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Triaje prehospitalario

basado en la evidencia

Alfredo Serrano MorazaAndrés Pacheco Rodríguez

Alejandro Pérez Belleboni

María Jesús Briñas Freire

www.mebe.org Conducta en la escenaResumen

Triage

Tratamiento

Transporte

T

T

T

SeguridadRescateDecontaminación

Es necesario re-evaluar todas las intervenciones

a la luz de la evidencia

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El método ideal

•Analítico y detallado• Capaz de diseñar estudios científicos de utilidad clínica

• Integrador• Hacia un modelo unificado • Dotado de un extenso banco de datos “a pie de obra”• Capaz de aprender de cualquier modelo, real o virtual

• Basado en un nivel de evidencia sostenible• En un equilibrio entre la experiencia y la investigación

Por el momento, tan sólo somos capaces dedescomponer el problema en sus elementos más simples

y aplicar nuestras técnicas actuales

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www.mebe.org La escala ideal

• Personalizada• Rápida• Eficaz• Dinámica• Aceptada/ble• Adaptable• Anterógrada

• Integrada• Basada en criterios científicos • Predictiva• Basada en la evidencia• Flexible y realista• Exportable• Capaz de evolucionar (feedback)

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Nota: existe frecuente confusión entre los métodos de abordaje para múltiples víctimas y desastres

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Ante todo,debe ser legible

www.mebe.orgTriaje avanzadoTriaje integrado

Triaje basado en la evidenciaTBE

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...

MedicinaMedicina

de emergenciade emergenciabasada en la evidenciabasada en la evidencia

mebemebe

catástrofescatástrofes

meCAbemeCAbe

www.mebe.org

A. Serrano MorazaA. Pacheco RodríguezA. Pérez Belleboni

www.mebe.org

• Current evidence on the effectiveness of MCI training for hospital staff is limited

• A number of studies suggest that disaster drills can be effective in training hospital staff.

• However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.

Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature reviewHsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C, Cosgrove SE, Green GB, Bass EB.

2004 Jul-Sep;19(3):191-9

Términos de búsqueda: "mass casualty", "disaster", "disaster planning", and "drill".

N = 21 estudios

Conclusiones:

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http://europa.eu.int/comm/environment/civil/prote/pdfdocs/disaster_med_final_2002/d-06_triage_position_statement_by_tj_hodgetts.pdf

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Pulse is shown as the discriminator for circulation.

An alternative is to use capillary return as it takes half the time (7 seconds compared to 15 seconds) which may be important in the rapid assessment of multiple casualties.

However, capillary return is unreliable in the cold[22] or the dark, even with street lighting [23], and was removed from the Trauma Score adult field triage system in 1989 because of this unreliability [24,25]

Triage Sieve

www.mebe.org START system

• Basado en el Triage Sort

• Estratificado de acuerdo con el Trauma Score (1981) y el Revised Trauma Score RTS (1989), con S 0.49 y E 0.92

• Permite una rápida clasificación de pacientes, que gana en exactitud a medida que se utiliza

• Se puede refinar con la escala anatómica.

www.mebe.org START system

• Does not [clearly] identify any patients in the T2 (‘urgent’) category

• It uses the term ‘dead or dying’, which may produce confusion when applying a triage label: should the casualty be labelled DEAD or T4 (‘expectant’), remembering that the T4 category is not routinely invoked?

• A lower limit of respiratory rate is not included as a discriminator.

• The absence of a radial pulse, rather than the pulse rate, is used to determine those with an immediate circulation problem. This reflects the dogma of the established advanced trauma life support course which teaches that if the radial pulse is palpable the systolic blood pressure is more than 80mmHg.[27,28] In an observational study […] the use of radial pulse alone may be considered a poorly sensitive discriminator of circulatory failure.[29]

• The inclusion of the instruction to control haemorrhage compromises the role of the triage officer.

• The Triage Sieve and START system are suitable for rapid primary triage of adult patients.

• Not useful for children.

Limitations:

START is not the best triage stategy http://bjsm.bmjjournals.com/cgi/reprint/36/6/473

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Triage sortWhere more time and more resources are available a more refined system may be used.

An accepted approach is the Triage Sort,[9] which is derived from the Triage Revised Trauma Score (TRTS).[25]

Glasgow13-159-126-84-53

Frecuencia respiratoria10-29> 29> 9

> 1-50

TA sistólica90 ó más

76-8950-751-49

0

Valor codificado43210

43210

3210

http://www.remotemedics.co.uk/ downloads/RemoteTriageBobMark.pdf

Mortalidad1-10 Rojo > 12 %12 Amarillo 3 %13 Verde 0.05 %< 3 Expectante

www.mebe.org START en desastres

• “Mass casualties’, or ‘MASCAL’, NATO term vs. “major [controlled] incidents” Unnecessary confusion has been introduced, for example, by recommending in UK military doctrine that the ‘P’ system is used in compensated major incidents and the ‘T’ system is used in MASCAL.

