1. DISASTER TRIAGE:
S.T.A.R.T. & S.A.V.E.
Carl H. Schultz, MD
Professor of Emergency Medicine
UC Irvine School of Medicine
2. Carl Spengler, MD
3rd Year EM Resident
Oklahoma City Bombing
―…We never saw a child come out of the
federal building alive. At one point, a
group of people began screaming for me.
A firefighter had brought out a little girl
who was still breathing. People were
preparing intravenous fluids, and a
paramedic was getting the intubation
equipment together. The crowd was
screaming for the doctors to work on the
child.
3. Nature of Triage…
I finally yelled for everybody to be quiet and calm
down. As I assessed the little girl, it was obvious
that she had catastrophic head and chest injuries
and that there was nothing left to save. I told a
paramedic to wrap up the child in a blanket and
do nothing. Several bystanders became
emotionally decompensated and screamed, ‗You
bastard!‘ As I walked off, several people
continued to curse me in the worst possible
fashion. Unfortunately, that is the nature of
triage‖.
4. Goal of Disaster Triage
Do the greatest good
for the greatest
number of casualties
5. Triage Origin
From the French verb, t r i e r , ―to sort‖
Napoleon‘s time, to assign treatment
priorities with limited resources
Attention given first to most salvageable with
most urgent conditions – get them back into
battle
6. Does Triage Work?
Lessons from history
Scene control
– Convergence behavior
7. Key Concepts
Resources are limited
– Supplies
– Personnel
Time for evacuation unknown or
prolonged (the cavalry isn‘t coming any
time soon)
– Only austere field interventions are
available
8. Triage Practices
Traditional
– Static, single
point in time
– Triage tags
frequently used
– Few patients
Disaster
– Dynamic, multiple
points in time
– Documentation
needs may exceed
triage tag capacity
– Large patient
numbers
9. Triage Practices
Traditional
– Scoop and run
– Designed to
work within
existing EMS
Disaster
– Secondary exam
and treatment
performed
– Assumes
nonfunctional
EMS system
10. Triage Practices
Traditional
– Used for
localized
disaster scenes
– Dependent on
communications
and
transportation
Disaster
– Used for wide-
spread disaster
scenes
– Does not depend
on communication
and less on
transportation
11. Patient Categories
1. Those who will die no matter what
2. Those who will do well no matter what
we do
3. Those who will derive long-term benefit
from acute intervention
Early identification of #3 important
– Others benefit from comfort care
12. START Triage
Simple Triage and Rapid Treatment
Designed to be performed by first
responders (paramedics)
Assumes personnel under a great deal of
stress
13. START Triage
Rapid method to perform INITIAL triage
Utilizes respiratory rate, palpable pulse,
and mental status (ability to follow
commands)
Begins by asking all that can walk to
move away from triage officer
Assess using START those that remain
14. START Triage
GREEN: those who are able to get up and
walk away
RED: those with respiratory compromise
(require airway assistance or have a
respiratory rate 30), no palpable pulse at
the wrist (but are breathing), or unable to
follow commands
YELLOW: those who are not red but can‘t
walk
BLACK: dead
16. SAVE Triage
Secondary Assessment of Victim
Endpoint
All patients with at least a 50% chance of
survival using available resources get
care
– Patient assessed by SAVE
methodology in order of priority
determined by START
19. SAVE Triage
Areas of Assessment
Vital Signs
Airway
Chest
Abdomen
Pelvis
Spine
Extremities
Skin
Neurologic Status
Mental Status
20. 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
21. SAVE Triage Categories
Periodic assessment of all categories is
important
Patients may move from one area to
another
22. SAVE Triage Guidelines
Crush Injury to Lower Extremity
– Patients are assessed using the MESS
score
– Score of 7 or more: amputate
– Score less than 7: attempt limb
salvage
23. SAVE Triage Guidelines
Head Injury (adults)
– Use the Glascow Coma Score (GCS)
– Score 8 or above: treat
Better than 50% chance of a normal
or good neurologic recovery
– Score 7 or less: comfort care only
24. SAVE Triage Guidelines
Burn Injury: less than 50% chance of
survival
– 70% TBSA burn
– Age > 60 with inhalational injury
– Age < 2 with 50% TBSA burn
– Age > 60 with 35% TBSA burn
Comfort care only
25. SAVE Triage Guidelines
Abdominal Injury
– No data to guide evaluation
– 4 ml/kg hypertonic saline X 2
– If no response, comfort care only
– Role of handheld ultrasound?
26. Initial Assessment: START
Case #1
61 year old male pulled from smoking
building. Complaining of shortness of
breath.
RR =28
Wrist Pulse: palpable
Mental Status: follows commands
START Category: yellow (delayed)
Treatment: nothing
27. Initial Assessment: START
Case #2
30 year old male found with bleeding head
wound
RR =22
Wrist Pulse: palpable
Mental Status: unresponsive
START Category: red (immediate)
Treatment: apply pressure to stop
bleeding
28. Initial Assessment: START
Case #3
20 year old female complaining of
crushed lower extremity
RR =20
Wrist Pulse: palpable
Mental Status: follows commands
START Category: yellow (delayed)
Treatment: nothing
29. Initial Assessment: START
Case #4
3 year old female found not breathing
RR =agonal
Wrist Pulse: palpable
Mental Status: unresponsive
– Open airway and give 15 seconds of
ventilation. No change in respirations.
START Category: black (dead)
30. Secondary Assessment: SAVE
Case #2
30 year old male found with bleeding head
wound
START Category: red (immediate)
EXAM: neurologic status
– Does not open eyes, does not speak,
and withdraws to pain
– GCS = 6
SAVE Category: black (unsalvageable)
31. Secondary Assessment: SAVE
Case #1
61 year old male pulled from smoking
building. Complaining of shortness of
breath.
START Category: yellow (delayed)
EXAM: airway
– Singed nasal hairs and eyebrows.
Coughing up carbonaceous material.
Wheezing. No skin burns
SAVE Category: black (unsalvageable)
32. Secondary Assessment: SAVE
Case #3
20 year old female complaining of
crushed lower extremity
START Category: yellow (delayed)
EXAM: extremities
– Crushed left leg. Massive tissue
avulsion and hemorrhage. Limb numb.
Patient is pale.
– MESS = 8 or 9
SAVE Category: red (immediate)