3.1

Triage

Chapter 3

Triage

Introduction

Modern combat casualty evacuation has become so immediate

and efficient that it can result in a mass casualty situation at

military treatment facilities (MTFs) within the military medical

care system. Consequently, a method of dealing with the

conflicting factors of severity of injury, the tactical situation, the

mission, and the resources available for treatment and

evacuation is essential. Triage is an attempt to impose order

during chaos and make an initially overwhelming situation

manageable.

Triage is the dynamic process of sorting casualties to

identify the priority of treatment and evacuation of the

wounded, given the limitations of the current situation, the

mission, and available resources (time, equipment,

supplies, personnel, and evacuation capabilities).

Triage occurs at every level of care, starting with buddy and

medic care, extending through the OR, the ICU, and the

evacuation system.

The ultimate goals of combat medicine are the return of

the greatest possible number of soldiers to combat and the

preservation of life, limb, and eyesight in those who must

be evacuated.

The decision to withhold care from a wounded soldier who in

another less overwhelming situation might be salvaged, is

difficult for any surgeon or medic. Decisions of this nature are

infrequent, even in mass casualty situations. Nonetheless, this

is the essence of military triage.
3.2

Emergency War Surgery

Triage Categories

It is anticipated that triage will be performed at many levels,

ranging from the battlefield to the battalion aid station to the

field hospital. Traditional categories of triage are Immediate,

Delayed, Minimal, and Expectant. This classification scheme

is useful for mass casualties involving both surgical and medical

patients. An additional category of Urgent has been used to

describe surgical patients who need an operation but can wait a

few hours.

 Immediate: This group includes those soldiers requiring lifesaving surgery. The surgical procedures in this category

should not be time consuming and should concern only those

patients with high chances of survival (eg, respiratory

obstruction, unstable casualties with chest or abdominal

injuries, or emergency amputation).

 Delayed: This group includes those wounded who are badly

in need of time-consuming surgery, but whose general

condition permits delay in surgical treatment without unduly

endangering life. Sustaining treatment will be required (eg,

stabilizing IV fluids, splinting, administration of antibiotics,

catheterization, gastric decompression, and relief of pain).

The types of injuries include large muscle wounds, fractures

of major bones, intra-abdominal and/or thoracic wounds,

and burns less than 50% of total body surface area (TBSA).

 Minimal: These casualties have relatively minor injuries (eg,

minor lacerations, abrasions, fractures of small bones, and

minor burns) and can effectively care for themselves or can

be helped by nonmedical personnel.

 Expectant: Casualties in this category have wounds that are

so extensive that even if they were the sole casualty and had

the benefit of optimal medical resource application, their

survival would be unlikely. The expectant casualty should

not be abandoned, but should be separated from the view of

other casualties. Expectant casualties are unresponsive

patients with penetrating head wounds, high spinal cord

injuries, mutilating explosive wounds involving multiple

anatomical sites and organs, second and third degree burns

in excess of 60% TBSA, profound shock with multiple injuries,

and agonal respiration. Using a minimal but competent staff,

provide comfort measures for these casualties.
3.3

Triage

Alternative Triage Categories

In practice, however, the division of patients into these four

categories is not useful for a surgical unit. The casualties should

be divided into emergent, nonemergent, and expectant. These

divisions are useful in dividing casualties into those requiring

further surgical triage (emergent), and those that are less injured,

still require care, but have little chance of dying (nonemergent).

It is anticipated that 10%–20% of casualties presenting to a

surgical unit will be in the emergent category, requiring urgent

surgery. The vast majority of wounded will not require intensive

decision-making, intervention, and care.

 Emergent: Although this category has been historically

subdivided into Immediate (unstable and requiring attention

within 15 minutes) and Urgent (temporarily stable but

requiring care within a few hours), except in the most

overwhelming circumstances, such division is rarely of

practical significance. This group of wounded will require

attention within minutes to several hours of arriving at the

point of care to avoid death or major disability.

ο Types of wounds include:

♦ Airway obstruction/compromise (actual or potential).

♦ Uncontrolled bleeding.

