A mass casualty event is a situation in which the need for medical care and resources, including personnel, exceeds that which is available. As the largest component of the health care workforce, nurses represent a significant resource that can be called on to act as first responders during a mass casualty. However, current education and national guidelines fail to provide specific instruction on pre-hospital nursing considerations and interventions. This article provides evidence-based guidelines designed for nurses to use when acting as first responders during a disaster and presents recommendations for future nursing practice related to mass casualty events.

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A mass casualty event is defined as a situation in which the number of casualties exceeds the medical care that is available, including both supplies and staff.1 With more than 2.5 million nurses nationally, the largest component of the health care workforce, nursing represents a significant professional group that can be called upon to provide medical care to victims of traumatic mass casualty events.2 In addition, the traditional nursing skill set of rapid assessment and implementation of interventions is invaluable during such a disaster. However, current education and practice do not adequately prepare nurses to act as first responders during these emergencies.3

Currently, nursing school curricula do not place a great emphasis on disaster preparedness or response to a mass casualty event. Research has demonstrated that the average amount of time spent on content related to disaster preparedness is 4 hours. Furthermore, students report feeling that faculty is not well prepared and lacks the expertise to teach such content.4 The small amount of time that is designated toward this material focuses more on disaster prevention and management than on the nursing response to victims in the field. There is no educational proficiency standard in existence for mass casualty preparation in nursing school curricula, and, similarly, there are no continuing education courses that cover this content for the already existing pool of nurses.5 In addition, once in the workforce, nurses often follow clearly defined practice guidelines. However, in the chaos of mass trauma, nurses who are called upon as first responders reported difficulty working in an environment when lacking clear responsibilities and duties.6

The nursing community, both nationally and internationally, recognizes the importance of providing nurses with the knowledge and basic skills to deal effectively with complex disaster situations, given that nurses are frequently the first medical responders on-site after a disaster occurs.7 Therefore, the World Health Organization and International Council of Nurses have developed the International Council of Nurses Framework of Disaster Nursing Competencies. The purpose of this framework is to help clarify the role of the nurse in disaster situations regarding the 4 stages of disaster management: prevention, preparedness, response, and recovery. Although there is adequate literature on prevention and preparedness from the nursing perspective, the framework fails to provide actual interventions that can be performed by the nurses in the field acting as first responders. Similarly, the recommendations of the American Nurses Association for nursing response during disaster situations is to use professional competency to guide the provision of care, given the limited resources and difficult environmental conditions.8 Although these statements refer to the importance of nurses during such events, a huge gap in the literature exists related to specific guidelines for nurses acting as first responders. Nurses are not provided with concrete and tangible interventions that can be used while caring for victims in the field during a mass casualty emergency. It is this missing gap of information, as well as a lack of training, that must be addressed if nurses are to fill the role of first responders competently and effectively.

These findings are particularly alarming, especially in light of recent events including the earthquake and tsunami in Japan in 2011, the earthquake in Haiti in 2010, and Hurricane Katrina in the United States Gulf Coast in 2005. Approximately 1 disaster occurs per week on the global level that requires international assistance; an average of 34 federally declared disasters occur in the United States annually.9 Not only are natural disasters of concern but man-made disasters such as acts of terrorism, fires, mass shootings, transportation accidents, and exposure to radiation and other hazardous materials can also cause a mass casualty crisis. This significant number of emergency disasters and mass casualties, both man-made and natural, requires adequate preparation of nurses to appropriately act as first responders.4 This article seeks to prepare nurses for such events by providing evidence-based pre-hospital guidelines for care of the mass casualty victim.

GUIDELINES

Triage

The guiding principle during a mass casualty event is to "do the greatest good for the greatest number of casualties."9 Integral to achieving this is the accurate and consistent use of a unified pre-hospital triage model. The guidelines and use of this model must be standardized, as research has shown variation in triage accuracy across medical disciplines.10 Mass casualty victims who are undertriaged have a significantly higher risk of mortality when adjusted for injury severity than those who are correctly triaged. In addition, victims triaged to a higher level of care inconsistent with the severity of injury can lead to a misappropriation of crucial resources such as staff and supplies.10 Research has demonstrated a direct correlation between the rate of overtriage and mortality of those actually critically injured.11

