Chapter 43

1. Chapter 43 Multiple Casualty Incidents Prehospital Emergency Care 7e Mistovich/Hafen/Karren

2. Topics 43 • Multiple Casualty Incidents • Identify Multiple Casualty Incidents • Incident Command System • Triage • Disaster Management • Enrichment Prehospital Emergency Care 7e Mistovich/Hafen/Karren

3. Introduction 43 • A multiple causality incident (MCI) is any event that places excessive demands on personnel and equipment. Typically, an MCI involves three or more patients. • Depending on the size, resources, and depth of a system, an MCI may be declared for a 2 car MVC with multiple trauma victims or a building fire with smoke inhalation. • The responsibility of the EMT-B is to recognize an MCI as early as possible and activate the appropriate plan. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

4. Introduction 43 • Preplanning is an essential corner stone of a successful MCI. • To preplan one must know the resources available on the local, regional, state, and federal levels. • Resources that may be requested include: • Additional personnel • Additional support vehicles • Food and shelter for victims and their providers • Portable communication trailers • Logistical support • Monetary support Prehospital Emergency Care 7e Mistovich/Hafen/Karren

5. Multiple Casualty Incidents 43 • Establishing Incident Management • Usually the most senior EMT who initially arrives on the scene of an MCI is designated as the EMS Incident Manager. • As EMS Incident Manager, this EMT is responsible for ensuring the initial triage, treatment, and transport of the victims. • In most areas a tiered response known as a Unified Command System involving EMS, law enforcement, and the fire service incorporates all the public safety forces. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

6. Multiple Casualty Incidents 43 • Unified Command System • Most jurisdictions are headed by the fire service with law enforcement and EMS playing an intricate role. • Once the incident command system is established, EMS sectors may be established: • Mobile command sector • Supply sector • Extrication sector • Triage sector • Treatment sector • Staging sector • Transport sector Prehospital Emergency Care 7e Mistovich/Hafen/Karren

7. Multiple Casualty Incidents 43 • The incident manager delegates duties to the various sector officers. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

8. Multiple Casualty Incidents 43 • EMS Incident Manager Responsibilities: • Usually the EMS Incident Manager will establish a mobile command sector in one of the first arriving ambulances. • Perform a rapid scene size-up. • Identify number(s) and severity of the patients. • Relay vital information to dispatch. • Type of incident • Potential hazards • Additional manpower/equipment needed • Integrate all efforts with the Incident Command System. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

9. Triage 43 • French term defined as the sorting of injured patients into treatment categories. • At an MCI, EMS is tasked with providing the highest level of care to the greatest amount of patients. In order to perform this the EMT-B will need to “sort” through patients who will need the most immediate attention to preserve life or limb. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

10. Triage 43 • Primary and Secondary Triage • Primary triage differentiates those patients who need immediate transport from those who have minor injuries. • Red – Immediate care and transport – Priority I • Yellow – Delayed emergency care and transport – Priority II • Green – Minor injuries and ambulatory patients – Priority III • Black – Deceased or fatal injuries – Priority IV • Secondary triage occurs in the triage zone and provides for an opportunity to upgrade the patients’ priority status. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

11. Triage 43 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

12. Triage 43 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

13. Triage 43 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

14. Triage 43 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

15. Triage 43 • START Triage System • Simple Triage And Rapid Transport • START system is a rapid assessment of the patients’ ability to (ARPM): • Ambulate • Respiratory status • Perfusion status • Mental status Prehospital Emergency Care 7e Mistovich/Hafen/Karren

16. Triage 43 START can be utilized for patients who are greater than 8 years of age or 100 pounds, and should not take longer than 30 seconds. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

17. Triage 43 • START Triage System • Ability to Walk: • Move those who can walk out of the immediate danger area. These patients are tagged as green or low priority. • Do not allow these patients to continue to “wander around.” • The EMT-B can utilize green tagged patients to help direct others or assist with simple tasks. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

18. Triage 43 • START Triage System • Respirations: • If the patient does not ambulate, assess their respiratory rate. • >30/min – red tag. • <30/min – move on to perfusion. • No respirations – open airway. • Still no respirations – black tag. • >30/min – red tag. • <30/min – move on to perfusion. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

19. Triage 43 • START Triage System • Perfusion: • Determined by assessing the capillary refill and radial pulse: • <2 seconds or radial pulse present – move to neurological exam. • >2 seconds or absent radial pulse – red tag. • Capillary refill is affected by numerous factors including age, ambient temperature, and perfusion status. To ensure an accurate evaluation assess the radial pulse. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

20. START Triage System 43 • Mental Status • Determined by assessing the patient’s ability to follow a simple command such as squeezing the examiner’s hands. • If the patient follows commands – yellow tag. • If the patient does not follow commands – red tag. • If the EMT-B is assessing a patient’s mental status they must have an adequate respiratory rate ( <30 bpm), radial pulse, capillary refill <2 seconds, and the ability to follow commands. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

21. JumpSTART 43 • Triage system utilized for children from 1 to 8 years of age. • This system takes into account certain physiological differences between adults and children including: • Respiratory failure as the primary cause of cardiopulmonary arrest in the child • Peripheral pulses as an adequate indicator of perfusion status in the child versus capillary refill in the adult Prehospital Emergency Care 7e Mistovich/Hafen/Karren

22. Treatment and Transport 43 • Treatment sector should be physically located close to the incident; however, it should be in a safe location. • As patients are triaged they should be moved to the treatment sector by their triage priority. • Treatment modalities are aimed at providing care for the most “salvageable patient.” If the providers all focus on one severe patient, many others may suffer or die. • Utilize walking wounded or the patients themselves to help with immobilization, hemorrhage control, and oxygen application. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

23. Treatment and Transport 43 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

24. Treatment and Transport 43 • Once the patient’s life-threats are managed the patient should be transported based on their triage priority. This is where secondary triage should be performed to determine who is in need of the most urgent transport and which patient(s) can wait. • Transport of the patient is directed by the Transport Sector Officer. This officer is in constant contact with the Staging Officer who arranges ambulances and equipment, along with the treatment sector, to determine who needs immediate transport and to which facility. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

25. Communications 43 • During an MCI decisions are made based on the most current information. In order to provide the section officers and incident commander with the appropriate information, a unified communication system must be in place. • An important aspect of preplanning is to establish communications that all public safety forces can utilize. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

26. Communications 43 • To ensure effective lines of communication during an MCI the providers should: • Preplan with all public safety forces to utilize a common radio system. • Designate a communication officer to interact with the public and media. • Establish a unified communication center near the incident but not necessarily right in the incident itself. • Limit communications to emergency traffic only. • If at all possible record the event for quality assurance purposes. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

27. Psychological Impact on Providers and Victims 43 • The EMT-B can be affected both psychologically and physically. The strain may become evident at the time of the incident or may kindle for months before it is released. • Attempt to reduce the stress by: • Assigning specific tasks and evaluating the providers’ effectiveness at completing that task. • Providing frequent rest breaks during and after the incident. • Immediately removing an injured provider from the scene. • Providing adequate nutritional food and drink. • Allowing the providers an opportunity to discuss the incident with their colleagues and others. Prehospital Emergency Care 7e Mistovich/Hafen/Karren