Prehospital Considerations Triage and EMS

1. Prehospital ConsiderationsTriage and EMS PDLS Version 2 Gretchen K. Lipke, MD FACEP

2. Objectives • To compare START and JumpSTART triage systems • To review EMS consideration in disaster situations and the unique needs of children • To review the NDMS/DMAT concept as a channel for federal assistance

3. Triage • “to sort” or place in order • Guides decisions about allocating scarce resources and limited time • “greatest good for greatest number” • Protocol helps makes decisions • ICS separates triage from treatment immediately: see everybody once briefly for focus

4. START • Most commonly used triage system across country • Not applicable for under 8 years old • Initial eval –not final • Time limited (plan 1 min/patient) • Categorize and move on

5. This needs to be the START flow sheet

6. START • “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. • Gen 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals)

7. START • EVAL (and tag) those unable to walk for transport: RPM • Resp: no => position airway = still no =>Black/ yes => RED (immediate). • Spont resp >30 => RED/ under 30 => next item of assessment

8. START • Perfusion: cap refill > 2 sec => control bleeding, label RED; <2 sec, next item • Mental status: Cannot follow simple commands => RED; CAN follow simple commands (and has cap refill < 2 sec and spont resp < 30) => YELLOW (delayed)

9. START • As soon as one can categorize a patient, STOP evaluating (if they are RED for breathing, they won’t be seen any faster for additional problems) and move on. • Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).

10. JumpSTART (under 8) • Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 15-40 instead of <30 • Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. • Mental status AV/PU instead of follow/not

11. This needs to be the JUMPSTART flow page

12. JumpSTART • “If you can hear me and you are able, walk over here for help.” • GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out. • Assess non-ambulatory patients as you find them using RPM.

13. JumpSTART • Respirations: NO  open airway => yes RED; no -> check peripheral pulse. • NO pulse = BLACK • Pulse  15 sec mask to mouth ventilation • Spont resp: NO  BLACK; YES  RED

14. JumpSTART • Breathing: RR <15, >40 or irregular =RED • RR 15-40, regular – check pulse • No peripheral pulse: RED • Peripheral pulse: check mental status • AV (appropriate) YELLOW • PU (inappropriate) RED

15. Kids in triage • Don’t follow commands. • May actually hide from rescuers in full gear (spaceman look). • May be extricated by GREEN parents/ adults with delay in triage and treatment. • Need distraction and dedicated supervisor able to run after wandering toddlers

16. ICS (Incident Command System) • Senior on scene: command – assess need for further resources and direct incoming resources to where needed. This starts with first to arrive. • Triage: initial fast assessment in place of every patient, sort for evacuation and first in line for care when additional resources arrive

17. ICS • Treatment: patients may outnumber transport, leading to time in field where treatment can be started. Sort patients by category (greens, yellow, red, black) and treat within areas. If greens self triaged, they need evaluation.

18. Treatment • Limited initial treatment – don’t delay evacuation if vehicle available • Oxygen, dressings, splints • Airway management? Remember, no intubations during triage, and no codes during mass casualty event, unless sufficient personnel and equipment that no other care is delayed

19. Treatment • Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)? • Does your locality stock a “disaster truck”? • Does it have kid size equipment and kid sized doses of Hazmat antidotes? • Do you have Broselow tapes to guide dosing?

20. Treatment - airway • Non breathing adult: BLACK (after airway maneuver) • Non breathing child (with pulse): rescue breaths, then if no response, BLACK • Non breathing child without pulse: BLACK • Oxygen: how administered? Do you have octopus adaptors to set more than one NRBM off each nozzle? REDs first.

21. Treatment • IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV? • BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygen

22. Treatment: • Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination • Pressure dressing for active bleeding • Recruit neighbor to help hold pressure during triage while awaiting transport/evacuation • Splint – extremity injuries

23. Treatment • Medications: pain control, specific antidotes with Hazmat event/team • Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – even if they respond to treatment, they have the same underlying injury)

24. Further field care • Depends on local plans • Send personnel and supplies to site, or bring patients to hospital (personnel and supplies) • EMS –patient to hospital • NDMS – personnel and supplies to site

25. ICS • Transport: decides which patients leave scene first and where they’re going. Remember that helpful bystanders and self transporters will fill nearest hospital first. Includes decisions about longer transport times for specialty care ( e.g. out of town for burn unit straight from scene rather than to hospital for transfer)

26. ICS • Scene control: limit access for civilians, media cameras, also maintain in/out routes for vehicles which do need entry. • Communications: notify hospitals rough numbers, kinds of injuries

27. NDMS • Federal level aid, formerly HHS, now under Homeland Security • Initial premise: damage to city/area overwhelming local hospitals, transport patients to hospitals in region/nation • In practice: Hospitals, supplies available, easier to bring caregivers in (DMAT teams)

28. NDMS • Victims in home environment, allows visitors, social support, easier transition home. • Caregivers away from their usual responsibilities, can focus on victims. • Volunteers, credentials established ahead of time, teams practice together, used to working together. Call rotates 3-4/yr/team

29. NDMS • Federal support: license good in every state, malpractice covered, insurance covered (disability, death) • Team transport, housing, food

30. DMAT teams • Staff: MD/RN/EMT-P/ RT/ pharmacy/ administration/ communications/ logistics • Stocked and supplied to be self-sufficient for 3 days, then back fill and restock should be available. • Theory: set up from scratch with hospital tent; in practice, any building can be adopted; running water and electric bonus

31. DMAT • Label recognition: people do best what they do all the time. Assign usual roles, label building parts in familiar fashion “ED”, “Asthma ward”, “rehydration” • Care for victims, rescuers, caregivers, site workers, bystanders