MCI Triage:Beyond Red, Yellow, Green

and Black

Lou E. Romig MD, FAAP, FACEP

Miami Children’s Hospital

Miami-Dade Fire Rescue

FL-5 DMAT

Topics

What is Triage?Triage

Categories

Triage Tools

What is Triage?

“Triage” means “to sort”

Looks at medical needs and urgency of each individual patient

Sorting based on limited data acquisition

Also must consider resource availability

Military vs. Civilian Triage

Priority is to get as many soldiers back into action as

possible.

Priority is to maximize

survival of the greatest number

of victims.

Military vs. Civilian Triage

Military modelThose with the least serious wounds may be the first treatment priority

Civilian modelThose with the most serious but realistically salvageable injuries are treated first

Military vs. Civilian Triage

In both models, victims with clearly lethal injuries or those

who are unlikely to survive even with extensive resource application are treated as the

lowest priority.

Ethical Justification

This is one of the few places where a "utilitarian rule" governs medicine: the

greater good of the greater number rather than the particular good of the patient at

hand. This rule is justified only because of the clear necessity of general public

welfare in a crisis.

A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine, http://eduserv.hscer.washington.edu/bioethics/topics/resall.html

Why Should Responders Care About Good Triage?

Provides a way to draw organization out of chaosHelps to get care to those who need it and will benefit from it the mostHelps in resource allocationProvides an objective framework for stressful and emotional decisions

Why Should Planners Plan For Good Triage?

As a system tool, it provides a way to draw organization out of chaos.

Helps to get care to those who need it and will benefit from it the most and speeds efficient patient evacuation.

Why Should Planners Plan For Good Triage?

Helps in resource planning and allocation.

Provides an objective framework for stressful and emotional decisions, helping rescue workers to be more efficient and effective.

Why are Resources Important in Triage?

Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources.

Daily emergency care is not usually constrained by resource availability.

Abundant resources relative to demand

Do the best for each individual

(P = Patient)

Resources challenged

Do the best for each individual

(P = Patient)

Do the greatest good for the greatest numberResources overwhelmed

(P = Patient)

Daily Emergencies

Do the best for each individual.

Disaster SettingsDo the greatest good for

the greatest number. Maximize survival.

Triage is a dynamic process and is usually done more than once.

Primary Disaster Triage

Goal: to sort patients based on probable needs for immediate care. Also to recognize futility.

Assumptions:

Medical needs outstrip immediately available resources

Additional resources will become available with time

Primary Disaster Triage

Triage based on physiology

How well the patient is able to utilize their own resources to deal with their injuries

Which conditions will benefit the most from the expenditure of limited resources

Primary Disaster Triage

The most commonly used adult tool in the US and Canada is the START tool.

The only recognized pediatric MCI primary triage tool used in the US and Canada is the JumpSTART tool.

Other tools exist but are less oriented to mass casualties than triaging smaller numbers of (adult) trauma patients.

Basic Disaster Life Support

National Disaster Life Support Education Consortium, via Medical College of Georgia’s Center of Operational Medicine

Endorsed by the American Medical Association

Disaster Medicine Online University (www.dmou.org)

Basic Disaster Life Support

MASS Triage

Move

Assess

Sort

Send

? Assessment guidelines

? Pediatric considerations

The Best Tool?

No MCI primary triage tool has been validated by outcome data.

Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the Neurosurgeon”, Neurosurg Focus 12(3), 2002. Available on the Internet at www.medscape.com/viewarticle/431314

Secondary Disaster Triage

Goal: to best match patients’ current and anticipated needs with available resources.

Incorporates:

A reassessment of physiology

An assessment of physical injuries

Initial treatment and assessment of patient response

Further knowledge of resource availability

Secondary Triage Tools

There is no widely recognized tool in the US that addresses secondary MCI triage.

California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint)

Many EMS systems use local trauma center triage criteria.

