TRIAGE

INTRODUCTION
Triage is the process of determining the priority of patients’ treatments based on the severity
of their condition. This rations patient treatment efficiently when resources are insufficient
for all to be treated immediately. The term comes from the French verb trier, meaning to
separate, sort, sift or select, Two types of triage exist: simple and advanced. Triage may result
in determining the order and priority of emergency treatment, the order and priority of
emergency transport, or the transport destination for the patient.
Bioethical concerns have historically played an important role in triage decisions, such as the
allocation of iron lungs during the polio epidemics of the 1940s and of dialysis machines
during the 1960s. As many health care systems in the developed world continue to plan for an
expected influenza pandemic, bioethical issues regarding the triage of patients and the
rationing of care continue to evolve. Similar issues may occur for paramedics in the Field in
the earliest stages of mass casualty incidents when large numbers of potentially serious or
critical patients may be combined with extremely limited staffing and treatment resources.

DEFINITION
Triage is a process of prioritizing patients based on the severity of their condition. This
rations patient treatment efficiently when resources are insufficient for all to be treated
immediately, the process of sorting injured patients on the basis of the actual or perceived
degree of injury and assigning them to the most effective and efficient regional care
resources, in order to insure optimal care and the best chance of survival.

TYPES OF TRIAGE
Simple triage
Simple triage is usually used in n scene of a "mass-casualty incident"(MCI), in order to sort
patients into those who need critical attention and immediate transport to the hospital and
those with less serious injuries, This step can be started before transportation becomes
available .the categorization of patients based on the severity of their injuries can be aided
with the use of printed triage tags or coloured flagging.
Simple triage and rapid treatment
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be
performed by lightly-trained lay and emergency personnel in emergencies. It is not intended
to supersede or instruct medical personnel or techniques. It has been (2003) taught to
California emergency workers for use in earthquakes. It was developed at Hoag Hospital in
Newport Beach, California for use by emergency services. It has been field- proven in mass
casualty incidents such as train wrecks and bus accidents, though it was developed for use by
community emergency response teams (CERTs) and fire-fighters after earthquakes. In 2009,
the Newport Beach Fire Department gave approval for a bilingual version of the S.T.A.R.T.
system to be included in a series of books called Emergency. Language Systems EMS panel,
produced by Emergency Language Systems
Triage separates the injured into four groups:
 The deceased who are beyond help
 The injured who can be helped by immediate transportation
 The injured whose transport can be delayed
 Those with minor injuries, who need help less urgently
Advanced triage
In advanced triage, doctors may decide that some seriously injured people should not receive
advanced care because they are unlikely to survive. Advanced care will be used on patients
with less severe injuries. Because treatment is intentionally withheld from patients with
certain injuries, advanced triage has an ethical implication. It is used to divert scarce
resources away from patients with little chance of survival in order to increase the chances of
survival of others who are more likely to survive.
In Western Europe, the criterion used for this category of patient is a trauma score of
consistently at or below 3. This can be determined by using the Triage Revised Trauma Score
(TRTS), a medically-validated scoring system incorporated in some triage cards.
Another example of a trauma scoring system is the Injury Severity Score (ISS). This assigns a
score from 0 to 75 based on severity of injury to the human body divided into three
categories: A (face/neck/head), B (thorax/abdomen), C (extremities/external/skin). Each
category is scored from 0 to 5 using the Abbreviated Injury Scale, from injured to critically
injured, which is then squared and summed to create the ISS. A score o66, for
"unsurvivable", can also be used for any of the three categories, and automatically sets the
score to 75 regardless of other scores, Depending on the triage situation, this may indicate
either that the patient is a first priority for care, or that he or she will not receive care due to
the need to conserve care for more likely survivors.
The use of advanced triage may become necessary y when medical professionals decide that
the medical resources available are not sufficient to treat all. The people who need help. The
treatment being prioritized can include the time spent on. Medical care, or drugs or other
limited resources. This has happened in disaster s such as volcanic eruptions, thunderstorms,
and rail accidents. In these cases some percentage of patients will die regardless of medical
care because of the severity of their injuries. Others would live if given immediate medical
care, but would die without it.
In these extreme situations, any medical care given to people who will die anyway can be
considered to be care withdrawn from others who might have survived (or perhaps suffered
less severe disability from their injuries) had they been treated instead. It becomes the task of
the disaster medical authorities to set aside some victims as hopeless, to avoid trying to save
one life at the expense of several others.
If immediate treatment is successful, the patient may improve (although this may temporary)
and this improvement may allow the patient to be categorized to a lower priority in the short
term. Triage should be a continuous process and categories should be checked regularly to
ensure that the priority remains correct. A trauma score is invariably taken when the victim
first comes into hospital and subsequent trauma scores taken to see a trauma score time series
from the start of the incident, which may allow definitive treatment earlier.
Typical triaging systems

