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Triage & Initial Treatment at the Active Shooter incident: Do you SALT your MCI?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

Triage of any MCI is one of those infrequently practiced skills that have massive implications for patient outcomes, and when it’s done “wrong” it leads to wasted resources and potentially deaths.  It also has virtually no science to back it up. It wasn’t until recently that we even recognized the gap between what we knew and what we assumed about MCI Triage.  

In fact, current ALTS-based physician-directed triage training doesn’t seem to make a difference in triage outcomes!

In 2008 this gap was acknowledged, and a “new” method of triage was developed based on the limited information available and compliant with the American College of Surgeons best-practices guidelines.   This new method, using the mnemonic SALT, takes into account (in fact, relies on) developments in tactical medical care such as the modern tourniquet, almost universal NPA use, specific antidotes for chemical agent exposure.  It also allows for genuine clinical acumen and incorporates resource availability into final decision making.

More importantly, SALT is far more compatible with Hartford Consensus III which sums up the recommended response to the active shooter with the acronym THREAT:

Threat suppression
Hemorrhage Control
Rapid Evacuation from the hot zone
Assessment by medical providers
Transport to care

In an active shooter situation the first people through the door are there for job 1, threat suppression and mitigation, and this frequently (28.1%) results in an exchange of fire between the perpetrator and the responding members. Where officers engaged the perpetrator, in 46% of the events an officer was injured or killed.

But once the threat has been suppressed it’s time for the rest of the THREAT mnemonic to kick in, and that’s where SALT can play a role.

SALT stands for Sort, Assess, Life Saving Treatment, Transport.

Sorting is conducted as a “Walk, wave, still” where the the walking are directed to a safe area (to be cleared by LEO in an active shooter) unmoving are assessed first, and the waving are checked after the unmoving.

Tac Responder KitThe SALT Assessment is conducted concurrently with limited treatment, and is even simpler than START. Obvious life-threatening injuries get treated! Tourniqueting major bleeds, opening airways with positioning, NPA or ESA, decompress tension pneumothorax (and seal obvious open pneumothorax) and administer 2PAM or other antidote as required are all reasonable and appropriate, depending on resources available.

In the Tactical Medical world, this limited treatment is what’s run out of the medic’s leg bag. The jump kit doesn’t get opened outside the casualty collection point (CCP) until the treatment areas are being established.

Simple SALT Algorithm

 

The critical difference between the Active Shooter MCI and the other MCI is the speed with which providers must act.  An Active Shooter is frequently an ongoing, open incident that will continue until the shooter is contained, killed, or surrenders.  The initial RTF medics must continue to push forward with the security element, providing appropriate hemcon and other interventions with the equipment on hand and leaving follow on personnel the job of further treatment and evacuation to the cold zone.

Consider adding some SALT to your MCI!  Simple, limited life-saving interventions performed at point of injury are the norm in tactical medicine, reducing the cognitive load is essential in performing at our finest. Add these life-saving steps to your Active Shooter and MCI training!

 

Check out the full SALT Online Training package courtesy of the National Disaster Life Support Foundation

How have we gotten here?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

65% of US States lacked specific guidelines on how and when to use a tourniquet!

Blow Out Kit for HemCon

Blow Out Kit for HemCon

After almost a decade and a half of continuous warfare, after achieving the best trauma outcomes in the history of medicine, after the formation of both the Committee for Tactical Emergency Casualty Care  and the Committee on Tactical Combat Casualty Care, even when the most recent best practices are available free online, we still can’t come up with a coherent extremity hemorrhage control strategy!

Ladies and gentlemen, the evidence is there, most of the tools are there, and the techniques are well developed;  There is no longer any excuse for any patient in prehospital care to die from exsanguinating extremity hemorrhage.

Know how to use a tourniquet! Put them on your ambulances, on your belt, in your pockets.  Have a primary, an alternate, a contingency, and know how to make a emergency tourniquet one.

See our post here for the evidence supporting their use.

