Disaster and Multi-Casualty Triage

START-Overview Remember RPM R- Respirations- 30 P-Perfusion- Radial Pulse M-Mental- Follows Commands START System and the Evidence Reverse Triage Used in mass-casualty lightning injuries The dead are treated first High potential for respiratory arrest Potential for resuscitative success Triage is a method of quickly identifying victims who have immediately lifethreatening injuries AND who have the best chance of surviving

Triage [French, from trier, to sort, from Old French.] A method of quickly identifying victims who have immediately life-threatening injuries AND who have the best chance of surviving. Tagging Complements Triage Rapid Identification of patient Color Coded / Bar Coded system Plastic bands can substitute tags START SYSTEM Created in the 1980s by Hoag Hospital and the Newport Beach CA Fire Dept Allows rapid assessment of victims It should not take more than 15 sec/ Pt Once victim is in treatment area more detailed assessment should be made START SYSTEM

Key elements of the START Triage System are: Respiration, Perfusion and Mentation Reverse Triage is used for mass casualty lightning incidents.

Triage Definition: A process for sorting injured [or sick] people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields and disaster sites, [and at night] when limited medical resources must be allocated. - American Heritage Dictionary Derived from the French word trier, meaning to sort First used by the chief surgeon of Napoleons army (Dominique-Jean Larrey) in the early 19th century TRIAGE mass- casualty or multi- casualty incident Involves >1 patient or situation that places great demand on resources (stretched to limit)

Clasification is based on three items Respiratory Perfusion Mental status evaluation START First Step START Step-2 START Step-3 START Step-4 Contaminated Patients Patients with exposure (potential or real) to contaminants should be tagged as BLUE This category will continue to stay until patient is adequately decontaminated then follow START as usual Some recommend a double tagging with blue and the standard START color

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 Triage is the sorting of two or more patients based on the severity of their conditions to establish priorities for care based on available resources Scene Safety 1. Size of hazard area 2. Safe and sheltered location to move patients 3. Self- protective measures THE TRIAGE PROCESS Triage Category: Red Red (Highest) Priority: Patients who need immediate care and transport as soon as possible Airway and breathing difficulties Uncontrolled or severe bleeding Decreased level of consciousness Severe medical problems Shock (hypoperfusion) Severe burns Triage Category: Yellow Yellow (Second) Priority: Patients whose treatment and transportation can be temporarily delayed Burns without airway problems Major or multiple bone or joint injuries Back injuries with or without spinal cord damage Triage Category: Green Green (Low) Priority: Patients whose treatment and transportation can be delayed until last Minor fractures Minor soft-tissue injuries Triage Category: Black Black (Lowest) Priority: Patients who are already dead or have little chance for survival. If resources are limited, treat salvageable patients before these patients Obvious death Obviously nonsurvivable injury, such as major open brain trauma Full cardiac arrest FORENSICS in Nursing Forensics: Pertaining to the Law Forensic Nursing: Application of Nursing to the Law What is Forensic Nursing? The application of forensic science, combined with clinical nursing practice as they are applied to public or legal proceedings in the law enforcement arena. It is the application of forensic aspects of health care combined with biopsychosocial education of the registered nurse in the scientific investigation and treatment of trauma, death, violent or criminal activity, and traumatic accidents within the clinical or community institution (Lynch, 1991). Forensic Nurses Trauma/ER SANE/FNE/SART Nurse Coroners/Forensic Nurse Death Investigators priority Purpose: to control, coordinate and direct emergency responders and resources Emergency Operations Plan TRIAGE TECHNIQUES START Special Triage Situations 1. Injured rescuer - Automatic Red 2. Hysterical patient or bystander - Receives higher then usual priority 3. Child - Receive higher category. If possible they should be transported with parent. Check cap-refill in children. 4. Lowered body temp in outdoor environment (hypothermia) - Hypothermic patients change to high

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Nurse Attorneys/Legal Nurse Consultants Psychiatric & Mental Health Correctional Health Domestic Violence ER/Trauma ER/Trauma Why are they needed Identification Care for the Survivor Care for the Perpetrator Identification & Collection of evidence Clothes Injury and patterns of injury

courtroom testimony SART-Sexual Assault Response Team Law Enforcement Rape Crisis Medical Response SANE/RN Physician ANP PA Crime Lab Counseling Services Forensic Scientist CPS/APS Prosecution

ER/Trauma Documentation What we do v. the crime committed Chain of custody Measurements in centimeters Location Description Photography SANE/ SART SANE A registered nurse who has been specially trained to provide comprehensive care to sexual assault patients, who demonstrates competency in conducting a forensic exam and the ability to be an expert witness. Benefits of a SANE TEAM Willingness Specialty training Comprehensive care Fact based documentation (drop all opinions) Forensic issue evidence collection chain of custody

