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Includes the Adobe Acrobat Reader for reading and printing publications.

Numerous illustrations and matrices.

Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:

TITLE: TRIAGE, 67 pages (slides)

SLIDE TOPICS, SUBTOPICS and CONTENTS:

TRIAGE

Triage
“Sorting”
Classifying of casualties
Establish priorities for treatment / evacuation
Dynamic process
Triage
Multiple casualties
Single casualty with multiple injuries
Triage Classification Systems
Military/International
START
Simple Triage and Rapid Treatment
Others

Color Coding
Casualties are color coded to quickly identify a casualty’s priority for medical treatment.
International Color Codes (METTAG) are:
Black – Expectant/Dead-Dying
Red - Immediate
Yellow - Delayed
Green – Minimal/Minor

US Military Color Code (MEDIC)
Blue - Expectant
Triage Categories
Triage Principles
Peacetime/Wartime
Life over limb
Bodily function over cosmetic appearance
Greatest good for the greatest number

Triage Officer
Physician
Dentist
Nurse
Physician Assistant
Technician
Triage Factors
Availability of transportation
Resources
Facilities
Continuous process
Minimal/Minor
Green tag
Minor threat to patient’s life
Classic “Walking Wounded”
Easily segregated
Tend to later
Self-Aid, buddy care
Treat and release,
return to duty/manpower pool
Minimal/Minor
Minor lacerations
Abrasions
Sprains
Contusions
Burns under 20% BSA
Rule of 9’s
Combat stress casualties
Immediate
Red tag
Threat to life is great
Simple procedure will be lifesaving
Reposition airway, control hemorrhaging,…
Must receive urgent treatment
Immediate
Airway obstruction
Sucking chest wounds
Massive external bleeding
Shock
Incomplete Amputation
2nd/3rd degree burns of face or neck
White phosphorus burns
Delayed
Injuries that are serious
Delay in treatment is not life threatening
Require care but no immediate life saving procedures
Treatment, including surgery may be delayed several hours
Delayed
Open chest wounds
Penetrating abdominal wound (evisceration)
Severe eye injury
Open wounds
Non-life threatening fractures
2nd/3rd degree burns not involving the face/neck
Expectant/Dead-Dying
Little hope of recovery
Great threat to life
Treatment is complicated/time consuming
Supportive vs curative treatment
Only used if resources are limited
Expectant/Dead-Dying
Large open head wounds with loss of tissue
Decapitation
Massive crush injury of the chest/neck
Large open chest wound
Penetrating injury to trachea/neck
2nd/3rd degree burns greater then 60% BSA
Multiple trauma
Contaminated
Not a true triage category
Be alert to possibility
Segregate immediately
Prevent contamination of other patients, medical staff, facility
Complicates management and treatment
Biological, not likely to have conventional injuries
Chemical, greater likelihood of combination conventional, chemical injuries
Decontaminate prior to any treatment
Patient Assessment
ATLS/BTLS TREATMENT
Primary Survey - ABC’s (Triage)
Resuscitation
Secondary Survey - Total Patient Evaluation
Definitive Care
Transfer
PRIMARY SURVEY
Airway maintenance / cervical spine control
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/Environmental control:
undress the patient, prevent hypothermia
RESUSCITATION
Management of life-threatening problems identified in the primary survey
Oxygenation and ventilation
Shock management - IV lines, Ringer’s
Monitoring
SECONDARY SURVEY
Head and skull
Maxillofacial
Neck
Chest
Abdomen
Perineum/rectum/ vagina
Musculoskeletal
Complete neurologic exam
Roentgenograms, lab tests
“Tubes and fingers”
DEFINITIVE CARE
After identifying patient’s injuries
After managing life-threatening problems
After obtaining special studies
Definitive care begins
TRANSFER
If the patient’s injuries exceed the immediate treatment capabilities
The process of transferring the patient is initiated as soon as the need is identified
Delay may significantly increase the patient’s risk of mortality
Availability of airlift
PATIENT CARE DECISION TREE
PATIENT CARE DECISION TREE
PATIENT CARE DECISION TREE
PATIENT CARE DECISION TREE

Triage Exercise
You are working in an ATH at a classified location in support of Operation Bellringer. At approximately 0430 hours a call comes into the command post that there are casualties lying outside the perimeter fence. You arrive on the scene and find a bus that has smashed into a large tree and then into a jeep. You are tasked to retrieve, triage, and prioritize the injuries for treatment/transport. There are six bodies with the following injuries:
TRIAGE EXERCISE
Bus Driver - unresponsive with a penetrating injury to the trachea region
Patient One - bullet wounds to the lower legs with bright red blood spurting out
Patient Two - lacerations to the face and a suspected sprain to the right foot
TRIAGE EXERCISE
Patient Three - conscious but somewhat confused & 3rd degree burns of the arms
Patient Four - partial amputation of the right arm and signs of shock
Jeep Driver - walking around the area with an open wound on his forehead

TRIAGE EXERCISE
Immediate - require life saving care but can be stabilized
Patient One - bullet wounds to the lower legs with bright red blood spurting out
Patient Four - partial amputation of the right arm and signs of shock
Delayed – significant injuries required treatment, but not immediately life threatening
Patient Three - conscious but somewhat confused & 3rd degree burns of the arms

