DISASTER TRIAGE

Basic Principles and Application

Asst. Prof. IV – Ulysses T. Abellana RN,MN
DISASTER Strikes!
 DISA STE R

BDE -7
UPCN 2010
 Learning Objectives
1. Define Triage
2. Identify the similarities and differences between
disaster triage and pre-hospital triage.
3. Identify the stages of triage.
4. Describe the procedures of the S.T.A.R.T. (Simple
Triage and Rapid Treatment) and S.A.V.E. triage
systems.(Secondary Assessment of Victim Endpoint)
5. Apply the S.T.A.R.T. triage system using table-top
exercises.
6. Appreciate the role of the nurse in disaster triage.
 Terminology
The following terms are useful when discussing
major medical/surgical incidents:
ü M.P.I. -- Multi-Patient Incident
(up to 25 patients)
ü M.C.I. -- Mass Casualty Incident
(25-100 patients)
ü Disaster -- Over 100 patients
 Mass Casualty Incident
• Low Impact Incident
– Manageable by local
emergency personnel
• High Impact Incident
– Stresses local EMS, Fire, and
Police resources
• Disaster, Terrorism Incident
– Overwhelms regional emergency
response resources
 Daily Emergencies
Do the best for each individual.

Disaster Settings
Do the greatest good for the
greatest number. Maximize
survival.
 What is Triage? (/triːɑːʒ/)

Triage: …the screening or classification of

sick, wounded or injured persons during
war or disaster, to determine the priority
needs for efficient use of manpower,
equipment and facilities
(Taber’s Cyclopedic Medical Dictionary)
 What is Triage? (/triːɑːʒ/)
• Triage is the term derived from the French verb
“trier” meaning to sort or to choose

It’s the process by which patients classified

according to the type and urgency of their
conditions to get the Right patient to the
Right place at the
Right time with the
Right care provider
 Principles of successful
disaster triage
• Never move a casualty backward (against the flow)
• Never hold a critical patient for further care.
• Salvage life over limb
• Triage providers do not stop to treat patients
• Never move patients before triage except in cases of:
– Risks due to bad weather
– Impending darkness or darkness has fallen
– A continued risk of injury
– Medical facilities are immediately available
– A tactical situation that dictates movement
(Hogan and Lairet, 2002)
 Benefits of Triage
There are three major reasons why triage is beneficial in the disaster response:

1. Separates out those who need rapid medical care to save life or
limb.
2. By separating out the minor injuries, it reduces the urgent burden on
medical facilities and organizations. On
average, only 10-15% of disaster casualties are serious enough to
require over-night hospitalization.
3. By providing for the equitable and rational distribution of casualties
among the available hospitals, triage reduces
the burden on each to a manageable level, often even to "non-
disaster" levels.
 Types of Triage
Pre-hospital Triage: Disaster Triage
• Multiple victims • Increased no. of victims
• Additional resources • Limited medical resources
available • Long scene times
• Medical infrastructure • Frequent reassessment
intact • Compartmentalized victim
• Transport to definitive treatment
care • Multiple victims
• Single scene • – Trauma
• – Medical
• Austere conditions
 Stages of Disaster Triage
Immediate
• – Local providers
• – Follows pre-hospital model
• – S. T. A. R. T. (Simple Triage and Rapid
Treatment)
Secondary
• – Disaster medical responders
• – S. A. V. E. (Secondary Assessment of
Victims Endpoint)
 Triage occurs at every stage of
patient assessment,
decontamination, treatment,
transport and each level of care.
 S T A R T Triage
S IMPLE
T RIAGE
AND
RAPID
T REATMENT
 Brief History
START Triage
• Developed in California in the early 1980’s
by Hoag Hospital and Newport Beach Fire
and Marine Department
• Rapid approach to triaging large numbers
of casualties
• Easy to remember
 START Triage

• Designed to be performed by first

responders (paramedics)
• One of several triage programs available
• Most common protocol used for triage
• Assumes personnel under a great deal of
stress
 S T A R T Triage
• Limited number of rescuers to rapidly triage a
large number of patients
• Patients systematically moved to treatment
areas for more detailed assessment, treatment
& transport
• Triage victims in less than 30 seconds
• Aim: Rapidly find Immediate patients
 Triage precautions