SMART TAG System METTAG system

Continuous integrated triage

1. Continuous Integrated Triage is an approach to triage in mass casualty situations which is
both efficient and sensitive to psychosocial and disaster behavioural health issues that affect
the number of patients seeking care (surge), the manner in which hospital or healthcare
facility deals with that surge (surge capacity) and the overarching medical needs of the event.
Continuous Integrated Triage combines three forms of triage with progressive specificity
most rapidly identify those patients in greatest need of care while balancing the needs of the
individual patients against the available resources and the needs of other patients.
Continuous Integrated Triage employs:
Group (Global) Triage (i.e., M.A.S.S. triage)
Physiologic (Individual) Triage (i.e., S.T.A.R.T.)
Hospital Triage (i.e., E.S.I. or Emergency Severity Index)
However any Group, Individual and/or Hospital Triage system can be used at the appropriate
level of evaluation.

Practical applied triage

During the early stages of an incident, first responders may be overwhelmed by the scope of
patients and injuries. One valuable technique is the Patient Assist Method (PAM); the
responders quickly establish a casualty collection point (CCP) and advise; either by yelling,
or over a loudspeaker, that" anyone requiring assistance should move to the selected area
(CCP)". This does several things at once; it identifies patients that are not so severely injured,
that they need immediate help, and it physically clears the scene, and provides possible
assistants to the responders. As those who can move, do so, the responders then ask, "Anyone
who still needs assistance, yell out or raise your hands"; this further identifies patients who
are responsive, yet maybe unable to move. Now the responders can rapidly asses the
remaining patients who are either expectant, or are in need of immediate aid. From that point
the first responder is quickly able to identify those in need of immediate attention, while not
being distracted or overwhelmed by the magnitude of the situation.

Reverse triage
In addition to the standard practices of triage as mentioned above, there are conditions where
sometimes the less wounded are treated preference to the more severely wounded. This may
arise in a situation such ns war where the military setting may require soldiers be returned to
combat as quickly as possible, or disaster situations where medical resources are limited in
order to conserve resources for those likely to survive but requiring. Advanced medical care.
Other possible scenarios where this could arise include situations where significant numbers
of medical personnel are among the affected patients where it may be advantageous to ensure
that they survive to continue providing care in the coming days especially if medical
resources are already stretched. In cold water drowning incidents, it is common to use reverse
triage because drowning victims in cold water can survive longer than in warm water if given
immediate basic life support and often those who are rescued and able to breathe on their own
will improve with minimal or no hep.

Labelling of patients

Upon completion of the initial assessment by medical or paramedical personnel, each patient
will be labelled with a device called a triage tag. This will identify the patient and any
assessment findings and will identify the priority of the patient's need for medical treatment
and transport from the emergency scene. Triage tags may take a variety of forms. Some
countries use a nationally standardized triage tag, while in other countries commercially
available triage tags are used, and these will vary by jurisdictional choice. The most
commonly used commercial systems include the METTAG, the SMARTTAG, and the
CRUCIFORM systems. More advanced tagging systems incorporate special markers to
indicate whether or not patients have been contaminated by hazardous materials, and also tear
off strips for tracking the movement of patients through the process. Some of these tracking
systems are beginning

Triage outcomes
Evacuation
Simple triage identifies which people need advanced medical care. In the field, triage also
sets priorities for evacuation to hospitals. In S.T.A.R.T., casualties should be evacuated as
follows person is not triaged "decreased" unless they are not breathing and an effort to
reposition their airway has been unsuccessful.
 Immediate or priority 1 (red) evacuation by MEDEVAC if available or ambulance as
they need advanced medical care at once or within'1 hour. These people are in critical
condition and would die without immediate assistance.
 Delayed or Priority 2 (yellow) can have their medical evacuation delayed until all
immediate persons have been transported. These people are in stable condition but
require medical assistance.
 Minor or Priority 3 (green) are not evacuated until all immediate and delayed persons
have been evacuated. These will not need advanced medical care for at least several
hours. Continue to re-triage in case their condition worsens. These people are able to
walk, and may only require bandages and antiseptic.

