LCEMS Triage Presentation
- 1. START and JumpSTART: Mass Casualty Incident Triage Tools © Lou Romig MD, 2006. Used with permission.
- 2. START:START: Multi Casualty Incident Triage for Adult Victims • Developed in 1983, jointly by Newport Beach California Fire and Marine Dept. and staff at Hoag Hospital • Initially designed for rescuers with basic first aid skills to use for primary triage during a Mass Casualty Incident • It is now the Gold standard for adult field MCI triage in the USA and numerous countries around the world • Defined as the method of triage designed to assess a large number of victims objectively, efficiently, and rapidly that can be used by personnel with limited medical training
- 3. JumpSTART: Multi Casualty Incident Triage for Pediatric Victims • Developed by Lou Romig MD, a pediatric emergency/EMS physician at Miami Children’s Hospital • JumpSTART was developed in 1995 to parallel the structure of the START system • The world's first objective tool developed specifically for the triage of pediatrics in the multi casualty/disaster setting • It is now utilized and taught in the USA, as well as other countries around the world • Incorporated into national-level courses and EMS/disaster textbooks
- 4. Materials and resources for START available for purchase at www.start-triage.com All materials for JumpStart available for download at no charge at www.jumpstarttriage.com
- 5. START:START: SSimpleimple TTriageriage AAndnd RRapidapid TTreatmentreatment • Components of Assessment • Ambulation • Respirations • Perfusion • Mental status • 5 step process that incorporates standard triage categories through an advanced color coding scheme. A tag or ribbon is to be applied to victims upper extremity in a visible location • Black-Black- Deceased (non- salvageable)Deceased (non- salvageable) • Red-Red- ImmediateImmediate • Yellow-Yellow- DelayedDelayed • Green-Green- AmbulatoryAmbulatory ((Minor)Minor)
- 6. START TriageSTART Triage RESPIRATIONSRESPIRATIONS NONO YESYES Dead or Expectant Immediate Position Airway NONO YESYES Over 30/min Immediate Under 30/min PERFUSIONPERFUSION Cap refill > 2 sec. Control Bleeding Immediate Cap refill < 2 sec. MENTALMENTAL STATUSSTATUS Failure to follow simple commands Can follow simple commands Immediate DelayedDelayed Used with permission, Newport Beach Fire and Marine Dept.
- 7. Step 1:Step 1: “Can you walk?”Can you walk?” • Locate and direct all of the walking wounded into one location, away from the incident, if possible • Assign someone to keep them together in this area • All ambulatory or minor patients are then tagged with GreenGreen tags • Medical professionals may begin secondary triage/treatment at this time, if the resources are available • Proceed to Step 2Step 2:: Breathing Assessment
- 8. Step 2:Step 2: “Are they“Are they breathingbreathing?”?” • Assess victims in order in which they are encountered • Assess all non-ambulatory victims where they lay • Look for presence or absence of spontaneous respirations • If apneic:apneic: • open airway • If patient remains apneicapneic, tag as Black tagBlack tag • If patient starts breathingbreathing, tag as Red tagRed tag • If breathing:breathing: • move to Step 3Step 3:: Respiratory Rate Assessment
- 9. Step 3:Step 3: “What is their respiratoryWhat is their respiratory raterate?”?” • Assess the victim’s respiratory rate • If victim is not breathingnot breathing • Open the airway and remove any obstructions if visible • Reassess rate and if still not breathingnot breathing • Tag victim as black tagblack tag • If rate is greater than 30/min • Tag victim as Red tagRed tag • If rate is less than or equal to 30/min • Proceed to Step 4Step 4: Pulse/Capillary Refill
- 10. Step 4:Step 4: “Do they have a radial pulse and/or how is their capillary refill time?” • Palpate for radial pulse and/or assess capillary refill (CR) time • If > 2 seconds and/or no radial pulse present • Tag victim as Red tagRed tag • If radial pulse present and/or capillary refill time is ≤ 2 seconds • Move to Step 5Step 5:: Mental Status Assessment
- 11. Step 5:Step 5: “Can they follow your commands?” • Assess mental status and ability to follow commands • Assess their orientation to person, place, and time (CAOx3) • Ask them to follow a simple command • If able to follow commands and CAOx3 • Green tagGreen tag • If unable to follow commands, unconscious, or is disoriented • Red tagRed tag NOTE:NOTE: Depending on injuries (ex: burns, fractures, bleeding, etc.) it may be necessary to prioritize Yellow tagYellow tag.
