Agenda

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Agenda

• Emergency Preparedness
• Probabilities / HVAs and Threats
• Active Shooting
• Bombing / Blast Injuries
• Emerging Re-emerging Infectious Diseases
• Medical Surge
• Discussion GAPS

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Storms are still the biggest threat!
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• FY 2014 Preparedness Plan

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(No Transcript)
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Potential Probability vs. Impact
BIOLOGICAL AGENT
NUCLEAR WEAPON
IMPROVISED NUCLEAR DEVICE
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
POTENTIAL IMPACT
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
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Human Hazards - RISK
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Natural Hazards - RISK
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The Threat

• Why hunt tigers when there are so many sheep
  from al Qaeda training manual captured in
  Afghanistan

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Aurora Shootings
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Aurora Shootings
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Primary Attack Location of 140 Active Shooter
Incidents from 2000 to 2014
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Police Response in Hospitals
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Core Capabilities Trend Analysis
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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.

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THREAT

• T - Threat suppression
• H - Hemorrhage control
• RE - Rapid Extrication to safety
• A - Assessment by medical providers
• T - Transport to definitive care

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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

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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.

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EMS response issues

• EMS may need to utilize scoop and scoot and
  load and go from the incident.

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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

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Physical Results of an Explosion
Imagine this apple as an arm, leg, or torso
struck by shrapnel.
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London Bombings
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London Bombings
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Boston Bombings
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Boston Bombings
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Texas Fertilizer Plant Explosion
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Alfred P. Murrah Building, Oklahoma City, April
19, 1995
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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

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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

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Definitions

• TBI or MTBI
• Traumatic Brain Injury or Mild Traumatic Brain
  Injury
• TM
• Tympanic Membrane damage to TM results in
  hearing loss

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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

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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

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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

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Bomb / Blast Injuries

• Four categories of injuries
• Primary
• Secondary
• Tertiary
• Quaternary

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Bomb / Blast Injuries
Category Characteristics Body Part Affected Type of Injury
Primary Unique to high explosives Results from impact of shock wave Gas filled structures Lungs GI tract Middle ear Blast Lung (pulmonary barotrauma or rapid change in pressure) TM rupture Middle ear damage Abdominal hemorrhage Abdominal perforation Globe (eye) rupture Concussion (TBI without physical signs of head injury)
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Bomb / Blast Injuries
Category Characteristics Body Part Affected Type of Injury
Secondary Results from flying debris and bomb fragments Any part Penetrating ballistic injuries (fragmentation) Blunt trauma injuries Eye injuries (can be occult)
Tertiary Results from individuals being thrown by the blast wind (shock wave) Any part Fracture Traumatic amputation Closed open brain injury
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Bomb / Blast Injuries
Category Characteristics Body Part Affected Type of Injury
Quaternary All explosion related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms Includes exacerbation of existing conditions Any part Burns (flash, partial, full thickness) Crush injuries Closed open brain injury Asthma, COPD, or other breathing problems from dust, smoke, or toxic fumes Angina Hyperglycemia Hypertension
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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

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Bomb / Blast Injuries

• Ear Injury
• 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)

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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

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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

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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

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Medical Management of Bomb / Blast Victims
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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

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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
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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

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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

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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

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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

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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

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Medical Management Options

• Communications with patients may need to be
  written due to tinnitus and sudden temporary or
  permanent deafness

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Helping Patients Cope with a Traumatic Event
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What is a Traumatic Event?

• Any event, or series of events, that causes
  moderate to severe stress reactions is called a
  traumatic event.
• Traumatic events are characterized by a sense of
  horror, helplessness, serious injury, or the
  threat of serious injury.

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Who is effected by Traumatic Events?

• Traumatic events affect survivors, rescue
  workers, and friends / relatives of those
  directly involved.
• Can also affect people who witnessed the event
  either in person or through the media.

