Triage

Here we discussing in a WAR:

Introduction:

Modern combat casualty evacuation has become so immediate and efficient that it can result in a mass casualty situation at military treatment facilities (MTFs) within the military medical care system. Consequently, a method of dealing with the conflicting factors of severity of injury, the tactical situation, the mission, and the resources available for treatment and evacuation is essential. Triage is an attempt to impose order during chaos and make an initially overwhelming situation manageable.

Triage is the dynamic process of sorting casualties to identify the priority of treatment and evacuation of the wounded, given the limitations of the current situation, the mission, and available resources (time, equipment, supplies, personnel, and evacuation capabilities).

Triage occurs at every level of care, starting with buddy and medic care, extending through the OR, the ICU, and the evacuation system.

The decision to withhold care from a wounded soldier who in another less overwhelming situation might be salvaged, is difficult for any surgeon or medic. Decisions of this nature are infrequent, even in mass casualty situations. Nonetheless, this is the essence of military triage.

Triage Categories

It is anticipated that triage will be performed at many levels,ranging from the battlefield to the battalion aid station to the field hospital. Traditional categories of triage are Immediate,Delayed, Minimal, and Expectant. This classification scheme is useful for mass casualties involving both surgical and medical patients. An additional category of Urgent has been used to describe surgical patients who need an operation but can wait a few hours.

• Immediate: This group includes those soldiers requiring lifesaving surgery. The surgical procedures in this category should not be time consuming and should concern only those patients with high chances of survival (eg, respiratory obstruction, unstable casualties with chest or abdominal injuries, or emergency amputation).

• Delayed: This group includes those wounded who are badly in need of time-consuming surgery, but whose general condition permits delay in surgical treatment without unduly endangering life. Sustaining treatment will be required (eg, stabilizing IV fluids, splinting, administration of antibiotics,catheterization, gastric decompression, and relief of pain). (The types of injuries include large muscle wounds, fractures of major bones, intra-abdominal and/or thoracic wounds, and burns less than 50% of total body surface area (TBSA).

• Minimal: These casualties have relatively minor injuries (eg, minor lacerations, abrasions, fractures of small bones, and minor burns) and can effectively care for themselves or can be helped by nonmedical personnel.

• Expectant: Casualties in this category have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival would be unlikely. The expectant casualty should not be abandoned, but should be separated from the view of other casualties. Expectant casualties are unresponsive patients with penetrating head wounds, high spinal cord injuries, mutilating explosive wounds involving multiple anatomical sites and organs, second and third degree burns in excess of 60% TBSA, profound shock with multiple injuries, and agonal respiration. Using a minimal but competent staff, provide comfort measures for these casualties.

Alternative Triage Categories

In practice, however, the division of patients into these four categories is not useful for a surgical unit. The casualties should be divided into emergent, nonemergent, and expectant. These divisions are useful in dividing casualties into those requiring further surgical triage (emergent), and those that are less injured, still require care, but have little chance of dying (nonemergent). It is anticipated that 10%–20% of casualties presenting to a surgical unit will be in the emergent category, requiring urgent surgery. The vast majority of wounded will not require intensive decision-making, intervention, and care.

• Emergent: Although this category has been historically subdivided into Immediate (unstable and requiring attention within 15 minutes) and Urgent (temporarily stable but requiring care within a few hours), except in the most overwhelming circumstances, such division is rarely of practical significance. This group of wounded will requireattention within minutes to several hours of arriving at the point of care to avoid death or major disability.

Types of wounds include:

♦ Airway obstruction/compromise (actual or potential).

♦ Uncontrolled bleeding.

♦ Shock.

◊ Systolic BP < 90 mm Hg.

◊ Decreased mental status without head injury.

♦ Unstable penetrating or blunt injuries of the trunk, neck, head, and pelvis.

♦ Threatened loss of limb or eyesight.

♦ Multiple long-bone fractures.

• Nonemergent: This category was historically divided between Delayed (would require intervention, however, could stand significant delay) and Minimal. This is the group of patients that, although injured and may require surgery, does not require the attention of the emergent group and lacks significant potential for loss of life, limb, or eyesight. Examples include:

ο Walking wounded.

ο Single long-bone fractures.

ο Closed fractures.

ο Soft tissue injuries without significant bleeding.

ο Facial fractures without airway compromise.

• Expectant: This group of wounded, given the situation and resource constraints, would be considered unsalvageable. Examples may include:

ο Any casualty arriving without vital signs or signs of life, regardless of mechanism of injury.

ο Transcranial gunshot wound (GSW).

ο Open pelvic injuries with uncontrolled bleeding; in shock, with decreased mental status.

ο Massive burns.

• Special categories: Patients who do not easily fit into the above categories and casualties who pose a risk to other casualties, the medics, and the treatment facility, may require special consideration:

ο Wounded contaminated in a biological and/or a chemical battlefield environment. The threat posed by these patients mandates decontamination prior to entering the

treatment facility. Appropriately protected medical personnel may treat emergent casualties prior to decontamination.

ο Retained, unexploded ordnance: These patients should be segregated immediately. See Chapter 1, Weapons Effects and Parachute Injuries, which describes the special

handling of these wounded.

