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CERT Triage & Mass Casualty Incidents Optional Unit

CERT Triage & Mass Casualty Incidents

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Page 1: CERT Triage & Mass Casualty Incidents

CERT Triage & Mass

Casualty Incidents

Optional Unit

Page 2: CERT Triage & Mass Casualty Incidents

2

Contents

Disaster Medical Operations – Triage and Mass Casualty Incidents 3 Good Samaritan Law Basics ........ 3

What Is Triage? .................................... 4 Phases of Death ........................... 4

Simple Triage and Rapid Treatment - START 5 CERT Size Up for Medical Operations . 6

Personal Protective Equipment .... 6

Obviously Deceased Found in Search & Rescue 6

HazMat/Terrorist Events? ............. 7 Approaching the Injured ............... 7

Review of Life-Threatening Conditions . 8 OPENING A BLOCKED AIRWAY 8

Head-Tilt/Chin-Lift Method for Opening an Airway 9 Jaw Thrust Maneuver for Opening an Airway 9

Maintaining an Open Airway ....... 10 Triage Flow Chart – Step 1: Airway10

CONTROLLING EXCESSIVE BLEEDING 11

Bleeding Control - Direct Pressure11 Bleeding Control - Tourniquet ..... 12

Triage Flow Chart – Step 2: Bleeding 13

TREATING FOR SHOCK ........... 13 Capillary Refill – Blanch Test ...... 14

Shock & Mental Status ............... 14

Triage Flow Chart – Step 3: Mental Status 15 How to Conduct Triage ....................... 16

Performing a Triage Evaluation – “30 -2-CAN DO” 17

Triage in a Disaster Environment 18

Triage Pitfalls .............................. 19 Documentation Form Sample ..... 20

Review ............................................... 21 Triage Flow Chart ....................... 21

Notes: ................................................. 22

Page 3: CERT Triage & Mass Casualty Incidents

3

Disaster Medical Operations – Triage and Mass Casualty Incidents

Mass casualty incidents of widespread nature may limit the ability of professional responders to help everyone. CERT volunteers can support their neighborhood, workplace, or school by learning and practicing what to do in a mass casualty incident. CERT Units 3 and 4 covered disaster medical skills that address life-threatening conditions such as airway blockage, uncontrolled bleeding, low body temperature, and shock.

This module will cover the advanced skills of Triage. Identifying and addressing the most critically injured in a mass casualty incident will save lives.

In CERT Unit 4, you learned what professional responders would do in a mass casualty event. If there is a delay in professional responders to the incident, CERT volunteers can help by recognizing and responding using the skills of Triage.

CERT volunteers can identify the most critically injured, provide immediate medical aid, and organize medical treatment areas to support their community, workplace, or school until professional responders arrive.

This module will cover the use of START, which stands for Simple Triage and Rapid Treatment. START is a critical concept for initially dealing with casualties in a disaster. Historic research shows that around 40% of disaster survivors can be saved with simple rapid medical care. Moreover, this care usually comes from bystanders—especially when there is a catastrophic emergency where many people are injured, and professional response is delayed.

Good Samaritan Law Basics 1. DO NOT practice outside the scope of your training

2. Once you start any medical assistance, DO NOT stop unless absolutely necessary to assist others or you become a survivor yourself

3. Accept NO compensation of any kind

4. Act in good faith; no gross negligence

Page 4: CERT Triage & Mass Casualty Incidents

4

What Is Triage?

Triage is a French term meaning, “to sort.”

During medical triage, the injured are evaluated, sorted by the urgency of the treatment needed, and set up for immediate, delayed or minor treatment.

Triage was initiated by the military and that experience has shown that triage is an effective strategy in situations where:

There are many more injured persons than rescuers

There are limited resources

Time is critical

Triage occurs as quickly as possible after survivors are located or rescued. Triage may be done as part of Search & Rescue or if CERT has set up a medical treatment area and injured persons are arriving.

