Triage
and
Mass Casualty Operations

MAJ Tom Garigan

Last Update: 8 May 1996

Purpose:

To familiarize family practice residents with:
- the triage process
- the organization and conduct of MASCAL Operations
To provide a basis for medical officers to prepare themselves and their units for mass casualty events

Triage

Process of prioritizing victims based upon:
- Immediacy
- Salvageability

Do the most for the most

Possible Scenarios

Accident
War
Terrorism
Epidemic
Toxin
Environmental Extremes

Mechanisms

Penetrating injury
Burn
Blast
Inhalation injury
Chemical agent/toxin
Biologic agent
Environmental
- Cold
- Heat
- Lightning
- Immersion Injury
Psychologic

Categories: US/NATO

Immediate- Briefly Stable
Delayed- Stable Major Wounds without Hemorrhage
Minimal- First Aid; Psychiatric
Expectant- "Not Salvageable"

Situational Factors

Numbers of Casualties
Extricability/Location of Casualties
Time
- of day
- to medical facility (Distance)
Transportation
- Vehicles
- Lines of Communication
Medical resources
- Personnel
- Facilities
- Transportation
- Distance
Clinical Considerations(3)
- Mechanism of Injury- inexact science
  - anatomic indicators
    - assess injury to specific organ systems:
    - require diagnosis---> time dependent
  - physiologic indicators
    - may not be immediately apparent---> time dependent
- Co-morbid Conditions- may be unknown
  - Extrinsic
    - Environmental
    - cold exposure
    - heat
    - fire
    - burn, CO, inhalation, cyanide
  - Intrinsic
    - age
    - preexisting disease
    - medications

Triage is:

Continuous (for each victim)
Repeated (for groups of victims at each site)
MASCAL Site
Treatment Areas
Entry
Exit/Evac

Principles of Triage(1)

Rapid assessment of every patient
Safety
Experienced Triage Officer
Triage "Captains" do not give medical care
Speed, with Thoroughness
Impassionate
Do not address treatment needs
Use simple criteria, without need for equipment
Return the Most to Combat

Problems

Humbling
Second-Guessing
Errors
Imprecise Process
Scoring Systems not any better than Experience, Knowledge, Instinct
Triage is at multiple levels-- everyone needs training

Preparation & Education

Anticipation
Analyze Afterwards
Study & Experience
solid clinical judgment
Drill, Drill, Drill
Build Realism into Training
Self-Confidence
Stamina
Physical
Emotional
Know your limits
Decisiveness and Tenacity

Field Triage Approach(1)

1. Determine if Salvageable

Alive?
Extricable?
Extent of Injury?
Speech (alertness, breathing)
Resp. Rate
Pulse presence and Character
Glasgow Coma Scale
Anatomic Location of Injury
Mechanism of Injury

2. If Salvageable, then Urgency?

3. If Immediate, then Extent of Treatment?

BASED ON RESOURCES AND EVAC TIME
- Airway
- Patency
- Support?
- Breathing
- Support?
- Technique?
- Circulation
- Control Hemorrhage
- IVF?
- CPR/ACLS?
- Immobilization?
- Analgesia?

TRIAGE CAPTAIN(2)

Experienced (or studious)
"Chance favors the prepared mind." Louis Pasteur
Leader
Does not treat
Receives Reports
BUT- may have to move forward to initiate the process
Clearly Communicates
Monitors
Readjusts

"To improve is to change; to be perfect is to change often." Winston Churchill

TRIAGE ORGANIZATION:

If many patients at once- use triage lieutenants as shown above

"The science and art of triage are predominantly based on anecdotage, collective opinion, and political necessity, none of which is supported by adequate documentation."(3)H. R. Champion

Only 5-10 % of trauma victims require a trauma center:(4)

"Optimal use of trauma centers, then, would direct victims with true life threats to a level-1 facility and those with lesser injuries to community hospitals."(5)

Severity Scores(6) :

Emerged in early 1970's
Should:
- Be simple to use
- Based on easily accessible data
- Have predictive validity (for death and disability)
- Have face validity (be intuitively reasonable to physicians, nurses, and paramedics)
- Have inter- and intra-observer reliability

