Triage for Patients with Combat Injuries

Combat Triage Lecture 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 ? What are the DECISIONS ? 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

“START” Triage Able to Walk No Yes Step 1 < 30/min > 30/min Delayed Assess Ventilation Step 1 Present < 30/min > 30/min Immediate Capillary Refill Position Airway Present? Expectant or Dead Step 2

“START” Triage Phase 2 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 Delayed Immediate

Overall Scheme for Modified “START” Triage

General Scheme for Field Triage

Triage Factors Affecting Triage Resource Modifiers (Manpower, Equipment, Expendables, Time) Disease Process Modifiers (Illness, Injury, NBC, etc) Triage INPUT (Patients to be sorted) OUTPUT (Sorted Patients) Immediate Urgent Delayed Expectant Situation Modifiers (Risk, Weather, MET-T, Combat Situation, etc.) Evacuation Modifiers (Assets, Distance, Threat)

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.

RESULT IN A CHANGE IN TRIAGE CATEGORY. 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.

A TRIAGE SITUATION IS NOT DETERMINED BY A SET NUMBER OF 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 Triage Lecture 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