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47 Advanced Considerations inCross-Sectional Imaging inTrauma
409
Fig. 47.2 Subtle fracture in
MVC trauma. A nondisplaced
right L1 transverse process
fracture which could easily be
overlooked or interpreted as
artifact on 5mm soft tissue
algorithm reconstructions
(black arrow, a) is much more
apparent on 1.25mm bone
algorithm reconstruction
(white arrow, b)
a
CT angio runoff imaging of the lower extremities may be
included as clinically indicated. CT angio of the upper extremities can also be performed at the time of initial CT but may
require repositioning of the patient. Detection and characterization of upper or lower fractures, including imaging for preoperative planning, can often be performed at the time of
initial CT, and may or may not mandate CT angio depending
on clinical neurovascular status. 3D reformatted images generated from these studies can assist in preoperative planning.
To reduce the total volume of administered contrast and
time on the table, the number of full contrast boluses
administered should be limited where possible. Depending
on specic scanner parameters, there may be restrictions to
the craniocaudad extent of adequate arterial phase imaging
that can be obtained with a single contrast bolus. This is of
particular importance given the increasing role of nonoperative management by Interventional Radiology, which often
requires administration of signicant volumes of iodinated
contrast but also requires good vascular road mapping for
procedure planning. This again emphasizes the importance
of good communication with the radiology department to
ensure all areas of concern are adequately imaged at the time
of initial CT.
Incorporating appropriate reformations into a baseline
trauma protocol or requesting these early in the imaging process can prevent delays in diagnosis of subtle injury. For
example, diaphragmatic injuries may be apparent only on
multiplanar reformatted images. A dedicated CT of the facial
bones should be added to initial imaging where clinically
appropriate. While a CT of the chest, abdomen, and pelvis
includes the entire thoracolumbar spine and sacrum, subtle
fractures may not be apparent without appropriate reformations (Fig.47.2). Imaging of the spine should be reviewed
with soft tissue and bone reformats in multiple planes, typically at a thickness of no less than 1.25mm [13].
Oral and rectal contrast can also be considered either as
part of a baseline trauma protocol or for specic clinical sce-
b
narios to better delineate potential bowel injury. While some
centers routinely administer oral and rectal contrast as part of
their baseline trauma protocol (so-called triple-contrast CT),
others selectively administer rectal contrast only in penetrating ank injuries or as a problem-solving tool after initial
imaging [14]. There are no randomized controlled studies
comparing single-contrast CT with rectal contrast in the
detection of bowel injury, although single-contrast CT has
been found to have comparable accuracy to triple-contrast
CT, and leakage of enteric contrast material is a relatively
insensitive marker for bowel injury seen in only 15–29% of
cases [15]. Workow and potential delays in imaging related
to enteric contrast administration must also be taken into
consideration. Ultimately, in the absence of denitive evidence one way or the other, local factors and preferences
should guide protocol selection in these cases.
Approaches toAdvanced Workup
After initial cross-sectional imaging there may be additional
diagnostic questions. Some of these will be raised by ndings on the initial imaging, as in equivocal ndings of bowel
or pancreatic ductal injury. Others may be clinical, as in the
case of suspected spinal cord injury with no vertebral fracture or dislocation identied on initial CT.Finally, there are
sometimes questions remaining after initial intervention,
whether invasive or noninvasive. Our discussion of this nal
category will be limited in scope, as these questions only
rarely fall under the umbrella of acute trauma management.
Adjunct CT Series Based onInitial CT Findings
Injury to the renal collecting system, ureters, or bladder may
be best characterized with delayed CT urography imaging.
First, the potential injury must be identied either based on
410
S. Holmes
clinical factors such as hematuria or unstable pelvic fracture
or by initial imaging review by the radiologist. Delayed
imaging is preferred for assessment of the renal collecting
systems and ureters, however, may not lead to sufcient
bladder distension to rule out bladder injury. Retrograde CT
or uoroscopic cystography is performed via Foley catheter,
where the bladder is distended to a minimum of 300 cc,
which is required for reliable assessment [16] (Fig.47.3). It
should be noted that delayed imaging will be ineffective for
assessment of the urinary tracts in the setting of severe renal
impairment due to lack of contrast excretion by the kidneys.
