pediatric multicasualty incident triage lou e. romig md, faap, facep miami children’s hospital...
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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
