medical triage of traumatic victims
TRANSCRIPT
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นพ.เพชรพงษ์� กำ��จรกำ�จกำ�รภ�ควิ�ช�เวิชศ�สตร�ฉุ�กำเฉุ�น
วิ�ทย�ลั�ยแพทยศ�สตร�กำร�งเทพมห�นครแลัะวิช�รพย�บ�ลั
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• PREVENTION
• TRAINING
• EVALUATION
AllInjuredPatients
MajorTraumaPatients
PREHOSPITAL• Communication• Medical Direction• Triage• Transport
ACUTE CARE FACILITY WITHIN A TRAUMA
SYSTEM other injured patients
TRAUMA CENTER most severity injured or
SPECIALTY CARE FACILITY peds, burns,
and so on
INTERFACILITYTRANSFER
REHABILITATION
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Triage
• Dispatch criteria (triage)
• Field triage– Triage of the single victim– Multiple- and mass-casualty triage
• Emergency department triage
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No. ofPatients
INCLUSIVE SYSTEM
FIELD TRIAGE
EXCLUSIVESYSTEM
MINOR MODERATE SEVERE
Injury Severity Risk*
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Dispatch Criteria - Triage
• - Individual Chief Complaints
• - Traumatic Incidents
• - Time/Life-Critical Events
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Type of Response
• - RED: response time within 8 minutes
• - YELLOW: response time within 15 minute
• - GREEN:
• - WHITE
• - BLACK
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Traumatic Incident Types
• ปั�จจ�ยที่��ใช้�ในการตั�ดสิ�นใจสิ�งที่�มปัฏิ�บั�ตั�การช้�วยเหลื�อ– กลืไกการบัาดเจ บั– อว�ยวะหร�อสิ�วนของร�างกายที่��ได�ร�บัการบัาดเจ บั– อาการ/อาการแสิดงที่��สิ$าคั�ญ
• ช้ อก• บัาดเจ บัศี�รษะ• การตักเลื�อดมาก• การหายใจม�ปั�ญหา• Specific injury
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Prehospital Care Process
ม เหต�ฉุ�กำเฉุ�นเกำ�ดขึ้#$น
แจ%งเหต�(วิ�ธี กำ�รแจ%ง?)
ร�บแจ%งเหต�
ประเม�น/ต�ดส�นใจในกำ�รออกำปฏิ�บ�ต�กำ�ร
แจ%งหน+วิยปฏิ�บ�ต�กำ�รฉุ�กำเฉุ�น(รถ/เร-อ/ฯลัฯ)ออกำปฏิ�บ�ต�กำ�ร
เด�นท�งถ#งท /เกำ�ดเหต�
ประเม�นสถ�นกำ�รณ์�แลัะต�ดส�นใจเพ-/อให%กำ�รร�กำษ์�พย�บ�ลั
เบ-$องต%นในท /เกำ�ดเหต�
ต�ดส�นใจส+งสถ�นพย�บ�ลั
ท /เหม�ะสมถ#งสถ�นพย�บ�ลั
ร�ยง�นเหต�กำ�รณ์�แกำ+ผู้2%เกำ /ยวิขึ้%อง
ให%กำ�รร�กำษ์�พย�บ�ลัณ์ ท /เกำ�ดเหต�
พบเหต�
จบกำ�รปฏิ�บ�ต�กำ�ร
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Emergency Medical Dispatcher (EMD)
Medical Instruction– คัวามเปั)นไปัได�
• ผู้+�แจ�งไม�ได�อย+�ก�บัผู้+�เจ บัปั,วย• โที่รศี�พที่/ไม�ได�อย+�ใกลื�ก�บัผู้+�เจ บัปั,วย• สิ��อสิารก�นไม�เข�าใจ
– คัวามเหมาะสิม• ผู้+�แจ�งได�ให�การช้�วยเหลื�อในสิ��งที่�� EMD จะให�คั$าแนะน$า
ไปัแลื�ว• สิถานการณ์//สิถานที่��ไม�เหมาะสิมที่��จะที่$า
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ถ2กำท��ร%�ย/บ�ดเจ3บ
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ถ2กำท��ร%�ย/บ�ดเจ3บ
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ถ2กำท��ร%�ย/บ�ดเจ3บ
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ถ2กำท��ร%�ย/บ�ดเจ3บ
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BURN
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BURN
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พลั�ดตกำหกำลั%ม/อ�บ�ต�เหต�/เจ3บปวิด
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พลั�ดตกำหกำลั%ม/อ�บ�ต�เหต�/เจ3บปวิด
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พลั�ดตกำหกำลั%ม/อ�บ�ต�เหต�/เจ3บปวิด
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อ�บ�ต�เหต�จร�จร
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อ�บ�ต�เหต�จร�จร
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อ�บ�ต�เหต�จร�จร
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Field TriageField Triage
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Single victim triage
• Single victim triage– aim– Scoring system (GCS, trauma score, etc.)– Triage decision scheme
• Antomical criteria• Mechanism of injury• Medical criteria
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Triage Decision Scheme
Measure vital signs and level of consciousness
Glasgow Coma Scale < 14 orSystolic blood pressure < 90 orRespiratory rate < 10 or > 29 orRevised Trauma Score < 11 Pediatric Trauma Score < 9
YES NO
Take to trauma center; alert trauma team
Assess anatomy of injury
Step 2
Step 1
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Triage Decision Scheme
