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Best Practices for Multicasualty Triage

Best Practices for Multicasualty Triage. Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT/MSRT South. What is Triage?. “Triage” means “to sort” Looks at medical needs and urgency of each individual patient Sorting based on limited data acquisition

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Best Practices for Multicasualty Triage

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  1. Best Practices for Multicasualty Triage Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT/MSRT South

  2. What is Triage? • “Triage” means “to sort” • Looks at medical needs and urgency of each individual patient • Sorting based on limited data acquisition • Also must consider resource availability

  3. Military vs. Civilian Triage Priority is to get as many soldiers back into action as possible. Priority is to maximize survival of the greatest number of victims.

  4. Military vs. Civilian Triage In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as the lowest priority.

  5. Ethical Justification This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis. A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine, http://eduserv.hscer.washington.edu/bioethics/topics/resall.html

  6. Daily Emergencies Do the best for each individual. Disaster Settings Do the greatest good for the greatest number. Maximize survival.

  7. When do we change from daily triage standards to MCI triage? Patient medical needs overwhelm local or regional response resources

  8. Triage Principles

  9. Primary Disaster Triage • Goal: to sort patients based on probable needs for immediate care. Also to recognize futility. • Assumptions: • Medical needs outstrip immediately available resources • Additional resources will become available with time

  10. Primary Disaster Triage • 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

  11. Primary Disaster Triage • The most commonly used adult tool in the US and Canada is the START tool. • The only recognized pediatric MCI primary triage tool used in the US and Canada is the JumpSTART tool. • Other tools exist but are less oriented to mass casualties than triaging smaller numbers of (adult) trauma patients.

  12. The Best Tool? No MCI primary triage tool has been validated by outcome data. Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the Neurosurgeon”, Neurosurg Focus 12(3), 2002. Available on the Internet at www.medscape.com/viewarticle/431314

  13. B.O.L.O. • Sacco Triage Method • Retrospective outcome data from over 100,000 trauma patients of all ages • 12 categories, based on RPM assessment • Watch for the August issue of Academic Emergency Medicine

  14. Triage is a dynamic process and is usually done more than once.

  15. Secondary Disaster Triage • Goal: to best match patients’ current and anticipated needs with available resources. • Incorporates: • A reassessment of physiology • An assessment of physical injuries • Initial treatment and assessment of patient response • Further knowledge of resource availability

  16. Secondary Triage Tools • Goal is to distinguish between: • Victims needing life-saving treatment that can only be provided in a hospital setting. • Victims needing life-saving treatment initially available on scene. • Victims with moderate non-life-threatening injuries, at risk for delayed complications. • Victims with minor injuries.

  17. Secondary Triage Tools • There is no widely recognized tool in the US that addresses secondary MCI triage. • California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint) • Many EMS systems use local trauma center triage criteria.

  18. Tertiary Disaster Triage • Goal: to optimize individual outcome • Incorporates: • Sophisticated assessment and treatment • Further assessment of available medical resources • Determination of best venue for definitive care

  19. Triage Categories

  20. Triage Categories • Red: Life-threatening but treatable injuries requiring rapid medical attention • Yellow: Potentially serious injuries, but are stable enough to wait a short while for medical treatment

  21. Triage Categories • Green: Minor injuries that can wait for longer periods of time for treatment • Black: Dead or still with life signs but injuries are incompatible with survival in austere conditions

  22. Triage Tools

  23. START • Simple Triage And Rapid Treatment • Developed jointly by Newport Beach (CA) Fire and Marine Dept. and Hoag Hospital • Gold standard for field adult multiple casualty (MCI) triage in the US and numerous countries around the world

  24. START • Utilizes the standard four triage categories • Used for Primary Triage • www.start-triage.com

  25. START Triage RESPIRATIONS Under 30/min YES PERFUSION NO Over 30/min Cap refill > 2 sec Cap refill < 2 sec. Position Airway Immediate Control Bleeding NO YES MENTAL STATUS Immediate Dead or Expectant Immediate Failure to follow simple commands Can follow simple commands Immediate Delayed

  26. START: Step 1 Triage officer announces that all patients that can walk should get up and walk to a designated area for eventual secondary triage. All ambulatory patients are initially tagged as Green.

  27. START: Step 2 • Triage officer assesses patients in the order in which they are encountered • Assess for presence or absence of spontaneous respirations • If breathing, move to Step 3 • If apneic, open airway • If patient remains apneic, tag as Black • If patient starts breathing, tag as Red

  28. START: Step 3 • Assess respiratory rate • If ≤30, proceed to Step 4 • If  30, tag patient as Red

  29. START: Step 4 • Assess capillary refill • If ≤ 2 seconds, move to Step 5 • If  2 seconds, tag as Red

  30. START: Step 5 • Assess mental status • If able to obey commands, tag as Yellow • If unable to obey commands, tag as Red

  31. R P M 30 2 Can do Mnemonic

  32. JumpSTART Pediatric MCI Triage • Developed by Lou Romig MD, FAAP, FACEP • Now in widespread use throughout the US and Canada • Being taught in Japan, Germany, Switzerland, the Dominican Republic, Africa, Polynesia

  33. JumpSTART Pediatric MCI Triage • Recognized by the US National Disaster Medical System • Published in Brady’s Prehospital Emergency Care, 7th ed. and the APLS course • www.jumpstarttriage.com

  34. Patients who are able to walk are assumed to have stable, well-compensated physiology, regardless of the nature of their injuries or illness.

  35. Secondary Triage • All green patients must be individually assessed in secondary triage. • Assess physiology • Assess injuries • Assess probability of deterioration • Assess needs vs. resource availability

  36. Secondary Triage • Some children may be carried to the green area by others. They have not proven their physiologic stability by performing the complex act of walking. • These children should be assessed first among all those in the green area.

  37. Position the upper airway of the apneic child. • If they start to breathe, tag them as

  38. If the child doesn’t start breathing with upper airway opening, feel for a pulse. • If no pulse is palpable, tag the patient as

  39. If the patient has a palpable pulse, give 5 mouth-to-barrier breaths to open the lower airways. Tag as below, depending on response to ventilations. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES.

  40. Assess the respiratory rate of the spontaneously breathing child.

  41. Move on to next assessment if respiratory rate is 15-45 breaths/minute. • If respiratory rate is <15 or >45, tag the patient as

  42. If the child’s pulse is palpable, move on to the next assessment. • If no palpable pulse, tag the patient as

  43. If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as • If patient is alert, responds to voice or appropriately responds to pain, tag as

  44. Modification for Nonambulatory Children • Children developmentally unable to walk due to young age or developmental delay • Children with chronic disabilities that prevent them from walking

  45. Modification for Nonambulatory Children • For nonambulatory children, assess using the JumpSTART algorithm. • If pt meets any red criteria tag as

  46. Modification for Nonambulatory Children • If patient meets yellow criteria and has significant external signs of injury, tag as • If patient meets yellow criteria and has no significant external signs of injury, tag as

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