Mass Casualty Management

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 todays 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, postmortems 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.