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USAMRICD

TRIAGE. TRIAGE and FIELD MANAGEMENT U.S. ARMY MEDICAL RESEARCH INSTITUTE OF CHEMICAL DEFENSE CHEMICAL CASUALTY CARE OFFICE. USAMRICD. PROTECT, PROJECT, SUSTAIN. Objectives. Describe components of Casualty Decon Site Discuss some principles of decontamination Define triage

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USAMRICD

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  1. TRIAGE TRIAGEand FIELD MANAGEMENTU.S. ARMY MEDICAL RESEARCH INSTITUTE OF CHEMICAL DEFENSECHEMICAL CASUALTY CARE OFFICE USAMRICD PROTECT, PROJECT, SUSTAIN

  2. Objectives • Describe components of Casualty Decon Site • Discuss some principles of decontamination • Define triage • Discuss the role of Triage Officer • Review categories of triage • Identify the triage category of a chemical casualty given the agent and severity of exposure Triage

  3. Contaminated Casualty Management • Arrival point • Triage points (dirty / clean) • Emergency-Medical-Treatment point • Casualty decontamination areas • Litter & Ambulatory Decon • Hot Line • Clean Treatment Area • Disposition areas (dirty / clean) Triage

  4. Casualty Decontamination Site CONTAMINATED DUMP 75M SHUFFLE PIT 4 3 2 6 ARRIVAL POINT 30M 60M CBPS 3 4 1 1TRIAGE 2 EMT 3 CLOTHING REMOVAL 4 SKIN DECON 5 CLEAN EMT 6 DISPOSITION 5 HOT LINE PREVAILING WINDS Triage

  5. Contaminated Dump • Purpose • Temporary storage of contaminated clothing and equipment • Location • 75M downwind of decon site • Identification • Markers from NATO NBC kit • Report of location and type of dump to HQ Triage

  6. Arrival Point • Purpose • Initial reception for potentially contaminated casualties • patient checked for contamination • Location • Close to triage point and EMT point • Arrival, Triage and EMT point may be co-located • Staffing • Personnel in MOPP4 Triage

  7. Triage Point • Purpose • Rapid initial assessment of patients to determine further disposition • Remove LBE, weapons from casualties • Location • Close to Arrival point and EMT point • Retriage on clean side • Staffing • Senior medic, litter team in MOPP 4 Triage

  8. EMT Point • Purpose • lifesaving emergency treatment (ABCs) • spot decontamination • Location • upwind of Triage point • Staffing • Medic(s) in MOPP4 • Capabilities • Limited BLS interventions Triage

  9. Litter Casualty Decontamination • Purpose • Decon of STABLE, nonambulatory (litter) patients • Location • Between Triage Point & Hot Line • Staffing • Medic (if possible) for supervision • 2-4 nonmedical augmentees in MOPP4 with butyl rubber apron Triage

  10. Ambulatory Casualty Decon • Purpose • Decontamination of ambulatory patients • Location • Parallel to litter decon line • May use unit personnel decon station (PDS) • Activities • Buddy system for decon and clothing removal • Minimal or no assistance from medic Triage

  11. Hot Line • Purpose • Delineates area of potential liquid agent hazard • Downwind of line = liquid hazard • Upwind of line (30-60M) = continued vapor hazard • Location • Between decon & clean TX areas • Activities at shuffle pit • Evaluate completeness of decon • Litter-exchange point • Field Medical Card rewritten Triage

  12. Clean Treatment Area • Purpose • Definitive medical treatment • Location • 60m upwind of Hot Line • Staff • Physician, PA, medics • MOPP 0, collective protection • Activities • Retriage of patients from dirty area • Prep for disposition (evacuation, return to duty) Triage

  13. Disposition Area • Purpose • Exit point from MTF for evacuation or return to duty • Location • In the clean and dirty area • Activities • Departure of treated casualties • Resupply point • Medical records/PAD initiated • Possible break area for unit personnel Triage

  14. Resources • Limited at BAS • ventilation support equipment • decontamination supplies • decontamination personnel • Higher echelons: more resources Triage

  15. Casualty Decon Issues • Augmentees • Assignment and availability • Training • Logistics • Replacement masks and clothing • Water and bleach • Environment • Heat stress, protection from cold • Changing winds • Time Triage

  16. Mechanical / Physical Decon • Physical removal is BEST • Wiping • May smear agent over unexposed areas • May drive agent into skin or wounds • Adsorption • Resins from M291 kit • Fuller’s earth, clay, flour, etc. • Must be followed by mechanical removal • Flushing with water or aqueous solutions • May splash, drive agent into skin or wounds Triage

  17. Chemical Methods • Water / Soap wash • physical removal + dilution + SLOW hydrolysis • Oxidative Chlorination • hypochlorite solution (BLEACH) • 0.5% for skin 5% for equipment • sulfur atoms in VX, HD attacked • increasing pH = increasing effectiveness Triage

  18. Chemical Methods • Alkaline Hydrolysis • OH ion attacks PO4 atoms in nerve agents • rate increases in solution > pH 8 • rate increases 4X for each 10 degree C increase • hypochlorite, ammonia, NaOH solutions Triage

  19. Wound Decontamination • Low risk to surgeon from liquid in wound • nerve agent / mustard react rapidly with tissues • large amount of NA in wound not survivable • Standard irrigation and debridement OK • Foreign material in wound • porous material acts as agent depot • risk to casualty and medical personnel • remove with no-touch technique Triage

  20. DEFINITION of TRIAGE • Triage (Webster): A system designed to produce the greatest benefit from limited treatment facilities for battlefield casualties by giving treatment to those who may survive with proper treatment and NOT to those who have no chance of survival or those who will survive without it. Triage

  21. DEFINITION • Simple Version: If treating one will cost the lives of two, then let the one die and treat the two. • Used whenever demand exceeds resources Triage

  22. When is Triage Done? • At each echelon of care • Repeated PRN with changes in status of: • casualty • workload • resources • Before and after casualty decontamination Triage

  23. Types of Sorting • Treatment • Delayed, Immediate, Minimal, Expectant • Evacuation (priorities) • urgent - within 2 hours • priority - within 4 hours • routine - within 24 hours • Decontamination Triage

  24. Triage Officer Must Know • Nature of injury, prognosis • Resources available • MTF personnel, capabilities • evac and resupply assets • status of decon lane • Patient load • present • anticipated Triage

  25. TRIAGE OFFICER • Conventional • senior surgeon • most experienced in trauma care • Contaminated Casualties • senior medic • PA • RN • dentist Triage

  26. CASUALTY TYPES • Conventional • Chemical, biological, nuclear • Mixed: NBC and Conventional • Psychological • Physiological • Malingering • Any combination Triage

  27. MIXED CASUALTY • Nerve Agent + Conventional • ABCs • Administer antidote • If casualty responds to antidote: • Re-triage according to conventional injury • with consideration of chemical injury Triage

  28. Assessing Contaminated Casualties • Casualty in MOPP • Health care provider in MOPP • Assessment skills of limited use Triage

  29. Categories (NATO) • Urgent • Immediate • Delayed • Minimal • Expectant Triage

  30. IMMEDIATE • Needs IMMEDIATE intervention to save life. • BRIEF INTERVENTION • Airway, Breathing, Circulation • Drugs (MARK I), • Decontamination (spot) Triage

  31. DELAYED • Care IS needed • NOT immediately • Delay in care will not change outcome Triage

  32. MINIMAL • Minor injury • Quick fix • Does not require physician • No evacuation • Return to duty shortly Triage

  33. EXPECTANT • Survival unlikely even with optimal resources • Care exceeds available resources • Not a justified expense of limited resources Triage

  34. Common Times of Death • Nerve Agents < 30 min • Cyanide < 30 min • Phosgene < 24 hours • Mustard 4 to 12 days Triage

  35. NERVE AGENT • Immediate • Symptoms in 2 or more organ systems • airway, GI, muscular • NOT including miosis, rhinorrhea • Unconscious, apneic with heartbeat Triage

  36. NERVE AGENT • Delayed • recovering from moderate / severe exposure • Minimal • walking and talking • assess effect of miosis on duty • Expectant • no heartbeat (resource dependent) Triage

  37. VESICANTS • Immediate • acute airway problem (resource dependent) • Delayed • skin burn > 5% but < 50% BSA • moderate - severe eye involvement • pulmonary sx, onset > 4 hr post-exposure Triage

  38. VESICANTS • Minimal • skin burn < 5% BSA (non-critical area) • minor eye irritation • Expectant • liquid burn > 50% BSA • pulmonary sx, onset < 4 hr post-exposure Triage

  39. PULMONARY AGENTS • Immediate • acute airway problem (resource dependent) • Delayed (for treatment) • onset of symptoms > 4 hr post-exposure • Expectant • onset of symptoms < 4 hr post-exposure • resource dependent Triage

  40. CYANIDE • Immediate • Unconscious, apneic, with heartbeat • Expectant • No circulation • Minimal or Delayed • Survival >15 minutes post vapor exposure Triage

  41. INCAPACITATING AGENTS • Immediate (unlikely) • Cardiorespiratory compromise, hyperthermia • Delayed • Severe, worsening signs/symptoms • Minimal • Mild effects • Expectant (unlikely) • Cardiorespiratory compromise, ltd resources Triage

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