While CT angio imaging of the neck is clearly indicated in
penetrating neck trauma, blunt cerebrovascular injury (BCVI)
is an increasingly recognized, potentially devastating entity
that is important to identify and treat early to reduce the risk of
complicating stroke [17]. As mentioned above, CT angio may
be performed in initial patient imaging when there are clinical
risk factors for BCVI including high energy mechanism, displaced midface, complex skull fracture, or near hanging. In
other cases, risk of BCVI may not be recognized until initial
noncontrast CT of the cervical spine is complete. In these
cases, either following on-table or other preliminary review of
the images by the radiologist, CT angio carotids should be
added where and when patient stability permits. The two most
widely applied sets of guidelines for BCVI screening are the
Western Trauma Association/modied Denver (WTA) recommendations and the Eastern Association for the Surgery of
Trauma (EAST) guidelines, which differ slightly in which categories of cervical spine fracture and/or ligamentous injury
merit screening [18, 19]. The more conservative WTA recommendations would advise BCVI screening in all cervical spine
fractures, subluxations, and conrmed ligamentous injuries.
Emergency Trauma MRI
Assessment of the pregnant trauma patient presents unique
challenges covered elsewhere (Chapter 41). Initial imaging
workup should minimize radiation exposure where possible,
but not at the expense of the immediate safety of the mother or
fetus. Accordingly in major trauma, the same initial CT protocol as in a nonpregnant patient is almost always the most
appropriate rst step in imaging. One entity unique to pregnancy which may be equivocal on initial CT is placental abruption. The heterogeneous appearance of the mature placenta can
mimic the appearance of partial abruption, in which case either
ultrasound or MRI can be used for further characterization in
the stable mother and fetus. MRI is the more sensitive and specic modality for retroplacental hemorrhage [20].
MRI may have a limited role in characterization of suspected abdominal injuries. Pancreatic transections and lacerations involving the main duct often require surgical repair
but can be subtle on initial imaging [21]. Short interval follow- up pancreatic protocol CT in 24–48h is recommended
in appropriate equivocal cases, but magnetic resonance cholangiopancreatography (MRCP) can be used as an alternative
for shorter interval problem-solving. Bile duct injuries can
also be well demonstrated by MRI, typically after initial
trauma management, particularly with the use of hepatobiliary contrast agents which can more precisely localize active
or contained bile leaks [22].
CT is the primary modality for assessment of patients
meeting criteria for spinal imaging [23]. However, MRI
offers markedly improved sensitivity for soft tissue ligamentous injury. Positive MRI ndings in the absence of CT ndings rarely require surgical intervention, so MRI is not
routinely undertaken as part of the initial trauma imaging
workup. However, this modality can serve as a highly useful
adjunct in settings including persistent pain and/or neurologic defects with negative CT or advanced degenerative
change on CT, unexaminable patients, for operative planning
in the mechanically unstable spine, or in other signicant
injury on CT [23, 24]. This typically does not require administration of gadolinium-based contrast.
Noncontrast head CT permits identication of pathologies requiring intervention but lacks assessment of underlying perfusion status and poorly visualizes underlying
posttraumatic parenchymal changes. CT perfusion imaging
a
Fig. 47.3 Assessment for bladder injury in the setting of pelvic hematoma. Initial CT cystogram performed using a delayed urography technique following intravenous contrast injection (a) demonstrates good
bladder opacication (*) but poor distension. A repeat examination was
b
performed with retrograde contrast administration via an indwelling
Foley catheter and demonstrates sufcient bladder distension to exclude
leak (b). Adjacent uid and hematoma (✩) can obscure or mimic leaks
when cystography is not included in the imaging workup
47 Advanced Considerations inCross-Sectional Imaging inTrauma
411
or MRI brain, with or without perfusion imaging, can typically be deferred until after resuscitation and initial management of concurrent injuries, but at some centers rapid
noncontrast MRI brain is now being trialed for initial imaging in certain settings including severe closed head trauma in
the pediatric population and may in the future expand into
more general usage [25].
Finally, MRI can be an appropriate adjunct in the stable
patient with contraindications to iodinated contrast administration and equivocal ndings on non-contrast CT. These
situations arise relatively infrequently, however, and should
be discussed with the radiologist to optimize workup.
