Disaster traige - Stritch School of Medicine

Disaster traige - Stritch School of Medicine

PEDIATRIC DISASTER TRIAGE UTILIZING THE JUMPSTART METHOD MARCH 2016 (4TH EDITION) Illinois Emergency Medical Services for Children is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago Disclaimer This slide set and all related training information provided in this session is in accordance with current practice at the time that this program was developed. Acknowledgements

This 4th edition education program was developed under the direction and guidance of the Illinois Pediatric Preparedness Workgroup. The original program was adapted in 2006 from a module developed by Childrens Memorial Hospital (now Ann & Robert H. Lurie Childrens Hospital of Chicago). This program was developed from an Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) grant. All training materials are considered under public domain and can be utilized by others in the conduction of similar educational programs, provided there is acknowledgement of the source of these materials. Objectives

Identify unique characteristics that make children more vulnerable in a disaster Discuss mass casualty triage and the pediatric patient Review START and JumpSTART Triage Tools and the SMART Triage Pacs Demonstrate the use of the START and JumpSTART Triage Tool Objectives (continued) Discuss the instructor role for JumpSTART Triage Training

Identify Healthcare Professionals in your EMS Region to target for JumpSTART Triage training Discuss the necessary steps to teach a JumpSTART Provider and Instructor Class Review the training materials that are necessary to teach a JumpSTART Provider and Instructor Class Introduction Background Illinois Emergency Medical Services for Children (EMSC) 1984: National EMSC Program established through federal

legislation Jointly sponsored by Maternal & Child Health Bureau National Highway Traffic Safety Administration States are charged with enhancing the pediatric component of their Emergency Medical Services (EMS) systems. 1994: Illinois EMSC was established. Illinois EMSC Pediatric Disaster Preparedness 2002:

Illinois Pediatric Bioterrorism Workgroup convened Name changed in 2011 to Pediatric Preparedness Workgroup to ensure a more all-hazards approach. Reports to EMSC Advisory Board and Illinois Terrorism Task Force Assists in assuring that the special needs of children are addressed during a disaster or terrorist event by: Enhancing awareness of pediatric needs Identifying/sharing best practices Developing resource documents, tools, and guidelines Integrating disaster preparedness into existing state initiatives Illinois Communities

Illinois is the 5th most populous state with a population of 12.9 million Almost 3 million children <18 years of age Approximately 800,000 are age five and younger. Children and Disasters Disaster A medical disaster occurs when the destructive effects of natural or man made forces overwhelm

the ability of a given area or community to meet the demand for health care. (Source: ACEP Disaster Medical Services Policy Statement, 2006) Natural Disasters Earthquake Flood Snow/ice storm Tornado Others Human Caused Disasters Terrorist Events

Arson Bombings Shootings Use of chemical, biological or nuclear agents Hazmat incidents Terrorist Events and the Pediatric Population Myth Kids are secondary victims of terrorism and inadvertently

targeted Fact Children may be intentionally targeted Harsh Realities: Children as Victims of Disasters 1984: Bhopal, India Industrial gas release (methyl isocyanate) Estimated 20% of victims were children 1999: Columbine High School

Shootings 12 students killed, 24 injured 2004: Beslan, Russia Three day hostage event at school 334 hostages killed including 186 (56%) children 2011: Oslo and Utoya Norway Attacks At least 60 children killed after a gunman opened fire at a youth summer camp 2012: Sandy Hook Elementary

School Shooting 26 people killed (20 children and 6 adults) Why Children are More Vulnerable During Disasters Lack of appropriate sized equipment and supplies Challenges related to

medical interventions and safety Gaps in pediatric preparedness in hospitals, agencies, communities, and on the state and federal levels Anatomical, physiological and

developmental differences Critical emergency care interventions performed infrequently Increased vulnerability during disasters

May be intentionally targeted during the disaster Respiratory Airway is smaller and more narrow Higher risk for respiratory issues Depend on diaphragm to

breath Equipment needs vary based on size Exposure Faster respiratory rates More susceptible to: infections

effects of agents prolonged exposures hypothermia Thinner skin/ greater body surface area Shorter stature Faster metabolism

Immature immune system Trauma Rib cage is higher Higher risk for injury, irreversible shock and death from traumatic events

