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Disaster Triage: START, then SAVE—A New Method of Dynamic Triage for Victims of a Catastrophic Earthquake

  • Mark Benson (a1), Kristi L. Koenig (a2) and Carl H. Schultz (a3)

Abstract

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of lime, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49–72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage.

The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of “Simple Triage and Rapid Treatment” (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, “Secondary Assessment of Victim Endpoint” (SAVE).

The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology.

Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources—both personnel and equipment—and would be triaged to an “expectant area.” Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a “treatment” area.

The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.

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Corresponding author

Highland General Hospital, Department of Emergency Medicine, 1411 E. 31st St., Oakland, CA 94602 USA; KristiK@hghed.com

Footnotes

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*Presented in part at the American College of Emergency Physicians Annual Meeting in Chicago, Illinois, October 1993

Footnotes

References

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1. Schultz, CH, Koenig, KL, Noji, EK: A medical disaster response to reduce immediate mortality after an earthquake. N Eng J Med 1996;334:438444
2. Schultz, CH, Koenig, KL: Earthquakes and the practicing physician. West J Med 1992;157:591
3. Koenig, KL, Schultz, CH: Advances in local disaster response. In: Young, CP (ed.), ACEP Critical Decisions in Emergency Medicine, Vol IX, Lesson 11 1994;24:95105.
4. Super, C, Groth, S, Hook, R, et al. : START: Simple triage and rapid treatment plan, Hoag Memorial Hospital Presbyterian. 1994.
5. Koenig, KL, Schultz, CH:. Disaster medicine: Advances in local catastrophic disaster response, Acad Emer Med 1994;1:133136.
6. Schriger, DL, Baraff, LJ: Capillary refill—Is it a useful predictor of hypovolemic states? Ann Emerg Med 1991;20:601605.
7. Schriger, DS, Baraff, LF: Defining normal capillary refill: Variation with age, sex, and temperature. Ann Emerg Med 1988;17:932935.
8. Klain, M, Ricci, E, Safar, P, et al. : Disaster reanimatology potentials: A structured interview study in Armenia: I. Methodology and preliminary results. Prehospital and Disaster Medicine 1989;4:131154.
9. Halbert, RJ, Simon, RR, Nasraty, Q: Surgical training model for advanced emergency medics in Afghanistan. Ann Emerg Med 1988;17:779784.
10. Johansen, K, Daines, M, Howey, T, et al. : Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568573.
11. Robertson, P: Prediction of amputation after severe lower limb trauma. J Bone Joint Surg 1991;73-B; 816818.
12. Koenig, KL, Schultz, CH, DiLorenzo, RA: The crush injury cadaver lab: A new method of training physicians to perform fasciotomies and amputations on survivors of a catastrophic earthquake. Ann Emerg Med 1992;21:196. Abstract.
13. Koenig, KL, Schultz, CH, Bade, R: Medical disaster response amputation and fasciotomy training. Prehospital and Disaster Medicine 1993;8:205. Abstract.
14. Oppenheim, JS, Camins, MB: Predicting outcome in brain-injured, patients using the Glasgow Coma Scale in primary care practice. Postgrad Med 1992;91:261269.
15. Marshall, LF, Gautille, T, Klauber, MR, et al. : The outcome of severe closed head injury. J Neurosurg 1991;75:S28–S36.
16. Salcman, M, Schepp, RS, Ducker, TB: Calculated recovery rates in severe head trauma. Neurosurg 1981;8:301308.
17. Lieh-Lai, MW, Theodorou, AA, Sarnaik, AP, et al. : Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury. J Pediatr 1992;120:195199.
18. Buys, RN: Hypertonic solutions in resuscitating patients in hemorrhagic shock. West J Med 1989;151:6970.
19. Bickell, WH, Bruttig, SP, Millnamow, GA, et al. : Use of hypertonic saline/dextran versus lactated Ringers solution as a resuscitation fluid after uncontrolled aortic hemorrhage in anesthetized swine. Ann Emerg Med 1992;21:1077–085.
20. Bickell, WH, Wall, MJ, Pepe, PE, et al. : Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:11051109.
21. Powell, RW, Green, JB, Ochsner, MG, et al. : Peritoneal lavage in pediatric patients sustaining blunt abdominal trauma: A reappraisal. J Trauma 1987;27:610.
22. Saladino, R, Lund, D, Fleisher, G: The spectrum of liver and spleen injuries in children: Failure of the pediatric trauma score and clinical signs to predict isolated injuries. Ann Emerg Med 1991;20:636640.
23. Bracken, MB, Shepard, MF, Collins, WF, et al. : A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. N Engl J Med 1990;20:14051411.
24. Merrell, SW, Saffle, JR, Sullivan, JJ, et al. : Increased survival after major thermal injury: A nine year review. Amer J Surg 1987;154:623627.
25. Manktelow, A, Meyer, AA, Herzog, SR, et al. : Analysis of life expectancy and living status of elderly patients surviving a burn injury. J Trauma 1989;29:203207.
26. Milzman, David P, Boulanger, BR, Rodriguez, A, et al. : Pre-existing disease in trauma patients: A predictor of fate independent of age and injury severity score. J Trauma 1992;32:236243.

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