Disaster Medicine

UNIT 9

CLINICAL CASUALTY
MANAGEMENT

Structure
9.0

Learning Outcome

9.1

Introduction

9.2

Clinical Casualty Management

9.2.1
9.2.2
9.2.3
9.2.4

Hospital Alerting and Response

Hospital Triage
Clinical Care
Documentation

9.3

Conclusion

9.4

References and Further Reading

9.5

Activity

9.0

LEARNING OUTCOME

After studying this Unit, you should be able to:

explain the aim and objectives of clinical casualty management in hospitals.

discuss the features of hospital alerting and response.

explain the methods of hospital triage and resuscitation; and

describe documentation and medico-legal aspects of clinical care.

9.1

INTRODUCTION

Hospitals are an integral part of health care delivery system. WHO Expert
Committee defines hospital as the residential establishment, which provides shortterm and long-term medical care consisting of observational, diagnostic,
therapeutic, and rehabilitated services for persons suffering or suspected to be
suffering from a disease or an injury.
Hospitals occupy an important place in the entire disaster management cycle.
They render medical care to those affected by disasters. It is necessary that a
list of referral hospitals is prepared to enable timely transportation of the seriously
affected to appropriate hospitals during disasters. For this purpose, hospitals
with specialisation and capabilities of handling mass casualities are to be
identified. This will help in providing quick treatment and clinical care to the
affected.

9.2

98

CLINICAL CASUALTY MANAGEMENT

Casualty management at the clinical side or in hospital begins with an alert call
to the hospital. Ideally, every hospital, whether big or small should have a disaster
plan, which should be put into action on receiving the initial alert regarding
disaster. Medical Superintendent of the hospital should try to get the maximum

information regarding type, place and time of disaster, and type and number of
casualties expected. The hospital phase begins with basic tasks pertaining to
alert and response, triage, clinical care, documentation, and medico-legal. We
will now deal with each one of these tasks.

Clinical Casualty
Management

9.2.1 Hospital Alerting and Response

It is the first step in the hospital phase and should include the following:
1) Alert: All medical and paramedical staff of the hospital is alerted to
assemble in the hospital casualty.
2) Expansion of casualty area: If it is expected that hospital casualty space
will not be enough, then the main O.P.D. hall (or some such place) should
be opened upon to receive the causalities. Adequate accommodation should
be arranged in various wards/side/rooms/seminar rooms/halls or any other
space, and later on by discharging certain categories of patients. All existing
operations theatres should be opened up. Every district hospital should gear
itself to commission a disaster ward at a short notice. The concept of
crises expansion should be employed, when number of casualties are high.
If space within the hospital is inadequate, nearby community hall, school,
etc. can be converted into a disaster ward.
3) Security arrangements by hospital security staff with the help of police
personnel: Police should also act as traffic-controllers and direct patients
and relatives to respective reception centres. Complexity of the problem
gets compounded when one finds that it is not merely the numerical load of
patients, but also a large number of relatives, attendants, and public, who
by their natural anxiety add further liability to the management of casualties.
If required, hospital entry/exit should be controlled by police personnel.
4) Management of casualties: Principle of triage is to be applied so that
casualties can be classified on the basis of need and treatment.
5) Brought in dead: or those who die while receiving resuscitation should be
segregated, and shifted to the place identified for temporary morgue. This
should be done on priority to keep the morale of victims and working staff.
6) Diagnostic services: Laboratory, Radiology, and Imaging Services should
be made fully operational and utilised as and when required.
7) Emergency light arrangements: Additional generators are to be provided
in casualty, blood bank, and x-ray department. A spare transformer of 500
KW should available as a standby.
8) Communication: Both extra-mural and intra-mural communication system
need to be strengthened.
9) Support and utility service: should be alerted. Engineering department
should ensure that water and electricity is made available without interruption.
10) Medical supplies: Both drug and non-drug items need to be augmented
and hospital buffer stock should be utilised. Spot purchases should be made
as per rules.
11) Blood bank services to be put on alert: Officer in-charge or the Medical
Officer should approach voluntary organisations and volunteers and arrange
for blood of all groups.

99

Disaster Medicine

12) Public relations and information system: Hospital should identify and
notify an officer who will give information to public, press, radio, and other
organisations. He alone will give the requisite and relevant information.
Hospital staff should not reveal information in an unqualified manner and
cause confusions and controversies. Panic is a dangerous element in disaster
and therefore, hospital should start functioning immediately.
13) Discharge procedure: After appropriate treatment, casualties fit to be
discharged should be sent home. Their destination has to be noted and the
police has to be kept informed.

9.2.2 Hospital Triage

Hospital triage is the process by which disaster causalities brought to hospital
are sorted, prioritised, and distributed according to their requirement for clinical
care. The aim is to provide appropriate clinical care to maximum number of
causalities. There is a need for optimum utilisation of resources and available
services. The objective of triage in a hospital is to minimise death and disability.
The goal of triage is two-fold:

To select those patients in greatest need to medical attention and to arrange

for their treatment.

To ensure that a patient goes for treatment only to the appropriate

forewarned medical faculty as a means of limited personnel and supply
sources.

Senior clinicians should perform the triage. When there is a heavy load, it is
suggested to have four teams, each consisting of:
1) One General Surgeon
2) One Orthopedic Surgeon
3) One Physician
4) One Anesthetist
5) Two Staff Nurses
6) Nursing Attendants
7) One Sweeper
8) Two teams of stretcher-bearers, each having a stretcher, and two stretcher
bearers.
In medical terms, triage means sorting out and classifying casualties. Triage
will help in classifying casualties into three categories:

100

Priority I are critically and severely ill, who need immediate resuscitation
and life and limb saving surgery in six hours.

