d SECTION 2 bk a Answers to Triage Scenarios Drege egaay concept of triage and encourage the students to reason through their choices rather than to arrive at a particular correct answer. There may be several sea also hand out these solutions tothe triage se-_ right answers for @ particular scenaria give specific doar cane end of the course. The most important local resources or twists that the faculty may intro aspect ofthe triage scenarios isto emphasize the duce and dlscuss. “The following suggested answers to the ATLS Tri> age Scenarios should be on hand during the course as a reference for the Course Director. ATLS sites404 SECTION 2 m Student Course Faculty Manual | Nee ese LCL Gas Explosion in the Gymnasium INSTRUCTOR GUIDELINE: The instructor should emphasize that priorities of care are based on rapid visual and auditory assessment and evaluation of patients’ symptoms. After identifying the problem, the student should establish the order in which patients should be treated (triage by priority) and describe simple basic resuscitative efforts, SCENARIO: You are surnmoned to @ triage area at construction site where 5 workers are injured in 2a gas explosion during the renovation of a gymnasium ceiling. You quickly survey the situation and determine that the patients’ concitions are as folows: PATIENT AA young man is screaming, "Please help me, my leg is kiling me!” PATIENT B—A young woman has cyanosis and tachypnea and is breathing very noisily. PATIENT C—A 50-year-old man is ling in @ pool of blood with his let trouser leg soaked in blood. PATIENT DA young man is lying face down on a stretcher and not moving, PATIENT E—A young man is swearing and shouting that someone should help him or he will call his lawyer. Questions and Response Key for Students’ Response 4. Foreach patient, what is the primary problem requiring treatment? ‘The students) should indicate that managernent priorities could be based on information gleaned by surveying all the victims from a distance. the student indicates that he or she needs to @- ‘amine each of the patients indhdualy before making a decision, the group should discuss this fesponse, The diection of the discussion shoul indicate that while information f being obtained ‘ona particular patient, another patient might de from a more serious injury. Als, the time taken te gather detalled information on ll the patients before establishing priorities based on that infomation could lead to disastrous results. If there is doubt as to which one of these patients is most severely injured, based on the avalable information, the decsion must be made to proceed ‘with the best information available at the time. ‘The instructor should then provide information that coud be obtained by surveying the situation from a distance, as follows: PATIENT Aisa young man screaming, “Please help me, my legis king met” ‘The patient has a probable fracture/dislocation of the lower extremity.) PATIENT B appears to have cyanos' and tachypnea and is breathing very Nosy {This patient likely has a compromised airway.) PATIENT Cis a 50-year-old man Wing in a poo! of blood wit his lft trouser leg soaked in biood, {This patient has potential blood loss.) PATIENT Dis ving face down on a stretcher and not moving (Ths patient may be comatose, dead, or havea spine injury) PATIENT is sweating and shouting that someone shoul help hi or he lc i aye. (6 this patient hemodynamically normal?)APPENDIX J m Answers to Triage Scenarios 405 Triage Scenario | (continued) Crees RRO UCL ~The instructor should ear expzin that all ofthe previously outined information could be obtained ‘vthout actual examining ary ofthese patents in deta and that, based on this information, @ wage eosin could be made. Te instructor may ask “Suppose you are in doubt as to which patient eres severely injured. How should you respond?” Students should be prompted to respond thatthe decsion must be made to proceed onthe basis ofthe best information avaible atthe time. sased on the information obtained by surveying the patient from a distance, the students are then eced to triage the veims and give the rationale for their choices, The convergent ot divergent mode! rmay be used here to facitate the discussions 2 Establish your patient priorities for further evaluation by placing 2 number (1 through 5; with 1 being the highest priority and 5 being the lowest) n the space ext 0 each patient letter. 4 Patient A 1 Patient 8 Patient C ues zl Patient D 5 Patient E Briefly outline your rationale for prioritizing these patients in this manner: Fre eaructor leads the discussion by asking the students to give the rationale for thelr prot Parerte these anewers are dkcissed among the students Atthe end ofthe discussion the students should arrive at the following priorities: PRIORITY 1—PATIENT B (AIRWAY COMPROMISE) Fatianolor The patient apparent isnot taking, Het respiratory efforts are api and ther is clinical Soe eof an obsruted alway (oreatting nobly). The canosé is addtional information Su porting respiratory compromise. PRIORITY 2—PATIENT D (COMAVSPINE INJURYIDEAD?) rar ut the patent bang face down and net moving, one must assure Wat te 0 se = ore eas 2 apne jury. o i ead, Had the patet been awake and cape of Taare & caption woud Rely have been asured. The ABCOES must be asase with the concem for altered level of consciousness and spinal inary. NOTE: Patients @ and D may be