Emergency Preparedness Aspects of DCR for Civilian Mass Casualty Scenarios

  • David W. Callaway
  • Reed Smith
  • Sean M. Fox


Damage control resuscitation (DCR) and remote damage control resuscitation (RDCR) are key components of effective modern trauma resuscitation. Traumatic Mass Casualty Incidents (T-MCI) create unique operational and clinical challenges for effective implementation of the core tenants of DCR principles. Proper readiness and response requires a whole of community approach to the challenges based on tiered application of the Tactical Emergency Casualty Care (TECC) guidelines in the prehospital, first receiver facility, and trauma center environments. Mitigation, preparedness, and planning activities are critical to ensuring robust blood product availability, comprehensive patient distribution protocols, and continuity of operations plans.


Damage control resuscitation Remote damage control resuscitation Tactical Emergency Casualty Care TECC DCR RDCR Trauma Mass Casualty Incident Emergency Management 


  1. 1.
    Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–7.CrossRefGoogle Scholar
  2. 2.
    Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350–8.CrossRefGoogle Scholar
  3. 3.
    Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148:127–36.CrossRefGoogle Scholar
  4. 4.
    National Association of State EMS Officials. Extended Definition Document NEMSIS/NHTSA 2.2.1 Data Dictionary. Available at: Accessed 10 Oct 2012.
  5. 5.
    Schenk E, Wijetunge G, Mann NC, Lerner EB, Longthorne A, Dawson D. Epidemiology of mass casualty incidents in the United States. Prehosp Emerg Care. 2014;18(3):408–16.CrossRefGoogle Scholar
  6. 6.
    Smith ER, Shapiro G, Sarani B. Fatal wounding pattern and causes of potentially preventable death following the pulse night club shooting event. Prehosp Emerg Care. 2018;22(6):662–8.CrossRefGoogle Scholar
  7. 7.
    Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86–92.CrossRefGoogle Scholar
  8. 8.
    Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. “Blood failure” time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016;56(Suppl 2):S182–9.Google Scholar
  9. 9.
    Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Mackersie RC, Pittet JF. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyper fibrinolysis. J Trauma. 2008;64(5):1211–7; discussion 1217CrossRefGoogle Scholar
  10. 10.
    Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr, Gross K, Stockinger ZT. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017;318(16):1581–91.CrossRefGoogle Scholar
  11. 11.
    Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS, PAMPer Study Group. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315–26.CrossRefGoogle Scholar
  12. 12.
    Callaway D, Bobko J, Smith ER, Shapiro G, McKay S, Anderson K, Sarani B. Building community resilience to dynamic mass casualty incidents: A multiagency white paper in support of the first care provider. J Trauma Acute Care Surg. 2016;80(4):665–9.CrossRefGoogle Scholar
  13. 13.
  14. 14.
  15. 15. Accessed 25 Nov 2017.
  16. 16.
  17. 17.
    Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. The ranger first responder program and tactical emergency casualty care implementation: a whole-community approach to reducing mortality from active violent incidents. J Spec Oper Med. 2015;15(3):46–53.PubMedGoogle Scholar
  18. 18.
    Callaway DW, Smith ER, Cain J, Shapiro G, Burnett WT, McKay SD, Mabry R. Tactical emergency casualty care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011;11(3):104–22.PubMedGoogle Scholar
  19. 19.
    Nessen SC, Eastridge BJ, Cronk D, Craig RM, Berséus O, Ellison R, Remick K, Seery J, Shah A, Spinella PC. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. Transfusion. 2013;53(Suppl 1):107S–13S.CrossRefGoogle Scholar
  20. 20.
    Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66(4 Suppl):S69–76.CrossRefGoogle Scholar
  21. 21.
    Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016;81(1):21–6.CrossRefGoogle Scholar
  22. 22.
  23. 23.
  24. 24.
    Meyer DE, Vincent LE, Fox EE, OʼKeeffe T, Inaba K, Bulger E, Holcomb JB, Cotton BA. Every minute counts: time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma Acute Care Surg. 2017;83(1):19–24.CrossRefGoogle Scholar
  25. 25.
    Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G, PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.CrossRefGoogle Scholar
  26. 26.
    Chapleau W, Al-Khatib J, Haskin D, et al. ATLS Subcommitte: American College of Surgeons’ Committee on Trauma. Advanced trauma life support (ATLS): the ninth edition. J Trauma Acute Care. Surg 2013;74(5):1363–6.Google Scholar
