3-杜斌-资源匮乏国家发生的大规模灾害事件：如何建立救治团队和进行适当的诊疗

MassCasualtyinResource-LimitedCountries:HowtoPrepareCareTeamsandHowtoDeliverAppropriateManagementBinDu,MDMedicalIntensiveCareUnitPekingUnionMedicalCollegeHospitalConflictsofInterestNoneDefinitionofMassCasualtyIncidentAsituationthatPlacesasignificantdemandonmedicalresourcesandpersonnelOften,butnotnecessarily,associatedwithdisastersBydefinition,duringadisaster,localresponsecapacitiesareoverwhelmedEvenwithoutadisasterwhenlocalresponsecapacitiesareintact,therearestillalargenumberofpatientsrequiringtriageLeeCH.Disasterandmasscasualtytriage.VirtualMentor2010;12:466-470MassCasualtyIncidentsNaturaldisastersAccidentsRoadtrafficaccidentsBlastsChemicalhazard…EpidemicsofinfectiousdiseasesTerrorismattacksWarfarePersonalExperiencewithMassCasualtyYearEventPatientPopulation2003BeijingSARSepidemicViralpneumonia2005StreptococcussuisepidemicSTSS,bacterialmeningitis2008WenchuanearthquakeMultipletrauma2009InfluenzaA/H1N1pandemicViralpneumonia2010Yushu

earthquakeMultipletrauma2010ZhouqudebrisflowMultipletrauma2013AvianinfluenzaA/H7N9epidemicViralpneumonia2013LushanearthquakeMultipletrauma2014KunshanfactoryblastSevereburns2015TianjinexplosionBlastinjuryNaturalDisastersin2013Guha-SapirD,HoyoisP,BelowR.AnnualDisasterStatisticalReview2013:TheNumbersandTrends.Brussels:CRED;2014.Availableathttp://www.cred.be/sites/default/files/ADSR_2013.pdfaccessedAugust26,2015CRED*

