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Mass Casualty Mark B. Shah, MD, FACEP Emergency Physician, Emergency Physicians; Medical Director, Utah Disaster Medical Assistance Team; Medical Director for Emergency management, Intermountain Healthcare Urban Central Regsion; Co-Medical Director, Intermountain Center for Disaster Preparedness Objectives: Discuss the lessons learned from recent terrorist events Identify the steps in preparing your hospital for a mass casualty response Discuss and demonstrate Tactical Combat Casualty Care techniques Develop an action plan to implement in your facility

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Page 1: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Mass Casualty

Mark B. Shah, MD, FACEP Emergency Physician, Emergency Physicians; Medical Director, Utah Disaster Medical Assistance Team; Medical Director for Emergency

management, Intermountain Healthcare Urban Central Regsion; Co-Medical Director, Intermountain Center for Disaster Preparedness

Objectives:

Discuss the lessons learned from recent terrorist events

Identify the steps in preparing your hospital for a mass casualty response

Discuss and demonstrate Tactical Combat Casualty Care techniques

Develop an action plan to implement in your facility

Page 2: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Mark Shah, MD FACEPUtah Emergency Physicians

Utah Disaster Medical Assistance TeamIntermountain Center for Disaster Preparedness

Emergency Management, Intermountain Healthcare UCRAdjunctive Faculty, University of Utah, Division of Emergency Medicine

Page 3: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 4: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 5: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 6: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 7: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 8: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 9: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 10: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 11: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 12: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 13: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 14: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 15: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 16: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 17: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

15% of Combat Deaths are

Preventable

• 9% Hemorrhage from extremity wounds

• 5% Tension pneumothorax

• 1% Airway obstruction e.g., maxillofacial

trauma

* Data is extrapolated from Vietnam to

present day Iraq and Afghanistan

From Chris Cook, RN, TEMS

Page 18: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Assessment: C‐ABCDE

•C•Airway

•B•C•D•E

Page 19: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Prehospital External Hemorrhage Control Protocol

Apply direct pressure/pressure dressing to injury

Direct pressure effective (hemorrhage controlled)

Wound amenable to tourniquet placement  (e.g. extremity injury)

Apply a tourniquet

Wound not amenable to tourniquet placement  (e.g. junctional injury)

Apply a topical hemostatic agent with direct pressure

Direct pressure ineffective or impractical (hemorrhage not controlled)

Doyle and Taillac, Prehospital Emergency Care 2008; 12(2): 241‐ 256 

Page 20: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Doyle and Taillac, Prehospital Emergency Care 2008; 12(2): 241‐ 256 

Reassess tourniquet for possible replacement with pressure dressing

Page 21: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 22: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Focus on effective packing of wounds and good direct pressure

Page 23: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 24: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 25: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 26: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 27: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

•Chest/abdomen/pelvis

Page 28: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

•Early administration of “whole blood” in a 

Page 29: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 30: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 31: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 32: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

https://www.ict.org.il/Article/77/Terrorist‐Attacks‐against‐Hospitals‐Case‐Studies

Page 33: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 34: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 35: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 36: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

POV Arrivals

Spot Check:1. Security2. HAZMAT

EMS Arrivals

Triage Director

Resuscitation Bays ED Bed

DECON

Page 37: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

POV Arrivals

Spot Check:1. Security2. HAZMAT3. Nurse Greeter

EMS Arrivals

Triage Director

Comprehensive TriageNot Sick

SickRed

Resuscitation Bays ED Bed Alternate Care Area

YellowGreen

DECON

Expectant

Black

Traffic Director

Page 38: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 39: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 40: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 41: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 42: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 43: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 44: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 45: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 46: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Disaster

Page 47: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Medical Care falls under Operations Section Chief

Page 48: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 49: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 50: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial
Page 51: Mass Casualty Mark B. Shah, MD, FACEP · 15% of Combat Deaths are Preventable •9% Hemorrhage from extremity wounds •5% Tension pneumothorax •1% Airway obstruction e.g., maxillofacial

Mark Shah: [email protected]

Intermountain Center for Disaster Preparedness:

Facebook: https://www.facebook.com/pages/Intermountain-Center-for-Disaster-

Preparedness

Karen Blackwood, Director: [email protected]

Barb Clark, Training Manager: [email protected]

https://nam.edu/wp-content/uploads/2016/06/Health-and-Medical-Response-to-

Active-Shooter-and-Bombing-Events.pdf

http://emergency.cdc.gov/masscasualties/pdf/surgecapacity.pdf

http://www.euro.who.int/en/health-topics/emergencies/disaster-preparedness-and-

response/publications/2011/hospital-emergency-response-checklist


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