62 SECTION I Pediatric Critical Care The Discipline lifesaving interventions (1) respiratory support, (2) fluid resusci tation, (3) vasopressors, (4) antidotes and antibiotics, and (5) analgesia and s[.]
Trang 1lifesaving interventions: (1) respiratory support, (2) fluid
resusci-tation, (3) vasopressors, (4) antidotes and antibiotics, and (5)
analgesia and sedation In order to provide adequate essential care
to a greater number of patients, some more resource-intensive
interventions may need to be delayed or foregone in EMCC
set-tings Examples include strict monitoring and frequent recording
of vital signs and fluid balance, parenteral nutrition, invasive
he-modynamic monitoring, intracranial pressure monitoring, renal
replacement therapy, and extracorporeal life support.2 , 22 Similarly,
lifesaving EMCC interventions can be extended to much larger
than usual numbers of patients by conservation of resources,
sub-stitution, adapting personnel, supplies, and spaces, reusing
se-lected items, and reallocation of resource-intense interventions
from patients not expected to survive to patients with a higher
likelihood of quick recovery and survival Patient care plans may
need to be based more on physical examination findings than on
ancillary studies; relying less on laboratory and imaging studies
may represent a fundamental shift in patient management
para-digms The degree of deviation from usual practices should be
proportional to the gap between patient needs and existing
re-sources, and EMCC should be implemented in an organized way
by each hospital’s ICS with the input of public health experts
How Can the Intensive Care Unit Support
the Emergency Department During a Public
Health Emergency?
To provide continuity of patient care and maintain situational
awareness, ICU teams must interact closely with the ED Rapidly
accommodating patients from the ED or operating room will be
essential to allow those areas to continue receiving new patients
Triage of patients to match needs with available resources evolves
as the PHE unfolds, according to shifting needs and available
re-sources Initial triage categories are assigned in the ED by an
ex-perienced clinician whose sole role is to act as triage officer and
should be based on existing triage algorithms In some cases, ICU
staff may be temporarily reassigned to work in the ED as a triage
team to speed this process and ensure appropriate patient allocation
Physiologic triage identifies patients needing immediate
life-saving interventions Physiologic triage tools identify patients in
five categories: (1) those needing immediate lifesaving
interven-tions; (2) those who need significant intervention that can be
delayed; (3) those needing little or no treatment; (4) those who
are so severely ill or injured that survival is unlikely despite major
interventions; and (5) those who have already died Care of
pa-tients triaged to group 4, often referred to as “expectant,” will
deviate most significantly from usual approaches to intensive care
Because of overall demands on the system, scarce resources must
be allocated to other patients who are more likely to survive, and
expectant patients should receive appropriate palliative care
While no single triage tool is always rapid, completely accurate,
appropriate for all ages and disorders, and already familiar to all
providers, triage and ED staff should be familiar with the
physio-logic triage tools in use locally.24 The local chosen tools should be
made available online and in printed form to all relevant areas so
that patients are triaged and treated in a standardized manner
Pe-diatric experts should partner with regional healthcare coalitions to
provide standardized pediatric healthcare education, such as
pediat-ric triage and other specialized pediatpediat-ric topics, prior to a PHE.25
When decontamination or infection control are central to the
PHE at hand, these should be incorporated into the ED and triage
response Decontamination reduces toxic effects for the victim and mitigates contamination of providers, staff, and the hospital facil-ity Antidotes are given after cleaning an area of the body for administration Consideration should be given to risks of hypo-thermia by using warm water preferentially for those at highest risk
of thermal instability Respiratory support during decontamina-tion may be necessary and should be planned for.26–28 For PHEs with highly virulent transmissible infections, infection control must begin outside the ED entrance and continue without inter-ruption in the hospital while the patient is infectious.29 , 30
How Can All Intensive Care Units Work Together?