- 12. STARTSTART MnemonicMnemonic RR PP MM 3030 22 Can doCan do Respirations, Perfusion, and Mental Status
- 13. • Designed to assess a large number of victims objectivelyobjectively,, efficientlyefficiently, and rapidlyrapidly • The first assessment that produces a red tagred tag stops further assessment • Only corrections of life-threatening problemslife-threatening problems (such as airway obstruction or severe hemorrhage) should be managed during triage • Triage of each patient should take 30 seconds30 seconds or less.or less. Remember the mnemonic R.P.M.R.P.M. • Physiological differences in children may necessitate the need to adapt either STARTSTART or JumpSTARTJumpSTART Things to consider when using STARTSTART
- 14. Triage Tags • There are many variations to triage tags and ribbons. Be sure to know which ones your agency carries so you can be familiar with them prior to a MCI. • Disaster Management System Tag (DMS Tag) • METTAGs • All Risk • And many others • The person doing the INITIALINITIAL STARTSTART triage does not fill out the tag. • Only tear off the color-strip and attaches the tag to the patient • It is suggested to also write the time and responders initial on the tag • Completion of the tag happen in second triage or the treatment area, ambulance, and/or the 2nd stage personnel.
- 15. Pediatric and adult physiology is NOT the same! Primary mass casualty incident triage is based on physiology
- 16. START:START: Complications to consider with Pediatrics • Apneic Child • Most likely to have a primary respiratory problem as compared to an adult. • Children compensate better than adults. Perfusion may be maintained for a short time and the child may be salvageable. • Over or under triage • RR +/- 30 may either over-triage or under-triage a child, depending on age. Consider “normal” values for a pediatric. • Capillary refill • May not adequately reflect peripheral hemodynamic status in a cool/wet environment. • This may be pertinent with adults also, consider assessing for a pulse.
- 17. START:START: Complications to consider with Pediatrics • Inability to follow commands •Age and comprehension can largely affect a child's understanding and ability or inability to follow commands properly and because of this, obeying commands may not be an appropriate gauge of mental status for younger children. • Physiological differences •Children necessitate an adaption of the standard STARTSTART triage method to those >8 years of age and/or those victims with the anatomical or physiological features of a child in the age group. • The same parameters (R.P.M.) should still be utilized
- 18. Why do we need a pediatric tool for triage? • Optimize the primary triage of injured children in the MCI setting objectivelyobjectively,, efficientlyefficiently, and rapidlyrapidly. • Enhance the effectiveness of resource allocation for allall MCI victims • Reduce the emotional burden on responding personnel who may have to make rapid life-or- death decisions that may involve injured children in taxing circumstances • Children necessitate an adaption of the STARTSTART triage method due to anatomical and physiological features that do not adequately suit them to be triaged as adults
- 19. JumpSTART:JumpSTART: What age group is it most appropriate to be used on? It was initially created in 1995 for the age group of 1-8 years old This was because the pertinent pediatric physiology (specifically the airway) approaches that of an adult by approximately eight years of age BUT…BUT…
- 20. We are 10! What now?What now?
- 21. JumpSTART: “How old are you?!” The current recommendation to use is: If a patient appears to be a childchild, use JumpSTARTJumpSTART If a patient appears to be a youngyoung adultadult, use STARTSTART The age of children and teenagers can be difficult to determine, use your best judgment.