interchanged as Priority 1 and 2, and Bow my be considered high priory, However the rationale must be given by the student “for example, Patient D may hhave a major airway problem as well. PRIORITY 3~PATIENT C (BLOOD LOSS) eae on the bas of the nforation theres ear evidence that Ne Pater has blood loss. The Sr od Wes and wees continuing are nat kw, The patent's |ABCDES must be assessed to determine the extent ofthe problem NOTE: The next2 patients may be considered low priority: (Continued)406 SECTION 2 m Student Course Faculty Manual Triage Scenario | (continued) Gas Explosion in the Gymnasium PRIORITY 4—PATIENT A (PROBABLE FRACTURE/DISLOCATION OF THE LOWER EXTREMITY) Rationale: The patient's ABCDEs would appear to be grossly normal. His chef symptom appears to ‘oe pain in is lower limb, vihch should be viewed iitaly as a bonysot-tissue injury or problem. PRIORITY 5—PATIENT E (HEMODYNAMICALLY NORMAL) Rationale? if the patient were just cursing, one could be concerned about hypoxia versus a perfect “table patient with a gious personaly. The patient is making judgments that are rational and protective, if argumentative and iritating, Briefly, describe the basic life support maneuvers or additional assessment techniques “you would use to further evaluate the problem(s). “The expected patient priorities, basic life support manewves, andor asitional assessment tech- niques used for each patient in this scenario are as follows: PRIORITY 1—PATIENT 8: This patient obvousY has respiratory cficulty and may have away obstruction, as evidenced by her noisy breathing, Clearing her away and establishing airway patency by performing the chin Ht or jaw-theust maneuver would be the highest prises fr this patient Assess for other fe treatening injries that may be the cause of her respiratory cstres, such as tension pneumothorax, open prec ‘mothorax, cardiac tamponade, and fal chesvpulmonary contusion. PRIORITY 2—PATIENT D: ‘Te patient i in the face down postion and not moving, He aso may have an airway problem be: Cause ofa depressed level of consciousness. His airway and breathing need tobe assessed, respiratory Gitor noted, and a patent airway established andor maintained. The patient then needs to be care” fully logrolle to his back and a patent airway restablisned as required by findings on Further essen ment, The patient unconscious, so once he ison hs back, his tongue may prolapse and occlude The cieway, Oxygen shouldbe administered, and protection of his entire spine should be maintained trate student ras identified this patent as beng deod, te instructor needs o ak the student how that determination was made. NOTE: Patients B and D may be interchanged s Priority 1 and, and both may be considered high priory However, the rationale must be given by the studentfor example, Patient 0 may ‘have a major airwey problem as well PRIORITY 3—PATIENT C: ‘is patent's ng in a pool of bcod andi al kethod has suffered 2 major exter Hy WA aahage tet must be stopped wit direct presure andor splinting the exreriy. The =A aaa ee vat patints B and Dare higher rors than patient Cis that they appea © Poe eet breathing probe, wheteas pa C appears o hav ccuatony proves Sn ny ge, Te patent shoul be reassessed for continuing bood ls rom the rey C8 haere te beeing and asses the patent fr sevety of sack—for example stn pala ay of pl, and eel of canzcouses. Ths patint maybe considered intrmadat i[APPENDIX m Answersto Triage Scenarios $07 Triage Scenario | (continued) Cesc esi CTU SLLY PRIORITY 4—PATIENT A con ceminaton from 2 dstance, this patient appears tobe suffering {rom intense pain fom 27 ef, Sarat jury, The examiner needs to asess the patent's ABCDES and ensure thatthe aruay Baia erry breathing is edequate. The doctor should next examine te patent’ extremities fr the res aor jury and vascular impaient, reduce any fracture thats present, and then apply splint PATIENT 5—PATIENT E: ‘his patient appears to be conscous and ale His ABCDES should be assessed to determine whether Free erenoe of espiaory compromise (eg, tension pneumotioran. He may req analgesia after his ainway, breathing, and cicuation are determined to be adequate INSTRUCTOR GUIDELINE: The instructor proceeds directly to discussion of Scenario I which 9 608 ere of Seana | At the conclusion of Scena I, the instructor provides a summary of beth Scenarios | andl408 SECTION 2 w Student Course Faculty Manual Ree CML (creates M RK CISL Lu} INSTRUCTOR GUIDELINE: This scenario isa continuation of Scenario | and emphasizes the resources, including the capabilites of personnel and the availabilty of resources. tao reinforces the educar tional process in Scenario | and initiates consideration of advanced life support and transport priorities. 41 Characterize the patients according to who receives basic Ife support (BLS) or ad- vanced life support (ALS) care and describe what that care would be. (Patients are listed in priority order as identified in Scenario 1.) PATIENT BLS DESCRIPTION OF CARE 8 Establish patent airway, administer oygen; estabish definitive sirway, perform needle decompression of tension pneumothorax: ‘poropraely seal open pneumothorax Estabish patent away; administer oxygen: protect entire spine; establish definite aimay Stop the bleeding; splint the injured extremity; asses for sevetity of shock: ata intravenous fds B Ensure patent away and adequate breathing spint injured & emt, asses for vascular impairment a Ensure patent arway 2 Prioritize patient transfers and identity destinations, Provide a brief rationale for your destination choice. PRIORITY PATIENT DESTINATION 1 8 (Trauma comer fa Nearest hospital “The patient’ life-threatening Ij require surg Therefore, she should go toa trauma center or te nearest hospital for uch care ad for further tiagin: a Tauma center Nearest hospital Because ths patients uncancious (coma) and as potential srvray problems anda posible spine injury, he need 0 be Manaported toa wauma center othe nearest hospital Bl Trauma center 1 Nearest hospital “his pationt may requie operative intervention and should we miported to a trauma center, avaiable, or the nearest hospital 4 {Trauma center [a Nearest hosital 5 £ (Cotrauma center [El Neacest hospital in situations involving muttple patients, what criteria would you use 0, identify and prioritize the treatment of these patients? ', Abnormal physiologic parameters 1. Altered level of consciousness 2, Respiratory distress 3. Continuing blood loss b. Anatomic abnormalities, eg orthopedic deformitiesAPPENDIX J Answers to Triage Scenarios go BEC ec Aon Ceres) CSN Gymnasium The aiway, breathing, creation, and disability prone of ATL ae the same prioites used to rake vage dedsions. Thats, in general, aiway problems are more epi lethal than breathing Problems, which are more repay lethal than cretion problems, which ae more rapidly lethal ‘hon neurologcnjures. Al avaiable information including vial sigrs when availabe, should be used to make each triage decision, What cues can you elicit from any patient that could be of assistance in triage? Some patients may report being injured. Such rears alow you toientify abnormal physiologic parameters of anatortic abnormalities as represented by pan and tenders ocazed fo certain areas Which patient injuries or symptoms should receive treatment at the scene before Pre- hospital personnel arrive? a atered level of conscousness—Naintain an away with simple basic fe support maneuvers. b. External hemorrhage controlDirect pressure isan example. Suspected spine injuries—Stabllze to protect spine from further injury “after prehospital personnel arrive, what treatment should be instituted, and what ‘principles govern the order of initiation of such treatment? ‘Attention should be directed to: a. Intubation if equipment is available. Airway b. Treat tension pneumathorar, if suspected. Breathing . Estabish IV therapy, if available. Circulation 4. Simple splinting of fracture). Circulation and disability in muttile-patient situations, which patients should be transported? Which should be transported early? ea speree wath erway compromise respiratory dress, and those who have been ifubated (early) b. Patients with hypotension and uncontrolled bleeding (early) . Patients with open fractures Which patients may have treatment delayed and be transported later? 2a, Patients with orthopedic inuries b. Patients with suspected spine fractures ‘Summary ‘he instructor should conclude the discussions of Scenarios | and I by summarizing the following ti ‘age principles that apply to these scenarios: Mefomation about the seventy of rjury often is obtained without deal assessment patent, and tage decisions are made based on that information Priorities are based on the ABCDEs whenever possible ‘once the immediate problem managed foreach patient, 2 secondary Se of each patient is ot ted anda deeson is mace regarding transport to the appropriate facility, based on the patient's needs, asidentfid by amore detailed esessment The instructor then proceeds with the remaining scenarios in a similar discussion format. ‘Scenarios Il through V are outined withthe expected student responses 7 the succeeding pages.410 SECTION 2. Student Course Faculty Manual Miele ere eco Niet ai nee sd ys Malt INSTRUCTOR GUIDELINE: Not all trauma centers manage bur injuries. Consequently, the instructor must emphasize that patients with burns should be treated at facilities with burn capability, and ‘rauma patients should be managed at trauma faites. Therefore, the primary doctor ata small ire ‘tution must recognize burn patients who have traumatic injuries. Because the major problem with bum patients is respiratory in nature, the instructor must emphasize the importance of recognizing inhalation injury ear. Furthermore, the students need o establish the fact that bur patients need to have fuids initiated and sustained until they arrive at the next institution. The fist 1 to 2 hours should not bea challenge. Intravenous ines need to be ntiated and fluids administered, as would befor any injured patient. The tertary-car facity can initiate the appropriate fluid forma. The intructr should relate that Scenarios I and IV ilustrateheat- and coldelate injuries and em hasze vital signs. These two scenarios also reinforce the pringples learned in Scenarios | andl and introduce the role of mechanisms of injury and selvageability. SCENARIO: An explosion and fie, due toa faulty gas ine, has involved one taler home in a nearby Talon par, Because of the cose proximity ofthe indent to the hospital, the prehospital personne} anspor the patents direct to the hospital without prior notation. The ve patents, ll meribas OF the same fail, are immobiized on long spine boards when they arive at your small hospital ‘emergency department. The injured patients ae: Patient AA 45-year-old man is coughing and expectorating carbonaceous material. Has sin his face ard head are singed. His voce & lar, and he reports pain in his hands, which hove erythema and eatly biter formation Vital signs are blood pressure 120 mm Hg S¥° talc; heart rate, 100 beats per minute, and respiratory rate, 30 breaths per minute. patient BA 6-year-old gle appears frightened ands crying. She reports pain from burns {erythema/bsters) over her back, buttocks, and both legs posterity, Vital sions 98 blood pressure, 110/70 rm Hg; hear. ate, 100 beats per minute, and respiratory rate, 25 breaths per minute. Patient C—A 70-year-old man is coughing, wheezing, and expectorting carbonacenes or eral. His seke is hoarse, and he responds only to palnful stimull. There are erythema, Dieters and charred skin onthe anterior chest and abdominal wal, and creumferentiat dane of both thighs Vital signs are blood presute, 80/40 mm Hg; heart rate 140 beats per minute, and respiratory rate, 35 breaths per minute patient DA 19-year-old woman is cbtunded ut responds o pain when her ght Panes Shag are moved. There sn obvious deformity ofthe arm, and the tah ‘swollen ai es aon spit Vital sign ae blood pressure, 1400 mm Hg; neat rate, 110 eats per minute, and respiratory rate, 32 breaths per minute patient A 45-year-old man s ale and reports pain in his pes, There cic evidence or racere wit abdominal dstertion and tenderness to papaton. Theres enna and Slsterng ofthe anterior chest and abdominal walls and thighs, He aso Was 8 laceration to vest ca, Vial sign ae bood pressure, 130/90 mm Hg; heat rate, 99 bens ex min ute, and respiratory rate, 25 breaths per minute.APPENDIX J m Answers to Triage Scenarios 411 al Stee asec CM Lan Pela uns toc RAL Questions and Response Key for Students’ Response ‘Answers to questions 1 through 5 are provided on the fllowing pages +. Identify which patient(s) has associated trauma and/or inhalation injury in addition ¢o body-surface burns. Establish priorties of care in your hospital emergency department by placing a num- ber (1 through 5, with 1 being the highest priority and 5 being the lowest) in the ‘space next to each patient letter. Estimate the percent of body-surface-area (BSA) burn for each patient. ‘4 Identity which patients) should be transferred to a burn center and which should be transferred to a trauma center, 5 _ Establish priorities for transfer. nee] Management priors in this scenario can be based on information cbtained by Sune the injured patents ata dstance, though thee may be doubt as to wich patient is Post severely injured, a icon mst be made 1o proceed with the best information avalable atthe time, The expected priorities for this scenario are as follows: PRIORITY 1—PATIENT C PRIORITY 1 PA the presence of coughing, wheerng,crbonaceous material emt“. a8 a ee tis pant dovousy hasan inlation injury. He alo has severe burrs SNONTS pear rn of hs body. Tis pale sin shock and hes an fre eve of ores tty reve pres woul ince essing an adequate Sway (most Way Mf ‘endotracheal rarer) and ination of warmed, intravenous id resuscation, This palertreautes srancfer aon center for ens Creo is inalaton injury end bun management NOTE: There could be discussion of salvageabilty ofthis patient patent represents your second transfer prot because of hs nkalation ify and body surface ane patients C8, and A may have interchangeable transfer proses) PRIORITY 2—PATIENT A PRR 2 PATE ry apc xnaton, ts att es no obvi sense | ated trauma, but does have evdence of bur jury an pethaps an inhalation injury. Although he oe is-currently speaking clearly, airway’ ‘compromise may occur rapidly ‘and require early management. (Continued)412 SECTION2 w Student Course Faculty Manual Triage Scenario IIl (continues) Pirie een sc Os CESLC Itis important to remember that this canditon can change and may be progressive, He requires thorough evaluation and posible intubation. Inthe absence of respiratory distress, intubation ‘ould be postponed. He also has minor burs, but they invohe the hands. Therefore, he requires transfer to a burn center, He may require treatment in an intensive care unit forthe inhalation injury, volume resuscitation for his burns, and specialty cre for his hands. Patient A represents your third transfer priory. (Patients C, B, and A may have interchangeable transfer priorities) PRIORITY 3-—PATIENT D Rationale: This patient has obvious orthopedic injuries and the potential for chest and abdominal robles, Her level of consciousness also is depressed, which may representa progressive airway problem. A rapid assessment could determine the need for intubation or an oral away. Ths patient needs to be transfered toa trauma center Patient D represents your lat transfer priority. PRIORITY 4—PATIENT E Rationale: There i evidence of burs inking major portions of this patient's body. Abdominal andy ‘peti injures wit associated blood iss also are evident. There i clinical evidence of bleod Tes, requirng volume resuscitation, He needs tobe transfered initial to 2 trauma centes for, tz minimum, evaluaton ofthe abdomen and pels and to determine whether his burns would best be managed at a bum center patient E represent the fist transfer pioity for assessment of associated injures, Note: Management prottes fr Patients A, D, and could be interchangeable, However, rationale fr change fom te order qlven here must be presented PRIORITY $—PATIENT B Ratignale: This 6yea-ld ge current is hemodynamically normal, but has significant and exten cra She undoubtedly wil sufer more profound from the effects of her bums than an alt oat ema azed bums. Warmed, intravenous fds nead to be itiated, and she should be Transferred to a bum center for volume resuscitation and burn care management. patient 8 represents your fourth transfer priory. (Patients C, B, and A may have interchangeable sransfer priotites) Summary Thetnsructrconcudes the dscussion of Scenario bysurmaring the pines of tage apie 4. Treatment and transfer of a single patient becomes mare complicated whan there He multiple patients with multiple probles. Patent injures must be pitied according 10 ‘the scope of treatment required and transfer needs ‘Salvageabilty i an issue in definitive care, 4 Resources, time, distance, and enironment can dictate how cares utimatly providedAPPENDIX J m Answers to Triage Scenarios, 413 Bee . Coto) LeLN INSTRUCTOR GUIDELINE: The insttuctr should relat that Scenarios and Vilustrele Peat and cold- vrered inries and emphasize Val signs. These two scenarios abo reinforce the pings earned in eerie | andl and introduce te role of mechanisms of injury and savageabilty. SCENARIO: You are in your hospital when you receive a call that ve members of a doctors family ari errtmooling on ake when the ie broke Four fami member fel into the ake Wak The vere was able to stop in ine ad lft to seek help. The response time of basic and advanced life Scpportassitance was 15 rinutes, By the time prehospital care providers artived, one individual hag crawled out of the lake and removed another vcim from the water. TWO individuals remained submerged: they were found by rescue divers and removed from the lake, Rescuers from the scene provided the following information: patient AThe doctor's 10-year-old grandson was removed from the lake By rescues The ECG monitor shows asystoe. patient The doctor's 65-year-old wife as emoved from the lake by rescues, The ECG ‘monitor shows asystole. patent C_The doctor's 35-year-old daughter, who was removed from the wate y fet Ser a cae buises ther anterior chest wal. He blood pressures 90 mm Hg Syste patient D_The doctor's 35-year-old daughterinaw, who had been submerged ond ard ont ofthe ak, has no obvious signs of trauma, Her bod pressures 110 mm Hg systolic patient E_The 76-year-old retired doctor, who never went ito the water repons ony ‘cold hands and feet. Establish the priorties for transport from the scene to your emergency department, and explain your rationale. Transport Priority 1 Patient C Transport Priority 2. Patient A Transport Priofty3 Patient B “Transport Priority 4 Patient D ‘ransoort Priority Patient E ationale: Patents A and 8 arin astoe. Compared with ates and € they are considered Sr apenas abnormal vial san, so she shoul be your Hit sya A Patients dead, Pate Ctra and can wat ul Paes A and Bae werepric, TORS {A should be 0 ar iad before Patent 8 becuse of is age. Patent your fouth transport pritity and Finally Patient E, who could go by ground anspor. inthe emergency department, all patients should have thelr core temperature measured. core temperatures for these patients are: Patient A: 29° € (84.2° F) Patient B: 34° C (93.2° F) Patient C: 33° C (91.4° F) Patient D: 35° € (95°F) Patient E: 36° €(96.8° F) (Continued)414 SECTION2 m Student Course Faculty Manual i eNs (MS YeS11 COMA RCSL Ce CMa Briefly outline your rationale for the remainder of the primary assessment, resuscita- ‘tion, and secondary survey. Patient C, with a blood pressure of 90 mm Hg systolic and a core body temperature of 33° 'C (91.4 F), needs a rapid assessment of her ABCDEs and chest and abdomen to exclude intrathoracic end intreabdominal injuries. Her core temperature of 33° C would require rewarming, Patient A remains asystolc with a core body temperature af 29° C (84.2° F), He should be in- ‘ubated, and bronchoscopy should be performed to determine whether his asystole is due +0 drowning or hypothermia, Rewarming by cardiopulmonary bypass is warranted ifthe patient has not drowned. The instructor should discuss high potassium levels in association ‘with hypothermia f this patient's potassium level is over 10, he is dead. PATIENT B remains asystolic with a core body temperature of 34° C (93.2° F). Ths patient could be pronounced dead because the asystole is most probably due to 2 cardiac episode rather than hypothermia PATIENT D has a core body ternperature of 35° C (95°F), and should have further heat loss prevented. PATIENT E has a core body temperature of 36° C (96.8° F) with evidence of frostbite to the hands and feet, requiring rapid rewarming, Summary ‘The instructor should conclude the discussion of Scenario IVb summarizing the principles of triage applied 4. The best decisions are made when the principles of triage are applied sporopriately. 