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SMART / START Triage
History of Triage
Probably developed in the Napoleonic Wars Army Surgeon Dominique Jean Larrey
Established a rule for triage of war causalities Treating wounded accordingly to injury Regardless of rank, nationality or member of
opposing army French term: ‘trier’, to separate,
sort, sift or select
History of Triage
Maintained an basis of “Best Guess” as opposed to real or meaningful assessment
Refined during the Vietnam war Process of prioritizing care to ensure the “sickest are
seen the quickest.” Mid 70’s adopted into civilian emergency dept
practice.
“To Sort” A system for assigning priorities Takes playing “GOD” away from thoughts Urgency and / or chance of survival to those with
the best criteria Sorting is based on extent of injuries Usually done where found, but also on-going Not much time spent on trapped or obvious mortal
wounds Save the largest # in shortest time Can be difficult
“To Sort”
All patients broken down into three basic categories: Those who are likely to live, regardless of what care
they receive. Those who are likely to die, regardless of what care
they receive Those for whom immediate care might make a
positive difference in outcome.
Modern Triage
Triage has become more scientific Grading and outcome based upon assessment
and physiological findings Utilizes analogies, anagrams, algorithms, tags,
colors and technology
Goal
The concept of triage is simply a method of quickly identifying victims who have immediately
life-threatening injuries AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed
first to those patients.
Golden Hour
Time frame from initial injury to definitive surgical care
Drastically decreases patient mortality rate
Effective triage should not prolong on scene time
Why? When? How?
Why? To get the right patient to the right facility at the
right time When?
Causalities exceed the number skilled rescuers How?
Using a system that is: Dynamic, Safe, Quick, and Reproducible
What makes a good triage system? Dynamic
Have the ability to upgrade or downgrade the priority of a patient
Quick Allows the ability to have a patient assessed and priority
applied within 30 to 60 seconds Safe
Must be clinically safe and evidence based Reproducible
Allow different personnel to arrive at the same decisions
START vs SMART START is a method of
triage SMART is a series of
triage products
START
Simple
Triage
And
Rapid
Treatment
START
Developed in California in the early 1980’s by Hoag Hospital and Newport Beach Fire and Marine (California)
Rapid approach to triaging large numbers of causalities
Easy to remember
START
Initial patient assessment and treatment should take less than 30 seconds for each patient
Consists of Primary Triage Secondary Triage Transport Hospital Triage
START
First - clear the walking wounded using verbal instructions. Be mindful of hearing impaired (bomb blast) Direct them to the treatment areas for detailed
assessment and treatment Tag These as MINOR
Now check your RPMs
START RPM Respiration's
None - Open the Airway Still None? - DECEASED Restored?- IMMEDIATE
Present? Above 30 - IMMEDIATE Below 30 - CHECK PERFUSION
START RPM Perfusion
Radial Pulse Absent or
Capillary Refill > 2 secs IMMEDIATE
Radial Pulse Presentor
Capillary Refill < 2 secsCHECK MENTAL STATUS
START RPM
Mental Status Can Not Follow Simple Commands
(Unconscious or Altered LOC)IMMEDIATE
Can Follow Simple CommandsDELAYED
START
If patient is immediate - priority 1 upon primary assessment, attempt to correct airway blockage or uncontrolled bleeding only before moving on to next patient.
STARTThe START process permits a very few rescuers
to rapidly triage a large number of patients without specialized training.
After patients are moved to treatment areas where more detailed assessment and treatment are conducted.
WalkingYES
PRIORITY 3
WalkingYES
PRIORITY 3
No
RespirationsNo
Position Airway Respirations
NoDEAD
Yes
PRIORITY 1
WalkingYES
PRIORITY 3
No
RespirationsNo
Position Airway Respirations
NoDEAD
Yes
PRIORITY 1
Yes
Under 30/minNo
WalkingYES
PRIORITY 3
No
RespirationsNo
Position Airway Respirations
NoDEAD
Yes
PRIORITY 1
Yes
Under 30/minNo
Yes
Cap RefillOver 2 sec.
Control Bleeding
WalkingYES
PRIORITY 3
No
RespirationsNo
Position Airway Respirations
NoDEAD
Yes
PRIORITY 1
Yes
Under 30/minNo
Yes
Cap RefillOver 2 sec.
Control Bleeding
Under 2 sec.
Obeys Simple Commands
YESPRIORITY 2
No
Secondary Triage Secondary triage uses refined
physiological scoring systems and anatomical examination.
It is carried out as and when resources become available. This normally is at the casualty clearing station.
Evaluates GCS, respiratory rate, and systolic blood pressure
Again, can be done within 30 –60 seconds
Secondary Triage Total GCS
13 – 15 9 – 12 6 – 8 4 – 5 3
4 3 2 1 0
Respiratory Rate 10 – 29 > 29 6 – 9 1 – 5 0
4 3 2 1 0
Systolic BP 90 or more 76 – 89 50 – 75 1 – 49 0
4 3 2 1 0
Total = + +
12 = MINIMAL 311 = DELAYED 210 or less = IMMEDIATE 1
Pediatric Triage
Over prioritizing of pediatric patients take valuable resources away from more seriously injured adults
Triage systems based on adult physiology will not provide accurate results
Not small adults A child’s length is proportional
to their physiology
SMART Triage
A series of products that utilizes the START Triage system
SMART Triage SMART Triage Pak
Easily deployable pack for field triage
Contains 20 SMART Triage Tags 10 ‘Dead’ Tags 10 WMD Cards Five Chem Lights Two Pencils One Pediatric Triage Tape One Casualty Count Card
SMART Triage SMART Commander
For use by the IC or Transport Officer
Contains Dry Erase Incident
Information Board Dry Erase Incident Control
Board Triage Tracking Tab Sleeves Permanent Marker
SMART Tape Provides rapid, safe,
triage of injured children
WMD Tag Basic questions of kind of
agent patient is exposed to
Indicates contaminated or decontaminated
Fire-EMS Role During MCIAn ICS Approach
Disclaimer
Always utilize your system’s policy and procedures when responding to MCIs.
Basics of MCI Management
First Arriving Unit Give accurate on-scene report Perform rapid hazard assessment Initiate traffic control Provide occupant hazard assessment Call for additional reources Assign crew(s) specific task Transfer command to command officer
Basics of MCI Management
First Arriving Command Officer Establish command post Develop appropriate command organization Establish objectives Request resources
Basics of MCI Management First Arriving EMS unit Assumes EMS Command and establishes command and control Components which are vital to successful outcome
Appropriate triage Appropriate patient management Appropriate patient transport
EMS responsibilities Care and transport of sick or injured victims Medical care of responders on the scene Establish triage area Establish treatment area Alert hospitals
EMS Command StructureEMS
Command
Support GroupSupervisor
Medical SupportUnit Leader
EMS BranchDirector
(EMS Ops)
Air OpsManager
Treatment GroupSupervisor
Transport GroupSupervisor
Triage GroupSupervisor
Staging AreaManager
Critical Factors of Successful MCI Operations
In a MCI, patients outnumber EMS providers. The first arriving EMS unit MUST establish medical
command and begin triage, not perform treatment. The Incident Management System (IMS) establishes an
EMS Branch under Operations; the key EMS areas are Triage, Treatment, and Transport.
Treatment is not effective without effective triage.
Critical Factors of Successful MCI Operations
The Treatment Area must coordinate with the Triage and Transport Areas.
The Treatment Area is a noisy, busy place and a major resource consumer.
On small scale MCI events, EMS Command may be able to coordinate the entire Operation; on large incidents a separate Treatment Area is needed.
Critical Factors of Successful MCI Operations
Large-scale incidents or disasters may require separate divisions; each division is a geographic area that is an IMS structure and requires support.
In terrorism or hazmat incidents, the scene can be dangerous. Total scene awareness is critical.
Patient and Communications
Flow Chart
INCIDENTCOMMAND
COMMCENTER
EMSCOMMAND
EMSOPS
STAGINGAREA
MANAGER
EMSVEHICLES
TREATMENTGROUP
SUPERVISOR
TRANSPORTGROUP
SUPERVISOR
TREATMENTSTRIKE TEAM
TRIAGESTRIKE TEAM
TRIAGEGROUP
SUPERVISOR
HOSPITALS
PATIENT FLOW
Face to Face Communications
COMMUNICATIONS FLOW
Primary Triage - Exercise
WalkingYES
PRIORITY 3
No
RespirationsNo
Position Airway Respirations
NoDEAD
Yes
PRIORITY 1
Yes
Under 30/minNo
Yes
Cap RefillOver 2 sec.
Control Bleeding
Under 2 sec.
Obeys Simple Commands
YESPRIORITY 2
No
Secondary Triage -Exercise