Phases of Death It is important to understand that death from trauma occurs in one or more of the following ways:

1. Death within minutes as a result of excessive, uncontrolled bleeding 2. Death within several hours as a result of severe trauma and damage to vital organs 3. Death in several days or weeks as a result of infection or multiple-organ failure such as

complications from injury.

Understanding these phases will allow you to identify the most serious injuries as soon as possible and treat those with life-threatening injuries first.

The possibility of saving survivors of severe trauma from uncontrolled bleeding or infection and multiple-organ failure is possible through prompt, simple medical care.

Page 5: CERT Triage & Mass Casualty Incidents

5

Simple Triage and Rapid Treatment - START

Simple Triage and Rapid Treatment (START) is a critical concept for initially dealing with casualties in a disaster. Professional responders recognize START as a tried and true process to quickly identify the most critically injured when time and resources are limited.

START is based on the premise that a simple medical assessment and rapid treatment of critical injuries uncovered by that assessment will yield positive and often lifesaving results. Triage can help organize a chaotic incident or emergency by bringing organization to the situation.

Triage is used when there are more injured than rescuers. The first phase of START, S T, or Simple Triage is the process by which the injured (survivors) are sorted based on severity of injury using validated criteria.

The second phase, ART—or And Rapid Treatment—consists of rapid treatment of injuries that pose an immediate threat to life (airway, uncontrolled bleeding and shock). Rapid treatment is not first aid (splinting and bandaging), it is the immediate response to help an injured person in immediate danger of dying.

The classification (sorting) in the simple triage phase also facilitates orderly transfer of injured persons to medical care after the initial triage process is complete and helps ensure that the most seriously injured receive care before those with minor injuries.

All CERT participants are encouraged to learn basic first aid and CPR training. CERT training covers disaster medical operations where time is critical to treat the injured and—if supported in their community—conducting triage.

CPR is not taught in this course, as it is labor intensive and inappropriate when there are many injured and professional help would be delayed, but you are encouraged to take it from organizations that offer the training, such as American Red Cross and American Heart Association.

CERT volunteers are encouraged to recognize assistance from others in the event of an emergency. CERT-trained volunteers can give clear instructions if help is needed. Bystanders can help with CPR, bleeding control or locating resources/equipment requests to help in a catastrophic emergency. Remember that CERT is a force multiplier for professional responders. Utilize additional bystander help as needed!

Page 6: CERT Triage & Mass Casualty Incidents

6

CERT Size Up for Medical Operations

Review the following steps to properly assess a situation. Keep in mind that assessing is a continual process that never stops.

• Gather Facts • Assess Damage • Consider Probabilities • Assess Your Situation • Establish Priorities • Make Decisions • Develop Plan of Action • Take Action • Evaluate Progress

CERT volunteers should apply START concepts in the event there is a delay of professional responders due to the emergency event.

Personal Protective Equipment Rescuers must first ensure that they have and use proper safety equipment such as a helmet, goggles, gloves, N95 mask, sturdy shoes or boots, and non-latex exam gloves before treating an injured person.

Non-latex exam gloves are necessary to prevent a reaction from survivors who may be allergic to latex. CERT volunteers should have multiple sets of gloves to ensure personal safety for everyone.

If rescuers run out of gloves, gloves may be sterilized between treating survivors by doing the following:

• Remove obvious soil from the gloves, preferably by washing with soap and water • Mix a solution of 1-part unscented bleach (preferably less than a year old) to 10-parts water • With the gloves still on, swish gloves in the solution for at least 6 seconds

Practice removing non-latex gloves in a safe manner to prevent self-contamination.

Obviously Deceased Found in Search & Rescue There may be situations where CERT encounters someone who is “obviously” deceased. This information should be documented and if possible, reported immediately. The area should be secured, and the deceased left at the location for the authorities to recover.

