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The Rhode Island Nightclub Fire One Hospitals

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Physicians: 4 ER / 2 internists/ 1 ICU MD / 1 surgeon / 2 PA's. ... 10 ER / 5 internists / 3 surgeons / 2 anesth / 2 ICU/ 4 PA's. Communication with Site ... – PowerPoint PPT presentation

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Title: The Rhode Island Nightclub Fire One Hospitals


1
The Rhode Island Nightclub FireOne Hospitals
Response
  • Michael Dacey, M.D.
  • Director, Intensive Care Unit
  • Kent Hospital

2
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3
Outline
  • History of nightclub fires
  • Timeline of events
  • Types of injuries
  • Triage issues
  • Communication issues
  • Airway management
  • Lessons learned

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6
History
  • 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

7
Dublin 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

8
Timeline
  • 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

9
Timeline 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

10
Types 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

11
Internal 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

12
Equipment 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

13
Station 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?

14
What 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

15
Staffing
  • 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
16
Communication 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

17
Communication 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

18
Communication 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

19
Communication 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

20
Airway Management
  • Not routine airways
  • Time critical
  • Risk of death high
  • Route of intubation?
  • Standard, fiber-optic, surgical?
  • Sedation?
  • Paralyze?

21
Are 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

22
How 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?

23
Initial 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

24
Diagnosis 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

25
Chest 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

27
Upper Airway Injury
  • Rapid edema formation and burn itself preventing
    access to mouth
  • Rapid tongue swelling
  • Supraglottic edema
  • Vocal cord edema
  • Infraglottic edema

28
Wilkinson, Norman Advanced airway management and
intubation, 2002
29
Normal Airway Appearance
Cole, Steve Advanced airway management, 2003
30
Supraglottic Edema at 12 Hours
Burnsurgery.org 2004
31
Sedation?
  • Yes --- for most patients
  • Etomidate (20 - 30 mg)
  • Morphine (large doses early for pain)
  • Midazolam
  • Propofol

32
Muscle 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

33
Recent 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

34
Conclusion 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

35
Inhalation 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.
36
CO 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

37
Demling 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.
38
20 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

39
Treatment 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
40
Demling 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.
41
Pain 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

42
Dealing 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

43
Lessons 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

44
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