TRIAGE

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TRIAGE

• START and JumpStart
• Triage
• The Basics

Edited and Compiled by LeMay Hupp, MPH, RN
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Triage

• Objectives
• The student will be able to
• Discuss the concept of triage
• Utilize the S.T.A.R.T. and JumpStart methods to
  triage victims
• Explain the international triage color code
  system and how it is utilized

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TRIAGE

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

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TRIAGE
GOLDEN HOUR

• Trauma patient has the best chance for recovery
  if ACLS within one hour from the time of the
  injury
• With multiple victims, the Golden Hour can slip
  away due to limited rescuers and / or resources

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TRIAGE
KEY PRINCIPLE

• Doing
• the
• Greatest
• Good,
• For the Greatest Number

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Goal of Multicasualty Triage
TRIAGE

• To do the best for the most
• using the least.

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Basic Disaster Life Support
Triage

• MASS Triage
• M ove
• A ssess
• S ort
• S end

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TRIAGE
Disaster Acronyms

• M.P.I. -- Multi-patient Incident
• M.C.I. -- Mass Casualty Incident
• M.O.I. -- Mechanism of Injury
• M.V.C. -- Motor Vehicle Collision
• M.V.A. Motor Vehicle Accident

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TRIAGE

Triage is an effective strategy in situations where There are many more victims than rescuers There are limited resources Time is critical
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TRIAGE
During triage Victims are evaluated Sorted by the urgency of the treatment needed Placed into immediate and delayed treatment areas
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Triage

• SCENE SAFETY Size Up
• Size up the scene, Make sure the scene is safe
  for you to enter
• CREATE ORDER
• Next, ask those who are not injured or who have
  minor injuries to identify themselves

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Walking wounded
Triage

• When entering room or area, shout out,
• if you can hear me, come to the sound
• of my voice.
• Self rescue is best rescue
• Tag GREEN for minor, Send to a safe area
• Ask about other victims in area

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Triage Categories
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International Triage Color Codes
Triage
Red immediate
Yellow delayed

• Green minor  

Black deceased
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TRIAGE
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TRIAGE
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S.T.A.R.T.

• Simple Triage and Rapid Treatment
• developed by
• Newport Beach Fire Department
• and
• Hoag Memorial Hospital
• Newport Beach, California

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S.T.A.R.T.

• When performing the triage
• function, regardless of
• incident size
• DONT GET DISTRACTED!
• Move quickly
• Focus your attention on IMMEDIATE patients
• The goal is to stay focused on RED

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S.T.A.R.T.
Triage Priorities

• Your initial goal is to find IMMEDIATE
• patients.
• You want to find the red and get it out
• (kind of like Visine!)
• Your efforts should focus on locating all
  IMMEDIATE patients, getting them treated and
  transporting them as soon as possible
• Once IMMEDIATE patients have been
• treated and transported
• Reassess all DELAYED patients and upgrade any to
  IMMEDIATE depending on their injury, age,
  medical history, etc.

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S.T.A.R.T.

• Victims who have self-extricated
• themselves prior to arrival can
• be labeled MINOR
• All other patients should be tagged
• IMMEDIATE, DELAYED
• or DEAD/DYING
• depending on your assessment

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S.T.A.R.T.

• With START one patient is assessed
• every 30 seconds
• First responder quickly assesses to
• categorize a patients condition
• Airway and respiration
• Pulse and / or capillary refill
• Level of consciousness

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S.T.A.R.T.

• The only treatment rendered by the triage
• team is to
• Open a patients airway by head tilt / neck lift
• Apply direct pressure to stop an obvious bleed
• Elevating the extremities

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S.T.A.R.T.

• Only three items are checked when using
• START
• Respiration
• Pulse
• Mental Status
• Just remember RPM

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TEST
Triage

• Put the triage evaluation steps in
• the correct order.
• Check mental status
• Check airway/breathing
• Check bleeding/circulation

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Triage

• ANSWER

Check mental status 3 Check
airway/breathing 1 Check bleeding/circulation 2

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Step 1
S.T.A.R.T.

• 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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Step 2
S.T.A.R.T.

• Assess respiratory rate
• If 30, assess Perfusion
• If ? 30, tag patient as Red

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Step 3
S.T.A.R.T.

