1. DISASTER TRIAGE:
S.T.A.R.T. & S.A.V.E.
Carl H. Schultz, MD
Professor of Emergency Medicine
UC Irvine School of Medicine

2. Carl Spengler, MD
3rd Year EM Resident
Oklahoma City Bombing
―…We never saw a child come out of the
federal building alive. At one point, a
group of people began screaming for me.
A firefighter had brought out a little girl
who was still breathing. People were
preparing intravenous fluids, and a
paramedic was getting the intubation
equipment together. The crowd was
screaming for the doctors to work on the
child.

3. Nature of Triage…
I finally yelled for everybody to be quiet and calm
down. As I assessed the little girl, it was obvious
that she had catastrophic head and chest injuries
and that there was nothing left to save. I told a
paramedic to wrap up the child in a blanket and
do nothing. Several bystanders became
emotionally decompensated and screamed, ‗You
bastard!‘ As I walked off, several people
continued to curse me in the worst possible
fashion. Unfortunately, that is the nature of
triage‖.

4. Goal of Disaster Triage
 Do the greatest good
for the greatest
number of casualties

5. Triage Origin
 From the French verb, t r i e r , ―to sort‖
 Napoleon‘s time, to assign treatment
priorities with limited resources
 Attention given first to most salvageable with
most urgent conditions – get them back into
battle

6. Does Triage Work?
 Lessons from history
 Scene control
– Convergence behavior

7. Key Concepts
 Resources are limited
– Supplies
– Personnel
 Time for evacuation unknown or
prolonged (the cavalry isn‘t coming any
time soon)
– Only austere field interventions are
available

8. Triage Practices
 Traditional
– Static, single
point in time
– Triage tags
frequently used
– Few patients
 Disaster
– Dynamic, multiple
points in time
– Documentation
needs may exceed
triage tag capacity
– Large patient
numbers

9. Triage Practices
 Traditional
– Scoop and run
– Designed to
work within
existing EMS
 Disaster
– Secondary exam
and treatment
performed
– Assumes
nonfunctional
EMS system

10. Triage Practices
 Traditional
– Used for
localized
disaster scenes
– Dependent on
communications
and
transportation
 Disaster
– Used for wide-
spread disaster
scenes
– Does not depend
on communication
and less on
transportation

11. Patient Categories
1. Those who will die no matter what
2. Those who will do well no matter what
we do
3. Those who will derive long-term benefit
from acute intervention
 Early identification of #3 important
– Others benefit from comfort care

12. START Triage
 Simple Triage and Rapid Treatment
 Designed to be performed by first
responders (paramedics)
 Assumes personnel under a great deal of
stress

13. START Triage
 Rapid method to perform INITIAL triage
 Utilizes respiratory rate, palpable pulse,
and mental status (ability to follow
commands)
 Begins by asking all that can walk to
move away from triage officer
 Assess using START those that remain

14. START Triage
 GREEN: those who are able to get up and
walk away
 RED: those with respiratory compromise
(require airway assistance or have a
respiratory rate  30), no palpable pulse at
the wrist (but are breathing), or unable to
follow commands
 YELLOW: those who are not red but can‘t
walk
 BLACK: dead

15. Modified START

16. SAVE Triage
 Secondary Assessment of Victim
Endpoint
 All patients with at least a 50% chance of
survival using available resources get
care
– Patient assessed by SAVE
methodology in order of priority
determined by START

17. SAVE Triage
Benefit
Value = ———— X Probability of survival
Resources required

19. SAVE Triage
Areas of Assessment
 Vital Signs
 Airway
 Chest
 Abdomen
 Pelvis
 Spine
 Extremities
 Skin
 Neurologic Status
 Mental Status

20. SAVE Triage Categories
 RED: require immediate intervention
 YELLOW: require intervention but can
tolerate a brief delay
 GREEN: do not require intervention to
prevent loss of life or limb
 BLACK: dead or unsalvageable

21. SAVE Triage Categories
 Periodic assessment of all categories is
important
 Patients may move from one area to
another

22. SAVE Triage Guidelines
 Crush Injury to Lower Extremity
– Patients are assessed using the MESS
score
– Score of 7 or more: amputate
– Score less than 7: attempt limb
salvage

23. SAVE Triage Guidelines
 Head Injury (adults)
– Use the Glascow Coma Score (GCS)
– Score 8 or above: treat
Better than 50% chance of a normal
or good neurologic recovery
– Score 7 or less: comfort care only

24. SAVE Triage Guidelines
 Burn Injury: less than 50% chance of
survival
– 70% TBSA burn
– Age > 60 with inhalational injury
– Age < 2 with 50% TBSA burn
– Age > 60 with 35% TBSA burn
 Comfort care only

25. SAVE Triage Guidelines
 Abdominal Injury
– No data to guide evaluation
– 4 ml/kg hypertonic saline X 2
– If no response, comfort care only
– Role of handheld ultrasound?

26. Initial Assessment: START
Case #1
 61 year old male pulled from smoking
building. Complaining of shortness of
breath.
 RR =28
 Wrist Pulse: palpable
 Mental Status: follows commands
 START Category: yellow (delayed)
 Treatment: nothing

27. Initial Assessment: START
Case #2
 30 year old male found with bleeding head
wound
 RR =22
 Wrist Pulse: palpable
 Mental Status: unresponsive
 START Category: red (immediate)
 Treatment: apply pressure to stop
bleeding

28. Initial Assessment: START
Case #3
 20 year old female complaining of
crushed lower extremity
 RR =20
 Wrist Pulse: palpable
 Mental Status: follows commands
 START Category: yellow (delayed)
 Treatment: nothing

29. Initial Assessment: START
Case #4
 3 year old female found not breathing
 RR =agonal
 Wrist Pulse: palpable
 Mental Status: unresponsive
– Open airway and give 15 seconds of
ventilation. No change in respirations.
 START Category: black (dead)

30. Secondary Assessment: SAVE
Case #2
 30 year old male found with bleeding head
wound
 START Category: red (immediate)
 EXAM: neurologic status
– Does not open eyes, does not speak,
and withdraws to pain
– GCS = 6
 SAVE Category: black (unsalvageable)

31. Secondary Assessment: SAVE
Case #1
 61 year old male pulled from smoking
building. Complaining of shortness of
breath.
 START Category: yellow (delayed)
 EXAM: airway
– Singed nasal hairs and eyebrows.
Coughing up carbonaceous material.
Wheezing. No skin burns
 SAVE Category: black (unsalvageable)

32. Secondary Assessment: SAVE
Case #3
 20 year old female complaining of
crushed lower extremity
 START Category: yellow (delayed)
 EXAM: extremities
– Crushed left leg. Massive tissue
avulsion and hemorrhage. Limb numb.
Patient is pale.
– MESS = 8 or 9
 SAVE Category: red (immediate)