TABLE 54 Triage Categories

WOUND CARE AND CRUSH SYNDROME This section addresses some concepts of care that are not found in the routine management of emergency patients. Wound infections may occur in virtually all types of disasters. Infected wounds and gangrene were major problems following an earthquake in Armenia (1988) and tornadoes in Illinois (1991).5 58 In hurricanes or tornadoes, persons may be cut by flying glass and other, potentially highly contaminated material. Because of this, all wounds should be copiously irrigated. Primary closure of heavily contaminated wounds may result in major complications, as was the case following the Armero volcanic eruption in Colombia in 1985.59 If lacerations are more than 6 to 12 h old or appear contaminated, they should be treated by debridement and left open for primary delayed closure. Tetanus prophylaxis and tetanus immunoglobulin should be administered if indicated.

Victims who have been trapped by rubble for several hours or days should be watched very closely for signs and symptoms of crush syndrome, such as cardiac arrhythmias, hyperkalemia, and renal failure. 6 ,61 Fulminant pulmonary edema or pneumonia from dust inhalation may also be a delayed cause of death for victims of building collapse.

RADIOGRAPHIC AND LABORATORY STUDIES Radiographic and laboratory studies should be used only if test results will change therapeutic intervention. For example, x-rays of closed, nonangulated potential fractures can be safely delayed for 24 to 48 h, during which time effective splinting, elevation, and ice can be utilized. On the other hand, cervical spine, pelvic, and femur x-rays may be indicated, considering their potential complications. A chest radiograph is needed in patients complaining of chest pain, dyspnea, or abnormal chest wall motion.

Indications for clinical laboratory studies are minimal. In cases of hemorrhagic shock, a baseline hematocrit and type and cross-matching for blood should be obtained. A urine dipstick test for blood may be useful in detecting renal or urinary tract injuries. All other laboratory studies should be considered accessory and ordered only in specific circumstances (e.g., determination of serum carboxyhemoglobin levels in cases of smoke inhalation).

BLOOD BANK In a disaster situation involving many casualties, it is recommended that the blood bank have as many as 50 units of blood available. 62 It is also important that the bank have ready access to a source of volunteer donors who can be rapidly mobilized. Other potential sources of blood include friends and family members of patients as well as those with minor injuries.

PATIENT IDENTIFICATION AND RECORD KEEPING Emergency department records of disaster victims have usually been poor or nonexistent in past disasters.63 The general absence of detailed and systematic record keeping in disasters, except for serious cases in which patients were admitted to hospitals for surgery or to intensive care units, has implications for reimbursement and quality improvement.

Documentation of the patient's hospital course starts in the triage area. Proper tagging with a triage tag is essential for patient identification, documentation of medical care rendered, and supplying information for relatives and the news media. Unfortunately, triage tags are frequently underutilized in actual disasters because they are a departure from normal emergency department routine.

One member of the triage team (admitting or medical records clerk) should be assigned to record the patient's name and triage destination. If identification of the patient is not available, race, gender, and approximate age should be noted on the tag. An initial diagnostic impression should also be registered on the tag. This information is entered in the triage area log.

MEDIA RELATIONS AND FAMILY The hospital may become inundated by more members of the media than disaster victims.64 Members of the news media should be directed to an area away from patient care. The pressroom should be closely supervised by a hospital administrator or public relations specialist who is in direct contact with the disaster command center. To ensure that consistent information is released by the hospital, the staff must leave all communications with the media to the public relations team.

Family members should not be allowed into patient care areas. Special policies should be developed for handling family members whose relatives are critically ill or who have died. The hospital operator will also be inundated with calls of inquiry. Such calls should be directed to a single predesignated desk or office.

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