The triage process in disaster involves:

FIELD TRIAGE

Field triage identifies severely injured trauma patients at the point of injury in the “field” and triggers a decision to transport severely injured patients to a hospital that has resources commensurate with patient needs. A common field triage decision scheme assesses the injured patient in four steps, each step linked to a determination about patient need for a level of care at a trauma center. The field triage decision scheme presented here (Figure 1), originally developed by the American College of Surgeons Committee on Trauma, was revised through an evidence-based review by an expert panel representing emergency medical services, emergency medicine, trauma surgery, and public health. The panel was convened by the Centers for Disease Control and Prevention (CDC), with support from the National Highway Traffic Safety Administration (NHTSA). Its contents are those of the expert panel and do not necessarily represent the official views of CDC and NHTSA.

Step 1 assesses physiology; step 2, anatomy of the injury; step 3, mechanism of injury and high-energy impact; and step 4, special patient or system considerations. Effective implementation of a triage decision scheme is enhanced by simplicity within relevant steps. In other words, scheme complexity harms good triage.

Steps 1 and 2 are screens of the severity of physiologic and anatomic injury, respectively, and rapidly identify the most critically injured patients requiring transport to higher levels of care within the trauma system. The initial physiologic assessment of the patient measures vital signs (systolic blood pressure and respiratory rate) and level of consciousness (Glasgow Coma Scale). Anatomic assessment emphasizes readily visualized or identifiable anatomic injuries, to include centrally located penetrating injuries, severe musculoskeletal injuries, and consequent paralysis. Patients without apparent life-threatening physiologic or anatomic issues are then screened in step 3 for further evidence of high-energy mechanisms that increase the risk for significant injury. Certain characteristics of falls, automobile crashes, pedestrian/bicyclist crashes, and motorcycle crashes are associated with a higher risk of injury that is less obvious, and yet merits further evaluation at a facility within the trauma system. Step 4 looks for patient characteristics antecedent to the traumatic event that exacerbate the consequences of injury (extremes of age, bleeding diatheses, end-stage renal disease, and pregnancy), isolated limb or eyesight-threatening injuries, and burns. The presence of patient characteristics or characteristic injuries prompts consideration for patient transport to specific centers within a trauma system.

The field triage decision scheme emphasizes the importance of explicitly defining the capabilities of facilities within the system of care and matching the patient to the facility with the most appropriate level of care. An inclusive trauma system brings all local prehospital agencies and acute care facilities together as a network for the focused application of system capabilities to the care of each acutely injured patient. The idea is to get the right patient to the right place within the right time. Underestimation of patient injuries can lead to undertriage to facilities without adequate resources for patient needs, and overestimation of patient injuries can lead to overtriage to facilities with resources far greater than patient needs. Effective triage requires an integrated and defined shared mental model of triage across all settings of care.

Triage

Do the very best for as many as possible.

Different systems use different triage algorithms.

Paramedic systems may use START in both emergency medicine and mass casualties. According to findings, emergency treatment is as follows: free airways, emergency intubation, cricothyrotomy, decompression of tension (pneumothorax), and mask ventilation, styptics.40 The sensitivity for START varies from 85%41 to 62%.42

Medic in-field triage is another type. This is performed in an established triage area by medics assisted by teams of helpers. It consists of minimal anamnesis: time of accident, mechanism of injury, condition, how the patient was found, primary measures taken, actual discomfort, pre-existing conditions, medications and allergies, and the following systematic medical check:

Physical investigation: external bleeding, penetrating injuries, burns, chemical burns, neurological status, and investigation of the head, spine, thorax, abdomen, pelvis, and extremities.

If possible, a few measurements are taken, e.g., respiration rate, pulse oximetry, and temperature.40

In burn victims, the TBSA burn is estimated by the Rule of Nines, and strictures, suspected inhalation injury, and the need for intubation are evaluated. Emergency treatment is performed in a treatment area by emergency physicians. Burn victims needing treatment for shock or intubation should be classified for urgent treatment. Because of the need to resuscitate as soon as possible, resuscitation should at least begin here.

