Tolesa Dida
Outline
Definition
 Triage classification
 5 level triage
 Decision making tree
 Patient assessment
 Cases

– Questions and answers
Definition

Triage comes from the French word “trier”

Trier mean to sort into different groups or categories.

Baron Dominique Jean Larré
– Napoleon’s surgeon
– Changed the treatment of injured soldiers
» Least injured first, return to war
ትርጉም ትሪያጅ
ምምማይ

“Sorting” -

Classifying of casualties ምውዳብ/ምክፍፋል

Establish priorities for treatment / evacuation
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
Dynamic process
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Why Triage?
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Benefits of Triage

Early assessment of the patient thus reducing any
harmful delays.
– This improves the standard of care given to the
patient

It reduces waiting times for non-urgent patients.

Investigations maybe commenced prior to seeing a
doctor

Requests may be made for old notes, X rays, results
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Benefits of Triage

The triage officer has the opportunity of seeing the
interaction between family and patient

Infection control may be initiated earlier

Emergency care is given thus making the patient more
comfortable

Promote and distribute health education literature
Triage Principles
Regular time/disaster time
 Life over limb
 Bodily function over cosmetic
appearance
 Greatest good for the greatest number

ትሪያጅ መን እዩ ክገብሮ
ዝግባእ?
ትሪያጅ መን እዩ ክገብሮ
ዝግባእ?
Who Should be the Triage Officer?
Physician
 Nurse
 Health Officer
 Technician
 Dentist

Triage Factors
Availability of transportation
 Resources
 Facilities
 Continuous process

Triage
Multiple casualties
 Single casualty with multiple injuries

Triage Classification Systems
START
– Simple Triage and Rapid Treatment
 Military/International
 Others

– Australian
– Manchester
– Cape Triage
Color Coding


Casualties are color coded to
quickly identify a casualty’s priority
for medical treatment.
International Color Codes are:
Black – Expectant/Dead-Dying
Red - Immediate
Yellow - Delayed
Green – Minimal/Minor
US Military Color Code (MEDIC)
Blue - Expectant
Australlian

5 level
– Red
– Orange
– Yellow
– Green
– Blue/Black
Australlian

5 colours
Red
 Orange
 Yellow
 Green
 Blue

Immediate
10 mins
60 mins
4 hours
Dead
TEWS: Triage Early Warning Score
TEWS: Adult
3
2
1
Mobility
0
1
2
Walking
With Help
Stretcher/
Immobile
9-14
15-20
21-29
more than
29
101-110
111-129
more than
129
RR
less than
9
HR
less than
41
41-50
51-100
71–80
81-100
101-199
more than
199
35-38.4
38.5 or more
SBP
Temp
less than
71
less than
35
AVPU
Alert
Reacts to
Voice
Trauma
No
Yes
over 12 years / taller than 150cm
Reacts to
Pain
3
Unrespon
sive
TEWS: Child
3
2
Mobility
1
0
1
2
Walking
With Help
Stretcher/
Immobile
RR
less than
15
15-16
17-21
22-26
27 or more
HR
less than
60
60-79
80-99
100-129
130 or more
SBP
less than
70
70-79
80-130
131-149
150 or more
less
than35
35-38.4
Temp
3
38.5 or more
AVPU
Alert
Reacts to
Voice
Trauma
No
Yes
3 to 12 years old / 96 to 150 cm tall
Reacts to
Pain
Unrespon
sive
TEWS: Infant
3
2
Mobility
1
0
1
2
Normal for age
Stretcher/
Immobile
3
RR
less than 20
20-25
26-39
40-49
50 or more
HR
less than 70
70-79
80-130
131-159
160 or more
SBP
less than 60
60-69
70-110
111 or more
less than 35
35-38.4
38.5 or more
Temp
AVPU
Alert
Reacts
to Voice
Trauma
No
Yes
Reacts to Pain
younger than 3 years / smaller than 95cm
Unresponsive
Steps To Follow
Step 1
Measure vital signs and document the
findings
Step 2
Take a brief history directed at the main
complaint and document this
Step 3
Calculate the TEWS
and document the total
value
Step 4
Match the score to the list and observe the discriminator list for issues not
picked up by the TEWS
Step 5
Document the triage code and act
accordingly
Example

