Disaster and

Multi-Casualty Triage

DR.RAMANUJAM.S
ASSISTANT PROFFESOR
CARE
 COMMON FEATURES OF MAJOR
DISASTERS
• MASSIVE CASUALTY
• DAMAGE TO INFRASTRUCTURE
• A LARGE NUMBER OF PEOPLE REQUIRING
SHELTER.
• PANIC AND UNCERTAINTY AMONG THE
POPULATION
• LIMITED ACCESS TO THE AREA
• BREAKDOWN OF COMMUNICATION
 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
 Sequence of relief efforts after a
disaster
• Establishing Chain Of Command
• Damage Assessment
• Mobilising Resources
• Rescue Operation
– First priority to prevent further damage
– Type of injuries ~ Time of rescue
• Coordination with relief agencies
• Safety of the helpers.
• Dealing with media.
 Sequence of relief efforts after a
disaster
• TRIAGE
• EVACUATION OF CASUALTY.
• FIELD HOSPITALS AND ON FIELD
MANAGEMENT.
• DEFINITIVE MANAGEMENT
 Triage

• [French, from trier, to sort, from Old

French.]
• A method of quickly identifying victims
who have immediately life-threatening
injuries AND who have the best chance
of surviving AND benefit the most by
treating the earliest.
• It ensures that the greatest good for the
greatest number.
 Triage

• In broader sense, it determines

– Who will be treated first.
– What mode of evacuation is best.
– Which medical facility is optimal for
the management of the patient.
 Triage

• Importance :
– Only 10-20% have serious injuries
requiring hospitalisation.
– It lessens the immediate burden on
medical facilities
 Triage
• Pitfalls:
– a daunting process.
– senior doctors have tendency to believe that
services better utilised in actual management of
patients rather than in triage.
– important to remember the changing clinical
picture of an injured person.
– Time factor – to keep pace triage to be
undertaken at various levels.
 Triage
• Components :
– Triage area – all injured brought to one
location : - which should have
• Good space for patient holding, emergency
treatment, decontamination and morgue and
• Good water supply.
– Practical triage – Emergency life saving
measures alongside triage.
 Triage
• Components :
– Documentation of triage –
basic patient data,
 vital signs with timing,
 brief details of injuries (diagrammatic) and
 treatment given

– Triage categories and color tagging

 Tagging

• Complements
Triage
• Rapid Identification
of patient
• Color Coded / Bar
Coded system
• Plastic “bands”
can substitute tags
Noji
Nojiet
etal,
al,NEJM
NEJM
 START SYSTEM

• Created in the 1980’s by Hoag Hospital

and the Newport Beach CA Fire Dept
• Allows rapid assessment of victims
• It should not take more than 15 sec/ Pt
• Once victim is in treatment area more
detailed assessment should be made
 START SYSTEM

Clasification is based on three items

• Respiratory
• Perfusion
• Mental status evaluation
 START First Step

Can the Patient Walk?

YES NO

Evaluate
Green Ventilation
(Minor) (Step-2)
 START Step-2
Ventilation Present?
NO YES

Open Airway

Ventilation Present? > 30/Min < 30/min

NO YES Red/ Immediate

Black Red/ Immediate Evaluate Circulation

(Step-3)
 START Step-3
Circulation

Absent Radial Pulse Present Radial Pulse

Control Hemorrhage
Evaluate Level of
Consciousness
Red/ Immediate
 START Step-4
Level of Consciousness

Can’t Follow Simple Can Follow Simple

Commands Commands

Red/ Immediate Yellow/ Delayed

 Contaminated Patients
• Patients with exposure (potential or
real) to contaminants should be tagged
as BLUE
• This category will continue to stay until
patient is adequately decontaminated
then follow START as usual
• Some recommend a “double tagging”
with blue and the standard START color
 START-Overview
• Remember RPM
• R- Respirations- 30
• P- Perfusion- Radial Pulse
• M- Mental- Follows Commands
 Reverse Triage

