Mass Casualty Triage

Triage

• Triage comes from the French verb "Trier" meaning to sort or choose

Triaging

• The process of sorting two or more patients based on the severity of their conditions
• Establishes priorities for care based on available resources

Triage Classification

• Patients are classified by type and urgency to ensure the right patient is in the right place at the right time with the right care provider

Objective of Triage

• Identify patients requiring immediate care
• Determine the appropriate area for treatment
• Facilitate patient flow and avoid unnecessary congestion
• Provide continued assessment and reassessment of arriving and waiting patients
• Provide information and referrals to patients and families
• Reduce patient and family anxiety and enhance public relations

Principles of Disaster Triage

• Move: Never move a casualty backward against the flow
• Hold: Never hold a critical patient for further care
• Salvage: Prioritize salvage of life over limb
• Treatment: Do not stop treating patients

Disaster Triage Systems

• Simple Triage and Rapid Treatment (START)
• JumpSTART
• Medical Disaster Response (MDR)
• MASS Triage
• Military Triage

Simple Triage and Rapid Treatment (START)

• A prehospital triage system
• Each assessment should only take 15-30 seconds
• Based on the person’s ability to respond verbally, ambulate, and their respiration, perfusion, and mental status (RPM)
• Only involves two interventions: opening the airway and stopping excessive bleeding

START Triage Categories

• Green (Delayed): For all patients who can walk, ask them to move away from the incident area to a specific location
• Yellow (Urgent): Respirations less than 30, perfusion with a pulse less than 2 seconds, and obeys commands
• Red (Critical): Respiration greater than 30, perfusion (capillary refill) greater than 2 seconds, and does not obey commands
• Black (expectant): For individuals who are dead or dying, with no respiration

JumpSTART

• Used to assess children less than 8 years of age
• Respiration (R) is "good" if 15-45 (1 breath/2-4 seconds), critical if less than 15 or greater than 45
• Pulse (P): weak or nonexistent distal pulse = red
• Mental Status (M): Alert, Vocal, Pain, and Unresponsive
• Red is assigned if unresponsive or inappropriate response to pain
• For a young child not breathing on initial assessment, check for a pulse
• If there is a pulse give 5 minutes of ventilatory breaths, if this is not successful classify as black and if breathing is restored classify as red
• AVPU Scale: Alert, Voice, Pain, Unresponsive

MDR or Medical Disaster Response

• Specially trained health personnel evaluate patients
• Permits the triage process to evolve and maximize survival by resulting in a more efficient use of resources
• Incorporates a modified version of triage that substitutes radial pulse for capillary refill
• Secondary Assessment of Victim Endpoint (SAVE) is implemented with limited, austere, field, ALS equipment

Triage Categories by Color

• Red (Highest Priority): Patients needing immediate care and transport; includes those with airway and breathing difficulties, uncontrolled or severe bleeding, decreased level of consciousness, severe medical problems, shock, and severe burns
• Yellow (Second Highest Priority): Able to wait longer before transport up to 45 minutes. Includes burns without airway problems, major or multiple bone or joint injuries, and back injuries with or without spinal cord damage
• Green (Low Priority): Walking wounded who are able to wait several hours for transport. Includes minor fractures and soft-tissue injuries
• Black (Lowest Priority): Patients who are already dead or have little chance for survival. Treat salvageable patients before these patients if resources are limited. Includes obvious death, nonsurvivable injuries, and full cardiac arrest

M.A.S.S. Triage

• Move, Assess, Sort, Send
• Utilizes US military triage categories and handles a large number of casualties in a mass casualty incident (MCI)

“ID-me”!

• Mnemonic for sorting patients during MCI triage
• Utilized effectively in the M.A.S.S. Triage model
  • I – Immediate
  • D – Delayed
  • M - Minimal
  • E – Expectant
  • D - DEAD

Military Triage

• Priority is to get as many soldiers as possible back into action
• Those with the least serious wounds may be the first treatment priority

Civilian Triage

• Priority is to maximize survival of the greatest number of victims
• Those with the most serious but realistically salvageable injuries are treated first

Triage Zones

• Hot Zone: Area immediately adjacent to the incident
  • Minimal triage and medical care only for airway and hemorrhage control, administration of antidotes, and identification of expectant cases
  • All staff are in protective gear
• Warm Zone: At least 300 feet from the outer perimeter of the hot zone, upwind and uphill from the contaminated area
  • Rapid triage takes place to sort victims to provide essential stabilization and commence decontamination
  • All staff wear PPE
• Cold Zone: Area adjacent, uphill, and upwind from the warm zone where decontaminated victims enter
  • Thorough triage is done as victims enter the area
  • Victims are directed to treatment areas based on the severity and nature of injury or illness
  • PPE is maintained