Anatomic Scores & Anatomic Criteria:

Abbreviated Injury Scale (AIS)
- 1971; multiple revisions
- Joint Committee on Injury Scaling
- AMA
- American Association for Automotive Medicine
- Society of Automotive Engineers
- Six categories of injury severity
- Minor---->Fatal:(7) For example:
  - muscle ache or chest wall stiffness
  - simple rib or sternal fracture
  - multiple rib fractures
  - flail chest
  - aortic laceration
  - fatal thoracic injury
- Ranks each injury separately
- Does not assess combined effect of multiple injuries
- Used as basis for ISS
- Cannot be calculated until discharge
Injury Severity Scale (ISS).(8)
- 1974
- sum of the squares of the highest AIS grades in each of the 3 most severely injured body regions
- ISS= 16 or more = major trauma---> 10% mortality---> level-1 trauma care
- Cannot be calculated until discharge
Anatomic Criteria(3)

Warrant level-1 trauma care
Anatomic Criteria
Penetrating injury to head, neck, torso, proximal extremity
Flail chest
Amputation proximal to wrist or ankle
Two or more proximal long bone fractures
Pelvic fracture
Limb paralysis
Burn >10% BSA or inhalation injury combined with trauma

Significant Mechanism of Injury(9)
Fall
>20 Feet
MVA
Death in same compartment
Ejection
Extrication >20 minutes
Speed >40 mph
Auto deformity >20 inches
Intrusion > 12 inches
Auto-pedestrian accident
thrown or run over
Impact >5 mph
Motorcycle accident
Speed >20 mph
Ejected

Physiologic Scores

Trauma Index(10)

1971
7 or less= minor
>18 mortality up to 50%
Revised11

Glasgow Coma Scale(12)
1974
motor<---CNS function
verbal<---integration within the CNS
eye<---brainstem function
Never meant as a pre-hospital tool:
Designed to provide a continuum for initial evaluation and response to therapy

Trauma Score(13) /Revised Trauma Score(14)
Now includes:
GCS, RR, SBP
CRAMS=Circulation, Respiration, Abdomen, Motor, Speech Scale15
normal--mildly abnormal--very abnormal
8 or lower (range, 0-10) =major trauma

Other Scores:

Pre-hospital Index(16)
Score: 0-20
4 point additive for penetrating thoraco-abdominal trauma
Trauma Triage Rule(17)
- Field Variables:
  
  SBP < 85
  GCS motor <5
  penetrating injury of the head, neck, or trunk
  Major trauma criteria (resource based)=
  non-orthopedic surgery and have positive operative findings within 48 hrs, or receive aggressive fluid resuscitation to maintain SBP > 89, or
  undergo invasive CNS monitoring with positive findings on head computed tomogram or increased ICP, or
  sustain fatal injuries

"These Scores (are) less effective as triage tools than the paramedics' qualitative judgment as to the presence of life- or limb-threatening injury"(3,18)

"...emergency medical technician and paramedic prediction of injury severity is as accurate in predicting mortality and severe morbidity as many of the established scoring systems."(19,20)

Scales predict mortality with a sensitivity and specificity of at least 85%(21)
Do NOT identify casualties with major injuries who appeared physiologically normal in the field

MASCAL

April 19, 1995
Oklahoma City(22 )

Teaching Points:

Surprise
Preparedness
Emotional Shock
Safety
Organization
Beforehand
On-Site
Delegation
Rapid Assessment
Triage
Decisiveness
Acceptance of consequences
Focus
Location of Triage Captain
Best location of physician
Initiative

MASS CASUALTY INCIDENT (MCI)(23) (24)

Level 1
- Manageable with local medical resources
- Normal medical care delivery altered
- single incident/scene
Level 2
- Exceeds normal medical response capability of community
- Multi-jurisdictional mutual aid required
Level 3= Medical Disaster
- Overwhelms local and regional resources
- State & federal support needed
- larger geographic scope

(25)

Philosophy of Disaster Care(22) :

Greatest Good for the greatest number of potential survivors-

Alterations in:

