Casualty Situation

Preferred choices Streptomycin, 1 g IM twice daily Gentamicin, 5 mg kg IM or IV once daily  

Alternative choices Doxycycline, lOOmg IV twice daily Choramphenicol, 15mg kg IV four times daily  

Streptomycin, 15mg kg IM twice daily (should not exceed 2g d ) 

Doxycycline, if weight 45 kg, lOOmg IV twice daily, if weight 45 kg, give 2.2mg kg  

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There are no published recommendations for isolation or protective action distances for carbamate nerve agents released in mass casualty situations. 

There are no published recommendations for isolation or protective action distances for these materials deliberately released in mass casualty situations. However, traditional isolation and protective action distances for most of these materials can be found in the Department of Transportation 2004 Emergency Response Guide (ERG). These recommendations are based on an accidental release during transportation of the material and involving a small spill (i.e., a commercial gas cylinder or 200 liters or less of liquid material), or a large spill (i.e., more than one gas cylinder, a large gas container such as a railcar, or more than 200 liters of liquid material). 

Improvement Item GVW Fire Department did not have adequate resources to conduct decontamination activities for mass casualty situation. 

Improvement Item Decontamination logs were not accurate due to chaotic state at the scene. Gross decontamination performed but quickly overwhelmed Fire Department did not have adequate resources to conduct decontamination activities for mass casualty situation. 

IMMEDIATE A casualty classified as immediate has an injury that will be fatal of he does not receive immediate care. In a non-mass casualty situation, he would be the first casualty to receive care. However, in a mass casualty situation, particularly in a far-forward medical treatment facility, he may not receive this care. The required care may not be available at that echelon (e.g., a casualty may need major chest surgeryjor the time needed to provide the care may be so prolonged that other casualties would suffer. 

EXPECTANT The expectant casualty is one for whom medical care cannot be provided at the medical treatment facility and cannot be evacuated for more advanced care in time to save his life. This category is used only during mass casualty situations. This category does not mean that these casualties will receive medical care. 

The nursing fundamentals practiced in normal daily situations and during smaller crises will be applicable during a special event or mass casualty situation. All nurses providing health care at mass gatherings must be competent in the basic principles of first aid, including cardiopulmonary resuscitation and the use of the automated external defibrillator. In addition, the nurse should possess the following minimum core competencies ... 

In a disaster or mass casualty situation, all hospitals may be called on to care for ill or injured children of varying degrees of symptom severity. Therefore, all hospital emergency departments need to be prepared to treat children likewise, pediatric hospitals must be prepared to treat injured or ill parents and adult family members. As part of their pediatric disaster planning, hospitals should anticipate a lack of prehospital triage establish protocols for care create pediatric antidote kits organize and store pediatric equipment in one setting and anticipate the need for extra personnel (Hohenhaus, 2005). 

Table 2.7 Inhalational treatment protocol for contained casualty situation, similar to that associated with the October 2001 bioterrorism attack... 

Table 2.8 Recommendations for treatment in mass casualty situation or postexposure prophylaxis for prevention of inhalational anthrax after intentional exposure to B. anthracis...

Table 2.11 Plague treatment in contained and mass casualty situation, and postexposure prophylaxis ...

Table 2.15 Tularemia treatment in a contained casualty situation ...

Table 2.16 Tularemia treatment in mass casualty situations and for mass prophylaxis ...

In mass casualty situations, intravenous antidotes may not be available. In that case, the intramuscular administration is acceptable. Most Emergency Medical Systems in the United States now stock military Autoinjector units containing atropine and pralidoxime, although kits with pediatric doses may not be available. However, in critical situations, children older than 2 or 3 years of age weighing at least 13 kg might benefit from 2 mg of atropine and 600 mg pralidoxime administered intramuscularly with auto-injectors (7). Experience with the accidental atropine auto-injection in 240 Israeli children unexposed to nerve agents revealed that... 

Positive airway pressure ventilation some experts recommend using positive pressure ventilation during the early, asymptomatic phase following phosgene exposure to prevent pulmonary edema. While positive pressure ventilation may reduce fluid accumulation, stabilize the intra-alveolar surfactant film and suppress arteriovenous shunts, many asymptomatic patients will find the treatment unacceptable (34). In addition, resources for providing prophylactic positive pressure ventilation may not be available in a mass-casualty situation. 

After stabilization and external decontamination, patients require assessment for radiation injury based on dose, specific isotope involved and the presence of internal contamination. By performing individual biodosimetry, physicians can predict the subsequent clinical severity, survivability and treatment required, as well as triage patients with subclinical or no exposure (2). The three most useful items for estimating exposure doses in a mass casualty situation are ... 

Immunosuppressed radiation victims may also be at risk for reactivation of cytomegalovirus (CMV) and Pneumocystis carinii pneumonia. In a limited casualty situation, if resources are available, clinicians should obtain CMV serology. In addition, patients should have a sensitive assay (antigen assessment or polymerase chain reaction test) every 2 weeks for 30 days postexposure, while those with documented previous CMV exposure should have the assay repeated until 100 days postexposure (2). Patients developing lymphopenia should have a CD4 cell count considered at 30 days postexposure. Those with a CD4 count below 0.2000 x 10 cells L" are at risk for Pneumocystis carinii pneumonia. Physicians should withhold trimethoprim-suha prophylaxis until the leukocyte count is above 3.0 x 10 cells L" or until the absolute neutrophil count is above 1.5 x 10 cells L . Atovaquone, dap-sone and aerosohzed pentamidine are alternative prophylactic agents. Patients should continue prophylactic treatment until the CD4 count reaches or exceeds 0.2000 X 10 cells L, which may occur over several months (2). 

In respect of potential CN terrorism we believe that the following three critical items should be added to the CDC recommendations. First, before antidotes are stockpiled there should be international agreement on the most appropriate antidote (or combinations) for the treatment of acute CN poisoning. It is our opinion that hydroxocobalamin is the optimum choice. In the context of mass casualty situations with terrorist release of cyanides on the public, the chosen antidote should be readily available, effective, easy to administer (even by responders with limited training), nontoxic, and does not adversely interact with other antidotes (Thompson, 2004). Second, with respect to CN analyses, there is a requirement for a portable equipment that is specific and, at least semiquantitative, that can be used for on-site reliable bioidentification of CN intoxication. There is also a need for a reliable and sensitive environmental method for the instantaneous measurement of HCN concentrations, and ideally continuous monitoring with automatic warning devices for installation in sites with a potential for HCN attack. Third, educational materials should be made immediately available for distribution to the general population so that they can be prepared for what to expect in the event of a CN terrorism event. 

A. The medical equipment needed for treatment of BW patients depends on the specific agent. Unlike a typical mass casualty situation, few BW patients will require surgery. Biological toxins,... 

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