Mass casualty management

Mass Casualty Management
Dr.Anil Haripriya
A disaster comprises a sudden massive disproportion

between hostile elements of any kind and the survival

resources that are available to counterbalance these in

the shortest period of time. Disaster is a calamity or a

sudden misfortune. Accoring to Colin Grant (1973) ,

disaster is a catastrophe causing injury and illness to

30 or more people. By WHO definition a disaster is any

occurrence that causes damage , economic disruption,

loss of human life and deterioration o health and health

services on a scale suffecient to warrant an

extraordinary response from outside the affected

community or area.

Classification:

Disaster can be classified as follows:

1. Natural Disorders- earthquakes and volcanic

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 always

exceeds the capabilities of both personnel and

facilities. The concept of mass casuality management

has occupied the attention of surgeons since the 17th

century. War casualities and sailing ship disasters were

the prime concerns in those eras. Over the last

decades , the spectrum of possible catastrophe has

dramatically increased as result of an increasingly

techonogically sophisticated society. In every hospital ,

it is necessary that the hospital emergency services

should function well . Disaster management is an

extension of emergency or casuality services.

Reduction of immediate mortality and morbidity is the

paramount objective. Team work at all levels is

essential to the successful management of a mass

disaster.

General Principles:

Disaster generally involve a significant number of

casualities in a localised region over a limited period of

time. Specific modifications are necessary if the

optimal salvage is to be obtained. In today’s rapidly

expanding mobile society no geographical distribution

is exempt from the possibility of any disaster including

a nuclear accident. Realastic advance planning is the

keystone to successful management of mass

casualities. A general estimate of the number and type

of casualities resulting from specific disasters can be

obtained and appropriate advance planning carried out.

In most civilian disasters , much of the inured

populationwill suffer multiple inuries after a combination

of thermal and blunt trauma. Thermonuclear explosions

may yield a large number of patients with extensive

radiation damage and thermal injuries, but relatively

few peneterating injuries.

General principles which should be included in the

structure of the disaster plans are as follows:

1. The basic disaster plan should include the basic

principles of mass casuality management which should

be applicable to all the catastrophes. Specific injuries

involved in the disaster should be dealt separately in

the secondary plans. Essential components of the

disaster plan are:

a. Criteria for designation of a disaster situation.

b. Authority for initiation and implementation of the

disaster plan.

c. Mechanisms for implementation of the disaster

plan.

d. Communication network.

e. Triage

f. Transport of injuries.

g. Riot and/ or crowd control.

2. The system should be flexible enough to

withstand the challanges of all types of disaster.If the

burn centre is not there, the possibility of handling burn

victims should be kept and appropriate arrangement

to transfer these patients to Burn Centre should be

made.

3. The plan should be realistic from the angle of

capability of medical fraternity to the response of

catastrophe.More sophisticated therapeutic

interventions must be avoided. Sophisticated

techniques such as microvascular surgery requiring the

extended services of highly trained surgeons,

complicated equipment and supplies should be

avoided. These services no doubt enhance the quality

of life but quantity of life is decreased in the mass

casualities.

4. The communication system should be such that

the appropriate resources can be mobilized quickly to

meet the demands.

Mass Casualty Planning:

This has following components:

Community Planning

Planning of disaster is the responsibility of all the

segments of casuality. Participitation of the police, fire

department, civil defense units, press industrial groups,

religious leaders and community groups is required to

formulate the predisaster planning so as to make the

functioning of plan effecient.First aid courses should be

tought to the groups of the community to be utilized in

the disaster situation. First aid teaching should stress

on the techniques of emergency care which do not

require the equipment , supplies and trained personnel

because these facilities may not be available at the

site. Other important points which should be

considered are:

1. Location of the disaster is always unknown.

Control Room site and location of site for collection of

casualities should always have primary site and

alternate arrangements.

2. Disaster plans have two systems :

a. The trauma team is transported to the site of

disaster with emergency mobile hospital facility. Except

in the selected disasters it has disadvantage that there

is time lapse between the occurrence of disaster and

arrival of the medical team. If the medical personnel

are shifted to the site there may be shortage of the

medical staff in the hospital where their services may

be utilized in a better way.

b. The trauma team is available in the hospital and

the disaster victims are transported to the hospital by

the skilled paramedicals after preliminary triage. This

option has better utilization.

3. Many injured victims remain at the site of

disaster, while severly injured are transported to the

hospital.Community planning should provide for

necessary personnel and supplies to look after these

victims.

4. Provision for food, clothing and housing for

nonhospitalized victims are a major stress on the

community. Coordinated community plan would

prevent these chaos.

5. Normal communication network may be involved

in the disaster. Predisaster planning must include

alternate mode of communication to initiate and

implement the disaster plan. Two-way radiosystems

and messenger systems should always be included in

the plan in the event of communication failure.

6. Community planning should include the initial

triage and transport of victims to the hospital. In

hospital transfers to meet the specific injury need

should be included in the plan.

