Triage TagsTriage Tags Patients brought by EMSPatients brought by EMS

Tag will be applied to patient by EMSTag will be applied to patient by EMS Patients directed to appropriate treatment area in Patients directed to appropriate treatment area in

the hospital based on color of triage tagthe hospital based on color of triage tag

MCI/Disaster patients presenting to ED by own MCI/Disaster patients presenting to ED by own transportation transportation Triage tags in disaster cage in basementTriage tags in disaster cage in basement Triage tags will be available in the EDTriage tags will be available in the ED

Decon roomDecon room At TriageAt Triage

Should be used and applied to patients as they Should be used and applied to patients as they enter the hospital via the triage area where-ever this enter the hospital via the triage area where-ever this has been establishedhas been established

TriageTriage

Primary triage- START and JumpStartPrimary triage- START and JumpStart Segregates casualties into groupsSegregates casualties into groups Walkers move to another areaWalkers move to another area The more critically injured, but still a smaller The more critically injured, but still a smaller

crowd, left to sort through to determine reds crowd, left to sort through to determine reds and yellowsand yellows

Secondary triageSecondary triage Refines our clinical pictureRefines our clinical picture Uses a physiological scoring system & Uses a physiological scoring system &

anatomical examinationanatomical examination

Primary vs Secondary Triage Primary vs Secondary Triage (The 1(The 1stst vs Subsequent vs Subsequent Triage)Triage)

JumpSTART triage will be performed in JumpSTART triage will be performed in the field – IF the patient is brought by the field – IF the patient is brought by EMSEMS

If the patient accesses the ED on their If the patient accesses the ED on their own, triage will need to be set up and own, triage will need to be set up and performed at the EDperformed at the ED

If the patient comes to ED via EMS, ED If the patient comes to ED via EMS, ED should use the secondary triage (RTS) should use the secondary triage (RTS) as their reassessment processas their reassessment process

Secondary TriageSecondary Triage Glasgow coma scale (GCS) – 3-15 pointsGlasgow coma scale (GCS) – 3-15 points

Best eye openingBest eye openingBest verbal responseBest verbal responseBest motor responseBest motor response

Respiratory rateRespiratory rate Systolic B/PSystolic B/P Secondary triage scores calculate RR Secondary triage scores calculate RR

and B/P based on adult normsand B/P based on adult norms Secondary triage scores have Secondary triage scores have notnot been been

modified for pediatric normal RR and B/Pmodified for pediatric normal RR and B/P

Glasgow Coma Scale Glasgow Coma Scale (GCS)(GCS)

Best eye opening 1 - 4 pointsBest eye opening 1 - 4 points Eyes spontaneously open, looking around; Eyes spontaneously open, looking around;

does does notnot have to focus (4 points) have to focus (4 points) Eyes open (or eyelids flutter) to verbal Eyes open (or eyelids flutter) to verbal

stimuli prior to tactile stimulation(3 points)stimuli prior to tactile stimulation(3 points) Eyes open (or eyelids flutter) to painful or Eyes open (or eyelids flutter) to painful or

tactile stimuli (2 points)tactile stimuli (2 points) There is absolutely no eye movement, There is absolutely no eye movement,

including no eyelid flutter or flicker (1 point)including no eyelid flutter or flicker (1 point)

Best verbal responseBest verbal response Patient oriented (5 points)Patient oriented (5 points) Patient confused, can carry on a conversation Patient confused, can carry on a conversation

but not always appropriate; infant has irritable but not always appropriate; infant has irritable cry (4 points)cry (4 points)

Patient using inappropriate words for the Patient using inappropriate words for the situation and you can understand what the situation and you can understand what the words are; this is beyond confusion (ie: “the words are; this is beyond confusion (ie: “the sky is blue”); infant cries to pain (3 points)sky is blue”); infant cries to pain (3 points)

