2019 Pediatric Disaster Triage Utilizing the JumpSTART © Method JUNE 2019 (5th Edition) Provider Course Welcome and introductions.

2019 Pediatric Disaster Triage Utilizing the JumpSTART © Method JUNE 2019 (5th Edition) Provider Course Welcome and introductions

2016 Disclaimer This slide set and all related training information provided in this session is in accordance with current practice at the time that this program was developed. Review this disclaimer note with the class.

2016 Acknowledgements This 5th edition education program was developed under the direction and guidance of the Illinois Pediatric Preparedness Workgroup. The original program was adapted in 2006 from a module developed by Children’s Memorial Hospital (now Ann & Robert H. Lurie Children’s Hospital of Chicago). This program is supported in part through the Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) grant. All training materials are considered under public domain and can be utilized by others in the conduction of similar educational programs, provided there is acknowledgement of the source of these materials.

2016 Objectives Identify unique characteristics that make children more vulnerable in a disaster Discuss mass casualty triage and the pediatric patient Review START and JumpSTART© Triage Tools as well as the SMART Triage Pacs™ Demonstrate the use of the START and JumpSTART© Triage Tool Listed here are the objectives that will be addressed during this workshop.

Training Initial JumpSTART© mass casualty triage training is recommended for all EMS, emergency department, and pediatric unit staff, as well as any health care professional who may need to assist during a mass casualty event. JumpSTART© refresher trainings are recommended every other year. Refresher trainings can consist of completing the full JumpSTART© mass casualty triage training, a refresher training defined by the organization, or a relevant online module.

2016 Introduction Before we begin, let’s briefly review the history of Illinois EMSC.

Background Illinois Emergency Medical Services for Children (EMSC)
2016 Background Illinois Emergency Medical Services for Children (EMSC) 1984: National EMSC Program established through federal legislation Jointly sponsored by Maternal & Child Health Bureau National Highway Traffic Safety Administration States are charged with enhancing the pediatric component of their Emergency Medical Services (EMS) systems. 1994: Illinois EMSC was established. Illinois EMSC is funded through a federal initiative aimed at improving pediatric emergency care.

Illinois EMSC Pediatric Disaster Preparedness
2002: Illinois Pediatric Bioterrorism Workgroup convened Name changed in 2011 to Pediatric Preparedness Workgroup to ensure an all-hazards approach. Reports to EMSC Advisory Board and Illinois Terrorism Task Force Assists in assuring that the special needs of children are addressed during a disaster or terrorist event by: Enhancing awareness of pediatric needs Identifying/sharing best practices Developing resource documents, tools, and guidelines Integrating disaster preparedness into existing state initiatives In 2002, Illinois EMSC became involved in disaster preparedness when the Pediatric Bioterrorism Workgroup was formed. The name of this Workgroup changed in 2011 to ensure a more all-hazards approach. The Pediatric Disaster Triage: Utilizing the JumpSTART Method program was originally developed in 2006, and is revised on an ongoing basis to ensure it is up to date with current practice.

Illinois Communities In 2018, Illinois is the 6th most populous state with a population of million 2.9 million children <18 years of age Approximately 764,000 are age five and younger Source: This slide illustrates the current population in the state of Illinois as well as the number of children who are less than 18 years of age. In addition, the current number of children aged five or younger is provided.

Children and Disasters
2016 Children and Disasters Let’s discuss children and disasters.

2016 Disaster “ A medical disaster occurs when the destructive effects of natural or man made forces overwhelm the ability of a given area or community to meet the demand for health care. ” A disaster is an event that overwhelms the available resources in a community. What defines a disaster will depend on the community that it occurs in. In an urban area, an event resulting in 20 patients may not be considered a disaster since many resources available. However, the same event in a rural area, or area with limited resources, may consider it a disaster situation. (Source: ACEP Disaster Medical Services Policy Statement, 2006)

Natural Disasters Earthquake Flood Snow/ice storm Tornado Others 2016
All of us that are involved in health care need to be familiar with the basic aspects of disaster management. However many of you may think that it won’t ever happen to you or in your community. Illinois has the potential to experience all of the natural disasters listed on this slide. In fact, in recent years, a number of areas within Illinois have experienced ALL of these types of disasters. For example: In December 2006, ice storms knocked out power for several weeks in some communities in central Illinois requiring families to relocate and impacting these communities April 18, 2008, an earthquake with magnitude of 5.4 occurred in southern Illinois and several aftershocks were reported. 12 counties in northern Illinois declared disaster areas from flooding in August of 2010 Blizzard in January brought snow and ice storms to a large portion of Illinois In 2017, there were 59 tornadoes reported in Illinois In 2019, the Midwest is affected by massive flooding involving several states along the Mississippi including Illinois Reference:

Man-Made Disasters Terrorist events Arson Bombings Shootings
2016 Man-Made Disasters Terrorist events Arson Bombings Shootings Use of chemical, biological or nuclear agents Hazmat incidents Some examples of man-made disasters are listed here. Similar to natural disaster, we cannot have the mindset that our communities are invincible. These events can occur in urban and rural areas of the state. For instance, the shootings at Northern Illinois University in February 2008, when a high school in Dixon, Ilinois was able to avoid tragedy when an officer stopped a shooter before injuries occurred in 2018, and the shootings at the Henry Pratt Company in Aurora in 2019 are examples of the terror humans can make. In addition to terrorist attacks, other non-intentional man-made disasters such as industrial accidents, or hazmat incidents such as a chlorine leak at a pool can have a tremendous impact on children.

