A disaster is an event that overwhelms the resources of the region or location in which it occurs.

1. Disaster Management
Dr.Ashutosh Kumar Singh

2. Definition
The World Health Organization defines a disaster as a sudden ecologic
phenomenon of sufficient magnitude to require external assistance.
A disaster is an event that overwhelms the resources of the region or
location
in which it occurs.
Furthermore, a hospital disaster may similarly be defined as an event
that overwhelms the resources of the receiving hospital.
Whether an event is a disaster further depends on the time of day,
nature of the injuries, type of event, and the amount of preparation time
before the arrival of patients.

3. Types Of Disaster

5. Disaster Characteristics
Regardless of the cause, most disasters have common
characteristics that are important for disaster preparedness and
planning.
In an acute disaster, or a disaster with an identifiable time of onset
that produces casualties (e.g., explosion, chemical release, fire,
earthquake), the event is followed by a large number of minimally
injured patients presenting to the nearest hospitals, usually without
prehospital triage or evaluation.

6. Hazard Vulnerability Analysis
The hospital planning group should address those disasters that are
most likely to occur in their community and geographic area.
The hazard vulnerability analysis can prioritize planning efforts
because different disasters are characterized by different
morbidity And mortality patterns and different challenges to
the ED and hospital.
For example, earthquakes may cause severe traumatic injuries
requiring a concentration on surge capacity of the critically ill patient

7. Hospital Community coordination
Every hospital should integrate its emergency operations plan with
those of community disaster management agencies.
This is especially important Regarding disaster notification and
communications, transportation of casualties, and provisions for
dispatch of hospital medical teams to a Disaster site.
Strong relationships with community agencies(e.g., fire department,
regional EMS system, local emergency management, or public
Health agency) are important to ensure a coordinated disaster
response

8. Training & Disaster Exercise
Regular training and exercises familiarize staff with their disaster
roles
and responsibilities and identify weaknesses or omissions in the
plans
that require additions or revisions.
The Joint Commission requires two annual exercises at least
one of which involves the movement of patients. The scenarios
should reflect incidents that are likely to occur in the community
as determined by the hazard vulnerability analysis.

9. Hospital Emergency operations
plan
The hospital emergency operations plan provides for an organized
response of the hospital from the time of notification of a disaster
until the situation normalizes

10. Access Hospital Capacity
Before the hospital can receive casualties, it must be determined
if the hospital itself has sustained any structural damage or loss
of use as a result of a disaster.
It includes blocked passageways or inoperable elevators;
Potential for fire, explosion, or building collapse, failure of utilities
or supplies and outside access problems.
Once it is determined that the hospital itself is safe, the
hospital should determine how many casualties from the
disaster site it can safely manage.

11. Create surge capacity
Surge capacity is the ability to increase hospital bed capacity over
normal limits. Intrahospital surge may include doubling patients in
rooms, converting an acute care ward to an intensive care level
unit, opening previously closed wards.
The standards of care should be altered only in the most extreme
circumstances, as patient surge has been linked to somewhat
worse outcomes for individual patients.

12. Establishment of support areas
Family Information Center During a disaster, families and
friends will arrive at the hospital seeking information about victims.
This convergence can seriously interfere with efforts of the hospital
to respond effectively to the situation.
Volunteer Coordination Center In major disasters, anticipate
the potential for large numbers of volunteers, including those
wishing to donate blood.
Media Center Identify a single hospital spokesperson to relay
information to the media. This public information officer ideally
should have Some training in handling media questions and making
clear statements to The press and public.

