Unit Four

1. Unit Four Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI)

2. Objectives • Define mass casualty incidents (MCI) • Describe the Multi-casualty Branch structure • Use of multiple Groups/Divisions under the Multi-casualty Branch Director • Discuss MCI response procedures • Review emergency medical service role in MCI • Describe “START” B461 Course

3. Objectives (cont'd) • Identify the relationship of MCI Groups (triage, treatment, transport) to overall scheme of the HIMS • Prioritize patients using the START method of triage for: • Decontamination • Treatment • Identify considerations in transporting patients to area hospitals B461 Course

4. Mass Casualty Incidents • Multi-patient Incidents - exceeds normal first responder capabilities • Major medical emergency – any emergency that would require the access of local mutual aid resources • Mass Casualty Incidents - combination of numbers of injured personnel and type of injuries going beyond the capability of an entity’s normal first response • Disaster – State and/or Federal resources are required B461 Course

5. Mass Casualty Incident Management • Do the greatest good for the greatest number of patients • Make the best use of: • Personnel • Equipment • Medical and facility resources • Limit the spread of the contamination • Minimize the effects of the disaster, incident, or event B461 Course

6. Triage Considerations • Triage - Term in early 1800s (derived from the French trier, meaning "to sort") • Immediate - Casualty requires lifesaving measures performed without delay if they are to survive • Delayed - Casualty whose treatment can wait without causing additional harm B461 Course

7. Triage Considerations (cont'd) • Expectant – Casualties that will not survive or will require extensive resources and time if they are to be saved • Minor – Casualties that are generally ambulatory and are injured only slightly B461 Course

8. 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 victimstransported by EMS • Set up triage area near the ED entrance • Shielded and secure • Readily accessible B461 Course

9. Triage • “Greatest good for the greatest number of casualties” • Psychological impact • Classification: RedYellowGreenBlack • Limitations: • Time consuming • User variability • Lack of familiarity B461 Course

10. TRIAGE CRITERIA: Respiratory status Perfusion and pulse Neurological status TRIAGE CATEGORIES: Walking wounded - “Green” or minimal (relocate when told) Normal findings - “Yellow” or delayed (unable to relocate) Abnormal - “Red” or immediate Non-salvageable - “Black” or expectant START Triage B461 Course

11. START - Respiratory Status Respiratory Status Respirations Normal No Respiratory Effort > 30 Respirations Go to Expectant Immediate Next Step B461 Course

12. START - Perfusion Perfusion Status Radial PulsePresent Radial PulseAbsent Cyanotic Go to Immediate Next Step Immediate B461 Course

13. START - Neurological Status Neurological Status NormalMental Status Change inMental Status Unconscious Move toNext Victim Immediate Immediate B461 Course

14. Nerve Agent Triage - “Immediate” • Unconsciousness or convulsions • Two or more body systems involved • Requires immediate antidote Rapid intervention should result in a good outcome B461 Course

15. Initial First Aid Treatment • Immediate removal from source of exposure • severity directly proportional to absorbed dose • Decontamination • Mild soap and water rinse • Antidote administration with airway management support as necessary • Must be provided by properly trained and equipped personnel B461 Course

16. Nerve Agent Antidote • Atropine • administered to block receptor sites of acetylcholine • 2-PAM Chloride • restores acetylcholinesterase • Mark I Kit or “Combo Pen” B461 Course

17. First Aid Treatment • Exit Agent Exposure Area • Minor Symptoms Administer: • One Mark I Kit • Major Symptoms Administer: • Three Mark I Kits • Diazepam Required for Severe Casualty • Monitor Patient’s Symptoms B461 Course

18. Nerve Agent Triage - “Delayed” • Initial symptoms are improving (miosis still present) • Recovering well from pre-hospital antidote therapy B461 Course

19. Nerve Agent Triage -“Minimal” & “Expectant” Minimal • Walking and talking which indicates intact breathing and circulation • Expectant • Apneic for more than 5 minutes • No pulse or blood pressure B461 Course

20. Delayed 2 to 50% BSA burns by liquid Eye involvement Minimal < 2% BSA burns by liquid in non-critical areas Mustard Triage • Immediate • Moderate to severe pulmonary symptoms • Expectant • > 50% BSA burns by liquid; apneic/no pulse B461 Course

21. 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 B461 Course

22. 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” B461 Course

23. TriageHospital Arrivals • Casualty arrival is uncoordinated • Arrival times vary • Closest hospital is typically overwhelmed • Medical needs of unaffected community continues • May present at distant hospitals to ensure treatment at clean facilities B461 Course

24. 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 B461 Course

25. Radiation Protection for Clinical Staff • Fundamental Principles - Time - Distance - Shielding • Personnel Protective Equipment • Contamination Control B461 Course

26. Protecting Staff from Contamination • Use standard precautions (N95 mask) • Survey hands and clothing frequently • Replace contaminated gloves or clothing • Keep the work area free of contamination B461 Course