Burn MASCAL –⁠ a comprehensive case report

Czech version

Authors: J. Šimek ¹; K. Šmejkal ¹; H. Trlica ²; P. Knížetová ³; L. Hána ⁴; T. Henlín ⁵; Radek Pohnán ⁴
Authors‘ workplace: Katerda válečné chirurgie, Fakulta vojenského zdravotnictví v Hradci Králové, Univerzita obrany v Brně ¹; Chirurgická klinika LF UK a FN Hradec Králové ²; 16. polní nemocnice, Agentura vojenského zdravotnictví, Hradec Králové ³; Chirurgická klinika 2. LF UK a ÚVN – VFN Praha ⁴; Klinika anesteziologie, resuscitace a intenzivní medicíny 1. LF UK a ÚVN – VFN Praha ⁵
Published in: Rozhl. Chir., 2026, roč. 105, č. 1, s. 35-44.
Category: Case Report
doi: https://doi.org/10.48095/ccrvch2026

Overview

Introduction: Managing a large number of seriously injured patients (massive casualties –⁠ MASCAL) is a situation faced by medical teams in war conflicts and during disasters. MASCAL is an incident with a mass receive of injured patients, where the number of casualties exceeds the capacity and capabilities of the healthcare facility, placing enormous demands on the work of medical teams and effective management of limited human and material resources.

Case report: In this communication, we describe a burn-related MASCAL that occurred in Kabul following a gas cylinder explosion. Within a 72-hour period, a ROLE 3 field hospital at the Kabul base received and treated 71 patients with deep burns covering 5–90% of their body surface area. Despite the exceptional scale of this tragedy, it was managed successfully through a staged system of care delivery and subsequent redistribution of burn patients to other alliance healthcare facilities.

Conclusion: Receiving a mass influx of patients with extensive burns is one of the most medically, organizationally, and logistically challenging situations, placing extreme demands on the healthcare delivery system. MASCAL situations require a rapid and coordinated response with established treatment priorities and a prepared strategy for the efficient distribution of personnel, supplies, and equipment.

Keywords:

triage – Burns – damage control resuscitation – damage control surgery – MASCAL – massive casualties – combat losses – ISAF – MTF KAIA