Considerations Guiding Advanced CrossSectional Imaging
Patients can always be returned for follow-up imaging after
a period of observation or after either operative or nonoperative management. Imaging should never lead to delays in
ongoing care of the acute trauma patient. Advances in crosssectional imaging and the availability of problem-solving
tools do not mandate that all imaging options be exhausted
prior to denitive management. Adjunct tools including CT
cystography, BCVI screening, and MRI for suspected biliary
or pancreatic ductal injury may be performed as part of initial imaging workup in a stable patient but may also be
appropriate to defer in the setting of other signicant injury.
Clinical factors remain the most important guide to the next
best step for a given patient.
Advanced Techniques inTrauma Imaging
Beyond considerations of general CT protocol selection and
of appropriate supplementation with MRI, there are several
techniques which can be pursued to optimize cross-sectional
imaging in the setting of trauma.
ECG-gated thoracic CT is a broad term encompassing
multiple techniques for reducing motion artifact which may
obscure or mimic cardiac and aortic root injury. Where available, this tool can be utilized either for immediate characterization of suspected injury or for short-term follow-up of
nonoperatively managed injury. ECG-gated CT also
improves detection of coronary artery lacerations and subtle
pericardial injury [26].
Dual-energy CT (DECT) is an emerging area of interest
in trauma imaging, with broad potential applications [27,
28]. This technique involves acquisition of data both at high
and low kilovolt peaks, allowing differentiation and quantication of materials with different X-ray absorption behaviors. Iodine selective imaging renders areas of abnormal
bowel wall enhancement and subtle solid organ parenchymal
injury more apparent. Virtual noncontrast images can
increase conspicuity of hemorrhage, including bowel wall
hemorrhage. Calcium subtraction from bone, particularly
vertebral bodies, is a promising alternative to MRI for identifying marrow edema in the settings of microfracture and in
age indeterminate fractures [29]. Virtual monoenergetic
images can be used to reduce artifact from hardware, from
equipment external to the patient, and from bullet or shrapnel
fragments (Fig.47.4).
Split bolus single pass CT was developed in an attempt
to reduce radiation exposure resulting from multiphase
imaging. This technique consists of two or three sequential boluses of intravenous contrast followed by a single
CT acquisition of the chest, abdomen, and pelvis reflecting a combination of arterial and portal venous phases,
plus or minus a urinary excretory phase. Subjective image
quality and diagnostic accuracy for abdominal injuries
are quite promising, but there remain concerns in the
assessment of splenic parenchyma, which can appear heterogeneous, and in the characterization of areas of active
extravasation particularly within the pelvis [30].
Accordingly, acceptance of this technique remains
site-specific.
Trajectory analysis can serve as an important tool in the
assessment of penetrating abdominal and pelvic trauma. This
consists of double-obliqued reformatted imaging based on
entry and exit wound sites to identify potential sites of subtle
injury along the tract (Fig.47.5) [31]. Trajectory analysis can
provide valuable information by drawing attention to injuries
which might otherwise have been overlooked, particularly in
the setting of complex polytrauma, and by conrming suspected artifacts are outside the path of potential injury. This
technique has been found to have similar accuracy with
improved sensitivity when compared to enteric contrast in
the detection of colorectal injury [32].
412
S. Holmes
Fig. 47.4 DECT for metal
artifact reduction in gunshot
injury of the lower extremity
with multiple bullet fragments
(white arrows). Axial (a and
b) and sagittal (c and d)
imaging demonstrating
improved image quality when
comparing baseline images (a
and c) to images following
application of metal artifact
reduction (b and d) using
dual-energy CT
a
c
b
d
a
Fig. 47.5 Trajectory analysis in gunshot injury of the abdomen. Axial
images (a) demonstrate blood products (*) in the retroperitoneum
tracking adjacent to the descending colon (d), raising concern for
Key Points
• The radiologist remains the principal resource for
determining how advanced cross-sectional imaging
may benet either a general institutional protocol or
an individual patient.
• Modern CT and MRI scanners allow a range of methods for problem-solving based either on clinical ndings or initial CT ndings. Good communication
between the trauma team and the radiologist and
prompt review of the initial CT are therefore critical.
b
colonic injury. Multioblique reformatted trajectory analysis (b) shows a
bullet tract away from the descending colon. Absence of colonic injury
was conrmed at laparotomy
• The increasing role of Interventional Radiology and
nonoperative management mandates both accurate
detection and characterization of signicant injuries
and good vascular road mapping.
