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Battlefield Casualty TriageBattlefield Casualty Triage

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Given multiple (simulated) casualties with varying Given multiple (simulated) casualties with varying injuries, requiring emergency medical care under injuries, requiring emergency medical care under simulated battlefield conditions, perform casualty simulated battlefield conditions, perform casualty triage and establish priorities of treatment and triage and establish priorities of treatment and medical evacuation. Perform all measures IAW medical evacuation. Perform all measures IAW FM 8-10-6, Medical Evacuation in a Theater of FM 8-10-6, Medical Evacuation in a Theater of Operations: Tactics, Techniques and Procedures Operations: Tactics, Techniques and Procedures and the principles of Tactical Combat Casualty and the principles of Tactical Combat Casualty Care. Care.

Terminal Learning ObjectiveTerminal Learning Objective

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Given the principles and techniques of casualty Given the principles and techniques of casualty triage on a conventional or integrated battlefield, triage on a conventional or integrated battlefield, apply the principles and decision-making apply the principles and decision-making processes for casualty triage to establish processes for casualty triage to establish priorities of medical treatment and evacuation priorities of medical treatment and evacuation IAW FM 8-10-6, Medical Evacuation in a Theater IAW FM 8-10-6, Medical Evacuation in a Theater of Operations: Tactics, Techniques and of Operations: Tactics, Techniques and Procedures and the principles of Tactical Procedures and the principles of Tactical Combat Casualty Care. Combat Casualty Care.

Enabling Learning ObjectivesEnabling Learning Objectives

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Given multiple (simulated) casualties with Given multiple (simulated) casualties with significant life-threatening injuries and a significant life-threatening injuries and a standardized medical aid bag stocked with a standardized medical aid bag stocked with a basic load, under simulated battlefield basic load, under simulated battlefield conditions, apply the principles and techniques conditions, apply the principles and techniques of casualty triage to determine the priority of of casualty triage to determine the priority of treatment and evacuation for the casualty IAW treatment and evacuation for the casualty IAW FM 8-10-6, Medical Evacuation in a Theater of FM 8-10-6, Medical Evacuation in a Theater of Operations: Tactics, Techniques and Procedures Operations: Tactics, Techniques and Procedures and the principles of Tactical Combat Casualty and the principles of Tactical Combat Casualty Care.Care.

Enabling Learning ObjectivesEnabling Learning Objectives

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Which casualty do you treat first?Which casualty do you treat first? Who’s most serious?Who’s most serious? Who’s most likely to survive?Who’s most likely to survive? What’s the tactical situation?What’s the tactical situation? What’s the mission?What’s the mission?

Triage is an attempt to impose order Triage is an attempt to impose order during chaos and make an initially during chaos and make an initially overwhelming situation manageable.overwhelming situation manageable.

IntroductionIntroduction

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A system used for categorizing and sorting A system used for categorizing and sorting patients according to severity of their patients according to severity of their injuries:injuries:– To rapidly sort the more serious casualties To rapidly sort the more serious casualties

from those less serious to facilitate the rapid from those less serious to facilitate the rapid care of the more serious patientscare of the more serious patients

– When problems exceed resources, triage When problems exceed resources, triage should facilitate “doing the greatest good for should facilitate “doing the greatest good for the greatest number”the greatest number”

– To bring order to chaos thus facilitating the To bring order to chaos thus facilitating the care of all casualtiescare of all casualties

Perform Casualty TriagePerform Casualty Triage

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Responsibility of medical personnel:Responsibility of medical personnel:─ Survey and classify casualties:Survey and classify casualties:

Number and location of casualtiesNumber and location of casualties Severity of injuriesSeverity of injuries Time constraintsTime constraints Assistance availableAssistance available Evacuation assetsEvacuation assets Supply and re-supplySupply and re-supply

Perform Casualty TriagePerform Casualty Triage

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Responsibility of medical personnel Responsibility of medical personnel cont’d:cont’d:

─ Treatment is first directed towards the Treatment is first directed towards the casualties who have the best chance to casualties who have the best chance to survivesurvive

─ Locate troops with minor wounds, and Locate troops with minor wounds, and return them to dutyreturn them to duty

