P re p a r i n g f o r M a s s C a s u a l t y

Events
a,b, c
Joseph McIsaac, MD, MS, MBA, CPE *, Brenda A. Gentz, MD

KEYWORDS

Mass casualties
CBRN
Chemical
Biological
Radiological
Nuclear

Pandemic
Simulation exercises
SALT triage

KEY POINTS

Mass casualty events occur regularly. Preparation reduces morbidity and mortality.
Training for infrequent events, like malignant hyperthermia, is already human nature.

The mass casualty surge is added to the usual burden of surgical disease and often re-
quires expansion of facilities to manage successfully.

Chemical, biological, radiological, and nuclear (CBRN) defense exposure can be a sepa-
rate event or combined with traumatic injuries. CBRN events seem to be increasing.

The Joint Commission requires twice-yearly hospital disaster exercises. Anesthesiology
departments should participate at both the leadership and staff levels.

There is a plethora of resources available for individual and team training.

INTRODUCTION

The best definition of a mass casualty incident (MCI) is any number of casualties that
exceeds the resources normally available. An ability to deal with any incident depends
on the number of injuries, severity of injuries, level of supplies, and support from the
health care community (Box 1). Mass casualties can come from many sources—hur-
ricanes, tornadoes, fires, mass shootings or stabbings, bombings, vehicle attacks,
and even viral pandemics.

TYPES AND CHARACTERISTICS OF MASS CASUALTY VICTIMS

The characteristics of MCI patients are determined by the type of mass casualty event.
Terrorist attacks tend to focus on soft targets where people tend to congregate, such

a
University of Connecticut School of Medicine, Farmington, CT, USA; b National Disaster
Medical System, US Department of Health and Human Services, Washington, DC, USA; c The
University of Arizona College of Medicine-Tucson, Banner University Medical Center-Tucson,
South Campus, 1625 North Campbell Avenue, Tucson, AZ 85719, USA
* Corresponding author. Department of Anesthesia, 263 Farmington Avenue, Farmington, CT
06030.
E-mail address: [email protected]

Anesthesiology Clin 38 (2020) 821–837

https://doi.org/10.1016/j.anclin.2020.08.008 anesthesiology.theclinics.com
1932-2275/20/Published by Elsevier Inc.

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
822 McIsaac & Gentz

Box 1
Characteristics of a mass casualty event

Time—sudden onset versus long time course

Type—trauma versus infection versus chemical/radiological intoxication

Geography—local versus regional versus national/international

Infrastructure—degree of degradation

as restaurants, wedding halls, funerals, dance/concert venues, sporting events, and

tourist locations. Many victims are young, and, in Israel, up to 61% were between
the ages of 15 and 29, with a male predominance.1 Earthquake survivors have a pre-
dominance of crush and extremity injuries. Combination injuries involving multiple re-
gions of the body tend to do worse. Head injuries, in combination with another body
region, such as the head/neck or torso, have the worst prognosis. Chemical and radi-
ation injuries need decontamination but may have concomitant trauma as well. In
addition, infected patients must be isolated.

DEPARTMENTAL PREPAREDNESS

Preparing for an MCI requires planning and training in 3 simultaneous areas: individual
knowledge, leadership preparation, and team/department/interdepartmental skills.
Templates, playbooks, and plans must be practiced, tested, and revised in an iterative
manner. Having a plan that is not widely known is not the same as implementing a well-
tested one. All disasters feature a lack of or degradation in infrastructure, people, or sup-
plies. Austere conditions tend to be the rule. It is, therefore, important to consider the 4
Ss—staff, space, stuff, and systems—during planning and training (Box 2).
At the start of planning, a hazard vulnerability analysis (HVA) should be performed.
This analysis results in a matrix of risks graded on impact and likelihood of occur-
rence.2,3 All hospitals are required by the Joint Commission to perform and report
an HVA. The institution’s HVA can be used as the basis for a departmental HVA
(Fig. 1).

INDIVIDUAL KNOWLEDGE

Individuals should be encouraged to develop their knowledge by ongoing reading and

course participation. There are many books, chapters, Web sites, courses, and arti-
cles available (Box 3).4

Box 2
4Ss: staff, space, stuff, systems

Staff—clinical and nonclinical

Space—units, patient flow, staff housing, and break areas

Stuff—logistics (medications, blood, food, sterile supplies, PPE, disposables, and medical
devices [ventilators, etc.])

Systems—infrastructure: power, water, sanitation, transportation, command and control,
information and computer systems, communications, etc.

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 823

Fig. 1. A portion of a hospital HVA template. (From Sample Template. FREE 9 Hazard Vulner-
ability Analysis Templates in PDF: MS Word: Excel. Available at: www.sampletemplates.com/
business-templates/analysis/hazard-vulnerability-analysis-template.html With permission.)

