Title: The Rhode Island Nightclub Fire One Hospitals
1The Rhode Island Nightclub FireOne Hospitals
Response
- Michael Dacey, M.D.
- Director, Intensive Care Unit
- Kent Hospital
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3Outline
- History of nightclub fires
- Timeline of events
- Types of injuries
- Triage issues
- Communication issues
- Airway management
- Lessons learned
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6History
- 1942 --- Cocoanut Grove nightclub fire in Boston
- 491 victims died
- Many died from smoke inhalation alone and CO
toxicity - 1979 --- MGM Grand hotel fire in Las Vegas
- 84 died, many from CO intoxication at the scene
- 1981 --- Stardust Nightclub fire in Dublin
- 48 died
- Scene meticulously reconstructed
7Dublin Reconstruction
- Visibility reduced to less than 1 meter
- Ambient temperatures can reach 1160 degrees C
(2120 F) - Oxygen reduced to less than 2
- CO increased to greater than 3
- HCN 250 ppm
- HCl 8500 ppm
8Timeline
- 2230 first notification to hospital of fire
- 2245 told it was a gas station fire
- 2255 no wait, its the station nightclub
- 2300 two of our MDs at scene and call disaster
code (but not the right one) - 2310 first patients arrive via POV
- 2315 first EMS transports arrive
- 2340 first of 4 helicopters land at hospital
9Timeline cont.
- 2345-0130 most critically injured arrive
- 2345-0130 least severely injured arrive (POV)
- 2400-0300 stabilization of critically injured
- 0130-0400 EMS delivers less severely injured
- 0400 most dispositions made
10Types of Injuries
- First 6 were in coma
- 21 required intubation
- Severity of burns varied but of the initial 25
patients, most had 2nd and 3rd degree on face,
hands and trunk - CO intoxication in 19 4 patients
- 4 with broken ribs, no other Fx.
- Only 8 had blood ETOH levels gt0.10
11Internal Set-up Plan
- E.R. (65K per year, built for 30K) most
seriously injured - E.R. Waiting room and radiology (adjacent) less
serious patients - Families sent to cafeteria some distance away
- Admissions to Recovery room O.R. as 15 ICU beds
already full
12Equipment Shortages
- Ventilators
- Suction tubing set-up for ventilators
- Central lines (most with hand/arm burns)
- Large volume IV tubing (too many micro-drip sets)
- Laryngoscope blades (disposable?)
- Lactated Ringers solution (had just enough)
- AVG volume 6 liters
13Station Fire Triage
- Triage by paramedics Firefighters at scene was
outstanding - Communication between scene and hospitals was
extremely poor during first few hours - Device failures
- Poor information about remaining capacity at
hospitals - Reasonably good communication between hospitals
- Crowd control at scene --- so many left on their
own ---can you really hold them?
14What we saw at Kent Hospital
- 64 patients in first 6 hours, 84 total
- 22 critically ill
- 21 intubated in E.D. (none of our patients
intubated in field) - 6 patients in coma upon arrival
- Too many patients taken by POV to hospital which
almost overwhelmed our capacity
15Staffing
- Timing of fire at change of shifts helped a lot
as we were able to effectively have double normal
workforce - Total of 7 respiratory therapists
- Physicians 4 ER / 2 internists/ 1 ICU MD / 1
surgeon / 2 PAs. Staffs, not physicians win
these battles
10 ER / 5 internists / 3 surgeons / 2 anesth / 2
ICU/ 4 PAs
16Communication with Site
- Very poor
- Almost no notice of what casualties were in-bound
- Hand held walkie-talkie like cell phones did not
work well for us (volume too low) - We sent two M.D.s to scene but should have sent
more per first responders - We heard more about what was happening at scene
via radio, TV, but had limited interaction with
site itself
17Communication cont.
- As receiving hospital, our E.D. physicians, staff
felt that our capacity was overestimated thru-out
the first few hours - Probably due to influx of victims arriving in
POVs unaccounted for by managers at scene - Some mis-information about remaining capacity at
other hospitals
18Communication cont.
- Arrival of senior leadership was both good and
bad - Senior leadership took the point on communication
- Usual staff was actually more capable re
communication as they do it day to day - Many of first responders we talked to were
unfamiliar to us - Had to give directions even though we were only 2
miles away --- one unit lost briefly
19Communication with other hospitals
- Biggest problem for us was finding who had
capacity - Capacity in E.D.s, ICUs, burn ICUs
- Later, managing family members became a problem
re location of patients - Faxing patient lists back and forth
- Must be a better way, web sites, etcprior to
states central coordination site standing up
20Airway Management
- Not routine airways
- Time critical
- Risk of death high
- Route of intubation?
- Standard, fiber-optic, surgical?
- Sedation?
- Paralyze?
21Are Burn Patients Different?
- Yes
- Upper airway burns/edema may obscure usual
landmarks making intubations difficult - Time essential complete upper airway obstruction
may develop quickly - Therefore greater risk of CVCI scenario
- Limited respiratory reserve
- Surgical airways always difficult --- more so in
this population with face/neck burns - Large volume little time per patient
- Volume depleted patients greater risk of
hypotension
22How to intubate?
- Should sedation be used?
- Should intubation be done while awake?
- Should muscle relaxant medications be used?
- Are these patients fundamentally different than
other EMS patients?
