Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX C n Trauma Care in Mass-Casualty, Austere, and Operational Environments
typically in the setting of limited information and
uncertainty about event evolution. During a mass
casualty event, the care paradigm shifts from the
greatest good for the individual to the greatest good
for the greatest number of casualties. This populationbased
standard of care is different from everyday trauma
care, in which all resources are mobilized for the good
of an individual injured patient. In the disaster setting,
decisions made for one casualty can affect decisions for
other casualties because of resource limitations and
circumstances. Increased mortality can result from
faulty decision making.
Casualty disposition in the aftermath of disaster
relates to the intersection of casualty, resource, and
situational considerations. Casualty characteristics
include immediately life-threatening injuries,
complexity of interventions to manage threats to life,
injury severity, and survivability. Inability to survive
is both absolute (e.g., 100% third-degree body-surface
area burns) and relative (e.g., extensive injuries
consume resources for one casualty that could be used
to save more than one casualty).
Resource considerations include what is available
(e.g., space, staff, supplies, systems) for care and
evacuation (transportation, roads), as well as the
timeline for resupply and casualty evacuation.
The situation involves event progression, secondary
events (i.e., additional events relating to the inciting
event, such as secondary bombs, structural collapse
after an explosion, and flooding after levees break), and
environmental conditions (i.e., time of day, weather,
and geography).
Pitfall
Key resources are
depleted during the care
of only a few casualties.
prevention
• Recognize and communicate
priorities of care
to all team members.
• Maintain situational
awareness by communication
through the
command structure
to know numbers of
potential causalities
and available resources.
logistics, and finance/administration functions for
integrated and coordinated response. An incident
commander has responsibility for the overall response
to ensure the safety of responders, save lives, stabilize the
incident, and preserve property and the environment.
Medical care falls under the Operations element of ICS.
Casualties in a disaster require more basic care than
specialty care; thus, health care functions in a more
general role in disaster response. Specialty physicians,
for example, may be part of the workforce pool for
logistics and casualty transport.
Triage is a system decision tool used to sort casualties
for treatment priority, given casualty needs, resources,
and the situation. The triage goal is to do the best for
most, rather than everything for everyone. Effective
triage is an iterative process done across all settings
of casualty care. At each setting, an experienced
acute care professional with knowledge of the health
system should serve as the triage officer. Triage is
not a one-time decision; it is a dynamic sequence of
decisions. Casualties, resources, and situations change,
leading to refined triage decisions. The ICS can provide
information about expected numbers and types of
patients and resources to enable triage decision making.
The triage decision at the incident scene by first
responders identifies who is alive and moves these
casualties to a safe area away from the scene to a
casualty collection point. The next triage decision
determines who is critically injured (i.e., who has
immediately life-threatening injuries). Use of a scene
triage system is helpful. A common system is SALT
(Sort, Assess, Lifesaving Interventions, Treatment/
Transport), which quickly “sifts the injured using
response to verbal command, presence of breathing,
and presence of uncontrolled bleeding. This initial
triage allows tagging of injured individuals with a colorcoded
category that identifies the necessary urgency
of care required (n BOX C-1). This approach helps to
rapidly separate the critically injured. The casualties
who can walk to another collection point or who can
wave an extremity purposefully are less likely to have
life-threatening injuries, while those who do not move
are likely critically injured or dead. Among the critically
box c-1 salt triage categories
1. Immediate: immediately life-threatening injuries.
Tools for Effective Mass-Casualty
Care
Incident command and triage are essential tools for
effective mass-casualty care. The Incident Command
System (ICS) is a management tool that transforms
existing organizations across planning, operations,
2. Delayed: injuries requiring treatment within 6 hours
3. Minimal: walking wounded and psychiatric
4. Expectant: severe injuries unlikely to survive with
current resources
5. Dead
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