13. Hospital Response
 Notification
 Preparation
 Receiving Casualties
 Stand down

14. Notification
• The hospital is informed about the disastrous event, type of
disaster, number of casualties and severity
•
• All the department should be notified prior arrival of case.
• Selected Physicians are nurses are sent at the site to assess &
prioritized critical cases

15. Preparedness
• Empty and expand the emergency room
• Immediate disposition decisions and movement
• Triage order - red and yellow for emergency room and green to
outpatient
Empty and expand hospital
– Early discharge
– Transferring patient
– Postponing elective surgery
Additional staff
• Staff as per duty and manage volunteers
• Stock all necessary medical supplies
• Inform the blood bank

16. Receiving Casualties
Quick and through assessment of victims
• Triage
• Rapid turnover of patient
• Life and limb threat should be given priority
Disaster paperwork

17. Stand Down
• Workload returns to normal
• Restocking of supplies
• Staff debriefing

18. Use of Triage
Usually four category system in used to sort out the case on the
basis of need for immediate, therapeutic intervention
Triage will need to be performed at the ED entrance even if it
was done at the scene.
Usual colours are
 Red
 Green
 Yellow
 Black

19. Red
First priority
• Most urgent
• Life-threatening shock or hypoxia is present or imminent, but
the patient can likely be stabilized and, if given immediate care,
will probably survive.

20. Yellow
Second priority
• Urgent
• The injuries have systemic implications or effects, but patients
are not yet in life- threatening shock or hypoxia; although
systemic decline may ensue, given appropriate care, patients
can likely withstand a 45- to 60-min wait without immediate risk.

21. Green
Third priority
• Non-urgent
• Injuries are localized without immediate systemic implications;
with a minimum of care, these patients generally are unlikely to
deteriorate for several hours, if at all.

22. Black
Dead
• No distinction can be made between clinical and biological death in a
mass casualty incident, and any unresponsive patient who has no
spontaneous ventilation or circulation is classified as dead. Some place
catastrophically injured patients who have a slim chance for survival
regardless of care in this triage category.

23. Disaster Management
Respond to disaster
Before the arrival of victims
• Collect information from the authorized Person in the disaster
site about type of disaster, number of casualties and severity
Activate the disaster protocol
• Specify the receiving area or casualty collection point the triage
area based number of injury
• Alert all department to remain stand by; operation theatre, all
indoor unit, laboratory, radiology, etc

24. Cont..
Assign definite task to people in disaster plan
• Suspend all other regular hospital activities except for the critical one
• Prepare standardized tag in advance
• Evacuation of minor cases
After the arrival of the victim
• Triage nurse or volunteer receive in the reception area
• Triage nurse keep the crowd away with the help of volunteer of team
• The nurse in charge mobilizes nurses and mobilizes to their duties

25. Cont..
• Patient are tagged before moving from reception area and tag
must include such information on patient as their name, age,
sex, triage category, diagnosis and initial treatment
• Triage nurse coordinates with different diagnostic facilities X-
ray, laboratory, etc for investigation required
• Triage nurse constantly assess the progress of patient and
report to physician if patient need change in his/her triage
category

26. Cont…
Crowd controlling
• Managed in collaboration with security and other volunteer
• The main hospital gate should be closed and only vehicle and
individual carrying casualty should be permitted

27. Cont…
Record and reporting
• Document all cases with full detail and as medico legal cases
• Inform the police if case are discharged, referred or expired
Never handoverthe deadbodyto relative withoutpost -mortem

28. Post Disaster Action/Recovery
• Routine tasks that were suspended in the emergency
management of disaster are resumed.
• After the disaster management the reports are analyzed to
assess the effectiveness of the disaster preparedness and
response activities is carried out

31. Airway devices & Adjuncts

32. Airway Devices
Supraglottic Devices
• Airway devices that facilitate oxygenation and ventilation without
endotracheal intubation.
• Bridge between BMV and endotracheal intubation
• Useful in “Cannot Intubate, Cannot Ventilate” situations.

33. Supraglottic Airway Devices –
Evolution
• First generation devices- simple airway tubes
a. Classic LMA
b. Flexible LMA
c. Cobra PLA
• Second generation – includes drainage tubes
a. ProSeal LMA
b. I-Gel
c. LMA Supreme
d. SLIPA
• Third generation - cuffless, two drain tubes, small bowl
a. Baska mask.

