triage of mass casualties msf 11th surgical day paris, 3 december 2011 marco baldan icrc head...

TRIAGE

OF MASS CASUALTIES

MSF 11th Surgical Day

Paris, 3 December 2011

Marco Baldan

ICRC Head Surgeon

Al Hussein HospitalKarbala, Iraq2 March 2004

First bomb attack in the city

Total victims = 277

Dead = 94

Wounded = 183

Hospital Situation

Beds in ER = 24 No place for cadavers No communication with/among ambulances Minimal hospital security system No triage system / disaster plan Medical supplies on 4th floor Operating theatres on 1st and 2nd floors 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 BuildingMonrovia 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:

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

Security 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

Triage team leader: co-ordinator

Clinical triage officer

Head nurse, matron: chief organiser

Nursing groups

Follow-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

Include basic information

Short-form Clear Concise Complete

Triage Documentation

Reality check

What really happens!

During post-triage evaluation:

decided to use plastic

sleeve to hold the documentation.

The triage process:

Sift

Place patients in main categories: priority

Sort

Priority amongst the priorities

Sift

1) Select those most severely injured and

2) identify and remove:

the dead

the slightly injured

the uninjured

Sort

Categorise the most severely injured based on:

life-threatening conditions (ABC)

anatomic site of injury

Red Cross Wound Score

treatment available in terms of personnel and supplies

ICRC TRIAGE CATEGORIES

I. Serious wounds: resuscitation and immediate Serious wounds: resuscitation and immediate surgerysurgery

II. Second priority: need surgery but can waitSecond priority: need surgery but can wait

III. Superficial wounds: ambulatory managementSuperficial wounds: ambulatory management

IV. Severe wounds: supportive treatmentSevere wounds: supportive treatment

Category I: Resuscitation and immediate Category I: Resuscitation and immediate surgerysurgery

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 waitCategory 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 woundsCategory III: Superficial wounds(no surgery, ambulatory treatment)(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 woundsCategory IV: Very severe wounds(no surgery, supportive treatment)(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

First AidDressing

30 - 40 %No surgery

12-15% Head10% Chest10% Abdomen60-65% Limbs

90% Surgery

Small woundsParaplegiaQuadriplegia

Observation

10% NO Surgery

60 - 70 %Hospital care

WW in the field(GSW, mine, blast)

100 wounded

Epidemiology of Triage:short evacuation time

Category I 5 - 10%

Category II 25 – 30%

Category III 50 - 60%

Category IV 5 - 7%

Triage in Monrovia 20033 June – 22 August

Total patients triaged = 2588

Total admitted = 1015 (40% of triaged)

War wounded = 88.5% of admissions

Operations = 1433

Admitted but not operated = 296

All category 1 patients triaged, admitted and operated within 24 hours

Patients triaged by date:three peaks

020

406080

100

120140160

180200

3.06

7.06

11.0

6

15.0

6

19.0

6

23.0

6

27.0

6

1 Ju

ly

5.07

9.07

13.0

7

17.0

7

21.0

7

25.0

7

29.0

7

2.08

6.08

10.0

8

14.0

8

18.0

8

22.0

8

Date

Nu

mb

er P

atie

nts

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.