Tasty Morsels of EM 115 – #FRCEM Major Incident

5 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

This was written in 2015 after an HMIMMS course. I’ve added a couple of bits to make it more FRCEM relevant and republished it here.

Define Major Incident

  • events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services.
  • can also be put as “major incidents occur when the resources available are unable to cope with the workload from the incident”
  • A major incident can remain “uncompensated” when still unable to manage despite mobilisation of additional resources

What does METHANE have to do with things?


M – Major incident declared

E – Exact location

T – Type of incident

H – Hazards

A – Access

N – Number & Type of casualties

E – Emergency Services Present and Required

What are the main principles?

7 main principles (abbreviated as the fairly unpronounceable CSCATTT)

  1. command
  2. safety
  3. communication
  4. assessment
  5. triage
  6. treatment
  7. transport

Phases of a major incident?


  • pre hospital
  • reception
  • definitive care
  • recovery

The Collapsible Heirarchy

  • still not sure if i like the term
  • refers to the system used to delegate staff
  • roles can be coloured red yellow green in order of importance
  • some folk may fill multiple roles until further help arrives
    • for example at 2am the only surgical doctor in the hospital may be the poor surgical SHO who will assume the role of “senior surgeon” (in charge of entire surgical response) until someone more senior arrives and the SHO can go and change his underwear, or perhaps even his career.

Priority roles that need filled

  • medical coordinator
  • senior EP
  • senior MLSO(lab)
  • senior surgeon
  • senior physician (often overlooked as we assume all major incidents are traumatic when they’re not – they can be toxicological or environmental

How does triage differ

  • the most important thing is that the expectant cases are low down the list. A resuscitative thoracotomy may not be appropriate when your resources are over stretched
  • start with a triage sieve, so simple you don’t need to be clinical to use it. For example if you can walk then you’re immediately a lower priority.
  • a triage sort is a bit more detailed that involves some physiologic variables (GCS, HR, RR) to determine your level of priority (which is essentially which physical space you are assigned to in the ED).
  • P1 – need immediate life saving treatment
  • P2- need treatment within 6 hours
  • P3 – need treatment with no specific time frame (note walking patients are automatically P3)
  • the expectant ones are those
    • who cannot survive
    • where intervention would seriously compromise treatment for others

There are some specific Irish documents available online looking at this in the Irish context. Your hospital will of course have it’s own major incident plan. it is no doubt dusty and out of date somewhere…


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