TRIAGE

TRIAGE IN
IN MASS
MASS CASUALTY
CASUALTY
INCIDENTS
INCIDENTS
PRESENTATION ROADMAP

• Definition of Terms
• Basic Principles
• Triage Categories
• Triage Tools
• Success Factors
DEFINITION OF TERMS
Triage
Medical Disaster
Multiple, Major, Mass
Casualty Incidents
BASIC PRINCIPLES
The Aim of Triage

“Principle of Rights”
Spock Principle
Triage is a Dynamic Process
The Applicability of Triage
SERIOUSLY INJURED WALKING INJURED

SINGLE

MULTIPLE
Abundant resources relative to demand

(P = Patient
health care
needs)

Do the best for each individual

 Resources
Do the greatest good overwhelmed
for the greatest number

(P = Patient health care

needs)
The Adaptability of Triage
Military vs. Civilian Triage

Priority is to get Priority is to

as many soldiers maximize survival
back into action of the greatest
as possible. number of victims.
TRIAGE CATEGORIES
 Level I

• Immediate or Critical Care

• Life-threatening
• Delay of a few minutes: Fatal
• Immediate degree of urgency
• Disposition: Immediate
resuscitation and transport
I
I

Examples
• Respiratory arrest
• Airway obstruction
• Sucking Chest Wound
• Cardiac arrest
• Severe bleeding
• Shock
• Unconsciousness
• Respiratory tract burns
• Acute Coronary Syndromes
• Suicidal attempts
• Status epilepticus
 Level II

• Delayed, Acute or Non-

ambulatory Care
• Serious but stable
• Delay of few hours: no impact
• Secondary degree of urgency
• Disposition: depends on patient
condition vs. resources
II
II
Examples
• Open thoracic wound
• Penetrating Abdominal wound
• Severe eye injury
• Avascular limb
• Significant burns other than the face, neck or perineum
• Moderate bleeding
• Conscious patients with head injuries
• Anxiety states
• Multiple fractures
 Level III
• Ambulatory or Primary Care
• Victims who do not require
hospitalization
• Delay: no impact
• Much delayed degree of
urgency
• Disposition: depends on
space availability
III
III

Examples
• Minor bleeding
• Minor soft tissue injuries
• Contusions, sprains
• Superficial burns
• Partial-thickness burns of
<20% BSA
 Level IV

• Expectant or Pending Care

• Dead and Dying
• Delay: no impact
• Much delayed degree of
urgency
• Disposition: custodial care
IV
IV

When to Classify a Victim as Dead

and Dying?
Know Disaster Response Level
1: < 2 hours
2: 2-12 hours
3: 12-24 hours
4: >24 hours
IV < 2 Hours
(Disaster Response Level I)

• Advanced neurological deficits (GCS<8)

• Injuries to the torso and a BP of < 50 mmHg
systolic and below despite initial resuscitation
• Massive burns (>85% BSA)
IV 2 - 12 Hours
(Disaster Response Level II)

• Disaster Response Level 1 victims

• Deteriorating neurovital signs
• Second or third degree burns involving
more than 50% of total BSA
IV 12 - 24 Hours
(Disaster Response Level III)

• Disaster Response Level 2 victims

• Those requiring formal surgical care
• Those requiring prolonged life support in
an intensive care unit
IV 24 Hours
(Disaster Response Level IV)

• Triage Level I victims

 Level V

• No Care
• Unaffected persons
• Delay: no impact
• No degree of urgency
• Disposition: Safe
evacuation
V
V

Examples

• Evacuees
• Relatives of victims
• Onlookers
• Press
 Color Coding

Triage Category Color Code

Level I Red
Level II Yellow
Level III Green
Level IV Black
Level V White
TRIAGE TOOLS
 PRIMARY SECONDARY TERTIARY
SITE Inner Perimeter Outer Perimeter/Safe Outer Perimeter/Safe
GOAL Basic Disaster Patient needs vs. Optimize Individual
Life Support or available resources outcome
“M.A.S.S.”
Triage
TOOLS Available None. More complex and demand more
sophisticated resources
RECOMMEMDATIONS START / Common Sense and Experience
JumpSTART
VALIDATION No MCI Not applicable
primary triage
tool has been
validated by
outcome data.
IMPLEMENTATION Tagging Geographical Geographical
SYSTEM Sorting Sorting
 S.T.A.R.T.
Simple Triage And Rapid
Treatment
 START Triage
All ambulatory patients are initially tagged as Green.

RESPIRATIONS YES Under 30/min

NO
PERFUSION
Over 30/min
Cap refill Cap refill
Position Airway Immediate > 2 sec < 2 sec.

Control
NO YES Bleeding MENTAL
STATUS
Dead or Immediate Immediate
Expectant
Failure to follow Can follow
simple commands simple commands

Immediate Delayed
 Mnemonic

R 30
P 2
M Can do
JumpSTART Triage
 Special Considerations
• AGE: If a victim appears to be a child, use JumpSTART. If a victim
appears to be a young adult, use START.

• NON-AMBULATORY CHILDREN:

– Evaluate using the JS algorithm

– If any RED criteria is satisfied, tag as RED.

– If patient satisfies any YELLOW criteria:

• YELLOW if significant external signs of injury are found (i.e.,

deep penetrating wounds, severe bleeding, severe burns,
amputations, distended tender abdomen)

• GREEN if no significant external injury

• Initial patient assessment and treatment should take less than 30

seconds for each patient.
 Tagging

• Classic
• Fluorescent flagging
ribbons
• Tear-off
• Pre-labeled
 Tagging
REQUIREMENTS DISADVANTAGES
•Durable •Organizational uncertainty
•Visible from great •Tunnel-vision mentality
distances •Some studies: no
•Simple/Self- improvement in patient
explanatory outcome
•Cost effective •Expensive
•Numbered •Delays patient care and
transport
 Geographic Sorting

• Disaster flags
• Chemical light
sticks
• Colored strobe
lights
SUCCESS FACTORS
Pre-planning
Medical Triage Officer
KISS-U Principle