START & JumpSTART Triage

START & JumpSTART Triage

Joe Immermann, EMT-P, BBAWith thanks to:

Joy Erb Moser, RN BSN CEN

Aim of Triage…

Greatest Good for the Greatest Number

Aim of Triage…

Greatest Good for the Greatest Number

STARTSTART

START facilitates patient triage in 60 seconds or less

Assess Ventilation Perfusion Mental status

START facilitates patient triage in 60 seconds or less

Assess Ventilation Perfusion Mental status

STARTSTART

Correct Life Threats Correct Life Threats

Blocked airways

Severe bleeding

Blocked airways

Severe bleeding

START AssessmentsSTART Assessments

1. Ambulation

2. Respirations

3. Perfusion

4. Mental status

1. Ambulation

2. Respirations

3. Perfusion

4. Mental status

RespiratoryRespiratory

Check ventilation rate and adequacy

Check for foreign objects causing airway obstruction

Reposition to open airway

Check ventilation rate and adequacy

Check for foreign objects causing airway obstruction

Reposition to open airway

PerfusionPerfusion

Check capillary refill in nail beds or

Palpate radial pulse

Check capillary refill in nail beds or

Palpate radial pulse

Mental StatusMental Status

Ask patient to follow simple commands

Open and close eyes

Touch finger to nose

Ask patient to follow simple commands

Open and close eyes

Touch finger to nose

GreenGreen—Minor/Ambulatory

RedRed—Immediate

YellowYellow—Delayed

Black—Dead or

nonsalvageable

GreenGreen—Minor/Ambulatory

RedRed—Immediate

YellowYellow—Delayed

Black—Dead or

nonsalvageable

Triage CategoriesTriage Categories

Separate from the general group at the beginning of the triage operation. (“Walking wounded”)

Direct patients away from the scene to a designated safe area.

Consider using these patients to assist in treatment of those patients tagged as immediate.

Separate from the general group at the beginning of the triage operation. (“Walking wounded”)

Direct patients away from the scene to a designated safe area.

Consider using these patients to assist in treatment of those patients tagged as immediate.

Minor (GREEN)Minor (GREEN)

Ventilations present only after repositioning the airway.

Respiratory rate greater than 30 per minute.

Delayed capillary refill (> 2 seconds)

Unable to follow simple commands.

Ventilations present only after repositioning the airway.

Respiratory rate greater than 30 per minute.

Delayed capillary refill (> 2 seconds)

Unable to follow simple commands.

Immediate (RED)Immediate (RED)

Any patient who does not fit into either the immediate or minor categories.

Any patient who does not fit into either the immediate or minor categories.

Delayed (YELLOW)Delayed (YELLOW)

No ventilations present even after attempting to reposition the airway.

No ventilations present even after attempting to reposition the airway.

Deceased (BLACK)Deceased (BLACK)

Pediatric MCI PatientsPediatric MCI Patients

Results in less over-triage by acknowledging differences in kids.

Addresses the emotional burden of tagging a child as “deceased” by allowing two extra steps.

Results in less over-triage by acknowledging differences in kids.

Addresses the emotional burden of tagging a child as “deceased” by allowing two extra steps.

JumpSTARTJumpSTART

If the victim looks like a child, use JumpSTART. If the victim looks like

a young adult, use START.--Dr. Lou Romig

If the victim looks like a child, use JumpSTART. If the victim looks like

a young adult, use START.--Dr. Lou Romig

Pediatric MCI PatientsPediatric MCI Patients

Not all children can walk

Respiratory rates may be normal at > 30/minute

Capillary refill influenced by environment

Obey commands? Kids??

Not all children can walk

Respiratory rates may be normal at > 30/minute

Capillary refill influenced by environment

Obey commands? Kids??

Pediatric MCI PatientsPediatric MCI Patients

If breathing spontaneously, go on to the next step: assessing respiratory rate.

If apneic or with very irregular breathing, open the airway using standard positioning technique.

If positioning results in resumption of spontaneous respirations, tag the patient REDRED and move on.

If breathing spontaneously, go on to the next step: assessing respiratory rate.

If apneic or with very irregular breathing, open the airway using standard positioning technique.

If positioning results in resumption of spontaneous respirations, tag the patient REDRED and move on.

Breathing?Breathing?

Physiological reason to believe an apneic child may still have a pulse.

Physiological reason to believe an apneic child may still have a pulse.

Pulse Check: Apneic ChildPulse Check: Apneic Child

If no breathing after airway opening, check for peripheral pulse (child may retain pulse while apnic longer than adult).

If no pulse, tag patient BLACK and BLACK and move on.move on.

If no breathing after airway opening, check for peripheral pulse (child may retain pulse while apnic longer than adult).

If no pulse, tag patient BLACK and BLACK and move on.move on.

Pulse Check: Apneic ChildPulse Check: Apneic Child

Provide 5 breaths with a mouth-to-barrier device.

If breathing returns, child is tagged as REDRED (Immediate).

If no spontaneous respirations return, the child is tagged BLACK.

Provide 5 breaths with a mouth-to-barrier device.

If breathing returns, child is tagged as REDRED (Immediate).

If no spontaneous respirations return, the child is tagged BLACK.

Pulse PresentPulse Present

Check respiratory rate:

<15 or > 45 are considered critical: tag patients as RED

Respiratory rate between 15-45: Check pulse

Check respiratory rate:

<15 or > 45 are considered critical: tag patients as RED

Respiratory rate between 15-45: Check pulse

Spontaneous RespirationsSpontaneous Respirations

Children with spontaneous respirations but no palpable pulse

(in the least injured limb) are tagged Immediate (RED).

Children with spontaneous respirations but no palpable pulse

(in the least injured limb) are tagged Immediate (RED).

Quick AVPU:

Alert (YELLOWYELLOW)

Verbal Stimuli (YELLOWYELLOW)

Physical Stimuli (YELLOWYELLOW))

Unconscious (RED)

Quick AVPU:

Alert (YELLOWYELLOW)

Verbal Stimuli (YELLOWYELLOW)

Physical Stimuli (YELLOWYELLOW))

Unconscious (RED)

Mental Status Assessment Mental Status Assessment

Infants who normally can’t walk yet

Children with developmental delay

Children with acute injuries preventing them from walking

Children with chronic disabilities

Infants who normally can’t walk yet

Children with developmental delay

Children with acute injuries preventing them from walking

Children with chronic disabilities

Non-Ambulatory Patient ModificationsNon-Ambulatory Patient Modifications

Non-Ambulatory Patient ModificationsNon-Ambulatory Patient Modifications

Evaluate with JS algorithm

If REDRED criteria, tag as RED.

If YELLOWYELLOW criteria, assess for external signs of significant injury.

If no significant external signs, tag as GREENGREEN.

If significant external sign of injury are found, tag as YELLOWYELLOW.

Evaluate with JS algorithm

If REDRED criteria, tag as RED.

If YELLOWYELLOW criteria, assess for external signs of significant injury.

If no significant external signs, tag as GREENGREEN.

If significant external sign of injury are found, tag as YELLOWYELLOW.

Unless clearly suffering from injuries incompatible with life, victims tagged in the BLACK

category should be reassessed once critical interventions have been completed for REDRED and

YELLOWYELLOW patients.

Unless clearly suffering from injuries incompatible with life, victims tagged in the BLACK

category should be reassessed once critical interventions have been completed for REDRED and

YELLOWYELLOW patients.

Deceased (BLACK) PatientsDeceased (BLACK) Patients

Apneic children are rapidly assessed for sustained circulation.

Apneic children with circulation receive a brief ventilatory trial as an additional airway opening and stimulating maneuver.

Respiratory rates are adjusted. (15-30-45)

Peripheral pulse is substituted for cap refill.

AVPU is used to assess mental status.

Apneic children are rapidly assessed for sustained circulation.

Apneic children with circulation receive a brief ventilatory trial as an additional airway opening and stimulating maneuver.

Respiratory rates are adjusted. (15-30-45)

Peripheral pulse is substituted for cap refill.

AVPU is used to assess mental status.

START/JumpSTART DifferencesSTART/JumpSTART Differences

Unresponsive

RR—36/min

No airway obstruction

CRT > 4 seconds

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Unresponsive

RR—36/min

No airway obstruction

CRT > 4 seconds

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient #1: Tammy TeacherPatient #1: Tammy Teacher

RR > 48/min

Weak pulse

Responds to pain

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

RR > 48/min

Weak pulse

Responds to pain

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient #2: Pre-School PaulaPatient #2: Pre-School Paula

No Respiratory effort

Faint pulse

Unresponsive

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

No Respiratory effort

Faint pulse

Unresponsive

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient #3: Pre-School SamPatient #3: Pre-School Sam

Patient # 4: Tom TeacherPatient # 4: Tom Teacher

Ambulated to curb, holding Jenny & Libby

RR—28/min

CRT 2 seconds

Alert; following commands

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Ambulated to curb, holding Jenny & Libby

RR—28/min

CRT 2 seconds

Alert; following commands

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 5: P.S. JennyPatient # 5: P.S. Jenny

Held by Tom Teacher

Crying for “Mommy”

RR—38/min

Pulse present

Clinging to Tom

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Held by Tom Teacher

Crying for “Mommy”

RR—38/min

Pulse present

Clinging to Tom

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 6: P.S. LibbyPatient # 6: P.S. Libby

Held by Tom Teacher

RR—32/min

Pulse present

Responds to verbal & tactile stimuli

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Held by Tom Teacher

RR—32/min

Pulse present

Responds to verbal & tactile stimuli

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 7: P.S. MikeyPatient # 7: P.S. Mikey

RR—28/min

Palpable pulse

Responds to tactile stimulation

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

RR—28/min

Palpable pulse

Responds to tactile stimulation

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 8: P.S. LucasPatient # 8: P.S. Lucas

RR—8/min

Pulse weak

Unconscious

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

RR—8/min

Pulse weak

Unconscious

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 9: P.S. AshleyPatient # 9: P.S. Ashley

RR—36/min

No palpable pulse

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

RR—36/min

No palpable pulse

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Patient # 10: P.S. TroyPatient # 10: P.S. Troy

Crying for Teacher; walked to Tom

RR—30/min

Pulse present

Scared of EMT

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Crying for Teacher; walked to Tom

RR—30/min

Pulse present

Scared of EMT

TRIAGE: GreenGreen//RedRed//YellowYellow/Black

Questions?Questions?