16. Emergency Preparedness Aspects of DCR for Civilian Mass Casualty Scenarios

David W. Callaway¹, Reed Smith^{2, 3} and Sean M. Fox⁴

(1)

Department of Emergency Medicine, Operational and Disaster Medicine, Carolinas Medical Center, Atrium Health System, Charlotte, NC, USA

(2)

Department of Emergency Medicine, George Washington University, Washington, DC, USA

(3)

Arlington County Fire Department, Arlington, VA, USA

(4)

Department of Emergency Medicine, Carolinas Medical Center, Atrium Health System, Charlotte, NC, USA

David W. Callaway

Keywords

Damage control resuscitationRemote damage control resuscitationTactical Emergency Casualty CareTECCDCRRDCRTraumaMass Casualty IncidentEmergency Management

Introduction

The goal of Mass Casualty Incident (MCI) preparedness and response is to reduce potentially preventable death during times of acute health system strain from patient volume and acuity [1–3]. An MCI is defined as an event which “generates more patients at one time than locally available resources can manage using routine procedures or resulting in a number of victims large enough to disrupt the normal course of emergency and health care services and would require additional non-routine assistance.” [4] Though extensively studied in the military, the epidemiology of mortality in civilian Traumatic-MCI (T-MCI ) is more variable. In the civilian setting, despite a decade of high-profile dynamic T-MCIs, there exists no standard injury pattern [5]. For example, a 2014 Emergency Medical Services database analysis revealed that although 40.7% of self-reported MCIs were categorized as “traumatic,” motor vehicle accidents accounted for 63% of the calls (i.e., blunt mechanism). In contrast, Smith et al. reported a majority of mortality from Civilian Public Mass Shootings was secondary to penetrating torso and neurologic trauma (i.e., penetrating mechanism) [6, 7]. Accordingly, health systems must implement an all-hazards approach to T-MCI, be prepared for much broader threats, and develop robust polytrauma response paradigms.

Damage control resuscitation (DCR) is the current standard of care for treatment of patients suffering from trauma-related massive hemorrhage. DCR is a bridging strategy that aims to minimize blood loss, hypothermia, acidosis, and coagulopathy through early hemorrhage control, aggressive hemostatic resuscitation, and rapid movement to surgical hemorrhage source control to enable definitive surgical stabilization. Early, aggressive, and rapid are the key phrases in the Emergency Department. However, the complexity, patient volume, and systems impact of T-MCI create unique challenges to DCR implementation.

This chapter will focus on the tiered application of damage control resuscitation, including remote DCR (RDCR) principles, as a key pillar of civilian T-MCI emergency readiness and response. The emergency management framework is a standard tool for developing a systems approach to DCR integration into the full spectrum of T-MCI and disaster response. For the purposes of this chapter, the doctrine will broadly divide disasters into readiness and response phases applied across the operational arenas of prehospital care, first receiver facilities (FRF), and trauma centers.

Readiness

In the hemorrhaging trauma patient, the development of oxygen debt that causes endotheliopathy and immunologic and hemostatic dysfunction is referred to as “blood failure ” [8]. Up to 25% of major trauma patients presenting to the ED suffer from acute traumatic coagulopathy (ATC) with resultant increased mortality [9]. Although, the mechanisms of ATC are complex, it is thought to be caused by hypoperfusion that leads to increased activated protein C and hyper-fibrinolysis. Thus, the DCR approach of hemostatic resuscitation is based on the principle of balanced blood product administration, limitation of crystalloid/colloid infusions, plus pharmacologic adjuncts in order to limit “blood failure,” and death from hemorrhage. Early initiation of hemostatic resuscitation at point of injury and continuation through FRF and on to the trauma center improves 24-hour and 30-day survival in trauma [10, 11]. However, the logistics of hemostatic resuscitation and DCR are challenging given the variable resources across systems, and success relies heavily on a systems commitment to readiness.

Readiness is broadly comprised of mitigation and preparedness activities. A critical initial step in T-MCI readiness is articulating the DCR priorities within the mitigation and preparedness context in order to align key response stakeholders from the prehospital, first receiver, and trauma center communities. Mitigation is the process of clearly defining the problem set, conducting a system gap analysis, articulating a plan for whole of community and regional healthcare response, and executing pre-disaster measures to reduce risk. Mitigation activities should build capabilities (i.e., training, equipment, etc.) and address physical assets with limited capacity (i.e., ambulances, hospital beds, blood collection/distribution, etc.). Delineation of priorities and goals allows for an accurate system gap analysis (Table 16.1). A common operating framework with common language allows all stakeholders to align expectations and resources [12]. Intentional collaboration and coordination across disciplines and health systems is vital for developing this common operating framework. Preparedness is a multiphase, continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action in an effort to ensure effective coordination during T-MCI incident response [13]. Preparedness requires building the resilience of each link in the chain of survival through focused application of DCR capability and capacity building exercises. The Parisian response to the November 13, 2015, terror attack illustrates the importance of preparation. As the attack unfolded, the French government activated their “White Plan” for the first time in the nation’s history. This robust plan, developed in the mitigation phase, had been frequently exercised; such familiarity allowed for a RDCR and fixed facility DCR plan to be deployed immediately.

