Welcome to Triage BECAUSE IT HAPPENS!. What Would You Do?

Welcome to TriageWelcome to TriageBECAUSE IT HAPPENS!BECAUSE IT HAPPENS!

What Would You Do?What Would You Do?

Are You Protected?Are You Protected?

Importance of ABC’sImportance of ABC’s

Keeps us all aliveKeeps us all alive Airway, breathing, circulationAirway, breathing, circulation Constant evaluation needed in any medical Constant evaluation needed in any medical

emergency situationemergency situation Your game plan as a rescuerYour game plan as a rescuer

Airway, Breathing, and Airway, Breathing, and CirculationCirculation

Concerning the A, B, C’sConcerning the A, B, C’s What do you know about some who is What do you know about some who is

talking?talking? Someone who is walking or standing?Someone who is walking or standing? Someone who is not responding?Someone who is not responding?

When “IT” HappensWhen “IT” Happens

First priority is rescuer’s safetyFirst priority is rescuer’s safety– Survey the sceneSurvey the scene– Personal protectionPersonal protection

Getting helpGetting help– 911911– Other peopleOther people

What is TriageWhat is Triage

French word “to sort”French word “to sort” Anymore than two victimsAnymore than two victims Overwhelms resources and people on scene Overwhelms resources and people on scene

STARTSTART System System

SSimple imple TTriage riage AAnd nd RRapid apid TTreatmentreatment Based on three important basic assessmentsBased on three important basic assessments

– RRespiratory Rate – How fastespiratory Rate – How fast– PPerfusion – Good radial pulse, or capillary refillerfusion – Good radial pulse, or capillary refill– MMental status – able to follow simple ental status – able to follow simple

commandscommands

RPMRPM

Patient Care Activities During Patient Care Activities During Initial AssessmentInitial Assessment

Open airwayOpen airway

Control profuse bleedingControl profuse bleeding

Treat for shockTreat for shock

Opening the AirwayOpening the Airway

BleedingBleeding

To control bleedingTo control bleeding

1.Direct pressure1.Direct pressure

2.Elevate above the heart2.Elevate above the heart

3.Pressure point3.Pressure point

Have patient , bystander, or Have patient , bystander, or walking wounded help with walking wounded help with direct pressuredirect pressure

Consider shock positionConsider shock position

(supine, legs elevated)(supine, legs elevated)

Capillary RefillCapillary Refill

Capillary refillCapillary refill

– Amount of time for a Amount of time for a compressed capillary compressed capillary bed to refill with bed to refill with bloodblood

Immediate PatientImmediate Patient

Respiratory Rate (how many times a minute do Respiratory Rate (how many times a minute do they breath)they breath)– Greater than 30 per minuteGreater than 30 per minute

Capillary Refill/PulseCapillary Refill/Pulse– Greater than 2 seconds or no radial pulseGreater than 2 seconds or no radial pulse

Altered Mental StatusAltered Mental Status– Unable to understand simple commandsUnable to understand simple commands

If any If any oneone criteria is met - the patient is criteria is met - the patient is classified classified

IMMEDIATEIMMEDIATE

Delayed PatientDelayed Patient

Patient is unable to walk Patient is unable to walk Respiratory RateRespiratory Rate

– Less than 30 per minuteLess than 30 per minute Capillary RefillCapillary Refill

– Less than 2 secondsLess than 2 seconds Mental StatusMental Status

– Able to understand simple commandsAble to understand simple commands

If the patient meets ALL of the criteria, the patient If the patient meets ALL of the criteria, the patient is classified as is classified as DELAYEDDELAYED

Minor Patient Minor Patient “Walking Wounded”“Walking Wounded”

Has a minor injury and is Has a minor injury and is able to walkable to walk from from the scene to the minor treatment areathe scene to the minor treatment area

Needs to be tagged but can wait a Needs to be tagged but can wait a significant amount of time to be treatedsignificant amount of time to be treated

If the patient meets the criteria and walks to If the patient meets the criteria and walks to the treatment area – classified as the treatment area – classified as MinorMinor

DeadDead

Non-breathing after the airway has been Non-breathing after the airway has been repositionedrepositioned

If the patient breathes spontaneously after If the patient breathes spontaneously after opening the airway, the patient is opening the airway, the patient is IMMEDIATEIMMEDIATE

Scenario ExamplesScenario Examples

35y/o female with 35y/o female with large laceration on large laceration on foreheadforehead– Respiratory = 25Respiratory = 25

– Blanch < 2 sec.Blanch < 2 sec.