♦ Shock.

◊ Systolic BP < 90 mm Hg.

◊ Decreased mental status without head injury.

♦ Unstable penetrating or blunt injuries of the trunk,

neck, head, and pelvis.

♦ Threatened loss of limb or eyesight.

♦ Multiple long-bone fractures.

 Nonemergent: This category was historically divided between

Delayed (would require intervention, however, could stand

significant delay) and Minimal. This is the group of patients

that, although injured and may require surgery, does not require

the attention of the emergent group and lacks significant

potential for loss of life, limb, or eyesight. Examples include:

ο Walking wounded.

ο Single long-bone fractures.

ο Closed fractures.

ο Soft tissue injuries without significant bleeding.

ο Facial fractures without airway compromise.
3.4

Emergency War Surgery

 Expectant: This group of wounded, given the situation and

resource constraints, would be considered unsalvageable.

Examples may include:

ο Any casualty arriving without vital signs or signs of life,

regardless of mechanism of injury.

ο Transcranial gunshot wound (GSW).

ο Open pelvic injuries with uncontrolled bleeding; in shock,

with decreased mental status.

ο Massive burns.

 Special categories: Patients who do not easily fit into the

above categories and casualties who pose a risk to other

casualties, the medics, and the treatment facility, may require

special consideration:

ο Wounded contaminated in a biological and/or a chemical

battlefield environment. The threat posed by these

patients mandates decontamination prior to entering the

treatment facility. Appropriately protected medical

personnel may treat emergent casualties prior to

decontamination.

ο Retained, unexploded ordnance: These patients should

be segregated immediately. See Chapter 1, Weapons Effects

and Parachute Injuries, which describes the special

handling of these wounded.

ο Enemy Prisoners of War (EPWs)/Internees: Although

treated the same as friendly casualties, it is essential that

the threat of “suicide bombers” and “human booby traps”

be prevented by carefully screening all EPWs prior to

moving into patient areas, including the triage area. See

Chapter 34, Care of Enemy Prisoners of War/Internees.

 Combat stress: Rapid identification and immediate

segregation of stress casualties from injured patients will

improve the odds of a rapid recovery. With expeditious care

these casualties can be returned to duty (80%). Do not use

them as litter bearers as this may increase the trauma you

seek to treat.

ο Place patient in one of two groups.

♦ Light stress: Immediate return to duty or return to unit

or unit’s noncombat support element with duty

limitations and rest.
3.5

Triage

♦ Heavy stress: Send to combat stress control restoration

center for up to 3 days reconstitution.

♦ Use BICEPS mnemonic where resources/tactical

situations allow.

◊ Brief: Keep interventions to 3 days or less of rest,

food, reconditioning.

◊ Immediate: Treat as soon as symptoms are

recognized—do not delay.

◊ Central: Keep in one area for mutual support and

identity as soldiers.

◊ Expectant: Reaffirm that we expect return to duty

after brief rest; normalize the reaction and their duty

to return to their unit.

◊ Proximal: Keep them as close as possible to their unit.

This includes physical proximity and using the ties

of loyalty to fellow unit members. Do this through

any means available. Do not evacuate away from

the area of operations or the unit, if possible.

◊ Simple: Do not engage in psychotherapy. Address

the present stress response and situation only, using

rest, limited catharsis, and brief support (physical

and psychological).

◊ Or, refer: Must be referred to a facility that is better

equipped or staffed for care.

If battlefield casualties do not have physical injuries, DO

NOT send them out of the battle area, as this will worsen

stress reactions, and possibly start evacuation syndromes!

Triage is a fluid process at all levels, with altered situations

and resources requiring a change in category at any time

and in any setting. In the extreme example, a casualty may

be triaged from emergent to expectant during surgery,

abruptly terminating the procedure (“on-the-table triage”).

Resource Constraints

Including all of the factors that influence triage decision

making would be encyclopedic and of little benefit. Rather, a
3.6

Emergency War Surgery

framework for thinking about this process in a logical fashion

is presented here.

 External factors. The surgeon/medic may have limited

knowledge of and no control over external issues.

