Reply

Emergency Medicine

(2001)

13

, 477–479

Blackwell Science, Ltd

Letters to the Editor

1000BEES SGML

‘Sieve’, ‘Sort’ or START

The article by Sammut, Cato and Homer (EmergencyMedicine 2001;

13

: 174–80) states that the triage moduleof the Major Incident Medical Management and Supportcourse (MIMMS) provides a means of achieving effec-tive triage of multiple casualties. The system advocatedis a two-stage system: triage ‘sieve’ and triage ‘sort’.

Published evidence on the value of the physio-logical components of the ‘sieve’ to predict severe injurysuggests that it is likely to have poor accuracy.

1–3

Thishas been confirmed by a direct comparison of triagealgorithms in which triage ‘sieve’ had significantlylower accuracy than the other algorithms tested

4

witha sensitivity of less than 50%, regardless of whethercapillary refill or heart rate is used as the circulatoryassessment. Other algorithms such as Simple Triageand Rapid Treatment (START)

5

have sensitivities ofgreater than 80%, with similar or significantly betterspecificity. START assesses the casualty’s ambulatorystatus, ability to follow commands, presence of apalpable radial pulse and respiratory rate.

Triage-Revised Trauma Score, which forms thebasis of the triage ‘sort’, has been demonstrated to lackadequate sensitivity when retrospectively applied tomultiple casualty incident situations

6,7

when the cutoff for critical injury was a score of 11. In MIMMS thecritical injury cut off is set at 10, which reduces thesensitivity even further. The resulting sensitivity issignificantly less than ‘first look’ algorithms such asSTART.

Additionally, triage tags are taught as the bestmethod of managing casualty flow at the scene andkeeping track of the number and types of casualties. Inreality they have failed repeatedly to assist in scenemanagement,

8

with no case reports in the literaturesuggesting that they were of assistance in incidentsinvolving more than 24 casualties. Alternative systemsthat do not use tags, such as geographical triage,

8

haveproved to be highly successful in multiple-casualtyincidents involving as many as 300 casualties.

9

We applaud the concept of standardized trainingfor these types of events. However such trainingshould adopt an evidence-based approach, especiallyin the area of triage. The continued promotion of triage‘sieve’ and ‘sort’, and triage tags as a methodology formultiple casualty situations is no longer appropriate.

References

1. McGee S, Abernathy WB, Simel DL. Is this patienthypovolemic?

JAMA

1999;

281

: 1022–9.

2. Baxt WG, Jones G, Fortlage D. The trauma triage rule. A new,resource-based approach to the prehospital identification ofmajor trauma victims.

Ann

.

Emerg Med

. 1990;

19

: 1401–6.

3. Fries GR, McCalla G, Levitt MA, Cordova R. A prospectivecomparison of paramedic judgement and the trauma triage rulein the prehospital setting.

Ann

.

Emerg

.

Med

. 1994;

25

: 885–9.

4. Garner A, Lee A, Harrison K, Schultz C. Comparative analysisof multiple casualty incident triage algorithms.

Ann. Emerg.Med.

2001 (in press).

5. Benson DO, Keonig KL, Schultz CH. Disaster triage. START thenSAVE: A new method of dynamic triage for victims of a cata-strophic earthquake.

Prehosp

.

Disaster Med

. 1996;

11

: 117–24.

6. Burkle FR, Newland C, Orebaugh S, Blood CG. Emergencymedicine in the Persian Gulf war: Part 2. Triage methodologyand lessons learned.

Ann

.

Emerg

.

Med

. 1994;

23

: 748–54.

7. Beyersdorf SR, Nania JN, Luna GK. Community medicalresponse to the Fairchild mass casualty event.

Am

.

J

.

Surg

.1996;

171

: 467–70.

8. Vayer JS, Ten Eyck RP, Cowan ML. New concepts in triage.

Ann

.

Emerg

.

Med

. 1986;

15

: 927–30.

9. Kerns DE, Anderson PB. EMS response to a major aircraft incident.Sioux City, Iowa.

Prehosp

.

Disaster Med

. 1990;

5

: 159–66.

Alan Garner FACEM, MSc

Medical Chairman,CareFlight/NSW Medical Retrieval Service,

Sydney, NSW, Australia

Antony Nocera FACEMEmergency Physician, St John of God Hospital,

Ballarat, Vic., Australia

134Decmber 2001273-2Letter to the EditorLetter to the Editor10.1046/j.1035-6851.2001.00273-2.xLetter to the Editor1000BEES SGML

Reply

The letter by Garner and Nocera raises several pointsin respect to triage. The writers advocate the use of theSTART/SAVE system as being better able to triagecasualties than the Sieve/Sort approach. In fact theMIMMS system agrees with Benson

et al.