 

How sick is he?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

I recently attended to a retired gentleman who had been picking up some work around the holidays.  He’d been an electrician for 25 years, and had retired the year before.  When his first grandchild was on the way right before Christmas he decided to pick up some work to get his daughter and son-in-law something special, and to help set up the nursery for them.NSR Pelvic Binding

He fell off a 12 foot ladder, and suffered a basal skull and sinus fracture, along with an obviously displaced fracture of his arm.  He was briefly unconscious and had some aspiration before we got there, but was awake and alert upon initial exam with a chief complaint of arm pain and a headache. His teeth were intact, he had no Battle’s sign or Raccoon Eyes, no epistaxis or discharge.

He “usually” took pills for his blood pressure, his angina, his afib, and a few others which he also couldn’t name, but he knew it was important to tell people he was on blood thinners.  He was mildly tachycardic and normotensive.  He didn’t look unwell.

How can you predict the degree of injury in this patient?  He’s medicated in such a way that his body’s response is blunted.  He’s at risk of increased ICP and Cushing’s, and of bleeding in general, but how to judge his vital signs?

There’s a great tool which allows you to predict otherwise difficult to detect shock states, the Shock Index.  There’s evidence to back it up in helping to differentiate major from minor injuries, and it’s even validated for use in geriatric patients, even when neither HR and SBP were useful on their own.

TXASI = HR / SBP.  The faster the heart rate the greater the degree of compensation, and the BP is indicating how well the body is achieving perfusion.  A normal range is 0.5-0.75 ( HR60 BPM / 120SBP = SI of 0.5, HR90 / 120SBP = SI 0.75, HR 120 / 120SBP = SI 1).

A Shock Index greater than 0.9 should be assumed to be actively bleeding!

 

10 Principles of Leadership

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

From the Canadian Armed Forces, these 10 principles of leadership are a great starting point for evaluating your performance as a leader.  Keep in mind, just because you don’t have bars on your shoulders or pips on your slip on doesn’t mean you don’t have a leadership role in your organization!

 

1. Achieve professional competence.

2. Appreciate your own strengths and limitations and pursue self-improvement.

3. Seek and accept responsibility.

4. Lead by example.

5. Make sure that your followers know your meaning and intent, then lead them to the accomplishment of the mission.

6. Know your followers and promote their welfare.

7. Develop the leadership potential of your followers.

8. Make sound and timely decisions.

9. Train your followers as a team and employ them up to their capabilities.

10. Keep your followers informed of the mission, the changing situation and the overall picture.

More on public access hemorrhage control

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

There is ample evidence that tourniquets work in controlling hemorrhage from extremities, and now various public bodies, including the White House, are adding their voices to a push for public access hemorrhage control:

“…make tourniquets as commonplace as heart defibrillators in U.S. schools, stadiums, airports, malls and other public places, to reduce fatalities from mass shootings and terror bombings.”

Department of Homeland Security and NAEMT have all added their voices to the call for public access hemcon and public training in hemcon techniques.

If you don’t know how to use a tourniquet, if you can’t apply one to yourself quickly, efficiently, and effectively, you are exposed to an easily controlled risk.  It’s not just hybrid targeted violence of the sort we’ve seen in Paris, Mali, Kenya, London, Madrid, but any exposure to a traumatic injury that warrants no-fail hemorrhage control measures!

More (well, some!) evidence to back up hemostatic dressings.

Unlike tourniquets and TXA, both of which have  a robust and growing body of literature to support their use, hemostatic dressings such as Quickclot, Combat Gauze, WoundStat etc have had limited published field experience to support their use.
EMS1 on Hemostatics

Blowout Kit

Blowout Kit

 

In US DoD studies, Combat Gauze was chosen as the agent of choice, but that decision was largely based on animal models, which are great, but provide limited value and don’t always translate well to clinical practice. Some suggest they are about 30% more effective than good wound packing with regular materials.

