Management of Mass casualties

• By - Dr. N. K. Gupta
• Date 16.06.2025 Time – 08.00 AM - 09.00 AM
• Target Learners – M.B., B.S. 2023
• Venue – LT 2
• Competency No. SU 17.3
• Resources
 MANAGEMENT OF MASS CASUALTIES - RESOURCES
• Biley & Love, SPS, 28th edition Part 4 Trauma Chapter 33 Disaster
surgery - PAGE 467 –
• Sabiston Chapter-25 The Surgeon's Role in Mass ASHER HIRSHBERG
AND MICHAEL STEIN 604/622
• Schwartz’ Principle of Surgery Chapter 7. Trauma .183 Clay Cothren
Burlew and Ernest E. Moore
• The Washington Manual of surgery 8th edition - 9 Trauma Resuscitation
and Adjuncts Emily J. Onufer and Jason A. Snyde
• Current diagnosis and treatment SURGERY 14th edition chapter 13-
page 191-Management of the Injured Patient Mark R. Hemmila, MD
Wendy L. Wahl, MD
• Statpearls -https://www.ncbi.nlm.nih.gov/books/NBK482234/ Reverse
triage & https://www.ncbi.nlm.nih.gov/books/NBK459369/
Mass Casualty Triage,
https://www.ncbi.nlm.nih.gov/books/NBK430800/ Trauma survey
• Medscape
 Management of Mass casualties
• LEARNING OBJECTIVES - Recognise & understand:
• Common features of various disasters
• Principles behind organisation of relief effort & of triage in
treatment & evacuation
• Role & limitations of field hospitals in disaster
• Features of conditions peculiar to disaster situations & their
treatment
• Anatomy of Accident
• Pathophysiology
• Role of DCR & DCS, Compartment Syndromes
• Morbidity & mortality of rescuers
• Ethical issues
• Transport of victims
Management of Mass casualties
• LEARNING OBJECTIVES
• ERAS
• Universal/Standard precautions
• Prevention measures – tetanus, coagulopathy, DVT etc
• Rehabilitation issues – financial, Physical, psychiatric
(PTSD), Vocational, social
• Medicolegal problems
• Future Direction - AI, Use of drones and satellite imagery
• Organ transplantation, harvesting , tissue culture & organ
farming
• Education – planning and resource allocation
 Management of Mass casualties – Bailey & Love’s SHORT PRACTICE OF SURGERY -28 TH
Edition
• INTRODUCTION
• DIS-ASTER – means “ Taare Gardish Mein”
• “Problems of medernisation and modern life”
• Natural disasters - constant reminder of power & capricious nature of
our planet.
• Depletion of ozone layer & global warming mean that future may hold in
store calamitous events with even greater magnitude than those
experienced before.
• National conflicts & ideological differences have not lessened &
resultant ‘unnatural disasters’ have potential to rival natural ones in
enormity.
• Disasters by their very nature are unpredictable & no two are alike.
• BUT numerous common elements & countries that invest in disaster
preparedness are better equipped to cope with such catastrophes.
• Recent wars & disasters highlighted increasingly crucial role of
surgeons.
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• COMMON FEATURES OF MAJOR DISASTERS
• Any event that results in loss of human life is disastrous, but most
accidents like aeroplanes & train crashes, are limited in number of
people involved.
• Conversely, natural disasters, like earthquakes & tsunamis - massive
destruction over large areas that can transcend national boundaries.
• All apparatus of a society that responds to such disasters (civil
administration, emergency services, fire brigades & hospitals) may
itself be involved & unable to respond (Figure 33.1).
• Large numbers of people may require immediate shelter, clean water
& food, in addition to any medical needs.
• Breakdown of communication is inevitable & can be accompanied by
widespread panic & disruption of civil order.
• Access to disaster area may be limited because of destruction of
bridges, affecting road and rail links.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• SUMMARY BOX 33.1 COMMON FEATURES OF MAJOR
DISASTERS
• Massive casualties
• Damage to infrastructure
• Large number of people requiring shelter
• Panic & uncertainty among population
• Limited access to area
• Breakdown of communication
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• FACTORS INFLUENCING RELIEF EFFORTS AND PROVISION OF MEDICAL AID
• Good communication is critical for authorities to respond quickly to disaster.
• Wireless technology, Drones, Artificial intelligence & satellite imagery have
revolutionised way in which real-time information can be obtained (Figure
33.2).
• But inevitable lag period between occurrence of disaster & response from
establishment.
• Location of disaster area has a bearing on relief efforts.
• In large cities, emergency and medical services are better developed – but
densely populated so limited access by road & air.
• Disasters in remote areas can be particularly difficult to manage because
relief efforts are hampered by geographical isolation & lack of infrastructure.
• Time frame in which a disaster occurs also impacts on relief efforts -
earthquakes can unleash havoc in seconds but foods & hurricanes may
continue for several days.
• Another important factor - state of resources of country; disasters in poorer
countries can seldom be managed without significant outside assistance.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• Summary box 33.2 Factors influencing rescue and relief
efforts
• Status of communications
• Location, whether rural or urban
• Accessibility of the location
• Time frame in which disaster occurs
• Economic state of development of the area
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• SEQUENCE OF RELIEF EFFORTS AFTER A DISASTER
• ESTABLISHING A CHAIN OF COMMAND – Decide for captain /
Leader / Manager / Director
• Many countries have dedicated organisations that deal with
disasters.
• In other countries, an administrative hierarchy is established to
coordinate teams participating in relief efforts (Figure 33.3).
• DAMAGE ASSESSMENT
• First objective in disaster management - assessment of damage &
number of casualties.
• All sources of information must be employed.
• 24-hour news services are frequently first on scene & can be an
important source of information.
• Drones - now quick & inexpensive option for a rapid view of
disaster area.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• SEQUENCE OF RELIEF EFFORTS AFTER A DISASTER
• MOBILISING RESOURCES
• Next step - mobilisation of human & material resources
appropriate to extent of disaster.
• Although all modes of transport need to be considered,
helicopters provide the quickest access for the first
responders (Figure 33.4).
• Teams that make up initial response must include
experienced staff who can assess situation & who have
authority to take immediate decisions.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• SEQUENCE OF RELIEF EFFORTS AFTER A DISASTER
• DEALING WITH THE MEDIA
• Disasters act like a magnet for the media.
• In today’s world of 24-hour news coverage, this plays an
important part in shaping public opinion.
• It is essential to establish a working relationship between
media & rescue teams.
• With careful handling media can become a powerful ally &
play constructive role in identifying problems, galvanising
aid & keeping public informed.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• Summary box 33.3 Sequence of the relief effort in major
disasters
• Establish chain of command - who, when, what, where
and how
• Set up lines of communication
• Carry out damage assessment
• Mobilise resources
• Initiate rescue operation
• Triage casualties
• Start emergency treatment
• Arrange evacuation
• Start definitive management
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• TRIAGE
• French verb trier, triage means ‘to sort’ & cornerstone of
management of mass casualties.
• Aim - to identify those patients who will benefit most by
being treated earliest, ensuring
*** ‘THE GREATEST GOOD FOR THE GREATEST
NUMBER’.
• Only 10–15% of disaster casualties - serious enough to
require hospitalisation.
• By sorting out minor injuries, triage lessens immediate
burden on medical facilities.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• TRIAGE
• Deciding who receives priority when faced with hundreds
of seriously injured victims is a daunting prospect.
• Triage should be undertaken by someone SENIOR,
EXPERIENCED and AUTHORITY to make critical
decisions.
• To keep pace with changing clinical picture of injured,
triage needs to be undertaken in the field, before
evacuation & again at hospital – DYNAMIC PROCESS.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• TRIAGE AREAS
• For efficient triage injured need to be brought together
into any undamaged structures that can shelter a
large number of wounded.
