Topics Topics TriageTriage

First respondersFirst responders

Role of AnaesthesiologistRole of Anaesthesiologist AIIMS Hospital disasterAIIMS Hospital disaster plan plan

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Triage - historyTriage - history

Origins from French word Origins from French word triertrier

Implying a division into three groupsImplying a division into three groups

Literally meaning “Literally meaning “to sort “to sort “

Credit goes to Credit goes to Dominique Jean LarryDominique Jean Larry

Triage - definitionTriage - definition

A brief clinical assessment that determinesA brief clinical assessment that determines the time and sequence in which patientsthe time and sequence in which patients

should be seen in the ED (or) in the field,should be seen in the ED (or) in the field,

speed of transport andspeed of transport and

choice of hospital destination choice of hospital destination

The necessity of triageThe necessity of triage

Allocation of limited resourcesAllocation of limited resources

Golden hour conceptGolden hour concept providing cost effective emg medical care to providing cost effective emg medical care to critically injured pts with in a defined time critically injured pts with in a defined time frame frame

Injury type Injury type

Crush:Crush:

limblimb

chest/abdomenchest/abdomen

head head

Uncontrolled ext hmgUncontrolled ext hmg

arterialarterial

venousvenous

Uncontrolled int hmg Uncontrolled int hmg

arterialarterial

venousvenous

visceralvisceral

22ndnd/3/3rdrd degree burns degree burns

Critical time to treat Critical time to treat

(hr)(hr)

6-126-12

0-10-1

0-0.1 0-0.1

0-10-1

1-61-6

0.5-10.5-1

1-61-6

3-83-8

1-61-6

Types of triageTypes of triage

Trauma triageTrauma triage

mechanism of injury mechanism of injury anatomic criteria anatomic criteria medical/physiological criteria medical/physiological criteria Disaster triage Disaster triage

simplesimple advancedadvanced

Clinical scores used in disaster Clinical scores used in disaster triagetriage

In simple triageIn simple triage

r p m scaler p m scale

a p v u score a p v u score

In advanced triage In advanced triage

revised traumarevised trauma score score

Simple triageSimple triage

Used at the scene of mass casualty Used at the scene of mass casualty to choose pts requiring immediate transport to choose pts requiring immediate transport to the hospitalto the hospital

Done by trained first responders, para Done by trained first responders, para medics and medical personnelmedics and medical personnel

STARTSTART

SSimpleimple

TTriageriage

AAndnd

RRapidapid

TTreatmentreatment

START TriageSTART Triage

IM M ED IA TE

O ver 30/m in

IM M ED IA TE

C ontro lB leeding

R adial Pu lseA bsent

O ver 2seconds

U nder 2seconds

C apillaryR efill

IM M ED IA TE

C an't Fo llowSim ple C om m ands

D ELA YED

C an FollowSim ple C om m ands

M ENTAL STATUS

R adial Pu lsePresent

PERFUSION

U nder 30/m in

Yes

IM M ED IA TE

Yes

D EC EA SED

N o

Position A irw ay

N o

RESPIRATIONS

All WalkingWounded

MINOR

STARTSTART

Performed by trained lay and emg personnelPerformed by trained lay and emg personnel Not intended to supersede or instruct medical Not intended to supersede or instruct medical

personnel or techniquespersonnel or techniques

Field-proven in mass casualty incidentsField-proven in mass casualty incidents

Identifies which persons need advanced careIdentifies which persons need advanced care

CategoryCategory

START separates the injured into four group START separates the injured into four group

Deceased : left where they fellDeceased : left where they fell

Immediate : evacuated at onceImmediate : evacuated at once

Delayed : until all immediate personsDelayed : until all immediate persons

have been transportedhave been transported

Minor : not evacuated Minor : not evacuated

Advanced triageAdvanced triage Done by paramedics, medical personnel or by Done by paramedics, medical personnel or by

skilled nurses skilled nurses

Done at the EDs of hospitalsDone at the EDs of hospitals

Triage tags are used for this purposeTriage tags are used for this purpose

Injured people are sorted into five categoriesInjured people are sorted into five categories

Color coding Color coding

Black//Expectant: eg large body Expectant: eg large body burns, cardiac arrest burns, cardiac arrest

RedRed/immediate : cannot wait/immediate : cannot wait

YellowYellow/observation: requires /observation: requires watching and re-triagewatching and re-triage

GreenGreen/wait: require care in hours /wait: require care in hours to daysto days

White/dismiss: minor injuriesWhite/dismiss: minor injuries

Revised Trauma ScoreRevised Trauma Score

Glasgow Glasgow Coma Coma ScaleScale

Systolic Systolic BP BP

(mm hg)(mm hg)