• Avoid hazardous materials

• Avoid unsafe situations
• Wear personal protective equipment
 Basic Principles
• Initial patient assessment and treatment
should take less than 30 seconds for each
REMEMBER
patient
• Patients are triaged based upon 4 factors
– Ability to walk away from the scene
– Respiration: > or < 30 respirations per minute
– Pulse: Radial pulse present or capillary refill < or
> 2 seconds
R espirations P ulseable/unable
– Mental Status: M ental to
Status
follow simple
commands
 S.T.A.R.T. Classifications
• IMMEDIATE • DEAD (Black)
(Red) – Mortal wounds
– Altered RPM – Die despite
• DELAYED medical
attention
(Yellow)
– Dead when
– Majority of
initially assessed
victims
– RPM “normal”
• MINOR (Green)
– “Walking
Triage Tag
• Standardized
• Basic information
• Color coded
• Means of attachment
• Tear-off sections for
tracking
• Need to apply new
tag when re-triaging
 Triage Ribbons
• Ribbons
– Roll
– Pre-cut strips
• Same colors as tags
• Placed on victim after RPM
• May initially substitute for triage
tag
• Supplement to tag
 Arrival at the Scene…
• As incident commander or first responder,
the first action is to assure that the scene
does not present any health or safety risks
for your team.
SAFETY COMES FIRST!
 S. T. A. R. T. Procedure
• First clear the walking wounded using
verbal instructions.
– “If you can walk, move over there”
• Direct them to the treatment areas for
“If you can walk, come to
detailed assessment & treatment
me.”
• These Patients are triaged MINOR
• RPM check for remaining patients
 S. T. A. R. T. Procedure
• Begin where you stand
• Move from starting point in a systematic
manner
• Stop at each victim and quickly assess RPM
• Maximum time 1 minute per victim
• Correct life-threatening airway problems
• Tag patient
• Move on!
 S T A R T Triage
• Respirations
– None - Open the Airway
• Still None? – DECEASED
• Restored?- IMMEDIATE
– Present?
• Above 30 - IMMEDIATE
•
Below 30 - CHECK PERFUSION
 S T A R T Triage
• Respirations How do you check
Airway takes
for respirations?
precedence over
C-Spine
Look for chest rise
Listen forprecautions
air exchange, in
Feel for abdominal
movement mass casualty
situations
 S T A R T Triage
• Perfusion
– Radial Pulse Absent or
Capillary Refill > 2 secs
IMMEDIATE
– Radial Pulse Present or
Capillary Refill < 2 secs
CHECK MENTAL STATUS
 S T A R T Triage
• Perfusion
The initial START triage scheme
utilized capillary refill as a
surrogate for circulatory status,
but a later revision demonstrated
better specificity (negative in
health) when utilizing radial
pulse as the perfusion indicator.
Some schools believe that the
absence of a radial pulse in an
adult roughly correlated with a
systolic blood pressure less than
80 mm Hg.
 S T A R T Triage
• Mental Status
• Can Not Follow
Simple Commands
(Unconscious or
Altered LOC)
IMMEDIATE
• Can Follow Simple
Commands
DELAYED
 S T A R T Triage
• Mental Status
The psychiatric patient is probably
the most challenging during a
disaster. These patients may not be
physically injured, but still be
classified as immediate if they
cannot follow commands.
Furthermore, they can take up
precious time and easily disrupt the
flow and assessment of other
victims.
 S T A R T Triage
• If patient is tagged immediate upon
initial assessment, only attempt to
correct airway blockage or uncontrolled
bleeding before moving on to next
patient.
NO MORE THAN 30
SECONDS PER PATIENT
 Triage Priorities
Your initial goal during triage is to find IMMEDIATE
patients. You want to “find the red and get it out”.
Your efforts should focus on locating all IMMEDIATE
patients, getting them treated and transporting them
as soon as possible.
Once IMMEDIATE patients have been treated and
transported, reassess all DELAYED patients and
upgrade any to “IMMEDIATE-by-mechanism,”
depending on their injury, age, medical history, etc.
 S T A R T Triage
• When things get hectic
with multiple patients rev
up your RPM’s.
• R - Respiration - 30
• P - Perfusion - 2
• M - Mental status - CAN DO