• A good water supply, good lighting and ease of access are
useful.
• Separate areas should be reserved for patient holding,
emergency treatment & decontamination (in the event of
discharge of hazardous materials).
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• PRACTICAL TRIAGE
• Emergency life-saving measures should proceed alongside
triage and can actually help the decision-making process.
• The assessment and restoration of airway, breathing and
circulation are critical
• Vital signs and a general physical examination should be
combined with a brief history, taken by a paramedic or by
a volunteer worker if one is available.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• DOCUMENTATION FOR TRIAGE
• Accurate documentation is an inseparable part of triage
and should include basic patient data, vital signs with
timing, brief details of injuries (preferably on a diagram)
and treatment given.
• A system of colour-coded tags attached to the patient’s
wrist or around the neck should be employed by the
emergency medical services.
• The colour denotes the degree of urgency with which a
patient requires treatment (Figure 33.7).
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• TRIAGE CATEGORIES
• All methods of triage use simple criteria based on vital
signs.
• Rapid clinical assessment should be made taking into
account patient’s ability to walk, their mental status &
presence or absence of ventilation or capillary perfusion.
• A commonly used four-tier system is presented in Table
33.1.
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
PRIORI COLOU Medical Clinical status Examples
• TABLE 33.1 TRIAGE CATEGORIES
TY R need

• First (I) Red Immediate Critical, but Severe facial trauma, tension
likely to survive pneumothorax, profuse external
if treatment bleeding, haemothorax, fail chest,
given early major intra-abdominal bleed,
extradural haematomas
Second Yellow Urgent Critical, likely to Compound fractures, degloving
(II) survive if injuries, ruptured abdominal viscus,
• Compound fractures, degloving injuries, ruptured treatment
abdominal viscus, pelvic fractures, spinal injuries spinal
Not breathing,
given pelvic fractures,
pulseless, so severely Simple fractures, sprains, minor lacerations Severe brain damage, very extensive burns,
injuries
major injured that no medical care is likely to helpwithin hoursof chest or abdominal wall structures
disruption/loss

Third Green Non-urgent Stable, likely to Simple fractures, sprains, minor

(III) survive even if lacerations
treatment is
delayed for
hours to days
Last (0) Black Unsalvageab Not breathing, Severe brain damage, very extensive
le pulseless, so burns, major disruption/loss of chest
severely injured or abdominal wall structures
that no medical
care is likely to
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• Triage is the earliest example of clinical risk management.
• This is done on the basis of need so that resources can be
allocated by good prioritisation.
• The process was frst used in 1792 by Baron Dominique
Jean Larrey, Surgeon in Chief to Napoleon’s Imperial
Guard.
• The concept of triage emerged from the French Service de
Santé des Armées so that resources could be used to the
optimum –
• ‘MOST FOR THE MOST’.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• FIELD HOSPITALS
• Decision to deploy field hospitals depends on location,
number of casualties & speed with which evacuation can
be organised (Figure 33.8).
• Whether traditional tented structure or modular type,
housed in containers, is employed, facility must be
equipped with radiograph capability, operating rooms,
vital signs monitors, sterilising equipment, blood bank,
ventilators & basic laboratory facilities.
• MANAGEMENT IN THE FELD
• Field hospitals principally function in 3 main areas (Table
33.2).
• Type of treatment given in field hospitals.
Management of Mass casualty
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition

TABLE 33.2 Examples Further

*First aid Suturing cuts and lacerations, splinting simple Review at local hospital
fractures

Emergency Endotracheal intubation, tracheostomy, After damage control surgery,

care for life relieving tension pneumothorax, stopping transfer patients to base
threatening external haemorrhage, relieving an extradural hospitals once stable
injuries haematoma, emergency thoracotomy/
laparotomy for internal haemorrhage

Initial care for Debridement of contaminated wounds, Transfer patients to base

non-life reduction of fractures and dislocations, hospitals for defnitive
threatening application of external fxators, vascular management
injuries repairs
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• FIRST AID
• Care for minor injuries involves cleaning & dressing
wounds, suturing lacerations & splinting simple fractures.
• Most of these ‘walking wounded’ can be sent away with
antibiotics & simple pain relief.
• DAMAGE CONTROL SURGERY
• DCS - concept that only life & limb-saving surgery should
be performed in field hospitals to allow safe transfer to
definitive treating facility - includes - airway is secure,
haemorrhage is under control & compartments are
decompressed in chest, skull, abdomen & limbs.
• Devitalized tissue should be removed & any
contamination prevented from developing into infection.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• FIRST AID
• Summary box 33.5 PRINCIPLES OF DCS
• Do minimum needed to allow safe transfer to definitive
facility
• Take actions that prevent deterioration of that patient
during transfer
• Secure the airway – may require tracheostomy
• Control bleeding – may require craniotomy, laparotomy,
thoracotomy, repair of major limb vessels
• Prevent pressure build-up – may require burr holes, chest
drain, laparotomy, fasciotomy
• Prevent infection by extensile exposure and removing dead
and contaminated tissue
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• EMERGENCY CARE FOR IMMEDIATE LIFE-THREATENING
INJURIES
• Many patients may be saved by relatively simple
measures, provided that these are taken urgently.
• Endotracheal intubation & tracheostomy may be needed
to provide secure airway.
• Needle thoracocentesis - tension pneumothorax & chest
drain will be needed before significant chest injury is
transferred by air.
• Open pneumothorax should be closed.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• EMERGENCY CARE FOR IMMEDIATE LIFE-THREATENING
INJURIES
• Damaged major vessels to limbs should be repaired if
possible.
• Fasciotomies - muscle compartments that are swelling
from injury or from reperfusion.
• Amputation for clearly devitalised limbs & gas gangrene -
at field hospitals as delay will be fatal.
• Specific aspects in relevant chapters.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• Summary box 33.4 ESSENTIALS OF CASUALTY
EVACUATION
• Re-triage to upgrade priorities among the injured
• Select appropriate medical facilities for transfer
• Choose appropriate means of transport
• Prevent the ‘second accident’ during transfer
• Ensure an adequate supply of materials to accompany the
patient
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• INITIAL CARE FOR NON-LIFE-THREATENING INJURIES
• Many patients sustain serious injuries that require
prolonged care - compound limb fractures, degloving
injuries, dislocations of major joints, major facial injuries &
complex hand injuries.
• Will need specialised care requiring transfer to appropriate
facility.
• Re-plantations of amputated limbs & other extensive
procedures should not be attempted in field hospitals -
time-consuming & divert resources & personnel to the
treatment of a few patients.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF SURGERY -
28TH Edition
• DEBRIDEMENT
• French - ‘unleash or cut open’, debridement - crucial part
in management.
• Wounds sustained in disasters are often heavily
contaminated, containing foreign bodies and non-viable
tissues (Figure 33.9).
• Debridement reduces the chances of anaerobic and
necrotizing infections and can prevent systemic sepsis.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - Principles apply to all contaminated
wounds:
• After administration of anaesthesia, injured area is copiously
irrigated with normal saline.
*Lavage using pressurised system is controversial, with
concerns over tissue trauma and spread of debris (Figure
33.10).
*Water jet-based system that simultaneously clears debris
after debriding is very useful.
*Wound is palpated & all foreign matter removed.
*Dirt & debris enmeshed in soft tissues can only be removed
by excision of those tissues.
*Open joints should be thoroughly irrigated & all foreign
material removed.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - all contaminated wounds:
• Wounds with extensive cavitation should be enlarged
longitudinally to gain better access and allow full decom
pression of the underlying muscles.
• This should be carried out under tourniquet.
