Multiple and mass casualties

In both major civil disasters and war, patient numbers may for a time exceed the capacity of medical teams to render normal care. Under these circumstances, it is necessary to sort casualties on the basis of need so that available resources and personnel can render the ‘most for the most’, to quote an American military surgeon. This is ‘triage’ and it is outlined below. Triage assessments and categorisation should be dele­gated to a senior, experienced and trained doctor. Failure to perform correct triage will disrupt optimal management for those most at need and divert scarce resources, often to those who can wait. Triage is a dynamic process and needs to be repeated at each level of care from point of injury until arrival in hospital. In general, field triage is for evacuation to hospital. Once in hospital, triage is for access to resuscitation and to operating rooms. The concept is at the heart of major incident planning and is outlined below.

Triage

Triage (from the French ‘trier’) means to sift or to sort and refers to the allocation of injured patients into certain categories for action by emergency teams. A common scheme of assessment is presented below.

• Triage sieve — a quick survey is made to separate the dead and the walking from the injured.

• Triage sort — remaining casualties are now assessed and allocated to three or four groups according to local protocols:

—    category 1 — critical and cannot wait. Airway obstruction and catastrophic haemorrhage are examples;

—    category 2 — urgent. Serious injury but can wait a short time, 30 minutes in most systems;

—    category 3 — less serious injuries. Not endangered by delay;

—    category 4 — expectant. Severe multisystem injury. Survival not likely;

—    (optional) — heavy manpower demands.

The system outlined above is only one of many. Readers should familiarise themselves with local custom and policy. The ABCDE of ATLS is now used increasingly as a means of assessment for grading.