, the authorsof the START/SAVE system; their paper states thatSTART/SAVE is designed for situations where ‘earlyevacuation is not possible, and local initial responderscannot expect significant outside assistance for at least49–72 hours’, as in the earthquake situation.

1

Benson

et al.

’s summary emphasizes that their system isdesigned for use over ‘many hours to days’.

1

The authorsalso make the point that their system is dynamic.

1

This

EMM273.fm Page 477 Monday, November 19, 2001 3:28 PM


478

approach is supported by Poon

2

who also divides thetriage into Initial Triage and Secondary and ContinuousTriage. For Secondary and Continuous Triage, START/SAVE is advocated. All of this is consistent with theMIMMS approach which uses Initial Triage for the rapidclearance of the disaster site and then emphasizes thattriage must be dynamic and continues by whatever isthe best system for the occasion, from the treatmentareas, to hospital admission and even to pre- andpostsurgical intervention. Unlike the START/SAVEsystem, the Sieve/Sort approach is used where rapidevacuation is required and facilities to do this areavailable. This method is suitable for CBR (NBC)incidents where START/SAVE is not ideal.

Triage tagging is also mentioned in the letter.Tagging is used extensively in major incidents aimingto indicate those that have been assessed and to showwhat is required initially. The military systems also usesuch tags to indicate treatment and history as the sceneevolves. The MIMMS system does not advocate taggingas a method of ‘keeping track of the number of, andtypes of, casualties’, as Garner and Nocera suggest.

In conclusion, MIMMS, an international system ofan all hazard approach, is also dynamic. It changes inaccordance with current practice and advances in thefield. We thank Garner and Nocera for their thoughtsand for their support for the concept of standardizedtraining. We also look forward to their paper oncomparative analysis of triage systems.

3

References

1. Benson M, Koenig KL, Schultz CH. Disaster Triage. START thenSAVE — A new method of dynamic triage for victims of cata-strophic earthquake.

Prehosp

.

Disaster Med

. 1996;

11

: 117–24.

2. Poon WK. Triage! triage! triage! (not treatment). Prehospitaland Disaster Medicine. http://pdm.medicine.wisc.edu Educa-tion and Training. Presented at 11th World Congress onDisaster and Emergency Medicine, 10–13 May 1999, Osaka,Japan. (Accessed August 2001).

3. Garner A, Lee A, Harrison K, Schultz C. Comparative analysisof multiple casualty incident triage algorithms.

Ann

.

Emerg

.

Med

. (in press).

John SammutEmergency Physician and Chair

Denys CatoExecutive Officer

Tony HomerDirector

MIMMS AustraliaLiverpool, NSW, Australia

134December 2001273-3Letter to the EditorLetter to the Editor10.1046/j.1035-6851.2001.00273-3.xLetter to the Editor1000BEES SGML

Tracheostomy is the only safe option

I have read with interest the case report of Semmondsand Doherty.

1

It adds to an increasing volume ofliterature witnessing the major haemorrhagic side-effects of thrombolytic therapy. I must, however, dis-agree with the recommended management of theairway in their otherwise well thought out discussion.

Endotracheal intubation was already difficult, ifnot impossible by the time of initial assessment of thisman. The statement that a situation where the subjectwas unable to lie flat, had minimal mouth opening anda large posterior pharyngeal wall haematoma wasstable is difficult to accept. Indeed, the events of thenext morning where the man suffered acute respira-tory obstruction, retrospectively supports the conclu-sion that conservative management was a poor option.

The assertion that general anaesthesia carriessignificant risks in the postinfarct period is true whenapplied to consideration of elective surgery, butmyocardial ischaemia will not be helped by profoundhypoxia nor the distress caused by partial /near totalobstructed breathing. Anaesthesia if required tosecure a precarious airway is a preferable option inthis circumstance. Nor should we consider that generalanaesthesia as stated will make a patent airwayunstable. A controlled inhalational induction withcontinuous positive airway pressure may well supportthe airway and improve the situation.

2

This hascertainly been my experience in the small number ofcases of upper airway obstruction that any oneclinician may expect to manage in their career.Thiopentone/Suxemethonium/Tube would, I agree,kill the patient very quickly in these circumstances.

The recommendation that blind nasal intubationshould be considered the option of choice is plainlydangerous and must be condemned. First, if one isconcerned for the risks of causing upper airwayhaemorrhage, this is the best method to ensure bleedingbecause the nasal route is vascular at the best of times.Blood in the airway will result rapidly in loss ofcontrol of the situation.

