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Mass-Casualty Incident (MCI) Triage & HAZMAT

Phillip Santos, MSN, RN, MICN

Emergency Management Officer

Program Manager, Disaster Resource Center - Region 6

Disaster Planner and Surge Coordinator

Office of Emergency Management

Los Angeles General Medical Center

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Objectives

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  1. Discuss the various roles involved in an MCI
  2. Triage disaster victims using the START triage principles
  3. Identify the Provider Impressions for Hazmat related events
  4. Identify resources available to support Hazmat incident

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References

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Metrolink Lessons Learned

  • Glendale 2005
    • Deaths: 11
    • Injured: ~180

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Metrolink II Lessons Learned

  • Chatsworth 2008
    • Deaths: 26
    • Injured: 135

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Definitions

  • Multiple Casualty Incident (MCI) - The combination of numbers of injured patients and the type of injuries going beyond the capability of an entity’s normal first response

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Goals of Multiple Casualty Incidents

  • To do the greatest good for the greatest number
  • Establish and maintain effective communication
  • Avoid relocating the incident from the scene to the hospital

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Management of Multiple Casualty Incidents

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Management of Multiple Casualty Incidents

Purpose of Reference 519 Policy

  • Provide guidelines for the efficient management of multiple casualty incidents through coordination between prehospital care personnel, receiving facilities & the Medical Alert Center.
  • To allow for maximum resource allocation, patient distribution & to prevent unnecessary delays in patient care & transport.

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Management of Multiple Casualty Incidents

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Incident Command System (ICS)

  • ICS is a standardized, on scene, all-hazard management concept.
  • ICS organization has the capability to expand or contract to meet the needs of the incident.
  • All incidents, regardless of size or complexity, will have an Incident Commander.
  • The Incident Commander is responsible for on-scene management.

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Levels of Response

  • Field / Hospital
  • Local Government
  • Operational Area (L.A. County)
  • Region (I)
  • State (California)
  • Federal

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Medical Alert Center (MAC)

  • Assists provider agencies and base hospitals with patient destination decisions and multiple casualty incidents.
  • Role:
    • Coordinate/support MCIs
    • Provides prehospital care personnel with hospital bed availability and diversion status
    • Activation and management of the DHS Medical Coordination Center (MCC)
    • Arrange additional transport units as requested by the FOAC or RDMHC
    • Coordinate activation of Regional Mobile Response Teams or Air ambulance resources

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Role of the Provider Agency

  • Institute ICS
  • Implement modified START/jump START
  • Establish early communication with:
    • MAC to support incident management
    • Base Hospital, if indicated, for medical direction and or patient destination
  • Determine if additional transport units are needed
  • Request Regional Mobile Response Team if necessary

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Role of the Provider Agency

  • Provide information to the MAC or Base:

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    • Nature of incident
    • Location of incident
    • Med Com unit & agency
    • Agency in charge of incident
    • Estimated numbers of immediate, delayed, minor, deceased, and pediatric
    • Nearest receiving facilities (TC, PMC, PTC, EDAP)
    • Transporting provider, unit # & destination
    • Type of hazardous material, contamination, level of decon completed

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Role of the Base Hospital

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  • Notify the MAC of the MCI as soon as possible

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  • MICN provides online medical direction
    • Document on modified assessment form
    • Give additional orders as needed
    • Assist prehospital care personnel with patient destination as needed
    • Notify receiving facilities of incoming patients

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Role of the Receiving Facility

  • Provide the MAC or base hospital with ED bed availability
    • Trauma Centers are designated to accept 20 Immediate patients from MCIs
    • Burn Resource Centers can accept up to to 20 critically burned patients
  • Accept MCI patients with minimal patient information.
  • Monitor the VMED28 and ReddiNet.
  • Provide the MAC or base hospital with patient disposition using ReddiNet system
  • Ensure patient information is entered into the ReddiNet MCI Victim List within 72 hours of the incident
  • Maintain the “Receiving Facility” copy of the EMS Report Form and/or triage tag as part of the patient’s medical record.
  • If resource needs exceed available resources, notify the MAC.

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Regional MCI Maps & Bed Availability�Worksheets Reference No. 519.6

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MCI tab in ReddiNet

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MCI Triage

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Definition

  • Etymology: “trier” (French): to separate, sort, pick, select
    • Evaluating the medical needs and urgency of each individual patient
    • Sorting based on limited data acquisition
    • Consideration of resource availability

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Triage

  • Routine
    • Do the best for the individual

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  • Disaster/MCI
    • Do the greatest good for the greatest number.
    • Maximize survival.

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Primary Triage

  • Goal:
    • SORT based on probable needs for immediate care.
    • Recognize futility.
  • Assumptions:
    • Medical Needs > Available Resources
    • Additional resources will become available with time
  • Based on physiology
    • How well the patient is able to utilize their own resources to deal with their injuries
    • Which conditions will benefit the most from the expenditure of limited resources

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MCI Categories

In Multiple Casualty Incident (MCI), policy #519.2 defines the following:

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    • Deceased: Do not have spontaneous respirations after repositioning airway
    • Immediate: Severe respiratory, circulatory, or neurological symptoms
    • Delayed: Neither immediate nor minor but will need a gurney on hospital arrival
    • Minor: Ambulatory patients

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IMMEDIATE

Life-threatening but treatable injuries requiring rapid medical attention.

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DELAYED

Potentially serious injuries but are stable enough to wait a short while for medical treatment.

