The document provides information on triage procedures for mass casualty incidents. It discusses sorting injured personnel into categories based on need for treatment. The categories include Immediate for life-threatening injuries, Urgent for injuries at risk if treatment is delayed, Delayed for non-life-threatening injuries, and Expectant for those unlikely to survive given available resources. It emphasizes that triage is a dynamic process that can change based on evolving conditions like available resources, patient status, or environmental factors. The document also discusses differences between military and civilian triage as well as considerations for treatment facilities in a mass casualty response.

1. Triage
Instructor Name:
Title:
Unit:

2. Triage – from the French sort
• In casualty management sorting of a large
number of injured personnel is the 1st stage
in establishing order
• Triage sets the stage for treatment and
eventuates in transport of the injured

3. Triage is not to be considered
with finality
• Triage categories change based upon
– Number of injured
– Available resources
– Nature and extent of injuries(s)
– State of hostile threat

4. Things change
• Number of patients
• Extent of resources
• Condition of patient
– Gets better
– Gets worse
– Transport arrives

5. If you have only 1 patient
• That patient is Pri 1 Immediate regardless of
anything else
• There is no real need for triage
• Once this number increases, the need for
triage arises

6. Categories
• Immediate
– Threat to life/limb
• A lightly injured is immediate if he can be
returned to duty with immediate simple
management

7. Urgent
• Patient is at risk if treatment or
transportation is delayed unreasonably

8. Delayed
• No risk to life or consequence if more
definitive care is not rendered quickly

9. Expectant
• Regardless of the level of care rendered,
patient is likely to expire
• Tough call to make for unit personnel

10. START – triage technique
• Simple treat/triage and rapid transport
• All of you within the sound of my voice
– Move towards me
– Doesn’t work well in no/low light or excess
noise

11. Military Triage
COL Cliff Cloonan
Assistant Professor
Military & Emergency
Medicine Department
Instructor Name:
Title:
Unit:

12. Triage
• Objectives – Upon completion of this block
of instruction the student will be able to:

13. Oklahoma City Federal Building Bombing

14. Oklahoma City Federal Building Bombing

15. Triage
• Definition –
– “To Sort”
– From the French word, “trier”
– Has been defined as “doing the greatest good
for the greatest number” BUT triage is simply a
sorting PROCESS that when applied creates a
situation that allows for “doing the greatest
good for the greatest number”

16. Triage
• What are the OBJECTIVES of doing Triage?
– Rapid sorting of the more serious patients from those
less serious to facilitate the rapid care of the more
serious patients
– When problems exceed resources, triage should
facilitate “doing the greatest good for the greatest
number”
– Bring order to chaos thus facilitating the care of all
patients

17. Triage
• What is the PROCESS?
– Sorting into categories for evacuation and treatment
• What are the DECISIONS?
– How will the patients be sorted – who goes in which
category?
– What will be done to/with the patients when sorted?
• What factors AFFECT/CHANGE the decisions?
– Resources
– Circumstances

18. Triage
Special Situations
• Persisting threat to providers/patients
•“Reverse” Triage Situation
TRIAGE - A CONTINUUM
“Normal”
Triage in
an ED
Triage in
A MASCAL
Situation
Sorting Patients

19. TRIAGE - A CONTINUUM
“Normal”
Triage in
an ED
Triage in
A MASCAL
Situation

20. Triage
• “Military” Disasters Occur In Civilian
Settings

21. Triage
• And… “Civilian” disasters occur in military
settings

22. Truck Accident on Pipeline Rd
Saudi Arabia – Desert Shield

23. Triage
INPUT
(Patients to
be sorted)
OUTPUT
(Sorted
Patients)
Immediate
Delayed
Minimal
Expectant
Resource
Modifiers
(Manpower,
Equipment,
Expendables,
Time)
Situation
Modifiers
(Risk, Weather,
MET-T, Combat
Situation, etc…)
Disease Process
Modifiers
(Illness,
Injury,
NBC, etc)
Evacuation
Modifiers
(Assets,
Distance, Threat)

