J. Duranteau

Department of Anaesthesia and Intensive Care

Hôpitaux universitaires Paris-Sud

A disaster in Paris

2

No conflict of interest

Stade de France

Bataclan

Rue de Charonne

Le Petit Cambodge

Cosa Nostra

Bd Voltaire

On November 13th 2015 in Paris, terrorists used explosives and assault rifles,

both on streets, café terraces, and in a theatre.

The city of Paris was exposed to 3 bomb explosions, 4 shooting scenes and

during 3 hours several hundreds people have been taken hostage

130 deaths and ≥ 540 injured victims

Stade de France

Bataclan

Rue de Charonne

Le Petit Cambodge

Cosa Nostra

Bd Voltaire

Most unstable patients were transferred to the six

trauma centers of the Paris

45 mobile intensive care units (MICU) of the SAMU (Services d’Aide

Médicale Urgente) and Fire-Brigade ambulances EMT with physicians

trained in disaster medicine had been mobilized and dispatched to the

six terrorist attack locations

Casualties were categorized as absolute (AE) or

relative (RE) emergencies

Uncontrolled admissions in closest non

trauma-oriented hospitals

Battle field

Scoop and run - Damage control strategy

Pre-hospital resuscitation procedures were

limited to essential measures

the on-going anti-terrorist action and the prolonged hostage-taking in the Bataclan

complicated access to the casualties, their prehospital care, and evacuation

Thirteen (4%) received orotracheal

intubation and 9 (3%)

catecholamine administration

No security on the battle field

Difficult and dangerous for emergency teams

(terrorist gunshots)

Transportation by ambulance convoys:

waves of patients

Inefficiency of

Advanced Medical Post

Scoop and run - Damage control strategy

Pre-hospital resuscitation procedures were

limited to essential measures

the on-going anti-terrorist action and the prolonged hostage-taking in the Bataclan

complicated access to the casualties, their prehospital care, and evacuation

Thirteen (4%) received orotracheal intubation and 9 (3%)

catecholamine administration

No security on the battle field

Difficult and dangerous for emergency teams

(terrorist gunshots)

Transportation by ambulance convoys: waves of patients

Inefficiency of

Advanced Medical Post

Massive mobilization of everyone, Solidarity and professionalism

What we learned from Paris terrorist attack

Controlled admissions in

trauma-oriented hospitals:

▪ 61 (51%) AE

▪ 94 (43%) RE

Controlled admissions in trauma-oriented

hospitals:

▪ 120 (36%) of absolute emergencies (AE)

▪ 217 (64%) of relatives emergencies (RE)

Uncontrolled admissions in closest

non trauma-oriented hospitals:

▪ 59 (49%) AE

▪ 123 (57%) RE

Hospital

mortality 2.1%

SMUR(Service Mobile d'Urgence et

Reanimation)Mobile Emergency and Resuscitation Service

Shock trauma room

Operating rooms

ICU

Emergency department

RE

AE

RE

Triage

AE

Spontaneousadmissions

Embolisation

Surgical wards

It become obvious that each hospital had to set-up

an in-hospital triage with a trio: ICU

physicians/surgeon/emergency physician

Only 119 (36%) casualties benefited from

the installation of an identification

bracelet during prehospital phase

What we learned from Paris terrorist attack

Rooms and Circuits

TriageEmergency department

Surgical Walls

ICU

Shock trauma room

Operating rooms

PediatricTrauma Room

Forward march

What we learned from Paris terrorist attack

Emergency surgery was required in 181 (54%) cases

50 % of the AE were in the OR in less than 2.5 hours after arrival

Forty-four extra operating rooms on top of 31 available (+ 141%) were recruited to

perform emergency surgery

Twenty-seven patients (8%) required transfer to another hospital within the first 24 hours

(because the operating theatres were saturated or to benefit from surgical expertise not

available in the initial hospital)

What we learned from Paris terrorist attack

Massive mobilization of everyone, Solidarity and professionalism

The recall of medical and nonmedical resources was performed in

collaboration with the crisis teams of hospital administrations

But also spontaneous mobilization of physicians and

nurses that we had to organize

Communications problems between hospital teams and out-

of-hospital emergency services

Thankfully, the Internet played a significant role and contact

was maintained throughout text messaging

Damage control resuscitation

Assessment and initial management

Management of respiratory and

hemodynamic failures

EFAST (extended focused assessment with sonography

for trauma) to augment clinical assessment

Major haemorrhage protocol activation

Peripheral + Central intravenous access + Arterial line

Fluid + Vasopressor resuscitation

Transfusion protocol

whole-body CT

Tourniquet - Pelvic binders

Training to manage successives “waves

of 10 patients”

▪ One team for one patient with an absolute emergency: 1

intensivist senior-1 intensivist junior / 2 nurses

▪ One team from the admission to the operating room

Afflux

Operating roomsICU

Shock Trauma

rooms

What we learned from Paris terrorist attack

Identification of victims

A key source of error and confusion

▪ Pre-admission with a pre-set anonymization

▪ 20 pre-admission nameless identities

▪ Each patient is identified also by a colour code and

the team in charge of the patient has an armband of

the same color

Nom : axbctnoviunPrénom : axbctnoviun

DDN : 01/01/1900

Family

Family area for the family of the victims with psychologists

and medical officers available to assist family and to provide

detailed personalized informations

Bed management

vision of bed capacity available and of the number of patients

that need to be discharged or transferred rapidly

Simulation

The morning of the day of the attacks, a multiple shooting simulation was organized in Paris!

Education

No plan, so complete it is, does not allow to plan everything,

and it is necessary to get ready to be surprised

▪ Referral to a non-trauma centre hospital of almost half of

patients categorized as AE

▪ None of these patients lacked essential resources, since

they were able to benefit in their hospital from all

necessary surgical specialities, apart from only three

cases who required secondary transfer to trauma centre

Hospital mortality <2.1%

What we learned from recent terrorist attacks

We have to be ready to take in charge « waves of patients»

We have to establish intra-hospital cicuits for these patients

We have to improve communications with the police

authorities and out-of-hospital emergency services

We have to be capable to identify patients

We have to train all the teams (simulation)

We have to educate physicians on damage control

B. Vigué

C. Laplace

C. Ract

P.E. Leblanc

G. Cheisson

A. Harrois

S. Figueiredo

S. Hamada

A. Rodrigues

G. Dubreuil

Department of Anaesthesia and Intensive Care

Hôpitaux Universitaires Paris-Sud

Bicêtre Hospital

« Change starts with one person standing up

and saying « no more » »