7. Riot and / crowd control . Mechanisms for

accesss of medical team to the victims in the hospital

and disaster site should be included in the plan. All the

factors which can prevent easy access may be looked

into during plan.

Hospital Planning

The Disaster Committee

All the hospitals should have a well designated disaster

committee comprising of both medical and nonmedical

reprentatives. The committee should formulate the

disaster plan that should be flexible, and able to meet

any disaster situation. In the hospital site for the

management of the disaster victims should be

identified which may near to the emergency services.

Hospital facilities in terms of equipment, trained

personnels and management of trauma patients should

be 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 the
other community services. Hospital disaster committee
has the responsibilty of dissemination of the plan to the
community and as well as in the hospital personnel.
The local personnel must be trained to receive the
following medical emergencies.

* Haemorrhages

* Dislocations

* Cardiovascular failure

* Burns

* Respiratory distress

* Exposure to toxic substances

* States of shock

* Electrocution

* Skull injuries

* Drownings

* Fractures

* Cases of accidental hypothermia

The types of emergency vary according to the type of

disaster and how and when it strikes. The disaster plan

director should be a medical personnel experienced

both in adminstration and trauma care . He is finally

responsible for the activation of disaster plan in the

event of catastrophe. Disaster alert has to be activated

by the authorised personnel. There are three phases of

disaster alert.

Phase I alert allows the identification of of an incident

with the potential for a major disaster.Bomb hoax in a

crowded place or leakage of toxic gas from an industry

are the examples of situations for phase I alert.

Phase II alert indicates that catastophe has occured

and that there are injured victims in the disaster.

Phase III alert designates a disaster situation in which

large number of the disaster victims would be arriving

at a particular designated hospital. Each phase implies

the need for mobilization of personnel and supplies ,

transport and provision of hospital beds for disaster

victims. A mechanism for rapid discharge of hospital

indoor patients is important for an effective disaster

plan.

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 it

instantaneously.

d. Adoptable during all hours - day and night

including holidays.

e. Extension of normal hospital working so that

people can act upon it immediately in a routine

manner.

Plan Parameters:

a. Distribution of Responsibilities:

The hospital should develop action cards mentioning

the responsibilities of various departments and

personnel involved - adminstrators, medical officers,

incharge casuality, matrons, nursing officers, telephone

operators, clerks, messengers and ward boys.

b. Chronological:

Initial alert can be by television, telephone, persons

and wireless ; the place and time of accident and the

type of casualities should be clearly communicated.

Based on the above, the hospital plan would be

activated. The medical officers, hospital adminstrator,

controller, the switch board operator should notify the

key personnel, particularly the department of radiology,

operation theatre, blood bank, laboratory, medical

stores, dietory, security, ambulances and the matrons.

The nursing officer should make all the arrangements

in the wards for receiving the casualities. Maximal

number of all the staff in the above department should

be available and on duty within 10 minutes of the call.

The coordination and control for disaster management

should be as follows:-

The medical superintendent / director would be

responsible for determining the priority for treatment

and evacuation / distribution. He would instruct the

medical officers and make adequate OT arrangements.

The nursing officer would be responsible for allocation

of the nursing and paramedical staff, deployment of

staffand recall of staff from hostels and homes. The

adminstrative would be responsible to deal with the

relatives, friends, public relations, fire brigades, police

and handling as well as utilization of voluntary workers.

The clinical and OT departments would be responsible

for clinical investigative and therapeutic activities.

Problems in Disaster Management

a. Clinical:

Lack of professional staff , iinvestigative facilities,

drugs, facilities for contaminated casualities,

decontamination, isolation, protective clothing

availibility and usage by the clinical staff.

b. Adminstrative:

Documentation of the injured - consciousness ,

unconsciousness, classification, nature of the

treatment given, documentation for police,

communication to various bodies, telephone, telex, fax,

and other other facilities, communication to friends and

relatives, conselling and support to the relatives and

friends, control of the crowd, voluntary workers,

protection of the patient properties, nature of

infirmation to be provided to the Press and

Broadcasting services , disposal of the dead, post-

mortems and protection of the bodies of VVIPs,

mortuary facilities.

The Triage System:

Triage implies the categorization and distribution of

casualities so as to establish the priority and proper

treatment. One of Senior Medical officer should be

authorised to coordinate the triage and transportation

of victims at the disaster site. Another disaster plan

director or his representative of the rank of Senior

Medical Officer should be made responsible for the

initial assessment of the injured patients and

assignment of appropriate treatment area.. Close to the

emergency room a well definedarea should be

demarcated for triage so that the treatment facilities are

not interfered with.In the nonoperative treatment ,

adequate resuscitation and prevention of further

complications should be the principle. Proper splinting

and immobilization of the injuries of spine and

extremeties will allow definitive treatment to be done at

the apprpriate elective time.In the operative

management , stress should be given for life saving

procedures only in mass casuality management so as

to reduce the mortality. Adequate debridement and

control of haemorrhage are important in the initial

management of mass casualities.

Three factors are essential components of effecient

triage system : Identification, Communication and ,

transport.

