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)