Table 16.1

Example DCR gap analysis: blood product availability

Topic	Risk	Impact	Priority	Current	Proposed	Gap
General	Determine the range of potential disasters likely to be faced	Predict the effect of these disasters on population, critical infrastructure, and government operations	1,2,3, etc. (1 = highest priority)	Quantitative or qualitative description of current system	Desired future state	Material, administrative, logistical, regulatory, and policy gaps
Prehospital RBC availability	Routine trauma T-MCI surge	Delayed DCR and potential increased mortality and overall system blood product use	8	25%	2 U	e.g., policies, quality assurance, blood storage
Prehospital plasma availability	Routine trauma T-MCI surge	Delayed DCR and potential increased mortality and overall system blood product use	5	Very few	2 U	e.g., policies, quality assurance, blood storage
Prehospital LTOWB	Routine trauma T-MCI surge	Delayed DCR and potential increased mortality and overall system blood product use	3	Very few	4 U	e.g., policies, quality assurance, blood storage
First receiver facility PRBC availability	Routine trauma T-MCI surge	Inability to provide state of the art trauma resuscitation or offload trauma centers in T-MCI	6	4 U (units)	8 U	e.g., Blood stewardship program
First receiver facility plasma availability	Routine trauma T-MCI surge	Inability to provide state-of-the-art trauma resuscitation or offload trauma centers in T-MCI	4	2 U (units)	4 U	e.g., Blood stewardship program
Trauma Center blood product availability	Routine trauma T-MCI surge	Required for standard of care trauma resuscitation	1	4 concurrent MTP	8 MTP 20 U LTOWB	e.g., No LTOWB policy or procedure, no financial model supporting
Local blood supplier product availability	Routine trauma T-MCI surge	Direct access required if >15 patients requiring MTP	2	40 U PRBC 20 U FFP 10 U PLT	60 U RBC 40 U FFP 20 U PLT 50 U LTOWB	e.g., Financial model for FWB
Regional blood bank product availability	T-MCI surge	Direct access required if >20 patients requiring MTP	7	60 U PRBC 40 U FFP 20 U PLT	80 U RBC 60 U FFP 20 U PLT 100 LTOWB	e.g. Financial model for FWB, regulatory compliance issues, ability to safely scale walking blood banks

Note the content and numbers listed are for illustrative purposes only

MTP Massive transfusion packs, RBC Red blood cells, FFP Fresh frozen plasma, PLT Platelets, LTOWB Low Titer Group O Whole Blood, U Unit

Prehospital

Early RDCR saves lives. Civilian prehospital T-MCI mitigation and preparedness activities should enable strategies that allow for rapid initiation of stabilizing trauma care at or near the point of wounding despite limited resources and personnel, followed by coordinated continuity of care across the entire medical response system. However, the complexity of the civilian healthcare system means that medical directors of EMS/fire agencies must clearly determine how to implement the basic principles of RDCR. They must then develop training standards, identify funding sources, standardize and ensure compatibility of equipment, and create sustainment plans that span community groups and professional first responders.

Unification around common response language is critical to successful interagency RDCR implementation. The US military demonstrated that the tiered prehospital application of RDCR principles through the systematic application of the Tactical Combat Casualty Care (TCCC) operational paradigm reduces mortality from trauma in combat [2]. The shared common language of TCCC allowed for clear outcomes, standardized training, and accountability. In the civilian pre-trauma center arena, the Committee for Tactical Emergency Casualty Care (C-TECC) high-threat trauma chain of survival offers a parallel framework for the integration of RDCR principles into T-MCI response [14–16].

The TECC guidelines provide a foundation for comprehensive civilian prehospital DCR plans [17]. The guidelines are based on the application of RDCR principles in a threat-based matrix comprised of three dynamic phases: direct threat, indirect threat, and evacuation care [18]. In direct threat care, the focus is on responder safety and the first principle of RCDR-aggressive control of life-threatening hemorrhage using a combination of direct pressure and tourniquets. Success requires preparing all levels of care providers, from the citizen through the highly trained Emergency Medical Providers to execute hemorrhage control in high-threat environments. In the indirect threat care phase, the external threat to victim and responder is present but is not direct and immediate. During this phase, depending on the resources and situation, additional aspects of RDCR can be initiated. The final phase of TECC is termed evacuation care and occurs when the injured and the provider are in areas where there is little ongoing threat. During this phase, all aspects of RDCR should be considered. Experience from the US military suggests that early, aggressive resuscitation with blood products, including whole blood, reduce mortality from trauma [19, 20]. However, in domestic operations data supporting whole blood use in trauma remains sparse [21]. Based upon community resources, operational constraints, and risk tolerance, appropriate resuscitation strategies may range from low-crystalloid resuscitation to prehospital administration of whole blood. During the readiness phase, leaders must determine where on this RDCR continuum their system will fall and create strategies to fill their gaps.