• This helps to visualise the damaged structures and allows
the surgeon to gain proximal and distal control of vascular
injuries and to identify severed ends of major nerves and
tendons.
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - to all contaminated wounds:
• Next step is excision of all dead & devitalised tissue.
*At this stage tourniquet is let down to check vascularity of tissues.
*Skin excision is kept to minimum & only margins of the wound
need be trimmed back to healthy bleeding edges.
*Excision of devitalised muscle should be undertaken generously.
*Muscle that is pale or dark in colour, that does not contract on
pinching and that does not bleed on cutting must be removed.
*In traumatic amputations, bone ends are tidied, skin and muscle
edges trimmed to lowest level possible & wound left open.
• In associated fractures, skeletal stabilisation should be obtained
before embarking on any repairs.
*External fixators are invaluable for this and make wound
management much easier (Figure 33.11).
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - apply to all contaminated wounds:
• In acute setting, only vascular repairs are justified.
*Lacerated vessels - ends are trimmed & anastomosed.
*IF loss of substance of vessel wall, vein patch or reversed
vein graft may be employed.
*Silicone tubing - temporary bypass (stent) while vascular
repair is being carried out in critically compromised distal
circulation.
• Nerves & tendons should not be dissected out nor should any
attempt be made at definitive repair in wounds with tissue
devitalisation, as this leads to poor results.
*Key structures should be identified & edges trimmed &
tagged with non-absorbable sutures to facilitate repair during
subsequent exploration.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - apply to all contaminated wounds:
• Wounds sustained in disasters - heavily contaminated & not
suitable for primary closure – But blood vessels & exposed
joint surfaces need to be covered - can be achieved by
loosely tacking adjoining muscle over the exposed area.
* Wound is then covered with fluffed gauze and sterile cotton
and the extremity splinted with a plaster of Paris slab.
* For extremity injuries, elevation is critical to reduce
oedema.
• Broad-spectrum antibiotics, as third-generation
cephalosporins, are started prophylactically & continued for
5–7 days.
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT - apply to all contaminated wounds:
• Reinspected at 24–48 hours to assess via viability.
*Wounds are closed between 4th & 6th day if there is no infection.
* AVOID Tension & should not hesitate to use skin grafts to cover.
• Gross infection no attempt at closure is made until infection is
eradicated - re-explored to ensure - no residual foreign bodies or
devitalised tissue.
*Tissue taken for microbiological culture.
*Vacuum-assisted closure (Vac-Pac) - very useful tool for deeply
cavitating wounds.
• Utilises low-pressure suction to evacuate exudate, promote
granulation tissue and reduce size of the wound (Figure 33.12).
• Once wounds are free from infection secondary closure can be
undertaken.
 Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEBRIDEMENT
• Summary box 33.6 PRINCIPLES OF DEBRIDEMENT & INITIAL
WOUND CARE
• Obtain generous exposure through skin and fascia
• Identify neurovascular bundles
• Excise devitalised tissue
• Remove foreign bodies
• Repair major vessels
• Obtain skeletal stabilisation with external fixators
• Only tag tendons and nerves that have been cut
• Leave the wound open and delay primary closure
• Avoid tight dressings
• Elevate the injured limb
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEFINITIVE MANAGEMENT
• Hospitals designated to undertake definitive management
- selected on basis of facilities available & number of
injured they can handle.
• Resources required - more than typical case mix of
hospital.
• Rule of thumb - only half the bed strength of hospital can
be utilised to provide optimum trauma care in an
emergency situation.
Management of Mass casualties - Bailey & Love’s SHORT PRACTICE OF
SURGERY -28TH Edition
• DEFINITIVE MANAGEMENT
• HOSPITAL REORGANISATION
• In hospitals receiving mass casualties some re-
organisation of services is unavoidable - includes transfer
non-urgent conditions to other facilities, augmenting
surgical services, re-organising specialist rota &
redesignating medical wards as surgical care areas.
• Appeal for blood donations should be broadcast.
Management of Mass casualties
• SPECIFIC ISSUES
• No injury that is peculiar to disasters & whole spectrum of
external injuries from minor cuts & compound # to
amputations is seen.
• Internal organ damage is frequent, unless immediate help
is available, this accounts for majority of early mortality
figures.
• People trapped under fallen buildings may suffer crush
injuries & crush syndrome if duration is prolonged.
• Crush injuries & missile injuries cause extensive tissue
damage, gross contamination, both favourable conditions
for anaerobic & microaerophilic infections.
 Management of Mass casualties
• SPECIFIC ISSUES - LIMB SALVAGE
• Mangled Extremity Severity Score (MESS) & its modifications - useful in
deciding about limb salvage.
• Extensive tissue loss, neurovascular damage & loss of long fragments of
bone are traditionally indications for amputation.
• Currently, wounds of any dimension can be covered with micro-vascular
flaps and distraction osteogenesis and vascularised bone can be used to
restore bony continuity.
• If performed in time, vascular repairs can salvage most acutely ischemic
limbs.
• Because of these developments the indications for amputation in trauma
have undergone a paradigm shift & majority of patients who reach a
tertiary-care facility within 24 hours are candidates for limb salvage
(Figure 33.13) - assumes that debridement & if required, vascular repairs
have been performed in a field medical facility.
• Limb is unlikely to survive if vascular repair of major limb vessels
delayed for >4–6 hours.
Management of Mass casualties
• SPECIFIC ISSUES -
• FACIAL INJURIES
• Management - same general principles of debridement &
delayed closure as already outlined.
• Functional & cosmetic importance of facial structures -
skin & soft-tissue excisions kept minimum.
• The face has a robust vascularity and a high ability to
counter infection.
• Even in patients who present late with gross
contamination, careful debridement followed by delayed
primary closure can lead to good results (Figure 33.14).
Management of Mass casualties
• SPECIFIC ISSUES - TETANUS
• Potentially fatal - ‘lockjaw’, -caused by Cl tetani, Gram +ve
spore-forming bacillus occurring naturally in intestines of
humans & soil.
• Produces tetanospasmin, exotoxin
• Median incubation period is 7 days, ranging from 4 to 14
days.
• Early symptoms are painful spasms of the facial muscles,
resulting in risus sardonicus (Figure 33.15).
• The spasms spread to involve the respiratory and laryngeal
musculature – opisthotonus- laryngeal muscle spasm leads
to apnoea, if prolonged, to asphyxia and respiratory arrest.
• Diagnosis is obvious once it is fully manifest.
 Management of Mass casualties
• SPECIFIC ISSUES - TETANUS
• 3 aspects of management:
• Prevention. - active immunisation - 0.5 mL of tetanus toxoid IM.
• Gross contamination - 250–500 U of human anti-tetanus globulin (ATG)
IM (passive immunisation) and to neutralise circulating toxin.
• In full-blown clinical tetanus, 3000–10 000 U of ATG - Wound
manipulation should be avoided for 2–3 hours after ATG administration
to minimise tetanospasmin release.
• Local wound care - thorough wound debridement to eliminate the
anaerobic environment. IV 10–24 × 106 U per day of penicillin G for
10–14 days. The wound should be closed using delayed primary or
secondary closure techniques.
• Supportive care for established disease – ICU - environment, free
from strong sensory stimuli.
• Diazepam - preventing onset of spasms - if sustained - paralysed,
intubated and placed on a ventilator.
 Management of Mass casualties
• SPECIFIC ISSUES NECROTISING FASCIITIS
• Rapidly spreading infection that produces necrosis of subcutaneous tissues & overlying skin.
• β-haemolytic streptococci and, occasionally, Staphylococcus aureus, but may take the form
of a polymicrobial infection associated with other aerobic and anaerobic patho gens,
including Bacteroides, Clostridium, Proteus, Pseudomonas and Klebsiella.