ο Enemy Prisoners of War (EPWs)/Internees: Although treated the same as friendly casualties, it is essential that the threat of “suicide bombers” and “human booby traps”

be prevented by carefully screening all EPWs prior to moving into patient areas, including the triage area. See Chapter 34, Care of Enemy Prisoners of War/Internees.

Combat stress: Rapid identification and immediate

segregation of stress casualties from injured patients will

improve the odds of a rapid recovery. With expeditious care

these casualties can be returned to duty (80%). Do not use

them as litter bearers as this may increase the trauma you

seek to treat.

Place patient in one of two groups.

♦ Light stress: Immediate return to duty or return to unit

or unit’s noncombat support element with duty

limitations and rest.

♦ Heavy stress: Send to combat stress control restoration

center for up to 3 days reconstitution.

♦ Use BICEPS mnemonic where resources/tactical

situations allow.

◊ Brief: Keep interventions to 3 days or less of rest,

food, reconditioning.

◊ Immediate: Treat as soon as symptoms are

recognized—do not delay.

◊ Central: Keep in one area for mutual support and

identity as soldiers.

◊ Expectant: Reaffirm that we expect return to duty

after brief rest; normalize the reaction and their duty

to return to their unit.

◊ Proximal: Keep them as close as possible to their unit.

This includes physical proximity and using the ties

of loyalty to fellow unit members. Do this through

any means available. Do not evacuate away from

the area of operations or the unit, if possible.

◊ Simple: Do not engage in psychotherapy. Address

the present stress response and situation only, using

rest, limited catharsis, and brief support (physical

and psychological).

◊ Or, refer: Must be referred to a facility that is better

equipped or staffed for care.

Triage is a fluid process at all levels, with altered situations

and resources requiring a change in category at any time

and in any setting. In the extreme example, a casualty may

be triaged from emergent to expectant during surgery,

abruptly terminating the procedure (“on-the-table triage”).

Resource Constraints

Including all of the factors that influence triage decision

making would be encyclopedic and of little benefit. Rather, a framework for thinking about this process in a logical fashion

is presented here.

External factors. The surgeon/medic may have limited

knowledge of and no control over external issues.

Nonetheless, optimal casualty care requires at least an

assessment of these factors.

ο Tactical situation and the mission. The decision to commit

scarce resources cannot be based on the current tactical/

medical/logistical situation alone. One severely wounded,

resource-consuming casualty may deplete available

supplies, and thus prevent future, less seriously injured

casualties from receiving optimal care. Liaison with the

tactical force operating in your area is essential to making

sound triage decisions. Operational security may make this

kind of information difficult to obtain in a timely fashion.

Education of, and communication with, line commanders

about the critical nature of this information is essential.

ο Resupply: Having a sense of how and when expended

internal resources will be resupplied may prove critical to

making the decision to treat or not treat the individual

casualty.

ο Time.

♦ Evacuation to the MTF. The shorter this time interval,

expect the complexity of triage decisions to increase,

especially sorting the worst emergent patients from the

expectant. Longer intervals will result in the opposite, with

“autotriage” of the sicker patients from the emergent to

the expectant/dead on the battlefield category.

♦ Time spent with the individual casualty. In a mass

casualty situation, time itself is a resource that must be

carefully triaged/husbanded. All patients receive an

evaluation, but only some receive operative

intervention. Time on the OR table is usually the choke

point. Apply the concepts of damage control to

minimize the time casualties spend in surgery. On-table

triage to expectant may be necessary due to

deteriorating casualty physiologic response and/or the

pattern of injury (aorta-vena cava GSW, dual exsanguination sites, extensive pancreatic-duodenal

injury, and so forth).

♦ Evacuation out. Casualties must move expeditiously

to the next echelon of care (EOC), otherwise valuable

local resources will be consumed in maintaining

patients, thereby preventing additional patients from

receiving care.

Internal factors. These issues are known to the surgeon/

nurse/medic and should be factored into triage decisions.

ο Medical supplies. These supplies include equipment,

drugs, oxygen, dressings, sutures, sterilization capability,

blood, etc. Immediate liaison with the logistics system in

the MTF and the theater of operation is essential to ensure

the availability and timely resupply of these items, to

include “surge” capabilities and local resource availability.

ο Space/Capability. This category includes the number of

OR tables and ICU beds: the holding capacity and ward

capacity; and the available diagnostic equipment—

ultrasound (US), X-ray, computed tomography (CT)—and

laboratory tests. For example, if your MTF has the only

CT scanner in theater, plan for an increased number of

head-injured patients.

ο Personnel. This includes knowing the professional

capability (type and experience of individual physician/

nurse/medic), and the emotional stability, sleep status, and

so forth, of your hospital personnel. This perishable

resource must be preserved; for example, 24 hours of

continuous operation may exhaust your only OR crew, and

may necessitate diversion of casualties to another facility.

ο Stress. Soldiers, including medical personnel, are

affected by the consequences of war; individual and unit

capability is degraded during sustained operations. The

personal impact of military triage on the medical team

cannot be overemphasized. It is extremely emotional,

and measures should be undertaken to minimize these

effects. This is best provided by trained staff. Cohesive

groups may tolerate stress better and assist each other

in dealing with traumatic events when allowed to