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Mass casualty CPR: Flawed, futile or a first responder mandate?

      The tragic crowd crush incident on 29th October 2022 in Seoul, South Korea resulted in at least 154 deaths.

      Abu Baker J. Seoul crowd crush: How it may have happened and what to do in such a situation. 2022. CNA Oct 31. https://www.channelnewsasia.com/asia/seoul-crowd-crush-what-happened-what-do-3034321 (Accessed Nov 2 2022).

      Early social media footage showed bystanders along with a large number of rescuers and Emergency Medical Services (EMS) personnel performing cardiopulmonary resuscitation (CPR) on multiple victims, triggering debates on the merits of such interventions in a mass casualty setting.
      The vast majority of human crush casualties result from traumatic asphyxia caused by external compression of the thorax or upper abdomen, leading to complete or partial cessation of respiration and subsequent cardiac arrest and death.
      • Ngai K.
      • Burkle F.
      • Hsu A.
      • Hsu E.
      Human stampedes: A systematic review of historical and peer-reviewed sources.
      Traditional mass casualty incident (MCI) triage concepts and teachings of de-prioritizing pulseless and unresponsive victims risk denying them potential life-saving CPR interventions.
      The purpose of triage is to maximise lives saved in mass casualty incidents when the resources are constrained,
      • Baker M.S.
      Creating order from chaos: Part I: triage, initial care, and tactical considerations in mass casualty and disaster response.
      however, very few systems take into account the context, resources, or mechanisms of injury, all of which are important determinants in survival outcomes. In a MCI due to a terrorist bombing, with penetrating injuries, pulseless victims will not survive with basic life support interventions. However, in a crowd crushing injury, with asphyxia as the leading cause of cardiac arrest, there is a much higher probability of survival if prompt CPR is initiated at the scene, as highlighted by the Hillsborough Stadium disaster in 1989.
      • Nolan J.P.
      • Soar J.
      • Cary N.
      • et al.
      Compression asphyxia and other clinicopathological findings from the Hillsborough Stadium disaster.
      In order to maximise lifesaving interventions in a human crowd crush incident, triage systems and disaster medicine training programs for first responders should include the flexibility to adapt to the uniqueness of each scenario, including initiation of prompt CPR with ventilation if indicated, and when resources are available.

      Conflict of Interest

      We declare no conflicts of interest and no financial interests.

      References

      1. Abu Baker J. Seoul crowd crush: How it may have happened and what to do in such a situation. 2022. CNA Oct 31. https://www.channelnewsasia.com/asia/seoul-crowd-crush-what-happened-what-do-3034321 (Accessed Nov 2 2022).

        • Ngai K.
        • Burkle F.
        • Hsu A.
        • Hsu E.
        Human stampedes: A systematic review of historical and peer-reviewed sources.
        Disaster Med Public Health Prep. 2009; 3: 191-195https://doi.org/10.1097/DMP.0b013e3181c5b494
        • Baker M.S.
        Creating order from chaos: Part I: triage, initial care, and tactical considerations in mass casualty and disaster response.
        Mil Med. 2007; 172: 232-326https://doi.org/10.7205/MILMED.172.3.232
        • Nolan J.P.
        • Soar J.
        • Cary N.
        • et al.
        Compression asphyxia and other clinicopathological findings from the Hillsborough Stadium disaster.
        Emerg Med J. 2020; : 1-5https://doi.org/10.1136/emermed-2020-209627