Clinical Care for Mass Casualties: Key Procedures and Protocols

When disaster strikes-whether an earthquake, building collapse, explosion, or industrial accident-hospitals face a sudden influx of patients requiring immediate, life-saving care. Clinical care for mass casualties differs significantly from everyday emergency medicine. Resources are stretched thin, time is critical, and healthcare providers must quickly prioritize who receives treatment first. Understanding the key procedures and protocols for mass casualty clinical care can mean the difference between life and death for dozens or even hundreds of victims.

Resuscitation protocols in mass casualty situations
Key modifications for disaster settings
Triage systems and color coding
Pediatric triage considerations
Managing common disaster injuries
Wound management
Fractures and musculoskeletal injuries
Burn injuries
Crush injuries and crush syndrome
Hospital preparedness principles
Setting priorities through the incident command system
Reverse triage and bed availability
Spectrum of care: conventional to crisis
Documentation and tracking
Special considerations for vulnerable populations
Training and preparedness exercises

Resuscitation protocols in mass casualty situations

The foundation of emergency resuscitation has long been built on the ABC model-Airway, Breathing, and Circulation. Developed by Dr. Peter Safar in the 1950s, this mnemonic helps medical professionals systematically address life-threatening conditions in order of priority. An open airway is necessary for breathing, and breathing provides oxygenated blood for circulation-each step depends on the one before it.

However, disaster medicine has evolved this approach. In trauma and mass casualty settings, research now supports modifications like the CABC or <C>ABC paradigm, where the first “C” stands for catastrophic hemorrhage. This change reflects a critical insight from military and civilian trauma care: in violent trauma cases, major blood loss can kill a casualty before airway obstruction becomes fatal. Immediate tourniquet application or hemostatic dressings may take priority over airway management.

Key modifications for disaster settings

Standard resuscitation protocols require adjustment during mass casualty incidents. The MARCH-PAWS algorithm used in tactical casualty care prioritizes massive bleeding control, then airway, respiration, circulation, hypothermia/head injuries, pain management, antibiotics, wounds, and splinting. Several factors make disaster resuscitation unique:

Limited time per patient: Unlike routine emergency care, providers may have only 30-60 seconds per victim during initial triage. Treatment during triage is minimal-the goal is rapid assessment and movement toward appropriate care.

Resource constraints: Equipment, medications, and personnel are limited. Providers must make quick decisions about who will benefit most from immediate intervention.

Hypotensive patients: Studies show that hypotensive trauma patients who receive blood transfusion before airway intubation have significantly better outcomes. Research indicates a 91% reduction in mortality odds within 24 hours when circulation is prioritized over intubation in exsanguinating injuries.

Triage systems and color coding

Effective triage is the backbone of mass casualty management. The START (Simple Triage and Rapid Treatment) system, developed in 1983 by Hoag Hospital and Newport Beach Fire Department in California, remains the most widely used triage method in the United States. It uses four color-coded categories:

Black (Deceased/Expectant): Injuries incompatible with life or absence of spontaneous respiration after airway opening. These patients should not consume limited resources.

Red (Immediate): Severe injuries with high survival potential if treated promptly. These patients receive priority transport and care. Criteria include respiratory rate above 30, absent radial pulse, capillary refill over 2 seconds, or inability to follow simple commands.

Yellow (Delayed): Serious injuries that are not immediately life-threatening. These patients can safely wait several hours for treatment without significant deterioration.

Green (Walking Wounded): Minor injuries. These patients can walk to designated collection points on their own.

Pediatric triage considerations

Children require modified triage approaches. The JumpSTART system adapts START for pediatric patients under eight years old. Key differences include giving five rescue breaths to apneic children with a pulse before assigning a black tag, adjusting normal respiratory rate parameters to 15-45 breaths per minute, and using the AVPU scale (Alert, Verbal, Painful, Unresponsive) for neurological assessment. Children with abnormal posturing to painful stimuli or who are unresponsive receive an immediate red designation.

Managing common disaster injuries

Mass casualty events produce predictable injury patterns. Understanding treatment priorities for each helps healthcare teams work efficiently under pressure.

Wound management

Open wounds require rapid assessment and basic intervention. Hemorrhage control takes absolute priority-direct pressure, tourniquets for extremity wounds, and hemostatic dressings when available. Wounds should receive antibiotics and tetanus prophylaxis when resources permit. Debridement of necrotic tissue may need to wait until the surge subsides, but contamination control is essential to prevent sepsis.

Fractures and musculoskeletal injuries

Splinting provides temporary stabilization and pain reduction while freeing staff to attend to more critical patients. Open fractures require wound care to prevent infection. Limb-threatening injuries involving vascular compromise need rapid surgical consultation but may be classified as yellow (delayed) if the patient is hemodynamically stable and other life-threatening injuries take precedence.

Burn injuries

Burn mass casualties present unique challenges. Key treatment priorities include:

Temperature management: Hypothermia is a frequent and dangerous complication of burn injury. Patients lose the ability to regulate temperature as skin is damaged, and hypothermic coagulopathy significantly increases mortality. Keep patients covered and dry; use fluid warmers.