Terrorist Events and the Pediatric Population
2016 Terrorist Events and the Pediatric Population Myth Kids are secondary victims of terrorism and inadvertently targeted Even in the United States, some terrorist attacks clearly demonstrate that children were the intended targets. The 2002 Washington DC sniper, Lee Malvo, stated at his trial that the way to get people’s attention is to target their children. In the 1995 Oklahoma City bombing, Timothy McVey strategically placed the bomb to not only cause the most devastation but to also produce the most casualties (namely in the day care center). There were 168 fatalities and over 800 injured in that bombing incident. Although only 10% of the victims were children, there was a higher mortality in the pediatric victim group (31% of the pediatric victims died versus 21% of adult victims). Fact Children may be intentionally targeted

Harsh Realities: Children as Victims of Disasters
2011: Oslo and Utoya Norway Attacks At least 60 children killed after a gunman opened fire at a youth summer camp 2012: Sandy Hook Elementary School Shooting 26 people killed (20 children and 6 adults) 2018: Stoneman Douglas High School (Parkland, FL) 17 people killed (14 students, 3 adults) 1984: Bhopal, India Industrial gas release (methyl isocyanate) Estimated 20% of victims were children 1999: Columbine High School Shootings 12 students killed, 24 injured 2004: Beslan, Russia Three day hostage event at school 334 hostages killed including 186 (56%) children The same is seen internationally, with children both largely affected and/or specifically targeted.

Why Children are More Vulnerable During Disasters
Increased vulnerability during disasters Anatomical, physiological and developmental differences Gaps in pediatric preparedness in hospitals, agencies, communities, and on the state and federal levels Need appropriate equipment and supplies scaled to physiological size Challenges related to medical interventions and safety Critical emergency care interventions performed infrequently May be intentionally targeted during the disaster From an emergency care perspective, we know that children present unique challenges. The unique differences in children’s physiology and development present a challenge to care providers. Critically ill and injured children are seen to a lesser degree than adult critical patients, so we don’t have opportunities to hone our skills on a day-to-day basis. Many hospitals and EMS agencies do not have the appropriately sized equipment to care for all pediatric age groups. In 2009, a report from the Homeland Security Council identified that the majority of disaster training, exercises, medicines, and equipment used were intended for adults. Children were lumped into broad categories such as “at-risk,” “vulnerable,” and “special needs.” There were no accountability measures to identify who would specifically be responsible for the needs of children before, during, and after disasters. Many of these challenges exist during day-to-day care of the pediatric patient and will only be exacerbated during a disaster. These are reasons why children are more vulnerable in disasters and tend to have higher morbidity and mortality rates. In the next few slides, some of these challenges will be discussed in greater detail.

Respiratory Smaller airway diameter, shorter trachea
Infants up to 6 months are obligate nasal breathers Equipment needs vary based on patient height and weight Respiratory arrest precedes cardiac arrest Airway and respiratory differences between adults and children are illustrated here. Child airway physiology begins to closely resemble adult physiology around 8 years of age. Until then, the smaller airway places them at higher risk for respiratory complications. Debris from trauma and secretions can quickly lead to respiratory distress in infants, who are obligate nasal breathers. In addition, debris can cause edema in an already small airway. These children may require frequent suctioning in order to maintain a clear airway. Airway needs will also vary based on the child’s height and weight. These are important considerations since respiratory arrest is more likely to precede cardiac arrest in children. Milici, J. J. (2019). Respiratory emergencies and thoracic trauma. In Brecher, D. (Ed.), Emergency Nursing Pediatric Course, An ENA Course (pp ). Burlington: Jones & Bartlett Learning. Conlon, P. M. (2017). The child with respiratory dysfunction. In Hockenberry, M. J., Wilson, D. & Rodger, C. C. (Eds.), Wong’s Essentials of Pediatric Nursing (pp ). St. Louis: Elsevier.

Exposure More susceptible:  Infections
 Effects of chemical, biologic, and other agents  Prolonged exposure  Hypothermia Faster respiratory rates Thinner skin/greater body surface area Shorter stature Immature immune system Faster metabolism Children also have faster respiratory rates which results in a more rapid exposure to inhalation agents. Remember, chemical agents may not be the result of a terrorist event, but can result from an industrial incident or tanker truck spill, that results in release of an agent into a community. Children also have thinner skin, which can cause increased susceptibility to vesicating agents such as nitrogen, sulfur mustard, and Lewisite; nerve agents such as Sarin, VX, Tabun, and Soman; and irritant and corrosives such as chlorine, ammonia, and phosgene. The combination of a large body surface area and thin skin increases their risk for skin absorption of these agents. Thinner skin increases their vulnerability to hypothermia. It is important to have warming measures in place, especially during the decontamination process. Some biological and chemical agents are denser than air and accumulate closer to the ground leading to prolonged exposures. The short stature of children can lead to prolonged exposures to chemicals such as Sarin, chlorine, or radiation. Since there is a higher concentration of the agent child’s primary breathing area, children may be more susceptible to agents absorbed through the pulmonary route. They may show earlier effects than adults with the same exposure. Newborns and infants are not only susceptible to infections, but possess less reserves to fight against these infections. In a pandemic flu, such as H1N1, this population is at higher risk. In addition, they are more vulnerable to effects from exposure to radiation and chemical agents. There is a high risk of leukemia and other cancers for those who experience radiation exposure. On a day-to-day basis, it is important to minimize unnecessary imaging to decrease the long term negative effects.

Trauma Trauma Rib cage is more pliable, abdominal muscles thin and less developed Larger head/higher center of gravity Smaller circulating blood volume In children, the rib cage more pliable, so rib fractures are uncommon. Therefore, there is a high chance for injury to the lungs and underlying organs. In addition, the abdominal muscles are thin and less developed resulting in the abdominal organs being less protected. This places the child at risk for injuries to the liver, spleen, and bowel. Children also have a proportionately larger head when compared to their overall height. This creates a higher center of gravity causing children to be “top heavy.” This increases their risk for lack of balance and head injuries. Lastly, children have smaller circulating blood volumes (although proportionate to weight) causing them to be more susceptible to dehydration and hypovolemia. Because they have less fluid reserve to draw upon, when they begin to crash, they do so very quickly. A child’s condition can change from stable to life-threatening instantly. Children can become dehydrated very quickly, and the blood/fluid loss can lead to irreversible shock or even death. Source: Goodman, R. (2014). Special populations: The pediatric trauma patient. In Gurney, D. (Ed.), Trauma Nursing Core Course: Provider Manual (pp ). Des Plaines, IL: Emergency Nurses Association. Higher risk for injury, irreversible shock, and death from traumatic events

Developmental Increased exposure and risk of injuries
May lack cognitive ability to sense a dangerous situation May lack motor skills to flee from danger Increased exposure and risk of injuries Young children lack the cognitive ability to sense a dangerous situation. They are unable to anticipate, recognize, or flee from danger. In addition, they may unknowingly place themselves in more danger. Infants, toddlers, and young children also lack the motor skills to escape. This can result in prolonged exposure to the danger.

