Comprehensive Disaster Nursing and Triage Protocols
The Chain of Survival and Cardiac Arrest Management
The Chain of Survival is a series of critical actions that, when implemented, reduces the mortality associated with cardiac arrest.
When each link in the chain is performed effectively, it is estimated that lives could be saved per population.
The specific links in the Chain of Survival include:
Immediate recognition of cardiac arrest and activation of the emergency response system.
Early Cardiopulmonary Resuscitation (CPR).
Rapid defibrillation.
Effective Advanced Life Support (ALS).
Post cardiac arrest care.
Management of the unresponsive patient involves several immediate steps:
Verification of unresponsiveness and absence of breathing or lack of normal breathing (only gasping).
Activation of the emergency response system.
Starting CPR, ensuring the responder pushes hard and pushes fast.
Obtaining a defibrillator.
Checking the rhythm and delivering a shock if indicated.
Repeating these cycles every minutes.
Mass Casualty Incidents (MCI)
A Mass Casualty Incident (MCI) is defined by three specific criteria:
Any call or scenario involving or more patients or victims.
Any event that places a great demand on available equipment or personnel.
Any event requiring a mutual aid response, which entails collaboration between multiple Emergency Departments (EDs) or Emergency Medical Services (EMS) units.
MCI events are often associated with triggers such as explosions or pollution.
Organizational Components of an MCI Response
The effective management of an MCI requires specific functional areas and roles:
Incident Commander: The individual using the Incident Command System (ICS) to manage the scene.
Command Post: The central location for coordination.
Secured Perimeter: To control access to the site.
On-site Communications System: Necessary for coordination between units.
Extrication and Retrieval Area: Where victims are removed from the hazard.
Decontamination Area: Utilized for Incident Hazmat situations.
Triage Area: Managed by a Triage Officer; includes a patient collection area and a patient treatment area, both of which must be staffed.
Treatment Area: Includes sections for Urgent and Emergent patients; a Supply/Central Sterile Supply (CSS) must be adjacent to the treatment area.
Staging Area: A designated location for resources including fire and law enforcement personnel, EMS, and Health Care Providers (HCPs).
Transport Area: Managed by a Transport Officer; handles stand-by transport vehicles and determines where patients are sent (nearest hospital versus farther hospitals).
Rehabilitation Area: For responder recovery.
Receiving Healthcare Facilities: The destination hospitals for victims.
Fundamental Principles and Definitions of Triage
The word triage is derived from the French word "trier," which means "to sort" or "to choose."
Triage is defined as the sorting or classifying of clients into priority levels based on the severity of their illness or injury.
In the Emergency Department (ED), triage describes a rapid, focused assessment of individuals seeking care to ensure the most efficient use of manpower, equipment, and facilities.
The triage nurse acts as the gatekeeper of the ED.
Key Concept: Clients presenting with the highest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization (e.g., X-rays).
The Primary Goal of Triage: To get the right patient to the right place at the right time for the right reason to receive the right treatment.
The Triage Process and Execution
The commonly cited goal for the triage process is to minutes per patient.
Triage duration varies based on factors:
The time is extended as patient age increases.
The time is significantly reduced if vital signs are not taken.
Comprehensive Triage Components:
An initial across-the-room look or visualization.
A rapid triage lasting seconds or less.
Elicitation of the chief complaint, key questions, and assessments.
Completion of a focused triage history and focused physical assessment.
The triage decision, resulting in the assignment of the patient’s triage acuity or level.
Clinical Triage Categories and Acuity Levels
Emergent (RED):
Indicates a condition posing an immediate threat to life or limb.
Defined by CAB (Circulation, Airway, Breathing) compromise.
Examples: Myocardial Infarction (MI), heart attack, shortness of breath, diaphoresis, active hemorrhage, Gunshot Wounds (GSW), acute severe chest pain, massive vomiting of blood, sudden loss of consciousness, major trauma with hypotension, and shock.
