Mass Casualties

Mass casualties is a term applied to the occurrence of inflicting injuries to human beings in one or adjoining district or area, such injuries will comprise at least a hundred persons.

Causes:

Such disasters could be caused by an earthquake, a hurricane or a train accident, a huge explosion or by air raid or due to an airplane crashing into s sky-scraper.

But the umber of casualties may reach more than a million from a nuclear explosion (please recall Hiroshima and Nagasaki). The irradiation injuries with one major nuclear strike of five megaton nuclear explosion will cause over 2 million living casualties and four times that number of dead people in a big city, the living casualties there after will have irradiation syndrome and may go into skin lesions and epilation and haemato logical changes.

Wars are a common cause of casualties, sustaining injuries by high velocity missiles but also by chemical and biological weapons.

Management:

There should be a setup or a plan to deal for disasters of mass casualties, rehearsals which should be done many times to get the optimal benefit during its actual use.

The plan should consist of properly equipped ambulances with trained medical staff, working with collaboration of civil defence personnel, police and fire-brigade, at the site of disaster.

Also the plan include a casualty receiving area with well trained medical staff headed by a senior experienced surgeon, the area of the hospital should be easily accessible by the ambulance cars.

The surgical operative theatres and wards should also be completely ready in every aspect to receive the injured.

The control of the plan is the function of the ministry of health as more than one hospital is used to contain the casualties.

The actual management consist of three distinct medical activities:

The first one is confined to the site of injury, it will comprise triage, life saving activities and transportation i.e. evacuation.

Triage aim is to decide promptly the priorities of evacuation of the injured according to their need of surgical intervention regarding time factor.

Priority one is to be evacuated first and should include those in need of urgent surgery but with a good chance of survival.

At the same time the medical staff should devote most of their attendance to the extensively injured persons and do a life saving manoeuvre, these may include:

Insure adequate airway, like clearing the mouth and pharynx, especially in faciomaxillary injury or unconscious patients with impeding respiratory obstruction. The best way is to introduce an oropharyngeal or endotracheal tube, while tracheostomy is the last resort. Respiratory failure may also be caused by a chest wound. Immediately seal by an air-tight occlusive support, while a flailing chest injury needs only strapping the segment with sandbag supports, but if time allows, chest-tube is the ideal procedure in such chest injuries.

Control of haemorrhage: most external bleeding can be stopped or controlled by direct firm dressing, or clamping bleeding vessel under direct vision, blind clamping is not permissible, tourniquet is rarely needed – it saves lives but it endangers the limb’s functions. If it is to be used, it should be released every thirty minutes, then reapplied again. Internal bleeding can be controlled only by surgery, so immediate evacuation with I.V. fluid is done keep the patient alive.

Control of shock: usually due to blood loss external or internal or both, I.V. fluid and plasma expands.

Control of infection and pain: antibiotic shot is given avoiding certain types of drugs based on allergies.

Application of dressings, splints and binders. All wounds should be changed promptly. All suspected limb/bone fractures should be splinted with pain relief injection. Abdomen penetrating wounds with extrusion of omentum or intestinal loop or both should be managed by sterile dressing without attempt to reduce the omentum or the loop inside the abdomen. Spine injury is evacuated in supine position with sand bag supports on the sides and should be moved “all in one piece”. Cervical spine is to be applied in suspected cases of cervical spine injury. The war casualties have longer time lag than those of the injured by civil disasters i.e. the time between inflicting injury and the time reaching the site of medical treatment, with the same extensive injury the latter has a better chance to survive. Observation and care of the injured should be maintained during evacuation in ambulance cars.

The second distinct medical activity in such disasters takes place where the ambulance evacuates the injured in the receiving area of casualty department of the district or nearest hospital.

Here triage has also a great importance for those who need immediate operation. Others may need immediate operations, others may need resuscitation and a change of dressing before sending them home.

In the operating theatre general surgeons have to deal with most of the cases, be it civilian or war casualties, as soft tissue injuries are the most common affliction.

Proper debridement imply full wound exposure in depth and tide extensions, removal of all foreign bodies and dead tissues leaving the wound opened for further inspection and delay or secondary sutures.

Usually skin is primarily closed in face wounds, sucking chest wound and head injury wounds.

It is well known that the best chance the patient has in the operative theatre is by the first surgeon. Thus the surgeon should stick to results of surgeons in these circumstances such as:

When a major blood vessel injury is doubted exploration is done.

In case of an end to end anastomosis of arteries breech is not possible an autogenous vein graft to be used, avoiding a primary vascular substitute.

In case of compound fractures after reduction, fixation is done by plaster of Paris rather than by primary internal fixation.

Attempt for soft tissues healing have priority to bone and nerve injury repair.

When abdominal injury is evident or suspected laparotomy is mandatory with a midline incision.

For large bowel injury, the safest procedure is to do primary resections together with double barrel colostomy with a skin bridge in between.

Burned casualties should be sorted out and treatment of the admitted ones by I.V. fluid plasma and blood if needed, control of infection by bath, special dressing and antibiotic.

The third distinct medical activity takes place for these mass casualties in specialised unites in general hospital or in specialised unites hospitals to treat cases of paraplegia, fasciomaxillary, injuries, neurosurgical, orthopaedic, reconstructive, chest & vascular, eyes and ear injures.

Thank you

Dr. Salim AL-Shamma

FRCS

Baghdad November 2001