Developmental May be preverbal, nonverbal, or not know personal information Age & developmental level influences response to stressful events Stress of the acute situation may limit ability to cooperate, assist in reunification, and increase risk for short and long term psychological effects. Children can be pre-verbal, nonverbal, or are unable to provide personal or medical information. This is even more common in children with special health care needs/functional and access needs. The separation from a parent or caregiver can lead to a delay in providing acute care or addressing the needs of their chronic medical conditions. In addition, the delay can cause an exacerbation on their chronic medical conditions, increasing their risk for complications. In addition, infants, toddlers, and young children who are unable to provide information to care providers are at risk for abduction, abuse, custodial issues, and long term emotional injury. During a disaster, children may be uncooperative with officials/providers. These events have the potential of long term psychological effects on children such as academic failure, post-traumatic stress disorder, depression, anxiety, bereavement, delinquency, and substance abuse.

Children with Special Health Care Needs (CSHCN)/Children with Functional and Access Needs (CFAN)
Can include those kids who are/have: Technology dependent (ventilators, G-tubes, shunts, insulin pumps) Developmentally delayed or disabled Chronic diseases Immunocompromised Psychiatric/behavioral illnesses Many emergency personnel and disaster responders are not used to dealing with this population As we talk about Children with Special Health Care Needs, its important to note that this population may also be referred to under the Functional Needs Category. These children represent a substantial percentage of children within our country and our own state. Because of advances in medicine, these children are able to live lengthier lives than in the past and many of these children are mainstreamed into regular schools. Since this population tends to be poor and socially disadvantaged, these families typically have less resources to draw upon in emergencies or disaster situations. REVIEW SLIDE (Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook. 2009–2010. Rockville, Maryland: U.S. Department of Health and Human Services, 2013) 23% of U.S. households have at least 1 child that meets criteria 15.1% (>11.2 million) children in U.S. meet criteria Illinois: 14.3% (452,574)

Mass Casualty Incident (MCI) Triage
2016 Mass Casualty Incident (MCI) Triage Let’s discuss Mass Casualty Incident, or MCI, triage.

Triage Sorting and prioritizing patients
2016 Triage Sorting and prioritizing patients Looks at the medical needs and urgency of each individual patient Conventional Triage Do the best for each individual Disaster/MCI Triage Do the greatest good for the greatest number Based on physiology Provides an objective framework for stressful and emotional decisions Helps in resource allocation Triage stems from the French word “trier” which means “to sort.” It is a dynamic, ongoing process that is completed multiple times throughout an incident. This process helps to prioritize patients in an organized manner. In conventional medicine, we strive to do the greatest good for each patient. In disaster, the patient population exceeds the available resources. Therefore, we must work to do the greatest good for the greatest number. The standards of care must be altered.

MCI Triage Primary Triage Secondary Triage
2016 MCI Triage Primary Triage Typically performed at the scene of the incident Helps prioritize patients for evacuation/transport Can occur at a hospital Secondary Triage Performed to re-evaluate the patient for possible changes in clinical status after primary triage has been completed Takes place at the scene of the incident if prolonged scene time or at an additional treatment location Can also be done once the patient arrives at the hospital. Primary Triage- Primarily occurs at the scene of the incident. It is simply about categorizing the patient based on the priority for evacuation and transport, then moving on to the next patient. Secondary Triage- Typically occurs at the scene of the incident if there is prolonged scene time or at an additional treatment location. Secondary triage can also occur once the patient arrives at the hospital.

Mass Casualty Incident
2016 Mass Casualty Incident Any incident in which there are more patients than rescuers MCI’s are incidents that overwhelm the available resources. It results in more patients than available resources can manage using routine procedures. Imagine an incident occurring in the picture above at an event at Grant Park in Chicago. Imagine responding to that incident. Imagine you are the initial responder to such a scene. What would your first steps be? Where would you begin? Source:

~80% of casualties self or buddy transport to the closest hospital
2016 ~80% of casualties self or buddy transport to the closest hospital The vast majority of mass casualty patients DO NOT WAIT FOR EMS. They self or buddy transport to the closest ED. For example, during the 2017 Las Vegas shootings, less than 20% of patients were transported to hospitals by EMS. The majority of patients were self transported or found other means of transportation. Therefore, both EMS and hospital personnel can benefit from knowing mass casualty triage and decontamination methods. To those who work in an emergency department…. You will be triaging these patients at your facility. They cannot be processed through your routine triage method (for example: 3 level triage system or 5 tier ESI (Emergency Severity Index) since it is likely that your ED will become quickly overwhelmed due to the sheer volume. A rapid triage system will be needed. Source: ASPR Blog. (2018). Healthcare Response to a No-notice incident: Lessons learned from Las Vegas Festival Shooting. Retrieved June 14, 2019 from

This includes children!
2016 MCI Triage All victims must have equal importance at the time of primary triage Sort patients based on the need for immediate care Be able to recognize futility No patient group can receive special consideration other than that dictated by their physiologic state It is important to utilize an objective triage system in order to achieve the greatest good for the greatest number. Mass casualty triage should be performed equally among all patients, regardless of age. Decisions should be based only on their physiological state. It is important to remember to resist the tendency to assign pediatric patients to a higher triage category just because they are children. This includes children! (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

MCI Triage Categories IMMEDIATE = Emergent DELAYED = Urgent
2016 MCI Triage Categories IMMEDIATE = Emergent DELAYED = Urgent MINOR = Non-urgent/walking wounded EXPECTANT/DECEASED = Dead/little to no hope of survival Let’s review the triage categories utilized in MCI triage tools. When we begin to go through the triage process using JumpSTART, you will see that not everyone agrees on the triage categories to assign individual patients. This emphasizes the importance of using an objective process based on the physiological components of the triage tools. This ensures we are triaging in a consistent manner. Providers frequently use colors, such as red, yellow, and green, to describe the MCI triage categories. Providers are now being encouraged to use plain terminology instead of colors for each of the categories: immediate, delayed, minor, and expectant/deceased. For the purpose of this training, the correct term as well as the corresponding color code to assist with the transition.

