Best Practices for Multicasualty Triage

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Best Practices for Multicasualty Triage

• Lou E. Romig MD, FAAP, FACEP
• Miami Childrens Hospital
• Miami-Dade Fire Rescue
• FL-5 DMAT/MSRT South

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Topics
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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

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Military vs. Civilian Triage
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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

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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.

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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/b
ioethics/topics/resall.html
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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

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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.

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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.

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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.

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When do we change from daily triage standards to
MCI triage?

• Patient medical needs overwhelm local or regional
  response resources

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Abundant resources relative to demand
R
(P Patient)
Do the best for each individual
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Resources challenged
(P Patient)
R
Do the best for each individual
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Resources overwhelmed
Do the greatest good for the greatest number
(P Patient)
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Triage Principles
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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

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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

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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.

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Basic Disaster Life Support

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

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Basic Disaster Life Support

• MASS Triage
• Move
• Assess
• Sort
• Send
• ? Assessment guidelines
• ? Pediatric considerations

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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
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B.O.L.O.

• Sacco Triage Method
• Retrospective outcome data from over 100,000
  trauma patients of all ages
• 12 categories, based on RPM assessment
• Watch for the August issue of Academic Emergency
  Medicine

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

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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.

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Secondary Triage Tools

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

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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

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NATO Guidelines

• Green
• Minor lacerations, contusions, sprains,
  superficial burns, partial-thickness burns of lt
  20 BSA
• Black
• Head injury with GCSlt8, burns gt85 BSA,
  multisystem trauma, signs of impending death

Burkle FM, Orebaugh S, Barendse BR, Ann Emerg
Med 23742-747, 1994
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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

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Primary Triage
Secondary Triage
Tertiary Triage
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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.

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Triage Categories
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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

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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

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Triage Tools
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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

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START

• Utilizes the standard four triage categories
• Used for Primary Triage
• www.start-triage.com

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START Triage
RESPIRATIONS
Under 30/min
YES
PERFUSION
NO
Over 30/min
Cap refill gt 2 sec
Cap refill lt 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
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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.

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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

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START Step 3

• Assess respiratory rate
• If 30, proceed to Step 4
• If ? 30, tag patient as Red

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START Step 4

• Assess capillary refill
• If 2 seconds, move to Step 5
• If ? 2 seconds, tag as Red

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START Step 5

• Assess mental status
• If able to obey commands, tag as Yellow
• If unable to obey commands, tag as Red

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Mnemonic

• R
• P
• M

• 30
• 2
• Can do

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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

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JumpSTART Pediatric MCI Triage

• Recognized by the US National Disaster Medical
  System
• Published in Bradys Prehospital Emergency Care,
  7th ed. and the APLS course
• www.jumpstarttriage.com

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

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Secondary Triage

• Some children may be carried to the green area by
  others. They have not proven their physiologic
  stability by performing the complex act of
  walking.
• These children should be assessed first among all
  those in the green area.

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• Position the upper airway of the apneic child.
• If they start to breathe, tag them as

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• If the child doesnt start breathing with upper
  airway opening, feel for a pulse.
• If no pulse is palpable, tag the patient as

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• If the patient has a palpable pulse, give 5
  mouth-to-barrier breaths to open the lower
  airways. Tag as below, depending on response to
  ventilations.

DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME
TRIAGE DUTIES.
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• Assess the respiratory rate of the spontaneously
  breathing child.

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• Move on to next assessment if respiratory rate is
  15-45 breaths/minute.
• If respiratory rate is lt15 or gt45, tag the
  patient as

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• If the childs pulse is palpable, move on to the
  next assessment.
• If no palpable pulse, tag the patient as

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• If patient is inappropriately responsive to pain,
  posturing, or unresponsive, tag as
• If patient is alert, responds to voice or
  appropriately responds to pain, tag as

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Modification for Nonambulatory Children

• Children developmentally unable to walk due to
  young age or developmental delay
• Children with chronic disabilities that prevent
  them from walking

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Modification for Nonambulatory Children

• For nonambulatory children, assess using the
  JumpSTART algorithm.
• If pt meets any red criteria tag as

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Modification for Nonambulatory Children

• If patient meets yellow criteria and has
  significant external signs of injury, tag as
• If patient meets yellow criteria and has no
  significant external signs of injury, tag as

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What about WMD?

• There is no widely recognized civilian MCI triage
  tool used in the US for any of the NRBC agents.

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WMD Triage Challenges

• Any triage model for WMD must consider
  decontamination
• Who goes first?
• At what stage does triage take place?
• Difficulty of conducting patient assessment and
  care with responders in protective gear.

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WMD Triage Challenges

• Agents of attack may be mixed. How do you triage
  victims who have injuries from a conventional
  attack in addition to a chemical or
  radiological/nuclear exposure?

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WMD Triage Challenges

• Biological agents may impact field triage mostly
  in choice of destination facility (quarantine
  hospital).
• Patterns of EMS calls may assist in
  identification of a occult biological agent
  attack or a natural epidemic
• Example biosurveillance tool is the First Watch
  program http//www.stoutsolutions.com/firstwatch

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WMD Triage Challenges

• Some agents cause toxindromes that allow for
  prediction of outcome based on presenting
  symptoms and signs.
• Agent-specific triage is dependent upon
  identification or strong suspicion of the agents
  use.
• Very difficult to train and maintain readiness
  with multiple agent-specific triage schemes.

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Chemical Toxindrome Examples

• Nerve agent
• Red severe distress, seizure, signs in two or
  more systems (neuromuscular, GI, respiratory
  excluding eyes and nose)
• Black pulseless or apneic, unless intensive
  resources are available

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Chemical Toxindrome Examples

• Phosgene and vesicants
• Red moderate to severe respiratory distress,
  only when intensive resources are immediately
  available
• Black burns gt50 BSA from liquid exposure, signs
  of more than minimal pulmonary involvement, when
  intensive resources are not available

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Chemical Toxindrome Examples

• Cyanide
• Red active seizure or recent onset of apnea with
  preserved circulation
• Black no palpable pulse

Sidell FR, Triage of Chemical Casualties
Chapter 14 in Medical Aspects of Chemical and
Biological Warfare, available on the Internet at
http//www.bordeninstitute.army.mil/cwbw/Ch14.pdf
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Key Points about MCI Triage

• Anything that can help organize the response to
  an MCI is a good thing.
• MCI triage is different than daily triage, in
  both field and ED settings.
• Resource availability is the limiting factor to
  consider in MCI triage.

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Key Points about MCI Triage

• In order for MCI triage to work toward its goal,
  all victims must have equal importance at the
  time of primary triage. No patient group can
  receive special consideration other than that
  dictated by their physiology.

This includes children!
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Key Points about MCI Triage

• Disaster research agendas should include efforts
  to validate and improve existing triage tools.

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• MCI triage will never be logistically,
  intellectually, or emotionally easy
• but we must be prepared to do it using the best
  of our knowledge and abilities.

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Thank You!

• LouRomig_at_bellsouth.net
• LouRomig_at_jumpstarttriage.com
• Powerpoint lecture available for download at
• www.jumpstarttriage.com

FL-5 DMAT MSRT South
MDFR
MCH