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DISASTER TRIAGE:DISASTER TRIAGE:S.T.A.R.T. & S.A.V.E.S.T.A.R.T. & S.A.V.E.
Carl H. Schultz, MDCarl H. Schultz, MD
Professor of Emergency MedicineProfessor of Emergency Medicine
UC Irvine School of MedicineUC Irvine School of Medicine
Carl Spengler, MDCarl Spengler, MD33rdrd Year EM Resident Year EM Resident
Oklahoma City BombingOklahoma City Bombing
“…“…We never saw a child come out of the We never saw a child come out of the federal building alive. At one point, a federal building alive. At one point, a group of people began screaming for me. group of people began screaming for me. A firefighter had brought out a little girl A firefighter had brought out a little girl who was still breathing. People were who was still breathing. People were preparing intravenous fluids, and a preparing intravenous fluids, and a paramedic was getting the intubation paramedic was getting the intubation equipment together. The crowd was equipment together. The crowd was screaming for the doctors to work on the screaming for the doctors to work on the child.child.
Nature of Triage…Nature of Triage…
I finally yelled for everybody to be quiet and calm I finally yelled for everybody to be quiet and calm down. As I assessed the little girl, it was obvious down. As I assessed the little girl, it was obvious that she had catastrophic head and chest injuries that she had catastrophic head and chest injuries and that there was nothing left to save. I told a and that there was nothing left to save. I told a paramedic to wrap up the child in a blanket and paramedic to wrap up the child in a blanket and do nothing. Several bystanders became do nothing. Several bystanders became emotionally decompensated and screamed, ‘You emotionally decompensated and screamed, ‘You bastard!’ As I walked off, several people bastard!’ As I walked off, several people continued to curse me in the worst possible continued to curse me in the worst possible fashion. Unfortunately, that is the nature of fashion. Unfortunately, that is the nature of triage”.triage”.
Goal of Disaster TriageGoal of Disaster Triage
Do the greatest good Do the greatest good for the greatestfor the greatestnumber of casualtiesnumber of casualties
Triage OriginTriage Origin
From the French verb, From the French verb, t r i e rt r i e r , “to sort” , “to sort”
Napoleon’s time, to assign treatment Napoleon’s time, to assign treatment priorities with limited resourcespriorities with limited resources
Attention given first to most salvageable with Attention given first to most salvageable with most urgent conditions – get them back into most urgent conditions – get them back into battlebattle
Does Triage Work?
Lessons from historyLessons from history
Scene controlScene control– Convergence behaviorConvergence behavior
Key ConceptsKey Concepts
Resources are limitedResources are limited– SuppliesSupplies– PersonnelPersonnel
Time for evacuation unknown or Time for evacuation unknown or prolonged (the cavalry isn’t coming any prolonged (the cavalry isn’t coming any time soon)time soon)– Only austere field interventions are Only austere field interventions are
availableavailable
Triage PracticesTriage Practices
TraditionalTraditional– Static, single Static, single
point in timepoint in time– Triage tags Triage tags
frequently usedfrequently used– Few patientsFew patients
DisasterDisaster– Dynamic, multiple Dynamic, multiple
points in timepoints in time– Documentation Documentation
needs may exceed needs may exceed triage tag capacitytriage tag capacity
– Large patient Large patient numbersnumbers
Triage PracticesTriage Practices
TraditionalTraditional– Scoop and runScoop and run– Designed to Designed to
work within work within existing EMSexisting EMS
DisasterDisaster– Secondary exam Secondary exam
and treatment and treatment performedperformed
– Assumes Assumes nonfunctional nonfunctional EMS systemEMS system
Triage PracticesTriage Practices
TraditionalTraditional– Used for Used for
localized localized disaster scenesdisaster scenes
– Dependent on Dependent on communications communications and and transportation transportation
DisasterDisaster– Used for wide-Used for wide-
spread disaster spread disaster scenesscenes
– Does not depend Does not depend on communication on communication and less on and less on transportationtransportation
Patient CategoriesPatient Categories
1. Those who will die no matter what1. Those who will die no matter what
2.2. Those who will do well no matter what Those who will do well no matter what we dowe do