All penetrating injured to head, neck, torso, and extremities proximal to elbow and knee Flail chest Combination trauma with burn Two or more proximal long bone fracture Pelvic fracture Limb paralysis Amputation proximal to wrist and ankle
YES NO
Take to trauma center; alert trauma team
Evaluate for evidence of mechanism of injury and high-energy impact
Step 3
Step 2
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Triage Decision Scheme Ejection from automobile Death in same passenger compartment Extrication time > 20 minutes Falls > 20 feet Rollover High-speed auto crash:
initial speed > 60 mphmajor auto deformity > 20 inchesintrusion into passenger compartment > 12 inches
Auto-pedestrian/auto-bicycle injury with significant (> 5 mph) impact Pedestrian thrown or run over Motorcycle crash > 20 mph or with separation of rider from bike
YES NO
Step 4
Step 3
Contact medical control and consider transport to a trauma centerConsider trauma team alert
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Triage Decision Scheme
Age < 5 or > 55 Cardiac disease, respiratory disease Insulin-dependent diabetes, cirrhosis, or morbid obesity Pregnancy Immunosuppressed patients Patient with bleeding disorder or patient on anticoagulants
YES NO
Reevaluate with medical control
Step 4
Contact medical control and consider transport to a trauma centerConsider trauma team alert
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Multiple- or mass-casualty triage
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Hot zone
Warm zone
Cold zoneDecontamination area
Wind direction
Command Center / supporting unit
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Predicted ED casualties
• With in 90 minutes following an event, 50-80% of the acute casualties will likely arrive at the closest medical facilities.
• The less-injured casualties often leave the scene under their own power and go to the nearest hospital.
Total Expected Casualties = (Number of casualties arriving in one hour window) x 2
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Multiple- or mass-casualty triage
• Multiple- or mass-casualty triage– Aim – categorize– How
• Ability to walk• Mental status• +/– of ventilation or capillary perfusion
– Tagging– Secondary and tertiary triage – every 15 min.– Shifting from the immediate-care to dead-and-
dying category
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Multiple- or mass-casualty triage
• Timing for triage : Dynamic Triage
• First look
• Clearing station
• Prior to evacuation
• Hospital ER
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Multiple- or mass-casualty triage
INCIDENT SITE
TRIAGE SIEVE TRIAGE SORT
ALP
RECEIVING HOSPITAL
RECEIVING HOSPITAL
RECEIVING HOSPITAL
1 - Immediate 1 - Immediate
2 - Urgent 2 - Urgent
3 - Delayed
4 - Expectant
Dead
4 - Expectant
Body Holding Area
TEMPORARY MORTUARY
CCS
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Multiple- or mass-casualty triage
• Common locations for triage– Primary triage ( Triage sieve )
• At the scene
• Ambulance personnel
– Secondary triage ( Triage sort )
• At CCS
• Medical personnel
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Multiple- or mass-casualty triage
• Triage Priority 1 (Immediate) • Casualties who require immediate life-
saving interventions
• Triage Priority 2 (Urgent)– Casualties who require surgical or other
interventions within 2 - 4 hours
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Multiple- or mass-casualty triage
• Triage Priority 3 (Delayed)– Casualties whose treatment may be
safely delayed for >4 hours
• Triage Priority 4 (Expectant) – Injuries are
1. So severe that they cannot survive, or
2. So severe that their treatment would compromise the care of others
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Multiple- or mass-casualty triage
• Triage decisions need to be made
quickly, safely
• If adequate resources become
available T3 T1
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WALKING
BREATHING
RESPIRATORY
RATE
CAPILLARY
REFILL
PRIORITY 3 (delayed)
DEAD
PRIORITY 1 (immediate)
PRIORITY 2 (urgent)
Yes
Yes
No
No
When airway
opened
10 - 29Ove
r 2 se
c
2 seconds or under
Triage Sieve Diagram
9 or less 30 or more
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Multiple- or mass-casualty triage
• Triage Sort
– More data needed
– Triage revised trauma score (TRTS)
• Respiratory rate
• Systolic BP
• Glascow Coma Scale
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Revised trauma score
GCS SBP RR Coded Value
13 – 15 > 89 10 – 29 4 9 – 12 76 – 89 > 29 3 6 – 8 50 – 75 6 – 9 2 4 – 5 1 – 49 1 – 5 1 3 0 0 0
TRTS = GCS + SBP + RR
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• T1 Immediate1 – 10
• T2 Urgent 11
• T3 Delayed 12
• T4 Expectant 0
Triage revised trauma score (TRTS)
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Multiple- or mass-casualty triage
INCIDENT SITE
TRIAGE SIEVE TRIAGE SORT
ALP
RECEIVING HOSPITAL
RECEIVING HOSPITAL
RECEIVING HOSPITAL
1 - Immediate 1 - Immediate
2 - Urgent 2 - Urgent
3 - Delayed
4 - Expectant
Dead
4 - Expectant
Body Holding Area
TEMPORARY MORTUARY
CCS
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Multiple- or mass-casualty triage
• Triage Labelling
– Essential, should be prepared
– Indicates that triage has been done
– Indicates the current triage priority
– Changes with patient’s condition
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Multiple- or mass-casualty triage
Single card system
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Multiple- or mass-casualty triage
Folding/Cruciform Card System
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Multiple- or mass-casualty triage
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Emergency Department Triage
Emergency Department Triage
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The Canadain E.D. Triage and Acuity Scale
Level Iresuscitation
Nurse – immediatePhysician - immediate
Usual Presentation
ArrestMajor traumaShock statusNear death asthmaSevere respiratory distressAltered mental state (unconscious, delerious)seizures
Sentinel Diagnosis
Traumatic shockPneumothorax - traumatic / tensionFacial burns with airway compromiseSevere burn > 30% TBSOverdose with hypotension/unconsciousAAAAMI with complications / CHF / low BPStatus asthmaticusHead injury – major / unconsciuosStatus epilepticus
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The Canadain E.D. Triage and Acuity Scale
Level IIemergency
Nurse – immediatePhysician – 15 min
Usual Presentation
Head injury (risk features – altered mental state)Severe trauma
Sentinel Diagnosis
Head injury
Trauma:- multiple sites, multiple rib fracture, neck injury / spinal cord
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The Canadain E.D. Triage and Acuity Scale
Level IIemergency
(con’t)
Nurse – immediatePhysician – 15 min
Usual Presentation
Altered mental state (lethargic, drawsy, agitated)Chemical exposure – eyesAllergic reaction (severe)Chest pain : visceral, non-traumatic : + associated symptomsOverdose (conscious), Drug withdrawal
Sentinel Diagnosis
Alkaline / caustic occular burnsAnaphylaxisAMI, unstable angina, CHF, chest pain NOSGastrointestinal refluxUnspecified drug / medicinal overdose
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The Canadain E.D. Triage and Acuity Scale
Level IIemergency
(con’t)
Nurse – immediatePhysician – 15 min
Usual Presentation
Abd pain (age > 50) with visceral symptomBack pain (nontrauma, not musculoskeletal)GI bleed with abnormal vital signsCVA with major deficitAsthma severe (PEFR < 40%)Moderate/severe dyspnea/ difficulty breathing
Sentinel Diagnosis
AAA, appendicitis, cholecystitis
Gastrointestinal bleed, hypotension
CVASevere asthmaCOPD, Croup
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The Canadain E.D. Triage and Acuity Scale
Level IIemergency
(con’t)
Nurse – immediatePhysician – 15 min
Usual Presentation
Vaginal bleeding: acute, pain scale > 5 + abnormal vital signsVomiting and/or diarrhea (with suspicious of dehydration)Signs of serious infection (purpuric rash, toxic)Chemotherapy or immunocompromisedFever (age < 3 mo.) temp > 38.0 (rectal)
Sentinel Diagnosis
Spontaneous abortionEctopic pregnancy/Rupture
Epiglottitis, meningitis, sepsis
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The Canadain E.D. Triage and Acuity Scale
Level IIemergency
(con’t)
Nurse – immediatePhysician – 15 min
Usual Presentation
Acute psychotic episode/ extreme agitationDiabetes: hypoglycemia, hyperglycemiaHeadache (pain scale 8 – 10/10)Pain scale 8 – 10 (CVA, back, eye)Sexual assaultNeonate (< 7 days old)
