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.

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

12. Earth, Wind, Water and Fire

13. Fire

14. Snow ?

15. Required Reading:
Sheri Fink’s Five Days at Memorial

16. Man-Made Disasters
 Accidents

17. Chemical Accidents

18. Man-Made Disaster: IED

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

21. Blast Pressure Waves

22. Signs & Symptoms of BLI
 Hypoxemia (P/F <200)
 “Butterfly” pattern on CXR
 Tachypnea
 Low Vt
 Restrictive defect
 Low Compliance
 R/O Hemothorax/pneumothorax
 Wheezing

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

24. Pandemic

26. The 400 pound gorilla in the Room

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)