The suggested method of triage is the revised version of the Field Triage Decision Scheme developed by the American College of Surgeons as outlined by the Centers for Disease Control and Prevention.11 The 3 criteria to determine level of triage are physiologic, anatomic, and mechanism of injury, with an additional category for special considerations. Findings that necessitate immediate transport to a trauma center are outlined in the Table. Victims meeting any 2 criteria should be triaged as the highest level severity and flagged for immediate transport to a trauma facility. Those meeting 1 criterion should be triaged as urgent and transported as soon as possible.12 It should be noted that the categories of physiologic and anatomic criteria attempt to identify the most seriously injured victims and those meeting previously described criteria should ideally be transported to the highest-level trauma center available. Included in this triage scheme is the mantra "When in doubt, transport to a trauma center." Although important to consider, the nurse must apply this with caution during a mass casualty, given the implications for continued overtriage of victims.

TABLE Criteria for Transport to a Trauma Center

Other adaptations to this standard of triage should also be considered during a mass casualty event. Rapid transport to a trauma facility may be difficult, if not impossible. The very infrastructure of access to the hospital and the building itself may be compromised. In the rural setting, sufficient transport resources may be inadequate for the volume of victims requiring care. Low-income countries may not have any trauma system or facility in place. The goal of identifying victims with a high risk of mortality through accurate triage remains the same; however, the nurse must continue to assess and initiate interventions in the field to improve outcomes in the interim.12 Depending upon the extent of the disaster and the number of victims involved, a more rapid method of triage may be required. Data have shown that respiratory rate can be used as an accurate predictor of trauma mortality. Adult victims found to have a persistent respiratory rate above 25 breaths per minute should be triaged as most critical.13 This method is particularly useful, as it is both uncomplicated and rapid. If a victim is found to be apneic and pulseless in a mass casualty situation, he or she is not categorized as a priority and cardiopulmonary resuscitation is not initiated. Although perhaps this may be the most difficult triage adaptation for nurse acting as first responders, it is necessary to provide resources to victims with survivable injuries.14

Interventions

Certainly, the ideal scenario for any victim during a mass casualty event includes rapid transport to the appropriate facility. Research has shown that more resources required by a trauma victim in the field correlate with an increase in morbidity and mortality.12 However, as previously mentioned, transport might be difficult, if not impossible. Therefore, it is of extreme importance for nurse as first responders to understand and initiate in-field interventions specifically designed to improve outcomes for the greatest number of trauma victims prior to transport to a definitive care setting. Professional consensus among experts in the trauma field suggests that respiratory status, presence of hemorrhage, and neurologic status most accurately predict trauma death. As such, the interventions provided focus on these areas with a concentration on maintaining airway patency and hemorrhage control, as these are integral to trauma victim survival.15

Respiratory Management

Respiratory management and airway protection of the mass casualty victim should certainly remain as priorities. The nature of such disasters, as previously noted, can pose unique challenges that must be taken into account when determining the appropriateness of any intervention. Although procedures such as intubation and cricothyroidotomy may be outside the scope of nursing practice in regular circumstances, mass casualty events may present an ethical dilemma for nurse as first responders. When personnel resources are limited, a nurse may be the only one available to assist a particular victim. If that victim is in severe respiratory distress and the nurse feels reasonably confident in his or her ability to attempt intubation, should the nurse step outside the scope of practice? To avoid these dilemmas, it would be best to answer such questions prior to these emergencies. Guidelines and protocols should establish an expanded scope of practice to use nurses' judgment when acting as first responders in the mass casualty situation.

If, however, it is clear that the victim may require advanced airway management and personnel and resources are available to do so, the nurse must also consider several other factors when assisting in the decision of whether or not to intubate or perform a cricothyroidotomy in the field. Pre-hospital endotracheal intubation of hypovolemic trauma victims has been associated with decreased survival rates compared with those intubated in the emergency department.16 In addition, victims intubated in the field were more likely to be hypotensive upon hospital arrival.16 For victims with a traumatic brain injury, current evidence does not demonstrate any benefit from pre-hospital intubation or mechanical ventilation.17 Furthermore, pre-hospital intubation in the victim with traumatic brain injury without an acutely lethal injury is actually associated with higher rates of mortality and morbidity.18 In addition, the practice of pre-hospital intubation to prevent mortality from aspiration is unsubstantiated. As most aspirate in the trauma victim is blood, adequate suctioning may be sufficient to maintain a patent airway.19

Finally, victims requiring advanced airway management may have significant anatomic upper airway disruption, such as in penetrating trauma. In this scenario, a primary attempt at endotracheal intubation will most likely be futile, wasting resources, thus a cricothyroidotomy is indicated.20 Endotracheal intubation remains the gold standard of advanced airway protection. However, as its benefit pre-hospital has not been demonstrated, the nurse must assess the severity of respiratory compromise, the ability to use other interventions such as suctioning, resources available, and the time to transport to a hospital when determining the appropriateness of this and other types of advanced airway management in the field.

