Review of START and Review of START and JumpStart TriageJumpStart Triage

Condell Medical Center EMS SystemCondell Medical Center EMS SystemECRN Disaster Training ModuleECRN Disaster Training Module

March 2009March 2009

Material development by Illinois EMSC and children’s Memorial Material development by Illinois EMSC and children’s Memorial Hospital. Modified for CMC staff by Sharon Hopkins, RN, BSN, Hospital. Modified for CMC staff by Sharon Hopkins, RN, BSN,

EMT-PEMT-P

Rationale for the PacketRationale for the Packet

Without training you will be ill-prepared to Without training you will be ill-prepared to respond to a disaster/multiple patient incidentrespond to a disaster/multiple patient incident

START and JumpSTART triage is the triage START and JumpSTART triage is the triage process in the Region X Multiple Patient Plan process in the Region X Multiple Patient Plan for disaster managementfor disaster management

This training is to review the triage processes This training is to review the triage processes referred to as START for the adult and referred to as START for the adult and JumpStart for the pediatric patientJumpStart for the pediatric patient

This triage is usually performed in the field but This triage is usually performed in the field but can be adapted to be performed in the EDcan be adapted to be performed in the ED

Pediatric Disaster Triage Utilizing the JumpSTART Method

March 2009

Development of this educational program was sponsored by Illinois EMSC and Children’s Memorial Hospital and supported in part by an Assistant Secretary for Preparedness and Response (ASPR) grant. This program was adapted from a module developed through HRSA funding by the Chicago Department of Public Health.

Program adapted to Condell ECRN CE by Sharon Hopkins, RN, BSN 3.09

DisclaimerDisclaimerNOTE: NOTE: This slide set and all related training information provided in this session is This slide set and all related training information provided in this session is

in accordance with current practice at the time that this program was in accordance with current practice at the time that this program was developed. developed.

This program was developed utilizing federal grant funding, therefore all This program was developed utilizing federal grant funding, therefore all training materials are considered under public domain and can be training materials are considered under public domain and can be utilized by others in the conduction of similar educational programs, utilized by others in the conduction of similar educational programs, provided there is acknowledgement of the source of these materials. provided there is acknowledgement of the source of these materials. When using these training materials, please include appropriate When using these training materials, please include appropriate acknowledgements which can be found on the last slide in this acknowledgements which can be found on the last slide in this presentation.presentation.

These training materials are available on the Illinois EMSC websiteThese training materials are available on the Illinois EMSC website

http://www.luhs.org/emschttp://www.luhs.org/emsc

ObjectivesObjectives

Review unique pediatric issues in a disaster Review unique pediatric issues in a disaster situationsituation

Review incorporating pediatrics into your disaster Review incorporating pediatrics into your disaster planningplanning

Review triage and the pediatric patientReview triage and the pediatric patient

Review START and JumpSTART triageReview START and JumpSTART triage

Complete triage scenario exercises in the packetComplete triage scenario exercises in the packet

Complete the quiz with a score of 80% or betterComplete the quiz with a score of 80% or better

““That That Won’t Won’t Happen in Happen in My My BackyardBackyard””

DisasterDisaster

“ “A medical disaster occurs when the A medical disaster occurs when the destructive effects of natural or man destructive effects of natural or man made forces overwhelm the ability of a made forces overwhelm the ability of a given area or community to meet the given area or community to meet the demand for health care.”demand for health care.”

ACEP Policy Statement June 2000ACEP Policy Statement June 2000

Mass Casualty IncidentMass Casualty Incident Any incident in which there are more Any incident in which there are more patientspatients than than rescuers rescuers withwith inadequate resources inadequate resources to immediately to immediately

care for themcare for them

Natural DisastersNatural Disasters

EarthquakeEarthquake FloodFlood Snow/ice stormSnow/ice storm TornadoesTornadoes OthersOthers

At least 19 dead, including 8 at the high school as At least 19 dead, including 8 at the high school as tornadoes rip through the South.tornadoes rip through the South.

