Disaster Triage START and SAVE


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Disaster Triage START and SAVE

  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 3 rd Year EM Resident Oklahoma City Bombing <ul><li>“… 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. </li></ul>
  3. 3. Nature of Triage… <ul><li>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”. </li></ul>
  4. 4. Goal of Disaster Triage <ul><li>Do the greatest good for the greatest number of casualties </li></ul>
  5. 5. Triage Origin <ul><li>From the French verb, t r i e r , “to sort” </li></ul><ul><li>Napoleon’s time, to assign treatment priorities with limited resources </li></ul><ul><li>Attention given first to most salvageable with most urgent conditions – get them back into battle </li></ul>
  6. 6. Does Triage Work? <ul><li>Lessons from history </li></ul><ul><li>Scene control </li></ul><ul><ul><li>Convergence behavior </li></ul></ul>
  7. 7. Key Concepts <ul><li>Resources are limited </li></ul><ul><ul><li>Supplies </li></ul></ul><ul><ul><li>Personnel </li></ul></ul><ul><li>Time for evacuation unknown or prolonged (the cavalry isn’t coming any time soon) </li></ul><ul><ul><li>Only austere field interventions are available </li></ul></ul>
  8. 8. Triage Practices <ul><li>Traditional </li></ul><ul><ul><li>Static, single point in time </li></ul></ul><ul><ul><li>Triage tags frequently used </li></ul></ul><ul><ul><li>Few patients </li></ul></ul><ul><li>Disaster </li></ul><ul><ul><li>Dynamic, multiple points in time </li></ul></ul><ul><ul><li>Documentation needs may exceed triage tag capacity </li></ul></ul><ul><ul><li>Large patient numbers </li></ul></ul>
  9. 9. Triage Practices <ul><li>Traditional </li></ul><ul><ul><li>Scoop and run </li></ul></ul><ul><ul><li>Designed to work within existing EMS </li></ul></ul><ul><li>Disaster </li></ul><ul><ul><li>Secondary exam and treatment performed </li></ul></ul><ul><ul><li>Assumes nonfunctional EMS system </li></ul></ul>
  10. 10. Triage Practices <ul><li>Traditional </li></ul><ul><ul><li>Used for localized disaster scenes </li></ul></ul><ul><ul><li>Dependent on communications and transportation </li></ul></ul><ul><li>Disaster </li></ul><ul><ul><li>Used for wide-spread disaster scenes </li></ul></ul><ul><ul><li>Does not depend on communication and less on transportation </li></ul></ul>
  11. 11. Patient Categories <ul><li>1. Those who will die no matter what </li></ul><ul><li>2. Those who will do well no matter what we do </li></ul><ul><li>Those who will derive long-term benefit from acute intervention </li></ul><ul><li>Early identification of #3 important </li></ul><ul><ul><li>Others benefit from comfort care </li></ul></ul>
  12. 12. START Triage <ul><li>Simple Triage and Rapid Treatment </li></ul><ul><li>Designed to be performed by first responders (paramedics) </li></ul><ul><li>Assumes personnel under a great deal of stress </li></ul>
  13. 13. START Triage <ul><li>Rapid method to perform INITIAL triage </li></ul><ul><li>Utilizes respiratory rate, palpable pulse, and mental status (ability to follow commands) </li></ul><ul><li>Begins by asking all that can walk to move away from triage officer </li></ul><ul><li>Assess using START those that remain </li></ul>
  14. 14. START Triage <ul><li>GREEN: those who are able to get up and walk away </li></ul><ul><li>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 </li></ul><ul><li>YELLOW: those who are not red but can’t walk </li></ul><ul><li>BLACK: dead </li></ul>
  15. 15. Modified START
  16. 16. SAVE Triage <ul><li>Secondary Assessment of Victim Endpoint </li></ul><ul><li>All patients with at least a 50% chance of survival using available resources get care </li></ul><ul><ul><li>Patient assessed by SAVE methodology in order of priority determined by START </li></ul></ul>
  17. 17. SAVE Triage <ul><li>Benefit Value = ———— X Probability of survival Resources required </li></ul>
  18. 19. SAVE Triage Areas of Assessment <ul><li>Vital Signs </li></ul><ul><li>Airway </li></ul><ul><li>Chest </li></ul><ul><li>Abdomen </li></ul><ul><li>Pelvis </li></ul><ul><li>Spine </li></ul><ul><li>Extremities </li></ul><ul><li>Skin </li></ul><ul><li>Neurologic Status </li></ul><ul><li>Mental Status </li></ul>
