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| Triaging blast victims |
Rapid triage in the ED is vital when handling a multipatient blast event, says Elizabeth Bridges, RN, PhD, CCNS, assistant professor of biobehavioral nursing and health systems, University of Washington School of Nursing, and clinical nurse researcher, University of Washington Medical Center, both in Seattle. “The general principle underlying triage is ‘the greatest good for the greatest number of casualties,’” she says. “This requires not only deciding who gets treated first, but also the maximization of available resources, which may lead to a decision to transfer a patient from your facility.”
The goal of triage, Bridges says, is to rapidly identify patients who are “immediate.” This includes patients with airway compromise that can be managed with an artificial airway; those who are comatose; and those with penetrating torso trauma, vascular trauma, major limb deformity, or deep partial- or full-thickness burns.
“There are individuals who, sadly, will die no matter what we do,” Bridges says. “Following an explosion, individuals who present with amputations with no signs of life or no respiration/pulse and dilated pupils were most likely very close to the explosion and have suffered fatal internal injuries. They should be triaged as ‘expectant.’”
In a mass-casualty situation, attempts to resuscitate expectant casualties with CPR or open-chest thoracotomy are generally futile and will take care away from the immediate casualties, Bridges says. “Triage is not an easy decision,” she adds. “During exercises, the health care providers who will be responsible for triage should be guided and educated regarding what injuries are or are not survivable after an explosion.”
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Bridges says nurses and other health care professionals should follow the
current recommendations for field care after blast injuries by remembering the ABCs — airway/ breathing (oxygen,
intubation), cervical spine stabilization, circulation (hemorrhage control via
direct pressure or with a tourniquet),
and stabilization of fractures.
With mass casualties, care in the ED should focus on the rapid triage of patients and the initial treatment of life- or limb-threatening injuries, Bridges says. Examples include advanced trauma life support resuscitation, definitive airway/ventilation, empiric tube thoracotomy, control of external bleeding with direct pressure, focused abdominal sonography for trauma, a CT scan of the head for patients with a low or deteriorating Glasgow Coma Scale score to rule out a mass lesion, temporary stabilization of fractures, decompression of the stomach and bladder, treating potential tetanus, administering antibiotics, and covering the wounds.
“Blood product administration in the emergency department may be delayed in lieu of taking the patient straight to the operating room,” Bridges says. “During a mass-casualty event, the use of routine radiographs, MRI, or angioplasty is not recommended. Depending on the number of casualties, surgical procedures may be damage-control only, such as ... stopping hemorrhage.”
Pattern plans
An important factor in planning care for patients with blast injuries is to recognize the typical pattern of how patients will arrive at the hospital after a disaster. “Generally, 50% of patients will come by private transportation,” Bridges says. “In Oklahoma City, the first casualties arrived within five minutes of the blast in a red Corvette, with the owner shuttling victims to the hospital. These initial victims tend to be less seriously injured, have not been triaged or received any initial care, and can overwhelm a medical facility, especially if it is near the site of the incident.”
Bridges says to expect a second wave of more seriously injured patients. To estimate the number of expected casualties, the Centers for Disease Control and Prevention suggests counting the number of patients who arrive within the first hour, then doubling that number.
“Recognition of this patient flow pattern is also important in planning staffing,” Bridges adds. “Although everyone wants to be involved in the initial response to a disaster, it is important to prepare for the continued care of those admitted to the hospital.”
Don Vaughan is a freelance writer.
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