Alternative care facilities

Alternative care facilities are places that are set up for the care of large numbers of patients,
or are places that could be so set up. Examples include schools, sports stadiums, and large
camps that can be prepared and used for the care, Feeding, and holding of large numbers of
victims of a mass casualty or other type of event. Such improvised facilities are generally
developed in cooperation with the local hospital, which sees them as a strategy for creating
surge capacity. While hospitals remain the preferred destination for all patients, during a
mass casualty event such improvised facilities may be required in-order to divert low-acuity
patients away From hospitals in order to prevent the hospitals becoming overwhelmed.

Secondary (in-hospital) triage

In advanced triage systems, secondary triage is typically implemented by paramedics,
battlefield medical personnel or by skilled nurses in the emergency departments of hospitals
during disasters; injured people are sorted into five categories.
(Black / Expectant: They are so severely injured that they will die of their injuries, possibly in
hours or days (large-area burns, severe trauma, lethal radiation dose), or in life- threatening
medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic
shock, severe head or chest wounds); they should be taken to a holding area and given
painkillers as required to reduce suffering.
  Red / Immediate: They require immediate surgery or other life-saving intervention,
and have first priority for surgical teams or transport to advanced facilities; they
"cannot wait" but are likely to survive with immediate treatment.
 Yellow / Observation: Their condition is stable for the moment but requires watching
by trained persons frequent re-triage will need hospital care (and would receive
immediate priority care under "normal" circumstances).
 Green /Wait (waking wounded): They will require a doctor's care in several hours or
days but not immediately may wait for a number of hours or be told to Go home and
come back the next day (broken bones without compound fractures, many soft tissue
injuries)
 White / Dismiss (waking wounded): They have minor injuries; first aid and. Home
care are sufficient, a doctor's care is not required. Injuries are along the lines of cuts
and scrapes, or minor burns.
Some crippling injuries, even if not life-threatening, may be elevated in priority based on the
available capabilities. During peacetime, most amputations may be triaged "Red" because
surgical reattachment must take place within minutes, even though in all probability the
person will not die without a thumb or hand.

TRIAGE NURSES
Triage nurses are nurses that provide advice to patients over the phone without the benefit of
a face to face consultation. They are not meant to diagnose a patient, b Lit rather to assess the
situation and give advice as needed. They can tell a patient whether they should immediately
seek medical treatment. Many triage nurses are also able to book appointments for physician
that they are associated with.
 PULSE OXIMETRY
Pulse oximetry works on the principle that blood saturated with oxygen is a different colour
from blood depleted of oxygen.
The probe for a pulse oximeter contains a red light source and a detector. These shine through
the tissues of the body and work together to measure the colour difference between
oxygenated and deoxygenated blood.
The machine detects the pulse from an arterial blood source and is able to calculate the
percentage of oxygen saturation by combining the detected colour changes of the blood
combined with the detected pulse of the artery.
Because of the way the pulse oximeter works, it is susceptible to error if it is not able to
accurately measure the transmission of light through the tissues or detect the pulse of the
artery.
Pulse oximetry provides estimates of arterial oxyhemoglobin saturation (sa02) by utilizing
selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin
(Sp02).
 Pulse oximetry may be performed by trained personnel in a variety of settings
including (but not limited to) hospitals, clinics, and the home.
 The need to monitor the adequacy of arterial oxyhemoglobin saturation. The need to
quantitate the response of arterial oxyhemoglobin saturation to therapeutic
intervention or to a diagnostic procedure (e.g. bronchoscopy)
 The need to comply with mandated regulations or recommendations by authoritative
groups.
 Monitoring effectiveness of oxygen therapy
 Sedation or anaesthesia
 Transport of patients who are unwell and r require oxygenation assessment
 Haemodynamic instability (e. g. cardiac failure or Myocardial Infarction)
 Respiratory illness e. g. Asthma, chronic obstructive pulmonary disease
 Monitoring during administration of respiratory depressant drugs, e. g. opiate epidural
or patient-controlled analgesia.

