Unit Four Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI)

Unit FourUnit Four

Hospital Incident Management Hospital Incident Management System (HIMS) for Mass Casualty System (HIMS) for Mass Casualty

Incidents (MCI)Incidents (MCI)

DHS/NTCDHS/NTC B461 CourseB461 Course 22

ObjectivesObjectives

Define mass casualty incidents (MCI)Define mass casualty incidents (MCI) Describe the Multi-casualty Branch structureDescribe the Multi-casualty Branch structure Use of multiple Groups/Divisions under the Multi-Use of multiple Groups/Divisions under the Multi-

casualty Branch Directorcasualty Branch Director Discuss MCI response proceduresDiscuss MCI response procedures Review emergency medical service role in MCIReview emergency medical service role in MCI Describe “START”Describe “START”


Objectives (cont'd)Objectives (cont'd)

Identify the relationship of MCI Groups (triage, Identify the relationship of MCI Groups (triage, treatment, transport) to overall scheme of the HIMS treatment, transport) to overall scheme of the HIMS

Prioritize patients using the START method of Prioritize patients using the START method of triage for:triage for: DecontaminationDecontamination TreatmentTreatment

Identify considerations in transporting patients to Identify considerations in transporting patients to area hospitalsarea hospitals


Mass Casualty IncidentsMass Casualty Incidents

Multi-patient Incidents - exceeds normal first responder Multi-patient Incidents - exceeds normal first responder capabilitiescapabilities

Major medical emergency – any emergency that would Major medical emergency – any emergency that would require the access of local mutual aid resourcesrequire the access of local mutual aid resources

Mass Casualty Incidents - combination of numbers of Mass Casualty Incidents - combination of numbers of injured personnel and type of injuries going beyond the injured personnel and type of injuries going beyond the capability of an entity’s normal first responsecapability of an entity’s normal first response

Disaster – State and/or Federal resources are requiredDisaster – State and/or Federal resources are required


Mass Casualty Incident ManagementMass Casualty Incident Management

Do the greatest good for the greatest number of Do the greatest good for the greatest number of patientspatients

Make the best use of:Make the best use of: PersonnelPersonnel EquipmentEquipment Medical and facility resourcesMedical and facility resources

Limit the spread of the contaminationLimit the spread of the contamination Minimize the effects of the disaster, incident, or Minimize the effects of the disaster, incident, or

eventevent


Triage ConsiderationsTriage Considerations

Triage - Term in early 1800s (derived from the Triage - Term in early 1800s (derived from the French French trier,trier, meaning "to sort") meaning "to sort")

Immediate - Casualty requires lifesaving measures Immediate - Casualty requires lifesaving measures performed without delay if they are to surviveperformed without delay if they are to survive

Delayed - Casualty whose treatment can wait Delayed - Casualty whose treatment can wait without causing additional harmwithout causing additional harm


Triage Considerations (cont'd)Triage Considerations (cont'd)

Expectant – Casualties that will not survive or will Expectant – Casualties that will not survive or will require extensive resources and time if they are to require extensive resources and time if they are to be savedbe saved

Minor – Casualties that are generally ambulatory Minor – Casualties that are generally ambulatory and are injured only slightlyand are injured only slightly


Hospital TriageHospital Triage

Use a triage system in an MCI Use a triage system in an MCI that parallels normal routinethat parallels normal routine

Practice regularly to ensure Practice regularly to ensure familiarityfamiliarity

Triage is a continual processTriage is a continual process Re-triage all victimsRe-triage all victims

transported by EMStransported by EMS Set up triage area near the Set up triage area near the

ED entranceED entrance Shielded and secureShielded and secure Readily accessibleReadily accessible


TriageTriage

““Greatest good for the greatest number of casualties”Greatest good for the greatest number of casualties” Psychological impactPsychological impact Classification:Classification:

RedRed YellowYellow GreenGreen BlackBlack Limitations:Limitations:

Time consumingTime consuming User variabilityUser variability Lack of familiarityLack of familiarity


START TriageSTART Triage

TRIAGE CRITERIA:TRIAGE CRITERIA: Respiratory statusRespiratory status

Perfusion and pulsePerfusion and pulse

Neurological statusNeurological status

TRIAGE CATEGORIES:TRIAGE CATEGORIES:

Walking wounded - “Walking wounded - “GreenGreen” or ” or minimal (relocate when told)minimal (relocate when told)

Normal findings - “Normal findings - “YellowYellow” or delayed ” or delayed (unable to relocate)(unable to relocate)

Abnormal - “Abnormal - “RedRed” or immediate” or immediate

Non-salvageable - “Non-salvageable - “BlackBlack” or ” or expectant expectant


START - Respiratory StatusSTART - Respiratory Status

Expectant

No RespiratoryEffort

Immediate

Respirations> 30

Go toNext Step

NormalRespirations

Respiratory Status


START - PerfusionSTART - Perfusion

Immediate

Radial PulseAbsent

Immediate

Cyanotic

Go toNext Step

Radial PulsePresent

Perfusion Status


START - Neurological StatusSTART - Neurological Status

Immediate

Change inMental Status

Immediate

Unconscious

Move toNext Victim

NormalMental Status

Neurological Status


Nerve Agent Triage - “Immediate”Nerve Agent Triage - “Immediate”

