Transcript Principles of Multicasualty Incident (Disaster) Triage

Principles of Multicasualty
Incident (Disaster) Triage
Photo used with permission of the Emergency Education Council of Maryland Region 5.
© Lou Romig MD, 2006. Used with permission.
What is Triage?
“Triage” means “to sort”
Looks at medical needs and
urgency of each individual patient
Sorting based on limited data
acquisition
Also must consider resource
availability
Why are resources important
in triage?
A medical disaster is commonly
defined as an incident in which
patient care needs overwhelm
local response resources.
Abundant resources relative to demand
(P = Patient)
Do the best for each individual
Resources challenged
Do the best for each individual
(P = Patient)
Resources
Do the greatest
good overwhelmed
for the greatest number
(P = Patient)
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
Daily Emergencies
Do the best for each individual.
Disaster Settings
Do the greatest good for
the greatest number.
Maximize survival.
Why Should Responders Care About
Good Triage?
Provides a way to draw
organization out of chaos
Helps to get care to those who
need it and will benefit from it the
most
Helps in resource allocation
Provides an objective framework
for stressful and emotional
decisions
Triage is a dynamic process and is
usually done more than once.
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
Primary Disaster Triage
Triage based on physiology
How well the patient is able to
utilize their own resources to deal
with their injuries
Patients unable to physiologically
compensate for their injuries are
assigned higher priority.
Primary Disaster Triage
The most commonly used adult tool in
the US and Canada is the START tool.
The pediatric MCI primary triage tool
most commonly used in the US and
Canada is JumpSTART.
Other tools are used but are less
oriented to mass casualties than
triaging smaller numbers of trauma
patients.
The Best Tool?
No MCI
primary triage
tool has been
validated by
outcome data.
Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the
Neurosurgeon”, Neurosurg Focus 12(3), 2002. Available on the
Internet at www.medscape.com/viewarticle/431314
Secondary Disaster Triage
Goal: to best match patients’ current and
anticipated needs with available resources.
Incorporates:
A reassessment of physiology
An assessment of physical injuries
Initial treatment and assessment of
patient response
Further knowledge of resource
availability
Secondary Triage Tools
Goal is to distinguish between:
Victims needing life-saving treatment
that can only be provided in a hospital
setting.
Victims needing life-saving treatment
initially available on scene.
Victims with moderate non-lifethreatening injuries, at risk for delayed
complications.
Victims with minor injuries.
Secondary Triage Tools
Goal is to distinguish between:
Victims needing life-saving treatment
that can only be provided in a hospital
setting.
Victims needing life-saving treatment
initially available on scene.
Victims with moderate non-lifethreatening injuries, at risk for delayed
complications.
Victims with minor injuries.
Secondary Triage Tools
There is no widely recognized tool in
the US that addresses secondary MCI
triage.
California “Medical Disaster
Response” course’s SAVE tool
(Secondary Assessment of Victim
Endpoint)
Many EMS systems use local trauma
center triage criteria.
NATO Guidelines
Red
Airway obstruction, cardiorespiratory
failure, significant external hemorrhage,
shock, sucking chest wound, burns of face
or neck
Yellow
Open thoracic wound, penetrating
abdominal wound, severe eye injury,
avascular limb, fractures, significant
burns other than face, neck or perineum
NATO Guidelines
Green
Minor lacerations, contusions, sprains,
superficial burns, partial-thickness
burns of < 20% BSA
Black
Head injury with GCS<8, burns >85%
BSA, multisystem trauma, signs of
impending death
Burkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23:742-747, 1994
Tertiary Disaster Triage
Goal: to optimize individual outcome
Incorporates:
Sophisticated assessment and
treatment
Further assessment of available
medical resources
Determination of best venue for
definitive care
Primary Triage
Secondary Triage
Tertiary Triage
MCI Triage: Key Points
Resources and patient numbers
and acuity are limiting factors.
Must be dynamic, responsive to
changes in both resources and
patient needs.
There is currently no civilian MCI
triage system that has been
validated by outcome data.
Triage Categories
Triage Categories
Red:
Life-threatening but treatable
injuries requiring rapid medical
attention
Yellow:
Potentially serious injuries, but
are stable enough to wait a short
while for medical treatment
Triage Categories: Local Option
Green:
Minor injuries that can wait for
longer periods of time for
treatment
Black:
Dead or still with life signs but
injuries are incompatible with
survival in austere conditions
Triage Categories: Local Options
Blue:
Probably nonsalvageable but
minimal signs of life present
Other:
Additional colors may be selected
to signify whether patient is
contaminated or not
Photo used with permission of the Emergency Education Council of Maryland Region 5.
What about WMD?
FEMA Photo Library
There is no widely recognized civilian
MCI triage tool used in the US for any
of the NRBC agents.
WMD Triage Challenges
Any triage model for WMD must
consider decontamination:
Who goes first?
At what stage does triage take
place?
Difficulty of conducting patient
assessment and care with
responders in protective gear.
WMD Triage Challenges
Agents of attack may be mixed. How do
you triage victims who have injuries
from a conventional attack in addition to
a chemical or radiological/nuclear
exposure?
WMD Triage Challenges
Biological agents may impact field triage
mostly in choice of destination facility
(quarantine hospital).
Patterns of EMS calls may assist in
identification of a occult biological agent attack
or a natural epidemic
Multiple software programs are available as
surveillance tools for trends in patterns of
illness
WMD Triage Challenges
Some agents cause “toxindromes” that
allow for prediction of outcome based
on presenting symptoms and signs.
Agent-specific triage is dependent upon
identification or strong suspicion of the
agent’s use.
Very difficult to train and maintain
readiness with multiple agent-specific
triage schemes.
Chemical Toxindrome Examples
Nerve agent
Red: severe distress, seizure,
signs in two or more systems
(neuromuscular, GI,
respiratory – excluding eyes
and nose)
Black: pulseless or apneic,
unless intensive resources are
available
Chemical Toxindrome Examples
Phosgene and vesicants
Red: moderate to severe
respiratory distress, only when
intensive resources are
immediately available
Black: burns >50% BSA from
liquid exposure, signs of more
than minimal pulmonary
involvement, when intensive
resources are not available
Chemical Toxindrome Examples
Cyanide
Red: active seizure or recent
onset of apnea with preserved
circulation
Black: no palpable pulse
Sidell FR, “Triage of Chemical Casualties” Chapter 14 in Medical
Aspects of Chemical and Biological Warfare, available on the
Internet at http://www.bordeninstitute.army.mil/cwbw/Ch14.pdf
Key Points about MCI Triage
Anything that can help organize
the response to an MCI is a good
thing.
MCI triage is different than daily
triage, in both field and ED
settings.
Resource availability is the
limiting factor to consider in MCI
triage.
Key Points about MCI Triage
In order for MCI triage to work
toward its goal, all victims must have
equal importance at the time of
primary triage. No patient group can
receive special consideration other
than that dictated by their physiology.
This includes children!
Key Points about MCI Triage
MCI triage will never be logistically,
intellectually, or emotionally easy…
FEMA Photo Library
but we must be prepared to do it
using the best of our knowledge and
abilities.