START Triage...

[DV_EMT]

START triage is epic... i use it very frequently even when its not a "disaster"... just to get a feel for what kind of trauma i might have... ie car accidents

 

[Lifeguards For Life]

START or "smart triage"?

Here is the START triage algorithm, for those unfamiliar with it.

Although START is nearly ubiquitous within the United States, surprisingly little research exists to support its use. START has been tested in simulations and in individual patients and found to produce consistent results with provider of different levels.

Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients.

-http://www.annemergmed.com/article/S0196-0644(09)00002-X/abstract

A mass casualty incident (MCI) demands rapid and efficient triage of victims. The Simple Triage and Rapid Treatment (START) protocol has been proposed to identify salvageable victims from those with imminent mortality. This study evaluates the efficacy of START triage to predict likelihood of mortality of an MCI trauma victim. METHODS: Trauma patients were randomly selected using the trauma database at a local Level II trauma center. Survival was defined as a discharge from the hospital with the primary endpoint being death. For respiratory rate <30, pulse <100, and Glasgow Coma Scale score >14, one point was given to the victim for each category. Persons who did not meet these criteria were given a score of zero. The scores were then tabulated and analyzed with respect to the primary endpoint. RESULTS: Of the 355 persons analyzed, 341 (96%) survived and 14 (3.9%) were categorized as deceased. For patients with a tabulated score /=2, the PPV and NPV were 0.08 and 0.99, respectively. DISCUSSION: Of the total victims, 75.77% with a respiratory rate <30, palpable radial pulse, and intact mental status survived. The deceased victims with tabulated scores of 1, 2, and 3 had mortalities of 50%, 28%, and 21%, respectively. The trend toward lower tabulated scores in the deceased victims suggests efficacy with START triage.

-Gebhart, Mark E (ME); Pence, Robert (R); Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio 45420, USA. mark.gebhart(-atsign-)wright.edu

The literature suggests that implication of START triage has shown uses for prioritizing the most critical patients for transport to the appropriate ER first.

 

[RescueYou]

It's an ABC. MOST things involving an abnormal ABC are red, but that can vary. 30 breaths per minute will not sustain life for a long time. They will hyperventilate until they pass out. If it is out of anxiety or fear and such, after they pass out, their breathing will return to normal. If not, you have a problem. Check their pulse as well and take a general impression. Just because one thing is off, doesn't mean they are in bad shape. Make sure they have no signs of [going into] shock. In a major MCI for triage, yellow here is considered "can wait for treatment up for 2 hours." Red is life threatening. You have to be able to individually make a good call based on the entire situation.

 

[redcrossemt]

I was surprised no one here mentioned SALT triage.

SALT stands for Sort, Assess, Life-saving interventions, Treatment and/or transport. It was developed by the ACS Committee on Trauma and revised by a panel convened by the CDC and NHTSA. Members of the revising committee included ACEP, AMA, ACS, NAEMT, NAEMSP, NASEMSO, and others.

SALT is only a proposed guideline, but has a lot of support and will likely soon become a national standard for mass casualty triage. According to the paper published, it was developed based on all of the currently available triage systems, including START, and the science available.

They published Lerner, et al: Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Preparedness. 2008; 2 (Suppl 1): S25-S34 which is available for free at this link.

As a general overview, SALT is to:

-Sort
-Assess
-Life-Saving Interventions
-Treat/Transport

The sort is based on:

-Anyone who can walk goes to the walking wounded area and is assessed last.
-Anyone who has purposeful movement to commands (i.e. can raise an arm or leg) is assessed second.
-Anyone who does not move is assessed first.

The assessment is based on:

-LSI (control major hemorrhage, open airway, pleural decompression, auto injector antidotes)

-Not breathing = Expectant

-Obeys commands / purposeful movement (otherwise red)
-Peripheral pulse (otherwise red)
-No respiratory distress (otherwise red)
-No uncontrolled major hemorrhage (otherwise red)

We use RPM (Respiratory, Pulse, Mental Status) to remember what to check...

 

[redcrossemt]

Training is learning the rules, experience is learning the exceptions

The stereo must always be louder than the siren

I'm here to save your a$$, not kiss it

The last people you see may shock you

Bad planning on your part does not automatically consitute an emergency on mine.

...perpetuating the poor image of EMS...

 

[zmedic]

I worry about the whole deciding who to triage based on movement. It assumes that you can see everyone, might not be true in a big scene. Also I like that START has you start where you stand and work from there. I feel like if you are running around bypassing people because they can move and then coming back to them you risk missing people. Also if you start from one point then everyone behind you has been triaged and transport/treatment teams can start working on them. It seems under SALT you'd have a bunch of triaged and non-triaged people together.

 

[Dean]

Yeah it's true everybody dies from shock in one way or another....

 

[Dean]

Yeah everyone dies from shock in one way or another....

 

[redcrossemt]

Sure... a triage protocol developed for us by Californian urban firefighters 3 minutes from the ER is what we should be using during a rural Colorado winter 3 hours from a trauma center just so we can all be standardized. :wacko:

Our protocols are viewed by guidelines and many things get fuzzy in an MCI.

Was wondering how close your local community hospitals are?