March 2, 2007March 2, 2007

Enterprise, AlabamaEnterprise, Alabama

Natural Disasters can involve pediatric patients

Terrorist eventsTerrorist events

ArsonArson BombingsBombings ShootingsShootings Use of chemical, Use of chemical,

biological or nuclear biological or nuclear agentsagents

The Old Way of The Old Way of Thinking…Thinking…

Kids wereKids were

secondary victimssecondary victims

of terrorism andof terrorism and

inadvertentlyinadvertently

targetedtargeted

The new way of thinking …

Photo courtesy of Charles H Porter IV

Children may be

intentionally targeted

Are you prepared?

Illinois DemographicsIllinois Demographics

Illinois is the 5Illinois is the 5thth most populous state with a most populous state with a population of 12.7 millionpopulation of 12.7 million

Over 3 million children <18 years of ageOver 3 million children <18 years of age

900,000 are age five and younger.900,000 are age five and younger.

Percent of Illinois children <18 y/o increased Percent of Illinois children <18 y/o increased 10% between 1990 - 200010% between 1990 - 2000

In the event of a disaster or terrorist event, In the event of a disaster or terrorist event, children would be one of our most vulnerable children would be one of our most vulnerable populations populations

Basic Pediatric Basic Pediatric DifferencesDifferencesAirwayAirway Mouth and nose are smaller Mouth and nose are smaller

More easily obstructedMore easily obstructed Infants are nose breathers so secretions Infants are nose breathers so secretions

can be a major issuecan be a major issue Trachea is much shorterTrachea is much shorter

ETT can be displaced easier ETT can be displaced easier Narrow AirwaysNarrow Airways

Easily obstructed Easily obstructed DiaphragmDiaphragm

Infants depend on diaphragm to breathe Infants depend on diaphragm to breathe so abdominal distention can be so abdominal distention can be problematicproblematic

Oral explorersOral explorers Germs with feetGerms with feet

Large Head = Risk of head injury

Large Body Surface area = hypothermia

Large unprotected intraabdominal organs =

Risk liver, spleen & bowel injury

Vulnerability of Children: Vulnerability of Children: Anatomic & Physiologic IssuesAnatomic & Physiologic Issues

Children are particularly vulnerable to Children are particularly vulnerable to aerosolized biological or chemical agents aerosolized biological or chemical agents and radiationand radiation Some agents (e.g., Sarin and Chlorine and Some agents (e.g., Sarin and Chlorine and

radiation) are heavier than air and radiation) are heavier than air and accumulate close to the ground—in accumulate close to the ground—in breathing zone of children.breathing zone of children.

Children have faster ventilatory rates than Children have faster ventilatory rates than adultsadults

Inhale larger doses of the substance in the Inhale larger doses of the substance in the same period of time. same period of time.

Vulnerability of Children: Vulnerability of Children: Anatomic & Physiologic IssuesAnatomic & Physiologic Issues

Thinner skin and proportionately greater Thinner skin and proportionately greater Body Surface Area (BSA)Body Surface Area (BSA) Increased risk for hypothermia during field Increased risk for hypothermia during field

decontamination and treatmentdecontamination and treatment Increased susceptibility to chemical agentsIncreased susceptibility to chemical agents

Vesicating agents (Nitrogen/Sulfur Mustard, Vesicating agents (Nitrogen/Sulfur Mustard, Lewisite)Lewisite)

Nerve agents (Sarin, VX, Tabun, Soman)Nerve agents (Sarin, VX, Tabun, Soman) Irritants and corrosives (chlorine, ammonia, Irritants and corrosives (chlorine, ammonia,

phosgene)phosgene) Increased susceptibility to infectionsIncreased susceptibility to infections

NewbornsNewborns Children with chronic illnessesChildren with chronic illnesses

Vulnerability of Children: Vulnerability of Children: Anatomic & Physiologic Anatomic & Physiologic IssuesIssues

A child’s condition can rapidly go from stable to life-A child’s condition can rapidly go from stable to life-threatening threatening Children have smaller circulating blood volumes Children have smaller circulating blood volumes

than adults. than adults. They have less blood and fluid reservesThey have less blood and fluid reserves

More vulnerable to the effects of agents that produce More vulnerable to the effects of agents that produce vomiting and/or diarrhea -- can become dehydrated vomiting and/or diarrhea -- can become dehydrated fasterfaster

Blood/fluid loss can lead to irreversible shock or deathBlood/fluid loss can lead to irreversible shock or death More sensitive to changes in body temperatureMore sensitive to changes in body temperature Higher basal metabolic and cellular growth ratesHigher basal metabolic and cellular growth rates