• New and emerging cross-sectional techniques for
initial trauma imaging including DECT and trajectory analysis are variably accessible and may lack
high-level evidence at this stage in their development but can provide valuable information when
integrated appropriately.
47 Advanced Considerations inCross-Sectional Imaging inTrauma
413
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Part VI
Tactical Emergency and Disaster Medicine
Disaster Medicine
MichelangeloBortolin andGregoryR.Ciottone
48
Abbreviations
CBRN Chemical, Biologic, Radiological, and
Nuclear
COVID-19 Coronavirus Disease 2019
CWA Chemical-Warfare Agents
EMS Emergency Medical Services
EOP Emergency Operations Plan
HIV Human Immunodeciency Virus
HVA Hazard and Vulnerabilities Assessments
IAP Incident Action Plan
IC Incident Commander
ICS Incident Command System
PTS Posttraumatic Stress
SARS Severe Acute Respiratory Syndrome
SOP Standard Operating Procedures
Disasters include natural events like the Australian bushre (2020) and the COVID-19 pandemic (2019–2020);
intentional events like the terrorist attacks in Paris (2015),
Nice (2016), and Vienna (2020); and accidental manmade events like the August 2020 Beirut explosion and
demonstrate the ubiquitous nature of such devastating
incidents.
Disaster is dened as any event that causes “A serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental
M. Bortolin (*)
BIDMC Fellowship in Disaster Medicine, Boston, MA, USA
CRIMEDIM - Center for Research and Training in Disaster
Medicine, Humanitarian Aid, and Global Health, UPO -
University of Eastern Piedmont, Novara, Italy;
http://www.disasterfellowship.org
G. R. Ciottone
BIDMC Fellowship in Disaster Medicine, Boston, MA, USA
Harvard Medical School, Boston, MA, USA
Harvard T.H.Chan School of Public Health, Boston, MA, USA
e-mail: gciotton@bidmc.harvard.edu;
http://www.disasterfellowship.org
losses and impacts, which exceeds the ability of the affected
community or society to cope using its own resources” [1].
Considering that any number of different events can strike
a population at any time, there is no place on earth completely immune to disasters. However, communities must be
able to mitigate against and be prepared to respond to these
situations, in short, be resilient to disaster.
Disaster Medicine was created as a broad specialty
grounded in Emergency Medicine but also utilizing the skill
sets of other surgical and medical specialties, in combination with the systems supported by Disaster Management,
which applies organizational, management, and leadership
knowledge to mitigate, prepare, and respond to these events.
For example, during an earthquake several specialties are
involved in the response and immediate care of the victims:
emergency physicians, surgeons, anesthesiologists, and
orthopedics; however, other subspecialties are also required
in the ongoing care of victims. These include nephrologists
to treat acute renal failure related to crush syndrome, and in
the days following the event, primary care, psychosocial,
and rehabilitation specialties for continued care. These medical and surgical specialists are only able to perform their
roles under the umbrella of Disaster Management. Without
being enabled by the logistics and operations capabilities
seen in a large-scale disaster response, these specialists
would not be functional. The global experience of the
COVID-19 pandemic has emphasized how Disaster
Medicine is a broad specialty that requires specic knowledge from different elds, including epidemiology, virology, emergency medicine, critical care, public health,
statistics, respiratory medicine, leadership, and crisis
management.
Natural or Man-made Disaster
Disasters are typically categorized as being from natural or
man-made events. Natural disasters such as oods, tsunamis,
and earthquakes typically have a more extensive impact on
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_48
417
418
M. Bortolin and G. R. Ciottone
population centers, causing more disruption. The 2020
Australian bushre crisis killed at least 25 people, destroyed
2000 homes, and burned more than 15.6million acres [2].
Hurricane Katrina in 2005 ravaged Louisiana, Mississippi,
Alabama, and Florida causing death, numerous casualties,
mass evacuations, and broad societal disruptions.
Natural disasters also include epidemics and pandemics.
In the past, inuenza, cholera, bubonic plague, and other diseases affected entire nations causing millions of casualties.
Today the entire world has gained rsthand experience with
a pandemic’s effect on populations and economies. The
COVID-19 pandemic has changed how everyone lives
through the implementation of non-pharmaceutical interventions (NPI). However, the consequences have not been the
same everywhere. Some countries have been more devastated by COVID-19 than others, whether because of incompetence, indifference, or ill luck [3], highlighting the
importance of Disaster Medicine to enhance resiliency.
