TRIAGE IN MASS CASUALTY INCIDENTS

PRESENTATION ROADMAPDefinition of TermsBasic PrinciplesTriage CategoriesTriage ToolsSuccess Factors

DEFINITION OF TERMS

Triage

Medical Disaster

Multiple, Major, Mass Casualty Incidents

BASIC PRINCIPLES

Principle of RightsThe Aim of Triage

Spock Principle

Triage is a Dynamic Process

SINGLEMULTIPLESERIOUSLY INJUREDWALKING INJUREDThe Applicability of Triage

Abundant resources relative to demandDo the best for each individual(P = Patient health care needs)

Do the greatest good for the greatest numberResources overwhelmed(P = Patient health care needs)

Military vs. Civilian TriageThe Adaptability of Triage

TRIAGE CATEGORIES

Immediate or Critical CareLife-threatening Delay of a few minutes: FatalImmediate degree of urgencyDisposition: Immediate resuscitation and transportLevel I

I

ExamplesRespiratory arrestAirway obstructionSucking Chest WoundCardiac arrestSevere bleedingShockUnconsciousnessRespiratory tract burnsAcute Coronary SyndromesSuicidal attemptsStatus epilepticusI

Delayed, Acute or Non-ambulatory CareSerious but stableDelay of few hours: no impactSecondary degree of urgency Disposition: depends on patient condition vs. resourcesLevel II

II

ExamplesOpen thoracic woundPenetrating Abdominal woundSevere eye injuryAvascular limbSignificant burns other than the face, neck or perineumModerate bleedingConscious patients with head injuriesAnxiety statesMultiple fracturesII

Ambulatory or Primary CareVictims who do not require hospitalizationDelay: no impactMuch delayed degree of urgencyDisposition: depends on space availability Level III

III

ExamplesMinor bleedingMinor soft tissue injuriesContusions, sprainsSuperficial burnsPartial-thickness burns of

Expectant or Pending CareDead and DyingDelay: no impactMuch delayed degree of urgency Disposition: custodial care Level IV

IV

When to Classify a Victim as Dead and Dying?Know Disaster Response Level1: < 2 hours2: 2-12 hours3: 12-24 hours4: >24 hours

IV

< 2 Hours(Disaster Response Level I)Advanced neurological deficits (GCS85% BSA)IV

2 - 12 Hours(Disaster Response Level II)Disaster Response Level 1 victimsDeteriorating neurovital signs Second or third degree burns involving more than 50% of total BSAIV

12 - 24 Hours(Disaster Response Level III)Disaster Response Level 2 victimsThose requiring formal surgical careThose requiring prolonged life support in an intensive care unitIV

24 Hours(Disaster Response Level IV)Triage Level I victimsIV

No CareUnaffected personsDelay: no impactNo degree of urgencyDisposition: Safe evacuation Level V

V

ExamplesEvacueesRelatives of victimsOnlookersPressV

Color Coding

Triage Category Color CodeLevel IRedLevel IIYellowLevel IIIGreen Level IVBlackLevel VWhite

TRIAGE TOOLS

Casualty Scene

INNER PERIMETER

SAFE AREA

OUTER PERIMETER

1

2

EOC

SCENE COMMAND CENTER

TEMPORARY MORGUE

HOSPITALS

EVACUATION CENTER

SECONDARY COLLECTION POINT

HELICOPTER LANDING ZONE

STAGING AREA

PRIMARY COLLECTION POINT

WIND DIRECTION

PRIMARYSECONDARYTERTIARYSITEInner PerimeterOuter Perimeter/SafeOuter Perimeter/SafeGOALBasic Disaster Life Support or M.A.S.S. TriagePatient needs vs. available resourcesOptimize Individual outcomeTOOLSAvailableNone. More complex and demand more sophisticated resourcesRECOMMEMDATIONSSTART / JumpSTARTCommon Sense and ExperienceVALIDATIONNo MCI primary triage tool has been validated by outcome data.Not applicableIMPLEMENTATION SYSTEMTaggingGeographical SortingGeographical Sorting

S.T.A.R.T.Simple Triage And Rapid Treatment

START TriageRESPIRATIONSNOYESDead orExpectantImmediatePosition AirwayNOYESOver 30/minImmediateUnder 30/minPERFUSIONCap refill> 2 secControlBleedingImmediateCap refill< 2 sec.MENTALSTATUSFailure to followsimple commandsCan followsimple commandsImmediateDelayed All ambulatory patients are initially tagged as Green.

MnemonicRPM302Can do

JumpSTART Triage

Special ConsiderationsAGE: If a victim appears to be a child, use JumpSTART. If a victim appears to be a young adult, use START.NON-AMBULATORY CHILDREN:Evaluate using the JS algorithmIf any RED criteria is satisfied, tag as RED.If patient satisfies any YELLOW criteria: YELLOW if significant external signs of injury are found (i.e., deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen)GREEN if no significant external injuryInitial patient assessment and treatment should take less than 30 seconds for each patient.

ClassicFluorescent flagging ribbonsTear-off Pre-labeledTagging

Tagging

REQUIREMENTSDISADVANTAGESDurableVisible from great distancesSimple/Self-explanatoryCost effectiveNumbered Organizational uncertaintyTunnel-vision mentalitySome studies: no improvement in patient outcomeExpensiveDelays patient care and transport

Disaster flagsChemical light sticksColored strobe lightsGeographic Sorting

SUCCESS FACTORS

Pre-planning

Medical Triage Officer

KISS-U Principle

THANK YOU!

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