Page 7: CERT Triage & Mass Casualty Incidents

7

Deceased persons are not removed unless verbal permission is granted by a professional responder due to emerging circumstances i.e., fire, rising water, or animal activity in the area. This is a discussion point to have with the local CERT sponsoring agency.

HazMat/Terrorist Events? If hazmat or terrorist event is suspected, CERT volunteers DO NOT respond. CERT rescuer safety IS PARAMOUNT.

CERT volunteers should leave the scene to avoid harm to themselves and to reduce the risk of spreading the contamination.

Approaching the Injured Take the following steps when approaching a survivor:

1. If the survivor is conscious, make sure they can see you. 2. Identify yourself by giving your name and indicating the organization with which you are

affiliated. Work with a partner or buddy to make sure information is documented. 3. ALWAYS request permission to treat an individual. If the individual is unconscious, they are

assumed to have given “implied consent,” and you may treat them. Ask a parent or guardian for permission to treat a child, if possible.

4. Whenever possible, respect cultural and gender differences. Consider gender matching the injured person or ask if they are comfortable with your assistance. If a family member is nearby, CERT volunteers can ask the family member to assist too.

5. Remember: all medical patients are legally entitled to confidentiality. When dealing with survivors, always be mindful and respectful of the privacy of their medical condition.

Address conditions as you find them. If the person is bleeding profusely, address this condition and check the other life-threatening conditions.

Page 8: CERT Triage & Mass Casualty Incidents

8

Lung

Bronchus

Larynx(voice box)

Pharynx(throat)

Nasal AirPassage

Trachea(wind pipe)

Lung

Bronchus

Larynx(voice box)

Pharynx(throat)

Nasal AirPassage

Trachea(wind pipe)

Review of Life-Threatening Conditions

Components of a respiratory system:

• Lung • Bronchus • Larynx • Pharynx • Nasal Air Passage • Trachea

Understand that the respiratory system includes the lungs, bronchus, larynx, pharynx, nasal cavity, and trachea.

OPENING A BLOCKED AIRWAY The most common airway obstruction is the tongue. When a survivor is unconscious or semiconscious state, especially one positioned on his or her back. The tongue, which is a muscle, may relax and block the airway.

A survivor with a suspected airway obstruction must be checked immediately for breathing and, if necessary, the airway must be opened.

There are different ways to position a patient to keep their airway open, depending on whether they are conscious or unconscious. Some of these methods include the head-tilt, chin-left, jaw-thrust maneuver and the recovery position

The best position for the body is one that allows the chest to expand fully while making sure the airway is not at risk of being obstructed.

In other words, the best position is one in which the tongue cannot flop back into the individual’s throat and one in which blood or fluid does not end up in the lungs (aspirated), particularly in the case with someone with facial trauma.

Tongue

Unconscious

Obstructed Airway

Tongue

Unconscious

Obstructed Airway

Page 9: CERT Triage & Mass Casualty Incidents

9

Head-Tilt/Chin-Lift Method for Opening an Airway In Triage, life-threatening conditions must be addressed. If there are no professional responders on scene or they are delayed, CERT volunteers may need to take the next step in conducting a Head-Tilt Chin-Lift maneuver to open a blocked airway or if head, neck or spinal injuries are suspected the Jaw-Thrust maneuver. The airway must be kept open or breathing may become blocked again.

Step Action

1 At an arm’s distance, shake the survivor by touching the shoulder and shout, “Can you hear me?”

2 If the survivor does not or cannot respond, place the palm of one hand on the forehead.

3 Place two fingers of the other hand under the chin and tilt the jaw upward while tilting the head back slightly.

4 Place your ear over the survivor’s mouth, looking toward the survivor’s feet, and place a hand on the survivor’s abdomen.

5 Look for chest rise. 6 Listen for air exchange. 7 Feel for abdominal movement.

CERT teams must look to bystanders to assist in this effort (if safe to do so). There may be situations where objects must be placed behind the shoulders to keep the head back and the airway open so that rescuers can help others.