23Initial Assessment
- Heat and smoke injury and extensive facial burns
- Intubate quickly
- Deep facial burns but no smoke injury
- Difficulty controlling secretions and high risk
for progression to airway obstruction ---
intubate early - Heat and smoke injury but no facial burns
- Observe carefully and intubate at earliest sign
of airway edema
24Diagnosis of Smoke Inhalation
- Singed nasal hair
- Hoarseness
- Stridor
- Dyspnea
- Wheezing
- All the above are unreliable signs of serious
smoke inhalation (i.e. may often be absent) - Carbonaceous sputum is a reliable sign
25Chest Films
- Chest films are unreliable signs of serious smoke
inhalation injury - ARDS may eventually develop but not immediately
- Pulmonary edema rare during resuscitation phase
(pulmonary vascular resistance elevated and
protective) - Often films are normal
26- Bronchoscopy is also a reliable test
- Common F.O.B. findings include
- Carbon particles in airways
- Mucosal ulcerations
- Inflammatory airway changes
27Upper Airway Injury
- Rapid edema formation and burn itself preventing
access to mouth - Rapid tongue swelling
- Supraglottic edema
- Vocal cord edema
- Infraglottic edema
28Wilkinson, Norman Advanced airway management and
intubation, 2002
29Normal Airway Appearance
Cole, Steve Advanced airway management, 2003
30Supraglottic Edema at 12 Hours
Burnsurgery.org 2004
31Sedation?
- Yes --- for most patients
- Etomidate (20 - 30 mg)
- Morphine (large doses early for pain)
- Midazolam
- Propofol
32Muscle Relaxants?
- TNTC studies supporting the use of RSI protocols
in E.D.s by experienced physicians - increased success rate first attempt
- decreased aspiration risk
- less airway trauma
- Studies done in field, in transport helicopters
and by non-physicians have suffered from poor
design with some raising concerns while others
suggest RSI preferable - No studies limited to burn patients although
trauma literature generally supports RSI in E.D.
setting - Succinylcholine OK in first few hours after burn
33Recent RSI Field Study
- San Diego paramedics
- Trauma patients
- RSI protocol using midazolam and succinylcholine
after 60 sec pre-oxygenation - Study stopped early as outcomes worse in RSI
group - Apparently due to prolonged oxygen desaturation
in 57
34Conclusion about RSI
- Caution advised
- Advantages to the spontaneously breathing patient
- We intubated 21 patients in first 2 hours
- 7 RSI with etomidate and succinylcholine
- 5 awake using topical anesthesia and laryngeal
nerve blocks - 1 fiber-optic
- 8 with just etomidate/morphine/midazolam
- MANY patients had already developed upper airway
edema as seen on laryngoscopy - 0 missed airways or esophageal intubations
- Frequent hypotension that responded to fluids in
all cases - Central access in more than 1/2 given arm burns
35Inhalation Injury By Site of Inflammation
Injury Onset Time Duration Complication Therapy
Supraglottic 0 - 24 hours 2 - 3 days Airway obstruction Intubation
Upper airway 0 - 24 hours 2 -7 days Pneumonia Suction and F.O.B.
Lower airway 4 - 7 days 1 -21 days Pneumonia Supportive
From Parrillo and Dellinger Critical Care
Medicine, 1485, 2002.
36CO Intoxication Diagnosis
- High Index of Suspicion
- Carboxy-Hgb level gt 10
- Unexplained metabolic acidosis
- Confusion, agitation, coma
- Measurement of PO2 or O2 saturations not useful
- 60 of all deaths from house fires are from CO
intoxication
37Demling RH. Pulmonary Problems in the Burn
Patient (A Leading cause of Morbidity and
Mortality in the Burn Patient). J Burns
Surg Wound Care serial online 20043(1)5.
3820 Feb 03
- 44 COHgb tests at Kent Hospital
- 19 gt 10
- All had clinical evidence of CO intoxication
- Not including 4 patients transported to
Boston/UMass during first hour via helicopter
39Treatment of CO Intoxication
Oxygen Therapy Room Air 100 FiO2 Hyperbaric _at_2.5 ATM Rec coma But no change in any outcome death or neuro
Time for 50Cohgb to 20 7 hours 2 hours 50 minutes
40Demling RH. Pulmonary Problems in the Burn
Patient (A Leading cause of Morbidity and
Mortality in the Burn Patient). J Burns
Surg Wound Care serial online 20043(1)5.
41Pain Treatment
- All of the first 35 patients required intravenous
pain control - We used over 1 gram of morphine in about 5 hours
- Typical dose for the 21 intubated patients was
15 20 mg initially - Anxiety a big problem IV midazolam or lorazepam
in dose averaging 5 mg to start
42Dealing with Press
- Keeping press away from patients in hospital and
families waiting to hear during emergency itself - Three press conferences, starting next morning
- Interviews coordinated by public relations
- Very large press area set up across street from
fire site - Attitude of press shifted 24 hours later
43Lessons Learned
- Airway management key to survival early on
- Disaster drills paid big dividends throughout
night at all levels of care - Communication between hospitals and scene very
poor - What is the current capacity that each has left?
- Communication between hospitals could be improved
- Need an immediate way to identify victims in
hospitals before central state agency up and
running - State wide and regional resources and expertise
were adequate - I.D. of victims who died went very well
- Simple names for disaster codes
- Be careful with the media
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