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www.mebe.org Triaje prehospitalario basado en la evidencia Alfredo Serrano Moraza Andrés Pacheco Rodríguez Alejandro Pérez Belleboni María Jesús Briñas.

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Presentación del tema: "www.mebe.org Triaje prehospitalario basado en la evidencia Alfredo Serrano Moraza Andrés Pacheco Rodríguez Alejandro Pérez Belleboni María Jesús Briñas."— Transcripción de la presentación:

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2 Triaje prehospitalario basado en la evidencia Alfredo Serrano Moraza Andrés Pacheco Rodríguez Alejandro Pérez Belleboni María Jesús Briñas Freire

3 Conducta en la escena Resumen Triage Tratamiento Transporte T Seguridad Rescate Decontaminación Es necesario re-evaluar todas las intervenciones a la luz de la evidencia

4 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 de descomponer el problema en sus elementos más simples y aplicar nuestras técnicas actuales

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

7 Ante todo, debe ser legible

8 Triaje avanzado Triaje integrado Triaje basado en la evidencia TBE

9 Medicina de emergencia basada en la evidencia mebe de emergencia basada en la evidencia mebe catástrofes catástrofes meCAbe A. Serrano Moraza A. Pacheco Rodríguez A. Pérez Belleboni

10 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 review Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C, Cosgrove SE, Green GB, Bass EB Jul-Sep;19(3):191-9 Términos de búsqueda: "mass casualty", "disaster", "disaster planning", and "drill". N = 21 estudios Conclusiones:

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12 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

13 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.

14 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

15 Triage sort Where 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] Glasgow Frecuencia respiratoria > 29 > 9 > TA sistólica 90 ó más Valor codificado downloads/RemoteTriageBobMark.pdf Mortalidad 1-10 Rojo > 12 % 12 Amarillo 3 % 13 Verde 0.05 % < 3 Expectante

16 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]

17 Trauma Score revisado RTS Buen predictor de mortalidad en el trauma Existen 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 interna Buen acuerdo interobservador Es 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 L Can J Emerg Med 2003;5(3):#002 Review article: is the revised trauma score still usefull? ANZ Journal of Surgery 2003 (Nov.); 73(11):944 Gabbe BJ, Cameron PA, Finch CF

18 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-triaje Ann Emerg Med 1996;28: 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.

19 Evaluación idx. triage Kennedy et al. Ann Emerg Med 1996; 28 (2):

20 Estudio de parámetros individuales Ann Emerg Med 2001 Nov;38(5):541-8 Comparative analysis of multiple-casualty incident triage algorithms Garner A, Lee A, Harrison K, Schultz CH

21 Care Flight Triage

22 Cone DC Objetivo: validar necesidad de protocolos que permitan no trasladar pacientes Método: asignación por niveles de gravedad Gold standard Médico SUH ciego simple Ojo: trabajo habitual, no MCI el modelo es paramédico Sobretriaje hasta 400 % S % VPP 50 % Subtriaje hasta 9.6 % E % VPN 68 % Conclusiones: EMS personnel without protocols cannot safely triage patients to no transport or alternate dest. We dont 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.

23 Sacco Triage Method

24 Triage pediátrico

25 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]

26 Conducta en la escena Resumen Triage Tratamiento Transporte T Seguridad Rescate Decontaminación Es necesario re-evaluar todas las intervenciones a la luz de la evidencia

27 Triage vs. transporte A menudo, las prioridades de tratamiento in situ no coinciden con la necesidad y modo de evacuación downloads/RemoteTriageBobMark.pdf

28 Descontaminación 1 Somos capaces de realizar descontaminación en masa Ver protocolo de descontaminación para tóxico desconocido

29 Descontaminación 2 Están preparados nuestros hospitales

30 Muchas gracias Jeffrey Arnold, MD Yale New-Haven Health. Connetticut-USA. Office of Emergency Preparedness Medical Director Ülkümen Rodoplu, MD Emergency & Disaster Medicine Research Center. Izmir-Turkey. A. Pacheco Rodríguez Emergencia CR/SESCAM Castilla-La Mancha - MECABE A. Pérez Belleboni SAMUR-SUMMA 112 M. R. Muro SAME Buenos Aires M. J. Briñas Freire SUMMA 112 F. E. Hermoso Gadeo Emergencia CR/SESCAM


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