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Mass Casualty in Resource-Limited Countries: How to Prepare Care Teams and How to Deliver Appropriate Management

Bin Du, MD

Medical Intensive Care Unit

Peking Union Medical College Hospital

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Conflicts of Interest

• None

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Definition of Natural Disaster

• A situation or event which– Overwhelms local capacity

– Necessitating a request to a national or international level for external assistance;

• An unforeseen of often sudden event that– Causes great damage, destruction, and human suffering

Rodriguez J, Vos F, Below R et al. Annual disaster statistical review 2008: the numbers and trends. Available at http://www.emdat.be/Documents/Publications/ADSR_2008.pdf (accessed August 17, 2009)

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Definition of Mass Casualty Incident

• A situation that– Places a significant demand on medical resources and personnel

– Often, but not necessarily, associated with disasters

• By definition, during a disaster, local response capacities are overwhelmed

• Even without a disaster when local response capacities are intact, there are still a large number of patients requiring triage

Lee CH. Disaster and mass casualty triage. Virtual Mentor 2010; 12: 466-470

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Mass Casualty Incidents

• Natural disasters

• Accidents– Road traffic accidents

– Blasts

– Chemical hazard

– …

• Epidemics of infectious diseases

• Terrorism attacks

• Warfare

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Personal Experience with Mass Casualty

Year Event Patient Population

2003 Beijing SARS epidemic Viral pneumonia

2005 Streptococcus suis epidemic STSS, bacterial meningitis

2008 Wenchuan earthquake Multiple trauma

2009 Influenza A/H1N1 pandemic Viral pneumonia

2010 Yushu earthquake Multiple trauma

2010 Zhouqu debris flow Multiple trauma

2013 Avian influenza A/H7N9 epidemic Viral pneumonia

2013 Lushan earthquake Multiple trauma

2014 Kunshan factory blast Severe burns

2015 Tianjin explosion Blast injury

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Natural Disasters in 2013

Guha-Sapir D, Hoyois P, Below R. Annual Disaster Statistical Review 2013: The Numbers and Trends. Brussels: CRED; 2014. Available at http://www.cred.be/sites/default/files/ADSR_2013.pdf accessed August 26, 2015

CRED* Fact Sheet

330natural triggered disasters

registeredless than the average annual disaster frequency

from 2003 to 2012 (388)

21,610people killed

96.5 mpeople affected

$ 118.6 beconomic damages

*Centre for Research on the Epidemiology of Disasters (CRED)

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What Defines Limited Resource

• WIKIPEDIA– Limited resources may refer to

• Non-renewable resources

• Scarcity

• Embedded systems, computing devices with reduced resource availability

• Poverty

• BusinessDictionary.com– Restricted amounts of inputs required by a business or economy

such as motivated staff, finances, production facilities, and raw materials

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World Bank List of Economies (2014)

Income Grouping Countries

LOWAfghanistan, Bangladesh, Benin, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Comoros, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Rwanda, Sierra Leone, Somalia, Tajikistan, Togo, Uganda, United Republic of Tanzania, Zimbabwe

LOWER MIDDLEArmenia, Bhutan, Bolivia (Plurinational State of), Cabo Verde, Cameroon, Congo, Côte d’Ivoire,

Djibouti, Egypt, El Salvador, Georgia, Ghana, Guatemala, Guyana, Honduras, India, Indonesia, Kiribati, Kyrgyzstan, Lao People’s Democratic Republic, Lesotho, Mauritania, Micronesia (Federated States of), Mongolia, Morocco, Nicaragua, Nigeria, Pakistan, Papua New Guinea, Paraguay, Philippines, Republic of Moldova, Samoa, Sao Tome and Principe, Senegal, Solomon Islands, South Sudan, Sri Lanka, Sudan, Swaziland, Syrian Arab Republic, Timor-Leste, Ukraine, Uzbekistan, Vanuatu, Viet Nam, Yemen, Zambia

