Tactical Triage 848th FST

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Tactical Triage848th FST
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Triage

• Term comes from French and means to sort
• Modern triage can refer to a number of clinical
  situations, ranging from civilian to military
• 848th focuses on triage as it applies to the
  tactical situation

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Objectives

• Describe the principles of triage
• Outline the NATO standards of triage
• Outline the principles of initial triage
• Describe the principles of ongoing subsequent
  triage
• List medical conditions falling into the
  immediate, delayed, minimal, and expectant
  categories
• Outline the military echelons of care

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History

• Baron Dominique Jean Larre
• The father of modern triage, a surgeon in
  Napoleans army
• American Civil War
• John Wilson observed that care to others could be
  expanded if care to those with likely lethal
  wounds was deferred
• WWI
• Military triage began to resemble modern methods,
  motorized ambulances where introduced

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History Continued

• WWII
• Brought dramatic improvements in survival, in
  part from better triage
• Korea Vietnam
• Further refinements in triage dramatic
  decreases in wound mortality
• Present Day
• FST units are highly mobile provide several
  echelons of care simultaneously

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Principles

• Primary Accomplish the greatest good for the
  greatest number of casualties
• Secondary Employ the most efficient use of
  available resources
• Tertiary Return key personnel to duty as quickly
  as possible

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Factors For Successful Triage

• Focus on easily treated conditions
• Perform rapid, accurate but focused assessments
• Continually reassess and retriage

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NATO Standard

• The most widely accepted tactical triage
  technique
• Used by United States, Canada, and Western Europe
  militaries

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Triage Categories

• Immediate
• Delayed
• Minimal
• Expectant

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Immediate

• Highest Priority
• The need for rapid intervention to save life,
  limb, or sight
• Within minutes to one hour

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Immediate Medical Conditions

• Upper Airway Obst.
• Life-threat Bleeding
• Tension Pneumo
• Extensive 2nd or 3rd Degree Burns to Face
• Untreated Poisoning

• Severe Resp. Distress
• Decompensated Shock
• Complicated OB Delivery
• Rapid Decrease in LOC
• Heat Stroke

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Delayed

• Next Highest Priority
• The need is not of a life saving nature, but
  requires surgery
• Can wait for a few hours

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Delayed Medical Conditions

• Compensated Shock
• Fracture, Dislocation, or Injury w. Circ.
• Controlled Severe Bleeding
• Compartment Syndrome
• Open Fractures or Dislocations
• Any Stable Penetrating Injury w/o Breathing Comp.

• Severe HA w. Alt. LOC
• Severe Abd. Pain w. Rigidity No Shock
• Uncomplicated C-Spine Inj. w. Immob.
• Fever
• Large Soft Tissue Wounds
• Moderate Dyspnea
• Severe CSS or Psychosis

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Minimal

• Lowest Priority
• The need is minor, but still requires some
  medical attention
• Not expected to deteriorate, can wait for
  several hours

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Minimal Medical Conditions

• Closed Fractures Dislocations Uncomp.
• Minor Lacerations
• Burns
• Frostbite
• Dental Pain

• Strains, Sprains, or Bruises
• Minor Head Injury
• Mild Resp. Distress
• Chest Pain
• Penetrating Injury to Extremities

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Expectant

• No Priority, palliative measures only
• Patients who are so gravely ill or injured
  survival is not likely
• Require large amount of resources

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Expectant Medical Conditions

• Cardiac Arrest From Any Cause
• Respiratory Arrest (except for poisoning, drugs,
  or obstruction)
• Massive Brain Injury

• 2nd or 3rd Degree Burns 70 BSA
• GSW to Head With GCS3
• Cardiogenic Shock (decompensated)

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Initial TriageSTART

• S simple
• T triage
• A and
• R rapid
• T treatment

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Before Initiating START, Insure Scene Safety
Get Help

• Two casualties for the price of one doesnt make
  for good medical practice
• The more medical personnel present, the more
  efficient triage will be performed

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Key Points For START Triage

• Able to walk (ambulate)?
• Ventilation present?
• Capillary refill
• Follows simple commands?

