Casualty Incident Management

Definition of Casualty

In the Oxford or English dictionary, casualty is usually used for someone killed or injured in war or an accident. In medicine or first aid, casualty means a seriously injured person or patient. When responding to a casualty, first responder must assess them for any life-threatening conditions or serious injuries. Spotting these early will allow them to be treated, with the recovery of the casualty significantly increasing.

Triage for a Multiple Casualty Incident

A first aider might be involved in a serious accident or incident with heavy casualties. When there are more civilian casualties than first aiders, a system of determining the priority of treatment is required, known as triage. Otherwise, a casualty is likely to die from an injury that could have been managed if treated promptly.

In the late 90s, Australia’s and New Zealand’s emergency and medical departments adopted an incident triage system known as the Australasian Triage Scale (ATS).

ATS Category Description Should be treated within

Resuscitation 0 minutes – immediate
Emergency 10 minutes
Urgent 30 minutes
Semi-Urgent 60 minutes
Non-urgent 120 minutes

In an emergency situation, first aid-trained people can use a simple triage system known as Simple Triage and Rapid Treatment (START), as per the following chart.

The goal of triage is to achieve the greatest good for the highest number of injured.

At times, emergency services are faced with a casualty whose condition is so severe that despite the best available advanced care, they cannot survive. If they treat this casualty, it would divert medical resources from a casualty who could be treated and saved and may then be compromised. This applies especially in circumstances where the casualty figures outweigh the number of responders or rescuers.

Managing a Multiple Casualty Incident, Directing a First Aid Team

During the initial stages of a multiple-casualty incident, first aiders may be overwhelmed by the scope of casualties and injuries, and as the head first aider or team leader, it is vital to show leadership. Try to remain calm and reassure the team. Never assume that every team member is okay and knows what they need to do. Review the situation. Give clear and precise directions to minimise confusion and anxiety. Effective leadership will instil confidence that the incident is being effectively managed.

Procedure for managing a multiple casualty incident

Conduct a scene assessment – what has occurred, estimate the number of casualties, what first aid equipment is required
Immediately call emergency services on triple zero (000) to ensure medical help is on the way – inform them of the incident
Have someone waiting at the main entry point to direct them to the correct location of the incident and assign a triage location
Manage the team of first aiders effectively to optimize the team size and skill level. Assure the well-being of the team
Determine if the incident scene is safe before entering. If not, render it as safe as possible
If chemicals or hazardous goods are involved, follow SDS directions and wear the appropriate PPE/C to handle the incident safely
Organise other people to assist with managing traffic or other hazards
Automatically take along first aid kit/s and the automated external defibrillator or AED to any incident
You may meet people who are self-evacuating the incident as you arrive. Direct these people to a suitable area of refuge so they can be later monitored and evaluated
Triage commences
Clear out remaining “walking wounded”. Do this by announcing, “If anyone is well enough to stand up and walk out of here, do so now.” Direct them to a suitable area of refuge so they can be later monitored and evaluated
Start assessing the first casualty that you encounter
Follow infection control principles at all times
Check for DRS ABCD(danger, response, airways, breathing, cardiopulmonary resuscitation or CPR, Defibrillation)
*For some, their first aid training uses the DRABC acronym.
Check vital signs and visual survey.
If appropriate, leave the casualty in the recovery position
Make a decision on what priority level they are
Move on to the next casualty and repeat steps 13 to 16
Repeat steps 13 to 17 until all casualties are assessed
Assign first aiders to begin more intensive treatment in order of categorization
Once treated, a casualty should be constantly monitored until the arrival of emergency services who will take over the care of the casualty

What if, on your first assessment, the casualty falls into the RED or immediate category? Before moving on to the next casualty, only attempt to rectify airway problems or uncontrolled bleeding. For this, assign one of your first aiders to manage. They can be assisted by a capable “walking wounded” by maintaining the casualty’s head position to keep an open airway or direct pressure on a large bleeding wound. You move on to assess the next casualty.