Triage depends upon easily verifiable vital parameters and clear types of injury to filter and classify patients according to the four treatment urgency groups shown in Table 5.1.

In Austria, Germany, Switzerland, and some other countries, triage group 4 includes the hopeless or unsalvageable who deserve ‘expectant’ treatment. This is very controversial because the duration of the disparity between supply and demand should be short, and when this period is over this group's priority changes to 1 or 2. In such countries, the dead are in no triage group. Thus, group 4 requires staff at least for comfort care. Dead victims need neither staff nor transport in the acute phase.

Revised Trauma Score

The Trauma Score (TS) and Revised Trauma Score (RTS) are physiologic trauma scores designed for field triage of patients who are significantly injured and require trauma center transfer. The TS is a simple sum of points based on the degree of derangement of the GCS, systolic blood pressure (SBP), respiratory rate (RR), respiratory expansion, and capillary refill time (CRT).43 The RTS is a simplification of the TS that includes only the GCS, BP, and RR.44 The RTS has been used as a tool for predicting survival by adding weighted coefficients based on logistic regression with values range from 0 (worst) to 7.84 (best). The RTS is heavily weighted toward the GCS to compensate for major head injury without significant physiological changes, and correlates well with survival.44

Field triage in a large-scale disaster, catastrophe or resource-poor environment

The Ural mountain train-gas pipeline explosion (Ufa train disaster) was a classic example of the need for field triage and secondary triage. During the initial stages following the Ufa train accident, victims were evacuated to nearby settlements where first aid was rendered, aseptic bandages placed, and fluid resuscitation started. During the second stage, victims were evacuated by medical vehicles and helicopters to Ufa and Techelyabinsk. Total evacuation took 16 hours and 45 minutes, and 806 people were admitted to hospitals and burn centers.22 Helicopters from a nearby military training base airlifted survivors to hospitals in the regional cities of Ufa, Asha, Gorky, and Chelyabinsk. Aeroflot organized a series of special flights, evacuating 160 of the most badly burned, including 37 children, to hospitals in Moscow.93,94 In the Ramstein air disaster, rapid initial transport to supporting hospitals was instituted, but further transport to designated hospitals and burn centers was not thought to have been carried out properly. The result was that some hospitals and burn centers were overloaded with patients while nearby hospitals and burn centers did not get any patients at all.35,82,83 Secondary or tertiary transfers could have relieved the problem. The result of good secondary triage is that none of the institutions will be overly taxed in providing disaster response; this will allow uninterrupted care of all patients, including the patients who are already in a facility.

Once patients are re-triaged to a specialty burn center, a surgeon directing a major disaster plan may not be able to personally see and assign priorities to a large number of patients because the true priority cannot be assigned until the last patient has arrived. Therefore, a first-come-first-served policy may be effective, reserving some resources for severe emergency problems. The better the prehospital communications the less likely unnecessary overload or misappropriation of resources will occur. To reexamine each of the patients thoroughly by removing all dressings is distressing for the patients and time-consuming for surgeons. Surgeons, therefore, may make hurried and incomplete examinations from which some minor mistakes may result. Further, the senior surgeon directing the surgical management of a major accident should stay out of the operating theater, freeing himself of all routine commitments for the day until the last patient has left the operating theater.46 The senior surgeon must, however, keep control of the surgical needs of the patients, interface with relatives, and arrange for transfers of patients to other hospitals if an overload occurs in the receiving hospital and also to eventually transfer patients closer to their homes when their care can be directed safely and appropriately from a hospital closer to home (see Figure 5.4).

