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Pediatric Multicasualty Incident Triage. Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Miami-Dade Fire Rescue FL-5 DMAT. Topics. Triage Categories. What is Triage?. Triage Tools. What is Triage?. “Triage” means “to sort”

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pediatric multicasualty incident triage

Pediatric Multicasualty Incident Triage

Lou E. Romig MD, FAAP, FACEP

Miami Children’s Hospital

Miami-Dade Fire Rescue



Triage Categories

What is Triage?

Triage Tools

what is triage
What is Triage?
  • “Triage” means “to sort”
  • Looks at medical needs and urgency of each individual patient
  • Sorting based on limited data acquisition
  • Also must consider resource availability
military vs civilian triage
Military vs. Civilian Triage

Priority is to get as many soldiers back into action as possible.

Priority is to maximize survival of the greatest number of victims.

military vs civilian triage5
Military vs. Civilian Triage
  • Military model

Those with the least serious wounds may be the first treatment priority

  • Civilian model

Those with the most serious but realistically salvageable injuries are treated first

military vs civilian triage6
Military vs. Civilian Triage

In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as the lowest priority.

ethical justification
Ethical Justification

This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis.

A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine,

why are resources important in triage
Why are Resources Important in Triage?
  • Disaster is commonly defined as an incident in which patient care needs overwhelm local response resources.
  • Daily emergency care is not usually constrained by resource availability.

Daily Emergencies

Do the best for each individual.

Disaster Settings

Do the greatest good for the greatest number. Maximize survival.

primary disaster triage
Primary Disaster Triage
  • Goal: to sort patients based on probable needs for immediate care. Also to recognize futility.
  • Assumptions:
    • Medical needs outstrip immediately available resources
    • Additional resources will become available with time
primary disaster triage13
Primary Disaster Triage
  • Triage based on physiology
    • How well the patient is able to utilize their own resources to deal with their injuries
    • Which conditions will benefit the most from the expenditure of limited resources
secondary disaster triage
Secondary Disaster Triage
  • Goal: to best match patients’ current and anticipated needs with available resources.
  • Incorporates:
    • A reassessment of physiology
    • An assessment of physical injuries
    • Initial treatment and assessment of patient response
    • Further knowledge of resource availability
secondary triage tools
Secondary Triage Tools
  • Goal is to distinguish between:
    • Victims needing life-saving treatment that can only be provided in a hospital setting.
    • Victims needing life-saving treatment initially available on scene.
    • Victims with moderate non-life-threatening injuries, at risk for delayed complications.
    • Victims with minor injuries.
secondary triage tools16
Secondary Triage Tools
  • There is no widely recognized tool in the US that addresses secondary MCI triage and also transport strategies.
  • California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint)
  • Many EMS systems use local trauma triage criteria.
tertiary disaster triage
Tertiary Disaster Triage
  • Goal: to optimize individual outcome
  • Incorporates:
    • Sophisticated assessment and treatment
    • Further assessment of available medical resources
    • Determination of best venue for definitive care

“Continuous Integrated Triage”

Primary Triage

Secondary Triage

Tertiary Triage

triage categories20
Triage Categories
  • Red:

Life-threatening but treatable injuries requiring rapid medical attention

  • Yellow:

Potentially serious injuries, but are stable enough to wait a short while for medical treatment

triage categories21
Triage Categories
  • Green:

Minor injuries that can wait for longer periods of time for treatment

  • Black:

Dead or still with life signs but injuries are incompatible with survival in austere conditions

the smart triage tape
The Smart Triage Tape®
  • Developed in Great Britain
  • Proprietary, TSG Associates
  • Length-based pediatric MCI triage tape
  • Age-adjusted physiologic parameters
  • In use in Europe, Africa and some states in the US

basic disaster life support
Basic Disaster Life Support
  • National Disaster Life Support Education Consortium, via Medical College of Georgia’s Center of Operational Medicine
  • Endorsed by the American Medical Association
basic disaster life support30
Basic Disaster Life Support
  • MASS Triage
    • Move
    • Assess
    • Sort
    • Send
  • ? Assessment guidelines
  • ? Pediatric considerations
salt triage
SALT Triage
  • Sort, Assess, Life-saving Interventions, Treatment/Transport
  • CDC grant project to standardize MCI triage in the US
  • Early in development
  • Derived from existing tools
  • Includes pediatric considerations
salt triage33
SALT Triage

Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline

E. Brooke Lerner, PhD, Richard B. Schwartz, MD, Phillip L. Coule, MD, et al


sacco triage method
Sacco Triage Method®
  • Proprietary tool, ThinkSharp Inc.
  • Only tool based on outcome data
  • 12 triage categories
  • Available software package for transport planning based on patient and resource info
  • Includes pediatric data and age adjustments
stm sample patient prioritization
STM Sample Patient Prioritization

Scene Characterization Triage Priority Order

Multiple casualty; resource levels stressed 4 5 6 3 2 7 1 8+ 2

Estimate about an hour or less to clear the scene.

