05 - LSI...Nice Try.

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Life Saving Intervention has a nice ring to it. Aside from SALT’s claims of being ‘science-based’ and derived from ‘best available evidence’, the ‘LSI’ component seems to create the most appeal to those that have not done the research. In reality there is no more science or evidence in SALT as there is in START. Some of SALT’s LSI components are either impractical, unproven or misplaced.

Stop the Bleeding Start the Breathing?:

‘Sound backward? That’s because it is. But not in a war zone. Based on lessons learned in Iraq and Afghanistan our military adopted a doctrine called Tactical Combat Casualty Care (TCCC) for treatment of injuries immediately after they are sustained. It uses X-A-B-C-D-E (eXsanguination, Airway, Breathing, Circulation, Disability (neuro), Expose/Evacuate) as opposed to A-B-C.

Possibly this is where the Working Group derived the concept. This would be valid if we were next to our patients when they were injured but we won’t be. An MCI is not an active battlefield. In non-combat scenarios it is more practical to check for breathing before controlling bleeding. Good ol’ ABC’s.

In SALT’s overly ambitious attempt to emphasize LSI they put this principal aside and recommend the application of hemorrhage control, chest decompressions or antidote use before confirming the patient has respirations.

Maybe this was just the Working Group’s attempt to simplify the algorithm and assumed we would apply a logical START-like confirmation of respirations before LSI application.
Or maybe, like other components of SALT, they just didn’t think it through. Tactical is not always practical. Regardless of how it came to be, if we obey SALT we apply LSI to dead patients. Anything can be fixed so we took the liberty of giving SALT some LSI of our own to prevent resources from wasting time caring for the dead. (See problem / solution to the right)

If for some reason an agency adopts SALT, they may want to consider implementing our fix to properly depict the medically-sound process for application of lifesaving intervention in the civilian sector.

An Open and Closed Case:

A preponderance of opinion does suggest that civilian pre-hospital tension pneumothorax needle or finger treatment is overall beneficial in traditional field triage assuming the patient receives immediate transport and is constantly monitored and reassessed. Questions remain as to best location to approach the needle but agencies can make their own call until the evidence is in. However, there is no evidence of this treatment being used in an MCI setting where conditions are chaotic, transport may be delayed and the prescribed constant patient monitoring and reassessment will potentiality not occur. To suggest that there is some evidence that this treatment in an MCI setting results in favorable patient outcome would be incorrect.

What is peculiar, however, is SALT’s omission of occlusive dressings for open pneumothorax. There is recent evidence indicating it is positive for patient outcome in MCI-like settings. Settings with hazard types we are more likely to encounter. Maybe SALT was written before the evidence was in and has already outdated itself.

Important Note: SALT’s ‘Step 1’ sorting process would require taking more steps and wasting more air, thereby reducing working time and resulting in fewer patients extracted. In a neurological event those that are ‘still’ when we arrive are likely unsalvageable. Even if triage was possible in a CBRNE environment, SALT’s ‘still-first’ sorting process would be non-intuitive, counter productive and over taxing. The only logical extraction process is to start where you stand.

SALT AlgorithmDecompression NeedleOcclusive Chest Seal

Antidote Reality Check:

If there’s a topic that’s likely to create controversy in these white papers this may be it. Not because it is directly related to SALT but in that it also extends into how many of us think with regard to HazMat triage response. Since avoiding the topic would do no justice to the information sharing objectives of these papers we elected to include it. At a minimum it will stimulate healthy discussion.

As much as some may wish it wasn’t true, austere triage cannot be conducted in a contaminated environment. In order to perform any algorithm based triage on a patient we must be able to check for perfusion via pulse in order to determine an acuity class. Proper level A or B PPE gloves prevent this. (Cap refill is not an option in a contamination zone for numerous reasons and regardless, SALT does not allow for it)

For that reason alone, SALT’s inclusion of LSI antidote administration as a step toward acuity class determination in a nerve agent or insecticide contaminated environment is fundamentally flawed.

It is another mind’s eye, skewed research-based component of SALT that was implemented without an understanding of real-world conditions and unarguably shows that this component of SALT was never field tested, for if it had been it would have become quickly apparent it would not work.

That is why it is not in START. The use of antidotes and austere triage are mutually exclusive.

So we don’t conduct austere triage in a CBRNE incident. Nor do we need to. The patient count we ultimately use to allocate trauma beds is that of the survivors of decon, not the ones laying in the contaminated zones. The initial scene size up has already alerted tertiary care and transport resources.

Until the science is in, we can assume the obvious; all salvageable non-ambulatory patients need immediate extraction from the contaminated zones and the sooner that happens the better off they are.

Auto-injectors are designed primarily to be used immediately upon any presents of SLUDGEM symptoms for maximum lifesaving effectiveness. That simply won’t occur in an MCI. By the time we don our OSHA / NFPA required PPE, identify the contaminate and head downrange (assuming we have access to an ample supply of injectors), patients that received lethal toxic dosages have already expired.

Time, although important, is less critical to patient outcome for those that would benefit from an antidote by the time we get to them.

Note: We are not advocating the use of any LSI over what START currently provides as there is no evidence to substantiate the time consumption impact of SALT’s additional LSI over achieving a rapid patient count and ‘greater good’ resource allocation.

Practical HazMat MCI response procedure recommendations are outside of the scope of these papers it is essentially comprised of these steps:

1. Separate the ambulatory from the non-ambulatory with a call for the walking to come to the ambulatory gross decontamination corridor.

2. PPE litter teams retrieve viable non-ambulatory patients, as they are encountered, starting with the closest sector and are brought to the entrance of the non-ambulatory decontamination corridor. No LSI is provided. If they have survived this long they will survive a few more minutes. Non-salvageable patients are marked with black/white ribbons so subsequent litter teams pass them by. (ribbons are used for their high visibility and low-dexterity ease of use)

3. LSI, in any available form, is administered prior to decon to the extent that such treatment will allow survival of the decontamination process.

4. Surviving patients are triaged as they exit decon.

Simplified HazMat MCI Response WorkflowThe ProblemThe Solution

TCCC: Time to Treatment Guidelines

Note: Zone nomenclature not yet ratified.

Time Is On Your Side:

Nerve gasses bind reversibly in the initial stages. That is why pralidoxime (2-PAM) antidotes work. They prevent irreversible binding. In some agents, like Soma there is only a 2-minute window depending on dosage, delivery system and toxicity. In other gases, such as VX or Sarin, it can take from 5 to 40 hours before they are irreversibly bound. This is why there is no to rush to apply auto injectors at the immediate point of contact with the patient. Instead the patient can be littered to the LSI cache in the decon corridor where a medical specialist can make an assessment as to whether the administration is prescribed based off manifestation, severity and supply. A HazMat MCI response is stressful enough. We don’t need to place the added stresses caused by the illusion that there is a patient outcome benefit to hasty PPE donning so we can rush downrange to get antidotes onboard. If we maintain a calm operational pace we will make fewer mistakes, burn less air and save more lives.

I’m Bleeding as Fast as I can:
START instructs to “control bleeding’”. In SALT’s haste to adopt TCCC guidelines they use the expression “control major hemorrhage”. Given our normal response time to an incident we are unlikely to experience these except for patients that have received traumatic articular injuries but had a means to prevent exsanguination via pressure or constriction. The expression does not account for injuries to smaller veins or artery nicks that present slower flows. These are not observed as major hemorrhages. Fortunately it can be assumed some responders will break the SALT rules and apply pressure dressings or tourniquets to these types of injuries as well, providing a more START-like patient outcome. This may be nitpicking at words but they should consider just using the word “hemorrhage”.