IMMEDIATE RESPONDERS

It has become more widely accepted that everyone can do something to help in a time
of crisis. In any disaster, there are injured casualties, first responders, and a new cate-
gory of provider defined as an immediate responder. An immediate responder is
defined as an individual who finds themselves at the incident of a scene and is able

Box 3
Individual training resources

Web sites and reading lists

 ASA Trauma and Emergency Preparedness Web site
 Department of Health and Human Services Web site (https://www.phe.gov/preparedness/
pages/default.aspx)
 Books and handbooks

Just-in-time training
 PPE charts and quick references (family and CBRN) (https://www.asahq.org/about-asa/
governance-and-committees/asa-committees/committee-on-trauma-and-emergency-
preparedness-cotep/emergency-preparedness)

Courses
 Basic, core, and advanced disaster life support (https://www.ndlsf.org/)
 Stop the Bleed (https://www.stopthebleed.org/)

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
824 McIsaac & Gentz

to assist others. These individuals may have only minor injuries or are uninjured.5
Through universal training and education of the citizenry, the United States has the op-
portunity to increase overall disaster resiliency and community outcomes following
large-scale disasters. The need for local population life-saving skill training and equip-
ping has been demonstrated and is a known, vital component of disaster risk reduc-
tion. Local communities are best positioned and suited to begin a response in the
aftermath of a disaster because they have a better understanding of people, politics,
resources, and local infrastructure.5

PREHOSPITAL MASS TRAUMA

SALT Triage
Triage refers to the evaluation and categorization of the sick or wounded when there
are insufficient resources for medical care of everyone at once.6 There are several
triage systems currently embraced. The SALT triage system focuses on sorting,
assessing, providing lifesaving interventions, and treatment/transport.7 Most triage
systems have at least 4 categories of patients:

Minor emergency (green) —non–life-threatening injuries

Delayed emergency (yellow) —urgent but can be transported in a second group

Immediate emergency (red) —need to be transported immediately

Expectant/dying (gray) and dead (black)
Triaging these patients correctly is critical because labeling a severely injured pa-
tient as walking wounded can be dangerous, but over-triage can be associated with
higher mortality by clogging up wards.

STOP THE BLEED

“Uncontrolled bleeding is the number one cause of preventable death from trauma.”
Launched in October 2015 by the White House, Stop the Bleed is a national awareness
campaign and a call to action. “Stop the Bleed is intended to cultivate grassroots ef-
forts that encourage bystanders to become trained, equipped, and empowered to
help in a bleeding emergency before professional help arrives.” The Stop the Bleed
campaign came out of the Hartford Consensus, which included the American College
of Surgeons and other medical groups, Department of Homeland Security, the Na-
tional Security Council, the Federal Bureau of Investigation, law enforcement, and
fire rescue and emergency medical services (EMS). “The overarching principle of
the Hartford Consensus is that no one should die from uncontrolled bleeding.”8
Provider Safety
For medical providers, there is a tendency to rush in. Caution is warranted in that the
first action in an emergency with mass casualties is to make sure that the scene is
safe. Only after a scene is determined to be safe should providers at a MCI evaluate
the number and severity of patients. Zones may be established within MCI scenes.
The hot zone is the area of danger containing the controlled threat. The warm zone
is an area that is not in direct immediate danger but has not been declared completely
safe. The cold zone is the safe area for triaging, staging, and transportation of the
patients.6
Critical Mortality
One of the most importance concepts in MCIs is critical mortality. That is the fraction of
those individuals who are admitted to a hospital with life-threatening injuries who go

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 825

on to die. A 2012 article, co-authored by Christine Gaarder, a doctor involved in the

Oslo attacks, found that between 2001 and 2007 the typical critical mortality rate after
a terrorist attack was between 15% and 37%.9,10 This critical mortality has substan-
tially improved over the past 2 decades. For example, no one died in the hospital after
the Boston Marathon bombings in 2013; the hospitals in Paris saved all but 2 of the
patients admitted after gunmen and suicide-bombers injured more than 400 people
and killed 130 on November 13, 2015; and, finally, of the 104 admissions to the Uni-
versity Medical Center of Southern Nevada, after the 2017 mass shooting incident,
just 4 died.10

Regional Hospital Systems—Hub and Spoke

Much of the success in decreasing critical mortality is due to the creation of hospital
hub-and-spoke systems. This is the structuring of trauma care around expert hospi-
tals. This occurred in Great Britain after a 2010 National Audit Office report that sug-
gested an increased number of lives could be saved by adopting this system. In the
hub-and-spoke system, critically injured patients travel to expert hospitals even if
that means passing a local hospital en route.10

CASUALTY BEHAVIOR

Patients at the scenes often do not follow rules. In the Last Vegas shooting, the “inci-
dent scene expanded from17.5 acres to 4 square miles as survivors fled the scene and
began to call 911.”11 Patients who self-evacuate may not know the location of clearing
stations and present themselves at the closest local hospital. In emergencies, all forms
of transportation are used—Uber, Lyft, buses, makeshift stretchers, police vehicles,
ambulances, and private cars. In the Las Vegas shooting, 80% of the patients arrived
by personal vehicles, cabs, or ride-sharing services from the incident—often 4 to a
vehicle.12 Rumors and misinformation can create a lot of confusion and fear during
a mass casualty event. In Las Vegas, incorrect reports circulated that the area’s
only Level 1 trauma center was closed. There also were rumors that there were addi-
tional active shooter incidents occurring, including at one of the hospitals.12

