PEDIATRIC DISASTER TRIAGE

UTILIZING THE JUMPSTART © METHOD

MARCH 2016 (4TH EDITION)

Illinois Emergency Medical Services for Children is a

collaborative program between the Illinois Department
of Public Health and Loyola University Chicago
Disclaimer

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 developed.
 Acknowledgements
• This 4th edition education program was developed under the direction and
guidance of the Illinois Pediatric Preparedness Workgroup. The original
program was adapted in 2006 from a module developed by Children’s
Memorial Hospital (now Ann & Robert H. Lurie Children’s Hospital of
Chicago).

• This program was developed from an Assistant Secretary for Preparedness

and Response (ASPR) Hospital Preparedness Program (HPP) grant. All
training materials are considered under public domain and can be utilized
by others in the conduction of similar educational programs, provided there
is acknowledgement of the source of these materials.
Objectives
• Identify unique characteristics that make
children more vulnerable in a disaster
• Discuss mass casualty triage and the pediatric
patient
• Review START and JumpSTART© Triage Tools
and the SMART Triage Pacs™
• Demonstrate the use of the START and
JumpSTART© Triage Tool
Objectives (continued)
• Discuss the instructor role for JumpSTART©
Triage Training
• Identify Healthcare Professionals in your EMS
Region to target for JumpSTART© Triage
training
• Discuss the necessary steps to teach a
JumpSTART© Provider and Instructor Class
• Review the training materials that are
necessary to teach a JumpSTART© Provider
and Instructor Class
Introduction
Background
Illinois Emergency Medical Services for Children (EMSC)

1984: National EMSC Program established through federal

legislation
• Jointly sponsored by
• Maternal & Child Health Bureau
• National Highway Traffic Safety Administration
• States are charged with enhancing the pediatric component of their
Emergency Medical Services (EMS) systems.
1994: Illinois EMSC was established.
Illinois EMSC
Pediatric Disaster Preparedness
• 2002:
• Illinois Pediatric Bioterrorism Workgroup convened
• Name changed in 2011 to Pediatric Preparedness Workgroup to
ensure a more all-hazards approach.
• Reports to EMSC Advisory Board and Illinois Terrorism Task
Force
• Assists in assuring that the special needs of children are
addressed during a disaster or terrorist event by:
• Enhancing awareness of pediatric needs
• Identifying/sharing best practices
• Developing resource documents, tools, and guidelines
• Integrating disaster preparedness into existing state initiatives
Illinois Communities

• Illinois is the 5th most populous state with a

population of 12.9 million

• Almost 3 million children <18 years of age

• Approximately 800,000 are age five and

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

(Source: ACEP Disaster Medical Services Policy Statement, 2006)

Natural Disasters
• Earthquake
• Flood
• Snow/ice storm
• Tornado
• Others
Human Caused Disasters

• Terrorist Events
• Arson
• Bombings
• Shootings
• Use of chemical,
biological or nuclear
agents
• Hazmat incidents
Terrorist Events and the Pediatric
Population

Myth
Kids are secondary victims
of terrorism and inadvertently
targeted

Fact
Children may be
intentionally targeted
Harsh Realities: Children as Victims of
Disasters
• 1984: Bhopal, India
– Industrial gas release (methyl isocyanate)
– Estimated 20% of victims were children
• 1999: Columbine High School
Shootings
– 12 students killed, 24 injured
• 2004: Beslan, Russia
– Three day hostage event at school
– 334 hostages killed including 186 (56%)
children

• 2011: Oslo and Utoya Norway Attacks

– At least 60 children killed after a gunman
opened fire at a youth summer camp
• 2012: Sandy Hook Elementary
School Shooting
– 26 people killed (20 children and 6 adults)
Why Children are More Vulnerable
During Disasters
Challenges
Lack of
related to
appropriate
medical
sized equipment
interventions
and supplies
and safety

Gaps in pediatric
Critical
preparedness in
emergency care
hospitals, agencies,
interventions
communities, and on
performed
the state and federal
infrequently
levels

