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Preparing Our Communities

• Welcome!

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Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Chapter 1bSALT Triage(Sort, Assess,
Life-Saving, Treatment/Transport Triage)
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Objectives

• Describe the S.A.L.T. Triage method
• Describe the steps to perform S.A.L.T Triage
• Describe the Life Saving Interventions that are
  performed in in S.A.L.T. Triage
• List the Triage Categories as defined in S.A.L.T.
  Triage.
• Describe injuries that would place a patient in
  each triage category

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What is Triage?

• French verb trier to sort
• Assign priorities when resources limited
• Do the greatest good for the greatest number

Source DoD Photo Library, Public Domain
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Whats Unique About Disaster Triage?

• Number of patients
• Infrastructure limitations
• Limited providers
• Limited equipment
• Limited transport capabilities
• Hospital resources overwhelmed
• Scene hazards
• Threats to providers
• Decontamination issues
• Multiple agencies responding

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SALT Triage

• Simple
• Easy to remember
• Groups large numbers of patients together quickly
• Applies rapid life-saving interventions early

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STEP 1 Global Sorting

• Priority 1 Still/Obvious life threat
• Priority 2 Wave/Purposeful movement
• Priority 3 Walk

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Global Sorting Action 1

• Action
• Everyone who can hear me and needs help, move to
  designated area
• Use loud speaker if available
• Goal
• Group ambulatory patients using voice commands
• Result
• Those who follow this command - last priority for
  individual assessment

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Global Sorting Action 2

• Action
• If you need help, wave your arm or move your leg
  and we will be there to help you in a few
  minutes
• Goal
• Identify non-ambulatory patients who can follow
  commands or make purposeful movements
• Result
• Those who follow this command - second priority
  for individual assessment

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Global Sorting Result

• Casualties are now prioritized for individual
  assessment
• Priority 1 Still, and those with obvious
  hemorrhage
• Priority 2 Waving
• Priority 3 Walking

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Step 2 Individual Assessment

• Provide Life Saving Interventions
• Controlling major hemorrhage
• Opening airway if not breathing
• If child, consider giving 2 rescue breaths
• Chest needle decompression
• Auto injector antidotes

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S.A.L.T. Triage Categories

• Immediate
• Delayed
• Minimal
• Expectant
• Dead

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Immediate

• Serious injuries
• Immediately life threatening problems
• High potential for survival.
• Examples
• Tension pneumothorax
• Nerve agent exposed patient
• severe shortness of breath or seizures

Photo Source www.swsahs.nsw.gov.au Public Domain
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Delayed

• Examples
• Long bone fractures
• neuro-vascular intact
• 40 BSA exposure to Mustard

• Serious injuries
• require care but management can be delayed
  without increasing morbidity or mortality.

Photo Source Phillip L. Coule, MD
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Minimal

• Injuries- require minor care or no care without
  adverse affect.
• Examples
• Abrasions
• Minor lacerations
• Nerve agent exposure with mild rhinorrhea

Photo source Phillip L. Coule, MD
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Expectant

• Important for preservation of resources
• DOES NOT MEAN DEAD!
• Should receive comfort care or resuscitation when
  resources are available
• Serious injuries
• very poor survivability even with maximal care in
  the hospital or pre-hospital setting.
• Examples
• 90 BSA burn
• Multiple trauma with exposed brain matter
• Severe traumatic brain injury with herniation

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Dead Patients

• Tag dead patients to prevent re-triage
• Do not move
• Except to obtain access to live patients
• Avoid destruction of evidence

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After Patients are Categorized

• Prioritization process is dynamic
• Changing patient conditions
• Changing resources
• Scene safety.
• After immediate patients have been cared for
• Expectant, delayed, or minimal patients should be
  re-assessed
• Some patients will have improved and others will
  have decompensated

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Treatment/Transport Priority

• Treatment and/or transport should be provided for
  immediate patients first
• Then delayed
• Then minimal
• Expectant patients should be provided with
  treatment and/or transport when resources permit
• Efficient use of transport assets may include
  mixing categories of patients and using alternate
  forms of transport

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Patient 1

• 63 y/o male, prone, unresponsive
• Burns on extremities
• Did not move at walk/wave phase

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Patient 2

• 42 y/o female
• Walks to safety when instructed
• No bleeding, normal pulses, normal breathing

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Patient 3

• 17 y/o male, lying supine, waving for help
• Breathing well, follows commands
• Normal vital signs
• Cant get up due to back pain and leg weakness

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Patient 4

• 26 y/o male, unresponsive
• Contusions on head
• Good pulses, HR 104, RR 12

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Patient 5

• 52 y/o female, unresponsive
• Breathes when airway opened needs to have
  airway maintained manually
• Bleeding heavily from abdominal injury
• RR 8, HR 124

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Questions?