2016 Pediatric Disaster Triage Utilizing the JumpSTART © Method March 2016 (4th Edition) Welcome and introductions Illinois Emergency Medical Services.

2016 Pediatric Disaster Triage Utilizing the JumpSTART © Method March 2016 (4th Edition) Welcome and introductions Illinois Emergency Medical Services for Children is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago

2016 Disclaimer This slide set and all related training information provided in this session is in accordance with current practice at the time that this program was developed. Review this disclaimer note with the class.

2016 Acknowledgements This 4th edition education program was developed under the direction and guidance of the Illinois Pediatric Preparedness Workgroup. The original program was adapted in 2006 from a module developed by Children’s Memorial Hospital (now Ann & Robert H. Lurie Children’s Hospital of Chicago). This program was developed from an Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) grant. All training materials are considered under public domain and can be utilized by others in the conduction of similar educational programs, provided there is acknowledgement of the source of these materials.

2016 Objectives Identify unique characteristics that make children more vulnerable in a disaster Discuss mass casualty triage and the pediatric patient Review START and JumpSTART© Triage Tools and the SMART Triage Pacs™ Demonstrate the use of the START and JumpSTART© Triage Tool Listed here are the objectives that will be addressed during this workshop.

2016 Introduction

Background Illinois Emergency Medical Services for Children (EMSC)
2016 Background Illinois Emergency Medical Services for Children (EMSC) 1984: National EMSC Program established through federal legislation Jointly sponsored by Maternal & Child Health Bureau National Highway Traffic Safety Administration States are charged with enhancing the pediatric component of their Emergency Medical Services (EMS) systems. 1994: Illinois EMSC was established. Illinois EMSC is funded through a federal initiative aimed at improving pediatric emergency care.

Illinois EMSC Pediatric Disaster Preparedness
2002: Illinois Pediatric Bioterrorism Workgroup convened Name changed in 2011 to Pediatric Preparedness Workgroup to ensure a more all-hazards approach. Reports to EMSC Advisory Board and Illinois Terrorism Task Force Assists in assuring that the special needs of children are addressed during a disaster or terrorist event by: Enhancing awareness of pediatric needs Identifying/sharing best practices Developing resource documents, tools, and guidelines Integrating disaster preparedness into existing state initiatives In 2002, Illinois EMSC became involved in disaster preparedness when the state Pediatric Bioterrorism Workgroup was formed. In 2011, the name of this Workgroup was changed to ensure a more all-hazards approach. The initial Pediatric Disaster Triage: Utilizing the JumpSTART Method program was developed in 2006 and revised in 2011 and again in 2016 to ensure it is up to date with current practice. Review slide

Illinois Communities Illinois is the 5th most populous state with a population of 12.9 million Almost 3 million children <18 years of age Approximately 800,000 are age five and younger.

Children and Disasters
2016 Children and Disasters

2016 Disaster “A medical disaster occurs when the destructive effects of natural or man made forces overwhelm the ability of a given area or community to meet the demand for health care.” A disaster is essentially an event that overwhelms the available resources in a community. What defines a disaster will depend on the community that it occurs in. For example, in an urban area an incident with 20 patients may not be considered a disaster because the resources are available to handle such an incident. However, that same incident in a rural area or area with limited resources may quickly overwhelm the available resources and would then be considered a disaster. (Source: ACEP Disaster Medical Services Policy Statement, 2006)

Natural Disasters Earthquake Flood Snow/ice storm Tornado Others 2016
All of us that are involved in health care need to be familiar with the basic aspects of disaster management. However many of you may think that it won’t ever happen to you or in your community. Illinois has the potential to experience all of the natural disasters listed on this slide. In fact, in recent years, a number of areas within Illinois have experienced ALL of these types of disasters. For example: April 18, 2008, an earthquake with magnitude of 5.4 occurred in southern Illinois and several aftershocks were reported. In the summer of 2008, the Midwest is affected by massive flooding involving several states along the Mississippi including Illinois 12 counties in northern Illinois declared disaster areas from flooding in August of 2010 In December 2006, ice storms knocked out power for several weeks in some communities in central Illinois requiring families to relocate and impacting in a number of other ways Blizzard in January brought snow and ice storms to a large portion of Illinois June 7, 2010, 15 tornados touched down in northern central Illinois

Human Caused Disasters
2016 Human Caused Disasters Terrorist Events Arson Bombings Shootings Use of chemical, biological or nuclear agents Hazmat incidents Some examples of man-made disasters are those listed on this slide. Just as with natural disasters, we cannot have the mind set that it won’t happen in our community. These events can occur in both urban and rural areas of Illinois. The shooting at Northern Illinois University in January 2010 is an example of a recent man-made disaster.

Terrorist Events and the Pediatric Population
2016 Terrorist Events and the Pediatric Population Myth Kids are secondary victims of terrorism and inadvertently targeted Some terrorist attacks that have occurred in the United States have demonstrated that children may be specifically targeted to gain more attention or create a larger impact. The 2002 Washington DC sniper, Lee Malvo, stated at his trial that the way to get people’s attention is to target their children. In the 1995 Oklahoma City bombing, Timothy McVey strategically placed the bomb to not only cause the most devastation but to also produce the most casualties (namely in the day care center). There were 168 fatalities and over 800 injured in that bombing incident. Although only 10% of the victims were children, there was a higher mortality in the pediatric victim group (31% of the pediatric victims died versus 21% of adult victims). Fact Children may be intentionally targeted

Harsh Realities: Children as Victims of Disasters
1984: Bhopal, India Industrial gas release (methyl isocyanate) Estimated 20% of victims were children 1999: Columbine High School Shootings 12 students killed, 24 injured 2004: Beslan, Russia Three day hostage event at school 334 hostages killed including 186 (56%) children Some terrorist attacks that have occurred both within the United States and internationally have demonstrated that children may be specifically targeted to gain more attention or create a larger impact. In addition to terrorist attacks, other non-intentional man-made disasters such as industrial accidents, hazmat incidents such as a chlorine leak at a pool can have a tremendous impact on children. 2011: Oslo and Utoya Norway Attacks At least 60 children killed after a gunman opened fire at a youth summer camp 2012: Sandy Hook Elementary School Shooting 26 people killed (20 children and 6 adults)

Why Children are More Vulnerable During Disasters
Increased vulnerability during disasters Anatomical, physiological and developmental differences Gaps in pediatric preparedness in hospitals, agencies, communities, and on the state and federal levels Lack of appropriate sized equipment and supplies Challenges related to medical interventions and safety Critical emergency care interventions performed infrequently May be intentionally targeted during the disaster From an emergency care perspective, we know that children present unique challenges. The unique differences in children’s physiology and development present a challenge to care providers. We see critical children to a lesser degree than adult critical patients, so we don’t have opportunities to hone our skills on a day-to-day basis. Many hospitals and EMS agencies do not have the appropriately sized equipment to care for all pediatric age groups. In 2009, a report from the Homeland Security Council identified that the majority of disaster training, exercising, medicines, and equipment used were intended for adults. Children were lumped into broad categories such as “at-risk” “vulnerable” and “special needs.” There were no accountability measures to identify who would specifically be responsible for the needs of children before, during, and after disasters. Many of these challenges exist during day-to-day care of the pediatric patient and will only be exacerbated during a disaster. These are reasons why children are more vulnerable in disasters and tend to have higher morbidity and mortality rates. In the next few slides, some of these challenges will be discussed in greater detail.

Respiratory Higher risk for respiratory issues
Airway is smaller and more narrow Depend on diaphragm to breath Equipment needs vary based on size Higher risk for respiratory issues Airway and respiratory differences between adults and children can be seen on this slide. Around 8 years of age, airway physiology in children begin to more closely resemble that of an adult. Until then, the smaller size of their airway puts them at higher risk for respiratory issues. Debris from trauma and secretions in the airway can quickly lead to respiratory distress in children. These children may require frequent suctioning in order to keep their airway clear. Easy to obstruct airway with debris and secretions so at higher risk for respiratory issues

Exposure More susceptible to: infections effects of agents
Faster respiratory rates Thinner skin/ greater body surface area Shorter stature Immature immune system Faster metabolism More susceptible to: infections effects of agents prolonged exposures hypothermia Children also have more rapid respiratory rates which results in a more rapid exposure to inhalational agents. And remember, these chemical agents may not necessarily be the result of a terrorist event but can be from an industrial incident or tanker truck spill that results in release of an agent into a community. Some biological or chemical agents are heavier than air and accumulate closer to the ground leading to prolonged exposures. Shorter stature in children can lead to prolonged exposure to chemicals like Sarin, Chlorine, or Radiation. These chemicals are heavier than air so higher concentrations of the substances accumulate closer to the ground in children’s breathing space. Children may be more susceptible to agents that are absorbed through the pulmonary route and may show earlier effects to these agents than adults with the same exposure. Increased risk for hypothermia during decontamination and treatment; increased susceptibility to chemical agents Thinner skin that is less keratinized leads to increased susceptibility to such chemical agents as: vesicating agents like Nitrogen/Sulfur Mustard, and Lewisite; nerve agents such as Sarin, VX, Tabun, and Soman; and irritants and corrosives like chlorine, ammonia, and phosgene. Their larger body surface area combined with the thinner skin means that they are at risk for these agents to be absorbed through the skin. Thinner skin also makes them more susceptible to hypothermia, so ensuring that you have warming measures in place is exceedingly important especially during decontamination. Newborns and infants are not only more susceptible to infections but have less reserves to fight against these infections. In a pandemic flu like H1N1 a couple of years ago, this age group is at higher risk. Increased susceptibility to effects from exposure to radiation and chemical agents There is also a much higher risk of leukemia and cancers in radiation exposed children under the age of 5 years. That’s why its important in our day-to-day work to try to minimize unnecessary x-rays and CT scans, since the long-term negative effects of radiation exposure can far outweigh the benefits.

Larger head/higher center of gravity Smaller circulating blood volume
Trauma Rib cage is higher Larger head/higher center of gravity Smaller circulating blood volume Higher risk for injury, irreversible shock and death from traumatic events Blood volume: Children are also more susceptible to dehydration and hypovolemia due to their smaller circulating blood volumes. They literally have less fluid reserve to draw upon, so when they begin to crash, they do so very quickly. A child’s condition can rapidly go from stable to life-threatening. Can become dehydrated faster and blood/fluid loss can lead to irreversible shock or death Children, especially younger children, have a higher center of gravity and essentially are “top heavy.” This makes them at higher risk for head injuries Abdominal organs are unprotected so there is an increased risk for liver, spleen and bowel injuries

Developmental Increased exposure and risk of injuries
May lack cognitive ability to sense a dangerous situation May lack motor skills to flee from danger Increased exposure and risk of injuries Young children lack cognitive ability to sense a dangerous situation. Unable to anticipate, recognize or flee from danger-may put themselves in more danger Infants, toddlers and young children lack motor skills to escape. May not be able to escape from danger; may have prolonged exposure

Developmental May be uncooperative Unable to help with reunification
May be nonverbal or not know personal information Age & developmental level influences response to stressful events May be uncooperative Unable to help with reunification Long term psychological effects are possible Children may be uncooperative with officials/providers. Events may have long term psychological effects on children. Examples of psychological effects on children include: academic failure, post-traumatic stress disorder, depression, anxiety, bereavement, delinquency and substance abuse. Unable to provide medical history or family information to assist in identification or reunification Many children are nonverbal or are unable to provide their personal or medical information. This can be even more common in children with special health care needs. Being separated from their parent or caregiver could lead to a delay in providing acute care or addressing the needs of their chronic medical conditions. This delay may lead to an exacerbation on these chronic medical conditions, putting them at higher risk for complications. Infants, toddlers and young children who may not be able to provide any information to providers are also at risk for abduction, abuse, custodial issues, as well as long term emotional injury.

