Medical Triage of Traumatic victims

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Medical Triage of Traumatic victims

  1. 1. นพ . เพชรพงษ์ กำจรกิจการ ภาควิชาเวชศาสตร์ฉุกเฉิน วิทยาลัยแพทยศาสตร์กรุงเทพมหานครและวชิรพยาบาล TRIAGE
  2. 2. LEADERSHIP LEGISLATION SYSTEM DEVELOPMENT FINANCE <ul><li>PREVENTION </li></ul><ul><li>TRAINING </li></ul><ul><li>EVALUATION </li></ul>All Injured Patients Major Trauma Patients <ul><li>PREHOSPITAL </li></ul><ul><li>Communication </li></ul><ul><li>Medical Direction </li></ul><ul><li>Triage </li></ul><ul><li>Transport </li></ul>ACUTE CARE FACILITY WITHIN A TRAUMA SYSTEM other injured patients TRAUMA CENTER most severity injured or SPECIALTY CARE FACILITY peds, burns, and so on INTERFACILITY TRANSFER REHABILITATION
  3. 3. Triage <ul><li>Dispatch criteria (triage) </li></ul><ul><li>Field triage </li></ul><ul><ul><li>Triage of the single victim </li></ul></ul><ul><ul><li>Multiple- and mass-casualty triage </li></ul></ul><ul><li>Emergency department triage </li></ul>
  4. 4. No. of Patients INCLUSIVE SYSTEM FIELD TRIAGE EXCLUSIVE SYSTEM MINOR MODERATE SEVERE Injury Severity Risk *
  5. 5. Dispatch Criteria - Triage <ul><li>- Individual Chief Complaints </li></ul><ul><li>- Traumatic Incidents </li></ul><ul><li>- Time/Life-Critical Events </li></ul>
  6. 6. Type of Response <ul><li>- RED : response time within 8 minutes </li></ul><ul><li>- YELLOW: response time within 15 minute </li></ul><ul><li>- GREEN : </li></ul><ul><li>- WHITE </li></ul><ul><li>- BLACK </li></ul>
  7. 7. Traumatic Incident Types <ul><li>ปัจจัยที่ใช้ในการตัดสินใจส่งทีมปฏิบัติการช่วยเหลือ </li></ul><ul><ul><li>กลไกการบาดเจ็บ </li></ul></ul><ul><ul><li>อวัยวะหรือส่วนของร่างกายที่ได้รับการบาดเจ็บ </li></ul></ul><ul><ul><li>อาการ / อาการแสดงที่สำคัญ </li></ul></ul><ul><ul><ul><li>ช็อก </li></ul></ul></ul><ul><ul><ul><li>บาดเจ็บศีรษะ </li></ul></ul></ul><ul><ul><ul><li>การตกเลือดมาก </li></ul></ul></ul><ul><ul><ul><li>การหายใจมีปัญหา </li></ul></ul></ul><ul><ul><ul><li>Specific injury </li></ul></ul></ul>
  8. 8. Prehospital Care Process มีเหตุฉุกเฉิน เกิดขึ้น แจ้งเหตุ ( วิธีการแจ้ง ?) รับแจ้งเหตุ ประเมิน / ตัดสินใจ ในการออกปฏิบัติการ แจ้งหน่วยปฏิบัติการฉุกเฉิน ( รถ / เรือ / ฯลฯ ) ออกปฏิบัติการ เดินทางถึงที่เกิดเหตุ ประเมินสถานการณ์ และตัดสินใจเพื่อให้การรักษาพยาบาล เบื้องต้นในที่เกิดเหตุ ตัดสินใจ ส่งสถานพยาบาล ที่เหมาะสม ถึงสถานพยาบาล รายงานเหตุการณ์ แก่ผู้เกี่ยวข้อง ให้การรักษาพยาบาล ณ ที่เกิดเหตุ พบเหตุ จบการ ปฏิบัติการ
  9. 9. Emergency Medical Dispatcher (EMD) <ul><li>Medical Instruction </li></ul><ul><ul><li>ความเป็นไปได้ </li></ul></ul><ul><ul><ul><li>ผู้แจ้งไม่ได้อยู่กับผู้เจ็บป่วย </li></ul></ul></ul><ul><ul><ul><li>โทรศัพท์ไม่ได้อยู่ใกล้กับผู้เจ็บป่วย </li></ul></ul></ul><ul><ul><ul><li>สื่อสารกันไม่เข้าใจ </li></ul></ul></ul><ul><ul><li>ความเหมาะสม </li></ul></ul><ul><ul><ul><li>ผู้แจ้งได้ให้การช่วยเหลือในสิ่งที่ EMD จะให้คำแนะนำไปแล้ว </li></ul></ul></ul><ul><ul><ul><li>สถานการณ์ / สถานที่ไม่เหมาะสมที่จะทำ </li></ul></ul></ul>
  10. 10. ถูกทำร้าย / บาดเจ็บ
  11. 11. ถูกทำร้าย / บาดเจ็บ
  12. 12. ถูกทำร้าย / บาดเจ็บ
  13. 13. ถูกทำร้าย / บาดเจ็บ
  14. 14. BURN
  15. 15. BURN
  16. 16. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด
  17. 17. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด
  18. 18. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด
  19. 19. อุบัติเหตุจราจร
  20. 20. อุบัติเหตุจราจร
  21. 21. อุบัติเหตุจราจร
  22. 22. Field Triage
  23. 26. Single victim triage <ul><li>Single victim triage </li></ul><ul><ul><li>aim </li></ul></ul><ul><ul><li>Scoring system (GCS, trauma score, etc.) </li></ul></ul><ul><ul><li>Triage decision scheme </li></ul></ul><ul><ul><ul><li>Antomical criteria </li></ul></ul></ul><ul><ul><ul><li>Mechanism of injury </li></ul></ul></ul><ul><ul><ul><li>Medical criteria </li></ul></ul></ul>
  24. 27. Triage Decision Scheme Measure vital signs and level of consciousness Glasgow Coma Scale < 14 or Systolic blood pressure < 90 or Respiratory rate < 10 or > 29 or Revised Trauma Score < 11 Pediatric Trauma Score < 9 YES NO Take to trauma center; alert trauma team Assess anatomy of injury Step 2 Step 1
  25. 28. Triage Decision Scheme <ul><li>All penetrating injured to head, neck, torso, and </li></ul><ul><li>extremities proximal to elbow and knee </li></ul><ul><li>Flail chest </li></ul><ul><li>Combination trauma with burn </li></ul><ul><li>Two or more proximal long bone fracture </li></ul><ul><li>Pelvic fracture </li></ul><ul><li>Limb paralysis </li></ul><ul><li>Amputation proximal to wrist and ankle </li></ul>YES NO Take to trauma center; alert trauma team Evaluate for evidence of mechanism of injury and high-energy impact Step 3 Step 2
  26. 29. Triage Decision Scheme <ul><li>Ejection from automobile </li></ul><ul><li>Death in same passenger compartment </li></ul><ul><li>Extrication time > 20 minutes </li></ul><ul><li>Falls > 20 feet </li></ul><ul><li>Rollover </li></ul><ul><li>High-speed auto crash: </li></ul><ul><li>initial speed > 60 mph </li></ul><ul><li>major auto deformity > 20 inches </li></ul><ul><li>intrusion into passenger compartment > 12 inches </li></ul><ul><li>Auto-pedestrian/auto-bicycle injury with significant (> 5 mph) impact </li></ul><ul><li>Pedestrian thrown or run over </li></ul><ul><li>Motorcycle crash > 20 mph or with separation of rider from bike </li></ul>YES NO Step 4 Step 3 Contact medical control and consider transport to a trauma center Consider trauma team alert
  27. 30. Triage Decision Scheme <ul><li>Age < 5 or > 55 </li></ul><ul><li>Cardiac disease, respiratory disease </li></ul><ul><li>Insulin-dependent diabetes, cirrhosis, or morbid obesity </li></ul><ul><li>Pregnancy </li></ul><ul><li>Immunosuppressed patients </li></ul><ul><li>Patient with bleeding disorder or patient on anticoagulants </li></ul>YES NO Reevaluate with medical control Step 4 Contact medical control and consider transport to a trauma center Consider trauma team alert
  28. 31. Multiple- or mass-casualty triage
  29. 32. Hot zone Warm zone Cold zone Decontamination area Wind direction Command Center / supporting unit
  30. 34. Predicted ED casualties <ul><li>With in 90 minutes following an event, 50-80% of the acute casualties will likely arrive at the closest medical facilities. </li></ul><ul><li>The less-injured casualties often leave the scene under their own power and go to the nearest hospital. </li></ul>Total Expected Casualties = (Number of casualties arriving in one hour window) x 2  