26. Triage
• Military vs. Civilian – Are there differences?
– Continuing risk to medical care providers
• Can occur in both situations
• More common in combat/military triage
– Resource limited
• Can occur in both situations
• More common in combat/military triage
– “Reverse” Triage Situation
• Care provided first to those who when treated can be quickly
returned to duty
• Usually only in a military situation but could occur in a civilian
MASCAL situation (when “Group” survival is at stake)

27. Civil War
Casualty Collection
Point

28. Civil War Casualty Collection Poin
and Treatment Station

29. Vietnam – Mass Heat
Casualties

30. MASCAL Exercise

31. TRIAGE
- A DYNAMIC
NOT
A STATIC PROCESS

32. WITHIN THE MILITARY ECHELONED
MEDICAL CARE SYSTEM, TRIAGE OF
CASUALTIES OCCURS (OR SHOULD), AT A
MINIMUM, AT EVERY ECHELON

33. MILITARY TRIAGE OFTEN
INCLUDES, BUT IS MORE THAN,
MEDICAL PRIORITIZATION

34. APPROPRIATE MEDICAL
PRIORITIZATION AND
TREATMENT OF INJURIES IN
A SINGLE PATIENT IS THE
GOAL OF ADVANCED TRAUMA
LIFE SUPPORT TRAINING

35. RPG Wound
Right Knee
- Somalia
What is the Priority
Injury?
What is the
Triage Category?
What is the
Evac Priority?

36. Burn Victim
- Kosovo
What is the
Priority Injury?
What is the
Triage
Category?
What is the
Evacuation
Priority?

37. Burn Victim
- Kosovo

38. SURGICAL PRIORITIZATION,
WHICH, PRIMARILY INVOLVES A
DETERMINATION OF OPERATIVE
PRIORITY, IS NOT TRIAGE

39. Triage
• Surgical Prioritization Involves -
– Recognizing
• Which patients require surgery to save life/limb/sight
– Knowing
• Numbers of OR’s, doctors, nurses, expendables, blood
(Resources) each operation requires
• Resources (manpower, equip, expendables, blood etc)
required to provide post-op care
• How long each operation will take (Time as a resource)
• The resources that each operation will consume (Must
consider manpower as a consumable resource)
• Probability of successful surgery

40. Triage
• The Goal of Surgical Prioritization
– Selection of cases with the highest probability
of success that consume the least amount
of resources.
– Make a decision - - and go with it!
• Once a MASCAL situation has been declared don’t
wait for the situation to evolve further before
making a decision.
• Making decisions is more important than what
decisions are made.
– Respect the Triage Decision

41. Grenade
Fragment
Wound –
Perforating
Bowel
-ICRC Hospital
Afghanistan

42. Transverse Abdominal
High Velocity Bullet Wound
-ICRC Hospital
Afghanistan

43. Triage
• Triage Categories used in ICRC Hospitals
– Category I – Priority for Surgery
• Patients who need urgent surgery and who have a good chance
of satisfactory recovery
– Category II – No Surgery
• Patients with wounds so slight that they do not need surgery
AND…
• Patients who are so severely injured that they are unlikely to
survive
– Category III – Can Wait For Surgery
• Patients who need surgery but not urgently

44. TRIAGE IN A DISASTER IS A MULTI-
DISCIPLINARY PROCESS. IT IS BEST
CARRIED OUT BY SOMEONE WHO IS
FAMILIAR WITH:
•SURGICAL, MEDICAL, AND
PSYCHIATRIC EMERGENCIES
•ALL THE PRE-HOSPITAL AND HOSPITAL-
BASED MEDICAL AND LOGISTICAL
RESOURCES NECESSARY TO EVACUATE
AND PROVIDE CARE FOR A LARGE
NUMBER OF CASUALTIES

45. BY DEFINITION, TRIAGE IN A DISASTER /
MASCAL SITUATION MEANS THAT LESS
THAN THE NORMAL STANDARD OF
CARE WILL BE PROVIDED FOR
MANY PATIENTS.