Patient has incomprehensible words (ie: Patient has incomprehensible words (ie: moans and groans and noises made but moans and groans and noises made but cannot be understood for any words); child cannot be understood for any words); child responds to pain (2 points)responds to pain (2 points)

There are no sounds, no moans, no groans, There are no sounds, no moans, no groans, nothing heard from the patient (1 point)nothing heard from the patient (1 point)

Best motor responseBest motor response Patient obeys commands (6 points)Patient obeys commands (6 points) Patient is purposeful & localizes; this is the Patient is purposeful & localizes; this is the

obnoxious patient who pulls at the equipment and obnoxious patient who pulls at the equipment and tries to remove the equipment; they try to hit your tries to remove the equipment; they try to hit your hand away; infant withdraws to hand away; infant withdraws to touchtouch (5 points) (5 points)

Patient responds to pain by withdrawal (the brain Patient responds to pain by withdrawal (the brain can no longer discern where the obnoxious can no longer discern where the obnoxious stimuli is felt so just withdraws); infant withdraws stimuli is felt so just withdraws); infant withdraws to to painpain (4 points) (4 points)

Patient flexes extremities (decorticate) (3 points)Patient flexes extremities (decorticate) (3 points) Patient extends extremities (decerebrate) (2 Patient extends extremities (decerebrate) (2

points)points) Patient is flaccid with no response (1 point) Patient is flaccid with no response (1 point)

Converting GCS Points to Converting GCS Points to RTSRTS Conversion score ranges from 0 – 4 pointsConversion score ranges from 0 – 4 points Total GCS 13 – 15 (4 points)Total GCS 13 – 15 (4 points) Total GCS 9 – 12 (3 points)Total GCS 9 – 12 (3 points) Total GCS 6 – 8 (2 points)Total GCS 6 – 8 (2 points) Total GCS 4 - 5 (1 point)Total GCS 4 - 5 (1 point) Total GCS 3 (0 points)Total GCS 3 (0 points) Add converted points (0 - 4) to respiratory Add converted points (0 - 4) to respiratory

rate score and systolic B/P scorerate score and systolic B/P score RTS score range 0 – 12 pointsRTS score range 0 – 12 points

Respiratory rate – 0 – 4 pointsRespiratory rate – 0 – 4 points 10 – 29 breaths per minute (4 points)10 – 29 breaths per minute (4 points) 30 or more breaths per minute (3 points)30 or more breaths per minute (3 points) 6 - 9 breaths per minute (2 points)6 - 9 breaths per minute (2 points) 1 – 5 breaths per minute (1 point)1 – 5 breaths per minute (1 point) 0 breaths (0 points)0 breaths (0 points)

Points added to GCS conversion points Points added to GCS conversion points (0 - 4) and to systolic B/P score (0 – 4)(0 - 4) and to systolic B/P score (0 – 4)

RTS score ranges 0 - 12RTS score ranges 0 - 12

Systolic blood pressure (0 – 4 points)Systolic blood pressure (0 – 4 points) 90 or more (4 points)90 or more (4 points) 76 – 89 (3 points)76 – 89 (3 points) 50 - 75 (2 points)50 - 75 (2 points) 1 – 49 (1 point)1 – 49 (1 point) 0 (0 points)0 (0 points)

Points added to GCS conversion points Points added to GCS conversion points (0 - 4) and to respiratory rate score (0 - 4) and to respiratory rate score (0 – 4)(0 – 4)

RTS score ranges 0 - 12RTS score ranges 0 - 12

Secondary Triage - RTSSecondary Triage - RTS

RTS score ranges from 0 to 12RTS score ranges from 0 to 12

Score of 12 (highest) – patient is GREENScore of 12 (highest) – patient is GREEN

Score of 11 – patient is YELLOWScore of 11 – patient is YELLOW

Score 10 or less – patient is REDScore 10 or less – patient is RED

Scenario PracticeScenario Practice

Use worksheet at end of power point as Use worksheet at end of power point as resource for START & JumpSTART triage and resource for START & JumpSTART triage and the secondary triage processthe secondary triage process

