What is the management of emergency cases in a casualty department?

Management of Emergency Cases in Casualty Department

Emergency casualty management follows a systematic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach with immediate life-saving interventions prioritized before definitive diagnosis, combined with rapid triage protocols to allocate resources based on survival likelihood during mass casualty events. 1, 2

Initial Assessment and Immediate Actions

Primary Survey: ABCDE Approach

Airway Assessment and Management

• Check responsiveness by gently shaking shoulders and asking loudly "Are you all right?" 1
• If unresponsive, immediately shout for help and open the airway using head tilt-chin lift maneuver 1
• Remove loose dentures and obvious obstructions; leave well-fitting dentures in place 1
• Look for chest movements, listen for breath sounds at the mouth, and feel for air with your cheek for 5 seconds 1

Breathing Assessment

• If not breathing but pulse present: deliver 10 breaths of expired air ventilation with head tilted and chin lifted 1
• Pinch the soft part of the nose closed and deliver mouth-to-mouth ventilation 1
• Identify patients with refractory hypoxemia, respiratory acidosis, or impending respiratory failure requiring urgent ICU review 3

Circulation Assessment

• Check carotid pulse for 5 seconds before deciding it is absent 1
• If no pulse: begin cardiopulmonary resuscitation with chest compressions at the middle of the lower half of the sternum, depressing 4-5 cm at a rate of 80 compressions per minute 1
• Use 15:2 compression-to-ventilation ratio 1
• Identify patients with hypotension and shock refractory to volume resuscitation requiring vasopressor support for urgent review 3

Disability and Exposure

• Assess level of consciousness and neurological status 2
• Expose the patient completely to identify all injuries while preventing hypothermia 2

Recovery Position for Breathing Casualties

• Turn unconscious but breathing patients to the recovery position to prevent tongue obstruction and reduce aspiration risk 1
• Keep head, neck, and trunk in a straight line to permit gravity drainage from the mouth 1
• Remove spectacles and bulky objects from pockets before positioning 1

Triage and Resource Allocation

Standard Triage Principles

If responsive and moving: Leave in current position unless in danger, check for injuries, reassess responsiveness at intervals, and obtain help if needed 1

Mass Casualty Event Protocols

• Establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional, and national levels to direct resource use 1
• Trigger critical care triage protocols only when resources across a broad geographic area are overwhelmed despite all efforts to extend capacity 1
• Apply objective, ethical, and transparent triage criteria equitably using inclusion and exclusion criteria 1
• Restrict ICU services to patients most likely to benefit during resource scarcity 1

Critical Care Surge Capacity Benchmarks:

• Hospitals with ICUs should prepare to provide emergency mass critical care (EMCC) for a critically ill patient census of at least 300% of usual ICU capacity 1
• Plan to deliver EMCC for 10 days without sufficient external assistance 1

High-Priority Cases Requiring Urgent Review

Trauma Cases

• Penetrating injuries, flail chest, two or more proximal long-bone fractures, crushed or mangled extremities, amputations, pelvic fractures, open or depressed skull fractures, and paralysis 3
• Trauma Injury Severity Score (TRISS) with predicted mortality >80% 3
• Patients on anticoagulation therapy with trauma and pregnant patients >20 weeks with trauma 3

High-Risk Patient Populations

• Severe baseline cognitive impairment, advanced untreatable neuromuscular disease, metastatic malignant disease, advanced irreversible immunocompromised conditions, severe irreversible neurologic conditions, and end-stage organ failure 3

Special Circumstances: Bioterrorism/Chemical Exposure

• Rapidly identify the offending agent and perform swift decontamination by well-protected personnel 1, 3
• Victims with combined physical trauma and chemical intoxication require special attention as these insults potentiate each other's detrimental effects 1
• For opioid overdose: administer naloxone cautiously with other resuscitative measures including airway maintenance, artificial ventilation, cardiac massage, and vasopressor agents 4
• Monitor for acute withdrawal syndrome in opioid-dependent patients, which may include tachycardia, hypertension, seizures, and cardiac complications 4

Coordination and Collaboration

Interface with Key Departments

• Develop systematic communication and coordination between emergency department, ICU, operating rooms, internal medicine, anesthesiology, surgery, laboratory services, radiology, and hospital administration 1
• Identify key functions requiring coordination: manpower utilization, surge capacity, reallocation of personnel, equipment, physical space, and smooth inter-departmental patient transfers 1

Personnel and Training Requirements

• Identify roles and responsibilities of key individuals for guideline implementation 1
• Ensure adequate training in basic life support, ABCDE assessment, high-risk procedures (aerosol-generating procedures), personal protection techniques, and ethical issues 1
• Train staff in disease management, environmental contamination protocols, and dealing with deceased patients and families 1

Critical Pitfalls to Avoid

• Do not delay CPR while waiting for equipment - begin immediately with available resources 1
• Do not use naloxone for non-opioid respiratory depression - it is ineffective against other drug classes 4
• Do not abruptly reverse opioids in dependent patients - this precipitates acute withdrawal with potentially life-threatening complications including seizures, ventricular arrhythmias, and pulmonary edema 4
• Do not perform triage based on "first come, first served" during mass casualty events - prioritize patients most likely to benefit from limited resources 1
• Do not forget child abuse screening - use protocols to detect abuse in pediatric trauma patients and know state reporting requirements 1

Documentation and Quality Improvement

• Maintain comprehensive documentation given medical-legal implications of emergency decisions 1
• Establish performance improvement committees with pediatric-focused issues for trauma centers 1
• Utilize trauma registries with ties to national databases for outcome benchmarking 1
• Implement mandatory systematic death review processes to identify emerging trends 1