Possible sources of error

Light transmission
 Barriers or obstruction, e. g. Nail varnish, dirt, Foreign objects, bright or fluorescent
room lighting, intravenous dyes used in imaging.
Pulse detection
 Movement, rigors or shivering, poor-circulation, atrial fibrillation vasoconstriction,
arterial constriction or shock.

Limitations of pulse oximetry and oxygen saturation

 Oxygen saturation is only one Factor oxygenation of the tissues.
  In anaemia it. Is possible to have high oxygen saturation readings, but inadequate
amounts of oxygen reaching the tissues.
 Carbon monoxide (CO) exposure will lead to uptake of CO molecules in preference to
02.
 As carboxyhaemoglobin is also bright red it can lead to significant overestimation of
oxygen saturation when using pulse oximeters. Saturations of less than 83% may not
be detected accurately.
 Pulse oximetry must be interpreted in the context of the patient's condition.

Equipment Required
 Pulse Oximeter
 PROCEDURE FOR PULSE OXIMETRY/SPO2

PROCEDURE RATIONAL
Refer to and follow care plan for the To know patient’s normal parameters.
management of the patient’s oxygen
saturations level.

Explain to the patient that an oxygen To ensure the patient understands the
saturation reading is needed and obtain procedure and is able to give valid informed
consent to continue. consent.

Ensure the patient is comfortable and warm To maintain patient comfort. Shivering will
enough, especially it continuous monitoring interfere with the pulse oximeter reading.
is needed.

Check the probe and equipment is clean and To minimize the risk of cross infection and
in good working order. ensure that the equipment is suitable for use.

Decontaminate hands. Use soap and water if To minimize the risk of cross infection.
hands are physically soiled, use alcohol gel
if hands appear clean.

Select a suitable area for the probe (usually N.B. not all probes are suitable for use on
fingertip). Other sites that may be all sites.
considered include ear lobes, bridge of nose
and toes.
Place the probe as directed by the Intravenous dyes, poor perfusion and skin
manufacturer’s instructions assessing any pigmentation will affect the reading.
barriers such as nail varnish, nicotine
staining or dirt.
Proper functions of the pulse oximeter will Make sure that the probe sensor is detecting
only be possible if the probe is placed as the pulse.
intended by the manufacturer.

Ensure that the patient’s pulse is also To assess the rate and character of the
checked manually. patient’s pulse.
Remove the probe and ensure the patient is
comfortable.

Once oxygen saturation monitoring is will minimize the risk of cross infection
complete, clean reusable sensor and
equipment with a Tuffle wipe and return to
storage as appropriate.

Cleaning of the equipment, including the will minimize the risk of cross infection
probe.

Decontaminate hands. Use soap and water if To minimize the risk of cross infection.
hands are physically soiled, use alcohol gel
if hands appear clean.

Record oxygen saturation in the patient’s To comply with trust record

record and inform patient. Also record the To provide a written record of the patient’s
flow concentration of any current oxygen condition and therapy.
therapy in litres per minute.
Record if the measurement was taken with
the patient at rest or walking.
Keeping policies.

Make the patient comfortable. To ensure patient comfort.

If the reading is outside the patient’s Reassure the patient and report immediately
parameters: Check tracing strength. to the case manager or General Practitioner
for further advice and guidance.

Explain result to patient and any necessary To check that the pulse oximetry is working
action needed to change current treatment properly.
plan and by when, if required. Document all To ensure that any patient problems are
actions in patient’s record. communicated.
HAZARDS/COMPLICATIONS
Pulse oximetry is considered a safe procedure, but because of device limitations, false-
negative results for hypoxemia and /or false-positive results for normoxemia or hyperoxemia
may lead to inappropriate treatment of the patient. In addition tissue injury may occur at the
measuring site as a result of probe misuse (e.g. pressure sores from prolonged application or
electrical shock and burns from the substitution of incompatible probes between instruments)

