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

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

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

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) www.mebe.org Nota: existe frecuente confusión entre los métodos de abordaje para múltiples víctimas y desastres

Ante todo, debe ser legible

Triaje basado en la evidencia Triaje avanzado Triaje integrado Triaje basado en la evidencia TBE

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

Conclusiones: 2004 Jul-Sep;19(3):191-9 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. Términos de búsqueda: "mass casualty", "disaster", "disaster planning", and "drill". N = 21 estudios Conclusiones: 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.

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

Triage Sieve 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]

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.

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

Frecuencia respiratoria 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 13-15 9-12 6-8 4-5 3 Frecuencia respiratoria 10-29 > 29 > 9 > 1-5 TA sistólica 90 ó más 76-89 50-75 1-49 Valor codificado 4 3 2 1 Mortalidad 1-10 Rojo > 12 % 12 Amarillo 3 % 13 Verde 0.05 % < 3 Expectante http://www.remotemedics.co.uk/ downloads/RemoteTriageBobMark.pdf

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]

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 http://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):944 Gabbe BJ, Cameron PA, Finch CF

Sobre y sub-triaje Objetivos ideales: Ann Emerg Med 1996;28:136-144 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 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. Un sistema efectivo debería optimizar Sub- y Sobre-triaje.

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

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

Care Flight Triage

Método: asignación por niveles de gravedad Cone DC http://www.naemsp.org/triageevidence.pdf 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 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.

Sacco Triage Method http://www.sharpthinkers.com/abc/ts_approach_triss.htm

Triage pediátrico

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]

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

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

Ver protocolo de descontaminación para tóxico desconocido Somos capaces de realizar descontaminación en masa ? Ver protocolo de descontaminación para tóxico desconocido http://www.atsdr.cdc.gov/MHMI/mmg170.pdf

Están preparados nuestros hospitales Descontaminación 2 Están preparados nuestros hospitales ?

Muchas gracias Jeffrey Arnold, MD Ülkümen Rodoplu, MD Yale New-Haven Health. Connetticut-USA. Office of Emergency Preparedness Medical Director Ülkümen Rodoplu, MD Emergency & Disaster Medicine Research Center. Izmir-Turkey. www.ulkumenrodoplu.com 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