Hemorrhage Control

Another primary concern of the nurse must be hemorrhage control, as trauma victims in the mass casualty situation frequently sustain injuries resulting in significant blood loss. Often this cannot be appropriately managed by applying manual pressure alone, and additional interventions are required. Two such methods of hemorrhage control that can be used in the field include tourniquets and hemostatic dressings. Tourniquets are a valuable tool to be used in the field, as they are quick to apply, inexpensive, and should be used when indicated as a preventive measure. In a retrospective study of tourniquet use in the military, no limbs were lost because of tourniquet use alone, regardless of when the tourniquet was applied, and resultant nerve palsies from tourniquet use were both infrequent and transient. Furthermore, this study found that victims with tourniquets applied pre-hospital had decreased instances of shock and better survival rates than those who did not.21 These data demonstrate the benefit of early tourniquet use to prevent and control hemorrhage. Thus, it is recommended that they be applied immediately to the victim with a suspected or confirmed extremity hemorrhage. When available, a hemostatic dressing can be used in addition to tourniquet use when rapid clotting of blood is necessary. Hemostatic dressings are polysaccharide polymers that adhere to the wounded tissue, creating a seal and accelerating accumulation of clotting factors at the site of injury.20 As research has not demonstrated significant complications or adverse outcomes from hemostatic dressing use pre-hospital, it is recommended that the nurse apply one to the mass casualty victim whenever clinically warranted and available. Depending upon the resources provided, various brands of hemostatic dressings may be present, and it is the nurse's responsibility to know the indications and applications of each type.

To establish hemodynamic stability in the hemorrhaging patient, appropriate fluid resuscitation is critical. Contrary to the widely held belief that a rapid, liberal volume of fluid be infused to the hemorrhaging victim regardless of mechanism of injury, current evidence calls for a more judicious approach. Factors such as concurrent head injury, hemodynamic status, and controllability of hemorrhage (ie, an internal bleed vs an extremity laceration) must also be considered.22 In fact, aggressive and immediate fluid replacement can be detrimental. As large volumes of fluid are replaced, hydraulic pressure within the vessels proportionately increases, creating a potential for further hemorrhage.22 In addition, soft clot formations may become dislodged and clotting factors further diluted.22 A large fluid infusion will also dilute circulating red blood cells, causing a potential decrease in oxygen-carrying capacity and subsequent tissue perfusion.22 Furthermore, research has identified deleterious effects from excessive volumes of the fluid itself.22 Finally, current research has identified an association between the establishment of pre-hospital venous access for fluid replacement and mortality in the critically injured victim.23

Given these implications, fluid replacement in the mass casualty situation should be initiated with careful consideration of the type and severity of injury, resources available related to volume of casualties, and time before transport. Indications and amounts for replacement therapy are outlined in Figures 1 to 5. The small fluid volumes and deliberate maintenance of hypotension for certain types of injury are supported by research that links lower systolic blood pressures (<=90 mm Hg) and minimal pre-hospital infusion (<=750 mL) to better outcomes.22 Although 250 mL of hypertonic saline is equivalent in efficacy to 1000 mL of a standard crystalloid solution such as lactated Ringer's and normal saline, there is insufficient evidence to support the use of one particular fluid over another.22,23 Thus, it is most feasible in the mass casualty scenario to use what is available. When attempting venous access, the nurse must also consider the time required (if more than 1 attempt is needed), the proximity and severity of injury of other victims, and the availability of resources to place alternative access such as an intraosseous device. Current research supports a maximum of 2 attempts as the most efficient use of time in such scenarios.24 The provision of pre-hospital fluid resuscitation by the nurse must be a balance between transport time, severity and type of injury, resources available, and volume of casualties.

Figure 1. Field guidelines for patients with penetrating injuries. Data from Cotton et al.

