Multiple Traumas: Where do I start?

1. Multiple Traumas:Where do I start? Lee Faucher, MD FACS

2. Objectives: • What is a Mass Casualty Incident ? • Review Incident Management from EMS perspective • Review Triage

3. Mass Casualty Incident (MCI) • Definition • An incident which produces multiple casualties such that emergency services, medical personnel and referral systems within the normal catchment area cannot provide adequate and timely response and care without unacceptable mortality and/or morbidity.

4. EMS Goal • To save the largest number of people of a multiple casualty incident

6. How do you start? • Command • Safety • Triage • Staging • Communication • Treatment

7. Communication • Obstacles • Terrain • Different Frequencies • Overloaded channels • Hospital • Medical Control • Patient Routing • Transportation Officer • Staging Officer

8. Things to Remember… • Maintain strict radio procedures • Enroute communications must be limited to urgent matters only • Transport patients in adequate vehicles • Transport patients with adequate escort staff • Maintain a log of all Patients (PCR)

9. THE INITIAL PROBLEM ON SCENE Casualties Resources

10. Casualties Resources THE OBJECTIVE

11. BUT - HOW IS EMS TRAINED? • BLS, ALS • CPR, ACLS, PALS • PHTLS, BTLS • CFR, EMT, EMT-I, EMT-CC, EMT-P How many patients are you taught to treat at one time?

12. WHAT CHANGES WHEN YOU HAVE AN MCI ? • What are my resources? • Who is a Patient? • Which Patient do I treat first? • Who can be salvaged? • Who gets transported first? • Who needs a Trauma/Specialty Center? • Who can help care for others?

13. TIME IS VERY IMPORTANT THE GOLDEN HOUR “The critical trauma patient has only 60 minutes from thetime of injuryto reach definitive surgical care, or the odds of a successful recovery diminish dramatically”

14. Time management • Arrival of resources • Distribution of resources • Effective patient treatment

15. Command Who is in Charge? Who is in charge of what? Who is going to do what? Who else needs to be here? Safety Is there a hazard or threat? Should I be here? Am I protected? What should I worry about? Scene Management

16. Assessment What is going on? How big is this, how many people? What do I need? How does what I do affect others? What are they doing that can affect me? Communications Who needs to know? What do they need to know? Does Command & Ops know? Do the other players know? Scene Management

17. Triage Who is doing it? Where are they doing it? What are they finding? Treatment What the typical EMS provider comes “preloaded” with… How to organize? How much can we do? Scene Management

18. Transport Who is doing it? From where are they doing it? Where are the patients going? How many patients going where? Scene Management

19. Triage • “Large scale triage is the hardest job anyone in pre-hospital care will ever do.” AJ Heightman

20. When do we triage • When casualties exceed the number of skilled rescuers

21. How often should you triage? • Primary • On scene • Secondary • Time of transport

22. Triage Protocol (START)Simple Triage And Rapid Treatment

23. Triage Tags

24. Primary Triage • Airway • Breathing

25. Primary Triage • Circulation

26. Primary Triage • Mental Status

27. Victims • Female, 30’s, walking • Female, teens, walking, pale, complaining of severe abdominal pain • Male, teens, walking, confused • Male, teens, you open airway, does not breathe • Male, 20’s, unconscious, breathing, RR 36, radial pulse absent • Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions

28. Victims • Female, 30’s, walking • Female, teens, walking, pale, complaining of severe abdominal pain • Male, teens, walking, confused • Male, teens, you open airway, does not breathe • Male, 20’s, unconscious, breathing, RR 36, radial pulse absent • Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions

29. Burn MCI • Bali Nightclub 2002 • Over 200 killed • Additional 250 injured • All burn beds filled in Australia

30. Burn Resources in the U.S. • Just over 100 facilities listed in ABA directory • Only 200 open beds at any time • It only takes a few to make a burn disaster

32. Common in most burn MCI • Up to 40% of casualties • 50% discharged from ED • Mortality 5%

33. EMS Considerations • Scene safety first • May require decontamination • Scene may be a crime scene • Designate field commander • Where to go may be different?

34. EMS considerations • Terrorism commonly has secondary devices targeting rescuers • Stage vehicles uphill and upwind

35. EMS supplies • LR • O2 • Clean sheets/plastic wrap • Narcotics • (hospitals need the same stockpile, might add burn ointment)

36. Disposition from scene • Severe: to burn center • Moderate: local care facilities • Minor: any care facility

37. Where to take them? • International classification • Type A: resuscitation only • Type B: first 48 hours • Type C: everything • What this means in WI • Two Type C • Level 2 hospitals are Type B

38. What does this really mean? • If burn > 20% and/or inhalation injury, this is severe. • All others can be triaged again at hospital

39. Triage Decision Table Benefit-to-Resource Ratio Based on Age & Total Burn Size

40. Summary • MCIs require • Change in EMS providers approach • Ability to apply limited resources effectively • Organization, coordination, communication • Appropriate distribution to definitive care • After action evaluation