46. EXAMPLE:
FAILURE TO PROVIDE COMPLETE
CONTROL OF THE CERVICAL SPINE IN A
PATIENT WITH MULTIPLE BLUNT TRAUMA
INJURIES IS CONSIDERED MALPRACTICE

47. EXAMPLE
COMPLETE CERVICAL SPINE
IMMOBILIZATION IS VERY TIME AND
RESOURCE CONSUMING. THE TIME
AND RESOURCES REQUIRED TO
STABILIZE A CERVICAL SPINE MAY
MEAN THAT OTHERS MAY DIE.

48. ADHERING TO THE PRINCIPLE OF
DOING THE GREATEST
GOOD FOR THE GREATEST NUMBER
MAY REQUIRE THAT LESS
THAN FULL CERVICAL SPINE
IMMOBILIZATION BE PERFORMED

49. REMEMBER
IF IT WASN'T ALL "SCREWED" UP
IT WOULDN'T BE A DISASTER

50. REMEMBER
NOT ONLY MAY CHANGES IN A PATIENT'S
MEDICAL CONDITION RESULT IN A CHANGE
IN HIS / HER TRIAGE CATEGORY BUT A
CHANGE IN AVAILABLE RESOURCES MAY ALSO
RESULT IN A CHANGE IN TRIAGE CATEGORY

51. CAN YOU THINK OF A SITUATION
WHERE IT WOULD EVER BE APPROPRIATE
TO NEGLECT THE MANAGEMENT OF THE
MOST SERIOUSLY WOUNDED IN ORDER TO
TREAT THOSE WITH MORE MINOR INJURIES?

52. REMEMBER
A TRIAGE SITUATION IS NOT
DETERMINED BY A SET NUMBER OF
PATIENTS BUT RATHER BY A MISMATCH
OF RESOURCE REQUIREMENTS WITH
RESOURCE AVAILABILITY. A TRIAGE
SITUATION MAY EXIST WHEN THERE ARE
ONLY TWO PATIENTS

53. THE DECISION TO NOT RESUSCITATE
A CRITICALLY INJURED PATIENT WHEN
THERE ARE RESOURCES AVAILABLE TO
DO SO IS NOT THE SAME AS PLACING
A PATIENT IN THE EXPECTANT
CATEGORY IN A DISASTER SITUATION

54. Triage
• MILITARY TRIAGE DECISIONS ARE
INFLUENCED BY:
– NUMBERS OF PATIENTS AND THEIR MEDICAL
PROBLEMS
– NUMBERS OF EXPENDABLE AND NON-
EXPENDABLE MEDICAL SUPPLIES AND
CAPABILITIES OF MEDICAL TREATMENT
FACILITIES
– NUMBERS AND CAPABILITIES OF MEDICAL
PERSONNEL

55. Triage
• MILITARY TRIAGE DECISIONS ARE
INFLUENCED BY(CONT):
– NUMBERS AND CAPABILITIES OF
EVACUATION ASSETS
– TACTICAL SITUATION
– WEATHER
– OTHER

56. TERMINOLOGY
CIVILIAN USE OF THE WORD
"TRIAGE" IS OFTEN NOT
THE SAME AS THE MILITARY
USE OF TRIAGE

57. IN A MULTI-CASUALTY INCIDENT WHERE
THERE ARE ADEQUATE RESOURCES THE
GOAL IS TO RAPIDLY AND EFFICIENTLY
IDENTIFY PATIENT NEEDS AND THEN TO
MATCH THE RESOURCES WITH THE
PATIENTS WHO REQUIRE THEM

58. IN A DISASTER SITUATION WHERE
THERE ARE LIMITED RESOURCES THE
GOAL IS TO IDENTIFY PATIENT NEEDS
AND THEN TO DISTRIBUTE THE RESOURCES
IN A MANNER THAT PROVIDES THE BEST
CARE FOR THE MOST POSSIBLE PATIENTS