• Fournier’s gangrene - perineal area
• Meleney’s gangrene - abdominal wall.
• Pathology - acute inflammatory infiltrate, extensive necrosis, oedema and thrombosis of
microvasculature.
• Area - oedematous, painful &very tender.
• Skin - dusky blue and black secondary to the progressive underlying thrombosis and
necrosis (Figure 33.16).
• May develop bullae and progress to overt cutaneous gangrene.
• Spreads contiguously but occasionally produces skip lesions that later coalesce.
• Accompanied by fever and severe toxicity.
• Renal failure may occur as a result of hypovolaemia and cardiovascular collapse caused by
septic shock.
• Rate of progression is dramatic and unless aggressively treated it leads to serious
consequences with mortality approaching 70%.
 Management of Mass casualties
• SPECIFIC ISSUES NECROTISING FASCIITIS
• Diagnosis - clinical grounds.
• Creatinine kinase levels may show enormous elevation & biopsy of the fascial layers
will confirm the diagnosis.
• Admitted in ICU and treated with careful monitoring of volume derangements and cardiac
status.
• Oxygen supplementation is benefcial and endotracheal intubation is required in patients
unable to maintain their airway.
• High-dose penicillin G along with broad-spectrum antibiotics, such as third-generation
cephalosporins and metronidazole, are given intravenously.
• Cornerstone of management is surgical excision of the necrotic tissue.
• Devitalised tissue is removed generously, going beyond the area of induration.
• Wound is lightly packed with gauze and dressed.
• This process is repeated daily as the necrosis is prone to spread beyond the edges of the
excised wound.
• In patients who survive, this results in a large wound, which will require skin grafting or fap
coverage.
• Recently, the role of hyperbaric oxygen (HBO) has become more established with a
reduction in mortality in patients treated with HBO (9–20%) compared with patients who
did not receive HBO (30–50%).
 Management of Mass casualties
• SPECIFIC ISSUES - GAS GANGRENE (CLOSTRIDIAL MYONECROSIS)
• Dreaded consequence of late-presenting missile wounds and crushing
injuries.
• Rapidly progressive, potentially fatal condition
• Characterised by widespread necrosis of the muscles and soft-tissue
destruction.
• Common causative organism - Clostridium perfringens, spore-forming, Gram
+ve saprophyte that flourishes in anaerobic conditions.
• Other organisms -Clostridium bifermentans, Clostridium septicum and
Clostridium sporogenes.
• Non-clostridial gas-producing organisms such as coliforms have also been
isolated in 60–85% of cases of gas gangrene.
• C. perfringens - many exotoxins, exact role is unclear.
• Alpha-toxin, the most important - lecithinase that destroys red and white
blood cells, platelets, fibroblasts and muscle cells.
• Phi-toxin produces myocardial suppres sion, kappa-toxin - destruction of
connective tissue & blood vessels.
 Management of Mass casualties
• SPECIFIC ISSUES - GAS GANGRENE (CLOSTRIDIAL MYONECROSIS)
• Devitalised tissue or premature wound closure provides anaerobic conditions necessary for
spore germination.
• Local signs are accompanied by pyrexia, tachycardia, tachypnoea and altered mental status.
• Diagnosis - history & clinical features.
• Peripheral blood smear – haemolysis, Gram stain of exudate -> large Gram-positive bacilli
without neutrophils.
• Biochemical profile - metabolic acidosis & renal failure.
• Radiography can visualise gas in soft tissues & particularly useful if chest & abdominal
involved.
• Admit in ICU
• Treat aggressively with careful monitoring.
• High-dose penicillin G & clindamycin, IV third-generation cephalosporins.
• Surgical treatment - same as for necrotising fasciitis.
• If established with systemic toxicity, amputate involved extremity is life-saving & should not
be delayed.
• No attempt is made at closure; amputation stumps left open & wound is lightly packed with
saline-soaked gauze & then dressed.
• Role of HBO is not as clear as in necrotising fasciitis - recommended in severe cases.
 Management of Mass casualties
• SPECIFIC ISSUES
• CRUSH INJURY AND SYNDROME A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being
squeezed between two heavy or immobile objects. Damage related to a crush injury includes lacerations, fractures, bleeding, bruising,
compartment syndrome and crush syndrome (Figure 33.18). Crush syndrome The association between crush injury, rhabdomyolysis and acute
kidney injury was frst reported in victims trapped during the ‘London Blitz’. It is seen in earthquake and mining accident survivors and in
battlefeld casualties. Prolonged crushing of muscle leads to a reperfusion injury when the casualty is rescued. This releases myoglobin and
vasoactive mediators into the circulation. It also sequesters many litres of fuid, reducing the intravascular volume and resulting in renal
vasoconstriction and ischaemia. The myoglobinuria leads to renal failure from tubular obstruction. The treatment of crushed casualties should
begin as soon as they are discovered. Rescuers must be alert to the presence of associated injuries (Figure 33.19). Aggressive volume loading of
patients, preferably before extrication, is the best treatment. After provision of frst aid and starting intravenous fuids the patient should be
catheterised to measure urine output. In adults, a saline infusion of 1000–1500 mL/h should be initiated. This should be continued until
myoglobin is no longer detectable in the urine. Mannitol administration can reduce the reperfusion component of this injury. Once a fow of urine
is observed, a mannitol–alkaline diuresis of up to 8 litres per day should be maintained, keeping the urinary pH greater than 6.5. An early
fasciotomy can decompress muscle compartments and prevent severe loss of limb function. A late fasciotomy, when it is obvious that the
muscles of that compartment must be dead, is only likely to cause a massive release of myoglobin, as well as potentially introducing infection
into dead tissue. It is therefore best not to perform a fasciotomy in cases where entrapment has been for over 12 hours. Intensive care is
required with close attention to fuid balance and renal dialysis if required.
• COMPARTMENT SYNDROME A compartment syndrome develops when the pressure within a muscle compartment starts to rise as a result of
trauma (see Chapter 32). This occurs in muscles enclosed in a fascia such as the calf and forearm muscles and the intrinsic muscles of the hand
and foot. A tight bandage or plaster, haemorrhage from a fracture or severe blunt trauma leads to a rise in pressure in the compartment until it
exceeds venous drainage pressure. If the pressure rises further, it will cut of perfusion of the muscle. Passive stretching of the afected muscle will
cause extreme pain and this is diagnostic of the condition. If the condition is left unrelieved, then nerves passing through the compartment will
cease to function and the muscle will die and then undergo fbrosis and shortening, producing a Volkmann’s ischaemic contracture. Removal of
any constricting agent and, if necessary, a fasciotomy will relieve the pressure and muscle perfusion will restart. Pressure studies are not reliable;
if in doubt, perform a fasciotomy.
• FROSTBITE AND IMMERSION INJURIES (TRENCH FOOT) Frostbite occurs when a part of the body freezes. The cells are disrupted and the
tissue dies. It is in efect a ‘cold’ burn and can be categorised according to the depth that it afects in the same way as a conventional burn. Other
mechanisms at play include vasoconstriction caused by cold, capillary sludging and reper fusion injury with the release of free radicals, which
occurs on rewarming the part. It commonly involves the fngers, toes, cheeks, the tip of the nose and the ears. When frozen the tissue feels hard
and cannot be indented. Immersion injury is a cold injury that does not involve actual freezing of the tissue and is commonly caused by
prolonged immersion in cold water (hence trench foot). The patient may also be hypothermic. Warming should be gentle as the heat used may
actually cause a burn! Rehydration with warm fuids and use of non-steroidal anti-infammatory drugs such as ibuprofen are benefcial.
