1. Triage Tags  Patients brought by EMS  Tag will be applied to patient by EMS  Patients directed to appropriate treatment area in the hospital based on color of triage tag  MCI/Disaster patients presenting to ED by own transportation  Triage tags in disaster cage in basement  Triage tags will be available in the ED  Decon room  At Triage  Should be used and applied to patients as they enter the hospital via the triage area where-ever this has been established

2. Triage  Primary triage- START and JumpStart  Segregates casualties into groups  Walkers move to another area  The more critically injured, but still a smaller crowd, left to sort through to determine reds and yellows  Secondary triage  Refines our clinical picture  Uses a physiological scoring system & anatomical examination

3. Primary vs Secondary Triage (The 1 st vs Subsequent Triage)  JumpSTART triage will be performed in the field – IF the patient is brought by EMS  If the patient accesses the ED on their own, triage will need to be set up and performed at the ED  If the patient comes to ED via EMS, ED should use the secondary triage (RTS) as their reassessment process

4. Secondary Triage  Glasgow coma scale (GCS) – 3-15 points Best eye opening Best eye opening Best verbal response Best verbal response Best motor response Best motor response  Respiratory rate  Systolic B/P  Secondary triage scores calculate RR and B/P based on adult norms  Secondary triage scores have not been modified for pediatric normal RR and B/P

5. Glasgow Coma Scale (GCS)  Best eye opening 1 - 4 points  Eyes spontaneously open, looking around; does not have to focus (4 points)  Eyes open (or eyelids flutter) to verbal stimuli prior to tactile stimulation(3 points)  Eyes open (or eyelids flutter) to painful or tactile stimuli (2 points)  There is absolutely no eye movement, including no eyelid flutter or flicker (1 point)

6.  Best verbal response  Patient oriented (5 points)  Patient confused, can carry on a conversation but not always appropriate; infant has irritable cry (4 points)  Patient using inappropriate words for the situation and you can understand what the words are; this is beyond confusion (ie: “the sky is blue”); infant cries to pain (3 points)  Patient has incomprehensible words (ie: moans and groans and noises made but cannot be understood for any words); child responds to pain (2 points)  There are no sounds, no moans, no groans, nothing heard from the patient (1 point)

7.  Best motor response  Patient obeys commands (6 points)  Patient is purposeful & localizes; this is the obnoxious patient who pulls at the equipment and tries to remove the equipment; they try to hit your hand away; infant withdraws to touch (5 points)  Patient responds to pain by withdrawal (the brain can no longer discern where the obnoxious stimuli is felt so just withdraws); infant withdraws to pain (4 points)  Patient flexes extremities (decorticate) (3 points)  Patient extends extremities (decerebrate) (2 points)  Patient is flaccid with no response (1 point)

8. Converting GCS Points to RTS  Conversion score ranges from 0 – 4 points  Total GCS 13 – 15 (4 points)  Total GCS 9 – 12 (3 points)  Total GCS 6 – 8 (2 points)  Total GCS 4 - 5 (1 point)  Total GCS 3 (0 points)  Add converted points (0 - 4) to respiratory rate score and systolic B/P score  RTS score range 0 – 12 points

9.  Respiratory rate – 0 – 4 points  10 – 29 breaths per minute (4 points)  30 or more breaths per minute (3 points)  6 - 9 breaths per minute (2 points)  1 – 5 breaths per minute (1 point)  0 breaths (0 points)  Points added to GCS conversion points (0 - 4) and to systolic B/P score (0 – 4)  RTS score ranges 0 - 12

10.  Systolic blood pressure (0 – 4 points)  90 or more (4 points)  76 – 89 (3 points)  50 - 75 (2 points)  1 – 49 (1 point)  0 (0 points)  Points added to GCS conversion points (0 - 4) and to respiratory rate score (0 – 4)  RTS score ranges 0 - 12

11. Secondary Triage - RTS  RTS score ranges from 0 to 12  Score of 12 (highest) – patient is GREEN  Score of 11 – patient is YELLOW  Score 10 or less – patient is RED

12. Scenario Practice  Use worksheet at end of power point as resource for START & JumpSTART triage and the secondary triage process  Place patients in the appropriate categories  Check answers at the end of the practice scenarios  Some scenarios are based in the field – does not matter as triage is performed the same in all settings (and you might be dispatched to help in the field if requested)

13. 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. There are 20 + kids either still in the bus and some are lying about the road. There are 3 adults.

14. JumpSTART Triage – Scenario #1 (Initial Triage) What color are you triaging these patients? Patient #1 Unresponsive; RR 30 and pale Patient #2 5 y/o looking around; RR 35 and open femur fracture Patient #3 Unresponsive; labored respirations 52 and open chest wound

15. Initial JumpSTART Triage Scenario #1  Patient #1 – RED  RR okay at 30 (between 15 and 45)  Patient is unresponsive  Patient #2 – YELLOW  Not able to walk so initially made yellow until retriaged – then may stay yellow or be triaged as green or red  Even though RR okay at 35 (between 15 and 45)  Even though looking around (awake)  Patient #3 – RED  Labored RR of 52 (> 45)  Unresponsive