Nursing and Patient Care Considerations

1. Assess patient's haemoglobin. SaO2 may not correlate well with PaO2 if haemoglobin is not
within normal limits.
2. Remove patient's nail polish because it can affect the ability of the sensor to correctly
determine oxygen saturation, particularly polish with blue or dark colours.
3. Correlate oximetry with ABG values and then use for single reading or trending of
oxygenation (does not monitor PacO2).
4. Display heart rate should correlate with patient's heart rate.
5. To improve quality of signal, hold finger dependent and motionless (motion may alter
results) and cover Finger sensor to occlude ambient light.
6. Assess site of oximetry monitoring for perfusion on a regular basis, because pressure ulcer
may occur from prolonged application of probe.
7. Device limitations include motion artefact, abnormal haemoglobins (carboxyhemoglobin
and methemoglobin), I. V. dye, and exposure of probe to ambient light, low perfusion states,
skin pigmentation, and nail polish or nail coverings, and nail deformities such as severe
clubbing.
8. Document inspired oxygen or supplemental oxygen and type of oxygen delivery device.
9. Accuracy can be affected by ambient light, I. V. dyes, nail polish, and deeply pigmented
skin, patients in sickle cell crisis, jaundice, severe anaemia, and use of antibiotics such as
sulphas

Conclusion
Although Pulse oximetry is used in most healthcare delivery settings, the reimbursement has
been either combined with other procedures or reduced to minimal levels. These devices have
become affordable so that today a stethoscope. In spite of the minimal reimbursements or in
most cases the lack of separate reimbursement, the clinical time spent for the procedure
performance and documentation does not seem equitable However, pulse oximetry may
impact medical decision making (MDM) by potentially increasing the amount and
complexity of data ordered or reviewed. Along with documentation of other medically
necessary MDM components, history, and/or physical examination, the, physician may be
able to report an increased visit level and indirectly receive additional payment for pulse
oximetry, when appropriate. Therefore, it is important that clinicians have a thorough
understanding of the evaluation and management guidelines and in particular the MDM
element.
 BLOOD TRANSFUSION
Introduction
Blood transfusion is the process of transferring blood or blood-based products from one
person into the circulatory system of another. Blood transfusions can be life-saving in some
situations, such as massive blood loss due to trauma, or can be used to replace blood lost
during. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia
caused by a blood disease. People suffering from haemophilia or sickle-cell disease may
require frequent. Blood transfusions. Early transfusions used whole blood, but modern
medical practice commonly uses only components of the blood.

Definition
A blood transfusion is a safe, common procedure in which blood is given to a person through
an intravenous (IV) line in one of your blood vessels.

Indications
 Many people who have surgery need blood transfusions because they lose blood
during their operations.
 People who have serious injuries-such as from car crashes, war, or natural disasters-
need blood transfusions to replace blood lost during the injury.
 Some people need blood or parts of blood because of illnesses.
 A severe infection or liver disease that stops the body from properly making blood or
some parts of blood.
 An illness that causes anaemia, such as kidney disease or cancer. Medicines or
radiation used to treat a medical condition also can cause anaemia. There are many
types of anaemia, including aplastic, Fanconi, haemolytic, iron-deficiency, and sickle
cell anaemia and thalassemia.
 A bleeding disorder, such as haemophilia or thrombocytopenia.

Contraindication
 Previous malaria or hepatitis.
 History of drug abuse donors who have received human pituitary hormone.
 Donors with high risk sexual behaviour donors who have previously been transfused.

Procedure
Pre-procedure
Before a blood transfusion, the blood is tested to find out the type of blood group (that is A,
B, AB or O and Rh –positive or Rh-negative). The nurse pricks the patient’s finger with a
needle to get a few drops of blood or draw blood from one of your veins. The blood type
used in transfusion must work with the client’s blood type. If it doesn't, antibodies (proteins)
in blood attack the new blood and the client sick. Some people have allergic reactions even
when the blood given does work with their own blood type. To prevent this, doctor may
prescribe a medicine to stop allergic reactions. Most people don't need to change their diets or
activities before or after a blood transfusion.
Care during the procedure
Blood transfusions take place in either a doctor's office or a hospital. Sometimes they're done
at a person's home, but this is less common. Blood transfusions also are done during surgery
and in emergency rooms. A needle is used to insert an intravenous (IV) line into other
patient's blood vessels. Through this line. The client receive healthy blood. The procedure
usually takes 1 to 4 hours. The time depends on how much blood is needed and what part of
the blood is received. During the blood transfusion, a nurse carefully watches, especially for
the first 15 minutes. This is when allergic reactions are most likely to occur. The nurse
continues to watch during the rest of the procedure as well.
Post procedure care
After a blood transfusion, vital signs are checked (such as your temperature, blood pressure,
and heart rate). The intravenous (IV) line is taken out, Bruising or soreness may be for a few
days at the site where the IV was inserted.

