Simple triage and rapid treatment
Encyclopedia
Simple triage and rapid treatment (START) is a method used by first responders to effectively and efficiently evaluate all of the victims during a mass casualty incident (MCI). The first-arriving medical personnel will use a triage
tool called a triage tag
to categorize the victims by the severity of their injury. Once they have a better handle of the MCI, the on-scene personnel will call in to request for the additional appropriate resources and assign the incoming emergency service personnel
their tasks. The victims will be easily identifiable in terms of what the appropriate care is needed by the triage tag
s they were administered. This method was developed in 1983 by the staff members of Hoag Hospital and Newport Beach Fire Department
located in California
.
Obviously these categories are only an indication of the desired treatment time; in a large scale emergency
, Minor patients may be seen days later, if at all.
When medical personnel first arrive on the scene, they quickly assess the situation and do a call-out; they ask that any victim who is able to walk to separate themselves from non-ambulatory victims and to relocate to a certain area, or they may be asked to assist the medical personnel with the other non-ambulatory victims. These ambulatory victims are either uninjured or have minor injuries that do not need immediate care, so they are labeled with a green tag (minor).
With the non-ambulatory victims, personnel assess their respiratory, circulatory, and neurological functions, and based on those conditions the patient is labeled with one of the three remaining triage categories (i.e. delayed, immediate, dead). The three functions to check, respiratory, circulatory, and neurological, can be remembered using the mnemonics RPM (respiration, perfusion or pulse, and mental status), or ABC (airway, breathing, and circulation/shock).
The victim’s respiratory function is assessed first.
To check the victim’s circulatory function, a capillary refill
test (blanch test) is conducted. Generally, the test is done at the tip of the finger. The personnel will apply pressure to the nail bed until it turns white.
Depending on the response time of how fast the blood flows back to the finger, the victim will be labeled with the yellow tag (medical attention can be delayed for up to an hour), or with the red tag (immediate care is needed).
A mnemonic for diagnosing shock is "30, 2, can do"; if the patient meets any one of the following criteria -- breathing rate is 30 or more breaths per minute, capillary refill is more than 2 seconds, or the patient has trouble following simple commands ("can do") -- then the patient should be labelled with a red tag.
The issues with using adult START for children that JumpSTART addresses are:
In addition, the typical respiratory dynamics due to injury differs between children and adults. In adults, lack of respiration is typically secondary to other very serious issues, usual cardiac. As such, an adult not breathing is a strong indication of irreversible decline or death, barring major intervention. In a child, less severe situations may cause an easily-reversible cessation of breathing, or a low rate. For this reason, in a child with absent or inadequate (<15) respirations even after airway intervention, the JumpSTART protocol requires an extra set of steps before black-tagging. The triage officer must check the pulse of the nonrespiratory victim first. If there is no pulse, then the child can be black-tagged. If there is a pulse, the victim is to receive 5 rescue breaths. If the child spontaneously begins breathing at least 15 times per minute after the rescue breaths, then the child is red-tagged; if the child continues to have less than 15 respirations per minute, then the child is black-tagged.
In addition, responders tend to overtriage children or have trouble psychologically dealing with children in an MCI, due to natural "protective instincts."
Instituting a unique protocol helps with all the above factors. It helps refocus the responder when emotional instincts get in the way of normal triage behavior. It helps the responder focus on the uniqueness of children and thus prevents the responder form voiding normal triage practices and overtriaging. And it helps the responder focus on the fragility of children so that they are not undetriaged or abandoned.
collaborated to create a bilingual English/Spanish version of the original JumpSTART algorithm, which is available from Dr. Romig at JumpSTART Triage or in EMSpañol books. The bilingual JumpSTART is for use with either English or Spanish speaking patients.
