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START TriageSTART Triage

R P MR P M

30 2 Can Do30 2 Can Do

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SS TT

AA RR

TT

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SS impleimple TT riageriage

AA ndnd RRapidapid

TT reatmentreatment

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In a mass casualty incident (MCI) weIn a mass casualty incident (MCI) wewant to quickly assess as manywant to quickly assess as manypatients as possible. Do the mostpatients as possible. Do the most

good for as many people as possible.good for as many people as possible.

START Triage is the tool that we use.START Triage is the tool that we use.

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START facilitates patient triage in 60START facilitates patient triage in 60seconds or lessseconds or less

AssessAssess

VentilationVentilation

PerfusionPerfusion

Mental StatusMental Status

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Along the way we only stop briefly toAlong the way we only stop briefly tocorrect a couple of life threateningcorrect a couple of life threateningconditionsconditions

Blocked AirwayBlocked Airway

Severe BleedingSevere Bleeding

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Triage ColorsTriage Colors GREENGREEN = Minor injuries / ambulatory= Minor injuries / ambulatory

YELLOWYELLOW = Delayed care may be needed= Delayed care may be needed

REDRED = Immediate care needed= Immediate care needed

BLACK = Dead or unsalvageableBLACK = Dead or unsalvageable

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Begin with theBegin with thewalking woundedwalking wounded(AKA the ambulatory / minor injuries)(AKA the ambulatory / minor injuries)

Take charge of the situationTake charge of the situation

Order everyone who can walk on theirOrder everyone who can walk on theirown or with assistance from anotherown or with assistance from another

victim to move to the designatedvictim to move to the designatedGREENGREEN areaarea

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People moved to thePeople moved to the GREENGREEN area will bearea will bereassessed appropriately by otherreassessed appropriately by otherresponders.responders.

[[ see flowchartsee flowchart]]

As an individual or a team you willAs an individual or a team you will

quickly assess the remaining patientsquickly assess the remaining patientsAssess, Treat, Color, STOP, Tag, Move onAssess, Treat, Color, STOP, Tag, Move on

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Respiratory AssessmentRespiratory Assessment Check ventilation rate and adequacyCheck ventilation rate and adequacy

Check for foreign objects causing airwayCheck for foreign objects causing airwayobstructionobstruction

Reposition to open the airwayReposition to open the airway

If present, should be less than 30/minIf present, should be less than 30/min[[ see flowchartsee flowchart]]

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If the patient is not breathing afterIf the patient is not breathing afterrepositioning to open the airway, thenrepositioning to open the airway, thenthe patient is unsalvageable andthe patient is unsalvageable and

should be BLACK tagged. Move on.should be BLACK tagged. Move on.

Remember your are trying to do theRemember your are trying to do the

most good for as many people asmost good for as many people aspossible. Donpossible. Dont hesitate on someonet hesitate on someone

who is unsalvageable.who is unsalvageable.

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If the patient is breathing over 30If the patient is breathing over 30times per minute or needed the airwaytimes per minute or needed the airwayopened to breath, then the patientopened to breath, then the patient

should beshould be REDRED tagged. Move on.tagged. Move on.

If the patient is breathing on their ownIf the patient is breathing on their own

at a rate of less than 30/min, thenat a rate of less than 30/min, thencontinue the assessment.continue the assessment.


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Perfusion AssessmentPerfusion Assessment Check for a radial pulseCheck for a radial pulse

Check capillary refillCheck capillary refill

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If the patient has a radial pulse, thenIf the patient has a radial pulse, thencontinue the assessment.continue the assessment.

If the patient does not have a radialIf the patient does not have a radialpulse but capillary refill is less thanpulse but capillary refill is less thantwo seconds, then continue thetwo seconds, then continue the

assessment.assessment.

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If the patient does not have a radialIf the patient does not have a radialpulse or capillary refill is greater thanpulse or capillary refill is greater thantwo seconds, then the patient shouldtwo seconds, then the patient should

bebe REDRED tagged. Control any bleedingtagged. Control any bleeding(consider using other, capable(consider using other, capable

patients). Move on.patients). Move on.[[ see flowchartsee flowchart]]

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Mental Status AssessmentMental Status AssessmentAsk the patient to follow simpleAsk the patient to follow simple

commandscommands

Open / close eyesOpen / close eyes Touch finger to noseTouch finger to nose

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If the patient canIf the patient cant follow simplet follow simplecommands, then the patient should becommands, then the patient should beREDRED tagged. Move on.tagged. Move on.

