START & JumpSTART Triage --A school bus full of students hits a patch of ice and swerves off the road. --A car plows through an active school crossing zone. --A set of bleachers collapses at a high school football game. --A banquet hall collapses under the weight of weight of wedding guests. --Five car pile-up after the night turns densely foggy. --A disgruntled father who loses a bitter custody battle opens fire on a day care. NIGHTMARES! In each scenario, victims large and small are scattered across the scene. Some victims are pulling themselves from the wreckage. You hear cries for help & shrill screams of fear. They all depend on you and your crew. How do you start? Who do you care for first? Joe Immermann, EMT-P, BBA With thanks to: Joy Erb Moser, RN BSN CEN

Greatest Good for the Greatest Number START Aim of Triage… Greatest Good for the Greatest Number MCI’s often force us to deal with an overwhelming situation where there are perhaps limited resources, supplies, and personnel. So, we have to be able to provide the best care to the most appropriate patients that have a chance of surviving. To do the best for the most using the least.

START START facilitates patient triage in 60 seconds or less Assess Ventilation Perfusion Mental status Patients need to be re-triaged multiple times. It can be done once with the ribbon, then again when applying a full triage tag and again just before transport.

Correct Life Threats Blocked airways Severe bleeding

START Assessments Ambulation Respirations Perfusion Mental status Most trauma patients die within the first hour after sustaining their injuries mostly due to respiratory complications and insufficiency, exsanguinations, or CNS trauma.

Respiratory Check ventilation rate and adequacy Check for foreign objects causing airway obstruction Reposition to open airway Every patient will be assessed for ventilatory rate & adequacy. If patient is not breathing, check for foreign objects causing airway obstruction. Reposition the head, using cervical spine precautions if this does not delay assessment. If the above procedures do not initiate respiratory efforts, TAG THE PATIENT BLACK. If the victim’s respiratory rate is above 30, TAG THE PATIENT RED. Victims who have respirations less than 30 are not to be tagged at this time. Go on to assess perfusion.

Perfusion Check capillary refill in nail beds or Palpate radial pulse Best method to assess perfusion is capillary refill (nail beds, lips). CRT should be < 2 seconds. If > 2 seconds, the patient is showing signs of inadequate perfusion and MUST BE TAGGED RED. If CRT < 2 seconds, pt is not tagged until mental status is assessed. If CRT cannot be assessed, palpate the radial pulse. In most cases, if the radial pulse cannot be felt, the SBP will be below 80 mmHg. Control significant bleeding by direct pressure and elevate the lower extremities. Utilize “walking wounded” to assist with hemorrhage control on himself or another patient.

Mental Status Ask patient to follow simple commands Open and close eyes Touch finger to nose The mental status evaluation is used for patients whose respirations and perfusion are adequate. To test, the rescuer should ask the victim to follow a simple command. If the patient cannot do this, then TAG RED. If the patient can follow these commands, the TAG YELLOW.

Triage Categories Green—Minor/Ambulatory Red—Immediate Yellow—Delayed Black—Dead or nonsalvageable

Minor (GREEN) Separate from the general group at the beginning of the triage operation. (“Walking wounded”) Direct patients away from the scene to a designated safe area. Consider using these patients to assist in treatment of those patients tagged as immediate. First announce that everyone who can get up and walk should do so and go to a designated point. There, the walking wounded will be further assessed in secondary triage. All walkers are initially triaged automatically into the GREEN category. Important note: This group may include victims with well-compensated but significant injuries. All GREEN victims must be assessed at the earliest possible opportunity, at which time some may need to be upgraded in triage category.

Immediate (RED) Ventilations present only after repositioning the airway. Respiratory rate greater than 30 per minute. Delayed capillary refill (> 2 seconds) Unable to follow simple commands.

Delayed (YELLOW) Any patient who does not fit into either the immediate or minor categories.

