Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106) Emergency and Disaster V
What is Triage? Triage means to sort Looks at medical needs and urgency of each individual patient Sorting is based on limited data acquisition Also must consider resource availability
MILITART vs. CIVILIAN TRIAGE Military Triage Civilian Triage Priority To get as MANY SOLDIERS back into ACTION as possible To MAXIMIZE SURVIVAL of the GREATEST NUMBER OF VICTIMS Treatment Those with the LEAST SERIOUS WOUNDS may be the first treatment priority Those with the MOST SERIOUS but realistically SALVAGEABLE INJURIES are treated first ****In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as lowest priority
ETHICAL JUSTIFICATION This is one of the few places where a utilitarian rule governs medicine: The greater good of the greater number, rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis
Why Should Responders Care about Good Triage?? 1. Provides a way to draw organization out of CHAOS 2. Helps to get care to those who need it and will benefit from it the most 3. Helps in RESOURCE ALLOCATION 4. Provides an objective framework for stressful and emotional decisions
Why are Resources Important to Triage?? 1. Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources 2. Daily emergency care is not usually constrained by resource availability
LOOKY HERE Topics Discussed Here Are: 1. What is Triage? a. Primary Disaster Triage b. Secondary Disaster Triage c. Tertiary Disaster Triage d. START Triage e. JumpSTART Triage 2. Managing Psychosocial Impact of Disaster a. Psychosocial Impact Considerations b. Psychosocial Response to Trauma c. Phases of Emotional Recovery after a Disaster 3. Critical Incident Stress Debriefing Abundant Resources Relative to Demand P P P P P P P P P P P P = Patient
Resources are Challenged
Do The Best For Each Individual
Daily Emergencies: Do the best for each individual Disaster Setting: Do the greatest good for the greatest number and maximize survival
Triage is a dynamic process and is usually done more than once jcmendiola_Achievers2013 Primary Disaster Triage: Goal: o To sort patients based on probable needs for immediate care. o Also to recognize futility Assumptions: o Medical needs outstrip immediately available resources o Additional resources will become available in time Triage based on Physiology o How well the patient is able to utilize their own resources to deal with injuries o Which conditions will benefit the most from the expenditure The most commonly used ADULT TOOL in the US and CANADA is the START Tool The only recognized PEDIATRIC MCI Primary Triage Tool used in the US and CANADA is the JumpSTART Tool Other tools exist but are less oriented to mass casualties than triaging small other number of adult trauma
Basic Disaster Life Support O National Disaster Life Support, Education, Consortium, via Medical College of Georgias Center of Operational Medicine O Endorsed by the American Medical Association O Disaster Medicine Online O MASS Triage: o Move o Assess o Sort o Send O Assessment Guidelines O Pediatric Considerations The Best Primary Triage Tool = No MCI primary triage tool has been validated by the outcome data
Secondary Disaster Triage: Goal: To best match patients current and anticipated needs with available resources Incorporates: o A reassessment of physiology o Assessment of Physical Injuries o Initial treatment and assessment of patient response o Further knowledge of resources available The Best Secondary Triage Tool There is no widely recognized tool in the US that addresses secondary MCI Triage California Medical Disaster Response or SAVE Tool (Secondary Assessment of Victim Endpoint)
NATO Guidelines Red SHACCB FN
o Shock, Significant External Hemorrhage, Airway Obstruction, Cardiorespiratory Failure, Sucking Chest Wound, Burns of Face or Neck Yellow B O FEAT o Significant Burns Other than Face, Neck and Perineum, Avascular Limb Fractures, Severe Eye Injury, Abdominal Wounds, Open Thoracic Wound Green CSB SPT L The Walking Wounded o Contusions, Sprains, Superficial Burns, Partial-thickness Burns of < 20% BSA, Minor Lacerations Black MD H GCS B >85%
o Multisystem Trauma, Signs of Impending Death, Head injury with GCS <8, Burns >85% BSA
