Declare Early, Triage Smart, Stay Organized.
A Mass Casualty Incident (MCI) is a term that encapsulates situations where the number of casualties overwhelms the immediate available resources, challenging the response capabilities of emergency services and places strain on the healthcare system.

These incidents are marked by a surge in casualties placing pressure on responders to act quickly and engage in complex interagency coordination. Beyond the immediate scene, MCI’s can have lasting psychological and community-wide impacts, emphasizing the importance of preparedness, communication, and post-incident support. Recognizing these challenges is essential to strengthening response systems and enhancing frontline readiness.
Remember: It’s not about a specific number, it’s about CAPACITY vs. DEMAND

Traditional MCI Roles:
In the management of a MCI, various roles may be assigned depending on the size and complexity of the incident, this may include: Site Coordinators, Incident Managers, Communication Officers, Scribes, etc. However, when operating with a two-paramedic crew, the primary roles are the Triage Officer and the Incident Commander. These roles are typically assumed by the first arriving ambulance crew. As additional personnel arrive, they may be assigned to other roles as needed. These individuals are the first ones in and the last ones out.

Triage Officer vs. Incident Commander

Triage Methods:
Two common methods used across the NW Region:

1. SALT (Sort, Assess, Lifesaving Interventions and Treatment/Tag)

2. START (Simple, Triage, And Rapid, Treatment)

Triage is a critical component in effective MCI management. By swiftly assessing and categorizing casualties based on severity, paramedics can prioritize medical care for those with the greatest need. Paramedics should familiarize themselves with the guidance and training provided by their service operator or base hospital.
Remember: Always affix triage tags directly to the patient. Tags left on the ground or in a pocket can lead to delayed treatment and unnecessary re-triaging.

Mass Casualty Incidents are dynamic, high-pressure events that demand rapid decision-making, clear communication, and coordinated teamwork. By understanding the key principles of MCI response and staying focused on role clarity, safety, and triage efficiency, paramedics can help bring order to chaos and improve outcomes in even the most challenging situations.

Key Points to Remember:
Call it early - If resources are overwhelmed, declare an MCI.
Establish an incident command - Assign roles and maintain structure.
Triage, tag, and move on - Prioritize rapid assessment over treatment.
Communicate clearly - Use structured radio reports and follow Incident Command direction.
Safety first - Ensure the scene is secure before committing crews.

Burns are a frequent presentation in the prehospital environment, ranging from minor surface injuries to life-threatening, multisystem trauma. Accurate identification of the type of burn (thermal, chemical, electrical, or radiation), the depth (superficial, partial-thickness, or full-thickness), and the total body surface area (TBSA) involved is essential for effective triage and timely intervention. Early and accurate assessment guides appropriate fluid resuscitation, pain management, wound care, and transport decisions—including the need for transfer to a burn centre. Prompt recognition and intervention can significantly reduce the risk of complications such as infection, hypovolemia, airway compromise, and long-term disability.

Types of Burns:

• Thermal Burns: Caused by heat sources (flames, scalds, contact)
• Chemical Burns: Exposure to acids, alkalis, or caustic substances
• Electrical Burns: From electric current; may have entry/exit wounds
• Radiation Burns: Sunburn or radiation exposure
• Inhalation Injury: Burn to airways from smoke/toxic fumes

Burn Depth Classification:
• Superficial (1st Degree): Red, painful, no blisters (e.g., sunburn)
• Partial Thickness (2nd Degree): Blisters, moist, painful
• Full Thickness (3rd Degree): Leathery, dry, painless
• Deep Full Thickness (4th Degree): Involves muscle, bone

Total Body Surface Area: The Rule of Nines
• Head: 9%
• Each Arm: 9%
• Each Leg: 18%
• Front Torso: 18%
• Back Torso: 18%                                                                                              
• Perineum: 1%

Pediatric Considerations
• Larger head relative to body: Head = 18%, Legs = 14% each

Initial Assessment (ABCs)
• Airway: Look for soot, stridor, hoarseness (early intubation if required and authorized)
• Breathing: High-flow oxygen, monitor SpO2
• Circulation: Check for shock; monitor vital signs

Management
• Attempt to determine the source of burn
• Stop the burning process (cool water, remove clothing)
• Cover with clean dry dressing or sheet
• Pain management (IV analgesia preferred)
• Avoid ice or ointments
• Estimate TBSA
• IV access (preferably in unburned area)
• Transport Early if Indicated

Complications of Burns
Burn injuries are more than just skin-deep. Depending on severity, location, and cause, they can trigger complex systemic responses that lead to life-threatening complications. Timely identification and management in the prehospital phase are critical to improving outcomes. Key complications include:

• Hypovolemic shock
Significant burns disrupt capillary integrity, leading to massive fluid shifts from the intravascular space into burned tissues (third spacing). This results in rapid plasma volume loss, reduced cardiac output, and ultimately hypovolemic shock.