34. Supraglottic Devices -
Classification
Cuffed Peri-laryngeal Sealers
• All LMAs
Without Esophageal Sealing
• SLIPA
• AirQ - SP
Cuffed Pharyngeal Sealers
• Combitube
• King Laryngeal Tube (King LT)
• Cobra Peri-laryngeal Airway
(PLA)
Cuff less Pre-shaped Sealers
With Esophageal Sealing
• Baska Mask
• I-Gel

35. Laryngeal Mask Airway (LMA)

36. Classic LMA

37. Classic LMA
cLMA Size Patient
1 Neonates/infants up to 5 kg
1.5 Infants between 5 and 10 kg
2 Infants/children between 10 and 20 kg
2.5 Children between 20 and 30 kg
3 Children 30 to 50 kg
4 Adults 50 to 70 kg

38. Classic LMA
Advantages / Disadvantages
Advantages Disadvantages
Increased speed and ease of
placement
Low pressure seal – increased
risk of gastric aspiration
Improved hemodynamic
stability
Suction not possible
Reduced anesthetic
Requirements
Tip may get folded causing
obstruction
Less coughing and sore throat Inadequate seal – PPV is
difficult
Can be done by inexperienced
personnel

39. ProSeal LMA

40. cLMA Vs ProSeal LMA
Modifications Over Classic LMA
 Larger & deeper bowl with no grille
 Gastric drainage tube running parallel to the airway
 Larger deeper bowl & dorsal extension of cuff
 Bite block

41. ProSeal LMA
Advantages Disadvantages*
Separate gastric tube port - for
gastric access, checking correct
positioning
More incidence of trauma
Bougie guided insertion f ETT Equivocal incidence of sore throat
as compared to cLMA
Dorsal cuff -provides better seal
and higher sealing pressures
Slightly longer insertion time
compared to cLMA
With drain tube occluded – less
incidence of gastric aspiration
20% more airway resistance than
classic airway in spontaneously
breathing patients.
Can be used for both spontaneous
and controlled ventilation
Less suitable as an intubation
device
Bite block. Requires a greater depth of
anesthesia for insertion

42. LMA Supreme

43. Modifications of LMA Supreme
1. Fixation Tab (FT) :
• Facilitates easy insertion and fixation of the LMA
• Visual guide to ‘correct’ size select - after inflation of the cuff, the FT
should be 1.5–2 cm from the upper lip
• If distance is less, the size chosen may be too small
• If >3.0 cm from the upper lip the size chosen may be too large

44. Modifications of LMA Supreme
cont..
2. Airway Tube:
• Unique, flattened, firm, anatomically shaped airway tube -elliptical in
cross-section
• Elliptical shape facilitates insertion in patients with reduced interdental
space, without increasing the resistance to breathing
• Firm, anatomical shape facilitates easy insertion without placing
fingers in the mouth
• Helps to minimize accidental rotation, once in place
• Lateral grooves on either side prevent kinking

45. Modifications of LMA Supreme
cont..
3. Drainage Tube:
• Runs from its rigid proximal end, through the middle of the airway
tube, continues along the posterior surface of the cuff
• Equalizes the pressure between UES and atmosphere
• Vents gastrointestinal gases and liquids
• Serves as a conduit for the passage of nasogastric tube
• Indicator of correct tube positioning

46. Modifications of LMA Supreme
cont..
4. Cuff:
• Modified and enlarged inflatable cuff
• Enhances the anatomical fit into the pharynx
• Glottic seal pressures between cLMA and ProSeal LMA
• Moulded distal cuff - strengthens the tip and prevent it from ‘folding
over’ during insertion
• Modified fins - prevent the epiglottis from becoming wedged in the
airway

