Presentation on theme: "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."— Presentation transcript:
1Triage“To Sort”Look at medical needs and urgency of each individual patientTriage in Daily EmergenciesDo the best for each individualDisaster TriageDo the greatest good for the greatest numberMake an impossible task manageableTriage comes from a French word and means “to sort”.It is a dynamic process and is usually done more than onceIt looks at medical needs and the urgency of each individual patient
2Following 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….
3Triage Categories RED- immediate/emergency YELLOW- Urgent GREEN- nonurgent/walking woundedBLACK- dead/ little to no hope of survivalBefore we go thru the JumpSTART algorithm, lets review the triage categories.Although these are the triage categories used in an MCI, when we begin to go thru the triage process using JumpSTART, we’ll see that we may not all agree on what color to assign to individual patients. That’s why its important to use an objective process such as JumpSTART to assure that we are triaging in a consistent manner.It is important to remember to not automatically assign pediatric patients with a priority for transport or highest triage category just because they are children.Also, in field triage, it is important that designated treatment areas are created for each of these triage color categories.
4SMART Tag System System of triage adopted by Illinois Triage tags have standard barcodes for tracking patients and reuniting familiesTriage tags have a unique folded design that allows patients to be re-triaged to another color classification without having to replace the tagIn Illinois, the SMART Triage tag system has been approved for statewide use to assure that a standardized triage tag system is in place. Federal grant funds were utilized by MABAS to purchase SMART triage tags and bags for each prehospital agency in the state.Each SMART bag should contain several triage tags as well as a START algorithm card and a JumpSTART algorithm card, which are both tethered to the inside of the bag. Please note that if you purchased Smart system bags separately from the vendor (Boundtree), you may have received a pediatric tape in the bag. DO NOT USE THIS TAPE. IT HAS NOT BEEN APPROVED FOR ILLINOIS USE AND SHOULD BE RETURNED TO THE SMART PRODUCT VENDOR (BOUNDTREE MEDICAL SUPPLIES) SO THAT THEY CAN SEND YOU A REPLACEMENT JUMPSTART CARD.Forms are available to return these pediatric tapes back to BoundTree so that you can receive a JumpSTART card. These forms are available with all the training materials provided for this course.
5START Triage Simple Triage And Rapid Transport Gold standard for field adult MCI triage in US and numerous other countriesUtilizes the four standard color triage categoriesUsed for primary triage
7JumpSTART Triage Tool for pediatric mass casualty field triage Provides objective frameworkBased primarily on physiologic differences between children and adultsUseful for kids of all agesDesigned for use in Disaster/MCI eventsIf positioning airway does not restart breathing, a ventilatory trial is administered in JumpSTARTPeripheral pulse is used to assess perfusion in JumpSTARTThe AVPU scale is used in JumpSTARTJumpSTART is a pediatric MCI system that was developed by Dr. Lou Romig, a pediatric emergency medicine physician, several years ago. It is based upon the START algorithm, but addresses key physiologic differences in children.Adapted from the Dr. Lou Romig slide set available at
8JumpStartIn 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.The JumpStart system has not been field tested in any large scale incidents, however it is recognized by the US National Disaster Medical System (NDMS).Unless there is a clear airway obstruction, respiratory failure in adults usually follows circulatory failure or catastrophic head injury. An apneic adult develops enough cardiac injury (due to hypoxia/ hypoperfusion) to make them nonsalvageable in the MCI setting.This differs in children in that respiratory failure usually precedes circulatory failure.Apnea may occur relatively rapidly, rather than after a prolonged period of hypoxia (i.e. airway obstruction, weak intercostal muscles, inhibition of diaphragm).There may be a brief period of time when the child is apneic but not yet pulseless because the heart has not experienced prolonged hypoxia. During this time, airway clearance and a brief trial of ventilations may stimulate spontaneous breathing that may be sustained until further medical assistance is available.This brief trial of ventilations during a period of potential salvage ability is considered a method to “jumpstart” the child’s respirations.
9Adult 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 useIf a victim appears to be a childuse JumpSTARTIf a victim appears to be a young adultuse START
11RED - ImmediateSeverely injured but able to be saved with relatively quick treatment and transportExamplesSevere bleedingShockOpen chest or Abdominal woundsEmotionally out of controlHow many of you would triage most pediatric patients to a RED category?All rescuers should be a RED to get them off the sceneThis picture is depicting a chest wound.
