Mihail Păduraru
BEING FAMILIAR WITH MEDICAL TRIAGE, THAT IS A SYSTEM USED TO CATEGORIZE INJURED IN ORDER TO OPTIMIZE EFFICIENCY, IS ESSENTIAL FOR DELIVERING OPTIMAL MEDICAL AID TO TRAUMA CASUALTIES AND WILL SAVE LIVES
TRIAGE : FRENCH TERM THAT MEANS TO SORT OR SELECT IS THE DYNAMIC PROCESS OF SORTING CASUALTIES TO PROVIDE THE GREATEST GOOD FOR THE GREATEST NUMBER OF CASUALTIES
“The best for the most with the available resources”
PRINCIPLES OF TRIAGE
TREATMENT OF MULTIPLE CASUALTIES EXCEEDING THE AVAILABLE RESOURCES = LIMITED TO THE AMOUNT OF EQUIPMENT / PERSONNEL
SORTING BY PRIORITY
TREAT THE PREVENTABLE DEATHS BY PRIORITY (MARCH)
ALSO GET THE WALKING WOUNDED BACK INTO ACTION
GOAL TO DO THE MOST GOOD FOR THE MOST PEOPLE (SOME CASUALTIES WILL NOT RECEIVE NEEDED TREATMENT)
THE LARGER NUMBER OF CASUALTIES OR THE FEWER RESOURCES TO RESPOND, THE MORE INCREASES THE IMPORTANCE OF ACCURATE TRIAGE
HISTORY – FIRST RECORD
FIRST APPLICATION ON NAPOLEON’S BATTLEFIELDS
BARON DOMINIQUE-JEAN LARREY (1766–1842), NAPOLEON’S SURGEON, ESTABLISHED AN AMBULANCE CORPS AND SYSTEM FOR PRIORITIZING WOUNDED FOR EVACUATION
WW I
CHEMICAL WARFARE AND MACHINE GUNS INCREASED THE NUMBER OF CASUALTIES and forced medics to use triage techniques to sort larger numbers of wounded
WW II
THE CONCEPT OF “BUDDY CARE” EMERGED
Every soldier was given a first aid kit & a tourniquet
KOREAN WAR
FIRST AERIAL EVACUATIONS
Mortality rates for soldiers sustaining wounds during combat decreased to less than 30%
VIETNAM WAR
Time from wounding to surgical care decreased from hours to minutes
PRESENT DAY
TRIAGE TOOK ON ITS MODERN FORM IN IRAQ AND AFGHANISTAN WARS
The troop mortality rate is less than 20%
TRIAGE NEEDS
A DECISIVE PLAN
SOMEONE TAKING CHARGE AND TASK ORGANIZING
MEDICAL EQUIPMENT (initially you will never have enough)
METHOD OF MARKING CASUALTIES
IT IS VERY IMPORTANT THAT CASUALTIES ARE PROPERLY MARKED
TRIAGE TOOLS
ASSISTS GETTING A PROPER ACCOUNTABILITY OF CASUALTIES
SHOWS CASUALTY WAS ALREADY CHECKED
AVOIDS UNNECESSARY RECHECKING
TRIAGE DOCUMENTATION
A PROPER DOCUMENTATION ON EACH CASUALTY
A CASUALTY CARD PER CASUALTY
MASTER TRACKER OF ALL THE CASUALTIES COVERING
CASUALTY NUMBER
WOUNDS SUSTAINED
ASSIGNED TRIAGE GROUP
EVACUATION PRIORITY
TRIAGE CATEGORIES
T1 – IMMEDIATE
THOSE CASUALTIES THAT NEED IMMEDIATE MEDICAL ATTENTION TO SAVE THEIR LIVES
UNRESPONSIVE
ALTERED MENTAL STATUS
RESPIRATORY DISTRESS
UNCONTROLLED HEMORRHAGE
AMPUTATIONS PROXIMAL TO THE ELBOW OR KNEE
SUCKING CHEST WOUNDS
UNILATERAL ABSENT BREATH SOUNDS
CYANOTIC PATIENT
ABSENT OR VERY WEAK RADIAL PULSES
T2 – DELAYED
THOSE CASUALTIES WHO ARE IN NEED OF DEFINITIVE MEDICAL CARE, BUT SHOULD NOT DECOMPENSATE RAPIDLY IF CARE IS DELAYED INITIALLY
DEEP LACERATIONS WITH BLEEDING CONTROLLED WITH GOOD DISTAL CIRCULATION
OPEN FRACTURES
ABDOMINAL INJURES WITH STABLE VITAL SIGNS
AMPUTATED FINGERS
STABLE HEAD INJURES WITH AIRWAY INTACT
T3 – MINIMAL
THOSE CASUALTIES WHO ARE WALKING WOUNDED
VITAL SIGNS ARE STABLE
REQUIRE MEDICAL ATTENTION BUT IT CAN BE DELAYED FOR DAYS, IF NECESSARY, WITHOUT ADVERSE EFFECT BECAUSE PATIENTS SUFFER FROM MINOR INJURIES TO INCLUDE:
ABRASION
CONTUSIONS
MINOR LACERATIONS
GET THEM BACK INTO ACTION!
