LOADING ………

TRIAGE and MASS CASUALTY

INCIDENTS
AUGUSTO A. TEODORO, JR.,MD
Emergency Physician

University of the Philippines-Manila

Philippine General Hospital
Department of
MFR COURSE Emergency
March 28, 2003 Medicine
Objectives
Define an Incident Command System (ICS)
Functions of the EMS sector of the ICS
Define triage
Categories of triage
START system of triage

RESUS
Incident Command System

A flexible system for managing people and

resources
Command structure to manage multiple
casualty incidents

RESUS
Problems in Developing Mass
Casualty Management
Limited human resources
Limited material resources
Number of hospitals for an area
Minimal transport resources
Lack of radio communications
Poor communication
Topography
Isolation

RESUS
MCI: Response Capacity

Personnel
Facilities
Equipment
Organization
Planning
Training

RESUS
MCI: Field Organization

Expect confusion caused by:

Emergency personnel
Samaritans
Relatives
Spectators
Media

RESUS
First Responding Agency

Establish Incident Command System

Assess the scene
Notify other responding agencies of MCI
First responding unit should remain on
scene and will not treat nor transport
patients
Begin triage

RESUS
First Responding Agency

ALERTING PROCESS
Purposes:
Confirm the initial warning
Evaluate the extent of the problem
Ensure that appropriate resources are
informed and mobilized

RESUS
First Responding Agency
ALERTING PROCESS
Confirmation Report: Issued by the First
Responding Agency
Who
Where
What
How many victims
Potential hazard
Population at risk
Approach route

RESUS
First Responding Agency

DRAWING THE FIELD MAP

North/South
Natural obstacles (trees, rivers, etc.)
Buildings
Roads
Wind direction

RESUS
First Responding Agency
FIELD RESTRICTED AREAS
Strictly Restricted (Impact zone)
- rescue operation
Restricted (Secondary zone)
- Incident command post
- Treatment
Reserved (Tertiary zone)
- VIP, media

RESUS
BACK GATE BACKGATE

ER
BOMB
SHRESTA
EXPLOSION
UNIVERSITY
HOSPITAL
ADMINISTRATION

MEDICAL
SCHOOL
BLDG

UNIVERSITY
QUADRANGLE

MAIN ENTRANCE/EXIT GATE

RESUS
BACK GATE N BACKGATE

ER
IMPACT
SHRESTA
ZONE
UNIVERSITY
HOSPITAL
ADMINISTRATION

SECONDARY

MEDICAL
SCHOOL
ZONE
BLDG

UNIVERSITY
QUADRANGLE

MAIN ENTRANCE/EXIT GATE

TERTIARY
RESUS
ZONE
Incident Commander (IC)
Person in over all charge of the incident
Usually the highest ranking Fire officer on scene
Determines the ff:
- over all strategy
- reassess the situation
- communicate the strategy to all
officers
Appoint an EMS officer, Public information officer

RESUS
EMS Officer

Designate the ff:

- Triage officer
- Communications officer
- Staging officer
- Location of the EMS staging area
Act as a liaison officer between IC and
EMS operations

RESUS
Triage Officer

Assess the medical scene

Report to EMS officer
Oversee patient triage (START system)

RESUS
Communications Officer
Establish medical control with a disaster control
hospital via radio system.
Records: Patient destination
Adult or pediatric
Priority
Body area involved
Determines radio frequency
Request ER capabilities

RESUS
Staging Officer

Management of ambulance staging area

- control ambulances until they are
needed on scene
Communicate with EMS and
Communications officers

RESUS
Triage

The process of sorting patients to

determine the order in which they will
receive care

RESUS
Mass casualty triage
Mass casualty triage -- allows
large numbers of injured be
given the best possible care in
the disaster situation.
The level of ambition may be
adjusted to the needs of the
situation.
Triage categories are:
a) Immediate
b) Delayed
c) Walking wounded
d) Dead and dying