NATO GuidelinesRedAirway obstruction, cardiorespiratory failure, significant external hemorrhage, shock, sucking chest wound, burns of face or neck

YellowOpen thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures, significant burns other than face, neck or perineum

NATO GuidelinesGreen

Minor lacerations, contusions, sprains, superficial burns, partial-thickness burns of < 20% BSA

Black

Head injury with GCS<8, burns >85% BSA, multisystem trauma, signs of impending death

Burkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23:742-747, 1994

Secondary Triage Tools

Goal is to distinguish between:

Victims needing life-saving treatment that can only be provided in a hospital setting.

Victims needing life-saving treatment initially available on scene.

Victims with moderate non-life-threatening injuries, at risk for delayed complications.

Victims with minor injuries.

Tertiary Disaster Triage

Goal: to optimize individual outcome

Incorporates:

Sophisticated assessment and treatment

Further assessment of available medical resources

Determination of best venue for definitive care

Primary Triage

Secondary Triage

Tertiary Triage

MCI Triage: Key Points

Resources and patient numbers and acuity are limiting factors.

Must be dynamic, responsive to changes in both resources and patient needs.

There is currently no civilian MCI triage system that has been validated by outcome data.

Triage Categories

Triage Categories

Red:

Life-threatening but treatable injuries requiring rapid medical attention

Yellow:

Potentially serious injuries, but are stable enough to wait a short while for medical treatment

Triage Categories

Green:

Minor injuries that can wait for longer periods of time for treatment

Black:

Dead or still with life signs but injuries are incompatible with survival in austere conditions

Triage Tools

START

Simple Triage And Rapid Treatment

Developed jointly by Newport Beach (CA) Fire and Marine Dept. and Hoag Hospital

Gold standard for field adult multiple casualty (MCI) triage in the US and numerous countries around the world

START

Utilizes the same four triage categories

Used for Primary Triage

www.start-triage.com

START Triage

RESPIRATIONS

NO

YES

Dead orExpectant

Immediate

Position Airway

NO YES

Over 30/min

Immediate

Under 30/min

PERFUSION

Cap refill> 2 sec

ControlBleeding

Immediate

Cap refill< 2 sec.

MENTALSTATUS

Failure to followsimple commands

Can followsimple commands

Immediate Delayed

START: Step 1

Triage officer announces that all patients that can walk should get up

and walk to a designated area for eventual secondary triage.

All ambulatory patients are initially tagged as Green.

START: Step 2

Triage officer assesses patients in the order in which they are encountered

Assess for presence or absence of spontaneous respirations

If breathing, move to Step 3

If apneic, open airway

If patient remains apneic, tag as Black

If patient starts breathing, tag as Red

START: Step 3

Assess respiratory rate

If ≤30, proceed to Step 4

If 30, tag patient as Red

START: Step 4

Assess capillary refill

If ≤ 2 seconds, move to Step 5

If 2 seconds, tag as Red

START: Step 5

Assess mental status

If able to obey commands, tag as Yellow

If unable to obey commands, tag as Red

Mnemonic

R

P

M

302Can do

JumpSTART Pediatric MCI Triage

Developed by Lou Romig MD, FAAP, FACEP

Now in widespread use throughout the US and Canada

Being taught in Japan, Germany, Switzerland, the Dominican Republic, Africa, Polynesia

JumpSTART Pediatric MCI Triage

Recognized by the US National Disaster Medical System

Published in Brady’s Prehospital Emergency Care, 7th ed.

Published in APLS course

www.jumpstarttriage.com

Patients who are able to walk are assumed to have stable, well-

compensated physiology, regardless of the nature of their injuries or illness.

Secondary Triage

All green patients must be individually assessed in secondary triage.

Assess physiology

Assess injuries

Assess probability of deterioration

Assess needs vs. resource availability

Secondary Triage

Some children may be carried to the green area by others. They have not proven their physiologic stability by performing the complex act of walking.

These children should be assessed first among all those in the green area.

Position the upper airway of the apneic child.