Mnemonic: 30 – 2 – CAN DO
Walking Wounded S T A R T Triage
Walking woinded
Respirations
MINOR YES NO

<30 >30 Position Airway

IMMEDIATE
Perfusion YES NO
IMMEDIATE DECEASED
Radial Pulse Radial Pulse
absent or Cap Present or Cap
refill > 2 seconds
Refill < 2 seconds Mental Status
IMMEDIATE
Can’t follow Simple Follows Simple
Commands Commands

Control bleeding IMMEDIATE DELAYED

S T A R T Triage
 JUMPSTART
• System for triaging pediatric patients is called
JUMPSTART
• Is used for age range 1 to 8 years
• Has similar algorithm to START system
• The primary differences in this method are
the respiratory effort and use of AVPU.
• Remember, cardiac arrest in children is most
often caused by respiratory complications
 Level of Consciousness

Awake and alert and needs no stimulus

A to respond to the environment
Alert

Requires a verbal stimulus to elicit a

V Verbal response

Requires a painful stimulus to evoke a

P Pain response

Unresponsive to applied stimulus

U Unresponsive
 Level of Consciousness

Awake and alert and needs no stimulus

A to respond to the environment
Alert

Does not respond quickly with

C Confused information about their name, location,
and the time (disoriented)
Sleepy and responds to stimuli only with
D Drowsy incoherent mumbles or disorganized
movements
Unresponsive to applied stimulus
U Unresponsive
 Level of Consciousness

Simplified Motor Score (SMS)

Obeys commands 2

Localizes pain 1

Withdraws to pain or
0
worse
Simplified Motor Score (SMS) may be an adequate substitute for the Glasgow
Coma Scale for use in triage decisions by EMS providers.
http://www.publicsafety.ohio.gov/links/EMS_Valdiation%20of%20Simplified%20Motor%20Score.pdf
S.T.A.R.T. TRIAGE
APPLICATION
 LET’s APPLY WHAT
WE JUST LEARNED!
Be ready to do Triage…

The following exercises were developed by the authors at the website cited.
Scenario and additional cases were provided for the purpose of this training.
 Respirations
• Assessment
• Greater than 30 breaths/min
• Treatment Allowed
• Position to open Airway

After the Game review RPM again. Remember that we are only
concerned with Respiration over 30, Respirations under 10 will cause
an altered Level of Consciousness.
Perfusion
• Assessment
• No Radial Pulse or CRT > 2 secs
• Treatment
• Direct patient to control
bleeding
• Position with feet elevated
Motor Function
• Assessment
• Follows simple commands
Green
• Minor Injuries
• Those that can walk
• Direct walking
wounded to
designated location
• Usually not
transported by
ambulance*
“Those who can walk, come to me.”

*This may vary depending on situation

 Yellow
• Delayed: If unable to
move on own

Some patients may appear that they should be Green, because they
do not have any obvious injuries or complain of problem that may
prevent them from walking out when requested. Many patients
sometimes do not know the full extent of their injuries.
 Red
• Critical
• Must fail RPM
• Do not label
Red because of
MOI

It is important to note, that in START Triage we are really only

concerned about the here and now, not what might happen 10
minutes later.
Black
• Deceased
• Do not perform CPR in
an MCI
• Consider opening
airway (just in case)
Sample Patient Profile 42 Year Old Male

Respirations = 24

CRT = 2

Mental Status = Shouting

Problem

Leg pain

A B C D
You prepare to begin triage
• You will be using the S.T.A.R.T.
system.
• Triage tape is available.
• You will be responsible for triage.
Use Colored Tapes to Triage!
The goal of Triage is to
do the greatest
amount of good for the
largest number of
victims.
SCENARIO
• In July 1990 at 16:26 hrs
local time, a severe
earthquake registering
7.7 on the Richter scale
struck the northern
Philippines. The
earthquake caused
damage over a region of
about 7700 square miles,
extending northwest
from Manila through the
densely populated
Central Plains of Luzon
and into the mountains
of the Cordillera Central.
SCENARIO
• Over 5,000 people
were affected, a
number severely
injured, reported
missing or dead as
buildings and
houses collapsed
or got buried by
landslides resulting
from the quake.
As You Arrive
You are told that there where about 40
people inside for a meeting when it struck.