Priority II- are moderately ill, who require resuscitation and early surgery
within next twenty four hours.

Priority III- are with minor illness and injuries. Moribund patients under
irreversible shock are also allotted priority III, as chances are negligible.

In mass causalities, triage can be supplemented by giving colour-coded tags,

such as:

Red

Yellow for moderately serious patients

Blue

for patients requiring observation

Black

for dead

Clinical Casualty
Management

for serious patients

9.2.3 Clinical Care

Clinical management of causalities has two procedures:

Resuscitation, if required

Treatment for different injuries or diseases

1) Resuscitation: The laid down protocols for resuscitation, which are to be

applied to individual patients in an hospital emergency department or casualty,
cannot be effectively applied in a disaster or mass casualty situation. In disaster
situations, the medical needs of victims may be out of proportion of the available
clinical facilities and services.
After the hospital triage, those identified for resuscitation should be given top
priority, and though, this is the group of patients known to have poor outcomes
even when maximal care is given, all attempts should be made to ensure their
lives.
In resuscitation, the ABC model had to be applied. This treatment mode involves
a sequential approach to the patient in the following manner:
a) Airway and cervical spine care
b) Breathing and ventilation
c) Circulatory support and control of hemorrhage, if any.
We have dealt with the resuscitatory procedures in detail in the Practical Manual
Unit of this Course. Do visit the casualty department of a busy hospital and see
how resuscitation is given. It is like giving a new life.
2) Treatment of different injuries or diseases: In a disaster, or when mass
causalities have reached a hospital, there will be requirement of treatment from
simple antiseptic dressings to major surgical operations. Although, simple
dressings are always done at the first aid camps posted at disaster sites.
Management of wounds is the most common clinical intervention, which is
required in such situations. Though it can be delayed, as it can wait, but at
times this process can dispose off maximum number of patients. After the triage,
the nursing staff should deal with those requiring simple management of wounds.
The wounds, which require urgent care, such as bleeding has to be immediately
managed. Dressing of wounds, tetvac injection, and painkillers should be given.
In earthquakes, cyclones, and building collapse, most of the victims suffer crush
injuries. Such patients will require I.V. fluids, painkillers, and management of
wounds and fractures.
Dislocation, if any, should be reduced and corrected as early as possible.
Definitive management of fractures can be deferred, but, it should be supported
by proper splints, immobilisation, and painkillers.

101

Disaster Medicine

There may be children who require special care and attention. It is very
important to maintain body temperature especially in children, as they are more
prone to hypothermia. Drug dosage should be adjusted for them based on their
body weight, and I.V. fluids should be carefully given.
Clinical management of those who have received severe burns must immediately
be given painkillers, mostly injectable painkillers, I.V. fluids, and burn dressings.
Victims with respiratory burns should be prioritised for treatment.
Mass burn causalities pose a big administrative problem, as existing burn units
in almost all hospitals are always fully occupied. Transferring of patients is also
very difficult. Hence, it is necessary that as soon as the extent of disaster and
approximate load of burn victims is known, a centralized emergency burn unit
should be made functional, so that, maximum number of burn victims can be
managed clinically.
In all, the important principles to prepare hospitals for disaster are:

Decide priorities and prepare for receiving about 100-200 patients.

Take Collectors permission for sample post-mortem.

Make no assumptions.

Use colour code.

Do not send teams, rather organise your hospital to receive casualties, and
manage them.

Take simultaneous actions.

Triage not only for patients but also for vehicles, telephones, drugs, etc.

9.2.4 Documentation
Identification of patients should be done simultaneously with first aid and triage.
System of rapid labelling can be followed for identifying patients by giving a
serial number and putting an identification tag to his/her wrist. The registration
number given can also be written by MC paint or GV paint on patients body.
Medico-legal aspects for disaster response include both patients and staff. Hence,
documentation should pertain to identification of responders and patients, and
all the care that has been given. Registers marking the staff on duty, their
duties, and their relieving time should be laid down. The injuries and the related
treatment given by the staff should also be written.

9.3

CONCLUSION

Every hospital needs to keep itself prepared for meeting emergencies arising
out of any disaster. There has to be an emergency control centre manned by
the Medical Superintendent, and other medical and paramedical officials, to
take immediate action during such times. Hospital should always draw its disaster
management plan, and acquaint its personnel through training and simulation.
Equally, all arrangements in terms of logistics should be made to meet such
contingencies. Focus has to be on trigger mechanism. All activities pertaining
to the hospital phase need to be smart, that is, specific, measurable, accurate,
reliable, and timely.

102

9.4

REFERENCES AND FURTHER READING

Clinical Casualty
Management

American College of Surgeons, 1994, Committee on Trauma, ATLS Reference

Manual, Chicago.
Auf der Heide, E., 1989, Disaster Response, Principles of Preparation and
Coordination, Mosby, St. Louis.
Champion, H.R., Sacco, W. J., 1983, Role of Trauma Score in Triage of Mass
Casualties, Disaster Medicine.

9.5 ACTIVITY
Visit the casualty department of a nearby hospital. See how the department
functions. Observe how triage and resuscitation is done. You can pen down
your observations and experiences.

103