Demarcation will occur between dead and viable tissue and at this stage no surgery should be undertaken as there is often considerable deep
recovery. The injured area should be kept clean and dry and eforts made to prevent further injury, as well as to prevent infection. Defnitive
surgery to excise dead tissue can be left for many months. Recent developments, such as the use of tissue plasminogen activator and nerve
blocks, show promising results in reducing amputations, but have to be started within 24 hours and are seldom possible in the feld.
 Management of Mass casualties
• SPECIFIC ISSUES
• GAS GANGRENE (CLOSTRIDIAL MYONECROSIS) Gas gangrene is a dreaded consequence of late-presenting missile wounds and crushing injuries. It is a rapidly progressive,
potentially fatal condition characterised by widespread necro sis of the muscles and soft-tissue destruction. The common causative organism is Clostridium perfringens, a spore-
forming, Gram-positive saprophyte that fourishes in anaerobic condi tions. Other organisms implicated in gas gangrene include Clostridium bifermentans, Clostridium septicum
and Clostridium sporogenes. Non-clostridial gas-producing organisms such as coliforms have also been isolated in 60–85% of cases of gas gangrene. C. perfringens produces
many exotoxins but their exact role is unclear. Alpha-toxin, the most important, is a lecithinase that destroys red and white blood cells, platelets, fbroblasts and muscle cells. The
phi-toxin produces myocardial suppres sion while the kappa-toxin is responsible for the destruction of connective tissue and blood vessels. Devitalised tissue or premature wound
closure provides the anaerobic conditions necessary for spore germination. The usual incubation period is These local signs are accompanied by pyrexia, tachycardia, tachypnoea
and altered mental status. The diagnosis is made on the basis of history and clinical features. A peripheral blood smear may suggest haemolysis and a Gram stain of the exudate
reveals large Gram-positive bacilli without neutrophils. The biochemical profle may show metabolic acidosis and renal failure. Radiography can visualise gas in the soft tissues and
is particularly useful in patients with chest and abdominal involvement. Patients should be admitted to the ICU and treated aggressively with careful monitoring. High-dose
penicillin G and clindamycin, along with third-generation cephalosporins, should be given intravenously. Surgical treatment is the same as for necrotising fasciitis (see Necrotising
fasciitis). In estab lished gas gangrene with systemic toxicity, amputation of the involved extremity is life-saving and should not be delayed. No attempt is made at closure;
amputation stumps are left open and the wound is lightly packed with saline-soaked gauze and then dressed. The role of HBO is not as clear as in necrotising fasciitis. However,
considering the frequent catastrophic outcomes, it is recommended in severe cases if the facilities are available.
• CRUSH INJURY AND SYNDROME A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or
immobile objects. Damage related to a crush injury includes lacerations, fractures, bleeding, bruising, compartment syndrome and crush syndrome (Figure 33.18). Crush
syndrome The association between crush injury, rhabdomyolysis and acute kidney injury was frst reported in victims trapped during the ‘London Blitz’. It is seen in earthquake
and mining accident survivors and in battlefeld casualties. Prolonged crushing of muscle leads to a reperfusion injury when the casualty is rescued. This releases myoglobin and
vasoactive mediators into the circulation. It also sequesters many litres of fuid, reducing the intravascular volume and resulting in renal vasoconstriction and ischaemia. The
myoglobinuria leads to renal failure from tubular obstruction. The treatment of crushed casualties should begin as soon as they are discovered. Rescuers must be alert to the
presence of associated injuries (Figure 33.19). Aggressive volume loading of patients, preferably before extrication, is the best treatment. After provision of frst aid and starting
intravenous fuids the patient should be catheterised to measure urine output. In adults, a saline infusion of 1000–1500 mL/h should be initiated. This should be continued until
myoglobin is no longer detectable in the urine. Mannitol administration can reduce the reperfusion component of this injury. Once a fow of urine is observed, a mannitol–alkaline
diuresis of up to 8 litres per day should be maintained, keeping the urinary pH greater than 6.5. An early fasciotomy can decompress muscle compartments and prevent severe
loss of limb function. A late fasciotomy, when it is obvious that the muscles of that compartment must be dead, is only likely to cause a massive release of myoglobin, as well as
potentially introducing infection into dead tissue. It is therefore best not to perform a fasciotomy in cases where entrapment has been for over 12 hours. Intensive care is required
with close attention to fuid balance and renal dialysis if required.
• COMPARTMENT SYNDROME A compartment syndrome develops when the pressure within a muscle compartment starts to rise as a result of trauma (see Chapter 32). This
occurs in muscles enclosed in a fascia such as the calf and forearm muscles and the intrinsic muscles of the hand and foot. A tight bandage or plaster, haemorrhage from a
fracture or severe blunt trauma leads to a rise in pressure in the compartment until it exceeds venous drainage pressure. If the pressure rises further, it will cut of perfusion of the
muscle. Passive stretching of the afected muscle will cause extreme pain and this is diagnostic of the condition. If the condition is left unrelieved, then nerves passing through the
compartment will cease to function and the muscle will die and then undergo fbrosis and shortening, producing a Volkmann’s ischaemic contracture. Removal of any constricting
agent and, if necessary, a fasciotomy will relieve the pressure and muscle perfusion will restart. Pressure studies are not reliable; if in doubt, perform a fasciotomy.
• FROSTBITE AND IMMERSION INJURIES (TRENCH FOOT) Frostbite occurs when a part of the body freezes. The cells are disrupted and the tissue dies. It is in efect a ‘cold’
burn and can be categorised according to the depth that it afects in the same way as a conventional burn. Other mechanisms at play include vasoconstriction caused by cold,
capillary sludging and reper fusion injury with the release of free radicals, which occurs on rewarming the part. It commonly involves the fngers, toes, cheeks, the tip of the nose
and the ears. When frozen the tissue feels hard and cannot be indented. Immersion injury is a cold injury that does not involve actual freezing of the tissue and is commonly
caused by prolonged immersion in cold water (hence trench foot). The patient may also be hypothermic. Warming should be gentle as the heat used may actually cause a burn!
Rehydration with warm fuids and use of non-steroidal anti-infammatory drugs such as ibuprofen are benefcial. Demarcation will occur between dead and viable tissue and at this
stage no surgery should be undertaken as there is often considerable deep recovery. The injured area should be kept clean and dry and eforts made to prevent further injury, as
well as to prevent infection. Defnitive surgery to excise dead tissue can be left for many months. Recent developments, such as the use of tissue plasminogen activator and nerve
blocks, show promising results in reducing amputations, but have to be started within 24 hours and are seldom possible in the feld.
 Management of Mass casualties
• SPECIFIC ISSUES
• GAS GANGRENE (CLOSTRIDIAL MYONECROSIS) Gas gangrene is a dreaded consequence of late-presenting missile wounds and crushing injuries. It is a rapidly progressive,
potentially fatal condition characterised by widespread necro sis of the muscles and soft-tissue destruction. The common causative organism is Clostridium perfringens, a spore-
forming, Gram-positive saprophyte that fourishes in anaerobic condi tions. Other organisms implicated in gas gangrene include Clostridium bifermentans, Clostridium septicum
and Clostridium sporogenes. Non-clostridial gas-producing organisms such as coliforms have also been isolated in 60–85% of cases of gas gangrene. C. perfringens produces
many exotoxins but their exact role is unclear. Alpha-toxin, the most important, is a lecithinase that destroys red and white blood cells, platelets, fbroblasts and muscle cells. The
phi-toxin produces myocardial suppres sion while the kappa-toxin is responsible for the destruction of connective tissue and blood vessels. Devitalised tissue or premature wound
closure provides the anaerobic conditions necessary for spore germination. The usual incubation period is These local signs are accompanied by pyrexia, tachycardia, tachypnoea
and altered mental status. The diagnosis is made on the basis of history and clinical features. A peripheral blood smear may suggest haemolysis and a Gram stain of the exudate
reveals large Gram-positive bacilli without neutrophils. The biochemical profle may show metabolic acidosis and renal failure. Radiography can visualise gas in the soft tissues and
is particularly useful in patients with chest and abdominal involvement. Patients should be admitted to the ICU and treated aggressively with careful monitoring. High-dose
penicillin G and clindamycin, along with third-generation cephalosporins, should be given intravenously. Surgical treatment is the same as for necrotising fasciitis (see Necrotising
fasciitis). In estab lished gas gangrene with systemic toxicity, amputation of the involved extremity is life-saving and should not be delayed. No attempt is made at closure;
amputation stumps are left open and the wound is lightly packed with saline-soaked gauze and then dressed. The role of HBO is not as clear as in necrotising fasciitis. However,
considering the frequent catastrophic outcomes, it is recommended in severe cases if the facilities are available.
