Emergency Casualty Cases Requiring Urgent Review
Cases requiring urgent review in an emergency casualty setting include those with respiratory failure, hemodynamic instability, severe trauma, and other life-threatening conditions that require immediate intervention to prevent mortality and reduce morbidity.
Critical Care Admission Criteria
Patients requiring urgent review in emergency casualty typically fall into two major categories:
Category A: Respiratory Compromise
- Refractory hypoxemia (SpO₂ <90% on non-rebreather mask/FiO₂ >0.85) 1
- Respiratory acidosis with pH <7.2 1
- Clinical evidence of impending respiratory failure 1
- Inability to protect or maintain airway (altered level of consciousness, significant secretions or other airway issues) 1
Category B: Hemodynamic Instability
- Hypotension (SBP <90 mmHg or relative hypotension) with clinical evidence of shock (altered level of consciousness, decreased urine output or other end organ failure) refractory to volume resuscitation requiring vasopressor/inotrope support 1
Trauma Cases Requiring Urgent Review
Severe Trauma
- All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee 1
- Flail chest 1
- Two or more proximal long-bone fractures 1
- Crushed, degloved, or mangled extremity 1
- Amputation proximal to wrist and ankle 1
- Pelvic fractures 1
- Open or depressed skull fracture 1
- Paralysis 1
- Severe trauma with Trauma Injury Severity Score (TRISS) with predicted mortality of >80% 1
Burns
- Severe burns with any two of the following: age >60 years, >40% of total body surface area affected, inhalation injury 1, 2
Cardiac Arrest
- Unwitnessed cardiac arrest 1
- Witnessed cardiac arrest not responsive to electrical therapy (defibrillation or pacing) 1
- Recurrent cardiac arrest 1
- A second cardiac arrest <72 hours following return of spontaneous circulation 1
Head Injury Cases
Head injuries require special attention as they are present in 60-90% of multisystem trauma and significantly impact post-traumatic prognosis 3. Urgent review is needed for:
- Impaired consciousness (Glasgow Coma Scale <14) 1, 4
- Neurologic deficits 4
- Signs of basal skull fracture (otorrhagia, otorrhea, rhinorrhea) 4
- Post-traumatic seizures 4
- Penetrating or perforating wounds 4
- Repeated episodes of vomiting after head trauma 4
High-Risk Patient Factors
Certain patient characteristics increase risk and require urgent assessment:
- Severe baseline cognitive impairment 1
- Advanced untreatable neuromuscular disease 1
- Metastatic malignant disease 1
- Advanced and irreversible immunocompromised patients 1
- Severe and irreversible neurologic conditions 1
- End-stage organ failure (heart, lungs, liver) 1
- Patients on anticoagulation therapy with trauma 1, 4
- Pregnancy >20 weeks with trauma 1
Mass Casualty Incidents
During mass casualty incidents (MCIs), triage protocols become essential but differ from daily emergency casualty operations:
- MCIs require modified triage approaches focusing on "the greatest good for the greatest number" 1, 5
- Standard triage guidelines are not intended for mass casualty or disaster situations 1
- In MCIs, minimal acceptable care becomes the key to staged management 5
Clinical Pitfalls and Caveats
- Hypoxia, hypercarbia, and hypotension can worsen primary brain injuries and cause secondary brain damage - address these immediately in head trauma patients 3
- Overtriage is common in multiple-casualty incidents - simplified triage algorithms may be more practical 5
- The realistic admitting capacity of a hospital during MCIs is determined primarily by the number of trauma teams that can be recruited 5
- Patients with seemingly minor head injuries but with risk factors (anticoagulation, previous neurosurgery, alcoholism, epilepsy) require urgent evaluation 4
- In severe head injury, avoid maneuvers that increase intracranial pressure (e.g., extreme head positioning) 3
Bioterrorism Considerations
In cases of suspected bioterrorism or chemical exposure: