TRIAGE, START, STB
STOP THE BLEED® Course Overview
Introduction
The training course is designed to educate people on how to assist in the case of severe bleeding incidents.
It emphasizes the importance of immediate action to save lives in emergency situations.
Importance of Training
#1 cause of preventable death after injury: Bleeding.
Recognizing the urgency of controlling bleeding can markedly increase survival chances.
Goals of the Course
Identify life-threatening bleeding.
Understand what constitutes life-threatening bleeding.
Stop the Bleed: Take steps to control bleeding.
Utilizing techniques such as:
Pressure
Packing
Tourniquets
Personal Safety
YOUR safety is the top priority:
An injured rescuer cannot help others.
Steps to ensure safety:
Assist others only when it's safe.
If the situation changes, stop and move to safety.
If possible, take the victim with you when you move to safety.
Protective measures:
Wear gloves if available to minimize exposure to blood.
Clean any part of your body that has come in contact with blood.
Inform health care providers about any blood exposure you had.
ABCs of Bleeding Control
A - Alert
Call 911 when serious injuries are present.
Know your location to provide accurate information.
Follow instructions provided by the 911 operator.
B - Bleeding
Find the source of the bleeding:
Look for indicators such as:
Continuous bleeding.
Large-volume bleeding.
Pooling of blood.
Spotting multiple sources:
There may be more than one area impacted by bleeding.
Be aware that clothing can obscure severe bleeding.
C - Compress
Pressure:
Apply direct pressure to the wound.
Focus attention on the bleeding site.
Use sufficient gauze or cloth to cover the injury.
Maintain pressure until professional help arrives.
Packing:
For large or deep wounds, packing the wound tight with gauze may be necessary.
Hold pressure until help arrives to control bleeding adequately.
Tourniquets:
Proper application of a tourniquet is essential in severe cases:
Place the tourniquet 2 to 3 inches above the wound but never over joints (elbow/knee).
Tighten it until the bleeding stops, and do not remove it once applied.
Tourniquets can be applied over clothing.
A second tourniquet might be necessary to achieve desired outcomes in severe cases.
Special Considerations
Bleeding Control in Children:
Tourniquets can usually be applied as they are for adults, except for very small children.
For infants or small children, direct pressure applied to the wound usually suffices.
For larger, deeper wounds, packing techniques are applicable, similar to adult procedures.
FAQs
Address common queries regarding:
Impaled objects.
Use of improvised tourniquets.
Management of limb loss.
Pain concerns during intervention.
Other related questions that may arise.
Summary of Important Steps
Personal Safety always comes first.
Alert 911 and provide critical information.
Find and Control Bleeding:
Identify the source of bleeding (B).
Compress to stop the bleeding using pressure, packing, or tourniquets (C).
Await professional help to arrive for further assistance.
Additional Resources
For further information, consult:
BLEEDINGCONTROL.ORG
STOPTHEBLEED.ORG
Final Thought
The most tragic death is one that could have been prevented. Understanding how to respond to severe bleeding can save lives.
Triage Vocabulary
Golden Hour: Refers to the critical first hour after a traumatic injury when immediate medical treatment is crucial for the best chance of survival.
START (acronym): Stands for Simple Triage and Rapid Treatment, a system used for quickly assessing the severity of injuries in mass casualty incidents.
Triage Tag: A colored label used to prioritize injuries, indicating the urgency of treatment needed for each victim.
PPE: Personal Protective Equipment worn by first responders to ensure safety from hazards in the environment.
VS: Vital Signs, crucial for assessing the clinical status of patients.
Incident Command System: A standardized approach to managing emergency incidents, enabling multiple agencies to work together efficiently.
Standard of Care: The degree of care and skill that the average qualified provider would provide in a similar situation.
Central Treatment Area: A designated location where patients are triaged and treated during a mass casualty incident.
MOI: Mechanism of Injury, which refers to how injury occurred and is crucial for understanding the potential injuries sustained.
Introduction to Triage
Definition of Triage: A method for quickly identifying victims with life-threatening injuries who are most likely to survive if given immediate help. This protocol helps prioritize patients when additional resources become available.
Historical Context of Triage
Origin: The term "triage" comes from the French word "trier," meaning to separate.
Historical Application: Triage practices date back to the 1930s, primarily within military contexts for assessing injured soldiers on battlefields.
Core Responsibilities in Triage
Primary Role of Triage Responders: The primary task is NOT to provide medical care, but to evaluate patient status to determine treatment priorities.
Implication in Disasters: In serious disasters, it may not be feasible to save everyone. The focus should be on the collective effort to save as many victims as possible, operating on the principle that "the good of many over the good of one."
Imagery and First Responses
Imagery Moment Questions:
What action will you take first at the scene of a serious accident?
What will you do first for a diabetic emergency?
What steps will you take if someone collapses in front of you?
What would you do if asked to assist in childbirth?
Importance of Triage
Planning Ahead: Triage creates a predetermined approach for effectively managing chaotic emergency situations.
Organizational Benefits: Enhances order during fast-paced, chaotic environments allowing multiple agencies to operate distinctly yet collaboratively at the scene.
The START System
Overview of START: The START (Simple Triage and Rapid Treatment) system helps prepare emergency responders to effectively allocate resources in multi-casualty emergencies.
Development: Created by Newport Beach Fire Department in Newport, California.
Assessment Timeframe: Facilitates a quick assessment of victims in under 1 minute.
Categorization: Each victim is classified based on the severity of their injuries, determined through checks of RPM (Respiration, Perfusion, Mental Status) into categories of Deceased, Immediate, Delayed, or Minor. Each victim is tagged accordingly.
Triage Tag Color Codes
Color Coding System:
Green: Minor
Yellow: Delayed
Red: Immediate
Black: Deceased
Steps for Proper Triage
Scene Safety: Ensure the safety of the scene before engaging.
BSI (Body Substance Isolation): Employ PPE to protect against potential hazards.
Nature of Illness: Identify the nature of the incident or mechanism of injury (MOI).
Number of Patients: Evaluate how many patients are present.
Resources Needed: Assess and request any necessary additional resources, including police, fire, and EMS.
Check Wounds & Treat: Begin the triage process by checking wounds and applying treatments appropriately.
Process of Triage
Order of Triage for Mass Casualty:
Check for scene safety and don PPE before patient contact.
Instruct non-injured individuals to identify themselves and remain close by.
Assign triage tags to injured victims as MINOR, DELAYED, IMMEDIATE, or DECEASED.
Triage Flowchart
Flow of Triage Decisions:
All Walking Wounded: Assign a tag of MINOR.
For patients with NO respirations:
Check for airway positioning; if no respiration, classify as DECEASED.
For patients with respirations:
If normal (under 30/min), assess further; if over 30/min, classify as IMMEDIATE.
For perfusion check:
If the radial pulse is absent, classify as IMMEDIATE.
If radial pulse is present, perform a capillary refill test:
If it is over 2 seconds, classify as IMMEDIATE.
If under 2 seconds, manage bleeding.
For mental status evaluation:
If the patient can follow simple commands, classify as DELAYED.
If not, classify as IMMEDIATE.
Respiratory Assessment
Respirations
Normal range is 12–20 breaths per minute.
Breathing should be regular and unlabored.
There should be no respiratory distress.
Perfusion
Capillary refill should be less than 2 seconds.
Radial pulse should be present and strong.
Skin should be warm and of normal color, where normal implies not pale, blue, or mottled.
Mental Status
Patient should be alert and awake.
Must be oriented to person, place, time, and situation.
Should be able to follow simple commands (e.g., “Open your eyes,” “Squeeze my hand”).
A strong, present radial pulse generally indicates a systolic blood pressure of at least ~80 mmHg.
A very fast pulse (>100 bpm) may indicate shock, pain, anxiety, or blood loss.
Clinical Evaluation Parameters
Clinical Parameters Used
Ability to walk.
Presence or absence of spontaneous breathing.
Respiratory rate greater or less than 30 breaths per minute.
Perfusion assessment using either the palpable radial pulse or visible capillary refill rate.
Mental status as assessed by the ability to obey commands.
Triage Categories
Minor (Green Triage Tag Color)
Victim with relatively minor injuries.
Delayed (Yellow Triage Tag Color)
Victim's transport can be delayed.
Includes serious and potentially life-threatening injuries, but status not expected to deteriorate significantly over several hours.
Immediate (Red Triage Tag Color)
Victim can be helped by immediate intervention and transport.
Requires medical attention within minutes for survival (up to 60 minutes).
Includes compromise to patient's airway, breathing, and circulation (the ABC's of initial resuscitation).
Expectant (Black Triage Tag Color)
Victim unlikely to survive given severity of injuries, level of available care, or both.
Palliative care and pain relief should be provided.
Triage Notes
Principle: “The good of many over the good of one.”
In a mass-casualty incident, responders focus on saving the greatest number of people possible, even if it means some individuals receive less immediate care.
Breathing Patterns
Normal Breath Duration
Inhalation: 1 to 1.5 seconds.
Exhalation: 1.5 to 2 seconds.
An automatic pause of almost no breathing for 1 to 2 seconds.
Triage Systems and Responsibilities
History of Triage
Originated on the battlefield during wartime.
Dates back to the Napoleonic Wars in the early 1800s.
Developed by French military surgeon Dominique Jean Larrey.
Primary Responsibility of Triage Responder
To rapidly assess victims and assign priority levels to maximize survival in a mass casualty incident.
Importance of Triage
To prioritize patients based on severity of injuries.
To use limited medical resources effectively.
To treat the greatest number of victims as quickly as possible.
START System
S.T.A.R.T: Simple Triage And Rapid Treatment.
Developed by Newport Beach Fire Department in California.
Allows responders to evaluate victims in less than 1 minute.
Uses RPM (Respiration, Perfusion, Mental Status).
Categorization in START
Color categories correspond to injury severity and treatment priority:
Black: Deceased/Expectant (Not breathing after airway reposition).
Red: Immediate (Life-threatening injuries).
Yellow: Delayed (Serious but not immediately life-threatening).
Green: Minor (Walking wounded).
Triage Process Steps
Steps for Proper Triage:
Ensure scene safety and put on PPE.
Call for additional resources if needed.
Identify walking wounded (Green category).
Assess breathing (Respiration).
Check perfusion (pulse or capillary refill).
Assess mental status and assign triage tag.
Initial Triage Steps in Mass Casualty
Scene Size-Up: Assess scene safety, hazards, and number of victims.
Initial Triage: Quickly classify victims based on RPM.
Treatment and Transport: Move victims to the central treatment area and prioritize for transport to hospitals.
Continuous Reassessment: Recheck and re-triage patients as conditions change.
Managing the Triage Scene
Managing a scene with multiple patients can be complicated. Follow these steps to ensure systematic triage and treatment:
Recognize that assigning patients to Delayed or Minor categories does not imply abandonment; those patients will be reassessed.
Immediate Patients (Red): First priority, at risk for early death, require stabilization and transport soon.
Delayed Patients (Yellow): Injuries may be serious; reassess them frequently, particularly if they have serious injuries.
Minor Patients (Green): Reassure and inform them, though transport will be based on more severe cases.
Deceased Patients (Black): Follow local protocols regarding moved deceased persons.
Emergency Response Vocabulary
Golden Hour: The first 60 minutes after traumatic injury when medical treatment is most likely to save a patient’s life.
START: Simple Triage And Rapid Treatment system for classifying victims.
Triage Tag: Color-coded tag indicating injury severity and treatment priority.
PPE: Personal Protective Equipment (gloves, masks, goggles, etc.).
VS: Vital Signs (pulse, breathing rate, blood pressure, consciousness level).
Incident Command System (ICS): Management system used for coordinating emergency response.
Standard of Care: Expected level of care provided by trained medical professionals.
Central Treatment Area: Designated location for triaged patients to receive care.
MOI: Mechanism of Injury describing how an injury occurred (car crash, fall, etc.).
Bleeding Control Techniques
ABCs of Bleeding Control:
A: Alert 911 with location and number of injured people.
B: Bleeding: Identify and locate the source, and possibilities of multiple bleeding sites.
C: Compress: Utilize various techniques to control bleeding:
Pressure: Direct pressure applied with clean cloth.
Packing: For large wounds, pack gauze into the wound firmly.
Tourniquet: Apply 2–3 inches above the wound, tighten until bleeding stops, do not remove.
Specific Notes on Bleeding Control for Children:
For infants or very small children, apply direct pressure to control bleeding without a tourniquet.
Wound packing can be performed similarly to adults for larger wounds.