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Mass casualty management


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Mass casualty management

  1. 1. Mass Casualty ManagementDr.Anil HaripriyaA disaster comprises a sudden massive disproportionbetween hostile elements of any kind and the survivalresources that are available to counterbalance these inthe shortest period of time. Disaster is a calamity or asudden misfortune. Accoring to Colin Grant (1973) ,disaster is a catastrophe causing injury and illness to30 or more people. By WHO definition a disaster is anyoccurrence that causes damage , economic disruption,loss of human life and deterioration o health and healthservices on a scale suffecient to warrant anextraordinary response from outside the affectedcommunity or area.Classification:Disaster can be classified as follows:1. Natural Disorders- earthquakes and volcanic
  2. 2. eruptions (beneath earth surface)2. Land slides, evalanches (at earth surfaces).3. Windstorms ( Cyclones, typhoon, hurricane) 4. Hailstorms, Snowstorms, sea surges, floods,droughts.5. Biological Phnomena; Locust swarms,Epedemics of diseases.6. Man made disorders- Conventional warfare,Nuclear, Biological and Chemical warfare.7. Caused by accidents- Vehicular ( Plane, Train,Ship, Boat and Bus) 8. Drowning , Collapse of building, explosions, fires,biological and chemical ( including poisoning)In mass casuality situations , the demands alwaysexceeds the capabilities of both personnel andfacilities. The concept of mass casuality managementhas occupied the attention of surgeons since the 17thcentury. War casualities and sailing ship disasters werethe prime concerns in those eras. Over the lastdecades , the spectrum of possible catastrophe hasdramatically increased as result of an increasinglytechonogically sophisticated society. In every hospital ,it is necessary that the hospital emergency services
  3. 3. should function well . Disaster management is anextension of emergency or casuality services.Reduction of immediate mortality and morbidity is theparamount objective. Team work at all levels isessential to the successful management of a massdisaster.General Principles:Disaster generally involve a significant number ofcasualities in a localised region over a limited period oftime. Specific modifications are necessary if theoptimal salvage is to be obtained. In today’s rapidlyexpanding mobile society no geographical distributionis exempt from the possibility of any disaster includinga nuclear accident. Realastic advance planning is thekeystone to successful management of masscasualities. A general estimate of the number and typeof casualities resulting from specific disasters can beobtained and appropriate advance planning carried out.In most civilian disasters , much of the inured
  4. 4. populationwill suffer multiple inuries after a combinationof thermal and blunt trauma. Thermonuclear explosionsmay yield a large number of patients with extensiveradiation damage and thermal injuries, but relativelyfew peneterating injuries.General principles which should be included in thestructure of the disaster plans are as follows:1. The basic disaster plan should include the basicprinciples of mass casuality management which shouldbe applicable to all the catastrophes. Specific injuriesinvolved in the disaster should be dealt separately inthe secondary plans. Essential components of thedisaster plan are:a. Criteria for designation of a disaster situation.b. Authority for initiation and implementation of thedisaster plan.c. Mechanisms for implementation of the disaster
  5. 5. plan.d. Communication network.e. Triagef. Transport of injuries.g. Riot and/ or crowd control.2. The system should be flexible enough towithstand the challanges of all types of disaster.If theburn centre is not there, the possibility of handling burnvictims should be kept and appropriate arrangementto transfer these patients to Burn Centre should bemade.3. The plan should be realistic from the angle ofcapability of medical fraternity to the response ofcatastrophe.More sophisticated therapeuticinterventions must be avoided. Sophisticatedtechniques such as microvascular surgery requiring theextended services of highly trained surgeons,
  6. 6. complicated equipment and supplies should beavoided. These services no doubt enhance the qualityof life but quantity of life is decreased in the masscasualities.4. The communication system should be such thatthe appropriate resources can be mobilized quickly tomeet the demands.Mass Casualty Planning:This has following components:Community PlanningPlanning of disaster is the responsibility of all thesegments of casuality. Participitation of the police, firedepartment, civil defense units, press industrial groups,religious leaders and community groups is required toformulate the predisaster planning so as to make thefunctioning of plan effecient.First aid courses should betought to the groups of the community to be utilized in
  7. 7. the disaster situation. First aid teaching should stresson the techniques of emergency care which do notrequire the equipment , supplies and trained personnelbecause these facilities may not be available at thesite. Other important points which should beconsidered are:1. Location of the disaster is always unknown.Control Room site and location of site for collection ofcasualities should always have primary site andalternate arrangements.2. Disaster plans have two systems :a. The trauma team is transported to the site ofdisaster with emergency mobile hospital facility. Exceptin the selected disasters it has disadvantage that thereis time lapse between the occurrence of disaster andarrival of the medical team. If the medical personnelare shifted to the site there may be shortage of themedical staff in the hospital where their services may