Children with Special Health Care Needs (CSHCN)/Children with Functional Access Needs (CFAN)
Can include those kids who are/have: Technology dependent (ventilators, G-tubes, shunts, insulin pumps) Developmentally delayed or disabled Chronic diseases Immunocompromised Psychiatric/behavioral illnesses Many emergency personnel and disaster responders are not used to dealing with this population As we talk about Children with Special Health Care Needs, its important to note that this population may also be referred to under the Functional Needs Category. These children represent a substantial percentage of children within our country and our own state. Because of advances in medicine, these children are able to live lengthier lives than in the past and many of these children are mainstreamed into regular schools. Since this population tends to be poor and socially disadvantaged their families typically have less reserves to draw upon in emergencies or disaster situations. REVIEW SLIDE (Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook. 2009–2010. Rockville, Maryland: U.S. Department of Health and Human Services, 2013) 23% of U.S. households have at least 1 child that meet criteria 15.1% (>11.2 million) children in U.S. meet criteria Illinois: 14.3% (452,574)

2016 Triage

Triage Sorting and prioritizing patients
2016 Triage Sorting and prioritizing patients Looks at the medical needs and urgency of each individual patient Conventional Triage Do the best for each individual Disaster/MCI Triage Do the greatest good for the greatest number Based on physiology Provides an objective framework for stressful and emotional decisions Helps in resource allocation Triage comes from a French word and means “to sort”. It is a dynamic, ongoing process that is usually done more than once. Triage helps to prioritize patients in an organized fashion. In conventional medicine, we strive to do the greatest good for each individual patient, while in a disaster we will have a patient population that outnumbers our resources. Therefore we need to work towards doing the greatest good for the greatest number of patients. In a disaster, we may need to alter our standards of care.

Triage Primary Triage Secondary Triage
2016 Triage Primary Triage Typically performed at the scene of the incident Helps prioritize patients for evacuation/transport Can occur at a hospital Secondary Triage Performed to re-evaluate the patient after primary triage has been completed Typically done once the patient arrives at the hospital. Can also take place at an alternate care site or at the scene of the incident if prolonged scene time or in casualty collection areas Primary Triage- Primarily occurs at the scene of the incident. It is simply about categorizing the patient based on the priority for evacuation and transport, then moving on to the next patient. Secondary Triage- Typically occurs in the medical sector at the hospital where further medical care is being provided. It can also take place at an alternate care site or at the scene if transport is delayed.

Mass Casualty Incident
2016 Mass Casualty Incident Any incident in which there are more patients than rescuers MCI’s are incidents that overwhelm the available resources. It results in more patients than available resources can manage using routine procedures. Imagine an incident occurring in the picture above at Time Square in New York on New Years Eve. Imagine responding to that incident. Imagine you are the initial responder to such a scene. What would your first steps be? Where would you begin? (Source: newyearseve.com)

~80% of casualties self or buddy transport to the closest hospital
2016 ~80% of casualties self or buddy transport to the closest hospital The vast majority of mass casualty patients DO NOT WAIT FOR EMS. They self or buddy transport to the closest ED. Therefore, both EMS and hospital personnel can benefit from knowing mass casualty triage and decontamination methods. To those who work in an emergency department…. You will be triaging these patients at your facility. They cannot be processed through your routine triage method (for example: 3 level triage system or 5 tier ESI (Emergency Severity Index)) since it is likely that your ED will become quickly overwhelmed due to the sheer volume. A rapid triage system will be needed.

This includes children!
2016 MCI Triage All victims must have equal importance at the time of primary triage Sort patients based on the need for immediate care Be able to recognize futility No patient group can receive special consideration other than that dictated by their physiologic state It is important to utilize an objective triage system in order to be able to do the greatest good for the greatest number. No age or other patient group should receive special consideration while performing mass casualty triage. It should be based only on their physiological state. This includes children. It is important to remember to resist the tendency to assign pediatric patients to a higher triage category just because they are children. This includes children! (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

MCI Triage Categories IMMEDIATE = Emergent DELAYED = Urgent
2016 MCI Triage Categories IMMEDIATE = Emergent DELAYED = Urgent MINOR = Non-urgent/walking wounded EXPECTANT/DECEASED = Dead/little to no hope of survival Before we go through how to use the JumpSTART algorithm, lets review the triage categories typically used in MCI triage tools. Although these categories are used in most MCI triage tools, when we begin to go through the triage process using JumpSTART, we’ll see that we may not all agree on what color to assign to individual patients. That’s why its important to use an objective process based on the physiological components of the triage tools. This will help ensure that we are triaging in a consistent manner. Providers frequently use the colors, such as Red, Yellow, Green, to describe the MCI triage categories. However, providers are being encouraged to use the actual terms to describe the triage categories instead of the color. For example, instead of triaging someone to the Red category, they would be triaged as Immediate. Because this will be a shift in thinking for most providers, for this module, we will use the correct term but keep it color coded to assist with this transition.

