Handbook of Disaster Medicine

Jan de Boer, Marcel Dubouloz, Jan de Boer, Marcel Dubouloz

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781000083187
• Edition: 1
• Topic: Medicina
• Subtopic: Teoria, pratica e riferimenti medici

Technological development has not only provided mankind with more prosperity, but with increased destructive power as well. These developments, combined with an explosive growth of the world population, have led to mass casualty situations, varying from traffic accidents to war. In the 20th Century over 200 million people were killed as a result of man-made disasters --- a figure unequalled in the history of mankind. It is not surprising, therefore, that a new medical discipline has emerged: disaster medicine. The realization that disasters have effects which cross the traditional boundaries of medical specialisms and nationality, led to the foundation of the International Society of Disaster Medicine (ISDM), which issued an international curriculum on education and training in disaster medicine. As a logical consequence the ISDM decided to develop its curriculum into a handbook, now available to the global community of disaster medicine specialists. This Handbook of Disaster Medicine contains contributions from international experts in the field and will be of value and interest to a wide variety of professionals in the discipline of disaster medicine and management.

Medical care

Part on I

Surgery and traumatology: Surgical management of severely injured patients when resources are limited

1

STEN LENNQUIST

1 INTRODUCTION

The role of trauma as a cause of death and disability is increasing as the world develops. Today it is the most common cause of death in young patients in developed countries. Disability caused by trauma is associated with extensive costs to the community. The number of injuries caused by intentional violence is also increasing in previously peaceful places, where stab wounds and missile injuries used to be rare.

The risk of major accidents that result in severely injured victims is also increasing, because of ever faster modes of transport of people and goods, with vehicles carrying more and more passengers, and the concentration of larger numbers of people in limited areas – occasional or permanent. Terrorists exploit these risks for personal or political reasons and there is a continuous threat of armed conflicts.

In all trauma care, accurate decision- making is essential. A correct decision made and the correct action taken in the right moment can mean the difference between life and death or between disability and health, in a young patient with many active years ahead. Quite apart from the obvious human benefits, even seen from the cost-benefit point of view, putting emphasis on, and effort into trauma management is therefore a most effective way to use resources.

Management of trauma in major accidents and disasters involves specific problems that require special consideration:

– The large number of casualties make it necessary to involve non-specialists at different levels of trauma management.

– Many injuries may come to treatment after a long delay, at greater risk of contamination and complications.

– Many injuries may be caused by trauma involving high velocity impact, with varying amounts of devitalised tissue; this increases the risk of infection of necrotic tissue or circulatory disturbances with secondary systemic complications.

– Less optimal treatment in the prehospital phase because of lack of resources increases the risk of late effects and complications that may lead to systemic reactions (intravascular coagulation, multiorganic failure or bacteraemia).

All this makes it necessary to use simple methods based on maximal safety. Usually there is no place for sophisticated methods of treatment that can be used in a well-equipped hospital by experienced experts within different fields (even if single patients can get access to such a treatment at such a time). It will also be necessary to set accurate priorities among patients and also among measures done for the same patient. There is no time, or resources, to do everything that is usually done and the (diagnostic and theraupetic) measures have to be restricted to those that will have the greatest effect on the patients chances of surviving without permanent disability.

Prehospital management of injured patients (organisational and technical) is dealt with extensively in special chapters in this book (part III: chapters 8 and 9) and will not be repeated here.

2 MANAGEMENT IN HOSPITAL

2.1 Initial management in hospital

The general principles for the initial management in the hospital do not differ appreciably from the principles valid for prehospital management, and the same management regimen can be used. There are many such regimens described by different authors in different textbooks, and they all have advantages and disadvantages.

The programme used in the ATLS (Advanced Trauma Life Support) courses has been adapted by numerous doctors (and also other medical staff) all over the world. It has been well tested and evaluated in numerous incidents and types of trauma and is considered accurate. To avoid confusion, the way of working should be as uniform as possible and a programme with such a wide application can be well recommended.

The ATLS regimen has not been accepted uncritically. Its applicability in centres that deal with a heavy load of trauma has been questioned. In such centres, the different steps in trauma management are usually run in parallel by a large team of specialised physicians, nurses and technicians. When it comes to more primitive conditions with less experienced people, however, the ATLS regimen is of benefit and it has been clearly shown that its wide application has resulted in significant improvements in trauma care.