Triage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
tool called a triage tag
Triage tag
A Triage Tag is a tool first responders and medical personnel use during a mass casualty incident. With the aide of the triage tags, the first-arriving personnel are able to effectively and efficiently distribute the limited resources and provide the necessary immediate care for the victims until...
to categorize the victims by the severity of their injury. Once they have a better handle of the MCI, the on-scene personnel will call in to request for the additional appropriate resources and assign the incoming emergency service personnel
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
their tasks. The victims will be easily identifiable in terms of what the appropriate care is needed by the triage tag
Triage tag
A Triage Tag is a tool first responders and medical personnel use during a mass casualty incident. With the aide of the triage tags, the first-arriving personnel are able to effectively and efficiently distribute the limited resources and provide the necessary immediate care for the victims until...
s they were administered. This method was developed in 1983 by the staff members of Hoag Hospital and Newport Beach Fire Department
Newport Beach Fire Department
The Newport Beach Fire Department is the agency that provides fire protection, lifeguard coverage, and emergency medical services for Newport Beach, California....
located in California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
.
Procedure
The whole evaluation process is generally conducted in 60 seconds or less. Once the evaluation is complete, the victims are labeled with one of the four triage categories.- Minor delayed care / can delay up to three hours
- Delayed urgent care / can delay up to one hour
- Immediate immediate care / life-threatening
- Deceased victim is dead or mortally wounded / no care required
Obviously these categories are only an indication of the desired treatment time; in a large scale emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
, Minor patients may be seen days later, if at all.
When medical personnel first arrive on the scene, they quickly assess the situation and do a call-out; they ask that any victim who is able to walk to separate themselves from non-ambulatory victims and to relocate to a certain area, or they may be asked to assist the medical personnel with the other non-ambulatory victims. These ambulatory victims are either uninjured or have minor injuries that do not need immediate care, so they are labeled with a green tag (minor).
With the non-ambulatory victims, personnel assess their respiratory, circulatory, and neurological functions, and based on those conditions the patient is labeled with one of the three remaining triage categories (i.e. delayed, immediate, dead). The three functions to check, respiratory, circulatory, and neurological, can be remembered using the mnemonics RPM (respiration, perfusion or pulse, and mental status), or ABC (airway, breathing, and circulation/shock).
The victim’s respiratory function is assessed first.
- If the victim is not breathing, then the personnel will try to clear the airway and perform any airway maneuvers to get the victim breathing. If all attempts fail, then the victim is presumed dead, and thus tagged with the black label.
- If the victim is breathing, then the personnel calculates the breathing rate.
- If the victim’s breathing rate is greater than 30 per minute, then the victim is tagged with a red label requesting immediate care because that is one of the primary signs for shock.
- If the victim’s breathing rate is less than 30 per minute, then perfusion will take place.
- During the perfusionPerfusionIn physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."...
phase, the victim’s pulse and circulatoryCirculatory systemThe circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...
function are checked.- If the victim lacks a radial pulse, then immediate attention is required, and thus tagged with a red label.
- If the radial pulse is present, then the personnel evaluates the victim’s mental status.
- The personnel will ask the victim to follow simple commands.
- If the victim is successful, then he is labeled with the yellow tag; medical attention can be delayed to a recommended one hour.
- If the victim is not able to follow simple commands, then he is labeled with the red tag; immediate care is needed because the situation may be life threatening.
- The personnel will ask the victim to follow simple commands.
- During the perfusion
To check the victim’s circulatory function, a capillary refill
Capillary refill
Capillary refill is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level , pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill...
test (blanch test) is conducted. Generally, the test is done at the tip of the finger. The personnel will apply pressure to the nail bed until it turns white.
Depending on the response time of how fast the blood flows back to the finger, the victim will be labeled with the yellow tag (medical attention can be delayed for up to an hour), or with the red tag (immediate care is needed).
- If the blanch test took more than two seconds, then the victim needs immediate care.
- If the blanch test took less than two seconds, then the mental status of the victim is evaluated.
- If the victim can follow simple commands, then he will be tagged with the yellow label, otherwise the red label.
A mnemonic for diagnosing shock is "30, 2, can do"; if the patient meets any one of the following criteria -- breathing rate is 30 or more breaths per minute, capillary refill is more than 2 seconds, or the patient has trouble following simple commands ("can do") -- then the patient should be labelled with a red tag.