RESUS
Triage Tag

RESUS
S.T.A.R.T. Method of Triage

Simple
Triage
And
Rapid
Treatment

RESUS
START Triage

Observe:
Respiration
Circulation (Perfusion)
Mental Status

Fill in the Blank

RESUS
START

Aims to correct the main threats to

life:
Blocked airways
Severe bleeding

RESUS
Triage Decision

MINOR
Walking wounded

DELAYED
Not life threatening

IMMEDIATE
Life threatening

MORGUE
Pulseless/Breathless

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

RESUS
Simple Triage And Rapid Treatment
YES
Patient Ambulatory ?

RESUS
Simple Triage And Rapid Treatment
YES
Patient Ambulatory ? GREEN

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

Patient Breathing ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

Patient Breathing ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

Patient Breathing ?
NO

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

Patient Breathing ?
NO
BLACK

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

YES
Patient Breathing ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO

NO
Patient Breathing ?
Open Airway

YES
Patient Breathing ? RED

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

NO
Adequate Respiration ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

NO
RED Adequate Respiration ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Perfusion

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

NO

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

Control NO
Bleeding

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

Control NO
Bleeding

RED

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

Can patient follow

simple orders ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

NO Can patient follow

simple orders ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

NO Can patient follow

RED simple orders ?

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

Can patient follow

simple orders ?
YES

RESUS
Simple Triage And Rapid Treatment

Patient Ambulatory ?

NO
YES
Patient Breathing ?

Adequate Respiration ?

YES

Radial Pulse Present ? Perfusion

YES Mental
Status

Can patient follow

simple orders ?
YES

YELLOW
RESUS
Simple Triage And Rapid Treatment
YES
Patient Ambulatory ? GREEN

NO

NO YES
Patient Breathing ?
Open Airway

YES NO
Patient Breathing ? RED Adequate Respiration ?
NO
YES
BLACK
Radial Pulse Present ? Perfusion

Control NO YES Mental

Bleeding Status

NO Can patient follow

RED simple orders ?
YES

YELLOW
RESUS
 MINOR

Walking wounded

RESUS
 MORGUE

Considered dead
Breathless even if airway is opened

RESUS
 IMMEDIATE

Life threatening
Can breathe when airway is opened
May be breathing adequately but radial
pulse is difficult to appreciate due to
bleeding
May be breathing adequately, with radial
pulse but cannot follow simple commands

RESUS
 DELAYED

Serious/Not life threatening

Non-ambulatory
Can breathe adequately
With radial pulse
Can follow simple commands

RESUS
Triage Decision
Move the walking wounded

No respirations after head tilt

Respirations over 30

Perfusion – Capillary refill over

2 sec
Mental status–unable to follow
simple commands
Others
RESUS
BACK GATE EVACUATION ENTRANCE FOR
AMBULANCE
AREA 2

ER STAGING
IMPACT AREA
SHRESTA
ZONE
UNIVERSITY
HOSPITAL
COMMAND
CENTER

MEDICAL SCHOOL
EVACUATION
AREA 2

MEDIA/
VIPs

ENTRANCE GATE EXIT GATE

RESUS
 
EVACUATION AREA 1 
STAGING AREA

SURGERY

DEAD
MEDICINE PEDIA


SURGERY

OB/GYN Triage Officer

WALKING
WOUNDED Area Officer
PEDIA
Patient Route
MEDICINE Ambulance
Route
RESUS
Staging Area
STAGING OFFICER


A1 A2 A3 A4
TO MEDEVAC AREA

RESUS
 FIRST ARRIVING UNIT
Initial Assessment

Establishes Incident Command

Safety Officer
Public Information Officer
Liaison Officer

Operations Planning Logistics Finance

EMS Officer

EMS Triage EMS EMS Staging

Officer Communications Officer
Officer

EMS Transportation
Officer

RESUS
 that’s
all
folks !
RESUS