1. 26
Introduction to Multiple-Casualty Incidents, the Incident Command System, and Triage

2. Define the following terms:
Objectives
Define the following terms:
Incident Command System (ICS)
Incident Commander
JumpSTART pediatric triage system
Multiple-Casualty Incident (MCI)
National Incident Management System (NIMS)
START triage system
Triage
(continued)

3. Explain the criteria that defines a Multiple-Casualty Incident.
Objectives
Explain the criteria that defines a Multiple-Casualty Incident.
Describe common causes of Multiple-Casualty Incidents.
Explain the role of the Emergency Medical Responder in the multiple-casualty situation.
Explain the key principles and structure of an Incident Command System.
(continued)

4. Explain the key principles of triage at a Multiple-Casualty Incident.
Objectives
Explain the key principles of triage at a Multiple-Casualty Incident.
Differentiate patient priorities related to triage.
Explain the assessment criteria of the START triage system.
Differentiate primary and secondary triage.
Demonstrate the ability to properly categorize patients of a simulated multiple-casualty situation.
(continued)

5. Objectives
Recognize the importance of patient priorities during a multiple-casualty event.

6. Topics
Multiple-Casualty Incidents
Incident Command System
Triage

7. MULTIPLE-CASUALITY INCIDENTS

8. Multiple-Casualty Incidents
Multiple-Casualty Incident (MCI): any emergency that involves multiple victims and overwhelms first responding units.
Multiple vehicles
Earthquakes
Floods
Large explosions
Building collapses
Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

9. Multiple-casualty incidents require the resources of many agencies.
Talking Point: An MCI is an emergency event, small or large, that overwhelms available resources.
Multiple-casualty incidents require the resources of many agencies.

10. Multiple-Casualty Incidents
Low-Impact Incidents
Manageable by local emergency personnel.
High-Impact Incidents
Stresses local EMS, fire, and police resources.
Disaster, Terrorism Incidents: overwhelms regional emergency response resources.
Discussion Question: Do all terrorism incidents result in an MCI?

11. Think About It
You respond alone to a serious MVC. You find two patients. One is bleeding severely from a neck wound and the other is complaining of head pain.
Which patient do you treat first?
Would you consider this scene an MCI?

12. INCIDENT COMMAND SYSTEM

13. Incident Command System
Incident Command System (ICS)
Model tool for command, control, coordination of resources at scene of large-scale emergency involving multiple agencies.
Procedures for organizing personnel, facilities, equipment, and communications.
Talking Point: The first formal incident command systems was formed as a result of a mandate from Congress to analyze the aftermath of a devastating series of wildfires in Southern California in the early 1970s.

14. Incident Command System
Incident Commander
Responsible for all aspects of an emergency response.
Modules in Incident Command System:
Command
Operations
Planning
Logistics
Finance
Talking Point: The Incident Commander is the first person (could be the EMR) to arrive on scene until other, more qualified individuals, can assume command.

15. The incident commander delegates duties to the various group officers.
Discussion Topic: Describe Unified Command; (used in large-scale, long term events, brings together the "Incident Commanders" of all major organizations involved in an incident to coordinate response while carrying out own jurisdictional responsibilities.)
The incident commander delegates duties to the various group officers.

16. Incident Command System
National Incident Management System (NIMS)
Developed so that federal, state, local, and tribal resources can respond more efficiently to natural disasters and emergencies.
Teaching Tip: Remind students that FEMA offers several free online instructional courses pertaining to both the incident command system and NIMS.
(continued)

17. Incident Command System
National Incident Management System
Teaches unified approach to incident management, standard command and management structures; emphasis on preparedness, mutual aid, resource management, common terminology among agencies
Discussion Questions: How might common ICS terminology improve the management of a large-scale incident? Do the agencies you interact with (police, fire, EMS) use common terminology on a routine basis? How do operations on a daily basis affect how well events are managed during an unexpected large-scale incident?

18. Incident Command System
The Medical Branch
Branch of ICS
Designates and coordinates three functional areas or groups:
Triage
Treatment
Transport
Talking Point: The Medical Branch is a branch of ICS within which EMRs will commonly function. Each group (triage, treatment, and transport) has a group leader. The group leader reports to the medical group supervisor who reports to the medical branch director.

19. Incident Command System
Triage Group
Determines location of triage areas.
Conducts primary triage and ensures all patients are assessed and sorted using START triage protocol (or similar)
The triage group leader communicates resource requirements to the medical group supervisor.
Teaching Tip: Discuss the triage system used in your area (e.g., START, SMART).
(continued)

20. Incident Command System
Triage Group
Communicates with treatment group leader to allow for movement of patients into treatment area for prehospital care.