Another viral pandemic that has resulted in differences in
transmission and death rate, particularly in developing countries, is Human Immunodeciency Virus (HIV). It is estimated that since its emergence in the early 1980s, HIV has
caused more than 33million deaths around the world, further
demonstrating that an estimated 97% of natural disasterrelated deaths occur in developing countries (World Bank,
2000–2001) [4].
Man-made disaster is dened as any event that is caused
by the activity of human beings. Explosions, building collapses, civil wars, and radiation accidents are some examples. The collapse of the Hyatt Regency Hotel in Kansas City
in 1981 is one such example. Investigations found that the
cause of the collapse was due to an engineering problem.
There were more than one hundred deaths and more than two
hundred casualties from that disaster.
The transportation industry is commonly involved in incidents that cause large numbers of injured and deaths. In
1998, a high-speed train derailed in Eschede, Germany,
causing 101 fatalities. Other industrial sectors, such as the
chemical industry, have also been involved in man-made
catastrophes. In December 1983in Bhopal, India, more than
half a million people were exposed to methyl isocyanate. In
the immediate phase after the leak almost 10,000 people
died. The Indian Government has calculated that this event
has caused over the years almost 600,000 casualties due to
lingering effects of the chemical exposures. The ammonium
nitrate explosion in Beirut in August 2020 caused more than
170 deaths, 6,500 injuries, and left an estimated 300,000
people homeless.
The 9/11/2001 terrorist attack in New York and the
Oklahoma City bombing (1995) are intentional man-made
disasters. It is important to recognize and underline that
disasters can also result from war, and conict zones, as well
as economic and social policies, particularly in developing
countries [5]. The Syrian civil war arose in 2011 and has
caused more than 400,000 deaths and 5.5 million refugees
since 2013 [6].
The Disaster’s Cycle
Disasters and the response to them follow a pattern called the
Disaster Cycle, which is dened in four phases: mitigation
and prevention, preparedness and planning, response, and
recovery.
Mitigation and prevention involve measures designed
either to prevent hazards from occurring or to lessen the
effects of the disasters [7]. These measures involve multiple
different agencies and commissions, for example, policymakers introduce regulations regarding the storage, transportation, and disposal of chemical substances. Another example
of mitigation is to empower a public health system to monitor and conduct surveillance for infectious diseases and at
the same time introduce rules regarding health screening at
the borders. The importance of the mitigation phase is to
avoid disaster or to reduce the impact on the population.
It becomes clear if we compare the 2010 earthquake in
Haiti, with a magnitude of 7.0, and similar earthquakes in
Japan where despite the same magnitude the number of dead
and injured was much more limited. The effects of a disaster
are often dependent on the underlying conditions of the area
affected. For decades Japan has introduced strict building
codes that follow seismic regulations. Nevertheless, it is not
possible to fully mitigate against all disaster events. For
instance, the 2011 earthquake in the Pacic Ocean produced
a tsunami that hit the east coast of Japan and caused severe
damage, in particular a failure of the nuclear plant in
Fukushima, with release of radiation that affected the local
community.
The preparedness and planning phase includes activities
that occur on an ongoing basis, in advance of any potential
incident. Preparedness involves an integrated combination of
assessment, planning, procedures and protocols, training and
exercises, personnel qualications, licensure, and certication and should undergo regular evaluation and revision [8].
The rst step of preparedness is dening what events are
more likely to strike and how well prepared the community
is for them. The Hazard Vulnerability Analysis (HVA) is a
way to objectively risk-stratify those hazards that are more
likely to strike a given community. The HVA takes into
account different events: natural, man-made, and CBRN
(Chemical, Biologic, Radiological, and Nuclear), among
others. The output from an HVA prioritizes the risks to which
a population is most susceptible and should therefore be prepared for. After the HVA, it is possible to then establish
Standard Operating Procedures (SOP) and the Emergency
Operations Plan (EOP) for the community or hospital. It is a
48 Disaster Medicine
419
good rule that the EOP adopts an all-hazards approach to
preparedness, with annexes and appendices specic for every
type of probable event [9].
