START & JumpSTART Triage

1. START & JumpSTART Triage Joe Immermann, EMT-P, BBA With thanks to: Joy Erb Moser, RN BSN CEN

2. START Aim of Triage… Greatest Good for the Greatest Number

3. START • START facilitates patient triage in 60 seconds or less • Assess • Ventilation • Perfusion • Mental status

4. Correct Life Threats • Blocked airways • Severe bleeding

5. START Assessments • Ambulation • Respirations • Perfusion • Mental status

6. Respiratory • Check ventilation rate and adequacy • Check for foreign objects causing airway obstruction • Reposition to open airway

7. Perfusion • Check capillary refill in nail beds or • Palpate radial pulse

8. Mental Status • Ask patient to follow simple commands • Open and close eyes • Touch finger to nose

9. Triage Categories • Green—Minor/Ambulatory • Red—Immediate • Yellow—Delayed • Black—Dead or nonsalvageable

10. Minor (GREEN) • Separate from the general group at the beginning of the triage operation. (“Walking wounded”) • Direct patients away from the scene to a designated safe area. • Consider using these patients to assist in treatment of those patients tagged as immediate.

11. Immediate (RED) • Ventilations present only after repositioning the airway. • Respiratory rate greater than 30 per minute. • Delayed capillary refill (> 2 seconds) • Unable to follow simple commands.

12. Delayed (YELLOW) • Any patient who does not fit into either the immediate or minor categories.

13. Deceased (BLACK) • No ventilations present even after attempting to reposition the airway.

14. Pediatric MCI Patients

15. JumpSTART • Results in less over-triage by acknowledging differences in kids. • Addresses the emotional burden of tagging a child as “deceased” by allowing two extra steps.

16. Pediatric MCI Patients If the victim looks like a child, use JumpSTART. If the victim looks like a young adult, use START.--Dr. Lou Romig

17. Pediatric MCI Patients • Not all children can walk • Respiratory rates may be normal at > 30/minute • Capillary refill influenced by environment • Obey commands? Kids??

18. Breathing? • If breathing spontaneously, go on to the next step: assessing respiratory rate. • If apneic or with very irregular breathing, open the airway using standard positioning technique. • If positioning results in resumption of spontaneous respirations, tag the patient RED and move on.

19. Pulse Check: Apneic Child • Physiological reason to believe an apneic child may still have a pulse.

20. Pulse Check: Apneic Child • If no breathing after airway opening, check for peripheral pulse (child may retain pulse while apnic longer than adult). • If no pulse, tag patient BLACK and move on.

21. Pulse Present • Provide 5 breaths with a mouth-to-barrier device. • If breathing returns, child is tagged as RED (Immediate). • If no spontaneous respirations return, the child is tagged BLACK.

22. Spontaneous Respirations • Check respiratory rate: • <15 or > 45 are considered critical: tag patients as RED • Respiratory rate between 15-45: Check pulse

23. Children with spontaneous respirations but no palpable pulse (in the least injured limb) are tagged Immediate (RED).

24. Mental Status Assessment • Quick AVPU: • Alert (YELLOW) • Verbal Stimuli (YELLOW) • Physical Stimuli (YELLOW) • Unconscious (RED)

25. Non-Ambulatory Patient Modifications • Infants who normally can’t walk yet • Children with developmental delay • Children with acute injuries preventing them from walking • Children with chronic disabilities

26. Non-Ambulatory Patient Modifications • Evaluate with JS algorithm • If RED criteria, tag as RED. • If YELLOW criteria, assess for external signs of significant injury. • If no significant external signs, tag as GREEN. • If significant external sign of injury are found, tag as YELLOW.

27. Deceased (BLACK) Patients Unless clearly suffering from injuries incompatible with life, victims tagged in the BLACK category should be reassessed once critical interventions have been completed for RED and YELLOW patients.

28. START/JumpSTART Differences • Apneic children are rapidly assessed for sustained circulation. • Apneic children with circulation receive a brief ventilatory trial as an additional airway opening and stimulating maneuver. • Respiratory rates are adjusted. (15-30-45) • Peripheral pulse is substituted for cap refill. • AVPU is used to assess mental status.

29. Patient #1: Tammy Teacher • Unresponsive • RR—36/min • No airway obstruction • CRT > 4 seconds TRIAGE: Green/Red/Yellow/Black

30. Patient #2: Pre-School Paula • RR > 48/min • Weak pulse • Responds to pain TRIAGE: Green/Red/Yellow/Black

31. Patient #3: Pre-School Sam • No Respiratory effort • Faint pulse • Unresponsive TRIAGE: Green/Red/Yellow/Black

32. Patient # 4: Tom Teacher • Ambulated to curb, holding Jenny & Libby • RR—28/min • CRT 2 seconds • Alert; following commands TRIAGE: Green/Red/Yellow/Black

33. Patient # 5: P.S. Jenny • Held by Tom Teacher • Crying for “Mommy” • RR—38/min • Pulse present • Clinging to Tom TRIAGE: Green/Red/Yellow/Black

34. Patient # 6: P.S. Libby • Held by Tom Teacher • RR—32/min • Pulse present • Responds to verbal & tactile stimuli TRIAGE: Green/Red/Yellow/Black

35. Patient # 7: P.S. Mikey • RR—28/min • Palpable pulse • Responds to tactile stimulation TRIAGE: Green/Red/Yellow/Black

36. Patient # 8: P.S. Lucas • RR—8/min • Pulse weak • Unconscious TRIAGE: Green/Red/Yellow/Black

37. Patient # 9: P.S. Ashley • RR—36/min • No palpable pulse TRIAGE: Green/Red/Yellow/Black

38. Patient # 10: P.S. Troy • Crying for Teacher; walked to Tom • RR—30/min • Pulse present • Scared of EMT TRIAGE: Green/Red/Yellow/Black

39. Questions?