COMMUNICATION

Problems with communication during a MCI are common. University of Washington

Harborview Medical Center researchers “created a system that utilized a combination
of text, voice and e-mail coupled with conference calls to communicate with staff in
their system. Their premise behind using text messaging was the higher likelihood
of successful transmission than voice calls.”13 Dr Ahmad also has been testing a sys-
tem called Panacea’s Cloud that is being developed as a “situational awareness oper-
ating system whose common operating picture includes communication with and
tracking of patients, first responders, healthcare providers and incident com-
manders.”13 Communication between hospitals can be poor. “In London on July
7th, 2005, with phone networks jammed, medical students were sent running from
site to site with messages on paper.” A decade later, although communication has
improved, Las Vegas responders still noted delays of 8 hours or longer in receiving
text messages.12

CRISIS LEADERSHIP

The consulting firm, McKinsey, recommends that “what leaders need during a crisis is
not a predefined response plan but behaviors and mindsets that will prevent them

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
826 McIsaac & Gentz

from overreacting to yesterday’s developments and help them look ahead.”14 They
define 5 leadership characteristic actions during a crisis. Leaders must demonstrate
calm and bounded optimism. They should establish a network of teams to deal with
issues at hand as well as maintaining ongoing activities. Leaders should resist the
temptation to make snap decisions based on emotion. Instead, pause, anticipate
events and consequences, and consult teams before a decision. Whenever possible,
give decision making authority to the teams.
Leaders should maintain transparency, be honest when there is uncertainty, and
give frequent updates to staff. Finally, time should be taken to express empathy to-
ward not only the victims but also the staff, who also may be worried about themselves
and their own families15 (Boxes 4 and 5).

DEPARTMENTAL PLANNING AND TRAINING

Planning and preparation were best evident by the events at Bastille Day in Nice,
France, on July 14, 2016, as well as the Boston Marathon bombings.16 After earlier at-
tacks in Paris, first responders in Nice completed an emergency event simulation
involving 60 actors in May 2016. The scenario involved patients going directly to a hos-
pital from the scene of a terrorist attack, which led to the implementation of an in-
hospital medical triage process. The 2 keys points learned during the exercise were
(1) the regional health system coordinated the medical and hospital resources and
(2) the preparation of a hospital team dedicated to damage control resuscitation.
The triage team was led by an emergency physician, a trauma surgeon, and an
anesthesiologist.
The Boston Marathon bombing was the first improvised explosive device incident to
cause mass casualty injuries in the United States. Bystanders pitched in to help stop
bleeding and evacuate victims before responders could arrive and save lives. Crucial
stabilization of trauma injuries was provided in the medical tent that was meant to
accommodate up to 2500 runners and stationed near the marathon finish line. Early
tourniquet use was key, and up to 26 tourniquets were place in the field. An incident
command center was in place. At area hospitals, all ongoing surgeries were finished
and no further elective cases were done. All 30 red-tagged patients were transported
within 18 minutes and the last of the injured patients was transported from the scene
within 45 minutes.17,18
After the World Trade Center collapsed on September 11, 2001, the US Government
established the Hospital Preparedness Program to “enhance the ability of hospitals
and healthcare systems to prepare for and respond to bioterror attacks...and other
public health emergencies, including pandemic influenza and natural disasters.”19
The National Preparedness Goal was updated in 2015. The goal is to establish “A
secure and resilient nation with the capabilities required across the whole community

Box 4
Crisis leadership tasks

Demonstrate deliberate calm and bounded optimism

Communicate effectively

Establish a network of teams and relinquish control

Pause to assess, then act

Display compassion

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 827

Box 5
Crisis communication points

State the crisis

 Known, unknown

State what is being done (teams, logistics, staff protection)

State plans for future

Stay calm and express bounded optimism

Give frequent updates

Express empathy for patients, staff (acknowledge stress and give thanks), and families

to prevent, protect against, mitigate, respond to, and recover from the threats and
hazards that pose the greatest risk.”20
The Whole Community Approach has 6 strategic themes: (1) understand community
complexity; (2) recognize community capabilities and needs; (3) foster relationships
with community leaders; (4) build and maintain partnerships; (5) empower local action;
and (6) leverage and strengthen social infrastructure, networks, and assets. There is
recognition by the government that the local populations are often best positioned
to begin response in the immediate aftermath of a disaster. The Whole Community
Approach goals include prevention, protection, mitigation, response, and recovery.
The implementation of this approach can be seen with the recent coronavirus
outbreak.

HOSPITAL-LEVEL PREPAREDNESS

Hospitals respond to mass casualty and other disaster incidents by setting up their
Hospital Incident Command System Command Center and implementing their Inci-
dent Response Plan.21 Anesthesiology departmental leadership (chair, vice, chair,
and clinical managers) should be familiar with the system. Federal Emergency Man-
agement Agency offers a series of free online courses for familiarization with the sys-
tem (IC100, Introduction to the Incident Response System, through IC 800,
Introduction to the National Response Framework, https://training.fema.gov/is/).
The ASA has a Guide to Anesthesia Department Administration, offering an easy to
read guide for the chair to implement a department preparedness plan (https://www.
asahq.org/quality-and-practice-management/quality-improvement/qmda-regulatory-
toolkit/guide-to-anesthesia-department-administration/defining-mass-casualty-events-
and-natural-disasters). The older but more complete version can be found at https://
www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-
on-trauma-and-emergency-preparedness-cotep/emergency-preparedness.
The ASA has also developed checklists for operating room management during mass
casualties, operating room power failures, and family preparedness (Fig. 2) (https://
www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-
on-trauma-and-emergency-preparedness-cotep/emergency-preparedness).