Nonetheless, optimal casualty care requires at least an

assessment of these factors.

ο Tactical situation and the mission. The decision to commit

scarce resources cannot be based on the current tactical/

medical/logistical situation alone. One severely wounded,

resource-consuming casualty may deplete available

supplies, and thus prevent future, less seriously injured

casualties from receiving optimal care. Liaison with the

tactical force operating in your area is essential to making

sound triage decisions. Operational security may make this

kind of information difficult to obtain in a timely fashion.

Education of, and communication with, line commanders

about the critical nature of this information is essential.

ο Resupply: Having a sense of how and when expended

internal resources will be resupplied may prove critical to

making the decision to treat or not treat the individual

casualty.

ο Time.

♦ Evacuation to the MTF. The shorter this time interval,

expect the complexity of triage decisions to increase,

especially sorting the worst emergent patients from the

expectant. Longer intervals will result in the opposite, with

“autotriage” of the sicker patients from the emergent to

the expectant/dead on the battlefield category.

♦ Time spent with the individual casualty. In a mass

casualty situation, time itself is a resource that must be

carefully triaged/husbanded. All patients receive an

evaluation, but only some receive operative

intervention. Time on the OR table is usually the choke

point. Apply the concepts of damage control to

minimize the time casualties spend in surgery. On-table

triage to expectant may be necessary due to

deteriorating casualty physiologic response and/or the

pattern of injury (aorta-vena cava GSW, dual
3.7

Triage

exsanguination sites, extensive pancreatic-duodenal

injury, and so forth).

♦ Evacuation out. Casualties must move expeditiously

to the next echelon of care (EOC), otherwise valuable

local resources will be consumed in maintaining

patients, thereby preventing additional patients from

receiving care.

 Internal factors. These issues are known to the surgeon/

nurse/medic and should be factored into triage decisions.

ο Medical supplies. These supplies include equipment,

drugs, oxygen, dressings, sutures, sterilization capability,

blood, etc. Immediate liaison with the logistics system in

the MTF and the theater of operation is essential to ensure

the availability and timely resupply of these items, to

include “surge” capabilities and local resource availability.

ο Space/Capability. This category includes the number of

OR tables and ICU beds: the holding capacity and ward

capacity; and the available diagnostic equipment—

ultrasound (US), X-ray, computed tomography (CT)—and

laboratory tests. For example, if your MTF has the only

CT scanner in theater, plan for an increased number of

head-injured patients.

ο Personnel. This includes knowing the professional

capability (type and experience of individual physician/

nurse/medic), and the emotional stability, sleep status, and

so forth, of your hospital personnel. This perishable

resource must be preserved; for example, 24 hours of

continuous operation may exhaust your only OR crew, and

may necessitate diversion of casualties to another facility.

ο Stress. Soldiers, including medical personnel, are

affected by the consequences of war; individual and unit

capability is degraded during sustained operations. The

personal impact of military triage on the medical team

cannot be overemphasized. It is extremely emotional,

and measures should be undertaken to minimize these

effects. This is best provided by trained staff. Cohesive

groups may tolerate stress better and assist each other

in dealing with traumatic events when allowed to
3.8

Emergency War Surgery

process the event in a group format according to their

own traditions.

Triage Decision Making

The complexity of decision making in triage varies greatly, often

depending on the level of training and experience of the triage

officer, as well as the location where the triage decision is being

made. At the front line, the medic must make a decision about

whether or not to evacuate patients from the battlefield and how

fast. The following decision tree is an example of a triage tool

that may be used in the field as an initial decision-making aid.

In the emergent treatment area, the surgeon must make decisions

about whether surgery is needed, the timing of the surgery, and

the priority of multiple surgical patients. Regardless of the type

of triage decision needed, the following information is of critical

importance in reaching that decision:

 Initial vital signs. Pulse (rate and quality), mentation,

difficulty breathing (eg, a casualty with normal mentation

Walking

Responsive to shake and shout

Palpable radial pulse and

comfortable breathing

Breathing with airway open

or with simple maneuver

NONEMERGENT

NONEMERGENT EMERGENT EXPECTANT/DEAD

YES NO

YES NO YES NO
3.9

Triage

and radial pulse quality is nonemergent). Respiratory rate

alone is not predictive of the appropriate triage category.

