Mass Casualty Incident Scenario

What should be your first action? 

You complete an initial report so ambulance control can notify other emergency services and start sending further resources. As you leave your car, more bystanders have seen you and are shouting for help. You are starting to think there may be many patients including some quite unwell.  

When should a major incident be declared? 

What does METHANE stand for? 

You have just declared a major incident and present your METHANE to control. Thankfully, an ambulance commander has arrived alongside initial police response. Police start making the scene safe and cordoning off the incident. The ambulance commander takes control of commander duties and agrees with the major incident declaration. He asks if you can quickly triage how many patients there are so he can get an idea of the severity and update control and the resources on route. 

Within the UK setting, what triage tool should you use to get your initial triage priorities? 

As you progress through the casualties to get an idea of the numbers, you finally get to the patient who is bleeding heavily. He is stuck in the vehicle and is in a bewildered state. You start your TST and find they have an open fracture to the lower left leg and a catastrophic bleed. 

What should you do next? 

You apply a trauma dressing which stops the bleeding and move onto the next patient. You come across a patient who has self-extricated out of the car but can no longer walk from the scene. They are talking, have no severe bleeding, but have a penetrating injury to their lower right abdomen. How would you grade this patient?

You complete your initial triage and report back to the ambulance commander; 3 P1, 2 P2, and 7 P3 patients. The ambulance commander has more resources arriving so is starting to assign patients to clinicians. You are assigned back to the 36-year-old male with an open lower left leg fracture. You start your usual assessment as if meeting the patient for the first time. They are acting quite anxious and are in a lot of pain, your questions are not really getting answered. You obtain observations of: 139 HR, 30 RR, 99/65 BP, 97% Sp02, 36.3 Temp and 4.2 BM. They are normally fit and well and take no medications. 

When recording these observations, what would be a major concern? 

Hypovolaemic shock can be classed into 4 categories increasing in severity. What class would you determine our patient is in?

You are concerned about the patient’s observations and suspect further bleeding. You re-check the bandage on the leg and it still seems to have stopped. You can’t see any other external haemorrhage, what are some of the other internal haemorrhage areas we should examine?

The patient’s abdomen is soft and only slightly tender superficially where the seatbelt was. The chest is clear with good bilateral air entry and deep inhalation is symmetrical. You suspect the patient’s pelvis has sustained injury as he states he had his left leg up on the dashboard when they crashed. What assessments should be completed when assessing specifically the pelvis?

A pelvis injury must be managed as a time-critical injury even if there is only a relevant mechanism of injury and hypotension?

Fire service staff ask your opinion on the patients’ condition and what method of extrication is required. They can cut the roof off but may take 20 minutes, or they can cut out the passenger side door to get the patient out quickly but may be more painful for the patient. You suspect pelvic injury but are unable to get access to secure a pelvic binder. You are still concerned that the patient has ongoing internal haemorrhage and may not remain stable for long. What method would you prefer?

You start to consider other treatment for the patient as you gain IV access whilst they cut the door out for faster extrication. You are concerned the patient may have a pelvic bleed and need to treat as soon as possible. What pain relief may be most appropriate to start if the patient is in severe pain whilst gaining IV cannulation?

Can Penthrox be given with a patient who has a systolic BP under 90mmHg? 

You gain IV access and record a second set of observations of: 142 HR, 34 RR, 89/54 BP, 95% Sp02, 36.0 Temp, 4.2 BM. What other treatments could you consider at this point?

What systolic blood pressure should we aim for for blunt trauma of the trunk or limbs?

You have started your treatment and the fire service are there to assist you to extricate the patient via a longboard. An ambulance crew has now arrived to take care of the patient and bring a stretcher ready. What equipment may you want to lay out on the stretcher to ease continuity of care and ensure swift placement?

You apply all your equipment set out on the stretcher and are happy with your current treatment. The crew have asked what hospital should they take the patient to, what do you recommend?