30 year old, electrical burn
– Walking
– RR 24
– HR 110
– SBP 115

- Temp 37
- Alert
- Trauma
TEWS total =
– Colour Code? ____________
Colour
RED
ORANGE
YELLOW
GREEN
BLUE
TEWS
7 or more
5-6
3-4
0-2
DEAD
Target time to
treat
Immediate
less than 10 mins
less than 60 mins
less than 240 mins
Mechanism of
injury
Discriminators: Adult
High energy transfer
Shortness of breath - acute
Coughing blood
Chest pain
• Final Triage
Haemorrhage - uncontrolled
Seizure – current
Haemorrhage - controlled
Seizure - post ictal
– ORANGE
Focal neurology - acute
Level of consciousness
reduced
Psychosis / Aggression
Threatened limb
Dislocation -
other joint
Fracture - compound
Presentation
Dislocation -
finger or
toe
Fracture -
closed
Burn over 20%
ALL
OTHER
PATIENTS
Burn - electrical
Burn –
face / inhalation
Burn - other
Burn - circumferential
Burn - chemical
Poisoning / Overdose
Hypoglycaemia glucose less than 3
Diabetic 11
Vomiting -
glucose over
& ketonuria
fresh blood
Abdominal pain
Diabetic glucose
over 17
(no
ketonuria)
Vomiting - persistent
Pregnancy & trauma
Pregnancy & abdominal
trauma or pain
Pregnancy &
Pain
Severe
PV bleed
Moderate
Senior Healthcare Professional’s Discretion
Mild
DEAD
Minimal/Minor
Green tag
 Minor threat to patient’s life
 Classic “Walking Wounded”

– Easily segregated
– Tend to later
Self-Aid, buddy care
 Treat and release,

– return to duty/manpower pool
Minimal/Minor
Minor lacerations
 Abrasions
 Sprains
 Contusions
 Burns under 20% BSA

– Rule of 9’s

Combat stress casualties
Immediate
Red tag
 Threat to life is great
 Simple procedure will be lifesaving

– Reposition airway, control hemorrhaging,…

Must receive urgent treatment
Immediate
Airway obstruction
 Sucking chest wounds
 Massive external bleeding
 Shock
 Incomplete Amputation
 2nd/3rd degree burns of face or neck

Delayed
Injuries that are serious
 Delay in treatment is not life threatening
 Require care but no immediate life
saving procedures
 Treatment, including surgery may be
delayed several hours

Delayed
Open chest wounds
 Penetrating abdominal wound
(evisceration)
 Severe eye injury
 Open wounds
 Non-life threatening fractures
 2nd/3rd degree burns not involving the
face/neck

Expectant/Dead-Dying
Little hope of recovery
 Great threat to life
 Treatment is complicated/time
consuming
 Supportive vs curative treatment
 Only used if resources are limited

Expectant/Dead-Dying







Large open head wounds with loss of tissue
Decapitation
Massive crush injury of the chest/neck
Large open chest wound
Penetrating injury to trachea/neck
2nd/3rd degree burns greater then 60% BSA
Multiple trauma
Contaminated





Not a true triage category
Be alert to possibility
Segregate immediately
Prevent contamination of other patients,
medical staff, facility
Complicates management and treatment
– Biological, not likely to have conventional injuries
– Chemical, greater likelihood of combination
conventional, chemical injuries

Decontaminate prior to any treatment
Patient Assessment
ATLS/BTLS TREATMENT
 Primary Survey - ABC’s (Triage)
 Resuscitation
 Secondary Survey - Total Patient
Evaluation
 Definitive Care
 Transfer
PRIMARY SURVEY
Airway maintenance / cervical spine
control
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability: Neurologic status
 Exposure/Environmental control:

– undress the patient, prevent hypothermia
RESUSCITATION
Management of life-threatening
problems identified in the primary
survey
 Oxygenation and ventilation
 Shock management - IV lines, Ringer’s
 Monitoring

SECONDARY SURVEY





Head and skull
Maxillofacial
Neck
Chest
Abdomen





Perineum/rectum/
vagina
Musculoskeletal
Complete neurologic
exam
Roentgenograms,
lab tests
“Tubes and fingers”
DEFINITIVE CARE
After identifying patient’s injuries
 After managing life-threatening
problems
 After obtaining special studies
 Definitive care begins