• Used in mass-casualty lightning

injuries
• The dead are treated first
• High potential for respiratory arrest
• Potential for resuscitative success
 Conclusions on TRIAGE
• Triage is a method of quickly identifying
victims who have immediately life-
threatening injuries AND who have the best
chance of surviving
• Key elements of the START Triage System
are: Respiration, Perfusion and Mentation
• Reverse Triage is used for mass casualty
lightning incidents.
 PHASE OF EVACUATION
• Retriage to prioritise the injured.
• Select appropriate medical facilities.
• Select appropriate means of transport.
• Prevent the ‘second accident’
• Ensure an adequate supply of materials.
 Pre-Hospital Care and
Transport
• The time from injury
to definitive care is a
determinant of
survival particularly
those with major
internal hemorrhage.
• Careful attention is
given to C-spine
immobilization,
breathing and
circulation…(ABC’s)
 Caveat!!!
• Research has indicated INCREASED
mortality with IV fluids BEFORE
hemorrhage control.
• Transport is not delayed to start IV
access!
 Transport
How is it decided?
• Travel time
• Terrain
• Availability of air or ground
transport
• Capability of personnel
• Weather
 Current Guidelines on
C-Spine Immobilization
• Although it has been challenged, C-
spine immobilization is still the
protocol for trauma patients until
diagnostically cleared (X-Ray)
MANGEMENT IN THE FIELD
• First aid – suturing/splinting.
• Emergency care for life threatening injuries.
– ET intubation, tracheostomy, tension
pneumothorax, stopping external bleeding,
EDH, DAMAGE CONTROL SURGERY.
• Initial care for non-life threatening injuries.
– debridement, fracture reduction, external
fixation, vascular repairs.
Principles of debridement and initial
wound care
• Obtain generous exposure through skin and fascia
• Identify neurovascular bundles.
• Excise devitalised tissues.
• Remove foreign bodies.
• Repair major vessels.
• Obtain skeletal stabilisation.
• Only tag cut tendons and nerves.
• Leave wound open and delay primary closure.
• Avoid tight dressings.
• Elevate injured limbs.
DEFINITIVE MANAGEMENT
• Hospitals alerted – expected number of
casualties
• Hospital reorganisation
• Hospital preparedness.
• Resource management.
Trimodal Distribution of
Death
• First peak- seconds to minutes from time
of injury to death—severe injuries:
lacerations of the brain, brainstem, high
spinal cord, heart aorta, large blood
vessels.
• Second peak- minutes to several hours:
subdural, epidurdal hematomas,
hemopneumothorax, ruptured spleen,
lacerated liver, pelvic fractures, other
injuries associated with major blood loss.
• Third peak-occurs several days to
weeks after the initial injury: most
often the result of sepsis and
multiple organ failure. At this stage,
outcomes are affected by care
previously provided.
 Mechanism of Injury

• Is vital to the initial assessment and

may raise suspicions about the
patients injury pattern.
• Blunt vs. penetrating injury
 BLAST INJURIES
• MECHANISM:
• Blunt & Blast injuries :- Pressure
wave & blast wave – injury to air fluid
interface – ear, lungs, heart and GIT
most affected.
• Penetrating injuries
• Thermal injuries
 Types of injury in
Disaster / Mass Casualty

• Most severe injuries in mass trauma

events are fractures, burns,
lacerations, and crush injuries.
• Most common injuries are eye
injuries, sprains, strains, minor
wounds and ear damage.
 Initial Patient
Assessment
• Clinical presentation
• Physical assessment
• History of traumatic event
• Pre-existing illness
 Primary Survey
• Most crucial assessment tool in trauma
care
• ABCD OF TRAUMA CARE
• 1-2 minutes MAX!
• Designed to identify life threatening
injuries ACCURATELY
• Establish priorities
• Provide simultaneous therapeutic
interventions.
 Resuscitation Phase
Secondary Survey:
EFGHI =
• E- Expose the patient
• F- *Full set of vital signs, *five interventions
(cardiac monitor, pulse oximetry, urinary
catheter, NG if not contraindicated, lab studies)
• G- giving comfort measures…pain control,
reassurance to patient and family
• H- history/ head to toe assessment
• I- inspect for hidden injuries-log roll patient to
inspect posterior aspect.
 Sequence of Diagnostic
Procedures
• Influenced by:

• Level of consciousness
• Stability of patient’s condition
• Mechanism of injury
• Identified injuries
 Priority Interventions
• Patent airway
• Maintaining adequate ventilation
• Adequate gas exchange
• Then:
• Control hemorrhage, replace
circulating volume, restore tissue
perfusion
Maintain Airway Patency
• Essential to trauma management
• EVERY trauma patient has potential for
airway obstruction
• Most common obstruction: Tounge
• Other common causes: blood or vomitus,
secretions, structural impairment,
depressed sensorium, absent gag reflex
How to open the airway?
• Jaw thrust or chin lift!!!
• These maneuvers do not hyperextend
the neck or compromise the integrity
of the C-spine
 Maintaining the airway
• Simple, simple!!