 Pattern of injury. A historical perspective aids the triage

decision maker in understanding the distribution of wounds

encountered on the modern battlefield and the likely

mortality associated with those wounds. The majority of

combat wounded will suffer nonfatal extremity injuries.

In general, these will be triaged as nonemergent.

 Response to initial intervention. Does the shock state

improve, remain unchanged, or worsen with initial

resuscitative efforts? A patient who fails to respond rapidly

to initial fluid resuscitation should be triaged ahead of a

patient with a good response to minimal fluid replacement;

alternatively, this nonresponder in a mass casualty situation

may need to be placed in the expectant category.

 The following data from the Vietnam War indicate the numerical

distribution of diagnoses that were seen in the low-intensity

light-infantry combat that characterized that war. Casualties from

armored combat can be expected to have a higher prevalence of

burns and multiple injuries. Of 100 injured in combat:

ο 30%—Minor or superficial wounds (minor burns,

abrasions, intraocular foreign body, ruptured tympanic

membrane/deafness).

ο 16%—Open comminuted fractures of a long bone. Several

patients with multiple fractures and injuries to named

nerves and blood vessels.

ο 10%—Major soft tissue injury or burn requiring

general anesthesia for treatment. Several had an injury

to major nerves.

ο 10%—Had laparotomies, two of which were negative, and

several involved extensive, complicated procedures.

ο 6%—Open comminuted fractures of hand, fingers, and feet.

ο 5%—Required closed thoracostomy and had soft tissue

wounds.

ο 4%—Major multiple trauma.

ο 3%—Major amputations (above the knee [AK], below the

knee [BK], below the elbow [BE], above the elbow [AE]).

In three out of four cases, the surgical procedure simply

required completion of the amputation.
3.10

Emergency War Surgery

ο 3%—Craniotomies. Two were for fragments and one for

a depressed skull fracture.

ο 3%—Vascular repair (one was to repair a femoral artery, and

another involved named nerves or fractures).

ο 3%—Major eye injuries, one involving enucleation.

ο 2%—Minor amputations (toes, fingers, hand, foot).

ο 2%—Maxillofacial reconstructions (one half were

mandibular injuries, and most of the rest were maxillary).

ο 1%—Formal thoracotomy.

ο 1%—Neck exploration.

ο 1%—“Miscellaneous.”

Data from more recent American combat operations in Iraq (OIF)

and Afghanistan (OEF), 2003–2004, indicating the spectrum of

injury type (Table 3-1), mechanism (Table 3-2), and anatomical

location (Table 3-3) are found below.

Table 3-1. Type of Injury.*

Type of Injury Frequency Percent

Penetrating 645 35.7%

Blast 425 23.5%

Blunt 410 22.7%

Unknown 84 4.6%

Crush 63 3.5%

Mechanical 49 2.7%

Thermal 48 2.7%

Undetermined 21 1.2%

Other 16 0.9%

Chemical agent 10 0.6%

Bites/Stings 8 0.4%

Degloving 8 0.4%

Electrical 7 0.4%

Heat Injury 7 0.4%

Inhalation 3 0.2%

Multiple Penetration System 3 0.2%

Total 1807 100%

* A casualty may have more than one type of injury. These numbers are based

on 1530 Level III casualties.
3.11

Triage

Setup, Staffing, and Operation of Triage System

 Initial Triage Area.

All casualties should flow through a single triage area and

undergo rapid evaluation by the initial triage officer.