Once all the casualties have been triaged, more intensive treatment can begin. For safety reasons, casualties may need to be moved to a safer treatment area. Casualties classified as RED or immediate are transferred first, followed by those tagged YELLOW or delayed. There is no need to move the casualties classified as BLACK. Your role is to assign the first aiders to the appropriately categorized casualties. Move from casualty to casualty, giving direction as required, encouragement, reassurance, and commendation to your team.

Evaluate Incident Response

Once the documentation and reporting process has been completed, the following steps must take place:

Review and assess the first aider’s and organisation’s management and responses to the incident
Were the required equipment and first aid resources deployed effectively and timely? Were there sufficient supplies and appropriate equipment?
Were all communications involving the incident handled correctly?
Did staff have the required level of training to manage the incident?
Review the First Aid Plan
Reviews can generate improvements in processes and procedures. If so:
Implement improvements as soon as possible
Communicate improvements and updates to all staff

First Aid Secondary Survey Assessment

The Primary Survey for any situation is known as DRS ABCD. If the casualty is unconscious, always follow DRS ABCD. If the casualty is conscious, follow a logical progression of questioning and a visual survey to determine what has occurred.

Once completed, you can conduct a more thorough assessment of the casualty, known as the Secondary Survey Assessment, commonly known as the head-toe assessment. Having gained consent from the casualty, inform the casualty of what you plan to do and why. For the assessment, be sensitive and mindful of the person’s age, gender and situation. Continue to calmly talk to the casualty as you go through each step. Carefully listen for any comments made by the casualty.

Note: Do not perform the head-to-toe assessment if the casualty objects.

Follow infection control principles at all times.

Head-to-Toe Assessment

Step 1: Head, Face and Neck

Starting from the top. Examine the head, face and then neck for signs of fractures, eye trauma, neck or head injuries
o Bleeding, sweating, swelling, bruising, pain and tenderness, tingling or numbness
Check scalp for bumps or bleeding
Check eyes for uneven pupil size and if it reacts to light. (refer to Image by Radomil) Is there swelling around the eyes and becoming discoloured
Is the nose bleeding or out of shape?
Check the mouth for loose teeth or bleeding
Is the casualty wearing a medical alert necklace?
Can casualty wiggle fingers and toes? Ask them to squeeze your hand with each arm
If a spinal injury is suspected, do not move the head or neck

Step 2: Shoulders, Chest, Abdomen and Pelvis

Check for chest movements. Signs and symptoms:
o Rise and fall, slow, fast or uneven breathing, gasping for breath and noisy breathing
Check for penetrating injuries (do not remove any penetrating objects)
Check for bleeding, sweating, swelling, bruising, pain and tenderness
Gently press against the chest and abdomen with the flat palm to assess for pain response
Are there signs of incontinence?

Step 3: Arms and Legs

Pat down the limbs to check for:
o Wetness that may indicate bleeding
o Deformities such as swelling, crooked limb or protruding bone will indicate an area of injury
o Bruising, tenderness
Ask the casualty to move their arms and legs one at a time
Is the casualty wearing a medical alert bracelet?
Observe the skin and note the colour. Feel the skin for temperature and note if it is hot, cold, clammy or perspiring (Applies to all steps)

After completing the head-to-toe assessment and the visual and verbal survey, the first aider should have a basic idea of the signs and symptoms indicating what first aid treatment is required.

Vital Signs

It is essential to take and record the casualty’s vital signs as soon as practical. Follow infection control principles at all times

The four vital signs are the casualty’s temperature, respiration, pulse, and blood pressure. Vitals should be taken and recorded regularly. This helps to establish a starting point for readings. Ongoing readings can help indicate if the condition is deteriorating or stabilizing.

A copy of the recorded results should be provided to the paramedics as a reference.

Temperature

Normal body temperature may vary by person, age, activity, time of day and which part of the body you take the temperature from. As per the chart, temperature readings that are too low or too high can indicate serious issues for casualty.

There are various methods of taking a person’s temperature. For first aid, either a digital thermometer or an ear thermometer is used.

Please avoid using mercury in glass thermometers, as they can easily break and prove to be highly toxic.

