TRIAGE

INTRODUCTION
 There are several times during the emergency response
in which triage may be necessary to best determine the
needs of injured victims.

 During a disaster, the goal is to maximize the number of

survivors by sorting the treatable from the untreatable
victims.

 In a disaster, the potential for survival and the

availability of resources are the primary criteria used to
determine which patients receive immediate treatment.
 TRIAGE: DEFINITION

 [French, from trier, to sort, from Old French.]

 The term first came into use during World

War 1 when casualties were sorted during
battle.

 A method of quickly identifying victims who

have immediately life-threatening injuries AND
who have the best chance of surviving.
 TRIAGE: TYPES
 Sorting patients by
seriousness of injury
 Primary triage takes
place at the scene.

 Secondary triage
takes place in the
treatment areas.
TRIAGE CATEGORIES
 TAGGING

 Complements
Triage
 Rapid
Identification of
patient
 Color Coded / Bar
Coded system
 Plastic “bands”
can substitute
tags
 TRIAGE TAGS
 Should be:
 Weatherproof

 Easy to read

 Color-coded

 Identify category
 TRIAGE TAGS
 Digital photos are sometimes used in
identification of victims.

 Another alternative: Assign 20–25 tags

at a time with a scorecard to mark
patient category and priority.
Noji et al, NEJM
 FROM TRIAGE TO
Incident
TREATMENT
Triage
AREAS
Treatment

Immediate

Search & Triage Urgent

Rescue Team(s)

Delayed

Morgue
 FROM TREATMENT TO
DEFINITIVE CARE
Treatment Transport Definitive Care

Immediate Ambulances
H

Urgent
Ambulances, H
Ambulettes, Buses,
Delayed etc
H

Appropriate
Facility
 PRIMARY TRIAGE

The
Scene
 PRIMARY TRIAGE

The first attempt at balancing

EMS resources and
casualties / injured
 PRIMARY TRIAGE

Determining whether there is an

airway and breathing
 PRIMARY TRIAGE

If breathing, at what rate & is it

good enough?
 PRIMARY TRIAGE

They have an airway, and are breathing.

Are they circulating blood sufficiently?
 START TRIAGE
 Simple Triage and Rapid
Treatment (START)
 Limited evaluation of:
Abilityto walk
Respiratory status
Hemodynamic status
Neurologic status
 START SYSTEM
 Created in the 1980’s by Hoag Hospital and the
Newport Beach CA Fire Dept

 Allows rapid assessment of victims

 It should not take more than 15 sec/ Pt

 Once victim is in treatment area more detailed

assessment should be made
START SYSTEM

Clasification is based on three items

 Respiratory
 Perfusion
 Mental status evaluation
START First Step

Can the Patient Walk?

YES NO

Evaluate Ventilation
Green
(Step-2)
(Minor)
START Step-2
Ventilation Present?

NO YES

Open Airway

Ventilation Present? > 30/Min < 30/min

NO YES
Red/ Immediate

Black Evaluate Circulation

Red/ Immediate
(Step-3)
 START Step-3

Circulation

Absent Radial Pulse Present Radial Pulse

Control Hemorrhage
Evaluate Level of
Consciousness
Red/ Immediate
START Step-4
Level of Consciousness

Can’t Follow Simple Can Follow Simple

Commands Commands

Red/ Immediate Yellow/ Delayed

 START TRIAGE FOR PEDIATRIC PATIENTS

 Used for
children
under 8
years old or
who appear
to weigh less
than 100 lbs

© Lou Romig MD, 2002.

 PEDIATRIC TRIAGE
 Children are involved in
multiple casualty
incidents.

 The over prioritizing of

children will take valuable
resources away from more
seriously injured adults.

 Triage systems based on

adult physiology will not
provide accurate triage.
 SMART PEDIATRIC TAPE
 Developed by
Pediatricians to use
the existing START
protocol but
modified to reflect
appropriate values
for pediatric
respirations and
circulation.
 CONTAMINATED PATIENTS
 Patients with exposure (potential or real) to
contaminants should be tagged as BLUE

 This category will continue to stay until

patient is adequately decontaminated then
follow START as usual

 Some recommend a “double tagging” with

blue and the standard START color
START-Overview
 Remember RPM

 R- Respirations- 30

 P-Perfusion- Radial Pulse

 M- Mental- Follows Commands

 REVERSE TRIAGE

 Used in mass-casualty lightning injuries

 The dead are treated first

 High potential for respiratory arrest

 Potential for resuscitative success

 TRIAGE SPECIAL
CONSIDERATIONS
 Hazardous
 Hysterical or
materials or
disruptive weapons of
patient mass
destruction
 Injured or sick
responder  Multiple teams
or areas of
triage
 DESTINATION DECISIONS
 Refer patients to trauma centers
using:

 Physiologic criteria
 Anatomic criteria
 Mechanism of injury
 Special considerations
 DESTINATION DECISIONS
 Consider which hospital has the
appropriate means to help a patient.

 Transport patients that are categorized

as immediate by ambulance or air
ambulance.
 Walking wounded can be transported by
bus if needed.
 DESTINATION DECISIONS
 Transport immediate patients two at a time.

 Transport delayed two or three at a time.

 Transport slightly injured last.

 Expectant patients are treated once all

patients have been transported.
 AFTER-ACTION REVIEW
 Include what worked and what didn’t
work

 All observations should be written

down.

 Never accuse someone of doing

something wrong during the incident.
 SUMMARY
 Major incidents require the involvement and
coordination of multiple jurisdictions,
functional agencies, and emergency response
disciplines.

 The National Incident Management System

(NIMS) provides a consistent nationwide
template to enable federal, state, and local
governments to work together effectively and
efficiently.
 SUMMARY
 The goal of triage is to do the greatest good
for the greatest number.

 The four common triage categories are

immediate (red), delayed (yellow), minimal
(green), and expectant (black; likely to die or
dead).

 It is vital to tag each patient during triage.

 SUMMARY
 START triage uses a limited assessment of the
patient to triage patients.

 START triage modifies the START triage

system to take into account the differences of
pediatric patients.

 Consider critical incident management before,

during, or after an event.
SECONDARY
TRIAGE
 SECONDARY TRIAGE
 Purpose
 Determine among like priority category, higher
priority patient

 When does it happen?

 Generally on extended duration events
 If treatment areas are established, there will
likely be a need for Secondary Triage before
transport
SECONDARY TRIAGE
SCENE MANAGEMENT
TIME
H

MANAGEME
Command
Safety
The
Scene Assessment
H
NT Communication

H
OPERATIONS

Triage
Treatment Definitive
Transport Care
EMS
 TOOLS TO HELP MANAGE

 Use of ICS


FOGs and SOGs (Field Operations Guides,
Standard Operations Guides)

 Command Boards

 Communications (Radios / Cellular, etc

 Verbal
 Documentation

 Scribes/Runners
SMART COMMANDER
 Organization for:
 Command, Control, Coordination

 Provides:
 Overall Incident Management Team
 EMS Operations Specifics
 Incident Communications
 Weather
 Hazards
 Primary Triage Status
 Destination Capability & Patient Distribution