MASS Triage Chapter 1 Part B V 2

® MASS Triage Chapter 1 Part B V 2. 6 03/06 ® BDLS is a registered trademark of the American Medical Association

Objectives • Define disaster triage • List components of MASS triage • Discuss importance and utilization of triage tags • Identify victim triage categories for simulated triage scenario 2

Triage System Types Triage systems “sort” patients for a variety of purposes and situations: • Military Triage • Emergency Department Triage • Disaster Triage 3

Disaster Triage • Sorting patients by the seriousness of their condition and the likelihood of their survival • To achieve the greatest good for the greatest number possible • Dependent on resources available 4

Disaster Triage Factors impacting available resources: • Volume and severity of patients • Limited providers • Infrastructure limitations • Inadequate hazard preparation (HAZMAT, etc. ) • Limited transport capabilities • Multiple agencies responding • Hospital Resources Overwhelmed 5

Disaster Triage Methods used must be: • Simple • Effective • Easily remembered • Able to sort large numbers of patients quickly 6

Disaster Triage Key Principles: • Life, Limb or Vision Threat • Medical Intervention Needed • Transportation Access 7

Disaster Triage • How do I identify the most injured victims quickly? • How do I get ambulatory or least injured victims out of the dangerous scene quickly? 8

D-I-S-A-S-T-E-R Paradigm Triage Categories: • “ID-me”! “Identify Me” – A mnemonic for sorting patients during triage I – Immediate D – Delayed M – Minimal E – Expectant D - DEAD V 2. 6 03/06 9

D-I-S-A-S-T-E-R Paradigm Triage M. A. S. S. Triage System M – Move A – Assess S – Sort S – Send V 2. 6 03/06 10

MASS Flow Chart V 2. 6 03/06 11

M. A. S. S Triage • Move • Anyone who can walk is told to MOVE to a collection area • Remaining victims are told to MOVE an arm or leg • Assess • Remaining patients who didn’t move (help these people first) • Sort • Categorize patients by “ID-me” • Immediate, Delayed, Minimal, Expectant, Dead • Send • Transport IMMEDIATE patients first • Send to Hospitals and Secondary Treatment Facilities 12

M. A. S. S Triage Key Principle of MASS Triage: • Group, then Sort! …then Transport! 13

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Step 1: • Goal • Group - Ambulatory Patients • Action: • “Everyone who can hear me and needs medical attention, please move to the area with the green flag” • “ID-me” Category • Minimal initial group 14

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” • Minimal group, initial screening – Airway, breathing, and circulation intact – Mental status: able to follow commands – Not likely low blood pressure or breathing trouble – Some conditions worsen, more urgent triage category – Must be reassessed and monitored – Limitations: not based upon individual assessment yet • Actively managing this group will reduce selftransports and perhaps unnecessary overburdening of nearest hospital ER’s • Assess last, after Immediate and Delayed groups 15

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” Step 2: • Goal – Group – can’t walk, but awake and able to follow commands to MOVE an arm or leg • Action: – Ask the remaining victims “everyone who can hear me please raise an arm or leg so we can come help you” • “ID-me” Category – Delayed initial group 16

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “MOVE” • Delayed group – Airway, breathing, and circulation adequate to follow simple commands – Mental status: Conscious & able to follow simple commands • May have low blood pressure or low oxygen level • Likely significant injuries present • Limitations: not based upon individual assessment yet • Assess second, after Immediate group 17

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” • Goal – Group – Identify location of who is left, unable to ambulate and unable to follow simple commands • Action: – Proceed immediately to these patients and deliver immediate life-saving interventions • “ID-me” Category – Immediate initial group 18

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” • Immediate group – – – ABC status unknown, immediate assessment Mental status: Unresponsive to verbal commands Likely low blood pressure or low oxygen level Life-threatening injuries present Expectant and dead patients may be in this group Minor injuries may be present due to: • Ruptured ear drums, hearing impaired, chronically disabled – Limitations: not based upon individual assessment • Assess these people FIRST! 19

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “ASSESS” IMMEDIATE patients • Rapidly Assess ABC’s : – – – Is airway open? Open it manually Is patient breathing? If not, EXPECTANT and go on Is uncontrolled bleeding present? Assign direct pressure (do not hesitate to use tourniquet!) – Is likely fatal injury present? If yes, EXPECTANT • • • Correct immediate life threats Accurate count of immediate patients Is transport available for anyone now? …Move on! 20

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” • Everyone should be able to complete the “Move” and “Assess” steps of Triage • “Sort” requires a level of patient assessment skills beyond basic first aid / buddy aid • If you are unable to “Sort”, then assure that appropriate emergency medical services are enroute and continue to “move and assess” 21

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” - “ID-me”: I – Immediate D – Delayed M- Minimal E – Expectant D - DEAD “SORT” them based upon individual assessment, …continue lifesaving treatment 22

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Immediate • Life or limb threatening injury • Usually persistent ABC problem • Examples: – Unresponsive, altered mental status, severe breathing trouble, uncontrollable bleeding, proximal amputations, turning blue, rapid and weak pulse… 23

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Delayed: • Need definitive medical care, but should not worsen rapidly if initial care is delayed • Examples: – Deep cuts or open fractures with controlled bleeding and good pulses; finger amputations; abdominal injuries with stable vital signs… 24

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Minimal: • “Walking Wounded” • Treated and released (preferably without transport) • Source of “volunteer” help • Examples: – Abrasions, contusions, minor lacerations, no apparent injury 25