Pediatric hospitals often have more than one ICU with at least some patient flux between the NICU, PICU, and CICU depending on census There may be flux between the PICU and adult ICUs de-pending on patient age, size, underlying conditions, and disease process During a PHE, usual boundaries for these areas should be evaluated and stretched to accommodate the greatest number of critically ill patients (Fig 9.4) Critical care may be represented by
a single ICU leader within the ICS in order to facilitate awareness
of the global pool of ICU beds, staff, equipment, and supplies
As many more infants require ICU admission compared with older children, there is a notably larger pool of NICU beds within any given region There is considerable variation in equipment and staffing between the four levels of NICUs, but all NICUs have at least one nurse with resuscitation and stabilization train-ing in the hospital at all times (Table 9.1).31 All NICUs have de-vices to deliver positive-pressure ventilation; intubation supplies, including endotracheal tubes between 2.5 to 4.0; warmer beds; and a supply of medications in pediatric doses Adult hospitals experiencing a surge of pediatric patients should engage local neonatal and pediatric providers and staff to aid in triage and stabilization of infants and children until transport to regional PICUs and pediatric hospitals becomes available
What Steps Can Be Taken to Maximize Intensive Care Unit Treatment in a Disaster?
Patient Spaces
Single-patient spaces may be converted for use by two or three patients with careful discussion of how to monitor additional patients if centralized monitoring is limited After exhausting PICU space, additional space for EMCC may also be created by
Young disproportionately affected
Adults disproportionately
affected
• Fig. 9.4 Intensive care unit flux and the continuum of critical care in
surgeevents.CICU,Cardiacintensivecareunit; ICU, intensivecareunit;
NICU,neonatalintensivecareunit;PICU,pediatricintensivecareunit.
Trang 2CHAPTER 9 Public Health Emergencies and Emergency Mass Critical Care
adapting intermediate care units, postanesthesia care units, EDs,
procedure suites, or non-ICU hospital rooms Considerations for
adapting non-ICU spaces include the availability of equipment,
monitoring, and staff and whether these areas are needed as part
of non-ICU surge activities The hospital ICS should coordinate
these decisions to ensure overall resource optimization Overflow
of critically ill adolescents or young adults may be shared between
PICUs and adult ICUs, while younger infants and children
should be shared with local NICUs CICUs provide an additional
pool of critical care services Nonhospital facilities should be used
for EMCC only if hospitals become unusable
Personnel
Supplemental providers may include healthcare workers who have
skills in non-ICU pediatrics or nonpediatric critical care Rapid
credentialing procedures, just-in-time education, and local or
distant supervision by experienced pediatric and neonatal ICU
clinicians can help extend the provider pool Hospitals should
expect and plan for a need for significant psychosocial support for
patients and providers during and after a PHE, especially for
those who were asked to work beyond their usual scope of care.32
Mechanical Ventilation
Most hospitals have only a small number of extra ventilators and
support devices It may be necessary to consider temporary use of
transport and anesthesia ventilators, bilevel positive-pressure
breathing devices, and noninvasive support devices Some pediatric
hospitals use a single type of ventilator for patients of all sizes, with appropriate circuits and software algorithms In other hospi-tals, ventilators usually used for adults that have high compli-ance circuits and adult algorithms may have to be adapted for use in infants or small children When local supplies have been exhausted in a major PHE, adult-focused pediatric-adaptable ventilators and supplies may be accessed through the Strategic National Stockpile.33
Some difficulties in adapting equipment may be encountered The inspiratory flow or pressure sensor may not be sensitive to an infant’s inspiratory effort—triggering of inspiration may fail for synchronized intermittent mandatory ventilation, assist control,
or pressure support Likewise, ventilator algorithms to terminate inspiration pressure support may fail in the presence of air leaks around endotracheal tubes if incorrectly sized tubes are being used owing to limited supply
In a volume-controlled mode, adult ventilators may be unable
