1. Triage

2. Triage? Triage is the sorting of patients by the severity of injury or illness so that resources can be more efficiently utilized to do the most good for the most people…

3. Mass Casualty Incident? A Mass Casualty Incident (MCI) is when there are more patients than there are resources immediately available. A Multi-victim Accident is when there is a large number of victims, but there ARE adequate resources.

4. Triage is a Dynamic Process… Regardless of whether patients are moved from point of injury/illness to another location for treatment, or if they are treated in place…triage is repeated before treatment begins. Triage is conducted at least four times: During the initial contact with Healthcare Providers, When the patient is moved to the treatment sector, When the patient is moved to the transportation sector, and When the patient is presented to the Emergency Department.

5. Triage, responsibilities The Triage Sector has four responsibilities. * Implement the triage system and tag patients according to the severity of their injuries or illness. * Report progress and needs to the EMS Command Officer. ONLY * Treat ONLY immediate threats to life, i.e. blocked airways and severe arterial bleeding. * Move patients by priority to treatment sector.

6. Triage Tags Triage tags are often used to document the patient condition and treatment received. Tags come in a variety of different designs. Different colors are used to represent priority of injury. Red: Immediate Yellow: Delayed Green: Walking Wounded, Minor Black: Expectant, deceased

7. What do the colors mean??? Green: Minimal/Walking wounded- These are patients that are ambulatory, and have only minimal injuries and are capable of making their own way to the casualty collection point/treatment sector. Yellow: Delayed- These are patients that have wounds that require attention, but are not immediately life threatening. These patients usually need assistance making their way to the treatment sector.

8. What do the colors mean? Red: Immediate- critically-injured patients with treatable life-threatening injuries or illnesses. This might include airway and breathing difficulties, decreased mental status, and uncontrolled bleeding. These patients will be treated and transported from the scene first.

9. What do the colors mean? Black: Expectant (morgue)- is used for dead and unsalvageable patients such as someone in cardiac arrest. These victims will be removed from the scene, but only after all of the living/salvageable patients.

11. DMS Triage Tag, Instructions The Contaminated strip running the length of the triage tag has three functions. First to prevent the tag from being used until patient contamination has been considered. Second, to identify victims who have been exposed to a hazardous material, and third to aid rescuers with identifying clothing (evidence) belonging to victims.

12. Triage Tag Instructions, Cont. After a victim's clothing has been removed and placed into an airtight clear plastic bag, the long CONTAMINATED tear off strip is placed inside the bag face out. The numbered tag allows for clear identification of items for retrieval by the owner or for investigative purposes.

13. Triage Tag Instructions, Cont. If contamination is not an issue, the strip may be removed and standard triage procedures may be initiated.

14. Triage Tag Instructions, Cont. The Personal Property Receipt/Evidence tag found at the top of the tag is to be used for identifying valuables removed from victims. (Jewelry, wallets, watches, cash etc..).

15. Triage Tag Instructions, Cont. These items should be collected and placed in a smaller one-gallon clear plastic bag. The back of the Personal Property Receipt tag may be used to record property of unusual value. The property tag is than placed with the valuables and sealed.

16. Triage Tag Instructions, Cont. At this point both the clothing bag and the property bag are placed into a second large plastic bag and sealed using duct tape or other air tight measures. At this point the remainder of the tag is placed over the victims head and becomes identification for the victim and a claim ticket for personal property after the incident.

17. Triage Tag Instructions, Cont. The Gross Decon and Secondary Decon check boxes are to be used after victims have undergone Decontamination procedures. The Solution used during decontamination will be recorded on the tag. It should be noted that no patient should be allowed to leave the exclusion zone without undergoing decontamination procedures.

18. Triage Tag Instructions, Cont. Once contamination has been ruled out or decon procedures completed, the next step will be to follow START triage guidelines. On the back of the tag the R.P.M. pneumonic will be used while referring to the flow chart located directly above. Once the patients have been categorized they are ready to be moved to the treatment area.

19. Triage Tag Instructions, Cont. The front of the tag is than used to record injuries and their anatomical locations, as well as vital signs and medications. (Atropine, 2-Pam, 1V solutions etc..)

20. Triage Tag Instructions, Cont. The second tear off tag from the top is to be used for recording patient destination. The tag may be removed just prior to the patient leaving the scene. Both the destination and how the patient was transported (ambulance number, helicopter, bus, etc.) shall be recorded on the tag.

21. Ok, now we know what triage is, and how to use the tags…. LET’S GET TO WORK!!!

22. How do we determine what color a patient gets? RPM Respirations? Perfusion? Mentation?

23. Respirations Is the patient breathing? !-If the patient is not breathing, open the airway and reassess. If the patient is still not breathing tag as expectant and move on. !- C-Spine control may have to be sacrificed in this situation. Do the best you can…as quickly as you can…

24. Respirations Assess the rate of respirations. !- If >30 or <8, tag as red and move on to the next patient. !- As the triage officer, you do not stop to ventilate the patient.

25. Respirations If the patient requires simple airway maintenance you will need to assign someone to this task. If no EMS personnel are available, remember that you have a pool of human resources in the green tag area. If no one there is available, you will need to improvise by placing something under the patient’s head/neck to keep the airway open. You may also consider placing a simple airway adjunct.

26. Perfusion Check for the presence of radial pulses. However, note that we are not concerned with a pulse rate at this time. If the patient has no radial pulses, he is critical and in immediate need of care. You apply a red tag to the patient and move on to the next patient.

27. Perfusion If there are no radial pulses, there is no need to check for carotid pulses !- If the patient is breathing, the heart is beating…if the radial pulses are absent, the BP is <80-90mmHG and requires attention from the treatment sector.

28. Perfusion Is there any immediately life threatening bleeding? !- Quickly address only life threatening bleeding. Use the cleanest dressing material available, and use green tagged patients to provide pressure.

29. Mentation (Mental Status) Unconscious patients, or patients that can not follow simple instructions require immediate attention from the treatment sector. Tag these patients with a red tag and move on. Patients that can follow instructions may be tagged yellow.

30. Putting it all together As soon as a patient meets any one of the criteria for triage as critical/immediate, you should apply a red tag, delegate someone to provide rapid treatment (e.g. maintain an airway or control bleeding), stop any further assessment and move on to the next victim.

31. Putting it all together Any patient who makes it through all three assessments, without any findings that would result in triaging as critical/immediate, is given a yellow tag.

32. Putting it all together No triage system is 100% fail safe. It is, however, reasonable to assume, that a patient who cannot walk, but is maintaining his own airway, breathing at a rate less than 30 breaths-per-minute, perfusing radial pulses, has no sign of uncontrolled bleeding and follows commands, is in need of medical attention at the hospital, but can wait until all of the critical/immediate (red tags) are removed from the scene.

33. Summary Anyone who gets up and walks to the designated area is given a green tag Anyone who is not breathing is given a black tag Anyone who fails one of the RPM assessments is given a red tag Anyone who cannot walk but passes all of the assessments is given a yellow tag

34. A note about MCIs Mass Casualty Incidents are stressful events, that are often overwhelming. As an emergency medical care provider, your are encouraged to seek CISD after event. As an Incident Commander, you are encouraged to hold after action debriefings, and make CISD resources available.