3

Second, this technique is notwidely practised and those who are good at it are froma previous generation of anaesthetists. This is not thesituation to try it for the first time. Third, the paper quotedin support reports a problem of lingual haematoma.

4

The distortion of the anatomy by a posteriorpharyngeal haematoma would almost certainly makethe nasal approach impossible. Indeed, if the authorsfailed to traverse the nasopharynx fibreoptically, howdo they hope to do so blindly?



479

I would recommend the following approach.Tracheostomy is the only safe option and should beperformed expediently, if possible after reversal of thethrombolytic agent. This should be performed eitherawake, under local anaesthesia, where the use ofadrenaline or POR8-containing solutions may offersome haemostatic advantage; or alternatively, after agaseous induction with the surgeon scrubbed andpatient ‘prepped’ — again infiltration of the tissueswith a vasoconstrictor could be performed. Awaketracheostomy is not for the faint-hearted, but then it ishard to think of a more difficult situation than that facedin theatre by the staff attending the blue, moribundpatient with a mad scramble to access the trachea.

The moral of the story, however uninviting thepresentation, is that early intervention to secure theairway in a controlled environment, thus preemptingdeterioration of the situation, is the only way to go.

References

1. Semmonds AK, Doherty S. Prevertebral haematoma afterthrombolysis. An unusual cause of airway obstruction.

Emerg

.

Med

. 2001;

13

: 251–4.

2. Motoyama EK, Cohen IT. Continuous positive airway pressure(CPAP) improves airway patency and ventilation during inhala-tion induction in children.

Anesthesiology

1992;

77

: A1198.

3. Miller RD (ed.).

Anesthesia

, 2nd edn. New York: ChurchillLivingstone, 1986; 1880–86.

4. Williams PJ, Jani P, McGlashan J. Lingual haematomafollowing treatment with streptokinase and heparin:Anaesthetic management.

Anaesthesia

1994;

49

: 417–18.

Russell BourneWangaratta Anaesthetic Group

Wangaratta Private Hospital

Wangaratta, Vic, Australia

134December 2001273Letters to the EditorLetters to the Editor10.1046/j.1035-6851.2001.00273.xBEES SGML

Reply

We thank Dr Bourne for his interest in our case andhis comments are a welcome addition to the issuesrelevant to this case.

Bourne correctly asserts that early intervention tosecure the airway is the ‘only way to go.’ When one ofus (SD) was first consulted the recommendation, aswritten in the case report,

1

was for ‘transfer to theoperating theatre … for his airway to be secured.’ Theanaesthetist and otolaryngologist, as is their right intaking over responsibility for management of the case,disagreed and preferred a conservative approach.

Bourne’s other main argument centres on the mostappropriate method of securing the airway. It is clearthat scenarios such as this require an airway doctorwith extensive experience with difficult airways.Given the infrequency of such problems it is likely thatthe preferred approach of any one clinician will beexperience based, and hence will be variable.

The comment that blind nasal intubation is‘dangerous and must be condemned’ is hyperbole.The risk of haemorrhage, in this case, was reducedgiven the passage of time since streptokinase wasadministered. This decreased haemorrhagic risk canalso be used to support Bourne’s case for proceedingto tracheostomy. The report by Walls and Pollackwould also suggest tracheostomy could be peformed.

2

The argument regarding experience with blind nasalintubation, indeed any procedure, is valid if the operatoris inexperienced with the technique. We would not recom-mend that any clinician undertake procedures they arenot familiar with, especially in emergent situations, andperhaps should have added this to the original article.

The best argument Bourne puts forward againstblind nasal intubation is that in the case described, itis unlikely to be successful. Unlike a haematoma ina more anterior structure such as the tongue, a largepharyngeal haematoma would distort the anatomyand render the procedure likely to fail. This assertionwas not considered when we reflected upon the caseand Bourne correctly states that literature supportingthis approach involved anterior haematomas.

Bourne’s preferred option, tracheostomy, was theultimate solution in our case, although it was notperformed as expeditiously as may have been expected.Even this option, as Bourne notes, is not for the ‘fainthearted.’

References

1. Semmonds AK, Doherty S. Prevertebral haematoma afterthrombolysis. An unusual cause of airway obstruction.

Emerg

.

Med

. 2001;

13

: 251–4.

2. Walls RM, Pollack CV. Successful cricothyrotomy afterthrombolytic therapy for acute myocardial infarction. A reportof two cases.

Ann

.

Emerg

.

Med

. 2000;

35

: 188–91.

Steven Doherty

FACEMEmergency Physician,

Emergency Department, Tamworth Base Hospital,

Tamworth, NSW,Australia


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