Preparedness

This would involve training HCW and other community members: To understand the basic Do's and Don'ts of Rescue work To be trained in First Aid To understand the principles of transporting patients To understand the concept of Triage Management of complications

Besides this, experts in managing trauma need to raise the general level of awareness of the unique requirements for dealing with injured children and their special needs by organizing hands-on workshops; book publications; and collaboration with other organizations concerned with the care of children. Physicians from all branches should be given a refresher course in simple surgical procedures. A database of Referral Centres capable of handling complex cases should be updated every now and then.

Do's and Don'ts of Rescue work

• Activate a disaster plan for large-scale building collapses. This type of rescue will need the "overhead lift" capability as well as some method (ie, torches, hydraulic cutting tools, saws) of "cutting" concrete and the steel reinforcing bars that are contained within most modern buildings.
• Immediately after a collapse, the debris of the building is very unstable and prone to additional movement. Rescuers must assess the pattern of the collapse before entering onto a pile of rubble to insure their own safety and that of victims.
• Continue to remove debris carefully and vertically. Consideration must be given to the fact that the rescue effort is NOT over until EVERY reasonable effort has been expended.
• Shut down all work at the site for a few minutes every hour to listen for calls for help. During that period, sound detection devices can be used to "listen" for movement or sounds deep within the debris.
• Concentrate preliminary efforts on areas where people were last seen or known to be.
• Great care must be taken when a person is located, either dead or alive, to ensure that additional collapse doesn't occur in the area of their entrapment Several instances of complete hemodynamic collapse and death have been noted upon release from confinement. Qualified personnel can also administer intravenous solutions as extrication continues. Caution should be urged in the use of morphine or other painkillers.
• Relief for both supervisory and field rescue personnel must be forthcoming and ensure that all rescuers eat and rest at frequent intervals, as circumstances permit.
• Establish an effective communication system as early as possible. Anticipate the need to constantly communicate with construction workers, their supervisors, and probably a dozen other agencies that you never thought of. Also remember that the need for coordination with local and state police may become necessary for crowd/access control and other purposes
• To handle media, it is suggested that there should be a designated Public Information Officer who should plan and giving frequent press briefing and updates.

Issues in First Aid

Electric Shock

• When a victim receives an electric shock, he/she may receive significant burns or the electric shock may interfere with the heart’s electrical system. Burns may be greater than they appear on the surface.
• When attending a victim exposed to electricity, DANGER is the priority. Be alert for danger to yourself and to other rescuers, and approach the scene with caution.
• It is urgent that the power supply is turned off at the main powerboard if possible. Approach the patient with non conducting materials, eg., wooden stick or board, rope, or blanket.
• Be careful not to touch the casualty’s skin before the electrical source is disconnected, and be alert for the presence of water or conducting materials which may be in contact.
• Damaged high voltage sources can cause the entire scene of an accident to become ‘live’, especially where water or other materials are in contact with the electricity. Protect yourself and others.
• When high voltage electricity is involved in an accident, DO NOT touch the victim until the scene has been declared safe by the relevant electrical authorities. DO NOT approach the scene if you feel any unusual sensations, such as ‘tingling’ through your footwear.
• The tyres insulate people inside a car with fallen power lines across them, so tell them to stay inside the car and not to jump out.
• Ensure that all bystanders do not approach the scene and remain at least six metres away from the nearest suspected energised material.

Signs And Symptoms

• difficult, or absent breathing
• absent, weak or irregular pulse
• evidence of burns
• evidence of fractures
• entrance and exit wound burns
• collapse and unconsciousness

Treatment

• Mantain airway, breathing and circulation.
• Inform electrical authorities if high voltage involved
• Commence CPR if required
• Cool and cover burns with non-adherent dressings
• Reassurance

Burns are classified as either

• Superficial - reddening (like sunburn), outer layer of skin only
• Partial Thickness - blistering, damage to deeper layers of skin
• Full Thickness - whitish or blackened areas, damage to all layers of skin, plus underlying structures and tissues

The severity of burns is dependent on certain factors such as; the age of the casualty, the depth of the burns, the part of the body burnt, and the area affected.

The burnt body is assessed as a 'percentage', and is arrived at by reference to 'The Rule of Nines'. Eleven areas of the body are designated each worth 9%, eg. arm = 9%, etc. The percentages are added, and the total given as the percentage of the total body area burnt.

