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Care of Clients in Cellular Aberrations,

Acute Biologic Crisis (ABC), Emergency and Disaster Nursing
(NCM106)
Emergency and Disaster V

What is Triage?
Triage means to sort
Looks at medical needs and urgency of each individual patient
Sorting is based on limited data acquisition
Also must consider resource availability

MILITART vs. CIVILIAN TRIAGE
Military Triage Civilian Triage
Priority To get as MANY
SOLDIERS back
into ACTION as
possible
To MAXIMIZE SURVIVAL of
the GREATEST NUMBER OF
VICTIMS
Treatment Those with the
LEAST
SERIOUS
WOUNDS may
be the first
treatment priority
Those with the MOST
SERIOUS but realistically
SALVAGEABLE INJURIES
are treated first
****In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive
resource application are treated as lowest priority

ETHICAL JUSTIFICATION
This is one of the few places where a utilitarian rule governs medicine: The greater good of the greater
number, rather than the particular good of the patient at hand. This rule is justified only because of the
clear necessity of general public welfare in a crisis

Why Should Responders Care about Good Triage??
1. Provides a way to draw organization out of CHAOS
2. Helps to get care to those who need it and will benefit from it the most
3. Helps in RESOURCE ALLOCATION
4. Provides an objective framework for stressful and emotional decisions

Why are Resources Important to Triage??
1. Disaster is commonly defined as an incident in which patient care needs overwhelm local response
resources
2. Daily emergency care is not usually constrained by resource availability












LOOKY
HERE
Topics Discussed Here Are:
1. What is Triage?
a. Primary Disaster Triage
b. Secondary Disaster Triage
c. Tertiary Disaster Triage
d. START Triage
e. JumpSTART Triage
2. Managing Psychosocial Impact of
Disaster
a. Psychosocial Impact
Considerations
b. Psychosocial Response to
Trauma
c. Phases of Emotional
Recovery after a Disaster
3. Critical Incident Stress Debriefing
Abundant Resources Relative to Demand
P P P P
P P P
P P P P
P = Patient

Resources are Challenged

Do The Best For Each Individual

Daily Emergencies: Do the best for each individual
Disaster Setting: Do the greatest good for the greatest
number and maximize survival

Triage is a dynamic process and is usually done more
than once
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Primary Disaster Triage:
Goal:
o To sort patients based on probable needs for immediate care.
o Also to recognize futility
Assumptions:
o Medical needs outstrip immediately available resources
o Additional resources will become available in time
Triage based on Physiology
o How well the patient is able to utilize their own resources to deal with injuries
o Which conditions will benefit the most from the expenditure
The most commonly used ADULT TOOL in the US and CANADA is the START Tool
The only recognized PEDIATRIC MCI Primary Triage Tool used in the US and CANADA is the
JumpSTART Tool
Other tools exist but are less oriented to mass casualties than triaging small other number of adult trauma

Basic Disaster Life Support
O National Disaster Life Support, Education, Consortium, via Medical College of Georgias Center of
Operational Medicine
O Endorsed by the American Medical Association
O Disaster Medicine Online
O MASS Triage:
o Move
o Assess
o Sort
o Send
O Assessment Guidelines
O Pediatric Considerations
The Best Primary Triage Tool = No MCI primary triage tool has been validated by the outcome data

Secondary Disaster Triage:
Goal: To best match patients current and anticipated needs with available resources
Incorporates:
o A reassessment of physiology
o Assessment of Physical Injuries
o Initial treatment and assessment of patient response
o Further knowledge of resources available
The Best Secondary Triage Tool
There is no widely recognized tool in the US that addresses secondary MCI Triage
California Medical Disaster Response or SAVE Tool (Secondary Assessment of Victim Endpoint)

NATO Guidelines
Red SHACCB
FN

o Shock, Significant External Hemorrhage, Airway Obstruction, Cardiorespiratory Failure,
Sucking Chest Wound, Burns of Face or Neck
Yellow B
O
FEAT
o Significant Burns Other than Face, Neck and Perineum, Avascular Limb Fractures, Severe
Eye Injury, Abdominal Wounds, Open Thoracic Wound
Green CSB
SPT
L The Walking Wounded
o Contusions, Sprains, Superficial Burns, Partial-thickness Burns of < 20% BSA, Minor
Lacerations
Black MD H
GCS
B
>85%

o Multisystem Trauma, Signs of Impending Death, Head injury with GCS <8, Burns >85%
BSA

