MASS CASUALTY

AND
TRIAGE
“Casualties are a certainty
“Casualties of anyofoperational
are a certainty any
plan – mainly
operational the–enemy’s
plan mainly theif itenemy’s
is a goodifplan,
it is
yours
a goodifplan,
it is not”
yours if it is not”
Brig Rupert
Brig Rupert SmithSmith
 INTRODUCTION
 Medical support plays an imp role in sustenance of
combat effectiveness
 In peace, medical care is focused on individual
casualties
 War is an epidemic of injuries
 Imposes strain on resources in terms of manpower,
skills, time and equipment
 Requires developing a med network for evac of cas
 Time rather than distance alone is a critical factor
Mass Cas are situations where the number of
casMass
are beyond the routine
Cas are handling
situations wherecapacity
the of
anumber of cas are beyond the routine
Medical Establishment
handling capacity of a Medical
Establishment
 DISASTERS
NATURAL
Meteorological
Topological
Biological
MAN -MADE
Accidents
Civil disturbances
Warfare
Refugees
DISASTER MANAGEMENT

 Planned & systematic approach to

understand disasters and attempt to solve
problems arising out of it
 Cannot prevent disasters but minimise it’s

impact
 Contd…
COMMUNICATION, COORDINATION,
CONTROL

PRE-DISASTER PHASE:
Prevention, prediction, planning & preparedness
DISASTER PHASE :
Response, rescue, relief and rehabilitation
Peace time hospitals of the army have well -
designed disaster management plans to act
upon in such situations

Fd med set ups have the advantage of

mobility and can reach the site/near the site
of disaster

The aim however is greatest benefit to

largest number
A significant proportion of managing
mass cas is administrative -
Communication, mob of tpt & other
resources
 PRINCIPLES
-Doing the best for most
-Triage
-Graded care of cas
-FA at site should only be life saving/restoring
vital functions
-Simple & std Rx principles
 GENERAL
 Med activity in fwd areas directed towards
essential treatment to save life and limb
 Prepare for speedy evac to a set up where
facility for adequate treatment exists
 Aim is to give wounded the best chance of
recovery in min time with least possible after
effects
TAC SP AT UNIT LEVEL (ROLE-
1)
 BASIC CARE UNDER MO, SUCH AS
RAP OR MAP
 MIN CAPABILITIES LIKE LOC CAS,
PROVIDING FA AND EMERGENCY
MED CARE, EVAC FROM SITE OF
INJURY TO SAFER LOC, SORTING AS
PER TREATMENT PRECEDENCE,
STABILISING AND PREPARING FOR
EVAC TO NEXT LEVEL
 TAC SP AT ENVIRONMENTAL
COMPONENT LEVEL (ROLE 2)
 ELEMENTS ATT TO LOWEL LEVEL ENV
FORM LIKE ADS WITH A BDE
 CAPABILITY OF EFFICIENT AND RAPID
EVAC OF STABILISED PATIENTS AND
SUSTAINING CARE EN ROUTE,
EMERGENCY LIFE SAVING RESUSCITATIVE
PROCEDURES MAY BE PERFORMED
 REPLENISHMENT OF MED STORES TO
FACILITIES IN ROLE 1
 OPERATIONAL LEVEL
SUPPORT (ROLE 3)
 ELEMENTS ATT TO TASKFORCE SUCH AS
CORPS OR DIV LIKE FSC, BORDER STATIC
HOSP, PERIPHERAL AND MID ZONAL HOSP
DEPLOYED CLOSE TO BORDER
 MIN CAPABILITIES FOR THIS ROLE ARE
RESUSCITATION, INITIAL WOUND
SURGERY, POST OP CARE, SHORT TERM
SURG AND MED INPATIENT CARE
 DIAGNOSTIC SERVICES LIKE X RAY, LAB
 PROVISIONING STOCKING, SUPPLY OF
MED STORES INCLUDING BLOOD AND
FLUIDS
STRATEGIC LEVEL SUPPORT
(ROLE 3)
 HIGHEST LEVEL OF SP LIKE LARGE MIL
HOSP AND VARIOUS REHAB UNITS
 ROLE INCLUDES RECONSTRUCTIVE
SURGERY, DEFINITIVE CARE HOSP,
REHABILITATION, STORAGE AND
DISTRIBUTION OF MED STORES AT
NATIONAL LEVEL, MAJOR REPAIR AND
REPLACEMENT OF MED EQUIP
 MASS CASUALTY
 Resp of GS Br to provide anticipated cas fig for any
battle or campaign
 Planning of med cover on basis of these fig
 Cas – battle and non battle
 Non battle cas 1% of entire field force for total
duration of op
 Fd med units geared to handle cas for peak day
 Peak day will be the intense engagement when max
cas are expected. May or may not be the first day of
engagement
 DOCTRINE OF EVACUATION
 Cas management must start at the place of
trauma
 Must be continued throughout the chain of
evac
 Rearward evac based on clinical condition
only to the point where the casualty gets
commensurate care to enable him to return
to duty early – holding and treating the cas
within the div sector
 DOCTRINE OF EVACUATION
 Past experience shows that probability
of saving life and limb increases
manifold if urgent resuscitative
interventions instituted at the site of
occurrence
 Maintained en route in the chain of
evac till surgical centre
 PRINCIPLES OF EVAC
 Evacuate only if fit to withstand journey
 Evacuate in maximum comfort
 Four hourly staging depending on time
taken to cover the distance from one med
unit to next
 Do not allow patients condition to
deteriorate enroute, maintain transfusion
and other treatment commenced earlier
 CONCEPT OF TRIAGE

 Triage derived from the French word ‘trier’

meaning to sort.

