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.