Sources

WHO. Burns. 2018 [online]. Available from: www.who.int/en/news-room/fact-sheets/detail/burns.
Hyldig N, Birke-Sorensen H, Kruse M. The impact of burn trauma on the patients treated in the tsunami disaster area. Burns 2006; 32(6): 688–691.
Hirshberg A, Holcomb J, Mattox K. Hospital trauma care in multiple-casualty incidents: a critical view. Ann Emerg Med 2001; 37(6): 647–652. doi: 10.1067/mem.2001.115650.
Paul BK, Stimers M. Exploring probable reasons for record fatalities: the case of 2011 Joplin, Missouri, Tornado. Nat Hazards 2012; 64(2): 1511–1526. doi: 10.1007/s11069-012-0313-3.
Neblett Fanfair R, Benedict K, Bos J et al. Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011. N Engl J Med 2012; 367(23): 2214–2225. doi: 10.1056/NEJMoa1204781.
Boston Trauma Center Chiefs’ Collaborative. Boston marathon bombings: an after-action review. J Trauma Acute Care Surg 2014; 77(3): 501–503. doi: 10.1097/TA.0000000000000397.
Ahmad S. Mass casualty incident management. Mo Med 2018; 115(5): 451–455.
Pohnán R, Hána L. Czech field surgical team in Afghanistan. MMSL 2019; 88(2): 63–70. doi: 10.31482/mmsl.2018.046.
Reiss E, Evans EI, Artz CP. Initial fluid therapy in severe burns; evaluation of physiologic criteria for guiding fluid administration. Ann Surg 1953; 137(4): 431–443.
Abbas J, Blakeney P. Fluid resuscitation in Burns. Treasure Island (FL): StatPearls Publishing 2024.
Pruitt BA. Fluid resuscitation for adult thermal injury. J Trauma 2000; 48(Suppl 3): S63–S64.
Evans EI, Purnell OJ, Butler EF et al. Fluid and electrolyte requirements in severe burns. Ann Surg 1952; 135(1): 804–817. doi: 10.1097/00000658-195206000-00006.
Robertson-Steel I. Evolution of triage systems. Emerg Med J 2006; 23(2): 154–155. doi: 10.1136/emj.2005.030270.
Rignault D, Wherry D. And finally: lessons from the past worth remembering: Larrey and triage. Trauma 1999; 1 : 85–89.
Blair JS. James Dominique, First Baron Larrey. J R Army Med Corps 2005; 151(3): 207–208. doi: 10.1136/jramc-151-03-13.
Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE-a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med 1996; 11(2): 117–124. doi: 10.1017/s1049023x0004276x.
Hogan DE, Burstein JL. Disaster medicine. Lippincott Williams & Wilkins 2007.
NATO. STANAG 2879 Med (edition 3) –⁠ principles of medical policy in the management of MASS casualty situation. [online]. Available from: https://share.google/0nzOS6VbdlI4JbLiD.
Keene DD, Penn-Barwell JG, Wood PR et al. Died of wounds: a mortality review. J R Army Med Corps 2016; 162(5): 355–360. doi: 10.1136/jramc-2015-000490.
Eastridge BJ, Mabry RL, Seguin P et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012; 73(Suppl 5): S431–S437. doi: 10.1097/TA.0b013e3182755dcc.
Penn-Barwell JG, Roberts SA, Midwinter MJ et al. Improved survival in UK combat casualties from Iraq and Afghanistan: 2003–2012. J Trauma Acute Care Surg 2015; 78(5): 1014–1020. doi: 10.1097/TA.0000000000000580.
Rhee P, Koustova E, Alam HB. Searching for the optimal resuscitation method: recommendations for the initial fluid resuscitation of combat casualties. J Trauma 2003; 54(Suppl 5): 52–62. doi: 10.1097/01. TA.0000064507.80390.10.
Ho AM, Dion PW, Cheng CA et al. A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Can J Surg 2005; 48(6): 470–478.
Holcomb JB, Jenkins D, Rhee P et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62(2): 307–310. doi: 10.1097/TA.0b013e3180324124.
Cotton BA, Au BK, Nunez TC et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and post-injury complications. J Trauma 2009; 66(1): 41–48. doi: 10.1097/TA.0b013e31819313bb.
Duchesne JC, Holcomb JB. Damage control resuscitation: addressing trauma induced coagulopathy. Br J Hospit Med 2009; 70(1): 22–25. doi: 10.12968/hmed.2009.70.1.37690.
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(2): 127–136. doi: 10.1001/2013.jamasurg.387.
Ausset S, Glassberg E, Nadler R et al. 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(Suppl 1): S70–S75. doi: 10.1097/TA.0000000000000640.
Pidcoke HF, Aden JK, Mora AG et al. Ten-year analysis oftransfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg 2012; 73(Suppl 5): S445–S452. doi: 10.1097/TA.0b013e3182754796.