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” Expectant • Severely injured with little or no chance of survival • Care resources not utilized initially • Comfort resources used as available • Remember death could be hours or days away! • Require reassessment and transport: – If alive after all immediate patients transported, resuscitate per available resources! 26

D-I-S-A-S-T-E-R Paradigm MASS Triage Model • How to handle the dead patients: – Dead patients should not be moved – May aid in identification of the deceased • Evidence is important! – Finding and convicting perpetrators. . and possibly. . . PREVENTING future attacks! – Excessive manipulation of human remains may destroy vital evidence 27

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SORT” is dynamic! Reassess! • Who is left? • Expectant group could become new Immediate group • “Most serious” injury present requires your immediate attention! 28

D-I-S-A-S-T-E-R Paradigm MASS Triage Model • When all patients have been triaged and immediate life saving procedures complete: – Accurate count in each category – Advise incident commander/triage officer – Move all immediate to collection point – Prepare for immediate transport – Often marked with red flag/tarp 29

D-I-S-A-S-T-E-R Paradigm MASS Triage Model “SEND” • Traditional syntax • Immediate →Delayed →Minimal →Expectant • Objective • Transport or release ALL living patients ASAP • Mission Focused • Send Minimal(s) with each Immediate (if unused space available in vehicle), etc… • Resourceful • Secondary treatment facilities for minimal pts (or on-scene treatment and release) • Utilize buses, taxis, trains, boats, etc. . 30

M. A. S. S Triage Key Principle of MASS Triage: • Group, then Sort! …then Transport! 31

Medical Record • Triage Tags • Communication – History & Physical – Treatment – Contact information – Personal message Front Back 32

Summary Now you can: • Define disaster triage • List components of MASS triage • Discuss importance and utilization of triage tags 33

Questions? 34

Triage “Tabletop” 35

Triage Scenario • Shooting incident at a Local Sporting Event – Multiple gunshots were fired – You are first at the scene – 10 victims • What do you do? 36

Is Need > Resources? • D- Detect – Is this a disaster / MCI? (need>resources) • I- Incident Command – Who is in charge? (incident commander) Who will you contact? • S- Scene Safety/Security – Is it safe enough to enter? • A- Assess Hazards – Active shooter? Secondary device? Further penetrating trauma • S- Support – Law enforcement, EMS, Medical Control, Trauma Center, etc. . • T- Triage/Treatment – 10 victims • E- Evacuation – What vehicles are available? What route is safe? • R- Recovery 37

MASS Triage • Move – Two walk – Three move • Assess – Five do not move • Sort – IDME categories • Send 38

MASS Triage • Move – Two walk (Minimal Group) – Three move (Delayed Group) • Assess – Five do not move (Immediate Group) • Sort – IDME categories • Send 39

MASS: Immediate Group Unable to “MOVE” • 29 yr male Immediate – GSW to left chest, awake in severe respiratory distress • 8 yr female Expectant – GSW to head (through and through) RR=4, HR=101 • 50 yr male Dead – GSW to abdomen & chest, RR=0, HR=0, not moving • 40 yr female Immediate – GSW to neck with gurgling respirations, marked respiratory distress • 16 yr male Immediate Vs Expectant – GSW right chest, No respiratory effort, HR=130 thready 40

MASS: Delayed Group Able to MOVE, not walk • 14 year male Immediate -Delayed** – GSW to R upper arm, active massive hemorrhage, good pulses **after pressure dressing • 65 year male Immediate – No obvious GSW, c/o severe chest pain, diaphoretic, and SOB • 22 year female Delayed – GSW to R leg, good pulses, no active bleeding, normal VS 41

MASS: Minimal Group Able to “MOVE” out • 29 yr male Minimal – Superficial “scratch” wound to L arm, no deeper penetration • 37 yr male Delayed – GSW to left hand, exposed muscle, tendon and bone fragments, capillary refill < 2 sec 42

Triage Status Category SORT Immediate Delayed Minimal Expectant DEAD 4 -5* 2 1 1 -2* 1 43

SORT: Immediate • 29 yr male Delayed – GSW to left chest, awake in severe respiratory distress: Needle decompression of L chest successful, VSS • 40 yr female Dead • 14 year male Delayed – GSW to neck with gurgling respirations, marked respiratory distress: Airway management unsuccessful, profuse bleeding occurred, pt now apneic and pulseless – GSW to R upper arm, active massive hemorrhage, good pulses: Now well controlled, no active bleeding, VSS • 65 year male Immediate – No obvious GSW, c/o severe chest pain, diaphoretic, and SOB: Symptoms continue 44

SORT: Delayed • 22 year female Delayed – GSW to R leg, good pulses, no active bleeding, normal VS: Splinted leg, VSS • 37 yr male Immediate – GSW to left hand, exposed muscle, tendon and bone fragments, initial capillary refill < 2 sec: Now L hand is pulseless and cyanotic 45

SORT: Minimal • 29 yr male Minimal – Superficial “scratch” wound to L arm, no deeper penetration: No clinical change, desires to leave and go home 46

SORT: Expectant • 16 yr male Dead – GSW right chest, No respiratory effort, HR=130 thready: Now no palpable pulse, no respiratory effort • 8 yr female IMMEDIATE? – GSW to head (through and through) RR=4, HR=101: RR=6 -8, HR=100 47

Triage Status Category SORT Immediate Delayed Minimal Expectant DEAD 4 -5* 2 1 1 -2* 3 3 1 0 1 3 48

Summary Now you can: • Define disaster triage • List components of MASS triage • Discuss importance and utilization of triage tags • Identify victim triage categories for simulated triage scenario 49

Questions? 50