  31. 35. Multiple- or mass-casualty triage <ul><li>Multiple- or mass-casualty triage </li></ul><ul><ul><li>Aim – categorize </li></ul></ul><ul><ul><li>How </li></ul></ul><ul><ul><ul><li>Ability to walk </li></ul></ul></ul><ul><ul><ul><li>Mental status </li></ul></ul></ul><ul><ul><ul><li>+/– of ventilation or capillary perfusion </li></ul></ul></ul><ul><ul><li>Tagging </li></ul></ul><ul><ul><li>Secondary and tertiary triage – every 15 min. </li></ul></ul><ul><ul><li>Shifting from the immediate-care to dead-and-dying category </li></ul></ul>
  32. 36. Multiple- or mass-casualty triage <ul><li>Timing for triage : Dynamic Triage </li></ul><ul><li>First look </li></ul><ul><li>Clearing station </li></ul><ul><li>Prior to evacuation </li></ul><ul><li>Hospital ER </li></ul>
  33. 37. 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
  34. 38. Multiple- or mass-casualty triage <ul><li>Common locations for triage </li></ul><ul><ul><li>Primary triage ( Triage sieve ) </li></ul></ul><ul><ul><ul><li>At the scene </li></ul></ul></ul><ul><ul><ul><li>Ambulance personnel </li></ul></ul></ul><ul><ul><li>Secondary triage ( Triage sort ) </li></ul></ul><ul><ul><ul><li>At CCS </li></ul></ul></ul><ul><ul><ul><li>Medical personnel </li></ul></ul></ul>
  35. 39. Multiple- or mass-casualty triage <ul><ul><li>Triage Priority 1 (Immediate) </li></ul></ul><ul><ul><ul><li>Casualties who require immediate life-saving interventions </li></ul></ul></ul><ul><li>Triage Priority 2 (Urgent) </li></ul><ul><ul><li>Casualties who require surgical or other interventions within 2 - 4 hours </li></ul></ul>
  36. 40. Multiple- or mass-casualty triage <ul><li>Triage Priority 3 (Delayed) </li></ul><ul><ul><li>Casualties whose treatment may be safely delayed for >4 hours </li></ul></ul><ul><li>Triage Priority 4 (Expectant) </li></ul><ul><ul><li>Injuries are </li></ul></ul><ul><ul><ul><li>So severe that they cannot survive, or </li></ul></ul></ul><ul><ul><ul><li>2. So severe that their treatment would compromise the care of others </li></ul></ul></ul>
  37. 41. Multiple- or mass-casualty triage <ul><li>Triage decisions need to be made quickly, safely </li></ul><ul><li>If adequate resources become available T3  T1 </li></ul>
  38. 42. WALKING BREATHING RESPIRATORY RATE CAPILLARY REFILL PRIORITY 3 (delayed) DEAD PRIORITY 1 (immediate) PRIORITY 2 (urgent) Yes Yes No No When airway opened 10 - 29 Over 2 sec 2 seconds or under Triage Sieve Diagram 9 or less 30 or more
  39. 43. Multiple- or mass-casualty triage <ul><li>Triage Sort </li></ul><ul><ul><li>More data needed </li></ul></ul><ul><ul><li>Triage revised trauma score (TRTS) </li></ul></ul><ul><ul><ul><li>Respiratory rate </li></ul></ul></ul><ul><ul><ul><li>Systolic BP </li></ul></ul></ul><ul><ul><ul><li>Glascow Coma Scale </li></ul></ul></ul>
  40. 44. 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
  41. 45. <ul><li>T1 Immediate 1 – 10 </li></ul><ul><li>T2 Urgent 11 </li></ul><ul><li>T3 Delayed 12 </li></ul><ul><li>T4 Expectant 0 </li></ul>Triage revised trauma score (TRTS)
  42. 46. 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