  27. 27.
    Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105–9.CrossRefGoogle Scholar
  28. 28.
    Cotton BA, Guy JS, Morris JA, Abumrad NN. The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock. 2006;26(2):115–21.CrossRefGoogle Scholar
  29. 29.
    Kasotakis G, Sideris A, Yang Y, de Moya M, Alam H, King DR, Tompkins R, Velmahos G, Inflammation and Host Response to Injury Investigators. Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. J Trauma Acute Care Surg. 2013;74(5):1215–21; discussion 1221–2PubMedPubMedCentralGoogle Scholar
  30. 30.
    Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma. 1997;42:857–61.CrossRefGoogle Scholar
  31. 31.
    Moren AM, Hamptom D, Diggs B, Kiraly L, Fox EE, Holcomb JB, Rahbar MH, Brasel KJ, Cohen MJ, Bulger EM, Schreiber MA, PROMMTT Study Group. Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition. J Trauma Acute Care Surg. 2015;79(6):920–4.CrossRefGoogle Scholar
  32. 32.
    Callcut RA, Cotton BA, Muskat P, Fox EE, Wade CE, Holcomb JB, Schreiber MA, Rahbar MH, Cohen MJ, Knudson MM, Brasel KJ, Bulger EM, Del Junco DJ, Myers JG, Alarcon LH, Robinson BR, PROMMTT Study Group. Defining when to initiate massive transfusion: a validation study of individual massive transfusion triggers in PROMMTT patients. J Trauma Acute Care Surg. 2013;74(1):59–65, 67–8; discussion 66–7CrossRefGoogle Scholar
  33. 33.
    Tapia NM, Chang A, Norman M, Welsh F, Scott B, Wall MJ Jr, Mattox KL, Suliburk J. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg. 2013;74(2):378–85; discussion 385–6.CrossRefGoogle Scholar
  34. 34.
    Smith ER Jr, Delaney JB. A new EMS response: supporting paradigm change in EMS operational medical response to active shooter events. JEMS. 2013;38(12):48–50, 52, 54–5PubMedGoogle Scholar
  35. 35.
    Smith ER, Iselin B, McKay WS. Toward the sound of shooting: Arlington county, VA., rescue task force represents a new medical response model to active shooter incidents. JEMS. 2009;34(12):48–55.PubMedGoogle Scholar
  36. 36.
    Autrey AW, Hick JL, Bramer K, Berndt J, Bundt J. 3 Echo: concept of operations for early care and evacuation of victims of mass violence. Prehosp Disaster Med. 2014;29(4):421–8.CrossRefGoogle Scholar
  37. 37.
    Band RA, Salhi RA, Holena DN, Powell E, Branas CC, Carr BG. Severity-adjusted mortality in trauma patients transported by police. Ann Emerg Med. 2014;63(5):608–614.e3.CrossRefGoogle Scholar
  38. 38.
    Wandling MW, Nathens AB, Shapiro MB, Haut ER. Police transport versus ground EMS: a trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes. J Trauma Acute Care Surg. 2016;81(5):931–5.CrossRefGoogle Scholar
  39. 39.
    Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, Santora TA, Pathak AS, Goldberg AJ. Prehospital procedures before emergency department thoracotomy: “scoop and run” saves lives. J Trauma. 2007;63(1):113–20.CrossRefGoogle Scholar
  40. 40.
    Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport with Mortality in Penetrating Trauma: Trauma System–Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018;153(2):107–13.CrossRefGoogle Scholar
  41. 41.
    Century Theater Shooting. Aurora Fire Department Preliminary Incident Analysis. City of Aurora; 2012.Google Scholar
  42. 42.
    National Model EMS Clinical Guidelines. September 2017. Version 2. National Association of State EMS Officers. Accessed online 30 Sept 2017.Google Scholar
  43. 43.
    Ausset S, Glassberg E, Nadler R, Sunde G, Cap AP, Hoffmann C, Plang S, Sailliol A. Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: a critical appraisal of the medical literature and available alternatives. J Trauma Acute Care Surg. 2015;78(6. Suppl 1):S70–5.CrossRefGoogle Scholar
  44. 44.
    Strosberg DS, Nguyen MC, Mostafavifar L, Mell H, Evans DC. Development of a prehospital tranexamic acid administration protocol. Prehosp Emerg Care. 2016;20(4):462–6.CrossRefGoogle Scholar
  45. 45.
    Wafaisade A, Lefering R, Bouillon B, Böhmer AB, Gäßler M, Ruppert M, Trauma Register DGU. Prehospital administration of tranexamic acid in trauma patients. Crit Care. 2016;20(1):143.CrossRefGoogle Scholar
  46. 46.
    Karl A, Pham T, Yanosky JD, Lubin J. Variability of uncrossmatched blood use by Helicopter EMS programs in the United States. Prehosp Emerg Care. 2016;20(6):688–94.CrossRefGoogle Scholar
  47. 47.
    Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care. 2015;19(1):1–9.CrossRefGoogle Scholar
  48. 48.
    O'Reilly DJ, Morrison JJ, Jansen JO, Apodaca AN, Rasmussen TE, Midwinter MJ. Prehospital blood transfusion in the en route management of severe combat trauma: a matched cohort study. J Trauma Acute Care Surg. 2014;77(3. Suppl 2):S114–20.CrossRefGoogle Scholar