Place patients in the appropriate categoriesPlace patients in the appropriate categories Check answers at the end of the practice Check answers at the end of the practice

scenariosscenarios Some scenarios are based in the field – does Some scenarios are based in the field – does

not matter as triage is performed the same in not matter as triage is performed the same in all settings (and you might be dispatched to all settings (and you might be dispatched to help in the field if requested) help in the field if requested)

Scenario 1: Bus CrashScenario 1: Bus CrashIt’s 7pm on a summernight when a busreturning from aday camp collides

with a train on a remote road.

There are 20 + kids either still in the bus and some are

lying about the road. There are 3 adults.

JumpSTART Triage – JumpSTART Triage – Scenario #1 (Initial Triage)Scenario #1 (Initial Triage)

What color are you triaging these patients?

Patient #1 Unresponsive;RR 30 and pale

Patient #2 5 y/o looking around; RR 35 and open femur fracturePatient #3

Unresponsive;labored respirations 52 and open chest wound

Initial JumpSTART Triage Initial JumpSTART Triage Scenario #1Scenario #1 Patient #1 – Patient #1 – REDRED

RR okay at 30 (between 15 and 45)RR okay at 30 (between 15 and 45) Patient is Patient is unresponsiveunresponsive

Patient #2 – Patient #2 – YELLOWYELLOW Not able to walkNot able to walk so initially made yellow until so initially made yellow until

retriaged – then may stay yellow or be triaged as retriaged – then may stay yellow or be triaged as green or redgreen or red Even though RR okay at 35 (between 15 and 45)Even though RR okay at 35 (between 15 and 45) Even though looking around (awake)Even though looking around (awake)

Patient #3 – Patient #3 – REDRED Labored Labored RR of 52RR of 52 (> 45) (> 45) UnresponsiveUnresponsive

9 y/o F9 y/o F RR 10RR 10 Distal pulseDistal pulse Groans to painful Groans to painful stimulistimuli

In ditch 15ft In ditch 15ft awayaway

50 y/o F50 y/o F RR 20RR 20 Cap refill < 2 Cap refill < 2 secsec

Obeys commandsObeys commands c/o dizzinessc/o dizziness

10 y/o M10 y/o M TalkingTalking Good distal Good distal pulsepulse

Asks for helpAsks for help WalkingWalking

8 y/o F8 y/o F RR 0RR 0 Faint distal Faint distal pulsepulse

UnresponsiveUnresponsive

Breathing after 5 rescue Breathing after 5 rescue breaths deliveredbreaths delivered

In rubble out In rubble out of busof bus

11 y/o M11 y/o M RR 22RR 22 Distal PulseDistal Pulse Obeys commandsObeys commands Can’t move or Can’t move or feel legsfeel legs

25y/o F25y/o F RR12RR12 Cap refill 4 secCap refill 4 sec Eye movement to tactile Eye movement to tactile stimulationstimulation

6 mo pregnant6 mo pregnant

Scenario #2

Scenario #2 Adult and Scenario #2 Adult and Pediatric Mixed TriagePediatric Mixed Triage

9 y/o – 9 y/o – REDRED (RR<15) (RR<15) 50 y/o – 50 y/o – GREENGREEN (RR, cap refill & neuro okay) (RR, cap refill & neuro okay) 10 y/o – 10 y/o – GREENGREEN (walking, neuro okay) (walking, neuro okay) 8 y/o – 8 y/o – REDRED (faint distal pulse, unresponsive) (faint distal pulse, unresponsive) 11 y/o – 11 y/o – YELLOWYELLOW (can’t walk so initially can’t be (can’t walk so initially can’t be

green; minimally will be yellow when you make it green; minimally will be yellow when you make it through the triage process and all other through the triage process and all other parameters are okay. Dparameters are okay. D Distal pulses and obeys commands okay so Distal pulses and obeys commands okay so

left yellow for nowleft yellow for now 25 y/o – 25 y/o – REDRED (cap refill >2 sec; not responding to (cap refill >2 sec; not responding to

commands given (only to painful/tactile)commands given (only to painful/tactile)

Scenario #2: F5 TornadoScenario #2: F5 Tornado

An F5 tornadoAn F5 tornadohas struck has struck within your within your city/town. Itcity/town. Itoccurred atoccurred at3pm while3pm whileschool wasschool wasletting out. Itletting out. Ittouched downtouched downnear 3 schoolsnear 3 schoolsand a mall.and a mall.