• Nasopharyngeal airway
• Oropharyngeal airways
 Definitive Nonsurgical
Airway
• Endotracheal intubation-Complete control
of the airway
• Nasotracheal intubation—INDICATED for
the spontaneously breathing
patient..CONTRAINDICATED in the
patient with facial, frontal sinus, basilar
skull or cribriform plate fractures.
 Choice of Airway
management
• Familiarity of procedure
• Clinical condition of the patient
• Degree of hemodynamic stability

• A PATENT AIRWAY IS THE

CORNERSTONE OF SUCCESSFUL
TRAUMA RESUSCITATION
 A LIFE THREATENING
CONDITION EXISTS
• Altered mental status (agitation)
• Cyanosis( nail beds and mucous membranes)
• Asymmetrical chest expansion
• Use of accessory muscles/abdominal muscles
• Sucking chest wounds
• Paradoxical movements of the chest wall
• Tracheal shift
• Distended neck veins
• Diminished or absent breath sounds
 Impaired Gas Exchange
• Follows airway obstruction as the next
most crucial problem for the trauma
patient.
• Reasons: decreased inspired air, retained
secretions, lung collapse or compression,
atelectasis, accumulation of blood in the
thoracic space.
 Decreased Cardiac
Output/Hypovolemia
• Acute Blood loss—MOST common
cause in acute trauma
• May be external or internal
 Additional Causes of
Decreased Cardiac Output
• (impaired venous return to the heart)
• Tension Pneumothorax
• Pericardial Tamponade (from
decreased filling and ventricular
ejection fraction)
 Control of External
Hemorrhage
• Direct Pressure
• Elevation
• Compression of pressure points
(arteries, veins)
• AVOID tourniquets…can compromise
loss of circulation and loss of limb
 Control of Internal
Hemorrhage
• Identification and correction of
underlying problem.
 Fluid Resuscitation
• Venous Access and Volume infused are key.
• Two large bore IV’s 14-16 gauge. (never
less that 18, that is the smallest to give
blood through rapidly and not have
hemolysis)
• Forearm and anti-cubital veins are
preferred
• Central lines are more beneficial as
resuscitation MONITORING tools
Fluid Resuscitation Cont…
• A pulmonary artery catheter may be
inserted in the critical care unit to monitor
volume.
• RULE: Venous access with largest bore
catheter possible.
• Isotonic fluids are used INITIALLY
• Ringer’s Lactate is first choice followed by
Normal Saline
Fluid Resuscitation Cont…
• Large bore catheters, short tubing, rapid
infuser devise that warms fluids and blood.
• An initial bolus of 2 liters of fluid is used
unless there is contraindication…
• 3:1 rule= 3mls of crystalloid for each 1ml
of blood loss.
• INITIAL response to fluid challenge is
urine output..should =50 ml in adult, LOC,
heart rate, BP and capillary refill.
Three Response Patterns
• Rapid Response- respond quickly to fluid
challenge and remains stable at completion
of bolus.
• Transient Response- responds quickly but
declines when fluids are slowed
(indicates continued blood loss)
**Non Response- fail to hemodynamically
respond to crystalloid and blood…require
immediate surgical intervention.
 Decision to give Blood
• Based on patients response to initial
fluid.
• ** if unresponsive to fluid, type
specific blood is given, IF LIFE
THREATENING…may give O positive.
• ***Crossmatched, type specific
should be given as soon as possible.
 Ongoing Signs and
Symptoms of Shock
• Deterioration of PaO2 and pH
• Rising base deficits
• Diminished UOP (less than
>.5ml/kg/hr)
• Increasing Lactate levels
 Assessment and
Management of specific
Organ Injuries
• Chest Injuries
• Spinal Cord Injuries
• Head Injuries
• Musculoskeletal Injuries
• Abdominal Injuries
 During resuscitative
phase
• Imperative to locate etiology of
hemorrhage:
• Chest and pelvis, extremity X-rays
• Abdominal ultrasound
• Abdominal CT can be used but in the case
of hemodynamic instability Peritoneal
lavage is the quick, invasive test of choice
