CONSIDERATIONS FOR MASS CASUALTY INCIDENTS

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CONSIDERATIONS FOR MASS CASUALTY INCIDENTS
csepp multi-hazard medical curriculum
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Objective

• List the four triage categories in the start
  system
• State three challenges associated with the
  management of a mass casualty incident

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Responding To A Hazardous Materials Event

• Challenges
• Multiple events occurring simultaneously
• Mixed trauma and hazmat casualties
• Self-protection
• Crime scene management and evidence preservation

IMAGE FEMA
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Multiple Casualties Incident - Definition

• In an MCI, available resources are taxed by an
  unusually high number of patients
• The availability of personnel and supplies will
  govern triage and treatment decisions

IMAGES FEMA, US Navy
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MCI - Hazardous Materials Challenges

• Challenges
• Risk of personal injury
• Large numbers of casualties
• Psychogenic casualties
• Transportation obstacles
• Patient decontamination
• Management of resources

IMAGES FEMA, US Navy
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MCI - Management

• Rapid establishment of a safe area for scene
  assessment and patient care
• Secure incident scene
• Implement incident command system - unified
  command

IMAGE FEMA
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MCI - Triage

• Greatest good for the greatest number of
  casualties
• Four-tiered system
• Red - immediate
• Yellow - delayed
• Green - minimal
• Black - expectant
• Limitations
• Time Consuming
• User variability
• Lack of familiarity

IMAGE USAF
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Simple Triage and Rapid Treatment (S.T.A.R.T.)

• Walking wounded - Green or minimal
• Direct walking wounded/worried to a collection
  point/receiving area
• Normal findings - Yellow or delayed
• Abnormal - Red or immediate

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S.T.A.R.T. Full Algorithm
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JumpSTART TRIAGE-Ages 1-8
RESPIRATIONS
ALL WALKING WOUNDED
MINOR
R - 15-40 P - 2 M - AVPU
NO
YES
Brief Ventilatory Trial
POSITION AIRWAY
Between 15 40/min
Spontaneous Respirations?
40/min
NO
PERFUSION (Brachial/Radial Pulses)
YES
IMMEDIATE
IMMEDIATE
EXPECTANT
Absent
Present
Control Bleeding
MENTAL STATUS
IMMEDIATE
Responds to painful stimuli/unresponsive
Responds to Verbal
DELAYED
IMMEDIATE
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Triage Tags

• Wide range of features
• Many similarities

Maryland Emergency Medical Services
Maryland Department of Transportation
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Triage - Nerve Agents

• Immediate
• Unconscious or convulsing
• Involves two or more body systems (miosis does
  not count)

Rapid intervention should result in a good
outcome
IMAGE SAIC
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Triage - Nerve Agents (contd)

• Delayed
• Initial symptoms are improving (miosis still
  present)
• Recovering well from pre-hospital antidote therapy

IMAGE SAIC
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Triage - Nerve Agents (contd)

• Minimal
• Walking and talking which indicates intact
  breathing and circulation

• Expectant
• Cardiac or respiratory arrest
• Unconscious greater than 5 minutes

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Special Considerations
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Triage - Mustard

• Immediate
• Moderate to severe pulmonary symptoms
• Expectant
• 50 BSA burns by liquid

• Delayed
• 2 to 50 BSA burns by liquid
• Critical areas
• Eye involvement
• Minimal

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Triage - Cyanide (Inhalation)

• Immediate
• Symptoms are improving (mild HA, nausea,
  vomiting, hyperventilation, and dizziness)

• Expectant
• Convulsions
• Apnea
• Sudden loss of consciousness

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Triage - Choking Agents

• Immediate
• Respiratory symptoms within 6 hours of exposure
  (with ICU support)

• Delayed
• Respiratory symptoms more than 6 hours after
  exposure

• Expectant
• Severe respiratory distress within 6 hours of
  exposure (ICU support unavailable)

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Bomb Blasts

• Instantaneous chain of events in which an
  explosive material is rapidly converted into a
  gas under extremely high temperature and pressure

IMAGES DOD, USAF
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Bomb Blasts - Pressure Waves
IMAGE US Army
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Blast Mechanics

• High-energy explosives
• Detonate faster than the speed of sound (TNT,
  diesel fuel, and fertilizer)
• Low-energy explosives
• React slower than the speed of sound (pipe bomb)
• A solid surface acts as a reflective force (up to
  9 times)

IMAGE FBI
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Explosive Properties

• The larger the explosive charge, the greater the
  shock wave
• Explosions generate multiple mechanisms for
  injury or death as listed below
• Direct exposure to the blast wave
• Reflective blast waves
• Acceleration-deceleration forces
• Penetrating and non-penetrating wounds
• Burns and inhalation of toxic gases
• Building collapse

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Mechanism Of Injury

• Primary Blast Injury - direct damage from the
  blast wave
• Secondary Blast Injury - from flying debris
• Tertiary Blast Injury - from being thrown against
  a stationary object
• Misc. Blast Effects - burns, crush injuries,
  inhalation Of toxic gases, neuropsychiatric
  conditions

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Injury Patterns

• Most survivors suffer secondary and tertiary
  blast effects
• Primary blast injury is infrequent in survivors
• The majority of survivors are treated and
  released from the emergency department

IMAGE SAIC
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General Management