• Schulz et al have recommended […] that only victims with a 50% or more probability of survival should receive treatment in a MASCAL situation

• There is no difference in the principles of triage in this situation other than invoking the T4 (‘expectant’) category.To solve this problem:

– Use TRTS 1-3 to identify the T4 category within the Major´ncident Medical Management and Support training programme. TRTS of 6 or more should receive treatment (has a probability of survival of 63%).– The ‘secondary assessment of victim endpoint’ (SAVE) system of secondary triage has been devised for the same reason.[46] It is stated to have particular application in incidents where delay in transport to definitive care may be several days, and specifically where transport within the hypothetical “golden hour” is impossible.[47]

www.mebe.org Trauma Score revisadoRTS

Buen predictor de mortalidad en el traumaExisten dudas tanto sobre su uso en el triage primario

como sobre su capacidad predictiva distinta a la mortalidad

S 0.49 E 0.92

Buena consistencia internaBuen acuerdo interobservadorEs tan válido como por médicos del SUH para predecir supervivencia

No predijo el ingreso en UCI ...siendo el tiempo de aplicación el factor determinante

Multicenter Comparison of GCS and RTS Scores at Scene Versus at Trauma Hospital Al-Salamah M, McDowell I, Stiell IG, Wells G, Nesbitt LCan J Emerg Med 2003;5(3):#002http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-5.2003/v53.179-209.htm#002

Review article: is the revised trauma score still usefull?ANZ Journal of Surgery 2003 (Nov.); 73(11):944Gabbe BJ, Cameron PA, Finch CF

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• rápida identificación de los heridos que, con mayor probabilidad, pueden beneficiarse de una atención médica inmediata• al tiempo que no se "malgastan" recursos útiles en aquellos pacientes con escasa probabilidad de recuperación

Sobre y sub-triajeAnn Emerg Med 1996;28:136-144

Un sistema efectivo debería optimizar Sub- y Sobre-triaje.

Objetivos ideales:

Baja sensibilidad para identificar los pacientes críticos Ocasiona mayor morbi-mortalidad debido a la asignación de un nivel inferior de triaje

Se clasifica y atiende como graves a pacientes que no requieren tratamiento inmediato. Perjudica a aquéllos más graves que se beneficiarían del lugar que éstos ocupan. Es más probable.

www.mebe.org Evaluación idx. triage

Kennedy et al. Ann Emerg Med 1996; 28 (2): 136-144

www.mebe.org Estudio de parámetros individualesAnn Emerg Med 2001 Nov;38(5):541-8

Comparative analysis of multiple-casualty incident triage algorithms Garner A, Lee A, Harrison K, Schultz CH

www.mebe.org Care Flight Triage

www.mebe.org

Cone DChttp://www.naemsp.org/triageevidence.pdf

Objetivo: validar necesidad de protocolos que permitan no trasladar pacientesMétodo: asignación por niveles de gravedad

Gold standard Médico SUH ciego simpleOjo: trabajo habitual, no MCI

el modelo es paramédico

Sobretriaje hasta 400 % S 22.1-81 % VPP 50 %Subtriaje hasta 9.6 % E 34-80.5 % VPN 68 %

Conclusiones:

• EMS personnel without protocols cannot safely triage patients to no transport or alternate dest.• We don’t yet know if they can do this safely with protocols, but attempts... Significant under-triage.• The mathematical yield has not been shown to be substantial.• The public policy and EMS/ED issues have not been adequately explored.

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http://www.sharpthinkers.com/abc/ts_approach_triss.htm

Sacco Triage Method

www.mebe.org Triage pediátrico

www.mebe.org TBE pediátrico

• Frequently involved in MCI [30-41]. Review some criticism [35]

• If an adult physiological triage system is used, ‘over-triage’ will result (where an inappropriately high category is assigned). Anxiety coupled with inexperience of the normal physiological values in children may also result in over-triage.

• Paediatric treatment resources at hospital are often limited.• Triage of children at the scene [must be] objective• To ensure children are transported in appropriate order from the scene and that hospital resources are not diverted from genuine T1 casualties.

The Paediatric Triage Tape is an evidence-based system that allows objective triage of children from 1 to 10 years old (Figure 4).[42,43]

www.mebe.org Conducta en la escenaResumen

Triage

Tratamiento

Transporte

T

T

T

SeguridadRescateDecontaminación

Es necesario re-evaluar todas las intervenciones

a la luz de la evidencia

www.mebe.org Triage vs. transporte

A menudo, las prioridades de tratamiento in situ no coinciden con la necesidad y modo de evacuación

http://www.remotemedics.co.uk/ downloads/RemoteTriageBobMark.pdf

www.mebe.org Descontaminación 1Descontaminación 1

Somos capaces de realizar descontaminación en masa

Ver protocolo de descontaminación para tóxico desconocidohttp://www.atsdr.cdc.gov/MHMI/mmg170.pdf

www.mebe.org Descontaminación 2Descontaminación 2

Están preparados nuestros hospitales

www.mebe.org Muchas graciasMuchas gracias

Jeffrey Arnold, MDYale New-Haven Health. Connetticut-USA.Office of Emergency PreparednessMedical Director

Ülkümen Rodoplu, MDEmergency & Disaster Medicine Research Center. Izmir-Turkey. www.ulkumenrodoplu.com

A. Pacheco RodríguezEmergencia CR/SESCAMCastilla-La Mancha - MECABE

A. Pérez BelleboniSAMUR-SUMMA 112

M. R. MuroSAME Buenos Aires

M. J. Briñas FreireSUMMA 112

F. E. Hermoso GadeoEmergencia CR/SESCAM