Triage This Patient: School age girl lying on roadway Breathing

10/min. Good distal

Pulse Groans to verbal

stimuli

JumpSTART triage category?

Patient is categorized as a Patient is categorized as a REDRED Respiratory rate (RR) is 10 (<15)Respiratory rate (RR) is 10 (<15) Do not even need to get to the type of AVPU Do not even need to get to the type of AVPU

response patient hasresponse patient has This patient is categorized influenced by This patient is categorized influenced by

respiratory rate and then rescuer must respiratory rate and then rescuer must move onto next patient for triagemove onto next patient for triage

Patient Patient carecare not delivered during triage not delivered during triage Patient care delivered in treatmentPatient care delivered in treatment

Triage This Patient: School age girl found; refuses to walk

Open arm fracture visible

RR 26, radial pulse present

Alert and talking

JumpSTART triage category?

Open arm fracture could be a distracting Open arm fracture could be a distracting injury – so injury – so don’tdon’t get distracted get distracted

Stay with physiological parametersStay with physiological parameters Not able to walk so automatically at Not able to walk so automatically at

minimum a minimum a YELLOWYELLOW Respiratory rate 26 (okay 15 - 45)Respiratory rate 26 (okay 15 - 45) Neurologically okay (alert and talking)Neurologically okay (alert and talking) Patient remains triaged as Patient remains triaged as YELLOWYELLOW In secondary triage may be upgraded to In secondary triage may be upgraded to

GREEN (RTS most likely a 12)GREEN (RTS most likely a 12)

Infants/Non-walkersInfants/Non-walkers

Evaluate this group of patients Evaluate this group of patients starting triage with the breathing starting triage with the breathing assessmentassessment

8 y/o8 y/o RR 10RR 10 Weak, thready Weak, thready pulsepulse

UnresponsiveUnresponsive Outside, Outside, face downface down

3 y/o3 y/o RR 18RR 18 Pulse present; Pulse present; HR irregularHR irregular

118118

Responds to Responds to PainPain

Trapped Trapped under under bookcasebookcase

9 mo9 mo Crying; Crying; RR 32RR 32

Pulse presentPulse present Responds to Responds to voicevoice

Mult minor Mult minor lacs to lacs to head/facehead/face

10 y/o10 y/o screamingscreaming Pulse presentPulse present Not focusingNot focusing Running in Running in hallhall

50 y/o50 y/o RR 32RR 32 Weak Pulse; Weak Pulse; cap refill 4 cap refill 4 secondsseconds

Not following Not following commandscommands

Trapped Trapped under under bookcasebookcase

7 y/o7 y/o apneaapnea Very weak Very weak PulsePulse

Unresponsive; Unresponsive; not breathing not breathing after 5 breathsafter 5 breaths

Trapped Trapped under under bookcasebookcase

Scenario Practice #2 –Patients From Tornado

Scenario #2 Patient Scenario #2 Patient TriageTriage 8 y/o – 8 y/o – REDRED (unresponsive) (unresponsive) 3 y/o – 3 y/o – YELLOWYELLOW (not walking; RR 15 – 45; “P” on (not walking; RR 15 – 45; “P” on

