1. Instructor Name: Title: Unit:
Triage
Instructor Name:
Title:
Unit:

2. 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

3. 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

4. Things change Number of patients Extent of resources
Condition of patient
Gets better
Gets worse
Transport arrives

5. 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

6. Categories
Immediate
Threat to life/limb
A lightly injured is immediate if he can be returned to duty with immediate simple management

7. Urgent
Patient is at risk if treatment or transportation is delayed unreasonably

8. Delayed
No risk to life or consequence if more definitive care is not rendered quickly

9. Expectant
Regardless of the level of care rendered, patient is likely to expire
Tough call to make for unit personnel

10. 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

11. Military Triage Instructor Name: Title: Unit: COL Cliff Cloonan
Assistant Professor
Military & Emergency
Medicine Department
Instructor Name:
Title:
Unit:

12. Triage
Objectives – Upon completion of this block of instruction the student will be able to:

13. Oklahoma City Federal Building Bombing

14. Oklahoma City Federal Building Bombing

15. 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”

16. 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

17. Triage 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/with the patients when sorted?
What factors AFFECT/CHANGE the decisions?
Resources
Circumstances

18. Triage Special Situations TRIAGE - A CONTINUUM “Normal” Triage in
an ED
A MASCAL
Situation
Sorting Patients
Special Situations
Persisting threat to providers/patients
“Reverse” Triage Situation

19. “Normal”
Triage in
an ED
TRIAGE - A CONTINUUM
Triage in
A MASCAL
Situation

20. Triage
“Military” Disasters Occur In Civilian Settings

21. Triage
And… “Civilian” disasters occur in military settings

22. Truck Accident on Pipeline Rd
Saudi Arabia – Desert Shield

23. Triage 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)

26. 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
“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)

27. Civil War
Casualty Collection
Point

28. Civil War Casualty Collection Point
and Treatment Station

29. Vietnam – Mass Heat
Casualties

30. MASCAL Exercise

31. TRIAGE
- A DYNAMIC
NOT
A STATIC PROCESS

32. WITHIN THE MILITARY ECHELONED MEDICAL CARE SYSTEM, TRIAGE OF
CASUALTIES OCCURS (OR SHOULD), AT A
MINIMUM, AT EVERY ECHELON

33. INCLUDES, BUT IS MORE THAN, MEDICAL PRIORITIZATION
MILITARY TRIAGE OFTEN
INCLUDES, BUT IS MORE THAN,
MEDICAL PRIORITIZATION

34. TREATMENT OF INJURIES IN GOAL OF ADVANCED TRAUMA
APPROPRIATE MEDICAL
PRIORITIZATION AND
TREATMENT OF INJURIES IN
A SINGLE PATIENT IS THE
GOAL OF ADVANCED TRAUMA
LIFE SUPPORT TRAINING

35. What is the Priority
Injury?
What is the
Triage Category?
Evac Priority?
RPG Wound
Right Knee
- Somalia

36. Burn Victim
- Kosovo
What is the
Priority Injury?
Triage
Category?
Evacuation
Priority?

37. Burn Victim
- Kosovo

38. SURGICAL PRIORITIZATION, WHICH, PRIMARILY INVOLVES A
DETERMINATION OF OPERATIVE
PRIORITY, IS NOT TRIAGE

39. Triage Surgical Prioritization Involves - Recognizing Knowing
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

40. 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

41. Grenade
Fragment
Wound –
Perforating
Bowel
ICRC Hospital
Afghanistan

42. Transverse Abdominal
High Velocity Bullet Wound
ICRC Hospital
Afghanistan

43. 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

44. TRIAGE IN A DISASTER IS A MULTI-DISCIPLINARY PROCESS
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

45. BY DEFINITION, TRIAGE IN A DISASTER / MASCAL SITUATION MEANS THAT LESS
THAN THE NORMAL STANDARD OF
CARE WILL BE PROVIDED FOR
MANY PATIENTS.

46. FAILURE TO PROVIDE COMPLETE CONTROL OF THE CERVICAL SPINE IN A
EXAMPLE:
FAILURE TO PROVIDE COMPLETE
CONTROL OF THE CERVICAL SPINE IN A
PATIENT WITH MULTIPLE BLUNT TRAUMA
INJURIES IS CONSIDERED MALPRACTICE

47. COMPLETE CERVICAL SPINE IMMOBILIZATION IS VERY TIME AND
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.

48. ADHERING TO THE PRINCIPLE OF DOING THE GREATEST
 GOOD FOR THE GREATEST NUMBER
MAY REQUIRE THAT LESS
THAN FULL CERVICAL SPINE
 IMMOBILIZATION BE PERFORMED

49. IF IT WASN'T ALL "SCREWED" UP IT WOULDN'T BE A DISASTER
REMEMBER
IF IT WASN'T ALL "SCREWED" UP
IT WOULDN'T BE A DISASTER

50. NOT ONLY MAY CHANGES IN A PATIENT'S
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

51. CAN YOU THINK OF A SITUATION WHERE IT WOULD EVER BE APPROPRIATE
WHERE IT WOULD EVER BE APPROPRIATE
TO NEGLECT THE MANAGEMENT OF THE
MOST SERIOUSLY WOUNDED IN ORDER TO
TREAT THOSE WITH MORE MINOR INJURIES?

52. 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

53. 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

54. 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

55. Triage MILITARY TRIAGE DECISIONS ARE INFLUENCED BY(CONT):
NUMBERS AND CAPABILITIES OF EVACUATION ASSETS
 TACTICAL SITUATION
 WEATHER
OTHER

56. CIVILIAN USE OF THE WORD THE SAME AS THE MILITARY
TERMINOLOGY
CIVILIAN USE OF THE WORD
"TRIAGE" IS OFTEN NOT
THE SAME AS THE MILITARY
USE OF TRIAGE

57. IN A MULTI-CASUALTY INCIDENT WHERE THERE ARE ADEQUATE RESOURCES THE
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

58. IN A DISASTER SITUATION WHERE THERE ARE LIMITED RESOURCES THE
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

59. PROBLEMS WITH STANDARD
TRIAGE TAGS

60. EVACUATION PRIORITIES
DON'T CONFUSE TRIAGE
CATEGORIES WITH
EVACUATION PRIORITIES

61. 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

62. MASS CASUALTY
TEACHING POINTS

63. 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

64. 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

65. 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)

66. 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

67. 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

68. 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

69. 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

70. 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)

71. 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?

72. 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

73. 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.

74. 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

75. 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.

76. Triage Immediate (examples – not all inclusive) Airway Breathing
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

77. 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

78. Triage Immediate (cont.) Disability
Closed head injury with deteriorating mental status
URGENT EVACUATION required

79. 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

80. 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

81. 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

82. S.T.A.R.T. - Triage Classification Protocol
Simple Triage And Rapid Treatment (adapted from Super, G: START instructor’s manual)

83. Able to Walk No
Yes
Delayed
Assess
Ventilation
Step 1
Present
< 30/min
> 30/min
Immediate
Assess Cap
Refill
Position
Airway
Present?
Expectant
or Dead
Step 2

84. Capillary
Refill
< 2 sec
> 2 sec
Immediate
Control
Bleeding
Assess
Mental
Status
Follows Simple
Commands
Fails to Follow
Simple Commands
Delayed
Step 3
Step 4