An important part of the preparedness phase is training. In
particular, every healthcare professional must be trained
when to activate disaster response and their own specic
roles and responsibilities within the framework of the
response. The drills commonly used are tabletop and fullscale exercises. They are important also to identify shortfalls,
bottlenecks, and gaps in the EOP.The staff should take part
in the training and the EOP should be tested, reviewed, and
updated at least once per year.
Response is the phase in which agencies and sections
with responsibility to deploy to disasters activate their emergency response plan as a result of specic threats or situations and can incorporate local, regional, and federal response
agencies [10]. The response is conducted through a collaboration between several agencies and must be exible and
adaptable for any type of event.
It is important to immediately establish a response framework with a unied command structure that establishes a
chain of command and control and coordinates the resources,
in terms of staff, stuff, and space. The Incident Command
System (ICS) provides a structure to enable agencies with
different legal, jurisdictional, and functional responsibilities
to coordinate, plan, and interact effectively on scene [11].
The medical response is provided at the scene by the
Emergency Medical Services (EMS), with triage, treatment,
and transport to the hospitals, which plays a crucial role in
the immediate phase of the response to disaster. The response
must be quick and effective, on-scene as well as in the determination of hospital destinations for every patient, to guarantee an appropriate standard of care and to avoid bottlenecks
and congestion at hospitals. Rarely, EMS is able to triage,
treat, and transport every single patient from the scene. More
often some casualties reach the closest hospital on their own,
giving rise to disruption in the chain of triage and to the hospital. The ability of a healthcare system to suddenly expand
its capacity beyond normal services to meet the increased
demand for qualied medical staff and services during a
large-scale event is dened as “surge capacity” [12]. The
surge capacity depends on the features of the healthcare system, but also by an effective EOP and training level of the
staff.
The post-impact period revolves around disaster recovery
in which the goal is to eliminate impairment caused by a
disaster and rebuild communities and infrastructures [13].
This phase involves several agencies and may be longlasting, ranging from weeks to years. People affected by a
catastrophic disaster often face a long recovery phase.
Survivors of the September 11, 2001, terrorist attacks on the
Twin Towers not only had immediate treatment in the eld
and in the hospitals that day, but their treatment has contin-
ued for years. The majority of people exposed to disasters do
well; however, some individuals develop psychiatric disorders, distress, or risky behaviors such as an increase in alcohol or tobacco use [14]. The Department of Health and
Human Services spent months and years addressing this following the 9/11 attacks and has gone on to provide healthcare, both physical and mental, to those who were, and
continue to be, affected and in need [15]. The recovery phase
often also involves rescue workers as their exposure to the
traumatic event can have a severe impact on their mental
health. Studies conrm that rescue workers are prone to have
diseases or documented behavioral health disturbances during and following events. For example, several articles
describe how the acute and prolonged exposures were both
associated with a large burden of asthma and posttraumatic
stress (PTS) symptoms years after the 9/11 attack. In addition, the suicides of a prominent NewYork City emergency
physician and a nurse in Italy, both of whom had been on the
frontlines of the COVID-19 response, are tragic indicators of
the traumatic events incurred by many healthcare workers
during disasters [16].
Incident Command System
During an incident the response must be effective and efcient. To achieve this, and thereby ensure that the best care
possible is rendered to victims, it is fundamental to have a
well-prepared and organized system. The Incident Command
System (ICS) is a standardized, on-scene, all-hazard incident
management system and allows its users to adopt an integrated organizational structure to match the complexities and
demands of single or multiple incidents without being hindered by jurisdictional boundaries [17].
The ICS was developed in the 1970s in California to manage, command, and control re brigades during their operations to extinguish wildres. It was then adopted by EMS
and other agencies, as well as endorsed by the U.S.Department
of Homeland Security as a fundamental element of incident
management.
The ICS is used for all events and is modied depending
on the size of the incident. Its goal is to manage and resolve
the incident with an efcient use of resources while protecting all persons involved. The ICS is a modular and exible
organizational system that can be standardized for multiple
uses. The ICS is modied according to the size and complexity of the incident, specicity of the hazard, environment
affected by the incident, the incident planning process, and
incident objectives (ICS expansion and contraction) [18].
The ICS establishes an Incident Commander (IC), who is
in charge of all the activities regarding the incident; a chain
of command; and unied command between the agencies.
The priorities of the IC are three: the safety of the casualties
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M. Bortolin and G. R. Ciottone
and the rescue team, incident stabilization, and property
preservation. Every incident must have an Incident Action
Plan (IAP) that establishes incident goals, operational period
objectives, set activities, and the response strategy dened by
the IC during response planning [19].
