Five Critical Clinical Periods for Managing Mass Burn Casualties in Formosa Fun Coast Dust Explosion Disaster - Experience of Tri-Service General Hospital

成功處理八仙塵爆大量傷患的五個關鍵臨床分期－三軍總醫院經驗

戴念梓(Niann-Tzyy Dai) ； 曾元生(Yuan-Sheng Tzeng) ； 王志信(Chih-Hsin Wang) ； 施宥任(Yu-Jen Shih) ； 黃曉芃(Hsiao-Peng Huang) ； 喬浩禹(Hao-Yu Chiao) ； 周昌益(Chang-Yi Chou) ； 江奕翰(I-Han Chiang) ； 王啟宇(Chi-Yu Wang) ； 張鈞凱(Chun-Kai Chang) ； 吳建儒(Chien-Ju Wu) ； 林進達(Chin-Ta Lin) ； 瞿子翔(Tzi-Shiang Chu) ； 劉虹慧(Hung-Hui Liu) ； 陳錫根(Shyi-Gen Chen) ； 陳天牧(Tim-Mo Chen)

《臺灣整形外科醫學會雜誌》 26卷1期 (2017/03) Pp. 1-13

摘要

Background: The well-known Formosa Fun Coast Dust Explosion (FFCDE) Disaster, causing 499 burn casualties with mostly moderate to severe burn injuries, happened in Taiwan on June 27, 2015. The Tri-Service General Hospital (TSGH) admitted 65 burn patients, the largest numbers among all involved single hospitals in Taiwan, eventually achieved total survival of all admitted burn cases through successful clinical works and administrative management. This study aimed to analyze the factors relative to successful management of large-scale burn disaster through five distinct consecutive clinical periods. Materials and Methods: There were totally 52 burn patients of FFCDE disaster emergently admitted to TSGH. Because some patients had incomplete data for analysis, 45 cases were finally included in this study. The factors related to successful management of mass burn casualties in the FFCDE disaster were analyzed based on five distinct consecutive clinical periods including: the emergency room period, the early admission/ distribution period, the acute admission period, the early admission period, and the middle/late admission period. The relevant treatment and outcomes of patients will be also analyzed in this study. Results: The valuable experiences for successful management of FFCDE disaster may conclude through five critical consecutive clinical periods as belows. The Emergency Room period: The rapid and early recruitment of available medical and nursing staffs right after the alarm of burn disaster resulted in recalling of 336 medical personnels including 102 medical staffs, 183 nursing staffs, and 51 administrative staffs. Early burn wound assessment was launched after the arrival of mass burn casualties based on burn surface area and depth immediately by both emergency room physicians and plastic surgeons. The early admission/distribution period: The effectiveness and flexibility of arrangement of burn ward and ICU beds allows for early admission and distribution of all burn patients in only 12 minutes to 2 hours and enables following encounter of medical team members with available working spaces. For the patients directly sent to our hospital, it took only about 20 minutes in average to be hospitalized. Among 52 cases of emergency admission, 20 cases were admitted to ICU directly and other patients were admitted to the isolated general ward. The acute admission period: In consideration of the limited numbers of plastic specialists, two lines of medical teams were established including the front line of general surgeons or medical doctors and residents, and the second line of plastic consultants and registry residents. This manpower arrangement makes sure the most effective and accurate medical care for burn patients. The effective management of fresh burns were assigned for adequate resuscitation of burn victims in the most early stage. Ten patients received the goal-directed fluid resuscitation protocol that proved to decrease fluid creep and pulmonary complications. The early admission period: Based on the requirements of treatment, four therapeutic teams were developed including ward, surgical, wound care and psychology/rehabilitation teams. It makes sure that all the burn patients may have holistic health care. The middle/late admission period: While the cohesive medical team works effectively to stabilize all the burn patients, advanced therapeutic modalities including Biobrane, Meek micro-skin graft, negative pressure wound therapy (NPWT), and autologous keratinocyte cell spray with widely meshed split-thickness skin grafts (STSG) were then applied for the bits to promote burn wound healing and scar remodeling. The promotion of wound healing and scar reduction were observed using these advanced therapeutic methods. All the factors mentioned above achieved the finest outcome of mass burn casualties of FFCDE disaster treated in TSGH. Conclusion: According to the precious experience of TSGH, The factors for successful management of mass burn casualties according to the above five consecutive periods may include rapid awareness of disaster, effective medical manpower arrangement, early burn resuscitation and burn wound managemet, efficient administration, available facilities and advanced burn wound treatment.

