Manchester Arena bombing: lessons learnt from a mass casualty incident

Paediatric mass casualty response through the lens of Functional Resonance Analytical Methodology- lessons learned

BACKGROUND

Mass Casualty Incidents are rare but can significantly stress healthcare systems. Functional Resonance Analytical Methodology (FRAM) is a systematic approach to model and explore how complex systems adapt to variations and to understand resilient properties in the face of perturbations. The aim of this study was to use FRAM to create a model of a paediatric trauma system during the initial response to the Manchester Arena Attack to provide resilience-based insights for the management of future Mass Casualty Incidents (MCI).

METHODS

Qualitative interviews in the immediate aftermath of a terrorist bombing, were followed up with further in-depth probing of subject matter experts to create a validated and verified FRAM model. This model was compared with real incident data, then simplified for future studies.

RESULTS

A Work As Imagined (WAI) model of how a paediatric emergency department provided resilient healthcare for MCI patients from reception and resuscitation to definitive care is presented. A focused model exploring the pathway for the most severely injured patients that will facilitate the simulation of a myriad of potential emergency preparedness resilience response scenarios is also presented.

CONCLUSIONS

The systematic approach undertaken in this study has produced a model of a paediatric trauma system during the initial response to the Manchester Arena Attack, providing key insights on how a resilient performance was sustained. This modelling may provide an important step forward in the preparedness and planning for future MCIs.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]

BACKGROUND

Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment.

OBJECTIVE

The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany.

MATERIAL AND METHOD

The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account.

RESULTS AND DISCUSSION

The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

Global assessment of military and civilian trauma systems integration: a scoping review

BACKGROUND

The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators.

METHODS

A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers.

RESULTS

Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%).

CONCLUSION

Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.

Polarization is the psychological foundation of collective engagement

The term polarization is used to describe both the division of a society into opposing groups (political polarization), and a social psychological phenomenon (group polarization) whereby people adopt more extreme positions after discussion. We explain how group polarization underpins the political polarization phenomenon: Social interaction, for example through social media, enables groups to form in such a way that their beliefs about what should be done to change the world-and how this differs from the stance of other groups-become integrated as aspects of a new, shared social identity. This provides a basis for mobilization to collective action.

Sustainable and economical alternatives to fragment capture materials in explosive and ballistic trials

Strawboard has been utilised as a fragmentation capture material since the 1960s, mainly employed to capture fragments from explosives and explosive devices from arena trials of munitions. As this material has historically been calibrated to a known standard, it has a proven record of allowing research establishments to ascertain the velocity of a fragment based on the depth of penetration of the strawboard. During the time of calibration, strawboard was used as a common building material which was both widely available and relatively affordable; however, due to the recent economic crisis and geopolitical supply issues, this is no longer the case. Building on initial testing, this paper investigates alternatives to strawboard to determine if a cheaper, more readily available material can be used instead. The alternatives are compared and judged based on the NATO ARSP-03 guideline for capture material which includes metrics such as price and attainability, as well as assessing environmental impact and its ability to be used as a viable alternative to strawboard in an explosive environment. Based on these NATO guidelines, explosive fragmentation and ballistic experiments were conducted, and ten materials were tested based on the following criteria: Handling, Density, Flammability, Calibration, Cost and Availability. Medium Density Fibreboard (MDF) was found to be a suitable alternative to strawboard. The data demonstrates that it provides the same capture performance as strawboard at approximately a quarter of the cost and is far more readily available. Other materials also showed potential and further testing should be undertaken to validate these materials as alternatives to MDF.

Communication failure in the prehospital response to major terrorist attacks: lessons learned and future directions

INTRODUCTION

Communication is key in efficient disaster management. However, in many major incidents, prehospital communication failure led to insufficient upscaling, safety concerns for the emergency responders, logistical problems and inefficient disaster management.

