Military vs Civilian Triage

Military vs. Civilian TriageMilitary modelThose with the least seriouswounds may be the firsttreatment priorityCivilian modelThose with the most serious butrealistically salvageable injuriesare treated first

Military vs. Civilian TriageIn both models, victims withclearly lethal injuries or thosewho are unlikely to surviveeven with extensive resourceapplication are treated as thelowest priority.

Ethical JustificationThis is one of the few places where a"utilitarian rule" governs medicine: thegreater good of the greater number ratherthan the particular good of the patient athand. This rule is justified only because ofthe clear necessity of general publicwelfare in a crisis.A. Jonsen and K. Edwards, “Resource Allocation” in Ethics inMedicine, Univ. of Washington School of Medicine,http://eduserv.hscer.washington.edu/bioethics/topics/resall.html

Why Should Responders Care AboutGood Triage?Provides a way to draworganization out of chaosHelps to get care to those whoneed it and will benefit from it themostHelps in resource allocationProvides an objective frameworkfor stressful and emotionaldecisions

Why are ResourcesImportant in Triage?Disaster is commonly definedas an incident in which patientcare needs overwhelm localresponse resources.Daily emergency care is notusually constrained byresource availability.

Abundant resources relative to demand(P = Patient)Do the best for each individual

Resources challenged(P = Patient)Do the best for each individual

Do the greatest Resources good overwhelmedfor the greatest number(P = Patient)

Daily EmergenciesDo the best for each individual.Disaster SettingsDo the greatest good forthe greatest number.Maximize survival.

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

Primary Disaster TriageGoal: to sort patients based onprobable needs for immediatecare. Also to recognize futility.Assumptions:Medical needs outstrip immediatelyavailable resourcesAdditional resources will becomeavailable with time

Primary Disaster TriageTriage based on physiologyHow well the patient is able toutilize their own resources to dealwith their injuriesWhich conditions will benefit themost from the expenditure oflimited resources

Primary Disaster TriageThe most commonly used adult tool inthe US and Canada is the STARTtool.The only recognized pediatric MCIprimary triage tool used in the US andCanada is the JumpSTART tool.Other tools exist but are less orientedto mass casualties than triagingsmaller numbers of (adult) traumapatients.

Basic Disaster Life SupportNational Disaster Life SupportEducation Consortium, viaMedical College of Georgia’sCenter of Operational MedicineEndorsed by the AmericanMedical AssociationDisaster Medicine OnlineUniversity (www.dmou.org)

Basic Disaster Life SupportMASS TriageMoveAssessSortSend? Assessment guidelines? Pediatric considerations

The Best Tool?No MCIprimary triagetool has beenvalidated byoutcome data.Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for theNeurosurgeon”, Neurosurg Focus 12(3), 2002. Available on theInternet at www.medscape.com/viewarticle/431314

Secondary Disaster TriageGoal: to best match patients’ current andanticipated needs with available resources.Incorporates:A reassessment of physiologyAn assessment of physical injuriesInitial treatment and assessment ofpatient responseFurther knowledge of resourceavailability

Secondary Triage ToolsThere is no widely recognized tool inthe US that addresses secondary MCItriage.California “Medical DisasterResponse” course’s SAVE tool(Secondary Assessment of VictimEndpoint)Many EMS systems use local traumacenter triage criteria.

NATO GuidelinesRedAirway obstruction, cardiorespiratoryfailure, significant external hemorrhage,shock, sucking chest wound, burns of faceor neckYellowOpen thoracic wound, penetratingabdominal wound, severe eye injury,avascular limb, fractures, significantburns other than face, neck or perineum

NATO GuidelinesGreenMinor lacerations, contusions, sprains,superficial burns, partial-thicknessburns of < 20% BSABlackHead injury with GCS85%BSA, multisystem trauma, signs ofimpending deathBurkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23:742-747, 1994

Secondary Triage ToolsGoal is to distinguish between:Victims needing life-saving treatmentthat can only be provided in a hospitalsetting.Victims needing life-saving treatmentinitially available on scene.Victims with moderate non-lifethreateninginjuries, at risk for delayedcomplications.Victims with minor injuries.

Tertiary Disaster TriageGoal: to optimize individual outcomeIncorporates:Sophisticated assessment andtreatmentFurther assessment of availablemedical resourcesDetermination of best venue fordefinitive care

Primary TriageSecondary TriageTertiary Triage

MCI Triage: Key PointsResources and patient numbersand acuity are limiting factors.Must be dynamic, responsive tochanges in both resources andpatient needs.There is currently no civilian MCItriage system that has beenvalidated by outcome data.

Triage Categories

Triage CategoriesRed:Life-threatening but treatableinjuries requiring rapid medicalattentionYellow:Potentially serious injuries, butare stable enough to wait a shortwhile for medical treatment

Triage CategoriesGreen:Minor injuries that can wait forlonger periods of time fortreatmentBlack:Dead or still with life signs butinjuries are incompatible withsurvival in austere conditions

Triage Tools

STARTSimple Triage And RapidTreatmentDeveloped jointly by NewportBeach (CA) Fire and MarineDept. and Hoag HospitalGold standard for field adultmultiple casualty (MCI) triagein the US and numerouscountries around the world

STARTUtilizes the same four triagecategoriesUsed for Primary Triagewww.start-triage.com

START TriageRESPIRATIONSNOYESOver 30/minUnder 30/minPERFUSIONPosition AirwayImmediateCap refill> 2 secCap refill< 2 sec.NODead orExpectantYESImmediateControlBleedingImmediateFailure to followsimple commandsMENTALSTATUSCan followsimple commandsImmediateDelayed

START: Step 1Triage officer announces that allpatients that can walk should get upand walk to a designated area foreventual secondary triage.All ambulatory patients are initiallytagged as Green.

