This document discusses mechanical ventilation strategies during disasters. It describes different types of disasters including natural disasters like fires, floods and earthquakes, as well as man-made disasters like explosions and pandemics. It emphasizes the need to plan for limited resources during disasters by considering restrictions on staff, facilities, equipment and supplies. The document also stresses the importance of fair allocation of scarce critical care resources through organized triage teams and sequential organ failure assessments. Specific strategies are provided for managing blast lung injuries from explosions and addressing ventilation needs during an infectious pandemic.
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Mechanical Ventilation during Disasters
1. T H O M A S J . J O H N S O N , M S , R R T
Mechanical Ventilation during
Disasters
2. 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
3. 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
4. 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 .
5. 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.
6. Rationing of Critical Care?
Relentless Assessment
DNR or DNI does not mean Do Not Rescue
7. 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?
8. Sequential Organ Failure Assessment (SOFA)
Components
PaO2 / FIO2
SaO2 / FIO2
Platelets
MAP
GCS
Creatinine
Get this app: Clincalc.com/IcuMortality/SOFA
9. ICU Triage in Disasters: Triage Officer & Triage
Team
Team Shift Duration: < 16 hours
Triage Officer : Highly Experienced Surgeon
Manages clinical activities during a crisis
Assesses all patients
Attends the High Priority Patients
Directs Logistics of resources and patient
transfers
Team Composition:
Experienced Critical Care Nurse
Respiratory Therapist and / or
Pharmacist
10. Evacuate: Risk – Benefit Analysis
When?
Who?
By Whom?
How?
Where?
How Long?
11. 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
20. 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
23. 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
29. “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)
Hinweis der Redaktion
Blast pressure wave travels at over 3,000 feet per second