to provide small tidal volumes and inspiratory flow appropriate for a small infant Extremely preterm infants often require tidal volumes of less than 5 mL of air and are especially at risk for ad-verse effects from dead space Pressure-dependent losses of tidal volume in compressible spaces of adult ventilator circuits exagger-ate breath-to-breath variation in delivered tidal volume if peak inspiratory pressure varies with patient effort or changing respira-tory mechanics Difficulties in providing small tidal volumes and variation in ventilation due to leaks around uncuffed endotracheal tubes may necessitate using a time-cycled, pressure-limited mode
of ventilation Supplemental providers need considerable assis-tance in caring for an infant on a ventilator, especially if nonstan-dard equipment and techniques are being employed
Manual Ventilation
Few hospitals stockpile enough mechanical ventilators to support three times the usual number of ICU patients The temporary use of manual ventilation with a self-inflatable bag may need to be consid-ered Manual ventilation has been used successfully via tracheostomy tubes for days in a polio epidemic, and for hours in a power failure and during weather emergencies.34–38 It provides similar gas ex-change compared with mechanical ventilation when provided via an ETT.39–41 However, manual ventilation is labor intensive, may ex-pose staff to infection risks as a result of close and prolonged bedside contact, and may prove to be insufficient respiratory support to meet patient needs In extreme circumstances, family members or non-clinical staff could be tasked with providing manual ventilation with just-in-time training to free up clinical staff
Equipment and Supplies
Mass critical care can be provided only if essential equipment and supplies are available on-site, as resupply and rental deliver-ies may be limited during a PHE Thus, hospitals must balance the benefits of an adequate stockpile against the costs of main-taining items on-site that may expire or become defunct before being needed The Task Force on Mass Critical Care has recom-mended that a hospital should first target a mass critical care capacity of three times the usual maximum ICU capacity for
10 days, but decisions regarding equipment stockpiles should be made by individual hospitals.2 Each hospital should also main-tain information on how to contact neighboring hospitals and clinical spaces to evaluate capacity for sharing supplies and equipment locally
Level Population Staffing
Respiratory Equipment a I: Nursery Late preterm
to term Pediatrician off site PPV II: Special
Care
Nursery
Moderately
preterm
to term
APP, pediatrician, or neonatologist
on site or home call 24/7
PPV HFNC
6 CPAP
III: NICU Extremely
preterm
to term
APP or resident
in house 24/7 Neonatologist on site or home call 24/7
PPV HFNC CPAP CMV
6 High-frequency ventilator IV: Regional
NICU Infants with
subspe-cialty needs
APP or resident
in house 24/7 Neonatologist usually on site 24/7
PPV HFNC CPAP CMV High-frequency ventilator
6 ECMO
a Lower-level NICUs may have a limited supply of ventilators for pretransport stabilization.
APP, Advanced practice provider (nurse practitioner, physician assistant); CMV, conventional
mechanical ventilator; CPAP, continuous positive airway pressure; ECMO, extracorporeal
membranous oxygenation; HFNC, high-flow nasal cannula; NICU, neonatal intensive care
unit; PPV, positive pressure ventilation.
TABLE
9.1 Levels of Neonatal Intensive Care Unit Treatment and Expected Pediatric Specific Resources
Trang 3Nonpediatric hospitals must also consider stocking critical
pediatric equipment to care for children until transport and
pedi-atric hospital bed spaces become available Although it may be
possible to carry out many interventions by adapting nearly
equivalent equipment and supplies, some adult equipment
can-not be adapted to infants and small children It is essential to
stock adequate numbers of resuscitation masks, endotracheal
tubes, suction catheters, chest tubes, intravenous catheters, and
gastric tubes in pediatric sizes If cuffed endotracheal tubes are
used, it may be possible to cover the majority of pediatric needs
with 3.0-, 4.0-, 5.0-, and 6.0-mm cuffed tubes without stocking
intermediate sizes.2 , 42
Medications
In order to extend medication stockpiles in mass critical care,
rules should be formulated prior to PHEs regarding appropriate
substitutions, dose and frequency reductions, reasonable
paren-teral to enparen-teral conversions, restrictive indications, and shelf-life
extension.2 Experience in recent PHEs indicates that large
quanti-ties of analgesics and sedatives will be needed.21 , 43 Weight-based
dosing may be simplified to improve efficiency by specifying a
limited number of weight range categories When time
con-straints make it difficult to weigh patients, length-based estimates
of weight may suffice.44
How Will the Intensive Care Unit Evacuate
if Needed?