But here’s a study from Israel that supports their effectiveness in the field about 90% of the time!  Keep in mind that this is a small study, but it’s pretty reflective of this authors experience with hemostatics in the military setting, includes extremity and junctional injuries, and acknowledges where there are gaps in the data.

Hemostatic agents in their current form seem to be a potent addition to the hemorrhage control arsenal, and have lots of cheerleaders in the military health care community, but are not a silver bullet that will stop every source of bleeding.  Here’s hoping one of the many gels, foams, CO2 delivered TXA interventions is THE answer to the bleeding patient!

Clinical Decision Making in a Team Context

Have you ever had one of those partners? The one you didn’t even need to speak to during the arrests, the profoundly collapsed CHF call, the multisystem trauma call? The one who had everything you needed in their hands as you felt your sphincter tighten and your heart rate increase? You turn and ask for an 16g in a big vein and they’re already doing it?  You mumble “maybe a NRFM?” and they’re already inflating the reservoir?  There’s a beauty to EMS when it runs like that, a precision and finesse that makes it look effortless.

For that call, and hopefully for many more, you were working with a shared mental model of what was wrong with the patient, what courses of action you had open to you, and how best to move the call forward to a good outcome.

You may have worked with that person a dozen years, or it could be your first call together.  You don’t need to be experienced to have that shared mental model.  Two brand new medics just out of school working on a classic EMS call are working from the same place of (over) confidence and unrecognized pitfalls, but from the same playbook of classic presentation and conservative treatment.

There are things you can do to enhance this, and improve your individual performance as well as that of your team, especially for uncommon procedures.  For those who don’t do thoracotomy or surgical airways, replace that with triage or childbirth. And it really works.

Classic cases are classic cases because they’re classic….

Far from the front: the role of trauma systems in IED/Active Shooter Events

HMMVW Amb on the flight line, KAFWith the recent release of the US DHS Guidance for IED and Active Shooter document, we’re taking a look at some of the key concepts within that document.  This week we’re looking at the Trauma Systems roles in preparing for and responding to these events.

To some extent we are lucky.  We’re lucky because there are probably few tertiary care trauma centers that don’t have a veteran of Afghanistan or Iraq on their surgical, ICU or resuscitation service.  Experience counts, and team leadership is essential in MCI, no matter where they happen. Many hospitals have regular MCI drills, and at the facility level it really doesn’t matter what the incident is.  Plane crash? Bus Crash? IED? Unless you move the MCI to the hospital during transport, or the incident targets a health care facility, MCI in hospitals (should be) are very different from the chaos of responding to the incident scene.

“EMS must rapidly and accurately triage casualties at the incident site and expeditiously transport those identified for “immediate care” into an appropriate hospital setting.”

All facilities, not just those designated trauma receiving facilities, need to be ready for an influx of patients.  Experience shows that in major events many casualties self-report to the nearest treatment facility if they are capable of doing so.  These facilities need to have triage systems in place and EMS needs to stage transport units at these facilities to effect secondary transport.  In a major event, secondary transport may include out of region and even out of province transfers.  We need to keep in mind that our health care system is currently operating with a very limited surge capacity.

Damage control resuscitation and surgery (DCR/DCS) is the name of the game.  Prevent hypothermia, treat with blood products not salt water, and stop ongoing hemorrhage.

DCR is based on the balanced administration of thawed plasma, pRBCs, and platelets in severely injured patients instead of solutions such as normal saline and lactated ringers.9 10 11 12 DCR also includes avoidance of hypothermia and pursuit of other measures to maximize oxygenation and reduce injurious factors in the blast-injured patient.

However, all the surgeons in all the OR’s aren’t much help if you can’t get the patient to them in the right sequence.  Triage is one of the most critical elements of any MCI response, and MCI triage is not what you’ve experienced in the Emergency Room during a normal visit.  Triage also can’t happen once.  Triage should happen at each stage of evacuation, again on arrival at the hospital, and again among the priority patients for surgical priority.