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Utilizing START

• An experienced medic should be able to triage
  each patient in 10-12 seconds.
• At this point, no time should be spent treating
  any casualties, for any reason, until initial
  triage is complete.

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Utilizing START

• Walking wounded should be instructed to move to a
  safe area (casualty collection point).
• With ambulatory patients out of the way attention
  can focused on the more severely injured
  casualties.
• This also automatically classifies the walking
  wounded into the category of minimal.

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START Method
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Utilizing START

• If a casualty is found with no ventilation in
  combat they are listed as expectant.
• If tachypnea is present (30 bpm) they are listed
  as immediate.
• Similar findings for capillary refill (perfusion)
  and ability to follow commands (mental status)
  warrant similar categoric placement.

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Ongoing Triage

• Triage is Fluid
• Retriage is continual and needs to take place at
  every point and during transport
• Categories can worsen

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Re-Triage

• It is human nature to think things wont change.
  In reality, a previously listed delayed patient
  can decline to immediate and if unchecked can
  move to expectant.
• Simple attention to detail can be the determining
  factor in a life or death situation.
• A combat casualty can always be expected to
  decline in status, but rarely will move from a
  pore category to one less severe.

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Subsequent Triage a Focused Assessment

• Airway
• Verbal Response
• Evidence of Obstruct.
• Breathing
• Rate Depth
• Breath Sounds Bilat.
• Circulation
• Pulse Rate

• Capillary Refill
• Gross Bleeding
• Disability (Neuro)
• Responsive (AVPU)
• Move All ExtremsX4
• Expose
• Undress Patient
• Exam For Maj. Probs.

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Evacuation of Casualties

• Priority I (Urgent) Emergency patients requiring
  evac. ASAP, within two hours
• Priority IA (Urgent Surgery) Surgical patients
  requiring evac. ASAP, within two hours
• Priority II (Priority) Need for evac. Within
  four hours
• Priority III (Routine) Patients are not expected
  to deteriorate evac. as time permits
• Priority IV (Convenient) Evac. when convenient

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Echelons of Care

• Echelon refers to stage, as in different points
  of care, from scene of injury to the hospital

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Military Echelons of Care

• I Emergency medical treatment
• II Resuscitative treatment
• III Resuscitative surgery
• IV Reconstructive surgery
• V Rehabilitation

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Echelon ISelf Buddy Aid, Medic

• Represents the most forward elements of care,
  usually a Navy Corpsman or an Army Combat Medic

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Echelon IIMedical Company

• Might be at a beachhead or airstrip, or onboard a
  ship (LST or LSH)
• Also can be FSMC or MSMC

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Echelon IIICombat Support Hospital
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Echelon IVGeneral Hospital or Regional Trauma
Center
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Echelon VMilitary or VA Hospital
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848th Echelon of Care

• Encompasses Three Levels of Care
• Echelon I
• Echelon II
• Echelon III

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Identifying CasualtiesTriage Tags

• Civilian Tag METTAG
• Colored Tag
• Very Simple
• Detachable Numbered Tabs
• Military Tag FMC
• Black White
• More Complex
• Carbonless Copies

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METTAG
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METTAG Field Triage Tag
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Field Medical Card

• Always use indelible ink
• Never attach to casualtys clothing
• Tie to wrist or ankle
• If time does not permit, only fill in the triage
  portion of tag
• As casualty moves up the echelon, the tag will be
  filled in completely

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Military Field Medical Card (FMC)
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References

• De Lorenzo, R., Porter, R. (2001). Tactical
  emergency care Military and operational
  out-of-hospital medicine. Brady, 1(10), 78-96.

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Questions
The overriding principle of triage is the
greatest good for the greatest number of
casualties. Christopher J. Copley 1LT