 Peritoneal Lavage
• Insertion of lavage catheter directly into
the abdomen
• Aspiration of greater than 10 mls blood
and patient goes directly for surgery.
• If less than 10 mls of blood, 1 liter of
warmed NS is infused into peritoneal
cavity, then drained and sent for cell
counts, amylase, bile, food particles,
bacteria, fecal matter.
Damage Control Surgery
• = Staged laporaotmy
• Trying to avoid hypothermia,
acidosis, coagulopathy
• Shown to improve outcomes of
critically ill patients with sever intra-
abdominal injuries.
Musculoskeletal Injuries
• Extremity Assessment= the 5 P’s
• Pallor pain, pulses, parethesia, paralysis
(describes the neurovascular status of the
injured extremity.
• When possible the injured extremity if
compared with the non-injured extremity
 Traumatic Soft Tissue
Injury
• Categorized as: contusions, abrasions,
lacerations, punctures, hematomas,
amputations, and avulsions.
• All wounds are considered contaminated.
• Tetanus Toxoid and antibiotics are always
CONSIDERED.
 Complications of
Musculoskeletal Injuries
CRUSH INJURY AND CRUSH SYNDROME :-
 Rhabdomolysis-a complication of crush injuries
—marked vasoconstriction and hypotension
followed by ARF.
 Results from muscle destruction
 Myoglobin and potassium are released from
the damage muscles
 Cont.
Can result in life threatening hyperkaemia.
Myoglobin excreted through the urine,
combined with hypovolemia, produces ARF
and ATN if not aggressively treated.
Treatment= Aggressive saline replacement,
alkalinization of urine, osmotic diuresis.
 Compartment Syndrome
• Places the patient at risk for limb
loss.
• More common in the legs and
forearms but can occur other places.
• The closed muscle compartment
contains neurovascular bundles
tightly covered by fascia.
 Cont…
• An increase in pressure within that compartment
produces the syndrome.
• Internal sources= hemorrhages, edema, open or
closed fractures, crush injuries
• External sources=PASG’s, casts, skeletal traction,
air splints.
• The pain is described as throbbing appearing
DISPROPORTIONATE TO THE INJURY.
Increases with muscle stretching. The affected
area is firm to touch. Paresthesia distal to the
compartment, pulselessness, and paralysis are
LATE signs.
• Treatment s immediate surgical fasciotomy.
 Fat Embolism
Usually associated with long bone, pelvis, and
multiple fractures.
Usually develops within 24 to 48 hours after injury.
Hallmark clinical signs: low grade fever, new onset
tachycardia, dyspnea, increased resp rate and
effort, abnormal ABG’s, thrombocytopenia and
petechiae.
Development of lipuria (fat in the urine) indicates
severe fat embolism syndrome.
 Fat embolism cont..
• Prevention is the best treatment.
• Treatment is directed at preserving
pulmonary function and maintenance
of cardiovascular function.
• Careful attention to EKG changes.
• See Box 18-2 on page 660
IMPORTANT!!!
 Critical Care Phase
• ABC’c
• Post OP standard VS= q5min x3,
q15minx3, q30min X2, q1 hour
forward.
• Shivering is to be avoided=increase in
metabolic rate and increase in oxygen
demands.
 Cont..
• Physical Assessment =FULL BODY
• Level of Consciousness
• Invasive Line assessment
• Pain Assessment
• Ongoing Assessments revolve around the
patient’s diagnosis and/or surgical
procedure.
• Anticipation and prevention of untoward
complications.
 Hypothermia
• Defined as a core temp of 35 degrees
Centigrade
• More susceptible person: older, using
alcohol or sedatives, severe injury, massive
transfusions.
• CAUSES :
– In presence of cooler atmospheric
temps
– Submersion in water
– Rapid infusion of room temp. IV fluids
 Hypothermia
• Affects the myocardium and the
coagulation system.
• Frost bites and immersion injuries.
• Can result in bradycardia, atrial and
ventricular fibrillation (28*).