Forty-seven patients from the Ramstein air disaster were re-triaged at the Homburg-Saar trauma center using Plan A (natural disasters, fires and explosions/departments of surgery, anesthesia, and radiology), Level II (20–50 victims, activates additional staff and an executive team of department chairs) of their hospital disaster plan. Forty-two patients arrived together on a bus less than 1 hour after the crash and activated the main secondary triage. Secondary triage took place in the triage zone of the trauma center by six emergency room shock teams. Twenty-four victims had deep dermal or full-thickness burns up to 90%. Eleven had additional trauma. Twenty-two were classified second priority and 8 with minor injuries went home after first aid treatment in the outpatient department. Patients were prepared for transfer to nearby hospitals; but this proved to be unnecessary. Four intensive care units were reinforced with additional staff. Six burned victims were transferred by helicopter to German and American burn centers during the following 48 hours. After discussion with burn center physicians, 5 patients with severe injuries (burns in combination with other injuries) were not transferred and expired of multiple organ failure.83 A thorough burn disaster plan addresses the contingency of disproportions between capacities and facilities as well as the ethical problems in mass burn disasters.24,96 Secondary triage or tertiary triage may occur when burn victims can be repatriated to their domestic hospitals. Eleven of the 22 hospitalized patients at the Homburg trauma center following the Ramstein air disaster were transferred to their domestic hospitals.

Triage

Triage sorts patients to match their needs with available resources. Triage is an evolving process relative to shifting needs and resources. Prehospital field triage and care is beyond the scope of this chapter, but when it is effective, patients are selected who will benefit from ED care. Some mild patients not requiring ED care may have been overtriaged, and others may arrive at the ED without prehospital assessment. The worried may well constitute a large proportion of patients arriving at an ED. Severely ill or injured patients may arrive later than those with less serious conditions in a sudden impact emergency. Triage categories are assigned in the ED by an experienced clinician whose sole role is to act as triage officer. Elements of the triage process may have to be repeated later according to evolving imbalances of patient needs and resources.

Triage at the ED is performed according to the nature of the PHE. When potential contamination of victims by toxins is involved, initial triage outside the hospital first identifies those needing immediate decontamination to protect the patient, staff, and entire hospital facility. Likewise, when a highly transmissible virulent infection is involved, triage prior to entering the ED identifies and isolates potentially infectious patients at the earliest time to avoid exposing staff and other patients. Failures of triage at the early stages of decontamination and infection control may subsequently incapacitate an entire hospital. When pertinent, the patient’s medical record should clearly indicate decontamination procedures done and the patient’s infection control status.

Physiologic triage identifies patients needing immediate lifesaving interventions. Physiological triage tools identify patients in five categories: (1) those needing immediate lifesaving interventions; (2) those who need significant intervention that can be delayed; (3) those needing little or no treatment: (4) those who are so severely ill or injured that survival is unlikely despite major interventions; and (5) those who have already died. Care of patients triaged to group 4, those who are so severely ill or injured that survival is unlikely, must deviate most significantly from usual approaches to intensive care. Because of overall demands on the system, scarce resources must be allocated to other patients who are more likely to survive. Group 4 patients are sometimes referred to as “expectant.” Expectant patients are defined by current resource constraints as well as physiological observations. Palliative care is always provided to expectant patients. Also see the discussion of rationing at the end of this chapter.

It is beyond the scope of this chapter to advocate one triage tool in preference to others. No single tool is always rapid, completely accurate, appropriate to all ages and disorders, and already familiar to all providers.21 Staff should be familiar with the physiological triage tool in use locally.

POSTINCIDENT ACTION

It is critically important that medical and rescue personnel coordinate their efforts in caring for victims of crush injury. Serious morbidity and mortality can occur with delay in treatment of a crush victim. Aggressive medical treatment of patients before and during extrication will help prevent renal and cardiac complications of crush injury.

Since the crush syndrome is the second most important reason for increasing morbidity and mortality, triage guidelines must incorporate this into patient assessments to facilitate the strategic use of hemodialysis resources.

