Igra Noah M, Schmulevich Daniela, Geng Zhi, Guzman Jessica, Biddinger Paul D, Gates Jonathan D, Spinella Philip C, Yazer Mark H, Cannon Jeremy W
From the Department of Surgery, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Igra, Geng, Cannon).
School of Medicine, Tel Aviv University, Tel Aviv, Israel (Igra, Yazer).
J Am Coll Surg. 2024 Jan 1;238(1):41-53. doi: 10.1097/XCS.0000000000000894. Epub 2023 Oct 23.
Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment.
Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided).
Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties.
In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.
美国城市地区越来越关注大规模伤亡事件（MCI）的应对。我们模拟了院前分诊场景，并假设利用医院的血液制品库存进行现场分诊决策可将治疗时间减至最短。
离散事件模拟对马萨诸塞州波士顿市一次模拟爆炸事件后的MCI伤亡情况及患者流程进行了建模。根据损伤模式将伤亡人员分为中度（损伤严重度评分9至15）和重度（损伤严重度评分>15）。收集了所有医院（n = 6）的血液制品库存。主要终点是在目标时间内采用1:1:1平衡复苏治疗的伤亡人员比例（中度，6小时内输注3.5单位红细胞；重度，1小时内输注10单位红细胞）。比较了三种分诊场景，包括伤员无障碍地前往附近医院（最近医院）、在各医院间平均分配（平均分配）以及基于血液制品库存的分诊（供应指导）。
模拟的MCI产生了平均±标准差为302±7名伤亡人员，包括57±2名中度和15±2名重度伤亡人员。最近医院分诊导致在目标时间内接受治疗的总体伤亡人员显著减少（55%，而平均分配为86%，供应指导为91%，p < 0.001）。这些差异主要是由于接受治疗的中度伤亡人员较少，但重度伤亡人员的治疗策略之间没有差异。
在这项比较不同分诊策略（包括基于实际血液制品库存的策略）的模拟研究中，最近医院分诊不如平均分配或供应指导策略。美国城市地区的灾难应对领导者应考虑对不同的MCI场景和伤亡人数进行建模，以根据医院数量和血液制品可用性确定其所在地区的最佳分诊策略。