• Assess capillary refill
• If 2 seconds, assess Mental Status
• If ? 2 seconds, tag as Red

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Step 4
S.T.A.R.T.

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

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S.T.A.R.T.
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Mnemonic
S.T.A.R.T.

• R 30
• P 2
• M Can Do

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S.T.A.R.T.
SELF TEST

• Patient I is 21 year old male complaining of
• pain to his upper right leg. You see an
• obvious open right femur fracture.
• What is your START assessment?

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S.T.A.R.T.
SELF TEST

• Patient I is 21 year old male complaining of pain
• To his upper right leg. You see an obvious open
• Right femur fracture.
• The patient is awake, his airway is open, hes
• talking) and his respirations are over
  30/minute.
• Using RPM, the patient is categorized as
  IMMEDIATE.
• Because his respirations are over 30 per minute.
• What is your treatment? None during triage.

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S.T.A.R.T.
SELF TEST

• Patient 2 is a 15-year-old female,
• complaining of numbness to her legs, is
• unable to move them. You see a 2
• laceration on left skull, moderate bleeding.
• What is your START assessment?

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S.T.A.R.T.
SELF TEST

• Patient 2 is a 15-year-old female, complaining of
• numbness to her legs, is unable to move them.
• You see a 2" laceration on left skull, moderate
• bleeding.
• She is awake, her airway is open, her
  respirations are under 30 a minute and she has a
  radial pulse.
• Her RPM assessment indicated she is DELAYED.
• Why? Her respirations were under 30, she has a
  radial pulse and she is alert and oriented.

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S.T.A.R.T.
SELF TEST

• Patient 3 is a 40-year-old male who looks
• Really bad. Hes unconscious, pale and
• limp.
• What is your START assessment?

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S.T.A.R.T.
SELF TEST

• Patient 3 is a 40-year-old male who looks really
• bad. Hes unconscious, pale and limp.
• When you open the patients airway, there is no
  breathing.
• What is your treatment? Should you work him?
• Maybe. Maybe not.

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S.T.A.R.T.

• To review, there are three medical
• treatments performed when utilizing
• START triage
• Open an airway
• Stop any visible bleeding
• Elevate the extremities for shock

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S.T.A.R.T.

• The DEAD / DYING are those who cannot
• breathe after the airway is opened and
• are mortally wounded
• The patient will probably die despite the best
  resuscitation efforts
• It is often a difficult decision to leave a dying
  patient, especially if it is a child
• Remember resources are often wasted on
  unsalvageable victims

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Triage is a dynamic process and is usually done
more than once.
Triage
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Triage
Primary Triage
Secondary Triage
Tertiary Triage
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Triage
CERT Manual Medical Operations
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Triage
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Triage Pitfalls
S.T.A.R.T.

• Time will be critical! Very little time with any
  single victim
• Take advantage of local exercises as a means of
  maintaining your triage skills and to avoid
  triage pitfalls
• Triage pitfalls include No team plan,
  organization, or goal
• Indecisive leadership - too much focus on one
  injury
• Treatment (rather than triage) performed

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Triage
Conducting a Triage Evaluation

• How would you tag each of the victims described
• below?
• G Green, Minor Y Yellow, Delay
• R Red, Immediate B Black, Dead
• No bleeding. Dazed and confused. Doesn't
  squeeze hand when asked.
• Ambulatory. Responds to voice triage. Minor
  bleeding. Normal blanch.
• Very bloody thigh. Unconscious. After two
  attempts to open airway, still not breathing.
• No signs of bleeding. Unconscious. Capillary
  refill takes 5 seconds.
• Minor bleeding. Conscious but disoriented.
  Breathing rate is 40 per minute.

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• JumpSTART
• Pediatric Triage

by Dr. Lou Romig
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Pediatric MCI Triage
JumpSTART

• Developed by Lou Romig MD, FAAP, FACEP
• Widespread use throughout US and Canada
• Being taught in Worldwide
• Recognized by the US National Disaster Medical
  System
• Published in Bradys Prehospital Emergency Care,
  7th ed.
• www.jumpstarttriage.com

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JumpSTART
We must assume each MCI will include children.
We must be able to assess and treat victims of
all ages with equal confidence and competence.
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JumpSTART

• The physiology of adults and children are not the
  same.

