S.T.A.R.T. Triage and MCI s

1. S.T.A.R.T. Triage and MCI�s Trinity EMS

2. S.T.A.R.T. Triage Simple Triage And Rapid Treatment

3. S.T.A.R.T. Triage Intended to be completed in about 30 seconds per patient.

4. S.T.A.R.T. Triage Begin by asking all patients who can walk (walking wounded) to get up and go to a collection point such as an ambulance or building. Those who can do this are: Conscious Able to follow commands Able to walk These patients will be tagged green for now and reassessed later.

5. S.T.A.R.T. Triage All patients left are either: Priority 2 (yellow) Priority 1 (red) Priority 0 (black)

6. S.T.A.R.T. Triage Start by making an initial sweep. Avoid patients who are obviously conscious. Only 3 treatments are done during this phase. Open an airway and insert an oropharyngeal airway. Apply pressure to bleeding. Elevate an extremity.

7. Assess Breathing Status First If patient is NOT breathing: Open the airway If patient does not begin breathing after airway is opened the patient will be tagged black (Priority 0).

8. Assess Breathing Status First If the patient STARTS BREATHING after the airway is opened. Tag as a priority 1 (red tag).

9. Assess Breathing Status First Breathing more than 30 times per minute? Tag as priority 1 (red tag) Breathing less than 30 times per minute? Tag as priority 2 (yellow tag)

10. Assess Radial Pulse If patient is UNRESPONSIVE, NOT BREATHING and has NO PULSE Tag as a priority 0 (black) If patient is BREATHING but has NO PULSE Tag as a priority 1 (red) If BREATHING and HAS A PULSE, go to the next step

11. Assess Level of Consciousness If ALERT Tag as a priority 2 (yellow) If ALTERED MENTAL STATUS Tag as a priority 1 (red)

12. Re-Triage Priority 3 Patients (green) Assess: Respiration Pulse Mental status

13. S.T.A.R.T. Summary Order the walking wounded to a collection point. They are considered Priority 3 (green).

14. S.T.A.R.T. Summary Assess the remaining patients for RPM (respirations, pulse, and mental status) and tag them as follows:

15. S.T.A.R.T. Summary Priority 1 (red) are patients who have: Altered mental status, or Absent radial pulse, or Respirations of > 30/minute

16. S.T.A.R.T. Summary Priority 2 (yellow) are patients who: Are alert, and� Have radial pulses present, and.. Have respirations < 30/minute

17. S.T.A.R.T. Summary Priority 0 (black) are patients who: Are not breathing (after an attempt to open the airway), or Have no pulse and are not breathing

18. S.T.A.R.T. Summary Re-triage all walking wounded.

19. Secondary Triage and Treatment As more personnel arrive at the scene they should be directed to assist with the completion of the initial triage. If this has been already completed, the EMT�s can initiate treatment.

20. Secondary Triage and Treatment Gather all patients into a Triage Sector

21. Secondary Triage and Treatment Treatment Sector (the area in which secondary triage takes place at an MCI). Each treatment sector should have its own Treatment Officer Treatment Officers oversee the triage and treatment within that sector. The Triage Officer should again triage the patients in that sector to determine the order in which they will receive treatment. Patients initially triaged may be upgraded or downgraded according to condition.

22. Transportation and Staging Logistics Once patients have been properly assessed and separated, and once treatment for the patients has been initiated according to their priority, consideration must be given to the order in which the patients will be transported to the hospital.

23. Staging Sector Staging Sector � area where ambulances are parked and other resources are held until needed. Ambulances will be called from the Staging Sector to transport patients.

24. Transportation Officer Transportation Officer � person responsible for communicating with sector officers and hospitals to manage transportation of patients to hospitals from an MCI. No ambulance should proceed to a treatment sector without being requested by a Transportation Officer and directed by the Staging Officer to proceed.

26. Incident Command Incident Command � the person or persons who assume overall direction of a large-scale incident. EMS Command � the senior EMS person on scene who oversees medical aspects of an MCI.

27. Scene Size-Up Arrive at the scene and establish EMS command. Put on proper identification. Do a quick walk through the scene and assess the number of patients, hazards, and degree of entrapment. Identify the number of patients, including the walking wounded, apparent priority of care, need for extrication, number of ambulances needed, etc. Get as calm and composed as possible to radio an initial scene report and call for additional resources.

