Prehospital ConsiderationsPrehospital ConsiderationsTriage and EMSTriage and EMS

PDLSPDLS

Version 2Version 2

Gretchen K. Lipke, MD FACEPGretchen K. Lipke, MD FACEP

ObjectivesObjectives

• To compare START and JumpSTART To compare START and JumpSTART triage systems triage systems

• To review EMS consideration in To review EMS consideration in disaster situations and the unique disaster situations and the unique needs of childrenneeds of children

• To review the NDMS/DMAT concept To review the NDMS/DMAT concept as a channel for federal assistanceas a channel for federal assistance

TriageTriage

• ““to sort” or place in orderto sort” or place in order• Guides decisions about allocating Guides decisions about allocating

scarce resources and limited timescarce resources and limited time• ““greatest good for greatest number”greatest good for greatest number”• Protocol helps makes decisionsProtocol helps makes decisions• ICS separates triage from treatment ICS separates triage from treatment

immediately: see everybody once immediately: see everybody once briefly for focusbriefly for focus

STARTSTART

• Most commonly used triage system Most commonly used triage system across countryacross country

• Not applicable for under 8 years oldNot applicable for under 8 years old

• Initial eval –not finalInitial eval –not final

• Time limited (plan 1 min/patient)Time limited (plan 1 min/patient)

• Categorize and move onCategorize and move on

• This needs to be the START flow This needs to be the START flow sheetsheet

STARTSTART

• ““If you can hear me and are able, walk If you can hear me and are able, walk over here” GREEN triage done – still over here” GREEN triage done – still need individual evaluation, but can need individual evaluation, but can await more staff, allows initial rescuers await more staff, allows initial rescuers to focus on more severely injured to focus on more severely injured people.people.

• Gen 80% of victims will be green, self Gen 80% of victims will be green, self extricate (may self transport – eases extricate (may self transport – eases burden on field but hard on hospitals)burden on field but hard on hospitals)

STARTSTART

• EVAL (and tag) those unable to walk EVAL (and tag) those unable to walk for transport: RPMfor transport: RPM

• Resp: no => position airway = still Resp: no => position airway = still no =>Black/ yes => RED no =>Black/ yes => RED (immediate). (immediate).

• Spont resp >30 => RED/ under 30 Spont resp >30 => RED/ under 30 => next item of assessment=> next item of assessment

STARTSTART

• Perfusion: cap refill > 2 sec => Perfusion: cap refill > 2 sec => control bleeding, label RED; <2 sec, control bleeding, label RED; <2 sec, next itemnext item

• Mental status: Cannot follow simple Mental status: Cannot follow simple commands => RED; CAN follow commands => RED; CAN follow simple commands (and has cap refill simple commands (and has cap refill < 2 sec and spont resp < 30) => < 2 sec and spont resp < 30) => YELLOW (delayed)YELLOW (delayed)

STARTSTART

• As soon as one can categorize a patient, As soon as one can categorize a patient, STOP evaluating (if they are RED for STOP evaluating (if they are RED for breathing, they won’t be seen any faster breathing, they won’t be seen any faster for additional problems) and move on.for additional problems) and move on.

• Minimal treatment during triage: airway Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).dress active blood loss (not scrapes).

JumpSTART (under 8)JumpSTART (under 8)

• Kids more airway dependent – rescue Kids more airway dependent – rescue breaths attempted if pulse present breaths attempted if pulse present (unlike adults) Resp 15-40 instead of <30(unlike adults) Resp 15-40 instead of <30

• Vascular system clamps down sooner, so Vascular system clamps down sooner, so cap refill less reliable. Use peripheral cap refill less reliable. Use peripheral pulse instead.pulse instead.

• Mental status AV/PU instead of follow/notMental status AV/PU instead of follow/not

• This needs to be the JUMPSTART flow This needs to be the JUMPSTART flow pagepage

JumpSTARTJumpSTART

• ““If you can hear me and you are If you can hear me and you are able, walk over here for help.” able, walk over here for help.”

