MCI Triage Beyond Red Yellow Green and Black Lou E Romig MD FAAP FACEP Miami Children’s Hospital Miami Dade Fire Rescue FL 5 DM by 0gNg7t


									      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
What is 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
Also must consider resource
   Military vs. Civilian Triage

 Priority is to       Priority is to
 get as many           maximize
soldiers back        survival of the
into action as      greatest number
   possible.           of victims.
Military vs. Civilian Triage
Military model
Those with the least serious
wounds may be the first
treatment priority

Civilian model
Those 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,
Why Should Responders Care About
         Good Triage?

    Provides a way to draw
    organization out of chaos
    Helps to get care to those who
    need it and will benefit from it the
    Helps in resource allocation
    Provides an objective framework
    for stressful and emotional
    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

                           (P = Patient)

    Do the best for each individual
Resources challenged              (P = Patient)

Do the best for each individual
       Resources for the greatest
Do the greatest good overwhelmednumber

 (P = Patient)
     Daily Emergencies
Do the best for each individual.

      Disaster Settings
   Do 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.
   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
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
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 (
Basic Disaster Life Support
 MASS Triage
 ? 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
 Secondary Disaster Triage
Goal: to best match patients’ current and
anticipated needs with available resources.
   A reassessment of physiology
   An assessment of physical injuries
   Initial treatment and assessment of
   patient response
   Further knowledge of resource
  Secondary Triage Tools
There is no widely recognized tool in
the US that addresses secondary MCI
California “Medical Disaster
Response” course’s SAVE tool
(Secondary Assessment of Victim
Many EMS systems use local trauma
center triage criteria.
     NATO Guidelines
Airway obstruction, cardiorespiratory
failure, significant external hemorrhage,
shock, sucking chest wound, burns of face
or neck

Open thoracic wound, penetrating
abdominal wound, severe eye injury,
avascular limb, fractures, significant
burns other than face, neck or perineum
              NATO Guidelines
       Minor lacerations, contusions, sprains,
       superficial burns, partial-thickness
       burns of < 20% BSA

       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
   Victims needing life-saving treatment
   initially available on scene.
   Victims with moderate non-life-
   threatening injuries, at risk for delayed
   Victims with minor injuries.
Tertiary Disaster Triage

Goal: to optimize individual outcome
    Sophisticated assessment and
    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

Life-threatening but treatable
injuries requiring rapid medical


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

Minor injuries that can wait for
longer periods of time for


Dead or still with life signs but
injuries are incompatible with
survival in austere conditions
Triage Tools
Simple Triage And Rapid
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

Utilizes the same four triage
Used for Primary Triage
                    START Triage
RESPIRATIONS               YES                  Under 30/min

       NO               Over 30/min
                                       Cap refill          Cap refill
  Position Airway       Immediate      > 2 sec             < 2 sec.

  NO          YES                       Bleeding          MENTAL
 Dead or    Immediate                  Immediate
                                    Failure to follow   Can follow
                                    simple commands     simple 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

R   30
P   2
M   Can 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
  Published in APLS course
   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
   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
These children should be assessed
first among all those in the green
Position the upper airway of the
apneic child.
If they start to breathe, tag them
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.

Assess the respiratory rate
of the spontaneously
breathing child.
Move on to next assessment if
respiratory rate is 15-45
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

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

  Children developmentally
  unable to walk due to young
  age or developmental delay
  Children with chronic
  disabilities that prevent them
  from walking
Modification for Nonambulatory

  For nonambulatory children,
  assess using the JumpSTART

  If pt meets any red criteria tag
Modification for Nonambulatory
  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
      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
  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
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
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
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
             Red: active seizure or recent
             onset of apnea with preserved
             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
Key Points about MCI Triage
 Anything that can help organize
 the response to an MCI is a good
 MCI triage is different than daily
 triage, in both field and ED
 Resource availability is the
 limiting factor to consider in MCI
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
       Thank You!
  For more information on
  JumpSTART please go to:

 You can contact Dr. Romig at:

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