2016 IMMEDIATE Severely ill/injured but treatable and able to be saved with relatively quick treatment and transport Examples: Severe bleeding Shock Open chest or abdominal wounds Severe respiratory distress Emotionally out of control Patients tagged as red are at risk for early death due to their life threatening injuries or illnesses. Examples include shock or severe head injury. These patients should be stabilized and transported as soon as possible. All rescuers should work to get the RED/IMMEDIATE patients off the scene quickly. The emotionally out of control patient can and will cause chaos at a scene. If efforts fail to calm the emotionally out of control victim, tag them as RED to remove them from the scene quickly. (Source: Optimistworld.com/anaphylaxis)

2016 DELAYED Injured/ill and unable to walk on their own; Potentially serious injuries/illnesses but stable enough to wait a short while for medical treatment Examples Burns with no respiratory distress Spinal injuries Moderate blood loss Conscious with head injury Here are some examples of patients that would be triaged to a YELLOW category. These patients should be reassessed when more personnel become available. (Source: Chemaxx.com)

2016 MINOR Minor injuries/illnesses that can wait for a longer period of time for treatment Examples Minor fractures Minor bleeding Minor lacerations GREEN patients are considered the “Walking Wounded.” Even though these victims may have minor injuries, they are still patients and may need reassurance that they will receive treatment and/or transport for care. These patients should be reassessed when more resources become available to ensure that their condition has not deteriorated. Some patients in this category may want to sign a refusal and leave the scene or hospital. However, you need to make sure that these patients have been appropriately evaluated and triaged. Any time a patient refuses treatment, the appropriate documentation must be obtained.

2016 EXPECTANT/DECEASED Dead or obviously dying; May have signs of life but injuries are incompatible with survival Examples Cardiac arrest Respiratory arrest with a pulse Massive head injury Unless clearly suffering from injuries incompatible with life, victims tagged in the EXPECTANT/DECEASED category should be reassessed once critical interventions have been completed for the RED and YELLOW patients. Check your local protocols to determine how and where deceased patients should be moved and transported.

Triaging Expectant/Deceased Patients
2016 Triaging Expectant/Deceased Patients Can be psychologically difficult to tag a child as Expectant/Deceased Can be hard to resist the tendency to assign pediatric patients a higher triage category just because they are children Using a MCI triage tool especially with children can help to eliminate the role of emotions in the triage process Objective triage criteria during an MCI can provide emotional support for triage personnel forced to make life or death decisions for children For the responder, there can be much psychological trauma associated with tagging a child to the EXPECTANT/DECEASED category especially if the child still has some signs of life. It is difficult to give up on a child. That is why using an objective triage process such as JumpSTART can help make that decision a bit easier.

MCI Triage Considerations
2016 MCI Triage Considerations Incident command (IC) Process what you see and hear in 30 seconds and paint as accurate a picture as you can in your report to IC Scene Safety Ensure the scene is safe before entering Assess for need for decontamination Designate Treatment Areas Establish areas for each triage color category Triaged patients should be moved to designated areas Regardless of where the MCI triage is occurring, there are a couple points that always need to be considered. The first is scene safety. For example, on-scene personnel need to assess for hazards and ensure it is safe for medical personnel to enter. Hospitals should assess the need for patients to be decontaminated before being allowed to enter the Emergency Department. On the scene of a MCI, bystanders and other victims may have difficulty coping when they see someone tagged as Expectant/Deceased, especially when it’s a child. This can add to the chaos of a scene, possibly jeopardizing the safety of the response personnel. This needs to be considered when assessing the scene safety. The second point to consider is that triage personnel need to be in contact with their incident command structure and provide them with as accurate of a report as possible. This allows for coordination of resources and efforts. One final consideration is during field triage, it is important that designated treatment areas are created for each of the triage color categories.

2016 MCI Triage Tools And now we’re going to review the START and JumpSTART triage tools and the SMART Triage Pacs.

MCI Triage Tools START Algorithm JumpSTART© Algorithm
2016 MCI Triage Tools START Algorithm JumpSTART© Algorithm SMART Triage Pacs™ The START and JumpSTART algorithms are the most commonly used MCI Triage tools in the United States. Currently, no primary MCI triage tools have been validated through research. Despite this, START and JumpSTART are most frequently used because they are based on physiology, are simple to use, and provide an objective approach to triaging patients of all ages.

START Triage

START Simple Triage And Rapid Treatment
2016 START Simple Triage And Rapid Treatment Joint development by the Fire & Marine Department and Hoag Hospital in New Port Beach, California Gold standard for field adult MCI triage in U.S. and numerous other countries Utilizes the standard four color triage categories Used for primary triage More information at Many of you may be familiar with the START Triage system which is considered the gold standard for field triage of adults in a mass casualty incident.

START Triage Algorithm
2016 START Triage Algorithm START triage is a rapid triage system that involves a quick ABC assessment of the patient and allows for the interventions of airway positioning and bleeding control to be completed during triage. We will briefly review the steps taken to use the START Triage Algorithm for adults.

2016 START Triage Algorithm Step 1: Requires the triage officer to announce 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.

2016 START Triage Algorithm Step 2: The triage officer then assesses patients in the order in which they are encountered. Assess each adult patient for presence or absence of spontaneous respirations. If breathing, move to Step 3.

2016 START Triage Algorithm If apneic, open the airway. If patient remains apneic, tag as EXPECTANT/DECEASED. If patient starts breathing, tag as RED/IMMEDIATE. Then move on to the next patient and start with step 2 again.

2016 START Triage Algorithm Step 3: Assess the respiratory rate. If less than or equal to 30, proceed to Step 4. If the respiration rate is greater than 30, tag patient as RED/IMMEDIATE.

2016 START Triage Algorithm Step 4: Assess for a radial pulse and/or capillary refill. If radial pulse is present or if capillary refill is less than 2 seconds, move to Step 5.

2016 START Triage Algorithm If there is no radial pulse and capillary refill is greater than 2 seconds, control any obvious bleeding and tag patient as RED/IMMEDIATE.

2016 START Triage Algorithm Step 5: Assess the mental status of the victim. If the patient is able to obey simple commands, tag as YELLOW/DELAYED. If unable to obey simple commands, tag the patient as RED/IMMEDIATE.