Figure 5. Field guidelines for patients with burns. Data from Cotton et al

Although evidence has failed to demonstrate a benefit of pre-hospital blood transfusions in victims with rapid transports times, it should be reemphasized that the nature of mass casualty may complicate or prevent victim transport, resulting in prolonged time spent in the field.23 Therefore, the Advanced Trauma Life Support protocol recommends blood transfusion pre-hospital as an option if hypotension continues following an initial bolus of fluid, as the primary concern is prevention of hemorrhagic shock.25 In a hospital setting, blood type and crossmatch should always be performed to ensure patient safety prior to transfusion. In a mass casualty event, however, the critically injured hypotensive and hemorrhaging victim may be managed by transfusion of uncrossmatched type O red blood cells (UORBCs), as ABO typing is rarely a possibility because of a lack of resources and time. According to several studies published between 1978 and 2005 that have explored the utilization of uncrossmatched transfusions in emergency situations, hundreds of patients received UORBCs with zero acute transfusion reactions noted.25 During the Vietnam War, 100 419 units of UORBCs were used by the US Army and there were no reported deaths due to acute transfusion reactions.25 Not only is the risk of acute transfusion reaction minimal, but the risk of alloimmunization, which could interfere with blood transfusions and crossmatching, in the future is also low.25 In addition, Rh-positive type O blood may be used when available for rapid emergent transfusion in the mass casualty setting for all male trauma victims and female victims older than 60 years (past childbearing years), as the risk of a future antibody reaction complication is very minimal.26 Although infusion of UORBCs may not be possible given the resources available, it is recommended for the critically injured hemorrhaging victim, as the risk of reactions and future complications are minimal.

Figure 3. Field guidelines for patients with identified or suspected uncontrolled hemorrhage. Data from Cotton et al

Figure 4. Field guidelines for patients with isolated extremity injuries and for the victim

Neurologic Status

In addition to hemorrhage control and respiratory management, the neurologic status of victims is another area of priority and concern for nurses as first responders in the field. Although the Revised Trauma Score is not a commonly used tool in the field, its criteria, which include abnormal measurements of systolic blood pressure, respiratory rate, and Glasgow Coma Scale (GCS) scores, may be beneficial in predicting trauma death.13 An abnormal GCS score can be used as a triage tool to identify victims of a critical nature who need to be transported immediately.13 In fact, the motor component of the GCS by itself can be used as an accurate predictor of morbidity and mortality outcome in victims with head injuries. Research has demonstrated that the motor component alone is equally effective as the total GCS score in predicting outcome and suggests that it may be a useful tool in triaging victims.27 In a mass casualty event where transport may not be possible, it is nurses' responsibility as first responders to identify and monitor patients presenting with altered neurologic status. These patients need to have vital signs, GCS score, and pupillary status monitored and documented as frequently as possible.28Figures 1 and 2 provide fluid replacement indications for victims of traumatic brain injuries and penetrating injuries with altered mental status. The goal for the neurologic patient is to be monitored, as patients with an abnormal GCS score have a significant risk of mortality. Further treatment option for the neurologically injured victim requires a computed tomographic scan. Because this is not a procedure that can be performed in the field, monitoring with concurrent airway management and hemorrhage control should be pre-hospital priorities. Primary neurologic damage is irreversible. Thus, it is critical for the nurse to prevent secondary neurologic insult by continuous and thorough assessment and maintenance of homeostasis.29

Figure 2. Field guidelines for patients with traumatic brain injuries. Data from Cotton et al

For patients with head injuries, it is also crucial for the nurse to consider the likelihood of a concurrent spinal cord injury. While spine immobilization is routine for a trauma victim under standard emergency medical protocol, this is not necessarily the case during a mass casualty event. Mass casualty events involve a lack of resources and time, complicated by an increased number of injured victims. According to Prehospital Trauma Life Support, for penetrating traumas to the head, neck, or torso without neurologic deficit, it is imperative that the nurse be selective when immobilizing patients previously described.30 Published literature approximates complete spine immobilization to take longer than 5 minutes--valuable time that delays transport and could be used toward other procedures.30 Immobilization is a procedure requiring 2 responders, preventing other interventions from being performed at the same time. In addition, a cervical spine collar may mask other complications in the penetrating trauma victim, such as tracheal deviation and subcutaneous emphysema.30

In a mass casualty event, the decision to forgo immobilizing patients with penetrating traumas without neurologic deficit does not compromise patient safety. Recent studies of immobilization strategies using the selective approach demonstrate that forgoing unnecessary immobilizations do not overlook those victims who could have benefited from the procedure when indicators such as altered mental status, cervical tenderness, and abnormal sensory and or motor function are measured.30 It is important for the nurse to be selective when considering spine immobilization for penetrating traumas, as time is a critical factor, not only because it delays transport but also because it is time that could be spent on other procedures that may improve outcomes for the particular victim or others injured. In addition, spine immobilization may even harm the patient if other complications go unnoticed.