Together Everyone Accomplishes More Dont tell other members of the TEAM how to do their jobs. Together we can make offenders want to relocate. SART Provide victim centered services Provide compassionate care Provide community awareness Where to come How we will treat you Encourage reporting of Sexual Assaults Encourage successful apprehension and prosecution of guilty offenders Aid in the identifying of false reporting Sexual Assault Every 45 seconds a women is Sexual Assaulted. 1:5 Women 1:10-20 Men Screen ALL Trauma Patients (LOC, clothing) Sexual Assault Exam Sexual Assault is rarely suspected unless an outcry is made. History from Patient (to diagnosis & treat)

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Head-to-toe Assessment Detailed Genital Exam Collection of forensic evidence Treatment for injuries, STDs & pregnancy 1/3 offenders convicted-alcohol 40% of 2,366 survivors urine-alcohol Multiple drugs: Ethanol, Benzos (valium, xanax, restoril, klonopin, rohypnol) Barbiturates, GHB, Ketamine, Chloral Hydrate, Muscle Relaxants, Opiates, Sedative Antidepressants Challenges: Drugs uses Reporting Collection of evidence Lab methodologies Dosages Health Network Statistics Nurse Coroners/ Forensic Nurse Death Investigators Nurse Coroner/Death Investigation The coroner is a public official who is primarily charged with the duty of determining how and why people under the coroners jurisdiction die (these jurisdictions vary form state to state, but typically include sudden, unexpected, unexplained, or traumatic death). Nurse Coroner/Death Investigation A licensed nurse who carries out the duties of a death investigator in accordance with the performance standards and procedures established under the medical examiner or coroners system of death investigating and the jurisdictional standards of practice. Nurse Coroner/Death Investigation Nurses have the educational background to understand exactly what causes death and what happens to a body after death occurs. Death may be

a criminal event, but it is always a medical event. Unlike law enforcement who look at the deceased and want to know, Who killed you? nurses look at a dead body and ask, Why are you dead? If it is determined that the death was due to criminal cause then it is law enforcements job to determine who. Who better to determine the manner of death than medical personnel? Nurse Coroner/Death Investigation Manner of death is the circumstances in which the cause of death arose, i.e. natural, accident, homicide, suicide, and undetermined. In some cases manner of death may be difficult to determine and may appear accidental (i.e. in a suicide without a note). Forensic nurses possess the skills necessary to complete a psychological autopsy and interpret the subtle nuances of medications, health history and circumstances surrounding suspicious deaths. Nurse Coroner/Death Investigation Mechanism of death is the physiologic derangement or biochemical disturbance incompatible with life, which is initiated by the cause of death, e.g. cardiac arrest. Forensic nurses are well educated in physiology and are therefore prepared to accurately distinguish between the cause and the physiologic mechanism of death. Nurse Attorneys/ Legal Nurse Consultants

Goals To establish a leadership role in health care policy making. To influence health care social policy, health care legislation and nursing practice acts. To educate the public about health law issues. To educate the public about nurse attorneys. To educate nurses about the legal system.

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To represent the public; client advocate. Nurse Attorneys/Legal Nurse Consultants Nurses want to make fundamental change in the way healthcare is delivered, and recognizing that it needs to occur through legislation and political process is a big piece of it. Like nurses, attorneys must interact with people who are vulnerable, who have been injured or traumatized, and who need assistance to regain their wholeness. Client advocacy is the skill nurses bring to the profession. Psychiatric and Mental Health Issues and Goals The enhancement of appropriate care for the severe and persistently mentally ill. The integration of psychiatric and addictions treatment. Strategies for promotion of mental health and prevention of psychiatric disorders. The provision of appropriate care within the criminal justice system. The equitable provision of care for children and adolescents. Issues and Goals Ensuring access to care for older adults and members of minority groups. Advocacy for access to psychiatric-mental health services as readily as access to medical services. The development of an evidence-based approach to teaching nursing students about psychiatric-mental health nursing, at both the undergraduate and the graduate levels of education. Correctional Health Correctional Health Nurses Correctional healthcare is a unique specialty area. Goals:

Facilitate an improved working relationship between the private sector and the correctional staff in jails, adult and juvenile detention centers, prisons to meet the needs of the inmate patient. Promote correctional healthcare as part of the public health continuum. Domestic Violence Intimate Partner Violence is an Epidemic The Surgeon General of the United States recently declared: Domestic Violence is the number one health issue facing the country today Domestic Violence DV is the leading cause of injury to women in the world. DV is the leading nonobstetric cause of death to pregnant women. Every 9 seconds a women is battered. 1:3 women are a victim of domestic violence Cycle of Violence Evas Top 5 Domestic Violence Myths/Facts MYTHS Poor/unemployed The victim spends a lot of time running to the doctor He would never hurt the children He only does this when he drinks He wouldnt kill her FACTS <15% unemployed Only 2/3 will seek medical assistance There is an increased incidence of child abuse 67% report alcohol abuse only 1/5 drinking at the time of abuse 2 women die each week at the hands of their husbands/Texas

