Pediatric_Multicasualty_Incident_Triage

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Published on January 12, 2009

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Pediatric Multicasualty Incident Triage : Pediatric Multicasualty Incident Triage Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT Topics : Topics What is Triage? : What is Triage? “Triage” means “to sort” Looks at medical needs and urgency of each individual patient Sorting based on limited data acquisition Also must consider resource availability Military vs. Civilian Triage : Military vs. Civilian Triage Military vs. Civilian Triage : Military vs. Civilian Triage Military model Those with the least serious wounds may be the first treatment priority Civilian model Those with the most serious but realistically salvageable injuries are treated first Military vs. Civilian Triage : Military vs. Civilian Triage In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as the lowest priority. Ethical Justification : 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. A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine, http://eduserv.hscer.washington.edu/bioethics/topics/resall.html “The needs of the many outweigh the needs of the few or the one." : “The needs of the many outweigh the needs of the few or the one." Star Trek Why are Resources Important in Triage? : Why are Resources Important in Triage? Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources. Daily emergency care is not usually constrained by resource availability. Triage is a dynamic process and is usually done more than once. : Triage is a dynamic process and is usually done more than once. Primary Disaster Triage : Primary Disaster Triage Goal: to sort patients based on probable needs for immediate care. Also to recognize futility. Assumptions: Medical needs outstrip immediately available resources Additional resources will become available with time Primary Disaster Triage : Primary Disaster Triage Triage based on physiology How well the patient is able to utilize their own resources to deal with their injuries Which conditions will benefit the most from the expenditure of limited resources Secondary Disaster Triage : Secondary Disaster Triage Goal: to best match patients’ current and anticipated needs with available resources. Incorporates: A reassessment of physiology An assessment of physical injuries Initial treatment and assessment of patient response Further knowledge of resource availability Secondary Triage Tools : Secondary Triage Tools Goal is to distinguish between: Victims needing life-saving treatment that can only be provided in a hospital setting. Victims needing life-saving treatment initially available on scene. Victims with moderate non-life-threatening injuries, at risk for delayed complications. Victims with minor injuries. Secondary Triage Tools : Secondary Triage Tools There is no widely recognized tool in the US that addresses secondary MCI triage and also transport strategies. California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint) Many EMS systems use local trauma triage criteria. Tertiary Disaster Triage : Tertiary Disaster Triage Goal: to optimize individual outcome Incorporates: Sophisticated assessment and treatment Further assessment of available medical resources Determination of best venue for definitive care Slide 18: Primary Triage Secondary Triage Tertiary Triage “Continuous Integrated Triage” MCI Triage: Key Points : MCI Triage: Key Points Resources and patient numbers and acuity are limiting factors. Must be dynamic, responsive to changes in both resources and patient needs. There are no validated tools available at this time. Many questions, few answers. Triage Categories : Triage Categories Triage Categories : Triage Categories Red: Life-threatening but treatable injuries requiring rapid medical attention Yellow: Potentially serious injuries, but are stable enough to wait a short while for medical treatment Triage Categories : Triage Categories Green: Minor injuries that can wait for longer periods of time for treatment Black: Dead or still with life signs but injuries are incompatible with survival in austere conditions Triage Tools : Triage Tools Simple Triage and Rapid Treatment (START) : Simple Triage and Rapid Treatment (START) JumpSTART Pediatric MCI Triage Tool : JumpSTART Pediatric MCI Triage Tool The Smart Triage Tape® : The Smart Triage Tape® Developed in Great Britain Proprietary, TSG Associates Length-based pediatric MCI triage tape Age-adjusted physiologic parameters In use in Europe, Africa and some states in the US www.tsgassociates.co.uk/English/Civilian/products/smart_tape.htm Triage Sieve : Triage Sieve Care Flight Triage : Care Flight Triage Basic Disaster Life Support : Basic Disaster Life Support National Disaster Life Support Education Consortium, via Medical College of Georgia’s Center of Operational Medicine Endorsed by the American Medical Association www.ndlsf.org Basic Disaster Life Support : Basic Disaster Life Support MASS Triage Move Assess Sort Send ? Assessment guidelines ? Pediatric considerations SALT Triage : SALT Triage Sort, Assess, Life-saving Interventions, Treatment/Transport CDC grant project to standardize MCI triage in the US Early in development Derived from existing tools Includes pediatric considerations SALT Triage : SALT Triage SALT Triage : SALT Triage Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline E. Brooke Lerner, PhD, Richard B. Schwartz, MD, Phillip L. Coule, MD, et al DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS - 2(Supplement_1): 25-34 2008 http://www.dmphp.org/cgi/content/full/2/Supplement_1/S25#R15-7 Sacco Triage Method® : Sacco Triage Method® Proprietary tool, ThinkSharp Inc. Only tool based on outcome data 12 triage categories Available software package for transport planning based on patient and resource info Includes pediatric data and age adjustments Sacco Triage Method® : Sacco Triage Method® Sacco Triage Method® : Sacco Triage Method® STM Sample Patient Prioritization : STM Sample Patient Prioritization Scene Characterization Triage Priority Order Multiple casualty; resource levels stressed 4 5 6 3 2 7 1 8+ 2 Estimate about an hour or less to clear the scene. Large multiple casualty or small mass casualty 5 6 7 8 4 9 3 2 1 9+ requiring staged resources Estimate 1½ to 2½ hours to clear the scene Mass casualty; resources overwhelmed Estimate 3 or more hours to clear the scene 6 7 8 5 9 10 4 3 2 1 11+ www.sharpthinkers.com/STM_Site/stm_home.htm Israeli Triage Practice : Israeli Triage Practice Little to no triage done on-scene “Save and run” philosophy Very hazardous scenes Reds to closest hospital Nearest hospital becomes triage center? Israeli Triage Practice : Israeli Triage Practice Uses physicians as triage officers Accuracy of physician triage called into question Metropolitan Israeli hospitals may be more uniformly capable of caring for trauma victims than in many areas of the US The Best Tool? : The Best Tool? No MCI primary triage tool has been validated by outcome data from MCIs. Mass-casualty triage: Time for an evidence-based approach. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL, Hsu EB Prehospital Disast Med 2008;23(1):3–8. The Best Tool? : The Best Tool? It’s likely that no existing MCI triage tool is suitable for use for all types of incidents. START/JumpSTART : START/JumpSTART Neither clinically validated Evidence accumulating against validity and/or inter-rater reliability Comparison of paediatric major incident primary triage tools. L A Wallis1, S Carley2 Emergency Medicine Journal 2006;23:475-478 Smart Tape and Care Flight more sensitive than START and JS No tool had > 48% sensitivity for critical patients START : START Simple Triage And Rapid Treatment Developed jointly by Newport Beach (CA) Fire and Marine Dept. and Hoag Hospital Gold standard for field adult multiple casualty (MCI) triage in the US and numerous countries around the world START : START Utilizes the usual four triage categories Used for Primary Triage Used on-scene and at hospitals Recommended for patients > 100 lbs www.start-triage.com START Triage : START Triage RESPIRATIONS NO YES Dead or Expectant Immediate Position Airway NO YES Over 30/min Immediate Under 30/min PERFUSION Cap refill > 2 sec Control Bleeding Immediate Cap refill < 2 sec. MENTAL STATUS Failure to follow simple commands Can follow simple commands Immediate Delayed START: Step 1 : START: Step 1 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. START: Step 2 : START: Step 2 Triage officer assesses patients in the order in which they are encountered Assess for presence or 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 START: Step 3 : START: Step 3 Assess respiratory rate If =30, proceed to Step 4 If ? 30, tag patient as Red START: Step 4 : START: Step 4 Assess capillary refill If = 2 seconds, move to Step 5 If ? 2 seconds, tag as Red START: Step 5 : START: Step 5 Assess mental status If able to obey commands, tag as Yellow If unable to obey commands, tag as Red Mnemonic : Mnemonic R P M 30 2 Can do JumpSTART Pediatric MCI Triage : JumpSTART Pediatric MCI Triage Developed by Lou Romig MD, FAAP, FACEP Now in widespread use throughout the US and Canada Being taught in Japan, Germany, Switzerland, the Dominican Republic, Africa, Polynesia National Committee on Management of Pediatric MCIs, 2006 : National Committee on Management of Pediatric MCIs, 2006 JumpSTART recommended for prehospital use throughout Israel Prehospital Response and Field Triage in Pediatric Mass Casualty Incidents: The Israeli Experience Yehezkel Waisman, MD, Lisa Amir, MD, MPH, Meirav Mor, MD, et al Clin Ped Emerg Med 7:52-58, 2006 JumpSTART Pediatric MCI Triage : JumpSTART Pediatric MCI Triage The physiologic parameters used in START are not suitable for all ages of children Walking Respiratory death vs cardiac death Respiratory rates Mental status assessment What age? : What age? JumpSTART: Age : JumpSTART: Age The ages of “tweens and teens” can be hard to determine so the current recommendation is: If a victim appears to be a child, use JumpSTART. If a victim appears to be a young adult, use START. Slide 60: Patients who are able to walk are assumed to have stable, well-compensated physiology, regardless of the nature of their injuries or illness. Secondary Triage : Secondary Triage All green patients must be individually assessed in secondary triage. Assess physiology Assess injuries Assess probability of deterioration Assess needs vs. resource availability Secondary Triage : Secondary Triage Some children may be carried to the green area by others. They have not proven their physiologic stability by performing the complex act of walking. These children should be assessed first among all those in the green area. Slide 63: Position the upper airway of the apneic child. If they start to breathe, tag them as Slide 64: If the child doesn’t start breathing with upper airway opening, feel for a pulse. If no pulse is palpable, tag the patient as Slide 65: If the patient has a palpable pulse, give 5 mouth-to-barrier breaths to open the lower airways. Tag as below, depending on response to ventilations. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES. Slide 66: Assess the respiratory rate of the spontaneously breathing child. Slide 67: Move on to next assessment if respiratory rate is 15-45 breaths/minute. If respiratory rate is <15 or >45, tag the patient as Slide 68: If the child’s pulse is palpable, move on to the next assessment. If no palpable pulse, tag the patient as Slide 69: If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as If patient is alert, responds to voice or appropriately responds to pain, tag as Modification for Nonambulatory Children : Modification for Nonambulatory Children Children developmentally unable to walk due to young age or developmental delay Children with chronic disabilities that prevent them from walking Modification for Nonambulatory Children : For nonambulatory children, assess using the JumpSTART algorithm. If pt meets any red criteria tag as Modification for Nonambulatory Children Modification for Nonambulatory Children : If patient meets yellow criteria and has significant external signs of injury, tag as If patient meets yellow criteria and has no significant external signs of injury, tag as Modification for Nonambulatory Children Certainties about MCI Triage : Certainties about MCI Triage Organization is a good thing in a disaster Triage tools must help match limited resources to an abundance of needs Physiologic tools should suit physiologic differences Triage tools should be kept as simple as possible and practiced often Slide 75: Disaster research agendas should include efforts to validate existing and future triage tools. Slide 76: Triage should be done with the head, not the heart. Slide 77: www.jumpstarttriage.com Thank You! : Thank You! LouRomig@bellsouth.net LouRomig@jumpstarttriage.com MDFR FL-5 DMAT MCH

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