  19. 20. SAVE Triage Categories <ul><li>RED: require immediate intervention </li></ul><ul><li>YELLOW: require intervention but can tolerate a brief delay </li></ul><ul><li>GREEN: do not require intervention to prevent loss of life or limb </li></ul><ul><li>BLACK: dead or unsalvageable </li></ul>
  20. 21. SAVE Triage Categories <ul><li>Periodic assessment of all categories is important </li></ul><ul><li>Patients may move from one area to another </li></ul>
  21. 22. SAVE Triage Guidelines <ul><li>Crush Injury to Lower Extremity </li></ul><ul><ul><li>Patients are assessed using the MESS score </li></ul></ul><ul><ul><li>Score of 7 or more: amputate </li></ul></ul><ul><ul><li>Score less than 7: attempt limb salvage </li></ul></ul>
  22. 23. SAVE Triage Guidelines <ul><li>Head Injury (adults) </li></ul><ul><ul><li>Use the Glascow Coma Score (GCS) </li></ul></ul><ul><ul><li>Score 8 or above: treat </li></ul></ul><ul><ul><ul><li>Better than 50% chance of a normal or good neurologic recovery </li></ul></ul></ul><ul><ul><li>Score 7 or less: comfort care only </li></ul></ul>
  23. 24. SAVE Triage Guidelines <ul><li>Burn Injury: less than 50% chance of survival </li></ul><ul><ul><li>70% TBSA burn </li></ul></ul><ul><ul><li>Age > 60 with inhalational injury </li></ul></ul><ul><ul><li>Age < 2 with 50% TBSA burn </li></ul></ul><ul><ul><li>Age > 60 with 35% TBSA burn </li></ul></ul><ul><li>Comfort care only </li></ul>
  24. 25. SAVE Triage Guidelines <ul><li>Abdominal Injury </li></ul><ul><ul><li>No data to guide evaluation </li></ul></ul><ul><ul><li>4 ml/kg hypertonic saline X 2 </li></ul></ul><ul><ul><li>If no response, comfort care only </li></ul></ul><ul><ul><li>Role of handheld ultrasound? </li></ul></ul>
  25. 26. Initial Assessment: START Case #1 <ul><li>61 year old male pulled from smoking building. Complaining of shortness of breath. </li></ul><ul><li>RR =28 </li></ul><ul><li>Wrist Pulse: palpable </li></ul><ul><li>Mental Status: follows commands </li></ul><ul><li>START Category: yellow (delayed) </li></ul><ul><li>Treatment: nothing </li></ul>
  26. 27. Initial Assessment: START Case #2 <ul><li>30 year old male found with bleeding head wound </li></ul><ul><li>RR =22 </li></ul><ul><li>Wrist Pulse: palpable </li></ul><ul><li>Mental Status: unresponsive </li></ul><ul><li>START Category: red (immediate) </li></ul><ul><li>Treatment: apply pressure to stop bleeding </li></ul>
  27. 28. Initial Assessment: START Case #3 <ul><li>20 year old female complaining of crushed lower extremity </li></ul><ul><li>RR =20 </li></ul><ul><li>Wrist Pulse: palpable </li></ul><ul><li>Mental Status: follows commands </li></ul><ul><li>START Category: yellow (delayed) </li></ul><ul><li>Treatment: nothing </li></ul>
  28. 29. Initial Assessment: START Case #4 <ul><li>3 year old female found not breathing </li></ul><ul><li>RR =agonal </li></ul><ul><li>Wrist Pulse: palpable </li></ul><ul><li>Mental Status: unresponsive </li></ul><ul><ul><li>Open airway and give 15 seconds of ventilation. No change in respirations. </li></ul></ul><ul><li>START Category: black (dead) </li></ul>
  29. 30. Secondary Assessment: SAVE Case #2 <ul><li>30 year old male found with bleeding head wound </li></ul><ul><li>START Category: red (immediate) </li></ul><ul><li>EXAM: neurologic status </li></ul><ul><ul><li>Does not open eyes, does not speak, and withdraws to pain </li></ul></ul><ul><ul><li>GCS = 6 </li></ul></ul><ul><li>SAVE Category: black (unsalvageable) </li></ul>
  30. 31. Secondary Assessment: SAVE Case #1 <ul><li>61 year old male pulled from smoking building. Complaining of shortness of breath. </li></ul><ul><li>START Category: yellow (delayed) </li></ul><ul><li>EXAM: airway </li></ul><ul><ul><li>Singed nasal hairs and eyebrows. Coughing up carbonaceous material. Wheezing. No skin burns </li></ul></ul><ul><li>SAVE Category: black (unsalvageable) </li></ul>
  31. 32. Secondary Assessment: SAVE Case #3 <ul><li>20 year old female complaining of crushed lower extremity </li></ul><ul><li>START Category: yellow (delayed) </li></ul><ul><li>EXAM: extremities </li></ul><ul><ul><li>Crushed left leg. Massive tissue avulsion and hemorrhage. Limb numb. Patient is pale. </li></ul></ul><ul><ul><li>MESS = 8 or 9 </li></ul></ul><ul><li>SAVE Category: red (immediate) </li></ul>