How to prioritize treatment for 30 traumatized patients from a mass road traffic accident (RTA) in a hospital with limited 15 bed capacity?

Mass Casualty Incident Triage Management in a Limited-Capacity Hospital

In a mass casualty incident with 30 traumatized patients and only 15 hospital beds available, priority must be given to life-threatening traumas and states (option B) to maximize survival outcomes.

Understanding Mass Casualty Incident (MCI) Triage

Mass casualty incidents require a systematic approach to patient prioritization when resources are overwhelmed. The key principles include:

• Triage decisions should be guided by the principle of seeking to help the greatest number of people survive the crisis 1
• The standard of care may need to shift from conventional to contingency or crisis standards based on available resources 1
• Field triage decision schemes provide a structured approach to identifying patients requiring immediate life-saving interventions 1

Implementing Effective Triage

Step 1: Initial Assessment and Categorization

• Use a standardized triage system such as the Simple Triage and Rapid Treatment (START) method to quickly categorize patients 2
• Assess vital signs and level of consciousness as primary triage indicators 1
• Categorize patients into four priority levels:
  • Red (immediate): Life-threatening but salvageable injuries requiring immediate intervention
  • Yellow (delayed): Serious injuries requiring treatment but can wait
  • Green (minimal): Walking wounded with minor injuries
  • Black (expectant): Dead or injuries incompatible with survival 1

Step 2: Identify Patients Requiring Urgent Surgical Treatment

• Prioritize patients with anatomical injuries that indicate severe trauma:

  • Penetrating injuries to head, neck, torso, and proximal extremities
  • Flail chest
  • Two or more proximal long-bone fractures
  • Crushed, degloved, or mangled extremities
  • Pelvic fractures 1

• Create a separate patient flow for those requiring immediate surgical intervention, bypassing standard processing to improve evacuation and treatment times 3

Step 3: Resource Allocation

• Allocate critical care resources based on:

  1. Interventions shown to improve survival without which death is likely
  2. Interventions not requiring extraordinarily expensive equipment
  3. Interventions implementable without consuming extensive staff or hospital resources 1

• Focus on providing essential critical care interventions:

  • Basic mechanical ventilation
  • Hemodynamic support
  • IV fluid resuscitation and vasopressors
  • Antibiotic or other disease-specific countermeasure therapy 1

Step 4: Staff Deployment

• Implement a two-tiered staffing model when critical care needs cannot be met by specialists alone:
  • Non-intensivists can manage approximately six critically ill patients each
  • Intensivists should coordinate the efforts of up to four non-intensivists
  • Non-critical care nurses can be assigned to no more than two critically ill patients 1

Optimizing Patient Distribution

• Distribute patients among available hospitals when possible to prevent overwhelming a single facility 4
• Consider transferring stabilized patients to other facilities to free up beds for more critical cases 1
• Implement a phased evacuation approach:
  • First phase: Patients with evident trauma requiring immediate intervention
  • Second phase: Patients with less urgent conditions 4

Avoiding Common Pitfalls

• Avoid treating all patients with equal priority (option A): This leads to inefficient resource utilization and potentially preventable deaths 1
• Avoid prioritizing only your specialty cases (option C): This creates inequitable care and fails to address the overall goal of saving the most lives 1
• Avoid undertriage: Missing severely injured patients who need higher-level care can result in preventable deaths 1
• Beware of overtriage: Sending too many non-critical patients to critical care areas can overwhelm limited resources 1

Special Considerations

• Reactive emergency mass critical care may be necessary as a temporizing strategy until additional resources become available 1
• The hospital incident commander should have authority to initiate emergency protocols and should not have direct patient care responsibilities 1
• Regularly reassess patients as their conditions may change, requiring adjustments to triage categories 2

By implementing a structured triage approach that prioritizes life-threatening injuries, you can maximize survival outcomes in this challenging scenario with limited resources.