DPT 8.0

Special Hospital Considerations

Part II

Triage, Planning and Exercises

DPT 8.0

Hospital Triage

• Use a triage system in an MCI that parallels normal routine

• Practice regularly to ensure familiarity

• Triage is a continual process

• Re-triage all victimstransported by EMS

• Set up triage area near the ED entrance

– Shielded and secure– Readily accessible

DPT 8.0

Triage

• “Greatest good for the greatest number of casualties”

• Psychological impact

• Classification:

Red Yellow Green Black

• Limitations:– Time consuming

– User variability

– Lack of familiarity

DPT 8.0

START Triage

TRIAGE CRITERIA:

• Respiratory status

• Perfusion and pulse

• Neurological status

TRIAGE CATEGORIES:

• Walking wounded - “Green” or minimal (relocate when told)

• Normal findings - “Yellow” or delayed (unable to relocated)

• Abnormal - “Red” or immediate

• Non-salvageable - “Black” or expectant

DPT 8.0

START - Respiratory Status

Expectant

No RespiratoryEffort

Immediate

Respirations> 30

Go toNext Step

NormalRespirations

Respiratory Status

DPT 8.0

START - Perfusion

Immediate

Radial Pulse Absent

Immediate

Cyanotic

Go toNext Step

Radial Pulse Present

Perfusion Status

DPT 8.0

START - Neurological Status

Immediate

Change inMental Status

Immediate

Unconscious

Move toNext Victim

NormalMental Status

Neurologic Status

DPT 8.0

Nerve Agent Triage - “Immediate”

• Unconsciousness or convulsions

• Two or more body systems involved

Rapid intervention shouldresult in a good outcome

DPT 8.0

Nerve Agent Triage - “Delayed”

• Initial symptoms are improving (miosis still present)

• Recovering well from pre-hospital antidote therapy

DPT 8.0

Nerve Agent Triage -“Minimal” & “Expectant”

Minimal

• Walking and talking which indicates intact breathing and circulation

Expectant

• Apneic for more than 5 minutes

• No pulse or blood pressure

DPT 8.0

Mustard Triage

Delayed

• 2 to 50% BSA burns by liquid

• Eye involvement

Minimal

• < 2% BSA burns by liquid in non-critical areas

Immediate

• Moderate to severe pulmonary symptoms

Expectant

• > 50% BSA burns by liquid; apneic / pulseless

DPT 8.0

Triage of Biological Casualties

• Triage of biological agent casualties is different

– Symptoms are delayed

– Initial cases may go unrecognized

– More difficult to detect

• Epidemiological information becomes critical

DPT 8.0

Radiological Triage

• Triage:

– Stabilize the patient first and only when this is done does one consider irradiation and contamination.

– Ensure ABCs

DPT 8.0

Triage - Psychological Casualties

• Disasters produce tremendous emotional and psychological stress, with large numbers of psychogenic casualties

• Presenting signs could be confused with organic disease

• Use of START triage system maintains focus on objective signs of disease & minimizes impact of subjective complaints on the triage process

• Psychological casualties are usually triaged as “minimal”

DPT 8.0

Triage - Hospital Arrivals

• Casualty arrival is

uncoordinated

• Arrival times vary

• Closest hospital is typically

overwhelmed

• Medical needs of unaffected

community continue

DPT 8.0

Triage - Contaminated Human Remains

• Problems are agent-specific

– Decontamination

– Containment

– Refrigeration until definitive disposal

• Follow local coroner and medical examiner protocols– Establish cooperative agreements for fatality management

• Secure personal effects– Not all can be decontaminated

DPT 8.0

Staff Preparedness

• Plan for the needs of the unaffected population

• Prepare to receive large numbers of casualties

• Prepare to receive large numbers of dead

• Rotate staff to avoid congestion and fatigue, especially personnel in PPE

DPT 8.0

Logistics / Supplies

• Highest priority: getting the right resources to the right place at the right time– Personal protective equipment and dosimetry

– Medications / antidotes / vaccines

– Mechanical ventilators

– Isolation rooms remote from other patients

• Identify current inventory and augment as necessary

• Develop a procedure to access external assets

DPT 8.0

Maximal Utilization of Hospital Space

• Identify alternative medical treatment areas

• Planning for use of available space

– Open areas

– Isolated areas

– Temporary morgue

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DPT 8.0

Handling of Evidence

• Maintaining evidence is critical for an investigation

– Clothing

– Embedded foreign bodies

– Decontamination runoff

• Chain of Evidence must be maintained

EVIDENCE

EVIDENCE

DPT 8.0

Exercising the Plan

• Start small - few casualties

• Be realistic

• Coordinate with other agencies / hospitals

• Exercise frequently

DON’T WAIT FOR A DISASTER TO HAPPEN

DPT 8.0

Scenario

A football championship was what the city needed to boost its national reputation, and tonight was the night. Every hotel within 30 miles was booked with fans eagerly awaiting the game.

After the national anthem was played the crowd began to loudly chant their team’s respective fight song. The sounds within the stadium were deafening.

DPT 8.0

Scenario

Just as the game was ready to begin fans from section “A” started to run from their seats. Total chaos ensues. In a rampage fans were pushing and shoving trying to get out through the exit doors. Many were being trampled upon during the exodus. Most were coughing, rubbing their eyes, and many appeared to be choking.

911 was called and the closest hospital, two blocks away, was also notified.

DPT 8.0

Scenario

Assume you are working in the emergency department, please answer the following:

• After notification, what would you do?

• Where would you set up triage?

• Who would function as the triage officer?

• Where would you set up & perform decon?

DPT 8.0

Scenario

Within 15 minutes of the incident 100 victims arrive at your hospital without the assistance of EMS

• How will you control access into your hospital?

• What level of protective gear should be worn?

• Should these victims be decontaminated?

• How will you decontaminate these victims?

• Where will you treat the first wave of victims?

DPT 8.0

Scenario

Victims are complaining of shortness of breath, cough, eye & throat irritation, and burning skin.

• What chemical were they exposed to?

• What clues would you look for to help you identify the agent?

• Lacking positive agent identification, how would you begin treatment?

• What medications/antidotes are necessary?

DPT 8.0

Teaching Points

• Hospitals must expand their emergency planning and scope of services to include NBC care

• Concentrate on the disaster planning process

• Develop policies & procedures

• Train frequently using realistic scenarios