47. LMA Fastrach

48. LMA Fastrach
“Intubating Laryngeal Mask Airway”
Uses:
• To facilitate tracheal intubation
• Can also be used as a primary airway device
• Rescue device for failed intubation
• Blind or fiberscopic guided insertion

49. LMA Fastrach - Disadvantages
• Pharyngeal pathology or limited mouth opening
• Cannot be used for intubation in patients below 30 kg
• Expensive & prolonged use is to be avoided
• The tracheal tube may be displaced downward or dislodged
• Unsuitable for use in the MRI unit
• Increased incidence of sore throat and difficulty swallowing
• Esophageal intubation

50. King LT

51. Advantages
• Easy insertion – less skill
• Minimal mouth opening required.
• High ventilation pressure can be used
• Can be used to intubate trachea

52. Combitube

53. Combitube
• “Esophageal Tracheal Airway”
• Blind insertion airway device (BIAD)
• Double lumen airway device designed for emergency ventilation of a
patient when visualization of the airway and endotracheal intubation
are not possible
• Ventilation can be achieved with either tracheal or esophageal
placement of tube

54. Combitube
Advantages:
• Blind insertion without the need for light, laryngoscope, or direct
visualization
• Effective ventilation and oxygenation with moderate protection against
• aspiration
• Proximal pharyngeal balloon provides better air seal
• Gastric contents can be aspired through lumen #2 when the device is
in the esophagus
Disadvantages:
• Pediatric sizes not available
• Expensive
• Increased chance of laryngeal and tracheal injury
• Latex hypersensitivity (the pharyngeal balloon contains latex)

55. Combitube - Contraindications
• The patient has intact gag-reflex
• The patient is less than 5 feet tall or under 16 years old
• History of ingestion of caustic substance
• Burns involving the airway
• History of esophageal disease
• History of latex hypersensitivity

56. iGEL

57. i-GEL
• Second generation Supraglottic airway device.
• Mask made of medical grade thermoplastic elastomer -Styrene
Ethylene Butadiene Styrene (SEBS)
• Adapts to patients airway - anatomical seal of the pharyngeal,
laryngeal and peri-laryngeal structures
• Provides effective seal without a cuff

58. i-Gel - Advantages
• Better anatomical fit – less compression trauma
• Less risk for injuries related to cuff hyperinflation
• Easy insertion - reduces the time for successful insertion
• Greater airway seal pressures and superior fibreoptic views as
compared to other SGAs*
• Wide lumen allows for airway rescue and assisted intubation
• Effective in prone position ventilation

59. Airway Rescue With i-Gel
• i-Gel is established in emergency airway control. Case reports are
present where it has been used for airway rescue when cLMA and
PLMA have failed
• I-gel has been used for airway rescue in prone position*

60. SLIPA - Streamlined Liner of the Pharynx
Airway

61. SLIPA - Streamlined Liner of the Pharynx
Airway
• Plastic uncuffed disposable
• Hollow boot shaped distal part
• Anatomically fits pharynx
– Toe rests in esophageal entrance
– Bridge fits in pyriform fossa
– Heel – anchors to soft palate
– Large size prevents aspiration of regurgitated fluid

62. SLIPA
Advantages
• Better airway sealing pressures for PPV
• Cuff less
Disadvantages
• More traumatic
• Occupies space upto soft palate

63. Baska Mask
• 3rd generation Supraglottic airway device
• Smaller bowl compared to other LMAs - less risk of including
esophageal opening
• Adjustable tab in shaft to increase angulation - allows easy
negotiation of oropharyngeal curve
• Double gastric channel - one
channel is open to air so less
chance of esophageal wall
impinging the gastric opening
during suction

64. Infraglottic Devices/Acesses
Supraglottic Access
Endotracheal Tube
Fibreoptic devices
Infraglottic Access
Cricothyroidotomy
Tracheostomy
Retrograde Intubation

