1. LESSON 26
INCIDENT MANAGEMENT

2. Introduction
Organized approach needed to manage scene and treat patients on priority basis
National Incident Management System (NIMS), through Incident Command System (ICS), directs response
Your role within NIMS may differ from your everyday role as an EMR

3. National Incident Management System
Large-scale emergency requires personnel and resources from multiple jurisdictions
NIMS created to coordinate and manage this response

4. Benefits of NIMS Unified approach to incident management
Standardized command and management structures
Emphasis on preparedness, mutual aid, resource management

5. Administration of NIMS
Administered by United States Department of Homeland Security
Includes many other agencies such as FEMA
NIMS has a National Response Plan (NRP)
NRP continues to be refined

6. Elements of NIMS Preparedness
Communications and Information Management
Resource Management
Command and Management
Ongoing Management and Maintenance

7. The Incident Command System
Part of NIMS that focuses on response to:
Acts of terrorism
Wildfires and urban fires
Hazardous materials spills
Nuclear accidents
Aircraft accidents
Earthquakes, hurricanes, tornadoes, floods and other natural disasters
War-related disasters
Other mass-casualty incidents

8. EMRs in ICS All EMS personnel have crucial role
Most EMRs will receive training related to their role in ICS

9. NIMS and ICS Training
All personnel should receive training in NIMS and ICS
Training is required to receive federal preparedness funding assistance
Includes federal, state and local government employees
Different courses required at different levels

10. Mass-Casualty Incidents
Emergency in which multiple patients need care
Mass-Casualty Incidents (MCIs) can be stressful
Large MCI can strain EMS resources
Different EMS systems define MCIs in different ways

11. Large MCIs
Small MCI may be handled within single EMS system, but larger MCIs require multiple jurisdictions
ICS directs and manages emergency response
ICS and triage used for giving medical care in MCIs

12. Incident Command System for Mass-Casualty Incidents
Oversees all aspects of response
Organizes, coordinates, controls resources and personnel
Similar functions grouped for maximum effectiveness
Lines of authority clearly identified
Advance planning for possible incidents prepares specific Incident Action Plans (IAP)

13. Incident Commander
Assigned overall supervisory responsibility for workers and resources
Directs the emergency response
First-responding unit announces to dispatcher that MCI exists
Command role is established
Command may be transferred to another person
Incident Commander functions from a command post

14. Sectors
Rescuers assigned to section, or sector, with specific responsibilities
Each section supervised by Section Chief who reports to Incident Commander
4 primary sections in ICS:
Operations
Planning
Logistics
Finance/Administration

15. Operations Sector
Focuses on providing medical care and controlling immediate hazards
May be further broken down into groups, each with its own leader
Personnel may be organized in task forces or strike teams
Common tasks for EMRs:
Triage
Treatment
Transportation
Staging

16. Role of EMRs in MCIs
If you are first to respond, recognize emergency, report in to and request assistance
First knowledgeable EMS provider on scene becomes triage officer
Triage assessment performed on all patients
Available personnel and equipment are first directed to highest-priority patients
EMRs may be assigned to different sections with different responsibilities

17. On Arrival at an MCI Report to staging section or command post
Identify yourself, level of training, follow directions
Report immediately to assigned section and individual in charge
Perform only task you are assigned
If you complete assigned task, report back for new assignment
Act only on direction of supervisory personnel

18. Differences in MCIs MCIs are stressful and may seem chaotic
Accept your assignment without question unless you are inadequately trained for the task
If asked to wait, be patient
Some of your usual procedures will likely be suspended
Perform whatever tasks you are assigned, regardless of your “normal” responsibilities

19. Triage

20. Triage
Process of sorting patients by severity of injuries and documenting location and transport needs
Different triage systems have been developed with varying categories
START system commonly used for rapidly triaging and treating large number of patients
START requires only limited medical training
<60 seconds/patient to complete

21. Triage Categories
Each patient is tagged with a colored tag indicating triage category:
Priority 1  Red  Immediate care needed
Priority 2  Yellow  Delayed care
Priority 3  Green  Minor care (hold)
Priority 4  Black  No care needed

22. Triage Process Quickly size up scene
With few patients, triage can proceed quickly and tags may not be needed
When there are many patients, tags are generally used
Triage officer designated
In scene with many patients, patients with minor injuries asked to walk to designated area, if they can walk without assistance

23. Triage Process (continued)

24. Triage Process (continued)
Remaining patients are triaged, each in <60 seconds
START system evaluates each patient’s breathing, perfusion or circulation, and mental status to assign triage category
Triage a patient and move immediately to next
When all patients triaged, personnel begin providing care for Priority 1 patients first

25. Acronym RPM for Steps of START Assessment
R = Respiration
P = Perfusion
M = Mental status

26. Step 1  Assess Breathing/Respiration

27. Step 2  Assess Perfusion
For patient breathing without opening airway, next check pulse or capillary refill
If pulse is present or capillary refill is under 2 seconds, assess mental status
If pulse is weak or irregular, tag Priority 1 (red tag)
If pulse is absent or capillary refill time is over 2 seconds, tag Priority 1 (red tag) – if patient is bleeding severely, apply pressure dressing

28. Step 3  Assess Mental Status
For patient who is breathing and has adequate circulation or perfusion, give simple command such as “Open your eyes” or “Squeeze my hand”
Patients who follow command are considered alert/responsive and tagged Priority 2 (yellow tag)
Patients who cannot follow command are considered unresponsive and are tagged Priority 1 (red tag)

29. After Triage Re-evaluation is ongoing
Observe or check status of patients originally categorized as Priority 2 or 3
Priority 2 may become unresponsive, making patient Priority 1

30. National Trauma Triage Protocol
Use the National Trauma Triage Protocol to determine where Priority 1 patients tagged red and Priority 2 patients tagged yellow should be transported

32. Pediatric Triage

33. Pediatric Triage
START system criteria less effective for infants and children:
Respiratory rate >30 breaths/minute may not be a problem in infant or child
Child who has just stopped breathing may have a pulse
Young child may not respond to command for other reasons or be too young to respond as expected

34. JumpSTART Triage for Pediatric Patients
Assess same characteristics; follow different criteria and take somewhat modified steps
First ask children who can walk to move to one side and tag them as green (Priority 3)

35. JumpSTART Pediatric Triage Process
Assess breathing
Assess circulation
Assess mental status

36. Step 1  Assess Breathing
Check whether child is breathing
If breathing at rate of breaths/minute, move on to assess circulation
If breathing <15 or >45 breaths/minute or if breathing is irregular, tag Priority 1 (red tag)
If not breathing, open airway

37. Step 1  Assess Breathing (continued)
If still not breathing, look in mouth for foreign body obstruction and remove
If now breathing, tag child Priority 1 (red tag)
If not breathing, check for a pulse
If no pulse, tag patient Priority 4 (black tag)
Give child with a pulse 5 ventilations; if breathing begins, tag red and move on
If no breathing, tag black

38. Step 2  Assess Circulation
For child breathing breaths/minute without opening airway, check pulse in an uninjured extremity
If you feel a pulse, assess mental status
If no pulse, tag patient Priority 1 (red tag)

39. Step 3  Assess Mental Status
For child who is breathing and has pulse, assess mental status with AVPU assessment
A child alert and responding is tagged Priority 2 (yellow tag)
A child not responding or responding inappropriately to pain is considered unresponsive and tagged Priority 1 (red tag)