Emergency radiology and mass casualty incidents—report of a mass casualty incident at a level 1 trauma center

AbstractIntroduction:Terrorist attacks have occurred in Tel-Aviv that have caused mass-casualties.The objective of this study was to draw lessons from the medical response to an event that occurred on 19 January 2006, near the central bus station, Tel-Aviv, Israel. The lessons pertain to the management of primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals and the operational mode of the participating hospitals during the event.Methods:Data were collected in formal debriefings both during and after the event. Data were analyzed to learn about medical response components, interactions, and main outcomes. The event is described according to Disastrous Incidents Systematic AnalysiS Through—Components, Interactions and Results (DISAST-CIR) methodology.Results:A total of 38 wounded were evacuated from the scene, including one severely injured, two moderately injured, and 35 mildly injured. The severe casualty was the first to be evacuated 14 minutes after the explosion. All of the casualties were evacuated from the scene within 29 minutes. Patients were distributed between three adjacent hospitals including one non-Level-1 Trauma Center that received mild casualties. Twenty were evacuated to the nearby, Level-1 Sourasky Medical Center, including the only severely injured patient. Nine mildly injured patients were evacuated to the Sheba Medical Center and nine to Wolfson Hospital, a non-Level-1 Trauma Center hospital. All the receiving hospitals were operated according to the mass-casualty incident doctrine.Conclusions:When a mass-casualty incident occurs in the vicinity of more than one hospital, primary triage, evacuation priority decision-making, and rapid distribution of casualties between all of the adjacent hospitals enables efficient and effective containment of the event.

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Practicing Mass Casualty Scenarios: Experience From a Developing Level 1 Trauma Center in the Himalayan Foothills

Disaster Medicine and Public Health Preparedness ◽

10.1017/dmp.2020.38 ◽

2020 ◽

pp. 1-6

Author(s):

Md Quamar Azam ◽

Mahesh Devasthale ◽

Chandu Raj B ◽

Ajay Kumar ◽

Bhaskar Sarkar ◽

...

Keyword(s):

Trauma Center ◽

Trauma Surgery ◽

Mass Casualty ◽

Low Resource Settings ◽

Low Resource ◽

Natural Beauty ◽

Increased Risk ◽

Himalayan Foothills ◽

Level 1 ◽

Level 1 Trauma Center

ABSTRACT Objective: Uttarakhand is an Indian state in the Himalayan foothills, a favored adventure destination in the country due to abundant natural beauty. However, the terrain has also conferred an increased risk of earthquakes, flash floods, and major road tragedies, resulting in as many as 8 major natural disasters in the state in the preceding 20 years. AIIMS Rishikesh, an autonomous central institute, has been entrusted to build a Level 1 Trauma Center in Uttarakhand, which would help improve the response, coordination, and hence outcome in mass casualty scenarios (MCSs). Methods: As a step toward the achievement of this larger goal, a workshop on MCS and management was conducted by the Department of Trauma Surgery in collaboration with Rambam Hospital, Haifa. We hereby present our template for conducting MCS drills in low resource settings like ours and the lessons learnt. Results: Process, logistics, limitations, workforce, scheduling, overview, and report of the MCS drill conducted are discussed hereafter. Conclusion: This template may be replicated by hospitals that intend to conduct similar MCS drills in low resource settings, realizing the real threat of MCS occurrence in our country at anytime.

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Tabletop Application of SALT Triage to 10, 100, and 1000 Pediatric Victims

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20000163 ◽

2020 ◽

Vol 35 (2) ◽

pp. 165-169

Author(s):

Nicholas McGlynn ◽

Ilene Claudius ◽

Amy H. Kaji ◽

Emilia H. Fisher ◽

Alaa Shaban ◽

...

