Transcript Triage & Treatment - Adirondack Area Network

SMART System &
START Triage
Bureau of Emergency Medical Services
New York State Department of Health
Jim Soto
Associate Director
Objectives:
• What is an MCI ?
• Review Incident Management from
EMS perspective
• Review Triage & Practice START
What is the Goal of MCI
Management?
EMS GOAL:
TO SAVE THE LARGEST NUMBER OF
SURVIVORS FROM A MULTIPLE
CASUALTY INCIDENT
What is an MCI Scene?
What are some Common things
affecting your MCI response?
• Typical staffing of your ambulance service?
• What does EMS routinely do daily?
• How do you handle the following?
– 4 victims in a two car “head-on”
– 17 victims in a “team” van
– 43 victims on a school bus
– 350 victims on a train
So what do you have to think about?
TRIAGE
STAGING
COMMUNICATIONS
COMMAND
IMMODIUM
TREATMENT
SAFETY
ASSESSMENT
THE INITIAL PROBLEM ON SCENE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
THE OBJECTIVE
Casualties
Resources
BUT - HOW IS EMS TRAINED?
• BLS, ALS
• CPR, ACLS, PALS
• PHTLS, BTLS
• CFR, EMT, EMT-I, EMT-CC, EMT-P
How many patients are you taught to
treat at one time?
WHAT CHANGES WHEN YOU
HAVE AN MCI ?
• What are my resources?
• Who is a Patient?
• Which Patient do I treat first?
• Who can be salvaged?
• Who gets transported first?
• Who needs a Trauma/Specialty Center?
• Who can help care for others?
TIME IS IMPORTANT
ARRIVAL OF REQUESTED
RESOURCES
TIME IS VERY IMPORTANT
THE GOLDEN HOUR
“The critical trauma patient has only 60
minutes from the time of injury to reach
definitive surgical care, or the odds of
a successful recovery diminish
dramatically”.
Pre-Hospital Trauma Life Support, Second Edition,
Patient Assessment and Management, page 42. 1990.
Balancing Act
Casualties
Resources Management
Time Management
Casualties
+
Resources
=
Maximum survivors
SCENE MANAGEMENT
MANAGEMENT
The
Scene
Command
Safety
Assessment
Communication
EMS OPERATIONS
TIME
Triage
Treatment
Transport
H
H
H
Definitive
Care
Scene Management
• Command
Who is in Charge?
Who is in charge of what?
Who is going to do what?
Who else needs to be
here?
EMS is generally in
Operations (Ops)
• Safety
Is there a hazard or threat?
Should I be here?
Am I protected?
What should I worry about?
Scene Management
• Assessment
What is going on?
How big is this, how
many people?
What do I need?
How does what I do
affect others?
What are they doing
that can affect me?
• Communications
Who needs to know?
What do they need to
know?
Does Command & Ops
know?
Do the other players
know?
Scene Management
• Triage
• Treatment
Who is doing it?
Where are they doing
it?
What are they finding?
What the typical EMS
provider comes
“preloaded” with…
How to organize?
How much can we do?
Scene Management
Transport
• Who is doing it?
• From where are they doing it?
• Where are the patients going?
• How many patients going
where?
TRIAGE
“Large scale triage is the hardest job anyone in
pre-hospital care will ever do”.
A.J Heightman, Mass Casualty Incident Management.
A practical approach to solving complex operational dilemmas.
TRIAGE
WHEN ?
Casualties exceed the number of
skilled rescuers.
Types of Triage
• Primary
– On Scene prior to movement
• Secondary
– Incident dependant, probably prior to or
during transport
TRIAGE CODING
Priority Treatment
Color
Immediate
Urgent
Delayed
Dead
RED
1
2
3
0
Yellow
Green
Black
TRIAGE TAGS
What is the same ?
What is improved ?
What is different ?
Triage Protocol (START)
PRIMARY TRIAGE
The
Scene
PRIMARY TRIAGE
The first attempt at balancing EMS resources and
casualties / injured
PRIMARY TRIAGE
Determining whether there is an
airway and breathing
PRIMARY TRIAGE
If breathing, at what rate & is it good enough?
PRIMARY TRIAGE
They have an airway, and are breathing.
Are they circulating blood sufficiently?
Circulatory Check…
PRIMARY TRIAGE
A
B
C
Mental
Status
PEDIATRIC TRIAGE
Children
are
involved
multiple casualty incidents.
in
The over prioritizing of children
will take valuable resources
away from more seriously
injured adults.
Triage systems based on adult
physiology will not provide
accurate triage.
SMART Pediatric Tape
• Developed by Pediatricians to use the
existing START protocol but modified
to reflect appropriate values for
pediatric respirations and circulation.
START
Triage Protocol (START)
START EXERCISE
• Female, 30’s, walking
• Female, teens, walking, pale, complaining of
•
•
•
•
severe abdominal pain
Male, teens, walking, confused
Male, teens, you open airway, does not breathe
Male, 20’s, unconscious, breathing, RR 36, radial
pulse absent
Male, 20’s, holding left ankle, cannot walk, RR
20, CRT 1, responds to instructions
1
START EXERCISE
• Female, 30’s, walking
• Female, teens, walking, pale, complaining of severe
abdominal pain
• Male, teens, walking, confused
• Male, teens, you open airway, does not breathe
• Male, 20’s, unconscious, breathing, RR 36, radial
pulse absent
• Male, 20’s, holding left ankle, cannot walk, RR 20,
CRT 1, responds to instructions
1A
START EXERCISE
• Female, 60’s, fracture LL leg, cannot walk, RR 25,
•
•
•
•
•
CRT 1, obeys commands
Male, 30’s, you open airway, does not breathe
Male, 30’s, lying on ground, breathing, gurgling
sounds, RR 37, pulse absent, unresponsive
Male, 50’s, you open airway, does not breathe
Male, child, 75 cm, not alert, breathing, RR 30,
CRT 2.5, pulse 100
Male, child, 130 cm, not walking, breathing, RR 24
CRT 1
2
START EXERCISE
• Female, 60’s, fracture LL leg, cannot walk, RR
•
•
•
•
•
25, CRT 1, obeys commands
Male, 30’s, you open airway, does not breathe
Male, 30’s, lying on ground, breathing, gurgling
sounds, RR 37, pulse absent, unresponsive
Male, 50’s, you open airway, does not breathe
Male, child, 75 cm, not alert, breathing, RR 30,
CRT 2.5, pulse 100
Male, child, 130 cm, not walking, breathing,
RR 24 CRT 1
2A
START EXERCISE
• Female, child, 145 cm, lying on ground
holding chest, breathing with gurgling
sounds, RR 37,
CRT 3
• Female, child, 47 cm, breathing, crying,
pulse 160
3
START EXERCISE
• Female, child, 145 cm, lying on ground
holding chest, breathing with gurgling
sounds, RR 37, CRT 3
• Female, child, 47 cm, breathing, crying,
pulse 160
3A
SECONDARY
TRIAGE
SECONDARY TRIAGE
• Purpose
– Determine among like priority category,
higher priority patient
• When does it happen?
– Generally on extended duration events
– If treatment areas are established, there will
likely be a need for Secondary Triage before
transport
SECONDARY TRIAGE
SCENE MANAGEMENT
EMS OPERATIONS
The
Scene
MANAGEMENT
TIME
Command
Safety
Assessment
Communication
Triage
Treatment
Transport
H
H
H
Definitive
Care
Tools to help manage
• Use of ICS
• FOGs and SOGs
– Field Operations Guides
– Standard Operations Guides
• Command Boards
• Communications
– Radios / Cellular, etc
– Verbal
– Documentation
• Scribes/Runners
Tools to Organize
SMART COMMANDER ™
EMS INCIDENT MANAGEMENT
SMART COMMANDER ™
• Organization for:
– Command, Control, Coordination
• Provides:
–
–
–
–
–
–
–
Overall Incident Management Team
EMS Operations Specifics
Incident Communications
Weather
Hazards
Primary Triage Status
Destination Capability & Patient Distribution
SMART Commander - EMS
Incident
Management
Team
EMS
Operations
ICS – 205
Communications
Plan
Incident
Weather
Conditions
Incident
Hazards
Triage Team &
Casualty Status
Hospital
Capability &
Patient
Distribution
SUMMARY
MCI’s require:
• Change of EMS provider’s approach
– Single Pt. vs. Multiple Pts.
• Applying limited resources effectively & timely
– Incident & Time Management
• Organizing, Coordinating & Communicating in
•
EMS Operations
Accountability of resources & patients
– Who is doing what & how many patients do you have
• Appropriate distribution & destinations
– Where are they going & why?
• After Action
– Lessons Learned & Review of Existing plans
From Triage to Treatment Areas
Incident
Triage
Treatment
Immediate
Search &
Rescue
Triage
Team(s)
Urgent
Delayed
Morgue
From Treatment to Definitive Care
Treatment
Transport
Immediate
Ambulances
Urgent
Ambulances,
Ambulettes,
Buses, etc
Delayed
Definitive Care
H
H
H
Appropriate
Facility