ICU providers must be aware of processes to ensure a safe and
timely evacuation in the event that this is ordered by the ICS
or government authorities Hurricane Sandy demonstrated a
lack of ICU evacuation knowledge, processes, and tools.45
Pe-diatric patients are especially vulnerable during ICU
evacua-tion, as few hospitals can serve as recipient hospitals and few
transport agencies are familiar with pediatric and neonatal
critical care Thus PICU, NICU, and CICU evacuation is
critically dependent on regional coordination of resources.46
ICU evacuation best practices are available from the Mass
Critical Care Taskforce, which include tools such as ICU
evacuation checklists and job action sheets that should be used
for preparedness and just-in-time training.47
How Should Pediatric Patients Be Tracked?
Hospital care of children is more efficient, more effective, and
less stressful when children are accompanied by a familiar
care-giver Unaccompanied children must be properly identified,
tracked, and reunited with their families Proper identification
of adult caregivers is necessary before releasing children
Ex-amples of child identification and tracking documents are
available online.12 A tracking and communication center
should be activated by a designee within the ICS in order to
centralize patient tracking and field calls from caregivers
Ev-ery pediatric patient should have a patient-specific tracking
identification number assigned upon arrival to the ED, and
the tracking center should be provided any potentially
identi-fying information to aid in reunification (such as physical
features, clothing, location where the patient was initially
found, information provided directly by verbal children, and a
photo whenever possible)
How Will Limited Services Be Ethically Rationed?
If a PHE overwhelms resources despite EMCC approaches, ra-tioning of resources may be needed Rara-tioning might occur on a first-come, first-served basis or by selecting patients most likely to survive as a result of brief lifesaving interventions.2 , 48 Proposed eligibility criteria to receive intervention include absence of severe chronic conditions, predicted mortality risk below a threshold chosen by the ICS or public health officials, and improving clini-cal status on periodic reevaluations Suggested algorithms exist for both children and adults.49 In pediatrics, however, there is little consensus about, or data to support, which mortality risk score to use, especially in light of typical PICU mortality of less than 5% and NICU mortality rate of less than 1%.19 , 50 Rationing should only occur using a formal hospital system or regional triage policy
or protocol and should be performed by triage officers with criti-cal care training under the direction of the ICS At present, neither evidence nor consensus of opinion supports a particular rationing strategy Thus, local ICSs need to evaluate needs and resources in real time in order to guide the triage team.51 , 52
Medical ethicists and community members are key partners in planning for crisis standards of care and potential rationing Dif-ficult questions surrounding the ethics of triaging patients as ex-pectant, removing life support, and which patient factors should
be considered when deciding who will (and who will not) be offered life support all benefit from careful consideration with trained bioethicists as well as community leaders Ideally, these discussions happen as part of the PHE planning phase to allow thorough discussion and input from members of the medical community and the public Public input can be accomplished with focus groups representative of local population demograph-ics and structured discussions of relevant issues The Institute
of Medicine specifically recommends community consultation during development of CSC to ensure that the final recommenda-tions “reflect the ethical values and priorities of the community.” This form of planning ensures transparency and provides reassur-ance to both affected patients and staff members during a PHE that issues have been sufficiently thought through beforehand A carefully considered plan created with public input creates a legal basis and liability protections.53
What Are the Mental Health Considerations Relevant to Emergency Mass Critical Care?
