TRIAGE

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LT COL TA AKINBO
FSS BNSC(Hons) RN RM ICN
Ag Chief Matron
MILITARY HOSPITAL LAGOS
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TRIAGE AND MANAGEMENT

OF MASS CASUALTIES
COL SB ONIFADE FSS MSS MBBS MSc MBA ACIPM DIP(French) FMCOG
Ag CMD
MILITARY HOSPITAL LAGOS
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INTRODUCTION
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INTRODUCTION
Triage is derived from Old French word “trier” which
means “to sort”….(to separate, sift or select). It is a
process for sorting injured people into groups based
on their need for or likely benefit from immediate
medical treatment.
Triage is used in hospital emergency rooms, on

battlefields, and at disaster sites when limited medical
resources must be allocated.
75 -85% of fatalities occur within first 20 minutes

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INTRODUCTION (CONT’D)
• It is a method of quickly identifying victims who
have immediate life-threatening injuries & who have
the best chance of surviving.
• A process by which priorities are set for the
management of mass casualties
• In a mass casualty situation, triage aims at doing the
best for the most and not everything for everyone
• Accomplish the greatest medical good for the
greatest number of people
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• Triage consists of rapidly classifying the injured
on the basis of severity of their injuries and their
survival with prompt medical intervention
• It is usually adapted to locally available skills
and resources
• It is the process of determining the priority of
patients’ treatments vis-à-vis the severity of their
conditions
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Primitive triage system classified patients based on:
a. Those who were likely to live, regardless of what
care they received.
b. Those who were likely to die, regardless of what
care they received.
c. Those for whom immediate care might make a
positive difference in outcome.
Modern approaches to triage are more scientific:
Outcome and grading of the victims is frequently
the result of clinical assessments
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Triage procedures are important in the
management of Mass Casualty.
A Mass Casualty incident is an event
which generates more patients at one
time than locally available resources can
manage using routine procedures.
Mass Casualty management requires
exceptional emergency arrangements
and additional or extraordinary
assistance.
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Adequate knowledge and good practice
of Triage, especially during Mass
Casualty management could enhance
efficient use of resources and
consequently safe lives.
It is therefore imperative that officers of
the NAMC have the basic and requisite
knowledge of Triage.
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AIM
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AIM
TO DISCUSS TRIAGE PROCEDURES DURING
MASS CASUALTY MANAGEMENT WITH
STUDENTS OF YOUNG OFFICERS COURSE
(MEDICAL) 35/2020.
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SCOPE
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SCOPE
1. PLANNING A TRIAGE
2. TRIAGE TEAM
3. TRIAGE DOCUMENTATION
4. TRIAGE PROCESS
5. TRIAGE CATEGORIES
6. TYPES OF TRIAGE
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PLANNING A TRIAGE
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PLANNING A TRIAGE
Preparation before an anticipated crisis
 Organisation of the personnel
 Organisation of the space
 Organisation of the infrastructure
 Organisation of the equipment
 Organisation of supplies
 Training
 Communication
 Security
 Convergence reaction = relatives, friends &
the curious (especially the armed ones)
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PLANNING A TRIAGE (CONT’D)
Triage involves a dynamic equilibrium between

needs and resources.
Needs: Number of wounded and types of wounds

Resources:
 Infrastructures/equipment
 Human Resources for Health (HRH)
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THE TRIAGE TEAM
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THE TRIAGE TEAM

• Triage team leader: co-ordinator
• Clinical triage officer
• Head nurse, matron: chief organiser
• Nursing groups
• Follow-up medical groups

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TRIAGE DOCUMENTATION
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TRIAGE DOCUMENTATION
• Include basic information
• Short-form
• Clear
• Concise
• Complete
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TRIAGE DOCUMENTATION (CONT’D)
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TRIAGE PROCESS
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TRIAGE PROCESS
Triage is a dynamic process:
 Begins at the point of injury
 Occurs all along the chain of casualty care
 Occurs at the hospital reception
 Continues inside the hospital wards
 Continuous reassessment of patients
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TRIAGE PROCESS (CONT’D)