Casualties will then be directed to separate treatment areas

(emergent, nonemergent, and expectant), each with its own

triage/team leader. The expectant will have a medical

attendant, ensuring optimal pain control. The dead should

Table 3-2. Mechanism of Injury.*

Mechanism of Injury Frequency Percent

IED 310 18.4%

MVA 207 12.3%

Gun Shot Wound (GSW) 188 11.1%

Grenade (includes RPG) 170 10.1%

Shrapnel/Fragment 141 8.3%

Unknown 119 7.0%

Machinery or Equipment 95 5.6%

Fall or Jump from height 90 5.3%

Mortar 84 5.0%

Burn 53 3.1%

Aggravated Range of Motion 31 1.8%

Landmine 29 1.7%

Other 27 1.6%

Knife or other sharp object 21 1.2%

Helicopter Crash 19 1.1%

Blunt object (eg, rock or bottle) 17 1.0%

Pedestrian 16 0.9%

Free Falling Objects 14 0.8%

Bomb 12 0.7%

None 12 0.7%

UXO 10 0.6%

Environmental 9 0.5%

Exertion/overexertion 5 0.3%

Flying debris 5 0.3%

Building Collapse 2 0.1%

Hot Object/Substance 2 0.1%

Altercation, fight 1 0.1%

Total 1689 100%

* A casualty may have more than one mechanism of injury. These numbers are

based on 1530 Level III casualties.
3.12

Emergency War Surgery

Table 3-3. Anatomical Location of Injury.*

Anatomical Location Frequency Percent

Multiple Sites 761 49.7%

Lower Extremity 248 16.2%

Upper Extremity 223 14.6%

Head/Face 174 11.4%

Thorax/Back 48 3.1%

Neck 20 1.3%

None 20 1.3%

Abdomen 16 1.0%

Unknown 9 0.6%

Buttock 6 0.4%

N/A 3 0.2%

Genitalia 1 0.1%

Soft Tissue 1 0.1%

Total 1530 100%

* Casualties with more than one injury location are included in ‘Multiple Sites’.

These numbers are based on 1530 Level III casualties.

be sent to the morgue and must remain separate from all other

casualties, especially the expectant. Unidirectional flow of

patients is important to prevent clogging the system. Reverse

patient flow in any treatment area is highly discouraged.

No significant treatment should occur in the triage area.

Casualties should be rapidly sent to the appropriate

treatment area for care.

ο Qualities of an ideal initial triage area should include

♦ Proximity to the receiving area for casualties—LZ,

ground evacuation, decontamination area.

♦ One-way flow both into and out of the triage area

through separate routes to easily identified, marked

(signs, colors, chemical lights, etc.) treatment areas.

♦ Well-lit, covered, climate-controlled (if possible) area

with sufficient space for easy access, evaluation, and

transport of casualties in and out.

♦ Dedicated casualty recorders to identify, tag, and record

initial triage/disposition.
3.13

Triage

◊ Using an indelible marker to place numbers on the

casualty’s forehead is an easy, fast way to track patients.

Any method that is reproducible and simple will suffice.

◊ If resources allow, casualty tracking may include

stationing administrative personnel at every entry/exit.

♦ Sufficient litter bearers (controlled by an NCO) to

ensure continuous casualty flow.

ο Initial triage office.

♦ Ideally, a surgeon experienced in dealing with combat

trauma should be used in this capacity. Unfortunately,

using a surgeon outside of the OR is a luxury that most

small forward surgical units cannot afford.

♦ It is essential that another person with clinical

experience be trained to assume this function. Using

mass casualty exercises or limited mass casualty

situations is one way to train/identify the right person

to fill this role in the absence of a surgeon.

 Emergent treatment area.

ο Setup.

♦ Close proximity to initial triage area with direct access.

♦ Administrative personnel stationed at entry and exit

doors to record patient flow. Ideally, a display board or

a computer should be used to record patient identity,

location, and disposition.

♦ Series of resuscitation bays (number depends on

available resources/personnel).

◊ Allow sufficient room for 3-person team to work.

◊ Easy access in and out of bay.

◊ Availability of equipment needed for ATLS style

resuscitation (Fig. 3-1 a,b).

ο Staffing.

♦ Team leader: a surgeon serves as the surgical triage officer.

◊ Responsible for determining priority for operative

interventions.

◊ Needs to identify patients that require early evacuation.

◊ If a surgeon is unavailable, may be a physician who maintains close communication with the operating surgeons.

