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START Triage 2018 NEAOHN Annual Conference
Steven Marks, DNP, RN, APN, COHN-S, FAAOHN Kathee Tyo, MS, RN Coordinator/Educator
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Objectives: Define a Mass Casualty Incident and the unique challenges of an MCI Understand the differences between day-to-day triage and triage during an MCI Increase the region’s healthcare providers’ awareness of disaster triage
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What is the Goal of MCI Management?
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GOAL: TO SAVE THE LARGEST NUMBER OF SURVIVORS FROM A MULTIPLE CASUALTY INCIDENT
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The Problem Casualties Resources
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Considerations During an MCI Response
Supply vs. Demand Resource Allocation Coordination Medical Management Ethics
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The Objective Casualties Resources
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What Could Be an MCI For You?
Workplace Accident Workplace Fire Natural Disaster Wildfires Floods Hurricanes Tornado Acts of Terrorism or Violence
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Incident Management Would any of those situations lead to shortage of personnel & equipment resources? Would decisions and changes need to be made in how you do business? Altered Standards of Care
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Incident Command System
Medical Command Triage Treatment Transport Immediate Delayed Minor Expectant
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Simple Triage and Rapid Transport
Disaster Triage START Triage Simple Triage and Rapid Transport
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Types of Triage Primary Secondary
On scene prior to movement or at hospital (self transports) Secondary Incident dependent, probably prior to or during transport or upon arrival to hospital
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Triage Protocol (START)
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Triage Protocol (START)
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Triage Coding Color Priority Treatment RED Yellow Green Black
Immediate Delayed Minor XX Deceased Color Priority Treatment RED Yellow Green Black
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Primary Triage The Scene
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The first attempt at balancing resources and
Primary Triage The first attempt at balancing resources and casualties/injured
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Minor PRIORITY 3 Not injured or “Walking wounded”
Have motor, respiratory, mental function Minor
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Example Patient walks over to you and has an obvious broken arm
Respirations are 22 Pulse is 124 (Radial) He is awake, alert, and crying
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Determining whether there is an
Primary Triage Determining whether there is an airway and breathing
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If breathing, at what rate & is it good enough?
Primary Triage If breathing, at what rate & is it good enough?
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Primary Triage They have an airway, are breathing.
Are they circulating blood sufficiently?
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Circulatory Check…
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Primary Triage A B C Mental Status
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Immediate PRIORITY 1 Opening airway, starts to breathe
Breathing is greater than 30 or less than 10 Delayed capillary refill time (> 2 seconds) Absent radial pulses Bleeding that needs to be controlled Does not follow instructions Immediate
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Example Patient has an open head Wound, bleeding controlled
Respirations are 16 Pulse is 88 (Radial) He is unconscious
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Delayed PRIORITY 2 Did not move out, when asked Airway OK
Breathing within 11 and 29 Capillary refill less than 2 seconds or radial pulses present Can follow instructions to move unaffected limb Delayed
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Example Patient states he can’t move or feel his legs
Respirations are 26 Pulse is 110 (Radial) He is awake and oriented
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EXPECTANT/DEAD Still require resources Focus of care is comfort
Psychologically most challenging for healthcare providers
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Examples Patient gurgles but can’t maintain an open airway
and Is not breathing Weak Carotid Pulse She is unresponsive
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Secondary Triage Generally used when there is an extended duration event After initial color coding triage Healthcare professionals who respond to the scene or PH/Hospital response teams may be utilized to further determine who gets transported from scene first
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Triage Tag
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Secondary Triage
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Secondary Triage REASSESS
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Scenarios
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Scenario #1 An improvised explosive device is detonated at a large outdoor sporting event. At least 50 people are confirmed injured. EMS is on scene, but patients begin to arrive at your hospital before EMS. Triage and “Tag” the following patients.
