MASS CASUALTY AND

TRIAGE
 INTRODUCTION
Mass casualty situations may impose
tremendous strain on the available
manpower and resources.
Military mass casualties handling
dependent on
 Severity of Injury
 Medical professionals
 Resuscitation equipment
 Evacuation capabilities
 CONCEPT OF TRIAGE
Triage derived from the French word ‘trier’
meaning to sort.

Triage is an attempt to impose order

during chaos and make an initially
overwhelming situation manageable.
HISTORICAL BACKGROUND
Initial development – Napoleonic wars
France 1800s.

American civil war

 Primary amputation mortality rate: 28%
 Secondary amputation rate: 52%

1900s in emergency departments

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

Medical triage is the categorisation of a

patient or casualty based on clinical
evaluation, for the purpose of establishing
priorities for treatment and evacuation.
United Nations
TRIAGE- CATEGORISATION
Goal of Combat Medicine
 Return of the greatest possible number of
soldiers to combat and the preservation of life,
limb and eyesight in those who must be
evacuated
Factors for Triage categorisation
 Requirement of resuscitation
 Surgery requirements
 Prognosis
Triage Condition and Examples
Category Surgical requirements
Emergent
Immediate Unstable and Airway obstruction/ compromise
requiring surgery Uncontrolled bleeding
within minutes Shock
Urgent Temporarily stable Unstable penetrating or blunt injuries
requiring surgical care of trunk, head, neck, pelvis
within few hours
Threatened loss of limb or eyesight
Multiple long bone fractures
Triage Condition and Examples
Category Surgical requirements
Non
Emergent
Delayed Would require Single long bone fractures
intervention but could Closed fractures
stand significant Soft tissue injuries with significant
delay bleeding
Facial fractures without air way
compromise
Minimal Minor injuries Fractures of small bones
Minor burns, lacerations, abrasions
Triage Condition and Examples
Category Surgical requirements

Expectant

Expectant Non salvagable Penetrating head wounds and high

paients spinal cord injuries
Mutilating explosive wounds involving
multiple anatomical sites and organs
Burns >60% TBSA
 TRIAGE CATEGORIES/PRIORITY
Triage Surgery Resuscitation Prognosis
Category Requirement Requirement
Immediate Life saving surgery Resuscitative High with immdt
PI required measures required measures

Delayed Require early Sustaining treatment Good

surgery but can will be required
P II wait without
endangering life
Minimal Not required Not required Can return to
P III active duty is
short time
frame after
recovery

Expectant - Only pain relief Survival

P IV unlikely
EXAMPLE
OF
TRIAGE
TAG
FLOW OF
PATIENTS
FROM
TRIAGE
AREAS
RESUSCITATION
AREA
ASSESSMENT OF CASUALTIES
Method of triage
Triage can be performed rapidly by
assessing
 Ability to walk 1
 Airway
 Respiratory rate
 Pulse rate or capillary return 2

ATLS
 ATLS methodology
Primary survey and resuscitation
 A = Airway and cervical spine
 B = Breathing
 C = Circulation and haemorrhage control
 D = Dysfunction of the central nervous system
 E = Exposure
Secondary survey
Definitive treatment
TRAUMA SCORING SYSTEMS
Evaluating trauma management and
outcome
Input
 Anatomical scoring systems
Abbreviated injury score
Injury severity score
 Physiological scoring systems
Glasgow coma scale
Trauma score
Revised trauma score
TRISS methodology
TRAUMA SCORING SYSTEMS
Evaluating trauma management and
outcome
Treatment
 Individual patient
 System of patient care
Outcome
 Morbidity
 Mortality
THANK YOU
METHOD FOR TRAIGE
 Airway and cervical spine

Always assume that patient has cervical spine injury

Place in hard collar and keep on until cervical spine has
been 'cleared'
If patient can talk then he is able to maintain own airway
If airway compromised initially attempt a chin lift and
clear airway of foreign bodies
If gag reflex present insert nasopharyngeal airway
If no gag reflex patient will need endotracheal intubation
If unable to intubate will require a cricothyroidotomy
Give 100% oxygen through a Hudson mask
 Breathing
Check position of trachea, respiratory rate
and air entry
If clinical evidence of tension
pneumothorax will need immediate relief
Place venous cannula through second
intercostal space in the mid-clavicular line
If open chest wound seal with occlusive
dressing
 Circulation and haemorrhage
control
Assess pulse, capillary return and state of neck veins
Identify exsanguinating haemorrhage and apply direct
pressure
Place two large calibre intravenous cannulas
Take venous blood for FBC, U+Es, and Cross match
Take sample for arterial blood gasses
Give intravenous fluids
Crystalloid or colloid in adequate volume
Attach patient to ECG monitor
Insert urinary catheter
 Dysfunction
Assess level of consciousness using
AVPU method
 A = alert
 V = responding to voice
 P = responding to pain
 U = unresponsive
Assess pupil size, equality and
responsiveness
 Exposure
Fully undress patients
Avoid hypothermia
 Injury severity score
Makes use of the Abbreviated Injury Scale (AIS)
Its value correlates with the risk of mortality
Patients with immediately or rapidly fatal injuries are excluded.
Injuries are assigned to five body regions
 General
 Head & neck
 Chest,
 Abdominal, 
 Extremities & pelvis
Each type of injury encountered is assigned a value from 1 to 5,
with:
 Minor injury
 Moderate injury
 Severe but not life-threatening injury
 Life-threatening but survival likely
Critical with uncertain survival
 Injury severity score
Highest score, indicating the Body AIS Injury
most severe injury, for each Region
region is selected.
General 1 Ist Degree
Ranked from the highest to
lowest value. burns
Three highest values are then General 3 50% 3rd
used to calculate the injury degree
severity score. burns
Injury severity score = (highest Chest 3 Haemothor
region score)2 + (second ax
highest region score)2 + (third
highest region score)2 Chest 4 Pericardial
Minimum score: 0 injury
Maximum score: 75 Abdomen 5 Ruptured
Mortality rate increases with Liver
score and age
 Mortality (%) according to ISS and
age
Mortality (%) Mortality (%) 50-
Score Mortality (%) >70
<49 69
5 0 3 13
10 2 4 15
15 3 5 16
20 6 16 31
25 9 26 44
30 21 42 65
35 31 56 82
40 47 62 92
45 61 67 100
50 75 83 100
55 89 100 100
GLASGOW COMA SCALE
 REVISED TRAUMA SCORE

Parameter Finding Points

Respiratory rate 10-29 per minute 4
> 29 per minute 3
6-9 per minute 2
1-5 per minute 1
Nil 0
Systolic blood pressure >89 mm Hg 4
76-89 mm Hg 3
50-75 mm Hg 2
1-49 mm Hg 1
Nil 0
 REVISED TRAUMA SCORE
Parameter Finding Points
Glasgow Coma Score 13-15 4
9-12 3
6-8 2
4-5 1
2 0

Revised trauma score = (points for respiratory

rate) + (points for systolic blood pressure) +
(points for Glasgow coma score)
Maximum score (indicating least affected) = 12
Minimum score (indicating most affected) = 0
 TRISS methodology
Trauma and Injury Severity Score (TRISS) was
designed to evaluate trauma care
Calculates expected survival based on patient
characteristics.
Intended to be used to compare outcomes from
different treatment centers.
Components
 Weighted Revised Trauma Score (RTS)
 Injury Severity Score (ISS)
 Score for patient's age
 Coefficients based on blunt versus penetrating trauma