TRANSFER
If the patient’s injuries exceed the
immediate treatment capabilities
 The process of transferring the patient is
initiated as soon as the need is identified
 Delay may significantly increase the
patient’s risk of mortality
 Availability of airlift

Triage Exercise
You are working in a hospital where number of
casualties brought to your Emergency Room.
You are tasked to retrieve, triage, and
prioritize the injuries for treatment/transport.
There are six bodies with the following
injuries:
TRIAGE EXERCISE

Bus Driver - unresponsive with a penetrating
injury to the trachea region

Patient One - bullet wounds to the lower
legs with bright red blood spurting out

Patient Two - lacerations to the face and a
suspected sprain to the right foot
TRIAGE EXERCISE

Patient Three - conscious but somewhat
confused & 3rd degree burns of the arms

Patient Four - partial amputation of the right
arm and signs of shock

Jeep Driver - walking around the area with an
open wound on his forehead
What is your assessment of these 6 patients?
TRIAGE EXERCISE
Immediate - require life saving care but can be
stabilized
– Patient One - bullet wounds to the lower legs with bright
red blood spurting out
– Patient Four - partial amputation of the right arm and
signs of shock
Delayed – significant injuries required treatment, but
not immediately life threatening
– Patient Three - conscious but somewhat confused & 3rd
degree burns of the arms
TRIAGE EXERCISE

Minimal – minor injuries, treatment can be delayed
– Jeep Driver - walking around the area with an open
wound on his forehead
– Patient Two - lacerations to the face and a suspected
sprain to the right foot

Expectant/Dead-Dying – life threatening injuries,
attempts to stabilize may jeopardize other lives
– Bus Driver - unresponsive with a penetrating injury to
the trachea region
When a patient is triaged as expectant,
what should you do with the patient?
a. Transport them first so that the bystanders
don’t have to see someone like this
b. Move them out of sight and worry about them
later
c. Care for them in the same manner as you
would anybody else
d. Stay with them and worry about the other
patients when time allows
Any time you respond to a call for help,
your first priority is to?
a. Assure your own safety
b. Do the best you can for the greatest
number of casualties.
c. Call medical control and ask them what
you should do
d. Get to the scene as fast as the
ambulance will allow you to travel
How often should you reassess your
patient in a mass casualty situation?
a.
b.
c.
d.
Every 5 minutes
Every 20 minutes
Whenever necessary
Never, this wastes time
What is the purpose of the various colors
on the triage tags?
a. To keep track of the number of
casualties
b. So that medical personnel know which
casualties to treat first
c. To allow the casualties to know where
they stand as far as treatment goes
d. To make them more interesting to look
at
START Triage System
Allows rescuers to quickly identify victims
at greatest risk for early death
 Gaining popularity

START Triage System

60 second assessment focusing on
– Ability to walk, walking wounded = minor pts
– Respiratory effort
– Pulses/perfusion
– Mental/Neurologic status

Only Treatment during Triage
– Open airway, insert OPA
– Stop any visible bleeding
– Elevate extremities for shock
START
PATIENT CARE DECISION TREE
Can the patient walk, talk, …..
walking wounded
YES
Minor Patients
NO
Asses Respirations
START (RPM’s)
TRIAGE DECISION TREE
Assess Respirations
>30
>10, <30
0
Immediate
Assess Perfusion
Position Airway
Respirations
Yes
Immediate
No
Expectant
START (RPM’s)
TRIAGE DECISION TREE
Assess Perfusion
Radial Pulse
Absent
Can Control
Bleeding
Immediate
Capillary
Refill
Over 2
Seconds
Under 2
Seconds
Radial Pulse
Present
Assess
Mental Status
START (RPM’s)
TRIAGE DECISION TREE
CAN THE PATIENT FOLLOW SIMPLE
COMMANDS
NO
YES
IMMEDIATE
DELAYED
Respiration's
Perfusion
Mental Status
START Triage
All Walking
Wounded
MINOR
0, 30
2, Radial Pulse
Can Do
RESPIRATIONS
Yes
No
Over 30/min
Under 30/min
IMMEDIATE
PERFUSION
Radial Pulse
Absent
Control
Bleeding
IMMEDIATE
Position Airway
Capillary
Refill
Over 2
seconds
Radial Pulse
Present
Under 2
seconds
MENTAL STATUS
Can't Follow
Can Follow
Simple Commands Simple Commands
IMMEDIATE
DELAYED
Yes
No
IMMEDIATE
DECEASED
Summary
No hard and fast rules for triage
 A simplified guide to help sort casualties
 Triage is a continuous process
 Accomplish the greatest good for the
greatest number