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Common Responses to Traumatic Events

• Cognitive
• Poor concentration
• Confusion
• Disorientation
• Indecisiveness
• Shortened attention span
• Memory loss
• Unwanted memories
• Difficulty making decisions

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Common Responses to Traumatic Events

• Emotional
• Shock
• Numbness
• Feeling overwhelmed
• Depression
• Feeling lost
• Fear of harm to self and/or loved ones
• Feeling nothing
• Feeling abandoned
• Uncertainty of feelings
• Volatile emotions

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Common Responses to Traumatic Events

• Physical
• Nausea Grinding of teeth
• Lightheadedness Fatigue
• Dizziness Poor sleep
• Gastro-intestinal problems Pain
• Rapid heart rate Hyper-arousal
• Tremors Jumpiness
• Headaches

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Common Responses to Traumatic Events

• Behavioral
• Suspicion
• Irritability
• Arguments with friends or loved ones
• Withdrawal
• Excessive silence
• Inappropriate humor
• Increased / decreased eating
• Change in sexual desire or function
• Increased smoking
• Increased substance abuse

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Summary

• Blast injuries no longer confined to military
  battlefields
• Probability of a terrorist event involving
  explosives higher than other possibilities
• Currently significant concern within
  Intelligence community about bomb / blast events
  in US
• Explosions can produce significant traumatic
  injuries beyond current ED experience

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Summary

• 50 of all blast / burn victims will present for
  ED treatment within 1 hour of event
• Remaining 50 will present over next 6 hours
• Above does not account for walking-worried or
  worried-sick

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Summary

• Emotional responses to traumatic burn / blast
  events will occur and will significantly
  complicate patient loads
• Advanced preparation to handle / treat emotional
  casualties is paramount

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Aerosol / Infectivity Relationship
Infection Severity
Particle Size (Micron, Mass Median Diameter)
The ideal aerosol contains a homogeneous
population of 2 or 3 micron particulates that
contain one or more viable organisms
Less Severe More Severe
18-20 15-18 7-12 4-6 (bronchioles) 1-5
(alveoli)
Maximum human respiratory infection is a
particle that falls within the 1 to 5 micron size
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Antibiotic Resistance Threats
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Influenza
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Influenza-like illness
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The public health threat of emerging viral
disease.

• Emerging diseases" are those that either have
  newly appeared in the population or are rapidly
  increasing their incidence or expanding their
  geographic range. Emerging viruses usually have
  identifiable sources, often existing viruses of
  animals or humans that have been given
  opportunities to infect new host populations
  ("viral traffic"). Environmental and social
  changes, frequently the result of human
  activities, can accelerate viral traffic, with
  consequent increases in disease emergence. Host
  factors, including nutrition, have often received
  less attention in the past but are of
  considerable importance.
• These factors, combined with the ongoing
  evolution of viral and microbial variants, make
  it likely that emerging infections will continue
  to appear and probably increase, emphasizing the
  need for effective surveillance.

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BW - Epidemiologic Clues

• Large epidemic with high illness and death rate
• HIV() individuals may have first susceptibility
• Respiratory symptoms predominate
• Infection non-endemic for region
• Multiple, simultaneous outbreaks
• Multi-drug-resistant pathogens
• Sick or dead animals
• Delivery vehicle or intelligence information

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Disease Outbreak - CRI
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Toxins as Biological Agents

• Botulinum
• Ricin
• Staphylococcal Enterotoxin B (SEB)

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Three Reports from Institute of Medicine

• Guidance for Establishing Crisis Standards of
  Care for use in disaster situations (2009)
• Crisis Standards of Care A Systems Framework
  for catastrophic Disaster Response (2012)
• Crisis Standards of Care Need for a Toolkit
  for Indicators and Triggers (2013)

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Indicators and Triggers

• Indicators and Triggers help guide operational
  decision making about providing care during
  public health and medical emergencies and
  disasters.
• Indicators are defined as measurements or
  predictors of change in demand for health care
  services or availability of resources
• Triggers are defined as decision points about
  adaptations to healthcare services delivery.
• Hospitals need to look at their HVA to decide for
  which Scenarios they need to come up with
  Indicators and Triggers.

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Triggers

• Conventional Standards ?
• Contingency Standards ?
• Crisis Standards of Care
• Contingency Standards ?
• Conventional Standards ?

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Crisis Situations

• Crisis situations may begin with a discrete
  indicator of excess demand (ventilators/medication
  s/staff) which can trigger crisis care process.

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Conclusion

• Questions?
• Discussion?
• Comments?
• Critique?