Jaw Thrust Maneuver for Opening an Airway If a patient is unconscious and not breathing and you suspect there is a spinal injury, you may be able to clear the airway using the jaw-thrust maneuver. The tongue may be the cause of the individual not breathing, and the jaw-thrust maneuver may move the tongue without moving the spine. This skill was discussed in CERT Unit 3.

Step Action

1 Put one hand on each side of the patient’s head with your thumbs near the corners of their mouth pointed toward their chin, using your elbows for support.

2 Slide your fingers into position under the angles of the patient’s jawbone without moving their head or neck.

Page 10: CERT Triage & Mass Casualty Incidents

10

Step Action

3 Thrust the jaw upward without moving the head or neck, to lift the jaw and open the airway.

Maintaining an Open Airway In a disaster environment, the CERT mission is to do the greatest good for the greatest number of people. For that reason, if breathing is not restored on the first try using of the airway opening methods, CERT volunteers should try again using the same method.

If breathing cannot be restored on the second try, CERT volunteers must move on to the next injured person. If breathing has been restored, the airway still must be maintained. One option is to use a volunteer or the “walking wounded” to hold the head in place so that the rescuer may help others.

The airway also can be maintained by placing soft objects (survivor’s shoes, blankets, jackets, etc.) under the survivor’s shoulders to elevate the shoulders slightly and keep the airway open. If conditions warrant, use someone who is not injured to help keep the airway open.

Triage Flow Chart – Step 1: Airway

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Assess & Position Airway/Check Breathing

NoNo

Reposition Airway

Reposition Airway

NoNo

DeadDead

YesYesNow Breathing?

If Breathing, The Check The RateIf Breathing, The Check The Rate

30 Per. Min

30 Per. Min

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

Check Circulation &

Control Bleeding

“I” Treat For

Shock

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Circulation & Control Bleeding

Perform the Blanch TestPerform the Blanch Test

2 Seconds

2 Seconds

2 Seconds

“I” Treat For

Shock

“I” Treat For

Shock

Check Mental Status

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Check Mental StatusCheck Mental Status

“I” Treat For

Shock

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than= More Than = Less Than

Page 11: CERT Triage & Mass Casualty Incidents

11

CONTROLLING EXCESSIVE BLEEDING Uncontrolled bleeding initially causes weakness. If bleeding is not controlled, the survivor will go into shock within a short period of time, and finally will die. An adult has about five liters of blood. Losing one liter can result in death.

There are three types of bleeding and the type can usually be identified by how fast the blood flows:

• Arterial bleeding. Arteries transport blood under high pressure. Bleeding from an artery is spurting bleeding.

• Venous bleeding. Veins transport blood under low pressure. Bleeding from a vein is flowing bleeding.

• Capillary bleeding. Capillaries also carry blood under low pressure. Bleeding from capillaries is oozing bleeding.

There are two main methods for controlling bleeding:

• Direct pressure • Tourniquet

Bleeding Control - Direct Pressure Direct pressure will stop 90% of most bleeding injuries.

Direct pressure can take 5 to 7 minutes to stop the bleeding completely. The use of a dressing and pressure bandage allows the rescuer to move on to the next survivor. A pressure bandage should be tied with a bow, so that it can be loosened—rather than cut—to examine the wound, and then retied. This procedure helps to conserve supplies and saves time.

Step Action

1 Find the source(s) of bleeding. 2 Use your non-latex exam gloves. 3 Apply firm, steady pressure directly on the source of the bleeding. Press hard to stop

or slow bleeding even if it is painful to the injured! 4 Tie a pressure bandage over the dressing to maintain pressure on the dressing over

the wound. Tie the end of the bandage into a bow so that it can be loosened easily without being cut to examine the wound and then re-tied.