Risk of blood transfusion

Allergic Reactions
Some people have allergic reactions to the blood given during transfusions. This can happen
even when the blood given is the right blood type.
Allergic reactions can be mild or severe. Symptoms can include
 Anxiety
 Chest and/or back pain
 Trouble breathing
 Fever, chills, flushing, and clammy skin
 A quick pulse or low blood pressure
 Nausea (feeling sick to the stomach)
A nurse or doctor will stop the transfusion at the first signs of an allergic reaction. The health
care team determines how mild or severe the reaction is, what treatments are needed, and
whether the transfusion can safely be restarted.
Viruses and Infectious Diseases
Some infectious agents, such as HIV, can survive in blood and infect the person receiving the
blood transfusion. To keep blood safe, blood banks carefully screen donated blood.
The risk of catching a virus from a blood transfusion is very low.
 HIV. Your risk of getting HIV from a blood transfusion is lower than your risk of
getting killed by lightning. Only about 1 in 2 million donations might carry HV and
transmit HIV if given to a patient.
  Hepatitis B and C. The risk of having a donation that carries hepatitis B is about 1 in
205, 000. The risk for hepatitis C is 1 in 2 million. If you receive blood during a
transfusion that contains hepatitis, you'll likely develop the virus.
 Variant Creutzfeldt-Jakob disease (vCJD). This disease is the human version of Mad
Cow Disease. It's a very rare, yet fatal brain disorder. There is a possible risk of
getting vCJD from a blood transfusion, although the risk is very low. Because of this,
people who may have been exposed to vCJD aren't eligible blood donors.
Fever
Patient may get a sudden fever during or within a day of your blood transfusion. This is
usually your body's normal response to white blood cells in the donated blood. Over-the-
counter fever medicine usually will treat the fever.
Iron overload
Getting many blood transfusions can cause too much iron to build up in blood (iron
overload). People who have a blood disorder like thalassemia, which requires multiple
transfusions, are at risk for iron overload. Iron overload can damage your liver, heart, and
other parts of body.
Lung Injury
Although it's unlikely, blood transfusions can damage your lungs, making jt hard to breathe.
This usually occurs within about 6 hours of the procedure.
Most patients recover. However, 5 to 25 per cent of patients who develop lung injuries die
from the injuries.
These people usually were very ill before the transfusion.
Doctors aren't completely sure why blood transfusions damage the lungs. Antibodies
(proteins) that are more likely to be found in the plasma of women who have been pregnant
may disrupt the normal way that lung cells work. Because of this risk, hospitals are starting to
use men's and women's plasma differently.
Acute Immune Haemolytic Reaction
Acute immune haemolytic reaction is very serious, but also very rare. It occurs if the blood
type the client gets during a transfusion doesn't match or work with the patient's blood type.
Patient's body attacks the new red blood cells, which then produce substances that harm
kidneys.
The symptoms include chills, fever, and nausea, pain in the chest or back, and dark urine. The
doctor will stop the transfusion at the first sign of this reaction.
Delayed Haemolytic Reaction
That is a much slower version of acute immune haemolytic reaction. Body destroys red blood
gems so slowly that the problem can go unnoticed until red blood cell level is very low.
Both acute and delayed haemolytic reactions are most common in patients who have had a
previous transfusion.
Graft-Versus-Host Disease
Graft-versus-host disease (GVH D) is a condition in which white blood cells in the new blood
attack your tissues. GVHD usually is fatal. People who have weakened immune systems are
the most likely to get GVHD.
Symptoms start within a month of the blood transfusion. They include fever, rash and
diarrhoea. To protect against GVHD, people who have weakened immune systems should
receive blood that has been treated so the white blood cells can't cause GVHD.