METHODS

A review of medical reports and news articles of mass-casualty terrorist attacks was performed using PubMed-archived and (non-)governmental reports. The terrorist attacks in Tokyo 1995, Oklahoma 1995, Omagh 1998, New York 2001, Myyr-manni 2002, Istanbul 2003, Madrid 2004, London 2005, Oslo/Utøya 2011, Boston 2013, Paris 2015, Berlin 2016, Brussels 2016, Wuerzburg 2016, Manchester 2017, London 2017 were included.

RESULTS

In all mass-casualty terrorist attacks, communication failure was reported. Some failures had significant impact on casualty numbers. Outdated communication equipment, overwhelmed communication services, failure due to damaged infrastructure by the terrorist attack itself, and lack of training were the major issues. Communication failures were most commonly observed in both attacks between 1995-2009 and 2011-2017.

DISCUSSION

Communication failure was reported in all mass-casualty terrorist incidents. In several cases, communication between the different responding actors was poor or non-existing. Malfunctioning of (outdated) telecommunication services, inadequate training in the use of communication devices, unfortunate damage of telecommunication network infrastructure were also worrisome.

CONCLUSION

Despite reports of lessons learned in previous EMS responses, communication failures were still reported in most recent terrorist attacks. Governments should provide sufficient resources to equip hospitals, emergency departments, and ambulance services with (back-up) communication systems and invest in training. A European registration system is warranted. We provide proposals for improvement.

Identifying challenges to critical incident decision-making through a macro-, meso-, and micro- lens: A systematic synthesis and holistic narrative analysis

It is predicted that emergency responses to critical incidents will increase over the next few decades, as society faces unique and dynamic challenges (e.g., pandemics, migrant crises, and terrorism). As such, it is necessary to breakdown, identify, and evaluate the unique barriers associated with decision-making in the context of critical incident responses. The aim of the current study was to synthesize the bibliographic characteristics of the research on decision making and present a holistic narrative analysis of the multi-layered factors. Additionally, the systematic synthesis of evidence facilitated a critical appraisal of the quality and distribution of evidence across macro-, meso-, and micro- levels. Results suggested that research was moderately heterogeneous, as evidence captured diverse narrative factors. However, micro-centric characteristics (e.g., cognitive-related factors) were not well represented. Instead, research primarily focused toward intermediate meso-level characteristics, capturing factors such as "interoperability" and "organization policy and procedure" as critical challenges to decision-making. Six key narratives were also identified and discussed. Both the quality appraisal and narrative findings suggested that research should seek opportunities to experimentally assess, evaluate and validate decision-making. Whilst this has previously appeared ethically and practically problematic, advances in technology, research and analysis have allowed high-fidelity simulation experimentation to recreate critical incidents.

Blast Injuries by an Improvised Explosive Device in Japan: A Case Report

Blast injuries caused by an improvised explosive device (IED) are becoming more common in civilian settings. However, physicians may not be familiar with the treatment and management of blast-injured victims. To the best of our knowledge, this is the first case report of a blast injury caused by an IED in Japan. A 64-year-old man was admitted to our hospital's emergency department after sustaining a blast injury. His vital signs were stable, but he had multiple small wounds with embedded foreign bodies that were consistent with injuries sustained by IED victims. The patient was treated for his injuries and was moved to another hospital on day 37. Knowledge about blast injuries caused by IEDs and management strategies for mass casualties are both necessary.

Thiolated gamma-cyclodextrin-polymer-functionalized CeFe3O4 magnetic nanocomposite as an intrinsic nanocatalyst for the selective and ultrasensitive colorimetric detection of triacetone triperoxide