If they start to breathe, tag them as

If the child doesn’t start breathing with upper airway opening, feel for a pulse.

If no pulse is palpable, tag the patient as

If the patient has a palpable pulse, give 5 mouth-to-barrier breaths to open the lower airways. Tag as below, depending on response to ventilations.

DO NOT CONTINUE TO VENTILATE THE PATIENT. RESUME TRIAGE DUTIES.

Assess the respiratory rate of the spontaneously breathing child.

Move on to next assessment if respiratory rate is 15-45 breaths/minute.

If respiratory rate is <15 or >45, tag the patient as

If the child’s pulse is palpable, move on to the next assessment.

If no palpable pulse, tag the patient as

If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as

If patient is alert, responds to voice or appropriately responds to pain, tag as

Modification for Nonambulatory Children

Children developmentally unable to walk due to young age or developmental delay

Children with chronic disabilities that prevent them from walking

For nonambulatory children, assess using the JumpSTART algorithm.

If pt meets any red criteria tag as

Modification for Nonambulatory Children

If patient meets yellow criteria and has significant external signs of injury, tag as

If patient meets yellow criteria and has no significant external signs of injury, tag as

Modification for Nonambulatory Children

What about WMD?

There is no widely recognized civilian MCI triage tool used in the US for any

of the NRBC agents.

WMD Triage Challenges

Any triage model for WMD must consider decontamination:

Who goes first?

At what stage does triage take place?

Difficulty of conducting patient assessment and care with responders in protective gear.

WMD Triage Challenges

Agents of attack may be mixed. How do you triage victims who have injuries

from a conventional attack in addition to a chemical or radiological/nuclear

exposure?

WMD Triage Challenges

Biological agents may impact field triage mostly in choice of destination facility (quarantine hospital).

Patterns of EMS calls may assist in identification of a occult biological agent attack or a natural epidemic

Example biosurveillance tool is the First Watch program http://www.stoutsolutions.com/firstwatch

WMD Triage Challenges

Some agents cause “toxindromes” that allow for prediction of outcome based on presenting symptoms and signs.

Agent-specific triage is dependent upon identification or strong suspicion of the agent’s use.

Very difficult to train and maintain readiness with multiple agent-specific triage schemes.

Chemical Toxindrome Examples

Nerve agent

Red: severe distress, seizure, signs in two or more systems (neuromuscular, GI, respiratory – excluding eyes and nose)

Black: pulseless or apneic, unless intensive resources are available

Chemical Toxindrome Examples

Phosgene and vesicants

Red: moderate to severe respiratory distress, only when intensive resources are immediately available

Black: burns >50% BSA from liquid exposure, signs of more than minimal pulmonary involvement, when intensive resources are not available

Chemical Toxindrome Examples

Cyanide

Red: active seizure or recent onset of apnea with preserved circulation

Black: no palpable pulse

Sidell FR, “Triage of Chemical Casualties” Chapter 14 in Medical Aspects of Chemical and Biological Warfare,

available on the Internet at http://www.bordeninstitute.army.mil/cwbw/Ch14.pdf

Key Points about MCI Triage

Anything that can help organize the response to an MCI is a good thing.

MCI triage is different than daily triage, in both field and ED settings.

Resource availability is the limiting factor to consider in MCI triage.

Key Points about MCI Triage

In order for MCI triage to work toward its goal, all victims must have

equal importance at the time of primary triage. No patient group can

receive special consideration other than that dictated by their physiology.

This includes children!

Key Points about MCI Triage

Disaster research agendas should include efforts to validate and improve

existing triage tools.

Key Points about MCI Triage

MCI triage will never be logistically, intellectually, or emotionally easy…

but we must be prepared to do it using the best of our knowledge and

abilities.

Thank You!LouRomig@bellsouth.net

LouRomig@jumpstarttriage.comPowerpoint lecture available for download

atwww.jumpstarttriage.com

MDFR FL-5 DMATMCH