Increased susceptibility to radiation, chemical agentsIncreased susceptibility to radiation, chemical agents Increased leukemia and cancer risk to radiation Increased leukemia and cancer risk to radiation

exposed children age < 5y/oexposed children age < 5y/o

Vulnerability of Children : Vulnerability of Children : Developmental Developmental ConsiderationsConsiderations Can’t anticipate, recognize or flee from Can’t anticipate, recognize or flee from

dangerous situationsdangerous situations Fear of strangers – inability to cooperate or Fear of strangers – inability to cooperate or

communicate with officials/providerscommunicate with officials/providers Family separation – unaccompanied minorsFamily separation – unaccompanied minors Sensitive to emotional state of parentsSensitive to emotional state of parents Children, Terrorism & Disasters ToolkitChildren, Terrorism & Disasters Toolkit

(AAP) (AAP) at at www.aap.orgwww.aap.org further identifies these further identifies these

vulnerabilitiesvulnerabilities

Decon ConsiderationsDecon Considerations Unlikely to be cooperativeUnlikely to be cooperative

Will be frightened of process and staff Will be frightened of process and staff in protective gearin protective gear

Hypothermia riskHypothermia risk Slippery when wetSlippery when wet How best to get them through the How best to get them through the

decon shower systemdecon shower system Laundry basketsLaundry baskets Car seats with padding removed. Car seats with padding removed.

Strap them in.Strap them in. Hospital plastic bassinettesHospital plastic bassinettes Stretcher or conveyor systemStretcher or conveyor system

Strip them, including the diaper!Strip them, including the diaper!

““Hello. Come with me. I’m going Hello. Come with me. I’m going to take you thru this shower over to take you thru this shower over here”here”

Decon ConsiderationsDecon Considerations

Warm WaterWarm Water High Volume/Low PressureHigh Volume/Low Pressure

Keeping the family unit Keeping the family unit together as much as possibletogether as much as possible

How will they hear you?How will they hear you? Showering process will take Showering process will take

more time with childrenmore time with children Identification issuesIdentification issues

Lessons learnedLessons learned

Decontamination of kids is “not a fun Decontamination of kids is “not a fun time”time”

Decon brushes can be rough on skinDecon brushes can be rough on skin Blankets, booties and towels work wellBlankets, booties and towels work well Age specific decision treeAge specific decision tree Use ink markers to write directly on skin Use ink markers to write directly on skin

to identifyto identify

EMS systems need plans to establish communication and restore unity of families

Pediatric IdentificationPediatric Identification

Kids come with Kids come with ParentsParents

You can find the CHAD sticker order form at www.dot.il.gov

1. Using the tool bar; select Doing Business

2. From the drop-down menu select Forms

3. Click on Traffic Safety Forms4. Scroll down to the bottom5. Select TS 2268 Public

Information and Education Materials

6. Fax your completed form to (217) 557-5937 or mail it to Melissa Schaive, Illinois Department of Transportation

7. 3215 Executive Park Drive, Springfield, IL 62794

School identification

Pediatric IdentificationPediatric IdentificationSchool Identification Medical History

Children with Special Health Children with Special Health Care needs (CSHCN)Care needs (CSHCN)

Technology DependentTechnology Dependent VentilatorsVentilators G-TubesG-Tubes ShuntsShunts Insulin PumpsInsulin Pumps

Developmentally DisabledDevelopmentally Disabled Chronic DiseasesChronic Diseases ImmunocompromisedImmunocompromised Psychiatric/Behavioral IllnessesPsychiatric/Behavioral Illnesses

Children with Special Health Children with Special Health Care needs (CSHCN)Care needs (CSHCN)

18% (13.5 million) of U.S. kids 18% (13.5 million) of U.S. kids meet criteriameet criteria

Over 20,000 families in Illinois Over 20,000 families in Illinois receive services from the Division receive services from the Division of Specialized Care for Children of Specialized Care for Children (DSCC)(DSCC)

CSHCN are disproportionately poor CSHCN are disproportionately poor & socially disadvantaged& socially disadvantaged

Strong need for healthcare provider Strong need for healthcare provider education & awarenesseducation & awareness

Key Principles of Medical Key Principles of Medical CareCare

Conventional Medical CareConventional Medical CareThe objective of conventional medical care is to…The objective of conventional medical care is to…

Do the greatest good for the individual patient.Do the greatest good for the individual patient.

