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					        TRIAGE

OF MASS CASUALTIES


   MSF 11th Surgical Day
   Paris, 3 December 2011
        Marco Baldan
    ICRC Head Surgeon
    Al Hussein Hospital
        Karbala, Iraq
       2 March 2004


4 First bomb attack in the city

4 Total victims = 277

4 Dead = 94

4 Wounded = 183
          Hospital Situation


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



     Normal clinical practice


                  Multiple-casualty
                  incident


                  Mass casualties
       Triage = Process




by which priorities are set for the
management of mass casualties.
The aim in a mass casualty situation is

     to do the best for the most,

                 not

       everything for everyone.
JFK Memorial Hospital, Maternity Building
            Monrovia 2003
Triage Tent
Inside the Triage Tent
JFK Memorial Hospital, Main Building
Main Building, Triage Department
Triage Department, in use
 Triage cannot be organised ad hoc.
         It requires planning:

4 Preparation before the crisis
4 Organisation of the personnel
4 Organisation of the space
4 Organisation of the infrastructure
4 Organisation of the equipment
4 Organisation of supplies
4 Training
4 Communication

4 Security
4 Convergence reaction = relatives, friends &
  the curious (especially the armed ones)
   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
        The Triage Team


4Triage team leader: co-ordinator

4Clinical triage officer

4Head nurse, matron: chief organiser

4Nursing groups

4Follow-up medical groups
     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.
Triage decisions must be respected.



        Discuss afterwards.
       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.
            Triage Documentation


4 Include basic
  information
4 Short-form
4 Clear
4 Concise
4 Complete
            Triage Documentation


Reality check
What really happens!

During post-triage
   evaluation:
decided to use plastic
sleeve to hold the
   documentation.
            The triage process:


4Sift

  8 Place   patients in main categories: priority

4Sort

  8 Priority   amongst the priorities
                  Sift

1) Select those most severely injured and

2) identify and remove:

4 the dead

4 the slightly injured

4 the uninjured
                    Sort

Categorise the most severely injured based on:

4 life-threatening conditions (ABC)

4 anatomic site of injury

4 Red Cross Wound Score

4 treatment available in terms of personnel and
  supplies
       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
 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)
Distal pulse absent
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 > 8.)
Category I for Airway; Category II for debridement
Femoral vessels intact
       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.
Multiple superficial fragments
       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.
   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
                 10% Abdomen        Quadriplegia
                 60-65% Limbs       Observation
  Epidemiology of Triage:
   short evacuation time


4Category I         5 - 10%

4Category II        25 – 30%

4Category III       50 - 60%

4Category IV         5 - 7%
        Triage in Monrovia 2003
           3 June – 22 August

4 Total patients triaged = 2588

4 Total admitted = 1015 (40% of triaged)

4 War wounded = 88.5% of admissions

4 Operations = 1433

4 Admitted but not operated = 296

4 All category 1 patients triaged, admitted and
  operated within 24 hours
Patients triaged by date:
      three peaks
   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.

				
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