see also: [[Weapons of Mass destruction|WMDs]], [[Radiation incidents]], [[Triage|ATS]] see: [Dunn - Emergency department response to disasters](x-devonthink-item://9064F3D0-1788-4301-B003-4BA50858CF98) mnemonic:: METHANE , CSCATTT # definitions - **[[#Sieve]]** -- primary triage, priorities for urgency of patient treatment - simple and fast; <1 min, no equipment or major training required - **[[#Triage sort|sort]]** -- secondary triage, priorities for urgency of pt transport - triaged based on assessment of physiologic parameters (RR, SBP, GCS) to calculate triage revised trauma score (TRTS) - **major incident** - external incident likely to disrupt or overwhelm the health service - **[[#ED surge|surge]]** - significant increase in demands placed on ED - **disaster** - a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. generally ==local capacity overwhelmed== and ==serious disruption== - WHO: "a sudden ecologic phenomenon of sufficient magnitude to require external assistance" - A disaster is an event that *overwhelms the resources of the region or location in which it occurs*. Furthermore, a hospital disaster may similarly be defined as an event that overwhelms the resources of the receiving hospital. - **mass casualty incident** - an event causing illness or injury among multiple patients simultaneously through a similar mechanism, such as a major vehicular crash, structural collapse, explosion or exposure to a hazardous material # mnemonics **Key elements of response** - C - command and control - S - safety - C - communications - A - assessment - T - triage - T - treatment - T - transport **communication** METHANE - Major incident declared, activate plan - Exact location - type of incident - hazards - access - number and type of casualties - emergency services present and required > **key features of disaster response** > - **staff** -- notify all staff, prepare for arrival , assign roles/teams, get help > - **space** - empty/decant department, prepare resus rooms, clear WR, utilise SSU, admit/d/c patients > - **stuff** - obtain additional resus equipment, ventilators, prepare fluids, blood, USS, sheets, etc > - **disaster-specific** - > - disaster triage tags > - radios/communication equipment > - specific decontamination or antidote supplies > - **other** - media, staff rostering, social work, food # Triage - ATS is not particularly helpful in a disaster - Goals of disaster triage - "most good for most people" - identify who is most likely to survive - take into account available resources - a few different strategies eg salt and start | disaster triage | emergency department triage | | --------------------------------------------------------------------------------------- | --------------------------------------------------------- | | goal is to deliver greatest good to greatest number with brief focused assessment | individualised more detailed approach in order of arrival | | dynamic process, repeated at multiple stages | single point of time, in order of arrival | | performed by disaster-trained senior medical or ambulance personnel | performed by senior nursing staff | | patients sorted into groups requiring immediate, delayed, minimal care, or unsalvagable | ATS categories based on urgency | ## Sieve - usually performed by first senior ambulance officer at site - use in conjunction with a casualty count card to help determine number of casualties in each group - <span style="color:red">Red</span> (P1) - highest priority for transport - RR <10 - >29, unable to maintain patent airway, cap refill >2 sec, HR >120 - <span style="color:orange">Yellow</span> (P2) - no criteria for P1, second priority for transport - cap refil <2 sec, or pulse <120 - <span style="color:green">Green</span> (P3) - walking wounded - black (P4)- no respiration despite airway patience. dead. not moved from scene ![[Pasted image 20240225010501.png]] ![[Pasted image 20240225010447.png]] ## Triage sort - usually occurs at the on site casuality clearing station - determine order of transprot from pt treatment post to hospital - can be used in hospital following triage sieve or if number of arrivals is small - ==much slower to perform and requires ore operator training than triage sieve== | | 1 | 2 | 3 | 4 | | --- | ---- | ----- | ----- | ----- | | **RR** | 1-5 | 6-9 | >29 | 10-29 | | **SBP** | 1-49 | 50-75 | 76-89 | >90 | | **GCS** | 4-5 | 6-9 | 9-12 | 13-15 | Table 1: triage sort | total points | triage sort priority | colour | | ------------ | -------------------- | ------------- | | 4-10 | P1 | **red** | | 11 | P2 | orange/yellow | | 