FactSheet330naturaltriggereddisastersregisteredlessthantheaverageannualdisasterfrequencyfrom2003to2012(388)21,610peoplekilled96.5mpeopleaffected$118.6beconomicdamages*CentreforResearchontheEpidemiologyofDisasters(CRED)WorldBankListofEconomies(2011)PeopleAffectedbyDisasters1975to200443%41%5%HurricaneKatrinaAugust28,2005HurricaneKatrinaAugust28,2005HurricaneKatrinaAugust28,2005EvacueescrowdtheflooroftheAstrodomeinHoustononSeptember2,2005.Thefacilityhoused15,000refugeeswhofledthedestructionofHurricaneKatrina.LondonBombingsJuly7,2005AylwinCJ,KönigTC,BrennanNW,etal.Reductionincriticalmortalityinurbanmasscasualtyincidents:analysisoftriage,surge,andresourceuseaftertheLondonbombingsonJuly7,2005.Lancet2006;368:2219-2225775peopleinjured,including55severelyinjured(Priority1&2),667walkingwounded(P3)patients,and53deathsatscene(P4)P1&P2P3P4LondonBombingsJuly7,2005AylwinCJ,KönigTC,BrennanNW,etal.Reductionincriticalmortalityinurbanmasscasualtyincidents:analysisoftriage,surge,andresourceuseaftertheLondonbombingsonJuly7,2005.Lancet2006;368:2219-2225LimitedResourcesasaUniversalProblemPoorfunctionalstatusoflocalhospitalsPossibilityofcollapsefromaftershockInfrastructuredamagePower,transportation,watersupply,telecommunicationDaystoweeksUnavailabilityofwell-equippedandself-sustainablemobilehospitals1.LlewellynM.Floodsandtsunamis.SurgClinNAm2006;86:557-578.2.SeverMS,VanholderR,LameireN.Managementofcrush-relatedinjuriesafterdisasters.NEnglJMed2006;354:1052-1063.3.CurrierM,KingDS,WoffordMR,etal.AKatrinaexperience:lessonslearned.AmJMed2006;119:986-992.4.NajafiI,vanBiesenW,SharifiA,etal.Earlydetectionofpatientsathighriskforacuteinjuryduringdisasters:developingofascoringsystembasedontheBamearthquakeexperience.JNephrol2008;21:776-782.5.KoppJB,BallLK,CohenA,etal.Kidneypatientcareindisasters:Lessonsfromthehurricanesandearthquakeof2005.ClinJAmSocNephrol2007;2:814-824LimitedResourcesasaUniversalProblemHealthcareResourcesStatusAfterYushuEarthquakeHospitalsGeneralHospitalTibetanMedicineHospitalWomenandChildrenHospitalNonfunctionalduetoBuildingcollapseInfrastructuredamageHealthcareworkers148physicians238assistantphysicians121nurses76(15.0%)injured10(2.0%)diedLimitedResourcesasaUniversalProblemGeorgeW.Bush:HurricaneKatrinaas“oneoftheworstnaturaldisastersinourNation’shistory”NoinhabitablestructuresObliteratedentirecoastalcommunitiesPoweroutagesin2.5millioncustomersDestroyedlocalcommunicationssystemBlockedandcollapsedwaterwaysandhighwaysIncapacitatingtelephoneservice,policeandfiredispatchcentersDestroyedand/orinoperablehealthcarefacilitiesTheWhiteHouse.ThefederalresponsetohurricaneKatrina:lessonslearned.ChapterFour:AweekofCrisis(August29-September5).Availableat/reports/katrina-lessons-learned/chapter4.htmlaccessedAugust25,2015LimitedResourcesasaUniversalProblemGreatdifficultywithFederalresourcemanagersKnowledgeWhatresourceswereneededWhatresourceswereavailableWherethoseresourceswereatanygivenpointintimeSourcingFederalgovernmentassetoralternativesourcesAllocationNoeffectivemechanismforefficientintegrationanddeployTheWhiteHouse.ThefederalresponsetohurricaneKatrina:lessonslearned.ChapterFive:Lessonslearned.Availableat/reports/katrina-lessons-learned/chapter5.htmlaccessedAugust25,2015MedicalCareDuringMassCasualtyMassCasualtyResponseSearchandRescueTriageandInitialStabilizationDefinitiveMedicalCareEvacuationLlewellynM.Floodsandtsunamis.SurgClinNAm2006;86:557-578InjuryPatternandTypeofDisasterearthquakehurricanesandfloodsManydeathsManydeathsduetodrowningManysevereinjuriesrequiringcomplexsurgicalandresuscitativemedicalcareFewseriousmedicalorsurgicalinjuriesAlarge,unmetneedforcomplexsurgicalandmedicalcareduetodevastatinglocalcapacityOftennooverloadontheexistingcurativemedicalsystemBartelsSA,VanRooyenMJ.Medicalcomplicationsassociatedwithearthquakes.Lancet2012;379:748-757InfectiousDiseasesAfterDisastersearthquakehurricanesandfloodswoundinfectionnecrotizingfasciitisaspirationpneumoniatetanuscholeramalariadenguefevertuberculosisFatalitiesAfterEarthquakeSevereTBISpinalcordinjuryunsaveableatsceneSubduralhematomaLiverorspleenlacerationsPelvicfracturesprompttreatmentwithinthefirstseveralhoursSepsisMultisystemorganfailureDICdaystoweeksBartelsSA,VanRooyenMJ.Medicalcomplicationsassociatedwithearthquakes.Lancet2012;379:748-757CasualtiesAfterWenchuanEarthquakeZhangL,LiuX,LiY,etal.Emergencymedicalrescueeffortsafteramajorearthquake:lessonsfromthe2008Wenchuanearthquake.Lancet2012;379:853-861AcuteInjuriesinNaturalDisastersAmongatotalof1,723patientsadmittedto3generalhospitalsinSichuan,ChinaWithintheinitial5daysafterWenchuanEarthquakeZhangL,LiH,CarltonJR,etal.Theinjuryprofileafterthe2008earthquakesinChina.Injury2009;40:84-86Injury%Lowerextremities36%Head18%Upperextremities13%Multiplesites10%AcuteInjuriesinNaturalDisastersNonsurvivors(n=36)Survivors(n=144)Total(n=180)Extremityfracture8(22%)81(56%)89(49%)Trunkfracture10(28%)52(36%)62(34%)Thoracicinjury9(25%)17(12%)26(14%)SevereTBI10(28%)7(5%)17(9%)Abdominalinjury6(17%)5(3%)11(6%)Infection19(53%)29(19%)47(26%)Acuterenalfailure8(22%)5(3%)13(7%)MSOF12(33%)1(1%)13(7%)Crushsyndrome5(14%)3(2%)8(4%)WenJ,ShiYK,LiYP,etal.Riskfactorsofearthquakeinpatientdeath:acasecontrolstudy.CritCare2009;13:R242010YushuEarthquake,ChinaFactSheetYushuCounty,QinghaiProvince4,493maveragealtitude357,267populationin2009BatangAirportsince2009No214NationalHighwayUntilMay302,698dead270missing12,135injuredOutpatientClinicAfterYushuEarthquakeApril14toApril202,521patients(85.4%)April21toApril30424patients(14.6%)MedicalProblemsAfterDisastersHurricaneAndrewTropicalStormAllisonHurricaneKatrinaBahamas,1992Texas,2001Louisiana,20055