2. Maximizing resource use is important.APPENDIX m Answers to Triage Scenarios 415 De SCO Car Crash INSTRUCTOR GUIDELINE: This scenario reinforces al of the triage principles. SCENARIO: You ae the only doctor avsble ina 10-bed community emergency depatnent. One Sea yon a aetant are aaiable to asset you. Ten minutes ago you were notified by rao are elarees woud be athng with patents fom a single motor vehi crash, No Fes ‘+t ae ambulances arve wit ve patients whe were ocupants i an automole oveling #2 60 mph (96 kph) before it crashed, The injured patients are ratient AA 45-year-old man was the diver of the car He apparently wes not wearing 2 ort le pon imac, he was throvm agaist the windshield. On admission, he is Rot yin severe espratry des. Te prehospital personnel rovie the flowing fern veo to you after preliminary ascessment: ues indude 1) severe malofacal aura an Bleeding from the nose and mouth, (2)an angulated deformity ofthe left freary wr multiple abrasions over the anterior chest wa. The vital signs ate blood presse ayaD omg, heart fate, 120 bets per minute; respirator rate, 40 breaths per minute and Giasgaw Coma Scale (GCS) sore 8 patient BA 38-year-old female pasenger was apparent thrown fem the font eat anc So fet © meter from theca. On admission she's awe alert, and reports 2b toa ra ehest pain, The report you ae given inctes tha, on palpating her ibs spe sere pan, and cured cepts fl. Theva sgn are ood pressure, 1090 rere heart ate, 140 beats pet minute and respiratory ate, 25 breaths per mint: patent CA a8 yeanokd male passenger was found unde the car. You ae told that on Ss Sree conte and responded sod) to verbal stimu rues nude mul ao" aor a ce ches, and dren, eth sounds are absent onthe ft and Wis aoe, Bons eaation. Te tal ss re lod presse, 9950 rm Hg; heat rate, 140 bets priate resprtorytte, 35 breaths pet minute; and GCS sce, 10 patient DA 25:ear-old woman was ericated from the backseat of he veils Se Sens pregnant, behaving hysterical, and reporting abdominal pain ste: anor Pe carains to her face and ame abdcinel wal. You ae tl hat Pe aoe ru tence to palpation, She sin acive abr. Te tal sans ar pod ress abdomen gy heat ate, 100 beats per minute and respiratory ate, 25 breths Pet minute patient A Gyenrold boy was exrcated rom the loo of he er sst AL he enero taking He now respond opal stimu ony by cying ov. inctude ape drans and an argued deformity ofthe ght lowe et, hee dried blood rd mouth, Theva sigs are ood press, 110/70 ren Hs; Near 2 beats per inte; respiratory rate, 35 breaths per minute. Questions and Response Key for Students’ Response + outline the steps you would take to triage these fve pation ution th Fs Yo mole cites, tage st be prom and been 16 infor When concrete ores te posible Adough acetal asesenet of 2 patent matin a ore comple rioration or deason mange re Se obtain + eyed infomation can rest nome patens detorsng ing while the others soe massed inthis scenario, some information such asthe sypes of nurs, vita signs, and GCS (Continued)416 SECTION 2 m Student Course Faculty Manual Triage Scenario V (continued) Car Crash score, i available from prehospital providers and should be used inthe triage process. When such information is not available, dedsions need to be made on a global, quick, and sometimes more superficial assessment. Establish your patient priorities by placing a number (1 through 5, with 1 being the ‘highest priority and 5 being the lowest) in the space next to each lettered patient. Briefly outline your rationale for prioritizing these patients in ths manner. PRIORITY 1—PATIENT A Rationale: This 45-year-old man as 2 major uper alway cbstructio, and as such corstutes the fist monty inthis group of patients As pres desatbed, els acuresand a hertoma dbstucing Fie natal and orl sways. Appropriate assessment and management of his away shoud be under- token Since nastracheal ad erovachea intubation are uke tobe sucessful and may jeopardize tis cancel spine, the patient maybe a candidate fr 2 ccohyridotomy. PRIORITY 2—PATIENT C Rationales The absent iet breath sounds, combined with this 48-year-old man’s hypotension, should make him your second priory. The combination ofthese two physica findings should lead you to the iagnoss of tension pneumothorax, which must be treated promptly with a needle or tube thoracostomy. PRIORITY 3—PATIENT E Rationale: A sense of urgency attends the treatment of children who sustain multiple trauma, This year-cld boy has sustained sgnifcat head teuma, as evidenced by hs lv! of consciousness, Joan nitial reatment protiy should be to secure and protect his airway. Eatly consideration should be given to transporting this patient 10 center with pediatric expertise PRIORITY 4—PATIENT B Pationaler inital, this patient i stable and shows only few signs of hemodynamic abnormality. However, her history of being thrown from the car and the pysicalfdings consistent with ae rctre make her a ely candidate for mutpeinjs and hemonhagic shock: Her via) Mies chow sme compersation for her condton, but she requires aggresse resusiaion and continuous reevaluation, PRIORITY 5—PATIENT D Paijonaler Ts pati sin active labor, probably preciitated by theca crash After she is xorined) oma stabized attention should be directed tothe possiblity of fetal stress. Delve. imminent ads to be managed by the nurse However, care ofthis patent coud wait unt the more im Tpediately if thresteing condtonsin the other four patents are aderessed Summary 4 Information from ater cre providers can be cuca or @ tage proces imoking muliple Pa tients The main ational for tiagein this senai ithe ABCDES and relative treat © Me posed PY the specic injuries. “ate dean with he ined robles a secondary suney ofa the patients alos ft Seas reer evecare and ese tooherres win he istuson 0 ther nsttutions that Fs mere appropriate resources to meet he need ofthe india patents.APPENDIX J m Answers to Triage Scenarios 417 Nee