Mass Casualty Incident

Aka: Mass Casualty Incident, Disaster Medical Management, Disaster Medical Preparedness, Field Trauma Assessment and Treatment, MARCH Field Trauma Protocol

1. See Also
   1. Trauma Team Activation (TTA)
   2. Trauma Primary Survey
   3. Trauma Secondary Survey
   4. Pediatric Trauma
   5. ABC Management (Cardiopulmonary Resuscitation)
   6. Emergency Procedure
   7. Trauma Center
   8. Trauma Triage in the Field
   9. JumpSTART Pediatric Multiple Casualty Incident Triage
   10. SALT Mass Casualty Triage Algorithm
   11. Simple Triage and Rapid Treatment (START Triage)
   12. Decontamination
   13. Contaminated Casualty Management
   14. Decontamination in Children
   15. Chemical Weapon
   16. Biological Weapon (Bioterrorism)
   17. Biological Neurotoxin
   18. Toxin Antidotes
   19. Violence in the Hospital
   20. Personal Protection Equipment
   21. Respiratory Personal Protective Equipment
2. Definitions
   1. Mass Casualty Incident
      1. Events resulting in injured patients that overwhelm the resources of local hospitals and health care providers
3. Preparation
   1. Mobilize resources
      1. General surgeons (as well as other surgeons such as OB/Gyn, Urology)
      2. Medical providers
      3. Set up a volunteer staging area and designate someone to facilitate the area
      4. Assign someone to obtain adequate supplies (e.g. bandages, splints)
   2. Clear potentially available beds
      1. ESI 4-5 patients may be dispositioned home with close follow-up arranged
      2. Pending ward and ICU admissions should be moved to their receiving location
         1. Hallway boarding on the medical ward may be needed
      3. Consider diverting other Ambulance traffic not related to Mass Casualty Incident
   3. Protective Equipment
      1. Personal Protection Equipment
      2. Respiratory Personal Protective Equipment
   4. Resuscitation equipment
      1. Mobilize hospital equipment (crash carts, airway equipment, Ventilators) to the immediate triage area
      2. Intravenous Fluid bags, Blood Products
   5. Documentation
      1. Switch to paper medical records (EHR dowtime paper forms for orders, documentation)
   6. Prepare triage areas
      1. Prior to mass casualty patient arrival, move non-critical ED patients to other areas of the hospital or ED
      2. Assign a triage leader who will quickly assess each patient and assign a triage status
         1. Each patient has a set of initial Vital Signs (Heart Rate, mentation, respiratory status)
         2. Location and pattern of injury
         3. Consider using skin marker or sharpie to write triage number on patient (if tags not available)
      3. Assign a specific, single triage area through which all casualties will flow
      4. Assign an area for each triage level (minor, delayed, immediate or deceased)
4. Exam: Triage
   1. Background
      1. MCI triage is rooted in battlefield medicine
      2. Original battlefield triage established by Jean Larrey, french surgeon under Napolean
         1. Larrey system categorized patients based on injuries as emergent, urgent and non-urgent
         2. Prior to battefield triage, wealth and standing determined who received medical care first
   2. Children
      1. JumpSTART Pediatric Multiple Casualty Incident Triage
   3. Adults
      1. Simple Triage and Rapid Treatment (START Triage)
      2. SALT Mass Casualty Triage Algorithm
5. Management: Field Trauma Assessment and Treatment (MARCH Field Trauma Protocol)
   1. Background
      1. Equivalent of Primary Survey for the field
      2. Follow with Secondary Survey
   2. Control Massive Hemorrhage
      1. See Massive Hemorrhage
      2. Tourniquets can prevent limb Exsanguination
      3. Hemostatic Agents (e.g. Combat Gauze) or pressure bandages to trunk
   3. Airway
      1. Advanced Airway management (e.g. Laryngeal Mask Airway until time to perform Endotracheal Intubation)
      2. Cricothyrotomy if needed
   4. Respirations
      1. Consider 2 rescue breaths in children
      2. Chest decompression (Tension Pneumothorax)
         1. At least #14 gauge needle (3.25 inch) at fifth intercostal space
   5. Circulation
      1. Evaluate Vital Signs (Heart Rate, extremity pulses, Blood Pressure)
      2. FAST Exam (if time permits)
      3. Rapid transfusers (or inflated Blood Pressure cuff can form a pressure bag)
   6. Head and Hypothermia
      1. Evaluate mentation including Glasgow Coma Scale (GCS)
      2. Consider Altered Mental Status causes
         1. Traumatic Brain Injury
         2. Hypoxia or hypercapnia
         3. Hypovolemia
      3. Prevent Hypothermia
         1. Increased mortality risk in major Trauma patients
6. Management: Toxin Exposures
   1. Decontamination
      1. Contaminated Casualty Management
      2. Decontamination in Children
   2. Agents
      1. Chemical Weapon
      2. Biological Weapon (Bioterrorism)
      3. Biological Neurotoxin
      4. Toxin Antidotes
7. Precautions: Children
   1. Unique physiologic aspects
      1. See Rapid Cardiopulmonary Asessment in Children
      2. Children physically decompensate rapidly without significant warning beyond Tachycardia
      3. Children are more likely to experience multsystem Trauma from blunt injury (large head, immature skeleton)
      4. Children are most sensitive to chemical or Biological Weapons
         1. Aerosolized agents have greater effects due to increased Respiratory Rate and decreased body size
         2. Chemicals are absorbed more easily into a smaller volume of distribution
         3. Chemical Burns involve a greater percentage of surface area
   2. Unique psychological aspects
      1. Lack self-preservation and coping skills of adults (more likely to be paralyzed by fear)
      2. Parent-child separation anxiety is likely to be exacerbated (avoid separating children from families)
8. Precautions: Debriefing
   1. Assists with emotional Trauma experienced by staff (second victim syndrome)
   2. Assists with future preparedness (see below)
      1. Update Emergency Procedures, training and equipment to improve readiness for future incidents
9. Prevention: Preparedness
   1. Disaster drills should include patients of all ages including children
   2. Local protocols should be based on National Incident Management System (NIMS) guidelines
   3. Equipment, medications and supplies to cover all ages of victim should be at the ready
   4. Broad involvement of all partners (including hospital systems and transfer agreements as well as EMS)
   5. Plan for emergency overflow facilities
   6. Plan for emergency power, utilities
   7. Plan for legal, Malpractice and documentation issues
   8. Plan for security issues including unattended children, quarantines
   9. Plan for patient tracking (pictures, names, descriptions, identification bands)
   10. Plan for media and communications
10. Resources
    1. See Psychological First Aid
    2. National Incident Management System (NIMS)
       1. https://www.fema.gov/national-incident-management-system
    3. Disaster Distress Help Line
       1. https://www.redcross.org/get-help/disaster-relief-and-recovery-services/recovering-emotionally.html
11. References
    1. Seeyave and Bradin (2014) Crit Dec Emerg Med 28(12): 2-13
    2. Spangler and Nichols in Herbert (2016) EM:Rap 16(12): 5-7