Triage the following utilizing SMART tags and the START method

Triage conditions include the following: It is a Saturday afternoon prior to Easter, time is 16:04 on a 60 degree day, and the scene is a local Wal-

Mart at I-35 and Slaughter Lane with the entry point at the South front entrance. The bulk of injured patients are near the registers and isles close to this entrance but patients do extend another 40 yards thru the store. Medic 15 is cleared to enter and you are tasked with triaging the

following.

PRIMARY TRIAGE – Practical Exercise

1. @72 y/o female with GSW to head large exit wound and noted and bleeding stopped. She is at the first counter and

has no motion.

• Walking- No• Breathing- No• Radial Pulse or Capillary refill <2 Seconds-No• Able to Follow Commands- NoHow do you tag this patient, (what color)?

Any immediate actions?

2. @80 y/o male next to patient number 1, with similar wound to head and to his upper chest.

• Walking- No• Breathing present and < 30 a minute- No• Radial Pulse Present or Capillary refill <2 Seconds-No• Able to Follow Commands- NoHow do you tag this patient?

Any immediate actions?

3. @ 30 y/o female teller, hiding behind counter with obvious facial trauma to nose and cheek. She has a RR of @30 and is tracking with

her eyes and following blink commands and moving fingers but is not ambulatory. Her capillary refill is instant or radial pulse present.

• Walking- No• Breathing present or <30 a minute- No• Radial Pulse Present or Capillary refill < 2 seconds- No• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

4. @ 45 y/o male hiding behind register 4 just behind patient 3, with GSW to left upper abdomen and upper right arm just above elbow. He is alert but lethargic with profuse bleeding coming from arm, controlled with a pair of

CAT TQ rapidly applied. He is not ambulatory but follows commands and has a 3-4 second capillary refill or weak to no radial pulse.

• Walking- No• Breathing Present and < 30 a minute-Yes• Radial Pulse Present and Capillary Refill < 2 seconds-No• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

5. @12 y/o female being held by patient number 4 with GSW to chest and abdomen. She is not responsive but has a RR of 8 with her capillary refill being 3-4 seconds or weak to no radial

pulse.• Walking- No• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- No• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

6. @18 y/o male in center hall of store, calling for help. He is unable to walk and is holding is right thigh with a GSW at mid-shaft with angulation of limb. His bleeding is heavy despite him holding DP with a shirt. He has a RR of 28 and is alert, following commands

with 2-3 second capillary refill or weak radial pulse.

• Walking- No• Breathing Present and < 30 a minute-Yes• Radial Pulse Present and Capillary Refill < 2 seconds-No• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

7. @30 y/o male APD officer also in center hall with SOB, he was shot in left lower chest but was wearing a ballistic vest (no penetration). He is alert and oriented with RR of 24, and grimace on inspiration.

He is able to follow commands and has instant capillary refill or good radial pulse.

• Walking- Yes• Breathing Present and < 30 a minute-Yes• Radial Pulse Present and Capillary Refill < 2 seconds-Yes• Able to Follow Commands- Yes

How do you tag this patient? (Pt is categorized as a first responder)

Any immediate actions?

8. @65 y/o female that APD carried to you from the automotive desk, she is alert and oriented with GSW to right upper hip. She has a

RR of 24, has instant capillary refill or strong radial pulse and follows commands but cannot walk.

• Walking- No• Breathing Present and < 30 a minute-Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

9. @40 y/o male that is face down in the men’s dressing room, GSW to face with large exit wound to back of head. This patient has no

respirations.

• Walking- No• Breathing Present and < 30 a minute- No• Radial Pulse Present and Capillary Refill < 2 seconds- No• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

10. @10 y/o boy found with patient 9 covered in blood, and not talking. His RR was 26-30, with instant capillary refill or strong radial pulse.

He was following commands and ambulatory. Upon quick inspection for a hemorrhage no wounds were found but he was

non-verbal.

• Walking- Yes• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

11. @25 y/o male found face down in rear auto bay. Pt is the shooter and has no respiratory effort and appears to have multiple GSWs.

• Walking- No• Breathing Present and < 30 a minute- No• Radial Pulse Present and Capillary Refill < 2 seconds- No• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

Triage the following utilizing SMART tags and the START method

Auto pedestrian accident P1. Dispatch information includes a Maroon Ford SUV has hit several people and a taxi at the intersection of Red

River and 6th Street. It is 01:04 am, on a cool night around 55 degrees. You have been assigned the role of triage. You find a very large crowd gathered with many people lying on the street and nearby sidewalks.

You see potential patients arranged in what appears to include an SUV, a taxi, on the sidewalks and street area encompassing about 25-30 yards of Red River as it approaches 6th street. Medic 6 is cleared to

enter and you are tasked with triaging the following patients.

