Triage

Instructor Name:
Title:
Unit:
 Triage – from the French sort
• In casualty management sorting of a large
number of injured personnel is the 1 st stage
in establishing order
• Triage sets the stage for treatment and
eventuates in transport of the injured
 Triage is not to be considered
with finality
• Triage categories change based upon
– Number of injured
– Available resources
– Nature and extent of injuries(s)
– State of hostile threat
 Things change
• Number of patients • Condition of patient
– Gets better
• Extent of resources – Gets worse

– Transport arrives
 If you have only 1 patient
• That patient is Pri 1 Immediate regardless
of anything else
• There is no real need for triage
• Once this number increases, the need for
triage arises
 Categories
• Immediate
– Threat to life/limb
• A lightly injured is immediate if he can be
returned to duty with immediate simple
management
 Urgent
• Patient is at risk if treatment or
transportation is delayed unreasonably
 Delayed
• No risk to life or consequence if more
definitive care is not rendered quickly
 Expectant
• Regardless of the level of care rendered,
patient is likely to expire
• Tough call to make for unit personnel
 START – triage technique
• Simple treat/triage and rapid transport
• All of you within the sound of my voice
– Move towards me

– Doesn’t work well in no/low light or excess

noise
 Military Triage

COL Cliff Cloonan

Assistant Professor
Instructor Name: Military & Emergency
Title: Medicine Department
Unit:
 Triage
• Objectives – Upon completion of this block
of instruction the student will be able to:
Oklahoma City Federal Building Bombing
Oklahoma City Federal Building Bombing
 Triage
• Definition –
– “To Sort”
– From the French word, “trier”
– Has been defined as “doing the greatest good
for the greatest number” BUT triage is simply a
sorting PROCESS that when applied creates a
situation that allows for “doing the greatest
good for the greatest number”
 Triage
• What are the OBJECTIVES of doing Triage?
– Rapid sorting of the more serious patients from those
less serious to facilitate the rapid care of the more
serious patients
– When problems exceed resources, triage should
facilitate “doing the greatest good for the greatest
number”
– Bring order to chaos thus facilitating the care of all
patients
 Triage
• What is the PROCESS?
– Sorting into categories for evacuation and treatment
• What are the DECISIONS?
– How will the patients be sorted – who goes in which
category?
– What will be done to/with the patients when sorted?
• What factors AFFECT/CHANGE the decisions?
– Resources
– Circumstances
 Triage
Sorting Patients
“Normal” Triage in
Triage in TRIAGE - A CONTINUUM A MASCAL
an ED Situation

Special Situations

• Persisting threat to providers/patients

•“Reverse” Triage Situation
“Normal” Triage in
Triage in TRIAGE - A CONTINUUM A MASCAL
an ED Situation
 Triage
• “Military” Disasters Occur In Civilian
Settings
 Triage
• And… “Civilian” disasters occur in military
settings
Truck Accident on Pipeline Rd
Saudi Arabia – Desert Shield
 Resource Disease Process
Modifiers Modifiers
(Manpower, (Illness,
Equipment, Injury,
Expendables, NBC, etc)
Time)

INPUT Triage OUTPUT

(Patients to (Sorted
be sorted) Patients)

Situation Immediate
Modifiers Evacuation Delayed
(Risk, Weather, Modifiers Minimal
MET-T, Combat (Assets, Expectant
Situation, etc…) Distance, Threat)
 Triage
• Military vs. Civilian – Are there differences?
– Continuing risk to medical care providers
• Can occur in both situations
• More common in combat/military triage
– Resource limited
• Can occur in both situations
• More common in combat/military triage
– “Reverse” Triage Situation
• Care provided first to those who when treated can be quickly
returned to duty
• Usually only in a military situation but could occur in a civilian
MASCAL situation (when “Group” survival is at stake)
Civil War
Casualty Collection
Point
Civil War Casualty Collection Poin
and Treatment Station
Vietnam – Mass Heat
Casualties
MASCAL Exercise
 TRIAGE
- A DYNAMIC

NOT

A STATIC PROCESS
 WITHIN THE MILITARY ECHELONED

MEDICAL CARE SYSTEM, TRIAGE OF

CASUALTIES OCCURS (OR SHOULD), AT A

MINIMUM, AT EVERY ECHELON

 MILITARY TRIAGE OFTEN

INCLUDES, BUT IS MORE THAN,

MEDICAL PRIORITIZATION
 APPROPRIATE MEDICAL

PRIORITIZATION AND

TREATMENT OF INJURIES IN

A SINGLE PATIENT IS THE

GOAL OF ADVANCED TRAUMA

LIFE SUPPORT TRAINING

What is the Priority
Injury?
RPG Wound
Right Knee
- Somalia
What is the
Triage Category?