Sift: Place patients in main categories: priority
Sort:
 Priority amongst the priorities
 Categorise the most severely injured based on:
o life-threatening conditions (ABC)
o anatomic site of injury
o Red Cross Wound Score
o treatment available in terms of personnel and
supplies
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TRIAGE CATEGORIES
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TRIAGE CATEGORIES
a. Serious wounds: Resuscitation and
immediate surgery.
b. Second priority: Need surgery but can
wait.
c. Superficial wounds: Ambulatory
management.
d. Severe wounds: Supportive treatment.
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Category I: Resuscitation and Immediate

Surgery
Patients who need urgent surgery:
life-saving – and have a good chance
of recovery
• (E.g. Airway, Breathing, Circulation:

tracheostomy, haemothorax, haemorrhaging
abdominal injuries, peripheral blood
vessels)
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AN INJURED VICTIM WITH HAEMOTHORAX
Source: Google Image

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Category II: Need surgery but can wait
Patients who require surgery but not on an

urgent basis.
A large number of patients will fall into this

group (e.g. non-haemorrhaging abdominal
injuries, wounds of limbs with fractures
&/or major soft tissue wounds, penetrating
head wounds GCS > 8)
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Category I for Airway; Category II for debridement
Source: Google Image 30

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Category III: Superficial wounds

(no surgery, ambulatory treatment)
Patients with wounds requiring little or
no surgery.
In practice, this is a large group, including

superficial wounds managed under local
anaesthesia in the emergency room or with
simple first aid measures.
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Multiple Superficial Fragments

(Bones are intact)
Source: Google Image

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Category IV: Very Severe Wounds

(No Surgery, Supportive Treatment)
Patients with such severe injuries that
they are unlikely to survive or would have
a poor quality of survival.
 The moribund or those with multiple major
injuries whose management could be
considered wasteful of scarce resources in a
mass casualty situation.
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WAR WOUNDED IN THE FIELD
WW in the field
(GSW, mine, blast)
100 wounded
30 - 40 % 60 - 70 %
No surgery Hospital care
First Aid 90% Surgery 10% NO Surgery

Dressing
12-15% Head Small wounds

10% Chest Paraplegia
10% Abdomen Quadriplegia
60-65% Limbs Observation
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EPIDEMIOLOGY OF TRIAGE:
SHORT EVACUATION TIME
• Category I 5 - 10%
• Category II 25 – 30%
• Category III 50 - 60%
• Category IV 5 - 7%
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Tagging
• Complements
Triage
• Rapid
Identification
of patient
• Color Coded /
Bar Coded
system
• Plastic
“bands” can
substitute tags
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FLOW OF PATIENT IN TRIAGE
Source:
Source:Google
GoogleImage
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TYPES OF TRIAGE
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TYPES OF TRIAGE
1. Simple triage
2. Advanced triage
In triage classification, different countries use different
triage systems. The most commonly used and
internationally accepted is the 4-color code system
viz:
a. RED: indicates high priority treatment or transfer
b. YELLOW: indicates medium priority
c. GREEN: indicates ambulatory patients
d. BLACK: indicates moribund or dead patients
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Simple Triage
Usually used in a scene of an accident of a
mass-casualty incident (MCI) in order to sort
patients into those who need critical attention
and immediate transportation to the hospital
and those with minor injuries
Can be started before transportation is
available
Patient categorization could be by printed
triage tags of color flagging
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START SYSTEM
START- Simple Triage And Rapid
Treatment
• Created in the 1980’s by Hoag Hospital
and the Newport Beach CA Fire Dept
• Allows rapid assessment of victims
• It should not take more than 15 sec/Pt
• Once victim is in treatment area more
detailed assessment should be made
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START SYSTEM (CONT)
Classification is based on three

items: RPM
• Respiration
• Perfusion
• Mental status evaluation
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START First Step
Can the Patient Walk?
YES NO
Evaluate Ventilation
Green
(Step-2)
(Minor)
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START Step-2
Ventilation Present?
NO YES
Open Airway
Ventilation Present? > 30/Min < 30/min
NO YES
Red/ Immediate
Black
Red/ Immediate Evaluate Circulation
(Step-3)
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START Step-3
Circulation
Absent Radial Pulse Present Radial Pulse
Evaluate Level of
Control
Consciousness
Hemorrhage
Red/
Immediate
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START Step-4
Level of Consciousness
Can’t Follow Simple Can Follow Simple