Larger head/higher center of gravity Smaller circulating blood volume Developmental May lack cognitive ability to sense a dangerous

situation Increased exposure and risk of injuries May lack motor skills to flee from danger Developmental May be nonverbal or not know personal information

Age & developmental level influences response to stressful events May be uncooperative Unable to help with reunification Long term psychological effects are possible Children with Special Health Care Needs

(CSHCN)/Children with Functional Access Needs (CFAN) Can include those kids who are/ have: Technology dependent (ventilators, 23% of U.S. households have at least 1 child that meet criteria

15.1% (>11.2 million) children in U.S. meet criteria Illinois: 14.3% (452,574) G-tubes, shunts, insulin pumps) Developmentally delayed or disabled Chronic diseases Immunocompromised Psychiatric/behavioral illnesses Many emergency personnel and disaster responders are not

used to dealing with this population Triage Triage Sorting and prioritizing patients Looks at the medical needs and urgency of each individual patient Conventional Triage Do the best for each individual

Disaster/MCI Triage Do the greatest good for the greatest number Based on physiology Provides an objective framework for stressful and emotional decisions Helps in resource allocation Triage

Primary Triage Typically performed at the scene of the incident Helps prioritize patients for evacuation/transport Can occur at a hospital Secondary Triage

Performed to re-evaluate the patient after primary triage has been completed Typically done once the patient arrives at the hospital. Can also take place at an alternate care site or at the scene of the incident if prolonged scene time or in casualty collection areas Mass Casualty Incident Any incident in which there are more patients than rescuers (Source: newyearseve.com)

~80% of casualties self or buddy transport to the closest hospital MCI Triage All victims must have equal importance at the time of primary triage Sort patients based on the need for immediate care Be able to recognize futility No patient group can receive special consideration other than that dictated by their physiologic state This includes children!

(Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System) MCI Triage Categories IMMEDIATE = Emergent DELAYED = Urgent MINOR = Non-urgent/walking wounded

EXPECTANT/DECEASED = Dead/little to no hope of survival IMMEDIATE Severely ill/injured but treatable and able to be saved with relatively quick treatment and transport Examples: Severe bleeding Shock

Open chest or abdominal wounds Severe respiratory distress Emotionally out of control (Source: Optimistworld.com/anaphylaxis) DELAYED Injured/ill and unable to walk on their own; Potentially serious injuries/illnesses but stable enough to wait a short while for medical treatment Examples Burns with no respiratory distress

Spinal injuries Moderate blood loss Conscious with head injury (Source: Chemaxx.com) MINOR Minor injuries/illnesses that can wait for a longer period of time for treatment Examples Minor fractures Minor bleeding Minor lacerations

EXPECTANT/DECEASED Dead or obviously dying; May have signs of life but injuries are incompatible with survival Examples Cardiac arrest Respiratory arrest with a pulse Massive head injury Triaging Expectant/Deceased Patients Can be psychologically difficult to tag a child as Expectant/Deceased

Can be hard to resist the tendency to assign pediatric patients a higher triage category just because they are children Using a MCI triage tool especially with children can help to eliminate the role of emotions in the triage process Objective triage criteria during an MCI can provide emotional support for triage personnel forced to make life or death decisions for children MCI Triage Considerations

Scene Safety Ensure the scene is safe before entering Assess for need for decontamination Designate Treatment Areas Establish areas for each triage color category Triaged patients should be moved to designated areas

Incident command (IC) Process what you see and hear in 30 seconds and paint as accurate a picture as you can in your report to IC MCI TRIAGE TOOLS MCI Triage Tools START Algorithm JumpSTART Algorithm

SMART Triage Pacs START TRIAGE START Simple Triage And Rapid Treatment Joint development by the Fire & Marine Department and Hoag Hospital in New Port Beach, California Gold standard for field adult MCI triage in U.S. and numerous other countries

Utilizes the standard four color triage categories Used for primary triage More information at www.start-triage.com START Triage Algorithm START Triage Algorithm START Triage Algorithm START Triage Algorithm START Triage Algorithm

START Triage Algorithm START Triage Algorithm START Triage Algorithm JumpSTART Triage JumpSTART Triage Developed in 1995 to parallel the START Triage system and revised in 2002

Designed for use in MCI events Provides an objective framework to decrease the emotional burden on medical personnel who have to make rapid life or death decisions about children Reflects unique aspects of pediatric physiology Originally used with children under 8 years old but now used on any victim that appears to be child Can be completed within 30 seconds (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