- 22. Breathing? YES Minor Secondary Triage*Ambulatory? No Position Upper Airway No Breathing Immediate Palpable Pulse Apneic No Deceased 5 Rescue Breaths Apneic Deceased Immediate Breathing Yes Yes Respiratory Rate Palpable Pulse? AVPU 15-45 Yes Delayed Immediate Appropriate (“A”, “V”, or “P”) “P” (Inappropriate), Posturing, or “U” No Immediate <15 or >45 Immediate TheThe JumpSTARTJumpSTART TriageTriage AlgorithmAlgorithm *Evaluate infants first in secondary triage using the entire JS algorithm START HERESTART HERE
- 23. JumpSTART Step 1:“Can you walkwalk ?” Same as STARTSTART Step 1Step 1:: •Locate and direct all of the walking wounded into one location, away from the incident, if possible. •Assign someone to keep everyone together in this area • All ambulatory or minorambulatory or minor victims are to be tagged with GreenGreen tagstags •Continue to Step2Step2:: Breathing Assessment EXCEPTION:EXCEPTION: **All children carriedcarried to the greengreen area by other ambulatory victims must be the first ones assessedmust be the first ones assessed by medical personnel.** (Keep in mind that < 1 years old is less likely to be ambulatory)
- 24. JumpSTART Step 2: “Are they breathing?” • Assess patient breathing for presence or absence of spontaneous respirations • If breathing and spontaneous:breathing and spontaneous: • Move to Step 3Step 3:: Respiratory Rate Assessment • If apneicapneic or very irregular:very irregular: • Open airway by repositioning • If positioning results in resumption of spontaneous respirations • Red tagRed tag • If positioning does notnot result in resumption of spontaneous respirations • Move to “JumpSTART”“JumpSTART”
- 25. The “JumpSTART” Part • If no breathing after airway opening: • check for peripheral pulse • If nono pulse: black tagblack tag • If a peripheral pulse is palpableis palpable: • give patient 5 rescue breaths • If resumption of spontaneous respirations: red tagred tag • If apnea persists after rescue breaths: black tagblack tag • If breathing resumes afterafter the “JumpSTART”“JumpSTART”:: rred taged tag Move to Step 3Step 3:: Respiratory Rate Assessment
- 26. JumpSTART Step 3: “What is their respiratory rate?” • If respiratory rate is <15 or >45/min and/or irregular: • Red tagRed tag • If respiratory rate is 15-45/min: • Move to Step 4Step 4:: Pulse Assessment
- 27. JumpSTART Step 4: “Is there a palpable pulse?” • If nono peripheral pulse is present (in the least injured limb): • Red tagRed tag • If peripheral pulse isis palpable: • Move to Step 5Step 5:: Mental Status Assessment
- 28. JumpSTART Step 5: Mental Status Assessment • Use AVPUAVPU scale to assess mental status • AAlert, VVerbal, PPainful, UUnresponsive • If alert, responsive to verbal, or appropriately responsive to pain: • Yellow tagYellow tag • If inappropriately responsive to pain or unresponsive: • Red tagRed tag
- 29. JumpSTART Modifications for Non-ambulatory children • A few examples that may fit the “non-ambulatory” criteria: • Infants who normally can’t walk yet • Children with developmental delay • Children with acute or chronic injuries preventing them from walking before the incident • Children with chronic disabilities • Individuals with special health care needs Keep an open mind and be patient with these children as they may be moreKeep an open mind and be patient with these children as they may be more difficult to communicate with and/or may not be able to comprehenddifficult to communicate with and/or may not be able to comprehend commands.commands.
- 30. JumpSTART Modifications for Non-ambulatory children Evaluated using JumpSTARTJumpSTART algorithm •Red tagRed tag criteria: • Ex: airway assistance/positioning required, irregular respiratory rate, no palpable pulse, but still breathing, and/or inappropriate mental status •Yellow tagYellow tag criteria: • Ex: significant external signs of injury such as deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen •Green tagGreen tag criteria: • No significant external injury
- 31. A patient’s limitations inA patient’s limitations in ambulation, communication,ambulation, communication, comprehension, and thecomprehension, and the differentiation between acutedifferentiation between acute and chronic neurologicaland chronic neurological conditions can be the mainconditions can be the main challenges faced whenchallenges faced when triaging children withtriaging children with special needs andspecial needs and disabilities.disabilities.