2016 IMMEDIATE Severely ill/injured but treatable and able to be saved with relatively quick treatment and transport Examples: Severe bleeding Shock Open chest or abdominal wounds Severe respiratory distress Patients who are triaged as immediate (red) are at risk for death due to their life threatening injuries or illnesses. Examples include shock or severe head injury. All rescuers should work to stabilize these patients, and transport them from the scene quickly. Past events and research has illustrated that uncontrolled bleeding is the number one cause of preventable death from trauma. If a patient has signs of uncontrolled bleeding, it is important that the bleeding is controlled as quickly as possible. Methods of bleeding control can include but are not limited to covering the wound and applying pressure with both hands, utilizing a tourniquet, or packing the wound and applying pressure with both hands. After controlling the bleeding yourself, or delegating to another person, categorize these patients as IMMEDIATE and continue triage duties. Source: American College of Surgeons. (2017). Stop the bleed brochure. (Source: Optimistworld.com/anaphylaxis) NOTE: If there are any sources of uncontrolled bleeding, apply a method of bleeding control, and categorize as IMMEDIATE.

2016 DELAYED Injured/ill and unable to walk on their own; Potentially serious injuries/illnesses but stable enough to wait a short while for medical treatment Examples Burns with no respiratory distress Spinal injuries Moderate blood loss Conscious with head injury This slide provides some examples of those victims that would be triaged as delayed (yellow). These patients should be reassessed as more personnel becomes available. (Source: EMSWorld.com)

2016 MINOR Minor injuries/illnesses that can wait for a longer period of time for treatment Examples Able to ambulate Fractures without neurovascular compromise or gross deformity Hemostatic, non-arterial bleed lacerations Minor patients are considered the “walking wounded.” Although these victims have minor injuries, they are still patients and may need reassurance that they will receive treatment and/or transport for care. These patients should be reassessed as more resources become available to ensure their condition has not deteriorated. Some patients in this category may refuse treatment/transport, and leave the scene or hospital. However, these patients need to have been appropriately evaluated and triaged, prior to signing a refusal. At any time a patient refuses treatment, the appropriate documentation must be obtained.

2016 EXPECTANT/DECEASED Dead or obviously dying; May have signs of life but injuries are incompatible with survival Examples Cardiac arrest Respiratory arrest with a pulse Note for children: Respiratory arrest with a pulse who are unresponsive to 5 rescue breaths Obvious traumatic brain injury Unless clearly suffering from injuries incompatible with life, victims tagged in the expectant/deceased category should be reassessed once critical interventions have been completed for the immediate and delayed patients. Remember, children are categorized as expectant/deceased if they are in respiratory arrest and remain unresponsive after 5 rescue breaths. Check your local protocols to determine how and where deceased patients should be transported

Triaging Expectant/Deceased Patients
2016 Triaging Expectant/Deceased Patients Can be psychologically difficult to tag a child as Expectant/Deceased Can be hard to resist the tendency to assign pediatric patients a higher triage category just because they are children Using a MCI triage tool especially with children can help to eliminate the role of emotions in the triage process Objective triage criteria during a MCI can provide emotional support for triage personnel forced to make life or death decisions for children As additional resources become available, patients tagged as expectant/deceased with signs of life can be re-evaluated When triaging a child to the expectant/deceased category, the process can be extremely difficult and cause psychological trauma. For the first responder, this is especially true if the child still has signs of life. It is difficult to terminate care for a child. This is why utilizing an objective triage process, such as JumpSTART, can help with the decision making process. Remember, as more resources become available, expectant/deceased patients with signs of life can be re-evaluated.

Special Considerations
2016 Special Considerations The emotionally out of control patient Consider utilizing the “buddy system” or other means to calm patient If effective, follow normal triage process If ineffective, tag as IMMEDIATE to remove them from the scene rapidly First Responders Tag as IMMEDIATE to initiate care. This will allow fellow responders to focus on triage and care responsibilities as opposed to their injured colleague Special considerations should be made for the emotionally out of control patient and for first responders. The emotionally out of control patient can increase havoc and panic at the scene. First, it will be important to try and calm the patient. Different calming techniques should be utilized, such as the buddy system. The buddy system pairs the patient with another individual whose responsibility is to keep the patient calm. If calming techniques or the buddy system are effective, follow the normal triage process. If these methods are ineffective, tag the patient as IMMEDIATE to remove them from the scene rapidly. Injured first responders can result in other first responders to become distracted due to their concern for their colleague. Tag these patients as IMMEDIATE to initiate care and allow fellow responders to focus on triage and care responsibilities.

MCI Triage Considerations
2016 MCI Triage Considerations Incident command (IC) Process what you see and hear in 30 seconds and paint as accurate a picture as you can in your report to IC Scene Safety Ensure the scene is safe before entering Assess for need for decontamination Designate Treatment Areas Establish areas for each triage color category Triaged patients should be moved to designated areas Scene safety is an important consideration during MCI triage. On-scene personnel need to assess for hazards and ensure the area is safe and secure for medical personnel to enter. In addition, bystanders and other victims may react when they see a victim categorized as expectant/deceased, especially if it’s a child. Their inability to cope can add chaos to the scene, and possibly jeopardize the safety of response personnel. Hospitals should determine if patients require decontamination before entering the facility. In addition, while performing MCI triage, it is important to designate treatments areas for each triage category that is safe and secure. Lastly, triage personnel need to maintain contact with their incident command structure. An accurate report is essential to coordinate adequate resources and efforts.

2016 MCI Triage Tools And now we’re going to review the START and JumpSTART triage tools and the SMART Triage Pacs.

MCI Triage Tools START Algorithm JumpSTART© Algorithm
2016 MCI Triage Tools START Algorithm JumpSTART© Algorithm SMART Triage Pacs™ The START and JumpSTART algorithms are the most commonly used MCI Triage tools in the United States. Currently, no primary MCI triage tools have been validated through research. Despite this, START and JumpSTART are most frequently used because they are based on physiology, are simple to use, and provide an objective approach to triaging patients of all ages.