12 | P3 | *green* | | 1-3 | P4 | blue/black | Table 2: triage sort score and scene triage priority ## triage categories # department layout | zone | description/roles/tasks | | ---- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | hot | - actual disaster area<br>- specialised and authorised rescue personnel only | | warm | - area immediately outside hot zone<br>- decontamination area (if required)<br>- triage of casualties<br>- safe area for personnel | | cold | - outside warm zone -- free of contamination<br>- casualty collection and treatment areas<br>- transport collection areas<br>- assembly point for non-injured/ambulatory<br>- perimeter - controlled access | # medical management - scene medical coordinator - wears identifiable vest - disaster team - usually 2 doctors and 4 nurses on teach team - rucksacks containing disaster packs - radio contact - treatment - confined to life-saving procedures # common disaster injuries - pelvic, spinal injuries - blast injuries - crush injury - compartment syndrome - amputation - traumatic asphyxia - relatively few intra-abdominal injuries # ED surge - significant increase in demands placed on ED - eg sudden mass casuality incident **strategies for surge** - recognise surge - initiate action in ED - escalate to whole institution involvement if needed - manage patient flow - divert inbound pts - decant ED patients to other areas - discharge selected patients - set clinical goals - immediate review of staff work practies - change goals to "most for the most" - maintain standard of care - deploy surge team for advance triage - ensure work environment safe from contamination - divert non-clinical visitors - decant walking wounded to designated reception area - space - decant ED patients - clear ED of admitted pts - prepare available areas - staff - allocate roles and provide job action cards - determine meeting points - request surgical and critical care liason points in ED - engage non-clinical staff for assistance (eg med student as scribe) - stuff - distribute radios, phones, etc - disaster packs - medical equipment - system operations and flow - divert inbound patients - notify EMS to arrange ED bypass - ensure rounds to force clinical decision making on remaining ED patients - commence surge-induced goals of care and investigation/treatment processes - plan security at all entry points # problems to expect and prepare for - Lack of access to radiology - Staff fatigue - Access to OT - ICU bed availability - Exhausted blood bank supply - Stock shortages – splints, drugs, antibiotics # Standing down mass casualty incident - Clarify if this a total or partial stand down – if partial which parts of the ED response will continue eg green pt area for stragglers - Re-institute normal ED function including decisions re staffing levels, which areas back on line first, re-establishing normal pt flow - Defusing – immediate informal debrief with staff to ascertain feelings and thoughts about the episode – attempt identification of traumatised staff for ongoing management, seek feedback re process improvement - Operational [[Debriefing|debrief]] – within one week have sought further feedback from staff for presentation to hospital wide operational debrief with heads of other departments to analyse the organisational response - Modification of ED disaster plan in response to Operational Debrief and internal analysis - Counselling of staff ie identified as affected by disaster incident – in conjunction with medical admin and staff health # OSCE see: [RMH 2018 station 2 - disaster management](x-devonthink-item://BBBB9951-BCBB-47C6-954D-23EBE8910283) , [SCBD 2013 earthquake](x-devonthink-item://DD07180E-ABC5-43EA-A985-AA2399BFC9AC?page=84) recall: - C - command and control - S - safety - C - communications - A - assessment - T - triage - T - treatment - T - transport Steps: 1. declare disaster and potential surge 1. activate hospital disaster management 2. notify relevant staff (executive, director) 3. notify outside resources (retrievial, tertiary centres) 2. establish leadership and command centre 3. clarify communication system 4. clarify documentation system 5. ? any need for decontamination or hot/warm/cold areas? 6. Space/Staff/Stuff / Patients 1. Space: safely decant current department and identify appropriate treatment spaces 2. staff: allocate teams, consider need for extra staff (security, media liason, transport, lab staff, radiology) 3. stuff: drugs, equipment (eg PPE, disaster-specific) 4. patients: teams to manage current patients in department, flow management for admission