2016 JumpSTART© Triage We will now go through step by step the process of JumpSTART Triage

2016 JumpSTART© Triage Developed in 1995 to parallel the START Triage system and revised in 2002 Designed for use in MCI events Provides an objective framework to decrease the emotional burden on medical personnel who have to make rapid life or death decisions about children Reflects unique aspects of pediatric physiology Originally used with children under 8 years old but now used on any victim that appears to be child Can be completed within 30 seconds JumpSTART is a pediatric MCI system that was developed by Dr. Lou Romig, a pediatric emergency medicine physician. It assists triage personnel who are forced to make life or death decisions about children in an MCI setting. Having an objective tool helps to eliminate the role of emotions in the triage process. In addition, it optimizes triage effectiveness to benefit ALL victims, not just children. JumpSTART is a TOOL to help you come to a triage decision. It doesn’t solve other issues such as any parent/child separation issues, but it can assist in more quickly assigning a triage category by using objective data versus subjective input. (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

2016 JumpSTART© Triage In children, typically respiratory failure precedes circulatory failure Apnea may occur relatively rapidly, rather than after a prolonged period of hypoxia There may be a brief period when the child is apneic but not pulseless since the heart has not yet experienced prolonged hypoxia. It is felt that providing a brief trial of ventilations may help “jumpstart” their respirations Unless there is a clear airway obstruction, respiratory failure in adults usually follows circulatory failure or catastrophic head injury. An apneic adult develops enough cardiac injury (due to hypoxia/ hypo-perfusion) to make them non-salvageable in the MCI setting. This differs with children in that respiratory failure usually precedes circulatory failure. Apnea can occur relatively rapidly. Airway clearance and a brief trial of ventilations may stimulate spontaneous breathing that may be sustained until further medical assistance is available. This brief trial of ventilations during a period when the child is potentially salvageable is considered a method to “jumpstart” the child’s respirations.

JumpSTART© Triage and Age
2016 JumpSTART© Triage and Age What age defines the pediatric patient? So at what age would the JumpSTART algorithm versus the START algorithm be used? We know that pediatrics covers a wide range – from neonate to adolescent. Typically, hospitals define the pediatric patient up through the age of 15 years old. It is at approximately age 8 when the airway physiology of a child approaches that of an adult. However, children at this age should not be classified as an adult because they still have different physiological needs.

JumpSTART© Triage and Age
2016 JumpSTART© Triage and Age It can be difficult to discern the age of a child especially pre-teen and early teen years, and which triage tool to use. If a victim appears to be a CHILD, use JumpSTART© If a victim appears to be a YOUNG ADULT, use START When we need to make a quick decision, how do we define who fits into the pediatric category? Children around the ages of 9 – 12 (prior to their teen years) are sometimes the most difficult to determine their age and therefore whether to utilize the JumpSTART versus START tool. In the 2002 revisions of JumpSTART Triage Tool, the age limit was removed and the guideline is now “if a victim appears to be a child, use JumpSTART and if a victim appears to be a young adult, use START.” (Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)

Differences Between START and JumpSTART©
2016 Differences Between START and JumpSTART© START JumpSTART© Airway If positioning the airway does not restart breathing, patient tagged as Expectant/Deceased If positioning the airway does not restart breathing, a ventilation trial is given if pulse is palpable Perfusion/Circulation Capillary refill or peripheral pulses can be used to assess perfusion Only peripheral pulses are used to assess perfusion Mental Status Ability to follow commands is used to assess mental status AVPU is used to assess mental status As discussed earlier, the different physiological differences between children and adults are built into the START and JumpSTART Triage tools. AIRWAY: Since an apneic adult typically has also developed cardiac injury due to hypoxia/ hypo-perfusion, if opening their airway does not restart breathing, they are considered non-salvageable in the MCI setting and labeled as expectant/deceased. Since respiratory failure usually precedes circulatory failure in children, a brief trial of 5 ventilations is given. PERFUSION: Since children are more sensitive to external temperature changes, capillary refill may not be an accurate method to assess perfusion like it is in adults. Therefore, peripheral pulses are used instead. MENTAL STATUS: The final difference between these two triage tools is how to assess mental status. Since children, especially infants and young children, may be limited in their ability to follow commands due to age related cognitive developmental levels, the AVPU method is used. A = Alert V = Verbal P = Pain U = Unresponsive

2016 This is the JumpSTART algorithm. We will be reviewing it in more detail shortly. The JumpSTART system has not been field tested in any large scale incidents. However it is recognized by the US National Disaster Medical System (NDMS) and is incorporated into PEPP, PALS and APLS courses. It is commonly used throughout the U.S. and Canada and is being taught in other countries such as Germany, Switzerland, and Japan.

2016 Step 1 Patients who are able to walk are assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illnesses. These are triaged as MINOR Identify and direct all ambulatory patients to the designated GREEN area for secondary triage and treatment. Kids are great at following directions so pick an area like by a tree and ask everyone to walk to that area. These are your green patients. The one exception to this are non-ambulatory children that are brought to the GREEN area, i.e. infants or young children that may not be ambulatory yet, or children who are developmentally delayed. We will talk about how to handle these children next. Step 1: Requires the triage officer to announce that all patients that can walk should get up and walk to a designated area for secondary triage and treatment. Kids are great at following directions so pick an area like by a tree and ask everyone to walk to that area. These are your GREEN patients.

Evaluate all non-ambulatory victims that are carried to the MINOR area
2016 Step 2 Evaluate all non-ambulatory victims that are carried to the MINOR area Step 2: Unlike with adults in the START triage method, not everyone that is in the GREEN area should be assumed to have minor injuries. Non-ambulatory children such as infants or young children that may not be ambulatory yet, or children who are developmentally delayed, may have been brought to the GREEN area. We will talk about how to handle these children next.