Explosives are powerful destructive weapons used by criminals and terrorists across the globe and their use within military installation sites poses serious environmental health problems. Existing colorimetric sensors for triacetone triperoxide (TATP) relies on detecting its hydrolysed H₂O₂ form. However, such detection strategy limits the practicability for on-site TATP sensing. In this work, we have developed a novel peroxidase mimic catalytic colorimetric sensor for direct recognition of TATP. Ceria (Ce)-doped Fe₃O₄ nanoparticles (CeFe₃O₄) were synthesized via the hot-injection organic synthetic route in the presence of metal precursors and organic ligands. Thereafter, the organic-capped CeFe₃O₄ nanoparticles were surface-functionalized with amphiphilic polymers (Amp-poly) to render the nanoparticle stable, compact and biocompatible. Thiolated γ-cyclodextrin (γ-CD) was adsorbed on the Amp-poly-CeFe₃O₄ nanocomposite (NC) surface to form a γ-CD-Amp-poly-CeFe₃O₄ NC. γ-CD served both as a receptor and as a catalytic enhancer for TATP. Hemin (H), used as a catalytic signal amplifier was adsorbed on the γ-CD-Amp-poly-CeFe₃O₄ NC surface to form a γ-CD-Amp-poly-CeFe₃O₄-H NC that served as a functional nanozyme for the enhanced catalytic colorimetric detection of TATP. Under optimum experimental reaction conditions, TATP prepared in BIS-TRIS-Trisma Ac-KAc-NAc buffer, pH 3, was selectively and ultrasensitively detected without the need for acid hydrolysis based on the catalytic oxidation of 3,3',5,5'-tetramethylbenzidine by H₂O₂ in the presence of the γ-CD-Amp-poly-CeFe₃O₄-H hybrid nanozyme. The obtained limit of detection of ∼0.05 μg/mL when compared with other published probes demonstrated superior sensitivity. The developed peroxidase mimic γ-CD-Amp-poly-CeFe₃O₄-H catalytic colorimetric sensor was successfully applied to detect TATP in soil, river water and tap water samples.

Survivors' experiences of informal social support in coping and recovering after the 2017 Manchester Arena bombing

BACKGROUND

Much of the psychosocial care people receive after major incidents and disasters is informal and is provided by families, friends, peer groups and wider social networks. Terrorist attacks have increased in recent years. Therefore, there is a need to better understand and facilitate the informal social support given to survivors.

AIMS

We addressed three questions. First, what is the nature of any informal support-seeking and provision for people who experienced the 2017 Manchester Arena terrorist attack? Second, who provided support, and what makes it helpful? Third, to what extent do support groups based on shared experience of the attack operate as springboards to recovery?

METHOD

Semi-structured interviews were carried out with a purposive sample of 18 physically non-injured survivors of the Manchester Arena bombing, registered at the NHS Manchester Resilience Hub. Interview transcripts were thematically analysed.

RESULTS

Participants often felt constrained from sharing their feelings with friends and families, who were perceived as unable to understand their experiences. They described a variety of forms of helpful informal social support, including social validation, which was a feature of support provided by others based on shared experience. For many participants, accessing groups based on shared experience was an important factor in their coping and recovery, and was a springboard to personal growth.

CONCLUSIONS

We recommend that people who respond to survivors' psychosocial and mental healthcare needs after emergencies and major incidents should facilitate interventions for survivors and their social networks that maximise the benefits of shared experience and social validation.

Remote training as a common tool for the different professionals involved in the acute phase after terror attacks across Europe: Perspectives from an expert panel

The acute response after a terror attack may have a crucial impact on the physical and psychological wellbeing of the victims. Preparedness of the professionals involved in the acute response is a key element to ensure effective interventions, and can be improved through trainings. Today in Europe there is a recognized lack of inter-professional and international trainings, which are important, among others, to respond to the needs and the rights of victims affected by a terrorist attack in another country than their home country. In this paper we report the perspectives of an expert panel composed by different categories of professionals on the possible role of interprofessional trainings provided remotely. The experts discussed the pertinence of remote trainings for professionals involved in the acute response of a terror attack, and highlighted their Strengths, Weaknesses, Opportunities and Threats (SWOT analysis). We concluded that, while remote trainings cannot replace in-person trainings, they may be useful to share knowledge about the role and the organization of the different categories of professionals, thus potentially improving response coordination, and to easily share good practices across professionals and countries.

Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.

