# START Triage...



## EMTecBOB (Dec 24, 2009)

In START Triage, a victim is tagged red if they are breathing more than 30 per minute. - Why is this considered an "immediate" threat to life?


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## dhaage (Dec 24, 2009)

Because it is outside the normal range of respirations for an adult, which could indicate a soon to be life threatening problem with breathing.


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## JPINFV (Dec 24, 2009)

Think for a minute. Why do you breath? How do you breath? How does the molecules exchanged during breathing get moved around the body? How does the body compensate if any of that goes wrong?


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## EMTecBOB (Dec 24, 2009)

I understand that it is out of norm. I was just wondering why someone with no other obvious signs of life threats, would be tagged red just because they were breathing fast. After all, if I had just been in a traumatic event, I might be breathing fast without a dent in the fender.


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## dhaage (Dec 24, 2009)

Because at the point that you are assessing them, they have already failed at being able to walk and do not qualify for a green tag, there is going to be something else going on with them.


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## akflightmedic (Dec 24, 2009)

EMTecBOB said:


> I understand that it is out of norm. I was just wondering why someone with no other obvious signs of life threats, would be tagged red just because they were breathing fast. After all, if I had just been in a traumatic event, I might be breathing fast without a dent in the fender.



Would you still be breathing that fast 6-10 minutes (urban...much longer for rural or remote) later when EMS arrives? If so, then there is a problem, hence the red tag.


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## Summit (Dec 24, 2009)

START is kinda silly. Just think of it as 
"insufficient respiration" (rate and/or depth) = RED
Because you might not really be stopping to take a rate in a real triage situation.

Also, peripheral cap refill is a horrible measure for most patients in many environments. Try central cap refill (like gums).


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## EMTecBOB (Dec 24, 2009)

OK...it is now making more sense to me. And you guys make great points....not walking, breathing fast? Could be something really bad going on, after all, even shock kills. 

What got me to thinking about this was the fact that > 30/min respiration's seemed to be so arbitrary. But I was not thinking about it in the context of a traumatic event with a significant MOI.   

Thanks guys

Keep warm, keep safe, don't keep the EMT's awake.


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## Shishkabob (Dec 24, 2009)

EMTecBOB said:


> after all, even shock kills.



Everyone dies from shock.


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## EMTecBOB (Dec 24, 2009)

Linuss said:


> Everyone dies from shock.




That is a good observation. If I remember correctly, on my dads full death certificate, it listed step by step what caused death...ending in cardiogenic shock. - It all comes down to the pump stopping, or having nothing left to pump...which also causes it to stop.


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## Shishkabob (Dec 24, 2009)

Well that just made me depressed.


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## EMTecBOB (Dec 24, 2009)

It used to get me too, now I just think about all the good times. - BTW, hug em while you got em.


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## MusicMedic (Dec 24, 2009)

EMTecBOB said:


> It used to get me too, now I just think about all the good times. - BTW, hug em while you got em.



Yeah i agree, my dad died of a suspected MI earlier this year

we didnt get an autopsy so they didnt list the steps of what happened


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## JPINFV (Dec 24, 2009)

EMTecBOB said:


> What got me to thinking about this was the fact that > 30/min respiration's seemed to be so arbitrary.



Any hard cutoff level is, by its nature, arbitrary.


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## Ediron (Dec 24, 2009)

Because the patient is breathing at a rapid rate, and not enough oxygen is 
reaching the alveoli. Therefore inadequate oxygen exchange


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## zmedic (Dec 25, 2009)

There is a reason that START is used, because it is a standard system so that everyone is trained the same way. You can disagree with their exact criteria, but if that's the system that your service is using you better be doing it by the book. You don't want to be in court explaining "oh, I know START uses cap refill, but I decided to use my own way of checking perfusion for making the patient a red." People straying from the protocols is why there is such variety in how the exact same patients are triaged by different people. 

The protocols are cut and dried and simple for a reason, so you don't have to think much when you have 30 injured an are trying to assess each in less than a minute. 

Oh, and keep count of how many of each color you've tagged. It pisses me off when my students just tagged 20 people and have no idea how many reds and yellows they have. (The others I'm less worried about. Greens are "do I need a bus or two" and there will be plenty of  time to count the black tags later.


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## zmedic (Dec 25, 2009)

There is a reason that START is used, because it is a standard system so that everyone is trained the same way. You can disagree with their exact criteria, but if that's the system that your service is using you better be doing it by the book. You don't want to be in court explaining "oh, I know START uses cap refill, but I decided to use my own way of checking perfusion for making the patient a red." People straying from the protocols is why there is such variety in how the exact same patients are triaged by different people. 

The protocols are cut and dried and simple for a reason, so you don't have to think much when you have 30 injured an are trying to assess each in less than a minute. 

Oh, and keep count of how many of each color you've tagged. It pisses me off when my students just tagged 20 people and have no idea how many reds and yellows they have. (The others I'm less worried about. Greens are "do I need a bus or two" and there will be plenty of  time to count the black tags later.


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## Summit (Dec 25, 2009)

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.


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## zmedic (Dec 25, 2009)

That's not what  said. If start doesn't fit well with your local situation your medical director should chose something else. But if as a department it's been decided that you are going to do START, than you should be doing start as it is written. 

It's percisely because things get "fuzzy" at an MCI that systems like START have very clear algorythms, because you don't have to think as much or make as many on the fly decisions. Yes, things will get messed up, and people will tweak the triage enough on their own. But I don't think people should be planning on going into a future MCI and making up their own triage criteria on the fly.


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## CAOX3 (Dec 26, 2009)

Not familiar with STAT triage just had to look it up.

In my experience in MCIs respiratory rate of 30 isnt usually a reliable finding and capillary refill never is.


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## DV_EMT (Dec 27, 2009)

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


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## Lifeguards For Life (Dec 27, 2009)

*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.


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## RescueYou (Dec 31, 2009)

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.


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## redcrossemt (Jan 4, 2010)

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...


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## redcrossemt (Jan 4, 2010)

RescueYou said:


> Training is learning the rules, experience is learning the exceptions
> 
> The stereo must always be louder than the siren
> 
> ...



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


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## zmedic (Jan 7, 2010)

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.


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## Dean (Jan 10, 2010)

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


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## Dean (Jan 10, 2010)

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


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## redcrossemt (Jan 10, 2010)

Summit said:


> 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?


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