SMART / START Triage

History of Triage

Probably developed in the Napoleonic Wars Army Surgeon Dominique Jean Larrey

Established a rule for triage of war causalities Treating wounded accordingly to injury Regardless of rank, nationality or member of

opposing army French term: ‘trier’, to separate,

sort, sift or select

History of Triage

Maintained an basis of “Best Guess” as opposed to real or meaningful assessment

Refined during the Vietnam war Process of prioritizing care to ensure the “sickest are

seen the quickest.” Mid 70’s adopted into civilian emergency dept

practice.

“To Sort” A system for assigning priorities Takes playing “GOD” away from thoughts Urgency and / or chance of survival to those with

the best criteria Sorting is based on extent of injuries Usually done where found, but also on-going Not much time spent on trapped or obvious mortal

wounds Save the largest # in shortest time Can be difficult

“To Sort”

All patients broken down into three basic categories: Those who are likely to live, regardless of what care

they receive. Those who are likely to die, regardless of what care

they receive Those for whom immediate care might make a

positive difference in outcome.

Modern Triage

Triage has become more scientific Grading and outcome based upon assessment

and physiological findings Utilizes analogies, anagrams, algorithms, tags,

colors and technology

Goal

The concept of triage is simply a method of quickly identifying victims who have immediately

life-threatening injuries AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed

first to those patients.

Golden Hour

Time frame from initial injury to definitive surgical care

Drastically decreases patient mortality rate

Effective triage should not prolong on scene time

Why? When? How?

Why? To get the right patient to the right facility at the

right time When?

Causalities exceed the number skilled rescuers How?

Using a system that is: Dynamic, Safe, Quick, and Reproducible

What makes a good triage system? Dynamic

Have the ability to upgrade or downgrade the priority of a patient

Quick Allows the ability to have a patient assessed and priority

applied within 30 to 60 seconds Safe

Must be clinically safe and evidence based Reproducible

Allow different personnel to arrive at the same decisions

START vs SMART START is a method of

triage SMART is a series of

triage products

START

Simple

Triage

And

Rapid

Treatment

START

Developed in California in the early 1980’s by Hoag Hospital and Newport Beach Fire and Marine (California)

Rapid approach to triaging large numbers of causalities

Easy to remember

START

Initial patient assessment and treatment should take less than 30 seconds for each patient

Consists of Primary Triage Secondary Triage Transport Hospital Triage

START

First - clear the walking wounded using verbal instructions. Be mindful of hearing impaired (bomb blast) Direct them to the treatment areas for detailed

assessment and treatment Tag These as MINOR

Now check your RPMs

START RPM Respiration's

None - Open the Airway Still None? - DECEASED Restored?- IMMEDIATE

Present? Above 30 - IMMEDIATE Below 30 - CHECK PERFUSION

START RPM Perfusion

Radial Pulse Absent or

Capillary Refill > 2 secs IMMEDIATE

Radial Pulse Presentor

Capillary Refill < 2 secsCHECK MENTAL STATUS

START RPM

Mental Status Can Not Follow Simple Commands

(Unconscious or Altered LOC)IMMEDIATE

Can Follow Simple CommandsDELAYED

START

If patient is immediate - priority 1 upon primary assessment, attempt to correct airway blockage or uncontrolled bleeding only before moving on to next patient.

STARTThe START process permits a very few rescuers

to rapidly triage a large number of patients without specialized training.

After patients are moved to treatment areas where more detailed assessment and treatment are conducted.

WalkingYES

PRIORITY 3

WalkingYES

PRIORITY 3

No

RespirationsNo

Position Airway Respirations

NoDEAD

Yes

PRIORITY 1

WalkingYES

PRIORITY 3

No

RespirationsNo

Position Airway Respirations

NoDEAD

Yes

PRIORITY 1

Yes

Under 30/minNo

WalkingYES

PRIORITY 3

No

RespirationsNo

Position Airway Respirations

NoDEAD

Yes

PRIORITY 1

Yes

Under 30/minNo

Yes

Cap RefillOver 2 sec.

Control Bleeding

WalkingYES

PRIORITY 3

No

RespirationsNo

Position Airway Respirations

NoDEAD

Yes

PRIORITY 1

Yes

Under 30/minNo

Yes

Cap RefillOver 2 sec.

Control Bleeding

Under 2 sec.

Obeys Simple Commands

YESPRIORITY 2

No

Secondary Triage Secondary triage uses refined

physiological scoring systems and anatomical examination.

