Pediatric Multicasualty
Incident Triage
Lou E. Romig MD, FAAP, FACEP
Miami Children’s Hospital
Miami-Dade Fire Rescue
FL-5 DMAT
Topics
What is Triage?
Triage
Categories
Triage Tools
What is Triage?
“Triage” means “to sort”
Looks at medical needs and urgency
of each individual patient
Sorting based on limited data
acquisition
Also must consider resource
availability
Military vs. Civilian Triage
Priority is to
get as many
soldiers back
into action as
possible.
Priority is to
maximize
survival of the
greatest number
of victims.
Military vs. Civilian Triage
Military model
Those with the least serious wounds
may be the first treatment priority
Civilian model
Those with the most serious but
realistically salvageable injuries are
treated first
Military vs. Civilian Triage
In both models, victims with
clearly lethal injuries or those
who are unlikely to survive even
with extensive resource
application are treated as the
lowest priority.
Ethical Justification
This is one of the few places where a
"utilitarian rule" governs medicine: the
greater good of the greater number rather
than the particular good of the patient at
hand. This rule is justified only because of
the clear necessity of general public welfare
in a crisis.
A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in
Medicine, Univ. of Washington School of Medicine,
http://eduserv.hscer.washington.edu/bioethics/topics/resall.html
“The needs of
the many
outweigh the
needs of the few
or the one."
Star Trek
Why are Resources
Important in Triage?
Disaster is commonly defined as
an incident in which patient care
needs overwhelm local response
resources.
Daily emergency care is not
usually constrained by resource
availability.
Daily Emergencies
Do the best for each individual.
Disaster Settings
Do the greatest good for
the greatest number.
Maximize survival.
Triage is a dynamic process and is
usually done more than once.
Primary Disaster Triage
Goal: to sort patients based on
probable needs for immediate care.
Also to recognize futility.
Assumptions:
Medical needs outstrip immediately
available resources
Additional resources will become
available with time
Primary Disaster Triage
Triage based on physiology
How well the patient is able to
utilize their own resources to deal
with their injuries
Which conditions will benefit the
most from the expenditure of
limited resources
Secondary Disaster Triage
Goal: to best match patients’ current and
anticipated needs with available resources.
Incorporates:
A reassessment of physiology
An assessment of physical injuries
Initial treatment and assessment of patient
response
Further knowledge of resource availability
Secondary Triage Tools
Goal is to distinguish between:
Victims needing life-saving treatment that
can only be provided in a hospital setting.
Victims needing life-saving treatment
initially available on scene.
Victims with moderate non-lifethreatening injuries, at risk for delayed
complications.
Victims with minor injuries.
Secondary Triage Tools
There is no widely recognized tool in
the US that addresses secondary MCI
triage and also transport strategies.
California “Medical Disaster Response”
course’s SAVE tool (Secondary
Assessment of Victim Endpoint)
Many EMS systems use local trauma
triage criteria.
Tertiary Disaster Triage
Goal: to optimize individual outcome
Incorporates:
Sophisticated assessment and
treatment
Further assessment of available
medical resources
Determination of best venue for
definitive care
“Continuous Integrated Triage”
Primary Triage
Secondary Triage
Tertiary Triage
Triage Categories
Triage Categories
Red:
Life-threatening but treatable
injuries requiring rapid medical
attention
Yellow:
Potentially serious injuries, but are
stable enough to wait a short while
for medical treatment
Triage Categories
Green:
Minor injuries that can wait for
longer periods of time for treatment
Black:
Dead or still with life signs but
injuries are incompatible with
survival in austere conditions
Triage Tools
Simple Triage and Rapid
Treatment (START)
JumpSTART Pediatric MCI
Triage Tool
The Smart Triage
®
Tape
Developed in Great Britain
Proprietary, TSG Associates
Length-based pediatric MCI triage tape
Age-adjusted physiologic parameters
In use in Europe, Africa and some states
in the US
www.tsgassociates.co.uk/English/Civilian/
products/smart_tape.htm
Triage Sieve
Care Flight Triage
Basic Disaster Life Support
National Disaster Life Support
Education Consortium, via Medical
College of Georgia’s Center of
Operational Medicine
Endorsed by the American Medical
Association
www.ndlsf.org
Basic Disaster Life Support
MASS Triage
Move
Assess
Sort
Send
? Assessment guidelines
? Pediatric considerations
SALT Triage
Sort, Assess, Life-saving Interventions,
Treatment/Transport
CDC grant project to standardize MCI
triage in the US
Early in development
Derived from existing tools
Includes pediatric considerations
SALT Triage
SALT Triage
Mass Casualty Triage: An Evaluation of the
Data and Development of a Proposed
National Guideline
E. Brooke Lerner, PhD, Richard B. Schwartz, MD,
Phillip L. Coule, MD, et al
DISASTER MEDICINE AND PUBLIC HEALTH
PREPAREDNESS - 2(Supplement_1): 25-34 2008
http://www.dmphp.org/cgi/content/full/2/Supplement_1/S25#
R15-7
Sacco Triage
®
Method
Proprietary tool, ThinkSharp Inc.
Only tool based on outcome data
12 triage categories
Available software package for transport
planning based on patient and resource
info
Includes pediatric data and age
adjustments
Sacco Triage
®
Method
Sacco Triage
®
Method
STM Sample Patient Prioritization
Scene Characterization
Triage Priority Order
Multiple casualty; resource levels stressed
Estimate about an hour or less to clear the scene.