– Follows commands and Follows commands and walks to treatment areawalks to treatment area

67y/o male with sub- 67y/o male with sub- sternal chest painsternal chest pain– Respiratory = 28Respiratory = 28

– Pulse is presentPulse is present

– Follows commands but Follows commands but remains seatedremains seated

MINORDELAYED

Scenario Examples

5y/o female with no 5y/o female with no sign of injurysign of injury– Respiratory = 0Respiratory = 0

– Blanch > 2 sec.Blanch > 2 sec.

– Fails to follow Fails to follow commandscommands

45y/o male with open 45y/o male with open fracture of the armfracture of the arm– Respiratory = 28Respiratory = 28



DEAD DELAYED

DELAYED


25y/o female 8 months 25y/o female 8 months pregnant and in active pregnant and in active labor.labor.– Respiratory = 28Respiratory = 28



18y/o male unable to move 18y/o male unable to move arms or legsarms or legs– Respiratory = 18Respiratory = 18


– Conscious and remains supineConscious and remains supine

DELAYED


15y/o female with 15y/o female with small laceration on small laceration on foreheadforehead– Respiratory = 35Respiratory = 35



57y/o male no sign of 57y/o male no sign of injuryinjury– Resp. = 18Resp. = 18


– Fails to follow Fails to follow commandscommands

IMMED.IMMED.


33y/o female with 33y/o female with severe back painsevere back pain– Respiratory = 25Respiratory = 25

– Blanch > 2 sec.Blanch > 2 sec.

– Follows commandsFollows commands

44y/o male broken left 44y/o male broken left forearmforearm– Respiratory = 0Respiratory = 0

– Blanch > 2 secBlanch > 2 sec

– UnconsciousUnconscious

IMMED.DEAD

Triage Steps ReviewTriage Steps Review

1) Protect yourself and use personal protective 1) Protect yourself and use personal protective equipmentequipment

2) Protect others from new injury2) Protect others from new injury3) Organize as the walking wounded remove 3) Organize as the walking wounded remove

themselves to a safe areathemselves to a safe area4) Assess everyone else with the RPM criteria4) Assess everyone else with the RPM criteria5) Treat and transport immediate patients first5) Treat and transport immediate patients first6) Revaluate, treat, and transport the delayed patients 6) Revaluate, treat, and transport the delayed patients

nextnext7) Revaluate, treat and transport the walking wounded7) Revaluate, treat and transport the walking wounded

Triage, Part 2Triage, Part 2

Multiple Casualty IncidentMultiple Casualty Incident

Low ImpactLow Impact

– – Manageable by local emergency Manageable by local emergency

personnelpersonnel

High Impact

– – Stresses local EMS, Fire, and Stresses local EMS, Fire, and

Police Police

Disaster, Terrorism IncidentDisaster, Terrorism Incident

– – Overwhelms regional Overwhelms regional

emergency response resourcesemergency response resources

Incident CommandIncident CommandSingular vs. UnifiedSingular vs. Unified

Singular commandSingular command

– – One person coordinatesOne person coordinates

––smaller, single-jurisdictional incidents.smaller, single-jurisdictional incidents.

Unified commandUnified command

– – Officers from different jurisdictions shareOfficers from different jurisdictions share

command.command.

• • Fire, EMS, Police, Public WorksFire, EMS, Police, Public Works

Low Impact Incident CommandLow Impact Incident Command

Incident Command

Police

EMS

SuppressionTriage Treatment Rescue/Extrication

Transport

FIRE* First arriving unit assumes command

* First arriving unit can delegate authority to another person

High Impact (Unified) CommandHigh Impact (Unified) CommandUnified Command

FIRE, EMS, Police, Public Works

Operations

EMS

Suppression

Triage Treatment

Rescue/Extrication

Transport

FIREPolicePublic Works

En route On site Staging Supply

Incident CommanderIncident Commander

First arriving unit First arriving unit Assumes command until authority delegated to anotherAssumes command until authority delegated to another Establish communicationsEstablish communications Request additional resourcesRequest additional resources Stabilize the incidentStabilize the incident Provide for life safety, accountability, and welfare of Provide for life safety, accountability, and welfare of

personnelpersonnel Ensure that all patients are extricated, triage/treated, Ensure that all patients are extricated, triage/treated,

and transported to medical facilitiesand transported to medical facilities

Triage UnitTriage Unit

• • Determine location of triage areasDetermine location of triage areas

• • Conduct primary triageConduct primary triage

• • Communicate resource requirementsCommunicate resource requirements

Review START TriageReview START Triage

** Initial Triage less ** Initial Triage less than 30 seconds per than 30 seconds per

patient patient

RPMsRPMs

R – Respiration: 30P - Perfusion: 2M- Mental status: CAN do

• When things get hectic with multiple patients rev up your RPM’s

PEDIATRIC TRIAGEPEDIATRIC TRIAGE

• • pediatric physiology differs from adults.pediatric physiology differs from adults.