If the patient IS able to follow simpleIf the patient IS able to follow simplecommands, then the patient should becommands, then the patient should be

YELLOWYELLOW tagged. Move on.tagged. Move on.[[ see flowchartsee flowchart]]

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R P MR P M


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JumpSTARTJumpSTART TriageTriage

Children are different than adults.Children are different than adults. They may be more resilient to injuries.They may be more resilient to injuries.

Rescuers may find it more difficult toRescuers may find it more difficult toBLACK tag a child.BLACK tag a child.

JumpSTARTJumpSTART triage was developed totriage was developed toaccommodate for the differencesaccommodate for the differences

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Not all children can walkNot all children can walk Respirations may beRespirations may be normalnormal at ratesat rates

greater than 30/minutegreater than 30/minute

Capillary refill in children is unreliableCapillary refill in children is unreliableand can be influenced by environmentand can be influenced by environment

Obey commands? Kids??Obey commands? Kids??

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If the victim looks like aIf the victim looks like achild, usechild, use JumpSTARTJumpSTART..

If the victim looks like aIf the victim looks like ayoung adult, use START.young adult, use START.

---- Dr. LouDr. Lou RomigRomig

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Again begin with theAgain begin with thewalkingwalkingwoundedwounded

Order everyone who can walk on theirOrder everyone who can walk on theirown or with assistance from anotherown or with assistance from anothervictim to move to the designatedvictim to move to the designated

GREENGREEN areaarea

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People moved to thePeople moved to the GREENGREEN area willarea willbe reassessed appropriately by otherbe reassessed appropriately by otherresponders.responders.


As an individual or a team you willAs an individual or a team you will

quickly assess the remaining patientsquickly assess the remaining patientsAssess, Treat, Color, STOP, Tag, Move onAssess, Treat, Color, STOP, Tag, Move on

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Respiratory AssessmentRespiratory Assessment Check ventilation rate and adequacyCheck ventilation rate and adequacy

Check for foreign objects causing airwayCheck for foreign objects causing airway

obstructionobstruction

Reposition to open the airwayReposition to open the airway

If present, respirations should beIf present, respirations should bebetween 15between 15--45/min45/min

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If the patient is breathing between 15If the patient is breathing between 15--45/min, then continue the assessment.45/min, then continue the assessment.

If the patient is breathing less thanIf the patient is breathing less than15/min or greater than 45/min, then15/min or greater than 45/min, thenthe patient should bethe patient should be REDRED tagged.tagged.

Move on.Move on.[[ see flowchartsee flowchart]]

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Children may maintain a palpableChildren may maintain a palpablepulse longer than adults even whenpulse longer than adults even whenthey are not breathing (they are not breathing (apneicapneic).).

If the patient is not breathing but doesIf the patient is not breathing but doeshave a palpable pulse, then providehave a palpable pulse, then provide

five rescue breaths.five rescue breaths. If after rescue breaths they begins toIf after rescue breaths they begins to

breath on their own, then the patientbreath on their own, then the patientshould beshould be REDRED tagged. Move on.tagged. Move on.

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If the patient is not breathing, doesnIf the patient is not breathing, doesnttbegin breathing on their own after fivebegin breathing on their own after fiverescue breaths, or did not have arescue breaths, or did not have a

palpable pulse, then the patient shouldpalpable pulse, then the patient shouldbe BLACK tagged. Move on.be BLACK tagged. Move on.


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Perfusion AssessmentPerfusion Assessment Check for a palpable pulseCheck for a palpable pulse

*Capillary refill is unreliable for children*Capillary refill is unreliable for children

If the patient has a palpable pulse,If the patient has a palpable pulse,then continue the assessment.then continue the assessment.

If the patient does not have a palpableIf the patient does not have a palpablepulse, then the patient should bepulse, then the patient should be REDREDtagged. Move on.tagged. Move on.


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Mental Status AssessmentMental Status Assessment Children may be unable or unwilling toChildren may be unable or unwilling tofollow simple commandsfollow simple commands

Use the AVPU scale to assess a childUse the AVPU scale to assess a childssmental statusmental status

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If the patient is unresponsive (U), thenIf the patient is unresponsive (U), thenthe patient should bethe patient should be REDRED tagged.tagged.Move on.Move on.