JumpSTART Triage In children, typically respiratory failure precedes circulatory failure Apnea may occur relatively rapidly, rather than after a prolonged period of hypoxia There may be a brief period when the child is apneic but not pulseless since the heart has not yet experienced prolonged hypoxia. It is felt that providing a brief trial of ventilations may help

jumpstart their respirations JumpSTART Triage and Age What age defines the pediatric patient? JumpSTART Triage and Age It can be difficult to discern the age of a child especially pre-teen and early teen years, and which triage tool to use. If a victim appears to be a CHILD, use JumpSTART If a victim appears to be a YOUNG ADULT, use START (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

Differences Between START and JumpSTART START JumpSTART Airway If positioning the airway does not restart breathing, patient tagged as Expectant/Deceased

If positioning the airway does not restart breathing, a ventilation trial is given if pulse is palpable Perfusion/Circulation Capillary refill or peripheral pulses can be used to assess perfusion

Only peripheral pulses are used to assess perfusion Mental Status Ability to follow commands is used to assess mental status AVPU is used to assess mental status Step 1

Patients who are able to walk are assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illnesses. These are triaged as MINOR Step 2 Evaluate all non-ambulatory victims that are carried to the MINOR area Non-ambulatory Children

Non-ambulatory children include: Infants who normally cant walk yet Children with developmental delays Children with acute injuries which prevented them from walking before the incident occurred Children with chronic disabilities CHILDREN MEETING THIS CRITERIA SHOULD BE EVALUATED USING THE JumpSTART ALGORITHM BEGINNING WITH STEP 2 Non-ambulatory Children

All children carried to the MINOR area by other ambulatory victims must be the first assessed by medical personnel in that area. If a child meets any red criteria, tag as IMMEDIATE If a child has significant external signs of injury, tag as If a child has no significant external signs of injury, tag as

If a child meets the criteria for the expectant/deceased category, tag as EXPECTANT/DECEASED DELAYED MINOR Step 3 Next begin triaging the remaining victims in the order that they are

encountered. Assess the breathing status of each child. If the child is breathing spontaneously, go on to step 4 If child is apneic, position the upper airway. If they start to breath on their own, tag them as IMMEDIATE Step 3 (Continued)

If the child is still apneic after positioning their upper airway in Step 2 and they have no palpable pulses, tag as EXPECTANT/ DECEASED Step 3 (Continued) If the child is still apneic after positioning their upper airway but has a palpable pulse, give 5 rescue breaths. If they start breathing

spontaneously, tag as IMMEDIATE If they remain apneic, tag as EXPECTANT/DECEASED FOR THOSE CHILDREN WHO REMAIN APNEIC AFTER 5 RESCUE BREATHS, DO NOT CONTINUE TO VENTILATE THE PATIENT RESUME TRIAGE DUTIES. Step 4

Assess the respiratory rate of each spontaneously breathing child. If <15 or > 45, tag as IMMEDIATE If 15-45, go to Step 5 Step 5 Assess the childs perfusion. If no palpable pulse, tag the child as IMMEDIATE If the childs pulse is palpable, move on to

Step 6 Step 6 Assess the childs mental status. If child is inappropriately responsive to pain, posturing, or unresponsive, tag as IMMEDIATE If child is alert, responds to voice or appropriately responds to pain, tag as

DELAYED SMART TRIAGE TAG SYSTEM State Mass Casualty Triage System 2004 - State committee identified need for consistency in MCI triaging throughout Illinois Various MCI triage systems reviewed Endorsement of SMART Incident Command System for use in Illinois

2007-Statewide distribution of SMART Triage Pacs Illinois Custom-Designed SMART Pacs Contains a START and JumpSTART algorithm card Does not have the SMART Pediatric Tape (tape not approved for use in Illinois) SMART Triage Pacs

MCI triage tags Part of a larger Command System product that includes ability to assist with tracking patients from the scene. Full system not necessary to use triage tag portion SMART Triage tags are recommended to use in Illinois (Source: emsstaff.buncombecounty.org)

SMART Triage Pacs Triage tags Equipment used to perform START and JumpSTART triage Have standard barcodes for tracking patients Card folds to the assigned color and only shows one color at a time Allows patients to be re-triaged to another color classification without having to replace the tag and reassessment can be documented on the same tag Separate tags for Expectant/Deceased category

(Source: emsstaff.buncombecounty.org) SMART Triage Pacs( Continued) SMART Triage Pacs( Continued) START Triage vs. the SMART Triage Pacs The START algorithm looks like this The SMART Triage Pacs algorithm looks like this...

