Triage (ALS)

Scene Scenario

You and your partner are the first unit to arrive on the scene of a bus explosion.
There seems to be at least 180 victims. You work in an environment where terrorist
activities are commonplace.

A multiple-casualty incident (MCI) is any medical or trauma incident involving

multiple patients.  An MCI is typically declared when the ability of an EMS system to
respond to the situation is challenged.  Traditional triage systems attempt to sort
victims into categories to best determine treatment and transport priorities.
Although no triage system is perfect, effective triage systems improve outcomes.
In the United States, the most common method of prioritizing patients for triage is
the START method.  START (Simple Triage and Rapid Treatment) should be
completed within 30 seconds per patient. START categorizes victims based on their
ability to walk, mental status, and the presence or absence of
ventilation or perfusion.

START Triage Is Based Upon The Simple Mnemonic RPM:

 Respiration
 Pulse
 Mental Status

The first task when performing START is to direct all patients that can walk to
proceed to a designated area. These patients, by definition, are conscious, able to
follow commands, and able to walk. These patients, initially, are all considered
GREEN. Your triage will now begin on the remaining patients who will be triaged as
BLACK, RED, or YELLOW.

At This Point, There Are Only 3 Treatments Provided During START Triage:

 Open the airway and insert an airway

 Apply pressure to bleeding
 Elevate an extremity

It is important to become very familiar with either the START triage system or the

triage system that your agency utilizes. The key to effective triage is preparation
and advanced planning. Remember, triage is not the time to perform time-
consuming treatment. The key to providing the most good to the greatest number
of patients is to effectively triage patients prior to treatment. This way, when more
help arrives, treatment can occur more quickly and efficiently on the higher priority
patients.
Color-Coded Tag System

 Red   - emergent
 Yellow   - urgent
 Green   - non-urgent
 Black   - dead or   injuries   incompatible with life

The BLACK Triage Category

Perhaps the most difficult color-coded assignment is "Black" in the patient that is
not yet dead. These patients have injuries that are either not compatible with life,
or the amount of effort needed to temporarily maintain them would exceed your
present capabilities. It is important to recognize that the goal of triage is to do the
most good for the greatest number of patients. If your number of patients exceeds
your ability to care for all of them in the typical manner, it is important to
remember that effective triaging, without becoming too attached to any one
particular patient, will produce the best results for the most patients.

Secondary Triage

As patients are initially sorted during primary triage, moved to treatment areas,
and taken to emergency departments, it is important to recognize that patient
conditions can change. The patient initially triaged as GREEN with apparent
minor  injuries  may need to be upgraded to YELLOW or even RED if his/her
condition changes.  Secondary triage  is the triage that takes place after patients
are moved to a treatment area.

Pearls of Wisdom

Do not allow emotions or personal sensitivities to impact your triage decisions.

Hospital Notification

It is always a good practice to notify receiving hospitals of the number and types of
patients they may be receiving from a MCI. This notification should occur as soon
as possible to allow the hospital to prepare for incoming wounded. It is also
important to keep the hospital informed of the type of patients they may be
expecting. Will the patients require  decontamination  prior to hospital entry? Will
there be special patients coming to the Emergency Department, i.e. pregnant
patients, handicapped patients, poisoned patients, or other types of patients that
may require special services? Giving the hospital frequent and accurate updates of
what they may expect will allow for preparations to be made in an effort to
maximize hospital care. Some hospitals may declare a disaster in order to mobilize
their workforce and to make more hospital beds available. Hospitals should always
be notified at the earliest possible time of mass casualty incidents.

Documentation During MCI Events

 Documentation of the individual patient may be difficult or even impossible

 Write neatly on   triage   tag
 Write clearly in easy-to-understand language

Glossary

Decontamination  : The process of removing hazardous materials from the body or

clothing of victims or rescuers. Includes the methods of dilution, absorption,
disposal, and (in rare cases only) neutralization.
Injuries  : Any unintentional or intentional damage to the body resulting from acute
exposure to thermal, mechanical, electrical, or chemical energy or from the absence
of such essentials as heat or oxygen.
Secondary Triage  : A type of patient sorting used in the treatment sector that
involves retriage of patients.
START Triage  : A patient sorting process that stands for simple triage and rapid
treatment and uses a limited assessment of the patient's ability to walk, respiratory
status, hemodynamic status, and neurologic status.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.
Triage  : To sort patients based on the severity of their conditions and prioritize
them for care accordingly.
Ventilation  : The process of moving air into and out of the lungs.

References

1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-

Hill.
2. Caroline, N. L. (2013). Nancy Caroline's Emergency Care in the Streets (7th
ed.). Massachusetts: Jones and Bartlett Publishers.
3. Kaplan, L.J. (Updated 2011, December 9). www.emedicine.com.Critical Care
Considerations in Trauma retrieved
from http://emedicine.medscape.com/article/434445-overview.