♦ Administrative person. Responsible for recording flow

of patients through unit.
3.14

Emergency War Surgery

Fig. 3-1a. Triage.

OR

Holding

Ward X-ray

ADMIN

Emergent Triage

Triage Area

Expectant Non-Emergent
3.15

Triage

♦ Resuscitation team. A physician, nurse, and medical

technician, ideally.

◊ Each individual treatment team will coordinate

movement of its patient via the team leader.

ο Operation.

♦ Manpower team delivers patient.

Fig. 3-1b. Resuscitation Station.

Instrument box contains:

Procedure tray

Laryngoscope

Suture material

Local anesthetics

Syringes and needles

Nasopharyngeal

Airways

Oropharyngeal Airways

Endotracheal

Tubes

Endotracheal Tubes

Ambu

Bag

Various sized masks

Various sized masks

O2

line

Suction

Typical items include:

Dressings, bandages, tape

Tubes (NG, Foley, Chest Tubes)

Gloves (Sterile, throw away)

IV's (solution, catheters, tubing)

Litter

Resus

Box
3.16

Emergency War Surgery

♦ Team Leader retriages patient and assigns resuscitation

team to patient.

♦ Resuscitation team treats patient and determines required

disposition (surgery, ICU, ward, air evacuation).

♦ Resuscitation team communicates to Team Leader the

recommended disposition.

♦ Team Leader coordinates movement of patient to next stop.

♦ Administrative person records disposition.

 Nonemergent treatment area.

An empty ward, a cleared out supply area, or other similar

space can be utilized. Appropriate medical and surgical

supplies should be stockpiled and easily identifiable. A

team consisting of a physician and several nurses and

medical technicians can form the nucleus of the treatment

team. Lacerations can be sutured, closed fractures splinted,

IVs placed, and radiographs taken. The team leader should

be alert to changing vital signs, mental status changes, and

any failure to respond to appropriate treatment measures.

Any evidence of deterioration should prompt a retriage

decision and a possible transfer to the emergent treatment

area.

 Expectant area.

Ideally, expectant casualties should be kept in an area away

from all other treatment areas. The team leader can be anyone

capable of giving parenteral pain medications. The patient

should be kept comfortable. After all other patients have

been treated, a retriage of these patients should be done

and treatment instituted if appropriate.

Additional Triage Operation Tips

 Diversion of casualties to another facility should be

considered. These options (sister service, local national

assistance, or local NATO assets) should be established prior

to the mass casualty event.

 As the casualties finally clear the OR suites, the pace will

slow for the surgeons. ICU and ward care will supplant

operative procedures. Casualties initially undertriaged

(~10%) will be discovered and will require care. The

recovery room and ICUs will become crowded, nursing
3.17

Triage

shifts will have to be extended, and fatigue will rapidly

become a hospital-wide factor.

 Numerous authors have stated that after the first 24 hours

of a mass casualty ordeal, the activities of the care

providers must be decreased by 50%, allowing for recovery

and rest for the participants, and a new rotation must be

established to sustain a modified but continuous effort.

Once the press is over, personnel must be encouraged to

rest rather than to socialize. Rest must be enforced because

the entire scenario may recur at any time.

 Prior to an actual mass casualty situation, all deployable

units should exercise a variety of triage scenarios to ensure

smooth patient flow and identification. ”Driving” litters

without running into things can be difficult unless

practiced! These scenarios should evaluate personnel,

supplies, and equipment.

Conclusion

Small, highly mobile units, either Special Operations or

conventional forces, are currently performing military

operations around the globe. These units are usually

supported by highly mobile, small footprint surgical elements

that have limited diagnostic, operative, holding, and resupply

capability. Evacuation may entail an extremely long transport

from point of wounding to the forward surgery team, then

another long transport directly to a Level IV/V. Air

superiority may be in question, especially the use of

helicopters for initial patient evacuation. In these situations

the tactical, logistic, and physiologic integration of triage

concepts becomes of paramount importance and needs to be

considered and extensively discussed prior to arrival of the

first casualty.
3.18

Emergency War Surgery