Exercise and Simulation

Resources for conducting simulations at whole hospital level and departmental level
are available that can help to provide vicarious experience to both leaders and staff.22
These can take the form of tabletop exercises for leaders, online simulations, and
hands-on unit/interunit training.23 Anesthesiologists can participate in hospital

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
828 McIsaac & Gentz

Fig. 2. Operating room procedures for mass casualty management step by step. (From
American Society of Anesthesiologists. Emergency Preparedness. Available at: https://
www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-trauma-
and-emergency-preparedness-cotep/emergency-preparedness With permission.)

exercises as a whole department or in as small as a single operating room, depending

on resources. Lessons learned from small exercises can be disseminated to the entire
department.24

Secondary Attacks
Hospitals may be targets of primary or secondary attacks (eg, Mumbai, India, 2008).
Be aware that if shootings or other incidents occur within hospitals, the hospital itself
can be declared a hot zone. Security personnel should maintain clear vehicle entry
points and monitor access to the emergency department (ED). All entrances to the fa-
cility will need to be controlled. “Ideally, law enforcement should be present to support
hospital security at the entrance and provide traffic control.”11 Police have to clear
staff prior to allowing them to enter and/or return to work. These lockdowns can con-
trol access to elevators, critical equipment, and operating rooms.18

Hospital Organization During Mass Casualty Events

Although patients may have been triaged in the field, it may be appropriate to perform
a second triage upon arrival to determine if patients have deteriorated. A zone should

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 829

be set up in the ED where the walking wounded may be monitored. There are patients
who arrive who either leave may on their own or go to another institution. Try to main-
tain unidirectional flow in the ED (ie, the patients should not return to the ED once they
have been taken to radiology, the operating room, or other areas). During a mass ca-
sualty event, failure of electronic systems may require staff to revert to paper. Simi-
larly, it is important to be able to back up electronic registration systems in the
event that the wireless networks are overwhelmed. Also, it should be ensured that
there is an adequate supply of paper triage tags and/or paper charts.11
Practical lessons from past MCIs include

Bringing essential assets to the ground floor, including carts, wheelchairs,
personnel, and, designated disaster supplies

Popping up heads on gurneys so patients are not placed on them backwards11,25

Using portable monitors

Before patients arrive, if possible, clearing the ED

Discharging as many preexisting patients as possible

Cohorting patients requiring additional work-up

Transporting admitted patients to their designated floors or intensive care units
(ICUs)

Identifing areas that may be used for expanded ED, floor, and/or ICU space

Patient Identification
Patients may arrive without identification or anyone who can identify them. “In Las
Vegas, many patients attended the concert wearing only their entrance wristbands,
cell phones and small amounts of cash.”11 Some hospital systems like to reassign
trauma patients to their correct names as quickly as possible. During MCIs, this can
increase confusion, especially if there are multiple family members with the same
last name or even senior and juniors. One suggestion is to change the unidentified
name to that of a state, town, city, or color so as to create a more obvious difference
between patients. Complicating identification further, during MCIs, patients may have
consumed variable amounts of alcohol. Identifying characteristics, such as body art
and piercings, may be helpful in matching unconscious patients with their family mem-
bers.11 During the Las Vegas shooting, a need was recognized for a centralized data
hub, where descriptions of identified patients in a massive emergency could be
uploaded and information accessed by all area hospitals.26

EARLY INTERVENTIONS

Because patients can deteriorate while waiting for care, the early placement of intra-
venous access can be critical. One of the actions that the Sunrise Hospital ED physi-
cians felt saved lives was placing intravenous access early in the patients who
presented from the Las Vegas mass shooting. They made sure that all patients had
14-gauge to 18-gauge intravenous catheters ready for the moment that they might
decompensate.25 EMS providers may be able to assist in placing intraosseous infu-
sions during the early response to the incident.27 Consider pairing a nurse, a medical
student, or another provider with each patient until there is a handoff to the operating
room, ICU, or floor. This is someone who knows about the patient’s medical history
and the interventions that have been completed and can monitor for changes in con-
dition.11 Provide focused care delivery when possible. This includes controlling critical
bleeding with tourniquets to convert patients from red to yellow. Plan to intubate pa-
tients who are unable to speak. Insert chest tubes, if needed. Consider intraosseous

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
830 McIsaac & Gentz

access to save time. Follow mental status changes and monitor motor examinatino
changes. Keep the patients warm and continually reassess.28

