TRIAGE

2. MEP � P Project This course is brought to you by the MEP-P (Medical Emergency Preparedness � Pediatrics) Project, and is funded by a grant from the federal government to the state of Alaska to increase preparedness for Alaska�s children.

3. Simple Triage and Rapid Treatment developed by Newport Beach Fire Department and Hoag Memorial Hospital, Newport Beach, CA www.start-triage.com JUMP START Triage developed by Dr. Lou Romig, Miami, FL www.jumpstarttriage.com

4. Objectives The student will be able to: Discuss the concept of triage Utilize the S.T.A.R.T. and JumpStart methods to triage victims Explain the international triage color code system and how it is utilized

5.  Triage means �to sort� Looks at medical needs and urgency of each patient Sorting based on limited data acquisition Must consider resource availability

6. Trauma patient has the best chance for recovery if ACLS within one hour from the time of the injury With multiple victims, the Golden Hour can slip away due to limited rescuers and / or resources

7. Doing the Greatest Good, For the Greatest Number

8. Goal of Multicasualty Triage �To do the best for the most using the least.�

9. Basic Disaster Life Support MASS Triage M ove A ssess S ort S end

10. M.P.I. -- Multi-patient Incident M.C.I. -- Mass Casualty Incident M.O.I. -- Mechanism of Injury M.V.C. -- Motor Vehicle Collision M.V.A. � Motor Vehicle Accident

13. SCENE SAFETY: Size Up Size up the scene, Make sure the scene is safe for you to enter CREATE ORDER: Next, ask those who are not injured or who have minor injuries to identify themselves

14. Walking Wounded� When entering room or area, shout out, �if you can hear me, come to the sound of my voice.� Self rescue is best rescue Tag GREEN for minor, Send to a safe area Ask about other victims in area

15. Triage Categories

16. Triage Color Codes GREEN � minor �

17. Sample Triage Tag

18. Sample Triage Tag

20. Triage tags should be placed: Where they can be seen quickly Attached to arm, wrist, leg, or ankle

21. Simple Triage and Rapid Treatment developed by Newport Beach Fire Department and Hoag Memorial Hospital Newport Beach, California

22. When performing the triage function, regardless of incident size DON�T GET DISTRACTED! Move quickly Focus your attention on IMMEDIATE patients The goal is to stay focused on RED

23. Your initial goal is to find IMMEDIATE patients You want to �find the red and get it out� (kind of like Visine!) Your efforts should focus on locating all IMMEDIATE patients, getting them treated and transporting them as soon as possible

24. Once IMMEDIATE patients have been treated and transported Reassess all DELAYED patients and upgrade any to �IMMEDIATE� depending on their injury, age, medical history, etc.

25. Victims who have self-extricated themselves prior to arrival can be labeled MINOR All other patients should be tagged IMMEDIATE, DELAYED or DEAD/DYING depending on your assessment

26. With START one patient is assessed every 30 seconds First responder quickly assesses to categorize a patient�s condition Airway and respiration Pulse and / or capillary refill Level of consciousness

27. The only treatment rendered by the triage team is to: Open a patient�s airway (head tilt / neck lift) Apply direct pressure to stop an obvious bleed Elevating the extremities

28. Only three items are checked when using START: Respiration Pulse Mental Status Just remember� RPM

29. TEST: Put the triage evaluation steps in the correct order. Check mental status Check airway/breathing Check bleeding/circulation

30. ANSWER:

31. Step 1 Triage officer announces that all patients that can walk should get up and walk to a designated area for eventual secondary triage. All ambulatory patients are initially tagged as Green

32. Step 2 Assess respiratory rate If =30, assess Perfusion If ? 30, tag patient as RED

33. Step 3 Assess capillary refill If = 2 seconds, assess Mental Status If ? 2 seconds, tag as RED

34. Step 4 Assess mental status If able to obey commands, tag as YELLOW If unable to obey commands, tag as RED

35. START Flow Chart

36. Mnemonic� R 30 P 2 M Can Do

37. Patient A is 21 year old male complaining of pain to his upper right leg. You see an obvious open right femur fracture. What is your START assessment?

38. Patient A is 21 year old male complaining of pain to his upper right leg. You see an obvious open right femur fracture. The patient is awake, his airway is open, he�s talking and his respirations are over 30/minute. Using RPM, the patient is categorized as IMMEDIATE - RED. Because his respirations are over 30 per minute. What is your treatment? None during triage.

39. Patient B is a 15-year-old female, complaining of numbness to her legs, is unable to move them. You see a 2� laceration on left skull, moderate bleeding. What is your START assessment?

40. Patient B is a 15-year-old female, complaining of numbness to her legs, is unable to move them. You see a 2" laceration on left skull, moderate bleeding. She is awake, her airway is open, her respirations are under 30 a minute and she has a radial pulse. Her RPM assessment indicated she is DELAYED - YELLOW. Why? Her respirations were under 30, she has a radial pulse and she is alert and oriented.