injuriesdirectlycausedbythehurricane48.9%

(507/1036)“generalmedicine”22.4%(232/1036)“trauma”43%triagedtothepharmacyunitonly55%triagedtothemedicalunit2%receiveddentalcareAlsonR,AlexanderD,LeonardRB,etal.AnalysisofmedicaltreatmentatafieldhospitalfollowingHurricaneAndrew.AnnEmergMed1993;22:1721-1728D’AmoreAR,HarinCK.AirForceExpeditionaryMedicalSupportUnitattheHoustonflood:useofamilitarymodelinciviliandisasterresponse.MilMed2005;170:103-108CurrierM,KingDS,WoffordMR,etal.AKatrinaexperience:lessonslearned.AmJMed2006;119:986-992MedicalProblemsAfterHurricaneKatrinaMostcommonmedicalproblems(56.9%ofvisits)Hypertension/cardiovasculardiseasesDiabetesNewpsychiatricconditionsOnsiterecordedprescriptionsCardiovascularmedications(30.8%of4,902prescriptions)LlewellynM.Floodsandtsunamis.SurgClinNAm2006;86:557-578CurrierM,KingDS,WoffordMR,etal.AKatrinaexperience:lessonslearned.AmJMed2006;119:986-992Disease/InjuryPatternsAfterEarthquakeMusculoskeletalinjuriesLacerations(65%)Fractures(22%)Soft-tissuecontusionsorsprains(6%)Crushsyndrome(2–15%)Chestinjuries(13–67%)NeurologicalproblemsSpinaltraumaTraumaticbraininjuryCardiovascularsystemAcutemyocardialinfarctionsCardiacarrhythmiasInfectiousdiseasesWoundinfectionsRespiratoryillnessWater-borneillnessMentalhealthDepression(6–72%)PTSD(3.3–81%)HematologyMassivetransfusionBartelsSA,VanRooyenMJ.Medicalcomplicationsassociatedwithearthquakes.Lancet2012;379:748-757SpecialConditionsinYushuEarthquakeYushuResident(n=2650,89.7%)DisasterRelief(n=245,8.3%)Age,year36.1±17.731.2±9.0Malesex49.9%(1322)95.9%(235)Earthquake-relatedtrauma88.3%(2340)12.2%(30)Nontraumadiseases11.8%(310)87.8%(215)Highaltitudeillness0.4%(10)78.4%(192)RenalDisasterAfterEarthquakeSeverMS,VanholderR,LameireN.Managementofcrush-relatedinjuriesafterdisasters.NEnglJMed2006;354:1052-1063RenalDisasterAfterWenchuanEarthquakeSeverMS,VanholderR,LameireN.Managementofcrush-relatedinjuriesafterdisasters.NEnglJMed2006;354:1052-1063RenalDisaster69,227deaths760crushsyndrome480dialysis1,857hospitalizations7.7%(147)crushsyndrome4.2%(78)dialysisDatafromWestChinaHospitalDatafromMOH96,544hospitalizationsRenalDisasterAfterNaturalDisastersRiskofcrushsyndromeand/oracuterenalfailureTypeofdisasterEarthquakevs.floods/tsunamisRescueabilityTimeofdisasteronsetMaterialsofthebuildingConcretevs.masonryvs.adobeSeverityandrapidityofbuildingcollapseRoyN,ShahH,PatelV,CoughlinRR.TheGujaratearthquakeexperienceinaseismicallyunpreparedarea:communityhospitalmedicalresponse.PrehospitalDisasterMed2001;17:186-195InternationalSocietyofNephrology.TheAsiaquake—ISN’saidinaction./isn/news/press_room/2005/0510/full/press_051014_1.html(accessedApril1,2009)SeverMS,ErekE,VanholderR,etal.TheMarmaraearthquake:epidemiologicalanalysisofthevictimswithnephrologicalproblems.KidneyInt2001;60:1114-1123AlexanderD.Localplanningbeatsforeigndogs.ReutersAlertNet,London,December30,2003./thefacts/reliefresources/107279716149.htm.(AccessedApril1,2009)GoldfarbDS,ChungS.Theabsenceofrhabdomyolysis-inducedrenalfailurefollowingtheWorldTradeCentercollapse.AmJMed2002;113:260BuildingMaterialsandFatalitiesNeedforSpecialistsAfterEarthquakeSurgeryOrthopedicsurgeonNeurosurgeonGeneralsurgeonsCardiothoracicsurgeonUrologist…MedicinePhysicianIntensiveCareIntensivistWeeksafterearthquake0124SurgeCapacityPredictionforMassCasualtyAbirM,DavisMM,SankarP,etal.Designofamodeltopredictsurgecapacitybottlenecksforburnmasscasualtiesatalargeacademicmedicalcenter.PrehospDisasterMed2013;28:23-32TriageBurn/TraumaIntensiveCareUnit(10beds)averagedailyoccupancy82%SurgicalStep-DownUnit(6beds)averagedailyoccupancy100%SurgeryWard(64beds)averagedailyoccupancy88%OperatingRooms(50)HOSPITALDischargevs.DeathMCIDischargevs.Death100burnspatientsnoburns2%2°burns24.5%3°burns73.5%Indoorfire0–30%TBSA>80%TBSARateofarrival1every3minSurgeCapacityBottleneckforMassCasualtyAbirM,DavisMM,SankarP,etal.Designofamodeltopredictsurgecapacitybottlenecksforburnmasscasualtiesatalargeacademicmedicalcenter.PrehospDisasterMed2013;28:23-3221admissionswithin120minafterarrivalofthefirstcasualty8ICUbedsnoICUpatientsdischargeableortransferrablesurgicalstep-downunitsevacuatedandconvertedtoICUwithin30minutes13surgerywardbeds00.52464876100168HoursafterfirstcasualtyarrivalatthehospitalRinger’sLactate279LSilverSulfadiazine38x400gtubesAlbumin123LPRBCAB2LSilverdressing768Gauzebandage1188rollsMassCasualtyinChinaFactoryBlast2August2014Lastupdatedat14:58ChinafactoryexplosioninJiangsu'killsatleast68'BBCNews.ChinafactoryexplosioninJiangsu‘killsatleast68’./news/world-asia-china-28619248accessedFebruary26,2015MassCasualtyinChinaFactoryBlastAll(n=167)Survivors(n=105)Non-Survivors(n=62)Totalburnsurfacearea(%)95