The IC manages and carries out their responsibilities with
three features of command that are important for every role
within the framework of the ICS: the chain of command, the
unity of command, and the span of control. The chain of
command is a key part of the ICS and is dened as a structure
with a clear line of authority. The unity of command infers
that every responder knows without question who their
supervisor is. Span of control describes the typically 6–7
people a supervisor directly leads.
During a disaster, it is extremely important to establish a
Unied Command, because it enables all responsible agencies to manage and coordinate an incident together by establishing a common approach and a single IAP.It permits the
integration of stafng and shared facilities, with everyone
having the same objectives and not replicating efforts [20].
The IAP describes activities, responsibilities, and communication procedures. This system is fundamental to avoid
confusion and lack of communication. Adequate and redundant communication systems are very important during the
response to disaster. It is essential that the ICS uses common
terminology and integrated communications among agencies
and establishes precise ways of communication. The communication systems should be: interoperable between agencies; reliable to function in the context of any kind of
emergency; portable, built on standardized radio technologies, protocols, and frequencies; scalable as the needs of the
incident dictate; resilient to perform despite damaged or lost
infrastructure; and redundant to enable use of alternate communication methods when primary systems go out [21].
The ICS is supported by a command staff that includes a
safety manager, a liaison ofcer, and a public information
ofcer. It is organized into four sections which support the
ICS: operation, planning, logistics, and nance/administration. The operation section is in charge of managing all activities on the scene including re brigades, EMS, and all
agencies required for the incident. The planning section is
responsible for drafting the IAP; receiving, assimilating, and
sharing information; and tracking all resources. The logistics
section provides the required equipment and facilities and
supports personnel with food and water. The nance/administration section provides funding, tracks all costs, and manages contracts.
These sections, like the ICS, are modular organizations
and can be further expanded into: units (the organizational
element with functional responsibility for specic incident
planning, logistics, or nance/administration activity), divisions (only for the operations section and used to divide an
incident geographically), groups (only for operation section
and established to divide the incident management structure
into functional areas), and branches (used when the number
of divisions or groups exceeds the span of control and can be
either geographical or functional for major aspects of incident operations) [22].
Triage
The word triage is derived from the French word “trier” that
literally means “to categorize, or to sort.” The concept of triage was proposed for the rst time by Baron Dominique Jean
Larrey, Surgeon in Chief to Napoleon’s Imperial Guard in
the eighteenth century. The innovation of Baron Larrey was
that he was the rst to implement the idea of treating the
sickest rst and evacuating them to the most appropriate care
facility in priority order, thereby maximizing the use of
available resources for optimal patient benet, and aiming
for a minimum time to denitive treatment [23].
The most commonly used disaster triage system places
casualties into four classes: black (expectant), red (immediate priority), yellow (delayed priority), or green (minor priority), depending on the severity of the injuries. When sorting
casualties, it is important to give immediate medical care to
critical patients that have a chance of survival with prompt,
advanced treatment. In less critical patients, and patients
who are so severely injured that they have very little chance
of survival, treatment is delayed. The goal is to provide the
greatest good for the greatest number of patients, forcing the
triage ofcer to decide whether the chance of a patient surviving is so low in comparison to the burden such care would
place on the medical system that the patient must be consigned to the “expectant” category (dying; little or no treatment) [24]. Triage will be discussed further in Chapter 49.
The concept of triage must be seen in a wider context and
is composed of the following elements: rapid evaluation of
all disaster victims; assessment of the nature and severity of
the injuries and its consequences on the vital functions of the
casualties, categorization of the casualties, resuscitation, stabilization for transport, distribution, and evacuation of the
casualties [25]. Triage is a quick and dynamic process. This
means that it must be repeated often and at every moment in
which a new healthcare professional takes control of a
patient. For example, during transport, upon arrival at the
hospital, or if there is a suspicion that the state of the patient
has changed.
One concern in disaster triage is the possible use of chemical or radiation weapons in a terrorist attack. The recent use
of chemical weapons (CW) on civilian populations, as seen
in the Syrian civil war and in assassination attempts in the
United Kingdom, Malaysia, and Russia, has increased that
concern. This has demonstrated the importance of a new system of triage to use for these CW attacks to quickly