  8. 8. be utilized in a better way.b. The trauma team is available in the hospital andthe disaster victims are transported to the hospital bythe skilled paramedicals after preliminary triage. Thisoption has better utilization.3. Many injured victims remain at the site ofdisaster, while severly injured are transported to thehospital.Community planning should provide fornecessary personnel and supplies to look after thesevictims.4. Provision for food, clothing and housing fornonhospitalized victims are a major stress on thecommunity. Coordinated community plan wouldprevent these chaos.5. Normal communication network may be involvedin the disaster. Predisaster planning must includealternate mode of communication to initiate andimplement the disaster plan. Two-way radiosystems
  9. 9. and messenger systems should always be included inthe plan in the event of communication failure.6. Community planning should include the initialtriage and transport of victims to the hospital. Inhospital transfers to meet the specific injury needshould be included in the plan.7. Riot and / crowd control . Mechanisms foraccesss of medical team to the victims in the hospitaland disaster site should be included in the plan. All thefactors which can prevent easy access may be lookedinto during plan.Hospital PlanningThe Disaster CommitteeAll the hospitals should have a well designated disastercommittee comprising of both medical and nonmedicalreprentatives. The committee should formulate thedisaster plan that should be flexible, and able to meet
  10. 10. any disaster situation. In the hospital site for themanagement of the disaster victims should beidentified which may near to the emergency services.Hospital facilities in terms of equipment, trainedpersonnels and management of trauma patients shouldbe reassessed by the committee.The disaster plan must be tested from time to time i.e.,minidrills at least twice in a year in conjunction with theother community services. Hospital disaster committeehas the responsibilty of dissemination of the plan to thecommunity and as well as in the hospital personnel.The local personnel must be trained to receive thefollowing medical emergencies.* Haemorrhages * Dislocations* Cardiovascular failure * Burns* Respiratory distress * Exposure to toxic substances* States of shock* Electrocution* Skull injuries
  11. 11. * Drownings* Fractures* Cases of accidental hypothermiaThe types of emergency vary according to the type ofdisaster and how and when it strikes. The disaster plandirector should be a medical personnel experiencedboth in adminstration and trauma care . He is finallyresponsible for the activation of disaster plan in theevent of catastrophe. Disaster alert has to be activatedby the authorised personnel. There are three phases ofdisaster alert.Phase I alert allows the identification of of an incidentwith the potential for a major disaster.Bomb hoax in acrowded place or leakage of toxic gas from an industryare the examples of situations for phase I alert.Phase II alert indicates that catastophe has occuredand that there are injured victims in the disaster.Phase III alert designates a disaster situation in which
  12. 12. large number of the disaster victims would be arrivingat a particular designated hospital. Each phase impliesthe need for mobilization of personnel and supplies ,transport and provision of hospital beds for disastervictims. A mechanism for rapid discharge of hospitalindoor patients is important for an effective disasterplan.The disaster plan should have the following features:a. Should be simple and understandable by all.b. Flexible and fit different types of disorders.c. Clear and concise - even in noise and confusion,hospital staff should be able to act upon itinstantaneously.d. Adoptable during all hours - day and nightincluding holidays.e. Extension of normal hospital working so thatpeople can act upon it immediately in a routine
  13. 13. manner.Plan Parameters:a. Distribution of Responsibilities:The hospital should develop action cards mentioningthe responsibilities of various departments andpersonnel involved - adminstrators, medical officers,incharge casuality, matrons, nursing officers, telephoneoperators, clerks, messengers and ward boys.b. Chronological:Initial alert can be by television, telephone, personsand wireless ; the place and time of accident and thetype of casualities should be clearly communicated.Based on the above, the hospital plan would beactivated. The medical officers, hospital adminstrator,controller, the switch board operator should notify thekey personnel, particularly the department of radiology,operation theatre, blood bank, laboratory, medical
  14. 14. stores, dietory, security, ambulances and the matrons.The nursing officer should make all the arrangementsin the wards for receiving the casualities. Maximalnumber of all the staff in the above department shouldbe available and on duty within 10 minutes of the call.The coordination and control for disaster managementshould be as follows:-The medical superintendent / director would beresponsible for determining the priority for treatmentand evacuation / distribution. He would instruct themedical officers and make adequate OT arrangements.The nursing officer would be responsible for allocationof the nursing and paramedical staff, deployment ofstaffand recall of staff from hostels and homes. Theadminstrative would be responsible to deal with therelatives, friends, public relations, fire brigades, policeand handling as well as utilization of voluntary workers.The clinical and OT departments would be responsiblefor clinical investigative and therapeutic activities.