Although these algorithms look different THEY ARE THE SAME Scenarios Scenario 1: Bus Crash Its 7pm on a summer night when a bus returning from a day camp collides with a train on a remote road. You are the first responder and you find 20 + kids. Some are still in the bus and train while some are lying about

the road. Scenario 1 (continued) 10 y/o female, open femur fracture, breathing 10/min, good distal pulse, groans to verbal stimuli 9 y/o M RR0

Faint distal pulse Unresponsive Lying outside the bus in a pile of debris 50 y/o F RR 20 Cap refill < 2 Obeys simple

sec commands Dizzy & unable to walk 10 y/o F RR 22 Good distal pulse

Asks for help Walking 9 y/o F RR 12 Distal pulse absent Groans to painful stimuli

Lying in the ditch 15 ft away 10 y/o M RR 26 Distal pulse present Obeys commands Unable to

move his legs 25y/o F RR12 Cap refill 4 sec Eye movement to stimulation 6 months

pregnant Scenario 2: F5 Tornado An F5 tornado has struck within your city/ town. It occurred at 3pm while school was letting out. The tornado touched down near 3 schools and a shopping mall. Scenario 2 (continued)

School Age Girl Open arm fracture RR 26, and pulse Alert and talking 8 y/o M RR 10 Weak, thready pulse Unresponsive

Outside, face down 3 y/o M RR 18 Pulse present but irregular Responds Deformity to appropriately to lower pain

extremity 9 m/o F RR 44 Pulse present Responds to voice Superficial lacs to head/ face

10 y/o M Screaming Pulse present Not focusing Running in hall 50 y/o F RR 32

Weak pulse Not following commands Trapped under bookcase 7 y/o M RR 0 Very weak

Pulse Unresponsive Trapped under rubble Scenario 3: High-Rise Fire Fire reported on 15th floor Smoke to the 16th and 17th floors. The buildings day

care center is located on the 17th floor with 30 kids and 6 employees. (Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE) 4 y/o F RR 38 Radial pulse present Knows name and recalls

incident Facial burns, coughing 53 y/o F RR 48 Cap refill > 2 sec Moaning 3 y/o F Unresponsive

Burns to abdomen; wheezing Found under desk RR 0 Weak pulse 4 y/o M RR 45 Pulse present Crying

No obvious injuries 2 y/o M RR 20 Palpable pulse Hoarse cry Soot to face 3 y/o M RR 28 Strong palpable Crying pulse 2nd/3rd degree burns to

extremities Scenario 3 (continued) 5 kids are carried out, all being given CPR. As lead triage officer, what do you do? , (Source: Used with permission from Paula Willoughby DeJesus DO, MHPE)

Recovery Taking Care of Yourself After a critical event, rescue workers often struggle to get back to their daily lives and deal with their experiences

Can have difficulty coping and feeling back to normal Look for mental health resources/professionals that may be available through your employer/organization or in your community No one should feel alone in this process or that one has to get through this completely on their own

Conclusion START/JumpSTART are the MCI triage systems used in Illinois SMART Triage Tags are recommended for use in Illinois JumpSTART incorporates unique aspects of pediatric physiology Provide an objective framework to assist responders with making difficult life or death decisions during a disaster Helps provide emotional support when responders know they followed the protocols APPLYING START AND

JUMPSTART Instructor Training Trainers Role Be an advocate for pediatric preparedness at your organization and within your region

Work within your EMS region to provide trainings Conduct JumpSTART Provider courses Conduct JumpSTART Train the Trainer Instructor courses JumpSTART Pediatric Mass Casualty Triage Course Guidelines Course Participant Guidelines Provider Course

Participants should ideally be healthcare professionals (i.e. physicians, registered nurses, EMTs, respiratory therapists) or other allied health personnel. Train-the-Trainer Course Participants must be licensed healthcare professionals (i.e. physicians, registered nurses, EMTs, respiratory therapists) with current educator experience/background. JumpSTART Pediatric Mass Casualty Triage Course Guidelines (continued) Course Instructor Guidelines

