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
table c-1 comparison of factors impacting trauma care in the civilian urban,
civilian rural, and operational/disaster environments
CIVILIAN URBAN CIVILIAN RURAL OPERATIONAL/DISASTER
Threat level none none high
Resources readily available may be limited severely limited
Personnel excess limited but expandable fixed and limited
Supplies/Equipment
fully equipped, resupply
readily available
adequately equipped, delay
to resupply
limited supplies, resupply
significantly delayed
Available expertise full subspecialty services limited specialties locally
available
no subspecialty services
immediately available
Transfer Availability immediately available available but longer
transport times
highly variable, may be no
option for transfer
Multiple or Mass
Casualty Events
uncommon rare common
Depending on the environment, key infrastructure
considerations, such as electrical power, lighting, and
communications, can also dramatically influence a
facility’s security posture. Although these security
needs are most apparent in times of armed conflict,
care must be taken to ensure that every treatment
facility’s operational plans fully address other
scenarios, such as when a local facility is overwhelmed
or incapacitated by natural disaster, riot, or intentional
mass-casualty event.
Likewise, reliable internal and external communication
remains a vexing problem. Lack of system
interoperability and reliance on native infrastructure,
such as vulnerable telephone landline, computer
networks, and cell phone systems, are frequent
communication limitations. Unfortunately, failed and
disrupted communications remain common issues in
operational, disaster, and rural environments; therefore,
contingency plans must be established in advance.
War Wounds
Healthcare providers in operational environments must
consider the unique wounding patterns associated with
war wounds, including the potential for significant
tissue devitalization and destruction from the increased
ballistic effects of high-velocity ammunition compared
with wounds typically encountered in civilian centers.
Although improvised explosive devices are most
often encountered in theaters of war, they are also
increasingly used as a weapon of choice for intentional
mass-casualty events at home and abroad. These
highly morbid and highly lethal weapons produce
complex multidimensional wounding that may
include components of penetrating injury, blunt
injury, primary blast overpressure, crushing, and
burning. Morbidity depends on the distance from the
device, extent of cover, and any protective gear that
may have been in place. Trauma teams must exercise
vigilance in search of internal damage including
vascular injuries, since patients often present a complex
combination of wounds, ranging from devastating
traumatic amputation to multiple small penetrating
wounds with highly variable penetration and wound
trajectories that are extremely difficult to assess without
adjunct imaging.
Military Trauma Care
Tactical Combat Casualty Care
A precedent for the modification of civilian trauma
training courses to incorporate military-specific needs
can be found in the example of Prehospital Trauma
Life Support (PHTLS) and Tactical Combat Casualty
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