DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
4. Manage Information
DEFINITION OF TERMS 5. Search / Rescue
6. Field care –mostly health activities
Mass Casualty Incident (MCI)
Any event resulting in a number of victims
large enough to disrupt the normal course
of emergency and healthcare services Hospital Care:
Produces several patients as few as six or
7. Transport /traffic control
as many as several hundred
8. Facility Reception at ER / A & ED
Patients are greater than resources of the
9. Hospital MCMS. & Command System
responders
Mass Casualty Management
Management of victim of a mass casualty
event
Objective is to minimize loss of life and
disabilities
Mass Casualty Management System
(MCMS) Mass Casualty Management System in
The group of Units, Organizations, sectors
which work jointly during a mass casualty
incident. Based on:
1. Pre-established procedures
2. Maximization of use of existing
resources
3. Multi-sectoral preparation and response
4. Strong pre-planned and tested the Field
Golden Hour Principle
That sixty-minute window from the time of
the injury to the time the surgeon begins
coordination
Establishing MCM System
Activities at various levels of responses:
Field Care:
1. Alerting process
2. Initial Assessment
3. Command /control/ coordinate
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DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
work is what trauma workers call the golden Number of patients
hour Extent of resources
- Transport arrives
Condition of patient
- Gets better
- Gets wors
If you have only 1 patient
That patient is immediate regardless of
anything else
There is no real need for triage
Once this number increases, the need for
triage arises
Emergency Severity Index (ESI) Triage
The Emergency Severity Index (ESI) is
a simple to use, five-level triage
algorithm that categorizes emergency
department patients by evaluating
both patient acuity and resource
needs.
ESI was designed in late 1990 in the
Mass Casualty Incident Triage System United States by two emergency
medical experts named Richard Weurz
Greatest good to the greatest amount of and David Eitel
people The purpose of triage in the
To move patients away from the incident emergency department (ED) is to
and toward resources that offer more prioritize incoming patients and to
comprehensive care identify those who cannot wait to be
Dynamic and fluid process seen.
Triage – from the French “sort” This system not only determines which
patient should be checked first but
In casualty management sorting of a also indicates which levels of facilities
large number of injured personnel is the and resources are needed to meet the
1st stage in establishing order patient’s needs (Wuerz et al.; & Eitel
Triage sets the stage for treatment and et al., 2003).
eventuates in transport of the injured
Emergency Severity Index Triage
Triage is not to be considered with Algorithm (2004)
finality
Triage categories change based upon:
1. Number of injured
2. Available resources
3. Nature and extent of injuries(s)
4. State of hostile threat
Things change
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DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
Is this patient unstable and in need of
immediate lifesaving intervention?
Is this a high-risk situation?
How many resources will this patient
need?
Do the patient’s vital signs warrant a
reassessment of the acuity level?
Four conceptual decision points used in the
ESI algorithm to determine an acuity level:
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DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
BLACK without spontaneous
respiration; should not be
moved forward to the collection
point
(Immediate) severe injuries
RED but high potential for survival
with treatment; taken to
collection point first
(Delayed) serious injuries but
YELLOW
not immediately life-
REVERSE TRIAGE threatening
GREEN (Walking wounded) minor
A way to refocus hospital resources on injuries
critically ill patients in the field or the Triaging and Prioritizing for In-Hospital
emergency department by identifying and Care
discharging admitted patients who have a
Red– immediate, priority one (life
relatively small risk of complication if
threatening condition)
discharged early, thus ensuring the best
reduction in morbidity and mortality for the Obstruction or damage to airway
greatest number of patients while treating Disturbance of breathing (resp. >
the largest number of patients in the shortest 30/min)
period of time Disturbance of circulation
Does not follow command or altered level
MASS CASUALTY INCIDENT TRIAGE
of consciousness
SYSTEM
Need for life-saving measures and urgent
START (simple triage and rapid treatment) hospital admission
SALT (sort, assess, interventions, Injuries demand definitive treatment in
treatment/triage) life-saving hospital
SAVE (Secondary assessment of victim
Yellow- intermediate, urgent, priority
endpoint).