59. PROBLEMS WITH STANDARD
TRIAGE TAGS

60. DON'T CONFUSE TRIAGE
CATEGORIES WITH
EVACUATION PRIORITIES

61. Triage
• EVACUATION PRIORITIES
– PRIORITY I – URGENT EVACUATION WITHIN
2 HOURS
– PRIORITY IA - URGENT SURGICAL
EVACUATION TO NEAREST SURGICAL
FACILITY WITHIN 2 HOURS
– PRIORITY II – PRIORITY EVACUATION
WITHIN 4 HOURS
– PRIORITY III – ROUTINE EVACUATION
WITHIN 24 HOURS
– PRIORITY IV - CONVENIENCE

62. MASS CASUALTY
TEACHING POINTS

63. MASCAL
• Field Response
– What / Who do you send to the disaster site?
• Equipment
– Type – Stick with the basics
» Dressings
» Backboards/litter with straps
» Tourniquets
» Airways / suction devices
– Quantity (lots)
• Personnel
– Type (Surgeon, EM…)(MD, Nurse, PA, EMT-P…)
– Quantity

64. MASCAL
• Actions on the scene
– Safety and site security FIRST
– Survey the scene
• Estimate number and type of casualties quickly
• Transmit brief initial report to Med Tx Facility
• Request additional equipment (#/type) and
personnel (#/type) as required

65. MASCAL
• Actions on the scene (cont)
– Quickly choose a casualty collection point
based upon:
• Proximity to patients
• Proximity to potential helicopter landing site
• Safety – Distance from potential hazards, secure
• Geography – Large enough and appropriate for
conduct of Geographic Triage) Separate sites for -
– Immediate (next to transportation)
– Delayed
– Minimal
– Expectant
– Deceased (out of sight of other victims)

66. MASCAL
• Actions on the scene (cont)
– Collect all ambulatory patients at CCP by
instructing them to walk to CCP
• These patients are mostly in the minimal category
although some may be delayed
• What they are NOT is in the Immediate / Expectant
(except in some burn cases) / Dead categories

67. MASCAL
• Actions on the scene (cont)
– Put one of the “walking wounded” in charge of
ambulatory patients if limited manpower at
scene
• Most important responsibility is to maintain
accountability and keep patients from leaving CCP
– If more than one medical responder divide the
scene into areas of responsibility and proceed to
rapidly assess / treat / triage all remaining
patients who were unable to walk to the CCP

68. MASCAL
• Actions on the scene (cont)
– Initially treat ONLY readily correctable airway
problems and obvious external, potentially life-
threatening, bleeding
– No treatment for pulseless /apneic patients.
– Place comatose patients in lateral decubitus
position – then move on
– Apply triage tag to identify location in CCP
where patient is to be taken

69. MASCAL
• Actions on the scene (cont)
– Have non-medical bystanders and uninjured or
minimally injured patients at the scene act as litter
bearers (at least one experienced litter bearer / team)
and move patients to CCP
– Triage Officer at CCP sorts (“triages”) patients into
separate geographic location based on tags
• Performs rapid reassessment and changes triage category as
required

70. MASCAL
• Actions on the scene (cont)
– Move rapidly from one patient to next – only
identify and if possible quickly treat life threats
– Identify ALL patients
– Avoid becoming involved in prolonged
procedures
– Avoid becoming distracted by distraught,
minimally injured patients
– Pay attention to administrative concerns – Keep
track of ALL patients (Trust me – you’ll be glad
you did)

71. MASCAL
• Actions on the scene (cont)
– Transportation Considerations / Decisions
• Do you put all immediate patients on the first
available ambulance?
• Do you send one of your health care providers if
there is no medical care on the transport
• To what facility do you send the ambulance?
– Travel time
– Level I, II, III trauma center?
• Do you wait for a helicopter?
• How secure is the route of travel?