1. Identification: Casuality categorization not only

includes the initial evaluation of the injuries but assigns

a value to the injury relative to the mass casuality

situation. A simple method of identification, such as a

tag or identification band tied to the victim, transmits

information regarding patient identification , diagnosis,

categorization and therapy. One of the methods for

disaster categorization widely used is as follows:

Category I - Green Tag: Casualities requiring minimal

treatment as outpatients or requiring domicillary care.

Category II - Red Tag: Casualities requiring immediate

treatmentand whose chances of recovery are good

after immediate definitive care ( e.g., Compound

fracturs, readily controllable haemorrhage and

correctable mechanical respiratory distress etc. ).

Category III - Yellow Tag: Casualities requiring

treatment but who could tolerate delay, with the

chances of recovery considered good after definitive

care ( e.g., blood replacement, closed fractures, limited

thermal injury ).

Category IV - Blue Tag: Casualities requiring

expectant treatment , with poor chances of recovery

because of the magnitude of injury and /or because an

excessive commitment of personnel and material

would be required.

Other method of categorization is as follows:

A. Those who must be sent urgently to the nearest

properly equipped hospital. Among these two orders of

priority may be distinguished:

A 1. Emergency cases that must be operated within

the 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 coma

A 2. Emergency cases in which it is possible to wait a

few hours before operating:

* ligatured vascular injury

* intestinal injuries, severe haemorrhage or

shock

* open joint and bone injuries

* multiple injuries with shock

* injuries to the eyes

* extensive closed fractures

* less severe burns

* skull injuries without coma

B. Those given attention on the spot. Priority is

given to the most serious cases with a chance of

surviving: there are those who are attended to while

waiting to be shifted to a specialised centre and those

who do not need major medical care and can be

treated on the spot.The B group also includes very

serious cases with no chances of survival that it would

be pointless to move.

2. Communication: The established

communication network must be functional. Rapid

notification of both medical and nonmedical support

groups about the activation of disaster plan is essential

for successful management of mass casualities.There

is provision of central nondesignated manpower at the

discretion of director for specific disaster needs.

Communication system must allow for continuous

reassessment of utilization of manpower and

equipment during the duration of disaster. There

should be effective communication network between

the disaster site , transport vehicles and referral

facilities such as hospital are essential in meeting the

changing demands of the disaster situation.

3. Transport: A disaster plan must provide

alternative mode of transport if ground transport

cannot be used. Suffecient air transport , often

involving the use of military facilities, must be available.

Mechanism for availing such facility for rapid

mobililization must be well defined.

Medical Supplies and Equipment

Hospital should be well prepared to maintain

reasonable quantity of stored supply and equipment for

use only in mass casualty management. These should

include intravenous lines, solutions, dressing supply,

airway equipment, anaesthetic agents, drainage tubes

such as chest tubes, nasogastric tubes and urinary

catheters, splints and drugs. There should be well

established procedures for procuring additional

requirement of blood and blood products and facilities

for emergency blood donation. Hypovolaemia is one of

the important cause of mortality in the victims of

disaster who arrive live in the hospital.

SPECIAL CONSIDERATIONS:

Anaesthesia. There is overwhelming demand of

anaesthesia in terms of personnel and time utilization

in a disaster situation.There is increase in the regional

anaesthesia utilization in disaster situations. Regional

anaesthesia provides relief of pain for prolonged

periods and minimal central nervous system ,

respiratory and cardiac depression. Equipment for

regional anaesthesia such as drapes and kits are

sterile and disposable. Thus regional anaesthesia

facility can made available at the disaster site, during

transport or at multiple sites within the hospital

designated for care of disaster victims.

Morgue Facilities. Unfortunately , all disaster plans

must provide for a temporary morgue facility and

method of identification of dead bodies. Newer

modalities of identification such as antemortem dental

records and medical records by telephoto , are being

continuously invesigated for rapid identification of the

fatally injured disaster victims.

Nuclear Accidents. These are the worst disaster

situations of the modern society. There are no clearly

defined risks in both time and space in nuclear

accidents as compared to the many tradional disaster

like earth quakes, , floods and airplane crashes.

Nuclear accidents can increase the risk zone including

the hospital itself. Disaster plan must include the area

wise evacuation in the nuclear accidents.

Decontamination. Procedures for biological, chemical

and irradiation decontamination must be included in the

disaster plan before the arrival of casualities at the

collection area. The main objective of decontamination

is to obviate the spread of contamination by disposing

the clothing of victims, treating the skin with the

neutralizing solutions before the victims reach the

central triage area.

Conclusion:

Mass casuality management includes well organised

predisaster planning , assessment of disaster situation

to avoid chaos. Accurate assessment of of the

magnitude of the disaster can lead to the effecient

management of the disaster so as to lead to the

decreased mortality and morbidity. There should be

suffecient provision of personnel and logistical support

to meet the demands of the mass disaster. Disaster

plan should be flexible, adoptable to all types of

disasters and is the key to the success of management

of mass casualities.

Mass casualty management

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