This document summarizes the key points from a seminar on disaster management. The seminar covered definitions of disasters, types of disasters, common features of major disasters, principles of organizing relief efforts and triage, the role of field hospitals, and treatment of conditions caused by disasters. It discussed organizing relief sequentially through establishing command, damage assessment, rescue operations, triage, evacuation, and definitive medical management. Safety of relief workers, media relations, and documentation were also addressed.

1. WELCOME TO WEEKLY SEMINAR
ON
DISASTER MANAGEMENT
Chairperson:
Prof. Md. Ashraf Uddin
FCPS (Surgery)
Professor & head of the department
of surgery, MMCH.
Speaker:
Dr. S. M. Sufi Shafi- Ul- Bashar
Assistant Registrar
Surgery unit-1,MMCH

2. To recognise and understand:
1. The common features of various disasters.
2. The principles behind the organisation of the
relief effort and of triage in treatment and
evacuation.
3. The role and limitations of field hospitals
4. The features of conditions peculiar to disaster
situations and their treatment.

3. WHAT IS DISASTER?
According to WHO-
“A disaster can be defined as any occurrence that
cause damage, ecological disruption, loss of human
life, deterioration of health and health services on a
scale, sufficient to warrant an extraordinary
response from outside the affected community or
area”.

4. WHAT IS DISASTER? CONTD.
According to American Red Cross (ARC)-
“A disaster can be defined as an occurrence either
nature or manmade that causes human suffering
and creates human needs that victims cannot
alleviate without assistance”.

5. WHAT IS DISASTER MANAGEMENT?

6. TYPES OF DISASTER.

7. COMMON FEATURES OF MAJOR DISASTERS.
 Massive casualties
 Damage to infrastructure
 A large number of people requiring shelter
 Panic and uncertainty among the population
 Limited access to the area
 Breakdown of communication

8. PICTURE OF DAMAGE TO EMERGENCY MEDICAL
SERVICES.

9. FACTORS INFLUENCING RESCUE AND RELIEF EFFORTS.
 Status of communications
 Location, whether rural or urban
 Accessibility of the location
 Time-frame in which disaster occurs
 Economic state of development of the area

10. SATELLITE IMAGE SHOWING DESTRUCTION OF A BRIDGE
AS A RESULT OF FLOOD.

11. SEQUENCE OF THE RELIEF EFFORT IN MAJOR DISASTERS.
 Establish chain of command
 Set up lines of communication
 Carry out damage assessment
 Mobilise resources
 Initiate rescue operation
 Triage casualties
 Start emergency treatment
 Arrange evacuation
 Start definitive management

12. ORGANISATION CHART FOR DISASTER MANAGEMENT.

13. TIME-LINE SHOWING THE TYPE OF INJURIES ENCOUNTERED
AT DIFFERENT TIMES IN A DISASTER.

14. SAFETY OF THE HELPERS.
Rescue and relief workers are a diverse group of volunteers
and may have little experience of dealing with the breakdown
in civil order that occurs in the wake of disasters. It is not
uncommon to encounter mobs looting stores of food and other
essentials, especially if help has arrived late. This results in
injuries, occasionally serious, to personnel trying to provide an
equitable distribution of goods. It is therefore imperative that
the local authorities make it a point to safeguard the lives and
property of aid workers to allow them to work without duress
and fear.

15. PICTURE OF OXFAM AND THE INTERNATIONAL COMMITTEE OF THE
RED CROSS PROVIDE GENERALISED RELIEF.

16. DEALING WITH THE MEDIA.
Disasters act like a magnet for the news media and, in today’s
world of 24-hour news coverage, it exerts a powerful influence in
shaping public opinion. It is frequently accused of dramatising
situations and emphasising the inadequacies of the relief effort.
Aid workers may find dealing with the media difficult as their
priorities are rightly different. Nevertheless, it is essential to
establish a working relationship between the two groups. With
careful handling, the media can become a powerful ally and play
a constructive role in identifying problems, galvanising aid and
keeping the public informed.

17. TRIAGE.
Derived from the French verb ‘trier’, triage means ‘to sort’ and
has been the cornerstone of the management of mass casualties
since the Napoleonic Wars. It aims to identify the patients
who will benefit the most by being treated the earliest, ensuring
the greatest good for the greatest number. In a broader sense, it
determines who will be treated first, what mode of evacuation is
best and which medical facility is optimal for the management of
the patient.

