Prehospital Considerations Triage and EMS PDLS Version 2 Gretchen K. Lipke, MD FACEP

Objectives To compare START and JumpSTART triage systems To compare START and JumpSTART triage systems To review EMS consideration in disaster situations and the unique needs of children To review EMS consideration in disaster situations and the unique needs of children To review the NDMS/DMAT concept as a channel for federal assistance To review the NDMS/DMAT concept as a channel for federal assistance

Triage “to sort” or place in order “to sort” or place in order Guides decisions about allocating scarce resources and limited time Guides decisions about allocating scarce resources and limited time “greatest good for greatest number” “greatest good for greatest number” Protocol helps makes decisions Protocol helps makes decisions ICS separates triage from treatment immediately: see everybody once briefly for focus ICS separates triage from treatment immediately: see everybody once briefly for focus

START Most commonly used triage system across country Most commonly used triage system across country Not applicable for under 8 years old Not applicable for under 8 years old Initial eval –not final Initial eval –not final Time limited (plan 1 min/patient) Time limited (plan 1 min/patient) Categorize and move on Categorize and move on

This needs to be the START flow sheet This needs to be the START flow sheet

START “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. Gen 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals) Gen 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals)

START EVAL (and tag) those unable to walk for transport: RPM EVAL (and tag) those unable to walk for transport: RPM Resp: no => position airway = still no =>Black/ yes => RED (immediate). Resp: no => position airway = still no =>Black/ yes => RED (immediate). Spont resp >30 => RED/ under 30 => next item of assessment Spont resp >30 => RED/ under 30 => next item of assessment

START Perfusion: cap refill > 2 sec => control bleeding, label RED; 2 sec => control bleeding, label RED; <2 sec, next item Mental status: Cannot follow simple commands => RED; CAN follow simple commands (and has cap refill YELLOW (delayed) Mental status: Cannot follow simple commands => RED; CAN follow simple commands (and has cap refill YELLOW (delayed)

START As soon as one can categorize a patient, STOP evaluating (if they are RED for breathing, they won’t be seen any faster for additional problems) and move on. As soon as one can categorize a patient, STOP evaluating (if they are RED for breathing, they won’t be seen any faster for additional problems) and move on. Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes). Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).

JumpSTART (under 8) Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp instead of <30 Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp instead of <30 Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. Mental status AV/PU instead of follow/not Mental status AV/PU instead of follow/not

This needs to be the JUMPSTART flow page This needs to be the JUMPSTART flow page

JumpSTART “If you can hear me and you are able, walk over here for help.” “If you can hear me and you are able, walk over here for help.” GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out. GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out. Assess non-ambulatory patients as you find them using RPM. Assess non-ambulatory patients as you find them using RPM.

JumpSTART Respirations: NO  open airway => yes  RED; no -> check peripheral pulse. Respirations: NO  open airway => yes  RED; no -> check peripheral pulse. NO pulse = BLACK NO pulse = BLACK Pulse  15 sec mask to mouth ventilation Pulse  15 sec mask to mouth ventilation Spont resp: NO  BLACK; YES  RED Spont resp: NO  BLACK; YES  RED

JumpSTART Breathing: RR 40 or irregular =RED Breathing: RR 40 or irregular =RED RR 15-40, regular – check pulse RR 15-40, regular – check pulse No peripheral pulse: RED No peripheral pulse: RED Peripheral pulse: check mental status Peripheral pulse: check mental status AV (appropriate) YELLOW AV (appropriate) YELLOW PU (inappropriate) RED PU (inappropriate) RED

Kids in triage Don’t follow commands. Don’t follow commands. May actually hide from rescuers in full gear (spaceman look). May actually hide from rescuers in full gear (spaceman look). May be extricated by GREEN parents/ adults with delay in triage and treatment. May be extricated by GREEN parents/ adults with delay in triage and treatment. Need distraction and dedicated supervisor able to run after wandering toddlers Need distraction and dedicated supervisor able to run after wandering toddlers

ICS (Incident Command System) Senior on scene: command – assess need for further resources and direct incoming resources to where needed. This starts with first to arrive. Senior on scene: command – assess need for further resources and direct incoming resources to where needed. This starts with first to arrive. Triage: initial fast assessment in place of every patient, sort for evacuation and first in line for care when additional resources arrive Triage: initial fast assessment in place of every patient, sort for evacuation and first in line for care when additional resources arrive

ICS Treatment: patients may outnumber transport, leading to time in field where treatment can be started. Sort patients by category (greens, yellow, red, black) and treat within areas. If greens self triaged, they need evaluation. Treatment: patients may outnumber transport, leading to time in field where treatment can be started. Sort patients by category (greens, yellow, red, black) and treat within areas. If greens self triaged, they need evaluation.

