ATLS 10th Edition Triage Answers for Appendix F: Triage Scenarios;PATIENT A-F Latest Update with Complete Solution

648 SECTION 4 ■ Student Course Resources TRIAGE sCENARIO I Mass Shooting at a Shopping Mall scENARIO You are summoned to a safe triage area at a shopping mall where 6 people are injured in a mass shooting. The shooter has killed himself. You quickly survey the situation and determine that the patients’ conditions are as follows: PATIENT A—A young male is screaming, “Please help me, my leg is killing me!” PATIENT B—A young female has cyanosis and tachypnea and is breathing noisily. PATIENT C—An older male is lying in a pool of blood with his left pant leg soaked in blood. PATIENT D—A young male is lying facedown and not moving. PATIENT E—A young male is swearing and shouting that someone should help him or he will call his lawyer. PATIENT F—A teenage girl is lying on the ground crying and holding her abdomen. QUESTIONS FOR RESPONSE 1. For each patient, what is the primary problem requiring treatment? The student(s) should indicate that management priorities could be based on information gleaned by surveying all of the victims from a distance. If the student indicates that he or she needs to examine each of the patients individually before making a decision, the group should discuss this response. The direction of the discussion should indicate that, while information is being obtained on one patient, another patient might die from a more serious injury. Also, the time taken to gather detailed information on all of the patients before establishing priorities based on that information could lead to disastrous results. If there is doubt about which one of these patients is most severely injured, based on the available information, the decision must be made to proceed with the best information available at the time. The instructor should then provide information that could be obtained by surveying the situation from a distance, as follows: PATIENT A—is a young male screaming, “Please help me, my leg is killing me!” Possible Injury/Problem:The patient has a probable fracture/open fracture of the lower extremity. PATIENT B—appears to have cyanosis and tachypnea and is breathing noisily. Possible Injury/Problem:This patient likely has a compromised airway. PATIENT C—is an older male lying in a pool of blood with his left pant leg soaked in blood. Possible Injury/Problem:This patient has potential blood loss from an open fracture or laceration. PATIENT D—is lying facedown and not moving. Possible Injury/Problem:This patient may be comatose, dead, or have a brain or spine injury. PATIENT E—is swearing and shouting that someone should help him or he will call his lawyer. Possible Injury/Problem:: Is this patient hemodynamically normal? This patient may be in shock, have a psychological problem, or a personality disorder. PATIENT F—A teenaged girl is lying on the ground crying and holding her abdomen. Possible Injury/Problem:Does this patient have a torso gunshot injury? The instructor should clearly explain that all of the previously outlined information could be obtained without actually examining any of these patients in detail and that, based on this information, a triage decision could be made. The instructor may ask, “Suppose you are in doubt about which patient is most severely injured. How should you respond?” Students should be prompted to respond that the decision must be made to proceed on the basis of the best information available at the time. Based on the information obtained by surveying the patients from a distance, the students are then asked to triage the victims and give the rationale for their choices. The convergent or divergent model may be used here to facilitate the discussions. Go back to last viewed page PART B ■ Answers for Appendix F: Triage Scenarios 649 Go back to last viewed page TRIAGE sCENARIO I (cONTINUEd) 2. Establish the patient priorities for further evaluation by placing a number (1 through 6, where 1 is the highest priority and 6 is the lowest) in the space next to each patient letter. 5 Patient A 1 Patient B 3 Patient C 2 Patient D 6 Patient E 4 Patient F 3. Briefly outline your rationale for prioritizing the patients in this manner. The instructor leads the discussion by asking the students to give the rationale for their priority choices, and these answers are discussed among the students. At the end of the discussion, the students should arrive at the following priorities: NOTE: Patients B and D may be interchanged as Priorities 1 and 2, and both may be considered high priority. However, the rationale must be given by the student—for example, Patient D may have a major airway problem as well. The reason for determining that patients B and D are higher priorities than patient C is that they appear to have airway and breathing problems, whereas patient C appears to have circulatory problems related to hemorrhage. Also, Patients A and E may be considered low priority. PRIORITY PATIENT RATIONALE 1 B – Airway compromise The patient apparently is not talking. Her respiratory efforts are rapid, and there is evidence of an obstructed airway (breathing noisily). The cyanosis is additional information supporting respiratory compromise. 2 D – Coma/brain/ spine injury/ dead? With the patient lying facedown and not moving, it must be assumed that he or she is comatose, has a spine injury, or is dead. Had the patient been awake and capable of moving, he or she likely would not be lying facedown. The ABCDEs must be assessed with the concern for altered level of consciousness and spinal injury. 3 C – Blood loss Based on the information provided, there is clear evidence that the patient has blood loss. The extent of the blood loss and whether it is continuing are not known. The patient’s ABCDEs must be assessed to determine the extent of the problem. 