4 5 6 3 2 7 1 8+ 2
Large multiple casualty or small mass casualty
requiring staged resources Estimate 1½ to 2½
hours to clear the scene
5 6 7 8 4 9 3 2 1 9+
Mass casualty; resources overwhelmed
Estimate 3 or more hours to clear the scene
6 7 8 5 9 10 4 3 2 1 11+
www.sharpthinkers.com/STM_Site/stm_home.htm
Israeli Triage Practice
Little to no triage done on-scene
“Save and run” philosophy
Very hazardous scenes
Reds to closest hospital
Nearest hospital becomes triage
center?
Israeli Triage Practice
Uses physicians as triage officers
Accuracy of physician triage called
into question
Metropolitan Israeli hospitals may be
more uniformly capable of caring for
trauma victims than in many areas of
the US
The Best Tool?
No MCI primary
triage tool has
been validated
by outcome data
from MCIs.
Mass-casualty triage: Time for an evidence-based approach. Jenkins JL,
McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL,
Hsu EB
Prehospital Disast Med 2008;23(1):3–8.
The Best Tool?
It’s likely that no existing MCI
triage tool is suitable for use for
all types of incidents.
START/JumpSTART
Neither clinically validated
Evidence accumulating against validity and/or
inter-rater reliability
Comparison of paediatric major incident
primary triage tools. L A Wallis1, S
Carley2 Emergency Medicine Journal
2006;23:475-478
Smart Tape and Care Flight more sensitive
than START and JS
No tool had > 48% sensitivity for critical
patients
START
Simple Triage And Rapid
Treatment
Developed jointly by Newport
Beach (CA) Fire and Marine
Dept. and Hoag Hospital
Gold standard for field adult
multiple casualty (MCI) triage
in the US and numerous
countries around the world
START
Utilizes the usual four triage
categories
Used for Primary Triage
Used on-scene and at hospitals
Recommended for patients >
100 lbs
www.start-triage.com
START Triage
RESPIRATIONS
PERFUSION
NO
Over 30/min
Position Airway
NO
Dead or
Expectant
Under 30/min
YES
YES
Immediate
Immediate
Cap refill
> 2 sec
Control
Bleeding
Immediate
Cap refill
< 2 sec.
MENTAL
STATUS
Failure to follow
simple commands
Can follow
simple commands
Immediate
Delayed
Mnemonic
R
P
M
30
2
Can do
JumpSTART Pediatric MCI Triage
Developed by
Lou Romig MD, FAAP, FACEP
Now in widespread use throughout
the US and Canada
Being taught in Japan, Germany,
Switzerland, the Dominican
Republic, Africa, Polynesia
National Committee on Management
of Pediatric MCIs, 2006
JumpSTART recommended for
prehospital use throughout Israel
Prehospital Response and Field Triage in Pediatric Mass
Casualty Incidents: The Israeli Experience
Yehezkel Waisman, MD, Lisa Amir, MD, MPH, Meirav Mor,
MD, et al Clin Ped Emerg Med 7:52-58, 2006
JumpSTART Pediatric MCI Triage
The physiologic parameters used
in START are not suitable for all
ages of children
Walking
Respiratory death vs cardiac
death
Respiratory rates
Mental status assessment
What age?
JumpSTART: Age
The ages of “tweens and teens” can be hard to
determine so the current recommendation is:
If a victim appears to be a child, use
JumpSTART.
If a victim appears to be a young adult,
use START.
Patients who are able to walk are
assumed to have stable, wellcompensated physiology, regardless of
the nature of their injuries or illness.
Secondary Triage
All green patients must be individually
assessed in secondary triage.
Assess physiology
Assess injuries
Assess probability of deterioration
Assess needs vs. resource availability
Secondary Triage
Some children may be carried to the
green area by others. They have not
proven their physiologic stability by
performing the complex act of
walking.
These children should be assessed first
among all those in the green area.
Position the upper airway of the
apneic child.
If they start to breathe, tag them as
If the child doesn’t start breathing
with upper airway opening, feel for a
pulse.
If no pulse is palpable, tag the
patient as
If the patient has a palpable pulse, give 5 mouth-tobarrier breaths to open the lower airways. Tag as
below, depending on response to ventilations.
DO NOT CONTINUE TO VENTILATE THE
PATIENT. RESUME TRIAGE DUTIES.
Assess the respiratory rate
of the spontaneously
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, tag the patient
as
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
Modification for Nonambulatory
Children
Children developmentally unable
to walk due to young age or
developmental delay
Children with chronic disabilities
that prevent them from walking
Modification for Nonambulatory
Children
For nonambulatory children,
assess using the JumpSTART
algorithm.
If pt meets any red criteria tag as
Modification for Nonambulatory
Children
If patient meets yellow criteria
and has significant external signs
of injury, tag as
If patient meets yellow criteria
and has no significant external
signs of injury, tag as
Certainties about MCI Triage
Organization is a good thing in a disaster
Triage tools must help match limited
resources to an abundance of needs
Physiologic tools should suit physiologic
differences
Triage tools should be kept as simple as
possible and practiced often
Disaster research agendas should include
efforts to validate existing and future
triage tools.
Triage should be done with
the head, not the heart.
The Jumpstart Pediatric MCI Triage Tool
and
other pediatric disaster and
emergency medicine resources
The JumpSTART Pediatric MCI Triage Tool
Principles of Multicasualty Triage
www.jumpstarttriage.com
Thank You!
LouRomig@bellsouth.net
LouRomig@jumpstarttriage.com
MCH
MDFR
FL-5 DMAT