3.3. Those who will derive long-term benefit Those who will derive long-term benefit from acute interventionfrom acute intervention
Early identification of #3 importantEarly identification of #3 important– Others benefit from comfort careOthers benefit from comfort care
START TriageSTART Triage
Simple Triage and Rapid TreatmentSimple Triage and Rapid Treatment Designed to be performed by first Designed to be performed by first
responders (paramedics)responders (paramedics) Assumes personnel under a great deal of Assumes personnel under a great deal of
stressstress
START TriageSTART Triage
Rapid method to perform INITIAL triageRapid method to perform INITIAL triage Utilizes respiratory rate, palpable pulse, Utilizes respiratory rate, palpable pulse,
and mental status (ability to follow and mental status (ability to follow commands)commands)
Begins by asking all that can walk to Begins by asking all that can walk to move away from triage officermove away from triage officer
Assess using START those that remainAssess using START those that remain
START TriageSTART Triage
GREEN: those who are able to get up and GREEN: those who are able to get up and walk awaywalk away
RED: those with respiratory compromise RED: those with respiratory compromise (require airway assistance or have a (require airway assistance or have a respiratory rate respiratory rate 30), no palpable pulse at 30), no palpable pulse at the wrist (but are breathing), or unable to the wrist (but are breathing), or unable to follow commandsfollow commands
YELLOW: those who are not red but can’t YELLOW: those who are not red but can’t walkwalk
BLACK: deadBLACK: dead
Modified STARTModified START
SAVE TriageSAVE Triage
Secondary Assessment of Victim Secondary Assessment of Victim EndpointEndpoint
All patients with at least a 50% chance of All patients with at least a 50% chance of survival using available resources get survival using available resources get carecare– Patient assessed by SAVE Patient assessed by SAVE
methodology in order of priority methodology in order of priority determined by STARTdetermined by START
SAVE TriageSAVE Triage
BenefitBenefitValue = Value = ———————— X Probability of survival X Probability of survival Resources required Resources required
SAVE TriageSAVE TriageAreas of AssessmentAreas of Assessment
Vital SignsVital Signs AirwayAirway ChestChest AbdomenAbdomen PelvisPelvis
SpineSpine ExtremitiesExtremities SkinSkin Neurologic StatusNeurologic Status Mental StatusMental Status
SAVE Triage CategoriesSAVE Triage Categories
RED: require immediate interventionRED: require immediate intervention YELLOW: require intervention but can YELLOW: require intervention but can
tolerate a brief delaytolerate a brief delay GREEN: do not require intervention to GREEN: do not require intervention to
prevent loss of life or limbprevent loss of life or limb BLACK: dead or unsalvageableBLACK: dead or unsalvageable
SAVE Triage CategoriesSAVE Triage Categories
Periodic assessment of all categories is Periodic assessment of all categories is importantimportant
Patients may move from one area to Patients may move from one area to anotheranother
SAVE Triage GuidelinesSAVE Triage Guidelines
Crush Injury to Lower ExtremityCrush Injury to Lower Extremity– Patients are assessed using the MESS Patients are assessed using the MESS
scorescore– Score of 7 or more: amputateScore of 7 or more: amputate– Score less than 7: attempt limb salvageScore less than 7: attempt limb salvage
SAVE Triage GuidelinesSAVE Triage Guidelines
Head Injury (adults)Head Injury (adults)– Use the Glascow Coma Score (GCS)Use the Glascow Coma Score (GCS)– Score 8 or above: treatScore 8 or above: treat
Better than 50% chance of a normal Better than 50% chance of a normal or good neurologic recoveryor good neurologic recovery
– Score 7 or less: comfort care onlyScore 7 or less: comfort care only
SAVE Triage GuidelinesSAVE Triage Guidelines
Burn Injury: less than 50% chance of Burn Injury: less than 50% chance of survivalsurvival– 70% TBSA burn70% TBSA burn– Age > 60 with inhalational injuryAge > 60 with inhalational injury– Age < 2 with 50% TBSA burnAge < 2 with 50% TBSA burn– Age > 60 with 35% TBSA burnAge > 60 with 35% TBSA burn
Comfort care onlyComfort care only
SAVE Triage GuidelinesSAVE Triage Guidelines
Abdominal InjuryAbdominal Injury– No data to guide evaluationNo data to guide evaluation– 4 ml/kg hypertonic saline X 24 ml/kg hypertonic saline X 2– If no response, comfort care onlyIf no response, comfort care only– Role of handheld ultrasound?Role of handheld ultrasound?
