MANAGEMENT OF MASS SURGICAL EMERGENCIES

1. MANAGEMENT OF MASS SURGICAL EMERGENCIES By; Col. Abrar Hussain Zaidi

2. SEQUENCE • INTRODUCTION / back ground • PRINCIPLES OF MANAGEMENT >TRAUMA CARE SYSTEM

3. Your view ?

4. 1-INTRODUCTION

5. 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

6. INTRODUCTION Primary considerations ‘Life’ and ‘quality of life’

7. INTRODUCTION What constitutes Mass surgical causalities Or emergencies ?

8. 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.

9. 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.

10. INTRODUCTION Major Incidents of recent past >9/11 >Kashmir earth quake >Frequent bomb blasts

14. 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

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

16. 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

17. 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

18. INTRODUCTION Special Ground situations Civilian vs. Army Mixed

19. INTRODUCTION Nature of mass surgical emergencies Most of the mass surgical emergencies are Traumatic in nature >Physical Mechanical-RTA Fire/heat - burns Fire arm injuries –Wars/terrorisms >Chemical >Others

20. INTRODUCTION AIMS OF MANAGEMENT Minimize human mortality and morbidity with Best use of available resources and expertise

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

22. How to achieve the goals--?

23. 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’

24. 2-PRINCIPLES OF MANAGEMENT Differences from ordinary trauma management-- ? One casualty vs tens reporting simultaneously

25. 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

26. 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

27. 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.

28. PRINCIPLES OF MANAGEMENT >Stresson a uniform approach of management >Developed with common consensus of world bodies -ATLS -PTC -BlS -Others

29. 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

30. 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

31. 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]

32. 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

33. 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

34. PRINCIPLES OF MANAGEMENT WHO GUID LINES Disaster planning [preparedness] • Local • Regional • National

35. PRINCIPLES OF MANAGEMENT ‘Trauma care system’ Regional Mass Casualty Support Units

36. 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 responsibilitiesto individuals and organizations. • Management structureconcerning the command of individual organizations and control across organizations. • Systemsdevelopment -actual medical aid for specific response and recovery. • Documentation: The written emergency plan w

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. PRINCIPLES OF MANAGEMENT 1-Triage Proirity-4 / Expectant- where out come is gloomy – severe head injury, spinal cord injury

44. PRINCIPLES OF MANAGEMENT 1-Triage –points to remember • It is primarily based on quick and orderly primary survey • It’s 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

45. 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

46. 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

47. PRINCIPLES OF MANAGEMENT 2-Primary survey & Resuscitation Quick appraisal : >what the person is suffering from >Is there an acute but treatable problem >What immediate measures are required >Does he need immediate shifting to OT

48. 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

49. 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.

50. 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.