41. Patient C is a 40-year-old male who looks really bad. He�s unconscious, pale and limp. What is your START assessment?

42. Patient C is a 40-year-old male who looks really bad. He�s unconscious, pale and limp. He is unconscious, pale, limp. He is not breathing. You reposition his airway, but no respirations. His RPM assessment is DEAD - BLACK. Why? His respirations were 0 and repositioning his airway did not help.

43. To review: There are three medical treatments performed when utilizing START triage: Open an airway Stop any visible bleeding Elevate the extremities for shock

44. The DEAD / DYING are those who cannot breathe after the airway is opened and are mortally wounded The patient will probably die despite the best resuscitation efforts It is often a difficult decision to leave a dying patient, especially if it is a child Remember, resources are often wasted on unsalvageable victims

45. Triage is a dynamic process and is usually done more than once.

48. 1. The goal of triage is to: c. Identify and treat victims who are �immediates� as rapidly as possible 2. The four triage categories are: b. Immediate, delayed, minor, dead

49. Use of Gloves Considerations in glove use during triage Change if become soiled After assessing all patients the first time In extreme field conditions, may need to sterilize by washing in bleach and water solution Check your agency policy

50. Triage Tips Time will be critical! There will be very little time with any single victim Take advantage of local exercises as a means of maintaining your triage skills

51. Triage Pitfalls No team plan, no organization and no goals Indecisive leadership - too much focus on one injury Too much treatment performed rather than just triage

52. How would you tag each of the victims described below? G = GREEN, Minor Y = YELLOW, Delay R = RED, Immediate B = BLACK, Dead No bleeding. Dazed and confused. Doesn't squeeze hand when asked. R <30, P 2 seconds Ambulatory. Responds to voice triage. Minor bleeding. R <30, P Normal blanch 2 seconds, M Responds

53. How would you tag each of the victims described below? G = GREEN, Minor Y = YELLOW, Delay R = RED, Immediate B = BLACK, Dead No bleeding. Dazed and confused. Doesn't squeeze hand when asked. R <30, P 2 seconds RED (Immediate) Ambulatory. Responds to voice triage. Minor bleeding. R <30, P Normal blanch 2 seconds, M Responds YELLOW (Delay)

54. How would you tag each of the victims described below? G = GREEN, Minor Y = YELLOW, Delay R = RED, Immediate B = BLACK, Dead Very bloody thigh. Unconscious. After two attempts to open airway, still not breathing No signs of bleeding. Unconscious. R <30. Capillary refill > 5 seconds Minor bleeding. R <30. Capillary refill < 2 seconds. Conscious - slightly disoriented, but obeys commands.

55. How would you tag each of the victims described below? G = Green, Minor Y = Yellow, Delay R = Red, Immediate B = Black, Dead Very bloody thigh. Unconscious. After two attempts to open airway, still not breathing. Black, Dead No signs of bleeding. Unconscious. R <30. Capillary refill > 5 seconds Red, Immediate Minor bleeding. R <30. Capillary refill < 2 seconds. Conscious - slightly disoriented, but obeys commands Green, Minor

57. Pediatric MCI Triage� Developed by Lou Romig MD, FAAP, FACEP Widespread use throughout US and Canada Being taught worldwide Recognized by the US National Disaster Medical System Published in Brady�s Prehospital Emergency Care, 7th ed. www.jumpstarttriage.com

59. The physiology of adults and children is not the same.

60. Age Initially ages 1-8 years chosen Less than one year of age is less likely to be ambulatory The pertinent pediatric physiology (the airway) approaches that of adults by approximately eight years of age

61. Current recommendation If a victim appears to be a child, use JumpSTART If a victim appears to be a young adult, use START

62. Checking Mental Status AVPU = Scale to measure consciousness level Only one indicator to assess responsiveness A Alert V Voice P Pain U Unresponsive

65. START and JumpSTART Quick Reference

66. Potential Problems with Children An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable RR +/- 30 may either over-triage or under-triage a child, depending on age

67. Potential Problems with Children Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment Obeying commands may not be an appropriate gauge of mental status for younger children

68. Modification for Nonambulatory children All children carried to the GREEN area by other ambulatory victims must be the first assessed by medical personnel in that area.