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Goal of the Secondary Triage is to Distinguish Between:
o Victims needing life-saving treatment that can only be provided in a hospital setting
o Victims needing life-saving treatment initially available on scene
o Victims with moderate non-life threatening injuries, at risk for delayed complications
o Victims with minor injuries

Tertiary Triage
Goal: To optimize individual outcome
Incorporates:
o Sophisticated assessment and treatment
o Further assessment of available medical resources
o Determination of best venue for definitive care

Primary Triage Can be transferred to ambulance
Can stay at the treatment area
Secondary Triage Can be transferred to ambulance if there is available resources
Tertiary Triage For green, stay at the treatment area

MCI Triage: Key Points
Resources and patient numbers and acuity are limiting factors
Must be dynamic, responsive to change both resources and patient
There is no apparent civilian MCI Triage that has been official

START Triage
Step 1:
The triage officer announces that all patients that can walk should get up and walk to a designated area for
eventual secondary triage
All ambulatory patients are initially tagged as GREEN

Step 2:
Triage officer assess patients in the
order in which they are encountered
Assess for presence and absence of
spontaneous respirations
If breathing, move to Step 3
If apneic, open airway
If patient remains apneic, tag as
BLACK
If patient starts breathing, tag as RED

Step 3:
Assess Respiratory Rate
Mnemonic
o R (Respiration)
o P (Pulse)
o M (Mental Status)
If any of these 3 are ABNORMAL,
tag as RED
If no problem in RPM, tag as GREEN
Low survival rate, tag as BLACK





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JumpSTART Pediatric MCI
Triage Steps
Patients who are able to walk are
assumed to have stable, well-
compensated physiology, regardless
of their nature of injuries, tag as
GREEN
All GREEN patients must be
individually assessed in Secondary
Triage:
o Assess PHYSIOLOGY
o Assess INJURIES
o Assess PROBABILITY of
DETERIORATION
o Assess NEEDS vs.
RESOURCE Availability
Some children may be carried to the
GREEN Area by others. They have
not proven their physiologic
stability by performing complex
acts of walking
These children should be assessed
first among those in the GREEN
Area
Position the Upper airway of the
apneic child
If they start to breathe, tag them as
RED
If the child does not start breathing
with the upper airway opening, start
feeling for pulse
If no pulse is palpated, tag them as
BLACK
If the patient has palpable pulse,
give 5 mouths to barrier breaths to
open lower airway. Tag as below,
depending on response to
ventilations:
o If no pulse: Deceased
o 5 Rescue Breaths: No Response Deceased
o 5 Rescue Breaths: Has Response Tag as RED
Do not continue to ventilate the patient. Resume tag duties
Assess the respiratory rate of the spontaneously breathing child
o Move on to next assessment if respiratory rate is 15 45 breaths/minute
o If Respiratory Rate is <15 or >45 breaths/minute = Tag as RED
o If the childs pulse is palpable, move on to the next assessment
o If no palpable pulse, tag as RED
o If patient is inappropriately responsive posturing, or unposturing tag as RED







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Triage Categories
Green Minor (Walking Wounded)
Can walk
Can wait for hours for treatment or be cared for on the scene
Includes minor fractures, lacerations, etc.
Yellow Delayed (Serious but Stable)
50-50 Survival
Can wait for 1 2 hours for treatment
Includes major fractures, moderate bleeding, abdominal injuries, etc.
Red Immediate Priority
Cardiopulmonary Problem
Victim will die without immediate treatment
Includes airway issues, tension pneumothorax, shock, unresponsive
uncontrolled hemorrhage and limb amputations
Black Expectant or Dead
(Little or no chance of survival)
May be Dead
No vital signs
Includes massive head or torso injuries, massive blood loss, severe
burns
Provide comfort care

Modifications for Non-ambulatory Children
+ Children developmentally unable to walk due to young age or developmental delay
+ For non-ambulatory children, assess using the JumpSTART Algorithm
+ If patient meets any RED criteria, tag as RED
+ If patient meets YELLOW criteria and has external signs of injury, tag as YELLOW
+ If patient meets YELLOW criteria and has NO external signs of injury, tag as GREEN

What about WMD (Weapons of Mass Destruction)?
There is no widely recognized civilian MCI Triage Tool used in the US for any of the NRBC Agents
o ILANG BESES NA TO INULIT @_@....

