Emergency Medicine

and
Management of Mass Casualty
Karn Suttapanit, M.D., FTCEP
Department of Emergency medicine, Faculty of Medicine Ramathibodi Hospital
Resuscitation in Emergency care

• Airway management
• Shock assessment
 Airway management

Advance

Airway assessment
and
Plan of Airway management

Basic
Airway assessment

• Difficult to ventilation and intubation? Prepared patient

- Anatomical assessment
Prepared equipment
- Criteria-based
- Scoring system Prepared team
- Physiological assessment Prepared backup plan
- Risk of Hypoxia
Aims
- Risk of Hypotension
1st pass success rate
- Pulmonary HT Avoid Hypoxemia
- Metabolic acidosis Avoid Hypotension
- Risk of aspiration Reduce mortality
A. Leigh. Airw ay trolley shadow board incorporating intubation checklist for critically ill adults. BJA 2019
Airway algorithm: Main airway
Airway algorithm: Difficult airway
Airway algorithm: Failed airway
Shock assessment

Patient history
Physical examination
Non-invasive
- Ultrasound evaluation
Invasive

Jean-Louis Vincent, N Engl J Med 2013; 369:1726-34

RUSH protocol

Crit Care Res Pract. 2012; 2012: 503254.

• CCUGDT can effectively improve the 6-h LCR and
reduce the 12- and 24-h
• Cumulative fluid infusion volume compared with
EGDT in patients with septic shock
Mass Gathering and Mass Casualty Management
Mass Gathering Vs Mass Casualty Incident

Large numbers of people in a defined events Need > Resources

(Common have at least 1000 people) (Patients have more than the ability of the
with appropriate resource of health care organization/operation to routine management)
 Goal: should be prevented in normal
situation
Mass Gatherings (Prevent or Minimize the risk of injury or ill
health and Maximize safety)
Type of Mass Gathering event
 • Sport events
• Injuries
Mass Gatherings • Ceremony
• Stampede
• Infection
• Music event
• Mood
• Battle and injuries
(rock)
• Substance
• Political rally
• Unexpected event
• Riot control
Mass Gatherings

RISK ASSESSMENT SURVEILLANCE RESPONSE

Risk assessment and analysis
Impact
Risk or Hazard Analysis
Limited Minor Moderate Significant Catastrophic
Extremely Extremely
High Medium Medium High
high high
Extremely
Medium high Low Medium High High
high
Probability
Medium Low Low Medium High High
Medium low Very low Low Low Medium Medium
Low Very low Very low Low Low Medium

Risk treatment
Very low – low = Acceptance
Medium =Avoidance + Mitigation
High-Extremely high = Avoidance + Mitigation + Transfer
 • Risk acceptance = ยอมรับได้
• Risk mitigation = มี แผนที่ ทำให้ควำมเสี่ยงนั้นมี ผลกระทบน้อยลง
Risk treatment • Risk Avoidance = หลีกเลี่ยงไม่ให้เกิด
• Risk transfer = กำรโอนถ่ำยควำมเสี่ยง
Preparedness