• Cerebral metabolism decreased
(20*)– hallucinations, coma.
 Treatment
• Warm fluids
• Warming blankets
• Overhead warmers & active
rewarming.
 ARDS
• Chapter 13 fully covers
• May occur 2 to 48 hours after
traumatic injury, however sometimes
up to 5 days or more before
RECOGNIZABLE clinical signs.
• There are direct and indirect causes.
 Cont…
• Clinical Manifestations: hypoxemia, rising
CO2 levels, tachypnea, dyspnea, pulmonary
hypertension, decreased lung compliance,
new diffuse bilateral lung infiltrates.
• Treatment: correction of underlying
cause---maximize O2 to the tissues,
decrease pulmonary congestion, prevent
further lung damage, support
cardiovascular system.
 DVT
• Increased incidence of DVT= patients with
obesity, age, malignancy, pregnancy, heart
failure, SCI, recent surgery, extremity
fractures, pelvic fractures, history of
DVT, prolonged immobilization, resp.
failure, # of transfusions,central venous
catheterization, vascular injury.
 Cont..
• Clinical Manifestations= pain and
tenderness, swelling fever, venous
distention, palpable cord, discoloration, +
Homan’s sign
• Treatment= prevention, prophylaxis, early
ambulation, sequential compression
devices, filter placement in the inferior
vena cava.
 Cont.
• Pulmonary embolism is an often fatal
complication of DVT
• Clinical manifestations of PE= sudden onset
dyspnea, sudden onset chest pain, rapid
shallow resps, SOB, Auscultation of
bronchial breath sounds, pale, dusky or
cyanotic skin, Anxiety, decreased LOC,
signs of hypovolemic shock (decreased BP,
narrowing pulse pressure, tachycardia)
 Acute Renal Failure
• From systemic effects of trauma
• OR from actual injury to the renal
system
• There is a reduction in renal blood
flow in the trauma patient associated
with shock or low cardiac output.
 Specific issues
• Limb salvage.
• Facial injuries.
• Tetanus and Gas Gangrene
• Infection.
• Nutrition.
 Infection
• Pulmonary
• Catheter Sepsis
• WOUND
• Necrotising Fascitis.
 Altered Nutrition
Nutritional demands are increased in the
trauma patient by alterations in
metabolism
Metabolism is increased by activation of the
sympathetic response.
Ebb (1st 24-48 hours after injury) and Flow
Phase (peaks 5-10 days after injury)
 Cont.
• Because of this increased need the
patient may demonstrated:
decreased body mass, increased O2
consumption, increased CO2
production, delayed wound healing,
and a weakened immune system
 Cont..
• Anthropometric measurements
• Nutrition replacement in 24 to 48
hours.
• Route based on individual status of
patient…can be enteral, or parenteral
 Multiple Organ
Dysfunction Syndrome
• Immune, inflammatory, and hormonal responses
are underlying causes.
• Defined as presence of altered organ function in
the acutely ill.
• There is incomplete understanding of its
pathophysiology.
• Management focuses on prevention, early
identification, elimination of sources of infection,
maint. Of tissue oxygenation and nutritional
support.
 Handing over
• Follow up and secondary problems.
– Second wave due to infections,
deformities. Rehabilitation.
• Referrals to designated specialized
centres
 Disaster plans
• Establishment of national level
disaster management organization
• Anticipating disaster.
• Evacuation planning.
• Organization of emergency services.
• Medical planning.
 Disaster management in
INDIA
• Statutory responsibility of state
governments
• Central government provides logistic and
financial support
• National coordinating body: National
Disaster Management Cell (NDMC),
Department of Agriculture and Co-
operation, Ministry of Agriculture
(http://www.ndmindia.nic.in/)
 GOVERNMENT OF INDIA : NODAL MINISTRIES /
DEPARTMENT FOR DISASTER MANAGEMENT

DISASTERS NODAL MINISTRIES

Natural Disasters Agriculture

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