Triage Tags
 Patients brought by EMS
 Tag will be applied to patient by EMS
 Patients directed to appropriate treatment area in
the hospital based on color of triage tag
 MCI/Disaster patients presenting to ED by own
transportation
 Triage tags in disaster cage in basement
 Triage tags will be available in the ED
 Decon room
 At Triage
 Should be used and applied to patients as they
enter the hospital via the triage area where-ever this
has been established
Triage
 Primary triage- START and JumpStart
 Segregates casualties into groups
 Walkers move to another area
 The more critically injured, but still a smaller
crowd, left to sort through to determine reds
and yellows
 Secondary triage
 Refines our clinical picture
 Uses a physiological scoring system &
anatomical examination
Primary vs Secondary Triage
(The 1st vs Subsequent Triage)
 JumpSTART triage will be performed in
the field – IF the patient is brought by
EMS
 If the patient accesses the ED on their
own, triage will need to be set up and
performed at the ED
 If the patient comes to ED via EMS, ED
should use the secondary triage (RTS) as
their reassessment process
Secondary Triage
 Glasgow coma scale (GCS) – 3-15 points
Best eye opening
Best verbal response
Best motor response
 Respiratory rate
 Systolic B/P
 Secondary triage scores calculate RR
and B/P based on adult norms
 Secondary triage scores have not been
modified for pediatric normal RR and B/P
Glasgow Coma Scale
(GCS)
 Best eye opening 1 - 4 points
 Eyes spontaneously open, looking around;
does not have to focus (4 points)
 Eyes open (or eyelids flutter) to verbal
stimuli prior to tactile stimulation(3 points)
 Eyes open (or eyelids flutter) to painful or
tactile stimuli (2 points)
 There is absolutely no eye movement,
including no eyelid flutter or flicker (1 point)
 Best verbal response
 Patient oriented (5 points)
 Patient confused, can carry on a conversation
but not always appropriate; infant has irritable
cry (4 points)
 Patient using inappropriate words for the
situation and you can understand what the
words are; this is beyond confusion (ie: “the
sky is blue”); infant cries to pain (3 points)
 Patient has incomprehensible words (ie:
moans and groans and noises made but
cannot be understood for any words); child
responds to pain (2 points)
 There are no sounds, no moans, no groans,
nothing heard from the patient (1 point)
 Best motor response
 Patient obeys commands (6 points)
 Patient is purposeful & localizes; this is the
obnoxious patient who pulls at the equipment and
tries to remove the equipment; they try to hit your
hand away; infant withdraws to touch (5 points)
 Patient responds to pain by withdrawal (the brain
can no longer discern where the obnoxious
stimuli is felt so just withdraws); infant withdraws
to pain (4 points)
 Patient flexes extremities (decorticate) (3 points)
 Patient extends extremities (decerebrate) (2
points)
 Patient is flaccid with no response (1 point)
Converting GCS Points to
RTS
Conversion score ranges from 0 – 4 points
Total GCS 13 – 15 (4 points)
Total GCS 9 – 12 (3 points)
Total GCS 6 – 8 (2 points)
Total GCS 4 - 5 (1 point)
Total GCS 3 (0 points)
Add converted points (0 - 4) to respiratory
rate score and systolic B/P score
 RTS score range 0 – 12 points
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 Respiratory rate – 0 – 4 points
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10 – 29 breaths per minute (4 points)
30 or more breaths per minute (3 points)
6 - 9 breaths per minute (2 points)
1 – 5 breaths per minute (1 point)
0 breaths (0 points)
 Points added to GCS conversion points
(0 - 4) and to systolic B/P score (0 – 4)
 RTS score ranges 0 - 12
 Systolic blood pressure (0 – 4 points)
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90 or more (4 points)
76 – 89 (3 points)
50 - 75 (2 points)
1 – 49 (1 point)
0 (0 points)
 Points added to GCS conversion points
(0 - 4) and to respiratory rate score
(0 – 4)
 RTS score ranges 0 - 12
Secondary Triage - RTS
 RTS score ranges from 0 to 12
 Score of 12 (highest) – patient is GREEN
 Score of 11 – patient is YELLOW
 Score 10 or less – patient is RED
Scenario Practice
 Use worksheet at end of power point as
resource for START & JumpSTART triage and
the secondary triage process
 Place patients in the appropriate categories
 Check answers at the end of the practice
scenarios
 Some scenarios are based in the field – does
not matter as triage is performed the same in
all settings (and you might be dispatched to
help in the field if requested)
Scenario 1: Bus Crash
It’s 7pm on a summer
night when a bus
returning from a
day camp collides
with a train on a
remote road.
There are 20 + kids
either still in the bus
and some are
lying about the road.
There are 3 adults.
JumpSTART Triage –
Scenario #1 (Initial Triage)
Patient #1
Unresponsive;
RR 30 and pale
Patient #3
Unresponsive;
labored respirations 52
and open chest wound
Patient #2
5 y/o looking
around;
RR 35 and open
femur fracture
What color are you triaging these patients?
