Pediatric Multicasualty Incident Triage

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

“The needs of the many

outweigh the needs of the few

or the one."Star Trek

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.

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

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

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.

Secondary Triage Tools

There is no widely recognized tool in the US that addresses secondary MCI triage and also transport strategies.

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

Many EMS systems use local trauma triage criteria.

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

“Continuous Integrated Triage”

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

Simple Triage and Rapid Treatment (START)

JumpSTART Pediatric MCI Triage Tool

The Smart Triage Tape®

Developed in Great Britain

Proprietary, TSG Associates

Length-based pediatric MCI triage tape

Age-adjusted physiologic parameters

In use in Europe, Africa and some states in the US

www.tsgassociates.co.uk/English/Civilian/products/smart_tape.htm

Triage Sieve

Care Flight Triage

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

www.ndlsf.org

Basic Disaster Life Support

MASS Triage

Move

Assess

Sort

Send

? Assessment guidelines

? Pediatric considerations

SALT Triage

Sort, Assess, Life-saving Interventions, Treatment/Transport

CDC grant project to standardize MCI triage in the US

Early in development

Derived from existing tools

Includes pediatric considerations

SALT Triage

SALT Triage

Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National GuidelineE. Brooke Lerner, PhD, Richard B. Schwartz, MD, Phillip L. Coule, MD, et al

DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS - 2(Supplement_1): 25-34 2008

http://www.dmphp.org/cgi/content/full/2/Supplement_1/S25#R15-7

Sacco Triage Method®

Proprietary tool, ThinkSharp Inc.

Only tool based on outcome data

12 triage categories

Available software package for transport planning based on patient and resource info

Includes pediatric data and age adjustments

Sacco Triage Method®

Sacco Triage Method®

STM Sample Patient Prioritization

Scene Characterization Triage Priority Order

Multiple casualty; resource levels stressed 4 5 6 3 2 7 1 8+ 2

Estimate about an hour or less to clear the scene.

Large multiple casualty or small mass casualty 5 6 7 8 4 9 3 2 1 9+

requiring staged resources Estimate 1½ to 2½

hours to clear the scene

Mass casualty; resources overwhelmed Estimate 3 or more hours to clear the scene 6 7 8 5 9 10 4 3 2 1 11+

www.sharpthinkers.com/STM_Site/stm_home.htm

Israeli Triage Practice

Little to no triage done on-scene

“Save and run” philosophy

Very hazardous scenes

Reds to closest hospital

Nearest hospital becomes triage center?

Israeli Triage Practice

Uses physicians as triage officers

Accuracy of physician triage called into question

Metropolitan Israeli hospitals may be more uniformly capable of caring for trauma victims than in many areas of the US

The Best Tool?

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

Mass-casualty triage: Time for an evidence-based approach. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL, Hsu EB Prehospital Disast Med 2008;23(1):3–8.

The Best Tool?

It’s likely that no existing MCI triage tool is suitable for use for

all types of incidents.

START/JumpSTART

Neither clinically validated

Evidence accumulating against validity and/or inter-rater reliability

Comparison of paediatric major incident primary triage tools. L A Wallis1, S Carley2 Emergency Medicine Journal 2006;23:475-478

Smart Tape and Care Flight more sensitive than START and JS

No tool had > 48% sensitivity for critical patients

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 usual four triage categories

Used for Primary Triage

Used on-scene and at hospitals

Recommended for patients > 100 lbs

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

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

National Committee on Management of Pediatric MCIs, 2006

JumpSTART recommended for prehospital use throughout Israel

Prehospital Response and Field Triage in Pediatric Mass Casualty Incidents: The Israeli Experience

Yehezkel Waisman, MD, Lisa Amir, MD, MPH, Meirav Mor, MD, et al Clin Ped Emerg Med 7:52-58, 2006

JumpSTART Pediatric MCI Triage

The physiologic parameters used in START are not suitable for all ages of children

Walking

Respiratory death vs cardiac death

Respiratory rates

Mental status assessment

What age?

JumpSTART: Age

The ages of “tweens and teens” can be hard to determine so the current recommendation is:

If a victim appears to be a child, use JumpSTART.

If a victim appears to be a young adult, use START.

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

Certainties about MCI Triage

Organization is a good thing in a disaster

Triage tools must help match limited resources to an abundance of needs

Physiologic tools should suit physiologic differences

Triage tools should be kept as simple as possible and practiced often

Disaster research agendas should include efforts to validate existing and future

triage tools.

Triage should be done with the head, not the heart.

The Jumpstart Pediatric MCI Triage Tooland

other pediatric disaster and emergency medicine resources

 The JumpSTART Pediatric MCI Triage Tool

Principles of Multicasualty Triage

www.jumpstarttriage.com

Thank You!LouRomig@bellsouth.net

LouRomig@jumpstarttriage.com

MDFR FL-5 DMATMCH