Paediatric patients in mass casualty incidents: a comprehensive review and call to action

The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

Towards an Understanding of the Effect of Adding a Foam Core on the Blast Performance of Glass Fibre Reinforced Epoxy Laminate Panels

This paper presents insights into the blast response of sandwich panels with lightweight foam cores and asymmetric (different thicknesses) glass fibre epoxy face sheets. Viscously damped elastic vibrations were observed in the laminates (no core), while the transient response of the sandwich panels was more complex, especially after the peak displacement was observed. The post-peak residual oscillations in the sandwich panels were larger and did not decay as significantly with time when compared to the equivalent mass laminate panel test. Delamination was the predominant mode of failure on the thinner facesheet side of the sandwich panel, whereas cracking and matrix failure were more prominent on the thicker side (which was exposed to the blast). The type of constituent materials used and testing conditions, including the clamping method, influenced the resulting failure modes observed. A probable sequence of damage in the sandwich panels was proposed, based on the transient displacement measurements, a post-test failure analysis, and consideration of the stress wave propagation through the multilayered, multimaterial structure. This work demonstrates the need for detailed understanding of the transient behaviour of multilayered structures with significant elastic energy capacity and a wide range of possible damage mechanisms. The work should prove valuable to structural engineers and designers considering the deployment of foam-core sandwich panels or fibre reinforced polymer laminates in applications when air-blast loading may pose a credible threat.

Refining mass casualty plans with simulation-based iterative learning

BACKGROUND

Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap.

METHODS

We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents.

RESULTS

Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared.

CONCLUSION

Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff.

Preventing and Mitigating Radiology System Failures: A Guide to Disaster Planning

Disaster planning is a core facet of modern health care practice. Owing to complex infrastructure requirements, radiology departments are vulnerable to system failures that may occur in isolation or during a disaster event when the urgency for and volume of imaging examinations increases. Planning for systems failures helps ensure continuity of service provision and patient care during an adverse event. Hazards to which a radiology department is vulnerable can be identified by applying a systematic approach with recognized tools such as the Hazard, Risk, and Vulnerability Analysis. Potential critical weaknesses within the department are highlighted by the Failure Mode and Effects Analysis tool. Recognizing the potential latent conditions and active failures that may impact systems allows implementation of strategies to prevent failure or to build resilience and mitigate the effects if they happen. Inherent system resilience to an adverse event can be estimated, and the ability of a department to operate during a disaster and the subsequent recovery can be predicted. The main systems at risk in a radiology department are staff, structure, stuff (supplies and/or equipment), and software, although individual issues and solutions within these are department specific. When medical imaging or examination interpretation needs cannot be met in the radiology department, the use of portable imaging modalities and teleradiology can augment the disaster response. All phases of disaster response planning should consider both sustaining operations and the transition back to normal function. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study

INTRODUCTION

System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes.

METHODS

This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices.

RESULTS

The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified.

DISCUSSION

Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident

BACKGROUND

Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident.

METHODS

A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering.

RESULTS

Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented.

CONCLUSIONS

Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

A composite sponge based on alkylated chitosan and diatom-biosilica for rapid hemostasis

Rapid control of bleeding is of great significance in military trauma and traffic accidents. In this study, alkylated chitosan (AC) and diatom biosilica (DB) were combined to develop a safe and effective hemostatic composite sponge (AC-DB sponge) for hemorrhage control. Due to the procoagulant chemical structure of AC-DB sponge, it exhibited rapid hemostatic ability in vitro (clotting time was shortened by 78% than that of control group), with favorable biocompatibility (hemolysis ratio < 5%, no cytotoxicity). The strong interface effect between AC-DB sponge and blood induced the erythrocyte and platelets activation, deformation and aggregation, intrinsic coagulation pathway activation, resulting in significant coagulation acceleration. AC-DB sponge had excellent performance in in vivo assessments with shortest clotting time (106.2 s) and minimal blood loss (328.5 mg). All above results proved that AC-DB sponge had great potential to be a safe and rapid hemostatic material.

The Direct and Indirect Costs of Treating the Victims of the 2016 Nice Terror Attacks in a Single Pediatric Hospital

OBJECTIVE

To analyze the cost of the terror attack in Nice in a single pediatric institution.

METHODS

We carried out descriptive analyses of the data coming from the Lenval University Children's Hospital of Nice database after the July 14, 2016 terror attack. The medical cost for each patient was estimated from the invoice that the hospital sent to public insurance. The indirect costs were calculated from the hospital's accounting, as the items that were previously absent or the difference between costs in 2016 versus the previous year.