Treatment Limited initial treatment – don’t delay evacuation if vehicle available Limited initial treatment – don’t delay evacuation if vehicle available Oxygen, dressings, splints Oxygen, dressings, splints Airway management? Remember, no intubations during triage, and no codes during mass casualty event, unless sufficient personnel and equipment that no other care is delayed Airway management? Remember, no intubations during triage, and no codes during mass casualty event, unless sufficient personnel and equipment that no other care is delayed

Treatment Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)? Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)? Does your locality stock a “disaster truck”? Does your locality stock a “disaster truck”? Does it have kid size equipment and kid sized doses of Hazmat antidotes? Does it have kid size equipment and kid sized doses of Hazmat antidotes? Do you have Broselow tapes to guide dosing? Do you have Broselow tapes to guide dosing?

Treatment - airway Non breathing adult: BLACK (after airway maneuver) Non breathing adult: BLACK (after airway maneuver) Non breathing child (with pulse): rescue breaths, then if no response, BLACK Non breathing child (with pulse): rescue breaths, then if no response, BLACK Non breathing child without pulse: BLACK Non breathing child without pulse: BLACK Oxygen: how administered? Do you have octopus adaptors to set more than one NRBM off each nozzle? REDs first. Oxygen: how administered? Do you have octopus adaptors to set more than one NRBM off each nozzle? REDs first.

Treatment IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV? IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV? BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygen BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygen

Treatment: Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination Pressure dressing for active bleeding Pressure dressing for active bleeding –Recruit neighbor to help hold pressure during triage while awaiting transport/evacuation Splint – extremity injuries Splint – extremity injuries

Treatment Medications: pain control, specific antidotes with Hazmat event/team Medications: pain control, specific antidotes with Hazmat event/team Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – even if they respond to treatment, they have the same underlying injury) Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – even if they respond to treatment, they have the same underlying injury)

Further field care Depends on local plans Depends on local plans Send personnel and supplies to site, or bring patients to hospital (personnel and supplies) Send personnel and supplies to site, or bring patients to hospital (personnel and supplies) –EMS –patient to hospital –NDMS – personnel and supplies to site

ICS Transport: decides which patients leave scene first and where they’re going. Remember that helpful bystanders and self transporters will fill nearest hospital first. Includes decisions about longer transport times for specialty care ( e.g. out of town for burn unit straight from scene rather than to hospital for transfer) Transport: decides which patients leave scene first and where they’re going. Remember that helpful bystanders and self transporters will fill nearest hospital first. Includes decisions about longer transport times for specialty care ( e.g. out of town for burn unit straight from scene rather than to hospital for transfer)

ICS Scene control: limit access for civilians, media cameras, also maintain in/out routes for vehicles which do need entry. Scene control: limit access for civilians, media cameras, also maintain in/out routes for vehicles which do need entry. Communications: notify hospitals rough numbers, kinds of injuries Communications: notify hospitals rough numbers, kinds of injuries

NDMS Federal level aid, formerly HHS, now under Homeland Security Federal level aid, formerly HHS, now under Homeland Security Initial premise: damage to city/area overwhelming local hospitals, transport patients to hospitals in region/nation Initial premise: damage to city/area overwhelming local hospitals, transport patients to hospitals in region/nation In practice: Hospitals, supplies available, easier to bring caregivers in (DMAT teams) In practice: Hospitals, supplies available, easier to bring caregivers in (DMAT teams)

NDMS Victims in home environment, allows visitors, social support, easier transition home. Victims in home environment, allows visitors, social support, easier transition home. Caregivers away from their usual responsibilities, can focus on victims. Caregivers away from their usual responsibilities, can focus on victims. Volunteers, credentials established ahead of time, teams practice together, used to working together. Call rotates 3-4/yr/team Volunteers, credentials established ahead of time, teams practice together, used to working together. Call rotates 3-4/yr/team

NDMS Federal support: license good in every state, malpractice covered, insurance covered (disability, death) Federal support: license good in every state, malpractice covered, insurance covered (disability, death) Team transport, housing, food Team transport, housing, food

DMAT teams Staff: MD/RN/EMT-P/ RT/ pharmacy/ administration/ communications/ logistics Staff: MD/RN/EMT-P/ RT/ pharmacy/ administration/ communications/ logistics Stocked and supplied to be self-sufficient for 3 days, then back fill and restock should be available. Stocked and supplied to be self-sufficient for 3 days, then back fill and restock should be available. Theory: set up from scratch with hospital tent; in practice, any building can be adopted; running water and electric bonus Theory: set up from scratch with hospital tent; in practice, any building can be adopted; running water and electric bonus

DMAT Label recognition: people do best what they do all the time. Assign usual roles, label building parts in familiar fashion “ED”, “Asthma ward”, “rehydration” Label recognition: people do best what they do all the time. Assign usual roles, label building parts in familiar fashion “ED”, “Asthma ward”, “rehydration” Care for victims, rescuers, caregivers, site workers, bystanders Care for victims, rescuers, caregivers, site workers, bystanders