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
• FY 2014 Preparedness Plan
Potential Probability vs. Impact
BIOLOGICAL
AGENT
NUCLEAR
WEAPON
IMPROVISED
NUCLEAR
DEVICE
POTENTIAL
IMPACT
RADIOACTIVE
MATERIAL
PROBABILITY/LIKELIHOOD
CHEMICAL AGENT
OR TOXIC
INDUSTRIAL
CHEMICAL
Human Hazards - RISK
Natural Hazards - RISK
The Threat
• “Why hunt tigers when there
are so many sheep” – from al
Qaeda training manual
captured in Afghanistan
Aurora Shootings
Aurora Shootings
Primary Attack Location of 140 Active
Shooter Incidents from 2000 to 2014
Police Response in Hospitals
Core Capabilities Trend Analysis
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.
London Bombings
London Bombings
Boston Bombings
Boston Bombings
Texas Fertilizer Plant Explosion
Alfred P. Murrah Building,
Oklahoma City, April 19, 1995
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
Category Characteristics
Primary
Body Part
Affected
Type of Injury
• Blast Lung
(pulmonary barotrauma or
Unique to high Gas filled
rapid change in pressure)
structures: • TM rupture
explosives
• Middle ear damage
• Abdominal hemorrhage
•Lungs
Results from
• Abdominal perforation
impact of
•GI tract
• Globe (eye) rupture
shock wave
•Middle ear
• Concussion (TBI without
physical signs of head injury)
Bomb / Blast Injuries
Category
Characteristics
Results from
Secondary flying debris and
bomb fragments
Tertiary
Results from
individuals being
thrown by the
blast wind
(shock wave)
Body Part
Affected
Type of Injury
• Penetrating ballistic injuries
(fragmentation)
Any part
• Blunt trauma injuries
• Eye injuries (can be occult)
•Fracture
Any part
•Traumatic amputation
•Closed & open brain injury
Bomb / Blast Injuries
Category
Characteristics
• All explosion
related injuries,
illnesses, or
diseases not due
to primary,
secondary, or
Quaternary tertiary
mechanisms
• Includes
exacerbation of
existing
conditions
Body Part
Affected
Any part
Type of Injury
• 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
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
Ear Injury
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•
•
•
•
•
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
Medical Management of
Bomb / Blast Victims
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 posttraumatic 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
Helping Patients Cope with a
Traumatic Event
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.
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.
Common Responses to Traumatic Events
 Cognitive
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•
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•
Poor concentration
Confusion
Disorientation
Indecisiveness
Shortened attention span
Memory loss
Unwanted memories
Difficulty making decisions
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
Common Responses to Traumatic Events
• Physical
Nausea
Lightheadedness
Dizziness
Gastro-intestinal problems
Rapid heart rate
Tremors
Headaches
Grinding of teeth
Fatigue
Poor sleep
Pain
Hyper-arousal
Jumpiness
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
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
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 worriedsick
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
Aerosol / Infectivity Relationship
The ideal aerosol contains
a homogeneous population
of 2 or 3 micron
particulates that contain
one or more
viable organisms
Particle Size
(Micron, Mass
Median Diameter)
Infection
Severity
Less Severe
18-20
15-18
7-12
Maximum human
respiratory infection is
a particle that falls
within the 1 to 5 micron
size
4-6
(bronchioles)
More
1-5 (alveoli) Severe
Antibiotic Resistance Threats
Influenza
Influenza-like illness
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.
BW - Epidemiologic Clues
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•
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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
Disease Outbreak - CRI
Toxins as Biological Agents
• Botulinum
• Ricin
• Staphylococcal
Enterotoxin B
(SEB)
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)
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.
Triggers
• Conventional Standards →
• Contingency Standards →
• Crisis Standards of Care
• Contingency Standards →
• Conventional Standards →
Crisis Situations
• Crisis situations may begin
with a discrete indicator of
excess demand
(ventilators/medications/staff)
which can trigger crisis care
process.
Conclusion
• Questions?
• Discussion?
• Comments?
• Critique?