Non-ambulatory Children
2016 Non-ambulatory Children Non-ambulatory children include: Infants who normally can’t walk yet Children with developmental delays Children with acute injuries which prevented them from walking before the incident occurred Children with chronic disabilities Infants or other children who may not be ambulatory (this may include children with special needs) may be carried to the GREEN area. All children that are carried to the GREEN area must be the first children that are assessed by medical personnel in that area. Non-ambulatory children who are taken to the GREEN area must undergo secondary triage using the “Modifications for Non-ambulatory Children” to determine the triage status. CHILDREN MEETING THIS CRITERIA SHOULD BE EVALUATED USING THE JumpSTART © ALGORITHM BEGINNING WITH STEP 2

Non-ambulatory Children
2016 Non-ambulatory Children All children carried to the MINOR area by other ambulatory victims must be the first assessed by medical personnel in that area. If a child meets any red criteria, tag as IMMEDIATE If a child has significant external signs of injury, tag as DELAYED If a child has no significant external signs of injury, tag as MINOR If a child meets the criteria for the expectant/deceased category, tag as EXPECTANT/DECEASED All non-ambulatory children that are carried to the GREEN area must be evaluated using the JumpSTART algorithm. These children should be assessed first. Triage for these non-ambulatory patients would start with Step 3 or with the assessment of their respiratory status. If a child meets any RED criteria, then the child is tagged as a RED. If a quick survey determines that there are any significant external signs of injury (i.e. deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen or multiple bruises), tag the patient as YELLOW Non-ambulatory children without any significant external injury (and all other aspects of the JumpSTART algorithm are normal) are tagged GREEN. If a child meets the criteria for the expectant/deceased category, tag as EXPECTANT/DECEASED

2016 Step 3 Next begin triaging the remaining victims in the order that they are encountered. Assess the breathing status of each child. If the child is breathing spontaneously, go on to step 4 If child is apneic, position the upper airway. If they start to breath on their own, tag them as IMMEDIATE Step 3: The triage officer then assesses patients in the order in which they are encountered. Assess each pediatric patient for presence or absence of spontaneous respirations. If the child is breathing spontaneously, then go on to Step 4 to assess the respiratory rate. If your patient is apneic or with any type of irregular breathing, first open the airway using standard positioning techniques. If the positioning results in spontaneous respirations tag the patient as RED (immediate) and move on to the next patient.

2016 Step 3 (Continued) If the child is still apneic after positioning their upper airway in Step 2 and they have no palpable pulses, tag as EXPECTANT/ DECEASED A child who is apneic is much more likely than an adult to have a primary respiratory problem. The perfusion in the apneic child may be maintained for a short period of time and it is during this brief time that the child may still be salvageable. If the child is apneic, check to see if the child has a pulse. If the patient does not have a pulse, tag the child as Expectant/Deceased and continue to triage other patients. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES

2016 Step 3 (Continued) If the child is still apneic after positioning their upper airway but has a palpable pulse, give 5 rescue breaths. If they start breathing spontaneously, tag as IMMEDIATE If they remain apneic, tag as EXPECTANT/DECEASED A child who is apneic is much more likely than an adult to have a primary respiratory problem. The perfusion in the apneic child may be maintained for a short period of time and it is during this brief time that the child may still be salvageable. If the child is apneic, check to see if the child has a pulse. If the patient does not have a pulse, tag the child as Expectant/Deceased and continue to triage other patients. DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES

2016 FOR THOSE CHILDREN WHO REMAIN APNEIC AFTER 5 RESCUE BREATHS, DO NOT CONTINUE TO VENTILATE THE PATIENT RESUME TRIAGE DUTIES. If the child remains apneic after opening the airway and does have a pulse, give 5 rescue breaths. If the “jumpstart” ventilation of 5 rescue breaths does not lead to the return of palpable pulses, do not continue to ventilate the patient. Tag the patient as Expectant/deceased and continue to triage other patients. If the patient starts breathing, tag the child as RED/IMMEDIATE and resume triage duties.

2016 Step 4 Assess the respiratory rate of each spontaneously breathing child. If <15 or > 45, tag as IMMEDIATE If 15-45, go to Step 5 Step 4: Assess the respiratory rate of each spontaneously breathing child. If the respiratory rate is less than 15 or greater than 45, tag the child as Red/Immediate and move on to the next child. If the respiratory rate is between 15 and 45, proceed to step 5.

Step 5 Assess the child’s perfusion.
2016 Step 5 Assess the child’s perfusion. If no palpable pulse, tag the child as IMMEDIATE If the child’s pulse is palpable, move on to Step 6 Step 5: Assess the child’s perfusion. Palpable pulses are a better indicator of perfusion than capillary refill in a child because capillary refill may not adequately reflect peripheral hemodynamic status if the environment is cool or cold. If no peripheral pulse is present (in the least injured limb), tag the patient RED/IMMEDIATE and move on to the next patient. If the child has a palpable pulse, proceed to step 6

Step 6 Assess the child’s mental status.
2016 Step 6 Assess the child’s mental status. If child is inappropriately responsive to pain, posturing, or unresponsive, tag as IMMEDIATE If child is alert, responds to voice or appropriately responds to pain, tag as DELAYED Step 6: Assess the mental status of the child. In the START system for adults, the mental status is assessed by determining if the patient can follow a simple command. This differs in the JumpSTART triage system. Since the cognitive abilities vary by the age and developmental level of the child, the mental status is assessed by using the AVPU mnemonic. If the patient is alert, responsive to verbal or appropriately responds to pain stimuli such as pulls away, cries, etc., tag as YELLOW/DELAYED and move on to the next patient. If the patient has no response to pain (“U”) or has an inappropriate response to pain such as having a staring gaze, or begins posturing, then tag as RED/IMMEDIATE and move on to the next patient.