Anatomical, Increased May be

physiological vulnerability intentionally
and
during targeted during
developmental
the disaster
differences disasters
Respiratory
Depend on
Airway is smaller
diaphragm to
and more narrow
breath

Equipment needs
Higher risk for vary based on
respiratory issues size
 Exposure
Faster Thinner skin/
respiratory greater body Shorter stature
rates surface area

More susceptible
to:
infections
Faster Immature
effects of agents metabolism immune
system
prolonged
exposures
hypothermia
Trauma

Larger
Rib cage is higher head/higher
center of gravity

Higher risk for

injury, irreversible Smaller
shock and death circulating blood
from traumatic volume
events
 Developmental
May lack
cognitive ability
to sense a
dangerous
situation

Increased exposure
and risk of injuries

May lack motor

skills to flee from
danger
Developmental
May be nonverbal or
not know personal
information

May be uncooperative
Unable to help with
reunification
Long term
psychological effects
are possible
Age & developmental
level influences
response to stressful
events
Children with Special Health Care Needs
(CSHCN)/Children with Functional Access
Needs (CFAN)
• Can include those kids who
are/have:
• Technology dependent
(ventilators, G-tubes, shunts,
insulin pumps)
• Developmentally delayed or
disabled
• Chronic diseases
• Immunocompromised
• Psychiatric/behavioral illnesses
• 23% of U.S. households • Many emergency personnel
have at least 1 child that and disaster responders are
meet criteria not used to dealing with this
• 15.1% (>11.2 million) population
children in U.S. meet criteria
• Illinois: 14.3% (452,574)
Triage
Triage
• Sorting and prioritizing patients
• Looks at the medical needs and
urgency of each individual patient
• Conventional Triage
• Do the best for each individual
• Disaster/MCI Triage
• Do the greatest good for the greatest
number
• Based on physiology
• Provides an objective framework for
stressful and emotional decisions
• Helps in resource allocation
Triage
• Primary Triage
• Typically performed at the scene of the incident
• Helps prioritize patients for evacuation/transport
• Can occur at a hospital

• Secondary Triage
• Performed to re-evaluate the patient after primary triage has
been completed
• Typically done once the patient arrives at the hospital.
• Can also take place at an alternate care site or at the scene of
the incident if prolonged scene time or in casualty collection
areas
Mass Casualty Incident

Any incident in which there are more patients than rescuers

(Source: newyearseve.com)
~80% of casualties self or buddy
transport to the closest hospital
MCI Triage
• All victims must have equal importance at the time of
primary triage
• Sort patients based on the need for immediate care

• Be able to recognize futility

• No patient group can receive special consideration other

than that dictated by their physiologic state

This includes children!

(Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)
MCI Triage Categories

• IMMEDIATE = Emergent
• DELAYED = Urgent
• MINOR = Non-urgent/walking
wounded
• EXPECTANT/DECEASED =
Dead/little to no hope of survival
IMMEDIATE
Severely ill/injured but
treatable and able to be saved
with relatively quick treatment
and transport

• Examples:
• Severe bleeding
• Shock
• Open chest or abdominal wounds (Source: Optimistworld.com/anaphylaxis)

• Severe respiratory distress

• Emotionally out of control
DELAYED
Injured/ill and unable to walk
on their own; Potentially
serious injuries/illnesses but
stable enough to wait a short
while for medical treatment
• Examples
• Burns with no respiratory distress
• Spinal injuries
• Moderate blood loss
• Conscious with head injury (Source: Chemaxx.com)
MINOR
Minor injuries/illnesses that
can wait for a longer period of
time for treatment

• Examples
• Minor fractures
• Minor bleeding
• Minor lacerations
EXPECTANT/DECEASED
Dead or obviously dying; May have
signs of life but injuries are
incompatible with survival

• Examples
• Cardiac arrest
• Respiratory arrest with a pulse
• Massive head injury
Triaging Expectant/Deceased Patients
• Can be psychologically difficult to tag a child as
Expectant/Deceased

