MCI Triage: Beyond Red , Yellow, Green and Black

1. MCI Triage:BeyondRed, Yellow, GreenandBlack Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT

2. Topics Triage Categories What is Triage? Triage Tools

3. What is Triage? • “Triage” means “to sort” • Looks at medical needs and urgency of each individual patient • Sorting based on limited data acquisition • Also must consider resource availability

4. Military vs. Civilian Triage Priority is to get as many soldiers back into action as possible. Priority is to maximize survival of the greatest number of victims.

5. Military vs. Civilian Triage • Military model Those with the least serious wounds may be the first treatment priority • Civilian model Those with the most serious but realistically salvageable injuries are treated first

6. Military vs. Civilian Triage In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as the lowest priority.

7. Ethical Justification This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis. A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine, http://eduserv.hscer.washington.edu/bioethics/topics/resall.html

8. Why Should Responders Care About Good Triage? • Provides a way to draw organization out of chaos • Helps to get care to those who need it and will benefit from it the most • Helps in resource allocation • Provides an objective framework for stressful and emotional decisions

9. Why Should Planners Plan For Good Triage? • As a system tool, it provides a way to draw organization out of chaos. • Helps to get care to those who need it and will benefit from it the most and speeds efficient patient evacuation.

10. Why Should Planners Plan For Good Triage? • Helps in resource planning and allocation. • Provides an objective framework for stressful and emotional decisions, helping rescue workers to be more efficient and effective.

11. Why are Resources Important in Triage? • Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources. • Daily emergency care is not usually constrained by resource availability.

12. Abundant resources relative to demand P P P P P P P R (P = Patient) Do the best for each individual

13. P P P P P P P P P P P P P P P P P P P P P P P P Resources challenged (P = Patient) R Do the best for each individual

14. Resources overwhelmed Do the greatest good for the greatest number P P P P P P P P P P P P P P P P P P R P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P (P = Patient)

15. Daily Emergencies Do the best for each individual. Disaster Settings Do the greatest good for the greatest number. Maximize survival.

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

17. Primary Disaster Triage • Goal: to sort patients based on probable needs for immediate care. Also to recognize futility. • Assumptions: • Medical needs outstrip immediately available resources • Additional resources will become available with time

18. Primary Disaster Triage • Triage based on physiology • How well the patient is able to utilize their own resources to deal with their injuries • Which conditions will benefit the most from the expenditure of limited resources

19. Primary Disaster Triage • The most commonly used adult tool in the US and Canada is the START tool. • The only recognized pediatric MCI primary triage tool used in the US and Canada is the JumpSTART tool. • Other tools exist but are less oriented to mass casualties than triaging smaller numbers of (adult) trauma patients.

20. Basic Disaster Life Support • National Disaster Life Support Education Consortium, via Medical College of Georgia’s Center of Operational Medicine • Endorsed by the American Medical Association • Disaster Medicine Online University (www.dmou.org)

21. Basic Disaster Life Support • MASS Triage • Move • Assess • Sort • Send • ? Assessment guidelines • ? Pediatric considerations

22. The Best Tool? No MCI primary triage tool has been validated by outcome data. Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the Neurosurgeon”, Neurosurg Focus 12(3), 2002. Available on the Internet at www.medscape.com/viewarticle/431314

23. Secondary Disaster Triage • Goal: to best match patients’ current and anticipated needs with available resources. • Incorporates: • A reassessment of physiology • An assessment of physical injuries • Initial treatment and assessment of patient response • Further knowledge of resource availability

24. Secondary Triage Tools • There is no widely recognized tool in the US that addresses secondary MCI triage. • California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint) • Many EMS systems use local trauma center triage criteria.

25. NATO Guidelines • Red Airway obstruction, cardiorespiratory failure, significant external hemorrhage, shock, sucking chest wound, burns of face or neck • Yellow Open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures, significant burns other than face, neck or perineum

26. NATO Guidelines • Green Minor lacerations, contusions, sprains, superficial burns, partial-thickness burns of < 20% BSA • Black Head injury with GCS<8, burns >85% BSA, multisystem trauma, signs of impending death Burkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23:742-747, 1994

27. Secondary Triage Tools • Goal is to distinguish between: • Victims needing life-saving treatment that can only be provided in a hospital setting. • Victims needing life-saving treatment initially available on scene. • Victims with moderate non-life-threatening injuries, at risk for delayed complications. • Victims with minor injuries.

28. Tertiary Disaster Triage • Goal: to optimize individual outcome • Incorporates: • Sophisticated assessment and treatment • Further assessment of available medical resources • Determination of best venue for definitive care

29. Primary Triage Secondary Triage Tertiary Triage

30. MCI Triage: Key Points • Resources and patient numbers and acuity are limiting factors. • Must be dynamic, responsive to changes in both resources and patient needs. • There is currently no civilian MCI triage system that has been validated by outcome data.

31. Triage Categories

32. Triage Categories • Red: Life-threatening but treatable injuries requiring rapid medical attention • Yellow: Potentially serious injuries, but are stable enough to wait a short while for medical treatment

33. Triage Categories • Green: Minor injuries that can wait for longer periods of time for treatment • Black: Dead or still with life signs but injuries are incompatible with survival in austere conditions

35. Triage Tools

37. START • Simple Triage And Rapid Treatment • Developed jointly by Newport Beach (CA) Fire and Marine Dept. and Hoag Hospital • Gold standard for field adult multiple casualty (MCI) triage in the US and numerous countries around the world

38. START • Utilizes the same four triage categories • Used for Primary Triage • www.start-triage.com

39. START Triage RESPIRATIONS Under 30/min YES PERFUSION NO Over 30/min Cap refill > 2 sec Cap refill < 2 sec. Position Airway Immediate Control Bleeding NO YES MENTAL STATUS Immediate Dead or Expectant Immediate Failure to follow simple commands Can follow simple commands Immediate Delayed

40. START: 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.

41. START: Step 2 • Triage officer assesses patients in the order in which they are encountered • Assess for presence or absence of spontaneous respirations • If breathing, move to Step 3 • If apneic, open airway • If patient remains apneic, tag as Black • If patient starts breathing, tag as Red

42. START: Step 3 • Assess respiratory rate • If ≤30, proceed to Step 4 • If  30, tag patient as Red

43. START: Step 4 • Assess capillary refill • If ≤ 2 seconds, move to Step 5 • If  2 seconds, tag as Red

44. START: Step 5 • Assess mental status • If able to obey commands, tag as Yellow • If unable to obey commands, tag as Red

45. R P M 30 2 Can do Mnemonic

46. JumpSTART Pediatric MCI Triage • Developed by Lou Romig MD, FAAP, FACEP • Now in widespread use throughout the US and Canada • Being taught in Japan, Germany, Switzerland, the Dominican Republic, Africa, Polynesia

47. JumpSTART Pediatric MCI Triage • Recognized by the US National Disaster Medical System • Published in Brady’s Prehospital Emergency Care, 7th ed. • Published in APLS course • www.jumpstarttriage.com

49. Patients who are able to walk are assumed to have stable, well-compensated physiology, regardless of the nature of their injuries or illness.

50. Secondary Triage • All green patients must be individually assessed in secondary triage. • Assess physiology • Assess injuries • Assess probability of deterioration • Assess needs vs. resource availability