Readiness activities must acknowledge the logistical challenges of RDCR and create solutions for scenarios where full operational medical resources may not be brought to bear. On a basic level, this means aggressively implementing whole of community hemorrhage control programs such as Stop the Bleed or FEMA’s Until Help Arrives. On a high level, it means examining decisions regarding out of hospital resuscitation standards. For example , for RDCR to have the greatest effect on survival, prehospital systems must embrace field blood transfusion programs, systemic and topical hemostatic adjuncts, tourniquets, and educating providers about the risks of using positive pressure ventilation for hemorrhagic shock patients. Protocols, procedures, training, and guidance for EMS providers on airway and prehospital blood management and administration must be developed. Transfusion-related material should include the medical aspects of transfusion, strategies for management of transfusion expenses, mitigation of regulatory compliance issues, strategies for quality control and medical quality assurance, training on transfusion indications, protocols for judicious product utilization, and strategies for recycling/rotation of blood products back to the blood bank to limit waste.

In addition, medical systems readiness must address the need for interoperable and coordinated communication. RDCR implemented on scene must be able to be communicated to first receiver facilities to efficiently transition from field RDCR to inhospital DCR. Without an effective communication system between prehospital public safety assets and fixed medical facilities, the gap in information will be a true barrier to real-time implementation. Additionally, the content and data points shared in this field report should be clearly defined. By defining and training to this communication flow, the real-time dissemination of medical information will allow for successful RDCR and DCR across the multiple levels of provider care.

First Receiver Facilities (FRF)

First receiver facilities (FRF) are defined as non-Level 1 trauma centers that by design or circumstance provide initial live-saving care for victims of T-MCI. While trauma centers are often the focus of preparedness funding, there are only 217 level 1 trauma centers in the United States [22]. As a result, first receiver facilities with limited resuscitation and operative capabilities may find themselves on the front line of T-MCI response and fill a key role in the TECC Chain of Survival. The response to the 2017 Las Vegas attack clearly demonstrated that non-level 1 trauma centers play a major role in mitigating the consequences of T-MCI. The Sunrise Medical Center in Las Vegas, a level 2 trauma center, received over 150 patients in less than an hour. Non-trauma facilities in the Valley Hospital System care for an additional 228 victims [23].

First receiver facilities often have only limited resuscitation resources (e.g., blood products such as platelets) and limited surgical coverage and may have little experience in managing T-MCI. The whole of community readiness process must acknowledge these limitations, catalogue existing resources, and intentionally strengthen this link in the chain of survival.

One model is to consider FRF as casualty collection points (CCP) where additional stabilization may occur prior to transfer to definitive care. Readiness efforts can focus on the nuanced application of RDCR. At the FRF, the key DCR operational goals should be hemorrhage control, hemostatic resuscitation (if possible), hypotensive resuscitation, hypothermia prevention, and rapid distribution of casualties to regional trauma centers. Material acquisition should focus on targeted purchases including tourniquets, hemostatic agents, and fluid warmers. Education programs should emphasize team training on key components of RDCR. Process development should focus on building robust transfer mechanisms. And, administration efforts should create expedited staff credentialing procedures to maximize utilization of fixed resources such as operating theaters.

In addition to playing a stabilizing role, FRFs should also investigate mechanisms to receive patients from trauma centers. Trauma centers could proactively move existing patients or transfer incident patients after initial stabilization. This “safety valve” model allows for urgent rather than emergent surge capacity and can offload postoperative caseloads from the trauma center.

While the above are important components of a robust readiness system, the major response gap at FRF is rapid access to adequate blood transfusion capabilities required for hemostatic resuscitation. Multiple studies have reported that earlier and increased use of RBCs, plasma, platelets, and whole blood are associated with improved outcomes [11, 20, 24, 25].

Again, reality and community limitations must be considered. So even in the absence of blood product availability, readiness activities can integrate other DCR components into the T-MCI resuscitation plan such as albumin-based resuscitation or low-volume crystalloid administration [26]. Since the landmark study by Bickell et al. in 1994, multiple studies have challenged the survival benefit of large volume or empiric intravenous fluid administration in trauma [27]. While maintenance of perfusion pressure is a core resuscitation principle, crystalloids result in dilutional anemia and coagulopathy, activate the inflammatory cascade, accelerate hypothermia, worsen acidosis, and result in interstitial edema due to increased permeability of capillary gap junctions [28–30].

During the readiness phase , it is critical that FRF develop continuity of operations plans (COOP). Ideally these plans improve daily operations in order to strengthen crisis response. For DCR, a key component of the COOP is close coordination with local and regional blood banks to create robust donor and vendor systems. The COOP must be realistic and tailored to community resources. For example, if the primary DCR plan is to initiate RBC and FFP transfusion augmented by TXA and restricted crystalloid use, some critical points include: