Pediatric Multicasualty Incident Triage

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Pediatric Multicasualty Incident Triage

• Lou E. Romig MD, FAAP, FACEP
• Miami Childrens Hospital
• Miami-Dade Fire Rescue
• FL-5 DMAT

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Topics
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What is Triage?

• Triage means to sort
• Looks at medical needs and urgency of each
  individual patient
• Sorting based on limited data acquisition
• Also must consider resource availability

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Military vs. Civilian Triage
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Military vs. Civilian Triage

• Military model
• Those with the least serious wounds may be the
  first treatment priority
• Civilian model
• Those with the most serious but realistically
  salvageable injuries are treated first

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Military vs. Civilian Triage

• In both models, victims with clearly lethal
  injuries or those who are unlikely to survive
  even with extensive resource application are
  treated as the lowest priority.

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Ethical Justification

• This is one of the few places where a
  "utilitarian rule" governs medicine the greater
  good of the greater number rather than the
  particular good of the patient at hand. This rule
  is justified only because of the clear necessity
  of general public welfare in a crisis.

A. Jonsen and K. Edwards, Resource Allocation
in Ethics in Medicine, Univ. of Washington School
of Medicine, http//eduserv.hscer.washington.edu/b
ioethics/topics/resall.html
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The needs of the many outweigh the needs of the
few or the one."
Star Trek
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Why are Resources Important in Triage?

• Disaster is commonly defined as an incident in
  which patient care needs overwhelm local response
  resources.
• Daily emergency care is not usually constrained
  by resource availability.

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Triage is a dynamic process and is usually done
more than once.
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Primary Disaster Triage

• Goal to sort patients based on probable needs
  for immediate care. Also to recognize futility.
• Assumptions
• Medical needs outstrip immediately available
  resources
• Additional resources will become available with
  time

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Primary Disaster Triage

• Triage based on physiology
• How well the patient is able to utilize their own
  resources to deal with their injuries
• Which conditions will benefit the most from the
  expenditure of limited resources

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Secondary Disaster Triage

• Goal to best match patients current and
  anticipated needs with available resources.
• Incorporates
• A reassessment of physiology
• An assessment of physical injuries
• Initial treatment and assessment of patient
  response
• Further knowledge of resource availability

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Secondary Triage Tools

• Goal is to distinguish between
• Victims needing life-saving treatment that can
  only be provided in a hospital setting.
• Victims needing life-saving treatment initially
  available on scene.
• Victims with moderate non-life-threatening
  injuries, at risk for delayed complications.
• Victims with minor injuries.

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Secondary Triage Tools

• There is no widely recognized tool in the US that
  addresses secondary MCI triage and also transport
  strategies.
• California Medical Disaster Response courses
  SAVE tool (Secondary Assessment of Victim
  Endpoint)
• Many EMS systems use local trauma triage criteria.

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Tertiary Disaster Triage

• Goal to optimize individual outcome
• Incorporates
• Sophisticated assessment and treatment
• Further assessment of available medical resources
• Determination of best venue for definitive care

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Continuous Integrated Triage
Primary Triage
Secondary Triage
Tertiary Triage
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MCI Triage Key Points

• Resources and patient numbers and acuity are
  limiting factors.
• Must be dynamic, responsive to changes in both
  resources and patient needs.
• There are no validated tools available at this
  time.
• Many questions, few answers.

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Triage Categories
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Triage Categories

• Red
• Life-threatening but treatable injuries requiring
  rapid medical attention
• Yellow
• Potentially serious injuries, but are stable
  enough to wait a short while for medical treatment

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Triage Categories

• Green
• Minor injuries that can wait for longer periods
  of time for treatment
• Black
• Dead or still with life signs but injuries are
  incompatible with survival in austere conditions

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Triage Tools
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Simple Triage and Rapid Treatment (START)
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JumpSTART Pediatric MCI Triage Tool
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The Smart Triage Tape

• Developed in Great Britain
• Proprietary, TSG Associates
• Length-based pediatric MCI triage tape
• Age-adjusted physiologic parameters
• In use in Europe, Africa and some states in the US

www.tsgassociates.co.uk/English/Civilian/products/
smart_tape.htm
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Triage Sieve
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Care Flight Triage
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Basic Disaster Life Support

• National Disaster Life Support Education
  Consortium, via Medical College of Georgias
  Center of Operational Medicine
• Endorsed by the American Medical Association
• www.ndlsf.org

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Basic Disaster Life Support

• MASS Triage
• Move
• Assess
• Sort
• Send
• ? Assessment guidelines
• ? Pediatric considerations

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SALT Triage

• Sort, Assess, Life-saving Interventions,
  Treatment/Transport
• CDC grant project to standardize MCI triage in
  the US
• Early in development
• Derived from existing tools
• Includes pediatric considerations

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SALT Triage
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SALT Triage

• Mass Casualty Triage An Evaluation of the Data
  and Development of a Proposed National Guideline
• E. Brooke Lerner, PhD, Richard B. Schwartz, MD,
  Phillip L. Coule, MD, et al
• DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS
  - 2(Supplement_1) 25-34 2008
• http//www.dmphp.org/cgi/content/full/2/Supplement
  _1/S25R15-7

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Sacco Triage Method

• Proprietary tool, ThinkSharp Inc.
• Only tool based on outcome data
• 12 triage categories
• Available software package for transport planning
  based on patient and resource info
• Includes pediatric data and age adjustments

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Sacco Triage Method
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Sacco Triage Method
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STM Sample Patient Prioritization

• Scene Characterization Triage Priority Order
• Multiple casualty resource levels stressed 4 5
  6 3 2 7 1 8 2
• Estimate about an hour or less to clear the
  scene.
• Large multiple casualty or small mass casualty 5
  6 7 8 4 9 3 2 1 9
• requiring staged resources Estimate 1½ to 2½
• hours to clear the scene
• Mass casualty resources overwhelmed Estimate 3
  or more hours to clear the scene 6 7 8 5 9 10 4
  3 2 1 11

www.sharpthinkers.com/STM_Site/stm_home.htm
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Israeli Triage Practice

• Little to no triage done on-scene
• Save and run philosophy
• Very hazardous scenes
• Reds to closest hospital
• Nearest hospital becomes triage center?

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Israeli Triage Practice

• Uses physicians as triage officers
• Accuracy of physician triage called into question
• Metropolitan Israeli hospitals may be more
  uniformly capable of caring for trauma victims
  than in many areas of the US

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The Best Tool?

• No MCI primary triage tool has been validated by
  outcome data from MCIs.

Mass-casualty triage Time for an evidence-based
approach. Jenkins JL, McCarthy ML, Sauer LM,
Green GB, Stuart S, Thomas TL, Hsu EB
Prehospital Disast Med 200823(1)38.
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The Best Tool?

• Its likely that no existing MCI triage tool is
  suitable for use for all types of incidents.

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START/JumpSTART

• Neither clinically validated
• Evidence accumulating against validity and/or
  inter-rater reliability
• Comparison of paediatric major incident primary
  triage tools. L A Wallis1, S Carley2 Emergency
  Medicine Journal 200623475-478
• Smart Tape and Care Flight more sensitive than
  START and JS
• No tool had gt 48 sensitivity for critical
  patients

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START

• Simple Triage And Rapid Treatment
• Developed jointly by Newport Beach (CA) Fire and
  Marine Dept. and Hoag Hospital
• Gold standard for field adult multiple casualty
  (MCI) triage in the US and numerous countries
  around the world

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START

• Utilizes the usual four triage categories
• Used for Primary Triage
• Used on-scene and at hospitals
• Recommended for patients gt 100 lbs
• www.start-triage.com

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START Triage
RESPIRATIONS
Under 30/min
YES
PERFUSION
NO
Over 30/min
Cap refill gt 2 sec
Cap refill lt 2 sec.
Position Airway
Immediate
Control Bleeding
NO
YES
MENTAL STATUS
Immediate
Dead or Expectant
Immediate
Failure to follow simple commands
Can follow simple commands
Immediate
Delayed
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START Step 1

• Triage officer announces that all patients that
  can walk should get up and walk to a designated
  area for eventual secondary triage.
• All ambulatory patients are initially tagged as
  Green.

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START Step 2

• Triage officer assesses patients in the order in
  which they are encountered
• Assess for presence or absence of spontaneous
  respirations
• If breathing, move to Step 3
• If apneic, open airway
• If patient remains apneic, tag as Black
• If patient starts breathing, tag as Red

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START Step 3

• Assess respiratory rate
• If 30, proceed to Step 4
• If ? 30, tag patient as Red

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START Step 4

• Assess capillary refill
• If 2 seconds, move to Step 5
• If ? 2 seconds, tag as Red

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START Step 5

• Assess mental status
• If able to obey commands, tag as Yellow
• If unable to obey commands, tag as Red

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Mnemonic

• R
• P
• M

• 30
• 2
• Can do

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JumpSTART Pediatric MCI Triage

• Developed by Lou
  Romig MD, FAAP, FACEP
• Now in widespread use throughout the US and
  Canada
• Being taught in Japan, Germany, Switzerland, the
  Dominican Republic, Africa, Polynesia

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National Committee on Management of Pediatric
MCIs, 2006

• JumpSTART recommended for prehospital use
  throughout Israel
• Prehospital Response and Field Triage in
  Pediatric Mass Casualty Incidents The Israeli
  Experience
• Yehezkel Waisman, MD, Lisa Amir, MD, MPH, Meirav
  Mor, MD, et al Clin Ped Emerg Med 752-58, 2006

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JumpSTART Pediatric MCI Triage

• The physiologic parameters used in START are not
  suitable for all ages of children
• Walking
• Respiratory death vs cardiac death
• Respiratory rates
• Mental status assessment

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What age?
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JumpSTART Age

• The ages of tweens and teens can be hard to
  determine so the current recommendation is
• If a victim appears to be a child, use JumpSTART.
• If a victim appears to be a young adult, use
  START.

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Patients who are able to walk are assumed to have
stable, well-compensated physiology, regardless
of the nature of their injuries or illness.
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Secondary Triage

• All green patients must be individually assessed
  in secondary triage.
• Assess physiology
• Assess injuries
• Assess probability of deterioration
• Assess needs vs. resource availability

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Secondary Triage

• Some children may be carried to the green area by
  others. They have not proven their physiologic
  stability by performing the complex act of
  walking.
• These children should be assessed first among all
  those in the green area.

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• Position the upper airway of the apneic child.
• If they start to breathe, tag them as

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• If the child doesnt start breathing with upper
  airway opening, feel for a pulse.
• If no pulse is palpable, tag the patient as

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• If the patient has a palpable pulse, give 5
  mouth-to-barrier breaths to open the lower
  airways. Tag as below, depending on response to
  ventilations.

DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME
TRIAGE DUTIES.
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• Assess the respiratory rate of the spontaneously
  breathing child.

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• Move on to next assessment if respiratory rate is
  15-45 breaths/minute.
• If respiratory rate is lt15 or gt45, tag the
  patient as

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• If the childs pulse is palpable, move on to the
  next assessment.
• If no palpable pulse, tag the patient as

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• If patient is inappropriately responsive to pain,
  posturing, or unresponsive, tag as
• If patient is alert, responds to voice or
  appropriately responds to pain, tag as

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Modification for Nonambulatory Children

• Children developmentally unable to walk due to
  young age or developmental delay
• Children with chronic disabilities that prevent
  them from walking

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Modification for Nonambulatory Children

• For nonambulatory children, assess using the
  JumpSTART algorithm.
• If pt meets any red criteria tag as

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Modification for Nonambulatory Children

• If patient meets yellow criteria and has
  significant external signs of injury, tag as
• If patient meets yellow criteria and has no
  significant external signs of injury, tag as

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Certainties about MCI Triage

• Organization is a good thing in a disaster
• Triage tools must help match limited resources to
  an abundance of needs
• Physiologic tools should suit physiologic
  differences
• Triage tools should be kept as simple as possible
  and practiced often

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• Disaster research agendas should include efforts
  to validate existing and future triage tools.

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Triage should be done with the head, not the
heart.
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www.jumpstarttriage.com
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Thank You!

• LouRomig_at_bellsouth.net
• LouRomig_at_jumpstarttriage.com

MDFR
FL-5 DMAT
MCH