RESULTS

The costs total 1.56 million USD, corresponding to 2% of Lenval Hospital's 2016 annual budget. Direct medical costs represented 9% of the total cost. The indirect costs were related to human resources (overtime, sick leave), revenue shortfall, and security and psychiatric reinforcement.

CONCLUSION

Indirect costs had a greater impact than did direct medical costs. Examining the level and variety of direct and indirect costs will lead to a better understanding of the consequences of terror acts and to improved preparation for future attacks.

Règle pédiatrique RC (Radiologique Chimique) : un outil pour optimiser la prise en charge préhospitalière de victimes pédiatriques d’un évènement chimique ou radiologique

En cas d’évènement impliquant des agents chimique ou radiologique, la prise en charge de nombreuses victimes pédiatriques incomberait principalement à des primo-intervenants non spécialisés en pédiatrie ou à des pédiatres peu au fait des modalités de prise en charge en milieu de type NRBC. Pour tenter de pallier cette problématique, nous avons développé un outil s’inspirant de la règle de Broselow pour déterminer le poids des enfants pris en charge et les posologies des thérapeutiques à utiliser en cas d’intoxication par des agents neurotoxiques organophosphorés ou par des agents cyanés. Les modalités de préparation (reconstitution, dilution) des différentes thérapeutiques sont mentionnées sur l’outil pour faciliter l’action des primointervenants. L’outil incorpore également une aide diagnostique s’appuyant sur les différents toxidromes des intoxications chimiques pour orienter les primo-intervenants ainsi que le rappel de quelques actes réflexes (décontamination d’urgence, déshabillage des victimes) à avoir dans un tel contexte qu’il soit radiologique ou chimique. La pertinence de l’outil proposé doit être évaluée lors d’exercices simulant la prise en charge de victimes pédiatriques d’un événement chimique ou radiologique afin de valider son intérêt et d’identifier les modifications ou évolutions nécessaires.

Postmortem CT and autopsy findings in nine victims of terrorist attack

In a foreign country, a religious terrorist group raided a restaurant, using pipe bombs, sharp-edged weapons, and various types of firearms (handguns, submachine guns, and AK-47 assault rifles) loaded with normal and prohibited bullets to kill foreigner customers, some of whom were Italian tourists. Local pathologists performed forensic autopsies on the bodies, but we were asked to perform additional external examinations, postmortem computed tomography (PMCT) scans, and then a second round of complete autopsies on nine victims (5 females and 4 males). Four victims had slash wounds inflicted by sharp-edged weapons, mostly localized in the head and neck. All but two victims had gunshot wounds. Finally, three casualties had injuries caused by the explosion of improvised explosive devices. In all cases, PMCT was a reliable source of information and provided strategic guide during autopsies, helping identify and describe the injuries and thus reconstruct the events. Therefore, in these cases, we suggest integrating the autopsy findings with the postmortem radiological data.

Understanding the psychological impacts of responding to a terrorist incident

BACKGROUND

Responding to a mass casualty event can cause significant distress, even for highly trained medical and emergency services personnel.

OBJECTIVE

The purpose of the study was to understand more about first responders' perspectives about their participation in major incident responses, specifically how and which individual and system factors contributed to their preparedness or may have enabled or hindered their response. The aim of the work was to improve preparedness and response for future incidents.

METHODS

This study reports a detailed analysis of qualitative interview data from frontline staff who responded to a large mass casualty terrorist incident in the UK in 2017. Data highlighted the psychological distress caused by responding to terrorist events and thus became the focus of further, detailed analysis.

RESULTS

Participants (n = 21) articulated in their own words the psychological distress experienced by many of the first responders to the event. Participants reported that they were not prepared to deal with psychological impact associated with this mass casualty terrorist incident and their role in the response, and that follow-up support was inconsistent. Multiple factors were identified as potentially increasing psychological distress. Social support provided by peers and organizational debriefs were identified as two most common support mechanisms. Organizational support was identified as inconsistent.