- 32. Special Consideration for black tagblack tag Patients of all ages Unless clearlyclearly suffering from injuries incompatible with life, patients tagged in the Black tag (deceased/ non-salvageable)Black tag (deceased/ non-salvageable) category should be reassessed AFTER critical interventions have been completedcompleted for red tag (immediate)red tag (immediate) and yellow tag (delayed)yellow tag (delayed) patients.
- 34. Let’s Practice!
- 35. A school bus carrying children of various agesA school bus carrying children of various ages and their chaperones are on a field trip. Theand their chaperones are on a field trip. The school bus driver loses control, slams into aschool bus driver loses control, slams into a median, and then rolls over…median, and then rolls over… You are the triage officer. Properly triage each patient.You are the triage officer. Properly triage each patient.
- 36. How do you triage this patient? • A young school aged boy is found lying on the roadway 10 ft. from the bus • Breathing 10/min • Good distal pulse • Groans to painful stimuli
- 37. How do you triage this patient? • An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk. • RR 20 • Capillary Refill: 2 sec • Obeys commands
- 38. How do you triage this patient? • A school aged girl crawls out of the wreckage. • She’s able to stand and walk toward you • She is actively crying • Jacket and shirt torn • No obvious bleeding
- 39. How do you triage this patient? • A toddler lies with his lower body trapped under a seat inside the bus • Apneic • Remains apneic with modified jaw thrust • No pulse
- 40. How do you triage this patient? • Adult female driver still in the bus. She is trapped due to her lower legs being stuck under the caved-in dash • RR 24 • Cap refill: 4 sec • Moans with verbal stimulus
- 41. How do you triage this patient? • A toddler lies among the wreckage • RR 50 • Palpable distal pulse • Withdraws from painful stimulus
- 42. How do you triage this patient? • A woman is carrying a crying infant. • She is able to walk. • RR 20 • Cap Refill: 2 sec • Obeys commands
- 43. How do you triage this patient? • An infant is being carried by the previous patient. • The infant is screaming, but the woman quiets him to RR of 34 • Good distal pulse • Focuses on rescuer, reaches for mom • No obvious significant external injuries
- 44. How do you triage this patient? • A young school aged boy props himself up on the road. • RR 28 • Good distal pulse • Answers question and commands • Has obvious deformity of both lower legs
- 45. How do you triage this patient? • Toddler found outside the bus, lying on the ground in a heap • Apneic • Remains apneic with jaw thrust • Faint distal pulse palpable OR
- 46. How do you triage this patient? • A school aged girl lies among the wreckage • RR 40 • Absent distal pulse • Withdraws from painful stimulus
- 47. How do you triage this patient? • A screaming infant is found among the bushes at the side of the road • RR 38 • Good distal pulse • Focuses and reaches for you • Has a partial amputation of the foot without active bleeding
- 48. How do you triage this patient? • An adult male lies inside the bus • Apneic • Remains apneic with jaw thrust
- 49. How do you triage this patient? • A young toddler is up and walking • The toddler is limping • Alert • Crying hysterically for his mother
- 50. How do you triage this patient? • A young teen girl lies among the wreckage. She is crying for someone to help her up. A man nearby says she needs her wheelchair. • RR 22 • Palpable distal pulse • Alert • Has minor cuts and bruises
- 51. How do you triage this patient? • An adult male lies on the ground • RR 20 • Good distal pulse • Obeys commands, but cries that he can’t move his legs OR
- 52. Summary • Primary triage is just the first lookfirst look at an MCI victim. This is similar to the primary/initial survey/assessment. • The physiology of adults and children differ; therefore different primary triage systems should be used. • Use JumpSTARTJumpSTART for ages 1-8 years old • Use STARTSTART for young adults and older