 In this session we shall talk about mass casualty incidents. A mass casualty incident is any incident where the number of injured overhwilms the capabilities of the first arriving teams. They usually involve trauma but could be acute radiation, biological weapons or poisoning from alcohol. It could be bomb blasts, it could be transportation crashes. They can involve road traffic injuries, collapsed buildings which are common every day. Three things are particularly important in lessening injuries and deaths in mass casualty incidents. One is immediate search and rapid triage. Two immediate first aid treatment. And three transport to the nearest medical center. Read the story on the bus collision. What things went wrong in that scenario? At the incident it is important to be composed. Search and rescue should be done methodically. Stop, look, listen and think and call for help. Choose a team leader. Usually security personnel are needed to secure the incident site. Zone one or ground zero as it is commonly called. Wear protected gadgets including gloves and helmets. Select a medical incident commander to manage, triage, treatment and transport the three T's. These are very important in mass casualty incidents. Triaging, treatment and transport patients. Some ambulances are able to sustain lives that require advanced support. Call for an ambulance. Triage is a French term meaning pick and sort or select and categorize. It involves classifying victims in order to assign priorities for medical care and transportation. Agency of the case handling to increase victims' likelihood of survival. The aim is to provide the greatest good for the greatest number of people injured. Triage categories. Triage uses agreed colors to communicate among the personnel. Triage ribuns of cards can be used, although in resource constrained countries we may use other calling systems. It tells the intervention teams the priority level would reach to handle each affected person. This is an example of a color coded triage card. Triage categories include those injured or affected persons that need immediate care, those that need delayed care, those that need minor care and those that can be classified as deceased. The red coded are the first priority at the mass casualty incident site. Immediate care should be stated. They have a compromised airway or are in shock and need immediate resuscitation. The yellow coded are the second priority. If immediate care is needed, they can deteriorate to red category in a short time. They are in impending shock. The green coded are the third category and include all walking wounded. Care can come later. However, they need monitoring for any sign of deterioration. The black coded are either dead or hopelessly wounded. The priority time and resources concentrate on those that can be served. How to triage? Begin by assessing all non-moving patients wherever they lie. Use start triage. Start meaning simple triage and rapid treatment. Where treatment here refers to first aid treatment and follow-up treatment. Triage can be performed by any individual including non-health workers. Because of scarcity of manpower, all who can should participate in triage. Triage techniques will consider three main aspects. Respiration, blood circulation and consciousness. Under respiration we check, are they breathing? If they are breathing, what are the breaks per minute? These are important criteria that may make us decide whether someone needs immediate care or delayed care. Under blood circulation we look, is there a pulse? And even if there is a pulse or if there is no pulse, how is the perfusion of blood into the tissues? Three, consciousness. Are they conscious? What is their mental status? All these three areas of assessment should take less than one minute per patient checking for respiration. If there is no respiration or if they are not breathing, open the airway and clear the airway by stretching the neck and clearing anything that may be in the mouth. If there is still none, label as black. If the respiration is restored, label as red. If the respiration was initially present, then their breathing rate is above 30 breaks per minute or visibly fast breathing label as red. However, if the breathing rate is below 30 and they were initially breathing, then go to the next stage of assessment and that is the circulation or the perfusion. Blood circulation is the same as perfusion. Check if the radiopulse is present and if it is not present or the capillary refill is greater than two seconds label as red. If the radiopulse is present and normal or the capillary refill is less than two seconds, then that means the circulation is okay. And for such patients, if they passed the respiration test and they have also passed the circulation test, we need to check the mental status. If in the mental status they cannot follow simple commands, then they are unconscious or have an altered level of consciousness. These are labeled as red. If they can follow simple commands and they have passed all previous tests, that is respiration and saturation, then label as yellow if they are unable to walk or green if they are walking. This is the summary algorithm. Take time to look at it in summary. Triage is the single most important decision involving management of mass casualty incidents. Triage evaluation involves airway breathing, that is respiration, checking the circulation and checking the mental status. However, after the triage, the triage teams need to hand over the serious cases to the first aid treatment teams. And later on, we shall look in another session, we shall look at first aid treatment. Medico facilities are encouraged to develop mass casualty plans for their facilities based on operating capacity and resources. District committees and local authorities should identify key players in search and rescue and in first aid. Thanks for listening.