SUPPORT SERVICES

Consider ordering a trauma panel for all patients, but beware of saturating the labora-
tory with unnecessary studies and blood bank with many type/screens that may not be
needed.28 “Dedicate pharmacy personnel and resources in the ED to ensure adequate
medication supplies. Automated medication dispensing stations may be unable to
keep up with the volume of needed medications.”11,25 Dedicate a respiratory therapist
for intubation support in the ED. Consider prepackaged disaster intubation or critical
care supply packs for bedside use.11 In extreme situations, ventilator splitting can be
considered. If there are 2 people who are approximately the same size and tidal vol-
ume, it is possible to double the tidal volume and connect them via Y tubing on 1 venti-
lator. But is this practical? Although this idea was discussed in the event of a serious
ventilator shortage during the coronavirus disease (COVID-19) outbreak, it tends to be
not practical because of the differences in cohort stage of disease, overall pulmonary
resistance, and compliance issues.25 Radiology can be a bottleneck on the way to the
ICU or operating room. Consider having the radiologist read the radiographs as they
are taken with a portable machine. Point-of-care ultrasound can be a helpful rapid
triage tool when available at the bedside and time allows.
Damage Control Surgery
Surgeons do the minimum necessary surgery to save a patient’s life. “Damage control
surgery involves performing only necessary amounts of surgery to control bleeding,
remove nonviable tissue, stabilize fractures and restore extremity perfusion.”29 The
first priority for the OR is unstable patients with isolated abdominal injuries, followed
by patients with chest injuries. Neurologic injuries are addressed on a case-by-case
basis. Vascular injury with threatened limb should be a high priority as well. Most ex-
tremity injuries (uncomplicated fractures and soft tissue injury without vascular
compromise) can be deferred for at least a few hours.

STAFFING ISSUES

In the London Bridge incident, many on-call staff found out an attack was under way
via Twitter or WhatsApp and set out unprompted.10 It is not beneficial for everyone to
respond in the first wave. Do not call in all personnel at the onset of the incident. Pro-
viders will become fatigued and need relief. Ask some to come in at a later time to
relieve staff who cared for the initial influx of patients. Staff members who may need
to be called in include environmental services, materials management, administrative
services (scribes), volunteers, and ancillary personnel (laboratory, radiology, and phar-
macy technicians and respiratory therapists).11 A system for calling in staff should be a
part of the institutional disaster plan.
Surge Discharge
During critical events, it is important to have hospitalists and intensivist do rounds and
assess inpatients for potential surge discharge.11 It also is important as the events
wind down to identify a single location where patients may wait (eg, discharge lounge)
while other arrangements are made if the incident delays their ability to leave the hos-
pital so that bed availability is maximized. “At Sunrise Hospital, they allowed released
patients to wait in the auditorium until other arrangements could be made. University
Medical Center arranged transportation to a designated pick-up location.”11

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 831

Do Not Return to a Normal Operating Room Schedule Too Quickly

After the surge subsides, hospitals try to return to their normal schedules as soon as
possible. A major incident can be declared over too soon. After the 2017 Manchester
Arena bombing, “some hospitals in Manchester (England) restarted elective surgeries
a few hours after the bombing yet in the following days, the injured required 139 hours
of additional theater time - about two normal weeks’ worth of surgery.”10 “Over
350 hours of extra surgery were required in the week after the terrorist attack in Man-
chester” (personal communication from Greater Manchester Trauma Network).30
There is a recovery period where the demand for services will slowly return to normal
and the demand will have been met.

NONTRADITIONAL ROLES OF ANESTHESIOLOGISTS

During a crisis, anesthesiologists are well suited to assume other roles in hospital set-
tings. In the EDs, anesthesiologists can re-evaluate and reassign triage levels and up-
date teams on status changes. They can assist with operating room staffing
requirements and create teams that can provide around-the-clock coverage for intu-
bation and line (arterial and central) placement. Anesthesiologists may be able to pro-
vide critical care services in the ICU. As operating room managers and directors,
anesthesiologists can enable information sharing and assessment. This can include
handoffs, where the anesthesiologist is acting as a bridge between the ED, operating
room, and the ICU. They may be able to assist with collecting patient information, pa-
tient identification, and providing family assistance. They also may provide assistance
with pain management.27

NONTRADITIONAL ROLES

Physicians and surgeons may want to help but may not know how. In Las Vegas, “pe-
diatric and obstetric surgeons assisted general surgery by performing ‘opening’ of
abdominal cases or scrubbing in to replace scrub nurses.”27 Pediatric emergency staff
may be able to provide care for ambulatory adult patients in the ED. “Non-clinicians
assisted with bleeding control as patients were being triaged, transported patients
throughout the hospital, rapidly turned overs room and participated in fatality manage-
ment activities in response to the Las Vegas no-notice incident.”27 If the hospital or
site becomes overwhelmed, it may be possible that triage must be turned over to
nonphysician colleagues.

SPECIAL POPULATIONS: PEDIATRICS AND OBSTETRICS

Children and pregnant women usually are a significant proportion of the casualty
burden and often present to the closest hospital, regardless of whether it normally
cares for these patients. Therefore, it is critical that all providers and institutions
make provisions for receiving children and parturients who may be casualties or
accompany casualties. Adequate supplies of pediatric equipment and the ability to
do both vaginal and cesarean deliveries should be part of preparation and planning.
Staff should have ready references and access to guidelines for special
populations.31,32

NUCLEAR/RADIOLOGICAL EVENTS

Radiological exposure consists of acute radiation syndrome (ARS), radiation burns,

and internal contamination.33 In such an incident, all casualties should be

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
832 McIsaac & Gentz

decontaminated externally to limit exposure. The ARS should be treated according to

the dose received.34 Internal contamination is treated with specific therapies depen-
dent on the radionuclide ingested.35,36 Alternatively, oral activated charcoal has
been advocated to remove gastrointestinal contamination. Surgeries should be limited
to immediate trauma care and delayed, when possible, until immune function returns
(Fig. 3).