What is the
Evac Priority?
What is the Burn Victim
Priority Injury? - Kosovo

What is the
Triage
Category?

What is the
Evacuation
Priority?
Burn Victim
- Kosovo
 SURGICAL PRIORITIZATION,

WHICH, PRIMARILY INVOLVES A

DETERMINATION OF OPERATIVE

PRIORITY, IS NOT TRIAGE

 Triage
• Surgical Prioritization Involves -
– Recognizing
• Which patients require surgery to save life/limb/sight
– Knowing
• Numbers of OR’s, doctors, nurses, expendables, blood
(Resources) each operation requires
• Resources (manpower, equip, expendables, blood etc)
required to provide post-op care
• How long each operation will take (Time as a resource)
• The resources that each operation will consume (Must
consider manpower as a consumable resource)
• Probability of successful surgery
 Triage
• The Goal of Surgical Prioritization
– Selection of cases with the highest probability
of success that consume the least amount
of resources.
– Make a decision - - and go with it!
• Once a MASCAL situation has been declared don’t
wait for the situation to evolve further before
making a decision.
• Making decisions is more important than what
decisions are made.
– Respect the Triage Decision
Grenade
Fragment
Wound –
Perforating
Bowel
-ICRC Hospital
Afghanistan
Transverse Abdominal
High Velocity Bullet Wound
-ICRC Hospital
Afghanistan
 Triage
• Triage Categories used in ICRC Hospitals
– Category I – Priority for Surgery
• Patients who need urgent surgery and who have a good chance
of satisfactory recovery
– Category II – No Surgery
• Patients with wounds so slight that they do not need surgery
AND…
• Patients who are so severely injured that they are unlikely to
survive
– Category III – Can Wait For Surgery
• Patients who need surgery but not urgently
TRIAGE IN A DISASTER IS A MULTI-
DISCIPLINARY PROCESS. IT IS BEST
CARRIED OUT BY SOMEONE WHO IS
FAMILIAR WITH:

•SURGICAL, MEDICAL, AND

PSYCHIATRIC EMERGENCIES

•ALL THE PRE-HOSPITAL AND HOSPITAL-

BASED MEDICAL AND LOGISTICAL
RESOURCES NECESSARY TO EVACUATE
AND PROVIDE CARE FOR A LARGE
NUMBER OF CASUALTIES
BY DEFINITION, TRIAGE IN A DISASTER /

MASCAL SITUATION MEANS THAT LESS

THAN THE NORMAL STANDARD OF

CARE WILL BE PROVIDED FOR

MANY PATIENTS.
 EXAMPLE:

FAILURE TO PROVIDE COMPLETE

CONTROL OF THE CERVICAL SPINE IN A

PATIENT WITH MULTIPLE BLUNT TRAUMA

INJURIES IS CONSIDERED MALPRACTICE

 EXAMPLE

COMPLETE CERVICAL SPINE

IMMOBILIZATION IS VERY TIME AND

RESOURCE CONSUMING. THE TIME

AND RESOURCES REQUIRED TO

STABILIZE A CERVICAL SPINE MAY

MEAN THAT OTHERS MAY DIE.

ADHERING TO THE PRINCIPLE OF
DOING THE GREATEST
GOOD FOR THE GREATEST NUMBER
MAY REQUIRE THAT LESS
THAN FULL CERVICAL SPINE
IMMOBILIZATION BE PERFORMED
 REMEMBER

IF IT WASN'T ALL "SCREWED" UP

IT WOULDN'T BE A DISASTER
 REMEMBER

NOT ONLY MAY CHANGES IN A PATIENT'S

MEDICAL CONDITION RESULT IN A CHANGE

IN HIS / HER TRIAGE CATEGORY BUT A

CHANGE IN AVAILABLE RESOURCES MAY ALSO

RESULT IN A CHANGE IN TRIAGE CATEGORY

 CAN YOU THINK OF A SITUATION

WHERE IT WOULD EVER BE APPROPRIATE

TO NEGLECT THE MANAGEMENT OF THE

MOST SERIOUSLY WOUNDED IN ORDER TO

TREAT THOSE WITH MORE MINOR INJURIES?