Disaster Medical CareDisaster Medical Care The key principle of disaster medical care is to…The key principle of disaster medical care is to…

Do the greatest good for the greatest number of patients.Do the greatest good for the greatest number of patients.

Briggs, S and Brinsfield, K (eds), Advanced Disaster Medical Response for Providers. Harvard Medical Briggs, S and Brinsfield, K (eds), Advanced Disaster Medical Response for Providers. Harvard Medical International, 2003.International, 2003.

TriageTriage

““To Sort”To Sort” Look at medical needs and Look at medical needs and

urgency of each individual patienturgency of each individual patient Triage in Daily EmergenciesTriage in Daily Emergencies

Do the best for each individualDo the best for each individual

Disaster TriageDisaster Triage Do the greatest good for the greatest Do the greatest good for the greatest

numbernumber Make an impossible task manageableMake an impossible task manageable

TriageTriage

Primary TriagePrimary Triage Triage that is performed at the scene or Triage that is performed at the scene or

point of first contact with patients.point of first contact with patients.

Secondary TriageSecondary Triage Triage that is performed after further Triage that is performed after further

intervention is provided. Usually done in a intervention is provided. Usually done in a medical sector.medical sector.

80% of casualties self or buddy transport to the closest hospital

Important Triage ConceptsImportant Triage Concepts

Helps to prioritize patients in a systematic Helps to prioritize patients in a systematic and organized fashionand organized fashion

Helps in resource allocationHelps in resource allocation Provides an Provides an objectiveobjective framework for framework for

stressful and emotional decisionsstressful and emotional decisions MCI (mass casualty incident) triage is MCI (mass casualty incident) triage is

different than daily triage, in both field different than daily triage, in both field and ED settingsand ED settings

MCI (Mass Casualty MCI (Mass Casualty Incident) TriageIncident) Triage

In order for MCI triage to work effectively, In order for MCI triage to work effectively, all victims must have equal all victims must have equal importance at the time of primary triage. importance at the time of primary triage.

No patient group can receive special No patient group can receive special consideration other than that dictated by consideration other than that dictated by their physiologic state. their physiologic state. This includes children!

Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com/

Triage CategoriesTriage Categories

REDRED - Immediate/emergent - Immediate/emergent

YELLOWYELLOW - Urgent - Urgent

GREENGREEN - Nonurgent - Nonurgent

BLACKBLACK- Dead/little to no hope of - Dead/little to no hope of survivalsurvival

RED YELLOW GREENBLACK

RED - ImmediateRED - Immediate

Severely injured but treatable injuries and able to be saved with relatively quick treatment and transport

ExamplesExamples Severe bleedingSevere bleeding ShockShock Open chest or abdominal Open chest or abdominal

woundswounds Emotionally out of controlEmotionally out of control

Yellow - DelayedYellow - DelayedInjured and unable to walk ontheir own. Potentially seriousinjuries but stable enough towait a short while for medicaltreatment ExamplesExamples

Burns with no respiratory distress

Spinal injuries Moderate blood loss Conscious with head

injuries

Green – Non-UrgentGreen – Non-Urgent

Minor injuries that can wait for a longer Minor injuries that can wait for a longer period of time for treatment.period of time for treatment.

May or may not be able to ambulateMay or may not be able to ambulate ExamplesExamples

Minor fracturesMinor fractures Minor bleedingMinor bleeding Minor lacerationsMinor lacerations

Black - DeceasedBlack - Deceased

Dead or obviously dying. May have signs of Dead or obviously dying. May have signs of life but injuries are incompatible with survival. life but injuries are incompatible with survival.

Handle based on local protocolsHandle based on local protocols ExamplesExamples

Cardiac arrestCardiac arrest Respiratory arrest with a pulseRespiratory arrest with a pulse Massive head injuryMassive head injury

Can be psychologically difficult to tag a child as Can be psychologically difficult to tag a child as blackblack

Review of START and Review of START and JumpSTART MCI Triage ToolsJumpSTART MCI Triage Tools

Photo courtesy of Miami Dade Fire Rescue

© Lou Romig MD, 2006. Used with permission.

