TRIAGE OF MASS CASUALTIES

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TRIAGEOF MASS CASUALTIES

• MSF 11th Surgical Day
• Paris, 3 December 2011
• Marco Baldan
• ICRC Head Surgeon

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Al Hussein HospitalKarbala, Iraq2 March 2004

• First bomb attack in the city
• Total victims 277
• Dead 94
• Wounded 183

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Hospital Situation

• Beds in ER 24
• No place for cadavers
• No communication with/among ambulances
• Minimal hospital security system
• No triage system / disaster plan
• Medical supplies on 4th floor
• Operating theatres on 1st and 2nd floors
• Lifts not functioning

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Clinical practice
Normal clinical practice
Multiple-casualty incident
Mass casualties
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Triage Process

• by which priorities are set for the management of
  mass casualties.

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The aim in a mass casualty situation isto do
the best for the most,noteverything for
everyone.
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JFK Memorial Hospital, Maternity
BuildingMonrovia 2003
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Triage Tent
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Inside the Triage Tent
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JFK Memorial Hospital, Main Building
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Main Building, Triage Department
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Triage Department, in use
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Triage cannot be organised ad hoc. 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)

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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

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The Triage Team

• Triage team leader co-ordinator
• Clinical triage officer
• Head nurse, matron chief organiser
• Nursing groups
• Follow-up medical groups

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Clinical Triage Officer

• No task in the medical services requires greater
  understanding,
• skill,
• and judgement
• than the sorting of casualties
• and the establishment of priorities for treatment.

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Triage decisions must be respected.

• Discuss afterwards.

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Triage is a dynamic process

• begins at the point of wounding,
• occurs all along the chain of casualty care,
• occurs at the hospital reception,
• and continues inside the hospital wards
• continuous reassessment of patients.

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Triage Documentation

• Include basic information
• Short-form
• Clear
• Concise
• Complete

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Triage Documentation

• Reality check
• What really happens!
• During post-triage evaluation
• decided to use plastic
• sleeve to hold the documentation.

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The triage process

• Sift
• Place patients in main categories priority
• Sort
• Priority amongst the priorities

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Sift

• 1) Select those most severely injured and
• 2) identify and remove
• the dead
• the slightly injured
• the uninjured

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Sort

• Categorise the most severely injured based on
• life-threatening conditions (ABC)
• anatomic site of injury
• Red Cross Wound Score
• treatment available in terms of personnel and
  supplies

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ICRC TRIAGE CATEGORIES

• I. Serious wounds resuscitation and immediate
  surgery
• II. Second priority need surgery but can wait
• III. Superficial wounds ambulatory management
• IV. Severe wounds supportive treatment

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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)

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Distal pulse absent
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Category II Need surgery but can wait

• Patients who require surgery but not on an urgent
  basis.
• A large number of patients will fall into this
  group.
• (E.g. non-haemorrhaging abdominal injuries,
  wounds of limbs with fractures and/or major soft
  tissue wounds, penetrating head wounds GCS gt 8.)

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Category I for Airway Category II for debridement
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Femoral vessels intact
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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.

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Multiple superficial fragments
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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.
• The moribund or those with multiple major
  injuries whose management could be considered
  wasteful of scarce resources in a mass casualty
  situation.

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War Wounded in the Field
WW in the field
(GSW, mine, blast)
100 wounded
30 - 40
60 - 70
No surgery
Hospital care
First Aid
90 Surgery
10 NO Surgery
Dressing
12-15 Head
Small wounds
10 Chest
Paraplegia Quadriplegia
10 Abdomen
60-65 Limbs
Observation
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Epidemiology of Triageshort evacuation time

• Category I 5 - 10
• Category II 25 30
• Category III 50 - 60
• Category IV 5 - 7

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Triage in Monrovia 20033 June 22 August

• Total patients triaged 2588
• Total admitted 1015 (40 of triaged)
• War wounded 88.5 of admissions
• Operations 1433
• Admitted but not operated 296
• All category 1 patients triaged, admitted and
  operated within 24 hours

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Patients triaged by datethree peaks
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Summary of triage theory philosophy sorting
by priority

• A simple emergency plan personnel, space,
  infrastructure, equipment, supplies system
• "Best for most" policy
• Priority patients are those with a good chance of
  good survival.