Since the terrorist suicide truck bombing of the U.S. Marine barracks in Beirut in 1983, the “imagination” of Americans has continued to be taxed with devastating consistency. Explosions and bombings remain the most common deliberate cause of disasters involving large numbers of casualties, especially as instruments of terrorism, yet we still have not learned how to anticipate and manage the tragic carnage they cause with any degree of effectiveness. These attacks virtually always are directed against the untrained and unsuspecting civilian population. Unlike the military, civilians are poorly equipped or prepared to handle the severe emotional, logistical, and medical burdens of a sudden large casualty load, and thus are completely vulnerable to terrorist aims.

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Medical management of disasters and mass casualties from terrorist bombings: how can we cope?

The term “golden hour” is commonly used to characterize the urgent need for the care of trauma patients This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury This concept justifies much of our current trauma system However, definitive references are generally not provided when this concept is discussed It remains unclear whether objective data exist This article discusses a detailed literature and historical record search for support of the “golden hour” concept None is identified

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2001.tb00201.x

The golden hour: scientific fact or medical "urban legend"?

Background: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. Study Design: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. Results: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. Conclusions: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors—MOI, LOMI, and SOL—should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.

https://www.journalacs.org/article/S1072-7515(99)00233-1/pdf

Survival after emergency department thoracotomy: review of published data from the past 25 years.

The main factor that distinguishes true mass casualty disasters from the routine management of injured patients is the large number of casualties that present essentially simultaneously, which outstrip the available resources required for their optimal care. The injuries themselves tend to be similar to those normally encountered in daily trauma practice, although they may be more severe and unique in certain settings (i.e. severe soft tissue disruption, shrapnel wounds or blast lung in victims of explosive disasters, cyanide poisoning in chemical events, acute radiation syndrome in radiological events). However, the large numbers of casualties greatly impede the ability to fully evaluate and treat each injured individual in a conventional manner. A major change in the approach to medical care is therefore required in order to optimize outcome. Medical evaluation and treatment must be rapid to allow for a continuing influx, and yet must remain accurate in identifying those critically injured victims who require immediate life-saving care. The focus of medical care can no longer be on each individual, but must shift to the population as a whole. The standard goal of providing the greatest good for each individual patient must change in a mass casualty setting to the greatest good for the greatest number. This requires a rationing of the limited resources to apply them where they are most beneficial for the most casualties. These concepts are antithetical to the morality and training of health care providers, yet are necessary to salvage the greatest number of lives in these circumstances (1–3). A key component of the delivery of medical care to mass casualties is the process of triage, from the French word triagere, meaning “to sort”. This concept was introduced by Napoleon’s battlefield surgeon, Baron Dominique Jean Larrey, and has since become a cornerstone of military medical care (4, 5). It involves matching the limited resources to the needs of casualties by assigning those who are most seriously injured to receiving priority care. This requires rapid identification of the severely injured in order to apply these resources most appropriately. The greater the casualty burden, the more difficult this becomes, and the more training and expertise is required. In fact, triage is practiced only occasionally and on small scales in the routine management of individual injured patients. The abundant medical resources in developed nations allow essentially unlimited application of care and expense to each patient, which makes rationing of care unnecessary. True mass casualty events are rare. The principles of triage are not taught in many medical schools or in residency training. This is why education and training assumes major importance in the care of mass casualties from any form of disaster, in view of how different the decision-making must be if the salvage of life is to be maximized (6).

https://journals.sagepub.com/doi/pdf/10.1177/145749690509400405

Triage: Principles and Practice

Background: The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy Methods: A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems. Results: Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92. Conclusion: The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

Advanced or basic life support for trauma: meta-analysis and critical review of the literature.

The Boston Emergency Medical Service system was studied to determine the effects of Advanced Life Support (ALS) prehospital trauma care compared to Basic Life Support (BLS) treatment. The severity of injury and clinical status of patients was defined and monitored using the Trauma Score (TS) described by Champion. The TS on arrival at the hospital increased significantly more for patients receiving field ALS care than for patients transported by BLS ambulances (p = 0.01). ALS resuscitation had most influence on patients with TS 4-13 and did not delay transport time. Furthermore, a positive change in prehospital TS was significantly related to an increased chance of long-term survival for any given severity of injury (p = 0.0002). From these data we conclude that the TS is useful for prehospital triage and that appropriate field ALS resuscitation results in more favorable outcomes following major trauma.

Prehospital advanced life support: benefits in trauma

External noninvasive cardiac pacing was applied outside the hospital to 19 patients who had experienced cardiopulmonary arrest and 1 patient with life-threatening bradycardia. Seven patients developed electrocardiographic evidence of pacemaker capture, although only 2 had palpable pulses. The patient with bradycardia was successfully paced. This study demonstrates the feasibility of cardiac pacing in out-of-hospital cardiac arrest but confirms the poor prognosis of asystolic cardiac arrest even with the application of pacing.

External noninvasive cardiac pacing in out-of-hospital cardiac arrest

The implementation of a contemporary comprehensive Emergency Medical Services System (EMSS) has resulted in a change in the method and character of initial response to and overall management of disaster situations. The focus of patient assessment and care responsibilities has shifted from the hospit

Anna Sinclair

Papers

Prehospital advanced life support: benefits in trauma

External noninvasive cardiac pacing in out-of-hospital cardiac arrest

The role of a trauma center in disaster management.