START TRIAGE EXERCISE
Working on an ambulance
 Dispatched as a second unit to a
bombing of a building
 As you arrive you hear shouts and
screams and several (19) victims lying
about
 After assuring your own safety, what is
the first action you take to begin the
Triage process

START TRIAGE EXERCISE


Instruct all walking wounded to get up and walk
to a designated area and await treatment
You now have 19 patients left to triage,
– Establish a triage category for each patient
– Give your rationale for their triage category.

Notes
– If no breathing, give triage category if respirations
begin/or are still absent after airway established
– If radial pulse is absent, most times you can assume
that bleeding can be controlled unless an obvious
mortal injury is presented
#1
Compound fracture of the left femur
 Respirations: Under 30
 Pulse (radial): Absent
 Mental Status: A O x 4
Immediate - Radial Pulse is absent
•If bleeding can be controlled
#2
Sudden onset of chest pain, no
shortness of breath
 Respirations: Under 30
 Pulse (radial): Present
 Mental Status: A O x 4
Delayed
No abnormalities noted according to criteria
#3
90% second degree burns over body
 Respirations: None
 Pulse (radial): Present
 Mental Status: Unconscious
Immediate if respiration begins after airway est
Dead/Dying if no respiration after airway est
#4
Patient states she is a diabetic. Skin
is moist and clammy
 Respirations: Under 30
 Pulse (radial): Absent
 Mental Status: A O x 4
Immediate
No radial pulse
#5
Unable to move legs
 Respirations: Under 30
 Pulse (radial): Present
 Mental Status: Confused
Immediate
Impaired mental status
#6
No apparent injuries
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: A O x 4
Delayed
No abnormalities noted according to criteria
#7
Sucking chest wound
 Respirations: Over 30
 Pulse (radial): Present
 Mental Status: Unconscious
Immediate
Respirations over 30/minute
#8
Dislocated right shoulder
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: A O x 4
Delayed
No abnormalities noted according to criteria
#9
No visible wounds
 Respirations : None
 Pulse: (radial): Absent
 Mental Status: Unconscious
Immediate – if respirations begin after airway est
Expectant – if no respiration after airway est
#10
Scalp wound with an estimated
blood loss of 500 cc
 Respirations: Over 30
 Pulse (radial): Present
 Mental Status: Confused
Immediate
Respirations over 30/minute
#11
Significant head injury
 Respiration: Under 30
 Pulse (radial): Absent
 Mental Status: Unconscious
Immediate
Radial pulse absent
#12
Three month old Infant
 Respirations: Under 30
 Pulse (radial): Present
 Mental Status: Unconscious
Immediate
Impaired mental status
#13
Impaled, 1 foot piece of shrapnel in RT
eye
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: Awake & Oriented
Delayed
No abnormalities noted according to criteria
#14
Female 6 mos. pregnant, broken left
lower leg
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: Awake & Oriented
Delayed
No abnormalities noted according to criteria
#15
Severe difficulty breathing, chest
sinks in on inspiration
 Respirations: Over 30
 Pulse (radial) Present
 Mental Status: Awake & Oriented
Immediate
Respirations over 30/minute
#16
Unable to move, no verbal response
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: Awake but stares into
space
Immediate
Impaired mental status
#17
Amputated left arm, bleeding
controlled
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: Awake & Oriented
Delayed
No abnormalities noted according to criteria
#18
Large head wound, brain matter
showing
 Respiration: None
 Pulse (radial): Absent
 Mental Status: Unconscious
Expectant
No respirations, obvious mortal injury
#19
Minor abrasions
 Respirations: Under 30
 Pulse (radial) Present
 Mental Status: Awake & Oriented
Delayed
No abnormalities noted according to criteria
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