STARTSTART SSimple imple TTriage and riage and RRapid apid TTransportransport Joint development by the Fire & Marine Joint development by the Fire & Marine

Department and Hoag Hospital in New Port Department and Hoag Hospital in New Port Beach, CaliforniaBeach, California

Gold standard for field adult MCI triage in U.S. Gold standard for field adult MCI triage in U.S. and numerous other countries and numerous other countries

Utilizes the standard four color triage Utilizes the standard four color triage categoriescategories

Used for primary triageUsed for primary triage More information at www.start-triage.comMore information at www.start-triage.com

START vs JumpSTART START vs JumpSTART TriageTriage

START triageSTART triage Used for the adult population (non-pediatric)Used for the adult population (non-pediatric)

JumpSTARTJumpSTART Used when the victim appears to be a childUsed when the victim appears to be a child Adult and pediatric patients do not share the Adult and pediatric patients do not share the

same normal values for vital signs hence the same normal values for vital signs hence the need for 2 different toolsneed for 2 different tools

At approximately age 8, the pediatric patient At approximately age 8, the pediatric patient is similar anatomically with the adult airwayis similar anatomically with the adult airway

ED TriageED Triage

Primary START or JumpSTART triage Primary START or JumpSTART triage does not have to be repeated at the point does not have to be repeated at the point of entry to the ED when patients are of entry to the ED when patients are transported by EMStransported by EMS

But, not all patients will come by EMSBut, not all patients will come by EMS Historically, we know patients will self-Historically, we know patients will self-

transporttransport Triage will be a valuable tool to perform Triage will be a valuable tool to perform

quick sorting when dealing with multiple quick sorting when dealing with multiple patients at one timepatients at one time

Understanding Field TriageUnderstanding Field Triage

The ED staff need to understand the The ED staff need to understand the triage performed in the fieldtriage performed in the field

Helps with the flow of continuity of careHelps with the flow of continuity of care If ED staff understand START and If ED staff understand START and

JumpSTART triage, they will understand JumpSTART triage, they will understand how EMS made the decisions they didhow EMS made the decisions they did

START and JumpSTART triage is a START and JumpSTART triage is a process that can be duplicated and process that can be duplicated and performed in the ED as needed – not all performed in the ED as needed – not all patients come by EMS!!! patients come by EMS!!!

START TriageSTART Triage This is just the 1This is just the 1stst process of triage process of triage It is meant to quickly and initially separate those It is meant to quickly and initially separate those

with life threatening injuries from the less with life threatening injuries from the less seriously wounded/illseriously wounded/ill

Secondary triage will allow retriage of a patient Secondary triage will allow retriage of a patient Patient may be placed into a different triage Patient may be placed into a different triage

category category Decision will be based on physiological Decision will be based on physiological

criteria criteria START triage attempts to remove the emotional START triage attempts to remove the emotional

reaction from the decision process reaction from the decision process

START TriageSTART Triage Start at the top of the algorithmStart at the top of the algorithm As soon as patient has been categorized, As soon as patient has been categorized,

stop assessment and move onto the next stop assessment and move onto the next patientpatient

Triage proceeds through a processTriage proceeds through a processCan patient get up and walk to triage area?Can patient get up and walk to triage area?Evaluate respirations (presence & rate)Evaluate respirations (presence & rate)Evaluate circulation (capillary refill)Evaluate circulation (capillary refill)Evaluate neurological status (obeys simple Evaluate neurological status (obeys simple

commands)commands)

START Triage Algorithm – START Triage Algorithm – Used For Adults Used For Adults

JumpSTART TriageJumpSTART Triage

Pediatric patients do not fit the START Pediatric patients do not fit the START triage criteriatriage criteria The youngest of our patients don’t walk yetThe youngest of our patients don’t walk yet Respiratory rates are differentRespiratory rates are different Circulation assessment is alteredCirculation assessment is altered Ability to follow directions changes with ageAbility to follow directions changes with age

START triage has been modified to be START triage has been modified to be able to be applied to this unique able to be applied to this unique populationpopulation

