Triage & Treatment by 6edh0EpV

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									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                                      SAFETY




      TREATMENT                         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

                          TIME
                                             H


        MANAGEMENT
                         Command
 The
                         Safety
Scene                    Assessment         H
                         Communication
        EMS OPERATIONS



                         Triage             H
                         Treatment
                         Transport       Definitive
                                           Care
         Scene Management

• Command                   • Safety
Who is in Charge?           Is there a hazard or threat?
Who is in charge of what?   Should I be here?
Who is going to do what?    Am I protected?
Who else needs to be        What should I worry about?
  here?
EMS is generally in
  Operations (Ops)
       Scene Management
• Assessment            • Communications
What is going on?       Who needs to know?
How big is this, how    What do they need to
  many people?            know?
What do I need?         Does Command & Ops
How does what I do        know?
  affect others?        Do the other players
What are they doing       know?
  that can affect me?
       Scene Management
• Triage                 • Treatment
Who is doing it?         What the typical EMS
Where are they doing       provider comes
 it?                       “preloaded” with…
What are they finding?   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     1       RED
Urgent        2      Yellow
Delayed       3      Green
Dead          0      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    in
        multiple casualty incidents.


        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

                           TIME
                                             H


        MANAGEMENT
                         Command
                         Safety
 The
Scene                    Assessment
        EMS OPERATIONS
                         Communication
                                            H



                         Triage
                                            H
                         Treatment
                         Transport       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 &     Triage      Urgent
 Rescue     Team(s)

                        Delayed




                        Morgue
From Treatment to Definitive Care
Treatment     Transport   Definitive Care

Immediate   Ambulances
                                H


 Urgent
            Ambulances,         H
            Ambulettes,
 Delayed    Buses, etc
                                H


                          Appropriate
                            Facility

								
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