WMD Triage Challenges
Any triage model for WMD must consider decontamination
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o Who goes first?
o At what stage does triage take place?
o Difficulty of conducting patient assessment and care for responders in protective gear
Agents of attack may be mixed. How do you triage victims who have injuries from a conventional
attack in addition to a chemical or radiological/nuclear exposure?
o Washing or Taking a bath can decontaminate radiation, but once you inhaled it, it is a serious
problem
Biological agents may impact field triage mostly in choice of destination facility (Quarantine
Hospitals)
Patterns of EMS calls may assist in identification of an occult biological agent attack or a natural
epidemic
o Example: Bio-surveillance tool is the First watch program
Some agents cause Toxindromes that allow for prediction of outcomes based on presenting
symptoms and signs
Agent-specific triage is dependent upon identification or strong suspicion of the agents use
Very difficult to train and maintain readiness with multiple agent-specific triage schemes

Chemical Toxindrome Examples
Nerve Agent
o Red: Severe distress, seizures, signs in two or more systems
(Neuromuscular, GIT, Respiratory Excluding eyes and nose)
o Black: Pulseless or Apneic, unless intensive resources are available
Phosphogene (Some substances burned at home forms Phosphogene Gases) and Vesicants
o Red: Moderate to severe respiratory distress, only when intensive resources are immediately
available
o Black: Burns greater than 50% BSA from liquid exposure, signs of more than minimal
pulmonary involvement, when intensive resources are not available
Cyanide
o Red: Active seizure or recent onset of apnea with preserved circulation
o Black: No Palpable pulse

Key Points About MCI Triage
Anything that can help organize the response to an MCI is a good thing
MCI Triage is different than daily Triage, in both fields, ED Settings
Resource availability is the limiting factor to consider in MCI Triage
In order for MCI Triage to work towards its goal, all victims must have equal importance at the time of
primary triage. No patient group can receive special consideration (Including children)
Disaster research agendas should include efforts to validate and improve existing triage tools
MCI Triage will never be logistically, intellectually or emotionally easy, but we must be prepared to do
it.

Managing Psychosocial Impact of Disaster
- Are we psychologically prepared?
- For every physical injury, there may be 5 6 psychological injuries

Critical Incident
Exposure to a traumatic event in which both of the following were present:
o The person experienced an event that involved actual/threatened death or serious injury of self or
others
o The persons response involved intense fear, helplessness / horror
Consequences of Critical Incident
o Often includes
(1) Tangible Loss (2) Intangible Loss
Loss of materials goods Loss of safety/security
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Loss of loved ones
Loss of home, employment/income
Loss of predictability
Loss of social connection
Loss of dignity
Loss of positive self-image
Loss of trust in the future
Loss of hope
Loss of control

Truth About Coping Mechanism
- People typically rely on past strategies to cope with new stressful situations
- Past coping mechanisms can be functional/dysfunctional

Vulnerable Groups
Children Elderly
They have no experience / known patterns of
action as a response to disaster
Has a degree of resilience that may lead to
unhealthy coping

PSYCHOSOCIAL IMPACT CONSIDERATIONS
- Prior experience with similar event
- Prior trauma
- Intensity of the disruption in the survivors lives
- Resilience of the individual
- Just because you have experienced disaster does not mean you will be damaged by it but you will be
changed by it (Weaver, 1995)

PSYCHOSOCIAL RESPONSE TO TRAUMA
- Experience shows that:
o No one who sees disaster and left untouched by it
o Most people pull together and function during and after a disaster, but their effectiveness is
diminished
o Most people do not see themselves as needing mental health services following a disaster and will
not seek such services
o Survivors may reject disaster assistance of all types
o Disaster mental health assistance is more practical than psychosocial in nature
o Social support systems are crucial to recovery
o People often experience strong and unpleasant emotional and physical responses following
exposure to traumatic events (e.g. Disaster)
o These may include a combination of:
Fear and anxiety
Grief and loss
Shock
Hopelessness
Loss of confidence
Mistrust
Sleep disturbances
Physical Pain
Confusion
Shame
Shaken Faith
Aggressiveness