To teach a Provider Course Instructors must: Successfully complete a JumpSTART Train-the-Trainer course Utilize current training materials available on the Illinois EMSC website Submit a copy of the Training Completion form and Student Tracking Form (course roster) to the Illinois EMSC office after each course completion JumpSTART Pediatric Mass Casualty Triage Course Guidelines (continued) Course Instructor Guidelines To teach a Train-the-Trainer Course

Instructors must: Successfully complete a JumpSTART Train-the-Trainer course Have current role/responsibilities that includes providing adult healthcare related education Have current background and experience in emergency medicine/disaster preparedness Utilize current training materials available on the Illinois EMSC website Submit a copy of the Training Completion form and Student Tracking Form (course roster) to the Illinois EMSC office after each course completion JumpSTART Pediatric Mass Casualty Triage

Course Guidelines (continued) Course Instructor Guidelines Course Coordinators Course coordinators are responsible for ensuring the overall coordination of the JumpSTART course by handling various responsibilities including but not limited to: Securing the course location Scheduling instructor Obtaining course supplies/needs Utilizing current training materials Adhering to the course agenda Completing appropriate documentation.

WhoNeedsTraininginyourRegion? Hospital Staff EMS personnel Fire department personnel School nurses and school health personnel Local clinics personnel Local public health department personnel Physician offices/groups Course Overview

3 hours in length Composed of lecture, skills demonstration, question & answer session, and evaluation Course certificate upon completion CE hours EMS CEs can be obtained through an IDPH code Nursing CEs Apply as a region or an organization Can be applied toward:

EDAP, SEDP or PCCC Facility Recognition requirements ECRN TNS Steps to Conduct a Class Identify course coordinator Identify target audience Determine class size Secure rooms at the location

Will need a lecture room and a skills station room Promote the training Develop a brochure Template brochure available thru EMSC Distribute brochure via email and/or mail Steps to Conduct a Class (continued) Coordinate course registrations Confirm course registration/details with participants

Secure other instructors Typical instructor/student ratio is 1/6 for the skills demonstration component Gather necessary supplies and materials Conduct the class After course completion, forward Student Tracking Form (roster) and Training Completion Form to EMSC

office Course Content Lecture Skills Demonstration Component

Scenarios provided to trainers in the Disaster Preparedness Exercises Addressing the Pediatric Population document Question & Answer Component PowerPoint Presentation provided in the course materials Post test provided to trainers

Evaluation Evaluation forms provided in the course materials Course Preparation Power point presentation with appropriate AV equipment Flat Stanleys, manikins, or other types of victims to use for skills demonstrations All forms:

Student Tracking Form or other sign in sheet Certificate of Completion Evaluation Form Patient Tracking Form

Post test Scenarios: Pediatric Disaster Triage Training Scenarios: Utilizing the JumpSTART Method START/JumpSTART algorithm cards Consider if food/beverages will be provided Course Preparation (Source: Pictures obtained from Flat Stanley Adventures, Stimulaid, and MCHC) Course Preparation For Information Purposes Only BLUE Category in MCI Triage

Not universally accepted Not used in START or JumpSTART Triage Tools Not part of the approved MCI Triage System for use in Illinois Course Preparation For Information Purposes Only Other MCI Triage Systems Examples: Sacco Triage Method (STM) http://saccotriage.com/ SALT MCI Triage Algorithm

http://register.ndlsf.org/mod/page/view.php?id=2056 Not universally accepted Not part of the approved MCI Triage System for use in Illinois Course Materials JumpSTART Algorithm START Algorithm PowerPoint presentation Pediatric Disaster Triage Training Scenarios: Utilizing

the JumpSTART Method Course Materials Certificate of Completion-Provider Certificate of Completion-Instructor Evaluation Form Course Materials Patient Tracking Form Student Tracking Form

Course Materials Training Completion Form Course Materials SMART Triage Pac Illinois Order Form SMART Triage Pac Illinois Order Form Resupply Conclusion

Use your available Resources! EMSC Can provide the START/JumpSTART algorithm cards Can provide guidance, ideas, and answer questions Obtain updated course materials Connect with additional instructors www.luhs.org/emsc 708-327-3672 www.jumpstarttriage.com Other JumpSTART instructors ANY QUESTIONS?

THANK YOU! www.luhs.org/emsc

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