In the field, disaster medical personnel can obtain relevant physiologic parameters from crush victims that do not require any specific devices. An initial field triage model for determining which patients may require early intervention for crush syndrome could consist of the following three factors:

pulse rate

delay of response activity (>3 hours)

macroscopic urine findings

A second triage model, applied in healthcare facilities, could be composed of other parameters, including the following laboratory tests:

Tachycardia (> 120/minute)

Macroscopic abnormal urine findings

White blood cell count

Hyperkalemia

Hemodialysis machines and filters, together with nephrologists, nurses, and technicians, should arrive within 24 to 36 hours as national and international resources are mobilized. Emergency dialysis units should be set up in easily accessible areas to avoid problems of transportation for those patients who may have other serious injuries requiring major surgery. On-scene doctors treating disaster victims can consult with remote renal experts using telemedicine or Internet linkages for advice on treating particularly complex cases. Decisions about which type of dialysis modalities to use should take into account the hypercatabolic state of the victims, the degree of electrolyte disturbances, the presence of polytrauma and bleeding tendency, as well as specific geographic and local conditions, transport problems, and other logistic difficulties. Conventional hemodialysis allows for efficient solute removal, treatment of multiple patients, and application without anticoagulants.

Peritoneal dialysis is difficult to administer in patients with abdominal trauma and often is inefficient for removal of potassium and other catabolic metabolites. It might offer temporary help, however, especially during disaster scenarios where conventional hemodialysis equipment is not ready available.9

Publisher Summary

Some may subscribe to the theory of making life and death decisions while others may view triage as a seldom-used skill that is practiced during mass casualty drills but rarely use in real life. In the medical field, triage is often described as the process of doing the most good for the most victims. It is in some ways fascinating to discuss triaging patients to see the imbalance between the allocation of medical assets in times of disasters compared to the dearth of medical care available in many developing countries. Triage may help with the initial medical assessment, but it may also be one of the most important functions when it comes to proper allocation of available resources. Regardless of the triage system used, it requires repetitive training for a staff to claim they can perform the skill in their sleep. It has been proven time and again that if one wants their staff to perform a skill in an emergency, they must practice or perform the skill on a regular basis.

Post-Incident actions

Once a BLEVE occurs, the resulting explosion typically burns up the fuel source, causing a large fireball. At this point the fire usually burns itself out as the fuel source is consumed, but extinguishing the fire may be necessary. The containment and clean up of leaked, unburned fuel may also be required, although LNG typically evaporates quickly. Casualties with burns and/or explosion injuries will necessitate field triage and treatment as well as transport to the hospital.

The incident area should be divided into three zones with access control points and establishing a contamination reduction corridor as recommended by the National Institute for Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA), U.S. Coast Guard (USCG), and Environmental Protection Agency (EPA).11 The first zone is the exclusion zone or “hot zone” and includes all the hazardous material contamination. The second zone is the contamination reduction zone or “warm zone” and contains all the decontamination stations. The last zone is the support zone or “cold zone,” which should be free from all hazardous material contamination and contains the command post.11

Historical perspective

The roots of disaster triage stretch back at least to eighteenth-century military casualty care. Baron Larré, a surgeon with Napoleon’s army, established a system under which wounded soldiers received initial treatment in the field before being transported to hospitals. In 1846, British naval physician John Wilson first proposed that treatment be deferred for casualties with either minor or likely fatal injuries, so that treatment could be provided to the severely injured, who were most likely to benefit.4 Military triage evolved sporadically, but, by World War II, a hierarchical structure for combat casualty care had been developed. During World War II, the average time from injury to definitive care was 12 to 18 hours. By the Vietnam War, improved triage and air-ambulance capabilities reduced this time to less than 2 hours.5 The early military history of triage was well reviewed by Kennedy.4

In the 1980s, civilian prehospital systems became interested in trauma triage for the individual trauma casualty. West et al.6 showed that serious trauma casualties had superior outcomes when cared for at specialized trauma centers. There were investigations of prehospital criteria for differentiating between individual casualties that should be taken to major trauma centers and those that could receive care safely at community medical centers (to avoid overburdening trauma centers with nonserious casualties). Trauma registries enabled the development and validation of various field triage decision rules, although such criteria have proven problematic (see the Triage Scoring System section). Such civilian trauma scoring in turn influenced modern military triage. In the 1991 Persian Gulf War, Burkle et al.7 explored the use of Champion’s Revised Trauma Score8 for triage of combat casualties. Triage classification schemes for military and civilian mass casualties, to a large extent, have converged. Both military (e.g., NATO) and civilian (e.g., color coding) triage systems make use of comparable levels of acuity, and the Trauma Sieve and START, which are similar triage decision systems, have been used by both civilian emergency medical service(s) (EMS) as well as British Army soldiers.9

