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.

Name: 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.
Uploaded: 2017-07-08T00:42:32+00:00
Duration: PTM23S16
Channel: Aracely Bales
Description: 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.

Triage “To Sort” Look at medical needs and urgency of each individual patient Triage in Daily Emergencies Do the best for each individual Disaster Triage Do the greatest good for the greatest number Make an impossible task manageable Triage comes from a French word and means “to sort”. It is a dynamic process and is usually done more than once It looks at medical needs and the urgency of each individual patient

Following a large disaster, 80% of people involved will transport themselves to the closest ER.
These people are ambulatory, most have minor injuries, and the sheer number will overwhelm most ER’s. Then, the critically ill patients start arriving by ambulance….

Triage Categories RED- immediate/emergency YELLOW- Urgent
GREEN- nonurgent/walking wounded BLACK- dead/ little to no hope of survival Before 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.

SMART Tag System System of triage adopted by Illinois
Triage tags have standard barcodes for tracking patients and reuniting families Triage tags have a unique folded design that allows patients to be re-triaged to another color classification without having to replace the tag In 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.

START Triage Simple Triage And Rapid Transport
Gold standard for field adult MCI triage in US and numerous other countries Utilizes the four standard color triage categories Used for primary triage

JumpSTART Triage Tool for pediatric mass casualty field triage
Provides objective framework Based primarily on physiologic differences between children and adults Useful for kids of all ages Designed for use in Disaster/MCI events If positioning airway does not restart breathing, a ventilatory trial is administered in JumpSTART Peripheral pulse is used to assess perfusion in JumpSTART The AVPU scale is used in JumpSTART JumpSTART 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

JumpStart In children, circulatory failure usually follows respiratory failure. Apnea may occur relatively rapidly, rather than after a prolonged period of hypoxia. There may be a brief period when the child is apneic but not yet pulseless since the heart has not yet experienced prolonged hypoxia. It is felt that providing a brief trial of ventilations may help “jumpstart” their respirations. 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.

Adult or Child?? It can be difficult to discern the age of a child especially pre-teen and early teen years, and which triage tool to use If a victim appears to be a child use JumpSTART If a victim appears to be a young adult use START

Differences Between START and JumpSTART©
Airway If positioning the airway does not restart breathing, pt tagged as black/deceased If positioning the airway does not restart breathing, 5 rescue breaths ( the jumpstart) is given Perfusion/Circulation Capillary refill is used to assess perfusion 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. Since an apneic adult typically has also developed cardiac injury due to hypoxia/ hypo-perfusion so if opening their airway does not restart breathing, they are considered non-salvageable in the MCI setting and labeled as black/deceased. Since respiratory failure usually precedes circulatory failure in children a brief trial of 5 ventilations is given. Since children are more sensitive to the external temperature, capillary refill may not be an accurate method to assess perfusion like it is in adults. Therefore, peripheral pulses are used instead. 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

RED - Immediate Severely injured but able to be saved with relatively quick treatment and transport Examples Severe bleeding Shock Open chest or Abdominal wounds Emotionally out of control How many of you would triage most pediatric patients to a RED category? All rescuers should be a RED to get them off the scene This picture is depicting a chest wound.

Yellow - Delayed Injured but unable to walk on their own Examples
Burns with no respiratory distress Spinal injuries Moderate blood loss Conscious with head injuries Here 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

Green – Non-Urgent Minor injuries that need to be assessed or treated but not right away Examples Minor fractures Minor bleeding GREEN 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.

Black - Deceased Dead or obviously dying Depends on local protocols
Examples Cardiac arrest Resp arrest with a Pulse Can be psychologically difficult to tag a child as black There 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.

START: Step 1 Patients who are able to walk are
assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illness. “If you can hear me, go stand near the big tree.”

START: Step 2 Next begin triaging the remaining victims
Open the airway of the apneic adult If they start to breathe, triage them a red

START: Step 3 If after opening the airway, the adult patient does not breathe, tag them a black

START: Step 4 Assess the respiratory rate of the breathing adult
Move on to the next assessment if respiratory rate is under 30/min If respiratory rate is over 30/min, tag the patient red

START: Step 5 If the radial pulse is absent OR
If the capillary refill is over 2 seconds, control bleeding and tag the patient red

START: Step 6 If the radial pulse is present, Assess the mental status
If the patient can follow simple commands, tag them yellow If the patient cannot follow simple commands, tag them red

JumpSTART: Step 1 Patients who are able to walk are
assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illness. “If you can hear me, go stand near the big tree.”

