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Mass Casualty

General Information

  • Initially, after a large mass casualty event, local-regional medical response assets may be diminished significantly, including response personnel, medical facilities, equipment, transportation, communication infrastructure, and availability of countermeasures, including drugs.
  • Usual "standards of care" for medical activities may need to be modified to reflect actual conditions and reduced availability of resources. Recently, these modifications have been called "crisis standards of care." It is important to remember that initial shortages of resources will change over time as replacement resources are brought to the affected area. However, some heavily damaged facilities may not be brought back on-line quickly or at all.
  • Guidance on creating, and implementing these "crisis standards of care" is the subject of an important recent report from the Institute of Medicine. (2009, read online at National Academies Press)
    • "Crisis standards of care" recommendations for mass casualty events will need to address use of triage, diagnostic and treatment protocols, populations monitoring, and supportive care.
  • Personal Protective Equipment for chemical mass casualty events.
  • Local event response leaders will decide when to initiate medical mass casualty protocols reflecting "crisis standards of care" in facilities like hospitals and public arenas in order to meet surge capacity. These plans should be developed and practiced in advance by all partners and stakeholders.
  • To meet local needs, event response leaders may need to procure additional supplies, including drugs, from the Strategic National Stockpile and/or regional partners.
  • Mass decontamination of large numbers of ambulatory victims, if needed, will probably need to be performed at home or in large staging areas away from the acute medical facilities, which will be needed for the acutely ill. (See information on decontamination.)
  • For large mass casualty events, procedures for "monitoring" large populations will need to be implemented.
  • In a large mass casualty incident associated with chemicals, the traditional triage categories assigned to patients may also need to be modified.

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Casualty Management Information

  • Hospital must develop an area for decontamination and provide staff training in decontamination;
  • Those assigned to decontaminate others must use personal protective equipment;
  • Triage before decontamination and again on entering the hospital;
  • Move deceased casualties to a site that is not readily observable, but require a thorough decontamination before moving to the morgue (see management of deceased);
  • Develop an admissions procedure to override existing procedures in a chemical emergency. This can include a numbering system, a bar code system, or using patient IDs to travel with them as identification.
  • Emergency treatment depends on the type of chemical agent and quick decisive decisions by emergency responders.
  • Transportation must be arranged in order to get supplies and equipment where it needs to go, to contain areas of contamination, and to transport large quantities of victims to hospitals. Consider using buses if ambulances are not enough.
  • Hospital floor plans and diagrams should be readily available, as well as a list of chemicals and antidotes;
  • Security needs to be heavily involved in these processes, and must wear PPE at all times in order to avoid contamination and spreading of contamination.
  • Recovery to normal operating procedures is sometimes difficult after the event is over. Be sure all equipment is decontaminated, all personal belongings of casualties have been returned, and most importantly, debrief to capture lessons learned for the next chemical event.
  • If available, means should be available to utilize "quasi-licensed" HCW (e.g., med students, nursing students, etc.) with useable skills to be part of the response plan (help with triage, etc.)

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  1. Gum, R.M., Hoyle, J.D. 2009. CBRNE - Chemical Warfare Mass Casualty Management. (Medscape, eMedicine Emergency Medicine)