HIGHER MIDDLE

Albania, Algeria, Angola, Argentina, Azerbaijan, Belarus, Belize, Bosnia and Herzegovina, Botswana, Brazil, Bulgaria, China, Colombia, Cook Islands**, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, Fiji, Gabon, Grenada, Hungary, Iran (Islamic Republic of), Iraq, Jamaica, Jordan, Kazakhstan, Lebanon, Libya, Malaysia, Maldives, Marshall Islands, Mauritius, Mexico, Montenegro, Namibia, Nauru, Niue, Palau, Panama, Peru, Romania, Saint Lucia, Saint Vincent and the Grenadines, Serbia, Seychelles, South Africa, Suriname, Thailand, The former Yugoslav Republic of Macedonia, Tonga, Tunisia, Turkey, Turkmenistan, Tuvalu, Venezuela (Bolivarian Republic of)

HIGHAndorra, Antigua and Barbuda, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Brunei Darussalam, Canada, Chile, Croatia, Cyprus, Czech Republic, Denmark, Equatorial Guinea, Estonia, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Lithuania, Luxembourg, Malta, Monaco, Netherlands, New Zealand, Norway, Oman, Poland, Portugal, Qatar, Republic of Korea, Russian Federation, Saint Kitts and Nevis, San Marino, Saudi Arabia, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, Trinidad and Tobago, United Arab Emirates, United Kingdom, United States of America, Uruguay

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World Bank List of Economies (2011)

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People Affected by Disasters 1975 to 2004

43%

41%

5%

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Indian Ocean Tsunami December 26, 2004

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Wenchuan Earthquake May 12, 2008

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Hurricane Katrina August 28, 2005

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Hurricane Katrina August 28, 2005

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Hurricane Katrina August 28, 2005

Evacuees crowd the floor of the Astrodome in Houston on September 2, 2005. The facility housed 15,000 refugees who fled the destruction of Hurricane Katrina.

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London Bombings July 7, 2005

Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219-2225

775 people injured, including 55 severely injured (Priority 1 & 2), 667 walking wounded (P3) patients, and 53 deaths at scene (P4)

P1 & P2

P3

P4

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London Bombings July 7, 2005

0

2

4

6

8

10

12

14

16

0 1 1.75 2.5 3.25 4 4.75 5.5 6.25

P1

/P2

Pat

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ED

Majors area

Resuscitation Room

Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219-2225

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Limited Resources as a Universal Problem

• Poor functional status of local hospitals

• Possibility of collapse from aftershock

• Infrastructure damage– Power, transportation, water supply, telecommunication

– Days to weeks

• Unavailability of well-equipped and self-sustainable mobile hospitals

1. Llewellyn M. Floods and tsunamis. Surg Clin N Am 2006; 86: 557-578. 2. Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006; 354: 1052-1063. 3. Currier M, King DS, Wofford MR, et al. A Katrina experience: lessons learned. Am J Med 2006; 119: 986-992. 4. Najafi I, van Biesen W, Sharifi A, et al. Early detection of patients at high risk for acute injury during disasters: developing of a scoring system based on the Bam earthquake experience. J Nephrol 2008; 21: 776-782. 5. Kopp JB, Ball LK, Cohen A, et al. Kidney patient care in disasters: Lessons from the hurricanes and earthquake of 2005. Clin J Am Soc Nephrol 2007; 2: 814-824

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Limited Resources as a Universal Problem

Healthcare Resources Status After Yushu Earthquake

Hospitals• General Hospital• Tibetan Medicine Hospital• Women and Children Hospital

Nonfunctional due to• Building collapse• Infrastructure damage

Healthcare workers• 148 physicians• 238 assistant physicians• 121 nurses

76 (15.0%) injured10 (2.0%) died

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Limited Resources as a Universal Problem

• George W. Bush: Hurricane Katrina as “one of the worst natural disasters in our Nation’s history”– No inhabitable structures

– Obliterated entire coastal communities

– Power outages in 2.5 million customers

– Destroyed local communications system

– Blocked and collapsed waterways and highways

– Incapacitating telephone service, police and fire dispatch centers

– Destroyed and/or inoperable healthcare facilities

The White House. The federal response to hurricane Katrina: lessons learned. Chapter Four: A week of Crisis (August 29-September5). Available at http://georgewbush-whitehouse.archives.gov/reports/katrina-lessons-learned/chapter4.html accessed August 25, 2015

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Limited Resources as a Universal Problem

