Disaster Triage START and SAVE
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Disaster Triage START and SAVE

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Review of START and SAVE triage

Review of START and SAVE triage

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    Disaster Triage START and SAVE Disaster Triage START and SAVE 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 3 rd 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
      • 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)