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...
Nature of Triage…
I finally yelled for everybody to be quiet and calm
down. As I assessed the little girl, it was obvious
...
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...
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 ...
Triage Practices
 Traditional
– Static, single
point in time
– Triage tags
frequently used
– Few patients
 Disaster
– Dy...
Triage Practices
 Traditional
– Scoop and run
– Designed to
work within
existing EMS
 Disaster
– Secondary exam
and trea...
Triage Practices
 Traditional
– Used for
localized
disaster scenes
– Dependent on
communications
and
transportation
 Dis...
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 d...
START Triage
 Simple Triage and Rapid Treatment
 Designed to be performed by first
responders (paramedics)
 Assumes per...
START Triage
 Rapid method to perform INITIAL triage
 Utilizes respiratory rate, palpable pulse,
and mental status (abil...
START Triage
 GREEN: those who are able to get up and
walk away
 RED: those with respiratory compromise
(require airway ...
Modified START
SAVE Triage
 Secondary Assessment of Victim
Endpoint
 All patients with at least a 50% chance of
survival using availabl...
SAVE Triage
Benefit
Value = ———— X Probability of survival
Resources required
SAVE Triage
Areas of Assessment
 Vital Signs
 Airway
 Chest
 Abdomen
 Pelvis
 Spine
 Extremities
 Skin
 Neurologi...
SAVE Triage Categories
 RED: require immediate intervention
 YELLOW: require intervention but can
tolerate a brief delay...
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...
SAVE Triage Guidelines
 Head Injury (adults)
– Use the Glascow Coma Score (GCS)
– Score 8 or above: treat
Better than 50...
SAVE Triage Guidelines
 Burn Injury: less than 50% chance of
survival
– 70% TBSA burn
– Age > 60 with inhalational injury...
SAVE Triage Guidelines
 Abdominal Injury
– No data to guide evaluation
– 4 ml/kg hypertonic saline X 2
– If no response, ...
Initial Assessment: START
Case #1
 61 year old male pulled from smoking
building. Complaining of shortness of
breath.
 R...
Initial Assessment: START
Case #2
 30 year old male found with bleeding head
wound
 RR =22
 Wrist Pulse: palpable
 Men...
Initial Assessment: START
Case #3
 20 year old female complaining of
crushed lower extremity
 RR =20
 Wrist Pulse: palp...
Initial Assessment: START
Case #4
 3 year old female found not breathing
 RR =agonal
 Wrist Pulse: palpable
 Mental St...
Secondary Assessment: SAVE
Case #2
 30 year old male found with bleeding head
wound
 START Category: red (immediate)
 E...
Secondary Assessment: SAVE
Case #1
 61 year old male pulled from smoking
building. Complaining of shortness of
breath.
 ...
Secondary Assessment: SAVE
Case #3
 20 year old female complaining of
crushed lower extremity
 START Category: yellow (d...
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  1. 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. 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. 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. 4. Goal of Disaster Triage  Do the greatest good for the greatest number of casualties
  5. 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. 6. Does Triage Work?  Lessons from history  Scene control – Convergence behavior
  7. 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. 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. 9. Triage Practices  Traditional – Scoop and run – Designed to work within existing EMS  Disaster – Secondary exam and treatment performed – Assumes nonfunctional EMS system
  10. 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. 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. 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. 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. 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
  15. 15. Modified START
  16. 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. 17. SAVE Triage Benefit Value = ———— X Probability of survival Resources required
  18. 18. SAVE Triage Areas of Assessment  Vital Signs  Airway  Chest  Abdomen  Pelvis  Spine  Extremities  Skin  Neurologic Status  Mental Status
  19. 19. 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
  20. 20. SAVE Triage Categories  Periodic assessment of all categories is important  Patients may move from one area to another
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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?
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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)
  29. 29. 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)
  30. 30. 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)
  31. 31. 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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