  15. 15. Problems in Disaster Managementa. Clinical:Lack of professional staff , iinvestigative facilities,drugs, facilities for contaminated casualities,decontamination, isolation, protective clothingavailibility and usage by the clinical staff.b. Adminstrative:Documentation of the injured - consciousness ,unconsciousness, classification, nature of thetreatment given, documentation for police,communication to various bodies, telephone, telex, fax,and other other facilities, communication to friends andrelatives, conselling and support to the relatives andfriends, control of the crowd, voluntary workers,protection of the patient properties, nature ofinfirmation to be provided to the Press andBroadcasting services , disposal of the dead, post-mortems and protection of the bodies of VVIPs,
  16. 16. mortuary facilities.The Triage System:Triage implies the categorization and distribution ofcasualities so as to establish the priority and propertreatment. One of Senior Medical officer should beauthorised to coordinate the triage and transportationof victims at the disaster site. Another disaster plandirector or his representative of the rank of SeniorMedical Officer should be made responsible for theinitial assessment of the injured patients andassignment of appropriate treatment area.. Close to theemergency room a well definedarea should bedemarcated for triage so that the treatment facilities arenot interfered with.In the nonoperative treatment ,adequate resuscitation and prevention of furthercomplications should be the principle. Proper splintingand immobilization of the injuries of spine andextremeties will allow definitive treatment to be done atthe apprpriate elective time.In the operative
  17. 17. management , stress should be given for life savingprocedures only in mass casuality management so asto reduce the mortality. Adequate debridement andcontrol of haemorrhage are important in the initialmanagement of mass casualities.Three factors are essential components of effecienttriage system : Identification, Communication and ,transport.1. Identification: Casuality categorization not onlyincludes the initial evaluation of the injuries but assignsa value to the injury relative to the mass casualitysituation. A simple method of identification, such as atag or identification band tied to the victim, transmitsinformation regarding patient identification , diagnosis,categorization and therapy. One of the methods fordisaster categorization widely used is as follows:Category I - Green Tag: Casualities requiring minimaltreatment as outpatients or requiring domicillary care.