2016 START Triage Let’s begin with START triage.

START Simple Triage And Rapid Treatment
2016 START Simple Triage And Rapid Treatment Joint development by the Fire & Marine Department and Hoag Hospital in Newport Beach, California Gold standard for field adult MCI triage in the U.S. and numerous other countries Utilizes the standard four triage categories Used for primary triage More information at START Triage Many of you may be familiar with the START Triage system which is considered the gold standard for field triage of adults in a mass casualty incident.

START Triage Algorithm
2016 START Triage Algorithm START triage is a rapid triage system that involves a quick ABC assessment. It also allows for interventions of airway positioning and bleeding control to be completed during the process. We will briefly review the steps in the START Triage Algorithm for adults.

2016 START Triage Algorithm Step 1: Requires the triage officer to announce that all patients that can walk should get up and walk to a designated area for eventual secondary triage. All ambulatory patients are initially tagged as MINOR (green).

2016 START Triage Algorithm Step 2: This area has two different paths. The triage officer assesses patients in the order in which they are encountered. Assess each adult patient for the presence or absence of respirations. If spontaneous breathing is absent, open the airway using standard positional techniques. If the patient starts breathing with repositioning, the patient is tagged as IMMEDIATE (red). Continue to the next patient. If the patient remains apneic despite repositioning the airway, tag as EXPECTANT/DECEASED. Continue to the next patient.

2016 START Triage Algorithm If spontaneous breathing is present, assess the rate. If the rate is less than 30/minute, move to step 3. If the respiratory rate is greater than 30/minutes, tag the patient as IMMEDIATE (red).

2016 START Triage Algorithm Step 3: The victim is next assessed for perfusion. Capillary refill or radial pulse can be used for assessment. If the radial pulse is absent or the capillary refill is greater than 2 seconds, control any signs of obvious bleeding, and tag the victim as IMMEDIATE (red). If a radial pulse is present or capillary refill is less than 2 seconds, continue to step 4.

2016 START Triage Algorithm Step 4: Assess the mental status of the patient. If the victim cannot follow simple commands, is unconscious, or has an altered mental status, tag as IMMEDIATE (red). If the victim can follow simple commands, tag as DELAYED (yellow).

2016 JumpSTART© Triage We will now go through step by step the process of JumpSTART Triage

2016 JumpSTART© Triage Developed in 1995 to parallel the START Triage system and revised in 2002 Designed for use in MCI events Provides an objective framework to decrease the emotional burden on medical personnel who have to make rapid life or death decisions about children Reflects unique aspects of pediatric physiology Originally used with children under 8 years old but now used on any victim that appears to be child Can be completed within 30 seconds JumpSTART is a pediatric MCI system developed by pediatric emergency physician Dr. Lou Romig. This tool assists triage personnel who have to make life or death decisions about children in a MCI setting. An objective tool eliminates the role of emotions in the triage process. It also optimizes triage effectiveness to benefit ALL victims, not just children. Remember, JumpSTART is a tool to facilitate making a triage decision. (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

2016 JumpSTART© Triage In children, typically respiratory failure precedes circulatory 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 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 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/ hypo-perfusion) to make them non-salvageable in the MCI setting. This differs with children in that respiratory failure usually precedes circulatory failure. Apnea can occur relatively rapidly. 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 when the child is potentially salvageable is considered a method to “jumpstart” the child’s respirations.

JumpSTART© Triage and Age
2016 JumpSTART© Triage and Age What age defines the pediatric patient? What age would the JumpSTART algorithm be used versus the START algorithm? Pediatrics covers a wide range of ages—from neonate to adolescent. Many hospitals define the pediatric patient through 15 years of age. As we have previously stated, the airway of a child approaches that of an adult at age 8. However, children at this age should not be classified as an adult since they still have different psychological needs.

JumpSTART© Triage and Age
2016 JumpSTART© Triage and Age 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 When we need to make a quick decision, how do we define who fits into the pediatric category? Children around the ages of 9 – 12 (prior to their teen years) are sometimes the most difficult to determine age and therefore whether to utilize the JumpSTART versus START tool. In the 2002 revisions of JumpSTART Triage Tool, the age limit was removed and the guideline is now “if a victim appears to be a child, use JumpSTART and if a victim appears to be a young adult, use START.” (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

Differences Between START and JumpSTART©
2016 Differences Between START and JumpSTART© START JumpSTART© Airway If positioning the airway does not restart breathing, patient tagged as Expectant/Deceased If positioning the airway does not restart breathing, a ventilation trial is given if pulse is palpable Perfusion/Circulation Capillary refill or peripheral pulses can be used to assess perfusion Only peripheral pulses are used to assess perfusion Mental Status Ability to follow commands is used to assess mental status AVPU is used to assess mental status As discussed earlier, the different physiological differences between children and adults are built into the START and JumpSTART Triage tools. AIRWAY: Since an apneic adult typically has also developed cardiac injury due to hypoxia/ hypo-perfusion, if opening their airway does not restart breathing, they are considered non-salvageable in the MCI setting and labeled as expectant/deceased. Since respiratory failure usually precedes circulatory failure in children, a brief trial of 5 ventilations is given. PERFUSION: Since children are more sensitive to external temperature changes, capillary refill may not be an accurate method to assess perfusion like it is in adults. Therefore, peripheral pulses are used instead. MENTAL STATUS: The final difference between these two triage tools is how to assess mental status. Since children, especially infants and young children, may be limited in their ability to follow commands due to age related cognitive developmental levels, the AVPU method is used. A = Alert V = Verbal P = Pain U = Unresponsive

2016 This is the JumpSTART algorithm. We will be reviewing it in more detail shortly. 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) and is incorporated into PEPP, PALS, and APLS courses. It is commonly used throughout the U.S. and Canada and is being taught in other countries such as Germany, Switzerland, and Japan.

2016 Step 1 Patients who are able to walk are assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illnesses. These are triaged as MINOR . Step 1: Requires the triage officer to announce that all patients that can walk should get up and walk to a designated area, such as a tree, for secondary triage and treatment. These are your MINOR patients.

Evaluate all non-ambulatory victims that are carried to the MINOR area
2016 Step 2 Evaluate all non-ambulatory victims that are carried to the MINOR area Step 2: Unlike adults in the START triage method, not everyone in the MINOR zone should be assumed to have minor injuries. Non-ambulatory children such as infants, or children who are developmentally delayed, may have been carried into the MINOR area. Let’s discuss how to handle these children.

Non-ambulatory Children
2016 Non-ambulatory Children Non-ambulatory children include: Infants and young toddlers who have not yet learned to walk Children with developmental delays Children with acute injuries which prevented them from walking before the incident occurred Children with chronic disabilities Infants, children with special needs, and other children who are not ambulatory may be carried to the MINOR area. All children that are carried to the MINOR area must be the first patients that are assessed by medical personnel in that area. Non-ambulatory children who are brought to the MINOR area must undergo secondary triage starting with step 2 to determine triage category. CHILDREN MEETING THIS CRITERIA SHOULD BE EVALUATED USING THE JumpSTART © ALGORITHM BEGINNING WITH STEP 2

Non-ambulatory Children
2016 Non-ambulatory Children All children carried to the MINOR area by other ambulatory victims must be the first assessed by medical personnel in that area. If a child meets any immediate criteria, tag as IMMEDIATE If a child has significant external signs of injury, tag as DELAYED If a child has no significant external signs of injury, tag as MINOR If a child meets the criteria for the expectant/deceased category (including remaining apneic after 5 rescue breaths with a pulse), tag as EXPECTANT/DECEASED All non-ambulatory children that are carried to the MINOR area must be evaluated using the JumpSTART algorithm and assessed first. Triage for non- ambulatory patients should start with step 2 or with the assessment of their respiratory status. If the child meets any IMMEDIATE criteria, they are tagged as IMMEDIATE. If a quick survey determines there are significant external signs of injury (i.e. deep penetrating wounds, severe bleeding, severe burns, amputations, distended & tender abdomen, or multiple bruises), tag the victim as DELAYED. Non-ambulatory children without signs of significant external injury, along with normal JumpSTART algorithm aspects, are tagged as MINOR. If a child meets the criteria for the expectant/deceased category, tag as EXPECTANT/DECEASED.

Triage the remaining victims in the order that they are encountered.
2016 Step 2 Triage the remaining victims in the order that they are encountered. Assess the breathing status of each child. If the child is breathing spontaneously, go on to step 3 If child is apneic, position the upper airway. If they start to breathe on their own, tag them as IMMEDIATE Step 2: The triage officer then assesses patients in the order in which they are encountered. Assess each pediatric patient for the presence or absence of spontaneous respirations. If the child is breathing spontaneously, continue to step 3 to evaluate the respiratory rate. If the patient is apneic or has irregular breathing, open the airway using standard positioning techniques. If positioning results in spontaneous respirations, tag the patient as IMMEDIATE (red) and continue to the next patient.

2016 Step 2 (Continued) If the child is still apneic after positioning their upper airway in Step 2 and they have no palpable pulses, tag as EXPECTANT/ DECEASED A child who is apneic is much more likely than an adult to have a primary respiratory problem. The perfusion in the apneic child may be maintained for a short period of time and it is during this brief time that the child may still be salvageable. If the child is apneic, assess for a pulse. If the patient does not have a pulse, tag the child as Expectant/Deceased, and continue to triage other patients. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES

2016 Step 2 (Continued) If the child is still apneic after positioning their upper airway but has a palpable pulse, give 5 rescue breaths. If they start breathing spontaneously, tag as IMMEDIATE If they remain apneic, tag as EXPECTANT/DECEASED If the apneic child has a palpable peripheral pulse, provide 5 rescue breaths. If this results in spontaneous breathing, tag the victim as IMMEDIATE (red). If the child remains apneic, tag them as EXPECTANT/DECEASED. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES

2016 FOR THOSE CHILDREN WHO REMAIN APNEIC AFTER 5 RESCUE BREATHS, DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES. To emphasize, if the “jumpstart” ventilation of 5 rescue breaths does not lead to the return of spontaneous respirations, do not continue to ventilate the patient. Tag the victim as expectant/deceased, and continue to triage other patients. Remember, as more resources become available, these patients can be re-evaluated. If the patient starts breathing, tag the child as IMMEDIATE (red).

2016 Step 3 Assess the respiratory rate of each spontaneously breathing child. If <15 or > 45, tag as IMMEDIATE If 15-45, go to Step 5 Step 3: Assess the respiratory rate of each spontaneously breathing child. If the respiratory rate is less than 15 or greater than 45, tag the child as IMMEDIATE (red) and move on to the next child. If the respiratory rate is between 15 and 45, proceed to step 4.

Step 4 Assess the child’s perfusion.
2016 Step 4 Assess the child’s perfusion. If no palpable pulse, tag the child as IMMEDIATE If the child’s pulse is palpable, move on to Step 5 Step 4: Assess the child’s perfusion. Palpable pulses are a better indicator of perfusion than capillary refill in a child because capillary refill may not adequately reflect peripheral hemodynamic status if the environment is cool or cold. If the child has a palpable pulse, proceed to step 5 If a palpable peripheral pulse is absent (in the least injured limb), tag the patient RED/IMMEDIATE and move on to the next patient.

Step 5 Assess the child’s mental status.
2016 Step 5 Assess the child’s mental status. If child is inappropriately responsive to pain, posturing, or unresponsive, tag as IMMEDIATE If child is alert, responds to voice or appropriately responds to pain, tag as DELAYED Step 5: Assess the mental status of the child. For adults, the START algorithm assesses mental status through ability to follow a simple command. However, due to cognitive abilities that can vary by age and developmental level in the child, the JumpSTART algorithm utilizes the AVPU mnemonic. If the patient is alert, responsive to verbal stimuli, or appropriately responds to painful stimuli (such as pulling away or crying), tag as DELAYED (yellow) and continue to the next patient. If the patient has no response to pain (U), or has an inappropriate response (such as a staring gaze), or begins posturing, categorize as IMMEDIATE (red) and continue to the next patient.