T4 – EXPECTANT
THOSE CASUALTIES THAT HAVE LITTLE OR NO CHANCE FOR SURVIVAL DESPITE MAXIMUM THERAPY
INITIALLY, RESOURCES SHOULD NOT BE DIRECTED TOWARDS THIS GROUP OTHER THAN COMFORT CARE
AS THE TRIAGE EVENT PROGRESS AND RESOURCES BECOME AVAILABLE, EVERY EFFORT SHOULD BE FOCUSED ON SAVING THEM AS WELL
DO NOT FORGET THEM!!!!!
DEAD
CASUALTIES THAT HAVE OBVIOUS FATAL WOUNDS AND NO SIGNS OF LIFE ARE TREATED AS T-4 AND EXPECTANT, UNTIL YOU CONFIRM THEY ARE DEAD DURING TRIAGE AND RE-TRIAGE
TREAT THESE CASUALTIES WITH THE UTMOST RESPECT!
TCCC IN RELATION TO TRIAGE
TRIAGE ON THE BATTLEFIELD PRESENTS ITS OWN CHALLENGES THAT ARE DIFFERENT THAN IN A CIVILIAN ENVIRONMENT
TRIAGE WILL VARY DEPENDING ON THE PRESENT PHASE OF TCCC
CARE UNDER FIRE
TACTICAL FIELD CARE
COMBAT CASUALTY EVACUATION CARE
CARE UNDER FIRE
FOCUS ON THE IMMEDIATE DANGER
ELIMINATE THE THREAT
IDENTIFY AND TREAT CASUALTIES WITH IMMEDIATE LIFE THREATENING INJURIES
GET THE CASUALTY TO A MORE SECURE LOCATION
TACTICAL FIELD CARE
ESTABLISH A SECURE PERIMETER
EXPECT THE ENEMY TO COUNTER ATTACK WITHOUT WARNING
CASUALTIES SHOULD BE PLACED INTO THE TRIAGE
CATEGORIES AND PRIORITIZED FOR EVACUATION
PROVIDE CASUALTIES WITH HIGHER LEVEL OF CARE
FOCUS ON T1 CASUALTIES FIRST
REASSESS T2
BUDDY CARE RENDERED TO THE TO GET THEM BACK IN THE FIGHT T3
COMBAT CASUALTY EVACUATION CARE
CASUALTIES MUST BE RE-TRIAGED
AS CASUALTIES ARE EVACUATED GREATER RESOURCES WILL BECOME AVAILABLE
THE T4 GROUP SHOULD BE EVACUATED TO PROVIDE BETTER CARE
IF EXCESS OF RESOURCES EXISTS, THEN RESUSCITATION SHOULD BE CONSIDERED
ASSESS THE SITUATION APPROACH
ASSESS SITUATION “Is the scene safe?” From…
ENEMY
ENVIRONMENTAL ISSUES
RETURN FIRE
ESTABLISH SECURITY
PRIORITIZE “How many casualties do I have?”
ESTABLISH CCP – CASUALTY COLLECTION POINT
“Is the scene safe?”