JumpSTART: Step 2 Next begin triaging the remaining victims
Open the upper airway of the apneic child. If they start to breathe, tag them as red If 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.

DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES.
JumpSTART: Step 3 If the patient has a palpable pulse but is not breathing, give 5 breaths to open the lower airways. Tag as below, depending on response to ventilations. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES. 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.

JumpSTART: 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

JumpSTART: Step 5 If the child’s pulse is palpable, move on to the next assessment. If no palpable pulse but child is breathing, tag the patient as The 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.

JumpSTART: Step 6 If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as If patient is alert, responds to voice or appropriately responds to pain, tag as In 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 = Unresponsive If 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.

Exercise

Scenario # 1 VICTIM: 39 y.o. male RESPIRATORY RATE: 28/min
PERFUSION: cap refill 4 seconds MENTAL STATUS: moaning OTHER: Bus driver trapped under collapsed dash in front RED YELLOW GREEN BLACK

PERFUSION: distal pulse present MENTAL STATUS: obeys commands OTHER: complains cannot move or feel legs RED YELLOW GREEN BLACK

Scenario # 3 VICTIM: 8 y.o. male RESPIRATORY RATE: 18, talking
PERFUSION: distal pulse present MENTAL STATUS: asking for help OTHER: Walks toward you, clothing is torn, no bleeding evident RED YELLOW GREEN BLACK

Scenario # 4 VICTIM: 8 y.o. female RESPIRATORY RATE: 24/min
PERFUSION: distal pulse present MENTAL STATUS: asking for her wheelchair OTHER: found wedged under bus seat RED YELLOW GREEN BLACK

PERFUSION: pulseless MENTAL STATUS: unresponsive OTHER: legs trapped under seat from bus RED YELLOW GREEN BLACK

PERFUSION: capillary refill >4 seconds MENTAL STATUS: eye movement in response to stimuli OTHER: appears six months pregnant RED YELLOW GREEN BLACK

PERFUSION: distal pulse present MENTAL STATUS: screaming OTHER: partial amputation of foot with minimal bleeding, found in ditch RED YELLOW GREEN BLACK

PERFUSION: distal pulse absent MENTAL STATUS: groans, stops when spoken to OTHER: lying near bus RED YELLOW GREEN BLACK

PERFUSION: pulseless MENTAL STATUS: withdraws from painful stimuli OTHER: arm deformity, sucking chest wound RED YELLOW GREEN BLACK

PERFUSION: distal pulse present MENTAL STATUS: not following commands OTHER: sitting on side of road, blood in ears RED YELLOW GREEN BLACK

PERFUSION: cap refill 2 seconds MENTAL STATUS: obeys commands OTHER: sitting on side of road complaining of dizziness RED YELLOW GREEN BLACK

PERFUSION: distal pulse present MENTAL STATUS: crying OTHER: limping near buses RED YELLOW GREEN BLACK

PERFUSION: distal pulse present MENTAL STATUS: blank stare OTHER: lying in wreckage, bilateral lower extremity deformity RED YELLOW GREEN BLACK

PERFUSION: faint distal pulse MENTAL STATUS: unresponsive OTHER: found in rubble outside rear bus, apneic after 5 rescue breaths RED YELLOW GREEN BLACK

Scenario # 15 VICTIM: 8 y.o. RESPIRATORY RATE: 28/min
PERFUSION: distal pulse present MENTAL STATUS: follows commands OTHER: facial and scalp lacerations, moderate bleeding RED YELLOW GREEN BLACK

PERFUSION: pulseless MENTAL STATUS: unresponsive OTHER: driver of rear bus, found under front of bus RED YELLOW GREEN BLACK

PERFUSION: capillary refill < 2 seconds MENTAL STATUS: obeys commands OTHER: walking at the scene RED YELLOW GREEN BLACK

Scenario # 18 VICTIM: 7 y.o.female RESPIRATORY RATE: 10/min
PERFUSION: distal pulse present MENTAL STATUS: groans in response to painful stimuli OTHER: lying in ditch 15 feet from accident RED YELLOW GREEN BLACK

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.

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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.

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