Page 12: CERT Triage & Mass Casualty Incidents

12

Here are some considerations to keep in mind when applying direct pressure:

Try to provide a barrier against the blood, if possible. Non-latex exam gloves are best. Do not use the same gloves or barrier on more than one person. If your barrier becomes blood soaked, replace it. If possible, try not to remove the first layer of gauze (or material). This removal may interfere with clotting. Add another layer on top and continue pressure. Keep the layers from becoming too bulky and difficult to maintain the pressure. Bulky layers between your hands and the source of the wound will decrease the effectiveness of the pressure. If the bleeding comes through the second layer move to a tourniquet.

Correctly, applied pressure will not be comfortable for the injured. Do not let up; hold pressure until help arrives or bleeding has stopped or slowed to a minimal amount. A bystander or survivor him/herself can maintain pressure, allowing the triage rescuer to move on to help others.

CERT volunteers continue to assess the survivor’s status, document actions, and then quickly move on to the next survivor. CERT volunteers continue to assess the survivor’s status.

Bleeding Control - Tourniquet A tourniquet is a tight bandage, which, when placed around a limb and tightened, cuts off the blood supply to the part of the limb beyond it. Tourniquets have been used effectively in combat to control bleeding in a wounded soldier’s extremities (arms or legs) and are increasingly being used by uniformed responders in civilian emergencies.

Tourniquets are safe and effective when applied appropriately; you are more likely to save a life than cause the loss of a limb if you use a tourniquet. If a commercial tourniquet is not readily available, you can try to create one yourself using something you can easily secure that is broad, flexible, and strong but not stretchy, such as a webbed belt, or luggage strap or use material that is at least two inches wide. The windlass or stick should be something very sturdy that is unlikely to break under pressure and able to be twisted, tightened, and secured.

Improvised tourniquets often fail, but you can attempt to use them as a last resort to at least slow the bleeding.

Step Action

1 Place the tourniquet at least two inches above (closer to the torso) than the wound. Do not place the tourniquet over a joint. You can place over clothing.

2 Pull the strap through the buckle.

3 Twist the rod tightly until bleeding stops or slows significantly. This will be very painful for the patient.

4 Secure the rod.

5 If bleeding does not stop, place a second tourniquet above the first, closer to the torso.

6 Mark the time the tourniquet was placed and if possible, on the victim’s forehead.

Page 13: CERT Triage & Mass Casualty Incidents

13

If possible, leave the tourniquet uncovered by such things as blankets. Only medical professional should loosen or remove a tourniquet.

Triage Flow Chart – Step 2: Bleeding

TREATING FOR SHOCK Shock is a life threatening condition that occurs when the body is not getting enough or effective blood flow. When blood does not circulate, oxygen and other nutrients are not carried to tissues and organs. Without sufficient blood flow, organs can stop functioning and death can result. Shock can happen quickly and its signs can be subtle.

The body will initially compensate for blood loss and mask the symptoms of shock. Therefore, it is important to continually evaluate patients for shock and monitor their condition. The main signs of shock are:

• Rapid and shallow breathing. • Capillary refill of greater than 2 seconds • Failure to follow simple commands, such as, “Squeeze my hand.” • Changes in skin color.

If there is a question about whether a survivor is in shock, treat for shock.

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Assess & Position Airway/Check Breathing

NoNo

Reposition Airway

Reposition Airway

NoNo

DeadDead

YesYesNow Breathing?

If Breathing, The Check The RateIf Breathing, The Check The Rate

30 Per. Min

30 Per. Min

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

Check Circulation &

Control Bleeding

“I” Treat For

Shock

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Circulation & Control Bleeding

Perform the Blanch TestPerform the Blanch Test

2 Seconds

2 Seconds

2 Seconds

“I” Treat For

Shock

“I” Treat For

Shock

Check Mental Status

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Check Mental StatusCheck Mental Status

“I” Treat For

Shock

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than= More Than = Less Than

Page 14: CERT Triage & Mass Casualty Incidents

14

Capillary Refill – Blanch Test Check for capillary refill by pushing on the finger at the base of the nailbed or on the fleshy fingertip until the normal color (pinkish) turns white and then release. Blood from the capillaries is pushed away by pressure. When pressure is released, the blood moves back in returning to a normal skin tone. Skin tone should return within two seconds signaling good circulation of blood. This is called the “blanch test.”