Situations requiring EMCC cause stress and trauma to patients, families, and staff Requiring care for a significant disaster-related illness or injury is a risk factor for severe mental health deteriora-tion Use of a mental health triage system such as psySTART can aid in allocation of psychiatric, behavioral, and psychosocial re-sources.54 For children at risk for significant mental health effects, attention to this should start as soon as possible Tracking children with the goal of identification and reunification, recording of indi-vidual exposures with known mental health effects, and protecting children from additive harm are key early steps For alert and in-teractive victims, ICU staff should follow basic support, including establishing safety and security, orienting to the situation in devel-opmentally appropriate ways, and facilitating communication with familiar caregivers and trained support staff Simple messag-ing that the child is in a safe place and that the family will join the child as soon as possible is appropriate for all pediatric patients
Trang 4CHAPTER 9 Public Health Emergencies and Emergency Mass Critical Care
Staff of all disciplines may also have significant mental health
effects during PHEs.55 Anxiety regarding risks to themselves, their
family, and their coworkers can combine with fatigue and trauma
from caring for multiple dead and dying patients in a short period
of time and lead to emotional and physical exhaustion To
miti-gate these effects, clear protocols and procedures for varying levels
of PHE should be created in the planning phase and shared with
front-line staff Job aids and just-in-time tools are important
methods to support staff Rest breaks and basic self-care—such as
access to bathrooms, food, and water—are necessary for any
sus-tained response In longer events, hospitals may consider shortening
shifts to allow recovery between intense exposures
What Is the Role of Medical Learners
in Public Health Emergencies?
Medical learners are a vital component of the healthcare team at
many pediatric centers Whenever a significant PHE occurs, the
needs of the patients and learners must be balanced Residents
and fellows provide extensive patient care in ICUs They are
rou-tinely trained to care for patients with contagious infections and
high-risk conditions; with supervision, they can provide care to
a large number of critically ill patients at a time Their value as
patient care providers must be weighed against potential risks to
their learning, their own health, and their families’ health Severe
PHEs—in which supplies of personal protective equipment are
inadequate, training insufficient, or supervision limited—place
learners at risk In this scenario, their role as junior team members
may discourage speaking up about these risks Very junior
learn-ers, such as observers and students, are especially vulnerable to
these issues—the decision to include them in PHE responses
should be carefully considered by their program, especially in
set-tings with limited PPE When learners of any stage are used in
PHE responses, care should be taken to ensure that they can safely participate to the benefit of the patients and their own education
Conclusion
It is essential that critical care providers are knowledgeable about and active in hospital and regional disaster planning, EMCC tri-age protocols, and surge strategies to be prepared for future events and maximize the survival of pediatric patients Preparedness ef-forts should include education on the local ICS, surge protocols, methods to extend care capacity, and triage techniques
Key References
American Academy of Pediatrics American College of Critical Care Medicine Consensus report for regionalization of services for
criti-cally ill or injured children Pediatrics 2000;105:152-155.
EMSC National Resource Center Checklist of Essential Pediatric Domains and Considerations for Every Hospital’s Disaster Preparedness Policies
Washington, DC: EMSC National Resource Center; 2014.
Kanter RK, Andrake JS, Boeing NM, et al A method for developing
consensus on appropriate standards of disaster care Disaster Med Public Health Prep 2009;3:27-32.
Kanter RK Strategies to improve pediatric disaster surge response:
potential mortality reduction and tradeoffs Crit Care Med
2007;35:2837-2842.
Phillips SJ, Knebel A Mass Medical Care with Scarce Resources: A Com-munity Planning Guide Rockville, MD: Agency for Healthcare
Research and Quality (AHRQ Publication No 07–0001); 2007.
Schreiber M The psySTART Rapid Mental Health Triage and Incident Management System Center for Disaster Medical Sciences, University
of California; 2010.
The full reference list for this chapter is available at ExpertConsult.com
Trang 51 US Census Bureau Age and Sex, Table S0101, American Community
Survey Washington, DC: US Census Bureau; 2006.
