EMS Systems, Mass Casualty Incidents & Disaster Medicine
Comprehensive prehospital systems and disaster medicine: direct vs. indirect medical control, air medical transport criteria, prehospital termination of resuscitation (TOR), Incident Command System (ICS), START and JumpSTART pediatric triage algorithms, and CBRNE decontamination zones.
Resuscitation Quick Actions • First 2 Minutes
Medical Direction
Direct (Online: real-time physician communication via radio/phone) vs. Indirect (Offline: written protocols, standing orders, QA/QI review).
Prehospital Termination of Resuscitation (TOR) Rule (BLS)
Adult medical cardiac arrest may be terminated without transport if: 1. Arrest was NOT witnessed by EMS; 2. No shock was delivered; 3. No ROSC was achieved before transport.
Traumatic Arrest TOR
Blunt trauma with no signs of life (apnea, pulselessness, unreactive pupils, asystole or PEA rate < 40 bpm) at the scene warrants field pronouncement; resuscitation is futile.
START Triage (Simple Triage and Rapid Treatment)
\n- Green (Minor): Anyone who can walk ('Walking Wounded').\n- Black (Expectant/Deceased): Not breathing after one airway repositioning maneuver.\n- Red (Immediate): Respiratory rate > 30 OR Radial pulse absent (cap refill > 2s) OR Cannot follow simple commands.\n- Yellow (Delayed): Breathing <= 30, radial pulse present, follows commands, but cannot walk.
JumpSTART Pediatric Triage
For children < 8 years. If apneic after airway opening, check peripheral pulse: if pulse present, deliver 5 rescue breaths. If breathing resumes -> Red (Immediate); if remains apneic -> Black (Deceased).
CBRNE Zones & Decontamination
Hot Zone (exclusion zone; contamination threat), Warm Zone (contamination reduction corridor; strip all clothing which removes 80-90% of contaminants; copious water wash), Cold Zone (support zone; clean triage and treatment area).
Bottom-Line Clinical Pearl
In mass casualty incidents (MCIs), disaster triage principles completely invert standard resuscitation: do the greatest good for the greatest number of casualties, and expend minimal resources on expectant patients. The START triage algorithm assesses Respiration, Perfusion, and Mental status (RPM) in under 30 seconds per victim.
DISASTER TRIAGE AXIOM: The Rule of the Black Tag
In a mass casualty incident with overwhelming patient volume exceeding local resources, performing chest compressions or advanced airway instrumentation on an apneic, pulseless casualty exhausts critical personnel and causes salvageable victims (Red tags) to die. Open the airway once. If spontaneous respirations do not resume, tag the patient Black (Expectant/Deceased) and move immediately to the next patient.
| Step | Clinical Assessment | Finding/Threshold | Assigned Triage Tag |
|---|---|---|---|
| Step 1: Walking | Instruct all patients: 'Anyone who can hear me and needs help, walk to the designated green area' | Can walk independently | Green (Minor/Walking Wounded) |
| Step 2: Respiration | Assess spontaneous breathing | No breathing -> Reposition airway once:\n- Still no breathing\n- Resumes breathing\nSpontaneous breathing:\n- Rate > 30 breaths/min\n- Rate 10 to 30 breaths/min | \nBlack (Deceased)\nRed (Immediate)\n\nRed (Immediate)\nProceed to Step 3 |
| Step 3: Perfusion | Assess radial pulse or capillary refill | Absent radial pulse OR capillary refill > 2 seconds (control severe external hemorrhage)\nRadial pulse present AND capillary refill < 2 seconds | Red (Immediate)\n\nProceed to Step 4 |
| Step 4: Mental Status | Assess ability to follow simple commands ('Squeeze my hand') | Cannot follow simple commands (unresponsive or inappropriate)\nFollows simple commands | Red (Immediate)\n\nYellow (Delayed) |
CBRNE stands for Chemical, Biological, Radiological, Nuclear, and High-Yield Explosive emergencies. The hospital must lock down to prevent contaminated patients from self-presenting directly into the ED waiting room:
1. Hot Zone (Exclusion Zone): Maximum hazard area. Responders require Level A (totally encapsulated vapor-tight suit with SCBA) or Level B PPE. No medical treatment performed other than self-defense antidotes (DuoDote auto-injectors) and gross tourniquets. 2. Warm Zone (Decontamination Corridor): Located outdoors upwind and uphill from the incident. Patients strip completely (removing clothing eliminates 80% to 90% of toxic contamination). Continuous high-volume, low-pressure lukewarm water shower with mild soap for at least 3 minutes, paying special attention to skin folds, hair, and axillae. 3. Cold Zone (Support & Treatment Zone): Clean area. Only fully decontaminated patients wearing clean gowns or hospital scrubs enter for triage, medical stabilization, and hospital admission.
- Allowing contaminated patients into the emergency department: A single patient contaminated with organophosphates or toxic chemicals can sicken hospital staff, shut down the entire emergency department, and turn the receiving facility into an active hazard zone.
- Transporting the first victims immediately: In mass casualty incidents, minimally injured 'walking wounded' often arrive first by private vehicle; do not commit critical surgical and ICU resources before the severely injured Red tags arrive.
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