Sailliol A, Martinaud C, Cap AP et al. The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed forces health service. Transfusion 2013; 53(Suppl 1): S65–S71. doi: 10.1111/trf.12038.
Nessen SC, Eastridge BJ, Cronk D et al. 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): S107–S113. doi: 10.1111/trf.12044.
Sailliol A, Plang S, Martinaud C et al. Haemovigilance and blood safety in overseas military. Transfus Clin Biol 2014; 21(4–5): 229–233. doi: 10.1016/j.tracli.2014.09.001.
Beckett A, Callum J, da Luz LT et al. Fresh whole blood transfusion capability for Special Operations Forces. Can J Surg 2015; 58(Suppl 3): S153–S156. doi: 10.1503/cjs.012614.
Garcia Hejl C, Martinaud C, Macarez R et al. The implementation of a multinational “walking blood bank” in a combat zone: the experience of a health service team deployed to a medical treatment facility in Afghanistan. J Trauma Acute Care Surg 2015; 78(5): 949–954. doi: 10.1097/TA.0000000000000618.
Ausset S, Meaudre E, Kaiser E et al. Transfusion for trauma: the French army policy. Anaesthesia 2009; 64(10): 1142. doi: 10.1111/j.1365-2044.2009.06087.x.
Sailliol A, Ausset S, Peytel E. Blood transfusion in emergency settings: French military health service experience. Transfus Clin Biol 2010; 17(5–6): 279–283. doi: 10.1016/j.tracli.2010.09.153.
Hartman EN, Daines B, Seto C et al. Assess, life-saving intervention, triage with drone assistance in mass casualty simulation: analysis of educational efficacy. Cureus 2020; 12(9): e10572. doi: 10.7759/cureus.10572.
Eastridge BJ, Butler F, Wade CE et al. Field triage score (FTS) in battlefield casualties: validation of a novel triage technique in a combat environment. Am J Surg 2010; 200(6): 724–727. doi: 10.1016/j.amjsurg.2010.08.006.
Toida C, Muguruma T, Abe T et al. Introduction of pediatric physiological and anatomical triage score in mass-casualty incident. Prehosp Disaster Med 2018; 33(2): 147–152. doi: 10.1017/S1049023X18000109.
Dahl JF. Burn injury assessment: 21st century advances. Crit Care Nurs Clin 2012; 24(4): 471–481.
Latarjet J, Choinere M, Trudeau P et al. Evaluation of burn wounds with a thermal camera. Burns 2008; 14(6): 444–448.
Sheikhbardsiri H, Raeisi AR, Nekoei-Moghadam M et al. Surge capacity of hospitals in emergencies and disasters with a preparedness approach: a systematic review. Disaster Med Public Health Prep 2017; 11(5): 612–620. doi: 10.1017/dmp.2016.178.
Morton MJ, DeAugustinis ML, Weinstock MA et al. Availability of medical supplies during disasters. JAMA Dermatol 2016; 152(8): 893–897.
Luke J, Franklin RC, Dyson J et al. Building toward a disaster resilient health system: a study of hospital resilience. Disaster Med Public Health Prep 2022; 17: e219. doi: 10.1017/dmp.2022.204.
Bentley S, Iavicoli L, Boehm L et al. A simulated mass casualty incident triage exercise: SimWars. MedEdPORTAL 2019; 15 : 10823. doi: 10.15766/mep_2374-8265.10823.
Moss R, Gaarder C. Exercising for mass casualty preparedness. Br J Anaesth 2022; 128(2): e67–e70. doi:10.1016/j.bja.2021.10.016.
Avni T, Levcovich A, Ad-El DD et at. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010; 340: c241. doi: 10.1136/bmj.c241.
Lachiewicz AM, Hauck CG, Weber DJ et al. Bacterial infections after burn injuries: impact of multidrug resistance. Clin Infect Dis 2017; 65(12): 2130–2136. doi: 10.1093/cid/cix682.
Salinas J, Chung KK, Mann EA et al. Computerized decision support system improves fluid resuscitation following severe burns: an original study. Crit Care Med 2011; 39(9): 2031–2038. doi: 10.1097/CCM.0b013e31821cb790.
Cancio LC, Friedrich JB, Williams FN et al. Fluid resuscitation of burn patients: a concise review of evidence-based practice. J Trauma Acute Care Surg 2018; 84(2): 449–457. doi: 10.1097/TA.0000000000001743.
Pruitt BA, Mason AD, Moncrief JA. The US Army Burn Center: clinical guidelines for burn care. U.S. Army Institute of Surgical Research 1971.
Cancio LC. Burn resuscitation: lessons learned from recent military experience. J Trauma 2005; 59(Suppl 6): S90–104. doi: 10.1097/01.ta.0000188274.99230.cb.