PLANNING EQUIPMENT TRAINING

Organization Planning Response to MCI
 Organization
Planning
Response
to MCI

SX, Med, Ped, MCATT

ER, ….. (Psychiatrist)
Depend on
plan
 MCI/Disaster response Question?
M : Major incident
E : Exact location
T : Type
DetectionMCI in H : Hazard
EMS operation A : Access
N : Number
center unit E : Emergency service
• Activate EMS operation
• Surge capacity
Detection MCI on scene
“Window report” situation to operation center unit
MCI/Disaster response Question?
M : Major incident
E : Exact location
T : Type
H : Hazard
A : Access
N : Number
E : Emergency service
• Activate EMS operation
• Surge capacity
Mass Casualty
incident
Management
 • Goals
• Using Limit resource for more than one patient. (Less is More)
•
Out-Hospital •
Manage Resource (Call for help and resource)
Don’t relocate the MCI or disaster
MCI • To reduce or eliminate to the extent possible the loss of life and
health , and physical and psychological suffering , incurred as a
consequence of MCI
COMMAND and Control
• Command = ICS
• Job descriptions
• Control = Control scene
Incident command system (ICS)
 CHAIN - สายบังคับบัญชาชัดเจน
OF
COMMAND - บุคลากรมีผบู้ งั คับบัญชาเพียงคนเดียว
Unity and Unify - ประสานภารกิจร่วมกันระหว่างหน่ วยงาน
 • Field medical commander
• Liaison ของ med field commander
• Safety officer
Medical • Triage officer
operation Team • Treatment officer ( zone เขียว, เหลือง, แดง)
• Loading
• Parking
 -คนที่ เชี่ยวชำญด้ำน MCI ที่ สดุ ในที ม (ในกรณี ที่ไปถึงเป็ นที มแรก)
Field medical Job
commander - Control scene
- Assign
 • รับข้อมูลทกุอย่ำง จดบันทึกข้อมูล อยู่ขำ้ ง IC
Liaison officer • สื่อสำรตำม chain of command
 Provider
Safety officer Scene and public
Patient
 Primary
- Emergency Medical Technician
Secondary
Triage officer - Doctor, Paramedic, Nurse
Prioritize treatment
 • Competency: Doctor, Paramedic, Nurse
• Treatment zone มี หัวหน้ำในแต่ละ zone
Treatment • Red: ใกล้ทำงเข้ำzone และใกล้ loading
officer • Yellow: ติดกับ red zone
• Green: อยู่ห่ำงไปไกลที่ สดุ
 • Competency: Paramedic Nurse or A-EMT
Loading officer • Prioritize transfer with treatment officer
• Surge hospital capacity
 • Entry and out the scene
Parking officer • Parking area
• Count patients transfer
Control
Control
• Bronze
• Silver
• Gold
Control
• Hot
• Warm
• Cold
 • Fuel or fire = 100 meters
Control • HAZMAT = 600 meters
• Upwind and uphill
Decontaminate
Decontaminate
Control
 Police

Parking point
2nd triage and treatment unit

1st triage
Fireman
Safety

Provider Public Patient

Provider safety
Public safety
 • Accurate Triage
Patient safety • Triage tag
• No prolong scene
Communicate
 • Primary triage (ควรใช้เวลำ 30 วินำที /คน)
• Scene safety -> at scene
• HAZMAT->Collecting area
Triage • After decontaminate
• Secondary triage
• Before treatment area
• After decontaminate
Triage
 Sieve

START
Primary triage
Jump-START (1-8years)

SALT
 SAVE
Secondary triage
SORT
SORT
 • No Prolong Scene time
And depend on
Treatment • Number of Patients and severity
• Capacity and Capability
Treatment
 • อยู่ใกล้จดุ ทำกำรรักษำให้มำกที่ สดุ เพื่ อทำให้กำรขนส่งเป็ นไปอย่ำงรวดเร็วและ
ปลอดภัย
• มี จดุ ทำงเข้ำ-ทำงออก ที่ สงั เกตได้งำ่ ยและปลอดภัย
• มี พื้นที่ จอดรถพยำบำล (ambulance parking point) แยกกับพื ้นที่
รับส่งผูบ้ ำดเจ็บ
Transport • มี เส้นทำงกำรเดินรถทำงเดี ยว
• เส้นทำงกำรนำส่งผูบ้ ำดเจ็บ ต้องไม่ตัดผ่ำนจุดเกิดเหตุ
• ไม่ทำให้โรงพยำบำลเกิด mass casualty แทน
Out Hospital MCI
• Goals
• Using Limit resource for more than one patient. (Less is More)
• Manage Resource (Call for help and resource)
• Don’t relocate the MCI or disaster
• To reduce or eliminate to the extent possible the loss of life and health , and
physical and psychological suffering , incurred as a consequence of MCI
 triage
20 45 /
cap. refill 4 sec
20 8 /
cap. refill 4 sec
30 40 /
cap. refill 1 sec
40
45
20 / 130 /
45 20 /
100 /
40
5
/
12
35 / cap. refill 1 sec
 triage
20 45 /
cap. refill 4 sec
20 8 /
cap. refill 4 sec
30 40 /
cap. refill 1 sec
40
45
20 / 130 /
45 20
100 /
40
5