Commands Commands
Red/ Immediate Yellow/ Delayed
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Contaminated Patients
• Patients with exposure (potential or real)

to contaminants should be tagged as
BLUE
• This category will continue to stay until
patient is adequately decontaminated
then follow START as usual
• Some recommend a “double tagging”
with blue and the standard START color
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START-Overview
Remember …..RPM
• R- Respirations- 30
• P- Perfusion- Radial Pulse
• M- Mental- Follows Commands
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ADVANCED TRIAGE
• In this form of triage, physicians may decide that
some seriously injured patients should not receive
advanced care as they are likely to die despite
treatment
• It is used on patients with less severe injury
• Also used to divert scarce resources away from
patients that have high probability of dying in order
to increase the chances of those more likely to
survive
• It has ethical implications
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ADVANCED TRIAGE (CONT’D)
• In advanced countries, the criterion used

for this category of patient is a trauma
consistent trauma score of ≤3
• It can be assessed using the Triage Revised
Trauma Score [TRTS]
• Another scoring system is the Injury
Severity Score [ISS]
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REVERSE TRIAGE
• Here the less wounded are treated
preferentially to the more severely wounded
• It may be used in war situations where there
is the need for soldiers to return to combat
roles as possible
• It could also be employed in situations where
medical staffers are among the wounded
where it may be advantageous for them to
survive to continue providing care to others
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Triage Tags:
o Comes in different varieties
o Can be nationally standardized according to the
country
o Most commercially available ones:
a. METTAG.
b. SMARTTAG.
c. E/T LIGHT.
d. CRUCIFORM
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Very advanced tagging systems
incorporate special markers to indicate
contamination of the patients by
hazardous substances and detachable
strips for tracking patients’ movt
throughout the process.
Some tracking systems equally
incorporate bar codes scanners & hand-
held computers.
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APPLIED TRIAGE
• This is used to quickly sort out cases in the
early stages of injury.
• First responders may be overwhelmed by
the scope of patients and injuries in the
early phases of a disaster.
• Patient Assist method [PAM] is used to
rapidly establish a Casualty Collecting
Point [CCP].
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APPLIED TRIAGE (CONT’D)

• The responder can inform the casualties by
yelling or speaking over the loud speakers
that “anyone requiring assistance should
move to the selected CCP
• This does many things at once:
a. It identifies patients that are not so badly
injured.
b. It physically decongests the scene & provides
possible assistance to the responders
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APPLIED TRIAGE (CONT’D)

• The responders can then ask people requiring
more assistance to “yell or raise their hands,”
which further identifies casualties that are
responsive but unable to move
• The respondents can now quickly assess the
remaining patients
The LIMITATION of this method is that in
situations of auditory impairment, the victims
may not be able to hear these instructions
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UNDER-TRIAGE & OVER-TRIAGE
Under-triage:
• This is the process of under-estimating the
severity of an illness or injury
• An example is the process of categorizing a
Priority 1[Immediate] patient as Priority
2[Delayed] or even Priority 3 [Minimal]
• Acceptable under-triage rate is 5%
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UNDER-TRIAGE AND OVER-TRIAGE
Over-triage:
 Is the process of over-estimating the level to which
an individual has been wounded or ill
 Example is categorizing Priority 3[Minimal] patient
as Priority 2 [Delayed] or Priority 1 [Immediate]
 Acceptable over-triage rate is 50% in an effort to
avoid under-triage
 Over-triaging may be minimized when triaging is
done by trained hospital medical teams instead of
paramedics or EMTs
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CONCLUSION
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CONCLUSION
• Triage is a method of quickly identifying victims
who have immediate life-threatening injuries and
who have the best chance of surviving.
• Disaster management poses challenges that are
distinct from normal medical practice
• There is paradigm shift in care and transport of
causalities when the number exceeds available
resources. Therefore, there are changes in response
plan and focus, thus mass causality management.
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THANK YOU FOR YOUR RAPT