The physician must examine the patient as soon as possible.
Urgent (YELLOW):
The client should be treated quickly, but there is no immediate threat to life at the moment.
Treatment may be delayed up to hour.
Sub-category - Strong Likelihood of Emergency: Requires full evaluation and treatment for conditions like acute dyspnea, acute abdominal pain, acute chest pain, acute confusion, or severe pain.
Sub-category - Potential for Emergency: Physician examination is required because an emergency cannot be excluded by initial screening. Prospective studies show that of these patients have high-risk conditions and require emergency admission.
Examples: Broken bones, minor cuts, renal colic, lacerations with bleeding, displaced fractures, and fever (provided respiratory failure is not present).
Non-Urgent / Non-Emergent (GREEN):
Patients can generally tolerate waiting without significant risk of clinical deterioration for up to hours.
Disorders are typically chronic, minor, or self-limiting.
Examples: Simple lacerations, sprains, strains, soft tissue injuries, viral or cold symptoms, skin rashes, and sore throat.
Deceased (BLACK):
The victim is dead and no care is required.
Classifications of Triage Processes
Triage is generally classified into three categories:
In-hospital Triage.
Pre-hospital Triage.
Disaster Triage.
Pre-Hospital versus Disaster Triage
Pre-Hospital Triage:
Usually involves multiple victims at a single scene.
Additional resources are typically available and the medical infrastructure (receiving facilities) remains intact.
Classification follows the in-hospital model: Emergent, Urgent, Non-emergent, Deceased.
Treatment and transport are based on standard triage priorities: transport the severely ill first, followed by lesser ones.
Process: Respond to scene → Triage/classify → Stabilize/treat → Transport with continuous assessment and treatment → Hand off the patient.
Disaster Triage:
Involves an increased number of victims, often at multiple scenes.
Medical resources are limited and scene times are long.
Goal: Identify injured or ill patients who have a good chance of survival with immediate care that does not require extraordinary circumstances.
Key Characteristic: Treatment and transport are based on reversed triage priorities, meaning the less ill are treated and transported first to preserve resources.
The START Model (Simple Triage And Rapid Treatment)
The START model is used for the rapid triage of victims in less than seconds.
Assessments focus on the RPM parameters:
Respiration.
Perfusion.
Mental Status.
START Categories:
Immediate (RED): Altered RPM.
Delayed (YELLOW): Includes the majority of victims; RPM is "normal."
Minor (GREEN): Known as the "walking wounded"; these individuals may be tagged later.
Dead (BLACK): Victims with mortal wounds who will die despite medical attention or are dead upon initial assessment.
Execution steps:
Begin where you stand and move in a systematic manner.
Spend a maximum of minute per victim.
Correct life-threatening airway problems immediately.
Tag the patient and move on.
Transition Phase:
Includes allocating available vehicles.
Determining priority for transport (Red tag/Immediate first during this transition).
Tracking victims using triage tag numbers or bar coding.
The SAVE Model (Secondary Assessment of Victim Endpoint)
The Secondary Assessment of Victim Endpoint (SAVE) model is designed for catastrophic disasters where evacuation to definitive care is significantly delayed (days).
Goal: Apply limited resources to gain the most benefit in environments where immediate on-scene care is provided but transport is unavailable.
SAVE Categories:
Those who will die regardless of care.
Those who will benefit from limited immediate field intervention.
Those who will survive whether or not they receive care.
The SAVE Process:
Reassess patients based on S.T.A.R.T. triage.
Assign patients to specific areas:
Observation Area: For those who will die (periodic reassessment for improvement) and those not needing immediate care (periodic reassessment for deterioration).
Treatment Area: Patients are treated in order of severity, available resources, and time.
Ongoing Management: If a patient in the treatment area does not respond to treatment, they are re-tagged and moved to the observation area. Patients who would benefit most from early transport are designated for such in case transport becomes available.