Triage :- triage is a French term which means to sort into groups according to quality and has been applied to sorting of battle casualties , therefore triage is the process of categorizing patients according to the degree of severity of injury.
The setting of priorities may require very difficult decision when a large number of casualties are received, and when facilities and resources are limited.
The aim of the triage in a mass casualty situation is to do the best for the most.
Triage can take place any where a long the line of evacuation of the casualty, from the point of wounding to the hospital where definitive treatment is to take place.
The aim of the triage is to categorize the wounded on the basis of:-
A. The severity of injury .
B. The need foe treatment.
C. The possibility of good quality survival.
The factors which affect the triage process are:-
A. The number and nature of the wounded.
B. The condition of the wounded.
C. The facilities and personnel available to treat them.
D. The lines of evacuation and the duration of transportation.
Rapid assessment of casualits can be carried out not only by doctors, but also by nurses, paramedical staff and first aid workers (under good training).
If a number of seriously injured casualties arrive with in a short space of time, triage should be done by the most experienced person will in and able to take on the responsibility, based on sound clinical judgement.
This person will decide:-
A. Which patients need immediate resuscitation.
B. Which patients require resuscitation and immediate surgery as a part of the resuscitation process.
C. Which patients have such small wounds that they can be managed by self help or simple treatment and dressings, these patients should be rapidly segregated from other groups kept out of the hospital and not allowed to interfere with the management of the severely wounded.
D. Which patients have such severe wounds that death is inevitable under the circumstances ( such as severe head or spinal injuries, severe multiple injuries and burns of more than 60%).
E. Which patients will tolerate some delay before receiving surgical attention.
The categorization of patients into priority groups should be simple and divided as following:-
1) Category (A): - serious wounds (resuscitation and immediate surgery (these patients have breathing or bleeding problem (such as abdominal injury , thoracic injuries and wounds of blood vessels ).
2) Category (B): - can wait for surgery (such as large soft tissue injuries and compound fractures).
3) Category (C): - superficial wounds ( ambulatory management, such as superficial wounds managed under local anesthesia in the emergency room).
4) Category (D): - severe wounds, this group are patients who have serious injury and they are likely to die or have a very poor quality of survival (these include the moribund or patients with multiple major wounds whose management could be considered wasteful of scarce resources including operative time and blood (such as severe head injury0.
Remember that the triage decision must be respected.
Good organization and prior planning it prevents poor performance when sudden arrival of large numbers of casualties occurs.
Security must be ensured by having gurds at the hospital gate, therefore only wounded persons, possibly accompanied by close relative, should be allowed to enter.
All weapons must be left out side the gate.
Triage area:- should be :-
a) Large space for the immediate reception of casualties and to permit easy movement of casualties and medical personnel.
b) All necessary equipment should be prepared and located in or close to the triage area( such as stretchers, ambulances, surgical equipments and e.t.c).
c) There should be a plan for relocation of in patients from the designated reception area, and the plan should be put in to operation as soon as notice is given of the expected arrival of mass casualties, there should be also a plan for the transfer of patients after triage to wards, x-ray department or operating theatre.
Job description of the personnel who has to work in the triage: -
First of all triage should be performed by an experienced nurse or doctor with a good understanding of the functioning and capacity of the hospital.
The above-mentioned person has full responsibility for categorizing the casualties, and should be supported by a team consisting of a nurse and an assistant.
The duty of the head nurse is to make plans for all staff including the non –medical staff working in the kitchen and the laundry.
Responsibility of nursing teams in triage should be:-
A. Penicillin and tetanus toxiod administration to all casualties .
B. Taking blood for grouping and cross matching (if indicated).
C. Setting up intravenous lines and giving analgesics and other medication as prescribed included bladder catheter if indicated .
D. Transfer of categorized casualties in to separate areas for immediate, delayed or minimal treatment.
E. Arranging the orderly flow of casualties to the operating theatre or x-ray department.
Note :-surgeons and theatre personnel should have prepared the operating theatre and be ready and waiting for casualties.
How to perform triage:- each casualty should be appropriately identified and assigned a medical chart .
Good records are essential, especially the aspects of the wounds, the treatment and the patient’s triage category .
Each patient must be checked and the whole body, including the back, must be examined.
It is important for the triage personnel to identify and mark the dead, so that time and effort are not wasted on them.
Note that the triage is continuous process and there is a need for continuous reassessment.
Wound classification: -
The red cross wound classification is based on the features of the wound it self and not on the weapondry or the the presumed velocity of the missile.
Wounds are given a six-figure score according to the size of the entry and exit wounds of the skin and whether there is a cavity fracture, injury to a vital structure or any metallic body.
The wound score is a useful clinical tool to communicate the severity of the wound with out to remove the dressings, and also to describe.
And document the characteristics of any wound from any weapon.
E: entry in centimeters.
X: exit in centimeters.
C: cavity (C0=no , C1= yes[two fingers]
F: fracture ( F0=no fracture, F1=simple fracture , F2 clinically significant comminution.
V: vital structure [V0=no , Vn=(neurological)penetration of the dura of the brain or spinal cord , Vt= (thorax or fracture ) VA=abdomen , VH=hematological injury ]
M=metallic body (M0=no, M1=yes, one metallic body , M2=yes, multiple metallic bodies).
Examples of wound scores associated with the wounds illustrated in figure1:
Wound E X C F V M
A 1 1 0 0 0 0
B 1 4 1 0 0 0
C 1 0 0 0 1 1
D 1 0 0 1 1 1
E 6 0 1 2 1 1
The wounding power af a missile depends on how much kinetic energy is given up when it strikes tissue.
E:MV2 , where M is the mass and V the velocity .
This determines the extent of tissue damage.