29. EMS Response to Terrorism Terrorism � a violent act dangerous to human life, in violation of the criminal laws of the United States or any segment to intimidate or coerce a government, the civilian population or any segment thereof, in furtherance of political or social objectives. (U.S. Department of Justice definition)

30. Domestic Terrorism Terrorism directed against the government or population without foreign direction.

31. International Terrorism Terrorism that is foreign based or directed.

32. Types of Terrorism Incidents Chemical Biological Radiological Nuclear Explosive These are often referred to as Weapons of Mass Destruction (WMD�s)

33. Secondary Devices Destructive devices, such as bombs, placed to be activated after the initial attack and timed to injure emergency responders and others who rush in to help care for those injured in the initial attack.

34. OTTO Clues to a terrorist incident may be categorized as: Occupancy or location Type of event Timing of an event On scene warning signs

35. Occupancy or Location Symbolic and historical targets include those that represent some organization or event that is particularly offensive in the minds of extremist individuals or groups. ATF IRS WTC

36. Occupancy or Location Public buildings or assembly areas which can cause numerous casualties: Shopping malls Convention centers Entertainment venues Tourist destinations

37. Occupancy or Location Controversial businesses: Family planning clinics Nuclear facilities Fur manufacturers

38. Occupancy or Location Infrastructure systems: Bridges Power plants Phone companies Water treatment plants Mass transit Hospitals

39. Type of Event Explosions and/or incendiaries may raise suspicions of terrorist involvement especially when combined with location or occupancy factors. Incidents involving firearms when combined with other indicating factors. Non-trauma mass casualty incidents can indicate some type of chemical or other agent in the CBRNE.

40. Timing of Event April 19th � anniversary of the fire at the Branch Davidian Compound in Waco, Texas and the bombing of the Alfred P. Murrah building in Oklahoma City and has become a rallying point for anti-government extremists. National holidays are also possible target dates. Every 9/11, the government operates on heightened security.

41. On-Scene Warning Signs Unexplained patterns of illness or deaths. Odors and/or tastes. Unexplained signs and symptoms of skin, eye, or airway irritation. Unexplained vapor clouds, mists, and plumes. Fires with unusual behavior.

42. Harms Posed by the Threat TRACEM-P Thermal Radiological Asphyxiation Chemical Etiological Mechanical Psychological

43. Thermal Harm Harm caused by either extreme heat, such as that generated by burning liquids or metals, or extreme cold from cryogenic materials.

44. Radiological Harm Danger from alpha, beta, or gamma rays, generally produced by sources such as nuclear fuels, by-products of nuclear power production, or nuclear bombs.

45. Asphyxiation Harm Heavier than air gases such as argon, CO2, or chemical vapors in a confined space.

46. Chemical Harm Toxic or corrosive materials. These can include acids, caustics such as lye, and chemical toxins ranging from cyanides to nerve agents.

47. Etiological Harm Etiological concerns the causes of disease, comes from either disease-causing organisms such as bacteria and viruses or toxins derived from living organisms.

49. Mechanical Harm Physical trauma such as gunshot wounds, injury from bomb fragments or shrapnel.

50. Psychological Harm Terrorist events designed to create fear, invoke panic, reduce faith in government and cause terror. Incidences of depression, panic attacks and overall fear went up significantly in New York City after the attacks on 9/11.

51. Self Protection Time � minimize your time at a dangerous scene if possible. Distance � maximize your distance from the hazard area. Shielding � shielding can consist of vehicles, buildings, turnout gear, airpack, etc.

52. Weaponization Packaging or producing a material, such as chemical, biological, or radiological agent, so that it can be used as a weapon, for example by dissemination in a bomb detonation or as an aerosol sprayed over an area or introduced into a ventilation system.

53. Biological Agent Considerations Infectivity Virulence Toxicity Incubation period Transmissibility Lethality Stability

54. Protection Make an initial scene survey to determine security threats. Request protection via radio as soon as practical. Establish vehicle staging and triage/treatment areas in protected locations. Advise EMS command about protection/security concerns. Immediately report suspicious people or activities.