 REMEMBER

A TRIAGE SITUATION IS NOT

DETERMINED BY A SET NUMBER OF

PATIENTS BUT RATHER BY A MISMATCH

OF RESOURCE REQUIREMENTS WITH

RESOURCE AVAILABILITY. A TRIAGE

SITUATION MAY EXIST WHEN THERE ARE

ONLY TWO PATIENTS

 THE DECISION TO NOT RESUSCITATE

A CRITICALLY INJURED PATIENT WHEN

THERE ARE RESOURCES AVAILABLE TO

DO SO IS NOT THE SAME AS PLACING

A PATIENT IN THE EXPECTANT

CATEGORY IN A DISASTER SITUATION

 Triage
• MILITARY TRIAGE DECISIONS ARE
INFLUENCED BY:
– NUMBERS OF PATIENTS AND THEIR MEDICAL
PROBLEMS
– NUMBERS OF EXPENDABLE AND NON-
EXPENDABLE MEDICAL SUPPLIES AND
CAPABILITIES OF MEDICAL TREATMENT
FACILITIES
– NUMBERS AND CAPABILITIES OF MEDICAL
PERSONNEL
 Triage
• MILITARY TRIAGE DECISIONS ARE
INFLUENCED BY(CONT):
– NUMBERS AND CAPABILITIES OF
EVACUATION ASSETS
– TACTICAL SITUATION
– WEATHER
– OTHER
 TERMINOLOGY

CIVILIAN USE OF THE WORD

"TRIAGE" IS OFTEN NOT

THE SAME AS THE MILITARY

USE OF TRIAGE
IN A MULTI-CASUALTY INCIDENT WHERE

THERE ARE ADEQUATE RESOURCES THE

GOAL IS TO RAPIDLY AND EFFICIENTLY

IDENTIFY PATIENT NEEDS AND THEN TO

MATCH THE RESOURCES WITH THE

PATIENTS WHO REQUIRE THEM

 IN A DISASTER SITUATION WHERE

THERE ARE LIMITED RESOURCES THE

GOAL IS TO IDENTIFY PATIENT NEEDS

AND THEN TO DISTRIBUTE THE RESOURCES

IN A MANNER THAT PROVIDES THE BEST

CARE FOR THE MOST POSSIBLE PATIENTS

PROBLEMS WITH STANDARD

TRIAGE TAGS
DON'T CONFUSE TRIAGE

CATEGORIES WITH

EVACUATION PRIORITIES
 Triage
• EVACUATION PRIORITIES
– PRIORITY I – URGENT EVACUATION WITHIN
2 HOURS
– PRIORITY IA - URGENT SURGICAL
EVACUATION TO NEAREST SURGICAL
FACILITY WITHIN 2 HOURS
– PRIORITY II – PRIORITY EVACUATION
WITHIN 4 HOURS
– PRIORITY III – ROUTINE EVACUATION
WITHIN 24 HOURS
– PRIORITY IV - CONVENIENCE
MASS CASUALTY

