1) In your own words (one sentence or less), please define a mass casualty event.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2) List the four MASCAL triage categories:
1 - ______________________________________________________
2 - ______________________________________________________
3 - ______________________________________________________
4 - ______________________________________________________
3) During a MASCAL situation involving a high number of casualties, you come
across a Soldier yelling loudly that he has a painful lower leg. Primary survey
reveals no airway, breathing, or bleeding abnormalities. His lower leg is
unremarkable to visual inspection and palpation except for exquisite tenderness
over the anterior tibia, and he is unable to bear weight on the extremity. You
suspect a fracture.
To what triage category do you assign this Soldier?
______________________________________________________________________________________________
4) During a MASCAL situation involving a high number of casualties, you come
across an unresponsive Soldier. You identify a penetrating head wound. He is
pulseless and apneic.
To what triage category do you assign this Soldier?
______________________________________________________________________________________________
5) During a MASCAL situation involving a high number of casualties:
Identify at least three additional personnel who you could utilize for assistance in
treating casualties. Identify potential appropriate roles for each.
Personnel
1)
2)
3)
4)
Potential assigned role
SIM questions, Burn Case:
Scenario 1: A male patient, age 22, coalition service member, weighing 50 kg is
brought via Air Medevac to your Combat Support Hospital (CSH) ER in Southern
Afghanistan. You are the receiving and treating physician initially. He was riding in
an up armored vehicle involved in a roadside bomb. The vehicle was intact, but,
unfortunately, the engine and fuel caught fire and the patient was unable to exit the
vehicle. The accident occurred at 1700 and it is now 1900. The patient arrives to the
ER with no IV in place. The medics revealed that, as a result of his burns and the
flight, they were unable to get an IV. On your initial evaluation, you note burns
involving both entire arms and the anterior chest. Answer the following questions
based on this scenario:
Question 1: Using a standard Lund and Browder chart, calculate the %TBSA:
________________
Answer: Arms each 8% x 2 = 16% + anterior chest 18% = 34%
Question 2: Using the JTTS protocol, calculate the fluid requirements for this patient:
_________
Answer: % TBSA x Wt (kg) x 1-2 mL/kg = 34 x 50 x 1-2mL/kg = 1700-3400 mL
Lactated Ringers
Question 3: Using the JTTS protocol, give the type, amount of IVF, and the timeline
for fluid resuscitation for this patient:
Answer:
At 1mL/kg: 1700mL total over 24 hours, start at 1900 but burn occurred at 1700,
therefore give 850mL from 1900-0300 (141mL/hr), then give 850mL from 03001700 (71 mL/hr).
At 2 mL/kg: 3400mL total over 24 hours, start at 1900 but burn occurred at 1700,
therefore give 1700mL from 1900-0300 (282mL/hr), then give 1700mL from 03001700 (141mL/hr)
Question 4: At 1100 the next morning, while rounding on the patient in the ICU, you
note that the patient’s foley contains 400mL. By nursing report, it was last emptied
3 hours ago. What should be done with the IVF rate?
a)
b)
c)
d)
Keep the rate the same
Increase the rate by 20%
Decrease the rate by 20%
Decrease the rate by 50%
Answer question 4: UOP 133 mL/hr, which is greater than 50mL/hr, therefore C.
Scenario 2: A female patient, approximate age 8, local national Afghan, is carried by
her uncle to your Forward Operating Base (FOB) Battalion Aid Station in NE
Afghanistan. The gate security call your medics and they bring her to you in the
Battalion Aid Station. You are the only medical provider in this Area of Operation
(AO). The nearest Forward Surgical Team (FST) is a 30 minute rotary wing flight
and the CSH is a 90 minute rotary wing flight. No aircraft are located on your FOB.
History given by her uncle through the interpreter is that she fell into the home
cooking fire. She has burns to her anterior arms bilaterally, anterior chest, groin,
and anterior legs bilaterally. She is crying and hysterical due to pain.
Question 1: Rank the following in order of completion :





Provide pain control measures
Calculate TBSA for the patient
Primary and secondary survey
Place IV and begin IVF resuscitation
Complete JTTS burn resuscitation flow sheet
Answer, question 1:
1.
2.
3.
4.
5.
Primary and secondary survey
Calculate TBSA for the patient
Place IV and begin IVF resuscitation
Provide pain control measures
Complete JTTS burn resuscitation flow sheet
Question 2: You complete the initial care of the patient and she is now sleeping
comfortably, receiving fluids, and without airway distress. Your next step(s) in the
care and disposition of the patient may be one of the following. Pick the 1 best
answer.
A)
B)
C)
D)
Call 9 line medevac for patient to go to the FST or the CSH for definitive care.
Call your Brigade Surgeon and DCCS of the CSH about medevac.
No further treatment from the above, refer to local national health care facility.
Continue treatment of the patient in your Aid Station and reassess in 48 hours.
Answer, question 2: C. Admittedly, this is a tough question, but based on her
calculated TBSA >50% and rules of engagement in theatre, this patient has a 0%
likelihood of surviving these injuries. She should not be medevaced into the
coalition medical system.
You are at a role 2 facility (not on the battlefield). In a patient in shock but without
visible active bleeding, which of the following is NOT a potential immediate lifesaving intervention (i.e. something done along with the primary survey)?
a.
Needle thoracostomy
b.
Endotracheal intubation
c.
IV fluid bolus
d.
Chest tube insertion **** (secondary intervention vice primary)
Your patient presented with dyspnea, hypotension, and an open airway. You
performed needle thoracostomy and got a rush of air and the hypotension
improved. This patient's most important NEXT need is:
a.
Chest tube insertion **** (always indicated after needle, others not yet
indicated)
b.
Thoracotomy
c.
IV fluid bolus
d.
Pericardiocentesis
Which of the following is an indication for thoracotomy following chest tube
placement?
a.
Immediate return of 1500mL blood ****
b.
Ongoing bloody output of 100mL/hr x 2hrs (correct is 200mL/hr x 4hrs)
c.
Hypotension
itself)
d.
Difficulty intubating
(not an indication in and of
(not solved by thoracotomy)
You have performed your primary survey, responded appropriately to sites of
visible hemorrhage and given 2L IV LR for hypotension. The patient's vitals
improved to SBP = 95 mmHg, MAP = 65 mmHg, HR=90, and his pallor
improved. Now, after 15 minutes, his SBP = 80, MAP = 50, HR = 110. You
correctly classify him as a transient responder to initial resuscitation. Which of the
following would you NOT perform in assessing and treating him further?
a.
Give blood IV
b.
Give hetastarch IV
c.
Target SBP > 120, MAP > 70 before transport **** (correct is SBP>90,
MAP>60)
d.
Move patient toward surgical care