EMS: Mass Casualty Triage

Phil Giddings PGY-2 

Mass Casualty: Resources are overloaded

-Type 1-3 -based on how many patients 

-Triage: to sort and select

                   – MUCCC: model Uniform Core Criteria-

Green: minimal injury- self-limited injury can tolerate extended delays in treatment without increased mortality risk

Yellow: Delayed-deep lacerations with hemostasis, open fractures, abdominal injuries with stable vitals, head injuries with intact airway 

Red: IMMEDIATE– unresponsive, AMS, Respiratory distress. Uncontrolled hemorrhage, amputation, proximal to elbow or knee, pneumothorax, cyanosis, weak pulses

Black: Deceased- no respirations following basic airway maneuvers 

 SALT TRIAGE 

Sort: 3 categories: Walk (assess 3), Wave/purposeful movements (assess 2^nd), Still Obvious life threaten assess 1^st) 

Assess:  individual assessment 

Life-saving interventions

• Control hemorrhage, open airway (consider rescue breaths in children), chest decompression, and auto injector antidotes
  • Minimal
  • Delayed
  • Immediate
  • Expectant
  • Dead

Treatment/transport 

START TRIAGE

-based off of respirations

                   Tachypneaperfusioncontrol bleedingcare 

Pediatrics- JUMP START for triage 

Respiratory Emergencies 

PEM-Dr. Said  

Croup: acute subglottic inflammatory process 

-6months to 3 years (morbidity is greatest in first year of life)

-etiology: Parainfluenza 1 and 3 most common (Influenza, human metapneumovirus, RSV) and COVID

– Presentation: 1-3 days URI sx and seal like cough, +/- stridor, clinical diagnosis 

       – if you cannot r/p epiglottitis or foreign body get a lateral neck x-ray (steeple sign) 

– Severity: Severe (barky cough and stridor at rest) 

             Moderate (stridor with agitation and barky cough)

             Mild barky cough no stridor 

-Treatment: Give Decadron 0.6 mg/kg

                 Racemic epi: stridor at restthen watch for 2-3 hours for rebound swelling

                 Other Therapies:  Heliox, if you need to intubate (use tube that is 1-1.5 smaller)

Foreign Body Aspiration

                   -Small children are at higher risk

                   -Anatomic immature: High epiglottis and immature swallowing coordination 

                   -Acute: lead to respiratory distress, immediate episode of coughing, gagging, choking or cyanosis  

                   -Delayed: younger kids (not verbal)

-may lead to: persistent febrile illness, chronic cough, recurrent pneumonia, recurrent croup, lung abscess, hemoptysis

-location: Larynx: obstruction, Trachea: biphasic stridor or dry cough, Bronchus (80-95%): cough wheeze and decreased breath sounds, Esophagus: can impinge the trachea in small children 

                   -CXR:

                                      50% will have negative CXR

• If high enough suspicion should be bronched, most sensitive indicator is witnessed aspiration
• Xray: hyperinflated lung, ATX, pneumonia (if delayed) 

Choking

-Infants <12 months: 5 back blows followed by 5 chest compressions using 2 fingers, baby’s head should be tilted

-Children >1 year: Heimlich maneuvers

Partially occluded airway

– Place child in sniffing position, provide supplemental oxygen, do not perform maneuvers that may dislodge the FB and move it to the central airway, Rigid Bronchoscopy needed 

Bronchiolitis: acute inflammation of lower airways, increased mucous production, edema of small airways, bronchospasm and V/Q mismatch 

-Most common respiratory wheezing under 2 years.  Occurs in winter

-Etiology: RSV

-Severe: 

respiratory rate depends on age (50 as a general number)

retractions: intercostal, sub costal, supraclavicular 

PO intake: Decreased 

Other: apnea, cyanosis

                   -Management:

-examine patient from waist up.  Evaluate signs of respiratory distress of heart disease

                                      – supportive care: O2 vs HFNC prn, IV, Suctioning

Asthma

-Clinical Presentation: Dyspnea wheezing and cough, can have retractions due to obstruction, AMS in those with impending ventilatory failure

