vandaag 13 jaar geleden 19/09/2014 Wetteren case 1 Patient Management of the Acrylonitrile-Disaster in Wetteren I. Demeyer, MD, An, CCM Onze Lieve Vrouw Hospital Aalst, Belgium Some hints and pitfalls about.. • • • • Beginners mistakes Communication errors “Waste of money”- story (non?)-experience experts 19/09/2014 Wetteren case 3 This presentation only reflects the author’s personal opinion and neither the official report nor public authority 19/09/2014 Wetteren case 4 Not every presentation is successful Definitions • Disaster • Disaster Relief Team – Tasks of medical task force • CP- Ops 19/09/2014 Wetteren case 6 Disaster ? • Starts with the ‘perception’ of a disaster • Retrospective view of the event(s) The Dendermonde day care center ‘Fabeltjesland’ assault (jan 29, 2009) – 10 victims – But 5 medical teams at the scene < 20 min 19/09/2014 Wetteren case 7 Wetteren 8 Disaster or not? “An occurrence of a natural catastrophe, technological accident, or human caused event that has resulted in severe property damage, deaths, and/or multiple injuries.” USA Federal Emergency Management Agency (FEMA) NOT: 1 death and 1 severely injured victim 19/09/2014 Wetteren case 9 Disaster or not? “The result of a vast ecological breakdown in the relations between man and his environment, a serious and sudden (or slow, as in drought) disruption on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.” WHO definition 19/09/2014 Wetteren case 10 Wetteren case a Disaster? YES 19/09/2014 Wetteren case 11 Disaster Relief Team in Belgium Team Discipline 1: Fire Dept Discipline 2: Medical Dept Discipline 3: Police Services Discipline 4: Technical Support Services Discipline 5: Communication Services 19/09/2014 Wetteren case 12 Disaster Relief Team in Belgium Discipline 2 East Flanders Medical Dept. 4 Medical Directors 16 Deputy Medical Directors 19/09/2014 Wetteren case 13 Discipline 2 Medical Director At the scene CP-Ops: operational command center Co-organizer of the disaster relief with specific attention towards the safety (mental & physical) of all rescueworkers, the care for the victims and the population … Reports to the Crisis Center (Provincial), (representative of the Government Discipl 2) 19/09/2014 Wetteren case 14 Discipline 2: Medical Victims Implicated, not wounded Population Wetteren, Schellebelle, Serskamp, Wichelen, … Rescue workers (fire dept., civil protection, police services …) Wounded 19/09/2014 Wetteren case 16 Victims Duration & number 19 days (May 4 – 21) provincial phase 1.979 evacuated civilians (May 18: “all – 1” habitants < 250 m back home) 1 dead victim 397 hospital visitors 1 severely injured victim (case report) 19/09/2014 Wetteren case 17 Time Lines May 4 2 a.m.: Derailment and fire of train 9:42 a.m.: high values arylonitrile in sewer system May 7 19/09/2014 7 a.m.: High values acrylonitrile in sewer system miles away …. Wetteren case 18 First communication 2:02 a.m. “Locomotive on fire” 2:08 a.m. 7 fire men at the scene In the middle of nowhere: no access possible Communication Cut the power transmission lines Up scaling “fire dept.” zonal alert Evacuation of neighborhood (150 m) 19/09/2014 Wetteren case 19 Victims 2:00 a.m. Evacuation perimeter 150 m ± 300 people (towards festival hall and fire station) Based on? Explosion risk? Toxic – chemical risk? Gut feeling 2:45 a.m. Decision taken at “hood mutual agreement” (discipl 1,2 &3) 19/09/2014 Wetteren case 20 Decision making • Based on: – Hazardous substance database: http://toxnet.nlm.nih.gov/ • Intikken: acrylonitrile • HSDB als keuze aanklikken 19/09/2014 Wetteren case 21 Evacuation 19/09/2014 22 ‘no worries…’ ‘no worries, it’s all right ‘ First Communication Police: summons people to leave their house from door to door & P.A. But “feelings” within policemen People refuse to leave their house! Discussion vs. urgency 19/09/2014 Wetteren case 25 Safety circles 26 CP-Ops Decision making Based on textbooks, databases, Based on experience (Toxicologists!!) Acrylonitrile: toxicity 19/09/2014 Tri-Ethyl-Aluminium explosion risk Ethylaluminiumdichloride explosion risk Wetteren case 27 Airway protection?? 