12. @35 y/o male driver of SUV lying on ground next to SUV with front end damage from hitting a parked taxi at @45 mph. He has gurgling blood in

his mouth with many teeth missing and a RR of 12-14 and 2 second capillary refill or present radial pulse. He opens his eyes to voice but does

not speak, he has spurting blood coming from his left wrist and forearm with a broken beer bottle lying next to patient on road.

• Walking- No• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

13. Unknown age, person found partially under front of SUV and the taxi cab that was struck. The patients head is crushed between

the two vehicles, no visible respirations.

• Walking- No• Breathing Present and < 30 a minute- No• Radial Pulse Present and Capillary Refill < 2 seconds- None• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

14. @30 y/ o female in passenger seat of SUV who is hysterical, crying that the guy was killing her husband. She had a RR of @30 with ability to follow commands once she was calmed down. Her capillary refill was instant or present radial pulse. She denied any

pain or illness but has airbag abrasions to both arms.

• Walking- Yes• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

15. @55 y/o male in driver seat of taxi. He is complaining of head ache and left arm pain, but was ambulatory and alert. He followed

commands without issue. His RR was 20 with instant capillary refill or present radial pulse.

• Walking- Yes• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

16. @20 y/o female in back of cab, she is alert to verbal but lethargic and unable to follow commands. She has a normal RR and effort of 12 a minute and instant capillary refill or present radial present. The male

passenger in the cab with her reports she had two much to drink and that is why he called a cab tonight, that she had to be helped to cab prior to

accident. The taxi has @ 12 inches of trunk intrusion and none to passenger compartment.

• Walking- No• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- No

How do you tag this patient?

Any immediate actions?

17. @25 y/o male in back of the cab that was hit by SUV, has no complaints of pain. His RR is 14 with instant capillary refill or present radial pulse

and no trouble following commands.

• Walking- Yes• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds-Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

18. @20 y/o female on the road in front of the cab, she cannot stand up or walk due to pain in her left knee. She has a RR of 16 with

instant capillary refill or present radial pulse and no problem following commands.

• Walking- No• Breathing Present and < 30 a minute- Yes• Radial Pulse Present and Capillary Refill < 2 seconds- Yes• Able to Follow Commands- Yes

How do you tag this patient?

Any immediate actions?

• Done after initial triage

• Ongoing

• Done as patients move through the treatment area

• Only done when you have time and resources

• Done immediately

• Quick

SECONDARY TRIAGE

Initial Triage Secondary Triage

SECONDARY TRIAGE

SECONDARY TRIAGEFemale 30, brought into the casualty clearing station as a priority two. Lying on back board and holding abdomen.

Eyes open spontaneously

Confused

Localizes to pain

4

4

5

13

4 Respiratory rate 32

3

2

Systolic BP 70

9

PERFORM A SECONDARY TRIAGE ON THE FOLLOWING PATIENTS

• 25 YO male Green tagged, seated in triage area after walking after a triage provider asked all that could walk to move there following a large group being hit by a speeding car. He has SOB, now is restless with the following vitals:• Spontaneous Eye Opening

• Verbally Oriented

• Obeying Commands

• Respiratory Rate of 34

• Systolic BP is 84

• What is his tag now?

LET US COMPARE

• From a Green that walked to triage to a …….?GCS is a 15 which = 4 Points in Secondary triage

Spontaneous Eye Opening

Verbally Oriented

Obeying Commands

• Respiratory Rate of 34 which = 3 Points in Secondary triage

• Systolic BP is 84 which = 3 Points in Secondary triage

• What is his tag now? 4+3+3 = 11 which equals a new Red Tag

LET US LOOK AT ONE MORE@20 y/o female in back of cab, she is alert to verbal but lethargic and unable to follow commands. She has a normal RR and effort of 12 a minute and instant capillary refill or present radial present. The male passenger in the cab with her reports she had two much to drink and that is why he called a cab tonight, that she had to be helped to cab prior to accident. The taxi has @ 12 inches of trunk intrusion and none to passenger compartment.

This patient was a Red on the initial triage due to her not following commands and being non-ambulatory.

Her vitals are reflected below:

• Eyes open to Voice = 3

• Confused Verbal Response = 4

• Localizes Pain =5 GCS = 12 or a 3 in Secondary Triage

• RR =12 (4) and SBP =134 (4)

• Secondary triage = 3 + 4 + 4 = 11 or a Yellow Tag (down graded from Red)

CONCLUSION• A rapid initial triage that is universal will allow for the most

accurate way to assess the needs of an incident.

• START triaging systems will allow multiple providers assess a large number of patients rapidly

• SMART tags will help prevent duplication of initial triage and reduce confusion in patient movement

• Secondary Triage is a tool to be used when time permits, usually in a treatment area or casualty collection point

• Knowledge is Power! Knowing the demands of this incident early will let us communicate to get resources and prompt hospitals to activate their MCI plans