Triage during a Mass Casualty

Incidents (MCI)

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Definitions
 Mass Casualty Incident
◦ A healthcare disaster where the number of
casualties is greater than the ability of the
healthcare system to care for them

Disaster = Need > Resources

◦ May result from natural or man-made incident
◦ Requires a clear understanding of your own
capabilities and capacities
 ＜Emergency Situation＞
Patient

Medical Resource
（Personnel・ Time
Medical Materials）
▲

＜Dasaster Situation＞
Medical Resource
（Personnel・ Time
Medical Materials）

Patients

▲
 Combined Disaster

Earthquake
High tide Tsunami

Flood Volcano eruption

Other natural
Heavy snowfall phenomenon
Disasters
Heavy rain Fire or wildfire
Storm Explosion
Release of Radiation Others
(train, plane)
Ship
accident
Huge tragedy
 Types of Disaster
◇Natural：
Earthquakes, Typhoons, Floods, Tornadoes, Droughts, Emerging
Infectious Diseases, etc.

◇Man-made：
Large Traffic Accidents; Train crash, Airplane crash, etc.
Large accidents; Fires, Explosions, Structural collapse, etc.
Terrorism, Bioterrorism, etc.

◇Complex Humanitarian Emergencies

Refugees, Conflict， Warfare, Terrorism, etc.
 Natural Disaster

Flood
earthquake

volcano
eruption
snow avalanche
 Man-made Disaster

terrorism
traffic

industrial mass gathering

Complex Humanitarian Emergency (CHE）
"A humanitarian crisis in a country, region or society where there is a
significant or total breakdown of authority resulting from internal or
external conflict and which requires an international response that
extends beyond the mandate or capacity of any single agency. In
complex emergencies, children and women may also need legal and
physical protection to prevent harm and ensure their access to
humanitarian assistance” (UNICEF)
Important Points at Disasters
Systematic Responses (CSCATTT)
▪ Command: Under whose command?
▪ Safety: Own safety
▪ Communication: How?
▪ Assessment: Should be given always
▪ Triage: Principles of triage
▪ Treatment: Who should be prioritized?
▪ Transportation: By what means?
UK standards for Great Disaster (MIMMS：Major Incident Medical
Management and Support)
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 Disaster Medical System

Affected area Non Affected

Area
On Site Medical
Activities
Rescue
Hospitals
Site Disaster Base
ＤＭＡＴ Hospital

Disaster Base
Hospital
Wide-area
Transportation
3T’s
in Disaster Nursing
Triage

Treatment

Transportation
 Decision to mobilized Depend on:
patient or conduct
treatment at the scene Patient condition
&
“stay & play” Resources
availabilities
(rescuers,
or
transport &
equipment)
“load & go”

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Triage criteria
 What is done
in Triage

1) Do not consume time and medical

resources for patients who have no
possibility to survive.
2) Exclude patients with minor injuries.
3) Give priority to patients with urgent
condition.
 Triage Category

❖Immediate
❖Delayed
❖Minor
❖Dead (No hope)
 Which category is the
most difficult to deal
with?
2 KEY PHASES OF MCI
TRIAGE PROCESS

“Sieve” and “Sort”

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Triage
‘Sieve’
Process

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Triage ‘sieve’ process

‘Sieve’ is the 1st triage decisions and is made

at the scene where the patients is found.

Those patients who are standing are able to

pass through the sieve mesh and those
not standing are sorted into 1 of the 5
categories.

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 START
（Simple Triage and Rapid Treatment）

Initial patient assessment and treatment should

take less than 30 seconds for each patient

Using
Respiration
Perfusion
Mental status
 START
（１） First - clear the walking wounded and
tag as
（２） ABCD is evaluated and categorize as

Airway
Breathing
Circulation
Dysfunction of CNS
During START triage medical care
should not be applied !

Except for

correct airway obstruction

stop active bleeding
START Triage

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27
TRIAGE FORM TRIAGE TAG

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Triage
‘Sort’
Process

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Triage ‘sort’ process

 ‘Triage sort’ occurs once the victims

arrive in a casualty clearing station.

 The method used:

1. Physiological triage
2. Anatomical triage

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 1. Physiological triage
 Uses the Triage Revised Trauma Score (TRTS)
 Measures 3 clinical parameters which are:
GCS, RR & SBP (Score for each parameters
range from 0 – 4)
 Combined total score description:
➢ 12 = maximal score (Green label)
➢ 11 = Orange label
➢ ≤ 10 = Red label
➢ 0 = Death (White or Black label
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TRIAGE REVISED TRAUMA SCORE (TRTS)
GCS AVPU Code
13 - 15 Awake 4
9 – 12 Verbal 3
6–8 Pain 2
4–5 Unresponsive 1
3 0

SBP Code RR Code

≥ 90 4 10 – 29 4

76 – 89 3 ≥ 29 3

50 – 75 2 6–9 2
1 – 49 1 1–5 1
0 0 0 0
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 Identifying blood loss
 Pulse: Rate, rhythm, strength
 Estimate Systolic BP via palpable pulse

Radial Pulse SPB 80 mm

Hg
Femoral Pulse SBP 70 mm Hg

Carotid Pulse SBP 60 mm Hg

 2. Anatomical triage
 Considered the mechanism of injuries to
predict the injury pattern

 Fast head-to-toe assessment of MCI

patients

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Features of Time of Disasters
Many Casualties but Few Medical Staff
◆Control of entrance/exit
◆One-way flow of patients
◆Zoning of emergency outpatient unit
・ Urgent treatment group
・ Semi-urgent treatment group
・ Non-urgent group (waiting for
treatment)
・ Unsavable group
 To avoid confusion in hospital
(Entrance control, layout, flow line, triage)
Entrance
Entrance
for victims Yellow tag

Closed
for ambulance
(Semi-urgent
treatment
group)
Triage
Triage Triage

Family waiting
room
Closed

Operation
Mild case

Red tag room, etc.