• Great difficulty with Federal resource managers– Knowledge

• What resources were needed

• What resources were available

• Where those resources were at any given point in time

– Sourcing

• Federal government asset or alternative sources

– Allocation

• No effective mechanism for efficient integration and deploy

The White House. The federal response to hurricane Katrina: lessons learned. Chapter Five: Lessons learned. Available at http://georgewbush-whitehouse.archives.gov/reports/katrina-lessons-learned/chapter5.html accessed August 25, 2015

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Medical Care During Mass Casualty

Search and

Rescue

Triage and Initial Stabilization

Definitive

Medical CareEvacuation

Mass Casualty Response

Llewellyn M. Floods and tsunamis. Surg Clin N Am 2006; 86: 557-578

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Injury Pattern and Type of Disaster

earthquake hurricanes and floods

Many deaths Many deaths due to drowning

Many severe injuries requiring complex surgical and resuscitative medical care

Few serious medical or surgical injuries

A large, unmet need for complex surgical and medical care due to devastating local capacity

Often no overload on the existing curative medical system

Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet 2012; 379: 748-757

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Infectious Diseases After Disasters

earthquake hurricanes and floods

wound infection necrotizing fasciitis

aspiration pneumonia

tetanus

cholera

malaria

dengue fever

tuberculosis

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Fatalities After Earthquake

Severe TBISpinal cord injury

unsaveable

at scene

Subdural hematomaLiver or spleen lacerations

Pelvic fractures

prompt treatment

within the first several hours

SepsisMultisystem organ failure

DIC

days to weeks

Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet 2012; 379: 748-757

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Casualties After Wenchuan Earthquake

Zhang L, Liu X, Li Y, et al. Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuanearthquake. Lancet 2012; 379: 853-861

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Acute Injuries in Natural Disasters

Among a total of 1,723 patients admitted to 3 general hospitals in Sichuan, China

Within the initial 5 days after Wenchuan Earthquake

Zhang L, Li H, Carlton JR, et al. The injury profile after the 2008 earthquakes in China. Injury 2009; 40: 84-86

Injury %

Lower extremities 36%

Head 18%

Upper extremities 13%

Multiple sites 10%

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Acute Injuries in Natural Disasters

Nonsurvivors(n = 36)

Survivors(n = 144)

Total(n = 180)

Extremity fracture 8 (22%) 81 (56%) 89 (49%)

Trunk fracture 10 (28%) 52 (36%) 62 (34%)

Thoracic injury 9 (25%) 17 (12%) 26 (14%)

Severe TBI 10 (28%) 7 (5%) 17 (9%)

Abdominal injury 6 (17%) 5 (3%) 11 (6%)

Infection 19 (53%) 29 (19%) 47 (26%)

Acute renal failure 8 (22%) 5 (3%) 13 (7%)

MSOF 12 (33%) 1 (1%) 13 (7%)

Crush syndrome 5 (14%) 3 (2%) 8 (4%)

Wen J, Shi YK, Li YP, et al. Risk factors of earthquake inpatient death: a case control study. Crit Care 2009; 13: R24

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2010 Yushu Earthquake, China

Fact Sheet

Yushu County, Qinghai Province

4,493 maverage altitude

357,267population in 2009

Batang Airportsince 2009

No 214National Highway

Until May 30

2,698dead

270missing

12,135injured

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Outpatient Clinic After Yushu Earthquake

14.4

42.4

0

10

20

30

40

50

Early Late

Pati

ents

wit

h M

edic

al D

isea

ses

(%)

April 14 to April 202,521 patients (85.4%)

April 21 to April 30424 patients (14.6%)

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Medical Problems After Disasters

Hurricane Andrew Tropical Storm Allison Hurricane Katrina

Bahamas, 1992 Texas, 2001 Louisiana, 2005

5 injuries directly caused by

the hurricane

48.9% (507/1036)

“general medicine”

22.4% (232/1036)

“trauma”

43% triaged to the

pharmacy unit only

55% triaged to the medical

unit

2% received dental care

1. Alson R, Alexander D, Leonard RB, et al. Analysis of medical treatment at a field hospital following Hurricane Andrew. Ann Emerg Med 1993; 22: 1721-1728

2. D’Amore AR, Harin CK. Air Force Expeditionary Medical Support Unit at the Houston flood: use of a military model in civilian disaster response. Mil Med 2005; 170: 103-108

