Mass Casualty Management: Primary Recommendation
The primary recommendation for managing victims in a mass casualty situation is to implement triage-based prioritization that maximizes population-based outcomes over individual outcomes, using systematic evaluation to do the greatest good for the greatest number of people. 1
Core Triage Principles
Management of life-threatening injuries takes precedence over radiologic surveys and decontamination. 1 The fundamental goal is to evaluate and sort individuals by immediacy of treatment needed, recognizing that resource limitations require medical care prioritization when demand overwhelms supply 1.
Essential Triage Components
The proposed management must be based on:
- Rapid identification of the offending agent (in chemical/biological events) 1
- Swift decontamination by well-protected emergency medical personnel 1
- Triage-guided mass evacuation to nearby medical facilities equipped and staffed for multifaceted events 1
Standards of Care Framework
Crisis standards of care should be implemented when resource limitations require shifting from conventional medical standards. 1 This framework operates on three levels:
- Conventional standard of care: Usual standard in non-crisis settings 1
- Contingency standard of care: Equivalent care using different methodologies, medications, or locations 1
- Crisis standard of care: Resource limitations require medical care prioritization, with population-based outcomes prioritized over individual outcomes 1
The shift between these standards occurs after local, state, and federal resource distribution has been maximized and patient transportation to alternative facilities has been employed 1.
Triage Team Structure
A local triage team comprising experts in clinical care, critical care, ethics, infectious disease, and triage should guide resource allocation. 1 This team ensures consistent, equitable, and fair practices during fluctuating resource availability 1.
The triage officer—typically an intensivist or surgeon with critical care experience—applies the triage protocol to decide patient disposition during the event 1.
Practical Triage Implementation
Inclusion Criteria
Patients who may benefit from critical care admission primarily focus on respiratory failure, since ventilatory support fundamentally differentiates ICU from other acute care areas 1.
Exclusion Criteria
Patients not candidates for ICU admission include those with:
- Poor prognosis despite ICU care 1
- Resource requirements that cannot be provided 1
- Underlying illness with poor prognosis and high likelihood of death 1
- Patients who are "too well" for critical care 1
Surgical Timing Considerations
Individuals requiring surgical intervention should undergo surgery within 36 hours (and not later than 48 hours) after exposure in radiation events. 1 Additional surgery should not be performed until 6 weeks or later 1.
Common Pitfalls to Avoid
Avoid attempting to assess detailed medical histories or vaccination records during the acute response phase, as this is often impractical when facilities are overwhelmed and medical staff must focus on lifesaving trauma treatments 1.
Do not apply conventional standards when resources are exhausted—recognize triggers for shifting to contingency or crisis standards, such as supply-demand imbalances where resources will not be available to diagnose or treat everyone presenting with illness 1.
Continuously reassess resource demand and supply, including healthcare capacity, and shift back to conventional or contingency standards at the earliest possible opportunity as additional resources become available 1.
Situational Awareness Requirements
Maintain awareness of both supply of and demand on resources throughout the event 1. Resource scarcity might not apply to all aspects of clinical management but may affect only specific aspects of diagnosis, management, or treatment 1.