-Complications: pneumothorax and pneumomediastinum 

-Management: CXR not routine

                   -albuterol

                   -ipratropium both nebulized

                   -magnesium 50-75mg/kg bolus 

-Ventilation: Intubation

                   -incidence is 0.55% associated with higher mortality

-Complications: can cause cardiac arrest, hypotension occurs as a result of hyperinflation leading to decreased cardiac preload 

-Expiratory time: 4-5 second I:E ratio should be 1:4

-Ketamine for sedation

Lightening Lectures

Pleural Effusions: Alaina Royalty, MD PGY1 

-Abnormal collection of fluid within the pleural space between parietal and visceral pleura

-Transudative: increased hydrostatic pressure or low oncotic pressure: CHF, Cirrhosis, Nephrotic, PE, Hypoalbuminemia, myxedema, peritoneal dialysis, SVC obstruction

-Exudative: occurs due to inflammation and increased capillary permeability: Pneumonia, Cancer, Tb, viral infection, PE, autoimmune, GI disorders, Chylothorax, medications 

-CXR: at least 200ml required to be seen on upright AP/PA 

– blunting of costophrenic angel 

-US thoracic: detects as little as 5-50cc’s best to have the patient is sitting up

-Thoracentesis: 

– New effusions with unknown cause likely need diagnostic thoracentesis: however, does not typically need to be done emergently 

–Therapeutic: should be done for massive effusions mediastinal shift, hemodynamic instability if you suspect empyema, or esophageal rupture this will be done in THE EMERGENCY DEPARTMENT

                   –Test: cell count differential, pH, protein, LDH, Glucose 

                                      – REMEMBER LIGHTS CRITERA via protein, LDH 

Acute Respiratory Distress Syndrome (ARDS):  Craig Schutzman PGY1

-Non cardiogenic pulmonary edema

-Clinical: worsening dyspnea, hypoxemia and bilateral diffuse crackles

-Many common cause: sepsis, pancreatitis, TRALI, trauma

-Pathophysiology:

-Exudative phase proliferative phase Fibrotic phase (bad prognosis)

– Berlin Criteria 

– Labs: are non specific But get proBNP/BNP

-ABG: elevated pH, low PaO2, Low PaCO2, low-normal HCO3 (acute hypercapnic respiratory acidosis indicated severe disease, impending respiratory arrest)  

-Imaging: CXR: diffuse ground glass opacities, CT chest: bilateral opacities widespread 

-Management: 

-treat underlying cause

-Supplemental oxygen

-Analgesia, sedation and paralysis

       – Sedation improves tolerance to ventilation and decrease oxygen consumption

-Lung protective Ventilation

       -Ventilator Mode: Volume AC

       – tidal Volume: low per Ideal body weight -6 cc/kg

       – Inspiratory flow rate 60-80 lpm

       -respiratory rate: 16-18

       -FIO/PEEP: titrate to spO2 goal 88-95% (can have permissive hypercapnia)

       -maintain plateau pressure <30 mmHg to prevent barotrauma 

–GO TO ARDS NET FOR ALL YOUR ARDS FRIENDLY INFORMATION!

-PRONING ventilation: V/Q mismatch improves as depending lung receives majority of blood flow as alveoli open 

-Steroids: only give if severe, look at the Meduri Protocol 

-ECMO:  early application <1 week is crucial for success 

COPD Exacerbation: Mitchell Weeman PGY1

-Persistent air flow limitation that is progress and assisted with enhanced chronic inflammatory response in the lungs to noxious particle or gas 

-Clinical: dyspnea, productive cough, decreased physical activities, +/-wheezing.  End stage: cor pulmonale, muscle wasting, chronic ventilatory failure

-Diagnosis: via PFT

-Management: 

                   – ABC: IV, telemetry, O2 saturation, vitals

                   – O2 correct to baseline if unknown 90-94%

                   -EKG, trop, BNP, CXR, CBC, CMP, ABG for accurate PaO2 

                   – Mild: DuoNeb or single agent +/-steroids and abx

-Moderate: same as mild plus Prednisone 60mg or Solumedrol 125mg IV and abx, /-Magnesium, BIPAP

-Severe: same as above: plus BIPAP (10/5 is a good setting) , IV steroids. 