• ABCs
• Patients at risk for air embolism and
  pneumothorax
• Extensive surgical debridement of penetrating
  foreign bodies with delayed wound closure
• Foreign bodies must be collected for evidence
• Tetanus toxoid and antibiotics

IMAGE US Navy
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Bomb Blast - Triage

• Immediate
• Decreased or loss of hearing
• Short of breath
• Change in mental status
• Penetrating and traumatic injuries

• Minimal
• Walk and talk
• Alert and oriented
• Intact hearing

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Bomb Blast Special Considerations

• Bombs containing nuclear, biological, or chemical
  materials
• First responders should follow local SOPs
• Don appropriate PPE
• Survey area for contamination
• Decontaminate victims
• Irrigate and dress wounds
• Notify hospital about patient transport

IMAGE DOD
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Acute Crush Syndrome

• Produced by prolonged and continuous pressure on
  extremities
• Skeletal muscle death releases cellular toxins
• Results in renal failure, lethal cardiac
  arrhythmias, and sudden death
• Clinical presentation depends upon length of
  time extremity has been crushed

IMAGE FEMA
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Acute Crush Syndrome Management

• Large volumes of IV normal saline before and
  after victim is freed
• 1 to 2 liter bolus (20 cc/kg) followed by 300 to
  500 cc/hr (5 cc/kg/hr)
• Maintains renal blood flow and urine excretion
• Sodium Bicarbonate
• Counteracts acidosis
• Limit effects of elevated potassium

IMAGE USAF
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Mass Fatalities Incident

• Any incident that will tax local resources
• Potential ethical responsibilities
• Reverence for deceased
• Treat deceased with dignity and respect
• Public (local, national, international) is
  watching

IMAGE FEMA
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Preservation Documentation

• Law enforcement coroner/medical examiner
  involved
• Preservation and collection of all evidence
• Document
• Location of bodies and body parts
• Personal effects
• Surrounding environment
• Pictures of the area and evidence

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Documentation/Labeling

• Body bags, separate bags for unattached human
  remains
• Attach personal affects in a separate bag.
• Label, secure and document exact location
  obtained
• Drivers License, SSN (if available)

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Incident Morgue

• Convenient to scene
• Adequate capacity
• Secure
• Assure accessibility for vehicles
• Out of public observation
• Ventilation control
• Proper drainage
• Electrical availability
• Communication ability

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Mass Fatalities special considerations

• Separate sites identified for
• Family Assistance Center (FAC)
• Antemortem data collection, Notification, DNA
  sample collection, child care
• Chapel area
• Media
• Rehabilitation/Rest
• Adequate resources for victim families and
  responders
• Port-a-potties
• Water

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WMD Fatalities

• Potential for fatalities from hazardous
  material/WMD incidents exists
• Biochemical terrorism incident is a medical and
  law enforcement issue
• Protection for first responders, transport, and
  autopsy personnel must be considered

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DMORT

• Specialty team
• Must be formally requested via state level
  government
• Paid by federal government
• Multiple resources
• Mobile incident morgue

IMAGE FEMA
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Fatality Recovery

• Obtain permission to move fatalities
• Determine location of fatalities, make a plan to
  move fatalities to decontamination
  site
• Inspect, photograph, mark (identify by flags,
  markers, numbers) exact location
• Tag fatality with appropriate number/name, use
  corresponding number on body bag after placing
  in body bag
• Correlate tag number with grid number on location

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Fatality Decontamination

• Purpose
• Minimize exposure/injury to responders
• Protect personnel

IMAGE SAIC
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Body Storage/Removal

• Refrigerated/cooler truck with metal floors
• No company names on trucks
• Use tarp to cover if necessary
• Verify that the body bag and body s match before
  removal
• Keep concise log

IMAGE FEMA
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Autopsy

• Autopsy
• Autopsy personnel should be briefed on agent
  involved and don appropriate PPE
• Confirm ID, tag s
• Once autopsy complete, wash internal
  cavities/organs potentially exposed
• ID and tag s remain in place

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Autopsy Hazards

• Infection transmission from direct inoculation
  and aerosolization to persons in close proximity,
  pathologists and assistants
• Infectious airborne particles 1-5 microns in
  diameter
• Can travel on air currents
• Can be created by oscillating saws used at
  autopsy
• Rinse water sprayed on tissues
• Lung dissection

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Disposition of Remains

• Release from morgue
• Signed consent from next of kin authorizing
  Funeral Home to retrieve deceased
• Log date, time, name and funeral home name
• Release in body bag with IDs in place
• Funeral Home receives deceased from morgue in
  body bag use appropriate universal/standard
  precautions

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Mass Fatality - Summary

• Overwhelmed local resources
• Security
• Identification, documentation, preservation
• Personnel hazards, exposure risks
• Funeral home and embalming safety

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Summary

• Training will help bring order to an MCI
• Training must include
• Personal protective equipment (PPE)
• Patient decontamination
• Antidote therapy
• Joint agency hands - on and
  table - top exercises

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Summary

• Minimize rescue attempts until scene is safe
• Utilize appropriate PPE
• Treatment areas should be secured, visible, and
  accessible
• Utilize one standard triage method
• Mass fatality preparation requires planning

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Summary

• Keep hospitals informed of the rescue operation
• Train frequently using realistic scenarios with
  all responding agencies
• Assessment, antidote therapy, and decontamination
  may need to occur simultaneously

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Questions
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