• GREENs are done. Screen GREEN GREENs are done. Screen GREEN adults for RED/YELLOW kids carried adults for RED/YELLOW kids carried out.out.

• Assess non-ambulatory patients as Assess non-ambulatory patients as you find them using RPM.you find them using RPM.

JumpSTARTJumpSTART

• Respirations: NO Respirations: NO open airway => open airway => yes yes RED; no -> check peripheral RED; no -> check peripheral pulse.pulse.

• NO pulse = BLACKNO pulse = BLACK

• Pulse Pulse 15 sec mask to mouth 15 sec mask to mouth ventilationventilation

• Spont resp: NO Spont resp: NO BLACK; YES BLACK; YES RED RED

JumpSTARTJumpSTART

• Breathing: RR <15, >40 or irregular Breathing: RR <15, >40 or irregular =RED=RED

• RR 15-40, regular – check pulseRR 15-40, regular – check pulse

• No peripheral pulse: REDNo peripheral pulse: RED

• Peripheral pulse: check mental statusPeripheral pulse: check mental status

• AV (appropriate) YELLOWAV (appropriate) YELLOW

• PU (inappropriate) REDPU (inappropriate) RED

Kids in triageKids in triage

• Don’t follow commands.Don’t follow commands.

• May actually hide from rescuers in full May actually hide from rescuers in full gear (spaceman look).gear (spaceman look).

• May be extricated by GREEN parents/ May be extricated by GREEN parents/ adults with delay in triage and treatment.adults with delay in triage and treatment.

• Need distraction and dedicated supervisor Need distraction and dedicated supervisor able to run after wandering toddlersable to run after wandering toddlers

ICS (Incident Command ICS (Incident Command System)System)

• Senior on scene: command – assess Senior on scene: command – assess need for further resources and direct need for further resources and direct incoming resources to where needed. incoming resources to where needed. This starts with first to arrive.This starts with first to arrive.

• Triage: initial fast assessment in Triage: initial fast assessment in place of every patient, sort for place of every patient, sort for evacuation and first in line for care evacuation and first in line for care when additional resources arrivewhen additional resources arrive

ICSICS

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

TreatmentTreatment

• Limited initial treatment – don’t delay Limited initial treatment – don’t delay evacuation if vehicle availableevacuation if vehicle available

• Oxygen, dressings, splintsOxygen, dressings, splints• Airway management? Remember, no Airway management? Remember, no

intubations during triage, and no intubations during triage, and no codes during mass casualty event, codes during mass casualty event, unless sufficient personnel and unless sufficient personnel and equipment that no other care is equipment that no other care is delayeddelayed

TreatmentTreatment

• Kids will be mixed in – do you have Kids will be mixed in – do you have enough supplies in kid size (oxygen, enough supplies in kid size (oxygen, IVs, splints)?IVs, splints)?

• Does your locality stock a “disaster Does your locality stock a “disaster truck”?truck”?

• Does it have kid size equipment and Does it have kid size equipment and kid sized doses of Hazmat antidotes?kid sized doses of Hazmat antidotes?

• Do you have Broselow tapes to guide Do you have Broselow tapes to guide dosing?dosing?

Treatment - airwayTreatment - airway

• Non breathing adult: BLACK (after airway Non breathing adult: BLACK (after airway maneuver)maneuver)

• Non breathing child (with pulse): rescue Non breathing child (with pulse): rescue breaths, then if no response, BLACKbreaths, then if no response, BLACK

• Non breathing child without pulse: BLACKNon breathing child without pulse: BLACK• Oxygen: how administered? Do you have Oxygen: how administered? Do you have

octopus adaptors to set more than one octopus adaptors to set more than one NRBM off each nozzle? REDs first.NRBM off each nozzle? REDs first.

TreatmentTreatment

• IV fluids? Depends on numbers: does IV fluids? Depends on numbers: does everyone need an IV? Are there enough everyone need an IV? Are there enough IV kits to give everyone an IV? Use IV kits to give everyone an IV? Use triage to guide => treat REDs first, triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV?then YELLOWs. Do GREENs need IV?