3. Currier M, King DS, Wofford MR, et al. A Katrina experience: lessons learned. Am J Med 2006; 119: 986-992

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Medical Problems After Hurricane Katrina

• Most common medical problems (56.9% of visits)– Hypertension/cardiovascular diseases

– Diabetes

– New psychiatric conditions

• Onsite recorded prescriptions– Cardiovascular medications (30.8% of 4,902 prescriptions)

Llewellyn M. Floods and tsunamis. Surg Clin N Am 2006; 86: 557-578Currier M, King DS, Wofford MR, et al. A Katrina experience: lessons learned. Am J Med 2006; 119: 986-992

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Disease/Injury Patterns After Earthquake

• Musculoskeletal injuries

– Lacerations (65%)

– Fractures (22%)

– Soft-tissue contusions or sprains (6%)

• Crush syndrome (2 – 15%)

• Chest injuries (13 – 67%)

• Neurological problems

– Spinal trauma

– Traumatic brain injury

• Cardiovascular system

– Acute myocardial infarctions

– Cardiac arrhythmias

• Infectious diseases

– Wound infections

– Respiratory illness

– Water-borne illness

• Mental health

– Depression (6 – 72%)

– PTSD (3.3 – 81%)

• Hematology– Massive transfusion

Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet 2012; 379: 748-757

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Special Conditions in Yushu Earthquake

Yushu Resident(n = 2650, 89.7%)

Disaster Relief(n = 245, 8.3%)

Age, year 36.1 ± 17.7 31.2 ± 9.0

Male sex 49.9% (1322) 95.9% (235)

Earthquake-related trauma 88.3% (2340) 12.2% (30)

Nontrauma diseases 11.8% (310) 87.8% (215)

High altitude illness 0.4% (10) 78.4% (192)

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Renal Disaster After Earthquake

Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006; 354: 1052-1063

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Renal Disaster After Wenchuan Earthquake

Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006; 354: 1052-1063

Renal Disaster

69,227deaths

760crush syndrome

480dialysis

1,857hospitalizations

7.7% (147)

crush syndrome

4.2% (78)

dialysis

Data from West China HospitalData from MOH

96,544hospitalizations

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Renal Disaster After Natural Disasters

• Risk of crush syndrome and/or acute renal failure– Type of disaster

• Earthquake vs. floods/tsunamis

– Rescue ability

– Time of disaster onset

– Materials of the building

• Concrete vs. masonry vs. adobe

– Severity and rapidity of building collapse

1.Roy N, Shah H, Patel V, Coughlin RR. The Gujarat earthquake experience in a seismically unprepared area: community hospital medical response. PrehospitalDisaster Med 2001; 17:186-1952.International Society of Nephrology. The Asia quake—ISN’s aid in action. http://www.isn-online.org/isn/news/press_room/2005/0510/full/press_051014_1.html (accessed April 1, 2009)3.Sever MS, Erek E, Vanholder R, et al. The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. Kidney Int 2001; 60: 1114-11234.Alexander D. Local planning beats foreign dogs. Reuters AlertNet, London, December 30, 2003. http://www.alertnet.org/thefacts/reliefresources/107279716149.htm. (Accessed April 1, 2009)5.Goldfarb DS, Chung S. The absence of rhabdomyolysis-induced renal failure following the World Trade Center collapse. Am J Med 2002; 113: 260

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Building Materials and Fatalities

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Need for Specialists After Earthquake

Surgery

Orthopedic surgeon

Neurosurgeon

General surgeons

Cardiothoracic surgeon

Urologist…

Medicine

Physician

Intensive Care

Intensivist

Weeks after earthquake

0 1 2 4

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Surge Capacity Prediction for Mass Casualty

Abir M, Davis MM, Sankar P, et al. Design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center. Prehosp Disaster Med 2013; 28: 23-32

Triage

Burn/Trauma Intensive Care Unit

(10 beds)average daily

occupancy 82%

Surgical Step-Down Unit (6 beds)average daily

occupancy 100%

Surgery Ward(64 beds)

average daily occupancy 88%

Operating Rooms

(50)

HOSPITAL

Discharge vs.