Temperature – Digital Thermometer

Before each use, place a plastic probe cover on the thermometer or sterilise the probe with an alcohol swab (based on brand type)
Press the button to turn the thermometer on.
Place the thermometer under the tongue for two minutes. Casualty to close mouth and breathe through the nose
Take the thermometer out of the casualty’s mouth to read the results and record them.
Dispose of probe cover or sterilise probe.

If the casualty cannot keep the thermometer under the tongue (could be an unconscious, too young, injured mouth, etc.), place the thermometer under the armpit for two minutes. Gently support in place.

Temperature – Ear Thermometer

Always read and follow the manufacturer’s directions
Place a plastic probe cover on the thermometer or sterilise the probe with an alcohol swab (based on brand type)
Gently insert the thermometer’s probe into the ear canal
Press the button on the thermometer to take the reading
Hold until the thermometer indicates that the reading has been taken
Remove the thermometer. Read results and record
Dispose of probe cover or sterilise probe

Respiration

Children have quicker respiratory rates than adults, and women breathe more often than men. The normal ranges for different age groups are listed as follows:

The respiration rate is the number of breaths a person takes per minute. Measure the rate while the casualty is at rest or unaware that you are counting breaths. You count breaths for one minute by counting how many times the chest rises.

Respiration rates may rise with fever, illness, and other medical conditions. When checking respiration, it is also important to note whether a person has any difficulty breathing or the quality of their breathing, e.g., irregular rhythm, rapid, slow, laboured, shallow, difficult, gurgling, or gasping.

Record respiration rate and any abnormal breathing characteristics.

Pulse

The heart rate, or pulse, is the number of times the heart beats per minute. Regular heart rate varies from person to person. The average resting heart rates, which vary with age, are as per the chart.

A typical pulse should be regular in rhythm and force.

Counting the pulse rate is a simple way to determine how fast the heart is beating. You are actually feeling an artery as the heartbeat pushes a wave of blood through it.

Regular pulse rhythm: Steady beat with even spacing between beats

Irregular pulse rhythm: No pattern. You may skip beats, and the spacing between beats may vary. Strong pulse force: The beat strength of the pulse is muscular. Easy to feel and steady. Weak pulse force: The beat strength of the pulse is weak. It is more challenging to think and is inconsistent

An irregular and weak pulse could indicate a serious health concern or illness.

Taking a Pulse

The pulse can readily be felt over two arteries:

Radial – in the wrist
Carotid – on each side of the neck

The most common and convenient place to measure the pulse is to feel the radial artery in the wrist. This area is located on the inside of the wrist on the thumb side.

Image: Pulse evaluation by Pia von Lützau

Use the pads of your index and middle fingers to press lightly to “feel” the pulsing artery. It is not always easy to find, so move your fingers around until you feel the pulse. Count the beats for 60 seconds using a second-hand watch or a timing device on a mobile phone.

Note: Do not use your thumb, as you may feel your pulse instead of the casualty’s.

Record the pulse rate and any abnormal characteristics of the rhythm or strength of the pulse.

Cultural Differences

Managing casualties is an integral part of first aid. It is a valuable skill that can save lives if done correctly. No matter where you go in the world, these skills remain relevant.

That said, it is essential to remember where one is in the world. While casualties must be saved, it is essential to remember that one must stay culturally respectful; what may work for an American may be inappropriate for an Arabic person. Chinese and Japanese casualties may both be from Asia, but they still have different cultures. Even the Portuguese, German, French, Italian, Spanish, Russian, and British cultures must be respected.

First aid is a universal set of skills used to save lives. These skills need to be sharpened and practised, but not without the guidance of the cultural practises and preferences a country or people may have. So, apart from brushing up on your first aid casualty management skills and languages other than English, remember to temper them for the place and people you are saving.

Take a First Aid Course Today

Whether a first aid training course or CPR training, any of these skills will be helpful in emergencies. Even an introductory first aid class will guide you on what to do in first aid situations, emergency first aid, the order of priority for first aid procedures, what to do with cardiac arrest, how to carry out chest compressions, and much more. Take a first aid course today!