TEACHING POINTS
 MASCAL
• Field Response
– What / Who do you send to the disaster site?
• Equipment
– Type – Stick with the basics
» Dressings
» Backboards/litter with straps
» Tourniquets
» Airways / suction devices
– Quantity (lots)
• Personnel
– Type (Surgeon, EM…)(MD, Nurse, PA, EMT-P…)
– Quantity
 MASCAL
• Actions on the scene
– Safety and site security FIRST
– Survey the scene
• Estimate number and type of casualties quickly
• Transmit brief initial report to Med Tx Facility
• Request additional equipment (#/type) and
personnel (#/type) as required
 MASCAL
• Actions on the scene (cont)
– Quickly choose a casualty collection point
based upon:
• Proximity to patients
• Proximity to potential helicopter landing site
• Safety – Distance from potential hazards, secure
• Geography – Large enough and appropriate for
conduct of Geographic Triage) Separate sites for -
– Immediate (next to transportation)
– Delayed
– Minimal
– Expectant
– Deceased (out of sight of other victims)
 MASCAL
• Actions on the scene (cont)
– Collect all ambulatory patients at CCP by
instructing them to walk to CCP
• These patients are mostly in the minimal category
although some may be delayed
• What they are NOT is in the Immediate / Expectant
(except in some burn cases) / Dead categories
 MASCAL
• Actions on the scene (cont)
– Put one of the “walking wounded” in charge of
ambulatory patients if limited manpower at
scene
• Most important responsibility is to maintain
accountability and keep patients from leaving CCP
– If more than one medical responder divide the
scene into areas of responsibility and proceed to
rapidly assess / treat / triage all remaining
patients who were unable to walk to the CCP
 MASCAL
• Actions on the scene (cont)
– Initially treat ONLY readily correctable airway
problems and obvious external, potentially life-
threatening, bleeding
– No treatment for pulseless /apneic patients.
– Place comatose patients in lateral decubitus
position – then move on
– Apply triage tag to identify location in CCP
where patient is to be taken
 MASCAL
• Actions on the scene (cont)
– Have non-medical bystanders and uninjured or
minimally injured patients at the scene act as litter
bearers (at least one experienced litter bearer / team)
and move patients to CCP
– Triage Officer at CCP sorts (“triages”) patients into
separate geographic location based on tags
• Performs rapid reassessment and changes triage category as
required
 MASCAL
• Actions on the scene (cont)
– Move rapidly from one patient to next – only
identify and if possible quickly treat life threats
– Identify ALL patients
– Avoid becoming involved in prolonged
procedures
– Avoid becoming distracted by distraught,
minimally injured patients
– Pay attention to administrative concerns – Keep
track of ALL patients (Trust me – you’ll be
glad you did)
 MASCAL
• Actions on the scene (cont)
– Transportation Considerations / Decisions
• Do you put all immediate patients on the first
available ambulance?
• Do you send one of your health care providers if
there is no medical care on the transport
• To what facility do you send the ambulance?
– Travel time
– Level I, II, III trauma center?
• Do you wait for a helicopter?
• How secure is the route of travel?
 MASCAL
• Medical Treatment Facility Actions
– Maintain Communication with the response
team
• Identify the scope of the problem
• Identify the need for additional resources at the
scene
– Medical
– Security
– Administrative
– Transportation – Ground / Air
– Arrange for helicopter transportation as
appropriate
 MASCAL
• Medical Treatment Facility Actions (cont.)
– Notify higher HQ and other medical facilities of the
situation and request that they standby
– Activate Medical Treatment Facility disaster
response plan
• Call in additional staff / keep staff in hospital at end of
shift
• Clear receiving area of all stable patients and set up
additional beds as required
• Cancel any non-emergent surgery
• Clear OR’s ASAP
• Prepare hospital beds
– Request higher echelons preposition ambulance at
your medical treatment facility.
 MASCAL – Major Teaching
Points
• When ability to provide medical care is
overwhelmed – Bringing organization to the
disaster site is the most important action.
• Avoid the overwhelming impulse to rush in
and being to take care of first patient you
come upon
• Make sure that you do not become a
casualty yourself
MASCAL – Major Teaching
Points
• Remember – All the resources that you
have to deal with a disaster did not come
with you to the scene
• Supervising medical care and ensuring the
proper evacuation order and disposition of
patients may not be glamorous but it will
ultimately be the most important
• Keeping track of the disposition of patients
may seem like a waste of manpower but its
not – trust me.
 Triage
• Immediate (examples – not all inclusive)
– Airway
• Generally either must be addressed immediately at which
point patient becomes either
– DELAYED
– DEAD
• Some exceptions
– Breathing
• Correctable on the scene – ie. tension pneumothorax which
when treated may turn patient from IMMEDIATE to
DELAYED
• Uncorrectable on the scene – ie. large pulmonary
contusion/flail chest with hypoxia
– Needs URGENT EVACUATION
 Triage
• Immediate (cont.)
– Circulation
• Exsanguinating hemorrhage
– External – usually correctable with a tourniquet
and/or direct pressure at which point patient
becomes DELAYED
– Internal – URGENT EVACUATION
• Cardiac Tamponade
– Even when treated with pericardiocentesis patient
remains IMMEDIATE because underlying cause is
wound to the heart
 Triage
• Immediate (cont.)
– Disability
• Closed head injury with deteriorating mental
status
• URGENT EVACUATION required
 Triage
• Delayed (examples – not all inclusive)
– All injuries that require surgery but for which a
delay of 4-8 hours will not cause loss of
life/limb/sight
• Penetrating abdominal wounds –
hemodynamically stable
• All fractures requiring ORIF – hemodynamically
stable
• Spinal cord injury – hemodynamically stable
 Triage
• Minimal (example – not all inclusive)
– Minor soft tissue wounds not requiring surgical
intervention
– Non-displaced, min. angulated, closed fractures
of the upper extremities or digits
 Triage
• Expectant
– When resources are adequate no patients are made
expectant
– The creation of this category presumes inadequate
resources and the types of patients included in this
category is largely dependent on the ratio of
resources/patients – the lower the ratio, the more
patients in this category.
– Examples:
• > 50% TBSA 2nd and 3rd degree burns
• Unresponsive patient with an open head wound and
exposed brain
• Documented exposure to > 500 RADs and immediate signs
of radiation sickness
 S.T.A.R.T. - Triage
Classification Protocol

Simple Triage And Rapid Treatment

(adapted from Super, G: START
instructor’s manual)
 Step 1

Yes Able to Walk No

Delayed Assess
Ventilation
Step 2
Ventilation
No Yes
Present
Position
Airway
Ventilation > 30/min < 30/min
Present?
No Yes Assess Cap
Immediate
Expectant Immediate Refill
or Dead
Step 3
Capillary
Refill
Control > 2 sec < 2 sec
Bleeding
Assess
Immediate Mental
Status
Step 4

Mental
Status
Fails to Follow Follows Simple
Simple Commands
Commands
Immediate Delayed