Deceased (BLACK) No ventilations present even after attempting to reposition the airway. Triaging people as DEAD on scene can be difficult for many provider—especially patients that are dying but not dead. Minds should be eased by reminding them that patients initially triaged black can be re-triaged as red if the other patients have all been transported and there are available resources to care for and transport them.

Pediatric MCI Patients What about kids? Pediatric patients: rescuers’ natural emotional responses to injured children can influence their clinical judgment during the triage process. Rescuers with insecurities in dealing with children may over-triage victims, while those with strong sympathy may waste time and resources in attempting to resuscitate a child who is not realistically salvageable. START originators admit that this system is NOT for use in pediatric patients.

JumpSTART Results in less over-triage by acknowledging differences in kids. Addresses the emotional burden of tagging a child as “deceased” by allowing two extra steps. JumpSTART optimizes triage effectiveness to the benefit of ALL victims; results in less over-triage of children than START by acknowledging their physiologic and developmental norms and great compensatory capabilities. At the same time, it acknowledges and addresses the heavy emotional burden of tagging a child as “deceased” by allowing the triage officer to take two extra but tightly limited steps to identify a potentially salvageable child.

Pediatric MCI Patients If the victim looks like a child, use JumpSTART. If the victim looks like a young adult, use START. --Dr. Lou Romig Due to the increased degree of flexibility in JumpSTART and an anticipated lower over-triage rate, Dr. Romig makes the following recommendation: Pertinent physiology (especially the airway) approaches that of adults by approximately 8 years of age.

Pediatric MCI Patients Not all children can walk Respiratory rates may be normal at > 30/minute Capillary refill influenced by environment Obey commands? Kids?? Patients are classified GREEN only if they can walk. Some kids are developmentally not capable of this so they could inadvertently be placed into a YELLOW category. (Developmentally or unwilling to leave family members.) Respiratory rate threshold of 30 may not work for the 4-month-old who breaths at a rate of 40. This would put him in the RED category even though this is normal for him. Slow respiratory rates for kids are not addressed by START. Capillary refill can be altered by environmental temperatures and is difficult to determine accurately in low light. Mental status: ability of patient to obey simple commands. Two-year-olds are not designed to do that on even “good” days! Who wants a bunch of red-tagged screaming two-year-olds pinned to backboards in their RED treatment area???

Breathing? If breathing spontaneously, go on to the next step: assessing respiratory rate. If apneic or with very irregular breathing, open the airway using standard positioning technique. If positioning results in resumption of spontaneous respirations, tag the patient RED and move on.

Pulse Check: Apneic Child Physiological reason to believe an apneic child may still have a pulse. Unlike adults, children usually have primary respiratory failure rather than cardiac failure. Because of this, an apneic child may still have varying degrees of circulation preserved until the heart suffers enough anoxic damage to stop beating effectively. This may occur in adults with primary airway obstruction as well, but adults are much more likely to sustain early cardiac collapse from acute traumatic insults on already compromised body systems. A child who is apneic but still has circulation may be in a “window of salvageability,” in which circulation may be preserved if the respiratory system can be restarted. This “jumpstart” can theoretically can be provided if the lower airways can be opened and the child stimulated to breaths. Rescuers should do pulse check distally.

Pulse Check: Apneic Child If no breathing after airway opening, check for peripheral pulse (child may retain pulse while apnic longer than adult). If no pulse, tag patient BLACK and move on.

Pulse Present Provide 5 breaths with a mouth-to-barrier device. If breathing returns, child is tagged as RED (Immediate). If no spontaneous respirations return, the child is tagged BLACK. As with the upper airway opening maneuver, if this lower airway opening maneuver triggers breathing, the patient is tagged RED, and the triage officer moves on without providing further resuscitation. If no spontaneous breathing results, it’s reasonable to assume that without immediate and sustained resuscitative measures the heart will likely fail very soon, so the patient is tagged BLACK and the triage officer moves on.