If the patient postures or movesIf the patient postures or movesinappropriately to painful stimuli (P),inappropriately to painful stimuli (P),

then the patient should bethen the patient should be REDREDtagged. Move on.tagged. Move on.

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If the patient is alert (A), responsive toIf the patient is alert (A), responsive toverbal stimuli (V) or respondsverbal stimuli (V) or respondsappropriately to painful stimuli (P),appropriately to painful stimuli (P),

then the patient should bethen the patient should beYELLOWYELLOWtagged. Move on.tagged. Move on.


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Back to our pneumonic:Back to our pneumonic:

RRPP

MM

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Back to our pneumonic:Back to our pneumonic:

R = 15 to 45 (30 point range)R = 15 to 45 (30 point range)P = palpable pulse presentP = palpable pulse present

M = AVPUM = AVPU

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Modifications for special nonModifications for special non--ambulatory patients:ambulatory patients:

Infants who normally canInfants who normally cant walk yett walk yet

Children with developmental delayChildren with developmental delay

Children with acute injuries preventingChildren with acute injuries preventing

them from walkingthem from walkingChildren with chronic disabilitiesChildren with chronic disabilities

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Evaluate withEvaluate with JumpSTARTJumpSTART algorithmalgorithmIfIfREDRED criteria, tag ascriteria, tag as REDRED..

IfIfYELLOWYELLOW criteria, assess for externalcriteria, assess for external

signs of significant injury.signs of significant injury.

If no significant external signs, tag asIf no significant external signs, tag as

GREENGREEN..If significant external sign of injury areIf significant external sign of injury are

found, tag asfound, tag asYELLOWYELLOW..

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START/START/ JumpSTARTJumpSTART TriageTriage

Unless clearly suffering from injuriesUnless clearly suffering from injuriesincompatible with life, victims tagged inincompatible with life, victims tagged inthe BLACK category should bethe BLACK category should be

reassessed once critical interventionsreassessed once critical interventionshave been completed forhave been completed for REDRED andand

YELLOWYELLOW patients.patients.

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Triage is a small but vital component ofTriage is a small but vital component ofthe Incident Management System (AKAthe Incident Management System (AKAIncident Command System or ICS).Incident Command System or ICS).

IncidentCommander

Logistics Planning Operations Finance

Triage Treatment Transport

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NIMS (National Incident ManagementNIMS (National Incident ManagementSystem) course ICSystem) course IC--700700

ICIC--100100Introduction to ICSIntroduction to ICS

ICIC--200200ICS for Single ResourceICS for Single ResourceResponseResponse

ICIC--300 and IC300 and IC--400 for company400 for companyofficers and command staffofficers and command staff

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Triage TagsTriage Tags

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The variousThe varioussections aresections arenumbered andnumbered and

bar coded forbar coded forpatientpatient

tracking.tracking.

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The STARTThe STARTTriageTriagepneumonic ispneumonic is

present:present:R P MR P M


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The variousThe varioussections aresections areperforated forperforated for

ease of useease of use

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Based on yourBased on yourassessmentassessmenttear off thetear off the

appropriateappropriatecolor(scolor(s))

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Keep half ofKeep half ofthe assessthe assess--mentment color forcolor for

each patienteach patientyou triage.you triage.

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TheTheContaminatedContaminatedtab is utilizedtab is utilized

during deduring de--contaminationcontamination

proceduresprocedures

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The rest of theThe rest of thetriage tag cantriage tag canbe filled out asbe filled out as

the patient isthe patient istreated andtreated and

transportedtransported

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Attach the tagAttach the tagsecurely to thesecurely to thepatientpatients limbs limb

Tags remainTags remainwith the pt.with the pt.

throughoutthroughouttheir caretheir care

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ExamplesExamples

Group 2 ready to go?Group 2 ready to go?

Scenario: A bus load of school ageScenario: A bus load of school agechildren has run into a cafchildren has run into a caf withwithoutdoor seating.outdoor seating.

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WhatWhat s your call?s your call?

A young boy is found lying on theA young boy is found lying on theroadway 10 ft from the bus.roadway 10 ft from the bus.

Breathing 10/minBreathing 10/min

Good distal pulseGood distal pulse

Groans to painful stimuliGroans to painful stimuli

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An adult kneels at the side of the road,An adult kneels at the side of the road,shaking his head. He says heshaking his head. He says hes toos toodizzy to walk.dizzy to walk.