Categories of Reaction
after an Incident



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Phases of Emotional Recovery after a Disaster
1. Heroic
2. Honeymoon
3. Disillusionment
4. Reconstruction

HEROIC PHASE
At the onset / impact of disaster
and immediately after disaster
Many people are strong and
focused
Strong sense of sharing, people
helping one another and

HONEYMOON
May take several weeks
Cohesion in the community
People meet together and are
relieved that they are safe and alive and that they have a place to stay until they can return back home

DISILLUSIONMENT
Second disaster
People have now been in care centers for > 1 month
They cannot wait on the government
Lasts a month or two to a year or two

RECONSTRUCTION
Lasts several years
Responsibility of recovery
Reconstruction and rebuilding may be going on around but the community has returned to its normal
routine

Essential Attributes and Skills
Good listening skills
Patience
Caring attitude
Trustworthy
Approachable
Culturally aware
Emphatic





Intense Emotions
Are often appropriate reactions if a disaster
Can often be managed by community responders

Support Communication
Conveys:
o Empathy
o Concern
o Respect
o





Helpful~ (Do Say)
- Can you tell me what happened?
- Im sorry
- This must be difficult for you
- Im here to be with you

Unhelpful (Avoid Saying)
- I understand what its like for you
- Dont feel bad
- Youre strong, youll get through this
- Dont cry
- Its Gods will
- It could be worse or At least you still have

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Psychological First Aid (PFA)
Guiding Principle in Providing Psychological Support
- Protect from danger
- Be direct and active
- Provide accurate information about what to do
- Reassure
- Do not give false reassurances
- Recognize the importance of taking action

Goals
- PFA Promotes and sustains an environment of:
1. Safety
2. Calm
3. Connectedness
4. Self-efficacy
5. Hope
1. Promote Safety
Help people meet basic needs for foods and shelter and obtain medical attention
Provide repeated, simple and accurate information on how to get these basic needs met
2. Promote Calm
Listen to people who wish to share their stories and emotion and remember that there are no
right/wrong way to feel
Be friendly and compassionate even if people are being difficult
Offer accurate information about the disaster/trauma and the relief efforts underway to help
victims understand the situation
3. Promote Connectedness
Help people contact relatives, loved ones and friends
Keep families together: Keep children with parents or other close relatives whenever possible
4. Promote Self-efficacy
Give practical suggestions that steer people towards helping themselves
Engage people in meeting their own need
Dont :
Tell people what you think they should be feeling, thinking or doing now or how they
should have acted earlier ( self-efficacy)
Tell people why you think they have suffered by giving reasons about their personal
behavior / beliefs (this also self-efficacy)

Critical Incident Stress Debriefing (CISD)
Debriefing/Defusing Is a specific technique designed to assist responders in dealing with the
physical/psychological symptoms that are associated with trauma exposure
Allows those involved with the incident to process the event and reflect on its impact
Allows for the ventilation of emotions and association with the crisis event
Provide ASAP but typically no longer than the first 24 72 hours after the initial impact of the critical
event

Steps in Stress Debriefing
Stage 1: Lay the groundwork for the session
- Set the goal with the victims
- Find out what happened
- Ask the members of the group to tell about the event that led up to the meeting

Stage 2: Explore the thoughts, feelings and reactions
- Reassure group members about their feelings. Be supportive
o What did you think why this happened?
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o How did you feel about this event when it occurred?
o What was the worst part for you?
o How do you feel about it now?

Stage 3: Explore the coping strategies the group members are using
- How are they dealing with the event / incident?
- Do you still have needs that are unmet?
- What would help them right now?
- What are their plans for dealing with this event (or similar events) in the future

Stage 4: Provide brief rest / diversion
- Have a cup of coffee / a short walk, direct relaxation exercises
- Provide the person time to recover their own sense of competency and direction

Stage 5: Follow-up
- Maintain an expectation that the person will rapidly return to his usual activity
- It may be appropriate to follow-up from a short period