Simple triage and rapid treatment

START is an acronym for Simple Triage and Rapid Treatment, and is defined as being a method that first responders use to effectively and efficiently evaluate all of the victims during a mass casualty incident (MCI). ^[1] The first-arriving medical personnel will use a triage tool called a triage tag to categorize the victims by the severity of their injury. Once they have a better handle of the MCI, the on-scene personnel will call in to request for the additional appropriate resources and assign the incoming emergency service personnel their tasks. The victims will be easily identifiable in terms of what the appropriate care is needed by the triage tags they were administered. This method was developed in 1983 by the staff members of Hoag Hospital ^[2] and Newport Beach Fire Department^[3] located in California.

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Procedure

The whole evaluation process is generally conducted in 60 seconds or less. Once the evaluation is complete, the victims are labeled with one of the four triage categories.

• Minor delayed care / can delay up to three hours
• Delayed urgent care / can delay up to one hour
• Immediate immediate care / life-threatening
• Deceased victim is dead / no care required

Obviously these categories are only an indication of the desired treatment time; in a large scale emergency, Minor patients may be seen days later, if at all.

When medical personnel first arrive on the scene, they quickly assess the situation and do a call-out; they ask that any victim who is able to walk to separate themselves from non-ambulatory victims and to relocate to a certain area, or they may be asked to assist the medical personnel with the other non-ambulatory victims. These ambulatory victims are either uninjured or have minor injuries that no not need immediate care so they are labeled with a green tag (minor).

With the non-ambulatory victims, personnel assess their respiratory, circulatory, and neurological functions, and based on those conditions the patient is labeled with one of the three remaining triage categories (i.e. delayed, immediate, dead). The three functions to check, respiratory, circulatory, and neurological, can be remembered using the mnemonics RPM (respiration, perfusion or pulse, and mental status), or ABC (airway, bleeding, and shock).

The victim’s respiratory function is accessed first.

1. If the victim is not breathing, then the personnel will try to clear the airway and perform any airway maneuvers to get the victim breathing. If all attempts fail, then the victim is presumed dead, and thus tagged with the black label.
2. If the victim is breathing, then the personnel calculates the breathing rate.
   1. If the victim’s breathing rate is greater than 30 per minute, then the victim is tagged with a red label requesting immediate care because that is one of the primary signs for shock.
   2. If the victim’s breathing rate is less than 30 per minute, then perfusion will take place.
      1. During the perfusion phase, the victim’s pulse and circulatory function are checked.
         1. If the victim lacks a radial pulse, then immediate attention is required, and thus tagged with a red label.
         2. If the radial pulse is present, then the personnel evaluates the victim’s mental status.
            1. The personnel will ask the victim to follow simple commands.
               1. If the victim is successful, then he is labeled with the yellow tag; medical attention can be delayed to a recommended one hour.
               2. If the victim is not able to follow simple commands, then he is labeled with the red tag; immediate care is needed because the situation may be life threatening.

To check the victim’s circulatory function, a capillary refill test (blanch test) is conducted. Generally, the test is done at the tip of the finger. The personnel will apply pressure to the nail bed until it turns white.

Depending on the response time of how fast the blood flows back to the finger, the victim will be labeled with the yellow tag (medical attention can be delayed for up to an hour), or with the red tag (immediate care is needed).

1. If the blanch test took more than two seconds, then the victim needs immediate care.
2. If the blanch test took less than two seconds, then the mental status of the victim is evaluated.
   1. If the victim can follow simple commands, then he will be tagged with the yellow label, otherwise the red label.

Pediatric START

There have been organizations that have adopted the procedures of START and modified it to provide better treatment for children. Lou E. Roming MD, FAAP, FACEP, created JumpSTART, which is a derivative approach of START that caters to the needs of children during a MCI. The Utah Bureau of Emergency Medical Services developed a training program ^[4] for teaching JumpSTART. Psychological studies have shown that people react outside of their ordinary scope of behavior when placed in a stressful environment; children's bodies are more fragile than adults, and thus it is important to handle children with more care because they lack the experience compared to adults to take care of themselves until help arrives.

However the only Evidence based method for the triage of children is the Smart Tape. As the Smart Tape gives the rescuer a tool to do the job it allows them to be much more objective, vital when dealing with sick and injured children. The pocket sized tape is tough enough to cope with the worst environments. ^[5]

See also

• First responders

Notes

1. ^ http://www.asisonline.org/councils/fire/MCI.ppt]
2. ^ http://www.hoaghospital.org/
3. ^ http://www.city.newport-beach.ca.us/FMD/default.htm
4. ^ http://www.health.state.ut.us/ems/emsc/jumpstart.ppt (PowerPoint file)
5. ^ http://www.tsgassociates.co.uk/English/Civilian/products/smart_tape.htm