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    Cdocumentsandsettingsschultzcmydocumentsmicrosoftworddisastermedicinecontentthemestartsave 091126172213-phpapp02 Cdocumentsandsettingsschultzcmydocumentsmicrosoftworddisastermedicinecontentthemestartsave 091126172213-phpapp02 Presentation Transcript

    • DISASTER TRIAGE: S.T.A.R.T. & S.A.V.E. Carl H. Schultz, MD Professor of Emergency Medicine UC Irvine School of Medicine
    • Carl Spengler, MD 3rd Year EM Resident Oklahoma City Bombing ―…We never saw a child come out of the federal building alive. At one point, a group of people began screaming for me. A firefighter had brought out a little girl who was still breathing. People were preparing intravenous fluids, and a paramedic was getting the intubation equipment together. The crowd was screaming for the doctors to work on the child.
    • Nature of Triage… I finally yelled for everybody to be quiet and calm down. As I assessed the little girl, it was obvious that she had catastrophic head and chest injuries and that there was nothing left to save. I told a paramedic to wrap up the child in a blanket and do nothing. Several bystanders became emotionally decompensated and screamed, ‗You bastard!‘ As I walked off, several people continued to curse me in the worst possible fashion. Unfortunately, that is the nature of triage‖.
    • Goal of Disaster Triage  Do the greatest good for the greatest number of casualties
    • Triage Origin  From the French verb, t r i e r , ―to sort‖  Napoleon‘s time, to assign treatment priorities with limited resources  Attention given first to most salvageable with most urgent conditions – get them back into battle
    • Does Triage Work?  Lessons from history  Scene control – Convergence behavior
    • Key Concepts  Resources are limited – Supplies – Personnel  Time for evacuation unknown or prolonged (the cavalry isn‘t coming any time soon) – Only austere field interventions are available
    • Triage Practices  Traditional – Static, single point in time – Triage tags frequently used – Few patients  Disaster – Dynamic, multiple points in time – Documentation needs may exceed triage tag capacity – Large patient numbers
    • Triage Practices  Traditional – Scoop and run – Designed to work within existing EMS  Disaster – Secondary exam and treatment performed – Assumes nonfunctional EMS system
    • Triage Practices  Traditional – Used for localized disaster scenes – Dependent on communications and transportation  Disaster – Used for wide- spread disaster scenes – Does not depend on communication and less on transportation
    • Patient Categories 1. Those who will die no matter what 2. Those who will do well no matter what we do 3. Those who will derive long-term benefit from acute intervention  Early identification of #3 important – Others benefit from comfort care
    • START Triage  Simple Triage and Rapid Treatment  Designed to be performed by first responders (paramedics)  Assumes personnel under a great deal of stress
    • START Triage  Rapid method to perform INITIAL triage  Utilizes respiratory rate, palpable pulse, and mental status (ability to follow commands)  Begins by asking all that can walk to move away from triage officer  Assess using START those that remain
    • START Triage  GREEN: those who are able to get up and walk away  RED: those with respiratory compromise (require airway assistance or have a respiratory rate  30), no palpable pulse at the wrist (but are breathing), or unable to follow commands  YELLOW: those who are not red but can‘t walk  BLACK: dead
    • Modified START
    • SAVE Triage  Secondary Assessment of Victim Endpoint  All patients with at least a 50% chance of survival using available resources get care – Patient assessed by SAVE methodology in order of priority determined by START
    • SAVE Triage Benefit Value = ———— X Probability of survival Resources required
    • SAVE Triage Areas of Assessment  Vital Signs  Airway  Chest  Abdomen  Pelvis  Spine  Extremities  Skin  Neurologic Status  Mental Status
    • SAVE Triage Categories  RED: require immediate intervention  YELLOW: require intervention but can tolerate a brief delay  GREEN: do not require intervention to prevent loss of life or limb  BLACK: dead or unsalvageable
    • SAVE Triage Categories  Periodic assessment of all categories is important  Patients may move from one area to another
    • SAVE Triage Guidelines  Crush Injury to Lower Extremity – Patients are assessed using the MESS score – Score of 7 or more: amputate – Score less than 7: attempt limb salvage
    • SAVE Triage Guidelines  Head Injury (adults) – Use the Glascow Coma Score (GCS) – Score 8 or above: treat Better than 50% chance of a normal or good neurologic recovery – Score 7 or less: comfort care only
    • SAVE Triage Guidelines  Burn Injury: less than 50% chance of survival – 70% TBSA burn – Age > 60 with inhalational injury – Age < 2 with 50% TBSA burn – Age > 60 with 35% TBSA burn  Comfort care only
    • SAVE Triage Guidelines  Abdominal Injury – No data to guide evaluation – 4 ml/kg hypertonic saline X 2 – If no response, comfort care only – Role of handheld ultrasound?
    • Initial Assessment: START Case #1  61 year old male pulled from smoking building. Complaining of shortness of breath.  RR =28  Wrist Pulse: palpable  Mental Status: follows commands  START Category: yellow (delayed)  Treatment: nothing
    • Initial Assessment: START Case #2  30 year old male found with bleeding head wound  RR =22  Wrist Pulse: palpable  Mental Status: unresponsive  START Category: red (immediate)  Treatment: apply pressure to stop bleeding
    • Initial Assessment: START Case #3  20 year old female complaining of crushed lower extremity  RR =20  Wrist Pulse: palpable  Mental Status: follows commands  START Category: yellow (delayed)  Treatment: nothing
    • Initial Assessment: START Case #4  3 year old female found not breathing  RR =agonal  Wrist Pulse: palpable  Mental Status: unresponsive – Open airway and give 15 seconds of ventilation. No change in respirations.  START Category: black (dead)
    • Secondary Assessment: SAVE Case #2  30 year old male found with bleeding head wound  START Category: red (immediate)  EXAM: neurologic status – Does not open eyes, does not speak, and withdraws to pain – GCS = 6  SAVE Category: black (unsalvageable)
    • Secondary Assessment: SAVE Case #1  61 year old male pulled from smoking building. Complaining of shortness of breath.  START Category: yellow (delayed)  EXAM: airway – Singed nasal hairs and eyebrows. Coughing up carbonaceous material. Wheezing. No skin burns  SAVE Category: black (unsalvageable)
    • Secondary Assessment: SAVE Case #3  20 year old female complaining of crushed lower extremity  START Category: yellow (delayed)  EXAM: extremities – Crushed left leg. Massive tissue avulsion and hemorrhage. Limb numb. Patient is pale. – MESS = 8 or 9  SAVE Category: red (immediate)