12Yellow - Delayed Injured but unable to walk on their own Examples Burns with no respiratory distressSpinal injuriesModerate blood lossConscious with head injuriesHere are some examples of patients that would be triaged to a YELLOW category. Remember that these patients can easily be upgraded since triage is a continual process
13Green – Non-UrgentMinor injuries that need to be assessed or treated but not right awayExamplesMinor fracturesMinor bleedingGREEN patients are considered the “Walking Wounded.”If patients in this category want to sign a refusal and leave the scene it will assist in decreasing the number that you are transporting. However, you need to make sure that these patients have been appropriately evaluated and triaged. Any time a patient refuses treatment the appropriate documentation must be obtained.All EMS Systems within Illinois need to have a procedure for managing school bus incidents that includes how to manage multiple victims. Currently in Chicago a refusal log sheet is used for minor bus crashes (i.e. a slow moving crash with little to no damage). This same procedure could be utilized during an MCI event for your GREEN patients.JumpSTART is a TOOL to help you come to a triage decision. It doesn’t solve all of our problems such as any mom/baby separation issues, however it can assist in more quickly assigning a triage category and getting to an end decision quicker by using objective data versus subjective input.
14Black - Deceased Dead or obviously dying Depends on local protocols ExamplesCardiac arrestResp arrest with a PulseCan be psychologically difficult to tag a child as blackThere is much psychological trauma associated with tagging a child to the BLACK category especially if they are still alive. It is difficult to give up on a child. That is why using an objective process such as JumpSTART can help make that decision a bit easier.Note on pediatric patients tagged to BLACK:Patients that are tagged BLACK should be reassessed once critical interventions have been completed for the RED and YELLOW patients.
15START: Step 1 Patients who are able to walk are assumed to have stable, wellcompensated physiology, regardless ofthe nature of their injuries or illness.“If you can hear me, go stand near the big tree.”
16START: Step 2 Next begin triaging the remaining victims Open the airway of the apneic adultIf they start to breathe, triage them a red
17START: Step 3If after opening the airway, the adult patient does not breathe, tag them a black
18START: Step 4 Assess the respiratory rate of the breathing adult Move on to the next assessment if respiratory rate is under 30/minIf respiratory rate is over 30/min, tag the patient red
19START: Step 5 If the radial pulse is absent OR If the capillary refill is over 2 seconds, control bleeding and tag the patient red
20START: Step 6 If the radial pulse is present, Assess the mental status If the patient can follow simple commands, tag them yellowIf the patient cannot follow simple commands, tag them red
21JumpSTART: Step 1 Patients who are able to walk are assumed to have stable, wellcompensated physiology, regardless ofthe nature of their injuries or illness.“If you can hear me, go stand near the big tree.”
22JumpSTART: Step 2 Next begin triaging the remaining victims Open the upper airway of the apneic child.If they start to breathe, tag them as redIf the patient is breathing spontaneously, then go on to the next step of assessing the respiratory rate.If your patient is apneic or with any type of irregular breathing, first open the airway using standard positioning technique. If the positioning results in spontaneous respirations resuming tag the patient as RED (immediate) and move on.
23DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES. JumpSTART: Step 3If 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.If no breathing is noted after opening the airway then check for a peripheral pulse. If no pulse, then tag as BLACK/deceased and moved on.If there is a peripheral pulse give 5 rescue breaths. If apnea persists then tag patient as BLACK/deceased and move on.If the breathing resumes after the “jumpstart”, then tag the patient as RED/ immediate and move on.
24JumpSTART: Step 4 Assess the resp rate of the breathing child Move on to next assessment if respiratory rate is breaths/minute.If respiratory rate is <15 or >45, tag the patient as
25JumpSTART: Step 5If the child’s pulse is palpable, move on to the next assessment.If no palpable pulse but child is breathing, tag the patient asThe palpable pulse is a better indicator of perfusion in a child, because their capillary refill may not adequately reflect peripheral hemodynamic status if the environment is cool or cold.
26JumpSTART: Step 6If patient is inappropriately responsive to pain, posturing, or unresponsive, tag asIf patient is alert, responds to voice or appropriately responds to pain, tag asIn the START system for adults, the mental status is assessed by determining if the patient can follow a simple command. This differs in the JumpSTART triage system where the mental status is assessed by using the AVPU pneumonic.Use the AVPU scale in children to assess their mental status:A = Alert, V = Verbal, P = Pain or U = UnresponsiveIf the patient has no response to pain (“U”) or has an inappropriate response to pain i.e. is dazed, has a staring gaze, or begins posturing, then tag as RED/immediate and move on.However, if the patient has an appropriate response to pain (pulls away, cries out, etc) then tag as YELLOW/Delayed and move on.If the patient is alert or responsive to verbal stimuli, then tag as YELLOW/ Delayed.