Triage

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Triage

• CPT James R. Rice, PA-CEmergency
  MedicineInterservice Physician Assistant Program

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Objectives

• Given casualties and no other medical assets,
  decide which casualty needs medical care
  first.
• Describe how to
• Prioritize injuries
• Establish triage areas
• Establish evacuation lanes
• Discuss establishing an LZ
• Discuss the use of the 9-Line MEDEVAC template

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References

• Emergency War Surgery, OTSG, 1988
• Textbook of Military Medicine, Part I, Vol 5
• Conventional Warfare, OTSG, 1991
• Gunshot Wounds, Swan Swan, Yearbook Medical
  Publishers, 1989
• Textbook of Surgery, Sabiston, editor
• W. B. Saunders, 1986
• SESAP VI and SESAP 97-98,
• American College of Surgeons, 1988, 1997
• photos from other books and journals

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What do I do?

• You might find yourself in this situation
• There are casualties, and either
• no other medical personnel available
• or so many casualties that medical assets are
  over-whelmed.
• You will be expected to do something.

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What do I do?

• You may find yourself with an overwhelming number
  of casualties.

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Preparation

• Establish your triage area and your category
  holding areas.
• DIME
• Develop a marking system
• Establish your evacuation holding areas
• Develop a marking system
• One-Way Traffic!!
• Ensure a traffic control NCO
• Your triage NCO/Officer needs to be VERY
  experienced
• Give them some basic class VIII

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Preparation

• Where are the security assets?
• Be prepared to jump quickly
• ?establish the BAS vs Tailgate Medicine?

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DIME

• D-Delayed
• I-Immediate
• M-Minimal
• E-Expectant

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Evacuation Lanes

• Urgent Surgical
• STAT to an FST
• Urgent
• STAT to a CSH
• Priority
• ASAP to FST or CSH
• Routine
• Whenever

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CAPT HR BohmanFRSS / STP Combat Casualties
Results

• OIF-I
• 338 -- Total casualties
• 90 (26) Operative cases
• 21--Number Unstable Pts
• 45 min Mean Time to Arrival
• All USMC survived

• OIF-II
• Total casualties 300
• Operative cases 125 (41)
• 39--Number Unstable Pts
• 74 min Mean Time to Arrival
• 8/26 USMC were DOW

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CAPT HR BohmanFRSS / STP Critical Patients
Results

• OIF-I
• 338 trauma cases
• 90 operative (26)
• Number Unstable Pts
• USMC 5
• Iraqi 16
• Mean Time to Arrival
• USMC 30 min (15-45)
• Iraqi 60 min
• All USMC survived

• OIF-II
• 300 trauma cases
• 125 operative (41)
• Number Unstable Pts
• USMC 26
• Iraqi 13
• Mean Time to Arrival
• USMC 63 min (20-110)
• Iraqi 85 min
• 8/26 USMC have DOW

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Movement of Critical Patients OIF-II CAPT HR
Bohman

• 23 km distance from point of injury
• 20/39 (51) of critical patients taken to BAS
  first
• 29 min time to presentation at BAS
• 36 min length of stay at BAS
• 8/20 (40) had any ATLS intervention at BAS
• 74 min time to arrival FRSS/STP

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M
Triage Area
Traffic Flow
I
D
E
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Initial Approach

• Call out to the casualties, If you can hear my
  voice, get up and come to me!
• If they get up and walk to you, they are Minimal
• They may be helpful as litter bearers/buddy aid
  and security assets
• Call out, All of you that can hear me, raise
  your hand or foot!
• If they raise a hand or foot, they are delayed
• If the casualties dont get up, or raise a
  hand/foot, they are immediate or expectant.get
  busy!

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Circulation

• Control the life threatening hemorrhage
• Check the radial pulse
• If it is presentsystolic pressure of 80mmHg
• If it is strong
• Good sign
• If it is bad
• Bad sign-may make your patient expectant

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Breathing

• Put your hands on both sides of the chest and
  count his respiratory rate, effort, symmetry
• Ausculate if possible
• The patient is breathing and in no distress
• Delayed vs minimal
• Is there respiratory distress?
• Immediate
• No breathingexpectant

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Airway and breathing

• Most casualties will NOT have an airway injury.
• If a casualty is talking or hollering,
  his airway is OK for the time being.

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Airway

• This wound seems small, but it could cause
  bleeding or direct injury to the airway or spine.
• Dont forget to continue to re-triage
• It is a DYNAMIC process!!

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Airway

• This man can breathe OK when sitting up.
• When you try to make him lie flat, he struggles
  and fights for air.
• Let him sit up!
• If there are medical personnel in the area, let
  them know about him first!
• And tell them that he cant breathe when lying
  flat.

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Airway

• In large flame burns,
  airway might start
  out OK,
  but within hours
  becomes
  narrowed by swelling.
• Get history while he can still talk.
• Then provide an airway before it becomes
  critical.
• Dont be alarmed by the facial burn. Most of
  them heal well if not very deep.