The blanch test is not valid in the case of a children, therefore mental status should be used as the main indicator for children.

Another way to check for circulation is the radial pulse test, which is an alternative to the blanch test and can be used in the dark or where it is cold.

Step Action

1 • Lay the survivor on his or her back. • Elevate the feet 6-10 inches above the level of the heart. • Maintain an open airway.

2 • Control obvious bleeding. 3 • Maintain body temperature (e.g., cover the ground and the survivor with a

blanket if necessary). 4 • Avoid rough or excessive handling unless the rescuer and survivor are in

immediate danger. • No food or drink.

Although survivors who are suffering from shock may be thirsty, they should not eat or drink anything, because they may also become nauseated.

Shock & Mental Status Another sign of shock is failure to follow simple commands, such as “squeeze my hand.” Evaluate mental status by asking: “Can you tell me your name or what happened and giving a simple command such as “squeeze my hand.”

If you are concerned that there might be a language barrier or hearing impairment, reach out with both hands and squeeze one of the survivor’s hands. The person will squeeze back if they can.

The body will initially compensate for blood loss and mask the symptoms of shock; therefore, shock is often difficult to diagnose. It is possible—and, in fact, common—for an individual suffering from shock to be fully coherent and not complaining of pain. Pay attention to subtle clues, as failure to recognize shock will have serious consequences.

Page 15: CERT Triage & Mass Casualty Incidents

15

Triage Flow Chart – Step 3: Mental Status

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Assess & Position Airway/Check Breathing

NoNo

Reposition Airway

Reposition Airway

NoNo

DeadDead

YesYesNow Breathing?

If Breathing, The Check The RateIf Breathing, The Check The Rate

30 Per. Min

30 Per. Min

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

Check Circulation &

Control Bleeding

“I” Treat For

Shock

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Circulation & Control Bleeding

Perform the Blanch TestPerform the Blanch Test

2 Seconds

2 Seconds

2 Seconds

“I” Treat For

Shock

“I” Treat For

Shock

Check Mental Status

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Check Mental StatusCheck Mental Status

“I” Treat For

Shock

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than= More Than = Less Than

Page 16: CERT Triage & Mass Casualty Incidents

16

How to Conduct Triage

In mass casualty events, rescuers:

• Identify the dead and those who are too severely injured to be saved • Send those with relatively minor injuries and wounds to a holding area to await treatment • Identify those who would die from life-threatening injuries and treat them immediately

Mass casualty incident actions steps will include

• Establish command and control of the incident area • Conduct size-up and set-up • Send survivors with relatively minor injuries to a hold area to await treatment • Identify survivors who will require life-saving intervention and treat them immediately • Identify deceased survivors as well as survivors too severely injured to save • Manage medical transportation for survivors who require additional treatment • Secure the area to protect responders, survivors, and evidence for law enforcement

investigations • Remove debris and other safety or health threats

During triage, survivors’ conditions are evaluated using criteria, prioritized, and labeled (tagged/marked) into four categories:

Category Label/Mark Condition

Immediate “I” color: RED

The survivor has life threatening (airway, uncontrolled bleeding, or shock) injuries that demand immediate attention to save his or her life; rapid, life-saving treatment is urgent.

Delayed “D” color: YELLOW

Injuries are not life threatening and do not jeopardize the survivor’s life. The survivor may require professional care, but treatment can be delayed.

Minor “M” color: GREEN

Injuries are superficial, requiring minor bandaging and observation. These survivors can walk, talk and help themselves. They may be able to assist rescuers with other survivors.

Deceased “DEAD” color: BLACK

No respiration after two attempts to open the airway or obviously deceased. The markings for DEAD or BLACK is never abbreviated to the letter D.