(87–98)91

(70–95)97.5

(95–99)Full-thicknessburnsurfacearea(%)82

(40–94)70

(25–90)91

(80–97)Bauxscore145

(134–155)140

(119–151)153

(145–158)Septicshock70%

(116)60%

(63)86%

(53)ARDS90%

(150)84%

(88)100%

(62)AKI-III53%

(88)30%

(31)92%

(57)CourtesyofDr.YingziHuang,andDr.HaiboQiufromDepartmentofCriticalCareMedicine,ZhongdaHospital,SoutheastUniversityHighRiskGroupinNaturalDisastersGeneralExtremesofageOver60yearsBetween5and9yearsChronicillnessEarthquakeEntrapmentOccupant’slocationwithinabuildingOccupant’sbehaviorduringtheearthquakeTimeuntilrescueBriggsSM.Earthquakes.SurgClinNAm2006;86:537-544HighRiskGroupinNaturalDisasterFactorOR(95%CI)SevereTBI253.3

(8.9to7208.6)0.001MSOF87.8(3.9to1928.3)0.005Comorbidity14.9(1.9to119.0)0.011Infection13.7(1.8to103.7)0.011WenJ,ShiYK,LiYP,etal.Riskfactorsofearthquakeinpatientdeath:acasecontrolstudy.CritCare2009;13:R24SimpleTriageandRapidTreatmentSchultzCH,KoenigKL,NojiEK.Amedicaldisasterresponsetoreduceimmediatemortalityafteranearthquake.NEnglJMed1996;334:438-444STARTAlgorithmforMassCasualtyTriageSimpletriageandrapidtreatment(START)Redsensitivity100%Greenspecificity89%Obuchowskistatistic0.81,meaningthatvictimsfromahigher-acuityoutcomegrouphadan81%chanceofassignmenttoahigher-acuitytriagecategoryKahnCA,SchultzCH,MillerKT.DoesSTARTtriagework?Anoutcomeassessmentafteradisaster.AnnEmergMed2009;54:424-430MassCasualtyTriageafterAirplaneCrash126survivingcasualtiesin14admittinghospitals(distancefromcrash:5.8–53.5km)133–213%oftreatmentcapacityin4hospitals89%ofcriticalcasualtiesinlevelItraumacenters3secondarytransfers0%mortalityratePostmaILE,WeelH,HeetveldMJ,etal.Patientdistributioninamasscasualtyeventofanairplanecrash.Injury,IntJCareInjured2013;44:1574-1578VictimEvacuationAfterYushuEarthquakeVictimEvacuationAfterYushuEarthquake*of2953patientsevacuateduntilApril30,2464(83.4%)weretransferredbyflightFlighttransfervs.air-medicalevacuationNoskilledtransportteamNospeciallydesignedormodifiedaircraft/helicopterNoin-transitcriticaleventsLowriskpatientpopulationMaterialofthebuildingsFewcrushsyndromes(2.8%vs.4.4-6.1%)Veryfewfatalities(0.5%)VictimEvacuationAfterYushuEarthquakeEarthquakeVictimEvacuationPatientSurgeinBackupHospitalsWestChinaHospital(WCH)Thelargeststate-levelanduniversityhospitalintheearthquake-affectedarea4,300bedswith64operatingrooms66ICUbedsPatientvolumefromJantoApril,2008Dailyhospitaladmissions322±167Dailyhospitalizedpatients3,928±567Dailyoperations135±91May12toJune11,20082,529patientstransferredtoWCH1,857admissions610transfers62dischargesMay12,2008Arrivaloffirstcaseon15:39hr141emergencyvisits34admissionsMay14,2008300emergencyvisits197admissionsMay21&26,2008170&152admissionsDailyOperationsinWCHWorldLoadinICU,WCHPredefinedHospitalPlanforMassCasualtyShahAA,RehmanA,SayyedRH,etal.Impactofapredefinedhospitalmasscasualtyresponseplaninalimitedresourcesettingwithnopre-hospitalcaresystem.InjuryIntJCareInjured2015;46:156-161PredefinedHospitalPlanforMassCasualtyShahAA,RehmanA,SayyedRH,etal.Impactofapredefinedhospitalmasscasualtyresponseplaninalimitedresourcesettingwithnopre-hospitalcaresystem.InjuryIntJCareInjured2015;46:156-161PredefinedHospitalPlanforMassCasualtyShahAA,RehmanA,SayyedRH,etal.Impactofapredefinedhospitalmasscasualtyresponseplaninalimitedresourcesettingwithnopre-hospitalcaresystem.InjuryIntJCareInjured2015;46:156-161March3,201370blastvictimspresentedtoEDNonereceivedfluidresuscitationorBLSduringtransit4pronouncedeadonarrival71%penetratingshrapnelinjury38patientsunderwentsurgeriesinOR14patientsadmittedtothespecialcareunit6patientsadmittedtoICU0fatalityLoadIndexModelforDecisionMakingLoadparametersOccupancyofORs/surgecapacityofORsSevere/moderatecasualtiesadmittedtosurgicaldepartmentsinthelast24h/no.physiciansSevere/moderatecasualtiesadmittedtosurgicaldepartmentsinthelast24h/ICUbedsSevere/moderatepatientshospitalizedinsurgicaldepartments/no.ICUphysiciansSevere/moderatepatientshospitalizedinsurgicaldepartments/no.surgeonsAdiniB,Aharonson-DanielL,