Lamorinda CERT Triage For All Ages Visual Released: 8 July 1.1 2013 How Prepared Are You? You came into this room -did you size up?
Exit Points Fire Extinguishers AED Defibrillator locations Hazards Assemble Area Visual 3.2 Triage TRIAGE French term meaning to sort Triage is the medical screening
of patients according to their need for treatment and the resources available. It applies to mass casualty situations, when conventional standards of medical care cannot be delivered to all victims. The goal is to optimize care for the maximum number of salvageable patients. Triage is a Perishable Skill and
must be practiced regularly Visual 3.3 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 Visual 3.4 The needs of the many outweigh the needs of the few or the one. Spock in
Star Trek II: The Wrath of Kahn Visual 3.5 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 Visual 3.6 Secure the Area Control Flow of Traffic Ideally one road in, one road out Control Flow of People Separate Injured Patients, Families, Media Protect Resources Visual 3.7 Secure the Area
Family Area Treatment Leader Expectant/ Morgue RED: Immediate ENTRY Control Point
er et rim Pe Visual 3.8 Medical Supply Coordinator 8 YELLOW: Delayed
GREEN: Minor EXIT Control Point Transportation Unit Pe rim et er
Pe er t e ir m M Pe ed rim ia et er
Triage Steps 1. Size-up 2. Conduct voice triage 3. Follow a systematic route 4. Start where you stand 5. Evaluate each victim and tag them 6. Document Triage results Immediatesairway, bleeding, recovery position Transfer Immediates to medical group immediately! Visual 3.9 CERT Size-up 1.
Make Decisions Develop Plan of Action Take Action Evaluate Progress Visual 3.10 The START Triage System Simple Triage And Rapid Treatment
Visual 3.11 START Victim Assessment Order START WHERE YOU STAND Every victim gets a tag. Identify all Walking Wounded first these are by definition Minor whether they are bruised, cut, have broken bones or other, non-life threatening injuries. If they are not breathing even after repositioning the airway they are Morgue. Next, if they fail any part of RPM they are Immediate. If they pass RPM they are Delayed.
Visual 3.12 Patient AssessmentRPM Three things to check Respirations Perfusion Mental Status Anyone who is unconscious is an Immediate by definition! Visual 3.13 RPM Mnemonic
Visual 3.14 R 30 P 2 M Can Do
RPMRespirations No breathing or Agonal respiration Position airway, if still not breathing try it again If pediatric and there is a peripheral pulse, give 5 mouth to barrier ventilations. If apnea persists, tag as MORGUE and move on to next person. Agonal respiration is an abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and muscle twitches. Visual 3.15 RPMRespirations RangeAdults under 30 breaths a minute
Children to 12 years: 15-45 breaths/min Out of range for breaths per minute Tag as IMMEDIATE and move on to next person Within range for breaths per minute Go to the next step Perfusion Visual 3.16 RPMPerfusionBlanch Test GoalAdult perfusion in under 2 seconds More than 2 seconds Tag as IMMEDIATE and move on to next
person Less than 2 seconds Go to next step Mental Status Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment, especially in children. Visual 3.17 RPMPediatric Pulse GoalPediatric peripheral pulse If no peripheral pulse is present (in the least injured limb), Tag as IMMEDIATE and move on to next person If peripheral pulse is palpable
Go to next step Mental Status Visual 3.18 RPMMental Status Goalfollow simple command Adult cannot follow directions Tag as IMMEDIATE and move on to next person Adult can follow directions Tag as DELAYED and move on to next person Visual 3.19
RPMMental Status Obeying commands may not be an appropriate gauge of mental status for younger children. Use AVPU system. Alert a fully awake (although not necessarily oriented) patient Verbal - the patient makes some kind of response when you talk to them Pain the patient responds to painful stimuli Unresponsive Visual 3.20 RPMMental Status
Child if unresponsive Tag as IMMEDIATE and move on to next person Child if Alert, responsive to Verbal, or appropriately responsive to Pain Tag as DELAYED and move on to next person Visual 3.21 S.T.A.R.T. Categories MINOR IMMEDIATE DELAYED
DECEASED Visual 3.22 START Algorithm Visual 3.23 MINOR Walking wounded Do not require immediate care
Screamers Use as helpers to care for others All children carried to the GREEN area by other ambulatory victims must be the first assessed by medical personnel in that area. Visual 3.24 MORGUE Non-breathers who fail to breathe after airway has been cleared Considered Non-Salvageable
Mortal injuries May be obviously dead Pulseless Also termed Expectant, Deceased, Dead, Non-Salvageable, etc. Visual 3.25 IMMEDIATE Life Threatening Injury
Victim Fails needs immediate care R P M check Adult >30 respirations per minute Child outside 15-45 respirations/m Pediatric, Capillary Mental Visual 3.26
no palpable pulse refill > 2 seconds check DELAYED Serious Non Life Threatening Injury Did not walk out of scene R-P-M within in acceptable limits
May have broken bones May be extrication problem May have chest pain, etc. Visual 3.27 Treatment During START Triage There are two treatments that may be given during triage: Stop haemorrhagic blood flow Open the airway External bleeding should be controlled by direct pressure. If direct pressure fails, a tourniquet should be used in the case
of severe hemorrhage that cannot be controlled by direct pressure. Tourniquet use in civilian first-aid is now advocated as part of the C-ABC approach. Other techniques such as elevation and pressure points are not always effective but should still be attempted. As a rule of thumb, anywhere you can feel a pulse can be used as a pressure point to stop bleeding (with the obvious exception of the carotid pulses!). Visual 3.28 BLACK Category Triage Unless clearly dead or suffering from injuries incompatible with life, victims tagged in the BLACK
category should be reassessed once critical interventions have been completed for RED and YELLOW patients. Comfort should be provided to Visual 3.29 those still alive. Victims Property Try to bag any property Bag any severed body part and keep cool, if possible Keep property with the victim, preferably attached
If a victim is dead, try to not touch the body. This is a crime scene. Preserve evidence Visual 3.30 S KIDS Visual 3.31 Special Considerations in Children Pediatric Age and Size Ages to 12 years Less than one year of age is less likely to be ambulatory.