• CRUSH INJURY AND SYNDROME A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or
immobile objects. Damage related to a crush injury includes lacerations, fractures, bleeding, bruising, compartment syndrome and crush syndrome (Figure 33.18). Crush
syndrome The association between crush injury, rhabdomyolysis and acute kidney injury was frst reported in victims trapped during the ‘London Blitz’. It is seen in earthquake
and mining accident survivors and in battlefeld casualties. Prolonged crushing of muscle leads to a reperfusion injury when the casualty is rescued. This releases myoglobin and
vasoactive mediators into the circulation. It also sequesters many litres of fuid, reducing the intravascular volume and resulting in renal vasoconstriction and ischaemia. The
myoglobinuria leads to renal failure from tubular obstruction. The treatment of crushed casualties should begin as soon as they are discovered. Rescuers must be alert to the
presence of associated injuries (Figure 33.19). Aggressive volume loading of patients, preferably before extrication, is the best treatment. After provision of frst aid and starting
intravenous fuids the patient should be catheterised to measure urine output. In adults, a saline infusion of 1000–1500 mL/h should be initiated. This should be continued until
myoglobin is no longer detectable in the urine. Mannitol administration can reduce the reperfusion component of this injury. Once a fow of urine is observed, a mannitol–alkaline
diuresis of up to 8 litres per day should be maintained, keeping the urinary pH greater than 6.5. An early fasciotomy can decompress muscle compartments and prevent severe
loss of limb function. A late fasciotomy, when it is obvious that the muscles of that compartment must be dead, is only likely to cause a massive release of myoglobin, as well as
potentially introducing infection into dead tissue. It is therefore best not to perform a fasciotomy in cases where entrapment has been for over 12 hours. Intensive care is required
with close attention to fuid balance and renal dialysis if required.
• COMPARTMENT SYNDROME A compartment syndrome develops when the pressure within a muscle compartment starts to rise as a result of trauma (see Chapter 32). This
occurs in muscles enclosed in a fascia such as the calf and forearm muscles and the intrinsic muscles of the hand and foot. A tight bandage or plaster, haemorrhage from a
fracture or severe blunt trauma leads to a rise in pressure in the compartment until it exceeds venous drainage pressure. If the pressure rises further, it will cut of perfusion of the
muscle. Passive stretching of the afected muscle will cause extreme pain and this is diagnostic of the condition. If the condition is left unrelieved, then nerves passing through the
compartment will cease to function and the muscle will die and then undergo fbrosis and shortening, producing a Volkmann’s ischaemic contracture. Removal of any constricting
agent and, if necessary, a fasciotomy will relieve the pressure and muscle perfusion will restart. Pressure studies are not reliable; if in doubt, perform a fasciotomy.
• FROSTBITE AND IMMERSION INJURIES (TRENCH FOOT) Frostbite occurs when a part of the body freezes. The cells are disrupted and the tissue dies. It is in efect a ‘cold’
burn and can be categorised according to the depth that it afects in the same way as a conventional burn. Other mechanisms at play include vasoconstriction caused by cold,
capillary sludging and reper fusion injury with the release of free radicals, which occurs on rewarming the part. It commonly involves the fngers, toes, cheeks, the tip of the nose
and the ears. When frozen the tissue feels hard and cannot be indented. Immersion injury is a cold injury that does not involve actual freezing of the tissue and is commonly
caused by prolonged immersion in cold water (hence trench foot). The patient may also be hypothermic. Warming should be gentle as the heat used may actually cause a burn!
Rehydration with warm fuids and use of non-steroidal anti-infammatory drugs such as ibuprofen are benefcial. Demarcation will occur between dead and viable tissue and at this
stage no surgery should be undertaken as there is often considerable deep recovery. The injured area should be kept clean and dry and eforts made to prevent further injury, as
well as to prevent infection. Defnitive surgery to excise dead tissue can be left for many months. Recent developments, such as the use of tissue plasminogen activator and nerve
blocks, show promising results in reducing amputations, but have to be started within 24 hours and are seldom possible in the feld.
 Management of Mass casualties
• Summary box 33.7 TETANUS
• Caused by C. tetani
• Spores are present in the soil
• Thrives in dead or contaminated tissue
• Produces tetanospasmin, an exotoxin
• Produces spasm of muscles
• Make sure patients are immunised
• For heavily contaminated wounds give ATG
• Summary box 33.8 NECROTISING FASCIITIS
• Caused by β-haemolytic Streptococcus or is polymicrobial
• Also called Fournier’s or Meleney’s gangrene
• Progress is rapid and renal failure is an early complication
• Treat with radical surgical excision repeated every 24 hours
• Give oxygen and penicillin
Management of Mass casualties
• Summary box 33.9 GAS GANGRENE
• Caused by C. perfringens
• Spores are present in the soil
• Thrives in anaerobic conditions and produces many exotoxins
• Treat with radical and regular surgical excision
• Give oxygen and penicillin
• Early amputation may be life-saving
• Summary box 33.10 CRUSH SYNDROME
• Arises as a result of reperfusion
• Acute kidney injury & renal failure (myoglobinuria)m- a
complication
• Late fasciotomy may make things worse not better
Management of Mass casualties
• Summary box 33.11 COMPARTMENT SYNDROME
• Commonest in a closed fracture or soft-tissue crush injury
• Pain on passive extension of the muscles is diagnostic
• Intra-compartmental pressure studies are not reliable
• If there is any suspicion, then fasciotomy must be
performed early
• Summary box 33.12 FROSTBITE
• Can be superfcial or deep like a burn
• Rewarm gently
• Allow demarcation to occur naturally
• Protect against further trauma and infection
 Management of Mass casualties
• HANDING OVER
• FOLLOW-UP AND SECONDARY PROBLEMS
• The medical aspect of disaster management does not involve a
single short-term efort. It requires a long-term commitment and
involvement of various disciplines. Because of the large numbers of
casualties, the initial treatment is directed towards the anatomical
restoration of damaged structures. There are therefore numerous
patients who will need secondary procedures for functional
restoration. This second wave of patients is encountered 3–6 months
after a major catastrophe and arrangements should be made to deal
with this.
• DESIGNATED CENTRES Initially, the casualties may be scattered
among many hospitals. After the frst few weeks most of the acute
problems have been dealt with and only those patients who require
longer term treatment remain. At this point it is advisable to
designate a particular hospital as a centre for these patients. This
concen trates resources and expertise and makes follow-up easier.
 Management of Mass casualties
• DISASTER PLANS
• Disasters are unforeseen events and planning for them may seem paradoxical. It has, however, been
shown that disaster planning not only works but also saves lives. Disaster planning is a wide feld but a
résumé of the important aspects follows.
• ESTABLISHMENT OF A NATIONAL DISASTER MANAGEMENT ORGANISATION This is the frst step in
the planning for disasters. Most resource-rich countries already have such an agency, which can formulate
policy at the national level and has the infrastructure to react quickly when the need arises.