Behind the scenes of any surgery are the hidden experts, radiology, lab techs, blood bank, and all the others without whom a modern OR can’t function, and they each have a job to do. This job will take a finite amount of time, and have a finite amount of stores on hand.

One area where significant efficiencies can be found is the role of the blood bank in trauma resuscitation, particularly development and implementation of Massive Transfusion (MT) Protocols.  Fascinating research in MT is ongoing, and developments like rotational thromboelastometry (ROTEM) are offering exciting developments

Any patient who may require MT should have already received TXA, preferably during tactical field care or casevac care. Despite best efforts, none of the prehospital blood replacements (or even Normal Saline for that matter!) show much benefit in hemorrhagic shock.  With that in mind, resuscitation with blood products is the gold standard.  Everything infused should be warm, it should be under pressure, and it should either help promote clotting or carry oxygen.

And let’s not forget that when these patients come out of resus and are off to the OR or ICU there is a finite amount of resources available for them even if they’ve made it this far.  We know that care of the traumatized patient is a long-term problem that will persist long after the event.

Trauma bays fullThe provider on scene is only the tip of what must be a vast concerted effort of allied health care providers working together towards a common goal:  Best care for the patients under less than ideal circumstances.

 

 

 

For more on Boston listen to this BBC Broadcast

To see what the New Yorker had to say about the hospital response to the Boston Marathon Bombing 

To learn more about Damage Control Surgery we recommend this #SMACC presentation.

Link

Tac Responder KitThere are  virtually no reasons not to use a tourniquet to stop hemorrhage that is amenable to one.  It’s not unreasonable to make one attempt at controlling bleeding with direct pressure, directly on the bleeding site (pinpoint pressure, not pillow pressure!) but while your using one hand to do that, the other hand should be reaching for a tourniquet.  Maybe your knee should be pressing down on the femoral or brachial artery too, depending on the injury.

The key to success in using a tourniquet, like many procedures in EMS, is making the decision to commit to it.  Once you’ve applied that device, it should not be coming off except in very specific circumstances, and very rarely in the civilian EMS setting.

The biggest pitfalls with using a tourniquet are:

  1. Not using one when indicated.  Delays in tourniquet application allow unacceptable hemorrhage.  There is no acceptable amount of blood loss!
  2. Using one for minimal bleeding.  Significant venous or arterial bleeding only!
  3. Taking it off!  If it’s working, leave it!  If it isn’t working, add another!
  4. Not making it tight enough.  Tourniquet slack is a killer.
  5. Not using a second (or third) tourniquet when needed.
  6. Periodically loosening it.  You’re not killing distal tissue with it, so you don’t need to worry about it in the short term!  Surgeons use 300mmHg on a femoral tourniquet in the OR regularly!

If you’re carrying one, you need to be proficient in it’s use, and it needs to be close to hand.  There is nothing worse than needing that one piece of kit that’s buried at the bottom of your duty bag or jump kit.

Law Officer.com on LEO TK Use

Interesting TK

One Step Closer to our Tactical Emergency Casualty Care Course

For the past several days I’ve been working the phone lines and email tree trying to nail down a venue for our next course offering, and I think we’ve found it.  I’ll be stopping by tomorrow to ensure that it meets our needs and is cost effective for our clientele.

Our Tactical Emergency Casualty Care Course is open to paramedics, law enforcement, and Canadian Armed Forces members.  TCCC and TECC teach the same material, but to different target audiences, in a slightly different format.  While sending the 9-Liner CasEvacReq is an essential skill for a deployed soldier, there isn’t much need to teach it to a street level paramedic or police member.

What each of them does have to know is how to handle themselves if they’re injured; how to apply a tourniquet to themselves, their patient, or their partner quickly and efficiently and get back to the job at hand.  How to control hemorrhage with wound packing, direct pressure, and with a variety of bandages.  How to place an airway, on the floor, in the dark, by touch. How to move someone by themselves over smooth terrain, over rough terrain.

Tomorrow, at 1300, I find out if we’ve got our venue!