Module 11: Triage system and Disaster triage principles

Triage

• patients are classified according to the type and urgency of their conditions

• get the Right patient to the Right place at the Right time with the Right care provider

• “Trier” French verb: to sort or to choose

• The sorting of two or more patients based on the severity of their conditions to establish priorities for care

Principles of Disaster Triage

• Emergency triage is a difficult and sometimes inconsistent process even on an average day.

• Disaster triage is used to decide who will get the resources that are available and who will not.

• Greatest good for the greatest number of people

Daily Triage

• performed by nurses on a routine basis in the Emergency Department (ED)

• identify the sickest patients to assess and treat them first

• highest intensity of care is provided to the most seriously ill or injured patients, even if those patients have a low probability of survival.

Incident Triage

• occurs when the ED is stressed by a large number of patients due to an acute incident

• Disaster plans are not activated and treatment priorities are not changed.

• The highest intensity of care is still provided to the most critically ill patients.

Disaster Triage

• A general term employed when local EMS and hospital emergency services are overwhelmed

• The terms “multiple casualty/multicausality” and “mass casualty” triage (both also known as “MCI triage”)

• The distinction between “multiple” and “mass” casualties is principally in the number of victims and the degree of restriction of resources

Minimal/Minor - Green

• physiologically well compensated and likely to remain so for an extended period of time

• These patients require only basic immediate care and can probably wait with minimal risk of deterioration.

• minor lacerations, burns, or other soft tissue or orthopedic injuries without significant bleeding or neurovascular compromise

Delayed - Yellow

• compensated physiology but a significant potential for deterioration if there are long delays before definitive care can be provided

• physiologically stable patients with possible spine or head injuries without acute neurological deficits, significant bleeding controlled with pressure dressings or tourniquets, and orthopedic injuries with signs of neurovascular compromise that improve after basic splinting

Immediate - Red

• uncompensated physiology and injuries that are life-threatening these patients may sustain significant morbidity unless they receive rapid care in both the field and the hospital

• patients with poorly controlled external bleeding, moderate burns, or penetrating trauma without other critical injuries, altered mental status, early shock, and respiratory distress (but not failure).

• They should be transported first from the scene

Deceased - Black

• No detectable vital signs, typically identified as victims not breathing on their own

• In everyday practice settings, we would attempt resuscitation if there are no signs of obvious death, but in a disaster situation we simply designate the victim as dead

• Patients in the deceased category include those who are not breathing even after performing simple airway-opening maneuvers

Expectant - Gray

• These patients are those who are still alive but due to their injuries and/or medical condition are unlikely to survive

• Patients in the expectant category might include those with agonal respirations, massive head injuries, dismemberment, extensive burns, crush injuries, critical penetrating trauma, or multiple life threatening injuries

• Should be reevaluated regularly

• Once there are sufficient resources, these patients may be treated

Disaster Triage Systems

1. Simple Triage and Rapid Treatment System

2. JumpSTART

3. MDR or Medical Disaster Response

4. MASS triage

5. Military Triage

Simple Triage and Rapid Treatment

• tool is a commonly used adult MCI primary triage tool

• The five basic parameters assessed are:

  • a.the ability to walk

  • b.the presence or absence of spontaneous respirations

  • c.the respiratory rate

  • d.an assessment of perfusion

  • e.the ability to obey commands

• These parameters are often referred to as respirations, perfusion, and mental status (RPM)

• the first action upon entering the scene (after identifying and starting mitigation of ongoing hazards) is to make an announcement stating

JumpSTART

• Pediatric MCI Triage Tool was the first objective tool developed specifically for the primary triage of children in the multicasualty/disaster setting

• any infant or child who is carried to the designated Minor area must be individually assessed and triaged at the first possible opportunity

• when the triaging responder finds an apneic child, he or she performs a jaw thrust.

• If the child starts to breathe, the child is triaged Emergent, just as in the START algorithm

• if the child does not start to breathe, the responder checks for the pulse with which he or she is most comfortable assessing on a child

Medical Disaster Response (MDR)

• Specially trained health providers evaluate pts.

• Permits the triage process to evolve over hrs or even days, maximizing pt. survival & resulting in a more efficient use of resources

• Incorporates a modified version of Triage that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed Secondary Assessment of Victim Endpoint (SAVE) only limited, austere, field, advanced life support equipment is readily available

Red: Highest Priority

Patients who need immediate care and transport ASAP

a. Airway and breathing difficulties

b. Uncontrolled or severe bleeding

c. Decreased level of consciousness

d. Severe medical problems

e. Shock (hypoperfusion)

f. Severe burns

Yellow: Second Highest Priority

able to wait longer before transport (45 mins)

a. Burns without airway problems

]b. Major or multiple bone or joint injuries

c. Back injuries with or without spinal cord damage

Green: Low Priority

walking wounded

able to wait several hours for transport

a. minor fractures

b. minor soft-tissue injuries

Black: Lowest Priority

patients who are already dead or have little chance for survival

if resources are limited, treat salvageable patients before patients

a. obvious death

b. obviously nonsurvivable injury, such as major brain trauma

c. Full cardiac arrest

Military Triage

• Priority is to get as many soldiers back into action as possible

• those with the least serious wounds may be the first treatment priority

Civilian Triage

• Priority is to maximize survival of the greatest number of victims

• Those with the most serious but realistically salvageable injuries are treated first

Principles of disaster triage

1. Never move a casualty backward

2. never hold a critical patient for further care

3. salvage life over limb

4. do not stop treating patients

5. never move patients before triage, except

   • bad weather

   • impeding darkness

   • continued risk of injury

   • medical facilities are immediately available

   • tactical situations that dictates movement

Decontamination

• removing contaminants on an object or area, including chemicals, micro-organisms or radioactive substances.

• through chemical reaction, disinfection or physical removal

Methods of decontamination

• physical removal

• chemical decontamination

• oxidation

• hydrolyzing agent

Physical removal

• remove clothing

• flush with water/aqueous solution

• absorb contaminating agent with absorbent materials

  • Rub with flour followed with wet tissue

  • spot decontamination only

• scrape bulk agent with wooden stick

Chemical Decontamination

• Chemical Warfare Agents

  a.Nerve Agents- eg. tabun, sarin, soman,

  b.Tissue (Blood) Agents- eg. Cyanidesicants

  c.Vesicants- sulfur mustard and lewisite

  d.Pulmonary Agents- phosgene and chlorine

  e.Riot control Agents (tear gas)- pepper spray

• WATER/SOAP Wash

• Chemical Solution- alkaline solutions of hypochlorite

• Oxidation- Hypochlorite solutions are universally effective in removing organophosphates and mustard agents

• Hydrolyzing Agents (Agents VX and G)- alkaline hypochlorite

Hot zone

• area immediately adjacent to the location of the incident.

  a. airway and hemorrhage control

  b. administration of antidotes

  c. identification of expectant cases

• All staff are in protective gear

Warm Zone

• a distance of at least 300 feet from the outer perimeter of the hot zone, which is upwind and uphill from the contaminated area.

• Rapid triage takes place to sort victims

a. to provide essential stabilization.

b. to commence decontamination

• All staff wear PPE

Cold Zone

• area adjacent (uphill and upwind) from the warm zone, into which decontaminated victims enter

• A more thorough triage is done as victims enter the area

• Victims are directed to treatment areas based on the severity and nature of injury or illness

• PPE is maintained