SMART Triage Tag System
2016 SMART Triage Tag System

State Mass Casualty Triage System
2016 State Mass Casualty Triage System State committee identified need for consistency in MCI triaging throughout Illinois Various MCI triage systems reviewed Endorsement of SMART Incident Command System™ for use in Illinois 2007-Statewide distribution of SMART Triage Pacs™ Illinois Custom-Designed SMART Pacs™ Contains a START and JumpSTART© algorithm card Does not have the SMART Pediatric Tape (tape not approved for use in Illinois) In 2004, a state committee was convened in Illinois in order to review various MCI triage systems and adopt a standardized triage system to ensure consistency throughout our state. The SMART Incident Command System, which has many components to it, was chosen. For this class, we will be focusing only on the SMART Triage Pacs within the SMART Incident Command System. In 2007, grant funds enabled the SMART triage pacs to be distributed to both hospitals and pre-hospital agencies throughout Illinois. These guidelines seek to ensure consistency throughout the state with the type of triage system that is being used. Utilizing only the SMART Triage pacs will promote consistency and ease of care across jurisdictions. Each Illinois SMART Pac should contain triage tags as well as a START and a JumpSTART algorithm card tethered to the inside of the bag. Please note that if you have purchased additional SMART pacs 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.

SMART Triage Pacs™ MCI triage tags
2016 SMART Triage Pacs™ MCI triage tags Part of a larger Command System product that includes ability to assist with tracking patients from the scene. Full system not necessary to use triage tag portion SMART Triage tags are recommended to use in Illinois The SMART Incident Management System is a product for use in an MCI event and includes the SMART triage pacs. The SMART triage pac is a product or equipment that can be used to organize and perform START and JumpSTART triage. It does not replace using either the START or JumpSTART Algorithm. INSTRUCTORS: Provide tags to participants, demonstrate how to use them and where the information on the next few slides can be found on the tags. (Source: emsstaff.buncombecounty.org)

SMART Triage Pacs™ Triage tags
2016 SMART Triage Pacs™ Triage tags Equipment used to perform START and JumpSTART© triage Have standard barcodes for tracking patients Card folds to the assigned color and only shows one color at a time Allows patients to be re-triaged to another color classification without having to replace the tag and reassessment can be documented on the same tag Separate tags for Expectant/Deceased category The SMART Incident Management System is a product for use in an MCI event and includes the SMART triage pacs. The SMART triage pac is a product or equipment that can be used to organize and perform START and JumpSTART triage. It does not replace using either the START or JumpSTART Algorithm. INSTRUCTORS: Provide tags to participants, demonstrate how to use them and where the information on the next few slides can be found on the tags. (Source: emsstaff.buncombecounty.org)

SMART Triage Pacs™( Continued)
2016 SMART Triage Pacs™( Continued) Inside each SMART Triage Tag, there are the three colors: Red, Yellow, and Green. In addition to the color sections, there are areas to document patient information if it is able to be obtained. This part of the card asks for patient details including gender, age, complaint, demographic information and medical history. In a true MCI event, obtaining much of this information may not be possible. If the parent is on scene with a child victim, attempt to obtain as much information about the child as possible including the parent’s name and contact information in case the child and parent get separated.

SMART Triage Pacs™( Continued)
2016 SMART Triage Pacs™( Continued) These show the other areas on the SMART Triage cards. Patient assessment, interventions and vital signs, and a Glasgow Coma Scale are included on each card. After filling in any information that was able to be obtained, fold the card up so the assigned priority color/level is facing out, put the card back in the plastic pouch and attach the tag to the patient. If the patient is expectant/deceased, slide both the Triage card as well as the black DEAD card (with the color facing out) into the pouch. Ensure that there is only one priority color visible to avoid confusion.

START Triage vs. the SMART Triage Pacs™
2016 START Triage vs. the SMART Triage Pacs™ The START algorithm looks like this… The SMART Triage Pacs™ algorithm looks like this... The adult algorithm that is in the SMART Triage PacsTM looks different than the official START algorithm. However, the same physiologic parameters apply as well as the same algorithm steps to determine whether to categorize the victim to immediate, delayed, minor, or expectant/deceased. The SMART Company simply formatted the algorithm a bit differently. Although these algorithms look different… THEY ARE THE SAME

2016 Scenarios Lets review some scenarios and apply the START and JumpSTART triage method.

2016 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. You are the first responder and you find 20 + kids. Some are still in the bus and train while some are lying about the road. Review scenario.

2016 Scenario 1 (continued) 10 y/o female, open femur fracture, breathing 10/min, good distal pulse, groans to verbal stimuli This is the first victim that you encounter. What color triage category would you assign to this patient?

Lying outside the bus in a pile of debris
2016 9 y/o M RR0 Faint distal pulse Unresponsive Lying outside the bus in a pile of debris 50 y/o F RR 20 Cap refill < 2 sec Obeys simple commands Dizzy & unable to walk 10 y/o F RR 22 Good distal pulse Asks for help Walking 9 y/o F RR 12 Distal pulse absent Groans to painful stimuli Lying in the ditch 15 ft away 10 y/o M RR 26 Distal pulse present Obeys commands Unable to move his legs; pt asking for wheelchair 25y/o F RR12 Cap refill 4 sec Eye movement to stimulation 6 months pregnant Here are more patients you encounter at the scene and need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 9 y/o male- Airway repositioned. Remains apneic. 5 rescue breaths given and patient starts breathing on his own. Tag as RED/IMMEDIATE. Tag as IMMEDIATE (red). 10 y/o male- Wheelchair found lying 15 feet away from victim. Victim asking to be helped back into his wheelchair. Tag as GREEN/NONURGENT. Tag as MINOR (green). INSTRUCTORS: address any questions that may arise after reviewing each of these “victims” triage color assignment.

2016 Scenario 2: F5 Tornado An F5 tornado has struck within your city/town. It occurred at 3pm while school was letting out. The tornado touched down near 3 schools and a shopping mall. Here is a second scenario to review.

Scenario 2 (continued) School Age Girl Open arm fracture
2016 Scenario 2 (continued) School Age Girl Open arm fracture RR 26, and pulse Alert and talking This is the first victim you encounter as you begin triaging. Based on the physiologic findings for this victim, the primary triage color assignment is MINOR (green).