Unconsciousness or Unconsciousness or convulsionsconvulsions

Two or more body Two or more body systems involvedsystems involved

Requires immediate Requires immediate antidoteantidote

Rapid intervention shouldresult in a good outcome


Immediate removal from source of exposureImmediate removal from source of exposure severity directly proportional to absorbed doseseverity directly proportional to absorbed dose

DecontaminationDecontamination Mild soap and water rinseMild soap and water rinse

Antidote administration with airway management Antidote administration with airway management support as necessarysupport as necessary

Must be provided by properly trained and equipped Must be provided by properly trained and equipped personnelpersonnel

Initial First Aid TreatmentInitial First Aid Treatment


Nerve Agent AntidoteNerve Agent Antidote

AtropineAtropine─ administered to block administered to block

receptor sites of receptor sites of acetylcholineacetylcholine

2-PAM Chloride2-PAM Chloride─ restores restores

acetylcholinesteraseacetylcholinesterase Mark I Kit or Mark I Kit or

“Combo Pen”“Combo Pen”


First Aid TreatmentFirst Aid Treatment

Exit Agent Exposure AreaExit Agent Exposure Area Minor Symptoms Administer:Minor Symptoms Administer:

One Mark I KitOne Mark I Kit

Major Symptoms Administer:Major Symptoms Administer: Three Mark I KitsThree Mark I Kits

Diazepam Required for Severe CasualtyDiazepam Required for Severe Casualty Monitor Patient’s SymptomsMonitor Patient’s Symptoms


Nerve Agent Triage - “Delayed”Nerve Agent Triage - “Delayed”

Initial symptoms are Initial symptoms are improving (miosis still improving (miosis still present)present)

Recovering well from Recovering well from pre-hospital antidote pre-hospital antidote therapytherapy


Nerve Agent Triage -Nerve Agent Triage -“Minimal” & “Expectant”“Minimal” & “Expectant”

MinimalMinimal

• Walking and talking Walking and talking which indicates intact which indicates intact breathing and breathing and circulationcirculation

Expectant

• Apneic for more than 5 minutes

• No pulse or blood pressure


Mustard TriageMustard Triage

DelayedDelayed

• 2 to 50% BSA burns 2 to 50% BSA burns by liquidby liquid

• Eye involvementEye involvement

MinimalMinimal

• < 2% BSA burns by < 2% BSA burns by liquid in non-critical liquid in non-critical areasareas

Immediate

• Moderate to severe pulmonary symptoms

Expectant

• > 50% BSA burns by liquid; apneic/no pulse


Triage of Biological CasualtiesTriage of Biological Casualties

Triage of biological agent Triage of biological agent casualties is different:casualties is different: Symptoms are delayedSymptoms are delayed Initial cases may go Initial cases may go

unrecognizedunrecognized More difficult to detectMore difficult to detect

Epidemiological information Epidemiological information becomes criticalbecomes critical


TriageTriagePsychological CasualtiesPsychological Casualties

Disasters produce tremendous emotional and Disasters produce tremendous emotional and psychological stress, with large numbers of psychological stress, with large numbers of psychogenic casualtiespsychogenic casualties

Presenting signs could be confused with organic Presenting signs could be confused with organic diseasedisease

Use of START triage system maintains focus on Use of START triage system maintains focus on objective signs of disease & minimizes impact of objective signs of disease & minimizes impact of subjective complaints on the triage processsubjective complaints on the triage process

Psychological casualties are usually triaged as Psychological casualties are usually triaged as “minimal”“minimal”


TriageTriageHospital ArrivalsHospital Arrivals

Casualty arrival is uncoordinatedCasualty arrival is uncoordinated

Arrival times varyArrival times vary

Closest hospital is typically overwhelmedClosest hospital is typically overwhelmed

Medical needs of unaffected community continuesMedical needs of unaffected community continues

May present at distant hospitals to ensure treatment at May present at distant hospitals to ensure treatment at

clean facilitiesclean facilities


Contaminated Human RemainsContaminated Human Remains

Problems are agent specific:Problems are agent specific: DecontaminationDecontamination ContainmentContainment Refrigeration until definitive disposalRefrigeration until definitive disposal

Follow local coroner and medical examiner Follow local coroner and medical examiner protocols:protocols: Establish cooperative agreements for fatality managementEstablish cooperative agreements for fatality management

Secure personal effects:Secure personal effects: Not all can be decontaminatedNot all can be decontaminated


Radiation Protection for Clinical Staff Radiation Protection for Clinical Staff

Fundamental PrinciplesFundamental Principles - Time - Time - Distance- Distance - Shielding- Shielding

Personnel Protective EquipmentPersonnel Protective Equipment

Contamination ControlContamination Control


Protecting Staff from ContaminationProtecting Staff from Contamination

Use standard Use standard precautions (N95 precautions (N95 mask)mask)

Survey hands and Survey hands and clothing frequentlyclothing frequently

Replace contaminated Replace contaminated gloves or clothinggloves or clothing

Keep the work area Keep the work area free of contaminationfree of contamination

Unit Four Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI)

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