1. Welcome to Triage BECAUSE IT HAPPENS!

2. What Would You Do?

3. Are You Protected?

4. Importance of ABC’s Keeps us all alive Keeps us all alive Airway, breathing, circulation Airway, breathing, circulation Constant evaluation needed in any medical emergency situation Constant evaluation needed in any medical emergency situation Your game plan as a rescuer Your game plan as a rescuer

5. Airway, Breathing, and Circulation Concerning the A, B, C’s What do you know about some who is talking? What do you know about some who is talking? Someone who is walking or standing? Someone who is walking or standing? Someone who is not responding? Someone who is not responding?

6. When “IT” Happens First priority is rescuer’s safety First priority is rescuer’s safety –Survey the scene –Personal protection Getting help Getting help –911 –Other people

7. What is Triage French word “to sort” French word “to sort” Anymore than two victims Anymore than two victims Overwhelms resources and people on scene Overwhelms resources and people on scene

8. START System Simple Triage And Rapid Treatment Based on three important basic assessments Based on three important basic assessments –Respiratory Rate – How fast –Perfusion – Good radial pulse, or capillary refill –Mental status – able to follow simple commands RPM

9. Patient Care Activities During Initial Assessment Open airway Open airway Control profuse bleeding Control profuse bleeding Treat for shock Treat for shock

10. Opening the Airway

11. Bleeding To control bleeding 1.Direct pressure 2.Elevate above the heart 3.Pressure point Have patient, bystander, or walking wounded help with direct pressure Consider shock position Consider shock position (supine, legs elevated)

12. Capillary Refill Capillary refill –Amount of time for a compressed capillary bed to refill with blood

13. Immediate Patient Respiratory Rate (how many times a minute do they breath) Respiratory Rate (how many times a minute do they breath) –Greater than 30 per minute Capillary Refill/Pulse Capillary Refill/Pulse –Greater than 2 seconds or no radial pulse Altered Mental Status Altered Mental Status –Unable to understand simple commands If any one criteria is met - the patient is classified IMMEDIATE If any one criteria is met - the patient is classified IMMEDIATE

14. Delayed Patient Patient is unable to walk Patient is unable to walk Respiratory Rate Respiratory Rate –Less than 30 per minute Capillary Refill Capillary Refill –Less than 2 seconds Mental Status Mental Status –Able to understand simple commands If the patient meets ALL of the criteria, the patient is classified as DELAYED If the patient meets ALL of the criteria, the patient is classified as DELAYED

15. Minor Patient “Walking Wounded” Has a minor injury and is able to walk from the scene to the minor treatment area Has a minor injury and is able to walk from the scene to the minor treatment area Needs to be tagged but can wait a significant amount of time to be treated Needs to be tagged but can wait a significant amount of time to be treated If the patient meets the criteria and walks to the treatment area – classified as Minor If the patient meets the criteria and walks to the treatment area – classified as Minor

16. Dead Non-breathing after the airway has been repositioned Non-breathing after the airway has been repositioned If the patient breathes spontaneously after opening the airway, the patient is IMMEDIATE If the patient breathes spontaneously after opening the airway, the patient is IMMEDIATE

18. Scenario Examples 35y/o female with large laceration on forehead 35y/o female with large laceration on forehead –Respiratory = 25 –Blanch < 2 sec. –Follows commands and walks to treatment area 67y/o male with sub- sternal chest pain –Respiratory = 28 –Pulse is present –Follows commands but remains seated MINOR DELAYED

19. Scenario Examples 5y/o female with no sign of injury 5y/o female with no sign of injury –Respiratory = 0 –Blanch > 2 sec. –Fails to follow commands 45y/o male with open fracture of the arm –Respiratory = 28 –Pulse is present –Follows commands but remains seated DEAD DELAYED

20. Scenario Examples 25y/o female 8 months pregnant and in active labor. 25y/o female 8 months pregnant and in active labor. –Respiratory = 28 –Blanch < 2 sec. –Follows commands but remains seated 18y/o male unable to move arms or legs –Respiratory = 18 –Pulse is present –Conscious and remains supine DELAYED

21. Scenario Examples 15y/o female with small laceration on forehead 15y/o female with small laceration on forehead –Respiratory = 35 –Blanch < 2 sec. –Follows commands but remains seated 57y/o male no sign of injury –Resp. = 18 –Pulse is present –Fails to follow commands IMMED.