18. TRIAGE CONTD.
Numerous studies show that only 10–15 per cent of
disaster casualties are serious enough to require hospitalisation.
By sorting out the minor injuries, triage lessens the immediate
burden on medical facilities. Deciding who should receive
priority when faced with hundreds of seriously injured victims
is a daunting prospect. Senior doctors tend to believe that their
services are better utilised in the actual management of patients,
rather than in triage. This is a mistake and it is crucial that this
task be undertaken by someone senior, who has the training
and experience, and authority to make these critical decisions.

19. TRIAGE AREAS.
For efficient triage, the injured need to be brought together
into any undamaged structures that can shelter a large number
of wounded. Examples are school buildings and stadia. A good
water supply, lighting and ease of access are useful. Separate
areas should be reserved for patient holding, emergency treatment
and decontamination (in the event of discharge of hazardous
materials). An area should also be designated to serve
as a morgue, preferably a little removed from the holding and
treatment areas.

20. PRACTICAL TRIAGE.
Emergency life-saving measures should proceed alongside triage
and actually help the decision-making process. The assessment
and restoration of airway, breathing and circulation are critical.
A simple visual check of the injuries of each casualty
is notoriously unreliable. Vital signs and a general physical
examination should be combined with a brief history taken
by a paramedic, or volunteer worker if one is available.

21. REVERSE TRIAGE.
Usually, triage refers to prioritising admission. A similar process can
be applied to discharging patients early when the medical system is
stressed. This process has been called "reverse triage". During a
"surge" in demand, such as immediately after a natural disaster,
many hospital beds will be occupied by regular non-critical patients.
In order to accommodate a greater number of the new critical
patients, the existing patients may be triaged, and those who will not
need immediate care can be discharged until the surge has
dissipated, for example through the establishment of temporary
medical facilities in the region.(Wikipedia)

22. DOCUMENTATION FOR TRIAGE.
Accurate documentation is an inseparable part of triage and
should include basic patient data, vital signs with timing, brief
details of injuries (preferably on a diagram) and treatment
given. In addition, a system of colour-coded tags attached to the
patient’s wrist or around the neck should be employed by the
emergency medical services. The colour denotes the degree of
urgency with which a patient requires treatment

23. TRIAGE TAG( AMERICAN CIVIL DEFENSE ASSOCIATION).

24. TRIAGE TAG (DISASTER MANAGEMENT SYSTEMS).

25. A COMMONLY USED FOUR-TIER SYSTEM IS PRESENTED IN TABLE.
Priority Colour Medical
need
Clinical status Examples
First (І) Red Immedi-
ate
Critical, but likely to
survive if treatment
given early
Severe facial trauma,
tension pneumothorax,
Flail chest, major intra
abdominal bleeding,
Extradural haematoma
Second
(ІІ)
Yellow Urgent Critical, but likely to
survive if treatment
given with in hours
Compound fractures,
degloving injuries, ruptured
abdominal viscus,
Pelvic fractures, spinal
injuries
Third (ІІІ) Green Non
urgent
Stable ,likely to
survive even if
treatment is delayed
for hours to days
Simple fractures, sprains,
Minor lacerations
Last (0) Black Unsal-
vageable
Not breathing,
pulseless, so severely
injured that no
medical care like to
help
Severe brain damage, very
extensive burns, major
disruption/loss of chest or
abdominal wall structures

26. TRIAGE CATEGORIES.
All methods of triage use simple criteria based on vital signs. A
rapid clinical assessment should be made taking into account the
patient’s ability to walk, their mental status and the presence or
absence of ventilation or capillary perfusion. Triage carries serious
consequences, especially for patients who are consigned to the
unsalvageable category. It should be carried out with compassion,
but should also be quick, clear and decisive.

27. ESSENTIALS OF CASUALTY EVACUATION
 Retriage to upgrade priorities among the injured.
 Select appropriate medical facilities for transfer.
 Choose appropriate means of transport.
 Prevent the ‘second accident’ during transfer.
 Ensure an adequate supply of materials to accompany the patient.

28. PICTIRE OF HELI-EVACUATION.

29. FIELD HOSPITALS
The need for field hospitals depends upon the location, the
number of casualties and the speed with which evacuation can
be organised. The two basic types of field hospitals are the
traditional tented structure and the modular type housed in
Containers. The modular type is self-contained and can
be operational as soon as it reaches the disaster area, but the
containers are heavy and require an intact road or rail link.

30. FIELD HOSPITALS CONTD.
The tented structures require an initial period of setting up, but they
are very portable and the components can be carried in small vehicles
or air dropped. Whichever type is chosen, the facility must be
equipped with an x-ray plant, operating rooms, vital signs monitors,
sterilising equipment, a blood bank, ventilators and basic
laboratory facilities.