Keyword(s):

Pediatric Patients ◽

Pediatric Trauma ◽

Mass Casualty Incident ◽

Mass Casualty ◽

Trauma Patients ◽

Kappa Test ◽

Life Saving ◽

Number Of Patients ◽

Level 1 ◽

Level 1 Trauma Center

AbstractIntroduction:The Sort, Access, Life-saving interventions, Treatment and/or Triage (SALT) mass-casualty incident (MCI) algorithm is unique in that it includes two subjective questions during the triage process: “Is the victim likely to survive given the resources?” and “Is the injury minor?”Hypothesis/Problem:Given this subjectivity, it was hypothesized that as casualties increase, the inter-rater reliability (IRR) of the tool would decline, due to an increase in the number of patients triaged as Minor and Expectant.Methods:A pre-collected dataset of pediatric trauma patients age <14 years from a single Level 1 trauma center was used to generate “patients.” Three trained raters triaged each patient using SALT as if they were in each of the following scenarios: 10, 100, and 1,000 victim MCIs. Cohen’s kappa test was used to evaluate IRR between the raters in each of the scenarios.Results:A total of 247 patients were available for triage. The kappas were consistently “poor” to “fair:” 0.37 to 0.59 in the 10-victim scenario; 0.13 to 0.36 in the 100-victim scenario; and 0.05 to 0.36 in the 1,000-victim scenario. There was an increasing percentage of subjects triaged Minor as the number of estimated victims increased: 27.8% increase from 10- to 100-victim scenario and 7.0% increase from 100- to 1,000-victim scenario. Expectant triage categorization of patients remained stable as victim numbers increased.Conclusion:Overall, SALT demonstrated poor IRR in this study of increasing casualty counts while triaging pediatric patients. Increased casualty counts in the scenarios did lead to increased Minor but not Expectant categorizations.

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Wound patterns in survivors of modern firearm related civilian Mass Casualty Incidents

American Journal of Disaster Medicine ◽

10.5055/ajdm.2019.0329 ◽

2019 ◽

Vol 14 (3) ◽

pp. 175-180

Author(s):

Chase Knickerbocker, MS ◽

Mario F. Gomez, DO ◽

Jose Lozada, MD ◽

Jonathan Zadeh, MD ◽

Eugene Costantini, MD ◽

...

Keyword(s):

Trauma Center ◽

Multidisciplinary Approach ◽

Mass Casualty ◽

Medical Examiner ◽

Fatality Rate ◽

Mass Shootings ◽

Fort Lauderdale ◽

Mass Shooting ◽

Level 1 ◽

Level 1 Trauma Center

Background: Civilian mass shooting events (CMSE) are occurring with increased frequency. Unfortunately, our knowledge of how to respond to these events is largely based on military experience and medical examiner data. While this translational knowledge has improved our basic response to such events, it is critical that we have a better understanding of the wound patterns observed and the resources utilized in civilian mass shootings. This will allow us to better prepare our systems for future events.Methods: Patients from two consecutive CMSEs presented to the same level 1 trauma center in Fort Lauderdale, Florida. The patients received by this center were studied for their wound patterns as well as the care they received while in the hospital. This included wound patterns and severity, subspecialty interventions, and hospitalization requirements.Results: Both events produced a total of 19 victims who were brought to the center as trauma activations. The events had a combined fatality rate of 55 percent. Fifty-five percent of patients also had at least one wound to an extremity, two with major vascular injuries who had field tourniquets applied. Sixty-three percent required an orthopedic intervention and 32 percent required intensive care unit (ICU) admission, half of these with prolonged ventilator support.Conclusions: Given the number of extremity wounds in these events, we should continue the efforts championed by the stop the bleed campaign. The variety and quantity of specialties involved in the care of these patients also highlights the importance of a multidisciplinary approach to preparation and implementation of care in mass shooting events.

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Comparison of Computerized Patients versus Live Moulaged Actors for a Mass-casualty Drill

Prehospital and Disaster Medicine ◽

10.1017/s1049023x15004963 ◽

2015 ◽

Vol 30 (5) ◽

pp. 438-442 ◽

Cited By ~ 10

Author(s):

Ilene Claudius ◽

Amy Kaji ◽

Genevieve Santillanes ◽

Mark Cicero ◽

J. Joelle Donofrio ◽

...