• BLACK/expectant: pain control (if drugs BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygenavailable) NO IV fluids, NO oxygen

Treatment:Treatment:

• Dressings – rinse gross dirt with sterile Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile fluids or tap water if available, sterile cover to prevent further contaminationcover to prevent further contamination

• Pressure dressing for active bleedingPressure dressing for active bleeding– Recruit neighbor to help hold pressure Recruit neighbor to help hold pressure

during triage while awaiting during triage while awaiting transport/evacuationtransport/evacuation

• Splint – extremity injuriesSplint – extremity injuries

TreatmentTreatment

• Medications: pain control, specific Medications: pain control, specific antidotes with Hazmat event/teamantidotes with Hazmat event/team

• Monitoring: repeat assessment after Monitoring: repeat assessment after triage, re-categorize if necessary (to triage, re-categorize if necessary (to worse, never better – even if they worse, never better – even if they respond to treatment, they have the respond to treatment, they have the same underlying injury)same underlying injury)

Further field careFurther field care

• Depends on local plansDepends on local plans

• Send personnel and supplies to site, Send personnel and supplies to site, or bring patients to hospital or bring patients to hospital (personnel and supplies)(personnel and supplies)– EMS –patient to hospitalEMS –patient to hospital– NDMS – personnel and supplies to siteNDMS – personnel and supplies to site

ICSICS

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

ICSICS

• Scene control: limit access for Scene control: limit access for civilians, media cameras, also civilians, media cameras, also maintain in/out routes for vehicles maintain in/out routes for vehicles which do need entry.which do need entry.

• Communications: notify hospitals Communications: notify hospitals rough numbers, kinds of injuriesrough numbers, kinds of injuries

NDMS NDMS

• Federal level aid, formerly HHS, now Federal level aid, formerly HHS, now under Homeland Securityunder Homeland Security

• Initial premise: damage to city/area Initial premise: damage to city/area overwhelming local hospitals, overwhelming local hospitals, transport patients to hospitals in transport patients to hospitals in region/nationregion/nation

• In practice: Hospitals, supplies In practice: Hospitals, supplies available, easier to bring caregivers available, easier to bring caregivers in (DMAT teams)in (DMAT teams)

NDMSNDMS

• Victims in home environment, allows Victims in home environment, allows visitors, social support, easier visitors, social support, easier transition home.transition home.

• Caregivers away from their usual Caregivers away from their usual responsibilities, can focus on victims.responsibilities, can focus on victims.

• Volunteers, credentials established Volunteers, credentials established ahead of time, teams practice ahead of time, teams practice together, used to working together. together, used to working together. Call rotates 3-4/yr/teamCall rotates 3-4/yr/team

NDMSNDMS

• Federal support: license good in Federal support: license good in every state, malpractice covered, every state, malpractice covered, insurance covered (disability, death)insurance covered (disability, death)

• Team transport, housing, foodTeam transport, housing, food

DMAT teamsDMAT teams

• Staff: MD/RN/EMT-P/ RT/ pharmacy/ Staff: MD/RN/EMT-P/ RT/ pharmacy/ administration/ communications/ logisticsadministration/ communications/ logistics

• Stocked and supplied to be self-sufficient Stocked and supplied to be self-sufficient for 3 days, then back fill and restock for 3 days, then back fill and restock should be available.should be available.

• Theory: set up from scratch with hospital Theory: set up from scratch with hospital tent; in practice, any building can be tent; in practice, any building can be adopted; running water and electric adopted; running water and electric bonusbonus

DMATDMAT

• Label recognition: people do best Label recognition: people do best what they do all the time. Assign what they do all the time. Assign usual roles, label building parts in usual roles, label building parts in familiar fashion “ED”, “Asthma familiar fashion “ED”, “Asthma ward”, “rehydration”ward”, “rehydration”

• Care for victims, rescuers, Care for victims, rescuers, caregivers, site workers, bystanderscaregivers, site workers, bystanders