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Patient #1 Apneic Pulse-less Missing LUE
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Patient #1 Apneic Pulse-less Missing LUE
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Patient #2 Eviscerated bowel
Multiple penetrating wounds to chest & head Brain matter exposed Unresponsive to tactile stimuli
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Patient #2 Eviscerated bowel
Multiple penetrating wounds to chest & head Brain matter exposed Unresponsive to tactile stimuli
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Patient #3 Abd. Tenderness and minor penetrating trauma Ambulating
A & O x 3 RR 24 Strong radial pulse
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Patient #3 Abd. Tenderness and minor penetrating trauma Ambulating
A & O x 3 RR 24 Strong radial pulse
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Patient #4 Multiple penetrating injuries, blood in ears
Responds only to pain Airway clear RR 20 Strong Radial pulse
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Patient #4 Multiple penetrating injuries, blood in ears
Responds only to pain Airway clear RR 20 Strong Radial pulse
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Patient #5 Extremity fractures, blood in ears A & O x 3 RR 26
Strong radial pulse
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Patient #5 Extremity fractures, blood in ears A & O x 3 RR 26
Strong radial pulse
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Patient #6 Child, screaming Minor lacs, blood in ears RR 28
Moving all extremities
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Patient #6 Child, screaming Minor lacs, blood in ears RR 28
Moving all extremities
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Patient #7 Amputated fingers, head injury A & O x 3 Dizzy RR 24
Smells like beer
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Patient #7 Amputated fingers, head injury A & O x 3 Dizzy RR 24
Smells like beer
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Patient #8 Chest pain, SOB No trauma noted RR 34 Shallow
Weak radial pulse
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Patient #8 Chest pain, SOB No trauma noted RR 34 Shallow
Weak radial pulse
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Patient #9 Blood in nose, mouth and ears Not breathing
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Patient #9 Blood in nose, mouth and ears Not breathing
What would you do?
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Patient #9 Blood in nose, mouth and ears Not breathing
RR 10 with manual opening
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Patient #10 Some penetrating trauma Unresponsive Apneic
No radial pulse Carotid 130/min
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Patient #10 Some penetrating trauma Unresponsive Apneic
No radial pulse Carotid 130/min
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Patient #11 Arterial bleed from leg Responsive to pain RR 34
No radial pulse Carotid 130/min
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Patient #11 Arterial bleed from leg Responsive to pain RR 34
No radial pulse Carotid 130/min
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Patient #12 Minor lacs Crying Ambulatory RR 24
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Patient #12 Minor lacs Crying Ambulatory RR 24
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Patient #13 Deviated trachea RR 40 Weak radial pulse +JVD Cyanosis
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Patient #13 Deviated trachea RR 40 Weak radial pulse +JVD Cyanosis
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Patient #14 Open fracture of RUE Non-ambulatory A & O x 3 RR 26
Strong radial pulse
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Patient #14 Open fracture of RUE Non-ambulatory A & O x 3 RR 26
Strong radial pulse
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Patient #15 100% TBS burns (partial and full) A & O x 2 RR 36
Coughing but, unable to maintain airway Strong radial pulse
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Patient #15 100% TBS burns (partial and full) A & O x 2 RR 36
Coughing but, unable to maintain airway Strong radial pulse
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Patient #16 CP, SOB Slurred speech R sided weakness A & O x 1 RR 24
Strong radial pulse
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Patient #16 CP, SOB Slurred speech R sided weakness A & O x 1 RR 24
Strong radial pulse
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Patient #17 Avulsion RUE Arterial bleed A & O x 2 RR 30 “I’m thirsty”
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Patient #17 Avulsion RUE Arterial bleed A & O x 2 RR 30 “I’m thirsty”
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Patient #18 Open fractures BLE Blood in ears A & O x 3 RR 28
Strong radial pulse
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Patient #18 Open fractures BLE Blood in ears A & O x 3 RR 28
Strong radial pulse
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Patient #19 Hysterical, screaming Blood in ears A & O x 3 RR 36
Strong radial pulse Can follow commands
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Patient #19 Hysterical, screaming Blood in ears A & O x 3 RR 36
Strong radial pulse Can follow commands
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Patient #20 Child Cyanotic from nipple line up Apneic
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Patient #20 Child Cyanotic from nipple line up Apneic
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What is the goal of Disaster Triage training?
Increase familiarity/proficiency of the START triage methodology Increase familiarity with the Triage Tag System Train with a standardized methodology and system
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Questions???
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Quick Demonstration
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Thank You!
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