Triage for Patients with Combat

Injuries

Combat TriageLecture Outline

• Triage definition

• Triage categories

• The “START” system

• Mass Casualty Triage

Triage Definition

• Definition :– “To Sort”– From the French word “trier” (“to divide into

3 groups”)– 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 Objectives

• 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 Choices

• 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 or with the patients when sorted ?

• What factors AFFECT / CHANGE the decisions ?– Resources– Circumstances

TRIAGE

IS A DYNAMIC

 

NOT

 

A STATIC PROCESS

Things Change, Affecting Triage

• Number of patients

• Extent of resources

• Condition of patient – Gets better– Gets worse

– Transport arrives

The environment may change :

weather

security

night

If you have only 1 patient

• That patient is Priority 1 Immediate almost regardless of anything else

(unless you know there will be additional patients soon and transport assets are limited)

• There is no real need for triage

• Once the number of patients increases, the need for triage arises

The Four Standard U.S. Military Triage Categories

• Immediate

• Urgent

• Delayed

• Expectant

These relate to the speed and priority for transporting the patients from the scene to a medical care facility

Triage Category “Immediate”

• You determine the patient has a threat to life or limb• A lightly injured patient is immediate if he can be

returned to duty with immediate simple and short time frame management

• Usually require emergency treatment to be initiated prior to transfer

• If transport is not truly immediate, should certainly be within one hour

Triage Category “Urgent”

• The patient is at risk if treatment or transportation is delayed unreasonably

• Generally should be transported to medical facility in less than 2 hours

Triage Category “Delayed”

• No risk to life or no bad consequences expected if more definitive care is not rendered quickly

• Ideally should be transported in less than 6 hours, but wait up to 24 hours may be required

Triage Category “Expectant”

• Regardless of the level of care rendered, the patient is likely to expire

• Is a difficult and stressful decision to make for unit personnel

• Comfort care would still be indicated

Examples of Each Triage Category

• Immediate– Airway injuries, unconscious, shock, respiratory

compromise, limb arterial injuries, trunk gunshot wounds, any major bleeding, major truncal burns

• Urgent– Closed proximal limb fractures, extremity burns

• Delayed– Distal extremity injuries, simple lacerations

• Expectant– Open brain injuries, major dismemberment

The “START” Triage System

• “Simple Treat / Triage & Rapid Transport”• To quickly identify the ambulatory patients

(most of whom will be in the delayed triage category) the first medical personnel on scene should shout : “All of you within the sound of my voice who can walk come toward me”

– However this doesn’t work well in low light or darkness or if excess noise

Able to Walk NoYes

Delayed AssessVentilation

Step 1

VentilationPresent Yes

< 30/min> 30/min

Immediate Assess Capillary

Refill

No

PositionAirway

Ventilation Present?

No Yes

ImmediateExpectantor Dead

Step 2

“START”

Triage

CapillaryRefill

< 2 sec> 2 sec

Immediate

ControlBleeding

AssessMentalStatus

Mental Status

Follows SimpleCommands

Fails to FollowSimple

Commands

Immediate Delayed

Step 3

Step 4

“START”

Triage

Phase 2

Overall Scheme for

Modified “START”

Triage

General Scheme for Field Triage

TriageINPUT(Patients tobe sorted)

OUTPUT(SortedPatients)ImmediateUrgentDelayedExpectant

ResourceModifiers(Manpower,Equipment,Expendables,Time)

SituationModifiers(Risk, Weather,MET-T, Combat Situation, etc.)

Disease ProcessModifiers

(Illness,Injury,NBC, etc)

EvacuationModifiers(Assets,Distance, Threat)

Factors

Affecting

Triage

Triage Considerations

• FIELD 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

– TRANSPORT ASSETS– TACTICAL SITUATION– WEATHER

Triage Categories Used In International Committee of the Red Cross (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

BY DEFINITION, TRIAGE IN A DISASTER OR

MASS CASUALTY SITUATION MEANS THAT LESS

THAN THE NORMAL STANDARD OF CARE WILL BE PROVIDED FOR

MANY PATIENTS.

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.

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.

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 Triage

• Actions on the scene :– Safety and site security FIRST– Don’t forget to use Universal Precautions

(gloves, etc.)– Survey the scene• Estimate number and type of casualties quickly• Transmit brief initial report to the Medical

Treatment Facility• Request additional equipment (number & type)

and personnel (number & type) as required

Mass Casualty Management

• Actions on the scene (cont.) :– Quickly choose a casualty collection point (CCP)

based upon :• Proximity to patients• Proximity to potential helicopter landing site• Safety : distance from potential hazards ; secure• Geography : Large enough area appropriate for

geographically separate sites for triaged groups : – Immediate– Urgent– Delayed– Expectant / Deceased (out of sight of other victims)

Mass Casualty Management

• Actions on the scene (cont.) :– Collect all ambulatory patients at Casualty

Collection Point (CCP) by instructing them to walk to the CCP• These patients are mostly in the Delayed

category but some will be Urgent• What they are NOT is in the Immediate or

Expectant (except in some burn cases) or Dead categories

Mass Casualty Management

• Actions on the scene (cont.) :– Put one of the “walking wounded” in charge of

ambulatory patients if there is limited manpower at the scene• Most important responsibility is to maintain

accountability and keep patients from leaving CCP

– If there is 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

Mass Casualty Management

• 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 each victim to identify

location in CCP where patient is to be taken.

Example of a commercially available triage tag

Mass Casualty Management

• 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

– Using a bus to transport the Delayed category patients saves using ambulances for the immediate and urgent patients

Completion of a Mass Casualty Event

• Once all the patients have been transported, the scene can be turned over to non-medical personnel

• Transport of dead (and any body parts) to morgue will then need to be arranged

• Scene should not be cleaned until cleared by law enforcement personnel

Combat TriageLecture Summary

• Use triage only when resources are mismatched with needs

• Don’t forget scene assessment and safety

• Use the “START” triage system if multiple patients

• Set up a CCP & classify patients as Immediate, Urgent, Delayed, or Expectant