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MINOR

Patients that are ambulatory on scene. Minor injuries that can wait for longer periods of time for treatment.

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EXPECTANT/DECEASED

  • No pulse or respirations
  • Patients not expected to survive due to the complexity of their injuries (still with life signs but injuries are NOT compatible with survival in austere conditions).

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Remember R P M’s

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Respirations 30 (less than or greater than)

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Perfusion Radial Pulse (present or absent)

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Mental Status Can they follow a simple command? (“with it” or “out of it”)

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Jump START

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Reference No. 519.2

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MCI Transport Priority Guidelines�Reference No. 519.4

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MCI Transport Priority Guidelines

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RED-YELLOW-GREEN

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Disaster Victim # 79

 

NAME: BURNS, ROBERT AGE:30 GENDER: M

 

Health History: None

 

Chief Complaint: Metal rod through right upper arm

 

HR: 120 RR: 28 BP: 148/88 Wt (Kg): 86 Temp (C): 37.2

 

Physical Exam: Metal rod piercing through right upper arm. No chest injury. Pulses intact and perfusing extremity well. No active bleeding. Diaphoretic

 

Other Information: Walked from construction site to hospital

GREEN

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Disaster Victim # 100

 

NAME: OCHOA, JIMMY AGE:75 GENDER: M

 

Health History: None

 

Chief Complaint: Unconscious

 

HR: 122 RR: 32 BP: 60/pp Weight (Kg): 68 SPO2: Temp (C): 37

 

Physical Exam: Multiple hematomas to the head

 

Other Information: Brought by EMS

RED

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Disaster Victim # 94

 

NAME: LEMUS, JOSE AGE:26 GENDER: M

 

Health History: None

 

Chief Complaint: Broken left leg

 

HR: 124 RR: 18 BP: 118/70 Weight (Kg): 75 SPO2: Temp (C): 36.7

 

Physical Exam: Patient appears to be in extreme pain. Right shoulder: tenderness, edema, deformity; tenderness, deformity and edema of right clavicle. Right leg: large, deep laceration with tibia and fibula fracture. Strong pulse to right hand and foot

 

Other Information: Brought by EMS

YELLOW

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Disaster Victim # 96

 

NAME: NUNEZ, JOAQUIN AGE:7 GENDER: M

 

Health History: None

 

Chief Complaint: limp, unresponsive after falling from nearby building explosion.

 

HR: cap refill 4 sec RR: 8 apneic BP: unable Weight (Kg):

 

Physical Exam: mottled, cold, presents in the arms of his mother asking to “save my baby”

 

Other Information: down time 5 minutes

 

BLACK

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Secondary Triage

  • Reassess ALL patients in Tx Areas
    • Physiology
    • Injury
    • Deterioration
    • Needs vs resource availability
  • Minor Tx Area
    • 1st assess infants or children carried: they have not proven their physiologic stability by performing the complex act of walking.
    • Utilize minor patients to assist with other patients

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Treatment Protocol: HAZMAT

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Hazmat vs.Terrorism

  • Assistant Secretary for Preparedness and Response National Bioterrorism Hospital Preparedness Program (ASPR NBHPP)
  • Focus on CBRNE

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Los Angeles County MICN Development Course Curriculum

Triage Algorithm & Decon Algorithm

Airway Management and Monitoring MCG

Airway Management and Monitoring MCG

Bradycardia or Tachycardia PI

Trauma PI

Shock PI

Cardiac Monitoring/

12-Lead ECG MCG

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Nerve Agents & Organophosphate Exposure

Penetrate skin, eyes, lungs

  • Massive OVER-stimulation of the central nervous system
    • Miosis
    • Headache
    • Restlessness
    • Convulsions
  • 3 Deadly B’s
    • Bronchospasm
    • Bronchorrhea
    • Bradycardia

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SLUDGE symptoms

Salivation

Lacrimation

Urination

Defecation

GI upset

Emesis

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Chemical Agent Antidotes

  • Duodote
  • One Chempack on each paramedic unit

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Los Angeles County Disaster Cache

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Chemical Terrorist Agents

  • Nerve Agents - Tabun, Sarin, Soman, VX

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  • Cyanide - Hydrogen Cyanide, Cyanogen Chloride

  • Pulmonary Intoxicants - Phosgene, Chlorine Ammonia

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  • Vesicants - Mustard, Lewisite

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Biological Terrorism

  • Microorganisms (bacteria, virus, fungi) used to intentionally produce death or disease in humans, animals or plants
  • Examples:
    • Anthrax
    • Botulism
    • Plague
    • Smallpox
    • Viral Hemorrhagic Fever

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Radiological / Nuclear Exposure

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Nuclear incidents involve detonation of a nuclear device whereas radiological incidents produce radiation without detonation of a nuclear device.

https://www.remm.nlm.gov/nukevsrad.htm

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Radiological Exposures

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Decontamination

  • CCR Title 8 Section 5192 (q): “Decontamination is the removal of hazardous substances from people and equipment to the extent necessary to preclude adverse health effects.”
  • Performed on living victims
    • Water only or Soap and water
    • Mild scrubbing or washing
  • Performed as soon as possible after exposure
    • At scene and before transport
    • At ED door BEFORE entry to hospital building

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Contaminated Patients (Ref. 519.5)

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Field Decontamination Guidelines �Reference No. 519.5

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Los Angeles County Disaster Resource Center (DRC) Map Reference No. 1102.1

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