22. Scenario Examples 33y/o female with severe back pain 33y/o female with severe back pain –Respiratory = 25 –Blanch > 2 sec. –Follows commands 44y/o male broken left forearm –Respiratory = 0 –Blanch > 2 sec –Unconscious IMMED.DEAD

23. Triage Steps Review 1) Protect yourself and use personal protective equipment 2) Protect others from new injury 3) Organize as the walking wounded remove themselves to a safe area 4) Assess everyone else with the RPM criteria 5) Treat and transport immediate patients first 6) Revaluate, treat, and transport the delayed patients next 7) Revaluate, treat and transport the walking wounded

24. Triage, Part 2

25. Multiple Casualty Incident Low Impact – Manageable by local emergency personnel High Impact – Stresses local EMS, Fire, and Police Disaster, Terrorism Incident – Overwhelms regional emergency response resources

26. Incident Command Singular vs. Unified Singular command – One person coordinates –smaller, single-jurisdictional incidents. Unified command – Officers from different jurisdictions share command. Fire, EMS, Police, Public Works Fire, EMS, Police, Public Works

27. Low Impact Incident Command Incident Command Police EMS SuppressionTriageTreatmentRescue/ Extrication Transport FIRE * First arriving unit assumes command * First arriving unit can delegate authority to another person

28. High Impact (Unified) Command Unified Command FIRE, EMS, Police, Public Works Operations EMS Suppression TriageTreatment Rescue/ Extrication Transport FIRE PolicePublic Works En routeOn siteStagingSupply

29. Incident Commander First arriving unit First arriving unit Assumes command until authority delegated to another Assumes command until authority delegated to another Establish communications Establish communications Request additional resources Request additional resources Stabilize the incident Stabilize the incident Provide for life safety, accountability, and welfare of personnel Provide for life safety, accountability, and welfare of personnel Ensure that all patients are extricated, triage/treated, and transported to medical facilities Ensure that all patients are extricated, triage/treated, and transported to medical facilities

30. Triage Unit Determine location of triage areas Determine location of triage areas Conduct primary triage Conduct primary triage Communicate resource requirements Communicate resource requirements

31. Review START Triage ** Initial Triage less than 30 seconds per patient

33. RPMs R – Respiration: 30 P - Perfusion: 2 M- Mental status: CAN do When things get hectic with multiple patients rev up your RPM’s

34. PEDIATRIC TRIAGE pediatric physiology differs from adults. pediatric physiology differs from adults. w/o an objective system, emotions may influence the triage of children. w/o an objective system, emotions may influence the triage of children. Kids have faster respiratory rates. Kids have faster respiratory rates. Younger kids may not follow commands normally. Younger kids may not follow commands normally. - Infants cannot walk - Infants cannot walk - lack of understanding verbal commands - lack of understanding verbal commands

35. JumpSTART Used on children between 1 – 8 (large range) Used on children between 1 – 8 (large range) 8 year olds, patients > 100 pounds  use START 8 year olds, patients > 100 pounds  use START Infants < 1, use JumpSTART Infants < 1, use JumpSTART Usually not walking, if Usually not walking, if able to be carried = MINOR & first to be re-triage at treatment area.

37. Multiple Casualty Discussion Exercise What resources do you have available to What resources do you have available torespond? What are the priorities at this phase of the What are the priorities at this phase of theresponse? How will the services of the How will the services of the responding agencies and jurisdictions be coordinated? What agency will assume What agency will assume Incident Command? How will you deal with the How will you deal with thepublic?

38. Multiple Casualty Discussion Exercise 7:49 Emergency dispatchers advise that multiple calls are coming in from witnesses who state there are people everywhere. 7:54 Your unit is the first on scene. You see great devastation but there are survivors in the field. 7:55 People are walking toward your unit. What is your plan of action?

39. Multiple Casualty Exercise Your partner assumes Incident Command while you begin triage operations. Triage the next 7 patients Remember – RPM!

40. Patient states he can’t move or feel his legs Respirations are 26 Pulse is 110 (Radial) He is awake and oriented What Triage Category? Group Exercise

41. Patient states he can’t move or feel his legs Respirations are 26 Pulse is 110 (Radial) He is awake and oriented Delayed

42. Group Exercise Patient is soaked with blood no obvious killer bleed Respirations are 38 Pulse is weak, no radial He is awake What Triage Category?

43. Group Exercise Patient is soaked with blood no obvious heavy bleeding Respirations are 38 Pulse is weak, no radial He is awake IMMEDIATE

44. Group Exercise Patient walks over to you and has an obvious broken arm Respirations are 22 Pulse is 124 (Radial) He is awake, alert, and crying What Triage Category?