CHEMICAL EVENTS

Chemical injuries can be categorized as inhalational injury, skin chemical burns, and
intoxification syndromes. They can be a result of a local event, a large-scale industrial
accident, or a chemical weapon. There often is associated conventional traumatic
injury. Patients should be decontaminated of any persistent agents while responders
should wear appropriate personal protective equipment (PPE). Lifesaving interven-
tions like respiratory support should not be delayed for decontamination, but decon-
tamination limits the injury. Toxic syndromes, like cyanide and nerve agent poisoning,
should be treated with specific antidotes, when available.37

BIOLOGICAL EVENTS

The classic biological event is an epidemic or pandemic. Influenza had been a com-
mon model until the current coronavirus (severe acute respiratory syndrome corona-
virus 2 and COVID-19) pandemic that originated in China and spread throughout the
world in a matter of months. Epidemics are not unprecedented and have been a
source of mass casualties since the earliest recorded history. Smallpox, plague, influ-
enza, and viral fevers, such as Ebola, are a few examples. Deliberate release of biolog-
ical agents, bioterrorism, and biological warfare, are 2 additional sources of mass
casualty generation.38

Fig. 3. ARS. BMT, bone marrow transplantation; G-CSF, granulocyte-colony stimulating fac-
tor; GM-CSF, granulocyte macrophage-colony stimulating factor; IL-3, interleukin 3. (From
“Diagnosis and Treatment of Radiation Injuries.” IAEA, No. 2, 1998. Safety Reports Series.
Pg. 20; with permission. Available at: https://www-pub.iaea.org/MTCD/publications/PDF/
P040_scr.pdf.)

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 833

There are 2 main principles for containment and protection of caregivers: isola-
tion and barrier protection using PPE. The most common PPE consists of barrier
protection (gloves, face shield, and gown) plus respiratory protection (surgical
mask, N95, N100, or powered air-purifying respirators). The highest levels of respi-
ratory protection are needed for aerosol-generating procedures, like intubation,
and for airborne transmissible diseases, like measles. Isolation, especially in a
negative pressure environment, prevents the further spread of disease from
infected individuals. Quarantine isolates potentially infected individuals until they
are proved ill or disease-free.39 It is critical to stockpile PPE and disinfectants in
advance. The COVID-19 pandemic demonstrated the massive need for PPE. Con-
tingency plans also should be made for conservation, recycling, and reprocessing
of PPE. Planning should also be done to facilitate routine surgical care for patients
who are infected or suspected of infection. This includes trauma and nonsurgical
procedures done under anesthesia.

EVACUATION AND INTERFACILITY TRANSFERS

During an MCI, trauma centers may not be able to accept transfers of patients whose
injuries are within their usual level of care. The emergency physician may need to make
plans to stabilize and manage high-acuity patients who normally would be immedi-
ately transferred to a trauma center. Tracking large numbers of patients who must
be transferred during an MCI can be difficult. “During the Santa Rosa fire, patients
had to emergently transferred out of the hospitals, they took photos of the patient’s
wristbands with smartphones because they didn’t have time to copy and write
down the information from the patient’s wrist bands.”26

RESILIENCE AND RECOVERY: POSTEVENT CONSIDERATIONS

“In 2011, the deadliest single tornado recorded in the U.S. since recordkeeping began
in 1950 struck Joplin, Missouri. It destroyed 7000 homes, resulted in 162 fatalities, and
over 1000 individuals were injured, and cost an estimated $3 billion in insured los-
ses.”13 “In a retrospective analysis, it was concluded that the high fatality rate was
due to the intensity of the tornado and the large size of the damage area, but also fac-
tors such as ignoring the warning sirens, having less than 15 minutes to seek shelter,
structural weakness in homes and disproportionate damage to a hospital and area
business where more people were gathered.”13,40 A component of delayed recogni-
tion of a rare fungal infection also contributed to late deaths—zygomycosis, which
is a fungal infection occurred when dirt becomes embedded under the skin, resulting
in patients succumbing to a widely disseminated infections.41

FOLLOW-UP: TRANSMITTED DISEASES, OPHTHALMIC, AUDITORY, AND

PSYCHOLOGICAL INJURIES

Patients can be placed at risk of blood-borne virus infection after MCIs and need
counseling, postexposure prophylaxis, and follow-up health screens."30,42 Human tis-
sue can be transferred from shrapnel or contaminated knives; thus, postexposure pro-
phylaxis should be considered. For example, in the Boston Marathon bombing, all of
the patients seen with evidence for external injury were screened for evidence of pre-
existing hepatitis B antibodies and treated accordingly. In addition, estimates of up-
ward of more than 100 patients out of 281 in Boston have been reported to have
sustained tympanic membrane or inner ear damage.18

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
834 McIsaac & Gentz

Fig. 4. Psychological first aid wallet card (front and back). (From Psychological First Aid
Wallet Card. NCTSN. 2016, Available at: https://www.nctsn.org/resources/psychological-
first-aid-pfa-wallet-card; with permission.)