Consult with local protocols and policies regarding which label or mark is preferred by the local professional responders.

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Because CPR is one-on-one care and is labor-intensive, CPR is not performed when there are many more survivors than rescuers.

Triage can be conducted in both indoor and outdoor Search & Rescue environments. For structures with light and moderate damage, search for survivors, conduct triage and then rescue and transport survivors. DO NOT enter structures with heavy damage. Consider who needs help now, who can wait, and who can get out now without assistance and then focus on clearing a path, packaging the injured using lift & carry techniques, and transporting the injured to the medical treatment area.

Disaster medical operations require careful planning, teamwork, and practice. Community, campus and workplace programs should plan and organize resources and equipment to support medical operations. Prepare signage, tags/marking tools, and equipment before a disaster. Stored supplies must be updated and inventoried annually.

Performing a Triage Evaluation – “30 -2-CAN DO” Using the Triage method START – Simple Triage and Rapid Treatment – look, listen and feel for the RPM’S.

RPM stands for Respiration, Perfusion and Mental status. At an arm’s distance, shake the survivor and shout. If they do not respond, follow these steps:

Respirations – “30”

• Position the airway. • Look, listen, and feel. • Check breathing rate. Abnormally rapid respiration (above 30 per minute) indicates shock.

Treat for shock and tag “Immediate” • If below 30 per minute, then move to Step 2. • If the survivor is not breathing after 2 attempts to open airway, then tag “DEAD” Perfusion – “2”

• Visually check for obvious signs of bleeding. • Take immediate action to control severe bleeding. • Check circulation using the blanch test (for capillary refill). • Time how long it takes for normal color to return (under or over 2 seconds). • Treat for shock if normal color takes longer than 2 seconds to return, and tag “Immediate” • Move to the next step if perfusion is under 2 seconds. Mental Status – “Can/Can’t Do”

• Ask, if they know their name and what happened. • Give a simple command, such as “Squeeze my hand.” • Inability to respond indicates that immediate treatment for shock is necessary. Treat for shock

and tag “Immediate”

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If the survivor fails one test (“can’t do”), his or her status is “Immediate.” All survivors tagged “Immediate” get airway control, bleeding control, and treatment for shock.

Remember that everyone gets a tag. This supports accountability efforts when scenes are chaotic.

If the survivor passes all tests but cannot walk, talk and move without assistance, tag/mark the survivor “Delayed.”

If the survivor passes all tests, can walk, and talk without assistance his or her status is tagged/marked “Minor.”

In search and rescue, teams identify and mark the injured using the RPM criteria. The search & rescue/transport team takes the survivor to the designated medical treatment area (immediate care, delayed care, and minor care.) It is important to move all injured survivors marked RED/I/Immediate first.

Most agencies or jurisdictions do not advocate moving persons who are deceased. Local protocols and policies should be identified, reviewed, and followed when dealing with deceased persons in a disaster.

Label the medical treatment areas using “Immediate,” “Delayed,” “Minor” and “DEAD” and or use colored ground tarps associated with the four categories. The transport teams, walking wounded, or other volunteers can take the survivors to the appropriate treatment area.

The morgue area identified will be used for injured persons in the medical treatment area that succumb to their injuries.

Triage in a Disaster Environment The rescuer’s safety is paramount during triage. Wear proper protective equipment so as not to endanger your own safety and health.

The general procedures for conducting triage are:

Step 1: Stop, Look, Listen, and Think. Before you start, stop and size up the situation by looking around and listening. THINK about your safety, capability, and limitations, and decide if you will approach the situation and how.

Step 2: Conduct voice triage. Begin by calling out, “Emergency Response Team. If you can walk, come to the sound of my voice.” If there are survivors who are ambulatory, instruct them to remain at a designated location, and continue with the triage operation. (If rescuers need assistance and there are ambulatory survivors, then these survivors should be asked to provide assistance.) These persons may also provide useful information about the location of the survivors.

