Specific Medical Problems
in Earthquakes
Lek.med.Ignacy Baumberg
Specific Medical Problems
in Earthquakes
Lek.med.Ignacy Baumberg
1/. THE MAIN SOURCE OF CASUALTIES ARE COLLAPSED BUILDINGS
2/. MOST INJURIES AND FATALITIES ARE CAUSED BY THE ENERGY
TRANSMITTED TO THE BODY OF THE VICTIM AND EXCEEDING THE
VALUE THE BODY CAN WITHSTAND.
3/. MOST COMMON CAUSES OF DEATH ARE MULTIPLY INJURIES, DUST
ASPHYXIATION AND HEAD TRAUMA, DROWNING HAPPENS AS WELL
4/. THE RISK OF DEATH IN EARTHQUAKE IS HIGHER FOR THOSE
LIVING ON HIGHER FLOORS BEFORE COLLAPSE
5/. MOST DEATHS OCCUR IMMEDIATELY
6/. MORE THAN 80% OF LIVING CASUALTIES ARE RESCUED BEFORE 24
HOURS
7/. ENTRAPPED PEOPLE SURVIVED SEVERAL DAYS – TO STOP
SEARCHING IS A DIFFICULT DECISION
MAIN STATEMENTS
1/. CONFINED SPACE MEDICINE – AMERICAN
IDEA – NO CHANCE FOR „SCOOP AND RUN
PHILOSOPHY”
2/. A BIG ROLE OF TECHNICAL EQUIPMENT
A/. SEARCHING:
- SENSITIVE LISTENING DEVICES
- THERMAL IMAGING CAMERAS
- FIBEROPTIC CAMERAS
- SEARCHING DOGS
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
B/. SAFETY:
- HAZMAT DETECTING DEVICES
- LIGHTING EQUIPMENT
- PROTECTIVE GEAR
- VENTILATING DEVICES
C/. ACCESS TO THE CASUALTY
- POWERFUL HYDRAUILIC TOOLS
- POWERFUL PNEUMATIC TOOLS AND DEVICES
- ALL TERRAIN VEHICLES
- HEAVY LOAD LIFTING DEVICES
- POWERFUL STABILISATION SYSTEMS
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
3/. CONFINED SPACE ATMOSPHERE
- EXTREMAL TEMPERATURES
- LACK OF OXYGEN ( BELOW 19,5 % - A NEED FOR
SUPPLEMENTAL OXYGEN !)
- CARBON MONOXIDE PRESENCE – OXYGEN SUPPLY
RISK
- FLAMMABLE GASES PRESENCE – OXYGEN SUPPLY RISK
- DUST PLUS ABOVE – OXYGEN SUPPLY RISK
- NEED FOR INSULATING AIRWAYS FROM AMBIENT
ATMOSPHERE
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
4/. SAFETY ACCESS TO THE CASUALTY
-
MANY SURVIVORS ARE EXTRICATED BY
BYSTANDERS BEFORE ARRIVAL OF RESCUERS
-
ALL SAFETY PRECAUTIONS SHOULD BE FOLLOWED:
-
GLOVES
-
HELMETS
-
COVERALLS
-
GOGGLES
-
RESCUE FOOTWEARS
-
SEARCHLIGHTS
-
PERSONAL LOCATING DEVICES
-
LIFELINES
-
RADIO RECEIVERS
-
PUBLIC ADDRESS SYSTEMS
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
5/. CASUALTY ASSESSMENT
INITIAL:
-
BY VOICE CONTACT ONLY
-
BY USE OF FIBEROPTIC CAMERA
FIRST:
-
OFTEN LIMITED ACCESS
-
ALWAYS ABC
DEFINITE ASSESSMENT AND TREATMENT:
-
ABC
-
ANALGESIA
-
INJURY ASSESSMENT AND TREATMENT
-
PSYCHOLOGICAL SUPPORT ( LONG LASTING
EXTRICATION MAY HAPPEN…)
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
6/. MEDICAL PROBLEMS
-
CASUALTIES:
-
HYPOTHERMIA
-
DEHYDRATATION
-
BLOOD LOSS
-
VOMITING
-
ILEUS
-
URINATION
-
DEFECATION
-
CRUSH SYNDROME
-
DIABETES
-
ARRHYTMIA
7/. MEDICAL PROBLEMS –RESCUERS
- HYPERTHERMIA
- HEAT STROKE
- INJURIES
- PSYCHOLOGICAL STRESS
- DEHYDRATATION
- INFECTION
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
8/. CHOSEN PROBLEMS:
- PAIN CONTROL -
ANALGESIA IS A VERY IMPORTANT FACTOR
OF SURVIVAL – SHOULD BE ADMINISTERED AS SOON AS
POSSIBLE WITH APPROPRIATE DOSAGE, INTRAVENOUSLY FOR
BETTER CONTROL
- INFECTIONS –
CONTAMINATED WOUNDS AND AIRBORNE
PULMONARY INFECTIONS – DUST MASKS FOR EVERYBODY AND
ANTIBIOTICS
( CEPHALOSPORINS?) – THE EARLIER- THE BETTER
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
- AIRWAYS/VENTILATION
–
SOMETIMES NEED FOR ENDOTRACHEAL
INTUBATION – MUSCLE RELAXANTS TO BE USED – CAUTION FOR
INTRACRANIAL PRESSURE AND HYPERKALEMIA WHILE USING SCOLINE,
GOOD OPINION OF KETAMINE ANYWAY…
-
„TOMAHAWK APPROACH” – NOT EASY, BUT SOMETIMES THE ONLY
SOLUTION – WAS ANYBODY TRAINED ?
-
NASAL TRACHEAL INTUBATION
-
CRICOTHYROIDOTOMY
-
TRANSTRACHEAL JET INSUFFLATION
-
PORTABLE GAS POWERED VENTILATOR
-
CARBON DIOXIDE DETECTOR
-
PULSE OXIMETER
-
ARDS CONSIDERATION
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
BLAST INJURY
– LIKELY IN TERRORIST ATTACKS
AIR EMBOLISM, TYMPANIC RUPTURE, CARBON MONOXIDE INTOXICATION,
INTESTINAL PERFORATION, TENSION PNEUMOTHORAX, OCULAR INJURIES SPLENIC RUPTURE
, PNEUMOPERITONEUM - WORSE IN CONFINED SPACE
FLUID RESUSCITATION
– ESSENTIAL FOR MANY VICTIMS
TWO 14 G CANNULAS TO BE INSERTED INTO PERIPHERAL VEINS, CENTRAL ACCESS AND/OR
VENOUS
CUTDOWN ARE TOO DIFFICULT AND DANGEROUS FOR ENTRAPPED CASUALTY, BUT
SOMETIMES
NECESSARY…
IN CHILDREN – INTRAOSSEOUS ROUTE TO BE CONSIDERED.
IN CONFINED SPACES PRESSURE INFUSION DEVICES SHOULD BE USED
IN THE RISK OR CONFIRMED HYPOTHERMIA INTRAVENOUS FLUIDS MUST BE WARMED,
OTHERWISE
COULD BE HARMFUL .
BLADDER CATHETERISATION – SHOULD BE CAREFULLY CONSIDERED –
DIURESIS INFO VERSUS THE RISK OF KILLING UROSEPSIS….
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
-
CRUSH INJURY AND CRUSH SYNDROME – „SMILING DEATH”
AMONG VARIOUS ACCIDENTS EARTHQUAKES ARE ASSOCIATED WITH
HIGHEST INCIDENCE OF CRUSH INJURIES. THE SEVERITY OF SYMPTOMS AND
LIFE THREAT DEPEND ON THE AMOUNT OF INJURED MUSCLES. USUALLY THE
MUSCLES OF LOWER LIMBS ARE AFFECTED AND IN FACT THIS INJURY MEANS
TRAUMATIC RHABDOMYOLYSIS AND THE CONTENTS OF DESTROYED
MYOCYTES ARE RELEASED INTO THE BLOOD. POTASSIUM, PHOSPHORUS,
MYOGLOBIN, PROTEOLYTIC ENZYMES ARE AMONG SUBSTANCES THAT MAY
AFFECT THE BODY FUNCTION IF THEIR LEVEL RAISES SUDDENLY. AND IN
FACT, SYMPTOMS APPEAR JUST AFTER RELEASING THE PRESSURE APPLIED
TO THE LIMBS BY THE COLLAPSED ELEMENTS. THE CASUALTY FEELS NO
PAIN IN CRUSHED LIMBS ( THIS IS SIGNIFICANT SYMPTOM) AND IS HAPPY,
SMILING AT APPROACHING RESCUERS. WHILE THE PRESSURE IS RELEASED
TOXIC SUBSTANCES RUSH INTO THE BLOOD STREAM AND MAY CAUSE
SUDDEN DEATH BECAUSE OF VENTRICULAR FIBRILLATION OD ASYSTOLE…..
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
SEVERE HYPERPHOSPHATEMIA AND HYPOCALCEMIA MAY LEAD TO
MYOCARDIAL INSTABILITY. MYOGLOBIN DEPOSIT AND OBSTRUCTION IS A
MAIN FACTOR CAUSING RENAL INSUFFICIENCY, ALSO IRON CAUSES KIDNEY
DAMAGE. THIS ACTIVITY DEPENDS ON THE CONCENTRATION OF THE
SUBSTANCES AND THEREFORE MASSIVE FLUID TRANSFUSION IS
RECOMMENDED. WHILE DIRECTLY CRUSHED CELLS DIE IMMEDIATELY
HYPOVOLEMIA AND ISCHEMIA CAUSE THE MUSCLE CELLS DEATH WITHIN
HOURS. THIS CAUSE THE FLUX OF SUBSTANCES FROM THE CELLS OUTSIDE,
INCREASING TISSUE EDEMA, DECREASING BLOOD FLOW, CAUSING FURTHER
DAMAGE. THE AFFECTED LIMB LOOK NOT TOO BAD, LACK OF PAIN SUGGESTS
SPINAL CORD INJURY ( THE LACK OF „SADDLE ANESTHESIA” AND THE ANAL
SPHINCTER TONE SUGGEST CRUSH INJURY) AND THE PATIENT NEEDS THE
AGGRESIVE FLUID TREATMENT. BEFORE THE RELEASE FROM UNDER THE
PRESSURE APPROX 1500 ML OF NON-ACIDOTIC, CALCIUM FREE FLUID SHOULD
BE ADMINISTER INTRAVENOUSLY AS A BEGINNING OF MASSIVE INFUSION OF
FLUIDS – TO ACHIEVE DIURESIS OF SOME 12 LITERS / 24 HOURS. TO CONSIDER
FASCIOTOMY IS A HOSPITAL PROBLEM
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
MEDICAL PROBLEMS IN
EARTHQUAKES- RESCUE
OPERATION
FIELD AMPUTATION
„TO SAVE A LIFE NOT A LIMB” PHILOSOPHY SOMETIMES LEADS TO THE VERY
DIFFICULT DECISION AS TO THE FIELD AMPUTATION.
THE MAIN INDICATION IS THE EXTERNAL RISK : FURTHER COLLAPSE, FIRE,
HAZARDOUS MATERIALS.
MEDICAL INDICATIONS ARE LIMITED – THE TIME SAVING FOR INTERNAL
BLEEDING TREATMENT – (REASONABLE IN LATE PREGNANCY WITH
PLACENTAL ABNORMALITIES), TO BE DISCUSSED AND DECISION MADE
PREFERABLY BY TWO DOCTORS AND RESCUE TEAM SHARING THE OPINION,
THAT THIS IS THE ULTIMATE SOLUTION.
THE OPERATION IS COMPLICATED IN CONFINED SPACE, BLEEDING CONTROL
IS DIFFICULT AND THE RISK OF INFECTION AND SEPSIS IS VERY HIGH.
THE APPROPRIATE ANALGESIA/ANESTHESIA IS A PROBLEM AND FIRST
RESPONDING GROUPS USUALLY DO NOT HAVE APPROPRIATE INSTRUMENTS…
IN EXTREME SITUATIONS HYDRAULIC TOOLS FROM FIRE SERVICE MAY BE
USED
PSYCHOEMOTIONAL CONSIDERATIONS
FOR ENTRAPPED PERSON THE RESCUER MAY BE THE ONLY CONTACT WITH
EXTERNAL WORLD. THEREFORE THE EMPATHY AND UNDERSTANDING ARE
VERY IMPORTANT. HOWEVER RESCUERS ARE EXPOSED TO MANY STRESSING
FACTORS AND DEHYDRATATION, HUNGER AND OVERLOADING MAY
CONTRIBUTE TO DESTROY THE EMOTIONAL STABILITY.
ALL MEMBERS OF MEDICAL TEAM MUST UNDERSTAND THE NEED AND
IMPORTANCE OF STRESS DEBRIEFING AND DEFUSING
MAJOR EARTHQUAKES ARE DISASTERS THAT OFTEN
AFFECT
PUBLIC HEALTH INFRASTRUCTURE. BELOW ARE SOME
INDICATIONS AS TO THE BASIC REQUIREMENTS THAT
SHOULD
BE CONSIDERED WHILE PREPARING DISASTER RESPONSE
PLAN
FOR THOSE, WHO SURVIVED:
WATER: 15 L/ PERSON/DAY
MINIMUM: 3-6 L
WITH HYGIENE: 20 L
FEEDING CENTRES: 25 – 30 L
HEALTH CENTRES: 60 L
FIELD HOSPITALS: 150 – 310 L
FOOD: 1900 – 2000 KCAL/PERSON/DAY
MINIMUM: 1900 KCAL/PERSON/DAY
1500 TONS OF FOOD FEEDS 1 MILLION PEOPLE FOR 1 MONTH
GRAIN: 85%, VEGETABLE OIL: 3%, BEANS/PROTEIN: 12%
MEDICAL PROBLEMS IN
EARTHQUAKES - PUBLIC HEALTH
MEDICAL PROBLEMS IN
EARTHQUAKES - PUBLIC HEALTH
SHELTER:
MINIMUM LIVING CONDITIONS: 3,5 SQUARE METER FLOOR AREA PER
PERSON
MINIMUM OF WHOLE CAMP SETTLEMENT: 30 SQUARE METER PER
PERSON
TENTS: FAMILY, 6 PERSONS, FIRE RESISTANT, LOW COST
BLANKETS: 1/PERSON ( WOOL/COTTON)
PLASTIC SHEETING: 1/HOUSEHOLD
WATER CONTAINERS: 1/HOUSEHOLD ( 5 GALLONS)
COOKING POTS: 2/HOUSEHOLD ( WITH LIDS)
POT STIRRER: 1 / HOUSEHOLD
SOAP: 200 GR/PERSON/MONTH
MATCHES: CRITICAL ITEM
SANITATION- MINIMUM FOR PUBLIC: 1 LATRINE/50 PERSONS
OPTIMAL: 1 LATRINE/20 PERSONS, MIN 15-30 MTRS FROM WATER
SOURCE – DEPENDING ON SOIL
FUEL: 1 KG OF WOOD/PERSON/DAY, 5-10 KG/HOUSEHOLD/DAY
MEDICAL PROBLEMS IN
EARTHQUAKES - PUBLIC HEALTH
IF THE RESOURCES ARE BELOW THE REQUIREMENTS
LISTED ABOVE PUBLIC IS EXPOSED TO A RISING RATE
OF MORBIDITY AND MORTALITY CAUSED BY NON-
TRAUMA FACTORS.
ALTHOUGH PROBLEMS OF EVERYDAY EXISTENCE
AFTER THE EARTHQUAKE ARE NOT PURE
EMERGENCY/RESCUE ISSUES THEY SHOULD BE
DISCUSSED TOGETHER WITH EMERGENCY PLANS.
MULTIDISCIPLINARY APPROACH IS AN ESSENTIAL
PART OF THE EFFECTIVE EMERGENCY/RESCUE
PHILOSOPHY AND IN FACT EVERYBODY SHOULD BE
INVOLVED AS EVERYBODY COULD BE AFFECTED.