21. Incident Command System
Treatment Group
Determines treatment group location.
Coordinates with triage group to move patients from triage to treatment areas.
Maintains communications with medical group supervisor.
Critical Thinking: Why is it important for the treatment group to have red, yellow, green, and black flags or tarps as markers?
(continued)

22. Incident Command System
Treatment Group
Reassesses patients, conducts secondary triage to match patients with resources
Directs movement to transport group

23. Incident Command System
Transport Group
Coordinates transportation of victims to appropriate facilities for treatment
Manages patient movement and accountability from scene to hospitals
Works with treatment group to establish adequately sized, easily identifiable patient loading area
Critical Thinking: How important are communications between treatment, transport, and staging to the overall facilitation of patient movement? Are procedures in place in your area to ensure that multiple agencies can communicate on one frequency?
(continued)

24. Incident Command System
Transport Group
Designates ambulance staging division
Maintains communication with medical group supervisor

25. Incident Command System
Medical Staging
Designates easily located site for resources to stage near incident area
Determines whether several staging divisions required
Determines whether staging will need to be relocated as situation evolves
Discussion Questions: Why is it important that medical staging be at an easily located site? Are there procedures in place in your area that ensures communication of the staging area to responding units?

26. Think About It
You are first on scene of a MVC involving 20 patients who have been ejected into the median after a bus overturned.
Should you immediately begin triage?
Do you have other immediate responsibilities?

27. TRIAGE

28. Triage
Triage
Method of sorting patients for care and transport based on severity of injuries or illnesses.
Used in hospital emergency departments, battlefields, emergencies when there are multiple victims and limited medical resources.
Critical Thinking: Why is it important to sort and prioritize patients by condition when dealing with a large number of patients?

29. At the scene of a multiple-casualty incident, triage is the system used to identify victims who are most in need of immediate medical care.

30. Triage
EMRs first on scene; must be able to triage patients and initiate care rapidly.
Patients with serious medical- or trauma-related problems (heart attack, shock, major injuries, heat stroke) must be transported quickly.
Patients with minor injuries or illnesses are transported later.

31. Triage START Triage System START: Simple Triage And Rapid Treatment
Based on rapid assessment of patients using three criteria: respirations, perfusion, mental status (RPM)
60 seconds or less per patient
Do not begin treatment during triage.
Teaching Tip: Discuss alternate Triage Systems if the one used in your area differs from START.
(continued)

32. Triage START Triage System
Patients classified into one of four categories; tagged with denoted color-coded tag indicator.
Immediate (red)
Delayed (yellow)
Minor (green)
Deceased (black)
Teaching Tip: Distribute Triage Tags for each student to examine.

33. An example of a standard triage tag, front and back.
Critical Thinking: Why are the color-coded indicators arranged in the order of green, yellow, red, and black?
An example of a standard triage tag, front and back.

34. The START triage algorithm.

35. Triage Primary triage Secondary triage
When patient is first identified and triaged.
Secondary triage
When patient is relocated to treatment area, he will immediately be re-triaged by treatment team.
Class Activity: Using patient volunteers or manikins and the START system (or triage system used in your area); provide an MCI scenario and direct students to demonstrate the ability to properly categorize patients.

36. START Triage System

37. Triage JumpSTART Pediatric Triage System
Specialized pediatric triage system designed for patients from one to eight years of age.
Assessment categories for JumpSTART system are the same as for START system: respirations, perfusion (peripheral pulses), mental status (AVPU).
Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

38. The JumpSTART pediatric triage algorithm.

39. Triage Be aware of your mental and physical stress levels.
Critical Incident Stress Debriefing (CISD) sessions or other qualified psychological support should be available after a disaster or unusual emergency to address needs of rescuers.
Point to Emphasize: CISD could be made available, but should not be mandated.

40. Think About It
You respond to an MCI following an explosion at an outdoor café. You are assigned to the triage group and are given tags. You see significantly injured patients everywhere. A woman with a localized ankle fracture screams out to you for help.
What do you do?
How will you proceed?

41. SUMMARY

42. Summary
While rare, Multiple-Casualty Incidents (MCIs) can easily overwhelm first responding units at scene.
First units quickly request additional resources and begin to establish command over incident.

43. Summary
Incident Command System (Incident Management System): tool used to manage overall control of large scenes involving many resources and multiple agencies.

44. Summary
Triage: sorting of patients based on severity of injuries or illnesses
Goal is to save as many patients as possible using available resources.

45. Summary Triage Categories
Immediate: for most critical but salvageable patients
Delayed: for less critical but still in need of care
Minor: for those ambulatory at scene
Deceased: who show no signs of life

46. Summary
START System—Simple Triage And Rapid Treatment program that uses respirations, perfusion, and mental status assessments to categorize patients into one of four treatment categories.

47. Summary
Variation of START Triage System designed specifically for pediatric patients is the JumpSTART system.
Takes into account unique needs and presentation of pediatric patients.

48. REVIEW QUESTIONS

49. What are the criteria that define a Multiple-Casualty Incident?
Review Questions
What are the criteria that define a Multiple-Casualty Incident?
What are common causes of Multiple-Casualty Incidents?
What is the role of the Emergency Medical Responder in the multiple-casualty situation?
What are the key principles and structure of an Incident Command System?
What are the key principles of triage at a Multiple-Casualty Incident?
(continued)

50. What are the assessment criteria of the START triage system?
Review Questions
What are the assessment criteria of the START triage system?
What is the difference between primary and secondary triage?

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