Unit Four
Hospital Incident Management
System (HIMS) for Mass Casualty
Incidents (MCI)
Objectives
 Define mass casualty incidents (MCI)
 Describe the Multi-casualty Branch structure
 Use of multiple Groups/Divisions under the Multicasualty Branch Director
 Discuss MCI response procedures
 Review emergency medical service role in MCI
 Describe “START”
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Objectives (cont'd)
 Identify the relationship of MCI Groups (triage,
treatment, transport) to overall scheme of the HIMS
 Prioritize patients using the START method of triage
for:
 Decontamination
 Treatment
 Identify considerations in transporting patients to
area hospitals
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Mass Casualty Incidents
 Multi-patient Incidents - exceeds normal first responder
capabilities
 Major medical emergency – any emergency that would
require the access of local mutual aid resources
 Mass Casualty Incidents - combination of numbers of
injured personnel and type of injuries going beyond the
capability of an entity’s normal first response
 Disaster – State and/or Federal resources are required
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Mass Casualty Incident Management
 Do the greatest good for the greatest number of
patients
 Make the best use of:
 Personnel
 Equipment
 Medical and facility resources
 Limit the spread of the contamination
 Minimize the effects of the disaster, incident, or
event
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Triage Considerations
 Triage - Term in early 1800s (derived from the
French trier, meaning "to sort")
 Immediate - Casualty requires lifesaving measures
performed without delay if they are to survive
 Delayed - Casualty whose treatment can wait
without causing additional harm
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Triage Considerations (cont'd)
 Expectant – Casualties that will not survive or will
require extensive resources and time if they are to
be saved
 Minor – Casualties that are generally ambulatory
and are injured only slightly
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Hospital Triage
 Use a triage system in an MCI
that parallels normal routine
 Practice regularly to ensure
familiarity
 Triage is a continual process
 Re-triage all victims
transported by EMS
 Set up triage area near the
ED entrance


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Shielded and secure
Readily accessible
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Triage
 “Greatest good for the greatest number of casualties”
 Psychological impact
 Classification:
Red
Yellow
Green
Black
 Limitations:
 Time consuming
 User variability
 Lack of familiarity
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START Triage
TRIAGE CRITERIA:
TRIAGE CATEGORIES:
 Respiratory status
 Walking wounded - “Green” or
minimal (relocate when told)
 Perfusion and pulse
 Neurological status
 Normal findings - “Yellow” or delayed
(unable to relocate)
 Abnormal - “Red” or immediate
 Non-salvageable - “Black” or
expectant
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START - Respiratory Status
Respiratory Status
No Respiratory
Effort
Expectant
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Respirations
> 30
Normal
Respirations
Immediate
Go to
Next Step
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START - Perfusion
Perfusion Status
Radial Pulse
Absent
Immediate
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Cyanotic
Immediate
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Radial Pulse
Present
Go to
Next Step
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START - Neurological Status
Neurological Status
Change in
Mental Status
Immediate
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Unconscious
Normal
Mental Status
Immediate
Move to
Next Victim
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Nerve Agent Triage - “Immediate”
 Unconsciousness or
convulsions
 Two or more body
systems involved
 Requires immediate
antidote
Rapid intervention should
result in a good outcome
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Initial First Aid Treatment
 Immediate removal from source of exposure
 severity directly proportional to absorbed dose
 Decontamination
 Mild soap and water rinse
 Antidote administration with airway management
support as necessary
 Must be provided by properly trained and equipped
personnel
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Nerve Agent Antidote
 Atropine
─ administered to block
receptor sites of
acetylcholine
 2-PAM Chloride
─ restores
acetylcholinesterase
 Mark I Kit or
“Combo Pen”
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First Aid Treatment
 Exit Agent Exposure Area
 Minor Symptoms Administer:
 One Mark I Kit
 Major Symptoms Administer:
 Three Mark I Kits
 Diazepam Required for Severe Casualty
 Monitor Patient’s Symptoms
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Nerve Agent Triage - “Delayed”
 Initial symptoms are
improving (miosis still
present)
 Recovering well from
pre-hospital antidote
therapy
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Nerve Agent Triage “Minimal” & “Expectant”
Minimal
• Walking and talking
which indicates intact
breathing and
circulation
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Expectant
• Apneic for more
than 5 minutes
• No pulse or blood
pressure
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Mustard Triage
Delayed
• 2 to 50% BSA burns
by liquid
• Eye involvement
Immediate
Minimal
• < 2% BSA burns by
liquid in non-critical
areas
Expectant
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• Moderate to severe
pulmonary symptoms
• > 50% BSA burns by
liquid; apneic/no pulse
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Triage of Biological Casualties
 Triage of biological agent
casualties is different:
 Symptoms are delayed
 Initial cases may go
unrecognized
 More difficult to detect
 Epidemiological information
becomes critical
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TriagePsychological Casualties
 Disasters produce tremendous emotional and
psychological stress, with large numbers of
psychogenic casualties
 Presenting signs could be confused with organic
disease
 Use of START triage system maintains focus on
objective signs of disease & minimizes impact of
subjective complaints on the triage process
 Psychological casualties are usually triaged as
“minimal”
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TriageHospital Arrivals
 Casualty arrival is uncoordinated
 Arrival times vary
 Closest hospital is typically overwhelmed
 Medical needs of unaffected community continues
 May present at distant hospitals to ensure treatment at
clean facilities
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Contaminated Human Remains
 Problems are agent specific:



Decontamination
Containment
Refrigeration until definitive disposal
 Follow local coroner and medical examiner
protocols:

Establish cooperative agreements for fatality management
 Secure personal effects:

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Not all can be decontaminated
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Radiation Protection for Clinical Staff
 Fundamental Principles
- Time
- Distance
- Shielding
 Personnel Protective Equipment
 Contamination Control
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Protecting Staff from Contamination
 Use standard
precautions (N95
mask)
 Survey hands and
clothing frequently
 Replace contaminated
gloves or clothing
 Keep the work area
free of contamination
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