Transcript Triage

Special Hospital Considerations
Part II
Triage, Planning and Exercises
DPT 8.0
Hospital Triage
• Use a triage system in an MCI that
parallels normal routine
• Practice regularly to ensure familiarity
• Triage is a continual process
• Re-triage all victims
transported by EMS
• Set up triage area near the
ED entrance
– Shielded and secure
– Readily accessible
DPT 8.0
Triage
• “Greatest good for the greatest number of
casualties”
• Psychological impact
• Classification:
Red
Yellow
Green
Black
• Limitations:
– Time consuming
– User variability
– Lack of familiarity
DPT 8.0
START Triage
TRIAGE CRITERIA:
TRIAGE CATEGORIES:
• Respiratory status
• Walking wounded - “Green” or
minimal (relocate when told)
• Perfusion and pulse
• Normal findings - “Yellow” or
delayed (unable to relocated)
• Abnormal - “Red” or immediate
• Neurological status
• Non-salvageable - “Black” or
expectant
DPT 8.0
START - Respiratory Status
Respiratory Status
No Respiratory
Effort
Respirations
> 30
Normal
Respirations
Expectant
Immediate
Go to
Next Step
DPT 8.0
START - Perfusion
Perfusion Status
Radial Pulse
Absent
Immediate
Cyanotic
Radial Pulse
Present
Immediate
Go to
Next Step
DPT 8.0
START - Neurological Status
Neurologic Status
Change in
Mental Status
Immediate
Unconscious
Normal
Mental Status
Immediate
Move to
Next Victim
DPT 8.0
Nerve Agent Triage - “Immediate”
• Unconsciousness or
convulsions
• Two or more body
systems involved
Rapid intervention should
result in a good outcome
DPT 8.0
Nerve Agent Triage - “Delayed”
• Initial symptoms are
improving (miosis still
present)
• Recovering well from
pre-hospital antidote
therapy
DPT 8.0
Nerve Agent Triage “Minimal” & “Expectant”
Minimal
Expectant
• Walking and talking
which indicates
intact breathing and
circulation
• Apneic for more
than 5 minutes
• No pulse or blood
pressure
DPT 8.0
Mustard Triage
Delayed
Immediate
• 2 to 50% BSA burns
by liquid
• Eye involvement
• Moderate to severe
pulmonary symptoms
Minimal
• < 2% BSA burns by
liquid in non-critical
areas
Expectant
• > 50% BSA burns by
liquid; apneic / pulseless
DPT 8.0
Triage of Biological Casualties
• Triage of biological agent
casualties is different
– Symptoms are delayed
– Initial cases may go
unrecognized
– More difficult to detect
• Epidemiological information
becomes critical
DPT 8.0
Radiological Triage
• Triage:
– Stabilize the patient first and only when this is
done does one consider irradiation and
contamination.
– Ensure ABCs
DPT 8.0
Triage - Psychological Casualties
• Disasters produce tremendous emotional and
psychological stress, with large numbers of psychogenic
casualties
• Presenting signs could be confused with organic disease
• Use of START triage system maintains focus on objective
signs of disease & minimizes impact of subjective
complaints on the triage process
• Psychological casualties are usually triaged as “minimal”
DPT 8.0
Triage - Hospital Arrivals
• Casualty arrival is
uncoordinated
• Arrival times vary
• Closest hospital is typically
overwhelmed
• Medical needs of unaffected
community continue
DPT 8.0
Triage - Contaminated Human Remains
• Problems are agent-specific
– Decontamination
– Containment
– Refrigeration until definitive disposal
• Follow local coroner and medical examiner protocols
– Establish cooperative agreements for fatality management
• Secure personal effects
– Not all can be decontaminated
DPT 8.0
Staff Preparedness
• Plan for the needs of the
unaffected population
• Prepare to receive large
numbers of casualties
• Prepare to receive large
numbers of dead
• Rotate staff to avoid
congestion and fatigue,
especially personnel in PPE
DPT 8.0
Logistics / Supplies
• Highest priority: getting the right resources to the right
place at the right time
– Personal protective equipment and dosimetry
– Medications / antidotes / vaccines
– Mechanical ventilators
– Isolation rooms remote from other patients
• Identify current inventory and augment as necessary
• Develop a procedure to access external assets
DPT 8.0
Maximal Utilization of Hospital Space
20
15
14 3
• Identify alternative medical
treatment areas
• Planning for use of available
space
12 13 10
5
19
17
9
7
11
4
18
– Open areas
– Isolated areas
6 1
16
– Temporary morgue
8
DPT 8.0
2
Handling of Evidence
• Maintaining evidence is
critical for an investigation
– Clothing
– Embedded foreign bodies
– Decontamination runoff
• Chain of Evidence must
be maintained
DPT 8.0
Exercising the Plan
• Start small - few casualties
• Be realistic
• Coordinate with other agencies / hospitals
• Exercise frequently
DON’T WAIT FOR A DISASTER TO HAPPEN
DPT 8.0
Scenario
A football championship was what
the city needed to boost its national
reputation, and tonight was the
night. Every hotel within 30 miles
was booked with fans eagerly
awaiting the game.
After the national anthem was
played the crowd began to loudly
chant their team’s respective fight
song. The sounds within the
stadium were deafening.
DPT 8.0
Scenario
Just as the game was ready to begin fans from section
“A” started to run from their seats. Total chaos ensues.
In a rampage fans were pushing and shoving trying to
get out through the exit doors. Many were being
trampled upon during the exodus. Most were coughing,
rubbing their eyes, and many appeared to be choking.
911 was called and the closest hospital, two blocks
away, was also notified.
DPT 8.0
Scenario
Assume you are working in the emergency
department, please answer the following:
• After notification, what would you do?
• Where would you set up triage?
• Who would function as the triage officer?
• Where would you set up & perform decon?
DPT 8.0
Scenario
Within 15 minutes of the incident 100 victims arrive
at your hospital without the assistance of EMS
• How will you control access into your hospital?
• What level of protective gear should be worn?
• Should these victims be decontaminated?
• How will you decontaminate these victims?
• Where will you treat the first wave of victims?
DPT 8.0
Scenario
Victims are complaining of shortness of breath,
cough, eye & throat irritation, and burning skin.
• What chemical were they exposed to?
• What clues would you look for to help you identify
the agent?
• Lacking positive agent identification, how would you
begin treatment?
• What medications/antidotes are necessary?
DPT 8.0
Teaching Points
• Hospitals must expand their emergency planning
and scope of services to include NBC care
• Concentrate on the disaster planning process
• Develop policies & procedures
• Train frequently using realistic scenarios
DPT 8.0