  49. 49.
    Rehn M, Weaver A, Brohi K, Eshelby S, Green L, Røislien J, Lockey DJ. Effect of pre-hospital red blood cell transfusion on mortality and time of death in civilian trauma patients. Shock. 2019;51(3):284–8.CrossRefGoogle Scholar
  50. 50.
  51. 51.
    Chapman MP, Moore EE, Chin TL, Ghasabyan A, Chandler J, Stringham J, Gonzalez E, Moore HB, Banerjee A, Silliman CC, al e. Combat: initial experience with a randomized clinical trial of plasma-based resuscitation in the field for traumatic hemorrhagic shock. Shock. 2015;44(Suppl 1):63–70.CrossRefGoogle Scholar
  52. 52.
    Mix FM, Zielinski MD, Myers LA, Berns KS, Luke A, Stubbs JR, Zietlow SP, Jenkins DH, Sztajnkrycer MD. Prehospital blood product administration opportunities in ground transport ALS EMS - a descriptive study. Prehosp Disaster Med. 2018;33(3):230–6.CrossRefGoogle Scholar
  53. 53.
    Martinaud C, Ausset S, Deshayes AV, Cauet A, Demazeau N, Sailliol A. Use of freeze-dried plasma in French intensive care unit in Afghanistan. J Trauma Acute Care Surg. 2011;71(6):1761–4; discussion 1764–5CrossRefGoogle Scholar
  54. 54.
    Sunde GA, Vikenes B, Strandenes G, Flo KC, Hervig TA, Kristoffersen EK, Heltne JK. Freeze dried plasma and fresh red blood cells for civilian pre-hospital hemorrhagic shock resuscitation. J Trauma Acute Care Surg. 2015;78(6. Suppl 1):S26–30.CrossRefGoogle Scholar
  55. 55.
    Martin RS, Kilgo PD, Miller PR, Hoth JJ, Meredith JW, Chang MC. Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank. Shock. 2005;24(2):114–8.CrossRefGoogle Scholar
  56. 56.
    Arthurs Z, Cuadrado D, Beekley A, Grathwohl K, Perkins J, Rush R, Sebesta J. The impact of hypothermia on trauma care at the 31st combat support hospital. Am J Surg. 2006;191(5):610–4.CrossRefGoogle Scholar
  57. 57.
    Jenkins D, Stubbs J, Williams S, Berns K, Zielinski M, Strandenes G, Zietlow S. Implementation and execution of civilian remote damage control resuscitation programs. Shock. 2014;41(Suppl 1):84–9.CrossRefGoogle Scholar
  58. 58.
    Zielinski MD, Jenkins DH, Schiller HJ, Berns KS, Zietlow SP. The effects of pre-hospital plasma on patients with injury: a pre-hospital plasma resuscitation. J Trauma Acute Care Surg. 2012;73(2. Suppl 1):S49–53.PubMedGoogle Scholar
  59. 59.
    Zielinski MD, Smoot DL, Stubbs JR, Jenkins DH, Park MS, Zietlow SP. The development and feasibility of a remote damage control resuscitation prehospital plasma transfusion protocol for warfarin reversal for patients with traumatic brain injury. Transfusion. 2013;53(Suppl 1):59S–64S.CrossRefGoogle Scholar
  60. 60.
    AABB. Standards for blood banks and transfusion services. 31st ed. Bethesda, MD: AABB; 2018.Google Scholar
  61. 61.
    Fu CY, Wu YT, Liao CH, Kang SC, Wang SY, Hsu YP, Lin BC, Yuan KC, Kuo IM, Ouyang CH. Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers. Am J Emerg Med. 2013;31(10):1432–6.CrossRefGoogle Scholar
  62. 62.
    Pizanis A, Pohlemann T, Burkhardt M, Aghayev E, Holstein JH. Emergency stabilization of the pelvic ring: clinical comparison between three different techniques. Injury. 2013;44(12):1760–4.CrossRefGoogle Scholar
  63. 63.
    Advanced Trauma Life Support, 10th Ed. 2018. American College of Surgeons, Committee on Trauma.Google Scholar
  64. 64.
    Moore LJ, Martin CD, Harvin JA, Wade CE, Holcomb JB. Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis. Am J Surg. 2016;212(6):1222–30.CrossRefGoogle Scholar
  65. 65.
    Brenner M, Inaba K, Aiolfi A, DuBose J, Fabian T, Bee T, Holcomb JB, Moore L, Skarupa D, Scalea TM, AAST AORTA Study Group. Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018;226(5):730–40.CrossRefGoogle Scholar
  66. 66.
    Prasarn ML, Conrad B, Small J, Horodyski M, Rechtine GR. Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: a cadaveric study of stability. Injury. 2013;44(12):1756–9. Scholar
  67. 67.
    Cannon JW, Johnson MA, Caskey RC, et al. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017;83(2):605–17.CrossRefGoogle Scholar
  68. 68.
    Karam O, Tucci M. Massive transfusion in children. Transfus Med Rev. 2016;30:213–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • David W. Callaway
    • 1
  • Reed Smith
    • 2
    • 3
  • Sean M. Fox
    • 4
  1. 1.Department of Emergency Medicine, Operational and Disaster MedicineCarolinas Medical Center, Atrium Health SystemCharlotteUSA
  2. 2.Department of Emergency MedicineGeorge Washington UniversityWashington, DCUSA
  3. 3.Arlington County Fire DepartmentArlingtonUSA
  4. 4.Department of Emergency MedicineCarolinas Medical Center, Atrium Health SystemCharlotteUSA

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