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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
Cdocumentsandsettingsschultzcmydocumentsmicrosoftworddisastermedicinecontentthemestartsave 091126172213-phpapp02
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)

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Cdocumentsandsettingsschultzcmydocumentsmicrosoftworddisastermedicinecontentthemestartsave 091126172213-phpapp02

  • 1. DISASTER TRIAGE: S.T.A.R.T. & S.A.V.E. Carl H. Schultz, MD Professor of Emergency Medicine UC Irvine School of Medicine
  • 2. 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.
  • 3. 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‖.
  • 4. Goal of Disaster Triage  Do the greatest good for the greatest number of casualties
  • 5. 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
  • 6. Does Triage Work?  Lessons from history  Scene control – Convergence behavior
  • 7. 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
  • 8. 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
  • 9. Triage Practices  Traditional – Scoop and run – Designed to work within existing EMS  Disaster – Secondary exam and treatment performed – Assumes nonfunctional EMS system
  • 10. 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
  • 11. 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
  • 12. START Triage  Simple Triage and Rapid Treatment  Designed to be performed by first responders (paramedics)  Assumes personnel under a great deal of stress
  • 13. 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
  • 14. 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
  • 16. 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
  • 17. SAVE Triage Benefit Value = ———— X Probability of survival Resources required
  • 19. SAVE Triage Areas of Assessment  Vital Signs  Airway  Chest  Abdomen  Pelvis  Spine  Extremities  Skin  Neurologic Status  Mental Status
  • 20. 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
  • 21. SAVE Triage Categories  Periodic assessment of all categories is important  Patients may move from one area to another
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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?
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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)
  • 30. 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)
  • 31. 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)
  • 32. 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)