Triage

• “To Sort”• Look at medical needs and

urgency of each individual patient• Triage in Daily Emergencies

– Do the best for each individual

• Disaster Triage– Do the greatest good for the greatest

number– Make an impossible task manageable

• Following a large disaster, 80% of people involved will transport themselves to the closest ER.

• These people are ambulatory, most have minor injuries, and the sheer number will overwhelm most ER’s.

• Then, the critically ill patients start arriving by ambulance….

Triage Categories

• RED- immediate/emergency

• YELLOW- Urgent

• GREEN- nonurgent/walking wounded

• BLACK- dead/ little to no hope of survival

SMART Tag System

• System of triage adopted by Illinois

• Triage tags have standard barcodes for tracking patients and reuniting families

• Triage tags have a unique folded design that allows patients to be re-triaged to another color classification without having to replace the tag

START Triage

• Simple Triage And Rapid Transport

• Gold standard for field adult MCI triage in US and numerous other countries

• Utilizes the four standard color triage categories

• Used for primary triage

JumpSTART Triage• Tool for pediatric mass casualty field triage• Provides objective framework• Based primarily on physiologic differences

between children and adults• Useful for kids of all ages• Designed for use in Disaster/MCI events

– If positioning airway does not restart breathing, a ventilatory trial is administered in JumpSTART

– Peripheral pulse is used to assess perfusion in JumpSTART

– The AVPU scale is used in JumpSTART

Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com

JumpStart• In children,

circulatory failure usually follows respiratory failure.

• Apnea may occur relatively rapidly, rather than after a prolonged period of hypoxia.

• There may be a brief period when the child is apneic but not yet pulseless since the heart has not yet experienced prolonged hypoxia. It is felt that providing a brief trial of ventilations may help “jumpstart” their respirations.

Adult or Child??

• It can be difficult to discern the age of a child especially pre-teen and early teen years, and which triage tool to use

• If a victim appears to be a child

use JumpSTART

• If a victim appears to be a young adult

use START

Differences Between START and JumpSTART©

START JumpSTART

Airway If positioning the airway does not restart breathing, pt tagged as black/deceased

If positioning the airway does not restart breathing, 5 rescue breaths ( the jumpstart) is given

Perfusion/Circulation Capillary refill is used to assess perfusion

Peripheral pulses are used to assess perfusion

Mental Status Ability to follow commands is used to assess mental status

AVPU is used to assess mental status

RED - Immediate

• Severely injured but able to be saved with relatively quick treatment and transport

• Examples– Severe bleeding– Shock– Open chest or Abdominal wounds– Emotionally out of control

Yellow - Delayed

Injured but unable to

walk on their own• Examples

– Burns with no respiratory distress

– Spinal injuries– Moderate blood loss– Conscious with head

injuries

Green – Non-Urgent

• Minor injuries that need to be assessed or treated but not right away

• Examples– Minor fractures– Minor bleeding

Black - Deceased

• Dead or obviously dying

• Depends on local protocols

• Examples– Cardiac arrest– Resp arrest with a Pulse

• Can be psychologically difficult to tag a child as black

START: Step 1

Patients who are able to walk areassumed to have stable, wellcompensated physiology, regardless ofthe nature of their injuries or illness.

“If you can hear me, go stand near the big tree.”

START: Step 2

• Next begin triaging the remaining victims– Open the airway of the apneic adult– If they start to breathe, triage them a red

START: Step 3

• If after opening the airway, the adult patient does not breathe, tag them a black

START: Step 4

• Assess the respiratory rate of the breathing adult

• Move on to the next assessment if respiratory rate is under 30/min

• If respiratory rate is over 30/min, tag the patient red

START: Step 5

• If the radial pulse is absent

OR

• If the capillary refill is over 2 seconds, control bleeding and tag the patient red

START: Step 6

• If the radial pulse is present, Assess the mental status

• If the patient can follow simple commands, tag them yellow

• If the patient cannot follow simple commands, tag them red

JumpSTART: Step 1

Patients who are able to walk areassumed to have stable, wellcompensated physiology, regardless ofthe nature of their injuries or illness.

“If you can hear me, go stand near the big tree.”

JumpSTART: Step 2

Next begin triaging the remaining victims• Open the upper airway of the apneic

child.

• If they start to breathe, tag them as red

JumpSTART: Step 3

If the patient has a palpable pulse but is not breathing, give 5 breaths to open the lower airways. Tag as below, depending on response to ventilations.

DO NOT CONTINUE TO

VENTILATE THE PATIENT.

RESUME TRIAGE DUTIES.