72. MASCAL
• Medical Treatment Facility Actions
– Maintain Communication with the response
team
• Identify the scope of the problem
• Identify the need for additional resources at the
scene
– Medical
– Security
– Administrative
– Transportation – Ground / Air
– Arrange for helicopter transportation as
appropriate

73. MASCAL
• Medical Treatment Facility Actions (cont.)
– Notify higher HQ and other medical facilities of the
situation and request that they standby
– Activate Medical Treatment Facility disaster
response plan
• Call in additional staff / keep staff in hospital at end of shift
• Clear receiving area of all stable patients and set up
additional beds as required
• Cancel any non-emergent surgery
• Clear OR’s ASAP
• Prepare hospital beds
– Request higher echelons preposition ambulance at
your medical treatment facility.

74. MASCAL – Major Teaching
Points
• When ability to provide medical care is
overwhelmed – Bringing organization to the
disaster site is the most important action.
• Avoid the overwhelming impulse to rush in
and being to take care of first patient you
come upon
• Make sure that you do not become a
casualty yourself

75. MASCAL – Major Teaching
Points
• Remember – All the resources that you have
to deal with a disaster did not come with
you to the scene
• Supervising medical care and ensuring the
proper evacuation order and disposition of
patients may not be glamorous but it will
ultimately be the most important
• Keeping track of the disposition of patients
may seem like a waste of manpower but its
not – trust me.

76. Triage
• Immediate (examples – not all inclusive)
– Airway
• Generally either must be addressed immediately at which
point patient becomes either
– DELAYED
– DEAD
• Some exceptions
– Breathing
• Correctable on the scene – ie. tension pneumothorax which
when treated may turn patient from IMMEDIATE to
DELAYED
• Uncorrectable on the scene – ie. large pulmonary
contusion/flail chest with hypoxia
– Needs URGENT EVACUATION

77. Triage
• Immediate (cont.)
– Circulation
• Exsanguinating hemorrhage
– External – usually correctable with a tourniquet
and/or direct pressure at which point patient
becomes DELAYED
– Internal – URGENT EVACUATION
• Cardiac Tamponade
– Even when treated with pericardiocentesis patient
remains IMMEDIATE because underlying cause is
wound to the heart

78. Triage
• Immediate (cont.)
– Disability
• Closed head injury with deteriorating mental
status
• URGENT EVACUATION required

79. Triage
• Delayed (examples – not all inclusive)
– All injuries that require surgery but for which a
delay of 4-8 hours will not cause loss of
life/limb/sight
• Penetrating abdominal wounds –
hemodynamically stable
• All fractures requiring ORIF – hemodynamically
stable
• Spinal cord injury – hemodynamically stable

80. Triage
• Minimal (example – not all inclusive)
– Minor soft tissue wounds not requiring surgical
intervention
– Non-displaced, min. angulated, closed fractures
of the upper extremities or digits

81. Triage
• Expectant
– When resources are adequate no patients are made
expectant
– The creation of this category presumes inadequate
resources and the types of patients included in this
category is largely dependent on the ratio of
resources/patients – the lower the ratio, the more
patients in this category.
– Examples:
• > 50% TBSA 2nd and 3rd degree burns
• Unresponsive patient with an open head wound and
exposed brain
• Documented exposure to > 500 RADs and immediate signs
of radiation sickness

82. S.T.A.R.T. - Triage Classification
Protocol
Simple Triage And Rapid Treatment
(adapted from Super, G: START
instructor’s manual)

83. Able to Walk No
Yes
Delayed Assess
Ventilation
Step 1
Ventilation
Present Yes
< 30/min
> 30/min
Immediate Assess Cap
Refill
No
Position
Airway
Ventilation
Present?
No Yes
Immediate
Expectant
or Dead
Step 2

84. Capillary
Refill
< 2 sec
> 2 sec
Immediate
Control
Bleeding
Assess
Mental
Status
Mental
Status
Follows Simple
Commands
Fails to Follow
Simple Commands
Immediate Delayed
Step 3
Step 4