• • w/o an objective system, emotions may influence w/o an objective system, emotions may influence the triage of children.the triage of children.

• • Kids have faster respiratory rates.Kids have faster respiratory rates.

• • Younger kids may not follow commands Younger kids may not follow commands normally.normally.

- Infants cannot walk- Infants cannot walk

- lack of understanding verbal commands- lack of understanding verbal commands

JumpSTARTJumpSTART

• • Used on children between 1 – 8 (large range)Used on children between 1 – 8 (large range)

• • 8 year olds, patients > 100 pounds 8 year olds, patients > 100 pounds use use STARTSTART

• • Infants < 1, use JumpSTARTInfants < 1, use JumpSTART

• • Usually not walking, if Usually not walking, if

able to be carried = able to be carried = MINORMINOR & &

first to be re-triage at first to be re-triage at

treatment area.treatment area.

Multiple Casualty Discussion Multiple Casualty Discussion ExerciseExercise

• • What resources do you have available to What resources do you have available to

respond?respond?

• • What are the priorities at this phase of the What are the priorities at this phase of the

response?response?

• • How will the services of theHow will the services of the

responding agencies andresponding agencies and

jurisdictions be coordinated?jurisdictions be coordinated?

• • What agency will assumeWhat agency will assume

Incident Command?Incident Command?

• • How will you deal with theHow will you deal with the

public?public?

Multiple Casualty DiscussionMultiple Casualty DiscussionExerciseExercise

7:497:49

Emergency dispatchers advise that multipleEmergency dispatchers advise that multiple

calls are coming in from witnesses who state there are calls are coming in from witnesses who state there are people everywhere.people everywhere.

7:547:54

Your unit is the first on scene. You see greatYour unit is the first on scene. You see great

devastation but there are survivors in the field.devastation but there are survivors in the field.

7:557:55

People are walking toward your unit.People are walking toward your unit.

What is your plan of action?

Multiple CasualtyMultiple CasualtyExerciseExercise

Your partner assumes Incident CommandYour partner assumes Incident Command

while you begin triage operations.while you begin triage operations.

Triage the next 7 patientsTriage the next 7 patients

Remember – RPM!Remember – RPM!

Patient states he can’tPatient states he can’tmove or feel his legsmove or feel his legs

Respirations are 26Respirations are 26

Pulse is 110 (Radial)Pulse is 110 (Radial)

He is awake and orientedHe is awake and oriented

What Triage Category?What Triage Category?

Group ExerciseGroup Exercise


Patient states he can’tPatient states he can’tmove or feel his legsmove or feel his legs



He is awake and orientedHe is awake and oriented

DelayedDelayed

Group ExerciseGroup ExercisePatient is soaked with bloodPatient is soaked with bloodno obvious killer bleedno obvious killer bleed


Pulse is weak, no radialPulse is weak, no radial

He is awake He is awake


Group ExerciseGroup ExercisePatient is soaked with bloodPatient is soaked with bloodno obvious heavy bleedingno obvious heavy bleeding


Pulse is weak, no radialPulse is weak, no radial

He is awakeHe is awake

IMMEDIATEIMMEDIATE


Patient walks over to you andPatient walks over to you andhas an obvious broken armhas an obvious broken arm



He is awake, alert, and cryingHe is awake, alert, and crying


Group ExerciseGroup ExercisePatient walks over to you andPatient walks over to you andhas an obvious broken armhas an obvious broken arm



He is awake, alert, and cryingHe is awake, alert, and crying

MinorMinor


Patient is face down in thePatient is face down in thefieldfield

Not BreathingNot Breathing

Weak Carotid PulseWeak Carotid Pulse

She is unresponsiveShe is unresponsive

What do you do first?What do you do first?


