MH SAQ practice Disaster and Environmental
You are the consultant on duty in a tertiary ED during a Saturday evening shift.
You have received notification of a mass casualty incident. A grandstand at a local football ground
has collapsed. There might be as many as 400 injured people on the scene.
1. List 8 important steps you would take to prepare for managing this situation. (8 marks)
______
______
______
______
______
______
______
______
2. List 6 problems that you may encounter during the first 24 hours. (6 marks)
______
______
______
______
______
1.
Activate hospital disaster plan
Notify hospital executive team
Call in extra staff – medical / nursing / other
Clear the ED
- Discharge those who can be
- Send pts to the ward who are waiting admission
- Clear the waiting room as well as possible
Create a triage area
Assemble teams
Gather extra resources likely to be required (plaster, antibiotics, analgesia etc)
Ready inpatient teams
- Surgical
- Orthopaedic
- Blood bank
- Anaesthetics
- Theatre staff
- Radiology
(I’m sure there are plenty of other things I couldn’t think of)
Pass 5 of 8
2.
Staff fatigue
Staff rotation
Exhausted stocks eg antibiotics, splints, sutures
Communication systems overloaded / non-functional
Overloaded radiology services
Overloaded pathology services
Limited access to timely OT
Pt identification and tracking
(probably some more)
Pass 3 of 6
Total pass 8 of 14 corrects to5.5/10
. A man staggers into your department and says that he and many other people have been on the Tube and were sprayed with a liquid. He then collapses.
Other than calling your ED consultant, give 4 actions you would take to manage the situation.
1. Isolate the pt- undress and destroy clothes, thoroughly wash- all done in protective gear
2.inform unit/hospital manager
3. declare major incident standby,
4.contact police to corroborate story
inform ambulance control,
[3 Marks]
Give four of the muscarinic effects of organophosphate poisoning
Diarrhoea
Urination
Miosis
Bronchospasm
Emesis
Lacrimation
Salivation
Piloerection
[4 Marks]
Give three drugs to treat organophosphate poisoning.
Diazepam- 10mg IV, or another benzodiazepine
Atropine- large doses may require 20mg or more infusion
Pralidoxime- specific antidote to organophosphate poisoning
SAQ One
You are working in an urban district hospital with no obstetric or neonatal service. A 28 week pregnant woman presents in premature labour. Examination reveals an absence of bleeding and a closed cervical os.
a) You decide she will need transfer to a tertiary centre 20 minutes down the road. Prior to this occurring, what will your initial management in the ED entail? (4 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
Assess maternal stability/exclude life threatening conditions (e.g. APH, sepsis, hypertensive disorders pregnancy - all RF for prem labour). Fetal monitoring as able.Liase with obstetrics re: 1) analgesia (consider nitrous, paracetamol/codeine) 2) decision re: tocolytics e.g. nifedipine 20mg stat then Q30min for 3 doses total if contractions persist (salbutamol as alternative), 3) betamethasone for fetal lung maturation if <34/40.
b) List the parties with whom you will communicate regarding her transfer (3.5 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______
Patient, relatives/NOK, nursing staff, retrieval service, receiving Obstetrician, ambulance service, receiving Emergency department (if via ED), administration/ward clerk, receiving Paediatric service
c) The decision is made to provide a medical escort for this patient. List ten essential pieces of equipment for a transfer bag (5 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______
8. ______
9. ______
10. ______
Respiratory - air viva, guedel, laryngoscope, ETT/laryngeal mask, (ETCO2)
Fluid administration - IV cannulae, syringes, giving sets
Drugs - resuscitation e.g. adrenaline, metaraminol, atropine; anaesthetic e.g. paralytics, induction agents
(Neonatal kit - neonatal respiratory, fluid administration and drugs as above, cord clamp, receiving blanket etc.)
d) Identify three problems associated with patient transfer and an action that may be taken to address them (3 marks)
Problem due to transfer / ActionProblem due to transfer / Action
Underestimation of transport time / Calculate supplies (e.g. O2) for 2-3 x journey time
Noise, light and movement fluctuations make monitoring difficult / Consider more invasive and accessible monitoring e.g art line, ensure alarms are visible in daylight, don't rely on auditory alarms
Patient access for interventions difficult / Prophylactic interventions may be appropriate e.g. antiemetics, intubation (not this patient)
Lines may be dislodged on transfers / Careful confirmation of position, patency and security lines/ETT, redundant lines operational
Injury to staff/equipment during loading/unloading; distraction from patient care / Reduce no. of transfers e.g. helicopters v fixed wing (latter increases secondary transfers); increased vigilance and staffing during these times
Communication breakdown, information loss / Careful handover, documentation
SAQ Two
You are working in a large regional emergency department. You receive a telephone call from a doctor at a small community hospital two hours away by road. This doctor is a general practitioner with limited emergency experience. He asks for advice regarding an 18 month old boy who presented with fever, pallor and stridor. Despite intramuscular and nebulised steroid the child has severe respiratory distress with stridor.
a) Give your initial instructions to the GP (5 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
Nurse in position of comfort (parent's lap, upright). Minimal handling. Nebulised adrenaline (1 mL of 1% adrenaline solution*plus 3mlNormal Saline, or 4ml of adrenaline 1:1000).O2 for hypoxia. No further steroids (check dose is appropriate - 0.6mg/kg (max 12mg) IM/IV dexamethasone). Call for immediate local help - anaesthetist, surgeon. NB pallor a sign of severe/critical croup.