CASUALTY COLLECTION POINT (CCP)
THE ESTABLISHMENT OF A CCP IS VERY IMPORTANT TO SET UP PRIOR TO BEGINNING OF THE TRIAGE
THE CCP SHOULD BE EASY TO DEFEND
EVERYONE SHOULD KNOW WHERE IT IS
ALSO EVERYONE SHOULD KNOW WHERE THE TRIAGE CATEGORIES ARE DESIGNATED IN THE CCP
THE SENIOR MEDIC NEEDS TO SITUATE HIMSELF WHERE HE CAN OVERSEE EVERYTHING AND BE EASILY FOUND BY THE TRIAGE PARTY IF NEEDED
THE JUNIOR AND SENIOR MEDIC NEED TO EASILY COMMUNICATE WITH EACH OTHER
THE MEDEVAC HLZ SHOULD BE IN A CLOSE PROXIMITY OF THE CCP
THE CCP LOCATION MAY CHANGE DEPENDING ON THE SITUATION
SALT3 TRIAGE PROCESS
SORT
ASSESS
LIFE SAVING INTERVENTIONS
TRIAGE: ASSIGN CATEGORY
TREATMENT, FURTHER
TRANSPORT
STEP 1 – SORT
GLOBAL SORTING
START BY GLOBALLY SORTING PATIENTS INTO GROUPS BASED ON VOICE COMMAND
ASK: “IF YOU ARE INJURED AND CAN WALK PLEASE MOVE OVER TO ME”
CASUALTIES WHO MOVED TO YOUR LOCATION HAVE THEM PROVIDE BUDDY AID TO THEMSELVES
THEN YOU SHOULD ASK:“IF YOU CAN, PLEASE WAVE YOUR HAND OR LEG, I WILL COME TO YOU”
CASUALTIES THAT DO NOT RESPOND OR HAVE OBVIOUS LIFE THREATENING INJURIES SHOULD BE ASSESSED FIRST
CASUALTIES THAT CAN WAVE AN ARM OR LEG SHOULD BE ASSESSED SECOND
THEN REASSESS THE BUDDY AID CASUALTIES WHEN TIME PERMITS
PRIORITY 1: STILL / OBVIOUS LIFE THREAT
PRIORITY 2: WAVE / PURPOSEFUL MOVEMENT
PRIORITY 3: WALKING
STEP 2 – ASSESS
INDIVIDUAL ASSESSMENT
SHOULD BE INITIATED ONCE CASUALTIES ARE SORTED ACCORDING TO STEP 1, THEN
CASUALTIES ARE ASSESSED USING THE MARCHON ACRONYM
FOR:
MASSIVE BLEEDING
AIRWAY OBSTRUCTION
RESPIRATORY IMPAIRMENT
THESE PROCEDURES ARE TIME LIMITED, THE MEDIC SHOULD MOVE QUICKLY TO THE NEXT CASUALTY
THIS STEP GOES HAND AND HAND WITH STEP 3
ASSESS IF THE CASUALTY
HAS MAJOR UNCONTROLLED HEMORRHAGE
OBVIOUS SEVERE BLEEDING
NON-OBVIOUS: BLOOD SWEEPS
HAS AIRWAY ISSUES
OPEN AIRWAY
LOOK / LISTEN / FEEL
CONSIDER TWO BREATHS FOR NON-BREATHING
IS IN RESPIRATORY DISTRESS
EXPOSE AND INSPECT NECK AND CHEST LOOKING FOR PENETRATING / BLUNT TRAUMA
OBEYS COMMANDS
HAS RADIAL PULSE
MEDIC MUST ASSESS IF
THE CASUALTY IS UNLIKELY TO SURVIVE GIVEN THE OBSERVED INJURIES AND AVAILABLE RESOURCES
THE CASUALTY NEEDS LIFE SAVING INTERVENTION
THE CASUALTY INJURIES APPEAR TO BE MINOR INJURIES FOR WHICH A DELAY IN CARE WILL NOT INCREASE MORTALITY
STEP 3 – LIFE SAVING INTERVENTION
STEP 3 GOES HAND IN HAND WITH STEP 2
IT IS LIMITED TO:
M: CONTROL MASSIVE BLEEDING
TOURNIQUET
PACK WITH GAUZE + APPLY PRESSURE BANDAGE
A: FREE AIRWAY
OPEN BY POSITIONING THE HEAD AND OR BODY
(recovery position or sitting up)
AIR WAY ADJUNCT – NPA, KING LT, CRIC
R: AVOID / TREAT TENSION PNEUMOTHORAX
SEAL OPEN CHEST WOUNDS WITH OCCLUSIVE DRESSING
NEEDLE DECOMPRESSION
STEP 4 – TRIAGE
T1 – IMMEDIATE
T2 – DELAYED