econ BRR s INSTRUCTOR GUIDELINE: This scenario draws the student into disaster planning and managers sre re wei cash has produced multiple victims with a varity of rjures to be addressed, the pene volved at he scene pose a threat not only to these patie and the rescuers Dut so f° raermunty. Disaster planing and management and how multiple agencies work together in SCENARIO: Two trains code head-on at 1800 hours One tain is 2 commercial tanker carrying Sah aorrsrears ands drven by an engineer and fireman. No other personnel ate on board, The tanks sara cd witha highly flammable quid. The other tain isa passenger ain traveling On the sine ae. Weather condions are mild, and the ambient temperature: 20° C (72°F), Upon artvalat the scene, EMTs and paramedics fin: Deceased: Two engineers and one frernan Five passengers, including one infant with a fatal head injury Injured: The freman from the commercial tain, ected 30 feet, with 4036 BSA ssecond- and third-degree burns Forty-seven passenge’s from the passenger tain > 12 category Re patients, 8 with extensive (20-50% BSA second: and thi-degree burns 8 category Yellow patients, 3 with fcel (<10% BSA) second-degree bums > 22 category Green patents, 10 with painful hand and forearm deformities 5 category Blue patents, 3 wth catastrophic 675% BSA) second: and third-degree buns “two fre companies and two atonal ambulances have been called. The loa} commu hospital hoe 26 beds, 5 primary care providers, and surgeons, 1 of whom ison vacaton The nearest trauma ase is 75 mies (120 kilometers) awa, and the nearest designated bum center Ver 200 miles (220 Klometers) away. Questions and Response Key for Students’ Response + Should community dsester plans be invoked? Why, or why no? rei runty dester plens should be invoked because the mecca needs of the patients lealy exceed focal resources fa mass-casualty event is decared, who should be the. ‘medical incident commander? ‘The highest ranking medical professional onthe scene who S ‘rained in disaster management should serve as the medical incident commander. What Is the first consideration of the medical incident commander at the scene? Safety and security a the scene, including protection ofall emergench ‘medical responders, is the fist priority ofthe medical incident commander What considerations should be taken into account medical operations at the scene? Mina hazards sucha fe, haardous materia, aation, and ‘structural collapse, should be ‘considered in medical operations atthe scene (Continued)a8 SECTION 2 @ Student Course Faculty Manual Merle (ees COM RCO) BIT RecM Cs What is the second consideration of the medical incident commander at the scene? ‘iter ensuring safety and security atthe scene, the medical incident commander should deter- rrine what additional patient care resources will be needed at the scene. What is the meaning of the red, yellow, green, blue, and black triage categories? Red = immediate, yellow = delayed, green = minor, blue = expectant, black = dead, Given the categories in Question 6, which patients should be evacuated to the hospi- tal, by what transport methods, and in what order? Red: by helicopter to trauma or burn center, Yellow: by ambulance to local emergency depart: ment; Green: by bus to local emergency department; Blue: by helicopter or ambulance to trauma cor burn center, after other victims have been evacuated. What efforts should be taken by the medical incident commander to assist with re- ‘sponse and recovery? The medical incent commander should mobilize additional medical personnel from adjacent _areas as per preexisting regional disaster plan. summary 41 Review the 6 Ps of disaster management and emergency preparedness Planning and Preparation Process and Practice Prehospital Cx Inpatient Cre Pathophysiology and Paters of fiury Pitfals Review each ofthe 6 Ps in detail 2. Planning and Preparation 1. Have a straightforward disaster plan «Follow the KISS principle «Train all hospital staff init application 2. Awareness, technician, patient care be Process and Practice 5. Have an incident command structure (eg, California EMS Authority HICS) 4, Train all staff in its application and use Dail, il, dit . Prehospital CareAPPENDIX J m Answers to Triage Scenarios 319 Stereos CO A So ARS Have a disaster triage scheme (eg, red, yellow, green, blue, bisck) ‘a. Perform only life-sustaining procedures 4. Minimum acceptable standard of care bb. Pathophysiology and Patterns of Injury 1. All naturaVmost teror disasters cause injury * Circumstances extraordinary, care ordinary 2, All chemical agents require decontamination «+ Beware potential contaminants after a bomb blast 3, All radiologic agents require decontamination ‘© Decontamination should not delay necessary core «. Pitfalls 4, All naturel'most terror disasters cause iniury * Circumstances extraordinary, care ordinary 2. Allchemical agents require decontamination «Beware potential contaminants after 2 bomb blast {Al radiologic agents require decontamination « Decontamination should not delay necessary care420 SECTION 2m Student Course Faculty Manual Niece On AL er EOE Saclay INSTRUCTOR GUIDELINE: This scenario draws the student into disaster planning and management. ‘While the bomb blast has produced multiple victims with a variety of injuries to be addressed, the hazards involved at the scene pose a threat not oni to these patients and thelr rescuers but