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Unit Four. Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI). Objectives. Define mass casualty incidents (MCI) Describe the Multi-casualty Branch structure Use of multiple Groups/Divisions under the Multi-casualty Branch Director Discuss MCI response procedures

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Unit Four

Hospital Incident Management System (HIMS) for Mass Casualty Incidents (MCI)

Objectives l.jpg

  • Define mass casualty incidents (MCI)

  • Describe the Multi-casualty Branch structure

  • Use of multiple Groups/Divisions under the Multi-casualty Branch Director

  • Discuss MCI response procedures

  • Review emergency medical service role in MCI

  • Describe “START”

B461 Course

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Objectives (cont'd)

  • Identify the relationship of MCI Groups (triage, treatment, transport) to overall scheme of the HIMS

  • Prioritize patients using the START method of triage for:

    • Decontamination

    • Treatment

  • Identify considerations in transporting patients to area hospitals

B461 Course

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Mass Casualty Incidents

  • Multi-patient Incidents - exceeds normal first responder capabilities

  • Major medical emergency – any emergency that would require the access of local mutual aid resources

  • Mass Casualty Incidents - combination of numbers of injured personnel and type of injuries going beyond the capability of an entity’s normal first response

  • Disaster – State and/or Federal resources are required

B461 Course

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Mass Casualty Incident Management

  • Do the greatest good for the greatest number of patients

  • Make the best use of:

    • Personnel

    • Equipment

    • Medical and facility resources

  • Limit the spread of the contamination

  • Minimize the effects of the disaster, incident, or event

B461 Course

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Triage Considerations

  • Triage - Term in early 1800s (derived from the French trier, meaning "to sort")

  • Immediate - Casualty requires lifesaving measures performed without delay if they are to survive

  • Delayed - Casualty whose treatment can wait without causing additional harm

B461 Course

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Triage Considerations (cont'd)

  • Expectant – Casualties that will not survive or will require extensive resources and time if they are to be saved

  • Minor – Casualties that are generally ambulatory and are injured only slightly

B461 Course

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Hospital Triage

  • Use a triage system in an MCI that parallels normal routine

  • Practice regularly to ensure familiarity

  • Triage is a continual process

  • Re-triage all victimstransported by EMS

  • Set up triage area near the ED entrance

    • Shielded and secure

    • Readily accessible

B461 Course

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  • “Greatest good for the greatest number of casualties”

  • Psychological impact

  • Classification:


  • Limitations:

    • Time consuming

    • User variability

    • Lack of familiarity

B461 Course

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Respiratory status

Perfusion and pulse

Neurological status


Walking wounded - “Green” or minimal (relocate when told)

Normal findings - “Yellow” or delayed (unable to relocate)

Abnormal - “Red” or immediate

Non-salvageable - “Black” or expectant

START Triage

B461 Course

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START - Respiratory Status

Respiratory Status



No Respiratory


> 30


Go to



Next Step

B461 Course

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START - Perfusion

Perfusion Status

Radial PulsePresent

Radial PulseAbsent


Go to


Next Step


B461 Course

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START - Neurological Status

Neurological Status

NormalMental Status

Change inMental Status


Move toNext Victim



B461 Course

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Nerve Agent Triage - “Immediate”

  • Unconsciousness or convulsions

  • Two or more body systems involved

  • Requires immediate antidote

Rapid intervention should

result in a good outcome

B461 Course

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Initial First Aid Treatment

  • Immediate removal from source of exposure

    • severity directly proportional to absorbed dose

  • Decontamination

    • Mild soap and water rinse

  • Antidote administration with airway management support as necessary

  • Must be provided by properly trained and equipped personnel

B461 Course

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Nerve Agent Antidote

  • Atropine

    • administered to block receptor sites of acetylcholine

  • 2-PAM Chloride

    • restores acetylcholinesterase

  • Mark I Kit or “Combo Pen”

B461 Course

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First Aid Treatment

  • Exit Agent Exposure Area

  • Minor Symptoms Administer:

    • One Mark I Kit

  • Major Symptoms Administer:

    • Three Mark I Kits

  • Diazepam Required for Severe Casualty

  • Monitor Patient’s Symptoms

B461 Course

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Nerve Agent Triage - “Delayed”

  • Initial symptoms are improving (miosis still present)

  • Recovering well from pre-hospital antidote therapy

B461 Course

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Nerve Agent Triage -“Minimal” & “Expectant”


  • Walking and talking which indicates intact breathing and circulation

  • Expectant

  • Apneic for more than 5 minutes

  • No pulse or blood pressure

B461 Course

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2 to 50% BSA burns by liquid

Eye involvement


< 2% BSA burns by liquid in non-critical areas

Mustard Triage

  • Immediate

  • Moderate to severe pulmonary symptoms

  • Expectant

  • > 50% BSA burns by liquid; apneic/no pulse

B461 Course

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Triage of Biological Casualties

  • Triage of biological agent casualties is different:

    • Symptoms are delayed

    • Initial cases may go unrecognized

    • More difficult to detect

  • Epidemiological information becomes critical

B461 Course

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TriagePsychological Casualties

  • Disasters produce tremendous emotional and psychological stress, with large numbers of psychogenic casualties

  • Presenting signs could be confused with organic disease

  • Use of START triage system maintains focus on objective signs of disease & minimizes impact of subjective complaints on the triage process

  • Psychological casualties are usually triaged as “minimal”

B461 Course

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TriageHospital Arrivals

  • Casualty arrival is uncoordinated

  • Arrival times vary

  • Closest hospital is typically overwhelmed

  • Medical needs of unaffected community continues

  • May present at distant hospitals to ensure treatment at clean facilities

B461 Course

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Contaminated Human Remains

  • Problems are agent specific:

    • Decontamination

    • Containment

    • Refrigeration until definitive disposal

  • Follow local coroner and medical examiner protocols:

    • Establish cooperative agreements for fatality management

  • Secure personal effects:

    • Not all can be decontaminated

B461 Course

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Radiation Protection for Clinical Staff

  • Fundamental Principles

    - Time

    - Distance

    - Shielding

  • Personnel Protective Equipment

  • Contamination Control

B461 Course

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Protecting Staff from Contamination

  • Use standard precautions (N95 mask)

  • Survey hands and clothing frequently

  • Replace contaminated gloves or clothing

  • Keep the work area free of contamination

B461 Course