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TRIAGE: - To sort - Medical needs and urgency of each individual patient - Sorting based on limited data acquisition - Consider

resource availability MILITARY VS CIVILIAN Military Priority is to get as many soldiers back into actions as possible serious wounds -> the first treatment priority

Civilian Priority is to maximize the survival of the greatest number of victims those with the most serious but realistically salvageable injuries are treated first

In both models, victims with lethal injuries or unlikely to survive even with extensive resource application are treated as the lowest priority ETHICAL JUSTIFICATION Utilitarian rule - Greater good of the greater number rather than particular good of the patient at hand. - Justified only because of clear necessity of general public welfare in a crisis Why should responders care about good triage? - Provides a way to draw organization out of chaos - Helps to get care to those who need it and will benefit from it the most - Helps in resource allocation - Provides an objective framework for stressful and emotional decisions Importance of Resources - Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources - Daily emergency care is not usually constrained by resource availability Abundant resources relative to demand (R Patient) *Resources challenged Daily emergencies - do the best for each individual Disaster Settings - Do the greatest good for the greatest number. Maximize survival rate Triage is a dynamic process and id usually done more than once I. Primary Disaster Triage (PRIORITIZATION) Goal: - to sort patients based on probable needs for immediate care - To recognize futility Assumptions: - Medical needs outstrip immediately available resources - Additional resources will become available with time Triage based on physiology: - How well the patient is able to utilize their own resources to deal with their injuries - Which conditions will benefit the most from the expenditure of limited resources

The most commonly used adult tool in US and Canada is START tool (Simple Triage and Rapid Treatment) The only recognized pediatric MCI primary triage tool is the JumpSTART tool Other tools exist but are used for small

Basic Disaster Life Support www.dmou.org MASS Triage (Move, Assess, Sort, Send) - Assessment guidelines - Pediatric considerations - No MCI primary triage tool validated II. Secondary Disaster Triage (ALLOCATING RESOURCES) Goal: to nest match patients current and anticipated needs with available resources Incorporates - A reassessment of physiology - Assess Physical injuries - Initial treatment and assessment of patient response - Further knowledge of resource availability SAVE Tool (Secondary Assessment of Victim Endpoint) California EMS NATO Guidelines (Traffic lights) Red - Immediate priority - Airway obstructions, Cardiorespiratory failure, significant ext hemorrhage, shock, sucking chest wound, burns of face and neck Yellow - Delayed - Open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb fractures, significant burns other than face, neck or perineum Green - Minor, Walking wounded - Minor lacerations, contusions, sprains, superficial burns, partial thickness burns less 20% BSA Black - Expectant or dead, No vital signs - Head injury with GCS less 8, burns 85% BSA, multisystem trauma, massive blood loss - Provide comfort care Secondary Triage Goal: Identify victims - Needing life saving treatment, can only be provided in hospital settings - Need life saving treatment initially available on scene - With moderate non-life threatening, at risk for delayed complications - With minor injuries III. Tertiary Disaster Triage

Goal: Optimize individual outcome Incorporates: - Sophisticated assessment and treatment - Further assessment of available medical resources - Determination of best venue for definitive care MCI Triage Key points: - Resources and patient number acuity are limiting factors - No definite tool used


RPM R 30 P 2 M Can do Modification for nonambulatory children - Developmentally unable to walk and disabled do not force to walk (-_-) Duh of course. - Assess using JumpSTART - Tag depending on the applicable criteria Green, Yellow, Red, Black

What about WMD (Weapons of Mass Destruction) There is no widely recognized civilian MCI triage tool used in the US for any NRBC agents Must consider decontamination: - Who goes first? - What stage does triage take place? - Difficulty of conducting patient assessment and care with responders in protective gear WMD Triage Challenges (Weapons of Mass Destruction) - Agents of attack may be mixed. How do you triage victims who have injuries from a conventional attack in addition to a chemical or radiological/nuclear exposure? - NIological agents may impact fiel triage mostly in choice of destination facility (quarantine hospital) - Patterns of EMS calls may assist in identification of a occult biological agent attack or natural epidemic - Biosurveillance tool - Some agents cause toxindromes that allow or prediction of outcome based on presenting symptoms and signs - Agent-specific triage is dependent upon identification or strong suspicion of agents use - Very difficult to train and maintain readiness with multiple agent-specific triage schemes

Chemical Toxindrome Examples Nerve Agent: - Red: severe distress, seizure, signs in two or more systems (neuro, GI, respi excluding eyes and nose) - Black: pulseless or apneic, unless intensive resources are available Phosgene and vesicants: - Red: moderate to sever RD, only when intensive resources are immediately available - Black: burns >50% BSA form liquid exposure, signs of more than minimal pulmonary involvement, when intensive resources are available Cyanide Displaces oxygen hypoxia - Red: active seizure, recent onset of apnea with preserved circulation - Black: no palpable pulse http://www.bordeninstitute.army.mil/cwbw/CH14.pdf Key points about MCI triage - anything that can help organize the response to an MCI is a good thing - MCI triage Is different than daily triage, in both field and ED settings - Resource availability is the limiting factor to consider in MCI triage - All victims must have equal importance at the time of primary triage, this includes children - Disaster research agendas should include efforts to validate and improve existing triage tools www.jumpstarttriage.com Managing MCI - Loss of lives results from inefficient mobilization of resources - The community is the first to provide emergency assistance during emergencies and disasters resulting in large number of injuries - Attention was given to the training for emergency personnel in first aid or first responders - First responders were trained to provide victims with basic triage and field care before evacuation to the nearest health facility Ozone Disco Tragedy 1996 Lung Center Fire 1998 Manor Hall incident 200MCI defined as an event resulting in a bumber of victims large enough to disrupt the normal course of emergency and health care services - Low impact - High impact - Terrorism The most sophisticated approach, including pre-established procedures for resource mobilization, field management and hospital reception Impact Zone Field/Pre-hospital management (utilize resource mobilization) Hospital Reception and Management

MIC Management First Responders first medically trained responder to arrive on the scene Second Responders vital to the restoration of the disaster sites FIRST RESPONDERS - Bureau of Fire - National Security - Emergency Medical Services SECOND RESPONDERS - Skilled construction workers - Police - Fire - Volunteers - Other responders Characteristics: - Incorporates linkages between field and health care facilities through a command post GOAL: Good of the majority (utilitarianism) Challenges: - Availability of resources - Efficiency of responders LEGAL BASIS - Department of Health A.O. 155 2004 o Known as Implementing Guidelines for Managing Mass Casualty Incidents during Emergencies and Disasters o Reduce possible loss of life and prevent disability in cases of MCI o Components: Operations and Dispathc Field Management Safety Measures Victim Management MANAGING MASS GATHERINGS Preparing for Mass Gatherings 1. Risk Assessment 2. Surveillance (How will we know when it happens) 3. Response (what will we do when it happens) Establish partnerships

Mass gatherings can cause: - Increase in the level of existing risks - Pose entirely new risks Major anticipated health risks: - Heat or cold related illness - Foodborne and waterborne illnesses

Communicable diseases Accidents and Injuries INJURIES AND PANIC RELATED, Trauma GI Heart problem

Strategies to reduce risks - Mass gatherings make responding to illnesses and injuries more difficult - Challenges in risk reduction includes: o Greater than usual movement of people o More interaction among large numbers of people in confined areas o Greater impact and stress on local infrastructure systems o Higher levels of chaors and confusion