It is carried out as and when resources become available. This normally is at the casualty clearing station.

Evaluates GCS, respiratory rate, and systolic blood pressure

Again, can be done within 30 –60 seconds

Secondary Triage Total GCS

13 – 15 9 – 12 6 – 8 4 – 5 3

4 3 2 1 0

Respiratory Rate 10 – 29 > 29 6 – 9 1 – 5 0

4 3 2 1 0

Systolic BP 90 or more 76 – 89 50 – 75 1 – 49 0

4 3 2 1 0

Total = + +

12 = MINIMAL 311 = DELAYED 210 or less = IMMEDIATE 1

Pediatric Triage

Over prioritizing of pediatric patients take valuable resources away from more seriously injured adults

Triage systems based on adult physiology will not provide accurate results

Not small adults A child’s length is proportional

to their physiology

SMART Triage

A series of products that utilizes the START Triage system

SMART Triage SMART Triage Pak

Easily deployable pack for field triage

Contains 20 SMART Triage Tags 10 ‘Dead’ Tags 10 WMD Cards Five Chem Lights Two Pencils One Pediatric Triage Tape One Casualty Count Card

SMART Triage SMART Commander

For use by the IC or Transport Officer

Contains Dry Erase Incident

Information Board Dry Erase Incident Control

Board Triage Tracking Tab Sleeves Permanent Marker

SMART Tape Provides rapid, safe,

triage of injured children

WMD Tag Basic questions of kind of

agent patient is exposed to

Indicates contaminated or decontaminated

Fire-EMS Role During MCIAn ICS Approach

Disclaimer

Always utilize your system’s policy and procedures when responding to MCIs.

Basics of MCI Management

First Arriving Unit Give accurate on-scene report Perform rapid hazard assessment Initiate traffic control Provide occupant hazard assessment Call for additional reources Assign crew(s) specific task Transfer command to command officer

Basics of MCI Management

First Arriving Command Officer Establish command post Develop appropriate command organization Establish objectives Request resources

Basics of MCI Management First Arriving EMS unit Assumes EMS Command and establishes command and control Components which are vital to successful outcome

Appropriate triage Appropriate patient management Appropriate patient transport

EMS responsibilities Care and transport of sick or injured victims Medical care of responders on the scene Establish triage area Establish treatment area Alert hospitals

EMS Command StructureEMS

Command

Support GroupSupervisor

Medical SupportUnit Leader

EMS BranchDirector

(EMS Ops)

Air OpsManager

Treatment GroupSupervisor

Transport GroupSupervisor

Triage GroupSupervisor

Staging AreaManager

Critical Factors of Successful MCI Operations

In a MCI, patients outnumber EMS providers. The first arriving EMS unit MUST establish medical

command and begin triage, not perform treatment. The Incident Management System (IMS) establishes an

EMS Branch under Operations; the key EMS areas are Triage, Treatment, and Transport.

Treatment is not effective without effective triage.

Critical Factors of Successful MCI Operations

The Treatment Area must coordinate with the Triage and Transport Areas.

The Treatment Area is a noisy, busy place and a major resource consumer.

On small scale MCI events, EMS Command may be able to coordinate the entire Operation; on large incidents a separate Treatment Area is needed.

Critical Factors of Successful MCI Operations

Large-scale incidents or disasters may require separate divisions; each division is a geographic area that is an IMS structure and requires support.

In terrorism or hazmat incidents, the scene can be dangerous. Total scene awareness is critical.

Patient and Communications

Flow Chart

INCIDENTCOMMAND

COMMCENTER

EMSCOMMAND

EMSOPS

STAGINGAREA

MANAGER

EMSVEHICLES

TREATMENTGROUP

SUPERVISOR

TRANSPORTGROUP

SUPERVISOR

TREATMENTSTRIKE TEAM

TRIAGESTRIKE TEAM

TRIAGEGROUP

SUPERVISOR

HOSPITALS

PATIENT FLOW

Face to Face Communications

COMMUNICATIONS FLOW

Primary Triage - Exercise

WalkingYES

PRIORITY 3

No

RespirationsNo

Position Airway Respirations

NoDEAD

Yes

PRIORITY 1

Yes

Under 30/minNo

Yes

Cap RefillOver 2 sec.

Control Bleeding

Under 2 sec.

Obeys Simple Commands

YESPRIORITY 2

No

Secondary Triage -Exercise

Questions/Comment?Thank you

Chris Starbuckcstarbuc@pcmh.com

252-847-6634