observations of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms
Bomb / Blast Injuries • Other Common Injuries • Sprains / Strains from attempting to escape, falling, being thrown or pushed down by force, or from carrying other victims • Scraping against debris or sharp objects can cause lacerations, wounds usually require thorough cleaning
New Realities • Blast injuries no longer confined to military battlefields • Should be considered for any victim exposed to an explosive force • Wounds can be grossly contaminated • Consider careful decontamination, delayed primary closure, and assess tetanus status • Close follow-up of wounds; head, eye, and ear injuries; and stress related complaints
Surge Capacity Needs • 50% of survivors will present at ED for treatment within 1 hour of event • Remainder will present within next 6 hours • Rapid surge capacity response needed to handle patient volume Source: CDC website
Medical Management Options • Penetrating & blunt trauma injuries are most common • Highest mortality is primary blast lung & abdomen injuries • Blast Lung is most common fatal injury in initial survivors
Medical Management Options • “Blast Lung” presents soon after exposure • Confirmed by finding a “butterfly” pattern on X-ray • Prophylactic chest tubes recommended prior to general anesthesia and / or air transport • Air embolism is common • Can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication (limping) • Hyperbaric oxygen therapy effective in some cases
Medical Management Options • Clinical signs of blast-related abdominal injuries: • Are initially silent • Can be missed until acute abdomen or sepsis are advanced • Traumatic amputation of any limb indicates potential for multi-system injuries
Medical Management Options • Compartment syndrome, rhabdomyolysis (muscle tissue breakdown), and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings • Always consider possibility of exposure to inhaled toxins and poisons
Medical Management Options • Auditory system injuries are often overlooked • Symptoms of mild TBI and post-traumatic stress disorder can be identical • Isolated TM rupture is usually non-fatal
Medical Management Options • Communications with patients may need to be written due to tinnitus and sudden temporary or permanent deafness
