Mass Casualty Preparedness

Educational Objectives

The goal of this program is to improve preparedness for mass casualty incident (MCI) response. After hearing and assimilating this program, the clinician will be better able to:

1. List the elements represented in the MARCH protocol for life-saving intervention.
2. Prioritize patients in the operating room during MCIs based on injury type.

Summary

Mass casualty incident (MCI) definition and scope: an MCI is defined not by a fixed number of patients but by the concept that casualties overwhelm available resources; 8 gunshot wounds may constitute an MCI at a community hospital but not at a level 1 trauma center accustomed to penetrating trauma; MCIs arise from multiple sources—mass violence events, natural disasters (tornadoes, flooding), weapons of mass destruction (chemical, biological, radiological, nuclear), industrial accidents with hazardous materials components, infrastructure failures (structural collapse, transportation incidents), and infectious disease outbreaks of high consequence; events range from no-notification incidents (mass shootings) to advance-warning scenarios (weather events) to planned mass gatherings (eg, Philadelphia papal visit with anticipated 1 million visitors)

Paradigm shift in mass casualty care: conventional emergency care delivers extensive resources to few critical patients; disaster care allocates limited resources to benefit the greatest number of patients; information from the field is often incomplete or unreliable—in the Aurora, Colorado theater shooting, emergency physicians were unaware of the event's scale until police arrived with victims in personal vehicles; social media creates public awareness rapidly but generates misinformation leading to chaos

Initial response and activation: identify before an event who can initiate the emergency operations plan or mass casualty plan; establish alert systems for both working staff and recall protocols for off-duty personnel; external agencies (emergency management, EMS, nearby healthcare facilities) may be unaware of unfolding events; request specialized teams (hazardous materials) early as deployment takes time; determine early who serves as physician in charge and nurse in charge, location of vests and job action sheets, and need for additional staff; involve case management immediately to facilitate emergency department and inpatient discharges

Incident Command System (ICS): developed by firefighting resources in 1970s Southern California to address communication difficulties, terminology variations, and unclear chain of command when multiple organizations respond; all-hazard model applicable to any event type; scalable and modular for different-sized events; there are key early roles; time unit—manages staff recall and future staffing needs; incident commander—requires identification of who assumes this role if administrators are unavailable (eg, 3 AM on a holiday); triage—position requires experienced provider; medical command physicians—provide online medical direction for clinical decisions and transport destination decisions to prevent nearest hospital from being overwhelmed; flexible staffing—Las Vegas shooting utilized obstetricians and pediatric surgeons to open cases in the operating room, allowing acute care surgeons to treat more patients

Area and resource establishment: rapidly establish triage area and treatment areas; review department footprint in advance to designate patient relocation plans and optimal area setup; gather equipment and supplies—ventilators, intubation kits, chest tube supplies, litters (most patients arrive outside traditional EMS), wound care supplies, medications for rapid sequence intubation and analgesia, and basic items (pens, tape); Las Vegas concert shooting with 800 casualties (200 to nearest Sunrise Hospital) experienced significant hemorrhage control challenges and rapid contamination of supplies like pens; consider additional linens for stretcher and room turnover

Triage fundamentals and systems: triage aims to avoid under-triage (lacking sensitivity, missing patients needing immediate treatment) and over-triage (misallocating limited resources); triage occurs at multiple points; primary triage—field determination of immediate transport needs; secondary triage—emergency department for immediate care provision; tertiary triage—definitive care allocation; patients require re-triage throughout care; triage systems address only traumatic injuries—myocardial infarction patients may not be triaged appropriately; categories progress from green (minimal) to yellow (delayed) to red (immediate) to black or gray (expected or deceased)

START triage: Simple Triage and Rapid Treatment is most prevalent model; only treatment provided is airway positioning; takes 30 to 40 seconds per patient

SALT triage: Sort, Assess, Life-saving interventions, Treatment/transport; developed by CDC committee incorporating best elements of different systems; includes life-saving interventions (massive hemorrhage control, chest decompression, auto-injector antidotes); endorsed by American College of Surgeons, National Association of EMS Physicians, and American College of Emergency Physicians

Ten-second triage algorithm: British National Health Service published in 2023 to triage more patients rapidly and train responders without medical sophistication; sorts walking patients; controls severe bleeding; assesses talking patients for penetrating injury to neck, torso, junctional areas (axilla, groins); determines breathing status; places patients in rescue position

JumpStart triage: modified START algorithm for pediatric patients

MARCH protocol for life-saving interventions: tactical combat casualty care mnemonic prioritizes Massive hemorrhage control, Airway, Respiration, Circulation, Hypothermia prevention (sometimes includes Head injury); massive hemorrhage control is prioritized above airway; American College of Surgeons endorses commercially produced tourniquets that occlude arterial flow (tourniquets occluding only venous flow are problematic), topical hemostatic agents, hemostatic gauze for wound packing, and modular bandages for pressure dressings

Airway management: ranges from simple positioning and airway adjuncts (oropharyngeal airways, nasopharyngeal airways) to intubations and cricothyrotomies; supraglottic airway devices can be inserted by basic EMTs in some states