• Infection/sepsis
Burned skin loses its barrier function, making patients highly susceptible to infection. Microbial invasion can progress to sepsis, a systemic inflammatory response with potentially fatal consequences.

• Hypothermia
With skin compromised, burn patients cannot effectively regulate body temperature. Even in warm environments, they rapidly lose heat through evaporation and radiation

• Compartment syndrome
Circumferential full-thickness burns can act like a tourniquet, restricting blood flow and lymphatic return. The resulting increased pressure within a limb or body compartment compromises circulation, leading to ischemia, nerve damage, and tissue necrosis.

• Respiratory distress (especially with inhalation injury)
Burns to the face, neck, or chest—or a history suggesting smoke or chemical inhalation—should raise concern for airway edema, carbon monoxide poisoning, or direct pulmonary injury.

• Renal failure (especially in electrical burns)
High-voltage electrical burns can cause extensive muscle breakdown (rhabdomyolysis), releasing myoglobin into the bloodstream. This pigment is nephrotoxic and can obstruct renal tubules, leading to acute kidney injury (AKI).

Tip of the Month – June

High-Quality CPR & Defibrillation

Paramedics play a vital role in improving survival outcomes for cardiac arrest patients. High-quality CPR and timely defibrillation are cornerstones of effective resuscitation. By maintaining skill proficiency and adhering to resuscitation guidelines, you help optimize perfusion, support neurologic recovery, and reinforce our essential contribution to emergency care.

What Is High-Quality CPR?

According to the Heart and Stroke Foundation, key elements of quality CPR include:

• Chest Compressions: At least 5 cm (2 inches) deep, 100–120 per minute, allowing full chest recoil.
• Minimal Interruptions: Aim for less than 10 seconds off the chest.
• Effective Ventilations: Use a 30:2 ratio with visible chest rise.
• Early Defibrillation: Apply and use the defibrillator as soon as available.
• Compressor Rotation: Switch every 2 minutes to avoid fatigue and maintain compression quality.

Pediatric Considerations

When to Start CPR:
Initiate chest compressions in infants and children if:

• The patient is vital signs absent
• The heart rate is < 60 bpm with signs of poor perfusion, despite adequate oxygenation and ventilation.

This recommendation aligns with the AHA PALS Guidelines (2020 & 2023 updates) and reflects the fact that pediatric cardiac arrest is often secondary to respiratory failure or hypoxia, not primary cardiac causes.

CPR Compression-to-Ventilation Ratios:

• Single rescuer: Use a 30:2 compression-to-ventilation ratio.
• Two rescuers: Use a 15:2 ratio to improve ventilation support.

✅ Remember: Children need more frequent ventilation than adults due to higher oxygen demand and lower functional reserves.

Compression Depth:

• Infants: About 4 cm (1.5 inches) — or one-third the depth of the chest.
• Children: About 5 cm (2 inches) — also one-third the depth of the chest.

Compression Technique:

• Infants: Two fingers (single rescuer) or two-thumb encircling hands (two rescuers).
• Children: One or two hands on the lower half of the sternum, as appropriate for the child’s size.

Defibrillation & Pad Placement

Why Pad Placement Matters:

• Ensures current flows through the heart for optimal shock efficacy.
• Minimizes risk to surrounding tissues.
• Improves chances of ROSC and survival.

Anterolateral (AL) Pad Placement

"Antero" = front | "Lateral" = side
Pads "sandwich" the heart to direct current through the myocardium.

Anterior (right) pad: Just below the right clavicle, Right of the sternum, avoiding bony structures.

Lateral (left) pad: Over the left lower chest, Around V6 ECG lead level, near the mid-axillary line.

✅ Think: Right upper chest & left side of the chest, near the nipple line or slightly lower.

 Anterior-Posterior (AP) Pad Placement & Vector Change Defibrillation (VCD)

What is VCD?