PSYCHOLOGICAL PREPAREDNESS/BEREAVEMENT/DEBRIEFING

“One doctor involved in the Manchester attacks still hears the voices of injured parents
who awoke screaming for lost children.”10 Providing psychological support for victims
and health care providers of MCIs is crucial. Posttraumatic stress disorder is not un-
common. As an ED physician involved in the Santa Rosa fires aptly stated, “You never
know how you are going to react until it comes your way.”26 Psychological first aid for
everyone involved is a must (Fig. 4). After an MCI, it is important to conduct debriefings
to evaluate the aspects that were handled well and those systems that should be
improved. It is important to admit mistakes. Hospitals need to have an open and
honest attitude toward error.

SUMMARY

Mass casualty events occur more often than we would like. Their frequency seems to
be increasing. Just as the rare malignant hyperthermia case is trained for, mass

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 835

casualty training should be integrated into routine preparation. Being prepared will
save lives and reduce suffering.

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

1. Peleg K, Aharonson-Daniel L, Michael M, et al. Patterns of Injury in Hospitalized

Terrorist Victims. Am J Emerg Med 2003;21(4):258–62.
2. Hazard Vulnerability/Risk Assessment. ASPR TRACIE. Available at: asprtracie.
hhs.gov/technical-resources/3/hazard-vulnerability-risk-assessment/1. Accessed
July 21, 2020.
3. FREE 9 Hazard Vulnerability Analysis Templates in PDF: MS Word: Excel. FREE 9
Hazard Vulnerability Analysis Templates in PDF j MS Word j Excel. 2020. Available
at: www.sampletemplates.com/business-templates/analysis/hazard-vulnerability-
analysis-template.html. Accessed July 21, 2020.
4. Available at: https://www.asahq.org/about-asa/governance-and-committees/asa-
committees/committee-on-trauma-and-emergency-preparedness-cotep. Accessed
July 21, 2020.
5. Harris C, McCarthy K, Liu E, et al. Expanding Understanding of Response Roles:
An Examination of Immediate and First Responders in the United States. Int J En-
viron Res Public Health 2018;15(3):534.
6. Edgerly D. The Basics of Mass Casualty Triage. JEMS 2019;41(5). Available at:
www.jems.com/2016/05/01/the-basics-of-mass-casualty-triage/.
7. SALT Mass Casualty Triage. National Disaster Life Support Foundation (NDLSF).
2020. Available at: www.ndlsf.org/salt/. Accessed July 21, 2020.
8. Stop the Bleed. Department of Public Safety, University of Utah. Available at: dps.
utah.edu/stopthebleed/. Accessed July 21, 2020.
9. Gaarder C, Jorgensen J, Kolstadbraaten KM, et al. The twin terrorist attacks in
Norway on July 22, 2011: the trauma center response. J Trauma Acute Care
Surg 2012;73(1):269–75.
10. Trauma Medicine Has Learned Lessons from the Battlefield. The Economist, The
Economist Newspaper 2017. Available at: www.economist.com/international/
2017/10/12/trauma-medicine-has-learned-lessons-from-the-battlefield. Accessed
April 22 2020.
11. No-Notice Incidents: Triage, Hospital Intake, and Throughput. Tracie. 2018. Avail-
able at: https://files.asprtracie.hhs.gov/documents/no-notice-incidents-triage-
intake-throughput.pdf. Accessed April 25, 2020.
12. No-Notice Incidents: Non-Trauma Hospital Considerations. Tracie. 2018. Avail-
able at: https://files.asprtracie.hhs.gov/documents/no-notice-incidents-non-
trauma-hospital-considerations.pdf. Accessed April 24, 2020.
13. Ahmad S. Mass Casualty Incident Management. Mo Med 2018;115(5):451–5.
14. D’Auria G and De Smet A. Leadership in a crisis: responding to the coronavirus
outbreak and future challenges. McKinsey & Company. Available at: www.
mckinsey.com/business-functions/organization/our-insights/leadership-in-a-crisis-
responding-to-the-coronavirus-outbreak-and-future-challenges. Accessed July 1,
2020.
15. McNulty EJ, Marcus L. Are You Leading Through the Crisis ... or Managing the
Response? Harvard Business Review 2020. Available at: hbr.org/2020/03/are-
you-leading-through-the-crisis-or-managing-the-response.