Large multiple casualty or small mass casualty 5 6 7 8 4 9 3 2 1 9+

requiring staged resources Estimate 1½ to 2½

hours to clear the scene

Mass casualty; resources overwhelmed Estimate 3 or more hours to clear the scene 6 7 8 5 9 10 4 3 2 1 11+

israeli triage practice
Israeli Triage Practice
  • Little to no triage done on-scene
  • “Save and run” philosophy
  • Very hazardous scenes
  • Reds to closest hospital
  • Nearest hospital becomes triage center?
israeli triage practice39
Israeli Triage Practice
  • Uses physicians as triage officers
  • Accuracy of physician triage called into question
  • Metropolitan Israeli hospitals may be more uniformly capable of caring for trauma victims than in many areas of the US
the best tool
The Best Tool?

No MCI primary triage tool has been validated by outcome data from MCIs.

Mass-casualty triage: Time for an evidence-based approach. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL,

Hsu EB

Prehospital Disast Med 2008;23(1):3–8.

the best tool41
The Best Tool?

It’s likely that no existing MCI triage tool is suitable for use for all types of incidents.

start jumpstart
  • Neither clinically validated
  • Evidence accumulating against validity and/or inter-rater reliability
    • Comparison of paediatric major incident primary triage tools. L A Wallis1, S Carley2Emergency Medicine Journal 2006;23:475-478
      • Smart Tape and Care Flight more sensitive than START and JS
      • No tool had > 48% sensitivity for critical patients
  • Simple Triage And Rapid Treatment
  • Developed jointly by Newport Beach (CA) Fire and Marine Dept. and Hoag Hospital
  • Gold standard for field adult multiple casualty (MCI) triage in the US and numerous countries around the world
  • Utilizes the usual four triage categories
  • Used for Primary Triage
  • Used on-scene and at hospitals
  • Recommended for patients > 100 lbs
start triage
START Triage


Under 30/min




Over 30/min

Cap refill

> 2 sec

Cap refill

< 2 sec.

Position Airway









Dead or



Failure to follow

simple commands

Can follow

simple commands








Can do

jumpstart pediatric mci triage
JumpSTART Pediatric MCI Triage
  • Developed by Lou Romig MD, FAAP, FACEP
  • Now in widespread use throughout the US and Canada
  • Being taught in Japan, Germany, Switzerland, the Dominican Republic, Africa, Polynesia
national committee on management of pediatric mcis 2006
National Committee on Management of Pediatric MCIs, 2006

JumpSTART recommended for prehospital use throughout Israel

Prehospital Response and Field Triage in Pediatric Mass Casualty Incidents: The Israeli Experience

Yehezkel Waisman, MD, Lisa Amir, MD, MPH, Meirav Mor, MD, et al Clin Ped Emerg Med 7:52-58, 2006

jumpstart pediatric mci triage50
JumpSTART Pediatric MCI Triage
  • The physiologic parameters used in START are not suitable for all ages of children
    • Walking
    • Respiratory death vs cardiac death
    • Respiratory rates
    • Mental status assessment
jumpstart age
JumpSTART: Age

The ages of “tweens and teens” can be hard to determine so the current recommendation is:

If a victim appears to be a child, use JumpSTART.

If a victim appears to be a young adult, use START.


Patients who are able to walk are assumed to have stable, well-compensated physiology, regardless of the nature of their injuries or illness.

secondary triage
Secondary Triage
  • All green patients must be individually assessed in secondary triage.
    • Assess physiology
    • Assess injuries
    • Assess probability of deterioration
    • Assess needs vs. resource availability
secondary triage56
Secondary Triage
  • Some children may be carried to the green area by others. They have not proven their physiologic stability by performing the complex act of walking.
  • These children should be assessed first among all those in the green area.
Position the upper airway of the apneic child.
  • If they start to breathe, tag them as
If the child doesn’t start breathing with upper airway opening, feel for a pulse.
  • If no pulse is palpable, tag the patient as
If the patient has a palpable pulse, give 5 mouth-to-barrier breaths to open the lower airways. Tag as below, depending on response to ventilations.


Move on to next assessment if respiratory rate is 15-45 breaths/minute.
  • If respiratory rate is <15 or >45, tag the patient as
If the child’s pulse is palpable, move on to the next assessment.
  • If no palpable pulse, tag the patient as
If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as
  • If patient is alert, responds to voice or appropriately responds to pain, tag as
modification for nonambulatory children
Modification for Nonambulatory Children
  • Children developmentally unable to walk due to young age or developmental delay
  • Children with chronic disabilities that prevent them from walking
modification for nonambulatory children65
Modification for Nonambulatory Children
  • For nonambulatory children, assess using the JumpSTART algorithm.
  • If pt meets any red criteria tag as
modification for nonambulatory children66
Modification for Nonambulatory Children
  • If patient meets yellow criteria and has significant external signs of injury, tag as
  • If patient meets yellow criteria and has no significant external signs of injury, tag as
certainties about mci triage
Certainties about MCI Triage
  • Organization is a good thing in a disaster
  • Triage tools must help match limited resources to an abundance of needs
  • Physiologic tools should suit physiologic differences
  • Triage tools should be kept as simple as possible and practiced often
thank you
Thank You!