Vector Change Defibrillation (VCD) involves repositioning defibrillation pads from the anterolateral (AL) to anterior-posterior (AP) position after failed shocks. This changes the direction of current flow, offering another opportunity to achieve ROSC.

✅ Think: New vector, new chance to convert refractory VF/pulseless VT.

Why Use AP Placement?

•  Redirects current through the heart’s vertical axis for deeper myocardial capture.
• Improves ROSC rates, especially in refractory VF/VT (supported by research like the DOSE-VF trial).
• Overcomes limitations like poor AL pad contact or challenging body habitus.

Anterior-Posterior Pad Placement

 Anterior pad: Center of the chest, over the sternum or left precordium.

• Posterior pad: Mid-back, between the scapulae, just left of the spine.

✅ Avoid bony landmarks — ensure good skin contact and full adhesion.

Quick Tip:
Prepare AP pads early during cases of known or suspected refractory VF/pulseless VT. Switching vectors may be the key step toward successful defibrillation and ROSC.

General Pad Placement Tips:

• Avoid bone: Pads work best when placed over muscle/soft tissue.
• Hair removal: Quickly shave the area if the chest is very hairy.
• Dry the skin: Wet skin (sweat, rain) can interfere with pad adhesion and shock delivery.
• Firm pressure: Make sure pads are fully adhered to the skin.
• Correct distance: Pads should not be too close together to ensure the electrical current effectively captures the heart.

Trauma Tip of the Month – May 2025

Trauma is the leading cause of death in adults under 45. In North America, 50 million people receive some sort of trauma related care, with 30% of those people accounting for all hospital admissions.  Prehospital care of trauma patients focuses on addressing immediate life threats, rapid assessments, key interventions, and appropriate and timely transport to minimize and prevent further injury and mortality.

Prehospital Trauma Management

Rapid Assessment (ABCDE approach)

This is a systematic evaluation of a patient’s condition to identify life threatening injuries.

• Airway with Cervical Spine Protection
  • Assess for patency; protect cervical spine during airway management
  • Consider supraglottic or endotracheal airway if the airway is compromised and BLS maneuvers fail
  • Ensure no foreign objects, blood or secretions in the airway
  • Use cervical collars or manual stabilization for suspected spinal injuries
• Breathing and Ventilation
  • Check for symmetrical chest rise, breath sounds and use of accessory muscles
  • Assess for potential injuries like pneumothorax or flail chest
  • Auscultate in at least two locations per lung to detect pneumothorax or hemothorax
  • Apply an occlusive dressing when necessary
  • Avoid over-ventilation, particularly in head injuries – target ETCO2 35-45mmHg
• Circulation with Hemorrhage Control
  • Assess pulse, blood pressure, and signs of external or internal bleeding
  • Immediate interventions: initiate hemorrhage control using direct pressure, tourniquets and hemostatic dressings as indicated
• Disability/Neurological status
  • Conduct a rapid neurological exam
  • Assess verbal response, pupil size/reaction and motor function
• Exposure and Environmental Control
  • Fully expose the patient to identify hidden injuries
  • Take appropriate steps to prevent hypothermia – remove wet clothing, insulate the patient with blankets, and prevent any further heat loss
  • Prevent the “trauma triad of death”: hypothermia, acidosis, coagulopathy

 Transport and Handover Considerations

• Minimize on-scene time < 10mins for unstable patients
• Consider air transport where applicable
• Provide a structured trauma handover
  • Age/Name
  • Time of incident
  • MOI
  • Injuries found
  • Vital Signs
  • Treatments provided

 Common Mistakes in Trauma Care

 Overlooking ongoing bleeding

• Failing to fully expose the patient
• Not reassessing bleeding control measures appropriately
• Distracting injuries

Misjudging airway patency

• Making assumptions about a patient's airway because they are able to speak
• Not reassessing the airway
• Not utilizing BLS airway maneuvers or airway adjuncts

Missing subtle signs of decompensation

• Not noticing subtle changes in respiratory rate or mental status
• Not performing frequent reassessments of vital signs
• Not recognizing downward trends in vital signs

Performing a rapid and systematic trauma assessment using the ABCDE approach, coupled with continuous reassessment, is essential to identify changes in the patient's presentation and determine the effectiveness of interventions, thereby mitigating these common mistakes and improving patient outcomes.