1. Unit Four Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI)

2. DHS/NTCB461 Course2 Objectives  Define mass casualty incidents (MCI)  Describe the Multi-casualty Branch structure  Use of multiple Groups/Divisions under the Multi- casualty Branch Director  Discuss MCI response procedures  Review emergency medical service role in MCI  Describe “START”

3. DHS/NTCB461 Course3 Objectives (cont'd)  Identify the relationship of MCI Groups (triage, treatment, transport) to overall scheme of the HIMS  Prioritize patients using the START method of triage for:  Decontamination  Treatment  Identify considerations in transporting patients to area hospitals

4. DHS/NTCB461 Course4 Mass Casualty Incidents  Multi-patient Incidents - exceeds normal first responder capabilities  Major medical emergency – any emergency that would require the access of local mutual aid resources  Mass Casualty Incidents - combination of numbers of injured personnel and type of injuries going beyond the capability of an entity’s normal first response  Disaster – State and/or Federal resources are required

5. DHS/NTCB461 Course5 Mass Casualty Incident Management  Do the greatest good for the greatest number of patients  Make the best use of:  Personnel  Equipment  Medical and facility resources  Limit the spread of the contamination  Minimize the effects of the disaster, incident, or event

6. DHS/NTCB461 Course6 Triage Considerations  Triage - Term in early 1800s (derived from the French trier, meaning "to sort")  Immediate - Casualty requires lifesaving measures performed without delay if they are to survive  Delayed - Casualty whose treatment can wait without causing additional harm

7. DHS/NTCB461 Course7 Triage Considerations (cont'd)  Expectant – Casualties that will not survive or will require extensive resources and time if they are to be saved  Minor – Casualties that are generally ambulatory and are injured only slightly

8. DHS/NTCB461 Course8 Hospital Triage  Use a triage system in an MCI that parallels normal routine  Practice regularly to ensure familiarity  Triage is a continual process  Re-triage all victims transported by EMS  Set up triage area near the ED entrance  Shielded and secure  Readily accessible

9. DHS/NTCB461 Course9 Triage  “Greatest good for the greatest number of casualties”  Psychological impact  Classification: RedYellowGreen Black  Limitations:  Time consuming  User variability  Lack of familiarity

10. DHS/NTCB461 Course10 START Triage TRIAGE CRITERIA:  Respiratory status  Perfusion and pulse  Neurological status TRIAGE CATEGORIES:  Walking wounded - “Green” or minimal (relocate when told)  Normal findings - “Yellow” or delayed (unable to relocate)  Abnormal - “Red” or immediate  Non-salvageable - “Black” or expectant

11. DHS/NTCB461 Course11 START - Respiratory Status Expectant No Respiratory Effort Immediate Respirations > 30 Go to Next Step Normal Respirations Respiratory Status

12. DHS/NTCB461 Course12 START - Perfusion Immediate Radial Pulse Absent Immediate Cyanotic Go to Next Step Radial Pulse Present Perfusion Status

13. DHS/NTCB461 Course13 START - Neurological Status Immediate Change in Mental Status Immediate Unconscious Move to Next Victim Normal Mental Status Neurological Status

14. DHS/NTCB461 Course14 Nerve Agent Triage - “Immediate”  Unconsciousness or convulsions  Two or more body systems involved  Requires immediate antidote Rapid intervention should result in a good outcome

15. DHS/NTCB461 Course15  Immediate removal from source of exposure  severity directly proportional to absorbed dose  Decontamination  Mild soap and water rinse  Antidote administration with airway management support as necessary  Must be provided by properly trained and equipped personnel Initial First Aid Treatment

16. DHS/NTCB461 Course16 Nerve Agent Antidote  Atropine ─ administered to block receptor sites of acetylcholine  2-PAM Chloride ─ restores acetylcholinesterase  Mark I Kit or “Combo Pen”

17. DHS/NTCB461 Course17 First Aid Treatment  Exit Agent Exposure Area  Minor Symptoms Administer:  One Mark I Kit  Major Symptoms Administer:  Three Mark I Kits  Diazepam Required for Severe Casualty  Monitor Patient’s Symptoms

18. DHS/NTCB461 Course18 Nerve Agent Triage - “Delayed”  Initial symptoms are improving (miosis still present)  Recovering well from pre-hospital antidote therapy

19. DHS/NTCB461 Course19 Nerve Agent Triage - “Minimal” & “Expectant” Minimal Walking and talking which indicates intact breathing and circulation Walking and talking which indicates intact breathing and circulation Expectant Apneic for more than 5 minutes No pulse or blood pressure

20. DHS/NTCB461 Course20 Mustard Triage Mustard Triage Delayed 2 to 50% BSA burns by liquid 2 to 50% BSA burns by liquid Eye involvement Eye involvementMinimal < 2% BSA burns by liquid in non-critical areas < 2% BSA burns by liquid in non-critical areas Immediate Moderate to severe pulmonary symptoms Expectant > 50% BSA burns by liquid; apneic/no pulse

21. DHS/NTCB461 Course21 Triage of Biological Casualties  Triage of biological agent casualties is different:  Symptoms are delayed  Initial cases may go unrecognized  More difficult to detect  Epidemiological information becomes critical

22. DHS/NTCB461 Course22 Triage  Psychological Casualties  Disasters produce tremendous emotional and psychological stress, with large numbers of psychogenic casualties  Presenting signs could be confused with organic disease  Use of START triage system maintains focus on objective signs of disease & minimizes impact of subjective complaints on the triage process  Psychological casualties are usually triaged as “minimal”

23. DHS/NTCB461 Course23 Triage  Hospital Arrivals  Casualty arrival is uncoordinated  Arrival times vary  Closest hospital is typically overwhelmed  Medical needs of unaffected community continues  May present at distant hospitals to ensure treatment at clean facilities

24. DHS/NTCB461 Course24 Contaminated Human Remains  Problems are agent specific:  Decontamination  Containment  Refrigeration until definitive disposal  Follow local coroner and medical examiner protocols:  Establish cooperative agreements for fatality management  Secure personal effects:  Not all can be decontaminated

25. DHS/NTCB461 Course25 Radiation Protection for Clinical Staff  Fundamental Principles - Time - Time - Distance - Distance - Shielding - Shielding  Personnel Protective Equipment  Contamination Control

26. DHS/NTCB461 Course26 Protecting Staff from Contamination  Use standard precautions (N95 mask)  Survey hands and clothing frequently  Replace contaminated gloves or clothing  Keep the work area free of contamination