4 F – Possible torso gunshot wound Given the mechanism of possible injuries—gunshot wounds, and that the patient is clutching her abdomen—responders must suspect a torso gunshot injury. A patient with a torso gunshot wound needs rapid assessment by a surgeon, even without obvious signs of blood loss. 5 A – Probable fracture/open fracture of lower extremity The patient’s ABCDEs would appear to be grossly normal. His chief symptom appears to be pain in his lower limb, which should be viewed initially as a bony/soft-tissue injury or problem. 6 E – Hemodyna mically normal If the patient were just cursing, the responder could be concerned about hypoxia versus a perfectly stable patient with a litigious personality. The patient is making judgments that are rational and protective, if argumentative and irritating. 650 SECTION 4 ■ Student Course Resources Go back to last viewed page TRIAGE sCENARIO I (cONTINUEd) 4. Briefly describe the basic life support maneuvers and/or additional assessment techniques you would use to further evaluate the problem(s). NOTE: Patients B and D may be interchanged as Priorities 1 and 2, and both may be considered high priority. However, the rationale must be given by the student—for example, Patient D may have a major airway problem as well. PRIORITY PATIENT BASIC LIFE SUPPORT MANEUVERS AND/OR ADDITIONAL ASSESSMENT TECHNIQUES 1 B This patient obviously has respiratory difficulty and may have airway obstruction, as evidenced by her noisy breathing. Clearing her airway and establishing airway patency by performing the chin-lift or jaw-thrust maneuver would be the highest priorities for this patient. Assess for other life-threatening injuries that may be the cause of her respiratory distress, such as tension pneumothorax, open pneumothorax, 2 D The patient is in the facedown position and not moving. He/she also may have an airway problem due to a depressed level of consciousness. The patient’s airway and breathing need to be assessed, respiratory effort noted, and a patent airway established and/ or maintained. The patient then needs to be carefully logrolled to his/her back, and a patent airway reestablished as required by findings on further assessment. The patient is unconscious, so once he/she is on his/her back, the tongue may prolapse and occlude the airway. Oxygen should be administered, and motion of the entire spine should be restricted. If the student has identified this patient as being dead, the instructor needs to ask the student how that determination was made. 3 C This patient is lying in a pool of blood and in all likelihood has suffered a major extremity injury. The hemorrhage must be stopped by splinting the extremity, direct pressure, wound packing, or a tourniquet. The patient should be reassessed for continuing blood loss from the extremity injury or other sites. Stop the bleeding and assess the patient for severity of shock—for example, skin pallor, quality of pulse, and level of consciousness. This patient may be considered intermediate priority. 4 F This patient is clutching her abdomen and crying. She may have a gunshot wound to the abdomen, but she is still awake. A teenager may not manifest hypotension as a sign of shock until quite late, so there will be uncertainty over the amount of blood loss she may have, if she has a gunshot wound. She may also just be frightened and manifesting this state via abdominal pain. The presence of a torso gunshot wound needs to be determined quickly. If a wound is present, she should be transferred as part of the “C-circulation group” with possible uncontrolled bleeding. If there is no external bleeding, little can be done at the scene. A bleeding torso wound could be treated with direct pressure and a hemostatic dressing, but any associated internal bleeding requires hospital procedures. 5 A On examination from a distance, this patient appears to be suffering from intense pain from an extremity injury. The examiner needs to assess the patient’s ABCDEs and ensure that the airway is patent and his breathing is adequate. The doctor should next examine the patient’s extremities for the presence of injury and vascular impairment, reduce any fracture that is present, and then apply a splint. If there is a bleeding wound in the extremity, it may need direct pressure, a hemostatic dressing, and/or a tourniquet. 6 E This patient appears to be conscious and alert. His ABCDEs should be assessed to determine whether there is evidence of respiratory compromise (e.g., tension pneumothorax). He may require analgesia after his airway, breathing, and circulation are determined to be adequate. PART B ■ Answers for Appendix F: Triage Scenarios 651 Go back to last viewed page TRIAGE sCENARIO II Mass Shooting at a Shopping Mall (cont’d) PATIENT BLS OR ALS DESCRIPTION OF CARE B BLS ALS Establish patent airway; administer oxygen; establish definitive airway; perform needle decompression of tension pneumothorax; appropriately seal open pneumothorax. D BLS ALS Establish patent airway; administer oxygen; restrict motion of entire spine; establish definitive airway. C BLS ALS Stop the bleeding; splint the injured extremity; apply dressing and/or tourniquet if external bleeding assess for severity of shock; ensure rapid transport; initiate intravenous line. F BLS ALS Ensure patent airway and adequate breathing; stop any bleeding with dressing and/or tourniquet if external bleeding, ensure rapid transport for internal bleeding; assess for severity of shock; initiate intravenous line. A BLS ALS Ensure patent airway and adequate breathing; splint injured extremity; assess for vascular impairment. E BLS ALS Ensure patent airway.