31. PIC OF FIELD HOSPITALS

32. PIC OF FIELD HOSPITALS
MODULAR TYPE

33. PIC OF FIELD HOSPITALS
TENTED STRUCTURES

34. PIC OF FIELD HOSPITALS
INTERIOR OF A TENTED FIELD HOSPITAL

35. MANAGEMENT IN THE FIELD HOSPITAL
Type of
treatment
Example Further
First aid Suturing cuts and
lacerations,splinting simple
fractures
Review at local hospital
Emergency
care of life
threatening
injuries
Endotracheal intubation,
tracheostomy, relieving
tension pneumothorax,
Stopping external
haemorrhage,relieving an
extradural
haematoma,emergency
thoracotomy, laparotomy for
internal haemorrhage
After damage control
surgery,transfer patient
to base hospitals once
stable
Initial care for
non life
threatening
injuries
Debridement of
contaminated wound,
reduction of fracture and
dislocations,application of
external fixators,vascular
repair
Transfer patient to base
hospitals for definitive
management

36. DAMAGE CONTROL SURGERY
Damage control surgery is the concept that in the temporary
surgical facility closest to the injured, only the minimum amount
of surgery should be performed to allow safe transfer of a patient
to a definitive treating facility.

37. PRINCIPLES OF DAMAGE CONTROL SURGERY
 Do the minimum needed to allow safe transfer to definitive facility
 Take actions which prevent deterioration of that patient
during transfer
 Secure the airway (tracheostomy?)
 Control bleeding (craniotomy, laparotomy, thoracotomy,
repair major limb vessels?)
 Prevent pressure build up (burr holes, chest drain,
laparotomy, fasciotomy?)
 Prevent infection by extensile exposure and removing dead
and contaminated tissue

38. PRINCIPLES OF DEBRIDEMENT AND INITIAL WOUND CARE
 Obtain generous exposure through skin and fascia
 Identify neurovascular bundles
 Excise devitalised tissue
 Remove foreign bodies
 Repair major vessels
 Obtain skeletal stabilisation with external fixators
 Only tag tendons and nerves which have been cut
 Leave the wound open and delay primary closure
 Avoid tight dressings
 Elevate the injured limb

39. DEFINITIVE MANAGEMENT
Definitive management is undertaken at major hospitals. They
should be given as much notice as possible as to the expected
number of casualties so that the staff are prepared. The hospitals
to which casualties are sent should be selected on the basis of
the facilities available and the number of injured that they can
handle.

40. DEFINITIVE MANAGEMENT CONTD.
The actual number of beds available is seldom a good
guide to capacity, as the ancillary resources required for trauma
patients are more than for the typical case mix of a hospital. A
rule of thumb is that only half the bed strength of a hospital can
be utilised to provide optimum trauma care in an emergency
situation.

41. HOSPITAL REORGANISATION
In hospitals receiving mass casualties during disasters, some
reorganisation of services is unavoidable. This includes transferring
patients with non-urgent conditions to other facilities,
augmenting surgical services, reorganising the specialist rotation
and redesignating medical wards as surgical care areas to accommodate
the patient load. A quick check of hospital inventories
should be undertaken to ensure availability of essential equipment
and medicines. An appeal for blood donations should be broadcast.

42. SOME SPECIFIC ISSUES
 Limb salvage
 Facial injuries
 Tetanus
 Necrotising fasciitis
 Gas gangrene
 Blast injuries
 Crush syndrome

43. LIMB SALVAGE
The Mangled Extremity Severity Score (MESS) and its modifications
are useful in making a judgement about limb salvage.
In the past, extensive tissue loss, neurovascular damage and
loss of long fragments of bone were all considered indications
for amputation. Currently, with the use of microvascular flaps,
wounds of any dimension can be covered with healthy tissue in
a single stage. If performed in time, vascular repairs can salvage
most acutely ischaemic limbs.

44. LIMB SALVAGE CONTD.
Distraction osteogenesis and vascularised bone transfers can restore
bony continuity in all but the most massive bone losses. In view
of these developments the indications for amputation in trauma have
undergone a paradigm shift and the majority of patients who reach a
Tertiarycare facility within 24 hours are candidates for limb salvage.
This assumes that debridement and, if required,vascular repairs have
been performed in a field medical facility. Restoration of vascular
continuity is the critical issue. A limb is unlikely to survive if vascular
repairs of major limb vessels has been delayed for more than 4–6 hours.

