triage of mass casualties msf 11th surgical day paris, 3 december 2011 marco baldan icrc head...
TRANSCRIPT
TRIAGE
OF MASS CASUALTIES
MSF 11th Surgical Day
Paris, 3 December 2011
Marco Baldan
ICRC Head Surgeon
Al Hussein HospitalKarbala, Iraq2 March 2004
First bomb attack in the city
Total victims = 277
Dead = 94
Wounded = 183
Hospital Situation
Beds in ER = 24 No place for cadavers No communication with/among ambulances Minimal hospital security system No triage system / disaster plan Medical supplies on 4th floor Operating theatres on 1st and 2nd floors Lifts not functioning
Clinical practice
Normal clinical practice
Multiple-casualty incident
Mass casualties
Triage = Process
by which priorities are set for the management of mass casualties.
The aim in a mass casualty situation is
to do the best for the most,
not
everything for everyone.
JFK Memorial Hospital, Maternity BuildingMonrovia 2003
Triage Tent
Inside the Triage Tent
JFK Memorial Hospital, Main Building
Main Building, Triage Department
Triage Department, in use
Triage cannot be organised ad hoc. It requires planning:
Preparation before the crisis Organisation of the personnel Organisation of the space Organisation of the infrastructure Organisation of the equipment Organisation of supplies Training Communication
Security Convergence reaction = relatives, friends &
the curious (especially the armed ones)
Triage involves a dynamic equilibrium between needs and resources.
Needs = number of wounded and types of wounds
Resources = infrastructure and equipment at hand & competent personnel present
The Triage Team
Triage team leader: co-ordinator
Clinical triage officer
Head nurse, matron: chief organiser
Nursing groups
Follow-up medical groups
Clinical Triage Officer
No task in the medical services requires greater understanding,
skill,
and judgement
than the sorting of casualties
and the establishment of priorities for treatment.
Triage decisions must be respected.
Discuss afterwards.
Triage is a dynamic process:
begins at the point of wounding,
occurs all along the chain of casualty care,
occurs at the hospital reception,
and continues inside the hospital wards:
continuous reassessment of patients.
Triage Documentation
Include basic information
Short-form Clear Concise Complete
Triage Documentation
Reality check
What really happens!
During post-triage evaluation:
decided to use plastic
sleeve to hold the documentation.
The triage process:
Sift
Place patients in main categories: priority
Sort
Priority amongst the priorities
Sift
1) Select those most severely injured and
2) identify and remove:
the dead
the slightly injured
the uninjured
Sort
Categorise the most severely injured based on:
life-threatening conditions (ABC)
anatomic site of injury
Red Cross Wound Score
treatment available in terms of personnel and supplies
ICRC TRIAGE CATEGORIES
I. Serious wounds: resuscitation and immediate Serious wounds: resuscitation and immediate surgerysurgery
II. Second priority: need surgery but can waitSecond priority: need surgery but can wait
III. Superficial wounds: ambulatory managementSuperficial wounds: ambulatory management
IV. Severe wounds: supportive treatmentSevere wounds: supportive treatment
Category I: Resuscitation and immediate Category I: Resuscitation and immediate surgerysurgery
Patients who need urgent surgery – life-saving – and have a good chance of recovery.
(E.g. Airway, Breathing, Circulation: tracheostomy, haemothorax, haemorrhaging abdominal injuries, peripheral
blood vessels)
Distal pulse absent
Category II: Need surgery but can waitCategory II: Need surgery but can wait
Patients who require surgery but not on an urgent basis.
A large number of patients will fall into this group.
(E.g. non-haemorrhaging abdominal injuries, wounds of limbs with fractures and/or major soft tissue wounds,
penetrating head wounds GCS > 8.)
Category I for Airway; Category II for debridement
Femoral vessels intact
Category III: Superficial woundsCategory III: Superficial wounds(no surgery, ambulatory treatment)(no surgery, ambulatory treatment)
Patients with wounds requiring little or no surgery.
In practice, this is a large group, including superficial wounds managed under local anaesthesia in the emergency room or
with simple first aid measures.
Multiple superficial fragments
Category IV: Very severe woundsCategory IV: Very severe wounds(no surgery, supportive treatment)(no surgery, supportive treatment)
Patients with such severe injuries that they are unlikely to survive or would have a poor quality of
survival.
The moribund or those with multiple major injuries whose management could be considered wasteful of scarce
resources in a mass casualty situation.
War Wounded in the Field
First AidDressing
30 - 40 %No surgery
12-15% Head10% Chest10% Abdomen60-65% Limbs
90% Surgery
Small woundsParaplegiaQuadriplegia
Observation
10% NO Surgery
60 - 70 %Hospital care
WW in the field(GSW, mine, blast)
100 wounded
Epidemiology of Triage:short evacuation time
Category I 5 - 10%
Category II 25 – 30%
Category III 50 - 60%
Category IV 5 - 7%
Triage in Monrovia 20033 June – 22 August
Total patients triaged = 2588
Total admitted = 1015 (40% of triaged)
War wounded = 88.5% of admissions
Operations = 1433
Admitted but not operated = 296
All category 1 patients triaged, admitted and operated within 24 hours
Patients triaged by date:three peaks
020
406080
100
120140160
180200
3.06
7.06
11.0
6
15.0
6
19.0
6
23.0
6
27.0
6
1 Ju
ly
5.07
9.07
13.0
7
17.0
7
21.0
7
25.0
7
29.0
7
2.08
6.08
10.0
8
14.0
8
18.0
8
22.0
8
Date
Nu
mb
er P
atie
nts
Summary of triage theory & philosophy: sorting by priority
A simple emergency plan: personnel, space, infrastructure, equipment, supplies = system
"Best for most" policy
Priority patients are those with a good chance of good survival.