Spontaneous Respirations Check respiratory rate: <15 or > 45 are considered critical: tag patients as RED Respiratory rate between 15-45: Check pulse

Children with spontaneous respirations but no palpable pulse (in the least injured limb) are tagged Immediate (RED).

Mental Status Assessment Quick AVPU: Alert (YELLOW) Verbal Stimuli (YELLOW) Physical Stimuli (YELLOW) Unconscious (RED) Those who respond inappropriately to pain ( nonlocalizing, generalized response), who posture or who are completely unresponsive are tagged RED. Those who are alert, responsive to voice or appropriately responsive to pain (e.g. localization and withdrawal) are tagged YELLOW. Note that to be tagged YELLOW in either system, a patient must be unable to walk but have adequately compensated oxygenation, ventilation and perfusion to sustain vital functions and adequate neurological status to be able to protect their own airway. If alert, responsive to verbal, or appropriately responsive to pain, tag as YELLOW and move on. If inappropriately responsive to pain or unresponsive, tag as RED and move on.

Non-Ambulatory Patient Modifications Infants who normally can’t walk yet Children with developmental delay Children with acute injuries preventing them from walking Children with chronic disabilities

Non-Ambulatory Patient Modifications Evaluate with JS algorithm If RED criteria, tag as RED. If YELLOW criteria, assess for external signs of significant injury. If no significant external signs, tag as GREEN. If significant external sign of injury are found, tag as YELLOW. Significant injury—deep penetrating wounds, severe bleeding, severe burns, amputations, distended abdomen.

Deceased (BLACK) Patients Unless clearly suffering from injuries incompatible with life, victims tagged in the BLACK category should be reassessed once critical interventions have been completed for RED and YELLOW patients.

START/JumpSTART Differences Apneic children are rapidly assessed for sustained circulation. Apneic children with circulation receive a brief ventilatory trial as an additional airway opening and stimulating maneuver. Respiratory rates are adjusted. (15-30-45) Peripheral pulse is substituted for cap refill. AVPU is used to assess mental status.

Patient #1: Tammy Teacher Unresponsive RR—36/min No airway obstruction CRT > 4 seconds TRIAGE: Green/Red/Yellow/Black

Patient #2: Pre-School Paula RR > 48/min Weak pulse Responds to pain TRIAGE: Green/Red/Yellow/Black

Patient #3: Pre-School Sam No Respiratory effort Faint pulse Unresponsive TRIAGE: Green/Red/Yellow/Black Give breaths; if apnea continues, tagged as black.

Patient # 4: Tom Teacher TRIAGE: Green/Red/Yellow/Black Ambulated to curb, holding Jenny & Libby RR—28/min CRT 2 seconds Alert; following commands TRIAGE: Green/Red/Yellow/Black

Patient # 5: P.S. Jenny TRIAGE: Green/Red/Yellow/Black Held by Tom Teacher Crying for “Mommy” RR—38/min Pulse present Clinging to Tom TRIAGE: Green/Red/Yellow/Black

Patient # 6: P.S. Libby TRIAGE: Green/Red/Yellow/Black Held by Tom Teacher RR—32/min Pulse present Responds to verbal & tactile stimuli TRIAGE: Green/Red/Yellow/Black

Patient # 7: P.S. Mikey TRIAGE: Green/Red/Yellow/Black RR—28/min Palpable pulse Responds to tactile stimulation TRIAGE: Green/Red/Yellow/Black

Patient # 8: P.S. Lucas TRIAGE: Green/Red/Yellow/Black RR—8/min Pulse weak Unconscious TRIAGE: Green/Red/Yellow/Black

Patient # 9: P.S. Ashley TRIAGE: Green/Red/Yellow/Black RR—36/min No palpable pulse TRIAGE: Green/Red/Yellow/Black

Patient # 10: P.S. Troy TRIAGE: Green/Red/Yellow/Black Crying for Teacher; walked to Tom RR—30/min Pulse present Scared of EMT TRIAGE: Green/Red/Yellow/Black

Questions?