Triaje prehospitalario basado en la evidencia

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Triaje prehospitalariobasado en la evidencia
Alfredo Serrano Moraza Andrés Pacheco
Rodríguez Alejandro Pérez Belleboni María Jesús
Briñas Freire
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Conducta en la escenaResumen

• Triage
• Tratamiento
• Transporte

T T T
Seguridad Rescate Decontaminación
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
de descomponer el problema en sus elementos más
simples y aplicar nuestras técnicas actuales
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(No Transcript)
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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
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Ante todo, debe ser legible
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Triaje avanzado Triaje integrado Triaje basado en
la evidencia TBE
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Medicina de emergenciabasada en la
evidenciamebe
catástrofes
meCAbe
A. Serrano Moraza A. Pacheco Rodríguez A. Pérez
Belleboni
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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-Sep19(3)191-9
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.

10
http//europa.eu.int/comm/environment/civil/prote/
pdfdocs/disaster_med_final_2002/d-06_triage_positi
on_statement_by_tj_hodgetts.pdf
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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
  cold22 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

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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.

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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
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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
• gt 29
• gt 9
• gt 1-5
• 0
• TA sistólica
• 90 ó más
• 76-89
• 50-75
• 1-49

Valor codificado 4 3 2 1 0 4 3 2 1 0 3 2 1 0
Mortalidad 1-10 Rojo gt
12 12 Amarillo 3 13
Verde 0.05 lt 3
Expectante
http//www.remotemedics.co.uk/ downloads/RemoteTri
ageBobMark.pdf
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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 Majorncident 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

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Trauma Score revisadoRTS
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 LCan J Emerg Med
20035(3)002 http//www.caep.ca/004.cjem-jcmu/00
4-00.cjem/vol-5.2003/v53.179-209.htm002
Review article is the revised trauma score
still usefull? ANZ Journal of Surgery 2003
(Nov.) 73(11)944 Gabbe BJ, Cameron PA, Finch
CF

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Sobre y sub-triaje
Objetivos ideales
Ann Emerg Med 199628136-144

• 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.
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Evaluación idx. triage
Kennedy et al. Ann Emerg Med 1996 28 (2)
136-144
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Estudio de parámetros individuales
Ann Emerg Med 2001 Nov38(5)541-8
Comparative analysis of multiple-casualty
incident triage algorithms Garner A, Lee
A, Harrison K, Schultz CH
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Care Flight Triage
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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 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.

22
Sacco Triage Method
http//www.sharpthinkers.com/abc/ts_approach_triss
.htm
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Triage pediátrico
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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

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Conducta en la escenaResumen

• Triage
• Tratamiento
• Transporte

T T T
Seguridad Rescate Decontaminación
Es necesario re-evaluar todas las
intervenciones a la luz de la evidencia
26
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/RemoteTri
ageBobMark.pdf
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Descontaminación 1
Ver protocolo de descontaminación para tóxico
desconocido http//www.atsdr.cdc.gov/MHMI/mmg170.p
df
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Descontaminación 2
29
Muchas gracias