Respiratory interventions: field treatment includes vented chest seals for sucking chest wounds; emergency department interventions include finger thoracostomies and chest tube insertions

Circulation and resuscitation: limit crystalloid use (varies by situation; crush injuries may require more); transfusion ratio should be 1:1:1 (packed red blood cells to plasma to platelets) or whole blood; tranexamic acid (TXA) is effective within first 3 hours

Pre-hospital coordination importance: rescue task forces—developed after Columbine when ambulances waited outside while scene was unsafe; when law enforcement clears an area to "warm zone" status, EMS enters with law enforcement to provide massive hemorrhage control and rapid extrication; distinct from tactical EMS (SWAT); centralized coordination systems—direct transports to appropriate facilities beyond nearest hospital

Philadelphia Amtrak derailment case study (2015): police and fire had separate communication systems; police training for "scoop and run" with penetrating trauma defaulted to usual operations; police transported majority of patients despite 5 level 1 trauma centers in Philadelphia; fire department complained to National Transportation Safety Board about site access blocked by police vehicles; Office of Emergency Management stated Temple University Hospital "is a huge trauma facility" despite 4 other level 1 trauma centers available; Penn Presbyterian received only 2 patients; Einstein Medical Center is less than 2.5 miles from Temple; demonstrates need for improved patient distribution

Boston Marathon bombing case study: medical tent already established near finish line; all patients transported from scene within 45 minutes; 30 red-tagged (immediate) patients transported within 18 minutes; all Boston trauma centers received equivalent patient numbers; success attributed to emergency preparedness programs, tourniquet use, and coordination by Boston EMS Dispatch Center

Hospital-based response considerations: first notification may come from first arriving victims; many patients arrive untriaged; less critical patients (walking wounded) arrive first—prepare for second wave (dual wave phenomenon) of more critical patients arriving later; consider decontamination early—once contaminated patient enters department, situation becomes problematic (Tokyo subway sarin attacks took 2 hours to recognize sarin involvement; many patients already in emergency departments and hospitals); registration unlikely to keep up with rapid large influx; contingency plans needed

Patient flow and identification: flow should be unidirectional—patients going to CT scanner should proceed to operating room, ICU, or other hospital areas, not return to emergency department; patient identification is typically problematic (Las Vegas concert attendees used electronic wristbands, lacked wallets); may rely on distinctive body markings or tattoos

Key personnel and resource management: respiratory therapy and pharmacy are critical department players; PYXIS medication systems impractical—Sunrise Hospital used 125 code cards in first 3 hours; environmental services are "unsung heroes" needed to clean and decontaminate areas and equipment for additional patients

Operating room prioritization: isolated abdominal injuries should proceed first; followed by chest injuries not responding to emergency department treatment; patients with uncontrolled hemorrhage; neurologic injuries and vascular injuries can often be delayed; patients with stable orthopedic injuries can transfer to other facilities for definitive care

Additional hospital considerations: discharging patients is problematic if they have nowhere to go; family members and companions seeking loved ones require designated areas; fatality management—hospital morgues quickly overwhelmed (seen during COVID-19 pandemic); patients with access or functional needs require special planning; pediatric patients—may become unaccompanied minors if adult is injured and hospitalized; non-English speakers—require language services; sensory impairments—require accommodations

Standards of care: goal is to avoid crisis standards of care; providers should not make these decisions at bedside; may employ contingency standards of care (functionally same level of care but outside daily practice)

Demobilization and recovery: consider demobilization (recovery phase and return to normal operations) as soon as incident starts; behavioral health care needs must be met for involved staff; hot washes allow formal discussion of what went well and what did not; occur more quickly than after-action reports, which require extensive information gathering to produce after-action plans

Community hospital preparedness: challenges include limited surgical coverage (eg, one surgeon possibly unavailable in clinic), potential for rapid escalation (4-person motor vehicle crash to 40 patients due to nearby schools, airports); focus on prioritizing patients and determining life-saving interventions needed immediately; most patients may not receive definitive treatment at facility but can be stabilized; staff recall systems essential; ability to flex staff from other sites within larger hospital systems if already credentialed; telltale counseling for admitted patients implemented (eg, Central Maine Medical Center after Lewiston shootings); trauma peer recovery programs at larger hospitals

Planning and training resources: familiarize with emergency operations plan and departmental policies/procedures; participate in facility education and exercises (tabletop to full-scale); coordinate with hospital emergency management committee; awareness of county, state, and regional resources; Administration for Strategic Preparedness and Response (ASPR) website "TRACIE" provides articles and resources; Los Angeles County published "15 till 50" toolkit (15 min until 50 patients need treatment) with extensive resources

Readings

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Furin was recorded at the Stowe Emergency Medicine Conference , held on January 21-24, 2025, in Stowe, VT, and presented by University of Vermont. For information about upcoming CME activities from this presenter, please visit https://www.stoweem.com. Audio Digest thanks Dr. Furin and University of Vermont for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

EM430602

Qualifies for:

Trauma

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.