2 Christian MD, Devereaux AV, Dichter JR, et al Introduction and
executive summary: care of the critically ill and injured during
pan-demics and disasters: CHEST consensus statement Chest 2014;
146(suppl 4):8S-34S.
3 Tilford JM, Simpson PM, Green JW, et al Volume outcome
rela-tionships in pediatric intensive care units Pediatrics 2000;106:
289-294.
4 Pollack MM, Alexander SR, Clarke N, et al Improved outcomes
from tertiary center pediatric intensive care: a statewide comparison
of tertiary and nontertiary care facilities Crit Care Med 1991;19:
150-159.
5 Osler TM, Vane DW, Tepas JJ, et al Do pediatric trauma centers
have better survival rates than adult trauma centers? An examination
of the National Pediatric Trauma Registry J Trauma 2001;50:
96-101.
6 Densmore JC, Lim HJ, Oldham KT, et al Outcomes and delivery
of care in pediatric injury J Pediatr Surg 2006;41:92-98.
7 Randolph AG, Gonzales CA, Cortellini L, et al Growth of pediatric
ICUs in the US from 1995 to 2001 J Pediatr 2004;144:792-798.
8 Goodman DC, Little GA, Harrison WN, et al, eds The Dartmouth
Atlas of Neonatal Intensive Care Lebanon, NH: The Dartmouth
In-stitute of Health Policy & Clinical Practice, Geisel School of
Medi-cine at Dartmouth; 2019.
9 Kanter RK Strategies to improve pediatric disaster surge response:
potential mortality reduction and tradeoffs Crit Care Med
2007;35:2837-2842.
10 American Academy of Pediatrics American College of Critical Care
Medicine Consensus report for regionalization of services for
criti-cally ill or injured children Pediatrics 2000;105:152-155.
11 EMSC National Resource Center Checklist of Essential Pediatric
Domains and Considerations for Every Hospital’s Disaster Preparedness
Policies Washington, DC: EMSC National Resource Center; 2014.
12 Auf der Heide E The importance of evidence-based disaster
plan-ning Ann Emerg Med 2006;47:34-49.
13 Deleted in review.
14 King MA, Koelemay K, Zimmerman J, et al Geographical
maldis-tribution of pediatric medical resources in Seattle-King County
Prehosp Disaster Med 2010;25(4):326-332.
15 Hazards Vulnerability Analysis Emergency Preparedness California
Hos-pital Association; 2017
https://www.calhospitalprepare.org/hazard-vulnerability-analysis
16 US Department of Homeland Security National response framework
4th ed Washington, DC: Department of Homeland Security; 2019
https://www.fema.gov/media-library/assets/documents/
17 Phillips SJ, Knebel A Mass Medical Care with Scarce Resources: A
Community Planning Guide Rockville, MD: Agency for Healthcare
Research and Quality (AHRQ Publication No 07–0001); 2007.
18 Kanter RK, Cooper A Mass critical care: pediatric considerations in
extending and rationing care in public health emergencies Disaster
Med Public Health Prep 2009;3:S166-S171.
19 Kissoon N, Task Force for Pediatric Emergency Mass Critical Care
Deliberations and recommendations of the Pediatric Emergency
Mass Critical Care Task Force: executive summary Pediatr Crit Care
Med 2011;12(suppl 6):S103-S108.
20 Gostin LO, Sapsin JW, Teret SP, et al The Model State Emergency
Health Powers Act JAMA 2002;288:622-628.
21 Mahoney EJ, Harrington DT, Biffl WL, et al Lessons learned from
a nightclub fire: institutional disaster preparedness J Trauma 2005;
58:487-491.
22 Eriksson CO, Uyeki TM, Christian MD, et al Care of the child
with Ebola virus disease Pediatr Crit Care Med 2015;16:97-103.
23 Kanter RK, Moran JR Pediatric hospital and intensive care unit
capacity in regional disasters Pediatrics 2007;119:94-100.