       – +/- intubation use ketamine or etomidate (FIO2100%, TV 6-8 cc/kg, RR: 8-10, PEEP 5-8) 

       -Magnesium

-Disposition:

-Uncomplicated: can go home- they have no comorbidities, <65 y/o <3 exacerbations per year, FEV >50% 

       -Give steroid 3-5 days, abx refill nebs and follow up with PCP 

-Complications: new or increased o2 requirements or needing BIPAP, AMS due to hypercapnia, inability for self care or risk of poor follow up 

Room 9 follow up

MB Hatch PGY3 

-for Boards do not take a hypotensive patient to the CT scanner 

-resuscitation is key 

Cognitive dispositions to respond

-Anchoring and diagnosis momentum

-Base rate bias, multiple alternative bias, and confirmation bias

-Commission and Omission Bias: feeling bias that you have to intervene 

-Feedback sanction: we don’t see the long-term consequences 

-Gamblers Fallacy thinking that everything is going to be fine because everything else has been fine 

-Overconfidence and sunk cost

-Vertical Line failure: patterns of thinking, and not straying from the regular thinking. You need to lateral think as well

-Visceral bias: doing things by anticipating what people want from you 

What can we do?

-Practice mindfulness, ask yourself “what else might this be?”, create metacognitive processes, contribute to a supportive culture, participate in institutional review 

Ventilator Management: 

Dr. Richie 

-Indications: Acute failure, airway protection, respiratory arrest, upper airway trauma, relive work of breathing operative procedures 

-Oxygenation improved with increased FIo2 and increase PEEP

-Ventilation: respiratory rate and tidal volume 

-PIP : Peek Inspiratory pressure

                   -pressure at the end of inspiration

                   -high peak pressures are not good >30 or 40

-Compliance: change in volume/change in pressure 

-most people >50, intubated about 30

-ARDS is 15 or less 

-decreased compliance: pulmonary edema, pneumonia, ARDS, pneumothorax, obesity, burns, ascites, abdominal compartment syndrome.

-Increased: COPD 

Modes of Ventilation: 

-Pressure: push in a constant pressure (flow will vary)

-Volume: push in a constant flow (pressure will vary) 

Types of breaths

-Mandatory: machine initiated, machine does the work  

-Assisted: patient initiates breath, patient does some work and ventilator assists 

Assist control Ventilation (AC) 

-set rate and set volume or pressure

-If patients breathe over set rate it will assist at the same preset volume or pressure

• If a patient wants to take a breath at 10 sec they will get 500cc regardless of whether he wants 300cc or 700cc

SIMV: similar to assist control but patient initiates breaths can be different set support

Pressure Control: set pressure. Variable flow, set rate, Cycle time: 

• You set I time 

Volume Assist control: set volume, variable pressure, set rate Cycle time 

• If patient wants more volume because they feel air hunger it wont let them get more flow, it can be very distressing
• COPD, increased dead space, may need larger volume, and patient can feel distress because they need a much larger flow and

Pressure Support: set pressure, variable flow, patient determined RR, cycle flow

• There is no back up rate 
• Most tolerable and most like natural breathing 
• Good for COPD, but you need to think about I:E Ratio 

PRVC: pressure give can change breath to breath 

• Best of both worlds 
• Need to give I time (set to 1 second) 

Trouble shooting: 

Peak inspiratory pressure vs Plateau Pressure 

High plateau: alveolar level problems

-inspiratory pause and they are very different: something wrong with large airways, or ventilator problem

                   – easy to bag vent problem, hard to bag large airway vs ET tube problem

-not very different think alveolar 

Air trapping: responds to increased PEEP, bronchodilators,

-Ineffective trigger: if patient is spontaneous breathing are they triggering the ventilator 

Ventilator induced lung injury