Essential health services – injury standard 1: Injury care
People have access to effective injury care during disasters to prevent avoidable morbidity, mortality and disability.
Key actions (to be read in conjunction with the guidance notes)
Ensure that local health workers and those coordinating the health-sector response are familiar with mass casualty management (see guidance note 1).
In mass casualty events, establish a standardised system of triage with clear guidance on assessment, prioritisation, basic resuscitation and referral (see guidance note 1).
Ensure essential principles and skills for provision of first aid and basic resuscitation are widely understood by health workers (see guidance note 2).
Ensure that local health workers are familiar with core principles of wound management (see guidance note 3).
Provide a tetanus vaccine that contains toxoid to those with dirty wounds and to those involved in rescue or clean-up operations (see guidance note 4).
Establish standardised protocols for the referral of injured patients for advanced care, including surgery and post-operative care (see guidance note 5).
Ensure that definitive trauma and surgical services and post-trauma and post-surgical rehabilitation are established only by agencies with appropriate expertise and resources (see guidance note 5).
Ensure standard assistive devices and mobility aids (e.g. wheelchairs, crutches) are available for injured patients and persons with disabilities as soon as practical and that these aids can be repaired locally (see guidance note 6).
Key indicator (to be read in conjunction with the guidance notes)
All health facilities have trained staff and systems for the management of multiple casualties.
- Triage: Triage is the process of categorising patients according to the severity of their injuries or illness, and prioritising treatmentaccording to the availability of resources and the patients’ chances of survival. In mass casualty events, those with severe, life-threatening injuries may receive a lower priority than those with more survivable injuries. There is no standardised system of triage and several are in use throughout the world. The most common classification uses the four-colour code system: red signals high priority, yellow for medium priority, green is used for ambulatory patients and black for deceased.
- First aid and basic medical care: Critical procedures include restoring and maintaining breathing which may require clearing and protecting the airway, along with controlling bleeding and administering intravenous fluids when required.These procedures may help to stabilise individuals with life-threatening injuries before transfer to a referral centre and greatly increase their chances of survival, even for severe injuries. Other non-operative procedures are equally vital, such as cleaning and dressing wounds and administering antibiotics and tetanus prophylaxis.
- Wound management: In most disasters, many patients will present for care more than six hours after injury. Delayed presentation greatly increases the risk of wound infection and preventable excess mortality. It is, therefore, critical that local healthcare workers are familiarised with appropriate principles and protocols to prevent and manage wound infection, which include delayed primary closure and wound toilet and surgical removal of foreign material and dead tissue.
- Tetanus: In sudden-onset natural disasters where there are usually a large number of injuries and trauma cases, risk of tetanus can be relatively high. While mass tetanus immunisation is not recommended, tetanus toxoid-containing vaccine (DT or Td – diphtheria and tetanus vaccines – or DPT, depending on age and vaccination history) is recommended for those with dirty wounds and for those involved in rescue or clean-up operations that put them at risk. Individuals with dirty wounds who have not previously been vaccinated against tetanus should receive a dose of tetanus immune globulin (TIG), if available.
- Trauma and surgical care: Trauma surgical care and war surgery save lives and long-term disability and require specific training and resources that few agencies possess. Inappropriate or inadequate surgery may do more harm than doing nothing. Moreover, surgery provided without any immediate rehabilitation can result in a complete failure in restoring functional capacities of the patient. Only organisations and professionals with the relevant expertise should, therefore, establish these services that save lives and prevent disability.
- Post-operative rehabilitation for trauma-related injury: Early rehabilitation can greatly increase survival and enhance the quality of life for injured survivors. Patients requiring assistive devices (such as prostheses and mobility devices) will also need physical rehabilitation. Where available, partnership with community-based rehabilitation programmes can optimise the post-operative care and rehabilitation for injured survivors.