• Can be hard to resist the tendency to assign

pediatric patients a higher triage category just
because they are children

• Using a MCI triage tool especially with children

can help to eliminate the role of emotions in the
triage process

• Objective triage criteria during an MCI can provide

emotional support for triage personnel forced to
make life or death decisions for children
MCI Triage Considerations
Scene Safety
• Ensure the scene is safe
before entering
• Assess for need for
decontamination
Incident command (IC)
• Process what you see and hear
in 30 seconds and paint as
accurate a picture as you can in
your report to IC

Designate Treatment
Areas
• Establish areas for each triage
color category
• Triaged patients should be
moved to designated areas
MCI TRIAGE TOOLS
MCI Triage Tools

• START Algorithm
• JumpSTART© Algorithm
• SMART Triage Pacs™
START TRIAGE
START
• Simple Triage And Rapid Treatment
• Joint development by the Fire & Marine
Department and Hoag Hospital in New Port
Beach, California
• Gold standard for field adult MCI triage in U.S.
and numerous other countries
• Utilizes the standard four color triage categories
• Used for primary triage
• More information at www.start-triage.com
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
START Triage Algorithm
JumpSTART© Triage
JumpSTART© Triage
• Developed in 1995 to parallel the START Triage
system and revised in 2002
• Designed for use in MCI events

• Provides an objective framework to decrease the

emotional burden on medical personnel who have to
make rapid life or death decisions about children
• Reflects unique aspects of pediatric physiology

• Originally used with children under 8 years old but now

used on any victim that appears to be child
• Can be completed within 30 seconds

(Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)
JumpSTART© Triage
• In children, typically respiratory failure precedes
circulatory failure

• Apnea may occur relatively rapidly, rather than after a

prolonged period of hypoxia

• There may be a brief period when the child is apneic

but not pulseless since the heart has not yet
experienced prolonged hypoxia. It is felt that
providing a brief trial of ventilations may help
“jumpstart” their respirations
JumpSTART© Triage and Age
What age defines the pediatric patient?
JumpSTART© Triage and Age
It can be difficult to discern the age of a child especially
pre-teen and early teen years, and which triage tool to use.

If a victim appears to be a CHILD,

use JumpSTART©
If a victim appears to be a YOUNG
ADULT, use START
(Source: Dr. Lou Romig-slide presentation: JumpSTART Pediatric Multi-casualty Triage System)
Differences Between START and
JumpSTART©
START JumpSTART©
Airway If positioning the airway If positioning the airway
does not restart does not restart
breathing, patient breathing, a ventilation
tagged as trial is given if pulse is
Expectant/Deceased palpable
Perfusion/Circulation Capillary refill or Only peripheral pulses
peripheral pulses can are used to assess
be used to assess perfusion
perfusion
Mental Status Ability to follow AVPU is used to assess
commands is used to mental status
assess mental status
 Step 1
Patients who are able to
walk are assumed to have
stable, well compensated
physiology, regardless of
the nature of their injuries or
illnesses. These are triaged
as MINOR
 Step 2
Evaluate all non-ambulatory
victims that are carried to
the MINOR area
Non-ambulatory Children

Non-ambulatory children include:

• Infants who normally can’t walk yet
• Children with developmental delays
• Children with acute injuries which prevented
them from walking before the incident
occurred
• Children with chronic disabilities
CHILDREN MEETING THIS CRITERIA© SHOULD BE
EVALUATED USING THE JumpSTART ALGORITHM
BEGINNING WITH STEP 2
Non-ambulatory Children
All children carried to the MINOR area by other
ambulatory victims must be the first assessed by
medical personnel in that area.
• If a child meets any red criteria, tag as IMMEDIATE