JumpSTART TriageJumpSTART Triage

Tool for pediatric mass casualty triageTool for pediatric mass casualty triage Provides objective frameworkProvides objective framework Based primarily on physiologic Based primarily on physiologic

differences between children and adultsdifferences between children and adults Designed for use in Disaster/MCI (mass Designed for use in Disaster/MCI (mass

casualty incident) eventscasualty incident) events

Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com

Differences Between Differences Between START and JumpSTARTSTART and JumpSTART

If positioning airway does not restart If positioning airway does not restart breathing, a ventilatory trial is administered breathing, a ventilatory trial is administered in JumpSTART (pediatrics)in JumpSTART (pediatrics)

Capillary refill is used to assess perfusion in Capillary refill is used to assess perfusion in START (adult) while peripheral pulse is used START (adult) while peripheral pulse is used in JumpSTART (pediatrics)in JumpSTART (pediatrics)

The ability to follow command is used to The ability to follow command is used to assess mental status in START (adult) while assess mental status in START (adult) while the AVPU scale is used in JumpSTART the AVPU scale is used in JumpSTART (pediatrics)(pediatrics)

JumpStartJumpStart In children, circulatory In children, circulatory

failure usually follows failure usually follows respiratory failure.respiratory failure.

Apnea may occur Apnea may occur relatively rapidly, relatively rapidly, rather than after a rather than after a prolonged period of prolonged period of hypoxia.hypoxia.

There may be a There may be a brief period when brief period when the child is apneic the child is apneic but not yet but not yet pulseless since the pulseless since the heart has not yet heart has not yet experienced experienced prolonged hypoxia. prolonged hypoxia. It is felt that It is felt that providing a brief providing a brief trial of ventilations trial of ventilations may help may help “jumpstart” their “jumpstart” their respirations.respirations.

The Pediatric PatientThe Pediatric Patient

What age?What age?

What age defines peds?

JumpSTART: AgeJumpSTART: AgeThe ages of “tweens and teens” can The ages of “tweens and teens” can

be hard to determine so the current be hard to determine so the current recommendation is:recommendation is:

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

If a victim appears to be a If a victim appears to be a young young adultadult, use START, use START

Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com

Triage – First StepTriage – First Step At a MCI there is panic and people are At a MCI there is panic and people are

looking for someone to “take charge”looking for someone to “take charge” The initial sorting is to determine who can The initial sorting is to determine who can

follow directions and walkfollow directions and walk Helpful is to call out for patients to self-Helpful is to call out for patients to self-

segregate (“if you can walk go over to …”) segregate (“if you can walk go over to …”) sending patients to a close but alternate sending patients to a close but alternate site (ie: the tree, the fence, the desk)site (ie: the tree, the fence, the desk)

Patients will be triaged and sorted again at Patients will be triaged and sorted again at this next sitethis next site

There is NO treatment at triageThere is NO treatment at triage

Using JumpSTART TriageUsing JumpSTART TriageAnyone that can Anyone that can hear me, get up hear me, get up

and walk if you can and walk if you can and come to…and come to…

The big treeThe big tree

Kids are good at following directions

START & JumpSTART: START & JumpSTART: Step 1Step 1

Patients who are able to walk are

assumed to have stable, well compensated physiology, regardless of the nature of their injuries or illness. Tag these patients GREEN

Walking & Carried Walking & Carried PatientsPatients These patients need to be triaged These patients need to be triaged

immediately in the new area immediately in the new area Think, no-one has really looked at or Think, no-one has really looked at or

evaluated these patientsevaluated these patients This group of patients were able to walk to This group of patients were able to walk to

an alternate site as a process to “thin” the an alternate site as a process to “thin” the group of patients that are potentially more group of patients that are potentially more critically injured/illcritically injured/ill

Start with the secondary triage process to Start with the secondary triage process to determine the color category (GCS, RR, determine the color category (GCS, RR, systolic B/P to get RTS)systolic B/P to get RTS)

JumpSTART: Step 2JumpSTART: Step 2Next begin triaging the remaining victimsNext begin triaging the remaining victims Position the upper airway of the apneic Position the upper airway of the apneic

child.child. If they start to breathe, tag them as REDIf they start to breathe, tag them as RED

JumpSTART: Step 3JumpSTART: Step 3If the patient has a palpable pulse, give 5 mouth-to-If the patient has a palpable pulse, give 5 mouth-to-barrier breaths to open the lower airways. Tag as barrier breaths to open the lower airways. Tag as below, depending on response to ventilations.below, depending on response to ventilations.

