Mass Casualty Management

MCI Triage - Sorting the Chaos

• Mass Casualty Incident (MCI): Event overwhelming local healthcare, demanding extraordinary response.
• Triage Principle: "Greatest good for greatest number." Prioritizes salvageable patients.

Triage Categories (Colors):

• 🔴 Red (Immediate): Life-threatening; needs rapid intervention (e.g., RR >30, Cap refill >2s, altered mental status).
• 🟡 Yellow (Delayed): Serious injuries, not immediately life-threatening.
• 🟢 Green (Minor): "Walking wounded," minor injuries.
• ⚫ Black (Expectant): Unlikely to survive given resources.

START Algorithm (Simple Triage And Rapid Treatment):

• Assess: Walking? → Breathing (spontaneous, rate >30/<10)? → Perfusion (cap refill >2s, radial pulse)? → Mental Status (obeys commands)?
• 📌 Mnemonic: RPM (Respiration, Perfusion, Mental Status).

SALT Algorithm: Sort, Assess, Lifesaving Interventions, Treatment/Transport.

⭐ Triage is dynamic; reassess patients frequently as conditions can change.

Anesthesia Logistics - Crisis Command Central

• Anesthesiologist Role (MCI): Leadership, triage support, airway management, resuscitation, pain control, critical care.
• Command Structure: Incident Command System (ICS) for organized response. Anesthesiologist may lead medical branch/anesthesia section.
• Communication (C3): Command, Control, Communication. Essential for coordination; use clear, closed-loop communication.
• Resource Management:
  • Equipment: Dedicated MCI carts, portable monitors, ventilators.
  • Drugs: Pre-drawn emergency drugs, TIVA kits, consider drug shortages.
  • Personnel: Defined roles, surge capacity, just-in-time training.
• Modified Anesthetic Techniques:
  • Total Intravenous Anesthesia (TIVA): Conserves gases, portable.
  • Regional Blocks: Opioid-sparing, hemodynamically stable, prolonged analgesia.

⭐ In MCI, the "Anesthesia Team Leader" often assumes a critical role within the ICS, coordinating anesthetic services and resource allocation for multiple casualties simultaneously.

Damage Control Anesthesia - Patch & Proceed

• Damage Control Resuscitation (DCR) Principles:
  • Permissive Hypotension: Target SBP <90 mmHg or palpable radial pulse (avoid in Traumatic Brain Injury).
  • Hemostatic Resuscitation: Early blood products, target ratio $1:1:1$ (PRBC:FFP:Platelets).
  • Avoid/Correct "Triad of Death" 📌: Hypothermia (<35°C), Acidosis (pH <7.2), Coagulopathy.
• Damage Control Surgery (DCS) Goals: "Life over Limb"
  • Control major hemorrhage & contamination.
  • Temporary physiological stabilization; abbreviated surgery.
  • "Patch & Proceed" to ICU for resuscitation before definitive surgery.
• Anesthetic Goals:
  • Rapid Sequence Induction (RSI).
  • Maintenance: Minimal cardiorespiratory depression (e.g., ketamine, low-dose volatiles).
  • Aggressive warming: Target core temperature >35°C.
  • Limit crystalloids; prioritize blood products.

⭐ The primary goal of Damage Control Surgery (DCS) is physiological restoration, not definitive anatomical repair, in critically injured patients at risk of the lethal triad.

MCI Challenges & Ethics - Tough Calls

• Ethical Dilemmas:
  • Resource allocation: Triage (e.g., START/SORT) to maximize survivors.
  • Futility: Decisions on withholding/withdrawing care when resources are overwhelmed.
• Psychological Impact:
  • Victims: Risk of acute stress disorder, PTSD.
  • Responders: Critical incident stress, burnout; peer support vital.
• Special Populations:
  • Pediatrics: Different triage (e.g., JumpSTART), consent, family reunification.
  • Pregnant: Two patients; altered physiology impacts care.
• Decontamination:
  • Essential for CBRNE incidents; protect staff & prevent secondary contamination.
• Post-Incident Actions:
  • Debriefing: Critical analysis for system improvement.
  • Psychological support for all affected.

⭐ In MCIs, the ethical principle of "utilitarianism" (greatest good for the greatest number) often guides resource allocation, overriding individual patient autonomy in extreme scarcity.

High‑Yield Points - ⚡ Biggest Takeaways

• Triage is paramount in MCI: START/SORT protocols guide immediate life-saving interventions.
• Damage Control Resuscitation (DCR) prevents the lethal triad (acidosis, hypothermia, coagulopathy).
• Prioritize simple airway maneuvers over advanced airways in initial MCI response.
• Employ multimodal analgesia; consider regional anesthesia when feasible.
• Effective communication and coordination are critical for successful MCI management.
• Optimize scarce resource allocation: personnel, equipment, and blood products.
• Address acute stress in casualties and responders with psychological first aid.