  43. 47. Multiple- or mass-casualty triage <ul><li>Triage Labelling </li></ul><ul><ul><li>Essential, should be prepared </li></ul></ul><ul><ul><li>Indicates that triage has been done </li></ul></ul><ul><ul><li>Indicates the current triage priority </li></ul></ul><ul><ul><li>Changes with patient’s condition </li></ul></ul>
  44. 48. Multiple- or mass-casualty triage Single card system
  45. 49. Multiple- or mass-casualty triage Folding/ Cruciform Card System
  46. 50. Multiple- or mass-casualty triage
  47. 51. Emergency Department Triage
  48. 52. The Canadain E.D. Triage and Acuity Scale Level I resuscitation Nurse – immediate Physician - immediate Usual Presentation Arrest Major trauma Shock status Near death asthma Severe respiratory distress Altered mental state (unconscious, delerious) seizures Sentinel Diagnosis Traumatic shock Pneumothorax - traumatic / tension Facial burns with airway compromise Severe burn > 30% TBS Overdose with hypotension/unconscious AAA AMI with complications / CHF / low BP Status asthmaticus Head injury – major / unconsciuos Status epilepticus
  49. 53. The Canadain E.D. Triage and Acuity Scale Level II emergency Nurse – immediate Physician – 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
  50. 54. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Altered mental state (lethargic, drawsy, agitated) Chemical exposure – eyes Allergic reaction (severe) Chest pain : visceral, non-traumatic : + associated symptoms Overdose (conscious), Drug withdrawal Sentinel Diagnosis Alkaline / caustic occular burns Anaphylaxis AMI, unstable angina, CHF, chest pain NOS Gastrointestinal reflux Unspecified drug / medicinal overdose
  51. 55. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Abd pain (age > 50) with visceral symptom Back pain (nontrauma, not musculoskeletal) GI bleed with abnormal vital signs CVA with major deficit Asthma severe (PEFR < 40%) Moderate/severe dyspnea/ difficulty breathing Sentinel Diagnosis AAA, appendicitis, cholecystitis Gastrointestinal bleed, hypotension CVA Severe asthma COPD, Croup
  52. 56. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Vaginal bleeding: acute, pain scale > 5 + abnormal vital signs Vomiting and/or diarrhea (with suspicious of dehydration) Signs of serious infection (purpuric rash, toxic) Chemotherapy or immunocompromised Fever (age < 3 mo.) temp > 38.0 (rectal) Sentinel Diagnosis Spontaneous abortion Ectopic pregnancy/Rupture Epiglottitis, meningitis, sepsis
  53. 57. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Acute psychotic episode/ extreme agitation Diabetes: hypoglycemia, hyperglycemia Headache (pain scale 8 – 10/10) Pain scale 8 – 10 (CVA, back, eye) Sexual assault Neonate ( < 7 days old) Sentinel Diagnosis Acute phychotic episode / agitation Hypoglycemia, DKA, hyperglycemia Migraine Renal colic, LBP / stain (disc), keratitis, Iriitis
  54. 58. The Canadain E.D. Triage and Acuity Scale Level III urgent Nurse – 30 min Physician – 30 min Usual Presentation Head injury, alert, vomiting Moderate trauma Abuse / neglect / assualt Vomiting and/or diarrhea ( < 2 yrs) Dialysis problem Signs of infection Mild / moderate asthma Sentinel Diagnosis Head injury Anterior dislocated shoulder, tibia/fibular fracture, bimalleolar or trimalleolar ankle fracture Pyelonephritis Asthma without status / COPD