Resuscitation

withheld from the most severely injured or ill
Diagnostic modalities
Results
Less is acceptable if life is saved
Function
Cosmesis
Surgical Priority and Timeliness
What is an acceptable delay in treatment
Delegation of responsibility
Altered Criteria for Admission
Paperwork
No Changes in:
Patient Assessment Techniques
incl. serial exams
Resuscitation Techniques

Elements of a MASCAL Incident:

Disease/Injury
Location
Safety
Environment
Medical Resources
Transportation

Conduct of MASCAL Initial Response

Notification/Alert
First Response
On-Site Activities
Safety
Security
Traffic Management
Communications
Personnel Management
Triage
Medical Care
Medical Facility Preparation
Communications
Transportation

Organization of the Staging Area/Triage and Treatment Site

Accessability to vehicles
Restricted/Controlled Access
Safety
Adequate Space
Separate areas for separate categories
Communications
Personnel- Initial "Staff" On Scene

Primary Rescuers
Triage Officer (Senior Medical Officer on scene)
Communications Liaison
Traffic Control (EMS Chief)
Personnel Control
Security Officer
Site Manager

FOR MORE DEVELOPED SITES:

Safety Officer
Record Keeper
Treatment Teams
Logistician
Public Affairs
Chaplain

On-Scene Activities(23, 22)

Extrication
Triage
Treatment
Evac

Primary Triage

On-Scene
To Determine Order of Evacuation to Initial Treatment Staging Area
Rx to Stabilize Only:

Lifesaving care only if signs of life
"Heroic" measures if sufficient rescuers
"BASIC"

Bleeding Control
Airway Positioning
Shock Prevention
Immobilization
Classification

Secondary Triage

During transport to on-scene treatment and staging areas
By on-scene Medical Triage Master

Transport Triage

Triage for priority of evacuation to hospital

Hospital Entry Triage

TREATMENT/STAGING AREAS On-Scene

Established during primary triage
To prevent first-found=first evac'd
Near evac pick-up sites
Walking Wounded walk there
Marked well
Voice control--megaphone

On-Scene Level of care and personnel are determined by delays:

On-Scene Care(26) :

Best done by EMS
Physicians only present for:

Medical care if prolonged evacuation
In charge of hospital-based mobile treatment teams
Complex triage
Support of inexperience EMT's

Physicians must retain:

freedom of movement
communication
access to facility based medical resources

Wartime Example of Physician Retaining Freedom of Maneuver:

TREATMENT PRIORITIES in the Initial Treatment/Staging Area:

Immediate
Delayed
Minimal
Expectant

METHOD OF MARKING

Tags
Markers
on person
on tag
Color Coding

EVAC PRIORITY

Urgent
Priority
Routine

KEY PERSONNEL(23)

In the Field

Rescuer/Primary Triage

To the patient

Medical Triage Master

At the egress point from site/entrance to treatment/staging area
Assigns Rescuers/Primary Triage to duties/locations

Medical Transportation Officer/EMS Chief

At traffic control point
Routes
Allocation of assets
Designation of Crews, Vehicles
Supplementary transportation
Distribution of patients to hospitals
Vehicle positioning
Liaison with Police

Medical Control Officer

In Charge of All Pre-Hospital Care
Distribution of patients to hospitals

OTHER PERSONNEL:

Communications Control
Personnel Management/Control
Supply
Police
Fire/Safety/Public Works
Transporters
Litter Bearers

Management of Trauma in the Medical Facility(27)

Key Hospital Hospital Personnel:

Entry Triage Officer
Treatment Teams
Medical Records
Physician-in-Charge (chief of medical operations in hospital)
Administrator-in-Charge
Ancillary Services
Communication Liaison

In charge of commo in and out of hospital treatment area

Preparatory Period

Develop Triage System
Analyze patient Flow
Analyze communication flow
Train Staff
in triage
monitoring
treatment
reporting/communication/documentation
Analyze/Train pre-hospital team
Talk thru
Walk Thru
Drill, Drill, Drill
Feedback/After Action Discussions
Study Trauma
Medical Threat Intelligence
Endemic Diseases
Enemy Weapons