The child has a transient improvement in stridor with adrenaline, becoming less pale but remains irritable and anxious. The GP is concerned they may be fatiguing.
b) You need to decide between arranging road ambulance or helicopter transfer. Give two advantages of each (2 marks).
Road ambulance / HelicopterRoad ambulance / Helicopter
Readily available, quickly activated / Reduces transit time (time of greatest risk)
Least resource intensive, cost effective / Retrieval team likely to reach patient faster
No altitude problems / Suitable for this intermediate distance 50-200 km
c) Give two consequence of travel at altitude and how they may be addressed
(2 marks)
1. ______
2. ______
Hypoxia - supplemental O2, pressurisation, gas expansion - vent pneumothoraces, teach patient equalisation techniques for middle ear e.g. Frenzel, Toynbee, Valsalva, monitoring of ETT cuff pressures on ascent/descent, pressurisation
d) Your retrieval registrar rings you prior to returning with the patient, after the patient has been resuscitated and stabilised. List five ways the patient should be prepared for transfer (5 marks).
1. ______
2. ______
3. ______
4. ______
5. ______
Secure airway/lines/catheters etc; IV access - dual preferable; IVF - drug line running; drugs - prophylactic antiemetic, analgesia, sedation/paralysis if intubated; communication - relatives, receiving unit. Thermoregulation. Documentation.
SAQ Three
You are the consultant in charge of the emergency department in a tertiary hospital. The ambulance service calls at 1000 hours on a weekday warning that they are at the scene of a major motor vehicle crash. They have 6 patients –5 adults and a 12-month-old infant, all in a serious condition. They will be arriving at your department in 10 minutes.
a) Define mass casualty incident (1 mark)
______
Event causing illness or injury in multiple patients simultaneously through a similar mechanism such as a major vehicular crash, structural collapse, explosion or exposure to hazardous material
b) What are four goals you will try and achieve in your preparation time? (4 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
Create space in the ED, allocate staff/create treatment teams, gather supplies/equipment, communicate/inform management/ED staff, consider diverting some patients to alternate service e.g. infant to paediatric hospital, inform theatres/surgical team
c) Give four actions you will undertake to create space for the incoming patients (4 marks)
1. ______
2. ______
3. ______
4. ______
Admitted patients to ward, waiting room patients to alternate services where appropriate (GP, other ED), discharge well patients from ED, senior ED 'ward round' to make clinical decisions on remaining ED patients, utilise overflow spaces e.g. SSU, fast track, corridor).
d) You identify that you have only one other consultant on the floor, one junior emergency registrar and one intern due to sick leave. List three ways you will access more medical staff to adequately care for the incoming patients (3 marks).
1. ______
2. ______
3. ______
Call in ED consultants on nonclinical service, ED director; trauma call for surgical/ICU/anaesthetic assistance; delegate nursing staff to ask ICU/surgical/medical/paediatric teams to send senior staff and residents; involve hospital management.
SAQ Four
You have been advised by Emergency Medical Servicesof a bus versus petrol tanker accident with mass casualties.
You are called upon to configure and deploy a medical team to the accident scene.
a) What injuries might you expect in this scenario? (2.5 marks)
1. ______
2. ______
3. ______
4. ______
5. ______
Pelvic, spinal injuries; blast injuries; crush injuries; compartment syndromes; amputations; traumatic asphyxia
b) How will the treatment goals of your medical team differ to routine Emergency department goals? (1 mark)
______
______
Life saving procedures e.g. provision of O2/airway manipulation, control of haemorrhage, splinting fractures, c-spines. Simple dressings. Advanced resuscitation e.g. intubation, CPR usually inappropriate.Greatest good to the greatest number of patients.
c) Describe the 'sieve and sort' triage process for disaster (1 mark)
______
______
Two stage algorithm - sieve a simple initial screen to determine who should be taken to which patient treatment posts and in which order, usually performed by ambulance officer. Sort a more complex assessment based on physiological parameters to determine the order of transportation to hospital.
d) As your team is leaving, the hospital is activating its external disaster plan. Give eight important elements of such a plan (7 marks).
