1. Rapid Assessment & Triage Methods:
The University of South Alabama
Center for Strategic Health Innovation
Funding for these courses provided through HRSA funds administered by Alabama Department of Public Health
Rapid Assessment & Triage Methods:
On-scene to the ER
© University of South Alabama Center For Strategic Health Innovations. All Rights Reserved.
These slides are a part of the ARRTC program and cannot be reproduced for commercial purposes.

2. simsf@cityofmobile.org 251.208.5873
Doug Sims RN MPA REMTP

3. Objectives
Identify situations when standard triage methods may be inadequate.
Identify appropriate triage locations for different types of mass casualty events.
Identify MCI triage acronyms: MASS, START, JumpSTART, SLUDGEM
4. Identify discipline-specific staffing needs for the four (4) main triage categories.

4. Mass Casualty Incident: What Is It?
An incident can be considered a mass casualty incident whenever the number of victims is greater than your resource capability to provide usual and customary standards of care.
Example: 20 victim incident for small, rural hospital to manage can be as much of a “mass” casualty incident as a hundred victim incident in a large metropolitan area with multiple hospitals / trauma unit(s).

5. Needs out of proportion
Disaster Triage
What’s a disaster?
Needs out of proportion
to resources.

6. Disaster Triage
Why Do I Need It????

7. Disaster Triage At least 4 die in gym shooting near Pittsburgh
At least 10 shooting victims arrived at the three major hospitals in the area.
A spokeswoman for Mercy Hospital confirmed five female shooting victims arrived at the facility with multiple gunshot wounds. Three were in serious condition, and two were listed as critical, she said.

8. Disaster Triage Fort Hood, Texas
Mass shooting killed 12 soldiers and one civilian and wounded 38 people at the Fort Hood Army Post in Texas.

9. Disaster Triage Gunman Opens Fire at Orlando Office
A gunman opened fire Friday in the offices of an engineering firm where he was let go more than two years ago, killing one person and injuring five others.

10. Disaster Triage West Nickel Mines School Shooting
10 young girls, between the ages of six and 13, all had at least one gunshot wound.

11. Disaster Triage Flight 1404 (Denver)
Thirty-six patients were initially identified as requiring transport

12. Principles of Disaster Triage
Do the greatest good for the greatest number of people
Employ the most efficient use of available resources
Treat as many as possible who have a chance of survival.
Base treatment on exclusion criteria
Agreed upon criteria = Triage Process
Return key personnel to duty as quickly as possible

13. Factors for Successful Triage
Focus on easily treated conditions
Perform rapid, accurate but assessments
Continually reassess and retriage

14. On-Scene Rapid Assessment
Assorted Methods
START : Simple Triage And Rapid Treatment
JumpSTART (Pediatric Version of START)
MASS : Move, Assess, Sort, & Send
Triage Sieve: Ambulate, Breathing, Pulse Rate
Pediatric Triage Tape: Length, Weight, Age
Care Flight Triage Algorithm: Qualitative Observations
Sacco Triage Method: Mathematical Model
MASS is a modified military triage method. In essence, both MASS and START involve rapid assessment and sorting of victims by physiological criteria so treatment of the most critical can be initiated before those less critical. JumpSTART is the START method revised to work with ages 1 through 8.
Note that Triage does NOT equate to treatment; other than repositioning airway to reestablish respirations, treatment should be initiated in the treatment area AFTER the patient is transferred there.

15. On-Scene Rapid Assessment
Secondary Methods
SAVE Triage: Detailed Guidelines
Triage Sort: Used in Conjunction with Triage Sieve
MASS is a modified military triage method. In essence, both MASS and START involve rapid assessment and sorting of victims by physiological criteria so treatment of the most critical can be initiated before those less critical. JumpSTART is the START method revised to work with ages 1 through 8.
Note that Triage does NOT equate to treatment; other than repositioning airway to reestablish respirations, treatment should be initiated in the treatment area AFTER the patient is transferred there.

16. START (Simple Triage And Rapid Treatment)
Developed by staff at Hoag Hospital and the Newport Beach Fire Department Newport Beach, CA. in 1986

17. START Triage Triage = “Sorting” Not a treatment role!
Only 2 treatments allowed:
Open & clear airway
Control of major external hemorrhage
~30 seconds per patient!

18. Respirations Airway / Breathing Pulse Circulation
START Triage
Exclusion criteria - based on rapid assessment of “RPM”
Respirations Airway / Breathing
Pulse Circulation
Mental Status Disability

19. Remember... Once any RED criteria are met, tag patient and move on!
All patients are reassessed at treatment areas.

20. On-Scene Rapid Assessment
Immediate Scene Assessment
This fits with the concept of “Situational Awareness”, and must be done before actual assessment / triage begins.

21. Triage Tags follow the 4 Color Triage Categories:
Adaptable for almost any type of incident, w/ SLUDGEM assessment triggers for chemical event
Identify triage category and contamination status
Provide easy record of vital patient data & tx that stays with patient
Bar codes enable patient ID (including valuables / clothing) throughout triage, tx, morgue
Do a talk through with class of how to use these tags:

24. On-Scene Rapid Assessment
Next slide has diagram for discussion of this subject.
2. Set-up of Victim Staging Areas

26. Transportation: Process and Problems
On-Scene Rapid Triage
Transportation: Process and Problems

27. On-Scene Rapid Assessment
Information Exchange to ER at Patient Delivery

28. Tips and Pitfalls in Triage
Move Quickly
Do Not Second Guess
Let the most experienced lead
Plan Ahead

29. JumpSTART: Pediatric START Triage Method
Developed by Lou E. Roming MD, FAAP, FACEP Miami Children’s Hospital Miami-Dale Fire Rescue Department Medical Director, FL/5 DMAT