(Urgent treatment group) Transfer
Green tag

Triage Triage
Mortuary
Exit Black tag
(waiting for treatment group) Inquest
 First Triage and Advanced Triage

Ambulatory
歩 Green
緑 area
行
可 エリア

ambulatory
Non-
歩 ト
行 リ

Triage post
不 ア
可 ー
ジ
ポ
ス
ト

a bろ cは dに e ほ
い
Carry-in triage Carry-in triage
搬入トリアージ 搬入トリアージ

Advanced
Triage Red赤area Yellow
黄
c dに eほ bろ a い
ろ エリア area
エリア
Low低 Level 緊急度・ 重症度
of Urgency/Severity High 高

Textbook p.9
 Triage must be
repeated many times !

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 ３T’s

Triage
Treatment
Transport
Treatment
Aim
 To allow the maximum number of
casualties to reach hospital safely

 Most treatment at the site of a major

incident will be directed towards
support of ABCs
Treatment at the site
resuscitation (stabilization)
A
 Airway adjuncts
 Tracheal intubation
 Surgical airway
 Cervical collar
application
Treatment at the site
resuscitation (stabilization)

B
 Bag-valve-mask
ventilation
 Intubation and
ventilation
 Needle thoracocentesis
 Chest drain insertion
Treatment at the site
resuscitation (stabilization)

C
 Venous access
◦ Peripheral
◦ Central
 Intraosseous access
 Infusion set-up
Treatment
Definitive care
 Definitive Surgery
 Hemodialysis
 Intensive care

 Applied at Hospital
 In large disaster, applied at the hospitals
out side of the affected area.
Nursing Intervention
in Each Area
 Triage Category: Red
・Places to be given the highest priority in all
responses
・Prevent “preventable death” through
appropriate initial response in order to improve
the quantity and quality of responses in the Red
Zone. Emergency medical care for traumatized patients
＊Multiple trauma
＊Head trauma
＊Chest/abdominal trauma
＊Pelvic fracture/Open fracture
＊Crash syndrom
＊Extensive burn
Nursing Intervention in Red Area
 Assist medical consultation: Stabilization of ABC
 Mental care
 Support for families
 Sharing of information
 Consideration of safety
 Privacy protection
 Consideration to hygiene
 Securing of manpower
 Preparation for wide-area transportation
 Responses for crash syndrome
 Triage Category: Yellow
Continue to perform re-triage till treatment starts
Assumed patients: those with injuries such as spinal cord
damage and fracture
＊Stable respiration/circulation dynamics
＊Clear consciousness
First aid & Follow-up
・ Physical assessment
＊See, listen and touch
・ Keeping of a peripheral intravenous access
・ Arrest of bleeding/fixation (stabilization)
・ Oxygen administration (priority to red area)
・Monitoring by ME device (minimum)
Nursing Intervention in Yellow Area
 Increased number of patients: To secure the area and manpower
 Sharing of information
 Responses to the complaints by patients and their families
 Re-triage: To secure ABC and find crash and spinal cord damage
 Selection and distribution of equipment & material: Monitoring
 Consideration of privacy protection
 Management of infusion, confirmation of treatment
 Heating
 Giving of words：response to anxiety
 Securing of means of transport to the Red Area and of
communication
 Division of the area into sub-areas
 Triage Category: Green
Therapy-waiting group
Re-triage should not be missed.
＊Re-triage
＊To perform medical examination, treatment and
care after completing all and majority of responses to
the emergency treatment group.
＊Cases without indication for hospitalization
・ Checking of the conditions of their house
・ Taking to an evacuation shelter
Nursing Intervention in Green Area
 To control a crowd of people. Posting of instructions on a white board
 To develop a collaborative network with a local community
 Re-triage
 First-aid treatment
 To let patients go home if they can do so
 Responses to complaints: Patients & their families
 Preparation and distribution of the area according to season and
weather
 Selection of equipment & material
 To understand medical records and injured persons
 Guiding to and introduction of an evacuation shelter
 Lifestyle guidance at home, requiring medical examination if any change
is felt or seen..
 Triage Category: Black
Response to patient’s families by regarding the
patients as “Treatment-waiting group” until
death is confirmed.
・Instruction on basic life support?
・Risk intervention
・Preparation of the place for the patient families to
stay at the patient’s deathbed
・Death certification, examination and morgue
procedures after the completion of all and majority
of responses to emergency treatment group.
Nursing Intervention in Black Area
 To secure a place in an invisible area, and cover the place with blanket
and curtain.
 To respond and explain to the patient’s families, followed by
subsequent response and the description of the conditions on a tag.
 To confirm and manage patient’s identity and describe a clue on the
tag.
 Management of belongings.
 Management of the corpse (to prevent family to take it away)
 To share and manage patients’ information (with headquarters)
 To divide those with vital sign from those without it into different
areas.
 To clean the patients as much as possible.
Reference

Curtis, K., Ramsden, C., & Friendship, J., (Eds).

(2007). Emergency and trauma nursing.
Philadelphia: Mosby.
Lecture Notes of Master of Advanced Nursing
Practice, 2010
Disaster nursing teleconference, GDLN Unhas
2013

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