T H O M A S J . J O H N S O N , M S , R R T

Mechanical Ventilation during Disasters

Objectives

Be able to differentiate types of disasters

Be able to list the types of man-made disasters

Be able to manage a blast-lung injury

Be able to list the most likely natural disasters

Be able to describe mass-critical care

Be able to describe the preparation to mitigate the impact of a disaster on the hospital

Be able to describe the management of blast lung injuries

Be able to describe the management of an infectious pandemic

Limitations on Resources

Human Resources: Numbers, types, skill-sets, physical limitations, and …

Physical Plant Resources, esp. HVAC, electricity, suction, oxygen, etc.

Durable Equipment Resources, e.g. ventilators, monitors, beds, surgical suite equipment

Medical Supplies: OXYGEN, PPE, medications, IV fluids and tubing, surgical supplies, catheters and other tubes,

Food: patients and staff (spoilage)

Water (potable or non potable)

Hygiene and Sanitation

Can We Master the Chaos or will Chaos Prevail?

T H E F A I R A N D E Q U I T A B L E A L L O C A T I O N A N D R A T I O N I N G O F S C A R C E C R I T I C A L C A R E R E S O U R C E S I N A D I S A S T E R R E Q U I R E S

T H A T C L I N I C I A N S A N D I N S T I T U T I O N S P L A N I N G O O D F A I T H , B E T R A N S P A R E N T I N T H E P L A N N I N G P R O C E S S .

CHAOS: Crisis Overwhelms Hospital, Municipality or Region and Nation

Potential for chaotic, inequitable/ unfair, unethical and possibly illegal provision of ‘care’.

Both patient and care providers needs must be anticipated and prepared for.

PPE

Changes in scope of practice and responsibilities

Training / Drills *

Supervisory systems (both during and after the crisis)

*Drills should be ruthlessly evaluated for opportunities to improve and fix.

Rationing of Critical Care?

Relentless Assessment

DNR or DNI does not mean Do Not Rescue

ICU RTs: 2 Questions

1. DO YOU DO DAILY SEQUENTIAL ORGAN FAILURE ASSESSMENTS (SOFA)?

2. ARE YOU A REGULAR PARTICIPANT AT THE CRITICAL CARE ETHICS AND TRIAGE COMMITTEE?

Sequential Organ Failure Assessment (SOFA) Components

PaO2 / FIO2

SaO2 / FIO2

Platelets

MAP

GCS

Creatinine

Get this app: Clincalc.com/IcuMortality/SOFA

ICU Triage in Disasters: Triage Officer & Triage Team

Team Shift Duration: < 16 hours Triage Officer : Highly Experienced SurgeonManages clinical activities during a crisisAssesses all patientsAttends the High Priority PatientsDirects Logistics of resources and patient

transfers Team Composition: Experienced Critical Care NurseRespiratory Therapist and / orPharmacist

Evacuate: Risk – Benefit Analysis

When?

Who?

By Whom?

How?

Where?

How Long?

Duration of the Emergency Mass Critical Care

(EMCC)

“Hospitals should prepare to deliver

EMCC for 10 days without sufficient

external assistance.”

Emergency Department (ED) response can

vary from hours (RI nightclub fire and London

bombings-3 h 14 m)

Critical Care LOS: average 21days (RI) to

12.4 [range 6 to 22 days] (London bombing)

Devereaux A, Christian MD et. al. Summary of Suggestions from the Task Force for

Mass Critical Care Summit January 26-27, 2007 Chest 2008; 133:1S-7

Earth, Wind, Water and Fire

Fire

Snow ?

Required Reading:

Sheri Fink’s Five Days at Memorial

Man-Made Disasters

Accidents

Chemical Accidents

Man-Made Disaster: IED

Blast Lung Injury

Potential to produce large number of victims

Nature of the blast: HE, Low order, etc.

Location: indoor, outdoor, reflective surface

Victim Severity: Location, Shielding, Distance

Overpressure of >15 psi (>100 kPa) Effects

Secondary Effect: Shrapnel, Thrown victims, body parts

Blast Pressure Waves

Signs & Symptoms of BLI

Hypoxemia (P/F <200)

“Butterfly” pattern on CXR

Tachypnea

Low Vt

Restrictive defect

Low Compliance

R/O Hemothorax/pneumothorax

Wheezing

CMV for BLI

Intubate using RSI and cervical neck immobilization

Mechanically ventilate

Mode of choice: keep PIP <40 and Vt ~6 ml/kg PBW

f <22 to keep pH >7.20 (after that consider HFPPV/HFOV)

PEEP up to 15 cm H2O then consider iNO

Monitor ET CO2 for increased VD due to emboli

Limit Fluids to prevent alveolar flooding

Pandemic

The 400 pound gorilla in the Room

“There is no applicable model of mass triage resulting from an infectious event…”

Devereaux AV, et.al. (2008) Definitive Care for the Critically Ill During a Disaster. Chest 133 (5_suppl)