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Mass Casualty Management for the Doctor, Nurse & Paramedic -Formerly ATLS Mass Casualty Management

Mass Casualty Management for the Doctor, Nurse & Paramedic -Formerly ATLS Mass Casualty Management. By Dr S. T. Boyd, BSc(Hons), MBChB, DA(SA), FCEM(SA), Dip.PEC(SA). Mass Casualty Management. Goal: To apply trauma triage principles in multiple patient scenarios Objectives:

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Mass Casualty Management for the Doctor, Nurse & Paramedic -Formerly ATLS Mass Casualty Management

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  1. Mass Casualty Managementfor the Doctor, Nurse & Paramedic-Formerly ATLS Mass Casualty Management By Dr S. T. Boyd, BSc(Hons), MBChB, DA(SA), FCEM(SA), Dip.PEC(SA)

  2. Mass Casualty Management • Goal: To apply trauma triage principles in multiple patient scenarios • Objectives: • Brief local / international history with mass casualties • Define triage • Understand and identify factors • Apply principles of triage with scenarios • Conclude with an example which is still today RSA’s biggest train accident

  3. You've carefully thought out all the angles. • You've done it a thousand times before. • It comes naturally to you. • You know what you're doing, its what you've been trained to do your whole life. • Nothing could possibly go wrong, right ?

  4. Natal & Durban Floods September 1987 Largest floods in living memory, Cyclone Demonia 1986 excluded

  5. Durban Umlaas Canal - EMPTY

  6. Loss of road, rail & almost all air communications (Durban International under water & Virginia nearly so)Loss of telephone & radio commsWashaways in informal settlement areas (>400 people washed away when rivers came down in flood)Mudslides with entrapments Problems created in Sept 1987? Similar to September 1987

  7. Pietermaritzburg Floods 25/12/1995

  8. Durban Floods Nov 1999

  9. Minibus Accidents

  10. Total number = 4 dead & 40 injured

  11. DC3 - Crash landed in the surf line

  12. M.V. Oceanos off the Transkei Coast

  13. A plan was needed to go from this……..

  14. Bus bombers - the sequel

  15. To this…..

  16. Mass casualties - why train accidents in India have so many injured

  17. Mass Casualty Management Interactive scenario session

  18. Disaster Management- Triage • French = “to sort or select” (“Sorting of differing grades of wool & later coffee beans”) • Napoleon’s surgeon Baron Larrey, applied the principle to the assessment & treatment of the injured • To sort into categories based on an assessment of: • A B C D E’s • Resources available RSA System: Red (P1), Yellow (P2), Green (P3) & Blue (P4)

  19. TRIAGE CATEGORIES: • RED (P1) = 1-5% • YELLOW (P2) = 5-10% • GREEN (P3) = 80% • BLUE (P4) = 1-5%

  20. Triage • "RED CODE" (“P1”) = The horizontal & groaning / gurgling patient (ABCD) seriously affected / malfunctional: • A life threatening condition requiring immediate treatment : • Airway obstruction • Inadequate ventilation / tension pneumothorax • Active bleeding • Shock

  21. Triage • "YELLOW CODE" (“P2”) = The horizontal but ABC intact patient who is demanding: • An injury which requires complex care but is not an immediate threat to life : • Fracture of a long bone • Spinal lesion • Abdominal injuries without shock • Vascular injuries • Large burns 20-60% BSA

  22. Triage • "GREEN CODE" (“P3”) = The walking talking but very demanding in terms of resources: • Patients with minor injuries requiring first aid or outpatient treatment : • Small lacerations • Burns <20% BSA • Musculoskeletal injuries without shock

  23. Triage • "BLUE CODE" (“P4”) = The gasping / agonal or obviously dead: (sometimes called black or grey codes): • Patients who are obviously dead or who have apparently mortal injuries.

  24. Triage - Fine Tuning based on Vital Signs = Green / P3 = Blue / Black / P4 = Red / P1 = Yellow / P2 = Green / P3

  25. Triage - Reality Check - KISS!!!! • To summarise - Keep it simple stupid!! : • remove the walkingABCD intactgreen codes = +/- 80% • the +/-20% left behind are all horizontal - • horizontal and gurgling withABCD compromised = red codes = 1st priority • horizontal withintact ABC so are able to cry for help = yellow codes = 2nd priority • and the horizontal with ABCD foo-baa anddead or dying = blue codes = leave alone

  26. Disaster Management Triage tags applied to patients, make one’s task of sorting much easier USA MILTAGS Back Front

  27. Disaster Management Triage tags come in all shapes & sizes

  28. P1 Urgent A B C Triage Tag - fold to show appropriate colour on outside Name___________Dept__________ Time____:____ Date___/__/____ BP___/___ P________ R________ IV____@__:__ ______________ ______________ ______________ P4 Dead or Dying P3 Walking wounded P2 Semi-Urgent D

  29. Triage Note Triage is on going / repeated: T1 on scene T2 at CCS/FAP T3 on route / at hospital T4 in the trauma unit

  30. Scenario I-Bank Hold-up • Customer involved in a bank hold-up. • 5 shot - 3 bank patrons & 2 bank employees. • Robbers hold you & 12 individuals in the bank as hostages while they negotiate with the police negotiators.