24 Chevalier MS, Chung W, Smith J, et al Ebola virus disease cluster
in the United States–Dallas County, Texas, 2014 MMWR Morb Mortal Wkly Rep 2014 https://www.cdc.gov/mmwr/preview/
25 Lerner EB, Schwartz RB, Coule PL, et al Mass casualty triage: an evaluation of the data and development of a proposed national
guid-ance Disaster Med Public Health Prep 2008;2:S25-S34.
26 Kenningham K, Koelemay K, King MA Pediatric disaster triage
education and skills assessment: a coalition approach J Emerg Manag 2014;12:141-151.
27 Fertel BS, Kohlhoff SA, Roblin PM Lessons from the “Clean Baby
2007” pediatric decontamination drill Am J Disaster Med 2009;4:
77-85.
28 Freyberg CW, Arquilla B, Fertel BS, et al Disaster preparedness: hospital decontamination and the pediatric patient—guidelines for
hospitals and emergency planners Prehosp Disaster Med 2008;23:
166-173.
29 US Department of Homeland Security Patient Decontamination
in a Mass Chemical Exposure Incident: National Planning Guidance for Communities 2014 https://www.dhs.gov/sites/default/files/ publications/Patient%20Decon%20National%20Planning%20
30 Siegel JD, Rhinehart E, Jackson M, et al Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007; https://www.cdc.gov/infectioncontrol/guidelines/
31 American Academy of Pediatrics Committee on Fetus and Newborn
Levels of neonatal care Pediatrics 2012;130(3):587-597.
32 Kanter RK, Andrake JS, Boeing NM, et al A method for developing
consensus on appropriate standards of disaster care Disaster Med Public Health Prep 2009;3:27-32.
33 Strategic National Stockpile Public Health Emergency US
Depart-ment of Health & Human Services; 2020 https://www.phe.gov/
34 Rubinson L, Vaughn F, Nelson S, et al Mechanical ventilators in US
acute care hospitals Disaster Med Public Health Prep 2010;4(3):199-206.
35 West JB The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory
physiology J Appl Physiol 2005;99:424-432.
36 O’Hara JF, Higgins TL Total electrical power failure in a
cardiotho-racic intensive care unit Crit Care Med 1992;20:840-845.
37 Norcross ED, Elliott BM, Adams DB, et al Impact of a major hurricane
on surgical services in a university hospital Am Surg 1993;59:28-33.
38 Nates JL Combined external and internal hospital disaster: impact
and response in a Houston trauma center intensive care unit Crit Care Med 2004;32:686-690.
39 Barkmeyer BM Practicing neonatology in a blackout: the University Hospital NICU in the midst of Hurricane Katrina: caring for
chil-dren without power or water Pediatrics 2006;117:S369-S374.
40 Gervais HW, Eberle B, Konietzky D, et al Comparison of blood
gases of ventilated patients during transport Crit Care Med
1987;15:761-763.
41 Hurst JM, Davis K, Branson RD, et al Comparison of blood gases
during transport using two methods of ventilatory support J Trauma
1989;29:1637-1640.
42 Johannigman JA, Branson RD, Johnson DJ, et al Out-of-hospital
ventilation: bag valve device vs transport ventilator Acad Emerg Med
1995;2:719-724.
43 Branson RD, Johannigman JA, Daugherty EL, et al Surge capacity
mechanical ventilation Respir Care 2008;53:78-90.
44 Kumar A, Zarychanski R, Pinto R, et al Critically ill patients with
2009 Influenza A (H1N1) infection in Canada JAMA 2009;302:
1872-1879.
45 Luten R, Zaritsky A The sophistication of simplicity: optimizing
emergency dosing Acad Emerg Med 2008;15:461-465.
46 Espiritu M, Patil U, Cruz H, et al Evacuation of a neonatal intensive
care unit in a disaster: lessons from Hurricane Sandy Pediatrics
2014;134(6):e1662-e1669.