Disaster Medicine & Mass Casualty Incidents
Comprehensive emergency management protocol for mass casualty incidents (MCI), hospital disaster activation, and chemical/biological/radiological/nuclear/explosive (CBRNE) events. Details START and SALT triage algorithms, pediatric JumpSTART modifications, blast injury primary-to-quaternary physics, and nerve agent antidote protocols.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
In disaster mass casualty triage, the guiding ethical principle shifts from 'doing everything possible for the individual patient' to 'doing the greatest good for the greatest number of salvageable patients' using rapid, objective physiologic criteria.
Standard mass casualty algorithms rapidly categorize patients into four universal color-coded priority levels:
| Color Category | Triage Classification | Physiologic Criteria (START System) | Action / Disposition |
|---|---|---|---|
| GREEN | Minor (Walking Wounded) | Able to walk and follow commands on verbal instruction | Direct to secondary staging area / outpatient overflow clinic. |
| RED | Immediate (Priority 1) | Spontaneous breathing only after airway opened OR Respiratory Rate > 30 bpm OR Absent radial pulse / Capillary refill > 2 sec OR Inability to follow simple commands | Immediate transfer to resuscitation bay / operating room. |
| YELLOW | Delayed (Priority 2) | Respirations < 30 bpm, strong radial pulse, follows commands, but cannot walk due to significant injury (e.g. open fracture, stable abdominal trauma) | Urgent care area; re-evaluate frequently for deterioration. |
| BLACK | Expectant / Deceased (Priority 0) | No spontaneous breathing after simple airway positioning (or catastrophic non-survivable trauma, e.g. open brain injury with arrest) | Palliative comfort care; resources conserved for salvageable casualties. |
Children have higher baseline respiratory rates and are prone to primary respiratory arrest where simple ventilation can restore life:
- The 5 Rescue Breaths Rule: If an apneic child has a palpable peripheral pulse after opening the airway, administer 5 rescue breaths via barrier/pocket mask. If breathing resumes, categorize as RED (Immediate). If breathing does not resume, categorize as BLACK (Expectant).
- Respiratory Rate Limits: Normal pediatric cutoff is 15-45 breaths/min (instead of 30 in adults). RR < 15 or > 45 = RED.
- Mental Status: Uses AVPU scale. Alert, Voice, or Pain (appropriate withdraw) = YELLOW. Inappropriate posturing (decorticate/decerebrate) or Unresponsive = RED.
| Blast Injury Category | Physical Mechanism | Classic Pathologies Encountered | Emergency Interventions |
|---|---|---|---|
| Primary Blast Injury | Supersonic overpressure shock wave impacting air-fluid tissue interfaces (lungs, bowel, ears) | Tympanic membrane perforation (most common overall), Blast Lung (pulmonary contusion, hemothorax, alveolar-capillary disruption), Bowel perforation, Air embolism | High-flow O2, low-pressure lung-protective ventilation (avoid high peak pressures that risk air embolism); chest tubes for pneumothoraces. |
| Secondary Blast Injury | Flying debris, shrapnel, and bomb casing fragments striking the body | Penetrating wounds, open fractures, lacerated major vascular structures | Tourniquets, wound exploration, massive transfusion protocol, update tetanus. |
| Tertiary Blast Injury | Displacement of the body: Patient is thrown by blast wind into walls, ground, or structures | Blunt head trauma, traumatic brain injury, spinal fractures, traumatic amputations | Full trauma spine precautions, ATLS primary and secondary survey, eFAST. |
| Quaternary Blast Injury | All explosion-related injuries not due to primary, secondary, or tertiary mechanisms | Thermal burns, inhalation injury, crush syndrome with rhabdomyolysis, toxic chemical release | Burn fluid resuscitation, cyanide/CO antidotes, IV bicarbonate for crush syndrome. |
| Quinary Blast Injury | Hyperinflammatory state induced by toxic materials or biological/radiological dirty bomb additives | Severe delayed fever, diaphoresis, vasodilatory shock, neutropenia | Supportive critical care, chelation/decontamination. |
Nerve Agent Resuscitation: Organophosphate and G/V-series nerve agents (Sarin, Soman, VX) irreversibly inhibit acetylcholinesterase, producing catastrophic cholinergic crises (SLUDGE / DUMBELS). Death results from the killer 'B's': Bronchorrhea, Bronchospasm, and Bradycardia. Steps: (1) Full PPE and external decontamination; (2) Atropine: 2 to 6 mg IV/IM every 3-5 minutes, doubling dose until bronchial secretions dry and work of breathing improves (do not titrate to heart rate or pupil size); (3) Pralidoxime (2-PAM): 1 to 2 g IV over 30 min (reactivates acetylcholinesterase); (4) Benzodiazepines: Midazolam 10 mg IM to treat or prevent seizure activity.
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