jcmendiola_Achievers2013 Goal of the Secondary Triage is to Distinguish Between: o Victims needing life-saving treatment that can only be provided in a hospital setting o Victims needing life-saving treatment initially available on scene o Victims with moderate non-life threatening injuries, at risk for delayed complications o Victims with minor injuries
Tertiary Triage Goal: To optimize individual outcome Incorporates: o Sophisticated assessment and treatment o Further assessment of available medical resources o Determination of best venue for definitive care
Primary Triage Can be transferred to ambulance Can stay at the treatment area Secondary Triage Can be transferred to ambulance if there is available resources Tertiary Triage For green, stay at the treatment area
MCI Triage: Key Points Resources and patient numbers and acuity are limiting factors Must be dynamic, responsive to change both resources and patient There is no apparent civilian MCI Triage that has been official
START Triage Step 1: The triage officer announces that all patients that can walk should get up and walk to a designated area for eventual secondary triage All ambulatory patients are initially tagged as GREEN
Step 2: Triage officer assess patients in the order in which they are encountered Assess for presence and absence of spontaneous respirations If breathing, move to Step 3 If apneic, open airway If patient remains apneic, tag as BLACK If patient starts breathing, tag as RED
Step 3: Assess Respiratory Rate Mnemonic o R (Respiration) o P (Pulse) o M (Mental Status) If any of these 3 are ABNORMAL, tag as RED If no problem in RPM, tag as GREEN Low survival rate, tag as BLACK
jcmendiola_Achievers2013 JumpSTART Pediatric MCI Triage Steps Patients who are able to walk are assumed to have stable, well- compensated physiology, regardless of their nature of injuries, tag as GREEN All GREEN patients must be individually assessed in Secondary Triage: o Assess PHYSIOLOGY o Assess INJURIES o Assess PROBABILITY of DETERIORATION o Assess NEEDS vs. RESOURCE Availability Some children may be carried to the GREEN Area by others. They have not proven their physiologic stability by performing complex acts of walking These children should be assessed first among those in the GREEN Area Position the Upper airway of the apneic child If they start to breathe, tag them as RED If the child does not start breathing with the upper airway opening, start feeling for pulse If no pulse is palpated, tag them as BLACK If the patient has palpable pulse, give 5 mouths to barrier breaths to open lower airway. Tag as below, depending on response to ventilations: o If no pulse: Deceased o 5 Rescue Breaths: No Response Deceased o 5 Rescue Breaths: Has Response Tag as RED Do not continue to ventilate the patient. Resume tag duties Assess the respiratory rate of the spontaneously breathing child o Move on to next assessment if respiratory rate is 15 45 breaths/minute o If Respiratory Rate is <15 or >45 breaths/minute = Tag as RED o If the childs pulse is palpable, move on to the next assessment o If no palpable pulse, tag as RED o If patient is inappropriately responsive posturing, or unposturing tag as RED
jcmendiola_Achievers2013 Triage Categories Green Minor (Walking Wounded) Can walk Can wait for hours for treatment or be cared for on the scene Includes minor fractures, lacerations, etc. Yellow Delayed (Serious but Stable) 50-50 Survival Can wait for 1 2 hours for treatment Includes major fractures, moderate bleeding, abdominal injuries, etc. Red Immediate Priority Cardiopulmonary Problem Victim will die without immediate treatment Includes airway issues, tension pneumothorax, shock, unresponsive uncontrolled hemorrhage and limb amputations Black Expectant or Dead (Little or no chance of survival) May be Dead No vital signs Includes massive head or torso injuries, massive blood loss, severe burns Provide comfort care
Modifications for Non-ambulatory Children + Children developmentally unable to walk due to young age or developmental delay + For non-ambulatory children, assess using the JumpSTART Algorithm + If patient meets any RED criteria, tag as RED + If patient meets YELLOW criteria and has external signs of injury, tag as YELLOW + If patient meets YELLOW criteria and has NO external signs of injury, tag as GREEN
What about WMD (Weapons of Mass Destruction)? There is no widely recognized civilian MCI Triage Tool used in the US for any of the NRBC Agents o ILANG BESES NA TO INULIT @_@....