• If a child has significant external signs of injury, tag as DELAYED

• If a child has no significant external signs of injury, tag as MINOR

• If a child meets the criteria for the expectant/deceased category, tag as

EXPECTANT/DECEASED
 Step 3
Next begin triaging the
remaining victims in the
order that they are
encountered.
Assess the breathing status of
each child.
• If the child is breathing
spontaneously, go on to
step 4
• If child is apneic, position
the upper airway. If they
start to breath on their
own, tag them as
IMMEDIATE
 Step 3
(Continued)
If the child is still apneic
after positioning their upper
airway in Step 2 and they
have no palpable pulses,
tag as EXPECTANT/
DECEASED
 Step 3
(Continued)
If the child is still apneic after
positioning their upper airway
but has a palpable pulse, give
5 rescue breaths.
• If they start breathing
spontaneously, tag as
IMMEDIATE
• If they remain apneic, tag
as
EXPECTANT/DECEASED
 FOR THOSE CHILDREN WHO
REMAIN APNEIC AFTER 5
RESCUE BREATHS, DO NOT
CONTINUE TO VENTILATE THE
PATIENT

RESUME TRIAGE DUTIES.

 Step 4
Assess the respiratory rate
of each spontaneously
breathing child.
• If <15 or > 45, tag as
IMMEDIATE
• If 15-45, go to Step 5
 Step 5
Assess the child’s
perfusion.
• If no palpable pulse, tag
the child as IMMEDIATE
• If the child’s pulse is
palpable, move on to
Step 6
 Step 6
Assess the child’s mental
status.
• If child is inappropriately
responsive to pain,
posturing, or unresponsive,
tag as IMMEDIATE

• If child is alert, responds to

voice or appropriately
responds to pain, tag as
DELAYED
SMART TRIAGE TAG
SYSTEM
State Mass Casualty Triage System
• 2004 - State committee identified
need for consistency in MCI
triaging throughout Illinois
 Various MCI triage systems reviewed
 Endorsement of SMART Incident
Command System™ for use in Illinois
• 2007-Statewide distribution of
SMART Triage Pacs™
• Illinois Custom-Designed SMART
Pacs™
 Contains a START and JumpSTART
algorithm card
 Does not have the SMART Pediatric
Tape (tape not approved for use in
Illinois)
SMART Triage Pacs™
• MCI triage tags
• Part of a larger Command
System product that includes
ability to assist with tracking
patients from the scene.
• Full system not necessary to
use triage tag portion

• SMART Triage tags are

recommended to use in Illinois

(Source: emsstaff.buncombecounty.org)
SMART Triage Pacs™
• Triage tags
• Equipment used to perform START and
JumpSTART© triage
• Have standard barcodes for tracking
patients
• Card folds to the assigned color and only
shows one color at a time
• Allows patients to be re-triaged to another
color classification without having to
replace the tag and reassessment can be
documented on the same tag
• Separate tags for Expectant/Deceased
category

(Source: emsstaff.buncombecounty.org)
SMART Triage Pacs™( Continued)
SMART Triage Pacs™( Continued)
START Triage vs. the SMART Triage
Pacs™
The START algorithm looks like The SMART Triage Pacs™
this… algorithm looks like this...

Although these algorithms look different…

THEY ARE THE SAME
Scenarios
Scenario 1: Bus Crash
It’s 7pm on a summer night
when a bus returning from a
day camp collides with a
train on a remote road.

You are the first responder

and you find 20 + kids. Some
are still in the bus and train
while some are lying about
the road.
Scenario 1 (continued)

10 y/o female, open

femur fracture,
breathing 10/min,
good distal pulse,
groans to verbal
stimuli
9 y/o M RR0 Faint distal Unresponsive Lying outside
pulse the bus in a
pile of debris
50 y/o F RR 20 Cap refill < 2 Obeys simple Dizzy &
sec commands unable to
walk
10 y/o F RR 22 Good distal Asks for help Walking
pulse
9 y/o F RR 12 Distal pulse Groans to painful Lying in the
absent stimuli ditch 15 ft
away
10 y/o M RR 26 Distal pulse Obeys commands Unable to
present move his
legs
25y/o F RR12 Cap refill 4 Eye movement to 6 months
sec stimulation pregnant
Scenario 2: F5 Tornado

An F5 tornado has
struck within your
city/town. It occurred
at 3pm while school
was letting out. The
tornado touched down
near 3 schools and a
shopping mall.
Scenario 2 (continued)

