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Triage

In casualty management sorting of a large number of injured personnel is the 1st stage in establishing order. Triage sets the stage for treatment and eventuates in transport of the injured

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Triage

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Triage - from the French sort

In casualty management sorting of a large number of injured personnel is the 1st 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

Extent of resources

Condition of patient

Gets better

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

Military & Emergency

Medicine Department

Triage

Objectives - Upon completion of this block of instruction the student will be able to:

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

Triage

"Military" Disasters Occur In Civilian Settings

Triage

And... "Civilian" disasters occur in military settings

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)

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

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

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

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

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


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)