Death

MCI

Dischargevs.

Death100 burns patients• no burns 2%• 2° burns 24.5%• 3° burns 73.5%Indoor fire• 0 – 30 %TBSA• > 80 %TBSA

Rate of arrival

1 every 3min

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Surge Capacity Bottleneck for Mass Casualty

Abir M, Davis MM, Sankar P, et al. Design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center. Prehosp Disaster Med 2013; 28: 23-32

21admissions within 120 min after arrival of the

first casualty

8 ICU beds

no ICU patients dischargeable or transferrable

surgical step-down units evacuated and converted to ICU

within 30 minutes

13 surgery ward beds

0 0.5 2 4 6 48 76 100 168

Hours after first casualty arrival at the hospital

Ringer’s Lactate279 L

Silver Sulfadiazine38 x 400 g tubes

Albumin123 L

PRBC AB2 L

Silver dressing768

Gauze bandage1188 rolls

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Mass Casualty in China Factory Blast

2 August 2014 Last updated at 14:58

China factory explosion in Jiangsu 'kills at least 68'

BBC News. China factory explosion in Jiangsu ‘kills at least 68’. http://www.bbc.com/news/world-asia-china-28619248accessed February 26, 2015

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Mass Casualty in China Factory Blast

All(n = 167)

Survivors(n = 105)

Non-Survivors(n = 62)

Total burn surface area (%) 95 (87 – 98) 91 (70 – 95) 97.5 (95 – 99)

Full-thickness burnsurface area (%) 82 (40 – 94) 70 (25 – 90) 91 (80 – 97)

Baux score 145 (134 – 155) 140 (119 – 151) 153 (145 – 158)

Septic shock 70% (116) 60% (63) 86% (53)

ARDS 90% (150) 84% (88) 100% (62)

AKI-III 53% (88) 30% (31) 92% (57)

Courtesy of Dr. Yingzi Huang, and Dr. Haibo Qiu from Department of Critical Care Medicine, Zhongda Hospital, Southeast University

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High Risk Group in Natural Disasters

• General– Extremes of age

• Over 60 years

• Between 5 and 9 years

– Chronic illness

• Earthquake– Entrapment

– Occupant’s location within a building

– Occupant’s behavior during the earthquake

– Time until rescue

Briggs SM. Earthquakes. Surg Clin N Am 2006; 86: 537-544

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High Risk Group in Natural Disaster

Factor OR (95%CI)

Severe TBI 253.3 (8.9 to 7208.6)

0.001

MSOF 87.8 (3.9 to 1928.3)

0.005

Comorbidity 14.9 (1.9 to 119.0)

0.011

Infection 13.7 (1.8 to 103.7)

0.0110%

10%

20%

30%

40%

50%

60%

0 1 2 3 4 >4

Mo

rtal

ity

Number of Risk Factors

Wen J, Shi YK, Li YP, et al. Risk factors of earthquake inpatient death: a case control study. Crit Care 2009; 13: R24

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Simple Triage and Rapid Treatment

Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996; 334: 438-444

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START Algorithm for Mass Casualty Triage

• Simple triage and rapid treatment (START)– Red sensitivity 100%

– Green specificity 89%

– Obuchowski statistic 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category

Kahn CA, Schultz CH, Miller KT. Does START triage work? An outcome assessment after a disaster. Ann Emerg Med 2009; 54: 424-430

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Mass Casualty Triage after Airplane Crash

• 126 surviving casualties in 14 admitting hospitals

(distance from crash: 5.8 – 53.5 km)

• 133 – 213% of treatment capacity in 4 hospitals

• 89% of critical casualties in level I trauma centers

• 3 secondary transfers

• 0% mortality rate

Postma ILE, Weel H, Heetveld MJ, et al. Patient distribution in a mass casualty event of an airplane crash. Injury, Int J Care Injured 2013; 44: 1574-1578

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Consensus-Based Standard for Triage

DEADAdults: a lack of palpable pulse and/or respiratory effort (i.e. cardiac or respiratory arrest) at initial EMS evaluation that is not responsive to needledecompression or airway repositioningChildren (< 12 yo): a lack of palpable pulse and/or respiratory effort (i.e. cardiac or respiratory arrest) at initial EMS evaluation that is not responsive to needle decompression or airway repositioning, or two rescue breathsLack of palpable pulse and EMS provided CPR (i.e. cardiac arrest) within the first 15 minutes of arrival on the scene

EXPECTANTIn patients age 0 to 49 yo: third degree (full thickness) burns to > 90% of the bodyIn patients over 50 yo: third degree (full thickness) burns to > 80% of the bodyPenetrating trauma to the head that crosses the midline with agonal respirations and/or no motor response, decorticate posturing, or decerebrateposturing (i.e., a motor GCS ≤ 3)Blunt trauma to the head with agonal respirations and/or no motor response, decorticate posturing, or decerebrate posturing (i.e., a motor GCS ≤ 3)Uncontrolled hemorrhage that resulted in cardiac arrest (defined as lack of palpable pulse and EMS provided CPR) prior to EMS transportChemical exposure with agonal respirations or cardiac arrest (defined as lack of palpable pulse and EMS provided CPR) after administration of any available antidotes and prior to EMS transportRadiologic exposure with any trauma or burns, where the patient has agonal respirations, seizures, nausea, or cardiac arrest (defined as lack of palpable pulse and EMS initiation of CPR) prior to EMS transport

IMMEDIATENeurologic, vascular, or hemorrhage-controlling surgery to the hand, neck, or torso performed within 4 hours of arrival at a hospitalLimb-conserving surgery performed within 4 hours of arrival at a hospital on a limb that was found to be pulseless distal to the injury prior to surgeryEscharotomy performed on a patient with burns within 2 hours of arrival at a hospitalChest tube placed within 2 hours of arrival at a hospitalAn advanced airway intervention (e.g., intubation, LMA, surgical airway) performed in the prehospital setting or within 4 hours of arrival at a hospitalIV vasopressors administered within 2 hours of arrival at a hospitalArrived in the ED with uncontrolled hemorrhageChemical exposure that require additional treatment with antidotes in the ED or in the hospital within 4 hours of arrival that was provided to correct symptoms and not given solely for patient comfort and/or the relief of minor symptoms (e.g. rhinorrhea)Patient who required EMS initiation of CPR (i.e. had a cardiac arrest) during transport, in the ED, or within 4 hours of arrival at a hospital

MINIMALDischarged from the ED with no X-rays or an extremity X-ray that was negative or showed an uncomplicated fracture (i.e., a closed extremity fracture without significant displacement or neurovascular compromise); no laboratory testing; received only simple wound repair (single layer suturing only); and received no medications intravenously (does not include fluids), or inhaled (does not include oxygen) from EMS or in the hospitalChemical or radiologic exposure that did not require any treatment beyond external decontamination in the field or in the hospital

DELAYED

Lerner EB, McKee CH, Cady CE, et al. A consensus-based gold standard for the evaluation of mass casualty triage systems. Prehosp Emerg Care 2015; 19: 267-271

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Consensus-Based Standard for Triage

DEAD Lack of palpable pulse and EMS provided CPR (i.e. cardiac arrest) within the first 15 minutes of arrival on the scene

EXPECTANT In patients age 0 to 49 yo: third degree (full thickness) burns to > 90% of the bodyBlunt trauma to the head with agonal respirations and/or no motor response, decorticate posturing, or decerebrate posturing (i.e., a motor GCS ≤ 3)

IMMEDIATE Neurologic, vascular, or hemorrhage-controlling surgery to the hand, neck, or torso performed within 4 hours of arrival at a hospitalEscharotomy performed on a patient with burns within 2 hours of arrival at a hospital

MINIMAL Discharged from the ED with no X-rays or an extremity X-ray that was negative or showed an uncomplicated fracture (i.e., a closed extremity fracture without significant displacement or neurovascular compromise)

DELAYED

Lerner EB, McKee CH, Cady CE, et al. A consensus-based gold standard for the evaluation of mass casualty triage systems. Prehosp Emerg Care 2015; 19: 267-271

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Victim Evacuation After Yushu Earthquake

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Victim Evacuation After Yushu Earthquake

*of 2953 patients evacuated until April 30, 2464 (83.4%) were transferred by flight

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• Flight transfer vs. air-medical evacuation– No skilled transport team

