Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

Volume 7 Number 2
32
Original Articles continued
Reflections on the clinical learning points from the the Royal
London Hospital Intensive Care Unit following July 7th 2005
terrorist attacks
P J Shirley, M Thavasothy, D McAuley,
D Kennedy, G Mandersloot, V Verma, M Healy
Background
The July 7 th bombings resulted in sudden,
significant increased pressures on emergency care
resources at Royal London Hospital (RLH), including
critical care services. A lengthy period of reflection
has resulted in some observations and learning
points from these events.
The RLH has 16 level 3 critical care beds, and a
six-bedded surgical HDU managed separately by
surgical teams. Of 703 ICU admissions in 2004,
98% were emergencies, approximately 30% being
trauma-related. This workload, coupled with a 95%
occupancy rate, means that capacity expansion at
short notice is difficult.
Major Incident Preparation
On 7 th July the first RLH intensive care unit (ICU)
admission occurred at 1300, the initial response
having commenced with the major incident
declaration at approximately 0930. Of 15 patients
in the ICU, 10 were ventilated, 3 of whom were
considered fit for transfer to St Bartholomew’s or
the London Chest (LCH) Hospitals, where level 3
capacity had been increased by cancelling all
elective cardiothoracic surgery. Fortuitously,
regional anaesthetic registrars attending training
were available to assist in patient transfers, and LCH
also despatched transport teams. A total of 7 ICU
consultants attended to assist, but none learned by
paging or mobile phones that a major incident had
been declared until late in the day (runners proved
more efficient in disseminating this information). It
was subsequently revealed that mobile networks
were blocked to prevent overload and to preserve
communications for emergency services.
Five non-ventilated patients were transferred to
ward areas. Five HDU beds were upgraded to level
3 status by moving patients to ward care, and 4
further level 3 beds were established in theatre
recovery. Although only staffed for 16 patients, the
main RLH ICU has 18 physical bed spaces, allowing
2 extra beds to be created. Three unrelated cardiac
arrest calls required attendance by the critical care
team during this period.
The ICU team were involved in the early
management of patients in the Emergency
Department (ED), subsequently managing patients
through triaging, CT scanning, and operating
theatres. This resulted in improved communication
with the ICU prior to admission as well as providing
continuity thereafter.
Clinical Load
Of 195 patients seen at the RLH, 27 were admitted,
and 7 required Level 3 critical care post-operatively
(Table 1). The average ICU stay was 12 days; one
patient stayed for 22 days and one died from
secondary brain injury resulting from prolonged
hypoxia and two pre-hospital cardiac arrests.
Learning Points
1. ED – TRAUMA
After ‘ABCDE’ management rapid transfer to
theatre, ideally accompanied by the same team
throughout. Secondary and tertiary surveys
should be performed / repeated in theatre and ICU
as initial ED surveys were often incomplete owing
to instability.
Send blood / urine for urgent toxicology (ED
should have Rapid Test Assay).
2. THEATRES – SURGERY
Appropriate decisions by trauma-experienced
surgeons on limb salvage, debridement and early
fasciotomies will improve functional limb outcome
and reduce systemic complications. Ensure all
entry / exit wounds are adequately explored, as
correlated with tertiary survey.
Frequent repeat debridements likely to be
required, necessitating close liaison with specialist
surgeons.
3. ICU
Anticipate massive fluid requirements; early
invasive haemodynamic monitoring.
If haemodynamically unstable consider FAST scan
and transthoracic echocardiogram (TOE if high
risk of blunt cardiac injury).
If transfusion requirements are high, consider
mediastinal / chest wall, retroperitoneal or femoral
haematomas.
Have a low threshold of suspicion for barotrauma
(pneumothoraces, perforated viscus).
July 2006
The Journal of the Intensive Care Society