AVPU)AVPU) 9 mo – 9 mo – GREENGREEN (pulse +; “V” on AVPU, minor (pulse +; “V” on AVPU, minor

external wounds)external wounds) 10 y/o – 10 y/o – REDRED (pulse+; not focusing, screaming, (pulse+; not focusing, screaming,

running around – distracting others so remove to running around – distracting others so remove to control the scene)control the scene)

50 y/o – 50 y/o – RED RED (cap refill >2 sec; not following (cap refill >2 sec; not following commands)commands)

7 y/o – BLACK (apnea not corrected with 5 rescue 7 y/o – BLACK (apnea not corrected with 5 rescue breaths)breaths)

Scenario #3: High-Rise Scenario #3: High-Rise FireFire

Fire reported on 15th floor

Smoke to the 16th and 17th floors.

The building Day Care Center is on the 17th floor

Reported 30 kids in the day care and 6 employees

• Fire Crews carry 5 kids all being given CPR.

• The day care is next to the hospital and triage is set up in the ED

• How would you triage these patients?

6 y/o6 y/o RR 38RR 38

Radial pulse Radial pulse presentpresent

Knows name Knows name and recalls and recalls

incidentincidentFacial Facial burns, burns, coughingcoughing

53 y/o53 y/o RR 48RR 48 Cap refillCap refill

> 2 sec> 2 sec

MoaningMoaning FB glass to FB glass to abdomen; abdomen; wheezingwheezing

3 y/o3 y/o RR 0RR 0 Weak pulseWeak pulse Unresponsive; Unresponsive; resumes resumes breathing after 5 breathing after 5 breaths givenbreaths given

Found Found under deskunder desk

4 y/o4 y/o RR 40RR 40 Pulse presentPulse present CryingCrying Soot to faceSoot to face

2 y/o2 y/o RR 20RR 20 Palpable Palpable PulsePulse

Hoarse cryHoarse cry Soot to faceSoot to face

5 y/o5 y/o RR 28RR 28 Strong Strong Palpable Palpable PulsePulse

Crying; can’t Crying; can’t walkwalk

22ndnd /3 /3rdrd degree degree burnsburns

Scenario #3 – High rise fire

Scenario #3 Patient Scenario #3 Patient TriageTriage

6 y/o – GREEN (walks; RR 15-45; awake/alert)6 y/o – GREEN (walks; RR 15-45; awake/alert) 53 y/o – RED (cap refill >2 sec)53 y/o – RED (cap refill >2 sec) 3 y/o – RED (weak pulse, unresponsive)3 y/o – RED (weak pulse, unresponsive) 4 y/o – GREEN (walks; RR 15- 45; pulse 4 y/o – GREEN (walks; RR 15- 45; pulse

present) present) 2 y/o – GREEN (walks; RR 15-45; pulse 2 y/o – GREEN (walks; RR 15-45; pulse

presentpresent 5 y/o – YELLOW (can’t walk; RR 15-45; strong 5 y/o – YELLOW (can’t walk; RR 15-45; strong

pulse)pulse)

Scenario #3Scenario #3 The patients made GREEN (1The patients made GREEN (1stst, 4, 4thth and and

55thth) have evidence of airway involvement ) have evidence of airway involvement from the fire (facial burns and soot to from the fire (facial burns and soot to face)face)

The patient, regardless of how initially The patient, regardless of how initially triaged, may deteriorate and need triaged, may deteriorate and need upgradingupgrading

Remember secondary triage should Remember secondary triage should occur rapidly and repeat assessments occur rapidly and repeat assessments should occur frequently to determine if a should occur frequently to determine if a patient needs to move up to a higher patient needs to move up to a higher level of triage level of triage

Disaster Triage DecisionsDisaster Triage Decisions

Remember the point of primary triageRemember the point of primary triage To sort patients to determine who is To sort patients to determine who is

the most critical and who is less criticalthe most critical and who is less critical Need to do the greatest good for the Need to do the greatest good for the

greatest numbergreatest number Disaster triage is Disaster triage is notnot routine daily routine daily

triage where you do the best for each triage where you do the best for each individualindividual