Regarding civilian triage, the past several decades have seen a litany of tragic events in industrialized countries, including bombings, fires, shootings, and plane crashes.10 These events show a consistency of scale, with immediately surviving casualties numbering in the dozens or hundreds. Unfortunately, many retrospective reports continued to note unsatisfactory execution of triage, particularly prehospital triage, for these events. In the mid-1980s, Vayer et al.3 cited Butman’s analysis of 51 mass-casualty incidents (MCI) that identified a universal failure to execute proper triage. Inadequate prehospital triage continues to be reported following MCIs: an aircraft crash in Singapore in 2000,11 the Tokyo sarin attacks,12 and the Gothenburg Fire Disaster.13 Typically, documentation of prehospital triage during an MCI is quite poor; therefore, retrospective analysis of field triage is simply not feasible, as was the case for the Oklahoma City Bombing.14

The urban community in a developed country may very well possess the resources necessary to treat dozens or even hundreds of casualties, provided the resources are mobilized and the patients in need of immediate care are identified in a timely fashion. Yet even in these settings, suboptimal use of available community resources is the rule rather than the exception; for instance, most casualties self-transport to the closest hospital and leave distant facilities underused.15 Community resources, such as urgent care centers and outpatient clinics, capable of treating the majority of casualties with relatively minor injuries, are almost always underused. Almogy et al.,16 reporting on the Israeli response to the Jerusalem Sbarro Pizzeria Bombing in 2001, observed: “in these circumstances (e.g., a MCI such as a suicide bombing), ordinary hospital resources are heavily burdened, yet delivery of efficient medical treatment is possible by recruitment of all available personnel and resources.”

In contrast to the many reports of poor triage after disasters, exemplary responses to MCIs have stemmed from exemplary mobilization of resources. After the bombing at the Atlanta Centennial Olympics, 30 EMS units evacuated all 111 casualties to area hospitals within 32 minutes. The vast majority of serious casualties were taken to Grady Memorial Hospital, where, “at one point, there were more physicians than victims in the emergency care center.”17 Those casualties all had good or excellent outcomes. After the Jerusalem Sbarro Pizzeria Bombing, the prehospital response was largely “scoop and run.” The Ein Kerem Campus, receiving 132 surviving casualties, performed two emergency department (ED) thoracotomies, with no apparent shortage of resources available for those less-critical casualties.16 After the 2013 Boston Marathon Bombings, all 30 “red-tagged” patients, the most critically ill, were transported to area hospitals within18 minutes, and all survivied.18 Almogy’s dictum pertains to most recent disasters in developed countries, which have been limited to dozens or hundreds of casualties. Popular field triage systems (see the Triage Scoring Systems section) are most appropriate for this scale of events.

Such triage systems, however, are less applicable to disasters of enormous scale. The greater the scope of the disaster, both in terms of geographic area and number of casualties, the more challenging triage becomes. Including the 1918 Influenza Pandemic and Hurricane Katrina, in 2005, there have been only nine nonmilitary disasters in the entire history of the United States that resulted in more than 1000 deaths. Internationally, massive disasters have produced tens or hundreds of thousands of dead and injured, such as earthquakes in Tangshan (1976), Armenia (1988), Hanshin-Awaji (1995), and Iran (2003), as well as the Indian Ocean Tsunami (2004) and the Tohoku Earthquake and Tsunami in Japan (2011). Field triage systems tend to be sensitive and not specific, leading to overtriage, and they may be too unwieldy to triage massive numbers of casualties spread over a wide area. Additionally, they are tailored to traumatic pathology, but broad medical pathology (e.g., infectious disease and metabolic disarray) occurs in the aftermath of these massive disasters, and baseline medical emergencies (e.g., myocardial infarctions and ectopic pregnancies) continue to occur unabated.

What is involved in triaging?

What are the 3 categories of triage?

What are the 5 levels of triage?

What is the purpose of triage in a disaster?