Respiration Rate (RR) 20/minRespiration Rate (RR) 20/min

Cap Refill (CR) is 2 secCap Refill (CR) is 2 sec

Obeys commandsObeys commands

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A school aged girl crawls out of theA school aged girl crawls out of thewreckage. Shewreckage. Shes able to stand ands able to stand andwalk toward you crying.walk toward you crying.

Jacket and shirt tornJacket and shirt torn

No obvious bleedingNo obvious bleeding

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A toddler lies with his lower bodyA toddler lies with his lower bodytrapped under a seat inside the bus.trapped under a seat inside the bus.

ApneicApneic

Remains apneic with modified jawRemains apneic with modified jawthrustthrust

No pulseNo pulse

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Adult female driver still in the bus, isAdult female driver still in the bus, isslumped over the steering wheel.slumped over the steering wheel.

Is not breathing even after you performIs not breathing even after you perform

a jaw thrust to open the airwaya jaw thrust to open the airway

No pulse presentNo pulse present

No response to any stimuliNo response to any stimuli

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A toddler lies among the wreckage.A toddler lies among the wreckage. RR 50RR 50

Palpable distal pulsePalpable distal pulse

Withdraws from painful stimulusWithdraws from painful stimulus

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A woman is carrying a crying infant.A woman is carrying a crying infant.She is able to walk.She is able to walk.

RR 20RR 20

CR 2 secCR 2 sec

Obeys commandsObeys commands

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WhatWhat s your call?s your call? The infant being carried by the previousThe infant being carried by the previous

victim is screaming but the womanvictim is screaming but the womanquiets him to RR of 34quiets him to RR of 34


Focuses on rescuer, reaches for mom.Focuses on rescuer, reaches for mom.

No obvious significant external injuries.No obvious significant external injuries.

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WhatWhat s your call?s your call?A young school aged boy props himselfA young school aged boy props himself

up on the road.up on the road.

RR 28RR 28


Answers question and commands.Answers question and commands.

Has obvious deformity of both lowerHas obvious deformity of both lowerlegs.legs.

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Toddler found outside the bus, lyingToddler found outside the bus, lyingon the ground in a heap.on the ground in a heap.

ApneicApneic

Remains apneic with jaw thrustRemains apneic with jaw thrust

Faint distal pulse palpable.Faint distal pulse palpable.

OR

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A middle aged woman lies among theA middle aged woman lies among thewreckage.wreckage.

RR 40RR 40

CR 4 secCR 4 sec weak radial pulse presentweak radial pulse present

Slurring her wordsSlurring her words

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WhatWhat s your call?s your call?A man is found among the bushes atA man is found among the bushes at

the side of the road.the side of the road.

RR 28RR 28

CR 2 secCR 2 sec

Opens his eyes and looks at you whenOpens his eyes and looks at you whenyou speak to himyou speak to him

Has a partial amputation of the footHas a partial amputation of the footwithout active bleeding.without active bleeding.

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An adult male lies inside the bus.An adult male lies inside the bus.ApneicApneic

Remains apneic with jaw thrustRemains apneic with jaw thrust

No pulse presentNo pulse present

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A school aged boy lies close to the bus.A school aged boy lies close to the bus.ApneicApneic

Weak distal pulse presentWeak distal pulse present

Begins breathing on his own after youBegins breathing on his own after yougive five breathsgive five breaths

Remains unresponsiveRemains unresponsive

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WhatWhat s your call?s your call?A young teen girl lies among theA young teen girl lies among thewreckage, crying for someone to helpwreckage, crying for someone to help

her up. A man with her says she needsher up. A man with her says she needsher wheelchair.her wheelchair.

RR 22RR 22 Palpable distal pulsePalpable distal pulse

AlertAlert

Has minor cuts and bruisesHas minor cuts and bruises

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An adult male lies on the groundAn adult male lies on the ground RR 20RR 20


Obeys commands but cries that heObeys commands but cries that hecancant move his legst move his legs

OR

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An older school aged child is foundAn older school aged child is foundsitting outside the bus.sitting outside the bus.

RR 28RR 28


Groggy, confused, stares blankly atGroggy, confused, stares blankly at

you and wonyou and wont get up and walk.t get up and walk.

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Questions?Questions?

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????

????

????????????????????????????????????

Documents

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