Airway concerns: Facial burns, singed nasal hair, hoarseness, or stridor may indicate inhalation injury requiring early intubation. Pediatric airways are smaller-less edema causes obstruction, making early intervention even more critical.

Fluid resuscitation: Burns greater than 20% total body surface area (TBSA) typically require intravenous fluid resuscitation. The Parkland formula (4 mL × body weight in kg × % TBSA burned) guides initial fluid therapy. Urine output is the best monitor of adequate resuscitation. Pediatric patients under 12 years need a dextrose source in addition to lactated Ringer’s solution.

Wound care: Cover wounds with clean, dry dressings-wet dressings cool patients dangerously. Patients needing grafting should be referred to verified burn centers when possible.

Crush injuries and crush syndrome

Crush syndrome is the second most common cause of death after earthquakes, following direct trauma. When victims remain trapped under debris for extended periods, muscle tissue breaks down, releasing toxic components including myoglobin, potassium, and phosphorus into the bloodstream upon rescue.

Treatment principles include:

Pre-extrication fluid resuscitation: Begin intravenous fluids before releasing the crushed body part whenever possible, especially if entrapment exceeds one hour. This helps prevent the sudden release of toxic metabolites from overwhelming the kidneys and heart.

Avoid potassium-containing fluids: Normal saline or lactated Ringer’s solution should be used-hyperkalemia from muscle breakdown can cause fatal cardiac arrhythmias.

Monitor for compartment syndrome: Watch for the five P’s: pain, pallor, paresthesias, paralysis, and pulselessness. Fasciotomy may be necessary but carries significant risks including infection and long-term disability.

Prepare for dialysis needs: Patients with acute kidney injury from rhabdomyolysis may require up to 60 days of dialysis treatment. Unless sepsis develops, most will regain normal kidney function.

Hospital preparedness principles

Surge capacity planning is a critical component of every healthcare facility’s emergency preparedness. When hospitals must manage 100-200 patients simultaneously, standard operations cannot continue. Three core elements define surge capacity: space, staff, and supplies.

Setting priorities through the incident command system

Hospitals should activate their incident command structure immediately upon notification of a mass casualty event. Published experience indicates that even in rapidly evolving disasters, hospitals have 2-4 hours with a preordained plan to prepare and expand capacity. This window allows for clearing patients from ICUs through discharge or transfer, converting non-clinical spaces for patient care, and calling in off-duty staff.

Reverse triage and bed availability

Hospitals typically operate near capacity under normal conditions. Reverse triage-rapidly discharging or transferring stable inpatients-creates space for incoming casualties. Emergency departments must divert boarded patients and discharge non-emergent cases. Staff call-in lists should be maintained and regularly updated.

Spectrum of care: conventional to crisis

Staff must understand that standard care protocols may be incompatible with disaster response. The spectrum runs from conventional care (normal operations) through contingency care (functionally equivalent care using adaptations) to crisis care (allocation of scarce resources with potential for increased mortality). Hospital ethicists should be involved in mass casualty planning so that triage decisions during extreme circumstances have been discussed and agreed upon in advance.

Documentation and tracking

Triage tags serve dual purposes: guiding immediate care decisions and collecting data for ongoing management. Tags typically include sections for vital signs, demographics, medical history, injury diagrams, and color-coded tear-off sections. Information can be added throughout triage and updated as patient conditions change. Some systems allow priority levels to be adjusted without complete re-tagging.

Special considerations for vulnerable populations

Children, elderly patients, pregnant women, and those with pre-existing medical conditions require modified approaches. Pediatric burn patients face unique risks including smaller airways prone to obstruction, different fluid requirements, altered drug pharmacokinetics, and psychological trauma. Burns greater than 10% TBSA in children under 10 warrant burn center referral.

Elderly patients may have reduced physiological reserve, making them more susceptible to complications from even moderate injuries. Pre-existing conditions can complicate management and prolong recovery.

Training and preparedness exercises

Tabletop exercises and simulation drills prepare staff for mass casualty response without the chaos of a real event. Regular re-training improves triage accuracy and reduces the psychological burden when providers face difficult decisions during actual disasters. Exercises should test surge capacity plans, communication systems, supply chains, and coordination with external agencies.

What do you think? How prepared is your local hospital to handle a sudden influx of 100+ casualties? What role can community members play in supporting disaster medical response?

References

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Table of Contents

Resuscitation protocols in mass casualty situations 🔗

Key modifications for disaster settings 🔗

Triage systems and color coding 🔗

Pediatric triage considerations 🔗

Managing common disaster injuries 🔗

Wound management 🔗

Fractures and musculoskeletal injuries 🔗

Burn injuries 🔗

Crush injuries and crush syndrome 🔗

Hospital preparedness principles 🔗

Setting priorities through the incident command system 🔗

Reverse triage and bed availability 🔗

Spectrum of care: conventional to crisis 🔗

Documentation and tracking 🔗

Special considerations for vulnerable populations 🔗

Training and preparedness exercises 🔗