1. Triage for Patients
with Combat Injuries

2. Combat Triage Lecture Outline
Triage definition
Triage categories
The “START” system
Mass Casualty Triage

3. 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”

4. 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

5. 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

6. TRIAGE
IS A DYNAMIC
NOT
A STATIC PROCESS

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. “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

17. “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

18. Overall Scheme for
Modified “START”
Triage

19. General Scheme for Field Triage

20. 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)

21. 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

22. 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

23. 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.

24. 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.

25. 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.

26. 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

27. 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

28. 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)

29. 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

30. 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

31. 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.

32. Example of a commercially available triage tag

33. 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

34. 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

35. 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