Keyword(s):

Student Performance ◽

Mass Casualty Incident ◽

Mass Casualty ◽

Simulated Patients ◽

Publication Type ◽

Multiple Modalities ◽

Computer Based ◽

Level 1 ◽

Computerized Simulation ◽

Level 1 Trauma Center

AbstractIntroductionMultiple modalities for simulating mass-casualty scenarios exist; however, the ideal modality for education and drilling of mass-casualty incident (MCI) triage is not established.Hypothesis/ProblemMedical student triage accuracy and time to triage for computer-based simulated victims and live moulaged actors using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) mass-casualty triage tool were compared, anticipating that student performance and experience would be equivalent.MethodsThe victim scenarios were created from actual trauma records from pediatric high-mechanism trauma presenting to a participating Level 1 trauma center. The student-reported fidelity of the two modalities was also measured. Comparisons were done using nonparametric statistics and regression analysis using generalized estimating equations.ResultsThirty-three students triaged four live patients and seven computerized patients representing a spectrum of minor, immediate, delayed, and expectant victims. Of the live simulated patients, 92.4% were given accurate triage designations versus 81.8% for the computerized scenarios (P=.005). The median time to triage of live actors was 57 seconds (IQR=45-66) versus 80 seconds (IQR=58-106) for the computerized patients (P<.0001). The moulaged actors were felt to offer a more realistic encounter by 88% of the participants, with a higher associated stress level.ConclusionWhile potentially easier and more convenient to accomplish, computerized scenarios offered less fidelity than live moulaged actors for the purposes of MCI drilling. Medical students triaged live actors more accurately and more quickly than victims shown in a computerized simulation.ClaudiusI, KajiA, SantillanesG, CiceroM, DonofrioJJ, Gausche-HillM, SrinivasanS, ChangTP. Comparison of computerized patients versus live moulaged actors for a mass-casualty drill. Prehosp Disaster Med.2015; 30(5): 438–442.

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Faculty Opinions recommendation of [CONFERENCE POSTER]: Outcomes of endoscopic realignment of blunt posterior urethral injuries at a Level 1 trauma center.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.11414968.12436067 ◽

2011 ◽

Author(s):

Sanjay Kulkarni

Keyword(s):

Trauma Center ◽

Level 1 ◽

Level 1 Trauma Center ◽

Urethral Injuries

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Prehospital Triage by Lay Person First Responders: A Scoping Review and Proposal for a new Prehospital Triage Tool

Disaster Medicine and Public Health Preparedness ◽

10.1017/dmp.2021.19 ◽

2021 ◽

pp. 1-11

Author(s):

Wesley D Jetten ◽

Jeroen Seesink ◽

Markus Klimek

Keyword(s):

Scoping Review ◽

Life Support ◽

First Responders ◽

Mass Casualty Incident ◽

Mass Casualty ◽

Mass Casualty Incidents ◽

Lay People ◽

Online Databases ◽

Healthcare Experience ◽

Prehospital Triage

Abstract Objective: The primary aim of this study is to review the available tools for prehospital triage in case of mass casualty incidents and secondly, to develop a tool which enables lay person first responders (LPFRs) to perform triage and start basic life support in mass casualty incidents. Methods: In July 2019, online databases were consulted. Studies addressing prehospital triage methods for lay people were analyzed. Secondly, a new prehospital triage tool for LPFRs was developed. Therefore, a search for prehospital triage models available in literature was conducted and triage actions were extracted. Results: The search resulted in 6188 articles, and after screening, a scoping review of 4 articles was conducted. All articles stated that there is great potential to provide accurate prehospital triage by people with no healthcare experience. Based on these findings, and combined with the pre-existing prehospital triage tools, we developed a, not-yet validated, prehospital triage tool for lay people, which may improve disaster awareness and preparedness and might positively contribute to community resilience. Conclusion: The prehospital triage tool for lay person first responders may be useful and may help professional medical first responders to determine faster, which casualties most urgently need help in a mass casualty incident.

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Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers

BMC Emergency Medicine ◽

10.1186/s12873-021-00487-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Charlie A. Sewalt ◽

Benjamin Y. Gravesteijn ◽

Daan Nieboer ◽

Ewout W. Steyerberg ◽

Dennis Den Hartog ◽

...

Keyword(s):

Logistic Regression ◽

Trauma Center ◽

Trauma Patients ◽

Trauma Centers ◽

Absolute Benefit ◽

Predicted Probability ◽

Prehospital Triage ◽

Level 1 ◽

Level 1 Trauma Center ◽

Level 2

Abstract Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.

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