Pulse present but irregular Responds appropriately to pain
2016 8 y/o M RR 10 Weak, thready pulse Unresponsive Outside, face down 3 y/o M RR 18 Pulse present but irregular Responds appropriately to pain Deformity to lower extremity 9 m/o F RR 44 Pulse present Responds to voice Carried to minor area by mother; Superficial lacs to head/face 10 y/o M Screaming Not focusing Running in hall; calming attempts unsuccessful 50 y/o F RR 32 Weak pulse Not following commands Trapped under bookcase 7 y/o M RR 0, after 5 rescue breaths; apneic Very weak Pulse Trapped under rubble Here is the list of the rest of the victims you need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 9 m/o female: Carried to the MINOR area by her mother 10 y/o male: Attempts to calm the patient are unsuccessful. Patient unable to respond appropriately to rescuers. 7 y/o male: 5 rescue breaths are given after positioning airway. Child continues to be apneic

Scenario 3: High-Rise Fire
2016 Scenario 3: High-Rise Fire Fire reported on 15th floor Smoke to the 16th and 17th floors. The building’s day care center is located on the 17th floor with 30 kids and 6 employees. Here is the last scenario that we’ll review. (Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE)

Burns to abdomen; wheezing
2016 4 y/o F RR 38 Radial pulse present Knows name and recalls incident Facial burns, coughing 53 y/o F RR 48 Cap refill > 2 sec Moaning Burns to abdomen; wheezing 3 y/o F RR 0 Weak pulse Unresponsive; airway repositioned with 5 rescue breaths resulting in spontaneous respirations Found under desk 4 y/o M RR 45 Pulse present Crying No obvious injuries 2 y/o M RR 20 Palpable pulse Hoarse cry Soot to face 3 y/o M RR 28 Strong palpable pulse Carried to minor area; crying 2nd/3rd degree burns to extremities These are the victims you need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 4 y/o F – Parameters indicate patient would be a MINOR since all within normal range. Discuss with student concepts of overtriaging if indicated patient would be a DELAYED 3 y/o F – The airway is repositioned with no response so 5 rescue breaths are given. The patient responds with return of spontaneous respirations so she is tagged as IMMEDIATE (red). 2 y/o – This patient is non ambulatory and has been carried into the MINOR area by a day care worker. As the patient is now being triaged, consider that the hoarse cry and soot to face may be indicative of pending respiratory compromise, so tag as DELAYED (yellow). Discussion point: compare this patient to initial 4 y/o patient and the difference between triaging the 2 y/o as a yellow but not the initial 4 y/o. The 2 y/o has signs of respiratory comprise at the time of triage compared to the 4 y/o who may develop respiratory comprise but at the time of initial triage, no signs of respiratory distress noted. For these patients it is so important to emphasize the information provided in columns 2, 3 and 4 (respiratory status, perfusion status and their mental status) as this evaluates their PHYSIOLOGIC state. With burns there is a tendency to want to triage to a higher level. Understand that this is PRIMARY triage. If the patient ‘s clinical condition deteriorates, then in secondary triage, they can always be advanced to the next highest category.

Scenario 3 (continued) 5 kids are carried out, all being given CPR.
2016 Scenario 3 (continued) 5 kids are carried out, all being given CPR. As lead triage officer, what do you do? Additional scenario information: The elevator doors open and you look up to find 5 rescuers performing CPR on 5 kids. As the lead triage officer, what should you do? Based on limited resources and these not being your only patients, they should all be triaged to Category Expectant/Deceased Questions to note: How many resources do you have? Are these your only patients? (Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE)

2016 Recovery Let’s continue to recovery.

Taking Care of Yourself
2016 Taking Care of Yourself After a critical event, rescue workers often struggle to get back to their daily lives and deal with their experiences Can have difficulty coping and feeling back to normal Look for mental health resources/professionals that may be available through your employer/organization or in your community No one should feel alone in this process or that one has to get through this completely on their own It is important as health care professionals that we take care of our own mental health needs. It may be difficult for responders to cope and continue daily activities after a traumatic event. It can be months or even years, before the full impact of the event is felt. Many times, it is a struggle to continue daily activities. In addition, there have been instances when the media has turned heroes into overnight sensations, adding additional stressors to daily life. Know that resources and organizations are available to assist after a traumatic event. Be sure to talk to others and seek help.

Conclusion START/JumpSTART are the MCI triage systems used in Illinois
2016 Conclusion START/JumpSTART are the MCI triage systems used in Illinois SMART Triage Tags are recommended for use in Illinois JumpSTART incorporates unique aspects of pediatric physiology Provide an objective framework to assist responders with making difficult life or death decisions during a disaster Helps provide emotional support when responders know they followed the protocols In conclusion, START and JumpSTART are the MCI triage systems in Illinois. In addition, the SMART Triage tags are recommended for use. Remember that MCI triage categorizes based on physiological assessments. JumpSTART incorporates the unique aspects of pediatric physiology. Because triaging is difficult in a mass casualty incident, this method provides an objective framework to assist responders with making life or death decisions.

2016 ANY QUESTIONS? Any questions?

Applying START and JumpSTART©
2016 Applying START and JumpSTART© And now we are going to have you get some practice using the START and the JumpSTART triage tools. You will be given SMART disaster tags as well as ‘victims’ that you will need to appropriately categorize. The information you need to correctly triage will be on a card that accompanies the victim. When assigning triage color categories, please don’t rip off the triage tag but simply turn it under so the color you assign is showing. Instead, mark your triage decision on the patient tracking from You will be organized into groups of___rescuers and will utilize the START and the JumpSTART triage methods to assist in assigning a triage category. You will have ___ minutes to triage your group of assigned victims. After that time we will come back together to discuss the proper triage category.

2016 Thank you!

2019 Pediatric Disaster Triage Utilizing the JumpSTART © Method JUNE 2019 (5th Edition) Provider Course Welcome and introductions.

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2019 Pediatric Disaster Triage Utilizing the JumpSTART © Method JUNE 2019 (5th Edition) Provider Course Welcome and introductions.

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