SMART Triage Tag System

State Mass Casualty Triage System
2016 State Mass Casualty Triage System State committee identified need for consistency in MCI triaging throughout Illinois Various MCI triage systems reviewed Endorsement of SMART Incident Command System™ for use in Illinois 2007-Statewide distribution of SMART Triage Pacs™ Illinois Custom-Designed SMART Pacs™ Contains a START and JumpSTART© algorithm card Does not have the SMART Pediatric Tape (tape not approved for use in Illinois) In 2004, a state committee was convened in Illinois in order to review various MCI triage systems and adopt a standardized triage system to ensure consistency throughout our state. The SMART Incident Command System, which has many components to it, was chosen. For this class, we will be focusing only on the SMART Triage Pacs within the SMART Incident Command System. In 2007, grant funds enabled the SMART triage pacs to be distributed to both hospitals and pre-hospital agencies throughout Illinois. These guidelines seek to ensure consistency throughout the state with the type of triage system that is being used. Utilizing only the SMART Triage pacs will promote consistency and ease of care across jurisdictions. Each Illinois SMART Pac should contain triage tags as well as a START and a JumpSTART algorithm card tethered to the inside of the bag. Please note that if you have purchased additional SMART pacs separately from the vendor (Boundtree), you may have received a pediatric tape in the bag. DO NOT USE THIS TAPE. IT HAS NOT BEEN APPROVED FOR ILLINOIS USE AND SHOULD BE RETURNED TO THE SMART PRODUCT VENDOR (BOUNDTREE MEDICAL SUPPLIES) SO THAT THEY CAN SEND YOU A REPLACEMENT JUMPSTART CARD. Forms are available to return these pediatric tapes back to BoundTree so that you can receive a JumpSTART card. These forms are available with all the training materials provided for this course.

SMART Triage Pacs™ MCI triage tags
2016 SMART Triage Pacs™ MCI triage tags Part of a larger Command System product that includes ability to assist with tracking patients from the scene. Full system not necessary to use triage tag portion SMART Triage tags are recommended to use in Illinois The SMART Incident Management System is a product for use in an MCI event and includes the SMART triage pacs. The SMART triage pac is a product or equipment that can be used to organize and perform START and JumpSTART triage. It does not replace using either the START or JumpSTART Algorithm. INSTRUCTORS: Provide tags to participants, demonstrate how to use them and where the information on the next few slides can be found on the tags. (Source: emsstaff.buncombecounty.org)

SMART Triage Pacs™ Triage tags
2016 SMART Triage Pacs™ Triage tags Equipment used to perform START and JumpSTART© triage Have standard barcodes for tracking patients Card folds to the assigned color and only shows one color at a time Allows patients to be re-triaged to another color classification without having to replace the tag and reassessment can be documented on the same tag Separate tags for Expectant/Deceased category The SMART Incident Management System is a product for use in an MCI event and includes the SMART triage pacs. The SMART triage pac is a product or equipment that can be used to organize and perform START and JumpSTART triage. It does not replace using either the START or JumpSTART Algorithm. INSTRUCTORS: Provide tags to participants, demonstrate how to use them and where the information on the next few slides can be found on the tags. (Source: emsstaff.buncombecounty.org)

SMART Triage Pacs™( Continued)
2016 SMART Triage Pacs™( Continued) Inside each SMART Triage Tag, there are the three colors: Red, Yellow, and Green. In addition to the color sections, there are areas to document patient information if it is able to be obtained. This part of the card asks for patient details including gender, age, complaint, demographic information and medical history. In a true MCI event, obtaining much of this information may not be possible. If the parent is on scene with a child victim, attempt to obtain as much information about the child as possible including the parent’s name and contact information in case the child and parent get separated.

SMART Triage Pacs™( Continued)
2016 SMART Triage Pacs™( Continued) These show the other areas on the SMART Triage cards. Patient assessment, interventions and vital signs, and a Glasgow Coma Scale are included on each card. After filling in any information that was able to be obtained, fold the card up so the assigned priority color/level is facing out, put the card back in the plastic pouch and attach the tag to the patient. If the patient is expectant/deceased, slide both the Triage card as well as the black DEAD card (with the color facing out) into the pouch. Ensure that there is only one priority color visible to avoid confusion.

START Triage vs. the SMART Triage Pacs™
2016 START Triage vs. the SMART Triage Pacs™ The START algorithm looks like this… The SMART Triage Pacs™ algorithm looks like this... The adult algorithm that is in the SMART Triage PacsTM looks different than the official START algorithm. However, the same physiologic parameters apply as well as the same algorithm steps to determine whether to categorize the victim to red, yellow, green or black. The SMART Company simply formatted the algorithm a bit differently. Although these algorithms look different… THEY ARE THE SAME

2016 Scenarios Lets review some scenarios and apply the START and JumpSTART triage method.

2016 Scenario 1: Bus Crash It’s 7pm on a summer night when a bus returning from a day camp collides with a train on a remote road. You are the first responder and you find 20 + kids. Some are still in the bus and train while some are lying about the road.

2016 Scenario 1 (continued) 10 y/o female, open femur fracture, breathing 10/min, good distal pulse, groans to verbal stimuli This is the first victim that you encounter. What color triage category would you assign to this patient?

Lying outside the bus in a pile of debris
2016 9 y/o M RR0 Faint distal pulse Unresponsive Lying outside the bus in a pile of debris 50 y/o F RR 20 Cap refill < 2 sec Obeys simple commands Dizzy & unable to walk 10 y/o F RR 22 Good distal pulse Asks for help Walking 9 y/o F RR 12 Distal pulse absent Groans to painful stimuli Lying in the ditch 15 ft away 10 y/o M RR 26 Distal pulse present Obeys commands Unable to move his legs 25y/o F RR12 Cap refill 4 sec Eye movement to stimulation 6 months pregnant Here are more patients you encounter at the scene and need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 9 y/o male- Airway repositioned. Remains apneic. 5 rescue breaths given and patient starts breathing on his own. Tag as RED/IMMEDIATE. 10 y/o male- Wheelchair found lying 15 feet away from victim. Victim asking to be helped back into his wheelchair. Tag as GREEN/NONURGENT. INSTRUCTORS: address any questions that may arise after reviewing each of these “victims” triage color assignment.

2016 Scenario 2: F5 Tornado An F5 tornado has struck within your city/town. It occurred at 3pm while school was letting out. The tornado touched down near 3 schools and a shopping mall. Here is a second scenario to review.