65. Endotracheal Tube

66. Endotracheal Tube

67. Types of Endotracheal Tube
■ Cuffed
■ Uncuffed
■ Double lumen

68. Requirements of an Ideal ET Tube
• Smoothness of outer surface to avoid damage to mucosa
• Smooth & non-wetable inner surface.
• Non-inflammable
• Transparent
• Easily sterilizable
• Non-kinking
• Sufficiently strong - to allow thin wall framework
• Thermo plasticity - to conform to anatomic passage and to be self
centering within the trachea.
• Non reactive with lubricants or anesthetic agents
• Latex free
• Non injurious catheter tip

69. ET Tube Cuff
• The cuff is an inflatable sleeve near the patient end of ETT.
• The cuff material should be strong and tear resistant but thin, soft and
pliable.
• Cuffs are usually made of the same material as the ETT.
• Provides a seal between tube & tracheal wall to prevent aspiration of
gastric contents
 Prevents air-leak
 Serves to center the tube in trachea
 Can be high volume - low pressure system or low volume -
high
 pressure system

71. Factors affecting Cuff
Pressures
Increase cuff pressure Decreased cuff pressure
Positive pressure ventilation Sedation
Ventilation with N20 Neuromuscular blockade
Bronchoconstriction Reduced core temperature
Laryngeal spasm Time
Edema Change in body position

72. GUIDELINES
THE GUIDELINES TO DETERMINE THE SIZE OF ETT
Ideal tube in average adult male – 8.5mm ID
Ideal tube in an average adult female - 7.5mm ID.
Age is recognized as the most reliable indicator of appropriate ETT
size for
children.
3 months & less ------ 3 mm ID
3 - 9 months ------ 3.5 mm ID
Older than 1 year ------ ID in mm = (16 + age in years)/4

73. GUIDELINES
THE GUIDELINES TO DETERMINE THE SIZE OF ETT:
• Younger than 6 years --- 3.5 + age in years/3 = ID in mm
• Older than 6years --- 4.5 + age in years / 4 = ID in mm
• Choosing a tube whose external diameter is same width as the
patient's distal end of little finger

74. Principles of ET Tube
 Internal diameter – Smaller tubes offer greater resistance
 Length – Increase in length of tube increases airway resistance
 Configuration - Abrupt change in the diameter and direction
increases the resistance

75. Guedal’s Oropharyngeal Airway
(OPA)

76. Oropharyngeal Airway

77. Oropharyngeal Airway
Uses –
• To maintain open airway
• Prevent endotracheal tube occlusion
• Prevent tongue bite
• Facilitate suction
• Conduit for passing devices into oropharynx
• Obtain a better mask fit
Contraindications –
• Intact gag reflex
• Oropharyngeal growth

78. ANY DOUBT ???

80. If the endotracheal tube cuff is significantly overinflated, which of
the following would likely occur?
A. Air leakage
B. Laryngospasm
C. Silent aspiration
D. Mucosal ischemia

81. Mucosal Ischemia

82. What is the purpose of using a cuffed artificial airway when
providing long-term positive pressure ventilation?
A. To facilitate the removal of secretions
B. To decrease the airway resistance
C. To prevent gas leaks and aspiration
D. To decrease the work of breathing

83. To prevent gas leaks and aspiration

84. Which of the following patients should you avoid the insertion of
an oropharyngeal airway?
A. A patient that has a foreign body obstruction
B. A patient that requires manual ventilation
C. A patient that is unconscious
D. A patient that is less than 12-years-old

85. A patient that has a foreign body
obstruction

86. In which of the following conditions would you most likely have a
difficult time establishing a patent airway?
A. ARDS
B. Morbid obesity
C. Pleural effusion
D. Ventilator-associated pneumonia

87. Morbid obesity

88. Name the marked area?
Role in airway
management?

89. Murphy’s Eye
It ensures that if there is any occlusion
in primary opening, ventilation will still
occur.