Perform Casualty TriagePerform Casualty Triage

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– ImmediateImmediate - Immediate treatment to save - Immediate treatment to save life, limb or eyesight life, limb or eyesight

– DelayedDelayed - Casualties who have less risk of - Casualties who have less risk of losing life or limblosing life or limb

– MinimalMinimal - "Walking wounded", self-aid or - "Walking wounded", self-aid or buddy-aid (buddy-aid (Casualties in this category usually Casualties in this category usually are notare not evacuated to a medical treatment facility) evacuated to a medical treatment facility)

– ExpectanExpectantt – Casualties so critically injured – Casualties so critically injured that only complicated and prolonged treatment that only complicated and prolonged treatment offers any hope of improving life expectancyoffers any hope of improving life expectancy

Triage CategoriesTriage Categories

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─ Airway obstructionAirway obstruction─ Open pneumothorax (with respiratory distress)Open pneumothorax (with respiratory distress)─ Tension pneumothorax Tension pneumothorax ─ Unstable abdominal wounds with shockUnstable abdominal wounds with shock─ Massive external bleeding (e.g., amputation)Massive external bleeding (e.g., amputation)─ Open fractures of long bones Open fractures of long bones ─ Hemorrhagic shockHemorrhagic shock─ Burns of the face, neck, hands, feet, or perineum Burns of the face, neck, hands, feet, or perineum

and genitalia or second or third degree burns of and genitalia or second or third degree burns of 15-40% or more of the total body surface area 15-40% or more of the total body surface area (TBSA)(TBSA)

ImmediateImmediate

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ImmediateImmediate

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DelayedDelayed─ Abdominal wounds (without shock)Abdominal wounds (without shock)─ Open chest wound (w/o respiratory distress)Open chest wound (w/o respiratory distress)─ Eye and CNS injuriesEye and CNS injuries─ Soft tissue wounds requiring debridementSoft tissue wounds requiring debridement─ Fractures requiring surgeryFractures requiring surgery─ 2nd and 3rd degree burns >20% TBSA2nd and 3rd degree burns >20% TBSA─ Maxillofacial wounds (w/o airway compromise)Maxillofacial wounds (w/o airway compromise)─ G/U tract disruption G/U tract disruption

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DelayedDelayed

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MinimalMinimal─ Minor lacerations, abrasionsMinor lacerations, abrasions─ ContusionsContusions─ Sprains and strainsSprains and strains─ Minor combat stress problemsMinor combat stress problems─ Burns 1st or 2nd degree <15% TBSABurns 1st or 2nd degree <15% TBSA─ Upper extremity fractures (w/o neurovascular Upper extremity fractures (w/o neurovascular

compromise)compromise)─ Behavioral disorders; psychiatric disordersBehavioral disorders; psychiatric disorders─ Suspicion of blast injury (w/ stable VS)Suspicion of blast injury (w/ stable VS)─ Symptomatic but unquantified radiation Symptomatic but unquantified radiation

exposureexposure

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MinimalMinimal

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ExpectantExpectant– Unresponsive casualties with penetrating Unresponsive casualties with penetrating

head wounds and signs of impending deathhead wounds and signs of impending death– Burns, mostly 3rd degree, covering more than Burns, mostly 3rd degree, covering more than

60% TBSA60% TBSA– Cervical (high) spinal cord injuriesCervical (high) spinal cord injuries– Mutilating explosive wounds involving multiple Mutilating explosive wounds involving multiple

anatomical sites and organsanatomical sites and organs– Profound shock with multiple injuriesProfound shock with multiple injuries– Agonal respirationsAgonal respirations– Convulsions and vomiting within 24 hours of Convulsions and vomiting within 24 hours of

radiation exposureradiation exposure

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Expectant cont’dExpectant cont’d– Without vital signs or signs of lifeWithout vital signs or signs of life– Transcranial gunshot wound (GSW)Transcranial gunshot wound (GSW)– Open pelvic injury w/ uncontrolled bleedingOpen pelvic injury w/ uncontrolled bleeding