T3 – MINIMAL
T4 – EXPECTANT
DEATH
ASSIGN CATEGORY
ASSIGN CASUALTIES TO 1 OF THE 5 CATEGORIES
DO NOT CONFUSE TRIAGE CATEGORIES WITH MEDEVAC CATEGORIES, THEY ARE DIFFERENT
THIS PROCESS CAN BE POSTPONED UNTIL THE CASUALTIES ARE MOVED TO THE CASUALTY COLLECTION POINT
PROPERLY MARK EACH CASUALTY WITH TRIAGE CATEGORY
ASSIGN THE CCP TRIAGE SPECIFIC
ASSIGN SOMEONE IN CHARGE OF EACH TRIAGE
SECTION
CASUALTIES WHO:
DO NOT OBEY COMMANDS
DO NOT HAVE A PERIPHERAL PULSE
ARE IN RESPIRATORY DISTRESS
HAVE UNCONTROLLED MAJOR BLEEDING
HAVE AMPUTATION ABOVE THE KNEE OR ELBOW
» SHOULD BE TRIAGED AS T1- IMMEDIATE
CASUALTIES WHO:
ARE STABLE
NEED DEFINITIVE CARE
» SHOULD BE TRIAGED AS T2- DELAYED
CASUALTIES WHO HAVE:
MINOR WOUNDS
IF NOT TREATED CAN TOLERATE A DELAY IN CARE WITHOUT A INCREASE TO MORTALITY
» SHOULD BE TRIAGED AS T3- MINIMAL
THOSE CASUALTIES HAVING INJURIES THAT ARE LIKELY TO BE INCOMPATIBLE WITH LIFE GIVEN THE CURRENT AVAILABLE RESOURCES
» SHOULD BE TRIAGED AS T4- EXPECTANT
CASUALTIES THAT ARE NOT BREATHING EVEN AFTER LIFE SAVING INTERVENTIONS ARE ATTEMPTED
» SHOULD BE TRIAGED AS T4- EXPECTANT UNTIL YOU RE-TRIAGE AND CONFIRM THEY ARE DEAD
THE DEAD SHOULD BE TREATED WITH THE UPMOST RESPECT
THEY GAVE THE ULTIMATE SACRIFICE AND SHOULD BE TREATED WITH HONOR AND DIGNITY
STEP 5 – TREATMENT, FURTHER
MARCHON
IN A MASS CASUALTY SCENARIO IT IS ACCEPTABLE
TREATMENT TO PATIENTS IS LIMITED TO WHAT YOU POSSESS
CASUALTIES WILL PROBABLY NOT RECEIVE THE REQUIRED CARE THAT THEY NEED
YOU HAVE A LOT GOING ON
YOU ARE RESPONSIBLE FOR EVERYTHING THAT HAPPENS OR DOESN’T HAPPEN
HAVE A PLAN, EXERCISE IT, BUT BE FLEXIBLE AND ADAPT TO CHANGES IN THE SCENARIO IN ORDER TO OVERCOME ANYTHING
YOU HAVE TO HAVE PROPER ACCOUNTABILITY OF ALL YOUR CASUALTIES AND EQUIPMENT
ENSURE THAT REASSESSMENT OF ALL PRIOR TREATMENTS IS CONDUCTED
DON’T ALLOW UNNECESSARY TREATMENT TO TAKE PLACE, YOU ARE NOT CONDUCTING A PRIMARY SURVEY ON ONE INDIVIDUAL, MAKE SURE EVERYONE IS WORKING TOGETHER
ENSURE THERE IS SOME ONE IN CHARGE OF EVERY TRIAGE SECTION
USUALLY THE JUNIOR MEDIC IS OVERSEEING ALL CASUALTIES T1- IMMEDIATE
ENSURE LSI’S HAVE BEEN PROPERLY CONDUCTED PRIOR TO MOVING ON TO FURTHER TREATMENTS
JUNIOR MEDIC: YOU NEED TO SUPPORT THE SENIOR MEDIC AT ALL TIMES
ASSIGN CASUALTIES TO PROPER EVACUATION PRIORITIES
SEND MEDEVAC 9 – LINE IN A TIMELY MANNER
SUPERVISE THAT EVERYTHING IS BEING DONE PROPERLY
REMEMBER TO ENFORCE RE-TRIAGING AND PROPER TREATMENT OF CASUALTIES
STEP 6 – TRANSPORT
THE IMPORTANCE ON PREPARING YOUR CASUALTIES FOR TRANSPORT CAN NOT BE OVERSTATED
IT IS VERY CRITICAL THAT A PROPER 9 – LINE MEDEVAC REQUEST IS SENT IN A TIMELY MANNER
SPECIAL EMPHASIS ON THE CORRECT NUMBER OF CASUALTIES BEING EVACUATED
DO NOT FORGET ANYONE!!!
