Notes

Outline

TRIAGE and FIELD MANAGEMENT U.S. ARMY MEDICAL RESEARCH INSTITUTE OF CHEMICAL DEFENSE CHEMICAL CASUALTY CARE OFFICE

Objectives Describe components of Casualty Decon Site Discuss some principles of decontamination Define triage Discuss the role of Triage Officer Review categories of triage Identify the triage category of a chemical casualty given the agent and severity of exposure

Contaminated Casualty Management Arrival point Triage points (dirty / clean) Emergency-Medical-Treatment point Casualty decontamination areas Litter & Ambulatory Decon Hot Line Clean Treatment Area Disposition areas (dirty / clean)

Casualty Decontamination Site

Contaminated Dump Purpose Temporary storage of contaminated clothing and equipment Location  75M downwind of decon site Identification Markers from NATO NBC kit Report of location and type of dump to HQ

Arrival Point Purpose Initial reception for potentially contaminated casualties patient checked for contamination Location Close to triage point and EMT point Arrival, Triage and EMT point may be co-located Staffing Personnel in MOPP4

Triage Point Purpose Rapid initial assessment of patients to determine further disposition Remove LBE, weapons from casualties Location Close to Arrival point and EMT point Retriage on clean side Staffing Senior medic, litter team in MOPP 4

EMT Point Purpose lifesaving emergency treatment (ABCs) spot decontamination Location upwind of Triage point Staffing Medic(s) in MOPP4 Capabilities Limited BLS interventions

Litter Casualty Decontamination Purpose Decon of STABLE, nonambulatory (litter) patients Location Between Triage Point & Hot Line Staffing Medic (if possible) for supervision 2-4 nonmedical augmentees                                    in MOPP4 with butyl rubber apron

Ambulatory Casualty Decon Purpose Decontamination of ambulatory patients Location Parallel to litter decon line May use unit personnel decon station (PDS) Activities Buddy system for decon and clothing removal Minimal or no assistance from medic

Hot Line Purpose Delineates area of potential liquid agent hazard Downwind of line = liquid hazard Upwind of line (30-60M) = continued vapor hazard Location Between decon & clean TX areas Activities at shuffle pit Evaluate completeness of decon Litter-exchange point Field Medical Card rewritten

Clean Treatment Area Purpose Definitive medical treatment Location 60m upwind of Hot Line Staff Physician, PA, medics MOPP 0, collective protection Activities Retriage of patients from dirty area Prep for disposition (evacuation, return to duty)

Disposition Area Purpose Exit point from MTF for evacuation or return to duty Location In the clean and dirty area Activities Departure of treated casualties Resupply point Medical records/PAD initiated Possible break area for unit personnel

Resources Limited at BAS ventilation support equipment decontamination supplies decontamination personnel Higher echelons:  more resources

Casualty Decon Issues Augmentees Assignment and availability Training Logistics Replacement masks and clothing Water and bleach Environment Heat stress, protection from cold Changing winds Time

Mechanical / Physical Decon Physical removal is BEST Wiping May smear agent over unexposed areas May drive agent into skin or wounds Adsorption Resins from M291 kit Fuller’s earth, clay, flour, etc. Must be followed by mechanical removal Flushing with water or aqueous solutions May splash, drive agent into skin or wounds

Chemical Methods Water / Soap wash physical removal + dilution + SLOW hydrolysis Oxidative Chlorination hypochlorite solution (BLEACH) 0.5% for skin    5% for equipment sulfur atoms in VX, HD attacked increasing pH = increasing effectiveness

Chemical Methods Alkaline Hydrolysis OH ion attacks PO4 atoms in nerve agents rate increases in solution > pH 8 rate increases 4X for each 10 degree C increase hypochlorite, ammonia, NaOH solutions

Wound Decontamination Low risk to surgeon from liquid in wound nerve agent / mustard react rapidly with tissues large amount of NA in wound not survivable Standard irrigation and debridement OK Foreign material in wound porous material acts as agent depot risk to casualty and medical personnel remove with no-touch technique

DEFINITION of TRIAGE Triage (Webster):  A system designed to produce the greatest benefit from limited treatment facilities for battlefield casualties by giving treatment to those who may survive with proper treatment and NOT to those who have no chance of survival or those who will survive without it.

DEFINITION Simple Version: If treating one will cost the lives of two, then let the one die and treat the two. Used whenever demand exceeds resources

When is Triage Done? At each echelon of care Repeated PRN with changes in status of: casualty workload resources Before and after casualty decontamination

Types of Sorting Treatment Delayed,  Immediate,  Minimal,  Expectant Evacuation (priorities) urgent - within 2 hours priority - within 4 hours routine - within 24 hours Decontamination

Triage Officer Must Know Nature of injury, prognosis Resources available MTF personnel, capabilities evac and resupply assets status of decon lane Patient load present anticipated

TRIAGE OFFICER Conventional senior surgeon most experienced in trauma care Contaminated Casualties senior medic PA RN dentist

CASUALTY TYPES Conventional Chemical, biological, nuclear Mixed:  NBC and Conventional Psychological Physiological Malingering Any combination

MIXED CASUALTY Nerve Agent + Conventional ABCs Administer antidote If casualty responds to antidote: Re-triage according to conventional injury with consideration of chemical injury

Assessing Contaminated Casualties Casualty in MOPP Health care provider in MOPP Assessment skills of limited use

Categories (NATO) Urgent Immediate Delayed Minimal Expectant

IMMEDIATE Needs IMMEDIATE intervention to save life. BRIEF INTERVENTION Airway, Breathing, Circulation Drugs (MARK I), Decontamination (spot)

DELAYED Care IS needed NOT immediately Delay in care will not change outcome

MINIMAL Minor injury Quick fix Does not require physician No evacuation Return to duty shortly

EXPECTANT Survival unlikely even with optimal resources Care exceeds available resources Not a justified expense of limited resources

Common Times of Death Nerve Agents < 30 min Cyanide < 30 min Phosgene < 24 hours Mustard 4 to 12 days

NERVE AGENT Immediate Symptoms in 2 or more organ systems airway, GI, muscular NOT including miosis, rhinorrhea Unconscious, apneic with heartbeat

NERVE AGENT Delayed recovering from moderate / severe exposure Minimal walking and talking assess effect of miosis on duty Expectant no heartbeat (resource dependent)

VESICANTS Immediate acute airway problem (resource dependent) Delayed skin burn > 5% but < 50% BSA moderate - severe eye involvement pulmonary sx, onset > 4 hr post-exposure

VESICANTS Minimal skin burn < 5% BSA (non-critical area) minor eye irritation Expectant liquid burn > 50% BSA pulmonary sx, onset < 4 hr post-exposure

PULMONARY AGENTS Immediate acute airway problem (resource dependent) Delayed (for treatment) onset of symptoms > 4 hr post-exposure Expectant onset of symptoms < 4 hr post-exposure resource dependent

CYANIDE Immediate Unconscious, apneic, with heartbeat Expectant No circulation Minimal or Delayed Survival >15 minutes  post vapor exposure

INCAPACITATING AGENTS Immediate (unlikely) Cardiorespiratory compromise, hyperthermia Delayed Severe, worsening signs/symptoms Minimal Mild effects Expectant (unlikely) Cardiorespiratory compromise, ltd resources