Other Interventions to Consider

Additional concerns in the field include concerns regarding wound care, hypothermia management, and documentation. In the pre-hospital setting, wounds should be treated in a basic fashion: irrigated and cleaned with normal saline and dressed with gauze. This would ideally be performed as a sterile procedure; however, it is often not feasible in the field. It is important for the nurse to keep the wound clean, given future complications of wound infection. In addition, the nurse should consider the victim's tetanus immunization status. Although a severe allergic reaction to the vaccination is possible, the rate is less than 1 in 1 million doses and therefore the potential benefits are greater than the risks of tetanus infection and should be considered as a preventative tool if available.31

Hypothermia of the trauma victim is another significant area of concern that must be addressed by the nurse.20 It is frequently seen in victims sustaining traumatic injuries for various reasons including long transport times to the hospital, environmental factors, and hemorrhage resulting in hypoperfusion, altering the ability of the body to regulate temperature.20 Prevention of hypothermia should be initiated immediately as responders appear on site, using any durable product that is nearby that can be layered onto the victim to maintain the recommended core temperature of 35[degrees]C or above.20,32

Another key component for nurses as first responders to consider is a method of documentation. It is essential for nurses to document assessment and interventions including medication administration, immunizations, fluid resuscitation, wound care, vital signs, neurologic status checks, and any other information deemed pertinent. Documentation is crucial in a mass casualty event, as it helps ensure efficiency and continuity of communication between first responders, thus preventing repeated interventions, maintaining patient safety, and saving time. Nurses can document interventions performed by writing directly on the victim's body with permanent marker, indicating the time and intervention performed.33

Recommendations

Nurses as first responders in the mass casualty situation are invaluable. Given the frequency of global disasters and proportion of nurses in the health care workforce, nurses stand in a unique position to "do the greatest good for the greatest number" during a mass casualty.9 Until current standards of nursing curricula change to reflect the importance of mass casualty education, the individual nurse must become independently prepared should the need to act as a first responder arise. Central to this preparation is developing an understanding of the current evidence-based pre-hospital interventions correlated with optimal outcomes for the mass casualty trauma victim. In addition, it is recommended that the nurse prepare a kit for such situations that can be easily transported and used with simple supplies such as a stethoscope, manual blood pressure cuff, pen light, tourniquets, dressing supplies, sterile normal saline, intravenous starter kit, and permanent marker. Nationally, a consensus on a universal standard of triage during the mass casualty situation must be established and disseminated. Discussion about the scope of nursing practice and ethical implications during a mass casualty must also continue. Guidelines for the nurse as a first responder must be clear and well understood by the practitioner prior to participation in care of the victim. In addition, more funds should be allocated toward resources that can be used by the nurse in the field to accurately assess mass casualty victims. For example, blood lactate monitors, which are the size of credit cards and can be easily carried with the nurse, have been demonstrated to accurately predict early signs of hypoperfusion and shock secondary to hemorrhage.34 A blood lactate reading can better predict shock than hypotension can, as a decreased systolic blood pressure is usually a late sign of shock.34

CONCLUSION

Nurses as first responders can be exceedingly valuable medical care providers during mass casualty events. The very nature of their training prepares them for the thorough assessment and rapid implementation of interventions required in the field. In order for nurses to be effectively used as first responders, nursing education and training programs need to incorporate disaster response and guidelines for pre-hospital interventions into the curricula. By providing nurses with unified, concrete, evidence-based guidelines for mass casualty response, the outcome of victims may be improved. Although the recognition of the vital role of the nurse during a mass casualty event is an important first step, supplying nurses with the necessary tools and skills to be effective first responders must be the next critical component of mass casualty preparation.

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Mass casualty event; Nurse as first responder; Pre-hospital interventions