TO INCLUDE THE DEAD
EVACUATION PRIORITIES
DO NOT CONFUSES THE AIR EVACUATION PRIORITIES WITH THE SORTING PRIORITIES OF STEP 1
SEND A PROPER ACCURATE 9-LINE AS SOON AS POSSIBLE
PATIENTS THAT NEED TO BE TRANSPORTED BY MEDEVAC SHOULD BE FURTHER SUBDIVIDED INTO EVACUATION PRIORITIES
PRIORITY I: URGENT
PRIORITY IA: URGENT – SURGICAL
PRIORITY II: PRIORITY
PRIORITY III: ROUTINE
PRIORITY IV: CONVENIENCE
PRIORITY I: URGENT
IS ASSIGNED TO PATIENTS THAT SHOULD BE EVACUATED AS SOON AS POSSIBLE, WITHIN MAXIMUM OF 2HRS IN ORDER TO SAVE LIFE, LIMB, OR EYE SIGHT, AND ALSO TO PREVENT COMPLICATIONS OF SERIOUS ILLNESS OR TO AVOID PERMANENT DISABILITY
PRIORITY IA: URGENT – SURGICAL
IS ASSIGNED TO PATIENTS WHO MUST RECEIVE FAR FORWARD SURGICAL INTERVENTION TO SAVE LIFE AND STABILIZATION FOR FURTHER EVACUATION
PRIORITY II : PRIORITY
IS ASSIGNED TO SICK AND WOUNDED PERSONNEL REQUIRING PROMPT MEDICAL CARE
THIS PRECEDENCE IS USED WHEN THE INDIVIDUAL SHOULD BE EVACUATED WITHIN FOUR HOURS
OR THEIR MEDICAL CONDITION COULD DETERIORATE TO SUCH A DEGREE THAT THE PATIENT BECOMES AN URGENT PRECEDENCE
OR WHOSE REQUIREMENT FOR SPECIAL TREATMENT ARE NOT AVAILABLE LOCALLY OR WHO WILL SUFFER UNNECESSARY PAIN OR DISABILITY
PRIORITY III : ROUTINE
IS ASSIGNED TO SICK AND WOUNDED PERSONNEL REQUIRING EVACUATION BUT WHOSE CONDITION IS NOT EXPECTED TO DETERIORATE SIGNIFICANTLY
THESE CASUALTIES SHOULD BE EVACUATED WITHIN 24 HOURS
PRIORITY IV : CONVEINENCE
IS ASSIGNED TO PATIENTS FOR WHOM EVACUATION BY MEDICAL VEHICLE IS A MATTER OF MEDICAL CONVENIENCE RATHER NECESSITY
FURTHERMORE, EFFICIENT USE OF ASSETS MAY REQUIRE THE MIXING OF PATIENTS DESIGNATED WITH DIFFERENT PRIORITIES RATHER THAN TRANSPORTING THEM STRICTLY IN THEIR PRIORITY ORDER
Standard Evacuation Priorities
NATO / International Security Assistance Force (ISAF) Standard Operating Procedure
Governs operations in Afghanistan
Follows NATO doctrine
Specifies THREE CATEGORIES for casualty evacuation
A = urgent (2 hours)
B = Priority (4 hours)
C = Routine (24 hours)
WARNING
NEW PROCEDURE PROVIDES GUIDANCE TO AVOID THE OVERCALLING OF CAT “A”, OR URGENT, EVACUATIONS
Category A – Urgent (2 hours)
Critical, life-threatening injury such as…
Significant injuries from a dismounted IED attack
Gunshot wound or penetrating shrapnel to chest,abdomen or pelvis
Any casualty with ongoing airway problem
Any casualty with ongoing respiration difficulty