Initial Assessment: STARTCase #1
61 year old male pulled from smoking 61 year old male pulled from smoking building. Complaining of shortness of building. Complaining of shortness of breath.breath.
RR =28RR =28 Wrist Pulse: palpableWrist Pulse: palpable Mental Status: follows commandsMental Status: follows commands START Category: yellow (delayed)START Category: yellow (delayed) Treatment: nothingTreatment: nothing
Initial Assessment: STARTCase #2
30 year old male found with bleeding head 30 year old male found with bleeding head woundwound
RR =22RR =22 Wrist Pulse: palpableWrist Pulse: palpable Mental Status: unresponsiveMental Status: unresponsive START Category: red (immediate)START Category: red (immediate) Treatment: apply pressure to stop Treatment: apply pressure to stop
bleedingbleeding
Initial Assessment: STARTCase #3
20 year old female complaining of 20 year old female complaining of crushed lower extremitycrushed lower extremity
RR =20RR =20 Wrist Pulse: palpableWrist Pulse: palpable Mental Status: follows commandsMental Status: follows commands START Category: yellow (delayed)START Category: yellow (delayed) Treatment: nothingTreatment: nothing
Initial Assessment: STARTCase #4
3 year old female found not breathing3 year old female found not breathing RR =agonalRR =agonal Wrist Pulse: palpableWrist Pulse: palpable Mental Status: unresponsiveMental Status: unresponsive
– Open airway and give 15 seconds of Open airway and give 15 seconds of ventilation. No change in respirations.ventilation. No change in respirations.
START Category: black (dead)START Category: black (dead)
Secondary Assessment: SAVECase #2
30 year old male found with bleeding head 30 year old male found with bleeding head woundwound
START Category: red (immediate)START Category: red (immediate) EXAM: neurologic statusEXAM: neurologic status
– Does not open eyes, does not speak, Does not open eyes, does not speak, and withdraws to painand withdraws to pain
– GCS = 6GCS = 6 SAVE Category: black (unsalvageable)SAVE Category: black (unsalvageable)
Secondary Assessment: SAVECase #1
61 year old male pulled from smoking 61 year old male pulled from smoking building. Complaining of shortness of building. Complaining of shortness of breath.breath.
START Category: yellow (delayed)START Category: yellow (delayed) EXAM: airwayEXAM: airway
– Singed nasal hairs and eyebrows. Singed nasal hairs and eyebrows. Coughing up carbonaceous material. Coughing up carbonaceous material. Wheezing. No skin burnsWheezing. No skin burns
SAVE Category: black (unsalvageable)SAVE Category: black (unsalvageable)
Secondary Assessment: SAVECase #3
20 year old female complaining of 20 year old female complaining of crushed lower extremitycrushed lower extremity
START Category: yellow (delayed)START Category: yellow (delayed) EXAM: extremitiesEXAM: extremities
– Crushed left leg. Massive tissue Crushed left leg. Massive tissue avulsion and hemorrhage. Limb numb. avulsion and hemorrhage. Limb numb. Patient is pale.Patient is pale.
– MESS = 8 or 9MESS = 8 or 9 SAVE Category: red (immediate)SAVE Category: red (immediate)