School Age Girl

• Open arm fracture
• RR 26, and pulse
• Alert and talking
8 y/o M RR 10 Weak, thready Unresponsive Outside,
pulse face down
3 y/o M RR 18 Pulse present Responds Deformity to
but irregular appropriately to lower
pain extremity
9 m/o F RR 44 Pulse present Responds to Superficial
voice lacs to
head/face
10 y/o M Screaming Pulse present Not focusing Running in
hall

50 y/o F RR 32 Weak pulse Not following Trapped

commands under
bookcase
7 y/o M RR 0 Very weak Unresponsive Trapped
Pulse under rubble
Scenario 3: High-Rise Fire

• Fire reported on
15th floor
• Smoke to the 16th
and 17th floors.
• The building’s day
care center is
located on the 17th
floor with 30 kids
and 6 employees.

(Source: Used with permission from Paula Willoughby DeJesus, DO, MHPE)
4 y/o F RR 38 Radial pulse Knows name Facial burns,
present and recalls coughing
incident
53 y/o F RR 48 Cap refill Moaning Burns to
> 2 sec abdomen;
wheezing
3 y/o F RR 0 Weak pulse Unresponsive Found under
desk
4 y/o M RR 45 Pulse present Crying No obvious
injuries
2 y/o M RR 20 Palpable pulse Hoarse cry Soot to face

3 y/o M RR 28 Strong palpable Crying 2nd/3rd degree

pulse burns to
extremities
Scenario 3 (continued)

5 kids are
carried out, all
being given
CPR.

As lead triage
officer, what do
you do?

,
(Source: Used with permission from Paula Willoughby DeJesus DO, MHPE)
Recovery
Taking Care of Yourself

• After a critical event,

rescue workers often
struggle to get back to
their daily lives and deal
with their experiences
• Can have difficulty coping
and feeling back to normal
• Look for mental health No one should feel alone
resources/professionals in this process or that one
has to get through this
that may be available
completely on their own
through your
employer/organization or in
your community
Conclusion
• START/JumpSTART are the MCI triage systems used in
Illinois
• SMART Triage Tags are recommended for use in Illinois
• JumpSTART incorporates unique aspects of pediatric
physiology
• Provide an objective framework to assist responders with
making difficult life or death decisions during a disaster
• Helps provide emotional support when responders know they
followed the protocols
APPLYING START AND
JUMPSTART ©
Instructor Training
Trainer’s Role

• Be an advocate for pediatric preparedness at your

organization and within your region

• Work within your EMS region to provide trainings

• Conduct JumpSTART© Provider courses

• Conduct JumpSTART© Train the Trainer Instructor

courses
JumpSTART© Pediatric Mass Casualty
Triage Course Guidelines
Course Participant Guidelines
• Provider Course
• Participants should ideally be healthcare professionals (i.e.
physicians, registered nurses, EMTs, respiratory therapists) or
other allied health personnel.
•
• Train-the-Trainer Course
• Participants must be licensed healthcare professionals (i.e.
physicians, registered nurses, EMTs, respiratory therapists) with
current educator experience/background.
JumpSTART© Pediatric Mass Casualty
Triage Course Guidelines (continued)
Course Instructor Guidelines
• To teach a Provider Course
• Instructors must:
• Successfully complete a JumpSTART© Train-the-Trainer course
• Utilize current training materials available on the Illinois EMSC
website
• Submit a copy of the Training Completion form and Student
Tracking Form (course roster) to the Illinois EMSC office after
each course completion
JumpSTART© Pediatric Mass Casualty
Triage Course Guidelines (continued)
Course Instructor Guidelines
• To teach a Train-the-Trainer Course
• Instructors must:
• Successfully complete a JumpSTART© Train-the-Trainer course
• Have current role/responsibilities that includes providing adult
healthcare related education
• Have current background and experience in emergency
medicine/disaster preparedness
• Utilize current training materials available on the Illinois EMSC
website
• Submit a copy of the Training Completion form and Student
Tracking Form (course roster) to the Illinois EMSC office after
each course completion
JumpSTART© Pediatric Mass Casualty
Triage Course Guidelines (continued)

