Prehospital Considerations

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Prehospital Considerations
Triage and EMS
PDLS
Version 2
Gretchen K. Lipke, MD FACEP
Objectives
• To compare START and JumpSTART triage
systems
• 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
Triage
• “to sort” or place in order
• Guides decisions about allocating scarce
resources and limited time
• “greatest good for greatest number”
• Protocol helps makes decisions
• ICS separates triage from treatment
immediately: see everybody once briefly
for focus
START
• Most commonly used triage system across
country
• Not applicable for under 8 years old
• Initial eval –not final
• Time limited (plan 1 min/patient)
• Categorize and move on
• 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.
• 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
• Resp: no => position airway = still no
=>Black/ yes => RED (immediate).
• Spont resp >30 => RED/ under 30 =>
next item of assessment
START
• Perfusion: cap refill > 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 < 2 sec and
spont resp < 30) => 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.
• 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 15-40 instead of <30
• Vascular system clamps down sooner, so
cap refill less reliable. Use peripheral pulse
instead.
• Mental status AV/PU instead of follow/not
• This needs to be the JUMPSTART flow
page
JumpSTART
• “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.
• Assess non-ambulatory patients as you
find them using RPM.
JumpSTART
• Respirations: NO  open airway => yes
RED; no -> check peripheral pulse.
• NO pulse = BLACK
• Pulse  15 sec mask to mouth ventilation
• Spont resp: NO  BLACK; YES  RED
JumpSTART
• Breathing: RR <15, >40 or irregular =RED
• RR 15-40, regular – check pulse
• No peripheral pulse: RED
• Peripheral pulse: check mental status
• AV (appropriate) YELLOW
• PU (inappropriate) RED
Kids in triage
• Don’t follow commands.
• May actually hide from rescuers in full
gear (spaceman look).
• May be extricated by GREEN parents/
adults with delay in triage and treatment.
• 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.
• 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
• Limited initial treatment – don’t delay
evacuation if vehicle available
• 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
Treatment
• Kids will be mixed in – do you have
enough supplies in kid size (oxygen, IVs,
splints)?
• Does your locality stock a “disaster truck”?
• Does it have kid size equipment and kid
sized doses of Hazmat antidotes?
• Do you have Broselow tapes to guide
dosing?
Treatment - airway
• Non breathing adult: BLACK (after airway
maneuver)
• Non breathing child (with pulse): rescue
breaths, then if no response, 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.
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?
• 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
• Pressure dressing for active bleeding
– Recruit neighbor to help hold pressure during
triage while awaiting transport/evacuation
• Splint – extremity injuries
Treatment
• 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)
Further field care
• Depends on local plans
• 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)
ICS
• 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
NDMS
• 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
• In practice: Hospitals, supplies available,
easier to bring caregivers in (DMAT teams)
NDMS
• Victims in home environment, allows
visitors, social support, easier transition
home.
• 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
NDMS
• Federal support: license good in every
state, malpractice covered, insurance
covered (disability, death)
• Team transport, housing, food
DMAT teams
• 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.
• 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”
• Care for victims, rescuers, caregivers, site
workers, bystanders
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