  55. 59. The Canadain E.D. Triage and Acuity Scale Level III urgent (con’t) Nurse – 30 min Physician – 30 min Usual Presentation Mild / moderate dyspnea Chest pain no viscal symptom (sharp) no previous heart disease GI bleed with normal vital signs Seizue, alert on arrival Acute psychosis + suicidal idea Pain scale 8-10/10 with minor injury Pain scale 4-7/10 (headache, CVA, back) Sentinel Diagnosis Bronchiolitis / croup, pneumonis Chest pain NOS (musculoskeletal, GI, respitatory) GI bleed, no complication Seizure Acute psychosis + suicidal idea Migraine, renal colic, LBP/strain (disc)
  56. 60. The Canadain E.D. Triage and Acuity Scale Level IV Less urgent Nurse – 60 min Physician – 60 min Usual Presentation Head injury, alert, no vomiting Minor trauma Abd pain (acute) Earache Chest pain, minor trauma or musculoskeleton, no distress Vomiting and diarrhea (> 2 yrs./no dehydration) Suicidal ideation / depression Sentinel Diagnosis Head injury, alert, no vomiting Colles fracture, ankle sprain Appendicitis, chelecystitis Otitis media / otitis externa Chest pain NOS (musculoskeletal, GI, respitatory) gastroesophageal reflux Suicidal ideation / depression
  57. 61. The Canadain E.D. Triage and Acuity Scale Level IV Less urgent (con’t) Nurse – 60 min Physician – 60 min Usual Presentation Allergic reaction (minor) Corneal foreign body Back pain (chronic) URI symptoms Pain scale 4-7 Headache (non-migraine / not sudden) Sentinel Diagnosis Urticaria Corneal foreign body LBP pain URI
  58. 62. The Canadain E.D. Triage and Acuity Scale Level V non urgent Nurse – 120 min Physician – 120 min Usual Presentation Minor trauma, not necessarity acute Sore throat, no respiratory symptoms Diarrhea alone (no dehydration) Vomiting alone, normal mental status (no dehydration) Menses Minor symptoms Sentinel Diagnosis LBP / strain URI Gastroenteritis Vomiting Disorder of menstruation Dressing changes, cast changes
  59. 63. The Canadain E.D. Triage and Acuity Scale Level V non urgent (con’t) Nurse – 120 min Physician – 120 min Usual Presentation Abd pain (chronic) Psychiatric complaints Pain scale < 4 Sentinel Diagnosis Constipation Symptoms / neurotic, personality and nonpsychotic mental disorders Unspecified superficial laceration Patient should have an initial triage assessment within 10 minutes of arrival
  60. 64. <ul><li>ผู้ป่วยชายไทยอายุ 18 ปี เกิดอุบัติเหตุขี่จักรยานยนต์ชนกับรถจักรยานยนต์ประมาณ 20 นาที ก่อนมาถึงโรงพยาบาล เพื่อนที่ขี่จักรยานยนต์ไปด้วยกันนำส่งโรงพยาบาล </li></ul>1 hr later good consciuos, pale, BP 80/40 mmHg, groos hematuria แรกรับ triage BP 110/70 mmHg RR 20/ min Lacerated wound above left eye brew 3 cm. Intraoperative finding: intraperitoneal blood 2,000 cc. ruptered speen, retroperitoneal hematoma, not expansion, zone 2
  61. 65. Retriage In 15 min. ATLS
  62. 66. Trauma victim ED Triage Evaluate in ED and Discharge Evaluate in ED and observe Resuscitate in ED and admit Resuscitate in ED and transport to OR Transport directly to OR for resuscitation Pronounce DOA
  63. 67. Mass casualty in ED ?
  64. 68. Thank you

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