Post on 16-Jan-2016
Triage for Patients with Combat
Injuries
Combat TriageLecture 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 ?– 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
Able to Walk NoYes
Delayed AssessVentilation
Step 1
VentilationPresent Yes
< 30/min> 30/min
Immediate Assess Capillary
Refill
No
PositionAirway
Ventilation Present?
No Yes
ImmediateExpectantor Dead
Step 2
“START”
Triage
CapillaryRefill
< 2 sec> 2 sec
Immediate
ControlBleeding
AssessMentalStatus
Mental Status
Follows SimpleCommands
Fails to FollowSimple
Commands
Immediate Delayed
Step 3
Step 4
“START”
Triage
Phase 2
Overall Scheme for
Modified “START”
Triage
General Scheme for Field Triage
TriageINPUT(Patients tobe sorted)
OUTPUT(SortedPatients)ImmediateUrgentDelayedExpectant
ResourceModifiers(Manpower,Equipment,Expendables,Time)
SituationModifiers(Risk, Weather,MET-T, Combat Situation, etc.)
Disease ProcessModifiers
(Illness,Injury,NBC, etc)
EvacuationModifiers(Assets,Distance, Threat)
Factors
Affecting
Triage
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.
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.
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 TriageLecture 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