RespiratoRespiratory ry

Rate Rate

CodedCoded

Value Value

13-1513-15 >89 >89 >29>29 44

9-129-12 76-89 76-89 10-2910-29 33

6-86-8 50-75 50-75 6-96-9 22

3-53-5 1-49 1-49 1-51-5 11

33 11 00 00

REVERSE TRIAGEREVERSE TRIAGE

There are conditions where sometimes the There are conditions where sometimes the less wounded are treated in preferenceless wounded are treated in preference to to the more severely woundedthe more severely wounded

Like situations where significant numbers of Like situations where significant numbers of medical personnel are among the affected medical personnel are among the affected patientspatients

First respondersFirst responders

A A certified first respondercertified first responder is a person is a person who has completed who has completed forty to sixty hours of forty to sixty hours of trainingtraining in providing care for medical in providing care for medical emergencies. They have more skill than emergencies. They have more skill than someone who is trained in first aid but are someone who is trained in first aid but are not emergency medical technicians.not emergency medical technicians.

The American Red Cross conducts a The American Red Cross conducts a course titled "Emergency Response" that course titled "Emergency Response" that fits this definition.fits this definition.

FIRST RESPONDER CATEGORYFIRST RESPONDER CATEGORY

Traditional First RespondersTraditional First Responders fire fighters, police personnelfire fighters, police personnel

Non Traditional First Responders Non Traditional First Responders teachers, childcare workers and teachers, childcare workers and school bus drivers, worker-school bus drivers, worker- volunteers in a large facility volunteers in a large facility (industrial plant), aviation pilots, (industrial plant), aviation pilots, sports coachessports coaches

First Responder SkillsFirst Responder Skills

Recognizing unsafe scenes and hazardous materials Recognizing unsafe scenes and hazardous materials emergenciesemergencies

Protection from blood borne pathogensProtection from blood borne pathogens

Controlling bleeding, applying splintsControlling bleeding, applying splints

Conducting a primary life-saving patient assessmentConducting a primary life-saving patient assessment

In-line spinal stabilization and transportIn-line spinal stabilization and transport

Emergency defibrillation when to call for more advanced Emergency defibrillation when to call for more advanced medical helpmedical help

The use of oxygen and airway adjuncts. The use of oxygen and airway adjuncts.

First responder training is a First responder training is a cost-effective cost-effective wayway to extend the reach of the emergency to extend the reach of the emergency medical system, but medical system, but not a substitutenot a substitute for for EMT-Basic training for those employed to EMT-Basic training for those employed to provide emergency medical services on a provide emergency medical services on a daily basis. daily basis.

First Responder SkillsFirst Responder Skills

AnesthesiologistAnesthesiologist & & disasterdisaster

managementmanagement

Anesthesiologists are Anesthesiologists are acute care physiciansacute care physicians with expertise in with expertise in airway managementairway management, , physiologic monitoringphysiologic monitoring, , patient stabilizationpatient stabilization and and life supportlife support, , fluid resuscitationfluid resuscitation, and , and crisis management.crisis management.

Can function adequately as Can function adequately as team membersteam members in field medical teams, the emergency in field medical teams, the emergency room and ICUroom and ICU

Can maintain the Can maintain the life support chain life support chain

WhatWhat is the role of Anesthesiologists in is the role of Anesthesiologists in Emergency Response?Emergency Response?

SortSort, , triagetriage, , stabilizestabilize, and , and resuscitateresuscitate casualtiescasualties

Establish Establish definitive airway controldefinitive airway control

Provide external Provide external hemorrhage controlhemorrhage control

Diagnose and treat life-threateningDiagnose and treat life-threatening conditions conditions commonly observed in victims of disasterscommonly observed in victims of disasters

Establish Establish intravenous accessintravenous access

Manage Manage intensive careintensive care patients in the ICU patients in the ICU

Cont ..Cont ..

Guide Guide fluid resuscitationfluid resuscitation and blood and blood component therapycomponent therapy

Perform Perform regional and general anesthesiaregional and general anesthesia wherever needed or feasiblewherever needed or feasible

TransportTransport critically ill patients critically ill patients

Manage Manage acute painacute pain

Alleviate painAlleviate pain and suffering among patients and suffering among patients triaged to dietriaged to die

A.I.I.M.S Disaster CommitteeA.I.I.M.S Disaster Committee

Chairman – Director, AIIMS.Chairman – Director, AIIMS.

Members -Prof. & Heads of following Members -Prof. & Heads of following departments : departments : Surgery, Orthopeadics, Medicine, Surgery, Orthopeadics, Medicine,

Forensic Medicine, Neuro surgery,Forensic Medicine, Neuro surgery,

Radio diagnosis, GI Medicine,Radio diagnosis, GI Medicine,

Anaesthesiology, Chief Nursing OfficerAnaesthesiology, Chief Nursing Officer

and Medical Superintendent. and Medical Superintendent.

