Page 611 - ACCCN's Critical Care Nursing

588 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

the receiving facility, and other documentation includes method of managing large numbers of battlefield casual-
initial medical evaluation, and medical officer to medical ties. Today it is applicable for treating multiple victims of
officer communication, with the names of the accepting illness or injury outside and within the hospital setting.
doctors and the receiving hospital. 44,47 Variations exist between states and countries regarding
disaster victim triage classifications. It is therefore impor-
11,12
PATIENT MONITORING DURING TRANSPORT tant to be familiar with local plans and policy.
Critically ill patients undergoing transport receive the Triage of mass victims may be necessary in common situ-
same level of monitoring during transport as they would ations, like vehicle collisions with multiple occupants, as
have in a critical care unit. Equipment essential for trans- well as large-scale disasters, such as earthquakes, floods,
port includes: public transport incidents or explosions. The principles
of triage vary little, though the methods used to com-
l equipment for airway management, sized appropri- municate triage information and to match victims with
ately transported with each patient (check for opera- available resources may differ. Triage at the scene of a
tion before transport) major incident or disaster is commenced by the first
l portable oxygen source of adequate volume to provide qualified person to arrive (i.e. the one with the most
for the projected timeframe, with a 30-minute reserve medical training). This person is initially responsible
l a self-inflating bag and mask of appropriate size for performing immediate primary surveys on all victims
l handheld spirometer for tidal volume measurement and to determine and communicate the numbers and
l available high-pressure suction types of resources needed to provide initial care and
l basic resuscitation drugs, and supplemental medica- transport. 8
tions, such as sedatives and narcotic analgesics (con-
sidered in each specific case) In Australia and New Zealand, disaster systems have up
l a transport monitor, displaying ECG and heart rate, to five triage categories (depending on jurisdictional and
oxygen saturation, end-tidal CO 2 , and as many inva- local protocols). To provide the best level of care and
sive channels as required for pressure measurements. ensure the highest number of survivors, those who are
The monitor should have a capacity for storing and mortally injured but alive may be given a low treatment
reproducing patient bedside data and printouts during priority, though this will almost certainly ensure their
transport. 48 death. These decisions are therefore best made by an
experienced doctor. In a situation with a large number of
Monitoring equipment should be selected for its reliable casualties, one or more doctors should be present at the
operation under transport conditions, as monitoring can site to lead the triage effort. Further, it is not within the
be difficult during transport; the effects of motion, noise scope of practice of non-physician emergency personnel
and vibration can make even simple clinical observations to pronounce a patient dead, but properly trained ambu-
(e.g. chest auscultation or palpation) difficult, if not lance or rescue personnel can recognise the signs of death
49
impossible. As transport of mechanically-ventilated for the purposes of triage until doctors can formally
patients is associated with risk, 29,56,58,59 consistent ventila- declare death. 50,51
tion and oxygenation should be a goal; transport ventila-
tors provide more constant ventilation than manual
ventilation. An appropriate transport ventilator provides EMERGENCY DEPARTMENT RESPONSE TO AN
full ventilatory support, monitors airway pressure with a EXTERNAL DISASTER: RECEIVING PATIENTS
disconnect alarm, and should have adequate battery and Disasters may produce mass victims on a scale that means
gas supply for the duration of transport. 47 routine processes and practices in the ED and hospital
Adverse events during transport of critically ill patients will be overwhelmed. The ED response to an external
fall into two categories: 46,48 (1) equipment dysfunction, disaster forms part of the overall hospital response, out-
such as ECG lead disconnection, loss of battery power, lined in a hospital disaster plan. These plans are reviewed
loss of IV access, accidental extubation, occlusion of the regularly for currency, and practised for preparedness.
endotracheal tube, or exhaustion of oxygen supply (at The following aspects form part of the ED’s planning
least one team member should be proficient in operating and response to receiving patients from an external
51,52
and troubleshooting all equipment); and (2) physiologi- disaster.
cal deteriorations related to the critical illness.
Department Preparation
MULTIPLE PATIENT TRIAGE/DISASTER If the disaster site is close to the hospital, a significant
number of disaster victims will self-evacuate from the
Disaster triage is a process designed to provide the great- site and arrive at the hospital without any prehospital
est benefit to multiple patients when treatment resources triage, treatment or decontamination before any formal
and facilities are limited. Disaster triage systems differ notification has been received. In this instance the ED
from the routine triage system used within the ED (e.g. will need to declare the incident and commence the
48
the ATS); system care is focused on those victims who notification process required. The ED may be quickly
may survive with proper therapy, rather than on those overwhelmed with arriving patients; the closest local
who have no chance of survival, or who will live without medical facility may receive up to 50–80% of the
52
treatment. The system was first devised during war as a disaster victims within 90 minutes of the incident. On