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Age
JumpSTART

• Initially ages 1-8 years chosen
• Less than one year of age is less likely to be
  ambulatory.
• The pertinent pediatric physiology (specifically,
  the airway) approaches that of adults by
  approximately eight years of age.

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Age
JumpSTART

• Current recommendation
• 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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Age

• Current recommendation
• 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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Potential Problems with Children

• An apneic child is more likely to have a primary
  respiratory problem than an adult. Perfusion may
  be maintained for a short time and the child may
  be salvageable.
• RR /- 30 may either over-triage or under-triage
  a child, depending on age .

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Potential Problems with Children

• Capillary refill may not adequately reflect
  peripheral hemodynamic status in a cool
  environment.
• Obeying commands may not be an appropriate gauge
  of mental status for younger children.

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Modification for nonambulatory children

• All children carried to the GREEN area by other
  ambulatory victims must be the first assessed by
  medical personnel in that area.

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Breathing?

• If breathing spontaneously, go on to the next
  step, assessing respiratory rate.
• If apneic or with very irregular breathing, open
  the airway using standard positioning techniques.
• If positioning results in resumption of
  spontaneous respirations, tag the patient
  immediate and move on.

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The Jumpstart Part

• If no breathing after airway opening, check for
  peripheral pulse. If no pulse, tag patient
  deceased/nonsalvageable and move on.
• If there is a peripheral pulse, give 5 mouth to
  barrier ventilations. If apnea persists, tag
  patient deceased/nonsalvageable and move on.
• If breathing resumes after the jumpstart, tag
  patient immediate and move on.

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JumpSTART Respiratory Rate

• If respiratory rate is 15-45/min, proceed to
  assess perfusion.
• If respiratory rate is lt15 or gt45/min or
  irregular, tag patient as immediate and move on.

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JumpSTARTPerfusion

• If peripheral pulse is palpable, proceed to
  assess mental status.
• If no peripheral pulse is present (in the least
  injured limb), tag patient immediate and move on.

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JumpSTART Mental Status

• Use AVPU scale to assess mental status.
• If Alert, responsive to Verbal, or appropriately
  responsive to Pain, tag as delayed and move on.
• If inappropriately responsive to Pain or
  Unresponsive, tag as immediate and move on.

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Modification for nonambulatory children

• Infants who normally cant walk yet
• Children with developmental delay
• Children with acute injuries preventing them from
  walking before the incident
• Children with chronic disabilities

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Modification for nonambulatory children

• Evaluate using the JS algorithm
• If any RED criteria, tag as RED.
• If pt satisfies YELLOW criteria
• YELLOW if significant external signs of injury
  are found (ie. deep penetrating wounds, severe
  bleeding, severe burns, amputations, distended
  tender abdomen)

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Modification for nonambulatory children

• GREEN if no significant external injury

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Individuals with special health care needs may
also be MCI victims!
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Note for Black Category Victims

• Unless clearly suffering from injuries
  incompatible with life, victims tagged in the
  BLACK category should be reassessed once critical
  interventions have been completed for RED and
  YELLOW patients.

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Whats your call?
JumpSTART

• A school aged girl crawls out of a house
• after an explosion. Shes able to stand
• and walk toward you crying.
• Jacket and shirt torn
• No obvious bleeding

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Whats your call?
JumpSTART

• A toddler lies with his lower body
• trapped under a seat inside the bus.
• Apneic
• Remains apneic with modified jaw thrust
• No pulse

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Whats your call?
JumpSTART

• A toddler lies in a seat after a
• motor vehicle wreckage.
• RR 50
• Palpable distal pulse
• Withdraws from painful stimulus

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Whats your call?
JumpSTART

• An infant is carried by the previous
• victim.
• Hes screaming but the woman quiets him to RR of
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• Good distal pulse
• Focuses on rescuer, reaches for mom.
• No obvious significant external injuries.

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Key Points about MCI Triage
Triage

• MCI triage will never be
• logistically, intellectually,
• or emotionally easy
• We must be prepared
• to do it using the best of
• our knowledge and
• abilities.

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For more information on JumpSTART
www.jumpstarttriage.com Lou Romig
MD LouRomig_at_bellsouth.net