Unconscious casualty
Casualty with known or suspected spinal injury
Casualty in shock
Casualty with bleeding that is difficult to control
Moderate / severe TBI
Burns greater than 20%TBSA
Category B – Priority (4 hours)
Serious injury such as…
Isolated, open extremity fracture with bleeding controlled
Any casualty with a tourniquet in place
Penetrating or other serious eye injury
Significant soft tissue injury without major bleeding
Extremity injury with absent distal pulse
Burns 10-20% TBSA
Category C – Routine (24 hours)
Mild to moderate injury such as…
Gunshot wound to extremity – bleeding controlled without
tourniquet
Minor soft tissue shrapnel injury
Closed fracture with intact distal pulse
Burns <10%TBSA
REASSESSMENT / RE-TRIAGING
ASSESSMENT & TRIAGE ARE DYNAMIC PROCESSES, WHEN A CYCLE IS COMPLETE VERIFY CONDITIONS TRATMENTS, CATEGORY & PRIORITY
AS MORE RESOURCES BECOME AVAILABLE, MORE TRAINED MEDICAL PERSONNEL INCLUDED, ALL THE CASUALTIES SHOULD BE REASSESSED/ RE-TRIAGED
REASSESSMENT AND RE-TRIAGING IS IMPORTANT SINCE PATIENTS CONDITIONS MAY CHANGE AND RAPID INITIAL EVALUATIONS MAY MISS IMPORTANT AND LIFE THREATENING INJURIES
START
Simple Triage And Rapid Treatment
SALT3 TRIAGE – IN CLOSING
THE SALT3 TRIAGE IS RAPID METHOD WHERE A MINIMUM NUMBER OF RESOURCES & RESCUERS ARE INVOLVED
INDIVIDUAL ASSESSMENT IS DEPENDENT ON THE PROVIDER’S SKILL LEVEL
PRIORITIZATION FOR TREATMENT & TRANSPORT IS DYNAMIC AND MAY BE EFFECTED BY CHANGING PATIENT CONDITIONS, RESOURCES AND SCENE SECURITY
UNFORTUNATELY IN A MASS CASUALTY SITUATION, YOU DON’T HAVE ENOUGH FOR EVERY CASUALTY AND THE GOAL HAS TO BE TO DO THE MOST GOOD FOR THE MOST PEOPLE
THIS MAY MEAN THAT SOME INDIVIDUAL WILL NOT RECEIVE THE TREATMENT THAT THEY NEED IN THE TIME THAT THEY NEED IT
ALSO, IF YOU DON’T HAVE A JOB, FIND A JOB!!!!
TRIAGE – WHAT NOT TO DO
DO NOT CONSIDER TRIAGE COMPLETE AFTER INITIAL TRIAGE, RETRIAGE IS JUST AS IMPORTANT
DO NOT IGNORE THE EXPECTANT CASUALTIES
DO NOT PROVIDE COMPLEX MEDICAL CARE DURING THE TRIAGE PROCESS: DUE TO THE AMOUNT OF RESOURCES AND PERSONNEL AVAILABLE TREATMENTS WILL BE LIMITED
CONCLUSION
YOU SHOULD HAVE A GOOD GRASP OF
PRINCIPLES OF TRIAGE
THE DYNAMICS OF THE SALT3 TRIAGE
A GOOD UNDERSTANDING ON HOW SALT3 IS EXECUTED AND MANAGING THE CONCEPT
WHAT IS EXPECTED OF YOU AS A LEADER
Stay Safe My Brothers !
SEMPER FI