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3-10 Million Children Witness DV Violence in Their Homes Each Year 63% of Young Men Ages 11 to 20 Who Are Serving Time for Homicide Have Killed Their Mothers Abusers The Leading Cause of Injury to 14 Year Old Boys More Facts.. DV kills as many women every 5 years as the total number of Americans killed in the Vietnam War54,000 Approximately 50% of all homeless women and children in the U.S. are fleeing DV. There are 7 animal shelters for every 1 DV shelter. DV & Healthcare Costs 3-5 billion dollars in health care claims 100 million dollars in absenteeism, high turnover and lost productivity Employees miss 1,175,000 days of work per year because of DV alone DV in the US costs an estimated $67 billion/year 13,000 acts of DV against women occur in the workplace every year Up to 52% of victims of DV have lost their jobs because batterers typically engage in behavior that makes it difficult to work Types of Abuse Physical Hitting, kicking, strangulation, weapons Emotional/psychological Threats, destruction of self worth, isolation Financial Work, advancement, access to finances, credit, Lack of identifying victims of Domestic Violence is consistent in community hospitals and trauma centers. Justice will only be achieved when those who are not injured are just as indignant as those who are.

King Solomon BIOTERRORISM Bioterrorism is one form of terrorism. Terrorism is defined as the unlawful use of force or violence against persons or property to intimidate or coerce a government or civilian population in the furtherance of political or social objectives. Terrorists use weapons of mass destruction. These are destructive devices which include bombs, missiles, poison chemicals, disease organisms, radiation or radioactivity at levels dangerous to human life. The 9/11 Commission Report stated referring to the terrorist threat ..we are not safe Time is not on our side.. Biologic agents are likely to be used by terrorists as weapons because: They are capable of damaging populations, economies, and food supplies Certain agents are inexpensive to make They can be directed at a small group of people or an entire population They can be used to attack people, economies and food supplies They cause fear, panic and social disruption Characteristics of biological agents that could be used as bioterrorist agents They have a wide range of effects They are obtained from nature They are easily made by relatively unsophisticated methods They are invisible to the senses Their effects may be delayed They can produce mass casualties DIFFERENCES BETWEEN A BIOLOGICAL ATTACK AND A NATURAL OCCURENCE

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A biological terrorist attack may mimic a large scale naturally occurring disease outbreak. There are differences. A biological attack:

In 1972, Bioweapons Convention created in which U. S. and U. S. S. R. were signatories Possible/probable active offensive bioweapons programs in N. Korea, Iran, China, Egypt, Algeria, India, Pakistan, Syria, Israel

Results from a deliberate act Will be treated as a crime scene May not be immediately recognized BIOLOGICAL ATTACK VS. NATURAL OCCURRENCE May be preceded by verbal or written threats from a terrorist group May find abandoned spray devices may be found Claims by a terrorist group to have released a biologic agent May result in contamination of critical facilities May expand rapidly from different source cases Will cause widespread public panic ROUTES OF ENTRY INTO THE HUMAN BODY Ingestion Dermal penetration Inhalation AEROSOL INHALATION The use of aerosols is an efficient way to affect the maximum number of people with a single attack. BIOWEAPONS RECENT HISTORY Bioweapons have a long history. Recent uses include: U.S, Canada, Great Britain, Japan, and the U.S.S.R experiment with anthrax during World War II (W.W.II)

BIOWEAPONS RECENT HISTORY In 1986, Bhagwan cult poisons Oregon salad bars with salmonella-715 people sick In 1995, Aryan Nation orders plague bacteria from supply house in Maryland and Minnesota Patriots Council members convicted for planning ricin use in assassination attempt BIOLOGICAL AGENTS There are several types of agents. They are classified as: Bacteria Rickettsia Viruses Biotoxins BACTERIA Single celled organisms capable of causing disease. These agents, grown on culture to produce large quantities, can be modified or weaponized for greater destruction Produces inflamation in tissues and/or toxins EXAMPLES ANTHRAX SMALL POX PLAGUE TYPHOID CHOLERA TULAREMIA RICKETTSIA Vector borne (ticks, lice, mosquitos) parasitic form of bacteria Diseases are difficult to treat Variants exist worldwide

In 1991, Iraq threatens use of bioweapons against U. S. troops in Persian Gulf war Post W.W.II , NATO and the Warsaw Pact nations had bioweapons programs BIOWEAPONS RECENT HISTORY In 1969, U. S. unilateral decision to destroy bioweapons