45. Group Exercise Patient walks over to you and has an obvious broken arm Respirations are 22 Pulse is 124 (Radial) He is awake, alert, and crying Minor

46. Group Exercise Patient is face down in the field Not Breathing Weak Carotid Pulse She is unresponsive What do you do first?

47. Group Exercise Patient is face down in the field Not Breathing Weak Carotid Pulse She is unresponsive Open The Airway

48. Group Exercise Patient gurgles but can’t maintain an open airway and is not breathing Weak Carotid Pulse She is unresponsive What Triage Category? What Triage Category?

49. Group Exercise Patient gurgles but can’t maintain an open airway and is not breathing Weak Carotid Pulse She is unresponsive DEAD DEAD

50. Group Exercise Patient is a 9-month old infant with a 3 inch cut on his forehead He is visibly upset, crying and wind-milling his arms and legs What triage category?

51. Group Exercise Patient is a 9-month old infant with a 3 inch cut on his forehead He is visibly upset, crying and wind-milling his arms and legs Minor

52. Group Exercise Patient is 4 years old Respirations are 10 Radial pulse is weak What Triage Category? What Triage Category?

53. Group Exercise Patient is 4 years old Respirations are 10 Radial pulse is weak IMMEDIATE

54. Group Exercise Patient has an open head wound, bleeding controlled Respirations are 16 Pulse is 88 (Radial) He is unconscious What Triage Category? What Triage Category?

55. Group Exercise Patient has an open head wound, bleeding controlled Respirations are 16 Pulse is 88 (Radial) He is unconscious IMMEDIATE IMMEDIATE

56. More Practice On a cool autumn day a sudden freak storm has hit a small area of Portland including a park where several parents and children are playing. High winds blow down trees and rip the corner of a roof off a garage. For 3 minutes, golf ball-sized hail pelts down, damaging plants, breaking windows and injuring people. Alerted by calls for help and children crying, you arrive at the park where you see several people wandering about in a dazed state, or sitting or lying on the ground. The first person you encounter is a girl about 8 - 9 years old, on the ground near the teeter-totter, crying. Her arm is obviously broken. Between hiccuping sobs she tells you the wind blew her out of the swing and she crawled under the teeter-totter for protection from the hail. What should you do first? Second? Third?

57. Most people would immediately rush to the aid of the child in distress, it's human nature. However, you are trained to resist that urge. Instead, you stop and look for hazards first. Look for downed power lines, precariously balanced broken tree branches, teetering chimneys, rising waters, etc. Next, try to get a handle on the entire incident, rather than blindly running from victim to victim. Without a search plan, a seriously wounded child could lie waiting for help for too long because you are busy treating someone else with minor cuts and scratches. The third thing the rescuer needs to do is assess the resources available. This could include first aid supplies, rescue gear, willing bystanders and neighbors, etc. Coordinating these into the rescue plan will make it much more likely that ALL the victims are taken of.

58. Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!“ A woman from across the street runs up to you and says, "I've called 911. What shall I do now?” Downed trees are blocking vehicular access to the park so you know the usual 3-min. emergency response time won't be met. How do you answer the woman?

59. "I've called 911. What shall I do now?" Since the woman lives nearby, she has a lot to offer. The ambulatory wounded could find refuge from the weather in her home. She probably has vital supplies at her house. Towels, blankets, water, bleach, lifting and cutting tools, flashlights, food and water could prove extremely valuable.

60. Triage these victims Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!” Who do you send to the woman’s house?

61. Farther on you can see a child the wind has deposited in the branches of a tree. A woman with a bloody head is huddled protectively over an infant. The infant is wailing, but the woman is not moving. A man is shaking a small, limp boy, calling "Peter! Peter! Wake up!" Two little girls are crouched, silent, by the fence. A 3-year-old is running around in circles shrieking, "Mommy! Mommy!” Other people in the neighborhood, at his point, are coming out to see if there is anyway they can help. Who do you send to the woman’s house?

62. Triage these victims You approach the child the wind has deposited in the branches of a tree. You remove him from the tree. He is not breathing, even after you attempt to open the airway. Radial pulse is absent. What is his triage category? DECEASED

63. Triage these victims As you head towards the woman with a bloody head, you notice she is not breathing. What do you do? She takes in a breath, but cannot maintain open airway. What do you do? What is her triage category? Open Airway Ask a neighborhood bystander to help maintain airway Immediate

64. Triage these victims Finally, you approach the limp boy, about 6 years old. You open the airway. He does not resume breathing. What do you do next? Radial pulse is weak. What do you do next? This child begins to resume shallow breaths. What is his triage category? Check Radial Pulse 5 rescue breaths Immediate