START: Step 2Triage officer assesses patients in theorder in which they are encounteredAssess for presence or absence ofspontaneous respirationsIf breathing, move to Step 3If apneic, open airwayIf patient remains apneic, tag as BlackIf patient starts breathing, tag as Red

START: Step 3Assess respiratory rateIf ≤30, proceed to Step 4If > 30, tag patient as Red

START: Step 4Assess capillary refillIf ≤ 2 seconds, move to Step 5If > 2 seconds, tag as Red

START: Step 5Assess mental statusIf able to obey commands, tagas YellowIf unable to obey commands,tag as Red

MnemonicRPM302Can do

JumpSTART Pediatric MCI TriageDeveloped byLou Romig MD, FAAP, FACEPNow in widespread usethroughout the US and CanadaBeing taught in Japan, Germany,Switzerland, the DominicanRepublic, Africa, Polynesia

JumpSTART Pediatric MCI TriageRecognized by the US NationalDisaster Medical SystemPublished in Brady’sPrehospital Emergency Care, 7 thed.Published in APLS coursewww.jumpstarttriage.com

Patients who are able to walk areassumed to have stable, wellcompensatedphysiology, regardless ofthe nature of their injuries or illness.

Secondary TriageAll green patients must beindividually assessed in secondarytriage.Assess physiologyAssess injuriesAssess probability of deteriorationAssess needs vs. resource availability

Secondary TriageSome children may be carried to thegreen area by others. They have notproven their physiologic stability byperforming the complex act ofwalking.These children should be assessedfirst among all those in the greenarea.

Position the upper airway of theapneic child.If they start to breathe, tag themas

If the child doesn’t start breathingwith upper airway opening, feelfor a pulse.If no pulse is palpable, tag thepatient as

If the patient has a palpable pulse, give 5 mouthto-barrierbreaths to open the lower airways. Tagas below, depending on response to ventilations.DO NOT CONTINUE TO VENTILATE THEPATIENT. RESUME TRIAGE DUTIES.

Assess the respiratory rateof the spontaneouslybreathing child.

Move on to next assessment ifrespiratory rate is 15-45breaths/minute.If respiratory rate is 45,tag the patient as

If the child’s pulse is palpable,move on to the next assessment.If no palpable pulse, tag thepatient as

If patient is inappropriately responsiveto pain, posturing, or unresponsive, tagasIf patient is alert, responds to voice orappropriately responds to pain, tag as

Modification for NonambulatoryChildrenChildren developmentallyunable to walk due to youngage or developmental delayChildren with chronicdisabilities that prevent themfrom walking

Modification for NonambulatoryChildrenFor nonambulatory children,assess using the JumpSTARTalgorithm.If pt meets any red criteria tagas

Modification for NonambulatoryChildrenIf patient meets yellow criteriaand has significant externalsigns of injury, tag asIf patient meets yellow criteriaand has no significant externalsigns of injury, tag as

What about WMD?There is no widely recognized civilianMCI triage tool used in the US for anyof the NRBC agents.

WMD Triage ChallengesAny triage model for WMD mustconsider decontamination:Who goes first?At what stage does triage takeplace?Difficulty of conducting patientassessment and care withresponders in protective gear.

WMD Triage ChallengesAgents of attack may be mixed. How doyou triage victims who have injuriesfrom a conventional attack in additionto a chemical or radiological/nuclearexposure?

WMD Triage ChallengesBiological agents may impact field triagemostly in choice of destination facility(quarantine hospital).Patterns of EMS calls may assist inidentification of a occult biological agentattack or a natural epidemicExample biosurveillance tool is the FirstWatch programhttp://www.stoutsolutions.com/firstwatch

WMD Triage ChallengesSome agents cause “toxindromes” thatallow for prediction of outcome basedon presenting symptoms and signs.Agent-specific triage is dependent uponidentification or strong suspicion of theagent’s use.Very difficult to train and maintainreadiness with multiple agent-specifictriage schemes.

Chemical Toxindrome ExamplesNerve agentRed: severe distress, seizure,signs in two or more systems(neuromuscular, GI,respiratory – excluding eyesand nose)Black: pulseless or apneic,unless intensive resources areavailable

Chemical Toxindrome ExamplesPhosgene and vesicantsRed: moderate to severerespiratory distress, only whenintensive resources areimmediately availableBlack: burns >50% BSA fromliquid exposure, signs of morethan minimal pulmonaryinvolvement, when intensiveresources are not available

Chemical Toxindrome ExamplesCyanideRed: active seizure or recentonset of apnea with preservedcirculationBlack: no palpable pulseSidell FR, “Triage of Chemical Casualties” Chapter 14 inMedical Aspects of Chemical and Biological Warfare,available on the Internet athttp://www.bordeninstitute.army.mil/cwbw/Ch14.pdf

Key Points about MCI TriageAnything that can help organizethe response to an MCI is a goodthing.MCI triage is different than dailytriage, in both field and EDsettings.Resource availability is thelimiting factor to consider in MCItriage.

Key Points about MCI TriageIn order for MCI triage to worktoward its goal, all victims must haveequal importance at the time ofprimary triage. No patient group canreceive special consideration otherthan that dictated by their physiology.This includes children!

Key Points about MCI TriageDisaster research agendas shouldinclude efforts to validate and improveexisting triage tools.

Key Points about MCI TriageMCI triage will never be logistically,intellectually, or emotionally easy…but we must be prepared to do itusing the best of our knowledge andabilities.

Special Thanks!To Dr. Romig for the permission touse this presentation.MWLCEMS System

Thank You!For more information onJumpSTART please go to:www.jumpstarttriage.comYou can contact Dr. Romig at:LouRomig@jumpstarttriage.comorlouromig@bellsouth.net