II. Preparation

  1. Mobilize resources
    1. General surgeons (as well as other surgeons such as OB/Gyn, Urology)
  2. Protective Equipment
    1. Personal Protection Equipment
    2. Respiratory Personal Protective Equipment
  3. Resuscitation equipment
    1. Mobilize hospital equipment (crash carts, airway equipment, Ventilators) to the immediate triage area
    2. Intravenous Fluid bags, Blood Products
  4. Prepare triage areas
    1. Prior to mass casualty patient arrival, move non-critical ED patients to other areas of the hospital or ED
    2. Assign a triage leader who will quickly assess each patient and assign a triage status
      1. Each patient has a set of initial Vital Signs (Heart Rate, mentation, respiratory status)
      2. Location and pattern of injury
      3. Consider using skin marker or sharpie to write triage number on patient (if tags not available)
    3. Assign a specific, single triage area through which all casualties will flow
    4. Assign an area for each triage level (minor, delayed, immediate or deceased)

IV. Management: Field Trauma Assessment and Treatment (MARCH Field Trauma Protocol)

  1. Background
    1. Equivalent of Primary Survey for the field
    2. Follow with secondary survey
  2. Control Massive Hemorrhage
    1. See Massive Hemorrhage
    2. Tourniquets can prevent limb Exsanguination
    3. Hemostatic Agents (e.g. Combat Gauze) or pressure bandages to trunk
  3. Airway
    1. Advanced Airway management including Cricothyrotomy
  4. Respirations
    1. Consider 2 rescue breaths in children
    2. Chest decompression (Tension Pneumothorax)
  5. Circulation
    1. Evaluate Vital Signs (Heart Rate, extremity pulses, Blood Pressure)
    2. FAST Exam (if time permits)
    3. Rapid transfusers (or inflated Blood Pressure cuff can form a pressure bag)
  6. Head and Hypothermia
    1. Evaluate mentation including Glasgow Coma Scale (GCS)
    2. Consider Altered Mental Status causes
      1. Traumatic Brain Injury
      2. Hypoxia or hypercapnia
      3. Hypovolemia
    3. Prevent Hypothermia
      1. Increased mortality risk in major Trauma patients

VI. Precautions: Children

  1. Unique physiologic aspects
    1. See Rapid Cardiopulmonary Asessment in Children
    2. Children physically decompensate rapidly without significant warning beyond Tachycardia
    3. Children are more likely to experience multsystem Trauma from blunt injury (large head, immature skeleton)
    4. Children are most sensitive to chemical or Biological Weapons
      1. Aerosolized agents have greater effects due to increased Respiratory Rate and decreased body size
      2. Chemicals are absorbed more easily into a smaller volume of distribution
      3. Chemical burns involve a greater percentage of surface area
  2. Unique psychological aspects
    1. Lack self-preservation and coping skills of adults (more likely to be paralyzed by fear)
    2. Parent-child separation anxiety is likely to be exacerbated (avoid separating children from families)

VII. Prevention: Preparedness

  1. Disaster drills should include patients of all ages including children
  2. Local protocols should be based on National Incident Management System (NIMS) guidelines
  3. Equipment, medications and supplies to cover all ages of victim should be at the ready
  4. Broad involvement of all partners (including hospital systems and transfer agreements as well as EMS)
  5. Plan for emergency overflow facilities
  6. Plan for emergency power, utilities
  7. Plan for legal, Malpractice and documentation issues
  8. Plan for security issues including unattended children, quarantines
  9. Plan for patient tracking (pictures, names, descriptions, identification bands)
  10. Plan for media and communications

VIII. Resources

  1. National Incident Management System (NIMS)
    1. https://www.fema.gov/national-incident-management-system

IX. References

  1. Seeyave and Bradin (2014) Crit Dec Emerg Med 28(12): 2-13
  2. Spangler and Nichols in Herbert (2016) EM:Rap 16(12): 5-7

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