28 Acrylonitrile (monomere in polymereproduction: lego) At room temp: good water soluble Mixture with air: highly explosive Highly exothermic reaction during polymerisation Density > air 19/09/2014 Sewing system, waterholes, lowlands Wetteren case 29 Acrylonitrile Skin, inhaled (toxic level < smell border) Short T 50% (20 min) quickly eliminated, metabolised to cyanide Incomplete combustion HCN Respiratory protection for rescue workers Hazmat equipment Urgent need for antidote (Cyanokit®) 19/09/2014 Wetteren case 30 Cyanide intoxicatie • Waterstofcyanide (HCN): acute cyanide intoxicatie • Aanpak/Therapie? – Geen internationale richtlijnen – EuSEM: • pre & in-hospitaal richtlijnen • literatuurreview Europese consensus 2013 HCN • • • • • Polyurethaan Verf, acryl Nylon Plastiek Papier,hout, wol,katoen May 4 02:02 a.m. Call from 112 to fire dept. Wetteren 02:08 a.m. Fire dept. at the scene 02:14 a.m. Upscaling for fire dept. alert Medical disaster plan initiated 02:45 a.m. Council phase 03:40 a.m. Provincial phase 19/09/2014 Wetteren case 36 CN intoxicatie • Afhankelijk van wijze van besmetting, concentratie en duur van blootstelling • LD50 = 1mg/kg • Ingestie • Transdermaal • Rookinhalatie bij brand (4-12u later cyanide) CN • 1704: Pruisisch blauw: synthetisch pigment (ijzer(III)hexacyanoferraat(II)) • 1783: Blauwzuur: Vloeibaar – gasvormig vanaf 26°C • WO II: Zyklon B • Geur van bittere amandelen • Toepassingen anno 2014 – Metaalreiniging – Mijnindustrie (goudextractie uit erts) – Plastics industrie CN intoxicatie • Literatuur: blootstelling tot 14 dagen = acuut • Acute Exposure Guidelines Levels (AEGL) – AEGL – 1: ongemak, irritatie snel voorbijgaand – AEGL – 2: duidelijk en ernstig gezondheidseffect – AEGL – 3: levensbedreigend/overlijden • Belgische werknemers: max 2 ppm/8u 19/09/2014 Wetteren case 39 Waarden in ppm Classificatie Duur van blootstelling 10 min 30 min 1 uur 4 uur 8 uur AEGL – 1 4.6 4.6 4.6 4.6 4.6 AEGL – 2 290 110 57 16 8.6 AEGL – 3 480 180 100 35 19 19/09/2014 Wetteren case 40 HCN toxiciteit Symptomen – Mild: neurologisch/respiratoir: • Hoofdpijn, verwardheid, duizeligheid, nausea, braken, palpitaties, tachypnee/dyspnee, amandelgeur, branderige droge keel, kersrode huid, mydriasis. – Ernstig: neuro/resp/cardiovasculaire depressie: • Epilepsie, coma • Initieel hyperdynamisch, nadien cardiovasculair falen: bradycardie, hypotensie, cardiorespiratoir arrest, † † Seconden / minuten afhankelijk van blootstelling – 100 ppm: † > 60 min – 300 ppm † > sec/min HCN toxiciteit Cyanide ion affiniteit 1. Cobalt 2. Fe3+ in methemoglobine 3. Cytochrome aa3 oxidase mitochondriaal 4. Fe2+ in hemoglobine Cytochrome aa3 oxidase mitochondriaal Cytochrome oxidase: – Op celniveau: mitochondriaal – Hersenen/hart/lever – Pyruvaat via acetyl-coA in aerobe Kreb cyclus ATP productie. – Fe houdend enzyme, essentieel voor NADH 19/09/2014 Wetteren case 43 2. HCN toxiciteit • Niet competitieve inhibitie met cyt.oxidase Kreb // • Pyruvaat Lactaat (anaeroob) metabole (lactaat) acidose. • Andere mechanismen: ? – Coronaire art VC Cardiac output zakt – Longoedeem via onduidelijk mechanisme • Afbraak: leverenzyme: rhodenase (S-donor): CN thiocyanaat renale klaring – trage reactie. CN• Inhibeert 40tal enzymesystemen • Inhibeert oxidatieve fosforylatie – Bindt aan cytochroom aa3 oxidase – Aeroob nr anaeroob metabolisme • Cellulair ATP tekort: lactaatacidose CN vs CO Information Exchange info between Operational Centre and Crisis Centre 6 press communications between 3:40 and 9:38 a.m. 6 a.m. first press conference 19/09/2014 Wetteren case 48 Communication Lack of Crisis Centre & Operational centre “experience” Disaster Time span, > 48 hrs vs 19 days E 40: Gas leak pipeline rupture: 48 hrs E 413: H2 gas transport collision: 48 hrs Mass communication Avoid highways during traffic jams Decision making and political consequences 19/09/2014 Wetteren case 49 Decision making • 1 PPM measured: evacuation • Case definition acrylonitrile intox: – Mucosa irritation: proves contact acrylonitrile – Other symptoms: metabolized towards CN 19/09/2014 Wetteren case 50 Behandeling • • • • Bron wegnemen 100% O2 Ondersteunende maatregelen Antidoot: – Methaemoglobine vorming (nitraten, 4-DMAP) – Sulfaatdonoren (thiosulfaat) – Cobaltverbindingen (hydroxycobalamine) Cyanokit • Dosis 70mg/kg (5g) over 15-20 min, te herhalen zo arrest/aanhoudende cardiovasculaire instabiliteit. Max 10g • 0 tot >99 jaar (max 140mg/kg in totaal), ook bij zwangerschap • Reeds prehospitaal: zo meerdere patiënten ter plaatse: geef 2,5 g IV per persoon, restdosis in hospitaal. • Nadelen: – ! Valse verhoging van Hb-CO – Niet in zelfde leiding als thiosulfaat. – Foutieve probleemmelding bij hemodialyse (blood leak) – Erytheem moeilijke beoordeling brandwonden nadien Biochemie • Cyanideconcentratie in bloed correleert zeer goed met plasmalactaat (> 90 mg/dl) • Geen snelle detectietechniek voor HCN (bloed) Lactaatbepaling • Omweg om ernst HCN intox te bepalen Lessons learned (1) PREPARE YOURSELVE to deal with negative press/public comments DOCUMENT / REPORT ALL EVENTS TIME REGISTRATION 19/09/2014 Wetteren case 55 Upscaling disaster planning 2:14 a.m. Medical Disaster Plan (MIP) 2:45 a.m. Council phase 3:40 a.m. Provincial phase 6:21 a.m. Telephone Information Centre What kind of information? Close doors, windows, stay inside, avoid Wetteren centre 19/09/2014 Wetteren case 56 Lessons learned (2) Inform your citizens a.s.a.p. - Updates through website/Facebook/twitter/domino - Telephone Information Centre (TIC) . Started at 06:21 a.m.!!! . 3000 calls/day Update your citizens Give correct information 19/09/2014 Wetteren case 57 Lessons learned (3) Towards Decision makers (Crisis center): Don’t take your whishes for real Message: return home vs. Message: Wait another day (May 9 – 12) Local population “aggressive” towards the CP-Ops staff 19/09/2014 Wetteren case 59 Home or not? 61 Lessons learned (4) – Case 1 “Acrylonitrile is carcinogenic” “No carcinogenic effects retrieved from literature” TV news interviews Prof. XXX, MD, toxicologist at University XXX Toxicologists at different Universities & Industrial MDs (follow up > 20 yrs.) 19/09/2014 Wetteren case 62 Lessons learned (4) – Case 2 “Large numbers of dead fish washing up on the shores of the Schelde downstream of Wetteren” “Not confirmed” TV broadcasts By river police: waste of money, time … 19/09/2014 Wetteren case 63 How to handle this evil? Deny first message of carcinogenic effect? - My answer: don’t do this - Public opinion: “they are hiding the truth” CC is “running behind the facts” - Inform the news broadcasting media - 19/09/2014 Provide them with experts able to explain “lay people” the risks Wetteren case 64 Lessons learned (5) Beginners mistake: when you see a camera - Think twice before expressing your “feelings” Circumstances - 3 days requesting for sanitary facilities, no feedback from the CC - May 8 visit from important politicians and the Mayors of the neighbouring villages: STOP of all activities… till 14 hrs: no decisions at the CC 19/09/2014 Wetteren case 65 Wat hebben we vandaag geleerd? 