Initial JumpSTART Triage
Scenario #1
 Patient #1 – RED
 RR okay at 30 (between 15 and 45)
 Patient is unresponsive
 Patient #2 – YELLOW
 Not able to walk so initially made yellow until
retriaged – then may stay yellow or be triaged as
green or red
 Even though RR okay at 35 (between 15 and 45)
 Even though looking around (awake)
 Patient #3 – RED
 Labored RR of 52 (> 45)
 Unresponsive
Scenario #2
9 y/o F
RR 10
Distal pulse
Groans to painful
stimuli
In ditch 15ft
away
50 y/o F
RR 20
Cap refill < 2
sec
Obeys commands
c/o dizziness
10 y/o M
Talking
Good distal
pulse
Asks for help
Walking
8 y/o F
RR 0
Faint distal
pulse
Unresponsive
Breathing after 5 rescue
breaths delivered
In rubble out
of bus
11 y/o M
RR 22
Distal Pulse
Obeys commands
Can’t move or
feel legs
25y/o F
RR12
Cap refill 4 sec
Eye movement to tactile 6 mo pregnant
stimulation
Scenario #2 Adult and
Pediatric Mixed Triage
9 y/o – RED (RR<15)
50 y/o – GREEN (RR, cap refill & neuro okay)
10 y/o – GREEN (walking, neuro okay)
8 y/o – RED (faint distal pulse, unresponsive)
11 y/o – YELLOW (can’t walk so initially can’t be
green; minimally will be yellow when you make it
through the triage process and all other
parameters are okay. D
 Distal pulses and obeys commands okay so
left yellow for now
 25 y/o – RED (cap refill >2 sec; not responding to
commands given (only to painful/tactile)
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Scenario #2: F5 Tornado
An F5 tornado
has struck
within your
city/town. It
occurred at
3pm while
school was
letting out. It
touched down
near 3 schools
and a mall.
Triage This Patient: School
age girl lying on roadway
 Breathing
10/min.
 Good distal
Pulse
 Groans to verbal
stimuli
 JumpSTART
triage category?
 Patient is categorized as a RED
 Respiratory rate (RR) is 10 (<15)
 Do not even need to get to the type of AVPU
response patient has
 This patient is categorized influenced by
respiratory rate and then rescuer must
move onto next patient for triage
 Patient care not delivered during triage
 Patient care delivered in treatment
Triage This Patient: School
age girl found; refuses to
walk
 Open arm
fracture visible
 RR 26, radial
pulse present
 Alert and
talking
 JumpSTART
triage
category?
 Open arm fracture could be a distracting
injury – so don’t get distracted
 Stay with physiological parameters
 Not able to walk so automatically at
minimum a YELLOW
 Respiratory rate 26 (okay 15 - 45)
 Neurologically okay (alert and talking)
 Patient remains triaged as YELLOW
 In secondary triage may be upgraded to
GREEN (RTS most likely a 12)
Infants/Non-walkers
 Evaluate this group of patients
starting triage with the breathing
assessment
Scenario Practice #2 –Patients From Tornado
Weak, thready
8 y/o
RR 10
Unresponsive
pulse
3 y/o
RR 18
Pulse present; Responds to
HR irregular
Pain
118
Pulse present Responds to
voice
9 mo
Crying;
RR 32
10 y/o
screaming Pulse present Not focusing
50 y/o
RR 32
Weak Pulse;
cap refill 4
seconds
7 y/o
apnea
Very weak
Pulse
Not following
commands
Outside,
face down
Trapped
under
bookcase
Mult minor
lacs to
head/face
Running in
hall
Trapped
under
bookcase
Unresponsive; Trapped
not breathing under
after 5 breaths bookcase
Scenario #2 Patient Triage
 8 y/o – RED (unresponsive)
 3 y/o – YELLOW (not walking; RR 15 – 45; “P” on
AVPU)
 9 mo – GREEN (pulse +; “V” on AVPU, minor
external wounds)
 10 y/o – RED (pulse+; not focusing, screaming,
running around – distracting others so remove to
control the scene)
 50 y/o – RED (cap refill >2 sec; not following
commands)
 7 y/o – BLACK (apnea not corrected with 5 rescue
breaths)
Scenario #3: High-Rise Fire
 Fire
reported on
15th floor
 Smoke to
the 16th and
17th floors.
 The building
Day Care
Center is on
the 17th floor
Reported 30 kids in the
day care and 6 employees
• Fire Crews
carry 5 kids
all being
given CPR.
• The day care
is next to the
hospital and
triage is set
up in the ED
• How would
you triage
these
patients?
Scenario #3 – High rise fire
Radial pulse
6 y/o RR 38 present
53 y/o RR 48 Cap refill
> 2 sec
3 y/o
RR 0
Weak pulse
Knows name
and recalls
incident
Facial
burns,
coughing
Moaning
FB glass to
abdomen;
wheezing
Unresponsive; Found
resumes breathing under desk
after 5 breaths
given
4 y/o
RR 40 Pulse present Crying
Soot to face
2 y/o
RR 20 Palpable
Pulse
RR 28 Strong
Palpable
Pulse
Hoarse cry
Soot to face
Crying; can’t
walk
2nd /3rd
degree
burns
5 y/o
Scenario #3 Patient Triage
6 y/o – GREEN (walks; RR 15-45; awake/alert)
53 y/o – RED (cap refill >2 sec)
3 y/o – RED (weak pulse, unresponsive)
4 y/o – GREEN (walks; RR 15- 45; pulse
present)
 2 y/o – GREEN (walks; RR 15-45; pulse
present
 5 y/o – YELLOW (can’t walk; RR 15-45; strong
pulse)
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Scenario #3
 The patients made GREEN (1st, 4th and
5th) have evidence of airway involvement
from the fire (facial burns and soot to
face)
 The patient, regardless of how initially
triaged, may deteriorate and need
upgrading
 Remember secondary triage should
occur rapidly and repeat assessments
should occur frequently to determine if a
patient needs to move up to a higher
level of triage
Disaster Triage Decisions
 Remember the point of primary triage
 To sort patients to determine who is the
most critical and who is less critical
 Need to do the greatest good for the
greatest number
 Disaster triage is not routine daily
triage where you do the best for each
individual