The pertinent pediatric physiology (specifically, the airway) approaches that of adults by approximately eight years of age. The ages of tweens and teens can be hard to determine so the current recommendation is: If a victim appears to be a child, use JumpSTART. If a victim appears to be a young adult, use START. Visual 3.32 Special Considerations in Children Pediatric Characteristic Special Risk During Disaster Respiratory
Higher minute volume increases exposure to inhaled agents. Nuclear fallout and heavier gases settle lower to the ground and may affect children more severely. Gastrointestinal May be more at risk for dehydration from vomiting and diarrhea after exposure to contamination. Skin Higher body surface area increases risk of skin exposure. Skin is thinner and more susceptible to injury from burns, chemicals and absorbable toxins.
Thermoregulation Less able to cope with temperature problems with higher risk of hypothermia. Developmental Less capability to escape environmental dangers or anticipate hazards. Psychological Prolonged stress from critical incidents. Susceptible to
separation anxiety. Visual 3.33 Special Considerations in Children Visual 3.34 Age Normal Normal Respiratory Pulse Rates
Preschooler (4-5 Yrs) 22-34 80-140 School Age (6-12 Yrs) 18-30 70-120 Adolescent (12-18 Yrs)
12-20 60-100 Special Considerations in Children Mechanisms of Injury Head injury. Head injuries account for approximately 60% of all MCI and disaster injuries in the pediatric population. This high rate can be explained by the large and heavy heads of children relative to their bodies. Furthermore, in states of unconsciousness, childrens upper airways tend to get obstructed by their relatively large, flaccid tongue or kinked because of the large head flexion induced by the short occiput. Skeletal injury. Children have more pliant and flexible bones than
adults and are therefore subject to fewer bone fractures. However, internal organ injuries in the absence of fractures of the overlying bones, in the chest or upper abdomen for example, are not uncommon. Visual 3.35 Special Considerations in Children Mechanisms of Injury Thermoregulation. The less mature thermoregulatory mechanism in children and higher surface area-to-mass ratio compared to adults make heat loss and hypothermia more common in the pediatric population, particularly during exposure to extreme conditions, such as cold weather, decontamination with cold water during biochemical events, or when undressed at triage.
Blood loss. As children have relatively small amounts of blood, what may seem to be minor bleeding may in effect represent a significant volume loss and severe shock. Their cardiovascular system is generally free of chronic disabling conditions, therefore, children may tolerate hypovolemic stress better than adults. Visual 3.36 Special Considerations in Children Mechanisms of Injury Emotional trauma. In addition to physical injuries, emotional trauma, caused for example by separation from the parents, is an important factor in pediatric care.
Visual 3.37 Special Considerations in Children Prognosis Children tolerate multiple organ injuries better than adults, and prognosis usually depends on the severity of the head injury, if present. Children have a better prognosis for most, if not all, disaster-related conditions. An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable. Visual 3.38
Modification for non-ambulatory children WHO Infants who normally cant walk yet Children with developmental delay Children with acute injuries preventing them from walking before the incident Children with chronic disabilities Visual 3.39 Modification for non-ambulatory children Evaluate using the JumpSTART algorithm
RED if any RED criteria GREEN if no significant external injury YELLOW if significant external signs of injury are found (i.e. deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen) Visual 3.40 Children with Disabilities Patients limitations in ambulation, communication and differentiation between acute and chronic neurological conditions are the
main challenges in the triage of children with special needs and disabilities. Visual 3.41 JumpSTART Algorithm Visual 3.42 Combined START /JumpSTART Algorithm Visual 3.43
Triage Systems Overview Many Triage Systems have been developed throughout the world. Some of the more common ones are: Visual 3.44 START
Triage Sieve Care Flight Triage MASS Triage SACCO Triage Method (STM) SALT Triage Sieve Visual 3.45 Care Flight Triage Visual 3.46
MASS Triage MASS Triage Move Assess Sort Send ? Assessment guidelines ? Pediatric considerations Visual 3.47 SACCO Triage Method (STM)
Visual 3.48 SMT 0 1 Likely Expectant. Extremely low survival probability. 2 4 Critical. Very low survival probability; likely rapid deterioration 5 8 Compromised/Salvageable. Salvageable, but accelerating deterioration without definitive care. 9 10 Delayed/Slow. High survival probability, with little deterioration expected in the first 60 minutes.
11 12 Likely Minor. High survival probability, slow rate of deterioration. Visual 3.49 SMT Scene Characterization Triage Priority Order Multiple casualty; resource levels stressed 4 5 6 3 2 7 1 8+ 2 Estimate about an hour or less to clear the scene. Large multiple casualty or small mass casualty 5 6 7 8 4 9 3 2 1 9+ requiring staged resources Estimate 1 to 2
hours to clear the scene Mass casualty; resources overwhelmed Estimate 3 or more hours to clear the scene 11+ Visual 3.50 6 7 8 5 9 10 4 3 2 1 SALT Triage Visual 3.51 Pediatric Assessment Triangle
Visual 3.52 Pediatric Assessment Triangle Visual 3.53 Pediatric SALT Triage Visual 3.54 Take Home Points Resist the urge to treat during triage.
Know that MCI Triage algorithms are NOT perfect and should be considered guidelines, not absolutes Continuous reassessment is a must, especially with pediatric Visual 3.55 patients.
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