ATTENTION
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REFERENCES
1. Triage and management of mass casualty. Précis for
young officers’ course medical. Nigerian Army School of
Medical Sciences
2. Trauma, triage and scoring. Available at
www.patient.info/doctor/trauma-triage-and-scoring.
Accessed on 14 August 2017
3. Kilner T; Triage decisions of prehospital emergency
health care providers, using a multiple casualty scenario
paper exercise. Emerg Med J. 2002 Jul;19(4):348-53.
4. Scoring Systems. Available at www.trauma.org. Accessed
on 14 August 2017
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REFERENCES (CONT’D)
5. Husum H, Strada G; Injury Severity Score versus New Injury Severity Score
for penetrating injuries. Prehosp Disaster Med. 2002 Jan-Mar;17(1):27-32.
6. Paffrath T, Lefering R, Flohe S; How to define severely injured patients?-An
Injury Severity Score (ISS) based approach alone is not sufficient. Injury.
2014 Oct;45 Suppl 3:S64-9. doi: 10.1016/j.injury.2014.08.020
7. Eid HO, Abu-Zidan FM; New Injury Severity Score Is a Better Predictor of
Mortality for Blunt Trauma Patients Than the Injury Severity Score. World J
Surg. 2014 Sep 5.
8. Jouni Pousi; 2014: Principles of TRIAGE - Medical point of view
9. World Health Organisation: 2001: Establishing a Mass Casualty
Management system.
10. CJC Igboanusi; 2017: Triage and Management of Mass Casualties. Lecture
delivered to Students of Senior Executive Management Course , Nigerian
Army School of Medical Sciences, Ojo-Lagos.
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TRIAGE

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MILITARY HOSPITAL LAGOS

TRIAGE AND MANAGEMENT

Triage is used in hospital emergency rooms, on

75 -85% of fatalities occur within first 20 minutes

PLANNING A TRIAGE (CONT’D)

Triage involves a dynamic equilibrium between

Needs: Number of wounded and types of wounds

THE TRIAGE TEAM

THE TRIAGE TEAM

• Clinical triage officer

• Head nurse, matron: chief organiser

• Follow-up medical groups

TRIAGE DOCUMENTATION (CONT’D)

 Begins at the point of injury

 Occurs all along the chain of casualty care

 Occurs at the hospital reception

 Continues inside the hospital wards

 Continuous reassessment of patients

TRIAGE PROCESS (CONT’D)

Category I: Resuscitation and Immediate

• (E.g. Airway, Breathing, Circulation:

AN INJURED VICTIM WITH HAEMOTHORAX

Source: Google Image

Category II: Need surgery but can wait

Patients who require surgery but not on an

A large number of patients will fall into this

Category I for Airway; Category II for debridement

Source: Google Image 30

Category III: Superficial wounds

In practice, this is a large group, including

Multiple Superficial Fragments

Source: Google Image

Category IV: Very Severe Wounds

WAR WOUNDED IN THE FIELD

First Aid 90% Surgery 10% NO Surgery

12-15% Head Small wounds

• Category III 50 - 60%

FLOW OF PATIENT IN TRIAGE

START SYSTEM (CONT)

Classification is based on three

START First Step

Can the Patient Walk?

Ventilation Present? > 30/Min < 30/min

Absent Radial Pulse Present Radial Pulse

Can’t Follow Simple Can Follow Simple

Red/ Immediate Yellow/ Delayed

• Patients with exposure (potential or real)

ADVANCED TRIAGE (CONT’D)

• In advanced countries, the criterion used

ADVANCED TRIAGE (CONT’D)

ADVANCED TRIAGE (CONT’D)

APPLIED TRIAGE (CONT’D)

APPLIED TRIAGE (CONT’D)

UNDER-TRIAGE & OVER-TRIAGE

UNDER-TRIAGE AND OVER-TRIAGE

THANK YOU FOR YOUR RAPT

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