16. 9 y/o F RR 10 Distal pulse Groans to painful stimuli In ditch 15ft away 50 y/o F RR 20 Cap refill < 2 sec Obeys commands c/o dizziness 10 y/o M Talking Good distal pulse Asks for help Walking 8 y/o F RR 0 Faint distal pulse Unresponsive Breathing after 5 rescue breaths delivered In rubble out of bus 11 y/o M RR 22 Distal Pulse Obeys commands Can’t move or feel legs 25y/o F RR12 Cap refill 4 sec Eye movement to tactile stimulation 6 mo pregnant Scenario #2

17. Scenario #2 Adult and Pediatric Mixed Triage  9 y/o – RED (RR<15)  50 y/o – GREEN (RR, cap refill & neuro okay)  10 y/o – GREEN (walking, neuro okay)  8 y/o – RED (faint distal pulse, unresponsive)  11 y/o – YELLOW (can’t walk so initially can’t be green; minimally will be yellow when you make it through the triage process and all other parameters are okay. D  Distal pulses and obeys commands okay so left yellow for now  25 y/o – RED (cap refill >2 sec; not responding to commands given (only to painful/tactile)

18. Scenario #2: F5 Tornado An F5 tornado has struck within your city/town. It occurred at 3pm while school was letting out. It touched down near 3 schools and a mall.

19. Triage This Patient: School age girl lying on roadway   Breathing 10/min.   Good distal Pulse   Groans to verbal stimuli   JumpSTART triage category?

20.  Patient is categorized as a RED  Respiratory rate (RR) is 10 (<15)  Do not even need to get to the type of AVPU response patient has  This patient is categorized influenced by respiratory rate and then rescuer must move onto next patient for triage  Patient care not delivered during triage  Patient care delivered in treatment

21. Triage This Patient: School age girl found; refuses to walk   Open arm fracture visible   RR 26, radial pulse present   Alert and talking   JumpSTART triage category?

22.  Open arm fracture could be a distracting injury – so don’t get distracted  Stay with physiological parameters  Not able to walk so automatically at minimum a YELLOW  Respiratory rate 26 (okay 15 - 45)  Neurologically okay (alert and talking)  Patient remains triaged as YELLOW  In secondary triage may be upgraded to GREEN (RTS most likely a 12)

23. Infants/Non-walkers  Evaluate this group of patients starting triage with the breathing assessment

24. 8 y/o RR 10 Weak, thready pulse Unresponsive Outside, face down 3 y/o RR 18 Pulse present; HR irregular 118 Responds to Pain Trapped under bookcase 9 mo Crying; RR 32 Pulse present Responds to voice Mult minor lacs to head/face 10 y/o screaming Pulse present Not focusing Running in hall 50 y/o RR 32 Weak Pulse; cap refill 4 seconds Not following commands Trapped under bookcase 7 y/o apnea Very weak Pulse Unresponsive; not breathing after 5 breaths Trapped under bookcase Scenario Practice #2 –Patients From Tornado

25. Scenario #2 Patient Triage  8 y/o – RED (unresponsive)  3 y/o – YELLOW (not walking; RR 15 – 45; “P” on AVPU)  9 mo – GREEN (pulse +; “V” on AVPU, minor external wounds)  10 y/o – RED (pulse+; not focusing, screaming, running around – distracting others so remove to control the scene)  50 y/o – RED (cap refill >2 sec; not following commands)  7 y/o – BLACK (apnea not corrected with 5 rescue breaths)

26. Scenario #3: High-Rise Fire   Fire reported on 15th floor   Smoke to the 16th and 17th floors.   The building Day Care Center is on the 17 th floor

27. Reported 30 kids in the day care and 6 employees Fire Crews carry 5 kids all being given CPR. The day care is next to the hospital and triage is set up in the ED How would you triage these patients?

28. 6 y/o RR 38 Radial pulse present Knows name and recalls incident Facial burns, coughing 53 y/o RR 48 Cap refill > 2 sec Moaning FB glass to abdomen; wheezing 3 y/o RR 0 Weak pulse Unresponsive; resumes breathing after 5 breaths given Found under desk 4 y/o RR 40 Pulse present Crying Soot to face 2 y/o RR 20 Palpable Pulse Hoarse cry Soot to face 5 y/o RR 28 Strong Palpable Pulse Crying; can’t walk 2 nd /3 rd degree burns Scenario #3 – High rise fire

29. Scenario #3 Patient Triage  6 y/o – GREEN (walks; RR 15-45; awake/alert)  53 y/o – RED (cap refill >2 sec)  3 y/o – RED (weak pulse, unresponsive)  4 y/o – GREEN (walks; RR 15- 45; pulse present)  2 y/o – GREEN (walks; RR 15-45; pulse present  5 y/o – YELLOW (can’t walk; RR 15-45; strong pulse)

30. Scenario #3  The patients made GREEN (1 st, 4 th and 5 th ) have evidence of airway involvement from the fire (facial burns and soot to face)  The patient, regardless of how initially triaged, may deteriorate and need upgrading  Remember secondary triage should occur rapidly and repeat assessments should occur frequently to determine if a patient needs to move up to a higher level of triage

31. Disaster Triage Decisions  Remember the point of primary triage  To sort patients to determine who is the most critical and who is less critical  Need to do the greatest good for the greatest number  Disaster triage is not routine daily triage where you do the best for each individual