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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.

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triage

Triage

Instructor Name:

Title:

Unit:

triage from the french sort
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 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

Things change
if you have only 1 patient
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
Categories
  • Immediate
    • Threat to life/limb
  • A lightly injured is immediate if he can be returned to duty with immediate simple management
urgent
Urgent
  • Patient is at risk if treatment or transportation is delayed unreasonably
delayed
Delayed
  • No risk to life or consequence if more definitive care is not rendered quickly
expectant
Expectant
  • Regardless of the level of care rendered, patient is likely to expire
  • Tough call to make for unit personnel
start triage technique
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

Military Triage

COL Cliff Cloonan

Assistant Professor

Military & Emergency

Medicine Department

Instructor Name:

Title:

Unit:

triage1
Triage
  • Objectives – Upon completion of this block of instruction the student will be able to:
triage2
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”
triage3
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
triage4
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
triage5

Sorting Patients

“Normal”

Triage in

an ED

TRIAGE - A CONTINUUM

Triage in

A MASCAL

Situation

Triage
  • Special Situations
    • Persisting threat to providers/patients
    • “Reverse” Triage Situation
slide19

“Normal”

Triage in

an ED

TRIAGE - A CONTINUUM

Triage in

A MASCAL

Situation

triage6
Triage
  • “Military” Disasters Occur In Civilian Settings
triage7
Triage
  • And… “Civilian” disasters occur in military settings
slide22

Truck Accident on Pipeline Rd

Saudi Arabia – Desert Shield

slide23

Resource

Modifiers

(Manpower,

Equipment,

Expendables,

Time)

Disease Process

Modifiers

(Illness,

Injury,

NBC, etc)

Triage

INPUT

(Patients to

be sorted)

OUTPUT

(Sorted

Patients)

Immediate

Delayed

Minimal

Expectant

Situation

Modifiers

(Risk, Weather,

MET-T, Combat

Situation, etc…)

Evacuation

Modifiers

(Assets,

Distance, Threat)

triage8
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)
slide27

Civil War

Casualty Collection

Point

triage9
TRIAGE

- A DYNAMIC

NOT

A STATIC PROCESS

slide32
WITHIN THE MILITARY ECHELONED

MEDICAL CARE SYSTEM, TRIAGE OF

CASUALTIES OCCURS (OR SHOULD), AT A

MINIMUM, AT EVERY ECHELON

slide33

MILITARY TRIAGE OFTEN

INCLUDES, BUT IS MORE THAN,

MEDICAL PRIORITIZATION

slide34

APPROPRIATE MEDICAL

PRIORITIZATION AND

TREATMENT OF INJURIES IN

A SINGLE PATIENT IS THE

GOAL OF ADVANCED TRAUMA

LIFE SUPPORT TRAINING

slide35

What is the Priority

Injury?

What is the

Triage Category?

What is the

Evac Priority?

RPG Wound

Right Knee

- Somalia

slide36

Burn Victim

- Kosovo

What is the

Priority Injury?

What is the

Triage

Category?

What is the

Evacuation

Priority?

slide37

Burn Victim

- Kosovo

slide38

SURGICAL PRIORITIZATION,

WHICH, PRIMARILY INVOLVES A

DETERMINATION OF OPERATIVE

PRIORITY, IS NOT TRIAGE

triage10
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
triage11
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
slide41

Grenade

  • Fragment
  • Wound –
  • Perforating
  • Bowel
    • ICRC Hospital
    • Afghanistan
slide42

Transverse Abdominal

  • High Velocity Bullet Wound
  • ICRC Hospital
  • Afghanistan
triage12
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
slide44

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
slide45

BY DEFINITION, TRIAGE IN A DISASTER /

MASCAL SITUATION MEANS THAT LESS

THAN THE NORMAL STANDARD OF

CARE WILL BE PROVIDED FOR

MANY PATIENTS.

slide46

EXAMPLE:

FAILURE TO PROVIDE COMPLETE

CONTROL OF THE CERVICAL SPINE IN A

PATIENT WITH MULTIPLE BLUNT TRAUMA

INJURIES IS CONSIDERED MALPRACTICE

slide47

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.

slide48

ADHERING TO THE PRINCIPLE OF

DOING THE GREATEST

 GOOD FOR THE GREATEST NUMBER

MAY REQUIRE THAT LESS

THAN FULL CERVICAL SPINE

 IMMOBILIZATION BE PERFORMED

slide49

REMEMBER

IF IT WASN'T ALL "SCREWED" UP

IT WOULDN'T BE A DISASTER

slide50

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

slide51

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?

slide52

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

slide53

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

triage13
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
triage14
Triage
  • MILITARY TRIAGE DECISIONS ARE INFLUENCED BY(CONT):
    • NUMBERS AND CAPABILITIES OF EVACUATION ASSETS
    •  TACTICAL SITUATION
    •  WEATHER
    • OTHER
slide56

TERMINOLOGY

CIVILIAN USE OF THE WORD

"TRIAGE" IS OFTEN NOT

THE SAME AS THE MILITARY

USE OF TRIAGE

slide57

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

slide58

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

slide60

DON'T CONFUSE TRIAGE

CATEGORIES WITH

EVACUATION PRIORITIES

triage15
Triage
  • EVACUATION PRIORITIES
    • PRIORITY I – URGENT EVACUATION WITHIN 2 HOURS
    • PRIORITY IA - URGENT SURGICAL EVACUATION TO NEAREST SURGICAL FACILITY WITHIN 2 HOURS
    • PRIORITY II – PRIORITYEVACUATION WITHIN 4 HOURS
    • PRIORITY III – ROUTINEEVACUATION WITHIN 24 HOURS
    • PRIORITY IV - CONVENIENCE
slide62

MASS CASUALTY

TEACHING POINTS

mascal
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
mascal1
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
mascal2
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)
mascal3
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
mascal4
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
mascal5
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
mascal6
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
mascal7
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)
mascal8
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?
mascal9
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
mascal10
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
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 points1
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.
triage16
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
triage17
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
triage18
Triage
  • Immediate (cont.)
    • Disability
      • Closed head injury with deteriorating mental status
      • URGENT EVACUATION required
triage19
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
triage20
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
triage21
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

S.T.A.R.T. - Triage Classification Protocol

Simple Triage And Rapid Treatment (adapted from Super, G: START instructor’s manual)

slide83

Step 1

Able to Walk

Yes

No

Assess

Ventilation

Delayed

Step 2

Ventilation

Present

No

Yes

Position

Airway

Ventilation

Present?

> 30/min

< 30/min

Yes

No

Assess Cap

Refill

Immediate

Expectant

or Dead

Immediate

slide84

Step 3

Capillary

Refill

> 2 sec

< 2 sec

Control

Bleeding

Assess

Mental

Status

Immediate

Step 4

Mental

Status

Fails to Follow

Simple Commands

Follows Simple

Commands

Immediate

Delayed