WMD Triage Challenges Any triage model for WMD must consider decontamination jcmendiola_Achievers2013 o Who goes first? o At what stage does triage take place? o Difficulty of conducting patient assessment and care for responders in protective gear Agents of attack may be mixed. How do you triage victims who have injuries from a conventional attack in addition to a chemical or radiological/nuclear exposure? o Washing or Taking a bath can decontaminate radiation, but once you inhaled it, it is a serious problem Biological agents may impact field triage mostly in choice of destination facility (Quarantine Hospitals) Patterns of EMS calls may assist in identification of an occult biological agent attack or a natural epidemic o Example: Bio-surveillance tool is the First watch program Some agents cause Toxindromes that allow for prediction of outcomes based on presenting symptoms and signs Agent-specific triage is dependent upon identification or strong suspicion of the agents use Very difficult to train and maintain readiness with multiple agent-specific triage schemes
Chemical Toxindrome Examples Nerve Agent o Red: Severe distress, seizures, signs in two or more systems (Neuromuscular, GIT, Respiratory Excluding eyes and nose) o Black: Pulseless or Apneic, unless intensive resources are available Phosphogene (Some substances burned at home forms Phosphogene Gases) and Vesicants o Red: Moderate to severe respiratory distress, only when intensive resources are immediately available o Black: Burns greater than 50% BSA from liquid exposure, signs of more than minimal pulmonary involvement, when intensive resources are not available Cyanide o Red: Active seizure or recent onset of apnea with preserved circulation o Black: No Palpable pulse
Key Points About MCI Triage Anything that can help organize the response to an MCI is a good thing MCI Triage is different than daily Triage, in both fields, ED Settings Resource availability is the limiting factor to consider in MCI Triage In order for MCI Triage to work towards its goal, all victims must have equal importance at the time of primary triage. No patient group can receive special consideration (Including children) Disaster research agendas should include efforts to validate and improve existing triage tools MCI Triage will never be logistically, intellectually or emotionally easy, but we must be prepared to do it.
Managing Psychosocial Impact of Disaster - Are we psychologically prepared? - For every physical injury, there may be 5 6 psychological injuries
Critical Incident Exposure to a traumatic event in which both of the following were present: o The person experienced an event that involved actual/threatened death or serious injury of self or others o The persons response involved intense fear, helplessness / horror Consequences of Critical Incident o Often includes (1) Tangible Loss (2) Intangible Loss Loss of materials goods Loss of safety/security jcmendiola_Achievers2013 Loss of loved ones Loss of home, employment/income Loss of predictability Loss of social connection Loss of dignity Loss of positive self-image Loss of trust in the future Loss of hope Loss of control
Truth About Coping Mechanism - People typically rely on past strategies to cope with new stressful situations - Past coping mechanisms can be functional/dysfunctional
Vulnerable Groups Children Elderly They have no experience / known patterns of action as a response to disaster Has a degree of resilience that may lead to unhealthy coping
PSYCHOSOCIAL IMPACT CONSIDERATIONS - Prior experience with similar event - Prior trauma - Intensity of the disruption in the survivors lives - Resilience of the individual - Just because you have experienced disaster does not mean you will be damaged by it but you will be changed by it (Weaver, 1995)
PSYCHOSOCIAL RESPONSE TO TRAUMA - Experience shows that: o No one who sees disaster and left untouched by it o Most people pull together and function during and after a disaster, but their effectiveness is diminished o Most people do not see themselves as needing mental health services following a disaster and will not seek such services o Survivors may reject disaster assistance of all types o Disaster mental health assistance is more practical than psychosocial in nature o Social support systems are crucial to recovery o People often experience strong and unpleasant emotional and physical responses following exposure to traumatic events (e.g. Disaster) o These may include a combination of: Fear and anxiety Grief and loss Shock Hopelessness Loss of confidence Mistrust Sleep disturbances Physical Pain Confusion Shame Shaken Faith Aggressiveness