JumpSTART: Step 4

• Assess the resp rate of the breathing child• Move on to next assessment if respiratory rate is 15-

45 breaths/minute.• If respiratory rate is <15 or >45, tag the patient as

• If the child’s pulse is palpable, move on to the next assessment.

• If no palpable pulse but child is breathing, tag the patient as

JumpSTART: Step 5

• 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

JumpSTART: Step 6

Exercise

Scenario # 1

• VICTIM: 39 y.o. male• RESPIRATORY RATE: 28/min• PERFUSION: cap refill 4 seconds• MENTAL STATUS: moaning• OTHER: Bus driver trapped under collapsed dash in front

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 2

• VICTIM: 7 y.o. male• RESPIRATORY RATE: 22/min• PERFUSION: distal pulse present• MENTAL STATUS: obeys commands• OTHER: complains cannot move or feel legs

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 3

• VICTIM: 8 y.o. male

• RESPIRATORY RATE: 18, talking

• PERFUSION: distal pulse present

• MENTAL STATUS: asking for help

• OTHER: Walks toward you, clothing is torn, no bleeding evident

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 4

• VICTIM: 8 y.o. female• RESPIRATORY RATE: 24/min• PERFUSION: distal pulse present• MENTAL STATUS: asking for her wheelchair• OTHER: found wedged under bus seat

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 5

• VICTIM: 6 y.o. female• RESPIRATORY RATE: 0/min• PERFUSION: pulseless• MENTAL STATUS: unresponsive• OTHER: legs trapped under seat from bus

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 6

• VICTIM: 25 y.o. female• RESPIRATORY RATE: 12/min• PERFUSION: capillary refill >4 seconds• MENTAL STATUS: eye movement in response to stimuli• OTHER: appears six months pregnant

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 7

• VICTIM: 8 y.o. male

• RESPIRATORY RATE: 36/min

• PERFUSION: distal pulse present

• MENTAL STATUS: screaming

• OTHER: partial amputation of foot with minimal bleeding, found in ditch

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 8

• VICTIM: 7 y.o. male• RESPIRATORY RATE: 38/min• PERFUSION: distal pulse absent• MENTAL STATUS: groans, stops when spoken to • OTHER: lying near bus

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 9

• VICTIM: 6 y.o. male• RESPIRATORY RATE: 40/min• PERFUSION: pulseless• MENTAL STATUS: withdraws from painful stimuli• OTHER: arm deformity, sucking chest wound

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 10

• VICTIM: 6 y.o. male• RESPIRATORY RATE: 28/min• PERFUSION: distal pulse present• MENTAL STATUS: not following commands• OTHER: sitting on side of road, blood in ears

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 11

• VICTIM: 50 y.o. female• RESPIRATORY RATE: 20/min• PERFUSION: cap refill 2 seconds• MENTAL STATUS: obeys commands• OTHER: sitting on side of road complaining of dizziness

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 12

• VICTIM: 7 y.o. female• RESPIRATORY RATE: 24/min• PERFUSION: distal pulse present• MENTAL STATUS: crying• OTHER: limping near buses

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 13

• VICTIM: 7 y.o. male

• RESPIRATORY RATE: 48/min

• PERFUSION: distal pulse present

• MENTAL STATUS: blank stare

• OTHER: lying in wreckage, bilateral lower extremity deformity

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 14

• VICTIM: 6 y.o. female

• RESPIRATORY RATE: 0/min

• PERFUSION: faint distal pulse

• MENTAL STATUS: unresponsive

• OTHER: found in rubble outside rear bus, apneic after 5 rescue breaths

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 15

• VICTIM: 8 y.o.• RESPIRATORY RATE: 28/min• PERFUSION: distal pulse present• MENTAL STATUS: follows commands• OTHER: facial and scalp lacerations, moderate bleeding

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 16

• VICTIM: 45 y.o. female• RESPIRATORY RATE: 0/min• PERFUSION: pulseless• MENTAL STATUS: unresponsive• OTHER: driver of rear bus, found under front of bus

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 17

• VICTIM: 30 y.o. male• RESPIRATORY RATE: 20/min• PERFUSION: capillary refill < 2 seconds• MENTAL STATUS: obeys commands• OTHER: walking at the scene

1. RED

2. YELLOW

3. GREEN

4. BLACK

Scenario # 18

• VICTIM: 7 y.o.female• RESPIRATORY RATE: 10/min• PERFUSION: distal pulse present• MENTAL STATUS: groans in response to painful stimuli• OTHER: lying in ditch 15 feet from accident

1. RED

2. YELLOW

3. GREEN

4. BLACK