TNCC Disaster Management 3 — Questions and Answers
Question 1: In the JumpSTART pediatric triage system, what additional step is performed for a non-breathing child that differs from adult START triage?
- Immediate chest compressions
- Five rescue breaths before classifying as Expectant (Correct answer)
- Needle decompression of both chest cavities
- Administration of epinephrine
Correct answer: Five rescue breaths before classifying as Expectant
JumpSTART includes five rescue breaths for apneic children with a palpable pulse, recognizing that pediatric cardiac arrest is more commonly respiratory in origin and potentially reversible with ventilation.
The JumpSTART triage system was developed specifically for pediatric patients (typically under age 8 or under 100 lbs). The key modification from adult START triage is that when a child is found apneic, the responder checks for a peripheral pulse. If a pulse IS present, five rescue breaths are administered. If the child resumes spontaneous breathing → Red (Immediate). If not → Black (Expectant). This additional step acknowledges that pediatric cardiac arrest is most commonly caused by respiratory failure (rather than primary cardiac events as in adults), and that brief ventilation may restart breathing in children with a perfusing rhythm. In adult START, an apneic patient who doesn't breathe after airway repositioning is immediately tagged Black. This modification can save children who simply need initial ventilatory support.
Question 2: A hospital is preparing for a surge of 200 patients from a mass casualty incident. Which strategy best manages this surge capacity?
- Treating all patients in the emergency department only
- Activating discharge protocols, opening auxiliary treatment spaces, and calling in off-duty staff (Correct answer)
- Diverting all patients to other facilities
- Limiting treatment to Red-tagged patients only
Correct answer: Activating discharge protocols, opening auxiliary treatment spaces, and calling in off-duty staff
Surge capacity management requires a multi-pronged approach: rapidly discharging stable inpatients, opening overflow treatment areas, and activating callback systems for additional staff.
Hospital surge capacity is the ability to manage a sudden influx of patients beyond normal operating capacity. Effective surge management uses multiple simultaneous strategies: (1) Accelerated discharge of stable inpatients to free beds. (2) Opening auxiliary treatment spaces (conference rooms, cafeterias, lobbies converted to treatment areas with pre-positioned supplies). (3) Activating staff callback systems to bring in off-duty nurses, physicians, and support staff. (4) Implementing crisis standards of care that modify normal care delivery (e.g., delayed documentation, expanded scope of practice, altered staffing ratios). (5) Coordinating with regional healthcare systems for mutual aid and patient distribution. Relying solely on the ED, diverting all patients, or treating only the most critical would fail to maximize the hospital's ability to save lives.
Question 3: Which type of disaster agent causes delayed symptom onset of hours to days, making initial triage particularly challenging?
- Blast injuries from explosives
- Biological agents such as anthrax (Correct answer)
- Structural collapse with crush injuries
- Chemical agents such as chlorine gas
Correct answer: Biological agents such as anthrax
Biological agents often have incubation periods of hours to days, meaning exposed individuals may appear asymptomatic during initial triage and present later with severe illness.
Biological agents (bacteria, viruses, toxins) present unique disaster management challenges because of their delayed onset. Anthrax inhalation has a 1-5 day incubation; smallpox 7-17 days; plague 2-4 days. During this latency period, exposed individuals appear well, making initial triage and even recognition that an attack occurred extremely difficult. Unlike chemical agents (immediate symptoms), blast injuries (immediate physical trauma), or radiation (identifiable by dosimetry), biological events may first be recognized through epidemiological surveillance — clusters of unusual illness presenting to multiple healthcare facilities days after exposure. This delay means triage occurs in the prodromal or symptomatic phase rather than at the scene. Healthcare system preparedness for biological events focuses on syndromic surveillance, rapid laboratory identification, mass prophylaxis distribution, and isolation/quarantine protocols.
Question 4: After a building collapse, a trapped patient is extricated after 6 hours of limb compression. The nurse should anticipate which life-threatening complication upon release?