45. BADLY TRAUMATISED LOWER LIMB. RECONSTRUCTION HAS BEEN
PERFORMED USING A MICROVASCULAR RECTUS ABDOMINIS FLAP COVERED WITH
A SKIN GRAFT.

46. LATE-PRESENTING FACIAL INJURY WITH GROSS CONTAMINATION. A
THOROUGH DEBRIDEMENT FOLLOWED BY DELAYED PRIMARY CLOSURE HAS YIELDED
GOOD RESULTS.

47. TETANUS
 Caused by Clostridium tetani
 Spores are present in the soil
 Thrives in dead or contaminated tissue
 Produce tetanospasmin, an exotoxin
 Produces spasm of muscles
 Make sure patients are immunised
 For heavily contaminated wound, give anti-tetanus globulin

48. NECROTISING FASCIITIS
Necrotising fasciitis is a dangerous and rapidly spreading infection
of the fascial planes leading to necrosis of the subcutaneous
tissues and overlying skin. It is caused by b-haemolytic streptococci
and, occasionally, Staphylococcus aureus, but may take the
form of a polymicrobial infection associated with other aerobic
and anaerobic pathogens, including Bacteroides, Clostridium,
Proteus, Pseudomonas and Klebsiella

49. NECROTISING FASCIITIS CONTD.
It is termed Fournier’s gangrene when it affects the perineal area,
and Meleney’s synergistic gangrene when it involves the abdominal
wall. The underlying pathology is identical wherever it occurs and
includes acute inflammatory infiltrate, extensive necrosis,
oedema and thrombosis of the microvasculature. The area becomes
oedematous,painful and very tender. The skin turns dusky blue and
Black secondary to the progressive underlying thrombosis and necrosis.
The area may develop bullae and progress to
overt cutaneous gangrene with subcutaneous emphysema.

50. NECROTISING FASCIITIS
It spreads to contiguous areas but occasionally also produces skip
lesions that later coalesce. It is accompanied by fever and severe
generalised toxicity. Renal failure may occur as a result of hypovolaemia
and cardiovascular collapse caused by septic shock.
The rate of progression can catch the unwary by surprise and
unless aggressively treated it leads to serious consequences with
a mortality rate approaching 70 per cent.
The diagnosis is usually made on clinical grounds. Creatinine
kinase levels may show enormous elevation and biopsy of
the fascial layers will confirm the diagnosis.

51. NECROTISING FASCIITIS
Patients should be admitted to the ICU and treated aggressively
with careful monitoring of volume derangements and cardiac status.
Oxygen supplementation is beneficial and endotracheal intubation is
required in patients unable to maintain their airway.
High-dose penicillin G along with broad-spectrum antibiotics,
such as third-generation cephalosporins and metronidazole,
should be given intravenously until the patient’s toxicity abates.
The cornerstone of management is surgical excision of the
necrotic tissue.

52. NECROTISING FASCIITIS
The fascial planes are opened with ease as the
infection produces inflammatory degloving and the yellowishgreen
necrotic fascia is visible. Devitalised tissue should be
removed generously, preferably going beyond the area of induration.
This can lead to profuse bleeding and it is wise to have
blood already cross-matched. The wound is lightly packed with
fluffed gauze and then dressed. This process should be continued
on a daily basis as the necrosis is prone to spread beyond the edges
of the excised wound. In patients who survive, this results in a
large wound, which will require skin grafting or flap coverage.

53. NECROTISING FASCIITIS
Recently, the role of hyperbaric oxygen (HBO) has become
more established. It is claimed that it is bactericidal, improves
neutrophil function and promotes wound healing. The patient
is placed in a high-pressure chamber and 100 per cent oxygen
administered at a pressure of 2–3 atmospheres. Studies have
shown a reduction in mortality rate in patients treated with
HBO (9–20 per cent) compared with patients who did not
receive HBO (30–50 per cent). The main limitation to its use is
availability of the pressure chamber.