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Alternate Triage CategoriesAlternate Triage Categories Emergent (immediate) - require attention within Emergent (immediate) - require attention within

minutes to hoursminutes to hours– Uncontrolled bleeding Uncontrolled bleeding – Airway obstructionAirway obstruction– Shock (SBP<90 and AMS w/o head injury)Shock (SBP<90 and AMS w/o head injury)– Unstable penetrating or blunt traumaUnstable penetrating or blunt trauma– Threatened loss of limb or eyesightThreatened loss of limb or eyesight– Multiple long-bone fracturesMultiple long-bone fractures

Non-Emergent (delayed and minimal)Non-Emergent (delayed and minimal)

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Triage is an Triage is an ongoingongoing process of reassessment process of reassessment

which may change the which may change the casualty’s triage category. casualty’s triage category.

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Triage Decision MakingTriage Decision MakingWalking Non-Emergent

(Minimal)

Responsive to shake and shout

Yes No

Palpable radial pulse, comfortable breathing

Breathing / airway open

or with simple maneuver

Yes No

Emergent(Immediate)

Non-Emergent(Delayed and

Minimal)

Yes No

Expectant/Dead

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Triage Decision MakingTriage Decision Making Modified “START” has Modified “START” has four key decision four key decision points points::

– Is the casualty able to walk (ambulate)?Is the casualty able to walk (ambulate)?

– Is the casualty responsive or unresponsive?Is the casualty responsive or unresponsive?

– Is the casualty breathing?Is the casualty breathing?

– Does the casualty have a radial pulse?Does the casualty have a radial pulse?

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Care Under Fire:Care Under Fire:* Return fire as required or directedReturn fire as required or directed

* Keep yourself from being shot Keep yourself from being shot

* Scene size upScene size up─ Once the shooting has stopped and it is Once the shooting has stopped and it is

safe to do so, triage casualties:safe to do so, triage casualties:

1) 1) “If you can hear my voice…..”“If you can hear my voice…..”

Perform Casualty TriagePerform Casualty Triage

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… … and can walk, move to this area now and can walk, move to this area now ((Non-Emergent/MinimalNon-Emergent/Minimal))

… … but can't walk, raise your hand and let me but can't walk, raise your hand and let me know (know (Non-Emergent/DelayedNon-Emergent/Delayed))

Request Additional Help: squad members Request Additional Help: squad members and/or CLS if availableand/or CLS if available

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2) What remains are the Emergent/Immediate 2) What remains are the Emergent/Immediate and Expectant/Deadand Expectant/Dead

Assess as you encounter each casualty and Assess as you encounter each casualty and continue to treat per TC-3 protocols (hemorrhage, continue to treat per TC-3 protocols (hemorrhage, A-B-Cs)A-B-Cs)

If you have assistance, you may direct immediate If you have assistance, you may direct immediate treatment and movement to secure area ASAP treatment and movement to secure area ASAP (CCP)(CCP)

NoteNote: Airway and breathing management is best : Airway and breathing management is best deferred until you are off the "X"deferred until you are off the "X"

Perform Casualty TriagePerform Casualty Triage

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RPG Wound Right Knee - Somalia

What is the PriorityInjury?

What is the Triage Category?

What is theEvac Priority?

Perform Casualty TriagePerform Casualty Triage

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Burn Casualty - Kosovo

What is the PriorityInjury?

What is the Triage Category?

What is theEvac Priority?

Perform Casualty TriagePerform Casualty Triage

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Establish Triage AreaEstablish Triage Area

Easy access.Easy access. Smooth traffic flow.Smooth traffic flow. Well marked (Well marked (I / D / M / E)I / D / M / E).. Proximity to treatment areas.Proximity to treatment areas. CBRN considerations.CBRN considerations.

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Triage AreaTriage Area

Expectant

EmergentNonemergent

Nonemergent

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Definition of triage.Definition of triage. Triage classification considerations.Triage classification considerations. Triage categories.Triage categories. Alternative triage categories.Alternative triage categories. Triage decision-makingTriage decision-making Establishing a triage area.Establishing a triage area.

Be prepared to perform casualty triage in any given Be prepared to perform casualty triage in any given situation in order to afford the greatest number of situation in order to afford the greatest number of

casualties the greatest chance of survival. casualties the greatest chance of survival.

SummarySummary

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Questions?Questions?