Notification((22)

alert the on-call team
analyze incoming reports
rapid brief of team
organize available personnel
triage
treatment teams
position personnel
check communications
check readiness of ancillary staff
EKG, X-Ray, Lab, Blood Bank, etc.
check emergency equipment and supplies
check readiness of OR/surgeons
review SOP's
safety, safety, safety INCLUDING BLOOD AND BODY FLUID PRECAUTIONS

Arrival of patients

Check your pulse
Exhibit calm demeanor
Control the flow of communication
Other personnel control flow of people
Assess number of casualties

up to 5 at once- triage OIC performs triage
6 or more at one time- consider delegating triage to subordinates
Triage by function
Tell ambulatory to move to side and wait
Ask others to raise their hand
Mark/designate by category
Record keeping
Feedback loop
Return to starting position
Debrief
Get Reports from
ER
OR
Staffing
Pre-hospital reports
Triage Team NCO
Reorganize
Encourage
Check Personnel

Communication

Hardware

radios
cellular phones
dedicated land lines
other radio bands
TV
fax
megaphones
loudspeakers
pagers
messengers
backup power

Software

Frequencies/Nets/Channels

Military
Evac
Admin/Support
Clinician Consultation
Telemedicine

Lines of Communication:

Medical Control Officer

--->EMS Chief
---> Each ambulance
---> Medical Triage Master
--->Hospital Command Post
---> Other hospitals
---> Special Staff
---> Police, Fire

Medical Triage Officer -->EMS Chief
EMS Chief ---> Each ambulance

(Medical Transport Ofcr)

---> Medical Control Officer
---> Medical Triage Officer
--->Hospital Command Posts

Ambulance

--->EMS Chief
(--->Medical Control Officer)

Medical Triage Officer

--->EMS Chief
--->Medical Control Officer
--->Hospital Command Post

Hospital Physician-In-Charge

--->EMS Chief
--->Medical Control Officer
--->Hospital Command Post

Hospital Command Post

--->Medical Control Officer
--->Physician-In-Charge
--->EMS Chief
---> Other hospitals
---> Police, Fire
---> Radio, TV

Hospital Disaster Plans(28)

JCAHO Requirement-->twice yearly exercise

Alert Process
Activation levels
Notification Procedures
Emergency privileging process
Operations

Triage areas
Marking Techniques
Standing Orders
Layout/Patient Flow at Medical Facility
Supplies
Backup Transportation
Organization of Health Care Providers
Echelons of Providers
Ancillary Personnel

litter bearers
drivers
traffic controllers
security
chaplains
Red Cross
housekeeping
runners/messengers
PAD
Communications
Command and Control
Medical Resources
Mobile Assets For:
Triage
Medical Care
Evacuation
Fixed Assets
supply
expansion of beds
overflow of recovering patients
Mutual Aid Plan from other hospitals and jurisdictions
Non-medical resources
Police
Firefighting
Utilities- Electricity, Backup generators, Water, etc.
Documentation
Marking Casualties
Tags/Field Medical Cards
Overprinted H&P's and Orders
Hospital Evacuation Plan
Alternate care sites
Alternate evacuation and supply routes
Alternate communications
Safety

TRAINING

Clinical Knowledge
Trauma assessment and treatment
Triage Skills
MASCAL Process
Organization
Command, Control, Communications
Logistics
Exercises

Partial
Complete
Mental/Spiritual Preparedness

DEBRIEFING/AFTER ACTION REPORTS

To analyze the good and the bad
Emotional venting & support
Make immediate reports
Make corrections quickly

BIBLIOGRAPHY
(1) From Lecture "Disaster Triage" by Waeckerle, Joseph F., MD, Chief of Dept. of Emergency Medicine, Baptist Medical Center, University of Missouri-Kansas City School of Medicine

(2) Armstrong, J. H.: "Triage: Principles and Leadership" from a forum taught at AMSUS 102nd Annual Meeting, 30 Oct 1995

(3) Champion, HR: Triage. In Cales RH, Heilig RW (eds): Trauma Care systems: A Gude to Planning, Implementation, Operation, And Evaluation. Rockville, MD, Aspen Publishers Inc, 1986, p 80

(4) Eastman AB, West JG: Field Triage. In Moore EE, Mattox KL, Feliciano DV (eds): Trauma, ed 2. Norwalk, CT, Appleton & Lange, 1991, p 67