54. NECROTISING FASCIITIS
 Caused by beta-haemolytic strep or is polymicrobial
 Also called Fournier’s or Meleney’s gangrene
 Progress is rapid and renal failure is an early complication
 Treat with radical surgical excision repeated every 24 hours
 Give oxygen and penicillin

55. NECROTISING FASCIITIS AT PRESENTATION

56. NECROTISING FASCIITIS RAPID PROGRESSION
SEEN AFTER 24 HOURS.

57. NECROTISING FASCIITIS
TYPICAL BULLAE AND INDURATION

58. GAS GANGRENE
 Caused by Clostridium perfringens
 Spores are present in the soil
 Thrives in anaerobic conditions and produces many
exotoxins
 Treat with radical and regular surgical excision
 Give oxygen and penicillin
 Early amputation may be life-saving

59. TYPICAL PICTURE OF SPREADING GAS GANGRENE CAUSED BY
CRUSH INJURY.

60. BLAST INJURIES
The explosive pressure accompanying the bursting of bombs or
shells ruptures their casing and imparts a high velocity to the
fragments. These can cause even more devastating injury to the
tissues than bullets. Injury to the ear, lungs, heart and, to
a lesser extent, the gastrointestinal tract is notable.

61. BLAST INJURIES
 Each fragment is a high velocity missile
 The blast wave hits air–fluid interfaces and bursts them
 Explore and fully excise each wound as all are likely to be
heavily contaminated.

62. GENERAL MANAGEMENT OF BLAST INJURIES
The structures injured by the primary blast wave, in order
of prevalence, are the middle ear, the lungs and the bowel.
However, the most common urgent clinical problem in survivors
are penetrating injuries caused by blast-energised debris and
fragments of the exploding device. Many of those exposed to a
blast will have blunt, blast and thermal injuries in addition to
more obvious penetrating wounds. The deafness of blast victims
caused by tympanic membrane rupture makes communication
difficult and may complicate early assessment.

63. GENERAL MANAGEMENT OF BLAST INJURIES
Here, the primarysurvey and resuscitation phases of a system such as
Advanced Trauma and Life Support (ATLS) are particularly apt. The
management of penetrating wounds differs little from that of missile
wounds referred to earlier. The soft-tissue wounds are usually
heavily contaminated and fragments may be driven deeply into
adjacent tissue planes opened up by the force of the explosion.
In blast injuries, one cannot be sure of complete wound excision and it is
imperative that wounds should be left open at the end of the initial
operation and delayed primary closure performed.

64. CRUSH INJURY AND SYNDROME
A crush injury occurs when a body part is subjected to a high
degree of force or pressure, usually after being squeezed between
two heavy or immobile objects. Damage related to a crush injury
includes lacerations, fractures, bleeding, bruising, compartment
syndrome and crush syndrome. It can have disastrous consequences
on local tissues with extensive destruction and devitalisation.

65. CRUSH INJURY AND SYNDROME
Prolonged crushing of muscle leads to a reperfusion injury When
the casualty is rescued.
This releases myoglobin and vasoactive mediators into the circulation.
It also sequesters many litres of fluid, reducing the effective
intravascular volume and resulting in renal vasoconstriction
and ischaemia. The myoglobinuria leads to renal failure from
tubular obstruction

66. CRUSH SYNDROME
 Arises as a result of reperfusion
 Renal failure from myoglobinuria is a complication
 A late fasciotomy may make things worse not better

67. EXTENSIVE CRUSH INJURY IN A MAN TRAPPED IN A FALLEN HOUSE.
THE DEPTH TO WHICH THE SOFT TISSUES HAVE BEEN DEVITALISED IS SEEN
CLEARLY.

68. COMPARTMENT SYNDROME
 Most common in a closed fracture
or soft-tissue crush injury
 Pain on passive extension of the muscles is diagnostic
 Intracompartmental pressure studies are not reliable
 If there is any suspicion, then fasciotomy must
be performed early

69. HYPOTHERMIA
 Occurs commonly after trauma
 Diagnosed by rectal temperature of 35°C or less
 Rewarming should be passive
 Cardiac arrhhthmias and clotting disorders are likely in
severe cases
 Continue resuscitation until the patient has been
rewarmed

70. FROSTBITE
 Can be superficial or deep like a burn
 Rewarm gently
 Allow demarcation to occur naturally
 Protect against further trauma and infection

71. HANDING OVER
 Follow up and secondary problems
 Designated centres

72. DISASTER PLANS
 Establishment of a national level disaster
management organisation
 Anticipating disasters
 Evacuation planning
 Organisation of emergency services
 Medical planning

73. MEDICAL PLANNING
Identification of hospitals able to take large numbers of
casualties and the location of areas that can be used for
patient holding and triage in case of mass casualties is
very important. Hospitals that offer specialised services
should be identified and their role during a major crisis
made clear. Suitable hospitals in the surrounding
areas must be designated as overflow hospitals in the
eventuality of a very large volume of patients.

74. THANK YOU ALL