TRIAGE EXERCISE
Minimal – minor injuries, treatment can be delayed
Jeep Driver - walking around the area with an open wound on his forehead
Patient Two - lacerations to the face and a suspected sprain to the right foot
Expectant/Dead-Dying – life threatening injuries, attempts to stabilize may jeopardize other lives
Bus Driver - unresponsive with a penetrating injury to the trachea region

When a patient is triaged as expectant, what should you do with the patient?
a. Transport them first so that the bystanders don’t have to see someone like this
b. Move them out of sight and worry about them later
c. Care for them in the same manner as you would anybody else
d. Stay with them and worry about the other patients when time allows
Any time you respond to a call for help, your first priority is to?
a. Assure your own safety
b. Do the best you can for the greatest number of casualties.
c. Call medical control and ask them what you should do
d. Get to the scene as fast as the ambulance will allow you to travel
How often should you reassess your patient in a mass casualty situation?
a. Every 5 minutes
b. Every 20 minutes
c. Whenever necessary
d. Never, this wastes time
What is the purpose of the various colors on the triage tags?
a. To keep track of the number of casualties
b. So that medical personnel know which casualties to treat first
c. To allow the casualties to know where they stand as far as treatment goes
d. To make them more interesting to look at
START Triage System
Hoag Memorial Hospital, Newport Beach, CA
Allows rescuers to quickly identify victims at greatest risk for early death
Gaining popularity
US EMS Systems,
Oklahoma, Trade Center bombings
France, Saudi Arabia, Israel

START Triage System
60 second assessment focusing on
Ability to walk, walking wounded = minor pts
Respiratory effort
Pulses/perfusion
Mental/Neurologic status
Only Treatment during Triage
Open airway, insert OPA
Stop any visible bleeding
Elevate extremities for shock
START PATIENT CARE DECISION TREE
START (RPM’s) TRIAGE DECISION TREE
START (RPM’s) TRIAGE DECISION TREE
START (RPM’s) TRIAGE DECISION TREE
START Triage
Summary
No hard and fast rules for triage
A simplified guide to help sort casualties
Triage is a continuous process
Accomplish the greatest good for the greatest number
START TRIAGE EXERCISE
Working on an ambulance
Dispatched as a second unit to a bombing of an abortion clinic
As you arrive you hear shouts and screams and several (19) victims lying about
After assuring your own safety, what is the first action you take to begin the Triage process
START TRIAGE EXERCISE
Instruct all walking wounded to get up and walk to a designated area and await treatment
You now have 19 patients left to triage,
Establish a triage category for each patient
Give your rationale for their triage category.
Notes
If no breathing, give triage category if respirations begin/or are still absent after airway established
If radial pulse is absent, most times you can assume that bleeding can be controlled unless an obvious mortal injury is presented
#1
Compound fracture of the left femur
Respirations: Under 30
Pulse (radial): Absent
Mental Status: A O x 4
#2
Sudden onset of chest pain, no shortness of breath
Respirations: Under 30
Pulse (radial): Present
Mental Status: A O x 4
#3
90% second degree burns over body
Respirations: None
Pulse (radial): Present
Mental Status: Unconscious
#4
Patient states she is a diabetic. Skin is moist and clammy
Respirations: Under 30
Pulse (radial): Absent
Mental Status: A O x 4
#5
Unable to move legs
Respirations: Under 30
Pulse (radial): Present
Mental Status: Confused
#6
No apparent injuries
Respirations: Under 30
Pulse (radial) Present
Mental Status: A O x 4
#7
Sucking chest wound
Respirations: Over 30
Pulse (radial): Present
Mental Status: Unconscious
#8
Dislocated right shoulder
Respirations: Under 30
Pulse (radial) Present
Mental Status: A O x 4
#9
No visible wounds
Respirations : None
Pulse: (radial): Absent
Mental Status: Unconscious
#10
Scalp wound with an estimated blood loss of 500 cc
Respirations: Over 30
Pulse (radial): Present
Mental Status: Confused
#11
Significant head injury
Respiration: Under 30
Pulse (radial): Absent
Mental Status: Unconscious
#12
Three month old Infant
Respirations: Under 30
Pulse (radial): Present
Mental Status: Unconscious
#13
Impaled, 1 foot piece of shrapnel in RT eye
Respirations: Under 30
Pulse (radial) Present
Mental Status: Awake & Oriented
#14
Female 6 mos. pregnant, broken left lower leg
Respirations: Under 30
Pulse (radial) Present
Mental Status: Awake & Oriented
#15
Severe difficulty breathing, chest sinks in on inspiration
Respirations: Over 30
Pulse (radial) Present
Mental Status: Awake & Oriented
#16
Unable to move, no verbal response
Respirations: Under 30
Pulse (radial) Present
Mental Status: Awake but stares into space
#17
Amputated left arm, bleeding controlled
Respirations: Under 30
Pulse (radial) Present
Mental Status: Awake & Oriented
#18
Large head wound, brain matter showing
Respiration: None
Pulse (radial): Absent
Mental Status: Unconscious
#19
Minor abrasions
Respirations: Under 30
Pulse (radial) Present
Mental Status: Awake & Oriented