Activating the planActivating the plan On receipt of the information the Duty officer On receipt of the information the Duty officer

will activate the plan will activate the plan

Inform the Director, MS and Security OfficerInform the Director, MS and Security Officer

Officer-in-charge : HOD of Hospital Officer-in-charge : HOD of Hospital Administration Administration

Chief Co-ordinator :MS Chief Co-ordinator :MS

Reception centreReception centre Moderate load : casualty OPDModerate load : casualty OPD

Heavy load : main hall of ground floor Heavy load : main hall of ground floor

OPDOPD

Police and AIIMS security personnel Police and AIIMS security personnel will act as traffic controllers under the will act as traffic controllers under the orders of the co- ordinatororders of the co- ordinator

First-aid & triageFirst-aid & triage For moderate load : existing casualty For moderate load : existing casualty

medical teammedical team

For heavy load : the centre will be For heavy load : the centre will be manned by 4 teams each consisting of:manned by 4 teams each consisting of:

1 Surgeon, 1 Orthopaedician, 1 1 Surgeon, 1 Orthopaedician, 1 Physician, 1 Anaesthesiologist, 2 Physician, 1 Anaesthesiologist, 2 Sisters, 2 Nursing orderlies, 1 Sisters, 2 Nursing orderlies, 1 Sweeper, 2 Teams of stretcher-Sweeper, 2 Teams of stretcher-bearers. bearers.

TriageTriage Priority one : needing immediate Priority one : needing immediate

resuscitationresuscitation Priority two : immediate surgery Priority two : immediate surgery

Priority three: needing first aid and Priority three: needing first aid and possibly surgerypossibly surgery

Priority four : needing only first aid Priority four : needing only first aid

ActionAction Priority one :attended in the casualty Priority one :attended in the casualty

and if need arises will be sent to AB8 ICUand if need arises will be sent to AB8 ICU

Priority two: transferred immediately to Priority two: transferred immediately to C.O.T and M.O.T.C.O.T and M.O.T.

Priority three : admitted or transferred to Priority three : admitted or transferred to other hospital other hospital

Priority four : given first aid and sent Priority four : given first aid and sent home home

Additional wards/bed spacesAdditional wards/bed spaces Corridors of AB and D wing first floorCorridors of AB and D wing first floor

Any vacant beds in the wardsAny vacant beds in the wards

Pre- anaesthesia roomPre- anaesthesia room

By discharging pre op elective casesBy discharging pre op elective cases

Ward side rooms and seminar rooms Ward side rooms and seminar rooms

Other servicesOther services Documentation centre Documentation centre Linen and general storeLinen and general store Hospital securityHospital security Food servicesFood services AmbulancesAmbulances Engineering and Maintenance servicesEngineering and Maintenance services

Drugs and equipmentsDrugs and equipments Medical and surgical store keepers will be called Medical and surgical store keepers will be called

at onceat once

Buffer stock in the casualty will be utilized as an Buffer stock in the casualty will be utilized as an immediate measureimmediate measure

All essential drugs and emergency trays will be All essential drugs and emergency trays will be issuedissued

Efforts will be made for blood upon the Efforts will be made for blood upon the responsibility of B.T.O./Asst. B.T.Oresponsibility of B.T.O./Asst. B.T.O

StaffStaff

Medical staff : members of regular clinical Medical staff : members of regular clinical units and para/pre clinical disciplinesunits and para/pre clinical disciplines

Nursing staff : a pool of nurses will be Nursing staff : a pool of nurses will be created by Nursing Supdt.created by Nursing Supdt.

Class Class VIVI staff : Sanitary Supdt will create a staff : Sanitary Supdt will create a poolpool

The duty roster will be available in the The duty roster will be available in the control room control room

Information servicesInformation services The Faculty In charge public relation officer The Faculty In charge public relation officer

(PRO) of the AIIMS will function as (PRO) of the AIIMS will function as information officer information officer

All information to press, radio, individuals All information to press, radio, individuals and organizations will be issued by him and organizations will be issued by him

CONCLUSIONCONCLUSION

Disaster strikes at unpredictable hours and placesDisaster strikes at unpredictable hours and places

Requires in-depth planning, logical thinking and Requires in-depth planning, logical thinking and suitable protocolssuitable protocols

Effective participation in emg medical care in disaster Effective participation in emg medical care in disaster is enhanced by acquisition of competency in ATLS, is enhanced by acquisition of competency in ATLS, basic principles of mass casualty management and basic principles of mass casualty management and knowledge of the anaesthetic methods and knowledge of the anaesthetic methods and techniques techniques

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