  31. Scenario I-Bank Hold-up • You are allowed to examine the victims and evacuate them one at a time, to an ambulance in exchange for cool-drinks, food, beers, whisky & sodas, etc (wheels & firearms are not permitted) . • The shootings occurred at noon - it is now 14:00 • The five injured are:

  32. Scenario I-Bank Hold-up • A - 45yr man with 2xGSW - 1st entered below the right nipple & exited through the right scapula while 2nd is a thro’ & thro’ injury to the palm of the right hand. Awake & alert. The hand & chest is wrapped with a torn shirt. Neither wound is bleeding. VS: P=90, RR=25 • B - 68yr diabetic man with a thro’ & thro’ GSW injury to the left thigh. C/O left leg & foot pain. A very large haematoma of the left thigh is noted & the distal foot is cool & pulseless. VS: P=110, RR=30

  33. Scenario I-Bank Hold-up • C - 50yr obese woman with a GSW to the right buttock - entry wound visible but no exit. She is lethargic, but responds to verbal stimuli. Her skin is cool & moist to the touch. VS: P=120, RR=35 • D - 25yr man with a thro’ & thro’ GSW to the left chest - entry wound 4th ICS midaxillary line & exited at the xiphoid. He is awake & alert, & C/O abdominal & chest pain. There is no obvious bleeding. VS: P=140, RR=25

  34. Scenario I-Bank Hold-up • E - 22yr woman was standing near a window & showered with glass from ricocheting bullets. She sustained multiple lacerations of the face & arms, including the right eyelid & globe. VS: P=90, RR=25 Who goes 1st, 2nd, 3rd, 4th & 5th in terms of evacuation - A, B, C, D, or E? (press right arrow for answer) Answer: Evacuate patients in the following order C, D, A, B & E.

  35. Scenario I-Bank Hold-up • How to triage: 1.ABCDE - boring, boring, boring but it works 2.MOI = Mechanism Of Injury - whose is the more severe 3.Who has the more deranged vital signs! • SIMPLE STUFF ESPECIALLY IF THE CROCODILES ARE BITING

  36. Scenario II-CarCrash • You are the only doc on a rural scene of a motor vehicle accident - MOI = rollover with ejections • You have available to assist you one paramedic student and AEA of 2 years standing • You have 5 patients who were occupants of the car travelling at 96kph before it crashed • The injured patients are:

  37. Scenario II-CarCrash • A- 45yr unrestrained male driver who was thrown against the windscreen. On arrival, he was in severe respiratory distress. Injuries include severe maxillofacial trauma with bleeding from the mouth & nose, an angulated deformity of the left forearm & multiple abrasions over the anterior chest - VS: BP= 150/80, HR= 120, RR= 40, GCS= 8

  38. Scenario II-CarCrash • B- 38yr woman front seat passenger who was thrown from the car & found 9meters from the car. On arrival she is awake, alert & C/O abdominal & chest pain. On palpating her hips, she complains of pain & fracture related crepitus is felt. - VS: BP= 110/90, HR= 140, RR= 25.

  39. Scenario II-CarCrash • C- 48yr male passenger was found under the car. He is confused & responds slowly to verbal stimuli. Injuries - multiple abrasions to his face, chest & abdomen. Breath sounds are absent on the left & abdomen is tender on palpation - VS: BP= 90/50, HR= 140, RR= 35, GCS= 10.

  40. Scenario II-CarCrash • D- 25yr hysterical woman extricated from the back seat of the vehicle. She informs you that she is 6/12 pregnant & C/O abdominal pain. Injuries include multiple abrasions to face & anterior abdominal wall - abdomen is tender to palpation & she is in active labour - VS: BP= 120/80, HR= 100, RR= 25.

  41. Scenario II-CarCrash • E- 6yr boy extricated from floor of rear seat who prior to your arrival was alert & talking. He now responds to painful stimuli by only crying out. Injuries include multiple abrasions & an an angulated deformity of right lower leg. There is dry blood around his nose & mouth - VS: BP= 110/70, HR= 180, RR= 35.

  42. Scenario II-CarCrash • Triage these patients as to who you would treat first, second, third, fourth & fifth (press right arrow for answer) Answer: A, C, B, E & D

  43. Scenario III-Disaster Planning • It is 14:00hrs on a Sunday afternoon - “snooze time”. You are in charge of a 100 bed rural community hospital. • Your available staff in the casualty include an ER physician, 2 nurses & four paramedics who are on clinical rotation as part of their clinical training. • Your rural hospital has three ground ambulances & availability of a helicopter from the EMS. Surgical services are also available at your facility on a callout basis afterhours.

  44. Scenario III-Disaster Planning • The nearest definitive care center is 160km away • A trucker calling on his radio, notifies the hospital that an overloaded minibus has run off the highway & rolled over. • He states the minibus has approximately 25 passengers, some of whom are children who are in various degrees of panic & injury. • The incident is approximately 10 minutes away from the hospital by ground ambulance.

  45. Scenario III-Disaster Planning • What calls need to be made & who should make them? • What areas in the hospital need to be designated or set up for this condition? • Who should go to scene? • What equipment & agencies should be deployed to scene?

  46. Scenario III-Disaster Planning • What categories of triage should you anticipate using, & how should they be employed? • What communications would you have available at the: • Scene? • Hospital?

  47. Scenario III-Disaster Planning • How would you manage the following: • Crowd control? • News media? • Ground ambulances? • Helicopter? • Traffic? • Patient indentification?

  48. Scenario III-Disaster Planning • Having considered all of the above: • Are you involved in disaster planning at your hospital? • Is the plan adequate for the hospital? • Is the plan adequate for the community? • What are the key elements to the successful management of a disaster plan?

  49. Concepts in Mass Casualty Management – Pre-Hospital COMMS • Principles: • FCP • IC / OC • FAP • CCS • CHA • Access • Egress • Comms • Hospitals CCS FAP Metro Control Incident IC FCP OC CHA: Toys Wheels/Wings People Primary & Secondary Hospitals Access route Egress route

  50. Marionhill Train Accident 8th March 1994 • Emergency Medical Services Disaster Management of the Scene - Summary: • >380 injured • >68 dead

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