D
A
C
Scene Survey
You determine that there are no immediate
hazards to you or the victims.

B
Victims
D
A
C
Remember!
• Begin where you stand.
• Do not become involved in treatment.
• One minute or less per patient.
• Keep moving.
• Be consistent.
For each of the following Patient Profiles,
determine the most appropriate triage
category.
You will be given 15 seconds per profile
to perform your rapid assessment.

A B C D
 You look into the Building and ask all
those who can walk to leave. About 10
people crawl out of the building some
helping others and move toward the empty
ground.

About 30 people remain in the Building.

Patient Profile 36 year old male

Talking to you

Respirations
20/min

Radial Pulse
Present
Problem

Profuse bleeding from scalp wound.

#1
A B C D
Patient Profile 33 year old female

Tells you her back

hurts

Respirations
20/min

Radial Pulse
Present
Problem

Complaining of severe back & pelvic pain.

#2
A B C D
Patient Profile 13 year old female

Unconscious

Respirations
8/min

Radial Pulse
Present
Problem

Nothing obvious, covered in debris.

#3
A B C D
Patient Profile 25 year old male

Talking to you,
attempting to stop
bleeding.

Respirations
25/min

Radial Pulse
Present
Problem

Amputation of left arm

#4
A B C D
Patient Profile 36 year old female

Tells you she feels

sick

Respirations
27/min

Radial Pulse
Present
Problem

Impaled object, very pale & sweaty

#5
A B C D
Patient Profile 9 Year Old Male

Crying, holding
injured eye

Respirations
16/min

Radial Pulse
Present
Problem

Enucleated Eye
#6
A B C D
Patient Profile 54 Year Old Male

Tells you his leg is

pinned.

Respirations
24/min

Radial Pulse

Problem
Present
Leg pinned by heavy beam, Open femur fx &
tib-fib fx to other leg
#7
A B C D
Patient Profile 16 Year Old Male

Tells you his nose

and neck hurts

Respirations
18/min

Radial Pulse
Present
Problem

Fractured nose, profuse bleeding.

#8
A B C D
Patient Profile 22 Year Old Female

Unconscious

Respirations
Absent

Radial Pulse
Absent
Problem

Neck sharply angulated

#9
A B C D
Patient Profile 24 Year Old Male

It hurts when I
breathe

Respirations
16/min

Radial Pulse
Weak/Present
Problem

Chest pain from blunt trauma, hurts

#10 with breathing
A B C D
Patient Profile 60 Year Old Male (Pastor)

My leg hurts

Respirations
26/min

Radial Pulse
Present
Problem

Severe right leg pain

#11
A B C D
Patient Profile Female, Early 20s

Moans weakly
when you talk with
her
Respirations
36/min

Radial Pulse
Absent
Problem

#12 Patient pinned under large bench

A B C D
Patient Profile Female, Early 70s

I am having
trouble breathing

Respirations
18/min

Radial Pulse
Present
Problem

Chest pain & Dyspnea, Cardiac history

#13
A B C D
Patient Profile 11 Year old Male

My shoulder

Respirations
26/min

Radial Pulse
Present
Problem

#14 Dislocated shoulder-bleeding

A B C D
Patient Profile 12 Year old Female

Unconscious

Respirations
Begins breathing when you
open the airway

Radial Pulse
Present
Problem

Cyanotic
#15
A B C D
Patient Profile 36 Year old Female

Conscious

Respirations
16/min

Radial Pulse
Present

Problem

#16 C/O Severe Abdominal Pain/Arm Lac

A B C D
Patient Profile 36 Year old Female

I am having an
asthma attack!