12
35 / cap. refill 1 sec
Case Scenario
In Mass casualty incident from traffic accident, you were assigned role in the triage officer. 3 victims come to your area.
Victim Number 1 reveal SBP 70, GCS 3, RR 6 breath/min
Victim Number 2 reveal SBP 100, GCS 15, RR 12 breath/min
Victim Number 3 reveal SBP 100, GCS 14, RR 30 breath/min
 • Manage following flow Planning and avoid over-
planning
• Surge capacity
Hospital • Hospital information center and media
management
Response • Logistic and Supply
• Psychological support
• Management and Identification of Dead Victims
 • Flow planning
• Equipment
Hospital • Hospital and Emergency department zoning
Response • Alarm code
• Action card cover all member involve ICS
system
Hospital and Emergency department zoning

ED, ward and ICU : Disposition all “ordinary”

patients as soon as possible
 Green code (Standby)
Yellow code (Response to receive patient under not full resource)
Red code (Large number, need full resource)

Alarm code Ramathibodi Alert code

- 000 -> ER ยังสำมำรถจัดกำรได้อยู่
- 111 -> ER ไม่สำมำรถจัดกำรได้ ต้องกำรหน่ วยอื่นๆมำช่ วยจัดกำร
- 333 -> internal hospital MCI
- ถ้ำเป็ นเหตุสำรเคมีหรื อมีกำรปนเปื ้อน จะมีคำว่ ำ “ล้ำงตัว” ต่อ code เช่ น 111 ล้ำงตัว เป็ นต้น
Action card

Action
Head of Red zone 1………………………
Treatment area 2………………………
3………………………
 Must be done before MCI
• Staff
• Intensive care and Intermediate care
• OR
• Ward (monitor and oxygen supply)
Surge Capacity • Other space in hospital
• In MCI: In experience, the number of beds is rarely or never
the limiting factor – there is always space, there are often
extra supplies of beds, and patients can even sleep on the
floor on mattresses
 Contact

Hospital
information
Set the press conference: answer
center question from public
and media
management Blood
component
Donation Water and
Food suuply
 Update all times: Use and remain stock
Logistic • Equipment
• Drug and IV fluid
and • Food and water
Supply • Electrical and power supply
 • A sense of safety
• A sense of self- and community efficacy
Psychological • Connectedness
support • Calming
• Hope
Management and Identification of Dead Victims
• Forensic
• Chain of custody
Hospital evacuation
• 96 h assessment – failures in critical areas
• Used to determine if a facility can provide safe patient care and
treatment for 96- hours (4 days) after an incident without assistance
from the community
• Communications
• Resources and assets
• Safety and security
• Staff responsibilities
• Utilities management
• Patient and clinical support activities
Patient evacuation

SHELTER IN PLACE EVACUATION

Evacuation
• Horizontal/ Vertical
• Evacuation beyond corridor fire doors and/or smoke
zones into adjacent secure area
• Partial
• Evacuation of certain groups of patients/ residents or
areas within facility
• Complete – Evacuation of entire facility
 • Level 4: self-sufficient, patients who are
ambulatory, minimal nursing care
• Level 3: Ambulatory, moderate nursing care
Patient
• Level 2: Non-ambulatory, frequent nursing
Prioritization supportive care (post-op, step-down units)
• Level 1: Non-ambulatory, continuous nursing
care and observation (ICU, Isolation)
Sequence of Evacuation
• Areas in greatest danger should be first to move, followed
by adjacent areas
• If no immediate threat, evacuate facility top to bottom
Check-list planning
National level Hospital level

• Using the experience of other country/evidence of • Planning

research • Surveillance system
• Co-ordination • Prioritize and triage
• Legal • External co-operation
• Insurance • Hospital incident command system
• Surge capacity • Surge capacity (human and resource)
• Covid-19/non-Covid-19 management
• Management of volunteer
• Hospital personnel management (psychological,
quarantine and workload)
• Education/Research
• Prevention and infection control
• Dead body management

Seyedin H. Developing a hospital preparedness checklist to assess the ability to respond to the COVID -19 pandemic. East Mediterr Health J. 2021.
Thank you
for
attention