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EXAMPLES TYPHUS ROCKY MT. SPOTTED FEVER Q FEVER INDIA TICK FEVER MEDITERANEAN TICK FEVER VIRUSES Smaller than bacteria RNA or DNA in a protein coat Use living cells to reproduce Not affected by antibiotics EXAMPLES EBOLA LASSA FEVER INFLUENZA VIRAL HEPATITIS VIRAL HEMORRHAGIC FEVERS BIOTOXINS Are poisonous by-products of bacteria, fungi, marine animals or plants Do not replicate in the host Are not communicable Highly toxic when delivered as an aerosol EXAMPLES BOTULINUM STAPHLOCCOCAL ENTEROTOXIN B RICIN Biological Agents most likely to be used in a terrorist attack Bacteria - anthrax, plague, tularemia Virus - small pox, viral hemorrhagic fever Biotoxin - botulism ANTHRAX Infectious agent: Bacillus anthracis gram +, spore forming bacteria

May enter the body from skin (cutaneous), digestive system or by inhalation (most likely route to be used by terrorists)

ANTHRAX Symptoms: itching, lesions, fever, fatigue, nonproductive cough, respiratory failure and hemodynamic collapse

Transmission: none person to person except with cutaneous Incubation period: 1 to 6 days Mortality: 5 to 20% percutaneous, 80 to 90% inhalation Treatment: antibiotics Prevention: vaccine PLAGUE In nature, fleas living on rodents spread infection to humans. As a bioterrorist weapon inhalation of aerosol leads to pneumonia, sepsis and infections of bodily organs

Infectious agent: Yersinia pestis a gram neg., nonmotile bacillus May be bubonic ( infection of lymph nodes) or pneumonic (infection of lungs)or septicemic Symptoms: cough with bloody sputum, fever, chill, shortness of breath PLAGUE Transmission: may occur person to person by respiratory droplet inhalation Incubation period: 2 to 3 days Mortality: 50 to 60% Treatment: antibiotics Prevention: vaccine ineffective against aerosol exposure TULAREMIA A zoonotic, bacterial infection caused by Francisella tularensis, a gram negative coccobacillus

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In nature, bacteria is commonly found in ticks living on rabbits and transmitted by handling the animal or by tick bite. Inhalation of aerosol leads to pneumonia and sepsis

SMALL POX Rash appears after about three weeks; progresses from macules (initial skin lesions) to papules to pustular vesicles, to scabs

TULAREMIA Symptoms:sudden and influenza-like with fever,chills, headache and nausea Transmission: not usually person to person Incubation period:3 to 5 days(range 1 to 14) Mortality:low unless untreated Treatment:antibiotics if early, vaccine available Prevention: in nature, avoid tick bites and using gloves when handling infected animals BOTULISM Infectious agent: Clostridium botulinum a spore forming, anaerobic bacillus In nature, may be food borne, wound, or intestinal. As a bioterrorist weapon, ingestion or inhalation leads to production of the neurotoxin and resulting flaccid paralysis

Transmission: may occur person to person by respiratory droplets or skin inoculation. Highly contagious when rash appears

Incubation period: 10 to 12 days Mortality: less than 1% in the minor form and 20 to50 % in the major form Treatment: supportive Prevention: vaccine VIRAL HEMORRHAGIC FEVERS These are highly infectious viral illnesses caused by the Filoviruses (Ebola and Marburg), Arenaviruses (Lassa fever), Bunyaviruses (Congo hemorragic fever and Hantaviral disease), and Flaviviruses

Symptoms: vary from one type to the next. They include: sudden onset of fever, muscle aches, headache, followed by vomiting, diarrhea, and rash and internal bleeding

BOTULISM Symptom: fatigue, weakness, blurred vision, difficulty in swallowing and speaking, descending muscle paralysis and respiratory failure

Complications: In severe forms, multiorgan failure occurs, primarily due to hemorrhagic and pulmonary complications

Transmission: none person to person Incubation period: 12 to 72 hours Mortality: most lethal compound per weight Treatment: antitoxins, respiratory support Prevention: vaccine available for types A and B SMALL POX Infectious agent: Variola virus - Orthopox virus Declared eradicated in 1980, but stockpiles may exist Not naturally acquired. It can be disseminated as and inhaled as an aerosol Symptoms: Fever, muscular rigidity, headaches, and vomiting. Severe cases experience prostration and hemorrhage into skin and mucous membranes

VIRAL HEMORRAGIC FEVERS Mode of transmission: handling infected wild animals, but may be used as an aerosol bioterrorist weapon

Incubation period: 2 to 21 days Reservoir: gorillas and chimpanzees Transmission: some may be spread person to person by contact with body secretions Mortality: Ebola rates have reached 90% but vary Treatment: supportive Prevention: Avoid contact with infected monkeys or other animal hosts End

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