DO NOT CONTINUE TO

VENTILATE THE PATIENT.

RESUME TRIAGE DUTIES TO THE

OTHER PATIENTS.

BLACK

RED

JumpSTART: Step 4JumpSTART: Step 4

Assess the respiratory rate Assess the respiratory rate of the spontaneously of the spontaneously breathing child.breathing child.

JumpSTART: Step 4JumpSTART: Step 4 If respiratory rate is 15-45 breaths/minute, If respiratory rate is 15-45 breaths/minute,

move to perfusion assessment.move to perfusion assessment. If respiratory rate is <15 or >45, tag the If respiratory rate is <15 or >45, tag the

patient as REDpatient as RED

If the child’s pulse is palpable, move on to If the child’s pulse is palpable, move on to the next assessment.the next assessment.

If no palpable pulse, tag the patient as REDIf no palpable pulse, tag the patient as RED

JumpSTART: Step 5JumpSTART: Step 5

If patient is alert, responds to voice or If patient is alert, responds to voice or appropriately responds to pain/touch, tag as appropriately responds to pain/touch, tag as YELLOWYELLOW

If patient is inappropriately responsive to If patient is inappropriately responsive to pain, posturing, or unresponsive, tag as REDpain, posturing, or unresponsive, tag as RED

JumpSTART: Step 6JumpSTART: Step 6

AVPUAVPU AAlert/awake – not necessarily orientedlert/awake – not necessarily oriented VVerbal – responds to verbal stimuli before erbal – responds to verbal stimuli before

tactile/touch stimulitactile/touch stimuli You shout for the patient to open their eyes and their You shout for the patient to open their eyes and their

eyelids flicker or they open their eyeseyelids flicker or they open their eyes In non-verbal children, evaluate the cryIn non-verbal children, evaluate the cry

PPainful – responds to tactile stimuli; does ainful – responds to tactile stimuli; does notnot have to be painful stimuli but can be to touchhave to be painful stimuli but can be to touch A flicker of the eyelids is a positive responseA flicker of the eyelids is a positive response

UUnresponsive – there is absolutely no response nresponsive – there is absolutely no response large or smalllarge or small

Children who classify as Children who classify as “non-ambulatory”“non-ambulatory”

Infants who normally can’t walk yetInfants who normally can’t walk yet Children with developmental delayChildren with developmental delay Children with acute injuries which Children with acute injuries which

prevented them from walking prevented them from walking before before the the incident occurredincident occurred

Children with chronic disabilitiesChildren with chronic disabilities

CHILDREN MEETING THIS CRITERIA SHOULD BE EVALUATED USING THE JumpSTART ALGORITHM

BEGINNING WITH STEP 2 - BREATHING

All children carried to the GREEN area by other All children carried to the GREEN area by other ambulatory victims must be the first assessed ambulatory victims must be the first assessed by medical personnel in that area.by medical personnel in that area.

If patient meets any red criteria tag as REDIf patient meets any red criteria tag as RED

If patient meets yellow criteria and has significant If patient meets yellow criteria and has significant external signs of injury, tag as YELLOWexternal signs of injury, tag as YELLOW

If patient has no significant external signs of If patient has no significant external signs of injury, tag as GREENinjury, tag as GREEN

Modification for Modification for Nonambulatory Children (and Nonambulatory Children (and used for adults)used for adults)

SMART Triage SystemSMART Triage System System of triage System of triage

adopted by Illinoisadopted by Illinois Triage tags have Triage tags have

standard barcodes for standard barcodes for tracking patientstracking patients

Triage tags have a Triage tags have a unique folded design unique folded design that allows patients to that allows patients to be re-triaged to another be re-triaged to another color classification color classification without having to without having to replace the tagreplace the tag

Folding Triage TagsFolding Triage Tags

Tags will only show one color at a timeTags will only show one color at a time If the triage category changes, refold the If the triage category changes, refold the

card to reflect the new color status and card to reflect the new color status and replace into the plastic sleevereplace into the plastic sleeve

Triage cards are dynamic – they can Triage cards are dynamic – they can change if the patient changeschange if the patient changes

Space provided to write notes, record Space provided to write notes, record vital signs, GCS, tally RTS (revised vital signs, GCS, tally RTS (revised trauma score), treatmentstrauma score), treatments