- Hypothermia only
- Crush syndrome with hyperkalemia and acute renal failure (Correct answer)
- Immediate wound infection
- Isolated compartment syndrome without systemic effects
Correct answer: Crush syndrome with hyperkalemia and acute renal failure
Crush syndrome occurs when prolonged compression causes rhabdomyolysis, releasing myoglobin, potassium, and other toxic metabolites into the circulation upon reperfusion, leading to hyperkalemia, cardiac dysrhythmias, and acute renal failure.
Crush syndrome is a systemic manifestation of rhabdomyolysis following prolonged muscle compression (generally >4-6 hours). While trapped, ischemic muscle cells accumulate toxic metabolites (potassium, myoglobin, phosphate, uric acid, lactic acid). Upon extrication and reperfusion, these substances flood the circulation. Hyperkalemia can cause fatal cardiac dysrhythmias within minutes of release. Myoglobin precipitates in renal tubules, causing acute kidney injury. Metabolic acidosis and hypovolemia (as fluid shifts into damaged muscle) compound the shock. Pre-hospital management includes aggressive IV fluid resuscitation (ideally 1-1.5 L/hour of normal saline starting BEFORE extrication if possible), cardiac monitoring, calcium gluconate for cardiac protection, and sodium bicarbonate to alkalinize urine and prevent myoglobin precipitation. Field amputation may be considered if extrication would be otherwise impossible.
Question 5: The concept of 'reverse triage' in disaster management refers to:
- Treating the least injured patients first
- Discharging current inpatients to create capacity for incoming casualties (Correct answer)
- Triaging patients in reverse alphabetical order
- Reassigning triage tags from Red to Black
Correct answer: Discharging current inpatients to create capacity for incoming casualties
Reverse triage involves evaluating current hospital inpatients and rapidly discharging those who can safely leave to free beds, staff, and resources for incoming disaster casualties.
Reverse triage is a surge capacity strategy where existing hospital inpatients are systematically evaluated for early discharge, transfer to lower-acuity facilities, or conversion to outpatient management. During an MCI, the limiting factor is often bed availability and staff-to-patient ratios. By rapidly identifying and discharging stable inpatients — surgical patients who are post-operative day 2+, medical patients nearing discharge, observation patients — the hospital can dramatically increase its capacity to receive disaster casualties. This requires pre-planned criteria, physician authorization protocols, and coordination with pharmacy (discharge medications), case management (home health setup), and transportation. Some hospitals maintain pre-calculated reverse triage lists that can be activated immediately, identifying which patients could be safely discharged within hours under crisis conditions.
Question 6: Which communication system is recommended for inter-facility coordination during a multi-hospital disaster response?
- Standard hospital telephone system only
- Regional Healthcare Coalition radio network and unified communication platform (Correct answer)
- Social media messaging between hospitals
- Individual cell phone calls between administrators
Correct answer: Regional Healthcare Coalition radio network and unified communication platform
Regional Healthcare Coalition (HCC) radio networks and unified communication platforms provide redundant, standardized communication across multiple hospitals during disasters when normal infrastructure may fail.
Effective multi-hospital disaster communication requires redundant, pre-established systems that function when normal infrastructure fails. Regional Healthcare Coalitions (HCCs) maintain dedicated radio networks (often UHF/VHF or 800 MHz) that connect hospitals, EMS, public health, and emergency management agencies. Many regions also use platforms like EMSystem/JUVARE, WebEOC, or state-specific health alert networks for bed tracking, resource requests, and situational awareness. Standard phones and cell towers frequently become overloaded or damaged during large-scale events. While social media can supplement communication, it lacks security, reliability, and standardized formatting. The key principle is pre-established, tested, interoperable communication systems with backup redundancy. Regular multi-hospital exercises (tabletop and full-scale) test these systems before they are needed in an actual event.
TNCC Disaster Management 3
In the JumpSTART pediatric triage system, what additional step is performed for a non-breathing child that differs from adult START triage?