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BACKGROUND Hemoglobin-Based Oxygen Carriers (HBOCs) can act as an "oxygen bridge" in acute severe anemia when transfusion is indicated, but not possible. We present data on 10 Expanded Access (EA) patients treated with high cumulative doses of Hemopure (HBOC-201), to assess the ability of HBOC-201 to safely treat life threatening anemia in situations where high volumes of product were administered over an extended period of time. STUDY DESIGN AND METHODS Inclusion in this study required that the patient receive at least 10 units of HBOC-201 between 2014 and 2017 under the FDA-sanctioned EA program. Depending on a patient's geographical location, treatment with HBOC-201 was obtained through either a single patient emergency Investigational New Drug (IND) application, or an intermediate size population IND. Of the 41 patients who were treated during this period, 10 patients received 10 or more units of the product. Data were obtained from medical records. RESULTS Treatments with HBOC-201 started within 24 hours of signing consent and were administered at an average rate of 1.99 (SD 0.17) units per day over a mean of 8.2 days (SD 2.9), during which patients received on average 16.2 units (SD 5.7 units) of HBOC-201. The median pre-treatment nadir corpuscular hemoglobin (Hb) concentration was 3.3 (SD 0.9) g/dL and post-treatment Hemoglobin was 7.3 (SD 1.7) g/dL. Common side effects included methemoglobinemia, gastrointestinal symptoms, and hypertension. However, no product-related serious adverse events (SAEs) were noted. All patients survived. CONCLUSIONS Administration of HBOC-201 over an extended period is a feasible and safe oxygen bridge for severely anemic patients who cannot be transfused with RBC.

This case describes a 46-year-old male recipient of a kidney-pancreas transplant who is Jehovah's Witness. Early in the postoperative period, he was found to have splenic vein thrombosis requiring heparin infusion. Two days later, he developed severe symptomatic anemia (hemoglobin

Large-scale explosions and plane crashes are good models for sudden mass casualty incidents (SMCIs) and may cause a large number of deaths and dismembered or fragmented bodies.

One of the major controversies on prehospital care for sudden chemical mass casualty incidents (SCMCIs) is whether to perform mass decontamination at the scene or at the hospital.

This is not another chapter about blast injuries but rather a brief summary of the main challenges encountered when treating patients with these catastrophic injuries.

Sudden exposure of multiple people to a chemical agent may be classified as a sudden chemical mass casualty incident (SCMCI). The vast majority of the contaminated patients will be mildly contaminated (“walking wounded”). The majority of contaminated patients will self-evacuate or be transported by nonrescue personnel to local hospitals. Although decontamination at the scene is desirable, it is time consuming in an unplanned, sudden event, and therefore unrealistic. Most critical patients, usually those with respiratory distress, will probably expire by the time scene decontamination is available. Therefore, critical contaminated patients should be transported rapidly to hospitals by first responders who must have personal protective equipment (PPE). Removal of all clothing may reduce contamination by 80–90% and should be done prior to getting into the ambulance. Once in the ambulance, patient can be kept covered and warm with blankets and sheets. High probability that a large number of self-evacuated patients will flood the hospital campus. Hospitals should plan to prevent patient flooding, have a decontamination facility, and further manage patients from a SCMCI.

The use of tourniquets, as a temporary procedure to control extremity bleeding, may be life saving. For many years, the use of tourniquets was banned from civilian prehospital protocols for management of limb hemorrhage due to concerns for complications, mainly loss of limbs. Military studies published by the Israeli, Americans, and British in the past 15 years, show that tourniquets are effective to control bleeding in the battlefield, are associated with minor complications and no limb loss. These outcomes were replicated in civilian studies as well. Recently, the advanced trauma life support (ATLS®) course introduced tourniquet use as an alternative for management of limb hemorrhage, when direct pressure fails to control bleeding. Nevertheless, in some situations when improvised tourniquets (cloths, ropes, ties) are applied by untrained bystanders, the opposite effect may occur, and the bleeding may increase. Therefore, tourniquet application should be limited to trained personnel. Untrained bystanders should be allowed to hold pressure directly on the bleeding site until trained personnel arrive. The “Stop the Bleed” training program, recently introduced by the American College of Surgeons (ACS), should increase the number of bystanders trained to control the bleeding until EMS arrives.

Search and rescue (S&R) need to start as early as possible. Possibility of finding survivors beneath the rubble is directly proportional to time (Fig. 11.1).

Crush injury – Occurs as a result of pressure applied to any part of the body, usually extremities, for a prolonged period of time. It may be associated or not with limb fractures. Complications of a crush injury are crush syndrome and compartment syndrome.

The major distinction between planning the medical response to earthquakes and other sudden mass casualty incidents (SMCI) is related to how severe damage will be the infrastructure of the city where the earthquake occurred.

On a cruise ship, there is an average of two physicians and three nurses on call for emergencies 24 h a day. Both the doctors and nurses are emergency medicine specialists.

Key components for planning exercises and drills for sudden mass casualty incidents (SMCIs): A plan for response to a SMCI needs to be written before the drill. Provide lectures to explain the plan to all individuals who may be involved in the response: For pre-hospital: all first responders For hospital: all medical, support personnel and administrators Organize tabletop exercises: Designed to bring together, into one room, all “players” that will respond to a SMCI (police, fire, EMS, hospitals, incident command, regional emergency operations center (REOC)). A large-scale incident is presented to them, and they have to resolve all challenges and pitfalls that it presents. Conduct sectorial pre-hospital exercises (Fig. 19.1): Constructed to train portions of the pre-hospital response separately. Examples: Scene deployment to a SMCI and triage of patients: could be performed at the ambulance station parking lot, using inflatable dummies or cards with description of injuries. Interaction between various ambulances and incident control: could be performed at an empty stadium parking lot, using inflatable dummies, where a few ambulances are deployed simultaneously. All paramedics perform triage, and the scene commander decides on transport priorities. Conduct sectorial hospital exercises: Constructed to train portions of the hospital response separately. Examples: Deployment of triage, patient arrival and photography Routes for emptying the emergency department Routes for influx of patients Deployment of alternate care sites Deploy a full exercise, preferably with pre-hospital and hospital training together (Fig. 19.2). There is no substitute for a well-organized, full-scale exercise testing all components of the response simultaneously.

Telemedicine is gaining increasing popularity in recent years as a new approach to assist with patient care in remote locations, where expert physicians may not be available. Today, most medical personnel have cellular phones with cameras capable of transmitting still images and videos to experts all around the world. For these reasons, some advocate the use of telemedicine to manage disasters in remote locations.

Information about specific treatment of anthrax, smallpox, botulinum, Ebola, and other infectious diseases can be found elsewhere.

This chapter focuses on planning and response for other types of sudden mass casualty incidents (SMCIs).

This last chapter of the manual focuses on special challenges when managing sudden mass casualty incidents (SMCIs) and includes specific medical tips when handling patients suffering crush and blast injuries, the most common identification processes of disfigured victims or body parts following explosions, and the importance of performing frequent live exercises and drills. In addition, the questionable use of telemedicine in SMCIs is discussed. The final section, “The Ten Commandments for Management of Sudden Mass Casualty Incidents,” highlights the most important topics that need to be in place to successfully respond to an SMCI.

Previously in this manual, I discussed the difference between progressive disasters and sudden events and the importance of a specific plan that addresses both types separately.