Scenario 2 (continued) School Age Girl Open arm fracture
2016 Scenario 2 (continued) School Age Girl Open arm fracture RR 26, and pulse Alert and talking This is the first victim you encounter as you begin triaging. Based on the physiologic findings for this victim, the primary triage color assignment is GREEN/NONURGENT.

Pulse present but irregular Responds appropriately to pain
2016 8 y/o M RR 10 Weak, thready pulse Unresponsive Outside, face down 3 y/o M RR 18 Pulse present but irregular Responds appropriately to pain Deformity to lower extremity 9 m/o F RR 44 Pulse present Responds to voice Superficial lacs to head/face 10 y/o M Screaming Not focusing Running in hall 50 y/o F RR 32 Weak pulse Not following commands Trapped under bookcase 7 y/o M RR 0 Very weak Pulse Trapped under rubble Here is the list of the rest of the victims you need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 9 m/o female: Carried to the Green area by her mother 10 y/o male: Attempts to calm the patient are unsuccessful. Patient unable to respond appropriately to rescuers. 7 y/o male: 5 rescue breaths are given after positioning airway. Child continues to be apneic

Scenario 3: High-Rise Fire
2016 Scenario 3: High-Rise Fire Fire reported on 15th floor Smoke to the 16th and 17th floors. The building’s day care center is located on the 17th floor with 30 kids and 6 employees. Here is the last scenario that we’ll review. (Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE)

Burns to abdomen; wheezing
2016 4 y/o F RR 38 Radial pulse present Knows name and recalls incident Facial burns, coughing 53 y/o F RR 48 Cap refill > 2 sec Moaning Burns to abdomen; wheezing 3 y/o F RR 0 Weak pulse Unresponsive Found under desk 4 y/o M RR 45 Pulse present Crying No obvious injuries 2 y/o M RR 20 Palpable pulse Hoarse cry Soot to face 3 y/o M RR 28 Strong palpable pulse 2nd/3rd degree burns to extremities These are the victims you need to triage. INSTRUCTORS: As you review each patient, then click/enter, and the correct triage color assignment will appear. Below is additional information provided for some of the victims that may be more challenging to triage 4 y/o F – Parameters indicate patient would be a green since all within normal range. Discuss with student concepts of overtriaging if indicated patient would be a yellow. 3 y/o F – The airway is repositioned with no response so 5 rescue breaths are given. The patient responds with return of spontaneous respirations so she is tagged as RED/IMMEDIATE 2 y/o – This patient is non ambulatory and has been carried into the green area by a day care worker. As the patient is now being triaged, consider that the hoarse cry and soot to face may be indicative of pending respiratory compromise, so tag as YELLOW/URGENT. Discussion point: compare this patient to initial 4 y/o patient and the difference between triaging the 2 y/o as a yellow but not the initial 4 y/o. The 2 y/o has signs of respiratory comprise at the time of triage compared to the 4 y/o who may develop respiratory comprise but at the time of initial triage, no signs of respiratory distress noted. For these patients it is so important to emphasize the information provided in columns 2, 3 and 4 (respiratory status, perfusion status and their mental status) as this evaluates their PHYSIOLOGIC state. With burns there is a tendency to want to triage to a higher level. Understand that this is PRIMARY triage. If the patient ‘s clinical condition deteriorates, then in secondary triage, they can always be advanced to the next highest category.

Scenario 3 (continued) 5 kids are carried out, all being given CPR.
2016 Scenario 3 (continued) 5 kids are carried out, all being given CPR. As lead triage officer, what do you do? Additional scenario information: The elevator doors open and you look up to find 5 rescuers performing CPR on 5 kids. As the lead triage officer, what should you do? Based on limited resources and these not being your only patients they should all be triaged to Category Expectant/Deceased Questions to note: How many resources do you have? Are these your only patients? (Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE)

2016 Recovery

Taking Care of Yourself
2016 Taking Care of Yourself After a critical event, rescue workers often struggle to get back to their daily lives and deal with their experiences Can have difficulty coping and feeling back to normal Look for mental health resources/professionals that may be available through your employer/organization or in your community Lastly, it is important as health care professionals that we take care of our own mental health needs. It may be difficult for rescue workers to deal with life after a traumatic event. It may be months or even years later before the full impact of the event is felt. Many times, rescue workers often struggle to get back to their daily lives. In addition, there have been instances when the media has turned heroes into overnight sensation. Their lives can spin out of control. Know that there are resources and organizations to help after a traumatic event. Be sure to talk to others and to seek help if difficulties occur. No one should feel alone in this process or that one has to get through this completely on their own

Conclusion START/JumpSTART are the MCI triage systems used in Illinois
SMART Triage Tags are recommended for use in Illinois JumpSTART incorporates unique aspects of pediatric physiology Provide an objective framework to assist responders with making difficult life or death decisions during a disaster Helps provide emotional support when responders know they followed the protocols

2016 ANY QUESTIONS?

Applying START and JumpSTART©
2016 Applying START and JumpSTART© And now we are going to have you get some practice using the START and the JumpSTART triage tools. You will be given SMART disaster tags as well as ‘victims’ that you will need to appropriately categorize. The information you need to correctly triage will be on a card that accompanies the victim. When assigning triage color categories, please don’t rip off the triage tag but simply turn it under so the color you assign is showing. Instead, mark your triage decision on the patient tracking from You will be organized into groups of___rescuers and will utilize the START and the JumpSTART triage methods to assist in assigning a triage category. You will have ___ minutes to triage your group of assigned victims. After that time we will come back together to discuss the proper triage category.

Thank you!

2016 Pediatric Disaster Triage Utilizing the JumpSTART © Method March 2016 (4th Edition) Welcome and introductions Illinois Emergency Medical Services.

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2016 Pediatric Disaster Triage Utilizing the JumpSTART © Method March 2016 (4th Edition) Welcome and introductions Illinois Emergency Medical Services.

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