• ANTICIPATING DISASTERS Areas near active volcanoes and geological fault lines are at risk from seismic
disturbances, whereas regions along major rivers are liable to fooding. The urban centres of all countries
are now potential targets for terrorist attacks. It is important to not only carry out threat assessments but
also, if possible, set up an early warning system.
• EVACUATION PLANNING Evacuation of large population centres as a prelude to, or in the wake of, an
impending disaster is a complex exercise. Yet it may be the most prudent course of action to remove as
many people as possible from harm’s way. Clear identification of exit routes must be determined and
communicated to the populations at risk.
• ORGANISATION OF EMERGENCY SERVICES Emergency services such as the fire brigade, police and
ambulance service must have defined roles and areas of responsibility to ensure a coordinated response
during a crisis. Members of these teams must be included in the planning phase to ensure that the final
plan is practicable and reflects the situation on the ground.
• MEDICAL PLANNING
• Identifcation of hospitals able to take large numbers of casu alties and the location of areas that can be
used for patient holding and triage in case of mass casualties is important. Hospitals that ofer specialised
services should be identifed and their role during a major crisis defned. Suitable hospitals in the
surrounding areas must be designated as overfow hospitals in the eventuality of a very large volume of
patients.
Management of Mass casualties
• Summary box 33.13 Disaster planning
• Disaster can be anticipated and should be prepared for
• Evacuation of a whole population may be the best option
• Coordination between military, police, fire, ambulance,
and medical services is important
Management of Mass casualties
• Summary box 1.9 A proactive ERAS approach to prevent
unnecessary aspects of the surgical stress response
• Minimal access techniques
• Blockade of afferent painful stimuli (e.g. epidural
analgesia, spinal analgesia, wound catheters)
• Minimal periods of starvation
• Early mobilisation
 Management of Mass casualties
• ENHANCED RECOVERY
• Approach to perioperative care of patients undergoing surgery.
• Designed to speed clinical recovery & reduce both cost & length of hospital stay
• Achieved by optimising health of the patient before surgery through
prehabilitation & then delivering evidence-based best care in perioperative
period.
• Postoperative strategies advocated by enhanced recovery protocols include:
• Early planned physiotherapy and mobilisation;
• Early oral hydration and nourishment;
• Opioid-sparing analgesia regimens that include use of regional blocks, regular
non-steroidal anti-infammatory drugs & paracetamol;
• Early discharge planning (started even before patient is admitted to hospital &
involving support from nurses, physiotherapists and other community care
workers).
• Early mobilisation is encouraged to reduce risks of DVT, urinary retention,
atelectasis, pressure sores & faecal impaction.
• Telephone follow-up is carried out to make sure that patient is recovering well.
Management of Mass casualties
• ERAS- strategy to reduce perioperative stress response,
thereby reducing potential complications, decreasing
hospital length of stay & enabling patients to return more
quickly to their baseline functional status.
• Principles in surgery.
• Postoperatively, limited respiratory reserve - so infection &
fluid overload to be avoided.
• Drains are removed when purpose is served.
• Mobilisation, breathing exercises & regular physiotherapy
– earliest when possible.
 Management of Mass casualties
• ERAS-
• Postoperative pain - deal effectively so that a normal breathing
pattern & gas exchange are achieved in the early postoperative
period.
• 4 strategies are routinely used in combination:
• 1 paravertebral/extrapleural or epidural catheter-delivered local
anaesthetic;
• 2 intercostal nerve blocks;
• 3 PCA with intravenous boluses of opiates;
• 4 background oral analgesia with paracetamol and/or non-steroidal
anti-inflammatory drugs.
• Long-term postsurgical pain can be reduced by careful attention to
detail during the operation.
• Sources of avoidable chronic pain - rib fracture & entrapment of
intercostal nerves during wound closure.
• Reverse triage focuses hospital resources on critically ill patients in the field or emergency
department by identifying and discharging admitted patients who have a relatively low risk of
complications if discharged early. This strategy aims to reduce morbidity and mortality for the
greatest number of patients while maximizing treatment capacity in the shortest time.
• Clinical Significance
• During a disaster, mass casualty incident, or epidemic, hospital systems often face a surge in
demand for healthcare services that exceeds the available resources. Developing strategies to
manage these periods of increased demand is crucial for maintaining healthcare system
functionality under resource constraints. Reverse triage is one such strategy that can help
allocate resources effectively, ensuring the greatest benefit to the highest number of patients. By
discharging inpatients who can safely continue their care at an outside acute care facility or
private residence, hospital beds become available for more critically ill patients.
• While reverse triage offers a means of expanding hospital capacity, a standardized system is
essential for determining which patients can be safely discharged. Such an approach ensures
that morbidity and mortality associated with premature discharge are minimized. Hospital
systems must evaluate discharge criteria at the individual level, considering factors such as risk
tolerance, capacity needs, and available postdischarge resources. Tailoring these criteria to the
specific needs of each system can enhance the effectiveness of reverse triage while maintaining
high-quality care
• Mass casualty incidents triage systems are implemented to offer the greatest good to the
greatest amount of people as healthcare resources are limited or strained due to the number
of injured individuals. Treatment during triage is minimal, and this is counterintuitive to normal
pre-hospital protocols. The goal is to move patients away from the incident and toward
resources that offer more comprehensive care.
• Most mass casualty incident triaging systems use tags or colored designations for
categorizing injured persons. It is important to designate areas where to tagged and/or labeled
individuals can relocate. These areas will dually serve as treatment and loading zones for
arriving ambulance crews. Triaging during a mass casualty incident is a dynamic and fluid
process that requires a certain degree of pre-incident training. Patients may initially be triaged
to one category but may be switched to another due to changes in their clinical status. Many
of the triage tags have fold-over tabs that are designed to switch patients between categories
easily. However, emphasis should be placed on rapid assessment and quick movement of
patients.
• Primary triage systems are not built for determining resource allocation. There may be various
implementation strategies for treatment and evacuation once patients have been triaged,
depending on the system or agency using the system. They do not rely on the number of
victims present or resources available, and some have argued the need for a more
sophisticated system allowing for consideration of these factors. Triaging algorithms are
simple, straightforward, and easy to use; however, they can allow for over or under triaging
depending on the situation. There are many available systems, and it is important to choose
one and have it in place as an important part of any disaster preparedness plan, which can
ultimately help save lives.
• Clinical Significance
• Multiple triage systems are currently being implemented around the world. Some of the more well-known algorithms
include START (simple triage and rapid treatment), SALT (sort, assess, life-saving interventions, treatment/triage),
STM (Sacco triage method), Care Flight Triage, and SAVE (Secondary assessment of victim endpoint). There is
limited data available to support one system over another. However, it is important to choose one and adhere to its
algorithm to maintain an ordered approach
• START Triage
• Simple triage and rapid treatment (START) is currently the most widely used triage system in the United States
for mass casualty incidents. It was developed in 1983 by staff at Hoag Hospital and Newport Beach Fire
Department in California for rescuers with basic first-aid skills. First responders delegate the movement of injured
victims to a designated collection point as directed by using four main categories based on injury severity:
• BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be
moved forward to the collection point
• RED: (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first
• YELLOW: (Delayed) serious injuries but not immediately life-threatening
• GREEN: (Walking wounded) minor injuries
• The triage colors may be assigned by giving triage tags to patients or simply by physically sorting patients into
different designated areas. (see the algorithm below) "Green" patients are assigned by asking all victims who can
walk to a designated area. All non-ambulatory patients are then assessed. Black tags are assigned to victims who
are not breathing even after attempts to open the airway. Red tags are assigned to any victim with the following:
• Respiratory rate greater than 30
• Absent radial pulse or cap refill greater than 2 sec
• Unable to follow simple commands
• Yellow tags are then assigned to all others. The mnemonic “RPM:30-2-can do” is an easy way to remember these
decision points.
