® BDLS is a registered trademark of the American Medical Association V /06 ® MASS Triage Chapter 1 Part B

2Objectives Define disaster triageDefine disaster triage List components of MASS triageList components of MASS triage Discuss importance and utilization of triage tagsDiscuss importance and utilization of triage tags Identify victim triage categories for simulated triage scenarioIdentify victim triage categories for simulated triage scenario

3 Triage System Types Triage systems “sort” patients for a variety of purposes and situations: Military TriageMilitary Triage Emergency Department TriageEmergency Department Triage Disaster TriageDisaster Triage

4 Disaster Triage Sorting patients by the seriousness of their condition and the likelihood of their survivalSorting patients by the seriousness of their condition and the likelihood of their survival To achieve the greatest good for the greatest number possibleTo achieve the greatest good for the greatest number possible Dependent on resources availableDependent on resources available

5 Disaster Triage Factors impacting available resources: Volume and severity of patientsVolume and severity of patients Limited providersLimited providers Infrastructure limitationsInfrastructure limitations Inadequate hazard preparation (HAZMAT, etc.)Inadequate hazard preparation (HAZMAT, etc.) Limited transport capabilitiesLimited transport capabilities Multiple agencies respondingMultiple agencies responding Hospital Resources OverwhelmedHospital Resources Overwhelmed

6 Disaster Triage Methods used must be: SimpleSimple EffectiveEffective Easily rememberedEasily remembered Able to sort large numbers of patients quicklyAble to sort large numbers of patients quickly

7 Disaster Triage Key Principles: Life, Limb or Vision ThreatLife, Limb or Vision Threat Medical Intervention NeededMedical Intervention Needed Transportation AccessTransportation Access

8 Disaster Triage How do I identify the most injured victims quickly?How do I identify the most injured victims quickly? How do I get ambulatory or least injured victims out of the dangerous scene quickly?How do I get ambulatory or least injured victims out of the dangerous scene quickly?

V /06 9 D-I-S-A-S-T-E-R Paradigm Triage Triage Categories: “ID-me”! “Identify Me”“ID-me”! “Identify Me” –A mnemonic for sorting patients during triage I –Immediate D – Delayed M – Minimal E – Expectant D - DEAD D - DEAD

V /06 10 D-I-S-A-S-T-E-R Paradigm Triage M.A.S.S. Triage System M – Move A – Assess S – Sort S – Send

V /06 MASS Flow Chart 11

12 M.A.S.S Triage MoveMove Anyone who can walk is told to MOVE to a collection areaAnyone who can walk is told to MOVE to a collection area Remaining victims are told to MOVE an arm or legRemaining victims are told to MOVE an arm or leg AssessAssess Remaining patients who didn’t move (help these people first) Remaining patients who didn’t move (help these people first) SortSort Categorize patients by “ID-me”Categorize patients by “ID-me” Immediate, Delayed, Minimal, Expectant, DeadImmediate, Delayed, Minimal, Expectant, Dead SendSend Transport IMMEDIATE patients firstTransport IMMEDIATE patients first Send to Hospitals and Secondary Treatment FacilitiesSend to Hospitals and Secondary Treatment Facilities

13 M.A.S.S Triage Key Principle of MASS Triage: Group, then Sort!Group, then Sort! …then Transport!

14 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Step 1: GoalGoal Group - Ambulatory PatientsGroup - Ambulatory Patients Action:Action: “Everyone who can hear me and needs medical attention, please move to the area with the green flag”“Everyone who can hear me and needs medical attention, please move to the area with the green flag” “ID-me” Category“ID-me” Category Minimal initial groupMinimal initial group

15 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Minimal group, initial screeningMinimal group, initial screening –Airway, breathing, and circulation intact –Mental status: able to follow commands –Not likely low blood pressure or breathing trouble –Some conditions worsen, more urgent triage category –Must be reassessed and monitored –Limitations: not based upon individual assessment yet Actively managing this group will reduce self- transports and perhaps unnecessary overburdening of nearest hospital ER’sActively managing this group will reduce self- transports and perhaps unnecessary overburdening of nearest hospital ER’s Assess last, after Immediate and Delayed groupsAssess last, after Immediate and Delayed groups

16 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Step 2: GoalGoal –Group – can’t walk, but awake and able to follow commands to MOVE an arm or leg Action:Action: –Ask the remaining victims “everyone who can hear me please raise an arm or leg so we can come help you” “ID-me” Category“ID-me” Category –Delayed initial group

17 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Delayed groupDelayed group –Airway, breathing, and circulation adequate to follow simple commands –Mental status: Conscious & able to follow simple commands May have low blood pressure or low oxygen levelMay have low blood pressure or low oxygen level Likely significant injuries presentLikely significant injuries present Limitations: not based upon individual assessment yetLimitations: not based upon individual assessment yet Assess second, after Immediate groupAssess second, after Immediate group

18 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” GoalGoal –Group – Identify location of who is left, unable to ambulate and unable to follow simple commands Action:Action: –Proceed immediately to these patients and deliver immediate life-saving interventions “ID-me” Category“ID-me” Category –Immediate initial group

19 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” Immediate groupImmediate group –ABC status unknown, immediate assessment –Mental status: Unresponsive to verbal commands –Likely low blood pressure or low oxygen level –Life-threatening injuries present –Expectant and dead patients may be in this group –Minor injuries may be present due to: Ruptured ear drums, hearing impaired, chronically disabledRuptured ear drums, hearing impaired, chronically disabled –Limitations: not based upon individual assessment Assess these people FIRST!Assess these people FIRST!

20 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” IMMEDIATE patients Rapidly Assess ABC’s :Rapidly Assess ABC’s : –Is airway open? Open it manually –Is patient breathing? If not, EXPECTANT and go on –Is uncontrolled bleeding present? Assign direct pressure (do not hesitate to use tourniquet!) –Is likely fatal injury present? If yes, EXPECTANT Correct immediate life threatsCorrect immediate life threats Accurate count of immediate patientsAccurate count of immediate patients Is transport available for anyone now? …Move on!Is transport available for anyone now? …Move on!

21 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Everyone should be able to complete the “Move” and “Assess” steps of TriageEveryone should be able to complete the “Move” and “Assess” steps of Triage “Sort” requires a level of patient assessment skills beyond basic first aid / buddy aid“Sort” requires a level of patient assessment skills beyond basic first aid / buddy aid If you are unable to “Sort”, then assure that appropriate emergency medical services are enroute and continue to “move and assess”If you are unable to “Sort”, then assure that appropriate emergency medical services are enroute and continue to “move and assess”

22 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” - “ID-me”: I – Immediate D – Delayed M- Minimal E – Expectant D - DEAD “SORT” them based upon individual assessment, …continue lifesaving treatment

23 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Immediate Life or limb threatening injuryLife or limb threatening injury Usually persistent ABC problemUsually persistent ABC problem Examples:Examples: –Unresponsive, altered mental status, severe breathing trouble, uncontrollable bleeding, proximal amputations, turning blue, rapid and weak pulse…

24 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Delayed: Need definitive medical care, but should not worsen rapidly if initial care is delayedNeed definitive medical care, but should not worsen rapidly if initial care is delayed Examples:Examples: –Deep cuts or open fractures with controlled bleeding and good pulses; finger amputations; abdominal injuries with stable vital signs…

25 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Minimal: “Walking Wounded”“Walking Wounded” Treated and released (preferably without transport)Treated and released (preferably without transport) Source of “volunteer” helpSource of “volunteer” help Examples:Examples: –Abrasions, contusions, minor lacerations, no apparent injury

26 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Expectant Severely injured with little or no chance of survivalSeverely injured with little or no chance of survival Care resources not utilized initiallyCare resources not utilized initially Comfort resources used as availableComfort resources used as available Remember death could be hours or days away!Remember death could be hours or days away! Require reassessment and transport:Require reassessment and transport: –If alive after all immediate patients transported, resuscitate per available resources!

27 D-I-S-A-S-T-E-R Paradigm MASS Triage Model How to handle the dead patients:How to handle the dead patients: –Dead patients should not be moved –May aid in identification of the deceased Evidence is important!Evidence is important! –Finding and convicting perpetrators....and possibly... PREVENTING future attacks! – Excessive manipulation of human remains may destroy vital evidence

28 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” is dynamic! Reassess! Who is left?Who is left? Expectant group could become new Immediate groupExpectant group could become new Immediate group “Most serious” injury present requires your immediate attention!“Most serious” injury present requires your immediate attention!

29 D-I-S-A-S-T-E-R Paradigm MASS Triage Model When all patients have been triaged and immediate life saving procedures complete:When all patients have been triaged and immediate life saving procedures complete: –Accurate count in each category –Advise incident commander/triage officer –Move all immediate to collection point –Prepare for immediate transport –Often marked with red flag/tarp

30 D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SEND” Traditional syntaxTraditional syntax Immediate →Delayed →Minimal →ExpectantImmediate →Delayed →Minimal →Expectant ObjectiveObjective Transport or release ALL living patients ASAPTransport or release ALL living patients ASAP Mission FocusedMission Focused Send Minimal(s) with each Immediate (if unused space available in vehicle), etc…Send Minimal(s) with each Immediate (if unused space available in vehicle), etc… ResourcefulResourceful Secondary treatment facilities for minimal pts (or on-scene treatment and release)Secondary treatment facilities for minimal pts (or on-scene treatment and release) Utilize buses, taxis, trains, boats, etc..Utilize buses, taxis, trains, boats, etc..

31 M.A.S.S Triage Key Principle of MASS Triage: Group, then Sort!Group, then Sort! …then Transport!

32 Medical Record Triage TagsTriage Tags CommunicationCommunication –History & Physical –Treatment –Contact information –Personal message Front Back

33Summary Now you can: Define disaster triageDefine disaster triage List components of MASS triageList components of MASS triage Discuss importance and utilization of triage tagsDiscuss importance and utilization of triage tags

34 Questions?

35 Triage “Tabletop”

36 Triage Scenario Shooting incident at a Local Sporting EventShooting incident at a Local Sporting Event –Multiple gunshots were fired –You are first at the scene –10 victims What do you do?What do you do?

37 Is Need > Resources? D- DetectD- Detect –Is this a disaster / MCI? (need>resources) I- Incident CommandI- Incident Command –Who is in charge? (incident commander) Who will you contact? S- Scene Safety/SecurityS- Scene Safety/Security –Is it safe enough to enter? A- Assess HazardsA- Assess Hazards –Active shooter? Secondary device? Further penetrating trauma S- SupportS- Support –Law enforcement, EMS, Medical Control, Trauma Center, etc.. T- Triage/TreatmentT- Triage/Treatment –10 victims E- EvacuationE- Evacuation –What vehicles are available? What route is safe? R- RecoveryR- Recovery

38 MASS Triage MoveMove –Two walk –Three move AssessAssess –Five do not move SortSort –IDME categories SendSend

39 MASS Triage MoveMove –Two walk (Minimal Group) –Three move (Delayed Group) AssessAssess –Five do not move (Immediate Group) SortSort –IDME categories SendSend

40 29 yr male29 yr male –GSW to left chest, awake in severe respiratory distress 8 yr female8 yr female –GSW to head (through and through) RR=4, HR= yr male50 yr male –GSW to abdomen & chest, RR=0, HR=0, not moving 40 yr female40 yr female –GSW to neck with gurgling respirations, marked respiratory distress 16 yr male16 yr male –GSW right chest, No respiratory effort, HR=130 thready MASS: Immediate Group Unable to “MOVE” Immediate Expectant Dead Immediate Immediate Vs Expectant

41 MASS: Delayed Group Able to MOVE, not walk 14 year male14 year male –GSW to R upper arm, active massive hemorrhage, good pulses 65 year male65 year male –No obvious GSW, c/o severe chest pain, diaphoretic, and SOB 22 year female22 year female –GSW to R leg, good pulses, no active bleeding, normal VS Immediate -Delayed** Immediate Delayed **after pressure dressing

42 MASS: Minimal Group Able to “MOVE” out 29 yr male29 yr male –Superficial “scratch” wound to L arm, no deeper penetration 37 yr male37 yr male –GSW to left hand, exposed muscle, tendon and bone fragments, capillary refill < 2 sec Minimal Delayed

43 Triage Status CategorySORT Immediate4-5* Delayed 2 Minimal1 Expectant1-2* DEAD 1

44 29 yr male29 yr male –GSW to left chest, awake in severe respiratory distress: Needle decompression of L chest successful, VSS 40 yr female40 yr female –GSW to neck with gurgling respirations, marked respiratory distress: Airway management unsuccessful, profuse bleeding occurred, pt now apneic and pulseless 14 year male14 year male –GSW to R upper arm, active massive hemorrhage, good pulses: Now well controlled, no active bleeding, VSS 65 year male65 year male –No obvious GSW, c/o severe chest pain, diaphoretic, and SOB: Symptoms continue SORT: Immediate Delayed Dead Immediate Delayed

45 SORT: Delayed 22 year female22 year female –GSW to R leg, good pulses, no active bleeding, normal VS: Splinted leg, VSS 37 yr male37 yr male –GSW to left hand, exposed muscle, tendon and bone fragments, initial capillary refill < 2 sec: Now L hand is pulseless and cyanotic Delayed Immediate

46 SORT: Minimal 29 yr male29 yr male –Superficial “scratch” wound to L arm, no deeper penetration: No clinical change, desires to leave and go home Minimal

47 SORT: Expectant 16 yr male16 yr male –GSW right chest, No respiratory effort, HR=130 thready: Now no palpable pulse, no respiratory effort 8 yr female8 yr female –GSW to head (through and through) RR=4, HR=101: RR=6-8, HR=100 IMMEDIATE? Dead

48 Triage Status CategorySORTSORT Immediate4-5*3 Delayed 23 Minimal11 Expectant1-2*0 DEAD 13

49Summary Now you can: Define disaster triageDefine disaster triage List components of MASS triageList components of MASS triage Discuss importance and utilization of triage tagsDiscuss importance and utilization of triage tags Identify victim triage categories for simulated triage scenarioIdentify victim triage categories for simulated triage scenario

50 Questions?