It is very important not only in the prehospital care, but also in the initial phase in hospital, to use simple measures, so simple they can also be used in hospitals that do not have access to adequate staff or equipment for optimal management of the patients. It is also important to train qualified staff in these simple measures as they may be called upon when there are many casualties, and they are often forgotten by doctors and nurses who are not used to working under primitive conditions. Such measures are:

– Simple diagnostic measures to evaluate breathing and circulation (clinical evaluation).

– Securing the airway by simple but correct positioning of the patient. There may not be resources for more advanced methods of airway control, and there may be no resources for continuous surveillance of the patient.

– Prevention of shock by correct positioning, avoiding cooling, and rapid control of every source of bleeding.

– Pain relief by proper immobilisation of fractures and careful and accurate management of the patient.

When there is a heavy load of injured patients, all these measures are applicable not only in the prehospital phase but also into the emergency room in the hospital. A simple regimen of management (such as the ATLS, which is known to all staff) should be followed.

2.2 Airway

The measures for control of a blocked, or potentially blocked, airway that are described for prehospital care (part III: chapters 6 and 7) should also be used in the primary management in the emergency room: clearing and suction of the airway, position of drainage, and nasopharyngeal tube. If airway control cannot be achieved in this way, ventilatory support should be started with bag – valve – mask ventilation, and the addition of oxygen (12 litres/minute) and endotracheal intubation should be considered.

In disasters or where there are many casualties, endotracheal intubation has to be done for more restricted indications. In patients with a poor prognosis (such as head injuries with no spontaneous ventilation) resources needed for endotracheal intubation and consequent surveillance may be better used for patients who have a better chance of survival. This means that in major accidents or disasters, consider the priority before doing an endotracheal intubation!

When doing endotracheal intubation, consider the risk of injury to the cervical spine (common in major trauma). If there is any suspicion or insecurity, apply a stiff collar before manipulating the neck (note that a stiff collar does not fully protect the neck!).

Inaccurate endotracheal intubation (insertion of a tube in the oesophagus or right main bronchus) are common errors among the less experienced. The position of the tube should always be carefully checked with auscultation of the chest, and (if possible) control of oxygenation. A cuff should always be used in adults, and an oropharyngeal tube should be inserted in parallel.

Deeply unconcious patients do not require drugs for intubation. In conscious patients, Ketamine is a good first choice, except in the case of head injuries when barbiturates could be the first choice.

If endotracheal intubation is indicated but is not possible because of severe maxillofacial injuries, oedema (burn) or severe bleeding, cricothyroidotomy should be considered. This can be done with simple instruments (knife, scissors) and the airway can be maintained and secured with simple devices.

If cricothyroidotomy is not done properly it can lead to strictures. Incisions should not encroach on the laryngeal or cricoid cartilages. Use a small horizontal incision in the membrane between the laryngeal cartilage and first cartilage, which can easily be palpated.

To gain time while waiting for more permanent securing of the airway with endotracheal intubation or cricothyroidotomy, a needle cricothyroidotomy could be done and oxygen given by the jet – insufflation technique: oxygen 15 litres/minute, intermittent insufflation with one second on plus 4 seconds off for a maximum of 30–45 minutes before permanent control of the airway can be achieved.

Note the risk of carbon dioxide accumulation, which merits special care with head injuries.

2.3 Breathing

Whenever possible, oxygen should be given to all severely injured patients who require assisted ventilation (see above).

Pay attention to the chest: are there any

– Penetrating injuries?

– Contusions?

– Rib fractures?

– Subcutaneous emphysema?

Pneumothorax is common in severe trauma and may be immediately life threatening if it is turned into a tension pneumothorax (for example when starting assisted ventilation). Signs and measures: See under ‘Chest injuries’.

Multiple rib fractures may cause instability of the chest and cause respiratory insufficiency. Signs and measures: See under‘Chest injuries’.

2.4 Circulation

Severe trauma always implies a risk of the development of circulatory shock. Observation of clinical signs of shock and potential sources of bleeding is therefore vital. Regardless of whether such signs are present, measures to prevent shock should be undertaken in all patients with severe injuries....