Sentinel Diagnosis
Acute phychotic episode / agitation
Hypoglycemia, DKA, hyperglycemia
Migraine
Renal colic, LBP / stain (disc), keratitis, Iriitis
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The Canadain E.D. Triage and Acuity Scale
Level IIIurgent
Nurse – 30 minPhysician – 30 min
Usual Presentation
Head injury, alert, vomitingModerate trauma
Abuse / neglect / assualtVomiting and/or diarrhea (< 2 yrs)Dialysis problemSigns of infectionMild / moderate asthma
Sentinel Diagnosis
Head injuryAnterior dislocated shoulder, tibia/fibular fracture, bimalleolar or trimalleolar ankle fracture
PyelonephritisAsthma without status / COPD
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The Canadain E.D. Triage and Acuity Scale
Level IIIurgent(con’t)
Nurse – 30 minPhysician – 30 min
Usual Presentation
Mild / moderate dyspneaChest pain no viscal symptom (sharp) no previous heart diseaseGI bleed with normal vital signsSeizue, alert on arrivalAcute psychosis + suicidal ideaPain scale 8-10/10 with minor injuryPain scale 4-7/10 (headache, CVA, back)
Sentinel Diagnosis
Bronchiolitis / croup, pneumonisChest pain NOS (musculoskeletal, GI, respitatory)
GI bleed, no complicationSeizure Acute psychosis + suicidal idea
Migraine, renal colic, LBP/strain (disc)
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The Canadain E.D. Triage and Acuity Scale
Level IVLess urgent
Nurse – 60 minPhysician – 60 min
Usual Presentation
Head injury, alert, no vomitingMinor traumaAbd pain (acute)EaracheChest pain, minor trauma or musculoskeleton, no distress
Vomiting and diarrhea (> 2 yrs./no dehydration)Suicidal ideation / depression
Sentinel Diagnosis
Head injury, alert, no vomitingColles fracture, ankle sprainAppendicitis, chelecystitisOtitis media / otitis externaChest pain NOS (musculoskeletal, GI, respitatory) gastroesophageal reflux
Suicidal ideation / depression
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The Canadain E.D. Triage and Acuity Scale
Level IVLess urgent
(con’t)
Nurse – 60 minPhysician – 60 min
Usual Presentation
Allergic reaction (minor)Corneal foreign bodyBack pain (chronic)URI symptomsPain scale 4-7Headache (non-migraine / not sudden)
Sentinel Diagnosis
UrticariaCorneal foreign bodyLBP painURI
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The Canadain E.D. Triage and Acuity Scale
Level Vnon urgent
Nurse – 120 minPhysician – 120 min
Usual Presentation
Minor trauma, not necessarity acuteSore throat, no respiratory symptomsDiarrhea alone (no dehydration)Vomiting alone, normal mental status (no dehydration)MensesMinor symptoms
Sentinel Diagnosis
LBP / strain
URI
GastroenteritisVomiting
Disorder of menstruationDressing changes, cast changes
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The Canadain E.D. Triage and Acuity Scale
Level Vnon urgent
(con’t)
Nurse – 120 minPhysician – 120 min
Usual Presentation
Abd pain (chronic)Psychiatric complaints
Pain scale < 4
Sentinel Diagnosis
ConstipationSymptoms / neurotic, personality and nonpsychotic mental disordersUnspecified superficial laceration
Patient should have an initial triage assessment within 10 minutes
of arrival
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ผู้+�ปั,วยช้ายไที่ยอาย3 18 ปั4 เก�ดอ3บั�ตั�เหตั3ข��จ�กรยานยนตั/ช้นก�บัรถจ�กรยานยนตั/ปัระมาณ์ 20 นาที่� ก�อนมาถ5งโรงพยาบัาลื เพ��อนที่��ข��จ�กรยานยนตั/ไปัด�วยก�นน$าสิ�งโรงพยาบัาลื
1 hr later good consciuos, pale, BP 80/40 mmHg,groos hematuria
แรกร�บั triage
BP 110/70 mmHg RR 20/minLacerated wound above left eye brew 3 cm.
Intraoperative finding: intraperitoneal blood 2,000 cc.ruptered speen, retroperitoneal hematoma, not expansion, zone 2
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Retriage
In 15 min.
ATLS
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Trauma victim
ED Triage
Evaluate in ED and Discharge
Evaluate in EDand observe
Resuscitate in EDand admit
Resuscitate in EDand transport to OR
Transport directly toOR for resuscitation
Pronounce DOA
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Mass casualty in ED ?
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Thank you
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