Patient is face down in thePatient is face down in thefieldfield

Not BreathingNot Breathing



Open The AirwayOpen The Airway

Group ExerciseGroup ExercisePatient gurgles but can’tPatient gurgles but can’tmaintain an open airwaymaintain an open airwayand is not breathing and is not breathing




Group ExerciseGroup ExercisePatient gurgles but can’tPatient gurgles but can’tmaintain an open airwaymaintain an open airwayand is not breathingand is not breathing



DEADDEAD


Patient is a 9-month old infantPatient is a 9-month old infantwith a 3 inch cut on his foreheadwith a 3 inch cut on his forehead

He is visibly upset, crying and He is visibly upset, crying and wind-milling his arms and wind-milling his arms and legslegs

What triage category?What triage category?

Group ExerciseGroup ExercisePatient is a 9-month old infantPatient is a 9-month old infantwith a 3 inch cut on his foreheadwith a 3 inch cut on his forehead

He is visibly upset, crying and wind-He is visibly upset, crying and wind-milling his arms and legsmilling his arms and legs

MinorMinor

Group ExerciseGroup ExercisePatient is 4 years oldPatient is 4 years old


Radial pulse is weakRadial pulse is weak


Group ExerciseGroup ExercisePatient is 4 years oldPatient is 4 years old


Radial pulse is weakRadial pulse is weak

IMMEDIATEIMMEDIATE

Group ExerciseGroup ExercisePatient has an open headPatient has an open headwound, bleeding controlledwound, bleeding controlled



He is unconsciousHe is unconscious


Group ExerciseGroup ExercisePatient has an open headPatient has an open headwound, bleeding controlledwound, bleeding controlled



He is unconsciousHe is unconscious

IMMEDIATEIMMEDIATE

More PracticeMore PracticeOn a cool autumn day a sudden freak storm has hit a small area of Portland including a park where several parents and children are playing. High winds blow down trees and rip the corner of a roof off a garage. For 3 minutes, golf ball-sized hail pelts down, damaging plants, breaking windows and injuring people.

Alerted by calls for help and children crying, you arrive at the park where you see several people wandering about in a dazed state, or sitting or lying on the ground.

The first person you encounter is a girl about 8 - 9 years old, on the ground near the teeter-totter, crying. Her arm is obviously broken. Between hiccuping sobs she tells you the wind blew her out of the swing and she crawled under the teeter-totter for protection from the hail.

What should you do first? Second? Third?

What should you do first? Second? Third?

Most people would immediately rush to the aid of the child in distress, it's human nature. However, you are trained to resist that urge. Instead, you stop and look for hazards first. Look for downed power lines, precariously balanced broken tree branches, teetering chimneys, rising waters, etc.

Next, try to get a handle on the entire incident, rather than blindly running from victim to victim. Without a search plan, a seriously wounded child could lie waiting for help for too long because you are busy treating someone else with minor cuts and scratches.

The third thing the rescuer needs to do is assess the resources available. This could include first aid supplies, rescue gear, willing bystanders and neighbors, etc. Coordinating these into the rescue plan will make it much more likely that ALL the victims are taken of.

Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!“

A woman from across the street runs up to you and says, "I've called 911. What shall I do now?”

Downed trees are blocking vehicular access to the park so you know the usual 3-min. emergency response time won't be met. How do you answer the woman?

"I've called 911. What shall I do now?"

Since the woman lives nearby, she has a lot to offer. The ambulatory wounded could find refuge from the weather in her home. She probably has vital supplies at her house. Towels, blankets, water, bleach, lifting and cutting tools, flashlights, food and water could prove extremely valuable.

Triage these victimsTriage these victims

Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!”

Who do you send to the woman’s house?

Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!”

Other people in the neighborhood, at his point, are coming out to see if there is anyway they Other people in the neighborhood, at his point, are coming out to see if there is anyway they can help.can help.

Who do you send to the woman’s house?


You approach the child the wind has deposited in the branches of a tree.

You remove him from the tree. He is not breathing, even after you attempt to open the airway. Radial pulse is absent.

What is his triage category?

DECEASED


As you head towards the woman with a bloody head, you notice she is not breathing. What do you do?

She takes in a breath, but cannot maintain open airway. What do you do?

What is her triage category?

Open Airway

Ask a neighborhood bystander to help maintain airway

Immediate


Finally, you approach the limp boy, about 6 years old. You open the airway.

He does not resume breathing. What do you do next?

Radial pulse is weak. What do you do next?Radial pulse is weak. What do you do next?

This child begins to resume shallow breaths. What is This child begins to resume shallow breaths. What is his triage category?his triage category?

Check Radial Pulse

5 rescue breaths

Immediate

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Welcome to Triage BECAUSE IT HAPPENS!. What Would You Do?