• cool only with clean water if possible, and resist using other substances
  • up to 20 minutes for thermal or radiation burns
  • 20-30 minutes for chemical burns
  • 30 minutes for bitumen burns
• cover with a clean, non-adherent burn dressing (or plastic wrap etc).
• remove tight clothing and objects, eg. jewellery
• treat for shock if the burn is severe.
• flush chemicals from the skin, pay special attention to eyes
• Do not break blisters
• Ensure that the cooling process does not become excessive and cause shivering.

Burns to the face inevitably have an effect on the victim's breathing, and these effects may take some time to appear. It is important that any patient who has inhaled smoke, or fumes, or has been burnt on the face, should seek medical aid as soon as possible after the incident.

REMEMBER — Severe burns can lead to shock and massive infection if not treated properly!

Cardio-Pulmonary Resuscitation:

Whenever you are faced with a victim who seems to be dead/dying, you must give him/her CPR

1. Call for Help if any is available.
2. Tilt the head back and listen for breathing. If not breathing normally, pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths. Each breath should take 2 seconds
3. If the victim is still not breathing normally, coughing or moving, begin chest compressions. Push down on the chest 11/2 to 2 inches 15 times right between the nipples. Pump at the rate of 100/minute, faster than once per second
4. CONTINUE WITH 2 BREATHS AND 15 PUMPS UNTIL HELP ARRIVES This ratio is the same for one-person & two-person CPR. In two-person CPR the person pumping the chest stops while the other gives mouth-to-mouth breathing.
5. Vomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn the head to the side and try to sweep out or wipe off the vomit. Continue with CPR.

In Children

1. If you are alone with the child give one minute of CPR before calling Help
2. Use the heel of one hand for chest compressions
3. Press the sternum down 1 to 1.5 inches
4. Give 1 full breath followed by 5 chest compressions

Control Bleeding

• Cover the wound with a dressing, and press firmly against the wound (direct pressure).
• Elevate the injured area above the level of the heart if you do not suspect that the victim has a broken bone.
• Cover the dressing with a roller bandage.
• If the bleeding does not stop:
  • Apply additional dressings and bandages.
  • Use a pressure point to squeeze the artery against the bone.
• Provide care for shock.

Care for Shock

• Keep the victim from getting chilled or overheated.
• Elevate the legs about 12 inches (if broken bones are not suspected).
• Do not give food or drink to the victim.

Tend Burns

• Stop the burning by cooling the burn with large amounts of water.
• Cover the burn with dry, clean dressings or cloth.

Care for Injuries to Muscles, Bones and Joints

• Rest the injured part.
• Apply ice or a cold pack to control swelling and reduce pain.
• Avoid any movement or activity that causes pain.
• If you must move the victim because the scene is becoming unsafe, try to immobilize the injured part to keep it from moving.

Be Aware of Biological/Radiological Exposure

Listen to local radio and television reports for the most accurate information from responsible governmental and medical authorities on what's happening and what actions you will need to take.

Reduce Any Care Risks

The risk of getting a disease while giving first aid is extremely rare. However, to reduce the risk even further:

• Avoid direct contact with blood and other body fluids.
• Use protective equipment, such as disposable gloves and breathing barriers.
• Thoroughly wash your hands with soap and water immediately after giving care.

Issues in Transport

The stretcher must be put down near the injured person. If no stretcher is available, one can be improvised with blankets, pieces of cloth or plastic, camp beds, ladders, doors, shutters, etc.

When lifting the injured person, certain rules must be followed:

• Movements must be calm and coordinated and carried out in accordance with the instructions of a rescue worker.
• The injured person must be moved as little as possible.
• The victim's head, neck and trunk must be kept in the same axis

Conveyance by stretcher to the local health establishment must follow certain simple, common-sense rules:

• The stretcher must go forward with the patient's head foremost.
• Jerkiness must be avoided (no sudden stops, bumps or tilting).
• No stretcher-bearer should walk backwards.
• The injured person, together with any ventilation equipment, must be fastened to the stretcher.
• If the victim is given artificial respiration (mouth-to-mouth, mask) the rescue worker responsible for it will get between the two shafts level with the victim's head; it is only in such a case, to avoid the rescue worker having to walk backwards, that the injured person will be transported feet first.

Adapted from : Coping with Natural Disasters: The Role of Local Health Personnel and the Community: Working guide (WHO - OMS, 1989, 108 p.)

Triage

After a massive disaster the quantity and severity of injuries will overwhelm the handling capacity of health facilities. The principle of "first come, first treated," which is applied in routine medical care, is not practical in mass emergencies. Although different triage systems have been adopted and are still in use in some countries, the most common classification uses the internationally accepted four-color code system. Red indicates high priority treatment or transfer, yellow signals medium priority; green is used for ambulatory patients, and black for dead or declining patients.

Triage should be carried out at the disaster site in order to determine transportation priority and admission to the hospital or treatment center where the patient's needs and priority for medical care will be reassessed. Persons with minor or moderate injuries should be treated near their own homes to avoid added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities.

Management of complications

Well-preparedness and promptness of management are the key to survival from renal failure due to crush syndrome.

1. Protocols for urgent measures to prevent renal failure. Manuals should be prepared and made available at all hospitals and health centres. These should be easily retrievable.
2. Training of personnel. All personnel working at Health facilities in the governmental sector as well as private sector should receive basic training in Disaster Management; and the issue of prevention and management of crush syndrome should be a part of that training.
3. Availability of urgent intravenous fluids and drugs. IV fluids and drugs (as mentioned under Rescue) should be stocked. Limited stocks may be kept at peripheral units, their availability and channels of prompt distribution should be ensured.
4. Identification of Dialysis Centres and trained medical and paramedical staff. All dialysis centres in the country should be identified. Nephrologists, trained nurses and technicians; and dialysis machines available should be listed. This information should be available with the Directorate of Health Services and with the Indian Society of Nephrology and Indian Pediatric Nephrology Group. These Nephrology Societies should prepare Disaster management plans and keep them updated. They should conduct their own training programs.

Rescue Phase

People must be reached and rescued. Relatives, friends and local volunteers will mostly carry out the rescue work spontaneously. Often it is essential to have available:

• ladders,
• ropes,
• heavy gloves,
• spades,
• picks,
• planks,
• pocket torches

When it is difficult to reach a victim or when there is a risk of further caving-in, it is advisable to leave the work of extrication to experts (firemen, trained volunteers, building workers, the army, etc). As soon as the rescuers reach an injured person, they should be careful to:

• Maintain and ease respiration.
• Clear the victim's airways by using fingers to clean the mouth and throat, taking out dentures and loosening collars, belts and clothing.
• Use blankets to prevent the victim catching cold.

During this phase of 1st 48 hours or so, maximum number of injured people (including children) report at the nearest medical facility. Eighty-five to 95 percent of persons rescued from collapsed buildings are rescued in the first 24-48 hours after the disaster, especially earthquakes. Regardless of the number of casualties, the majority of injuries is likely to be minor cuts and bruises, with a smaller group suffering from simple fractures, and a minority with serious multiple fractures or internal injuries requiring surgery and other intensive treatment. Pending further assessments, appropriate medical assistance should target the secondary prevention of crush syndrome among injured cases. This implies that trauma patients need to receive intravenous fluids and that such fluids need to be available in large quantities in the damaged areas. The proper management of severe crush syndrome cases may also require dialysis for renal failure.

Important to remember

• Transport of victims to the hospital should be staggered, and patients should receive adequate field treatment, allowing them to tolerate delays. However in reality, most injured persons will converge spontaneously on health facilities if they are at a reasonable distance, using whatever transport is available, regardless of the facility's operating status. Some victims may not request or be able to seek medical care, which makes active case finding an important part of any casualty relief effort. This is sufficient reason for creating mobile health-care teams to be deployed to the disaster site in addition to fixed first aid stations located near existing health facilities.
• Provisions should be made for food and quarters for health personnel.
• A center should be established to respond to inquiries from patients' relatives and friends; it should be staffed round-the-clock, using non-health personnel as necessary. The Red Cross may be well equipped to direct this function.
• Priority must be given to victim identification, which is becoming an increasingly specialized issue. Adequate mortuary space and services also must be provided.
• All patients must be identified with tags stating their name, age, sex, place of origin, triage category, diagnosis, and initial treatment. Standardized tags must be chosen or designed in advance as part of the national disaster plan. Health personnel should be thoroughly familiar with their proper use.

At the hospital, triage should be the responsibility of a highly experienced clinician, as it may mean life or death for the patient, and will determine the priorities and activities of the entire staff. Preparation and dissemination of standardized procedures, such as extensive debridement, delayed primary wound closure, or the use of splints instead of circular casts, can produce a marked decrease in mortality and long-term impairment.

While health care facilities within a disaster area may be damaged and under pressure from mass casualties, those outside the area may be able to cope with a much larger workload or provide specialized medical services such as neurosurgery. Ideally, there will be a metropolitan system of emergency medical treatment that allows hospitals to function as part of a referral network. At different levels of complexity, a network of prehospital relief teams can coordinate referrals from the disaster area. The decision to redistribute patients outside the disaster area should be carefully considered, since unplanned and possibly unnecessary evacuation may create more problems than it solves.

Recovery Phase

Hospitals, according to their geographic location, starting with those closest to the impact area, with a visual display of the number of beds available, medical or nursing personnel required for round-the-clock services, shortages of essential medical items, and other needs should be listed to permit the Health Disaster Coordinator to direct external assistance to areas where needs and expected benefits are greatest. Patterns for redistributing resources or patients will emerge from analysis of the data. Such monitoring of hospital resources will be most useful when medical care is likely to be required for an extended period.

If the Health Disaster Coordinator finds that the region's total health care capacity is insufficient to meet disaster-related needs, several alternatives must be considered. The best is rapid expansion of the region's own permanent facilities and staff, which has the advantage of fulfilling immediate needs and leaving behind permanent benefits. Another alternative, which has proved to be less desirable, may be staffed, self-sufficient, mobile emergency hospitals available from government, military, Red Cross, or private sources. If such a hospital is necessary, one from the disaster-affected country, or a neighboring country with the same language and culture should be considered first, and those from more distant countries considered second.

Foreign mobile hospitals may have several limitations. First, the time needed to establish a fully operational mobile hospital may be several days, while most casualties resulting from the immediate impact require treatment in the first 24 hours. Second, the cost of such a hospital, especially when airlifted, can be prohibitive and is often deducted from the total aid package given by the governmental or private relief source providing it. Third, such hospitals are often quite advanced technologically, which raises the expectations of the people they serve in a way that will be difficult if not impossible for local authorities to meet during the recovery period. Finally, it must be recognized that such hospitals are of great public relations value to the donor agency, which may inappropriately urge their use.

Crush syndrome and acute renal failure (ARF)

In major earthquakes the incidence of crush syndrome is estimated to be a minimum of 3-5%. However, in total collapse of a large multistorey building up to 40% of the extracted survivors may be affected. Crush syndrome is characterized by extensive damage to muscles (rhabdomyolysis) and myoglobin induced ARF. Besides that, hypovolemic shock (due to sequestration of large amounts of fluids in the damaged muscles and lack fluid of intake) is a major contributory factor in the pathogenesis of ARF. Muscle tissue comprises 40-50% of body weight. Injury to sarcolemmal membrane leads to movement of water, Na+, and Ca++ into the cells and that of K+, proteins, phosphorus, lactate, myoglobin, thromboplastin and creatine kinase in the reverse direction. Biochemical abnormalities that follow include hyperkalemia (the commonest cause of death), hypocalcemia, hyperphosphatemia ,hyperuricemia raised blood myoglobin,and lactic acidosis. Urine is brown colored from heme pigment. Muscle damage to a large extent takes place during reperfusion and thus ARF mostly develops after the victim has been released from under the rubble.

Management of crush syndrome The principles of management include the following: Urgent volume expansion Recognition and treatment of major metabolic derangements (hyperkalemia, acidosis) Prevention of acute renal failure due to rhabdomyolysis (mediating factors being myoglobin, hypoxia-ischemia, phosphate, urate) Treatment of acute muscle compartment syndrome Management of established acute renal failure

Fluid resuscitationA solution of 0.9% saline with 2.5% glucose should be immediately started, if possible even before removing the patient from the overlying debris and beams. Along with the IV fluid, 1 unit of insulin/kg body weight and 1 ml of 50% glucose/kg body weight should be infused over a period of 30 minutes, and a bolus of 1 ml/kg of 10% calcium gluconate given. Potassium should not be administered.

Treatment of hyperkalemiaHyperkalemic cardiotoxicity is the most proximate cause of mortality and it is therefore crucial to counteract it and lower the raised serum K level. Administartion of 10% calcium gluconate 1 ml/kg over 3-5 minutes (the same dose could be repeated, if necessary, after 10 minutes and another after 2 hours) will antagonise the toxic effect of hyperkalemia on the myocardium, without lowering serum K+. Other urgent measures to lower serum K+ include i) nebulised salbutamol 0.2 mg/kg dissolved in saline ii) IV bolus salbutamol 0.01 mg/kg, or continuous infusion of salbutamol 4 mcg/kg over 20 minutes, iii) NaHCO3 1-2 mEq/kg IV over 5-10 minutes iv), insulin 1 U/kg with 50% glucose 1ml/kg over 30 minutes, repeated at 30-60 minutes if needed. The K+-lowering effect of these measures is short-lived. To promote intestinal elimination of potassium exchange resin (Na+ polysterene resin, Kayexalate) is used. It is given orally 1-2 Gm with 3 ml sorbitol /Gm resin at 8-hourly intervals. It can also be administered rectally 1-2 Gm/kg with 5 ml sorbitol /Gm resin as retention enema at 4-6 hour intervals.

Evaluation and management of multisystem injuries

Availability of parenteral fluids, antibiotics and resuscitative drugs and immediate institution of appropriate treatment can permit transfer of patients to suitable centres for further management. The patient should be quickly examined for the presence of injury to other organs. The common injuries are to lower limbs, upper limbs, trunk and lower limbs both, trunk alone, upper and lower limbs together and head and neck. The mortality appears to be highest when the trunk and lower limbs are injured together.

Evaluation and treatment of acute compartment syndrome: Trauma and ischemia lead to swelling of the muscle with tamponade of the muscle in the facial compartments, which eventually leads to ischemia and death of the limb. Surgical fasciotomy is urgently indicated for rapid decompression and may be needed in almost 50% cases. A delay may cause loss of vitality and necessitate amputation.

Further measures

Following initial stabilization IV fluid therapy is continued at 10-20 ml/kg/hour, the rate depending upon clinical evaluation of volume status and vital signs. NaHCO3 at 20mEq/l of IV fluids should be added. The following assesses the response to fluid resuscitation:

1. Rise in systolic BP to >80mm
2. Increase in pulse pressure to >20mm
3. Decrease in heart rate to <130/min
4. Improved alertness
5. Improvement in skin color and warmth in non-crushed extremities

If at the end of 4 hours of successful restoration of circulation there is no urine output, 5mg/kg of mannitol is infused along with 2 mg/kg of furosemide. If that fails to induce a diuresis, established ARF should be presumed and managed according to standard ARF regimen.

If urine output is observed, IV fluids are continued (0.5% NaCl, with NaHCO3 20mEq/L) and 20% mannitol is added at 0.75g/kg at 6-hourly intervals. The rate of fluid administration is adjusted to maintain a urine output of >6 ml/kg/hour with adequate circulatory stability. Urine pH is kept over 6.5; in case it increases >7.5, acetazolamide (diamox) 5-10 mg/kg IV can be given at 6-12 hour intervals. Adequacy of mannitol administration can be judged by the plasma osmolal gap (the difference between measured osmolality and calculated osmolality), which should be kept more than 60 mOsm. Calculated osmolality is derived by the formula: 2 x Na + glucose (mg/dl) /18 + blood urea (mg/dl)/8. The infusion of NaHCO₃ and mannitol is continued until the urine no longer shows myoglobin, which usually takes 48-72 hours.

Organization of further care and establishment of infrastructure

Duties of the local/frontline medical and paramedical staff. Such workers should be involved in urgent therapeutic measures, patient selection and their immediate transfer. They should preferably not carry out major surgery and intensive care, since such treatment in poorly equipped, dysfunctional hospitals carries a very high mortality. It is better to transport victims with major problems to proper centres.

Making hemodialysis available. Various hemodialysis facilities and their capacity should be identified. In addition, it would be necessary to set up such units in safe areas to avoid problems of transportation for those patients who may not have other serious injuries requiring major surgery. The Indian Pediatric Nephrology Group and the Indian Society of Nephrology should prepare Disasters Plans. They should communicate with the International Pediatric Nephrology Association and the International Society of Nephrology (which has a Renal Disaster Relief Task Force of Commission on acute renal failure).

It is absolutely vital that all these problems are recognized and clear rules framed to avoid administrative hurdles and unnecessary delays.

Rehabilitation Phase

The aim of restoring should not be to come back to the original state and in fact it should be taken as an opportunity to refine the existing health facilities by factoring the need to create state-of-art trauma centers.<p>