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No breathing or pulse

• In a mass casualty situation, with many truly
  injured people,
• If you find a casualty who is not breathing and
  has no pulse,
  leave him and go on to the next.
• Do not compel personnel to try to revive a dead
  casualty, when the living still need their help.
• Reminder - this goes for a mass casualty
  situation with many truly injured people.

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But what about CPR?

• Trauma patients who are dead at the scene can
  rarely by revived, even under the best of
  circumstances.
• The few who might live will require skilled care
  and equipment that is not available to you.
• The living need your help more.

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But what about CPR?

• CPR IS used in cases of
• drowning
• hypothermia (freezing)
• electrical shock
• sudden cardiac death
• But not during mass casualties involving many
  truly injured people.

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What can be done during triage?

• Stop bleeding
• Decompress a tension pneumothorax
• Insert a nasopharyngeal airway

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Serious head injury

• In an over-whelming mass casualty situation,
  if a casualty does not open his eyes, talk, or
  move, leave him and go on to the next.
• In Vietnam, casualties with direct GSW to the
  head who were comatose either did not survive,
  or survived with serious
  impairment.
• Casualties who are comatose will require
  more care than you can give them in an
  over-whelming mass casualty situation.

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Priorities in general

• Life has priority over limb or eye-sight
• Life threatening hemorrhage has priority over
  airway and breathing problems
• Airway and breathing problems have priority.
• Torso injuries might have priority over limbs.
• A limb with no pulse has priority over a limb
  with a pulse.
• Open fractures have priority over closed.

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Helicopter Landing Zone

• Clear all debris.
• Mark obstacles (Panels/Chemlites/Glint Tape).
• LZ should be generally level not gt16 deg. And
  preferably lt 8 deg.
• Cleared diameter for UH-60 50m, CH-47 80m.
• Aircraft will land facing into the wind.
• UH-60s in particular may forward roll after
  landing 10-50 to avoid
• a Brownout. Anticipate it.
• Avoid landing aircraft down slope
• Ensure marking devices (Bean Bag/ Lights /
  Chemlites / VS17 Panels) are properly secured to
  avoid them being sucked up in the rotor wash.
• Ground guides are NOT NEEDED to land.
• Regardless of how the HLZ is marked, the pilot
  will determine where to land.

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INVERTED Y LZ
STEM LIGHT
7m
WIND DIRECTION
STEM LIGHT
14m
LEFT LEG LIGHT
RIGHT LEG LIGHT
14m
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Helicopter Landing Zone

• DAYLIGHT MARKING PROCEDURES
• Determine method of marking (Smoke/Panels/Strobe/S
  tar Cluster).
• Do not pop smoke of fire star cluster until pilot
  requests it.
• NIGHT MARKING PROCEDURES
• Use light discipline as pilots will be on NODs
• (Only marking lights should be on as
  aircraft approaches.)
• Determine the marking method
• (Bean Bag Lights/Chemlites/Strobe).
• May use an IR chemlite spun on a length of 550
  cord to mark the HLZ or to indicate where the
  casualties/medics are located on the LZ.

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Helicopter Landing Zone

• MEDIC RULES
• Package patient to withstand a rigorous
  evacuation in which no CASEVAC care may occur.
  All interventions should be secured/splinted/space
  or wool blanket on/litter straps on and snug.
• Secure any loose items on or around the patient.
• Remove weapons/pyro/sensitive items prior to evac
  and give them to 1SG/S4.
• Ensure patient has an FMC or equivalent secured
  to their person.
• Never approach the aircraft unless directed by a
  crewmember. Flight medics will normally
  disembark and come to you to evaluate your
  casualties.
• Watch for, and obey immediately, any commands
  given by crewmembers.
• Ensure that you have pertinent patient data
  recorded prior to them leaving.
• Always have/wear a pair of goggles.

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9 Line MEDEVAC

• LINE 1 LOCATION OF PICKUP SITE
• LINE 2 RADIO CALL SIGN FREQUENCY
• LINE 3 NUMBER OF PATIENTS BY PRECEDENCE
• A Urgent
• B Urgent Surgical
• C Priority
• D Routine
• E Convenience
• LINE 4 SPECIAL EQUIPMENT NEEDED
• A None
• B Hoist
• C Extraction Equipment
• D Ventilator
• LINE 5 NUMBER OF PATIENTS BY TYPE
• L Number of Litter Patients
• A Number of Ambulatory Patients

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9 Line MEDEVAC

• LINE 6 SECURITY OF PICK-UP SITE (WAR)
• N No Enemy Troops in the Area
• P Possible Enemy Troops in the Area (Approach
  with Caution)
• E Enemy Troops in the Area (Approach with
  Caution)
• X Enemy Troops in the Area (Armed Escort
  Required)
• LINE 7 METHOD OF MARKING HLZ
• A VS-17 Panel
• B Pyro, Type
• C Smoke, Color
• D None
• E Other
• LINE 8 PATIENT NATIONALITY AND STATUS
• A US Military
• B US Civilian
• C Military, Non-U.S.
• D Civilian, Non-U.S.
• E EPW
• LINE 9 DETAILS OF LANDING SITE

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Questions??