Respirations
28/min

Radial Pulse
Present

Problem

#17 Asthma Attack - audible wheezing

A B C D
Patient Profile 10 Year old Female

I can’t feel my legs

Respirations
18/min

Radial Pulse
Present
Problem

Pinned by beam now removed

#18 No feeling in legs
A B C D
Patient Profile 65 Year old Female

Does not respond

to commands

Respirations
16/min

Radial Pulse
Present
Problem

No obvious injuries
#19
A B C D
Patient Profile 26 Year old Male

I think I am going
to throw up

Respirations
26/min

Radial Pulse
Rapid & Thready

Problem

#20 Multiple lacerations from glass

A B C D
Patient Profile 30 Year old Male

I feel dizzy

Respirations
28/min

Radial Pulse
Non -palpable
Problem

Patient soaked with blood, no obvious killer

#21 bleed
A B C D
Patient Profile Female, Early 50s

I can’t move nor

feel my legs

Respirations
18/min

Radial Pulse
Present
Problem

Lower extremities under wooden debris

#22
A B C D
Patient Profile 40 Year old Female
Open airway

Unresponsive

Respirations
Not breathing

Carotid Pulse
Weak
Problem

Patient is face down on the floor

#23 What are you allowed to do?
A B C D
 Group Exercise
Patient is face down in the
field

Not Breathing

Weak Carotid Pulse

She is unresponsive

What
OPENdo youAIRWAY
THE do first?
Patient Profile 42 Year old Female

Unresponsive

Respirations
Gasps

Radial Pulse
Absent
Problem

Patient gurgles but can’t maintain an open

#24 airway
A B C D
Patient Profile 13 year old female

Unconscious

Respirations
16/min

CRT
2
Problem

Patient has an open head wound, bleeding controlled

#25
A B C D
Patient Profile 22 Year Old Male

Awake..touches his
shoulder where it hurts

Respirations
27/min

Radial Pulse
Present
Problem

Dislocated right shoulder

#26
A B C D
Patient Profile 32 Year Old Male

It hurts when I
breathe

Respirations
35/min

CRT =2

Problem

Facial injury
#27
A B C D
Patient Profile 22 Year Old Female

Unconscious

Respirations
18/min

Radial Pulse
Absent
Problem

Massive head injury

#28
A B C D
Patient Profile 28 Year old Female

I can’t feel my legs

Respirations
23/min

CRT = 1
Problem

Third degree burns over front of both

#29 legs
A B C D
Patient Profile 28 year old male

I am hurt, my
arm… its painful
(crying)

Respirations
22/min

Radial Pulse
124
Problem

Walks over to you and, has an obvious mangled arm

#30
A B C D
Summary
• Triage only suggest a transport order
• Mass Casualty is really a BLS skill
• Be creative
• No ambulances?
• Reassess Delayed patients as soon
as possible and upgrade to
Immediate if necessary (Serious
MOI / Age/ HX).
 Common Pitfalls at MCIs
• Failure to alert
• Failure to triage
• Slow “primary” stabilization
• Inappropriate, time consuming care
• Premature transportation

From Responding to the Mass Casualty Incident :