Course Instructor Guidelines

• Course Coordinators
• Course coordinators are responsible for ensuring the
overall coordination of the JumpSTART© course by
handling various responsibilities including but not limited
to:
• Securing the course location
• Scheduling instructor
• Obtaining course supplies/needs
• Utilizing current training materials
• Adhering to the course agenda
• Completing appropriate documentation.
Who Needs Training in your Region?
• Hospital Staff
• EMS personnel
• Fire department personnel
• School nurses and school health personnel
• Local clinics personnel
• Local public health department personnel
• Physician offices/groups
Course Overview
• 3 hours in length
• Composed of lecture, skills demonstration, question &
answer session, and evaluation
• Course certificate upon completion
• CE hours
• EMS CE’s can be obtained through an IDPH code
• Nursing CE’s
• Apply as a region or an organization
• Can be applied toward:
• EDAP, SEDP or PCCC Facility Recognition requirements
• ECRN
• TNS
Steps to Conduct a Class
• Identify course coordinator
• Identify target audience
• Determine class size
• Secure rooms at the location
• Will need a lecture room and a skills station room
• Promote the training
• Develop a brochure
• Template brochure available thru EMSC
• Distribute brochure via email and/or mail
Steps to Conduct a Class (continued)
• Coordinate course registrations
• Confirm course registration/details with participants
• Secure other instructors
• Typical instructor/student ratio is 1/6 for the skills demonstration
component
• Gather necessary supplies and materials
• Conduct the class
• After course completion, forward Student Tracking
Form (roster) and Training Completion Form to EMSC
office
Course Content
• Lecture
• PowerPoint Presentation provided in the course materials
• Skills Demonstration Component
• Scenarios provided to trainers in the Disaster Preparedness
Exercises Addressing the Pediatric Population document
• Question & Answer Component
• Post test provided to trainers
• Evaluation
• Evaluation forms provided in the course materials
Course Preparation
• Power point presentation with appropriate AV
equipment
• Flat Stanleys, manikins, or other types of “victims” to
use for skills demonstrations
• All forms:
• Student Tracking Form or other sign in sheet
• Certificate of Completion
• Evaluation Form
• Patient Tracking Form
• Post test
• Scenarios: Pediatric Disaster Triage Training
Scenarios: Utilizing the JumpSTART Method
• START/JumpSTART© algorithm cards
• Consider if food/beverages will be provided
Course Preparation

(Source: Pictures obtained from Flat Stanley Adventures, Stimulaid, and MCHC)
Course Preparation
For Information Purposes Only

BLUE Category in MCI Triage

• Not universally accepted
• Not used in START or JumpSTART Triage Tools
• Not part of the approved MCI Triage System for
use in Illinois
Course Preparation
For Information Purposes Only

Other MCI Triage Systems

• Examples:
• Sacco Triage Method (STM)
• http://saccotriage.com/
• SALT MCI Triage Algorithm
• http://register.ndlsf.org/mod/page/view.php?id=2056
• Not universally accepted
• Not part of the approved MCI Triage
System for use in Illinois
Course Materials

• JumpSTART© Algorithm
• START Algorithm
• PowerPoint presentation
• Pediatric Disaster Triage
Training Scenarios: Utilizing
the JumpSTART Method
Course Materials

Certificate of Completion-Provider Evaluation Form

Certificate of Completion-Instructor
Course Materials
Patient Tracking Form

Student Tracking Form

Course Materials

Training Completion Form

Course Materials

• SMART Triage Pac Illinois

Order Form
• SMART Triage Pac Illinois
Order Form – Resupply
Conclusion
• Use your available Resources!
• EMSC
• Can provide the START/JumpSTART© algorithm
cards
• Can provide guidance, ideas, and answer questions
• Obtain updated course materials
• Connect with additional instructors
• www.luhs.org/emsc
• 708-327-3672
• www.jumpstarttriage.com
• Other JumpSTART instructors
ANY QUESTIONS?
THANK YOU!
www.luhs.org/emsc