Pediatric START
There have been organizations that have adopted the procedures of START and modified it to provide better treatment for children. Lou E. Roming, M.D., FAAP, FACEP, created JumpSTART. She took the approach of START and modified it to avoid overtriage and undertriage for children victims of MCI. The Utah Bureau of Emergency Medical Services developed a training program for teaching JumpSTART.The issues with using adult START for children that JumpSTART addresses are:
- Physiological differences in respiration
- Different levels of mentation or social integration that affect the mentation check
- Common nonambulatory evaluations that should not affect Green status
- Creating a special class of triage evaluation to help the triage officer control his or her own psychological reactions
Respiratory physiology
Children breathe more quickly than adults. Therefore, the "thirty breaths" rule would often cause children to be treated as seriously injured, when they are breathing normally. In addition, since children are supposed to breathe quickly, a slow respiratory rate that signals serious instability might not be noticed, because the child is breathing, just not breathing often enough for adequacy. For this reason, the JumpSTART respiratory standard is 15-45 respirations per minute, instead of up to 30 per minute.In addition, the typical respiratory dynamics due to injury differs between children and adults. In adults, lack of respiration is typically secondary to other very serious issues, usual cardiac. As such, an adult not breathing is a strong indication of irreversible decline or death, barring major intervention. In a child, less severe situations may cause an easily-reversible cessation of breathing, or a low rate. For this reason, in a child with absent or inadequate (<15) respirations even after airway intervention, the JumpSTART protocol requires an extra set of steps before black-tagging. The triage officer must check the pulse of the nonrespiratory victim first. If there is no pulse, then the child can be black-tagged. If there is a pulse, the victim is to receive 5 rescue breaths. If the child spontaneously begins breathing at least 15 times per minute after the rescue breaths, then the child is red-tagged; if the child continues to have less than 15 respirations per minute, then the child is black-tagged.
Mentation
Due to normal development stages, and also due to a higher percentage among the child population of social or mental deficiencies, the START mentation test, which asks the victim to follow simple directions, may result in a false positive in the child population. Therefore, the JumpSTART mentation test allows a variant, where the child is checked for pain stimulus response. An uninjured limb is squeezed or pinched. If the child's reactions are within normal limits, then the child passes the mentation test. If the child is unresponsive, or responds in an unusual way (flinches the wrong body part, flinches toward the pain source instead of away, abnormal posturing), then the child fails the mentation test and is red-tagged.Nonambulatory patients
Due to normal development , a large percentage of child victims will be nonambulatory without regard to the MCI. A baby would always be tagged yellow under START, due to being nonambulatory. But this is overtriage, if there is no other injury. For this reason, JumpSTART adds a special check at the end of the cycle, if the patient is about to be yellow tagged. For a "yellow" patient who might be nonambulatory for reasons other than injury, the patient is quickly checked for signs of significant injury (major bleeding, distended tender abdomen, and other gross abnormalities). If any are found, the patient remains "yellow" and is tagged as such. If no such signs are found, then the patient is tagged green.Psychology of the responder
Psychological studies have shown that people react outside of their ordinary scope of behavior when placed in a stressful environment; children's bodies are more fragile than adults, and thus it is important to handle children with more care because they lack the experience compared to adults to take care of themselves until help arrives.In addition, responders tend to overtriage children or have trouble psychologically dealing with children in an MCI, due to natural "protective instincts."
Instituting a unique protocol helps with all the above factors. It helps refocus the responder when emotional instincts get in the way of normal triage behavior. It helps the responder focus on the uniqueness of children and thus prevents the responder form voiding normal triage practices and overtriaging. And it helps the responder focus on the fragility of children so that they are not undetriaged or abandoned.
Spanish version
In 2010, Dr. Romig and Emergency Language SystemsEmergency Language Systems
Emergency Language Systems is a Maryland S-Corporation in the business of publishing Emergency Medical Services language translation field guides...
collaborated to create a bilingual English/Spanish version of the original JumpSTART algorithm, which is available from Dr. Romig at JumpSTART Triage or in EMSpañol books. The bilingual JumpSTART is for use with either English or Spanish speaking patients.
External links
- Official site (Newport Beach Fire Department)
- MCI
- Newport Beach Fire Department
- Smart Tape