vandaag 13 jaar geleden
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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
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This presentation only reflects the author’s personal opinion and neither the official report nor public authority
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Not every presentation is successful
Definitions • Disaster • Disaster Relief Team – Tasks of medical task force
• CP- Ops
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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
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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
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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
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Wetteren case a Disaster?
YES
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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
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Disaster Relief Team in Belgium Discipline 2
East Flanders
Medical Dept. 4 Medical Directors
16 Deputy Medical Directors
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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
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Discipline 2: Medical Victims
Implicated, not wounded
Population Wetteren, Schellebelle, Serskamp, Wichelen, …
Rescue workers (fire dept., civil protection, police services …)
Wounded
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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
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Time Lines May 4
2 a.m.: Derailment and fire of train 9:42 a.m.: high values arylonitrile in sewer system
May 7
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7 a.m.: High values acrylonitrile in sewer system miles away ….
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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
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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)
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Decision making • Based on: – Hazardous substance database: http://toxnet.nlm.nih.gov/ • Intikken: acrylonitrile • HSDB als keuze aanklikken
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Evacuation
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‘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
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Safety circles
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CP-Ops Decision making
Based on textbooks, databases, Based on experience (Toxicologists!!) Acrylonitrile: toxicity
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Tri-Ethyl-Aluminium
explosion risk
Ethylaluminiumdichloride
explosion risk
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Airway protection??
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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
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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
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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
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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
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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
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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
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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
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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
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Decision making • 1 PPM measured: evacuation • Case definition acrylonitrile intox: – Mucosa irritation: proves contact acrylonitrile – Other symptoms: metabolized towards CN
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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
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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
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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
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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
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Home or not?
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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.)
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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 …
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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
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Provide them with experts able to explain “lay people” the risks
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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
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Wat hebben we vandaag geleerd?
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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
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Lessons learned (6) • > 20 different occupational doctors • > 10 General practioners Different approach in follow up: minimizing vs maximizing
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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
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QUESTIONS ??
(& ANSWERS …?) 19/09/2014
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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
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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