A Guide for EMS Personnel by Alexander Butman
 Common Pitfalls at MCIs (cont)
• Improper use of personnel
• Poor distribution of patients
• Poor EMS Command
• Lack of preparation or training
• Failure to adapt
• Poor communication
From Responding to the Mass Casualty Incident :
A Guide for EMS Personnel by Alexander Butman
 Transition Phase
• After S. T. A. R. T. completed
• Move victims to secondary triage based on
tagging
– Resource dependent
– Safe secondary area available
– May involve just grouping patients together at
scene
– Provide stabilizing care
– Re-triage if condition changes (SAVE)
 Treatment Unit
• Determine location for treatment area
• Coordinate with the Triage unit to move patients
from the triage area to treatment areas
• Establish communication
with Incident Command
• Reassess patients, conduct
secondary triage to match
patient with resources
• Direct movement to
ambulance loading area
 Transportation Unit
• Management of patient movement from
the scene to the receiving Hospitals
• Works with Treatment unit to establish
adequately sized, easily identifiable
patient loading area
• Designates an ambulance staging area
• Maintain communication with Incident
Command
 Staging Area
• Location designated to collect available
resources near incident area
• Several staging areas may be required
• Should be easy for arriving resources to
locate
• Staging area may need to be relocated as
the situation dictates
 S. A. V. E.
• Secondary Assessment of Victim
Endpoint
• Benson, Koenig, and Schultz – Pre-
hospital and Disaster Medicine, 11(2), 1996
– Apply limited resources to gain most good
– Designed for catastrophic disasters
– Provide immediate on-scene care but transport
significantly delayed (days)
 S. A. V. E. Assumptions
• Local providers have triaged victims
(S. T. A. R. T.)
• Previously trained local providers
• Limited medical and transport resources
• Prolonged evacuation to definitive care
– Patients may deteriorate because of transport
delay
 S. A. V. E. Categories
• Those who will die regardless of care
• Those who will survive whether or not they
receive care
• Those who will benefit from limited
immediate field intervention
– These will receive more than basic care and
comfort measures
Benefit expected
(Probability of survival) = Value
Resources required
 S. A. V. E. Procedure
• Reassess patient based on S. T. A. R. T. triage
• Assign patients to areas
– Observation
• Those that will die
– Periodic reassessment for improvement
• Those not needing care
– Provide basic care
– Periodic reassessment
– Treatment area
• Treated in order of severity and resources
 SAVE Triage
Areas of Assessment

• SpineSigns
Vital
• Airway
Extremities
• Chest
Skin
• Abdomen Status
Neurologic
• Pelvis Status
Mental
 SAVE Triage Categories
• RED: require immediate intervention
• YELLOW: require intervention but can
tolerate a brief delay
• GREEN: do not require intervention to
prevent loss of life or limb
• BLACK: dead or unsalvageable
 S.A.V.E. Treatment
• Patients triaged to treatment area are
treated in priority according to severity,
resources, and time.
• If patient does not respond to treatment,
re-tag and send to observation area.
• Patients who would benefit most from
early transport should be so designated in
the event transport becomes available.
NEXT STOP….
In a number of countries there are increasing efforts to
improve the education and training of nurses regarding
disaster preparation. …our training and education as
nurses often has not prepared us for working in
emergencies beyond the walls of hospitals where there
are many resources at our disposal. What happens if
our hospital is destroyed or badly damaged? Or
suddenly we are faced with a calamity in our district
that is outside of the scope of usual practice?
(Turale, S. Nurses: Are we ready for a disaster?
J Nurs Sci Vol.28 No.1 Jan - Mar 2010)
• The recently developed World Health
Organization (WHO) International Council of
Nurses (ICN) Disaster Nursing Competencies
aims to provide a clear framework for the work of
nurses in disasters and to assist in programs
and short courses in nursing and midwifery.
International Council of Nurses and World Health Organization Western Pacific ICN framework of
disaster nursing competencies. Geneva: ICN; 2009, 73
“Nurses, as the largest group of committed health
personnel, often working in difficult situations with limited
resources, play vital roles when disasters strike, serving as
first responders, triage officers and care providers,
coordinators of care and services, providers of information
or education, and counsellors. However, health systems and
health care delivery in disaster situations are only successful
when nurses have the fundamental disaster competencies
or abilities to rapidly and effectively respond. “
Hon. Hiroko Minami
Pres. ICN, 2009
• Benson, M., Koenig K.L. & Schultz C.H. (1996). Disaster
triage: START, then SAVE. Prehospital and Disaster
Medicine, 11, pp. 117-24.
• Disaster Nursing Competencies
www.icn.ch/images/stories/documents/publications
• Nursing Emergency Preparedness Education Coalition
www.nursing.vanderbilt.edu/incmce/modules.html
• Schultz C.H, Disaster Triage: START and SAVE.
www.slideshare.net/mobile/ schultzc/disaster-triage-
start-and-save
• www.C3softworks.com
• www.citmt.org
THANK YOU!!!
Asst.Prof.IV – Ulysses Abellana RN,MN
Asst.Prof.IV – Dexter Tariman RN, MAN