Module 6: Task specific response

Topic 6.3: Medical treatment & Triage

Presentation 6.3.1: Triage related to CBRN
Learning objective: To familiarize with triage in relation to CBRN
scenarios
 Triage
• French verb “trier” = to sort

• Assign priorities when resources are limited

• Do the greatest good for the greatest number

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 Triage systems
• Conventional triage:
• Assign priority to those needing immediate life saving interventions

• Disaster triage (field triage):

• maximise survival / minimise disability within available resources

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 Triage Categories:
Patients requiring emergency life-saving
= 1. Immediate (red) treatment

Delay in medical treatment permitted,

= 2. Delayed (yellow) patient generally not able to walk

Relatively minor signs and symptoms,

= 3. Minimal (green) patient is able to walk independently

X= Patient lacks vital life signs and

4. Dead/expectant (black) unresponsive to stimuli
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 TRIAGE in the field
Two types of triage systems that are discussed

• START Triage (Single Triage and Rapid Treatment)

• System based on individual physiological indicators
• Divide victims based on severity of injuries (ABCDE)
• Quick triage (in +/- 30 seconds)

• MASS Triage (Move, Assess, Sort, Send)

• System based on rapid grouping of victims
• Divide victims based on health status
• Verbal commands to separate groups
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START Triage - Physiological effects
Triage category Physiological effects Treatment order

Breathing only after airway is cleared, OR

1. IMMEDIATE Respiratory rate: <9/min, or, >30/min, OR IMMEDIATE TREATMENT
Capillary refill time >2 sec.

Unable to walk, AND,

2. DELAYED Respiratory rate 10-30/min, AND DELAYED TREATMENT
Capillary fill rate ≤ 2 sec

3. MINIMAL Wounded but able to walk independently NO RISK TO LIFE AND HEALTH

Not breathing, even after clearance of NO TREATMENT

4. DEAD/EXPECTANT
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 ALL WALKING PATIENTS

MINIMAL RESPIRATIONS

START Triage
Scheme

PERFUSION

OVER 2 SECONDS

UNDER 2 SECONDS MENTAL STATUS

IMMEDIATE CARE
CAN’T FOLLOW SIMPLE
COMMANDS

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 START Triage Tag
Mettag
• AVPU – alert, verbal, painful,
unresponsive
• BP – blood pressure
• RESP – respiratory rate.

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 MASS Triage System
• M ove the patients into groups – patients with ability or lack of ability to
walk

• A ssess the patients' clinical condition individually – assign triage categories

• S ort the patients to victims collection points

• S end the patients to hospitals or other medical treatment facilities

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 MASS – Step by step action

• Step 1
• Goal: to separate the ambulatory patients

• Action:
• Verbal instructions: ”Everyone who needs medical attention, should walk
to the area marked by the green color”.
• Result: Patients with ability to walk will walk to the designated area

• Result:
• Minimal Group of patients
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 MASS – Step by step action
• Step 2
• Goal: to separate the patients, which do not need immediate medical attention

• Action:
• Verbal instruction: ” Everyone who needs medical attention, should wave using
an arm or a leg so we can find you ”
• Result: patients with ability to move their arms or legs will obey

• Result:
• Delayed Group of patients
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 MASS – Step by step action

• Step 3
• Patients not moving categorized as:
• Immediate (red)
• Dead/expectant (tag)

• Patients not able to walk but able to move belong to the Delayed Group
• Patients able to walk belong to the Minimal Group

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 MASS – Step by step action

• Step 4: Medical assessment of patients not moving:

• Dead (black)
• Tag dead victims

• Differentiate Immediate (red) from expectant (grey)

• Medical assessment required
• Stabilize patients and tag them

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 MASS – Step by step action

• Step 5: Sort patients

• Count the victims in each triage category

• Move the victims to the areas designated for each triage category

• Report number of victims

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 MASS – Step by step action

• Step 6: Treatment and evacuation of patients according to

triage categories

Immediate →Delayed→ Minimal→ Expectant/Dead

• Alternative transportation (buses, minivans) for minimal patients

• Alternative medical treatment facilities for minimal patients

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 MASS – Step by step action

• Step 7
• At the point of care, perform reassessment (re-triage) to confirm the
Immediate and Expectant triage categories and to provide necessary
medical assistance.

• On the scene, manage dead victims

• Potential source of secondary contamination or infection
• Do not move bodies (exception – providing access to living patients)
• Avoid destruction of evidence

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 Summary MASS – Step by step action

1. Verbal instruction: Walk to area  Minimal Group

2. Verbal instruction: Wave an arm or a leg  Delayed Group
3. Tag the Dead victims
4. Perform medical assessment to differentiate Immediate from
expectant
5. Move victims to the designated areas and count the number of victims
in each category. Report this.
6. Medical treatment and evacuation. Priority: Immediate →Delayed→
Minimal→ Expectant
7. Reassessment (re-triage)
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 Decontamination triage
Decontamination triage should be performed after medical triage.
Not all victims require decontamination.

• Ambulatory victims who are symptomatic Highest priority

• Can follow simple directions.
• Easiest to decontaminate

• Non-ambulatory victims

• Ambulatory, non-symptomatic Lowest priority

• Have been exposed to the contaminant
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 At the hospital
• Inform hospital on patient status (Triage Tag)
• Pay attention to the walking wounded (non-triaged patients)
• Decontamination prior to entry into healthcare facilities
• Removal of clothing is highly effective
• Perform re-triage

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 Examples of triage related to CBRN incident
• ANTHRAX
• Patients presenting the initial signs of inhalation anthrax should be
placed in the Immediate category, as early aggressive treatment is
lifesaving. Depending on the numbers of cases and available resources,
patients presenting the late phase of inhalation anthrax should be placed
in the Immediate or Expectant categories.

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 Examples of triage related to CBRN incident
• RICIN
• Triage categories will vary according to severity of illness and available
resources. Respiratory distress would result in placement of the patient in
the Immediate category, if respiratory support was available, or
Expectant if respiratory support was not available. Patients with milder
presentations would be candidates for the Delayed category.

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 Examples of triage related to CBRN incident
• NERVE AGENT
• Immediate: Recovering with antidotes
• Delayed: Mild respiratory distress
• Minimal: Walking, talking, capable of self aid
• Expectant: Unconscious, failed circulation

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 Examples of triage related to CBRN incident
• BLISTER AGENT
• Immediate: Skin injury over 5- 50% of body surface area, moderate to
severe eye injuries
• Delayed: Skin injury < 5% of body surface area, minor eye irritation
• Expectant: Skin injury over 50% of body surface area

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 Examples of triage related to CBRN incident
• Radiological exposure
• Immediate: Raised temperature, continuous vomiting, normal blood
pressure, headache
• Delayed: Normal temperature, no headache, nausea, asthenia
• Expectant: loss of consciousness, systolic blood pressure <80

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 Take Home Message
• Two basic disaster triage systems are START and MASS
• START uses medical assessment of victims
• MASS uses verbal commands for rapid separation of victims in 7 steps
• Triage divides groups of victims into groups
immediate  delayed  minimal  expectant/dead
• Decontamination triage should be performed after medical triage
• (re)Triage should be performed before admitting to the hospital

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 Thank you

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