– No specially designed or modified aircraft/helicopter

– No in-transit critical events

• Low risk patient population– Material of the buildings

– Few crush syndromes (2.8% vs. 4.4-6.1%)

– Very few fatalities (0.5%)

Victim Evacuation After Yushu Earthquake

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Earthquake Victim Evacuation

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Wenchuan

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Patient Surge in Backup Hospitals

• West China Hospital (WCH)– The largest state-level and university hospital in the earthquake-

affected area

– 4,300 beds with 64 operating rooms

– 66 ICU beds

• Patient volume from Jan to April, 2008

– Daily hospital admissions 322 ± 167

– Daily hospitalized patients 3,928 ± 567

– Daily operations 135 ± 91

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May 12 to June 11, 20082,529 patients transferred to WCH• 1,857 admissions• 610 transfers• 62 discharges

May 12, 2008Arrival of first case on 15:39 hr• 141 emergency visits• 34 admissions

May 14, 2008• 300 emergency visits• 197 admissions

May 21 & 26, 2008• 170 & 152 admissions

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Daily Operations in WCH

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World Load in ICU, WCH

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Predefined Hospital Plan for Mass Casualty

Shah AA, Rehman A, Sayyed RH, et al. Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system. Injury Int J Care Injured 2015; 46: 156-161

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Predefined Hospital Plan for Mass Casualty

Shah AA, Rehman A, Sayyed RH, et al. Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system. Injury Int J Care Injured 2015; 46: 156-161

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Predefined Hospital Plan for Mass Casualty

Shah AA, Rehman A, Sayyed RH, et al. Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system. Injury Int J Care Injured 2015; 46: 156-161

• March 3, 2013

• 70 blast victims presented to ED– None received fluid resuscitation or BLS during transit

– 4 pronounce dead on arrival

– 71% penetrating shrapnel injury

• 38 patients underwent surgeries in OR

• 14 patients admitted to the special care unit

• 6 patients admitted to ICU

• 0 fatality

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Load Index Model for Decision Making

• Load parameters– Occupancy of ORs/surge capacity of ORs

– Severe/moderate casualties admitted to surgical departments in the last 24 h/no. physicians

– Severe/moderate casualties admitted to surgical departments in the last 24 h/ICU beds

– Severe/moderate patients hospitalized in surgical departments/no. ICU physicians

– Severe/moderate patients hospitalized in surgical departments/no. surgeons

Adini B, Aharonson-Daniel L, Israeli A. Load index model: an advanced tool to support decision making during mass-casualty incidents. J Trauma Acute Care Surg 2015; 78: 622-627

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Load Index Model for Decision Making

Adini B, Aharonson-Daniel L, Israeli A. Load index model: an advanced tool to support decision making during mass-casualty incidents. J Trauma Acute Care Surg 2015; 78: 622-627

hospital’s index valuehighest hospital index value

sum of parameters

relative importance of index [site]

= x

Load Index Model

Simulation Exercises

Actual Implementation

600 simulated casualties in 11 admitting hospitals

variability 18 times greater before the model introduction than afterward

420 casualties in 9 admitting hospitals in November 2012 in Southern Israel

“[All]…reported that the model contributed significantly to the ability to

delineate patient evacuation policy, and they recommended its adoption as

an integral support mechanism for emergency management nationally.”

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How to Enhance System Surge Capacity

Nation level

• Nationally coordinate resources

• Establish goals (20% of usual bed capacity)

• Prepare standard operating procedures

• Constantly monitor and maintain surge capacity

• Design expandable facilities

• Distribute severe injured casualties among several hospitals

• Assign an EMS liaison to each receiving hospital

• Frequently conduct rigorous, full-scale drills

Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA 2009; 302: 565-567

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How to Enhance System Surge Capacity

Hospital level

• Avoid ED crowding

• Promptly clear EDs to accommodate incoming casualties

• Reinforce medical workforce

• Designate an adjoining site to treat patients with minor injuries

• Designate a triage hospital

Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA 2009; 302: 565-567

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Importance of Preparedness for Disaster

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Summary

• Mass casualty incidents common worldwide, with significant morbidity and mortality

• Knowledge of the mechanism of relevant injuries and illness important

• Preparedness for mass casualty crucial