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Step 3: Start where you stand and follow a systematic route. Start with the closest survivors and work outward in a systematic fashion.

Step 4: Evaluate each survivor and tag or mark: Immediate, Delayed, Minor, or DEAD. Remember to evaluate and tag the walking wounded.

Step 5: Treat “Immediate” survivors immediately. Initiate airway management, bleeding control, and treatment for shock.

Step 6: Document triage results for:

• Effective deployment of resources. • Information on the survivors’ locations. • A quick record of the number of casualties by degree of severity.

Triage Pitfalls Time will be critical in a disaster and you may not be able to spend very much time with every injured survivor. The importance of doing the greatest good for the greatest number to help survivors is key for CERT. In order to respond effectively in a mass casualty event, CERT volunteers must have a plan based on a thorough size-up. CERT should follow that plan and document their actions. CERT Volunteers should take advantage of local exercises as a means of maintaining triage skills to help avoid the triage pitfalls. Triage pitfalls include:

• No team plan, organization, or goal • Indecisive leadership • Too much focus on one injury • Treatment (rather than triage) performed

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Documentation Form Sample Status as of (Date/Time)

Category Label Location A

Location B

Location C

Location D

Totals

Immediate “I” or red 1 2 0 1 4 Delayed “D” or

yellow 0 2 5 3 10

Minor “M” or green

10 11 7 15 43

Deceased “DEAD” or black

3 7 1 0 11

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Review

The procedure for conducting triage evaluations involves checking: • The airway and breathing rate – RESPIRATIONS - OVER or UNDER 30 per minute • Circulation and bleeding – PERFUSION – OVER or UNDER 2 SECONDS • Mental status – CAN or CANNOT FOLLOW SIMPLE COMMANDS • Remember the acronym - 30-2-Can Do

Triage is a skill that must be practiced often for retention. Teams should practice disaster medical skills and exercise various scenarios annually to stay current. Skills and knowledge should include:

• Identify life-threatening injuries. • Know how to apply Jaw-Thrust and/or the Head-Tilt/Chin-Lift method to open airway • Know how to control bleeding using direct pressure or a tourniquet • Know how to to treat shock for saving lives. • Understand how to conduct triage by evaluating survivor’s injuries and prioritizing treatment • Know the 6 steps of triage:

1. Stop, Look, Listen and Think, and make a quick plan. 2. Conduct voice triage. 3. Begin where you stand and work systematically. 4. Evaluate and tag all survivors 5. Treat those tagged “immediately” first. 6. Document your findings.

Triage Flow Chart

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Step 1

Assess & Position Airway/Check Breathing

No

Reposition Airway

No

Dead

YesNow Breathing?

If Breathing, The Check The Rate

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

“I” Treat For

Shock

Assess & Position Airway/Check Breathing

NoNo

Reposition Airway

Reposition Airway

NoNo

DeadDead

YesYesNow Breathing?

If Breathing, The Check The RateIf Breathing, The Check The Rate

30 Per. Min

30 Per. Min

30 Per. Min

30 Per. Min

Check Circulation &

Control Bleeding

Check Circulation &

Control Bleeding

“I” Treat For

Shock

“I” Treat For

Shock

Step 1

Check Circulation & Control Bleeding

Perform the Blanch Test

2 Seconds

2 Seconds

“I” Treat For

Shock

Check Mental Status

Step 2

Check Circulation & Control Bleeding

Perform the Blanch TestPerform the Blanch Test

2 Seconds

2 Seconds

2 Seconds

“I” Treat For

Shock

“I” Treat For

Shock

Check Mental Status

Check Mental Status

Step 2

Check Mental Status

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

Check Mental StatusCheck Mental Status

“I” Treat For

Shock

“I” Treat For

Shock

“D” Delayed

Step 3

Fails to Follow Simple

Commands

Follows Simple

Commands

= More Than = Less Than= More Than = Less Than

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Notes: