triage

toc clinical home

=Triage of multiple casualties =

** Triage (sorting) is needed when the immediate demands exceed the available resources. **

** The aim of the triage sieve is to identify as rapidly as possible those patients/casualties who require care most urgently. **

 If there are more casualties than people to care for them, triage //must// be carried out before starting treatment.

 Remember the casualty shouting the most may be the most physiologically intact - //worry about the casualties who are making no noise.//

The triage methods below are used in the UK. Other approaches are used elsewhere, though the aim is consistent.

Whichever triage system is used it is vital to remember that triage is a dynamic process  - being repeated as casualties are moved, their condition changes or the availability of resources alters.

Triage is a difficult task, and should be carried out by the most senior/experienced personnel possible (one rule of thumb is for the most experienced clinician to take overall charge and for the next most senior clinician to carry out triage).

The Triage Sieve
Is used in incidents with **multiple** casualties. Casualties must be triage before treatment - it is difficult for clinicians to move away from someone who is clearly badly injured. Stop the assessment as soon as you are able to assign a triage category. Do not do the complete triage assessment on all casualties as this will slow down triage. When triaging make a note of the number of casualties in each triage category. **Do this as you are going along.**

<span style="font-family: Georgia,serif;">media type="custom" key="21375078" width="140" height="140"

<span style="font-family: Georgia,serif;">The triage categories are:
 * <span style="color: #46a70b; font-family: Verdana,Geneva,sans-serif;">delayed [P3] **


 * <span style="background-color: #a19c9c; color: #ffff00; font-family: Georgia,serif;">urgent [P2 **


 * <span style="background-color: #ffffff; color: #ff0000; font-family: Georgia,serif;">immediate [P1] **


 * <span style="background-color: #000000; color: #ffffff; font-family: Georgia,serif;">dead **

<span style="font-family: Georgia,serif;">It operates as follows: <span style="font-family: Georgia,serif;"> 1) <span style="font-family: Verdana,Geneva,sans-serif;"> **Those who can //mobilise independently// are** **<span style="color: #46a70b; font-family: Verdana,Geneva,sans-serif;">delayed [P3] **<span style="font-family: Verdana,Geneva,sans-serif;"> **(lowest priority).** <span style="font-family: Georgia,serif;">Once other casualties have been assessed the P3 casualties should be reassessed as conditions do change. <span style="font-family: Georgia,serif;">Watch for ambulant casualties carrying other casualties (especially adults carrying their children); //every// casualty must be triaged.

<span style="font-family: Georgia,serif;"> 2) <span style="font-family: Verdana,Geneva,sans-serif;">**In those who cannot walk determine if the casualty is //breathing//** <span style="font-family: Georgia,serif;"> (done very quickly if the casualty can talk). <span style="font-family: Georgia,serif;">If there is no breathing ensure the airway is open (basic manoeuvres + adjuncts only). <span style="font-family: Georgia,serif;">- if breathing is absent still the casualty is treated as **<span style="background-color: #000000; color: #ffffff; font-family: Georgia,serif;">dead **<span style="font-family: Georgia,serif;"> and no further resuscitation undertaken. <span style="font-family: Georgia,serif;">- if breathing does return after airway opening the casualty is **<span style="background-color: #ffffff; color: #ff0000; font-family: Georgia,serif;">immediate [P1] **<span style="font-family: Georgia,serif;">(top priority); efforts should be made to ensure the airway remains patient: this must not delay the triage - get someone else to maintain airway position. <span style="font-family: Georgia,serif;">No further assessment is needed for triage in P1 patients.

<span style="font-family: Georgia,serif;"> 3) <span style="font-family: Verdana,Geneva,sans-serif;"> **In those who are breathing without the need for airway opening assess the //__respiratory rate__//.** <span style="font-family: Georgia,serif;">If high ( more than 29) or low (less than 10) the casualty is **<span style="background-color: #ffffff; color: #ff0000; font-family: Georgia,serif;">immediate [P1] **<span style="font-family: Georgia,serif;">. <span style="font-family: Georgia,serif;">No further assessment is needed for triage in P1 patients.

<span style="font-family: Georgia,serif;"> 4) <span style="font-family: Verdana,Geneva,sans-serif;">**In those who are uncategorised so far assess the //circulation//** <span style="font-family: Georgia,serif;">either by capillary refill (be aware this may be delayed by cold rather than by shock) or by the pulse rate. <span style="font-family: Georgia,serif;">If these are abnormal (more than 2 seconds, or HR more than 120/minute) the casualty is <span style="color: #ff0000; font-family: Georgia,serif;">P1 <span style="font-family: Georgia,serif;">, if normal they are **<span style="background-color: #a19c9c; color: #ffff00; font-family: Georgia,serif;">urgent [P2] **<span style="font-family: Georgia,serif;">.

<span style="font-family: Georgia,serif;"> 5) <span style="font-family: Verdana,Geneva,sans-serif;">**As soon as the casualty has been assigned a triage category further assessment stops** <span style="font-family: Georgia,serif;">, <span style="font-family: Georgia,serif;">and personnel carrying out triage move to the next casualty to triage them. <span style="color: #0000ff; font-family: Georgia,serif;">**Treatment does not start until casualties have been triaged.**

<span style="font-family: Georgia,serif;"> 6) <span style="font-family: Verdana,Geneva,sans-serif;"> **Casualties' triage category should be indicated on them** <span style="font-family: Georgia,serif;">, <span style="font-family: Georgia,serif;">so P1 casualties can be identified and treated first.

<span style="font-family: Georgia,serif;"> 7) <span style="font-family: Verdana,Geneva,sans-serif;">**Personnel carrying out triage should maintain a record of the total number of casualties they triage and the numbers within each category.**



<span style="font-family: Georgia,serif;">NB the criteria for respiratory rate - 10 to 29 is OK <span style="font-family: Georgia,serif;">Some books/sites wrongly have 10 to 30

<span style="font-family: Georgia,serif;">This is an **alternative sieve**. Although similar to most of the algorithm above it changes the "C" assessment to presence or absence of the radial pulse. Since this is the parameter used to determine whether or not to start IV fluids prehospital [at least in the UK] it makes sense to use it for triage too. It does not assess the ability of the casualty to mobilise independently but does include as assessment of "D".



<span style="font-family: Verdana,Geneva,sans-serif;">The triage sort
<span style="font-family: Georgia,serif;">This is a slightly longer assessment using the revised trauma score, <span style="font-family: Georgia,serif;"> It generates a numerical value; the lower this is the more urgent the patient's management.

<span style="font-family: Georgia,serif;"> 3 aspects of the patient's physiology are assessed in the RTS: <span style="font-family: Georgia,serif;"> Glasgow Coma Score (15 point version) <span style="font-family: Georgia,serif;"> Systolic BP <span style="font-family: Georgia,serif;"> Respiratory Rate

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> TRTS score triage category <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> 1-10 immediate <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> 11 urgent <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> 12 delayed

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> The triage assessment should be documented and should accompany the patient.


 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">**<span style="font-family: 'CenturyOldst BT','serif';">GCS ** ||  ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">13-15 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">4 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">9-12 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">3 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">6-8 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">2 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">4-5 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">1 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">3 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">0 ||
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">**<span style="font-family: 'CenturyOldst BT','serif';">RESPIRATORY RATE ** ||  ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">10-29 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">4 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">>29 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">3 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">6-9 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">2 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">1-5 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">1 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">0 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">0 ||
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">**<span style="font-family: 'CenturyOldst BT','serif';">SYSTOLIC BLOOD PRESSURE ** ||  ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">>89 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">4 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">76-89 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">3 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">50-75 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">2 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">1-49 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">1 ||
 * <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">0 || <span style="color: #000000; font-family: 'CenturyOldst BT','serif';">0 ||

<span style="font-family: Verdana,Geneva,sans-serif;">Expectant Category
(very) Occasionally resources are so overwhelmed that it is impossible to deal with all the immediate category casualties. In this situation a decision //may// be taken to subdivide this group into immediate and expectant. The immediate casualties remain the top priority for treatment and transport. The expectant category casualties are even more badly injured and are unlikely to survive even if treated promptly. Resources directed the them are less likely to yield benefit than if directed to immediate casualties. The decision to use the expectant category is not one to be taken lightly. It is the responsibility of the most senior clinician to initiate its use.

<span style="font-family: Verdana,Geneva,sans-serif;">Links
[|Paper] on critical appraisal of papers describing triage systems Short [|video]about triage in Rwanda [|Presentation] on triage from USA [|Guidelines for field triage of injured patients]