關鍵字

Formosa Fun Coast Dust Explosion (FFCDE) disaster ； mass burn casualties ； burn disaster ； meek micro-skin graft ； negative pressure wound therapy (NPWT) ； split-thickness skin graft (STSG)

並列摘要

背景：於西元2015年6月27日發生於台灣新北市八仙樂園的塵爆意外，造成共499名年輕男女的嚴重燒傷，三軍總醫院最終成功的處理這次多達65位燒傷病人的大規模燒傷事件，達成零死亡率的成果。本文主要根據燒傷後五個重要的臨床分期來深入探討這次三軍總醫院成功處理大規模燒傷的重要因素。材料與方法：於新北市八仙樂園發生塵爆意外後，三軍總醫院陸續收治了共65名燒傷患者，意外發生後第一時間緊急收治了52名燒傷病患，其中45名病患因為入院資料較齊全列入此研究報告中。作者根據此次成功處理大量燒傷的臨床經驗，將整個處理的關鍵臨床過程區分為：急診室大量傷患期、入院分流期、入院急性期、入院初期、入院中/後期等五期。本研究工作係根據以上五個關鍵的臨床分期深入分析三軍總醫院處理八仙塵爆大量傷患的成功因素。結果：根據五個關鍵的臨床分期來分析三軍總醫院處理八仙塵爆大量燒傷的主要成功原因包括：一、急診室大量傷患期，能先期進行全體醫護的動員，並立即有效處理大量燒傷病患。結果顯示三軍總醫院當時立即召集了336名醫務人員，包括102名的醫務人員，183名護理人員及51名行政人員。當病患到院時，首先由急診室醫師和整形外科醫師判斷燒傷面積和深度，並進行燒傷嚴重程度分類，多數中至重度燒傷病患在早期就開始進行輸液治療。其中的10名入住加護中心並使用呼吸器患者接受了目標導向的輸液治療方式，事後分析證明可減少水份自擴張的微血管流出至間質組織及肺部併發症的發生。二、病患入院分流期，能迅速及彈性調度加護病房與普通病房做為收療燒傷病人之用，使病患能於12分鐘至2小時內全部完成緊急住院。對於直接由意外現場送往本院的病人，只需平均約20分鐘就可完成辦理緊急住院。在緊急住院的52例中，20例直接入住加護病房，其他患者則入住隔離的普通病房。三、入院急性期，緊急動員組成兩線跨科醫護人員一對一照顧急性期燒傷病患，第一線以非整形專科主治醫師為主，第二線以整形外科具燒傷專長醫師為主，使所有急性期傷患能受到必要且適切的醫療照護。四、入院初期，進行醫護治療團隊有效率之混合編組，共成立病房組/手術組/換藥組/心理復健組等四個醫療團隊，各司其職，使傷患的照護工作能做到鉅細靡遺。五、入院中/後期，進一步加強跨團隊共同照護與各項創新性醫療作為，應用包括各項生物膜，微型皮膚移植，負壓傷口治療和具有大範圍網狀皮分層植皮搭配自體角質細胞噴霧的先進治療模式以促進燒傷傷口癒合和疤痕重塑。在使用這些先進的治療方法後，可觀察到有促進傷口癒合和疤痕減少之功效。以上所有的重要因素使三軍總醫院雖然收療了65名大量燒傷病患，卻締造了零死亡率的成果。結論：依據上述五個關鍵之臨床分期歸納分析，三軍總醫院最終能成功處理大規模八仙塵爆燒傷並且降低死亡率的原因在於：有效的醫療人力動員與安排，高效率的緊急入院管理，充足的醫療設施和充分應用先進的燒傷治療技術等。