(5) Maslanka, AM: Scoring Systems and Triage from the Field. In Marx, JA (ed): Emergency Medicine Clinics of North America, 11:1 pp 15-27 February 1993

(6) Center for Health Systems Research and Analysis: Report on the Trauma Severity Index Conference. Madison, WI, University of Wisconsin, 1980

(7) Maslanka, AM: Scoring Systems and Triage from the Field. Table 1, In Marx, JA (ed): Emergency Medicine Clinics of North America, 11:1 p 18 February 1993

(8) Baker SP, O'Neill B, Haddon W, et al: The Injury Severity Score: A Method for Describing Patients With Multiple Injuries and Evaluation Emergency Care, J Trauma 14:187, 1974

(9) Maslanka, AM: Scoring Systems and Triage from the Field. Table 3, In Marx, JA (ed): Emergency Medicine Clinics of North America, 11:1 p 19 February 1993

(10) Kirkpatrick JR, Youmans RL: Trauma Index: An Aide in Evaluation of Injury Victims. J Trauma 14:934, 1971

(11) Smith JS Jr, Bartholomew MJ: Trauma Index Revisited: A Better Triage Tool. Crit Care Med 18:174, 1990

(12)Teasdale G, Jennet B: Assessment of coma and Impaired Consciousness: A Practical Scale. Lancet 2:81 1974

(13) Champion HR, Sacco WJ, Hannan DS, et al: Assessment of Injury Severity: The Triage Index. Crit Care Med 8:201, 1980

(14) Champion HR, Sacco WJ, Copes WS, et al: A Revision of the Triage Score. J Trauma 20:188, 1989

(15)Gormican SP: CRAM Scale: Field Triage of Trauma Victims. Ann Emerg Med 11:132, 1982

(16) Koehler, JJ, Baer LJ, Malafa SA, et al: Pre-hospital Index: A Scoring System for Field Triage of Trauma Victims. Ann Emerg Med 15:178, 1986

(17) Baxt WG, Jones G, Fortlage D: The Trauma Triage Rule: A new, Resource-based Approach to the Pre-hospital

(18) Ornato J, Mlinek EJ Gr, Craren EG: Ineffectiveness of the Trauma Score and the CRAMS scale for accurately Triaging Patients into Trauma Centers. Ann Emerg Med 14:1061, 1985

(19) Emerman CL, Shade B, Kubincanek J: A Comparison of EMT Judgment and Pre-hospital Trauma Triage Instruments. J Trauma 31:139, 1991

(20) Maslanka AM, Marx JA, Tkach T, et al: Paramedic Assessment of Vehicular Damage Predicts Injury Severity. Presented at the 1991 Scientific Assembly at the American College of Emergency Physicians Annual Meeting. Boston, October 7-10, 1991

(21) Maslanka, AM: Scoring Systems and Triage from the Field. In Marx, JA (ed): Emergency Medicine Clinics of North America, 11:1 p 23 February 1993

(22)Spengler, C: How Could God Allow This? Guideposts May 1996 p6-10

(23) Doyle, CJ: Mass Casualty Incident: Integration with Pre-hospital Care. Emergency Medicine Clinics of North America Vol 8:1 Feb 1990 p163-175

(24) Mitchell, GW: The Triage Process. Topics in Emergency Medicine Vol. 7:34-45, Jan 1986
(25) Doyle, CJ: Mass Casualty Incident: Integration with Pre-hospital Care. Emergency Medicine Clinics of North America Vol 8:1 Feb 1990 p164 Figure 1

(26) Doyle, CJ: Mass Casualty Incident: Integration with Pre-hospital Care. Emergency Medicine Clinics of North America Vol 8:1 Feb 1990 p 165-6

(27) Schmidt J, Moore GP: Management of Multiple Trauma. In Marx, JA (ed): Emergency Medicine Clinics of North America,11:1 p 29-51 February 1993

(28) Doyle, CJ: Mass Casualty Incident: Integration with Pre-hospital Care. Emergency Medicine Clinics of North America Vol 8:1 Feb 1990 pp166-8

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Triage and Mass Casualty Operations