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
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•
•
•
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 retriaged 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
•
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.
JumpStart
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 Peripheral pulses are
assess perfusion
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 are
assumed to have stable, well
compensated physiology, regardless of
the 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 are
assumed to have stable, well
compensated physiology, regardless of
the 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 1545 breaths/minute.
• If respiratory rate is <15 or >45, tag the patient as
JumpSTART: Step 5
• 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 6
• 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
Exercise
Scenario # 1
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 2
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 3
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 4
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 5
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VICTIM: 6 y.o. female
RESPIRATORY RATE: 0/min
PERFUSION: pulseless
MENTAL STATUS: unresponsive
OTHER: legs trapped under seat from bus
1.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 6
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 7
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 8
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 9
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VICTIM: 6 y.o. male
RESPIRATORY RATE: 40/min
PERFUSION: pulseless
MENTAL STATUS: withdraws from painful stimuli
OTHER: arm deformity, sucking chest wound
1.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 10
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 11
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 12
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VICTIM: 7 y.o. female
RESPIRATORY RATE: 24/min
PERFUSION: distal pulse present
MENTAL STATUS: crying
OTHER: limping near buses
1.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 13
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 14
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 15
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VICTIM: 8 y.o.
RESPIRATORY RATE: 28/min
PERFUSION: distal pulse present
MENTAL STATUS: follows commands
OTHER: facial and scalp lacerations, moderate bleeding
1.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 16
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 17
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VICTIM: 30 y.o. male
RESPIRATORY RATE: 20/min
PERFUSION: capillary refill < 2 seconds
MENTAL STATUS: obeys commands
OTHER: walking at the scene
1.
2.
3.
4.
RED
YELLOW
GREEN
BLACK
Scenario # 18
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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.
2.
3.
4.
RED
YELLOW
GREEN
BLACK