Clinical practice TRIAGE Normal clinical practice OF MASS CASUALTIES Multiple-casualty incident C. Giannou Mass casualties Hat Yai July 2012 Triage = Process The aim in a mass casualty situation is to do the best for the most, not by which priorities are set for the management of mass casualties. everything for everyone. Improvised bamboo triage post Most medical personnel who deal with trauma on a regular basis have the clinical skills to deal with mass casualties. A new mindset and change in the way of thinking, however, is required. 1
JFK Memorial Hospital, Maternity Building Improvised triage post: underground garage Monrovia 2003 Triage Tent Inside the Triage Tent Main Building, Triage Department JFK Memorial Hospital, Main Building 2
Triage cannot be organised ad hoc. Triage Department, in use It requires planning: � Preparation before the crisis � Organisation of the personnel � Organisation of the space � Organisation of the infrastructure � Organisation of the equipment � Organisation of supplies � Training � Communication � Security � Convergence reaction = relatives, friends & the curious (especially the armed ones) Triage involves a dynamic equilibrium between needs and resources. Needs = number of wounded and types of wounds Resources = infrastructure and equipment at hand & competent personnel present The Triage Team Clinical Triage Officer � Triage team leader: co-ordinator � Clinical triage officer: does not treat � Head nurse, matron: chief organiser No task in the medical services requires greater understanding, skill, and judgement than the � Nursing groups sorting of casualties and the establishment of priorities for treatment . � Follow-up medical groups 3
Triage is a dynamic process: � begins at the point of wounding, Triage decisions must be respected. � occurs all along the chain of casualty care, � occurs at the hospital reception, � and continues inside the hospital wards: Discuss afterwards. � continuous reassessment of patients. Triage Documentation Triage Documentation � Include basic Reality check information What really happens! � Short-form � Clear During post-triage evaluation: � Concise decided to use plastic � Complete sleeve to hold the documentation. The triage process: Sift � Sift 1) Select those most severely injured and 2) identify and remove: � Place patients in main categories: priority � the dead � Sort � the slightly injured � Priority amongst the priorities � the uninjured 4
Sort ICRC TRIAGE CATEGORIES Categorise the most severely injured based on: � life-threatening conditions (ABC) I. Serious wounds: resuscitation and immediate Serious wounds: resuscitation and immediate surgery surgery � anatomic site of injury II. Second priority: need surgery but can wait Second priority: need surgery but can wait � Red Cross Wound Score III. Superficial wounds: ambulatory management Superficial wounds: ambulatory management � treatment available in terms of personnel and supplies IV. Severe wounds: supportive treatment Severe wounds: supportive treatment Thoraco-abdominal bullet wound Category I: Resuscitation and immediate surgery Patients who need urgent surgery – life-saving – and have a good chance of recovery. (E.g. Airway, Breathing, Circulation: tracheostomy, haemothorax, haemorrhaging abdominal injuries, peripheral blood vessels) Distal pulse absent Category II: Need surgery but can wait Patients who require surgery but not on an urgent basis. (E.g. non-haemorrhaging abdominal injuries, wounds of limbs with fractures and/or major soft tissue wounds, penetrating head wounds GCS > 8.) 5
Category I for Airway; Category II for debridement Femoral vessels intact Limb salvage Category III: Superficial wounds (no surgery, ambulatory treatment) Patients with wounds requiring little or no surgery. In practice, this is a large group, including superficial wounds managed under local anaesthesia in the emergency room or with simple first aid measures . Multiple superficial fragments Multiple superficial fragments 6
Eventration Category IV: Very severe wounds (no surgery, supportive treatment) Patients with such severe injuries that they are unlikely to survive or would have a poor quality of survival. Summary of triage theory & philosophy: Epidemiology of Triage: short evacuation time sorting by priority � Category I 5 - 10% A simple emergency plan: personnel, space, infrastructure, equipment, supplies = system � Category II 25 – 30% "Best for most" policy � Category III 50 - 60% Priority patients are those with a good chance of good survival. � Category IV 5 - 7% Triage: conclusions Emergency security and hospital disaster plans are not equivalent: no one single model. Evaluation of hospital capacity is essential in emergency planning. Hospital teams must always practice the mass influx of wounded: conflict or natural disaster. Triage is essential to put – a little bit of – order into chaos. 7
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