19-9-2014 multidisciplinair leverlijden 66 Lessons learned (6) • Occupational medicine: no collaboration (Belgium) – Fire dept: each unit has his own occup. Med. – Fire dept: fire fight unit doctor • • • • Police: own medical dept. Civil protection Hospitals GP’s 19/09/2014 Wetteren case 67 Lessons learned (6) • > 20 different occupational doctors • > 10 General practioners Different approach in follow up: minimizing vs maximizing 19/09/2014 Wetteren case 68 Ongoing problems Mr J. Haek, CEO, announces: “Infrabel will pay all costs: ship, cleaning, civilians…” Blood collections/results: communicated “not clearly” to the public Epidemiologic follow-up of the local population and rescue workers Large evacuation planning 19/09/2014 Wetteren case 69 QUESTIONS ?? (& ANSWERS …?) 19/09/2014 Wetteren case 71 Take home • Denk aan CN intoxicatie naast CO, ook bij minder gekende stoffen/chemische rampen acrylonitril in Wetteren • Behandel zo snel mogelijk – Bij grote waarschijnlijkheid van intoxicatie (brand met polymeren), tachypnee, hypotensie, bradycardie, epilepsie, cardiovasculaire collaps, cardiorespiratoir arrest. – Veranderd bewustzijn (desoriëntatie, verwardheid, mydriasis) – Lactaatacidose, zeker zo >8 mmol/L Diagnose Labo-analyse – Sterke correlatie tussen cyanide waardes en lactaat, echter aspecifiek – Cyanide bepaling op bloed • Korte t ½ (60’) • Duurt 2u in labo – Arterieel/ Veneus bloedgas: hoge Pv02, hoge veneuze 02 sat Pa02 – Pv02 klein, echter door R/ met 100% 02 moeizame interpretatie. Besluit: – Behandel meteen zo Behandeling • Safety first! – Bron verwijderen. • BLS • 100% 02 – 1. Zowel bij vermoeden CO als CN. – 2. Vermoedelijk directe reactivatie van mitochondriale enzymes. • Supportief: – Vasopressie – Convulsieve therapie • Antidota Antidota 1. Vorming van methemoglobine: – 4 - DMAP – Nitriten 2. S-donoren – Natriumthiosulfaat 3. Cobaltgroepen – Dicobaltedetaat – Hydroxycobolamine 19/09/2014 Wetteren case 76 HCN detoxificatie • Conversie naar thiocyanaat • Conversie naar cyanocobalamine (via hydroxycobalamine) 1. Methemoglobinevorming • 4-DMAP (4-dimethylaminophenol ) / nitrieten – Vorming van methemoglobine (Hb-Fe3+) snelle chelatie met cyanide cyanomethemoglobine trage disscociatie in cyanide omzetting via rhodenase in thiocyanaat renale klaring. – Nevenwerkingen: • VD met hypotensie, hemolyse, nefrotoxiciteit. • Reeds bestaande hypoxemie + methemoglobinemie: hydroxycobalamine • Chelator cyanide: vormt vit B 12 (cyanocobalamine), via nieren uitgescheiden • Urticaria, huidverkleuring • Bloeddrukstijging • Lang halfleven (1 dosis genoeg) • 70 mg/kg (5 gr) 2. Natriumthiosulfaat • S – donatie: versnelt rhodenase x 3: acceleratie van enzymwerking/renale klaring. • Eerder add-on therapie: werkt traag, add-on bij 1 of bij 3. • Dosis: 12,5g traag IV (0,5g/kg IV) 3. Cobalt (Cyanokit, ...) • Cyanide ion hoogste affiniteit voor cobalt. • 2 vormen: – Dicobalt edetaat: 2e lijnstherapie (anaphylaxis, vrij cobalt is toxisch) – Hydroxycobalamine (Cyanokit) • + cyanide cyanocobalamine (vorm van vit B12) renale excretie. • Voordelen: – Minimale nevenwerkingen: urticaria, angioneurotisch oedeem, uiterst zeldzaam anaphylaxis,photosensiviteit, erythema (tot 15 dagen), chromaturie (48u tot 30 dagen). – Verminderd zuurstof-transport capaciteit niet, itt Welk antidotum? • Elke regio eigen algoritmes • In VS: 4-DMAP/nitrieten en thiosulfaat. • Frankrijk: cyanokit, ook pre-hospitaal • Vergelijking tussen 1 – 2 en 3: tendens tot meerwaarde voor cyanokit, voornamelijk door sneller herstel van de MAP. • Geen bewezen survival benefit/ invloed op metabole acidose. • Prijs: – cyanokit € 681 voor 2 vials van 2,5g. – Nithiodote (Nanitriet – natriumthiosulfaat): $ 422
© Copyright 2024 ExpyDoc