  18. 18. Category II - Red Tag: Casualities requiring immediatetreatmentand whose chances of recovery are goodafter immediate definitive care ( e.g., Compoundfracturs, readily controllable haemorrhage andcorrectable mechanical respiratory distress etc. ).Category III - Yellow Tag: Casualities requiringtreatment but who could tolerate delay, with thechances of recovery considered good after definitivecare ( e.g., blood replacement, closed fractures, limitedthermal injury ).Category IV - Blue Tag: Casualities requiringexpectant treatment , with poor chances of recoverybecause of the magnitude of injury and /or because anexcessive commitment of personnel and materialwould be required.Other method of categorization is as follows:A. Those who must be sent urgently to the nearestproperly equipped hospital. Among these two orders of
  19. 19. priority may be distinguished:A 1. Emergency cases that must be operated withinthe hour : * Acute cardio-respiratory insuffeciency * severe haemorrhages * internal bleeding * rupture of the spleen * injuries to the liver * severe chest injury * severe cervico-maxillary lesions * state of shock * severe burns ( over 20% ) * skull injuries with comaA 2. Emergency cases in which it is possible to wait a
  20. 20. few hours before operating: * ligatured vascular injury * intestinal injuries, severe haemorrhage orshock * open joint and bone injuries * multiple injuries with shock * injuries to the eyes * extensive closed fractures * less severe burns * skull injuries without comaB. Those given attention on the spot. Priority isgiven to the most serious cases with a chance ofsurviving: there are those who are attended to whilewaiting to be shifted to a specialised centre and thosewho do not need major medical care and can betreated on the spot.The B group also includes very
  21. 21. serious cases with no chances of survival that it wouldbe pointless to move.2. Communication: The establishedcommunication network must be functional. Rapidnotification of both medical and nonmedical supportgroups about the activation of disaster plan is essentialfor successful management of mass casualities.Thereis provision of central nondesignated manpower at thediscretion of director for specific disaster needs.Communication system must allow for continuousreassessment of utilization of manpower andequipment during the duration of disaster. Thereshould be effective communication network betweenthe disaster site , transport vehicles and referralfacilities such as hospital are essential in meeting thechanging demands of the disaster situation.3. Transport: A disaster plan must providealternative mode of transport if ground transportcannot be used. Suffecient air transport , often
  22. 22. involving the use of military facilities, must be available.Mechanism for availing such facility for rapidmobililization must be well defined.Medical Supplies and EquipmentHospital should be well prepared to maintainreasonable quantity of stored supply and equipment foruse only in mass casualty management. These shouldinclude intravenous lines, solutions, dressing supply,airway equipment, anaesthetic agents, drainage tubessuch as chest tubes, nasogastric tubes and urinarycatheters, splints and drugs. There should be wellestablished procedures for procuring additionalrequirement of blood and blood products and facilitiesfor emergency blood donation. Hypovolaemia is one ofthe important cause of mortality in the victims ofdisaster who arrive live in the hospital.SPECIAL CONSIDERATIONS:Anaesthesia. There is overwhelming demand of
  23. 23. anaesthesia in terms of personnel and time utilizationin a disaster situation.There is increase in the regionalanaesthesia utilization in disaster situations. Regionalanaesthesia provides relief of pain for prolongedperiods and minimal central nervous system ,respiratory and cardiac depression. Equipment forregional anaesthesia such as drapes and kits aresterile and disposable. Thus regional anaesthesiafacility can made available at the disaster site, duringtransport or at multiple sites within the hospitaldesignated for care of disaster victims.Morgue Facilities. Unfortunately , all disaster plansmust provide for a temporary morgue facility andmethod of identification of dead bodies. Newermodalities of identification such as antemortem dentalrecords and medical records by telephoto , are beingcontinuously invesigated for rapid identification of thefatally injured disaster victims.Nuclear Accidents. These are the worst disaster
  24. 24. situations of the modern society. There are no clearlydefined risks in both time and space in nuclearaccidents as compared to the many tradional disasterlike earth quakes, , floods and airplane crashes.Nuclear accidents can increase the risk zone includingthe hospital itself. Disaster plan must include the areawise evacuation in the nuclear accidents.Decontamination. Procedures for biological, chemicaland irradiation decontamination must be included in thedisaster plan before the arrival of casualities at thecollection area. The main objective of decontaminationis to obviate the spread of contamination by disposingthe clothing of victims, treating the skin with theneutralizing solutions before the victims reach thecentral triage area.Conclusion:Mass casuality management includes well organisedpredisaster planning , assessment of disaster situation
  25. 25. to avoid chaos. Accurate assessment of of themagnitude of the disaster can lead to the effecientmanagement of the disaster so as to lead to thedecreased mortality and morbidity. There should besuffecient provision of personnel and logistical supportto meet the demands of the mass disaster. Disasterplan should be flexible, adoptable to all types ofdisasters and is the key to the success of managementof mass casualities.