• SALT Triage
• The sort, assess, life-saving interventions, and triage/treatment approach is similar
to the START system; however, it is more comprehensive and adds simple life-
saving techniques during the triage phase.
• SORT: sort the walking, waving, and still. This can be achieved by asking
everyone at the scene to walk to a designated casualty collection point similar to
the START method; however, this is followed by asking to wave an arm or leg if
they need help. Those who cannot move or follow commands should be assessed
first.
• ASSESSMENT: assessment and life-saving interventions go hand in hand. When
you assess a victim and find life-threatening injuries, you should intervene.
• LIFE-SAVING INTERVENTIONS: simple techniques such as controlling major
hemorrhage, opening airways, needle decompression, and auto-injector antidotes
should be performed as long as it is not time intensive. Once performed, the
provider should assign a color-coded tag similar to the START system and move
onto the next patient to ensure the forward flow of patients.
• TREATMENT AND TRANSPORT: Once tagged, patients will be moved to the
designated casualty collection point for transport by emergency management
services to receiving facilities.
• JumpSTART
• JumpSTART is a modification to the START system and takes into
account the difference in “normal” respiratory rates for children.
This tool acts to assess pediatric patients better. The age cutoff for
use is eight years old. If the child’s age is unknown, the rescuer
can assess for underarm hair in males or breast development in
females as an indicator of adult age and exclusion from this
cohort.
• The differences in this algorithm include:
• Five rescue breaths are to be given to apneic children with a pulse;
then, they are given a black tag.
• Normal RR are more than 15 or less than 45
• Neurological assessment is done using the mnemonic AVPU (alert,
responds to verbal stimuli, responds to painful stimuli, and
unresponsive). Any patient who has abnormal posturing to painful
stimuli or is unresponsive gets a red tag designation.
• Introduction
• Catastrophic events include natural disasters such as Hurricane Maria, which devastated Puerto Rico on September 20, 2017,
and mass casualty terrorist attacks like the destruction of the World Trade Center on September 11, 2001
• A multi-casualty incident (MCI) occurs when available resources, including rescue personnel, healthcare providers, facilities, and
equipment, are insufficient to manage the crisis. A disaster not only overwhelms resources but also disrupts communication and prevents
resource distribution. Local rescue workers and healthcare personnel may become casualties or be unable to report for duty, and
healthcare facilities may be damaged or destroyed.
• Issues of Concern
• Earthquakes
• Hurricanes and Floods
• Radiation Emergencies
• Infectious Disease
• Terrorist Attacks
• Complex Humanitarian Emergencies
• CHEs arise from political instability or armed conflict, leading to violent deaths, malnutrition, and disease. Recent examples include
conflicts in Syria, Afghanistan, Bosnia, Rwanda, Kosovo, the Democratic Republic of Congo, and East Timor. Violent deaths result from
shootings, shrapnel, and landmines, while infectious diseases remain the leading causes of morbidity and mortality in CHE across Asia and
Africa. Common diseases include diarrheal infections, acute respiratory tract infections, measles, meningitis, and malaria. Malnutrition,
mental health disorders, and sexual violence are also prevalent.
• CLINICAL SIGNIFICANCE
• Role of Emergency Medical Services
• Emergency Medical System Issues
• Fundamental Treatment Issues
• Transport of Victims
• Field Hospitals
• Mortality and Morbidity of Rescuers
• Ethical Issues
• In a catastrophe, most ethicists agree that the primary goal is to save as many lives as possible, prioritizing the needs of the majority over
the individual. Under normal circumstances, the sickest patients receive priority care. However, in a disaster, individuals with minimal
chances of survival who require extensive resources may not be treated, as doing so would divert critical care from a greater number of
patients.
• The World Health Organization
defines mass casualty incidents as disasters and
major incidents characterized by quantity, severity,
and diversity of patients that can rapidly overwhelm the
ability of local medical resources to deliver
comprehensive and definitive medical care. They have
been occurring more frequently in recent decades and
affect countries of all socioeconomic backgrounds.
Preparedness and planning are vital, as these events
can happen in any community at any given time.
Defined pre-hospital triage systems are essential in
saving lives and optimizing the initiation of resource
allocation when these disasters strike.
• Contraindications
• There are no contraindications to performing the primary trauma survey. Even patients who appear extremely stable but
have a traumatic mechanism of injury, which can range from a fall from standing to an apparently mild penetrating
wound, should still undergo a primary trauma survey to ensure that otherwise inapparent injuries are not missed.
• In a trauma survey, cABCD (Circulation, Airway, Breathing, Disability) represents a systematic assessment of a trauma
patient, prioritizing life-threatening issues first. It's a mnemonic device that guides responders to identify and address
critical problems, including hemorrhage, airway obstruction, breathing difficulties, and neurological dysfunction.
• Here's a breakdown of each component:
• C - Circulation (Catastrophic Hemorrhage):
• This focuses on identifying and controlling major bleeding, which is a leading cause of death in trauma. Look for obvious
signs of hemorrhage, such as external bleeding, and assess the patient's vital signs (heart rate, blood pressure, and
oxygen saturation).
• A - Airway:
• Assess the patient's ability to breathe and identify any obstructions to the airway. Look for signs like noisy breathing,
stridor, or inadequate air exchange.
• B - Breathing:
• Evaluate the patient's breathing effort and oxygenation, and look for signs of respiratory distress or failure.
• D - Disability:
• Assess the patient's neurological status by checking their level of consciousness, pupillary response, and motor
function. Look for signs of head trauma or other neurological injuries.
• E - Exposure/Environment:
• Remove the patient's clothing to fully assess for injuries and ensure they are kept warm.
• The order of the cABCD assessment reflects the priority of life-threatening conditions. It's crucial to address
hemorrhage, airway problems, and respiratory distress before moving on to other assessments. The cABCD assessment
is a critical step in the initial assessment and management of trauma patients, allowing for rapid identification and
treatment of life-threatening conditions.
• Pearls and Other Issues
• Mortality rates have substantially decreased in the last two decades as trauma centers have streamlined
the approach to diagnosis and management. However, abdominal gunshot wounds are, unfortunately,
still extremely common in the US. Healthcare professionals have the opportunity to emphasize safe
practices regarding firearms. As part of the society as a collective unit, the healthcare system can be
intentional with patients and families in society to emphasize prevention and decreased violence regarding
weapons such as firearms. Educational messages such as the danger of firearms and how they should be
safely used and stored can be promoted.
• Pearls and Other Issues
• Mortality rates have substantially decreased in the last two decades as trauma centers have streamlined
the approach to diagnosis and management. Mortality rates do vary from 2% to 10% and are most
common in people with multiple organ injuries who present with shock and frank hemorrhage.
• According to the Centers for Disease Control, traumatic injury is the leading cause of death in people
younger than the age of 44. Many traumatic injuries can be prevented, beginning with awareness and
education. Blunt abdominal trauma is in the top three categories of preventable injuries. These include
older adults falls and preventable motor vehicle accidents in teens.
• Pearls and Other Issues
• Contrecoup brain injury has multiple manifestations in addition to the primary one of contralateral
intracerebral hemorrhage, which is used to define contrecoup injury in most cases.
• Key contributing factors include head impact combined with acceleration, deceleration, rotational stress, or
angular stress. Several of these factors are necessary to cause contrecoup injury.
• Acceleration, deceleration, and rotation injuries, such as those observed in shaken baby syndrome in the
absence of impact directly to the head, are not typically associated with contrecoup injury.
• The prognosis is favorable in about half of the cases.