Pediatric Multicasualty Incident Triage Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT
Topics Triage Categories What is Triage? 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 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, 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 Settings Do the greatest good for the greatest number. Maximize survival.
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
“Continuous Integrated Triage” Primary Triage Secondary Triage Tertiary Triage
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
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
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 Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline E. 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
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 Carley2Emergency 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 Under 30/min YES PERFUSION NO Over 30/min Cap refill > 2 sec Cap refill < 2 sec. Position Airway Immediate Control Bleeding NO YES MENTAL STATUS Immediate Dead or Expectant Immediate Failure to follow simple commands Can follow simple commands Immediate Delayed
R P M 30 2 Can do Mnemonic
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