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______
Notification - via ambulance to hospital disaster controller (will be on duty ED in charge after hours otherwise medical director).Stand by phase - hospital advised, preparation begins, staff remain on duty, theatres prepared, ED and hospital create space. Activation - confirmation of casulaties number/type, ED patients asked to leave if able, visitors leave hospital. Arrival - triage, ID labelling. Control centre - hospital board room. Patient reception - ED if seriously injuried, outpatients for walking wounded. Information centre for relatives, news media.Debriefing.
SAQ 8
A 35 year old man presents after collapsing during a marathon on a hot day. His vitals are HR 143, BP 92/68, RR 24 bpm, O2sats 94% 15L NRB, temp 40.8, GCS 9 (E2 V3 M4)
1. What are the life threats he is presenting with and what do you think are causing them?
Shock
Hypotension & tachycardia
May be due to dehydration or high-output cardiac failure
Altered level of consciousness
Airway at risk
Due to hyperthermia + shock
Respiratory failure
Due to ALOC
May be pulmonary oedema
Severe hyperthermia
Due to heat stroke
(4 marks)
2. What is the likely diagnosis?
Heat stroke
(1 mark)
3. What are your differential diagnoses?
Neurological
CVA
SAH
Seizure
Infectious
Meningitis
Encephalitis
Toxicological
Anticholinergic syndrome
Sympathomimetic OD
Serotonin syndrome
Neuroleptic malignant hyperthermia
Endocrine
Thyroid storm
Pheochromocytoma
DKA
(6 marks)
4. What is your initial resuscitative management?
Resuscitation
Airway
Intubation
Breathing
Ventilation
Circulation
Judicious fluid boluses
Assess whether degree of failure
Start inotropes (vasopressors may interfere with heat loss and increase afterload)
Start to cool
(4 marks)
5. What are the potential complications of this condition?
Hypotension from hypovolaemia or cardiac failure
Cardiac
High out-put cardiac failure
Myocardial damage
Respiratory
Pulmonary oedema
ARDS
Renal
Failure due to hypovolaemia or rhabdo
Muscles
Rhabdomyolysis
Neuro
Delirium
Coma
Seizures
Cerebral oedema
Encephalopathy
May get permanent neuro deficit
Metabolic
hypoK and later hyperK
HyperNa or HypoNa
HypoCa
haematological
thrombocytopaenia
DIC
Hypothermia due to overshoot
(10 marks)
6. Describe options for cooling this patient in order of escalation.
Non-invasive
Evaporation
Tepid water + fan
Can cause shivering
Ice water immersion
Can cause shivering
Impractical and unsafe in intubated/sick patient
Ice packs in neck, axilla, groin
Can cause shivering
Limited effect
Cooling blankets
Limited effect
Minimally invasive
Cold fluid infusion
Not recommended in high volumes due to cardiac failure
Invasive
Gastric, bladder, rectal lavage with cool fluid
Less invasive that other options
Easier to do
Pleural or peritoneal lavage
Very invasive
Takes time to do
Cardiopulmonary bypass
Very effective
Hard to do
(10 marks)
SAQ 9
A 35 year old man is brought to your emergency department after being struck by lightning. His vital signs are HR 120, BP 100/60, RR 18, Temp 35, GCS 9
1. What type of injuries can occur with lightning strike?
Directly due to the lightning strike e.g. Keraunoparalysis, cardiac arrest
Blunt trauma from being thrown
Blast injury e.g. tympanic membrane rupture, organ contusion
Thermal burns e.g. from direct hit, contact with metal that has been hit
(4 marks)
2. What might be the cause of this patient’s reduced GCS?
ICH
SDH
EDH
Traumatic SAH
Cerebral contusion/diffuse axonal injury
Heat-induced coagulation of the cerebral cortex
Keraunoparalysis
(3 marks)
3. What cardiac effects can lightning strike have?
Cardiac arrest immediately
Asystole usually
Can recover with even prolonged CPR
Global myocardial depression
Coronary artery spasm
Pericardial effusion
Dysrhythmias
(4 marks)
4. What vascular effects can occur with lightning strike and how are they treated?
Vasomotor spasm in extremities can occur
Usually recovery spontaneously
(2 marks)
5. What ocular and auditory injuries can occur with lightning strike?
Cataract formation
Tympanic membrane rupture
(2marks)
6. List and describe 4 dermatological manifestations of lightning strike
Lichtenberg figures
Fine fern-like pattern on skin
Due to electron showering and not true burns
Flash burns
Mild erythema or corneal damage
Punctate burns
< 1 cm full-thickness burns
Look like cigarette burns
Contact burns
From metal close to skin that is heated when lighten strikes
Thermal burns
Superficial epidermal and superficial dermal burns
Linear burns
< 5 cm wide in skin folds e.g. axilla
(4 marks)