 Triage is an attempt to impose order during

chaos and make an initially overwhelming
situation manageable.
 TRIAGE - DEFINITION
 Triage is the dynamic process of sorting
casualties to identify the priority of treatment
and evacuation of wounded, given the
limitations of the current situation, the mission
and available resources (time, equipment,
supplies, personnel and evacuation
capabilities).
US Dept of Defense
 TRIAGE - DEFINITION

 Medical triage is the categorisation of a patient

or casualty based on clinical evaluation, for the
purpose of establishing priorities for treatment
and evacuation.
United Nations
 TRIAGE- CATEGORISATION
 Goal of Combat Medicine
 Return of the greatest possible number of soldiers to
combat and the preservation of life, limb and
eyesight in those who must be evacuated
 Factors for Triage categorisation
 Requirement of resuscitation
 Surgery requirements
 Prognosis
 TRIAGE
 Triage of cas for treatment and evac
 Classified into following priorities
 Priority I – Cases requiring immediate resuscitation and
urgent surgery
 Priority II – Cases requiring early surgical attention and
possible resuscitation
 Priority III - All other wounded and sick. Generally sitting
cases. Also includes moribund cases
Moribund cases are those who will not be able to
withstand journey on long routes and will consume
resources with doubtful outcome (Priority IV)
I. Extensive burns
II. Multiple injuries
III. Severe head injuries
IV. High & lethal radiation
 TRIAGE
CATEGORIES/PRIORITY
Triage Category Surgery Requirement Resuscitation Prognosis
Requirement
Immediate Life saving surgery Resuscitative measures High with immdt
PI required required measures

Delayed Require early surgery Sustaining treatment Good

but can wait without will be required
P II endangering life

Minimal Not required Not required Can return to

P III active duty in
short time frame
after recovery

Expectant - Only pain relief Survival unlikely

P IV
 ASSESSMENT OF CASUALTIES
 Method of triage
 Triage can be performed rapidly by assessing
 Ability to walk

 Airway

 Respiratory rate

 Pulse rate or capillary return

 PRIORITY I
 GSW abdomen with gross intra-abdominal
haemorrhage due to injury to viscera
 Maxillofacial wounds with compound fractures of
lower jaw and respiratory obstruction
 Sucking chest wounds with tension pneumothorax
 Injury to extremities with compound fracture, gross
muscle wounds and main vessel injuries
 Cases of severe burn in a state of shock
 PRIORITY II
 Abdominal injuries in a good general
condition and fit to be evacuated
 Thoracic injuries with no respiratory
obstruction
 Injuries to extremities with compound
fractures and soft tissue wounds with good
distal pulsations
 Closed cerebral injuries requiring observation
 Moderately severe burns
 ATLS METHODOLOGY
 Primary survey and resuscitation
 A = Airway and cervical spine
 B = Breathing
 C = Circulation and haemorrhage control
 D = Dysfunction of the central nervous system
 E = Exposure
 Secondary survey
 Definitive treatment
 BREATHING
 Check position of trachea, respiratory rate and
air entry
 If clinical evidence of tension pneumothorax
will need immediate relief
 Place venous canula through second
intercostal space in the mid-clavicular line
 If open chest wound seal with occlusive
dressing
 CIRCULATION AND
HAEMORRHAGE CONTROL
 Assess pulse, capillary return and state of neck veins
 Identify exsanguinating haemorrhage and apply direct
pressure
 Place two large calibre intravenous cannulas
 Take venous blood for grouping & cross match
 Give intravenous fluids
 Crystalloid or colloid in adequate volume
 Attach patient to ECG monitor
 Insert urinary catheter
 EXPOSURE
 Fully undress patients
 Avoid hypothermia
TRAUMA SCORING SYSTEMS
Evaluating trauma management and outcome
 Anatomical scoring systems

 Abbreviated injury score

 Injury severity score

 Physiological scoring systems

 Glasgow coma scale

 Trauma score

 Revised trauma score

 TRISS methodology
 GLASGOW COMA SCALE

BEST EYE OPENING RESPONSE

• Spontaneous 4
• To speech 3
• To pain 2
• None 1
BEST VERBAL RESPONSE
• Oriented 5
• Confused 4
• Inappropriate words 3
• Incomprehensible sounds 2
• None 1
BEST MOTOR RESPONSE
• Obeys 6
• Localises 5
• Withdraws to pain 4
• Flexion 3
• Extn 2
• None 1
 GCS
 3- 15
 3 = Worst
 15 = Best
 Based on Eye opening / Best verbal
response / Best motor response
 >=13 Mild Brain injury
 9-12 Moderate injury
 <8 Severe Injury
THANK YOU