also to the community. Disaster planning and management and how multiple agencies work together in response wil be discussed. This scenario reinforces al of the triage principle. ‘SCENARIO: A suicidal bomb blast has been reported at an evening political rally. The area is 30 minutes away from your level Il trauma center. You are summoned tothe scene as one of the triage officers. Initia report reveals 12 mortalities and 40 injured. Many rescue teams are busy in evacuation. You artive at an area where you find 3 dead bodies and 6 injured patients, ‘The condition ofthe 6 injured patients is as follows: PATIENT AA young male, conscious and alert, has a small penetrating wound in the lower neck just to the left side of the trachea, wth mid neck sweling, hoarse voice, no active beeing, PATIENT BA young male is soaked in blood, pale, and lethargic, yet responding to verbal ‘commands, Both legs are deformed anc attached only by thin muscular tissue and skin below the knees bilateral. PATIENT C—A young female is complaining of breathlessness, with tachypnee, cyanosis, and ‘multiple, small, penetrating wounds to the eft side of her chest PATIENT DA middle-aged male has multiple penetrating wounds to the left side of abdomen and left flank, pale looking and complaining of severe abdominal pain Second: and third- ‘degree burns visible over the lower abdomen. PATIENT EAn elderly male, breathless and coughing up blood-stained sputum, disorientated, ‘and has multiple bruises and lacerations over his upper torso. PATIENT FA young male has large wound on anterior aspect of the right lower leg with visible bone ends projecting from wound, and is complaining of severe pain. There is nO active bleeding. Questions and Response Key for Students’ Response 4 Based on the information, describe the potential A, B, C problems for each patient: PATIENT A: Airway PATIENT B: Circulation PATIENT C: Breathing + Airway PATIENT D: Circulation PATIENT E: Breathing + Away (possible bast lng injury), neurological disability PATIENT F: Circulation What initial ie support maneuvers can be offered before transport to @ trauma ¢2n- ter (assuming that typical prehospital equipment is availabe a this time)? PATIENT A: Keep airway patent and give supplemental oxygen PATIENT 8: Touriquets to both legs, splint the ibs, and cover the wounds with dean gauzeAPPENDIX) m Answers to Triage Scenarios 421 Triage Scenario VII (continued) CHCA Mesa ene eC Ly PATIENT C: Keep airway patent and give supplemental oxygen PATIENT D: Cover the wounds with clean gauze PATIENT E: Keep airway patent and ive supplemental oxygen PATIENT F: Realign and splint the limb, and cover the wound What other considerations do you keep in mind during triage at the scene of this incident? Personal safety in a hazardous environment (toxic fumes, fre, and bio-weapons, etc) Early triage and quick evacuation due to danger of buiding/tructuralcolapse, and possi- ity of second explosion or terrorists fring Use of contaminated material in the explosive devices and potentially contaminated human material (e.g., bone fragments) acting as secondary missiles Multiple, inorJooking puncture sites causing potential life-threatening intemal injuries “The trajectory does not give any idea of internal damage/organ injury due to utile entry wounds and injuries Blast lung injury may not be obvious immediately and a high index of suspicion is required, especially in dosed-space explosions Describe the transfer to trauma center of each patient in order of priority with your rationale (1 being the highest and 6 being the lowest) Priority 1: Patient A Rationale: Away problem jority 2: Patient C Rationale: Potential airway problem and obvious breathing problems (Patients C and A may be interchangeable) Priority 3: Patient € Rationale: Old age, potential away problem and obvious breathing problem. Has neuro- fogical dsabilty and wil likely noed define aay with mechanical ventilation due to blast lung injury Priovity 4: Patient D Rationale: Circulatory problem and abdominal injury Priority 5: Patient F Rationale: Potential vascular injury and open fracture Priority 6: Patient B fourniquets placed; needs bilateral amputations (Continued)422 SECTION 2 m Student Course Faculty Manual Triage Scenario VII (continued) eC ECC EN elec Meee 5S What should be your main management considerations upon arrival of the patients at the trauma center? 4. Quick second triage for changing condition/deterioration during transfer 2. Patient E ~ endotracheal intubation b. Patient A ~ tracheostomy (crcothyroldotomy contraindicated as the patient has sus- pected larynxtracheal injury) U, Breathing a. Patient C — needs left-sided intercostal tbe for suspected hemopneumothorax b. Patient E - may need bilateral chest intubation for blast lung injury before mechani cal ventilatory support 1M, Creulation| 2. Patient D—FASTIDPL followed by early laparotomy as he may have splenic laceration ‘andlor perforation of splenic flexure of colon bo. Patient B — definitive control of vessels and formal 8K amputations after timely removal of tourniquets Patient F— vascular evaluation and early orthopedic consultation for open fractures of tibia and fibula WW. Disability a. Patient E-— needs early neurosurgical consultation, the patient may have a subdural hematoma requiring evacuation \V. Environment ‘a. Complete exposure for detaied examination Prevent hypothermia