CONCLUSIONS

This research contributes to the literature the voices of first responders to UK terrorist incidents, building on existing findings while further contributing unique contextual perspectives. This research reinforces the importance of psychosocial support for those who respond to these tragic incidents, and offers a number of recommendations for organizational preparedness for future events.

ABBREVIATIONS

A&E: Accident and Emergency; EPRR: Emergency Preparedness, Resilience and Response; ERD: Emergency Response Department; HEPE: Health Emergency Preparedness Exercise; PHE: Public Health England; PHE REGG: Public Health England Research Ethics and Governance Group; MCI: Mass Casualty Incident; NHS: National Health Service.

Manchester Arena Attack: management of paediatric penetrating brain injuries

PURPOSE

The Manchester Arena bombing on 22 May 2017 resulted in 22 deaths and over 160 casualties requiring medical attention. Given the threat of modern- era terrorist attacks in civilian environments, it is important that we are able to anticipate and appropriately manage neurological injuries associated with these events. This article describes our experience of managing paediatric neurosurgical blast injuries, from initial triage and operative management to longer-term considerations.

MATERIALS AND METHODS

Case study and literature review.

RESULTS

Paediatric traumatic and penetrating brain injury patients often make a good neurological recovery despite low GCS at time of injury; this should be accounted for during triage and operative decision making in major trauma, mass casualty events. Conservative management of retained shrapnel is advocated in view of low long-term infection rates with retained shrapnel and worsened neurological outcome with shrapnel retrieval. All penetrating brain injuries should receive a prolonged course of broad-spectrum antibiotics and undergo long term follow-up imaging to monitor for the development of cerebral abscesses. MRI should never be utilised in penetrating brain injury cases, even in the absence of macroscopically visible fragments, due to the effect of MRI ferromagnetic field torque on shrapnel fragments. Anti-epileptic drugs should only be prescribed for the initial seven days after injury, as continuing beyond this does not incur any benefit in the reduction of long term post-traumatic epilepsy.

CONCLUSION

All receiving neurosurgical units should become familiar with optimum management of these thankfully rare, but complex injuries from their initial presentation to long term follow up considerations. All neurosurgical units should have well-rehearsed local plans to follow in the event of such incidents, ensuring timely deliverance of appropriate neurosurgical care in such extreme settings.

[Mass casualty incidents and attacks involving a multitude of children and adolescents-Overview of policy recommendations and challenges]

Fortunately, mass casualty incidents involving a large number of children and adolescents are rare and the experience in this field, both in terms of medical as well as psychosocial emergency care is comparatively low. Children represent a vulnerable group and have a particularly high risk of developing posttraumatic stress disorder in the aftermath of experiencing disasters. A selective literature search was carried out in Medline. The peculiarity of damaging events with a large number of children and adolescents affected is that in addition to emergency medical care, an early approach to psychosocial emergency care must be provided. Accordingly, it makes sense to integrate such structures into the respective deployment concepts. A specific screening algorithm for children could so far not prevail but due to the physiological and anatomical characteristics appropriate emergency medical care concepts should be provided. Furthermore, hospitals must adapt to this patient group in a suitable manner.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield

Objectives

Catastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival.

Method

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome.

Results

Of 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75).

Conclusion

We have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.

Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation

INTRODUCTION

Paediatric traumatic cardiac arrest (TCA) is a high acuity, low frequency event. Traditionally, survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population, there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable with that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop an algorithm for the management of paediatric TCA for adoption in the UK.

METHODS

A modified consensus development meeting of UK experts involved in the management of paediatric TCA was held. Statements discussed at the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three-round online Delphi study. 19 statements relating to the diagnosis, management and futility of paediatric TCA were initially discussed in small groups before each participant anonymously recorded their agreement with the statement using 'yes', 'no' or 'don't know'. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm.

RESULTS

41 participants attended the meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma.

CONCLUSION

In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first consensus-based algorithm specific to the paediatric population. While this algorithm was developed for adoption in the UK, it may be applicable to similar healthcare systems internationally.