30. The JumpSTART Field Pediatric Multicasualty Triage System ©
(Patients aged 1- 8 years)
Black = Deceased/expectant
Red = Immediate
Yellow = Delayed
Green = Minor/Ambulatory
Identify and direct all ambulatory patients to designated
Green area for secondary triage and treatment. Begin
assessment of nonambulatory patients as you come to them.
Proceed as below:
MINOR
Spontaneous respirations?
YES NO
Check resp. rate
Open airway
< 15/min or
> 40/min
or irregular
/ min,
regular
Spontaneous respirations? NO
YES
Peripheral pulse? NO
Peripheral pulse?
IMMEDIATE
IMMEDIATE
YES NO
YES
DECEASED
Still follows the RPM method, but with values and interventions appropriate for children. Triage sorting categories are the same.
Perform 15 sec.
Mouth to Mask
Ventilations
Check mental status
(AVPU)
IMMEDIATE
Spontaneous respirations? A V
P (appropriate)
P (inappropriate) U
YES
IMMEDIATE NO
DECEASED
IMMEDIATE
DELAYED
© Lou Romig MD, FAAP, FACEP, 1995

31. Alabama Trauma System Good trauma care is no accident!
Designated Trauma Centers
Classified by Level I,III,III
Four Entry Criteria

32. EMS & Trauma Regions

33. Alabama Trauma Communications Center
Business Phone
SouthernLink : Fleet 55 Talkgroup 10 or private 55*380
Nextel 154*132431*4

34. Entry Criteria Physiological
Physiologic Criteria (generally triaged to Level I Trauma Center)
A systolic BP<90mmHg in an adult or <80mmHg in a child 5 years old or younger
Respiratory distress - A respiratory rate of <10 or >20 in adults or <20 or >40 in a child one year old or younger
Altered mental status as evidenced by Glasgow Coma Score of 13 or less
GCS of 9 or less go to Level I
GCS of go to Level II or possible Level III if they have neurosurgical coverage

35. Entry Criteria Anatomical
Anatomic Criteria (generally triaged to Level I Trauma Center)
Flail chest
Two or more obvious proximal long bone fractures (humerus, femur)
Penetrating injury of the head, neck, torso, or groin (not just laceration)
Has in the same body area a combination of trauma and burns (partial and/or full thickness) of 15% or greater
Amputation proximal to the wrist or ankle
One or more limbs that are paralyzed
Unstable pelvic fracture, as evidenced by a positive "pelvic movement" exam

36. Entry Criteria Mechanism of injury
Mechanism of Injury Criteria (may go to Level II or III if closer than Level I Trauma Center)
A patient with the same method of restraint and in the same seating area as a dead victim
Ejection of the patient from an enclosed vehicle
Motorcycle/bicycle/ATV crash with the patient being thrown at least 10 feet from the vehicle
Auto versus pedestrian with significant impact with the patient being thrown, or run over by a vehicle
An unbroken fall of 20 feet or more onto a hard surface

37. Entry Criteria EMT Discretion
EMT Discretion Criteria (May go to a Level II or III if closer than Level I Trauma Center)
If the EMT is convinced the patient could have a severe injury that is not yet obvious, the patient should be entered into the trauma system
The EMT's suspicion of severity of trauma/injury may be raised by the following factors:
Age >55
Age <5
Environment (hot/cold)
Patient's previous medical history:
Insulin dependent diabetes Cardiac condition Immunodeficiency disorder Bleeding disorder COPD/Emphysema Pregnancy Extrication time >20 minutes with heavy tools utilized History of more than momentary loss of consciousness

38. Entry Criteria Special Cases
No Airway - to closest emergency department
Unable to control severe hemorrhage - to closest emergency department
Hemodynamically unstable and unable to establish IV - to closest emergency department
Age 14 years old or younger
Pediatric Level I Center if transport is <45 minutes Closest Level I or II Trauma Center if >45 minutes to Pediatric Center Closest Level III if transport is >45 minutes to Level I or Level II
Pregnancy
To Level I if <45 minutes transport To Level II or III if >45 minutes transport
Hospitals will also be able to enter patients into the Trauma System

39. Transition

40. ER ~ Secondary Triage & Tx
1. Set-up and appropriate staffing for Emergency Room and Adjacent Treatment Areas

41. ER ~ Secondary Triage & Tx
Hand-off/Information Exchange from EMS/Ambulance Services

42. Triage Tags follow the 4 Color Triage Categories:
Adaptable for almost any type of incident, w/ SLUDGEM assessment triggers for chemical event
Identify triage category and contamination status
Provide easy record of vital patient data & tx that stays with patient
Bar codes enable patient ID (including valuables / clothing) throughout triage, tx, morgue
Do a talk through with class of how to use these tags:

43. ER ~ Secondary Triage & Tx
3. Management of Self Referral
(walk-up) Patients

44. ER ~ Secondary Triage & Tx
Secondary triage methods:
START Categories* vs. ER Categories
* (START, Jump-START, MASS, etc..)

45. ER ~ Secondary Triage & Tx
5. Staffing and Resource Issues

46. ER ~ Secondary Triage & Tx
6. Re-Transport

47. Lessons learned from disasters
Actions which save lives (early)
ABC’s
control of hemorrhage
chest decompression
Actions which save lives (delayed)
IV antibiotics
dressings & splints

48. Lessons learned from disasters
The hopelessly injured die regardless.
Unrealistic triage results in increased death rates among those who could & should survive.