two
START Triage
Needs to be treated within one hour,
Most widely used triage system in the United otherwise, will become unstable
States for mass casualty incidents. Severe burns, burns involving hands, feet
or face (excluding resp. tract), burns
It was developed in 1983 by staff at Hoag complicated by major soft tissue trauma
Hospital and Newport Beach Fire Department Hospital admission is required
in California for rescuers with basic first-aid Moderate blood loss; back injuries, head
skills. injuries with normal level of
consciousness
Green-delayed, priority three
Minor injuries not threatened by airway,
breathing and circulatory instability
START Triage Minor fractures, minor soft tissue injuries,
(Deceased/expectant) minor burns
injuries incompatible with life or May or may not be admitted
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DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
Black- dead, last priority Yellow treatment area with yellow
treatment officer
Patient is clinically dead Green treatment area
Patient who sustained injuries so severe Deceased (black category) victims
that have no chance of survival area
Those who die while awaiting treatment 2. Decontamination Area for chemical,
Response Actions Upon Receiving biological, radiologic, nuclear and
explosives
Victims
SALT Triage
1. Hospital Triage and Triage Officer-
Red treatment area with red Sort, assess, life-saving interventions, and
treatment officer triage/treatment. more comprehensive and
adds simple life-saving techniques during the
triage phase
SORT: sort the walking, waving, and still.
This can be achieved by asking everyone at
the scene to walk to a designated casualty
collection point similar to the START method;
however, this is followed by asking to wave
an arm or leg if they need help. Those who
cannot move or follow commands should be
assessed first.
ASSESSMENT: assessment and life-saving
interventions go hand in hand. When you
assess a victim and find life-threatening
injuries, you should intervene. major
LIFE-SAVING INTERVENTIONS: simple
techniques such as controlling hemorrhage,
opening airways, needle decompression, and
auto-injector antidotes should be performed
as long as it is not time intensive. Once
performed, the provider should assign a
color-coded tag similar to the START system
and move onto the next patient to ensure
the forward flow of patients.
TREATMENT AND TRANSPORT: Once
tagged, patients will be moved to the
designated casualty collection point for
transport by emergency management
services to receiving facilities.
JumpSTART
This tool acts to assess pediatric patients
better.
The age cutoff for use is eight years old.
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DISASTER NURSING
ST. LUKE’S COLLEGE OF NURSING
TOPIC 4: MASS CASUALTY AND TRIAGE
If the child’s age is unknown, the rescuer 5. Hospital DRRM-H Plan and systems 6.
can assess for underarm hair in males or Chief of Hospital support to MCM
breast development in females as an policies and guidelines
indicator of adult age and exclusion from
this cohort
The differences in this algorithm
include:
Five rescue breaths are to be given to
apneic children with a pulse; then,
they are given a black tag.
Normal RR are more than 15 or less
than 45
Neurological assessment is done using
the mnemonic AVPU (alert, responds
to verbal stimuli, responds to painful
stimuli, and unresponsive). Any
patient who has abnormal posturing to
painful stimuli or is unresponsive gets
a red tag designation.
Response Actions to Mass Casualty
Incidents in the Hospital
1. Activate the DRRM-H Response Plan
2. Implement the Code Alert System
3. Execute the Hospital Incident
Command System
4. Activate the Contingency and Service
Continuity Plan
5. Activation of Hospital EOC
6. Coordination with partners
7. Streamlining service delivery (no
elective surgery)
8. Staff recall and strategic mobilization
of hospital personnel
9. Prepare ER and extra areas for the
victims
10.Designate areas for relatives, VIPs,
and media
Requirements for Responding to Mass
Casualty Incidents in the Hospital
1. Capable of handling trauma victims
2. Ready ER to manage MCI victims
3. Has emergency commodities and teams
4. Ready equipped ambulances