Categories of Reaction after an Incident
jcmendiola_Achievers2013 Phases of Emotional Recovery after a Disaster 1. Heroic 2. Honeymoon 3. Disillusionment 4. Reconstruction
HEROIC PHASE At the onset / impact of disaster and immediately after disaster Many people are strong and focused Strong sense of sharing, people helping one another and
HONEYMOON May take several weeks Cohesion in the community People meet together and are relieved that they are safe and alive and that they have a place to stay until they can return back home
DISILLUSIONMENT Second disaster People have now been in care centers for > 1 month They cannot wait on the government Lasts a month or two to a year or two
RECONSTRUCTION Lasts several years Responsibility of recovery Reconstruction and rebuilding may be going on around but the community has returned to its normal routine
Essential Attributes and Skills Good listening skills Patience Caring attitude Trustworthy Approachable Culturally aware Emphatic
Intense Emotions Are often appropriate reactions if a disaster Can often be managed by community responders
Support Communication Conveys: o Empathy o Concern o Respect o
Helpful~ (Do Say) - Can you tell me what happened? - Im sorry - This must be difficult for you - Im here to be with you
Unhelpful (Avoid Saying) - I understand what its like for you - Dont feel bad - Youre strong, youll get through this - Dont cry - Its Gods will - It could be worse or At least you still have
jcmendiola_Achievers2013 Psychological First Aid (PFA) Guiding Principle in Providing Psychological Support - Protect from danger - Be direct and active - Provide accurate information about what to do - Reassure - Do not give false reassurances - Recognize the importance of taking action
Goals - PFA Promotes and sustains an environment of: 1. Safety 2. Calm 3. Connectedness 4. Self-efficacy 5. Hope 1. Promote Safety Help people meet basic needs for foods and shelter and obtain medical attention Provide repeated, simple and accurate information on how to get these basic needs met 2. Promote Calm Listen to people who wish to share their stories and emotion and remember that there are no right/wrong way to feel Be friendly and compassionate even if people are being difficult Offer accurate information about the disaster/trauma and the relief efforts underway to help victims understand the situation 3. Promote Connectedness Help people contact relatives, loved ones and friends Keep families together: Keep children with parents or other close relatives whenever possible 4. Promote Self-efficacy Give practical suggestions that steer people towards helping themselves Engage people in meeting their own need Dont : Tell people what you think they should be feeling, thinking or doing now or how they should have acted earlier ( self-efficacy) Tell people why you think they have suffered by giving reasons about their personal behavior / beliefs (this also self-efficacy)
Critical Incident Stress Debriefing (CISD) Debriefing/Defusing Is a specific technique designed to assist responders in dealing with the physical/psychological symptoms that are associated with trauma exposure Allows those involved with the incident to process the event and reflect on its impact Allows for the ventilation of emotions and association with the crisis event Provide ASAP but typically no longer than the first 24 72 hours after the initial impact of the critical event
Steps in Stress Debriefing Stage 1: Lay the groundwork for the session - Set the goal with the victims - Find out what happened - Ask the members of the group to tell about the event that led up to the meeting
Stage 2: Explore the thoughts, feelings and reactions - Reassure group members about their feelings. Be supportive o What did you think why this happened? jcmendiola_Achievers2013 o How did you feel about this event when it occurred? o What was the worst part for you? o How do you feel about it now?
Stage 3: Explore the coping strategies the group members are using - How are they dealing with the event / incident? - Do you still have needs that are unmet? - What would help them right now? - What are their plans for dealing with this event (or similar events) in the future
Stage 4: Provide brief rest / diversion - Have a cup of coffee / a short walk, direct relaxation exercises - Provide the person time to recover their own sense of competency and direction
Stage 5: Follow-up - Maintain an expectation that the person will rapidly return to his usual activity - It may be appropriate to follow-up from a short period
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