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A disaster involves multiple casualties that require more resources than are currently available. Triage is the system for quickly allocating the few medical resources.
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Patient Classification
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Patients are generally classified into one of four groups, depending upon the gravity of their medical problem: Immediate/Emergent (Red), Delayed/Urgent (Yellow), Minor/Non-urgent (Green), and Dead/Unsalvageable/Expectant (Black).
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Use easily recognized triage tags to avoid confusion, to accurately transmit information to other providers, and to avoid duplicated triage efforts. At least initially, premade (formal) triage tags may not be available. Informal tags include marking the patient with the generally accepted triage term, such as "Immediate" or "Delayed" or prominently tying on ribbons that are the triage color (e.g., Black is Expectant or Dead). Paper tags can be secured to the patient's clothes with a clothespin or safety pin and to an extremity with twine or a rubber band. Or write on the patient's forehead (easily seen) with an available marker, such as lipstick or a grease pencil.
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An alternative is to use the system the Japanese developed after the sarin subway attack. They use large colored clothespins not only to deal with the standard triage categories, but also to separate patients into those who need "wet" and "dry" decontamination after a chemical exposure. The Simple Triage and Rapid Decontamination of Mass Casualties with Colored Clothes Pegs (STARDOM-CCP) system uses inexpensive (~5 cents each, US) plastic clothespins in the typical triage colors: red, yellow, green, and black, as well as white for patients needing dry decontamination and blue for wet decontamination. Each patient gets a standard (welfare) and decontamination clothespin.
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The clothespins are large enough to be easily handled and recognized by responders in protective gear. The tags also survive wet decontamination, although the patients must often hold the pins after their clothes are removed. They recommend having a large sign on-site describing the triage process and colors.38 This type of triage tag can be quickly fashioned from standard clothespins and colored markers or paint.
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START (Simple Triage and Rapid Treatment)
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This system (Table 7-5) is designed for adult patients in the prehospital setting. Ideally, it allows providers to triage each patient in <30 seconds with the goal of finding the sickest, or "immediate," patients.39 This system (and those who use it) tends to overestimate ("over-triage") the severity of the patients evaluated. The Australians use an almost-identical system that they call Triage Sieve/Triage Sort.40
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For children, use JumpSTART (rather than START) for triage (Table 7-6), since children may normally have a respiratory rate >30/minute, may not follow commands (age and behavioral), and may have a "salvageable period" where they are apneic with a pulse.
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SAVE (Secondary Assessment of Victim Endpoint)41
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SAVE triage is designed for catastrophic disasters where there are limited transportation and medical resources. Transport may be delayed for days and prolonged when it occurs, and the patient's condition may deteriorate during the interim. This is a secondary (and tertiary) triage system and assumes that START triage has already been done. The system's priorities are based on the following equation:
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Value = (Benefit expected ÷ Resources required) × Probability of survival
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Patient Classification (in Order of Priority)
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- A. Those who will benefit from limited, immediate field intervention. Provide treatment based on two questions:
- 1. What is the patient's prognosis with minimal treatment?
- 2. What is the patient's prognosis with treatment using available resources?
- B. Those who will survive whether or not they receive treatment. Provide basic care, as available. Periodically reassess patient status.
- C. Those who will die regardless of treatment. Periodically reassess for improvement.
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Patients who are treated should be reclassified if they do not respond. Identify and mark those who would benefit most from transportation to a medical facility (should transportation become available).
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Hospital/Health Care Facility
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The Israelis use a "continuous" triage method to avoid under-identifying seriously injured patients. They have found that, although experienced triage officers may not be able to initially identify as many as 50% of the victims who suffered life-threatening injuries, the continuous triage system reduced that number to <4%.
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The Israeli method incorporates both the decisions made by the triage officers and the primary evaluations performed in the ED. The Israelis divide their ED into three sections according to the severity of injury: (a) mild, (b) moderate, and (c) severe. The decisions made by the triage officer help distribute the victims between the various sections. Once the casualty arrives at the appropriate site, medical personnel quickly perform primary and secondary surveys to identify the severely injured victims. The medical team refrains from using diagnostic resources on those whose exam suggests that they are not seriously injured. If a patient is identified as suffering a life-threatening injury, the trauma surgical team assumes care and transfers the patient to a secondary treatment site. This method has worked well in more than 20 multi-casualty incidents involving >600 patients, missing only 3.8% of those suffering from life-threatening injuries. These patients all had distracting injuries.42
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ICU Admission Triage in Disasters
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Initial Triage Criteria for ICU Treatment in Disasters/Resource Scarcity
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The most useful criteria for deciding which patients should not receive limited intensive care resources come from those developed for use in pandemics (Table 7-7). These patients should then receive standard medical and, when appropriate, palliative care.43–45
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