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
836 McIsaac & Gentz

16. Lord D. France Terror Attack: What Is Bastille Day? Ajc, Cox Media Group Na-
tional Content Desk. 2016. Available at: www.ajc.com/news/national/france-
terror-attack-what-bastille-day/dyivVC3SptQIddE0AXjUWI/. Accessed April 22,
2020.
17. Biddinger PD, Baggish A, Harrington L, et al. Be prepared–the Boston Marathon
and mass-casualty events. N Engl J Med 2013;368(21):1958–60.
18. Gates JD, Arabian S, Biddinger P, et al. The Initial Response to the Boston Mara-
thon Bombing: Lessons Learned to Prepare for the next Disaster. Ann Surg 2017;
260(6):960. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5531449/.
19. Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital
Preparedness Program and Priorities Going Forward. UPMC Biosecurity. 2009.
Available at: https://www.centerforhealthsecurity.org/our-work/pubs_archive/
pubs-pdfs/2009/2009-04-16-hppreport.pdf. Accessed April 26, 2020.
20. National Preparedness Goal. Fema.gov. 2015. Available at: https://www.fema.
gov/media-library-data/1443799615171-aae90be55041740f97e8532fc680d40/
National_Preparedness_Goal_2nd_Edition.pdf. Accessed April 26, 2020.
21. Hospital Incident Command System – Current Guidebook and Appendices.
EMSA, State of California. 2016. Available at: emsa.ca.gov/disaster-medical-
services-division-hospital-incident-command-system/. Accessed July 21, 2020.
22. Hospital Surge Evaluation Tool. Phe.gov. 2017. Available at: www.phe.gov/
preparedness/planning/hpp/surge/pages/default.aspx. Accessed July 21, 2020.
23. Free Joint Commission Emergency Management Training for Hospitals. Emer-
gency Preparedness. 2017. Available at: www.calhospitalprepare.org/post/free-
joint-commission-emergency-management-training-hospitals. Accessed July
21, 2020.
24. Drills & Exercises. Emergency Preparedness. 2017. Available at: www.
calhospitalprepare.org/exercises. Accessed July 21, 2020.
25. Menes K. How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass
Shooting in U.S. History. Emergency Physicians Monthly. 2017. Available at:
epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-
lives-worst-mass-shooting-u-s-history/. Accessed April 25, 2020.
26. Ibarra AB. Hospitals’ Best-Laid Plans Upended By Disaster. Kaiser Health News
2018. Available at: khn.org/news/hospitals-best-laid-plans-upended-by-
disaster/. Accessed April 25, 2020.
27. No-Notice Incidents: Expanding Traditional Roles to Address Patient Surge. Tra-
cie. 2018. Available at: https://files.asprtracie.hhs.gov/documents/no-notice-
incidents-expanding-traditional-roles.pdf. Accessed April 25, 2020.
28. No-Notice Incidents: Trauma Surgery Adaptations and Lessons. Tracie. 2018.
Available at: https://files.asprtracie.hhs.gov/documents/no-notice-incidents-
trauma-surgery-adaptations-and-lessons.pdf. Accessed April 24, 2020.
29. Elster EA, Butler FK, Rasmussen TE. Implications of Combat Casualty Care for Mass
Casualty Events. JAMA 2013;310(5):475. pubmed.ncbi.nlm.nih.gov/23925612/.
30. Moran CG, Webb C, Brohi K, et al. Lessons in Planning From Mass Casualty
Events in UK. BMJ (Clin Res Ed) 2017. pubmed.ncbi.nlm.nih.gov/29070605/.
31. Pediatric Anesthesia. OpenAnesthesia. Available at: www.openanesthesia.org/
pediatric_anesthesia_anesthesia_text/. Accessed July 21, 2020.
32. Cognitive Aids in Medicine. OB Anesthesia Emergency Manual. Cognitive Aids in
Medicine. 2020. Available at: med.stanford.edu/cogaids/obanesem.html. Ac-
cessed July 21, 2020.
33. Radiation Emergency Medical Management, REMM. Available at: www.remm.
nlm.gov/. Accessed July 21, 2020.

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 Preparing for Mass Casualty Events 837

34. Time Phases of Acute Radiation Syndrome (ARS). Radiation Emergency Medical
Management, REMM. 2020. Available at: www.remm.nlm.gov/ars_timephases1.
htm. Accessed July 21, 2020.
35. HHS/ASPR. A decision makers guide: medical planning and response for a nu-
clear detonation. 2nd edition. Washington, DC: Assistant Secretary for Prepared-
ness and Response, Department of Health and Human Services;; 2017. p. 38.
36. International Atomic Energy Agency. Diagnosis and Treatment of Radiation In-
juries. Safety Reports Series No. 2. Vienna (Austria): IAEA; 1998.
37. McIsaac J, McQueen K, Kucik C. Essentials of disaster anesthesia. Cambridge
(UK): Cambridge University Press; 2020.
38. Bioterrorism. Phe.gov. 2011. Available at: www.phe.gov/emergency/bioterrorism/
Pages/default.aspx. Accessed July 21, 2020.
39. Available at: https://www.asahq.org/about-asa/governance-and-committees/asa-
committees/committee-on-occupational-health/ebola-information. Accessed July
21, 2020.
40. Paul BK, Stimers M. Exploring probable reasons for record fatalities: the case of
2011 Joplin, Missouri, Tornado. Nat Hazards 2012;64:1511–26.
41. “Latest Joplin Victims Had Rare Fungus from Dirt.” NBCNews.com, NBCUniver-
sal News Group. 2011. Available at: www.nbcnews.com/id/43358247/ns/health-
infectious_diseases/t/latest-joplin-victims-had-rare-fungus-dirt/. Accessed July
21, 2020.
42. England, Public Health. “Bloodborne Viruses: Managing Severe Serial Pene-
trating Injuries.” GOV.UK. 2017. Available at: www.gov.uk/government/
publications/bloodborne-viruses-managing-severe-serial-penetrating-injuries.
Accessed July 21, 2020.

Downloaded for Anonymous User (n/a) at CES University from ClinicalKey.com by Elsevier on October 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.