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

70. The �Jumpstart� Part If no breathing after airway opening, check for peripheral pulse. If no pulse, tag patient BLACK (deceased /nonsalvageable) move on If there is a peripheral pulse, give 5 mouth to barrier ventilations. If apnea persists, tag patient BLACK (deceased/nonsalvageable) move on If breathing resumes after the �jumpstart�, tag patient RED (immediate) and move on

71. JumpSTART: Respiratory Rate If respiratory rate is 15 - 45/min, proceed to assess perfusion If respiratory rate is <15 or >45/min or irregular, tag patient as RED (immediate) and move on

72. JumpSTART: Perfusion If peripheral pulse is palpable, proceed to assess mental status If no peripheral pulse is present (in the least injured limb), tag patient RED (immediate) and move on

73. JumpSTART: Mental Status Use AVPU scale to assess mental status If Alert, responsive to Verbal, or appropriately responsive to Pain, tag as YELLOW (delayed) and move on If inappropriately responsive to Pain or Unresponsive, tag as RED (immediate) and move on

74. Modification for nonambulatory children Infants who normally can�t walk yet Children with developmental delay Children with acute injuries preventing them from walking before the incident Children with chronic disabilities

75. Modification for nonambulatory children Evaluate using the JumpSTART algorithm If any red criteria, tag as RED

76. Modification for nonambulatory children If patient satisfies YELLOW criteria: YELLOW if external signs of injury are found (i.e. penetrating wounds, bleeding, burns, distended tender abdomen) Patient satisfies GREEN if no significant external injury

78. Note for Black Category Victims 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.

79. What�s your call? A school aged girl crawls out of a house after an explosion. She�s able to stand and walk toward you crying. Jacket and shirt torn No obvious bleeding

80. What�s your call? A school aged girl crawls out of a house after an explosion. She�s able to stand and walk toward you crying. Jacket and shirt torn No obvious bleeding She is standing, walking and crying with no obvious bleeding. Tag GREEN and move on.

81. What�s your call? A toddler lies with his lower body trapped under a seat inside the bus. Apneic Remains apneic with modified jaw thrust No pulse

82. What�s your call? A toddler lies with his lower body trapped under a seat inside the bus. Apneic Remains apneic with modified jaw thrust No pulse His body is under the seat and trapped. He is not breathing and repositioning the airway does not cause spontaneous respirations and he has no pulse. Tag BLACK move on.

83. What�s your call? A toddler lies in a seat after a motor vehicle collision. RR 50 Palpable distal pulse Withdraws from painful stimulus

84. What�s your call? A toddler lies in a seat after a motor vehicle collision. RR 50 Palpable distal pulse Withdraws from painful stimulus The toddler is lying in the seat with RR >45. Tag RED and move on.

85. What�s your call? An infant is carried by a young woman. He�s screaming but the woman quiets him to RR of 34 Good distal pulse Focuses on rescuer, reaches for mom No obvious significant external injuries, but some blood on his foot

86. What�s your call? An infant is carried by a young woman. He�s screaming but the woman quiets him to RR of 34 Good distal pulse Focuses on rescuer, reaches for mom No obvious significant external injuries, but some blood on his foot The infant is crying with RR 34 with palpable pulse. He is alert and responding to mom. Tag YELLOW until further assessment of �blood on foot� and move on.

87. Key Points about MCI Triage� MCI triage will never be logistically, intellectually, or emotionally easy� We must be prepared to do it using the best of our knowledge and abilities

89. 1. Put the triage evaluation steps in the correct order. Check mental status Check airway/breathing Check bleeding/circulation 2. There are three medical treatments performed when utilizing START triage: ____________________________ ____________________________ ____________________________

90. 1. Put the triage evaluation steps in the correct order. Check mental status 3 Check airway/breathing 1 Check bleeding/circulation 2 2. There are three medical treatments performed when utilizing START triage: Open an airway Stop any visible bleeding Elevate the extremities for shock

91. 3. The goal of triage is to: a. Ensure an even flow of victims to patient treatment areas b. Decide who will treat victims c. Identify and treat victims who are �immediates� as rapidly as possible 4. The four triage categories are: a. Critical, noncritical, undetermined, dead b. Immediate, delayed, minor, dead c. Emergency, delayed, elective, dead

92. 3. The goal of triage is to: c. Identify and treat victims who are �immediates� as rapidly as possible 4. The four triage categories are: b. Immediate, delayed, minor, dead

93. 5. JumpSTART triage guidelines include: a. Tag immediate for RR 50 b. Tag immediate for RR 20 c. Tag immediate for RR 40 6. JumpSTART triage guidelines are for children: a. All children under 13 years b. Ages 1-8 years c. Only nonambulatory patients

94. 5. JumpSTART triage guidelines include: a. Tag immediate for RR 50 6. JumpSTART triage guidelines are for children: b. Ages 1-8 years

95. Evaluation and Continuing Education Units After completion of this module, please submit your evaluation with contact info, including mailing address, to receive Continuing Education Units (CEUs). You may submit your evaluation by fax or mail to: ALASKA NURSE ALERT SYSTEM 3701 East Tudor Road, Suite 208 Anchorage, Alaska 99507 Fax: 907-272-0292 For questions regarding this offering call 907-274-0827.